INTRODUCTION The leading cause of erectile dysfunction (ED) is arterial dysfunction, with cardiovascular disease as the most common comorbidity. Therefore, ED is typically linked to a web of closely interrelated cardiovascular risk factors such as physical inactivity, obesity, hypertension, and metabolic syndrome. Physical activity (PA) has proved to be a protective factor against erectile problems, and it has been shown to improve erectile function for men affected by vascular ED. This systematic review estimated the levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or manifest cardiovascular diseases. AIM To provide recommendations of levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. METHODS In accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed of research articles specifically investigating PA as a possible treatment of ED. The review included research on ED from physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. All available studies from 2006 through 2016 were checked for the predetermined inclusion and exclusion criteria to analyze the levels of PA needed to decrease ED. RESULTS 10 articles met the inclusion criteria, all suggesting various levels of PA needed to decrease ED for men with relevant risk factors for ED. The results of the review provided sufficient research evidence for conclusions regarding the levels of PA necessary to decrease ED. CONCLUSION Recommendations of PA to decrease ED should include supervised training consisting of 40 minutes of aerobic exercise of moderate to vigorous intensity 4 times per week. Overall, weekly exercise of 160 minutes for 6 months contributes to decreasing erectile problems in men with ED caused by physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies. Sex Med 2018;6:75-89.


title: Staying Connected In The COVID-19 Pandemic: Telehealth At The Largest Safety-Net System In The United States.

text: NYC Health + Hospitals (NYC H+H) is the largest safety net health care delivery system in the United States. Prior to the novel coronavirus disease (COVID-19) pandemic, NYC H+H served over one million patients, including the most vulnerable New Yorkers, and billed fewer than 500 telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve existing patients and treat the surge of new patients. Starting in March 2020 we were able to transform the system using virtual care platforms through which we conducted almost 83,000 billable televisits in one month and more than 30,000 behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, post-discharge follow-up, and palliative care for COVID-19 patients. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].


title: De Novo Computational Design for Development of a Peptide Ligand Oriented to VEGFR-3 with High Affinity and Long Circulation.

text: The overexpression of VEGFR-3 is correlated with a worse prognosis in lung cancer and has been regarded as a rational target for specific drug delivery. Here, VEGFR-3 homing peptide library was efficiently established by computational design. Strong fluorescent signals of selected peptides were observed in A549 cells, but much weaker in other cells. The positive immunostaining overlapped with VEGFR-3 confirmed high affinity and selectivity of one novel peptide (CP-7). In addition, cell uptake of FITC-CP-7 peptide was significantly blocked by coinjection of excess CP-7 peptide. After labeled with 131I, the profile of pharmacology and biodistribution could be traced in vivo. The 131I-radiolabeled CP-7 peptide conjugates were >85% stable in serum over 4 h and exhibited a specific uptake of 18.04 ± 2.04% ID/g at 0.5 h after injection to high VEGFR-3 expressing A549 tumor mice. More importantly, lower uptake concentration in heart (1.06 ± 0.15% ID/g) after 2 h demonstrated the safety of peptide in vivo. The high uptake in the kidneys revealed that renal clearance was the main route of 131I-CP-7 peptide elimination from the body. Lower accumulation of 131I-CP-7 peptide in VEGFR-3 negative HeLa tumor mice further indicated that CP-7 peptide exhibited a higher tumor-homing efficiency. These studies provided a straightforward analytical access to design and screen bioactive peptide based on protein structure and revealed that CP-7 peptide represented a promising homing peptide of VEGFR-3-positive cancer in vitro and in vivo which could be used as a novel target molecule to achieve efficient drug delivery.


title: Endovascular treatment of ruptured intracranial aneurysms.

text: Aneurysmal subarachnoid hemorrhage (SAH) is a catastrophic neurologic event. Early triage of patients with SAH should include cardiopulmonary stabilization, neurologic assessment, and imaging. Conventional angiography with 3-dimensional rendering is necessary to accurately assess aneurysm morphology and location, so that treatment can be planned appropriately. Current evidence suggests that coil embolization can be beneficial for aneurysms amenable to endovascular treatment. The use of remodeling techniques has expanded the range of aneurysms treatable by endovascular means. Balloon remodeling can be a powerful technique for treating ruptured aneurysms with unfavorable morphology. However, stent-assisted technique is associated with significantly higher complication rates in ruptured aneurysms and requires dual antiplatelet agents, and should therefore be considered with great caution for ruptured aneurysms. Complications of ruptured aneurysm embolization include aneurysm perforation, which should be addressed with immediate occlusion of the aneurysm, and thromboembolism, which can be managed most effectively with glycoprotein IIb/IIIa inhibitors.


title: Practical document on the management of hyponatremia in critically ill patients.

text: Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.


title: Phase diagram of the frustrated FCC antiferromagnet from effective-field theory.

text: The phase diagram of a face-centred cubic (FCC) antiferromagnet is calculated from the effective field theory (EFT) of Honmura and Kaneyoshi taking into account not only the effect of interaction with nearest neighbours, $J_1$, but also the effect of second neighbours, $J_2$. The phase diagram for the nearest neighbour case away from the triple point, which in our calculations is predicted to be at $H=4$ and $T=0$, is close to cluster variation method (CVM) and Monte Carlo (MC) results. Similar to MC and CVM predictions, we observe that the increasing second neighbours interaction pushes the triple point towards zero field. Our calculations also show that for $\alpha=-J_2/J_1=0.3$, the triple point merges with the transition point of the L1$_{0}$ phase, one of the ground states, at $H=0$ and changes the nature of phase transition from first- to second-order, in full agreement with Monte Carlo predictions. The phase diagram with the effect of second neighbours calculated for several values of $\alpha$ are in good agreement with available MC and CVM predictions.


Will covid-19 change US healthcare for the better?


title: Breast contrast-enhanced MR imaging: semiautomatic detection of vascular map.

text: BACKGROUND The diagnostic value of breast vascular maps using contrast-enhanced MR imaging has recently been explored. We propose a semiautomatic method to obtain breast vascular maps and to measure the number of blood vessels in the breast. METHODS From January 2011 to December 2013, 188 patients underwent breast contrast-enhanced MRI; patients with unilateral and histopathologically confirmed breast lesions were included in this study; 123 patients had malignant lesions and 65 patients had benign tissue diagnoses. Breast semiautomatic vascular map detection was performed using Hessian matrix-based method and morphologic operators. Blood vessels detection was compared with radiologic interpretation findings to evaluate algorithm goodness. Increase in vascularity associated with ipsilateral cancer was also assessed. Chi square test was used to observe statistically significant difference. RESULTS A total of 1315 blood vessels were identified using semiautomatic procedure; 1034 were correctly classified (78.7 %), 261 (19.8 %) were incorrectly classified, and 20 (1.5 %) were missing. A significant association was found between one-sided increased breast vascularity and ipsilateral malignancy (p < 0.001). CONCLUSIONS In conclusion, detection of vascularity increase as risk factor for developing breast cancer could be performed with semiautomatic vascular mapping of contrast-enhanced MR imaging.


title: Self-gripping versus sutured mesh fixation methods for open inguinal hernia repair: A systematic review of clinical trials and observational studies.

text: BACKGROUND We performed this systematic review and meta-analysis to compare the outcomes of Lichenstein hernia repair using either self-gripping mesh or techniques of sutured mesh fixation. METHODS We searched PubMed, Cochrane CENTRAL, Scopus, Embase, and Web of Science for all clinical trials and observational studies that compared self-gripping mesh versus sutured mesh fixation in Lichtenstein hernia repair. Combined outcomes were pooled as odds ratios or mean differences in a fixed-effect model, using Comprehensive Meta-Analysis software for Windows. RESULTS Twelve randomized, controlled trials and 5 cohort studies (n = 3,722 patients) were included in the final analysis. The two groups, using self-gripping mesh or sutured mesh fixation, did not differ significantly in terms of recurrence rate (odds ratio = 0.66, 95% confidence interval 0.18-2.44; P = .54) or postoperative chronic groin pain (odds ratio = 0.75, 95% confidence interval 0.54-1.05; P = .09). The operative time was less in the self-gripping mesh group (mean difference = -7.85, 95% confidence interval -9.94 to -5.76; P < .0001). For safety analysis, there were comparable risks between self-gripping mesh and sutured mesh fixation groups in terms of postoperative infection (odds ratio = 0.81, 95% confidence interval 0.53-1.23; P = .32), postoperative hematoma (odds ratio = 0.97, 95% confidence interval 0.7-1.36; P = .9), and urinary retention (odds ratio = 0.66, 95% confidence interval 0.18-2.44; P = .54). CONCLUSION Data from our analysis did not favor either of the two fixation techniques over the other in terms of recurrence or postoperative chronic groin pain. Decreased operative time in the self-gripping mesh group cannot justify a recommendation for its routine use. Longer follow-up studies are needed to compare the risk of long-term recurrence for both meshes.


title: Endovascular management of distal ACA aneurysms: single-institution clinical experience in 22 consecutive patients and literature review.

text: BACKGROUND AND PURPOSE Distal ACA aneurysms remain difficult to treat with endovascular therapy, but improved technology and experience allows for the treatment of some of these aneurysms with excellent results. The purpose of this study was to assess the status of endovascular treatment of distal ACA aneurysms by comparing our results with recent endovascular and microsurgical series of distal ACA aneurysms. MATERIALS AND METHODS Between 2000 and 2008, a total of 22 consecutive patients (14 women; mean age, 58.4 years) with distal ACA aneurysms underwent coil placement at Barrow Neurological Institute. Clinical presentations, radiographic findings, endovascular management, and outcomes were reviewed retrospectively. RESULTS Of the 22 patients, 13 (59%) presented with subarachnoid hemorrhage. Six patients were HH grade I or II, 1 was grade III, 5 were grade IV, and 1 was grade V. Frontal lobe hematomas occurred in 5 patients with ruptured aneurysms. The mean aneurysm size was 7.5 mm (range, 2.8-25 mm); 55% were smaller than 7 mm. Twelve aneurysms (55%) arose from the origin of the callosomarginal artery (55%). Complete occlusion was achieved in 50% of the cases and near-complete occlusion in 45%. The few periprocedural complications included 1 retroperitoneal hematoma and 1 intraoperative rupture. Four patients had thromboembolic events adequately treated intraprocedurally with abciximab. No deaths occurred in the patients treated. CONCLUSIONS The characteristics of the patients and aneurysms treated in our series were comparable to previous reports of endovascular treatment of ACA aneurysms with respect to rupture status. Periprocedural morbidity and mortality rates in our series fared well compared with previous reports, as did our combined rate of complete or near-complete occlusions. Recent advances in endovascular devices and techniques have improved outcomes of distal ACA aneurysms.


Neurologic manifestations in an infant with COVID-19.


title: p64 Flow Modulation Device in the treatment of intracranial aneurysms: initial experience and technical aspects.

text: BACKGROUND Experience with the endovascular treatment of cerebral aneurysms by flow diverter devices (FDDs) is limited to four devices (Pipeline, Covidien; FRED, Microvention; Silk, Balt Extrusion; Surpass, Stryker), as reported in different studies. OBJECTIVE To describe the initial experience and the technical innovations of a new-generation FDD (p64 Flow Modulation Device, Phenox, Bochum, Germany). METHODS Between December 2014 and February 2015, six intracranial aneurysms in five patients (four women, one man; mean age 63 years) were treated with the p64 Flow Modulation Device. RESULTS Immediate post-treatment angiography showed reduced flow into all aneurysms. No long-term angiographic data are available. The device may be easily deployed and totally retrieved with a unique mechanical detachment. No periprocedural technical complications occurred. No early or delayed aneurysm rupture, no ischemic or hemorrhagic complications, and no neurological morbidity or death were seen. CONCLUSIONS Treatment of cerebral aneurysms with the p64 Flow Modulation Device is a safe procedure with no technical complications. The mechanical detachment and the 100% retrievability are significant advantages of this new device. However, large prospective studies with long-term clinical and angiographic follow-up are necessary to assess the role of the p64 in the endovascular treatment of intracranial aneurysms.


title: Assessment of the preparedness of obstetrics and gynecology healthcare systems during the COVID-19 pandemic in Libya.

text: Cases of COVID-19 have been reported in neonates, and although these were either asymptomatic or non-severe [1], it is apparent that obstetricians are at increased risk of infection. As a result, safety procedures must be reinforced by ensuring the availability of personal protective equipment (PPE) and the application of infection control measures [2].


Cerebral hyperperfusion syndrome after spontaneous recanalisation of carotid in-stent thrombosis.


title: Association Between Hyponatremia and Higher Bronchiolitis Severity Among Children in the ICU With Bronchiolitis.

text: BACKGROUND AND OBJECTIVES It remains unclear whether hyponatremia independently predicts a higher severity of bronchiolitis in children. The objective of this study was to investigate the association between hyponatremia and bronchiolitis severity in children hospitalized in the ICU for bronchiolitis. METHODS We conducted a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis during the winters of 2007 through 2010. Patients were classified into 2 groups (normonatremic [135-145 mEq/L] and hyponatremic [<135 mEq/L]) based on the first-measured serum sodium concentration on the day of hospitalization. Outcomes were use of mechanical ventilation and ICU length of stay (LOS). To examine the association of sodium status with outcomes, we fit logistic and linear regression models with propensity score adjustment. RESULTS Of 231 children hospitalized in the ICU for bronchiolitis, 193 (84%) were categorized into the normonatremic group and 38 (16%) into the hyponatremic group. Compared with children with normonatremia, those with hyponatremia had higher risks of mechanical ventilation use (40% vs 58%; P = .04) and longer ICU LOS (median, 3 vs 6 days; P = .007). Likewise, in the adjusted analyses, children with hyponatremia had significantly higher risks of mechanical ventilation use (odds ratio, 2.14 [95% confidence interval, 1.03-4.48; P = .04) and longer ICU LOS (β-coefficient, 2.21 days [95% confidence interval, 0.68-3.73; P = .005]). CONCLUSIONS In this prospective, multicenter study of children hospitalized for bronchiolitis, hyponatremia on the day of hospitalization was associated with a higher severity of disease. Our data support hyponatremia as a prognostic factor that might improve the ability of clinicians to predict the disease course of children with severe bronchiolitis.


Covid-19: Low skilled men have highest death rate of working age adults.


title: Periprosthetic Capsule Formation and Contracture in a Rodent Model of Implant-Based Breast Reconstruction With Delayed Radiotherapy.

text: INTRODUCTION Capsular contracture (CC) is the most common complication of breast implantation, with an incidence of nearly 50% in patients undergoing breast reconstruction with subsequent radiotherapy. Although the move toward submuscular (SM) device placement led to a decreased incidence of CC, subcutaneous (SQ) implantation has seen a resurgence. The purpose of this study was to use a rodent model of breast reconstruction with smooth silicone implants and delayed radiotherapy to assess the occurrence of CC in SQ versus SM implantation. METHODS Custom 2 mL smooth round silicone implants were placed bilaterally into 12 female Sprague Dawley rats that were randomized into 4 groups of 3, with each group differing by implantation plane (SQ vs SM) and irradiation status (irradiated vs nonirradiated). Rats from the SQ group received implants bilaterally underlying the skin on the flank. Rats in the SM groups received implants bilaterally under the latissimus dorsi muscle. Irradiated rats received 20 Gy localized to each implant on postoperative day 10. One rat from each group was imaged with a micro-computed tomography scanner at baseline and at explant 3 months later, whereupon capsules from all rats were examined histologically. RESULTS Rats in the SQ group showed evidence of contracture on gross examination and greater evidence of morphologic disruption per micro-computed tomography scan. There was no evidence of contracture or morphologic disruption in either SM group. Mean ± SD capsule thickness was 39.0 ± 9.0 μm in the SQ versus 37.6 ± 9.8 μm in the SM nonirradiated groups and 43.9 ± 14.9 μm in the SQ versus 34.3 ± 8.3 μm in the SM irradiated groups (all P > 0.05). CONCLUSIONS In a rodent model of smooth silicone breast implantation and delayed radiotherapy, although there did not appear to be differences in capsule thickness regardless of device placement plane, SQ implants demonstrated gross evidence of CC. These data indicate that capsule thickness is only part of a larger pathogenetic picture, which should take into consideration the contribution from all peri-implant tissue.


title: Early angiographic signs of acute thrombus formation following cerebral aneurysm treatment with the Pipeline embolization device.

text: BACKGROUND AND OBJECTIVE Acute thrombus formation following aneurysm treatment with the Pipeline embolization device (PED) is a potentially devastating complication that may result in significant thromboembolic sequelae if not promptly treated. We therefore evaluated PED cases complicated by acute thrombus formation at our institution, with an emphasis on identifying early angiographic signs that may portend this event. MATERIALS AND METHODS We retrospectively identified cases of acute thrombosis following PED placement in 100 consecutive procedures performed at our institution from a prospectively maintained clinical database. Angiographic findings were analyzed for early signs of acute thrombus formation. We also evaluated the efficacy of treatment of this complication with a glycoprotein IIb/IIIa inhibitor (abciximab), as well as the results of pre-procedure platelet inhibition testing. RESULTS Acute thrombus formation was encountered in five patients following PED placement (5%). Early angiographic signs were present in all cases and included progressive stagnation of blood flow in covered side branches, occlusion of covered side branches, excessive stagnation of blood flow in the target aneurysm, as well as occlusion of the target aneurysm. These sequelae completely resolved following abciximab treatment in all five cases, with no permanent neurological morbidity or mortality. Four of the five patients had a pre-procedure P2Y12 value >200 (range 201-227). CONCLUSIONS Progressive stagnation or occlusion of covered side branches or target aneurysm are early angiographic signs of acute thrombus formation following PED placement and should prompt immediate treatment with a glycoprotein IIb/IIIa inhibitor. Platelet inhibition testing may help identify those patients who are at an increased risk for this complication.


title: Treatment of dysplasia in barrett esophagus.

text: Barrett esophagus is recognized as a risk factor for the development of dysplasia and adenocarcinoma of the esophagus. Cancer is usually diagnosed at an advanced stage with a 5-year survival rate of 15%. Most of these patients present de novo and are not part of a surveillance program. Endoscopic screening with improvement in recognition of early lesions may change this pattern. In the past, patients diagnosed with dysplasia and mucosal cancer were best managed by esophagectomy. Endoscopic techniques such as endoscopic mucosal resection and radiofrequency ablation have resulted in high curative rates and a shift away from esophagectomy. This pathway is supported by the literature review of esophagectomies performed for mucosal disease, as well as pathologists' interpretation of endoscopic mucosal specimens, which document the low risk of lymph node metastasis. The role of endoscopic therapy for superficial submucosal disease continues to be a challenge.


Coronavirus shutdown forces research ship to break out of Arctic ice.


title: The Well-Being Index (WBI) for schools: A brief measure of adolescents' mental health.

text: Schools are increasingly concerned with the well-being of the whole child - likely, more so since the COVID-19 pandemic - and goals here were to document the psychometric properties of a brief new measure of adolescent mental health, the Well-Being Index (WBI). The measure assesses 4 symptom areas, 2 each of internalizing and externalizing symptoms-Depression, Anxiety, Rule-Breaking, and Substance Use-and an optional scale on Isolation at School. A total of 2,444 students from 2 high schools completed the WBI, the Youth Self-Report (YSR), and other related measures. Alpha coefficients showed acceptable internal consistency, with values for the 5 WBI subscales at .83, .84, .78, .79, and .74, respectively. Both exploratory and confirmatory factor analyses demonstrated consistent factorial validity. Correlations with corresponding YSR subscales indicated good convergent and discriminant validity. The WBI Substance Use and Isolation at School subscales, similarly, had high correlations with subscales from preexisting measures. Criterion-related validity was indicated in significant correlations between WBI subscales and conceptually related dimensions of close relationships. Also examined was the percentage of youth falling above clinical cutoffs on both the WBI and YSR, and findings demonstrated high concurrent validity. Collectively, results suggest the promise of the WBI as a brief, psychometrically sound measure to assess the adjustment of adolescents, along with perceptions of school climate that can be modified toward fostering their overall well-being. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Impact of pain in overweight to morbidly obese women: preliminary findings of a cross-sectional study.

text: OBJECTIVES To evaluate the effect of body mass index (BMI) on the prevalence, intensity and interference of pain in women, and how it affects quality of life and level of physical activity; and to determine independent predictors of pain intensity. DESIGN Cross-sectional observational study. SETTINGS Obesity treatment clinic, community and university laboratory. PARTICIPANTS Seventy-three of 133 women aged 25-75 years reported the presence of pain for at least 2 weeks and were categorised according to BMI (normal weight, overweight, obese or morbidly obese). MAIN OUTCOME MEASURES BMI and questionnaires [McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI), Short-Form Health Survey-36 (SF-36) and Baecke Physical Activity Questionnaire]. RESULTS Pain intensity was 3 and 4.5 times higher in the MPQ and BPI, respectively, in morbidly obese women compared with women of normal weight. Morbidly obese women had 10.7 times higher pain interference and lower scores on the SF-36 domains of physical function and role function-physical compared with women of normal weight. Obese and morbidly obese women had less pain relief from treatment. Regression analysis showed that high BMI and low level of physical activity contributed to the intensity of pain, and these variables explained 16% of the variance of pain intensity. CONCLUSIONS This study found that the prevalence and intensity of pain are greater in morbidly obese women than women of normal weight, and pain is negatively associated with physical activity. The causal inter-relationships between pain, obesity and physical activity are complex and require further study.


title: Computed tomography and histopathological findings after embolization with inherently radiopaque 40μm-microspheres, standard 40μm-microspheres and iodized oil in a porcine liver model.

text: PURPOSE The present study compared standard computed tomography (CT) and histopathological findings after endovascular embolization using a prototype of inherently radiopaque 40μm-microspheres with both standard 40μm-microspheres and iodized oil in a porcine liver model. MATERIALS AND METHODS Twelve pigs were divided into six study groups, of two pigs each. Four pigs were embolized with iodized oil alone and four with radiopaque microspheres; two animals in each group were sacrificed at 2 hours and two at 7 days. Two pigs were embolized with radiopaque microspheres and heparin and sacrificed at 7 days. Two pigs were embolized with standard microspheres and sacrificed at 2 hours. CT was performed before and after segmental embolization and before sacrifice at 7 days. The distribution of embolic agent, inflammatory response and tissue necrosis were assessed histopathologically. RESULTS Radiopaque microspheres and iodized oil were visible on standard CT 2 hours and 7 days after embolization, showing qualitatively comparable arterial and parenchymal enhancement. Quantitatively, the enhancement was more intense for iodized oil. Standard microspheres, delivered without contrast, were not visible by imaging. Radiopaque and standard microspheres similarly occluded subsegmental and interlobular arteries and, to a lesser extent, sinusoids. Iodized oil resulted in the deepest penetration into sinusoids. Necrosis was always observed after embolization with microspheres, but never after embolization with iodized oil. The inflammatory response was mild to moderate for microspheres and moderate to severe for iodized oil. CONCLUSION Radiopaque 40μm-microspheres are visible on standard CT with qualitatively similar but quantitatively less intense enhancement compared to iodized oil, and with a tendency towards less of an inflammatory reaction than iodized oil. These microspheres also result in tissue necrosis, which was not observed after embolization with iodized oil. Both radiopaque and standard 40μm-microspheres are found within subsegmental and interlobar arteries, as well as in hepatic sinusoids.


title: HbA1c (Glycated Hemoglobin) Levels and Clinical Outcome Post-Mechanical Thrombectomy in Patients With Large Vessel Occlusion.

text: Background and Purpose- We analyzed the relationship between HbA1c (glycated hemoglobin) levels and clinical outcomes in patients with large vessel occlusion treated with mechanical thrombectomy (MT). Methods- A total of 534 patients with acute ischemic stroke (AIS) treated with MT were enrolled in this prospective cohort study. The primary outcome measured was the modified Rankin Scale score at 3 months, according to HbA1c level. High HbA1c levels were defined as a plasma level of HbA1c >6.5%. Favorable outcomes were defined as functional independence, with modified Rankin Scale scores of 0 to 2. Secondary functional outcomes included mortality, early clinical outcomes, and intracranial hemorrhage. Results- The number of patients with a favorable outcome was significantly lower in patients with HbA1c >6.5% than in those with HbA1c ≤6.5% (28.8% versus 42.1%; P=0.006). In multivariate analysis, high HbA1c levels (especially >7.0% HbA1c) were significantly associated with poor functional outcomes 3 months after AIS in patients with large vessel occlusion treated with MT. High HbA1c was also significantly associated with increased mortality and worse early clinical outcomes after AIS in patients treated with MT. Subgroup analyses showed that HbA1c >6.5% was associated with significantly lower odds of functional independence at 3 months after AIS, when comparing the recanalized group with nonrecanalized patients. Conclusions- These results suggest that high HbA1c level is an independent predictor of a poor outcome at 3 months after AIS in patients with large vessel occlusion treated with MT, particularly in those with recanalization, and may augment the risk of mortality and early clinical worsening after AIS.


title: SILK flow-diverting device for intracranial aneurysms.

text: BACKGROUND The SILK intracranial stent is a Conformité Européenne mark-approved endovascular device. This flow-diversion device is being used in Europe for intracranial aneurysm treatment by aneurysm occlusion. The device construct creates an intracranial bypass conduit that reconstructs the parent vessel while maintaining patency of the perforating arteries and branch arteries. The investigators report the first two patients in which the SILK stent was used for intracranial aneurysms in the United States. CASE DESCRIPTION Two patients, one with a symptomatic giant posterior communicating artery aneurysm and one with a symptomatic fusiform vertebrobasilar junction and basilar artery aneurysm, were treated at two separate institutions with the device. A total of three SILK stents were placed in these patients. In the first patient, a single device was sufficient to cause immediate angiographic stasis within the posterior communicating artery aneurysm. However, reversal of anticoagulation and antiplatelet therapy was required due to a spontaneous bleed from an intercostal artery, and this led to in-stent thrombosis and major stroke. In the second patient, the placement of two devices resulted in immediate stasis of the basilar artery aneurysm. The patient remained on antiplatelet therapy and was discharged without complication. His follow-up angiogram at approximately 2 months showed complete occlusion of the aneurysm with parent vessel reconstruction. In both patients, immediate stasis was identified, and no immediate neurological complications occurred. However, in one patient, a complication occurred that was related to reversal of/cessation of antiplatelet therapy. CONCLUSION In this initial U.S. experience with SILK flow-diversion devices, these devices were deployed easily and immediate flow stasis in the aneurysm was achieved. Further evaluation of this device is needed at multiple centers with adequately trained and experienced operators.


title: Randomized comparison of the effectiveness of nasal intubation using a GlideScope video laryngoscope with Magill forceps versus vascular forceps in patients with a normal airway.

text: PURPOSE The GlideScope® video laryngoscope (GVL) is widely used for nasotracheal intubation in dental and facial plastic surgery. The angle of the Magill forceps is different from that of the GVL blade, which suggests that the Magill forceps are not the ideal forceps for use with the GVL. The purpose of this study was to compare the effectiveness of the Magill forceps vs vascular forceps for nasotracheal intubation using the GVL. METHODS This study included 60 patients scheduled to undergo elective surgery requiring nasotracheal intubation. Patients were assigned to one of two groups-i.e., Magill forceps (group M) or vascular forceps along with a tube exchanger (group V), by computer randomization. The primary outcome was total intubation time, defined as the time from when the anesthesiologist picked up the device to the time when three successive end-tidal CO2 waves were obtained following intubation. Secondary outcomes were blood in the endotracheal tube and trauma to the oral tissues or teeth. A blind observer assessed the presence of sore throat one hour and 24 hr after surgery. RESULTS The total intubation time was significantly different between group M and group V (96.1 sec and 78.1 sec, respectively; mean difference, 18 sec; 95% confidence interval (CI), 13.7 to 49.7). The incidence of epistaxis in group M was significantly greater than that in group V (46.7% vs 16.7%, respectively; relative risk, 2.8; 95% CI, 1.2 to 6.8). CONCLUSION The total intubation time was significantly less with the vascular forceps (and tube exchanger) than with the Magill forceps. Using vascular forceps also reduced the incidence of epistaxis compared with that using the Magill forceps. Using a tube exchanger and vascular forceps offers advantages over use of Magill forceps when a GlideScope video laryngoscope is used for nasotracheal intubation. TRIAL REGISTRATION http://www.who.int/ictrp/network/cris2/en/ , CRIS, KCT0001310. Registered 29 July 2014.


title: Bariatric/Metabolic Surgery to Treat Type 2 Diabetes in Patients With a BMI <35 kg/m2.

text: OBJECTIVE Global usage of bariatric surgery has been dictated for the past quarter century by National Institutes of Health recommendations restricting these operations to individuals with a BMI ≥35 kg/m(2). Strong evidence now demonstrates that bariatric procedures markedly improve or cause remission of type 2 diabetes mellitus (T2DM), in part through weight-independent mechanisms, and that baseline BMI does not predict surgical benefits on glycemic or cardiovascular outcomes. This impels consideration of such operations as "metabolic surgery," which is used expressly to treat T2DM, including among patients with a BMI <35 kg/m(2) who constitute the majority of people with diabetes worldwide. Here, we review available evidence to inform that consideration. RESULTS A meta-analysis of the 11 published randomized clinical trials (RCTs) directly comparing bariatric/metabolic surgery versus a variety of medical/lifestyle interventions for T2DM provides level 1A evidence that surgery is superior for T2DM remission, glycemic control, and HbA1c lowering. Importantly, this is equally true for patients whose baseline BMI is below or above 35 kg/m(2). Similar conclusions derive from meta-analyses of high-quality nonrandomized prospective comparisons. Meta-analysis of all pertinent published studies indicates that T2DM remission rates following bariatric/metabolic surgery are comparable above and below the 35 kg/m(2) BMI threshold. The safety, antidiabetes durability, and benefits on other cardiovascular risk factors from bariatric/metabolic surgery appear roughly comparable among patients with a BMI below or above 35 kg/m(2). Further studies are needed to extend long-term findings and measure "hard" macrovascular/microvascular outcomes and mortality in RCTs. CONCLUSIONS Extant data, including level 1A evidence from numerous RCTs, support new guidelines from the 2nd Diabetes Surgery Summit that advocate for the consideration of bariatric/metabolic surgery as one option, along with lifestyle and medical therapy, to treat T2DM among patients with a BMI <35 kg/m(2).


docid: khleizia

title: Review of emerging surgical robotic technology.

text: BACKGROUND The use of laparoscopic and robotic procedures has increased in general surgery. Minimally invasive robotic surgery has made tremendous progress in a relatively short period of time, realizing improvements for both the patient and surgeon. This has led to an increase in the use and development of robotic devices and platforms for general surgery. The purpose of this review is to explore current and emerging surgical robotic technologies in a growing and dynamic environment of research and development. METHODS This review explores medical and surgical robotic endoscopic surgery and peripheral technologies currently available or in development. The devices discussed here are specific to general surgery, including laparoscopy, colonoscopy, esophagogastroduodenoscopy, and thoracoscopy. Benefits and limitations of each technology were identified and applicable future directions were described. RESULTS A number of FDA-approved devices and platforms for robotic surgery were reviewed, including the da Vinci Surgical System, Sensei X Robotic Catheter System, FreeHand 1.2, invendoscopy E200 system, Flex® Robotic System, Senhance, ARES, the Single-Port Instrument Delivery Extended Research (SPIDER), and the NeoGuide Colonoscope. Additionally, platforms were reviewed which have not yet obtained FDA approval including MiroSurge, ViaCath System, SPORT™ Surgical System, SurgiBot, Versius Robotic System, Master and Slave Transluminal Endoscopic Robot, Verb Surgical, Miniature In Vivo Robot, and the Einstein Surgical Robot. CONCLUSIONS The use and demand for robotic medical and surgical platforms is increasing and new technologies are continually being developed. New technologies are increasingly implemented to improve on the capabilities of previously established systems. Future studies are needed to further evaluate the strengths and weaknesses of each robotic surgical device and platform in the operating suite.


title: The wisdom of crowds in action: Forecasting epidemic diseases with a web-based prediction market system.

text: BACKGROUND The quest for an effective system capable of monitoring and predicting the trends of epidemic diseases is a critical issue for communities worldwide. With the prevalence of Internet access, more and more researchers today are using data from both search engines and social media to improve the prediction accuracy. In particular, a prediction market system (PMS) exploits the wisdom of crowds on the Internet to effectively accomplish relatively high accuracy. OBJECTIVE This study presents the architecture of a PMS and demonstrates the matching mechanism of logarithmic market scoring rules. The system was implemented to predict infectious diseases in Taiwan with the wisdom of crowds in order to improve the accuracy of epidemic forecasting. METHODS The PMS architecture contains three design components: database clusters, market engine, and Web applications. The system accumulated knowledge from 126 health professionals for 31 weeks to predict five disease indicators: the confirmed cases of dengue fever, the confirmed cases of severe and complicated influenza, the rate of enterovirus infections, the rate of influenza-like illnesses, and the confirmed cases of severe and complicated enterovirus infection. RESULTS Based on the winning ratio, the PMS predicts the trends of three out of five disease indicators more accurately than does the existing system that uses the five-year average values of historical data for the same weeks. In addition, the PMS with the matching mechanism of logarithmic market scoring rules is easy to understand for health professionals and applicable to predict all the five disease indicators. CONCLUSIONS The PMS architecture of this study affords organizations and individuals to implement it for various purposes in our society. The system can continuously update the data and improve prediction accuracy in monitoring and forecasting the trends of epidemic diseases. Future researchers could replicate and apply the PMS demonstrated in this study to more infectious diseases and wider geographical areas, especially the under-developed countries across Asia and Africa.


docid: ngesohbz

title: Composition vector method based on maximum entropy principle for sequence comparison.

text: The composition vector (CV) method is an alignment-free method for sequence comparison. Because of its simplicity when compared with multiple sequence alignment methods, the method has been widely discussed lately; and some formulas based on probabilistic models, like Hao’s and Yu’s formulas, have been proposed. In this paper, we improve these formulas by using the entropy principle which can quantify the nonrandomness occurrence of patterns in the sequences. More precisely, existing formulas are used to generate a set of possible formulas from which we choose the one that maximizes the entropy. We give the closed-form solution to the resulting optimization problem. Hence, from any given CV formula, we can find the corresponding one that maximizes the entropy. In particular, we show that Hao’s formula is itself maximizing the entropy and we derive a new entropy-maximizing formula from Yu’s formula. We illustrate the accuracy of our new formula by using both simulated and experimental data sets. For the simulated data sets, our new formula gives the best consensus and significant values for three different kinds of evolution models. For the data set of tetrapod 18S rRNA sequences, our new formula groups the clades of bird and reptile together correctly, where Hao’s and Yu’s formulas failed. Using real data sets with different sizes, we show that our formula is more accurate than Hao’s and Yu’s formulas even for small data sets.


title: Determinants of systemic hypertension in older adults in Africa: a systematic review.

text: BACKGROUND An estimated 55% of older adults in Africa have systemic hypertension, a major risk factor for stroke, heart failure and dementia in the region. The risk factors associated with hypertension in this population group in Africa have not been systematically evaluated. We, therefore, undertook a systematic review to identify these risk factors. METHODS We searched for population-based studies of adults aged ≥50 years living in Africa and reporting an estimate of hypertension and associated risk factors. We included articles published in any language between January 1980 and May 2018 using a comprehensive search strategy. We extracted data including the sample characteristics, prevalence of hypertension and risk factors with their effect sizes. RESULTS From an initial 10,719 records, we retained 63 eligible full text articles for review out of which we analyzed 23 studies made up of 19 primary and four multiple publications which had data on risk factors from bivariate or multivariable analysis. The primary studies, published from 2010 to 2018, involved a total of 30,500 participants in 12 different countries with mean ages ranging from 62.7 ± 9 years to 76.9 ± 8.4 years. Through narrative synthesis, we found consistent determinants of hypertension (overweight/obesity and history of stroke), less consistent but frequent determinants (including older age group, female sex and urban residence), inconsistent determinants (including education, wealth index, alcohol intake and physical activity) and nonsignificant covariates (marital status and having health insurance). Overall, the highest adjusted odds ratios were those associated with obesity and history of stroke. CONCLUSION The key determinants of systemic hypertension in older adults in Africa are older age group, overweight/obesity, history of stroke and female sex. Health programmes should promote weight reduction throughout the life course, including during the middle and older age of African adults.


title: Routine versus selective computed tomography in non-traumatic acute abdominal pain: meta-analysis of randomised trials.

text: PURPOSE To compare the routine vs. selective use of computed tomography (CT) in patients presenting with non-traumatic acute abdominal pain (AAP) to a surgical service. METHODS We conducted a systematic review of literature and meta-analysis of outcomes according to PRISMA statement standards to compare the routine vs. selective use of CT in adult patients presenting with non-traumatic AAP. RESULTS Analysis of 722 patients from 4 randomised controlled trials showed no difference between the routine CT and selective CT groups in terms of proportion of correct diagnoses (OR 1.36,95% CI 0.89, 2.07, P = 0.15), mortality (RD 0.03, 95% CI - 0.08, 0.02, P = 0.27] and length of hospital stay (LOS) [MD - 0.26, 95% CI - 2.07, 1.55, P = 0.78). CONCLUSIONS The routine use of CT does not improve the proportion of correct diagnoses and mortality compared to selective use of CT in adult patients with non-traumatic AAP. The available evidence regarding the influence of routine CT on LOS may be subject to type 2 error. These findings, however, may not apply to the elderly patient with AAP and further studies are required.


title: Transcatheter arterial embolisation in upper gastrointestinal bleeding in a sample of 29 patients in a gastrointestinal referral center in Germany.

text: OBJECTIVE This is a retrospective analysis of interventional embolisation performed with catheter angiography in 29 patients with upper gastrointestinal bleeding in the setting of a secondary care hospital. PATIENTS, MATERIALS, AND METHODS From April 2007 to February 2013, 29 patients with upper gastrointestinal bleeding underwent endovascular diagnostics and treatment. The diagnosis was established by endoscopy, computed tomography or clinically based on a significant decrease in hemoglobin. Transcatheter arterial embolisation was performed with coils, liquid embolic agents, and particles. The technical and clinical outcomes were assessed by postinterventional endoscopy, hemoglobin concentrations, number of necessary transfusions, or surgical interventions, as well as by post-interventional mortality within 28 days after the procedure. RESULTS Selective angiographic embolisation in upper gastrointestinal bleeding was primarily successful technically and clinically in 22 of 29 patients. In 4/29 cases an angiographic reintervention was performed, which was successful in 3 cases. In 3 cases of primarily technically unsuccessful procedures reintervention was not attempted. No catheterisation-related complications were recorded. Peri-interventional mortality was 31%, but only 2 of these patients died due to uncontrolled massive bleeding, whereas the lethal outcome in the other 7 patients was due to their underlying diseases. CONCLUSION Transcatheter arterial embolisation is an effective and rapid method in the management of upper gastrointestinal bleeding. Radiological endovascular interventions may considerably contribute to reduced mortality in GI bleeding by avoiding a potential surgical procedure following unsuccessful endoscopic treatment. The study underlines the importance of the combination of interventional endoscopy with interventional radiology in secondary care hospitals for patient outcome in complex and complicated upper gastrointestinal bleeding situations.


title: Pregnancy and non-pregnancy related immune thrombotic thrombocytopenic purpura in women of reproductive age.

text: Pregnancy is a precipitating factor for immune thrombotic thrombocytopenic purpura (iTTP). We compared the clinical course and outcomes of iTTP in women of reproductive age, between those with pregnancy- and non-pregnancy-related iTTP. A review of all reproductive-aged women diagnosed with iTTP during 2010-2019 in seven university hospitals in Israel. Of 42 cases of iTTP, 12 (28.6%) were pregnancy-related. At presentation, the laboratory profiles did not differ significantly between those with pregnancy- and non-pregnancy-related iTTP, including hemoglobin (median 8.4 vs 8.0 g/dL), platelet count (12.5 vs. 11.5 X 109/L); and levels of bilirubin (1.23 vs. 1.82 mg/dL), lactate dehydrogenase (1615 vs. 1701 U/L), creatinine (0.61 vs. 0.79 mg/dL) and anti-ADAMTS13 antibodies titer (75 vs. 82 U/mL). The proportions of women with renal, neurologic, or hepatic involvement were similar between the groups. Cardiac involvement was more common among those with pregnancy-related disease (25.0% vs. 3.3%, P = 0.06). The median number of courses of plasma-exchange therapy was 11 for both groups. All the women were treated with parenteral corticosteroids and the rate of adjunctive treatments did not differ between the groups (P = 0.30). Four women (one-third) with pregnancy-related disease had preeclampsia. Two women (16.7%) with pregnancy-related iTTP died during the acute episode (P = 0.07); no deaths were observed in the non-pregnancy-related group. Among reproductive-aged women with iTTP, most clinical and laboratory profiles were similar between those with pregnancy- and non-pregnancy-related disease. However, the higher rates of cardiac involvement and mortality among women with pregnancy-related iTTP highlight its challenging management.


title: Development of a virtual reality robotic surgical curriculum using the da Vinci Si surgical system.

text: INTRODUCTION This study aimed to develop a training curriculum to evaluate the basic robotic skills necessary to reach an 80 % preset proficiency score and correlate the level of surgical experience with the overall performance obtained using the da Vinci Surgical Skills simulator. METHODS Twenty-two participants (4 faculty, 4 senior, and 14 junior residents) were enrolled in a 4-week robotic training curriculum developed at our institution. A set of seven robotic skills were selected based on the manufacturer's exercise primary endpoint. During their pretesting session, participants completed one trial of each of the seven simulated exercises. In two individual sessions over a 2 week period, trainees practiced a different set of exercises that evaluated the same basic robotic skills assessed during pretesting with the objective of reaching an overall score of 80 % on two consecutive attempts. If proficiency was not achieved, then a maximum of six trials per exercise was allowed before advancing to the next skill. During their fourth week of training, participants completed a post-testing session with the same set of exercises used during pretesting. Participants' overall performance and various metrics were recorded in an online database for further analysis. RESULTS A significant skills gain from pre- to post-test was observed for each of the seven basic robotic skills regardless of participant's level of training (p < .001). Interestingly, participants only achieved an overall score of 80 % or more in only five of the seven exercises. No statistical difference in gain of skills was found between groups suggesting robotic skills development is independent of level of prior surgical expertise. CONCLUSION A dedicated virtual reality robotic training curriculum significantly improves the seven basic robotic surgical skills necessary to operate the da Vinci Si surgical console. Six training trials appear to be insufficient to reach proficiency levels on more advanced skills.


title: Power Morcellation Using a Contained Bag System.

text: BACKGROUND AND OBJECTIVES The well-known advantages of minimally invasive surgery make the approach well suited for hysterectomy and other gynecological procedures. The removal of specimens excised during surgery has been a challenge that has been answered by the use of power morcellation. With this study we sought to assess the feasibility of power morcellation within a specimen bag. METHODS This was a retrospective cohort study including patients from a private practice in suburban Chicago, Illinois, who underwent contained electromechanical power morcellation during a laparoscopic or robot-assisted hysterectomy or myomectomy from May 2014 through December 2015. Contained power morcellation was performed with the Espiner EcoSac 230 (Espiner Medical Ltd., North Somerset, United Kingdom) specimen bag. Descriptive statistics were performed for both categorical and continuous data. RESULTS Of the 187 procedures performed, 73.8% were myomectomies, and 26.2% were hysterectomies. The patients' mean age was 40 (range, 25-54) years and mean body mass index was 28.7 (range, 17.3-57.6). The average specimen weight was 300 g, with the largest weighing 2134 g. Estimated blood loss averaged 98.4 mL. The postoperative admission rate was 12.3%, most of which were due to nausea and urinary retention. Seventeen patients (9.1%) had postoperative complications, most of which were minor, and 4 (2.1%) were readmitted. There were no bag failures or complications that were due to the use of the specimen bag or to power morcellation. CONCLUSIONS Performing electromechanical power morcellation within the Espiner EcoSac 230 specimen bag was successfully performed in 187 patients with no bag-related complications. This method of contained power morcellation is feasible, reliable, and reproducible, even for a large specimen.


Letter to the Editor: Use of Dental Radiography in the COVID-19 Pandemic.


docid: owqjwpxr

title: Comparison of minilaparoscopy and single-incision intragastric surgery for gastric submucosal tumor resection in a porcine model.

text: BACKGROUND The aim of this study was to develop an easy-to-induce and reproducible model of gastric submucosal tumor in swine to compare minilaparoscopy (ML) with single-incision (SI) intragastric surgery. METHODS Twelve healthy female pigs (weight 30.94 ± 2.49 kg) underwent a transparietal injection of sterile alginate at the level of Z-line (n = 6) and at the pre-pyloric area (n = 6) creating a model of gastric submucosal pseudotumor. The operative procedures included intragastric resection with ML and SI approaches of cardiac and pre-pyloric lesions, with gastroscopic assistance. After resection, the gastric mucosal layer was closed using intracorporeal sutures. The operative time, complication rate and clinical evolution after 1 month were compared in the four groups that the pigs were arranged. RESULTS The pseudotumors ranged in size from 3 to 6 cm in diameter. The access of the gastric cavity and resection of the experimental SMP and suturing of the mucosa were performed successfully in 12 animals using both approaches. Mean time to perform the exeresis of gastric cardia tumors was significantly higher in single-incision approach. No significant differences were observed in the surgical time during pyloric surgery. Minilaparoscopic approach reduced significantly the mucosa closure time in esophagogastric and pyloric pseudotumors. One month after, no alterations were shown in the abdominal cavity using exploratory laparotomy. CONCLUSIONS The technical feasibility of performing safe and efficient intragastric approach of submucosal pseudotumors in swine model was verified in this study. Intragastric ML has advantages over SI, namely regarding the reduction in total surgical times and the fewer technical difficulties.


title: Biosensors as rapid diagnostic tests for tropical diseases.

text: Effective diagnosis of infectious pathogens is essential for disease identification and subsequent adequate treatment, to prevent drug resistance and to adopt suitable public health interventions for the prevention and control of epidemic outbreaks. Particular situations under which medical diagnostics operate in tropical environments make the use of new easy-to-use diagnostic tools the preferred (or even unique) option. These diagnostic tests and devices, usually based on biosensing methods, are being increasingly exploited as promising alternatives to classical, "heavy" lab instrumentation for clinical diagnosis, allowing simple, inexpensive and point-of-care testing. However, in many developing countries the lack of accessibility and affordability for many commercial diagnostic tests remains a major cause of high disease burden in such regions. We present a comprehensive overview about the problems of conventional medical diagnosis of infectious pathologies in tropical regions, while pointing out new methods and analytical tools for in-the-field and decentralized diagnosis of current major infectious tropical diseases. The review includes not only biosensor-based rapid diagnostic tests approved by regulatory entities and already commercialized, but also those at the early stages of research.


Laparoscopic repair of Morgagni hernia: an interesting case and complication.


title: Human leukocyte antigens A*3001 and A*3002 show distinct peptide-binding patterns of the Mycobacterium tuberculosis protein TB10.4: consequences for immune recognition.

text: High-tuberculosis (TB)-burden countries are located in sub-Saharan Africa. We examined the frequency of human leukocyte antigen (HLA) alleles, followed by recombinant expression of the most frequent HLA-A alleles, i.e., HLA-A*3001 and HLA-A*3002, to study differences in mycobacterial peptide presentation and CD8(+) T-cell recognition. We screened a peptide library (9-mer peptides with an 8-amino-acid overlap) for binding, affinity, and off-rate of the Mycobacterium tuberculosis-associated antigen TB10.4 and identified only three TB10.4 peptides with considerable binding to HLA-A*3001. In contrast, 22 peptides bound to HLA-A*3002. This reflects a marked difference in the binding preference between the two alleles, with A*3002 tolerating a more promiscuous peptide-binding pattern and A*3001 accommodating only a very selective peptide repertoire. Subsequent analysis of the affinity and off-rate of the binding peptides revealed a strong affinity (8 nM to 7 μM) and moderate off-rate (20 min to 3 h) for both alleles. Construction of HLA-A*3001 and HLA-A*3002 tetramers containing selected binding peptides from TB10.4, including a peptide which was shared among both alleles, QIMYNYPAM (TB10.4(3-11)), allowed us to enumerate epitope-specific T cells in HLA-A*3001- and HLA-A*3002-typed patients with active TB. HLA-A*3001 and HLA-A*3002 major histocompatibility complex-peptide complexes were recognized in individuals with active TB, irrespective of their homozygous HLA-A*3001 or HLA-A*3002 genetic background. The antigen-specific T cells exhibited the CD45RA(+) CCR7(+) precursor phenotype and the interleukin-7 receptor (CD127), which were different from the phenotype and receptor exhibited by the parental CD8(+) T-cell population.


title: A contemporary comparative analysis of immediate postoperative prosthesis placement following below-knee amputation.

text: BACKGROUND Despite advances in the treatment of peripheral arterial disease, a significant number of patients ultimately require major amputations. Traditionally, postoperative management of a below-knee amputation involves soft compressive dressings to allow for complete stump healing before initial prosthesis fitting. This technique is associated with a prolonged period of limited mobility, placing patients at risk for deconditioning or fall with a risk of injury to the stump. In contrast, immediate postoperative prosthesis (IPOP) placement allows patients to begin ambulation and rehabilitation on postoperative day 1, which may be of significant physiologic and psychological benefit. The purpose of this study is to compare the outcomes of patients undergoing IPOP placement to those of a historical control group managed with traditional soft compressive dressing placement. METHODS Medical records of all consecutive below-knee amputation patients who underwent IPOP (IPOP group; 37 patients, 2007-2010) and all patients who underwent traditional soft compressive dressing placement and were IPOP candidates (non-IPOP group; 35 patients, 2006-2007) were retrospectively reviewed. Patient comorbidities and preoperative ambulation status were compared between the IPOP and the non-IPOP groups. Primary outcomes evaluated included perioperative systemic complications, wound complications, need for surgical revision, and the time until placement of a definitive prosthesis. Data were analyzed using the chi-squared and Student's t-test. RESULTS Preoperative comorbidities and patient characteristics of the 2 groups were similar, although the IPOP group was younger (61.5 vs. 69.0 years; P=0.01). Immediate perioperative systemic complication rates were not significantly different between the 2 groups (IPOP 29.7% vs. non-IPOP 31.4%; P=0.876). Postoperative wound complication rates were as follows: wound infection (IPOP 18.9% vs. non-IPOP 25.0%; P=0.555), wound dehiscence (IPOP 29.7% vs. non-IPOP 25.0%; P=0.673), and skin breakdown separate from the incision (IPOP 18.9% vs. non-IPOP 3.6%; P=0.062). Patients in the IPOP group trended towards fewer postoperative falls (IPOP 10.8% vs. non-IPOP 21.4%; P=0.240). The need for revision was significantly greater in the non-IPOP group (IPOP 5.4% vs. non-IPOP 27.6%; P=0.013). The time from surgery to placement of the preparatory prosthesis was 51 days in the IPOP group. CONCLUSIONS Patients undergoing IPOP have similar perioperative systemic and wound complication rates compared to those patients undergoing conventional below-knee amputation, but are less likely to require surgical revision. The use of IPOP allows for early ambulation and rehabilitation, which may be of psychological benefit and may decrease the sequelae of prolonged immobilization. IPOP application should be considered for all appropriate candidates requiring below-knee amputation.


title: Risk for Major Bleeding in Patients Receiving Ticagrelor Compared With Aspirin After Transient Ischemic Attack or Acute Ischemic Stroke in the SOCRATES Study (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes).

text: BACKGROUND Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)-defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). METHODS An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. RESULTS A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52-1.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. CONCLUSIONS Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994720.


title: Systematic Review and Meta-analysis of Diagnostic Accuracy of Percutaneous Renal Tumour Biopsy.

text: CONTEXT The role of percutaneous renal tumour biopsy (RTB) remains controversial due to uncertainties regarding its diagnostic accuracy and safety. OBJECTIVE We performed a systematic review and meta-analysis to determine the safety and accuracy of percutaneous RTB for the diagnosis of malignancy, histologic tumour subtype, and grade. EVIDENCE ACQUISITION Medline, Embase, and Cochrane Library were searched for studies providing data on diagnostic accuracy and complications of percutaneous core biopsy (CB) or fine-needle aspiration (FNA) of renal tumours. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for diagnosis of malignancy. The Cohen kappa coefficient (κ) was estimated for the analysis of histotype/grade concordance between diagnosis on RTB and surgical specimen. Risk of bias assessment was performed (QUADAS-2). EVIDENCE SYNTHESIS A total of 57 studies recruiting 5228 patients were included. The overall median diagnostic rate of RTB was 92%. The sensitivity and specificity of diagnostic CBs and FNAs were 99.1% and 99.7%, and 93.2% and 89.8%, respectively. A good (κ = 0.683) and a fair (κ = 0.34) agreement were observed between histologic subtype and Fuhrman grade on RTB and surgical specimen, respectively. A very low rate of Clavien ≥ 2 complications was reported. Study limitations included selection and differential-verification bias. CONCLUSIONS RTB is safe and has a high diagnostic yield in experienced centres. Both CB and FNA have good accuracy for the diagnosis of malignancy and histologic subtype, with better performance for CB. The accuracy for Fuhrman grade is fair. Overall, the quality of the evidence was moderate. Prospective cohort studies recruiting consecutive patients and using homogeneous reference standards are required. PATIENT SUMMARY We systematically reviewed the literature to assess the safety and diagnostic performance of renal tumour biopsy (RTB). The results suggest that RTB has good accuracy in diagnosing renal cancer and its subtypes, and it appears to be safe. However, the quality of evidence was moderate, and better quality studies are required to provide a more definitive answer.


title: Aging-Related Reduced Expression of CXCR4 on Bone Marrow Mesenchymal Stromal Cells Contributes to Hematopoietic Stem and Progenitor Cell Defects.

text: Aging impairs the regenerative potential of hematopoietic stem cells (HSC) and skews differentiation towards the myeloid lineage. The bone marrow (BM) microenvironment has recently been suggested to influence HSC aging, however the mechanisms whereby BM stromal cells mediate this effect is unknown. Here we show that aging-associated decreased expression of CXCR4 expression on BM mesenchymal stem cells (MSC) plays a crucial role in the development of the hematopoietic stem and progenitor cells (HSPC) aging phenotype. The BM MSC from old mice was sufficient to drive a premature aging phenotype of young HSPC when cultured together ex vivo. The impaired ability of old MSC to support HSPC function is associated with reduced expression of CXCR4 on BM MSC of old mice. Deletion of the CXCR4 gene in young MSC accelerates an aging phenotype in these cells characterized by increased production of reactive oxygen species (ROS), DNA damage, senescence, and reduced proliferation. Culture of HSPC from young mice with CXCR4 deficient MSC also from young mice led to a premature aging phenotype in the young HSPC, as evidenced by reduced hematopoietic regeneration and enhanced myeloid differentiation. Mechanistically, CXCR4 signaling prevents BM MSC dysfunction by suppressing oxidative stress, as treatment of old or CXCR4 deficient MSC with N-acetyl-L-cysteine (NAC), improved their niche supporting activity, and attenuated the HSPC aging phenotype. Our studies suggest that age-associated reduction in CXCR4 expression on BM MSC impairs hematopoietic niche activity with increased ROS production, driving an HSC aging phenotype. Thus, modulation of the SDF-1/CXCR4 axis in MSC may lead to novel interventions to alleviate the age-associated decline in immune/hematopoietic function.


title: Technical approaches to single port/incision laparoscopic appendicectomy: a literature review.

text: INTRODUCTION Single port/incision laparoscopic surgery (SPILS) is a modern advancement toward stealth surgery. Despite the paucity of high-quality scientific studies assessing its effectiveness, this procedure is being used increasingly. This review aims to describe commonly used techniques for SPILS appendicectomies (SPILA), to summarise complication rates in the literature and to provide discussion on indications and implementation. METHODS All available databases including the Cochrane Central Register of Controlled Trials, MEDLINE(®) and Embase™ were searched in February 2011 and cross-referenced for available English literature describing SPILA in patients of any age. RESULTS Three broad technical approaches are described: procedures using laparoscopic instruments through a single skin incision in the abdominal wall, regardless of the number of fascial incisions, with or without the additional use of percutaneous sutures or wires to 'assist' the operation, and hybrid procedures, in which the appendix is exteriorised using a single incision laparoscopically assisted operation but subsequently divided using a conventional 'open' appendicectomy technique. Complication rates seem to be highest in SPILA procedures unassisted by sutures or wires. CONCLUSIONS Future research assessing the efficacy of single incision laparoscopic procedures should consider variation in technique as a possible factor affecting outcome.


title: Use of technology by orientation and mobility professionals in Australia and Malaysia before COVID-19.

text: PURPOSE Orientation and Mobility (O&M) professionals teach people with low vision or blindness to use specialist assistive technologies to support confident travel, but many O&M clients now prefer a smartphone. This study aimed to investigate what technology O&M professionals in Australia and Malaysia have, use, like, and want to support their client work, to inform the development of O&M technologies and build capacity in the international O&M profession. MATERIALS AND METHODS A technology survey was completed by professionals (n = 36) attending O&M workshops in Malaysia. A revised survey was completed online by O&M specialists (n = 31) primarily in Australia. Qualitative data about technology use came from conferences, workshops and interviews with O&M professionals. Descriptive statistics were analysed together with free-text data. RESULTS Limited awareness of apps used by clients, unaffordability of devices, and inadequate technology training discouraged many O&M professionals from employing existing technologies in client programmes or for broader professional purposes. Professionals needed to learn smartphone accessibility features and travel-related apps, and ways to use technology during O&M client programmes, initial professional training, ongoing professional development and research. CONCLUSIONS Smartphones are now integral to travel with low vision or blindness and early-adopter O&M clients are the travel tech-experts. O&M professionals need better initial training and then regular upskilling in mainstream O&M technologies to expand clients' travel choices. COVID-19 has created an imperative for technology laggards to upskill for O&M tele-practice. O&M technology could support comprehensive O&M specialist training and practice in Malaysia, to better serve O&M clients with complex needs. Implications for rehabilitation Most orientation and mobility (O&M) clients are travelling with a smartphone, so O&M specialists need to be abreast of mainstream technologies, accessibility features and apps used by clients for orientation, mobility, visual efficiency and social engagement. O&M specialists who are technology laggards need human-guided support to develop confidence in using travel technologies, and O&M clients are the experts. COVID-19 has created an imperative to learn skills for O&M tele-practice. Affordability is a significant barrier to O&M professionals and clients accessing specialist travel technologies in Malaysia, and to O&M professionals upgrading technology in Australia. Comprehensive training for O&M specialists is needed in Malaysia to meet the travel needs of clients with low vision or blindness who also have physical, cognitive, sensory or mental health complications.


title: Cocirculation of two distinct genetic and antigenic lineages of proposed influenza D virus in cattle.

text: UNLABELLED Viruses with approximately 50% homology to human influenza C virus (ICV) have recently been isolated from swine and cattle. The overall low homology to ICV, lack of antibody cross-reactivity to ICV in hemagglutination inhibition (HI) and agar gel immunodiffusion assays, and inability to productively reassort with ICV led to the proposal that these viruses represented a new genus of influenza virus, influenzavirus D (IDV). To further our understanding of the epidemiology of IDV, real-time reverse transcription-PCR was performed on a set of 208 samples from bovines with respiratory disease. Ten samples (4.8%) were positive and six viruses were successfully isolated in vitro. Phylogenetic analysis of full-genome sequences of these six new viruses and four previously reported viruses revealed two distinct cocirculating lineages represented by D/swine/Oklahoma/1334/2011 (D/OK) and D/bovine/Oklahoma/660/2013 (D/660), which frequently reassorted with one another. Antigenic analysis using the HI assay and lineage-representative D/OK and D/660 antiserum found up to an approximate 10-fold loss in cross-reactivity against heterologous clade antiserum. One isolate, D/bovine/Texas/3-13/2011 (D/3-13), clustered with the D/660 lineage, but also had high HI titers to heterologous (D/OK) clade antiserum. Molecular modeling of the hemagglutinin esterase fusion protein of D/3-13 identified a mutation at position 212 as a possible antigenic determinant responsible for the discrepant HI results. These results suggest that IDV is common in bovines with respiratory disease and that at least two genetic and antigenically distinct clades cocirculate. IMPORTANCE A novel bovine influenza virus was recently identified. Detailed genetic and antigenic studies led to the proposal that this virus represents a new genus of influenza, influenzavirus D (IDV). Here, we show that IDV is common in clinical samples of bovine respiratory disease complex (BRDC), with a prevalence similar to that of other established BRDC etiological agents. These results are in good agreement with the near-ubiquitous seroprevalence of IDV previously found. Phylogenetic analysis of complete genome sequences found evidence for two distinct cocirculating lineages of IDV which freely reassort. Significant antigenic differences, which generally agreed with the surface glycoprotein hemagglutinin esterase phylogeny, were observed between the two lineages. Based on these results, and on the ability of IDV to infect and transmit in multiple mammalian species, additional studies to determine the pathogenic potential of IDV are warranted.


title: Percutaneous Microwave Ablation of Histologically Proven T1 Renal Cell Carcinoma.

text: OBJECTIVES To assess the safety and efficacy of percutaneous microwave ablation (MWA) of histologically proven T1 renal cell carcinoma (RCC). METHODS We analysed patients with a histologically proven RCC (≤ 7 cm) treated by MWA from April 2012-April 2018. Primary and secondary efficacy, local tumour recurrence (LTR), morbidity and mortality were reported. Efficacy was defined as no residual tumour enhancement on follow-up imaging 1 month after the first ablation (primary efficacy) and after re-ablation(s) for residual disease (secondary efficacy). Adverse events (AE) were registered by the Clavien-Dindo classification and the common terminology criteria for AE. Univariable and multivariable logistic regression analyses were performed to investigate a relation among pre-treatment factors incomplete ablation and complications. RESULTS In 100 patients, a total of 108 RCCs (85 T1a and 23 T1b) were treated by MWA. Median size was 3.2 cm (IQR 2.4-4.0). Primary efficacy was 89% (95%CI 0.81-0.94) for T1a lesions and 52% (95%CI 0.31-0.73) for T1b lesions (p < 0.001). Fifteen lesions (7 T1a) were re-ablated for residual disease by MWA in one (n = 13) and two (n = 2, both T1b) sessions resulting in secondary efficacy rates of 99% (T1a) and 95% (T1b, p = 0.352). LTR occurred in four tumours (2 T1a, 2 T1b) after 10-60 months. Six (4%) AEs grade > 3-5 were observed (2 T1a, 4 T1b, p = 0.045). Multivariable analysis showed that mR.E.N.A.L. nephrometry was independently associated with incomplete ablation (p = 0.012). CONCLUSION Microwave ablation is safe and effective for T1a and T1b RCC lesions with a significantly lower primary efficacy for T1b lesions.


title: Tidal volume measurement error in pressure control modes of mechanical ventilation: A model study.

text: UNLABELLED Tidal volume (VT) measurement during pressure control (PC) ventilation with preset inspiratory time may produce errors due to patient inspiratory effort. We evaluated VT error in 3 common ICU ventilators. METHODS Simulated patient: 60kg adult with ARDS using IngMar Medical ASL 5000 having moderate inspiratory effort. Ventilators evaluated: Covidien PB 840, Maquet Servo-i, and Dräger Evita XL, PC breaths at preset inspiratory time (TI) 0.6-1.4s. VT error was defined as ventilator displayed VT minus the simulator displayed VT (mL/kg or % of true). RESULTS Relaxation of inspiratory effort caused flow reversal (exhalation) during TI, which led to VT error. For the PB 840, VT error was proportional to TI (maximum -2.0mL/kg, -19%). For the Servo-i, VT error was not related to TI (maximum error -0.2mL/kg or -1.2%). Volume error for Evita XL was not related to TI (maximum error was -0.7mL/kg or -6%). CONCLUSIONS Calculation of VT as the integral of flow over the preset inspiratory time rather than the period between zero crossings of flow may result in underestimation of both inhaled and exhaled volumes. The size of VT error can be large enough to potentially affect patient outcomes on some ventilators.


title: Resolution of cranial neuropathies following treatment of intracranial aneurysms with the Pipeline Embolization Device.

text: OBJECT Intracranial aneurysms, especially those of the cavernous segment of the internal carotid artery (ICA), can present with cranial nerve (CN) palsies. The Pipeline Embolization Device (PED) has demonstrated safety and efficacy in the treatment of cerebral aneurysms by flow diversion, but little data exist reporting the outcomes of cranial neuropathies following treatment with the device. METHODS The prospectively maintained Barrow Neurological Institute's endovascular database was reviewed for all patients treated with the PED after presenting with one or more CN palsies secondary to a cerebral aneurysm since May 2011. Patient charts and digital subtraction angiograms were reviewed to report clinical and angiographic outcomes. Only patients with clinical follow-up were included in the analysis. RESULTS A total of 127 patients were treated with the PED at the authors' institution after FDA approval. Twentytwo patients presented with cranial neuropathies, for initial inclusion in this study. Of these, 20 had sufficient followup for analysis. Cranial neuropathies included those of CN II, III, V, and VI, with presenting symptoms of diplopia, decreased visual acuity, and facial numbness and/or pain. Thirteen lesions were cavernous segment ICA aneurysms, whereas the remainder included supraclinoid and petrous segment ICA, posterior communicating artery, and basilar trunk aneurysms. At an average clinical follow-up of 9.55 months, 15 patients (75%) had resolution or significant improvement of their cranial neuropathies, and the remaining 5 had stable symptoms. Of the 18 patients with angiographic follow-up, 12 (66.7%) demonstrated complete obliteration or small neck residual, whereas 6 (33.3%) had residual lesion. Patients with complete or near-complete obliteration of their lesion were significantly more likely to demonstrate symptomatic improvement at follow-up (p = 0.009). Two patients with persistent symptoms were eventually treated with microsurgical bypass. Transient complications in this series included 6 (30%) extracranial hemorrhagic complications related to dual-antiplatelet therapy, all of which were managed medically. There was 1 delayed right ICA occlusion following retreatment that led to microsurgical bypass. CONCLUSIONS Intracranial aneurysms presenting with one or more CN palsies show a high rate of clinical improvement after treatment with the PED. Clinical outcomes must be weighed against the risks and challenges faced with flow diverters. Further research is warranted for patients whose symptoms do not respond optimally to device placement.


title: Analysis of coagulation parameters in patients with COVID-19 in Shanghai, China.

text: To investigate the characteristic of coagulation function in 303 patients with Coronavirus disease 2019 (COVID-19), we evaluated the correlation between coagulation function and disease status. We retrospectively analyzed 303 patients diagnosed with COVID-19 and evaluated the clinical data of 240 patients who were discharged. The coagulation function of the two groups (mild and severe) was compared. Compared with the mild group, majority of patients in the severe group were male (76.9% vs. 49.8%) and elderly (median age 65 vs. 50), and the proportion with chronic underlying diseases was higher (73.1% vs. 36.1%). There were 209 abnormalities (69.0%) of coagulation parameters in 303 patients admitted to hospital. Comparison of various indexes of coagulation function between the two groups in admission, the proportion of abnormal coagulation indicators in the severe group was higher than that in the mild group (100% vs. 66.1%). The median coagulation parameters in the severe group were higher than those in the mild group: international normalized ratio (1.04 vs. 1.01), prothrombin time (13.8 vs. 13.4) seconds, activated partial thromboplastin time (43.2 vs. 39.2) seconds, fibrinogen (4.74 vs. 4.33) g/L, fibrinogen degradation products (2.61 vs. 0.99) µg/mL, and D-dimer (1.04 vs. 0.43) µg/mL, the differences were statistically significant (p < 0.05). Coagulation dysfunction is common in patients with COVID-19, especially fibrinogen and D-dimer elevation, and the degree of elevation is related to the severity of the disease. As the disease recovers, fibrinogen and activated partial thromboplastin time also return to normal.


title: A protocol for an updated and expanded systematic mixed studies review of fear of cancer recurrence in families and caregivers of adults diagnosed with cancer.

text: BACKGROUND Fear of cancer recurrence (FCR) is reportedly common, persistent, associated with significant morbidity and often higher in cancer caregivers than cancer patients. This review will summarise empirical research on FCR to understand its prevalence, severity, correlates, course and impact in families and caregivers of adults diagnosed with cancer, and identify tested interventions that reduce its effects. METHODS This review will include peer-reviewed, empirical, qualitative and/or quantitative studies on fear, worry or concern of patients' cancer returning or progressing among adult family members or caregivers of the cancer patient. It will exclude records reporting no original empirical research on FCR. We will search CINAHL, Embase, PubMed, PsycINFO, ProQuest Dissertations and Theses GLOBAL from 1997 onwards. Pairs of reviewers will conduct independent screening, data extraction and risk of bias assessment. Risk of bias will be assessed with the Cochrane Risk of Bias tool for randomised studies, the Risk of Bias Assessment tool for Nonrandomized Studies and the questions for qualitative studies in the mixed methods appraisal tool. We will conduct a narrative synthesis of quantitative studies and a thematic synthesis of qualitative studies. DISCUSSION This review will provide further clarity on the prevalence and severity of FCR in families and caregivers and differences by caregiver and care recipient demographic and medical characteristics. Any intervention studies located may indicate therapies or treatments that could reduce FCR in families and caregivers. Findings are expected to provide guidance for individuals and organisations working to manage FCR in families and caregivers of those with cancer. SYSTEMATIC REVIEW REGISTRATION This protocol will be registered with PROSPERO after peer-review.


title: Respiratory viral detection and small airway inflammation in lung tissue of patients with stable, mild COPD.

text: BACKGROUND Viral respiratory tract infections are implicated in the pathogenesis of chronic obstructive pulmonary disease (COPD). In lung tissue specimens from patients with stable, mild COPD and from control smokers without airflow obstruction, we determined the prevalence and load of nucleic acid from common respiratory viruses and concomitant inflammation of small airways measuring less than 2-mm in diameter. METHODS Frozen lung tissue obtained from patients with stable, mild COPD (n = 20) and control subjects (n = 20) underwent real-time quantitative PCR (qPCR) for 13 respiratory viruses, and quantitative histology for inflammation of small airways. The two groups were compared for viral prevalence and load, and airway inflammation. The relationship between viral load and airway inflammatory cells was also analyzed. RESULTS Viral nucleic acid were detected in lung tissue of 18/40 (45.0%) of the individuals studied and included seven co-infections that were characterized by a "dominant virus" contributing to most of the total measured viral load. Lung tissue of COPD patients had a significantly higher prevalence of viral nucleic acid (particularly influenza A virus), and increased inflammation of small airways by macrophages and neutrophils versus controls. In qPCR-positive individuals, linear regression analysis showed a direct correlation between viral load and airway neutrophils, and between influenza A virus load and airway macrophages. CONCLUSION The lung tissue of patients with stable, mild COPD has a higher prevalence and load of respiratory viruses versus non-obstructed control subjects, and increased inflammation of small airways. Respiratory viruses may represent potential targets in COPD patient management.


title: The use of a fibrin glue with a low concentration of thrombin decreases seroma formation in postbariatric patients undergoing circular abdominoplasty.

text: BACKGROUND The serum collection under the abdominal flap is the most common complication after a lipo-abdominoplasty. The frequency of seroma increases further among obese patients, who have achieved massive weight loss after bariatric surgery. The purpose of this study is to demonstrate the effectiveness of fibrin glues with a low concentration of thrombin in reducing seroma formation after a lipo-abdominoplasty. METHODS Thirty patients, that had achieved a significant weight loss after an intervention of laparoscopic adjustable gastric banding (LAGB), underwent a circular lipo-abdominoplasty at our bariatric surgery department. Patients were divided into two groups of 15 subjects each: group A underwent traditional surgery; in group B, we applied a slow-clotting variant of fibrin glue (ARTISS, Baxter) under the abdominal flap. All subjects were evaluated clinically using an ultrasound device on postoperative day 15. We considered positive for seroma, those cases with a liquid collection greater than 20 cc. RESULTS The groups were homogeneous for age, BMI, male/female ratio, and diabetic or smoker patients. The mean hospital stay was significantly longer in group A than in group B. We found eight cases of serum collection >20 cc in group A and only one case in group B. Hematoma, umbilicus necrosis, and surgical site infection occurred in both groups, but overall complication rate was lower in group B. CONCLUSIONS The use of a fibrin glue with a low concentration of thrombin could be useful during wound closure and may decrease seroma formation in postbariatric patients undergoing lipo-abdominoplasty.


title: Cardiac arrest is a predictor of difficult tracheal intubation independent of operator experience in hospitalized patients.

text: BACKGROUND Placement of advanced airways has been associated with worsened neurologic outcome in survivors of out-of-hospital cardiac arrest. These findings have been attributed to factors such as inexperienced operators, prolonged intubation times and other airway related complications. As an initial step to examine outcomes of advanced airway placement during in-hospital cardiac arrest (IHCA), where immediate assistance and experienced operators are continuously available, we examined whether cardiopulmonary resuscitation efforts affect intubation difficulty. Additionally, we examined whether or not the use of videolaryngoscopy increases the odds of first attempt intubation success compared with traditional direct laryngoscopy. METHODS The study setting is a large urban university-affiliated teaching hospital where experienced airway managers are available to perform emergent intubation for any indication in any out-of-the-operating room location 24 hours a day, 7 days-a-week, 365 days-a-year. Intubations occurring in all adults >18 years-of-age who required emergent tracheal intubation outside of the operating room between January 1, 2008 and December 31, 2012 were examined retrospectively. Multivariate logistic regression was used to estimate the odds of difficult intubation during IHCA compared to other emergent non-IHCA indications with adjustment for a priori defined potential confounders (body mass index, operator experience, use of videolaryngoscopy versus direct laryngoscopy, and age). RESULTS In adjusted analyses, the odds of difficult intubation were higher when taking place during IHCA (OR=2.63; 95% CI 1.1-6.3, p=0.03) compared to other emergent indications. Use of video versus direct laryngoscopy for initial intubation attempts during IHCA, however, did not improve the odds of success (adjusted OR = 0.71; 95% CI 0.35-1.43, p = 0.33). CONCLUSIONS Difficult intubation is more likely when intubation takes place during IHCA compared to other emergent indications, even when experienced operators are available. Under these conditions, direct laryngoscopy (versus videolaryngoscopy) remains a reasonable first choice intubation technique.


title: Effect of palatal implants on continuous positive airway pressure and compliance.

text: OBJECTIVE Determine if the Pillar palatal implant system reduces continuous positive airway pressure (CPAP) pressure and improves patient compliance with CPAP therapy. STUDY DESIGN Randomized, double-blind, placebo-controlled study. SETTING Four geographically dispersed tertiary sleep disorder referral centers. METHODS Subjects with mild to moderate sleep apnea dissatisfied with CPAP because of pressure-related complaints were randomized to receive Pillar implants or a sham procedure performed in double-blind fashion. Active and sham groups were compared for changes in therapeutic CPAP pressures (primary outcome) with a 90-day follow-up sleep study and CPAP compliance (secondary outcome) with a 90-day smart card report. RESULTS Twenty-six subjects were randomized to Pillar implants and 25 to a sham implant procedure. There were no differences between groups with regard to demographics and baseline parameters. Both sham and active groups had reduced mean CPAP pressure (-1.1 vs -0.5 cm H(2)O) with no difference between groups (P = .32) at 90-day follow-up. In addition, there was no difference in average daily CPAP use between groups (P = .80). Both groups experienced improvements in Epworth sleepiness scores and Functional Outcome of Sleep Questionnaire scores at 90 days with no differences between groups. The active group reported significantly higher CPAP satisfaction scores than the sham group (P = .04). CONCLUSION Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance.


title: Bioactivity and potential health benefits of licorice.

text: Licorice is an herbal plant named for its unique sweet flavor. It is widely used in the food and tobacco industries as a sweetener. Licorice is also used in traditional Chinese medicine (TCM) and complementary medicine. Because the use of licorice has long been a part of TCM, the details of its therapeutic applications have been thoroughly established. In modern science, licorice is of interest because of its broad range of applications. Extracts of and compounds isolated from licorice have been well studied and biologically characterized. In this review, we discuss the nutraceutical and functional activities of licorice as well as those of the extracts of and the isolated compounds from licorice, including agents with anti-inflammatory activity, cell-protective abilities, and chemopreventive effects. The side effects of licorice are also enumerated. A comparison of the activities of licorice described by modern science and TCM is also presented, revealing the correspondence of certain characteristics.


title: Validation of predictors of adverse outcomes in hospital-acquired pneumonia in the ICU.

text: OBJECTIVE To validate a set of predictors of adverse outcomes in patients with ICU-acquired pneumonia in relation to clinically relevant assessment at 28 days. DESIGN Prospective, observational study. SETTING Six medical and surgical ICUs of a university hospital. PATIENTS Three hundred thirty-five patients with ICU-acquired pneumonia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Development of predictors of adverse outcomes was defined when at least one of the following criteria was present at an evaluation made 72-96 hours after starting treatment: no improvement of PaO2/FIO2, need for intubation due to pneumonia, persistence of fever or hypothermia with purulent respiratory secretions, greater than or equal to 50% increase in radiographic infiltrates, or occurrence of septic shock or multiple organ dysfunction syndrome. We also assessed the inflammatory response by different serum biomarkers. The presence of predictors of adverse outcomes was related to mortality and ventilator-free days at day 28. Sequential Organ Failure Assessment score was evaluated and related to mortality at day 28.One hundred eighty-four (55%) patients had at least one predictor of adverse outcomes. The 28-day mortality was higher for those with versus those without predictors of adverse outcomes (45% vs 19%, p<0.001), and ventilator-free days were lower (median [interquartile range], 0 [0-17] vs 22 [0-28]) for patients with versus patients without predictors of adverse outcomes (p<0.001). The lack of improvement of PaO2/FIO2 and lack of improvement in Sequential Organ Failure Assessment score from day 1 to day 5 were independently associated with 28-day mortality and fewer ventilator-free days. The marginal structural analysis showed an odds ratio of death 2.042 (95% CI, 1.01-4.13; p=0.047) in patients with predictors of adverse outcomes. Patients with predictors of adverse outcomes had higher serum inflammatory response accordingly to biomarkers evaluated. CONCLUSIONS The presence of any predictors of adverse outcomes was associated with mortality and decreased ventilator-free days at day 28. The lack of improvement in the PaO2/FIO2 and Sequential Organ Failure Assessment score was independently associated with mortality in the multivariate analysis.