title: An experimental investigation of the hemodynamic variations due to aplastic vessels within three-dimensional phantom models of the circle of Willis.

text: A complete circle of Willis (CoW) is found in approximately 30-50% of the population. Anatomical variations, such as absent or surgically clamped vessels, can result in undesirable flow patterns. These can affect the brain's ability to maintain cerebral perfusion and the formation of cerebral aneurysms. An experimental test system was developed to simulate cerebral physiological conditions through three flexible 3D patient-specific models of complete and incomplete CoW geometries. Flow visualizations were performed with isobaric dyes and the mapped dye streamlines were tracked throughout the models. Three to seven flow impact locations were observed for all configurations, corresponding to known sites for aneurysmal formation. Uni and bi-directional cross-flows occurred along the communicating arteries. The greatest shunting of flow occurred for a missing pre-communicating anterior (A1) and posterior (P1) cerebral arteries. The anterior cerebral arteries had the greatest reduction (15-37%) in efferent flow rates for missing either a unilateral A1 or bilateral P1 segments. The bi-directional cross-flows, with multiple afferent flow mixing, observed along the communicating arteries may explain the propensity of aneurysm formation at these sites. Reductions in efferent flow rates due to aplastic vessel configurations may affect normal brain function.


title: Survey on Knowledge and Psychological Crisis Related to COVID-19 among Nursing Staff: A Cross-sectional Study.

text: BACKGROUND Background: Since December 2019, the prevalence of COVID-19 is rapidly spreading in the world. Nurses play a key role in fighting this disease and are at risk of infection by coronavirus. Therefore, there is a urging need to assess their mental health condition and set up appropriate interventions to reduce the negative psychiatric outcomes. OBJECTIVE The objective of this study was to evaluate the knowledge and psychological crisis related to COVID-19 among nursing staff, and to provide evidence for targeted training and psychological intervention. METHODS This cross-sectional online survey study was performed in a class three grade A general hospital from a southwest province of China from March 1 to March 15, 2020. A self-designed questionnaire of COVID-19 related prevention and control knowledge and the Triages Assessment Form (TAF) were used to assess nursing staff's knowledge of COVID-19 and their degree of psychological crisis. SPSS 23.0 was applied to compute the collected data. RESULTS A total of 979 nursing staff completed the questionnaire. The results showed that nursing staff have lower number of correct answers of continuous viral nucleic acid testing specifications (38.7%), debarment criteria (55.1%), and management measures for patients with suspected symptoms (72.8%). The overall score of the TAF was 7.0 (5.0-12.0), and there were statistical significance in scores between different types of personnel, years of work experience and department (P <.05). CONCLUSIONS This study indicated that nursing staff have insufficient knowledge about COVID-19. Meanwhile, despite the psychological damage of nursing staff is slight, nurse manager must continue to monitor their mental health and take timely interventions. CLINICALTRIAL


title: COVID-19: the critical balance between appropriate governmental restrictions and expected economic, psychological and social consequences in Italy. Are we going in the right direction?

text: Since the declaration of COVID-19 pandemic infection by the World Health Organization, many governmental restrictions have been differently applied in the involved countries in order to contain the spread of the infection; Italy applied severe restrictive, public measures actually confining the entire population to an almost complete lockdown for several weeks; the restrictive quarantine can be considered controversial when excessively prolonged over time, due to many possible economic, psychologic and social consequences with a remarkable impact on the population. In this article we analyze possible collateral damages related to the prolonged quarantine.


title: Measuring and improving quality of care in an academic medical center.

text: The Donabedian definition of quality—structure, process, and outcome—provides a useful framework. A relentless focus on measuring process adherence and outcome is critical. Systemic improvements usually require teams to plan and to implement them. The lean or Toyota production system for process improvement is one useful method of organizing work, although different approaches are often necessary at the physician, practice unit, and statewide level. Challenges include scalability of the change (ie, rolling them out across the institution or system), tailoring the information technology tools, and building systems for sustainability.


Postacute Care Preparedness for COVID-19: Thinking Ahead.


Latin American scientists join the coronavirus vaccine race: 'No one's coming to rescue us'.


title: Combined paraesophageal hernia repair and partial longitudinal gastrectomy in obese patients with symptomatic paraesophageal hernias.

text: BACKGROUND Obesity is a risk factor for gastroesophageal reflux disease and hiatal hernia. Studies have demonstrated poor symptom control in obese patients undergoing fundoplication. The ideal operation remains elusive. However, addressing both obesity and the anatomic abnormality should be the goal. METHODS This study retrospectively identified 19 obese (body mass index [BMI], >30 kg/m(2)) and morbidly obese (BMI, >40 kg/m(2)) patients who presented between December 2007 and November 2011 for management of large or recurrent paraesophageal hernia. All the patients underwent a combined primary paraesophageal hernia repair and longitudinal gastrectomy. Charts were retrospectively reviewed to collect preoperative, operative, and short-term postoperative results. Quantitative data were analyzed using Student's t test and qualitative data with χ(2) testing. RESULTS Laparoscopy was successful for all 19 patients. The mean preoperative BMI was 37.8 ± 4.1 kg/m(2), and the mean operative time was 236 ± 80 min. Preoperative endoscopy showed that 5 patients who had undergone prior fundoplication experienced anatomic failures, whereas the remaining 14 patients had type 3 and one type 4 paraesophageal Hernia. Mesh was used to reinforce the hiatus in 15 of the 19 cases. The postoperative complications included pulmonary embolism (n = 1) and pulmonary decompensation (n = 2) due to underlying chronic obstructive pulmonary disease. The mean hospital stay was 5.3 ± 3 days. Upper gastrointestinal esophagography was performed for all the patients, with no short-term recurrence of paraesophageal hernia. Weight loss was seen for all the patients during the first month, with a mean BMI drop of 2.7 ± 1 kg/m(2). All the patients experienced near to total resolution of their preoperative symptoms within the first month. CONCLUSION Combined laparoscopic paraesophageal hernia repair and longitudinal gastrectomy offer a safe and feasible approach for the management of large or recurrent paraesophageal hernias in well-selected obese and morbidly obese patients. In a short-term follow-up period, this approach demonstrated effective symptom control and weight loss.


title: Health-related quality of life among Chinese adolescent girls with Dysmenorrhoea.

text: BACKGROUND Primary dysmenorrhoea is common in girls who have begun menstruating. However, few studies have examined its effect on the quality of life of a young population. The study aimed to evaluate the quality of life of adolescent girls with dysmenorrhoea in Hong Kong. METHODS The study adopted a cross-sectional descriptive approach. A convenience sample of 653 girls aged 13 to 19 years old was recruited from three secondary schools in Hong Kong. The 36-item Short-Form Health Survey was used to examine the health-related quality of life of the participants. The severity of dysmenorrhoea was assessed using a 10-point visual analog scale. RESULTS Girls suffering from dysmenorrhoea reported high pain prevalence and intensity. However, the majority of girls with dysmenorrhoea did not seek medical advice (93.2%) or self-medicate (82%). The role-physical, bodily pain, general health and social functioning domain scores of girls with dysmenorrhoea were significantly lower than those without dysmenorrhoea. Moreover, girls with severe dysmenorrhoea had a significantly lower quality of life in the bodily pain domain than those with mild and moderate forms of condition. CONCLUSIONS Findings suggest that dysmenorrhoea is highly prevalent among adolescent girls in Hong Kong. Girls may suffer severe pain, which degrades their quality of life.


title: An analysis of skills acquisition during a training program for experienced laparoscopists in laparoendoscopic single-site surgery.

text: BACKGROUND Laparoendoscopic single-site surgery has been presented in the past few years as an innovative minimally invasive approach, one which despite its advantages is also challenging and requires specific training. We propose to analyze the performance of attendants in a specific LESS training course. METHODS Following the LESSCAR 2010 guidelines, we focused on level 1 hands-on simulator tasks and level 2 hands-on training on animal model for skills acquisition during a LESS-specific training course. Each attendant completed coordination and cut tasks on simulator, followed by a cholecystectomy on an ex vivo porcine liver. Hands-on animal model each trainee performed 1 cholecystectomy and at least 2 nephrectomies (N1, N2). Performance was analyzed through video recording and reviewed by 3 independent observers. Each result was registered according to a modified objective structured assessment of technical skills. Total task or procedure completion time was also determined. RESULTS Regarding coordination and cut tasks, attendants improved on their performance from first to third attempts with an accompanying decrease in completion time. Surgeons completed the cholecystectomy on animal model significantly faster than on simulator, although with lower performance quality. Regarding N1 and N2, attendants showed improvement both in quality and total completion time. CONCLUSIONS A gradual and positive evolution of attendants was observed throughout the training course. Thus, we believe a structured program for the acquisition of basic skills in new minimally invasive surgical approaches should be recommended. Considering that this is a small study, it would be advisable to increase the number of study subjects on future opportunities.


Endotracheal tube holders and the prone position: a cause for concern--reply.


title: Receptor-binding domain as a target for developing SARS vaccines.

text: A decade ago, severe acute respiratory syndrome (SARS) coronavirus (SARS-CoV) caused a global pandemic with a mortality rate of 10%. Reports of recent outbreaks of a SARS-like disease caused by Middle East respiratory syndrome coronavirus (MERS-CoV) have raised serious concerns of a possible reemergence of SARS-CoV, either by laboratory escape or the presence of a natural reservoir. Therefore, the development of effective and safe SARS vaccines is still needed. Based on our previous studies, we believe that the receptor-binding domain (RBD) in the S1 subunit of the SARS-CoV spike (S) protein is the most important target for developing a SARS vaccine. In particular, RBD of S protein contains the critical neutralizing domain (CND), which is able to induce highly potent neutralizing antibody response and cross-protection against divergent SARS-CoV strains. Furthermore, a RBD-based subunit vaccine is expected to be safer than other vaccines that may induce Th2-type immunopathology. This review will discuss key advances in the development of RBD-based SARS vaccines and the possibility of using a similar strategy to develop vaccines against MERS-CoV.


title: Challenges of T cell therapies for virus-associated diseases after hematopoietic stem cell transplantation.

text: IMPORTANCE OF THE FIELD Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for many hematological malignancies and genetic disorders. The majority of patients do not have a human leukocyte antigen (HLA) identical sibling donor, and alternative stem cell sources include HLA-matched or mismatched unrelated donors and haploidentical related donors. However, alternative donor HSCT are associated with three major complications i) graft rejection; ii) graft-versus-host disease (GvHD); and iii) delayed immune reconstitution leading to viral infections and relapse. AREAS COVERED IN THIS REVIEW Graft rejection and the risk of GvHD can be significantly reduced by using intensive conditioning regimens, including in vivo T cell depletion as well as ex vivo T cell depletion of the graft. However, the benefits of removing alloreactive T cells from the graft are offset by the concomitant removal of T cells with anti-viral or anti-tumor activity as well as the profound delay in endogenous T cell recovery post-transplant. Thus, opportunistic infections, many of which are not amenable to conventional small-molecule therapeutics, are frequent in these patients and are associated with significant morbidity and high mortality rates. This review discusses current cell therapies to prevent or treat viral infections/reactivations post-transplant. WHAT THE READER WILL GAIN The reader will gain an understanding of the current state of cell therapy to prevent and treat viral infections post-HSCT, and will be introduced to preclinical studies designed to develop and validate new manufacturing procedures intended to improve therapeutic efficacy and reduce associated toxicities. TAKE HOME MESSAGE Reconstitution of HSCT recipients with antigen-specific T cells, produced either by allodepletion or in vitro reactivation, can offer an effective strategy to provide both immediate and long-term protection without harmful alloreactivity.


title: Immune thrombocytopenia (ITP): Pathophysiology update and diagnostic dilemmas.

text: Immune thrombocytopenia (ITP) is a common autoimmune bleeding disorder. The understanding of ITP pathogenesis is rapidly evolving. We now recognize ITP as a complex and heterogeneous syndrome that results from a combination of humoral and cell-mediated attacks on platelets peripherally and megakaryocytes in the bone marrow. Autoantibody-mediated ITP also varies in the pathway used to clear platelets, which depends on the platelet glycoprotein being targeted. Moreover, ITP patients present with variable bleeding severities and treatment responses that do not closely correlate with platelet count. A gold standard diagnostic test for ITP is lacking, and biomarkers to assess disease severity are in their infancy. This review provides an update on the immunopathogenesis of ITP and summarizes currently available tests for ITP diagnosis, prediction of disease severity, and treatment responses. Given the heterogeneous pathogenesis and clinical presentation of ITP, we highlight the need for the development of diagnostic and prognostic tests that would allow for the individualized management of a complex disease.


title: Hybrid y stenting with the waffle-cone. A technical note.

text: Endovascular treatment of wide-neck bifurcation aneurysms is challenging and often requires adjunctive techniques and devices. We report our experience with the hybrid Y stenting with the waffle-cone technique, combining Y stent-assisted coiling and waffle-cone stenting techniques. This approach has been described only in a single case report using a combination of open and closed cell stents. We describe four cases treated by hybrid Y stenting with the waffle-cone procedure with a variation from the originally reported technique, consisting in deploying two closed cell stents. All patients were successfully treated without complications. We propose hybrid Y stenting with the waffle-cone for the treatment of wide-neck bifurcation aneurysms as a bailout technique after failure of Y stent-assisted coiling.


title: Long-term results after laparoscopic adjustable gastric banding in adolescent patients: follow-up of the Austrian experience.

text: BACKGROUND During the last 30 years a threefold increase in the number of overweight children has been reported in Western countries. More than 15% of adolescents have a body mass index (BMI) higher than the 95th percentile. The use of surgical strategies in adolescent patients is still controversial due to the impact on the continuing maturing process. Laparoscopic adjustable gastric banding (LAGB) is considered a minimal invasive procedure that does not alter the physiological behavior of the bowel and has already shown promising results in short-term studies. METHODS Between 1998 and 2004, 50 adolescent patients above the 99.5th age- and gender-adjusted growing percentile were treated with LAGB. The surgical procedure was performed at three highly experienced centers for bariatric surgery. Mean age was 17.1 ± 2.2 years (range = 9-19 years) at the time of surgery. Follow-up investigations were performed in the outpatient clinic of the treating hospitals. Psychological changes were analyzed using the BAROS questionnaire. RESULTS The mean BMI decreased from 45.2 ± 7.6 kg/m(2) at the time of surgery to 38.3 ± 6.2 kg/m(2) 1 year after surgery, 31.5 ± 6.6 kg/m(2) after 3 years, and 27.3 ± 5.3 kg/m(2) after 5 years. Mean excessive weight loss was 49.7 ± 29.2, 76.8 ± 27.5, and 92.6 ± 24.5% at 1, 3, and 5 years after surgery. Quality of life showed a further significant improvement between 3 and 5 years after surgery (BAROS: 5.5 ± 1.9 increased to 6.3 ± 2.2, p = 0.01). All preoperative comorbidities resolved in patients with a functional band after 5 years of follow-up. CONCLUSION LAGB shows promising results in the long-term follow-up with continuous weight loss in patients with a functional band. Nevertheless, most of the weight loss is within the first 3 years after surgery. Thereafter, further weight reduction is about 10% over the following 2 years. Perioperative comorbidities resolve within the first 5 years after treatment.


title: Laparoscopic ventral hernia repair during pregnancy.

text: BACKGROUND Laparoscopic ventral hernia repair in comparison to open herniorrhaphy results in reduced length of stay, less post-operative pain, earlier return to work, and reduced complications for the repair of complex ventral hernias. The laparoscopic approach has been the standard of care for complex or large ventral hernias for non-pregnant patients over the past decade. Despite evidence that demonstrates that laparoscopy is safe during pregnancy, there is currently no consensus regarding the indications, contraindications, patient selection and post-operative care of pregnant patients evaluated for laparoscopic ventral herniorrhaphy. METHODS The medical records of our pregnant patient who underwent laparoscopic ventral herniorrhaphy were reviewed for demographics, operative indications, surgical technique, perioperative complications, recurrence, and outcome of the pregnancy. A Medline search using the terms: laparoscopy, surgery, and pregnancy was performed to review the literature from 1997 to 2007. RESULTS This case report represents the first published description of a safe and successful laparoscopic approach to the repair of a complex ventral hernia in a woman at 21 weeks gestation. The discussion reviews the current literature regarding the safety of laparoscopy in pregnant women and highlights techniques to reduce perioperative morbidity and risk to the fetus. CONCLUSIONS Laparoscopic ventral hernia repair can be safe during pregnancy with appropriate fetal monitoring and consideration of physiologic changes that occur during parturition. Elective procedures should be delayed until after delivery and all semi-elective surgeries until organogenesis is completed during the second trimester.


title: Fluorescence in Situ Hybridization (FISH) for the Diagnosis of Periprosthetic Joint Infection in Formalin-Fixed Paraffin-Embedded Surgical Tissues.

text: BACKGROUND As the number of arthroplasties performed increases, periprosthetic joint infection (PJI) represents a common and challenging problem. The Musculoskeletal Infection Society (MSIS) recommends diagnosing PJI according to its guidelines. The aim of the current study was to assess whether fluorescence in situ hybridization (FISH) analysis of formalin-fixed paraffin-embedded periprosthetic membranes can successfully improve the diagnosis of infection in patients with orthopaedic implants. METHODS We retrospectively analyzed 88 periprosthetic membranes of joint prostheses using FISH analysis according to a standard protocol, with a probe targeting a sequence found in most bacteria. We compared the results with routine clinical classification according to the guidelines of the MSIS, microbiological culture, and histopathological classification according to Morawietz and Krenn. We additionally performed FISH analysis using 2 species-specific probes for several culture-positive cases. RESULTS FISH successfully detected bacteria in 38 (95%) of 40 periprosthetic membranes that were rated positive by clinical classification. FISH results compared with clinical classification demonstrated a sensitivity of 95% (95% confidence interval [CI], 83.08% to 99.39%), a specificity of 85.42% (95% CI, 72.24% to 93.93%), a positive predictive value of 84.44% (95% CI, 70.55% to 93.50%), and a negative predictive value of 95.35% (95% CI, 84.19% to 99.43%). FISH results compared with histopathological classification demonstrated a sensitivity of 95.12% (95% CI, 83.47% to 99.40%), a specificity of 87.23% (95% CI, 74.26% to 95.17%), a positive predictive value of 86.67% (95% CI, 73.21% to 94.95%), and a negative predictive value of 95.35% (95% CI, 84.19% to 99.43%). We successfully detected Pseudomonas aeruginosa and Staphylococcus aureus with species-specific FISH probes in all cases that were positive for these respective bacteria by microbiological culture. CONCLUSIONS FISH-based diagnosis of PJI is feasible and can be used as an additional diagnostic criterion. FISH not only can detect bacteria in periprosthetic membranes but can also differentiate pathogens at the species level. FISH represents a fast and reliable tool for detecting PJI in periprosthetic membranes, especially in combination with clinical and histopathological classification. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.


title: Microembolism after endovascular coiling of unruptured cerebral aneurysms: incidence and risk factors.

text: OBJECTIVE The incidence and risk factors of microembolic lesions on MR diffusion-weighted imaging (DWI) were analyzed after the endovascular coiling of unruptured intracranial aneurysms (UIAs). METHODS Data obtained from 271 consecutive patients (70 men and 201 women; median age 57 years; range 23-79 years) who presented with UIA for coil embolization between July 2011 and June 2013 were analyzed. Two independent reviewers examined the DWI and apparent diffusion coefficient maps obtained the following day for the presence of restrictive diffusion spots and counted the number of spots. Multivariate analysis was then performed to identify independent risk factors for developing microembolism following the coiling of an aneurysm. RESULTS Microembolic lesions were noted in 101 of 271 patients (37.3%). The results of the multivariate analysis showed that the following factors significantly influenced the risk for microembolism: age, diabetes, previous history of ischemic stroke, high-signal FLAIR lesions in the white matter, multiple aneurysms, and the insertion of an Enterprise stent (all ORs > 1.0 and all p values < 0.05). Previously known risk factors such as prolonged procedure duration, aneurysm size, and decreased antiplatelet function did not show any significant influence. CONCLUSIONS The incidence of microembolism after endovascular coiling of UIA was not low. Lesions occurred more frequently in patients with vascular status associated with old age, diabetes, and previous stroke. Aneurysm multiplicity and the type of stent used for treatment also influenced lesion occurrence.


title: Studying microbial pathogenesis and bacterial diseases. Interview by Hannah Branch.

text: B Brett Finlay speaks to Hannah Branch, Commissioning Editor B Brett Finlay is Professor in the Michael Smith Laboratories in addition to the Departments of Microbiology and Immunology, and Biochemistry and Molecular Biology at the University of British Columbia, Canada. He received a BSc (Honors) and a PhD (1986) in biochemistry at the University of Alberta, Canada. In 1989, he started work as Assistant Professor in the Biotechnology Laboratory at the University of British Colombia. He has focused his research on host-pathogen interactions at the molecular level. He has been at the forefront of the cellular microbiology field and contributed towards a number of important discoveries in this area while publishing over 400 manuscripts. Research in his laboratory is focused on, but not restricted to, Escherichia coli and Salmonella interactions with host cells. He is known across the globe for his research and has been honored with a number of prestigious awards, including the EWR Steacie Prize, the Canadian Society of Microbiology Fisher Scientific Award, a Medical Research Council scientist award, five Howard Hughes International Research Scholar Awards, a Canadian Institute of Health Research Distinguished Investigator award, British Columbia Biotech Innovation Award, the Michael Smith Health Research Prize, the Infectious Diseases Society of America Squibb award and the Jacob Biely Prize. He is a Fellow of the Royal Society of Canada and the Canadian Academy of Health Sciences, is an Officer of the Order of Canada, and is the University of British Columbia Peter Wall Distinguished Professor. He cofounded Inimex Pharmaceuticals, Inc. (BC, Canada), and is Director of the Severe Acute Respiratory Syndrome Accelerated Vaccine Initiative. He is also a valued member of several advisory and editorial boards, including that of Future Microbiology.


Socio-demographic and epidemiological consideration of Africa's COVID-19 response: what is the possible pandemic course?


title: Blood-feeding, susceptibility to infection with Schmallenberg virus and phylogenetics of Culicoides (Diptera: Ceratopogonidae) from the United Kingdom.

text: BACKGROUND Culicoides biting midges (Diptera: Ceratopogonidae) are responsible for the biological transmission of internationally important arboviruses of livestock. In 2011, a novel Orthobunyavirus was discovered in northern Europe causing congenital malformations and abortions in ruminants. From field studies, Culicoides were implicated in the transmission of this virus which was subsequently named Schmallenberg virus (SBV), but to date no assessment of susceptibility to infection of field populations under standardised laboratory conditions has been carried out. We assessed the influence of membrane type (chick skin, collagen, Parafilm M®) when offered in conjunction with an artificial blood-feeding system (Hemotek, UK) on field-collected Culicoides blood-feeding rates. Susceptibility to infection with SBV following blood-feeding on an SBV-blood suspension provided via either (i) the Hemotek system or via (ii) a saturated cotton wool pledglet was then compared. Schmallenberg virus susceptibility was defined by RT-qPCR of RNA extractions of head homogenates and related to Culicoides species and haplotype identifications based on the DNA barcode region of the mitochondrial cytochrome c oxidase 1 (cox1) gene. RESULTS Culicoides blood-feeding rates were low across all membrane types tested (7.5% chick skin, 0.0% for collagen, 4.4% Parafilm M®, with 6029 female Culicoides being offered a blood meal in total). Susceptibility to infection with SBV through membrane blood-feeding (8 of 109 individuals tested) and pledglet blood-feeding (1 of 94 individuals tested) was demonstrated for the Obsoletus complex, with both C. obsoletus (Meigen) and C. scoticus Downes & Kettle susceptible to infection with SBV through oral feeding. Potential evidence of cryptic species within UK populations was found for the Obsoletus complex in phylogenetic analyses of cox1 DNA barcodes of 74 individuals assessed from a single field-site. CONCLUSIONS Methods described in this study provide the means to blood-feed Palaearctic Culicoides for vector competence studies and colonisation attempts. Susceptibility to SBV infection was 7.3% for membrane-fed members of the subgenus Avaritia and 1.1% for pledglet-fed. Both C. obsoletus and C. scoticus were confirmed as being susceptible to infection with SBV, with potential evidence of cryptic species within UK Obsoletus complex specimens, however the implications of cryptic diversity in the Obsoletus complex on arbovirus transmission remains unknown.


title: Drug repurposing for antimicrobial discovery.

text: Antimicrobial resistance continues to be a public threat on a global scale. The ongoing need to develop new antimicrobial drugs that are effective against multi-drug-resistant pathogens has spurred the research community to invest in various drug discovery strategies, one of which is drug repurposing-the process of finding new uses for existing drugs. While still nascent in the antimicrobial field, the approach is gaining traction in both the public and private sector. While the approach has particular promise in fast-tracking compounds into clinical studies, it nevertheless has substantial obstacles to success. This Review covers the art of repurposing existing drugs for antimicrobial purposes. We discuss enabling screening platforms for antimicrobial discovery and present encouraging findings of novel antimicrobial therapeutic strategies. Also covered are general advantages of repurposing over de novo drug development and challenges of the strategy, including scientific, intellectual property and regulatory issues.


Miniature worlds.


Telerehabilitation during COVID-19: Experiences in service delivery from South India.


title: Covering of an exposed vascular graft in the groin with an external oblique muscle rotational flap.

text: Abdominal muscles, such as the oblique- and transverse muscles, find their blood supply from multiple segmental pedicles from the iliac artery. Besides its superior vascularization, its release is simple, leaving two abdominal muscles for securing abdominal wall strength. The release of the muscle and coverage of the graft requires partial muscle mobilization and is a minor reconstruction, but extension of the mobilization cranially enables coverage of larger defects. We present a case of an infected vascular graft in the groin successfully preserved through coverage with an external oblique muscle flap.


Olfactory Dysfunction in COVID-19: Diagnosis and Management.


Palliative care: Essential support for patients with heart failure in the COVID-19 pandemic.


title: Safety and efficacy of drug-induced sleep endoscopy using a probability ramp propofol infusion system in patients with severe obstructive sleep apnea.

text: BACKGROUND Drug-induced sleep endoscopy (DISE) uses sedative-hypnotics to induce moderate obstruction in sleep apnea patients, thereby facilitating anatomic assessment of obstructive physiology. Implementation of DISE with propofol requires a dosing strategy that reliably and efficiently produces obstruction while minimizing oxygen desaturation. METHODS The surgeon in a prospective study of transoral robotic resection of the tongue base enrolled 97 patients with obstructive sleep apnea confirmed by polysomnography who failed continuous positive airway pressure. All patients were screened by DISE. Propofol dose was determined using custom software written in MATLAB, which has been previously described. Studies were performed in an operating room with standard monitors and resuscitation equipment. No topical anesthesia was used, and no IV drugs other than propofol were used. All patients received 2 L/min supplemental oxygen via a nasal cannula placed in the mouth. After initiation of propofol sedation, a pediatric bronchoscope was positioned via the naris to observe the velopharynx. The sedation sequence was continued until the clinical end point of obstruction onset was noted. Observation of the pharynx was performed for a sufficient period to obtain images of the anatomic site(s) of obstruction. The infusion was then terminated. Statistical analysis was performed with MATLAB (MathWorks, version 2012b). Comparison of saturation nadirs between DISE and subject sleep studies was performed with both the paired and unpaired Student t test. RESULTS The subject population was characterized by a median body mass index of 32.1 (interquartile range [IQR] 6.8) kg/m and apnea-hypopnea index of 48 (IQR 32). All patients demonstrated obstruction within the design variables. Obstruction was observed after 236 (±57.9) seconds at an estimated effect-site concentration of 4.2 ± 1.3 mcg/mL. The median saturation nadir during DISE was significantly higher (91.4% (IQR 5.1)) than that during standard sleep studies (81.0% [IQR 11.2], P < 0.0001). Ninety-five percent confidence intervals for correlations between DISE saturation nadir and body mass index, age, apnea-hypopnea index, or administered propofol dose included zero in all cases. CONCLUSIONS A propofol infusion strategy that requires limited experience with propofol dose selection and only 1 pump dosing change reliably produced airway obstruction in patients with severe sleep apnea. Clinical obstruction was achieved faster than target-controlled infusion-based systems for similar procedures reported in the literature. The observed degree of oxygen desaturation in the model system was within a clinically acceptable range.


title: Response of bispectral index to neuromuscular block in awake volunteers.

text: BACKGROUND The bispectral index (BIS) monitor is a quantitative electroencephalographic (EEG) device that is widely used to assess the hypnotic component of anaesthesia, especially when neuromuscular blocking drugs are used. It has been shown that the BIS is sensitive to changes in electromyogram (EMG) activity in anaesthetized patients. A single study using an earlier version of the BIS showed that decreased EMG activity caused the BIS to decrease even in awake subjects, to levels that suggested deep sedation and anaesthesia. METHODS We administered suxamethonium and rocuronium to 10 volunteers who were fully awake, to determine whether the BIS decreased in response to neuromuscular block alone. An isolated forearm technique was used for communication during the experiment. Two versions of the BIS monitor were used, both of which are in current use. Sugammadex was used to antagonise the neuromuscular block attributable to rocuronium. RESULTS The BIS decreased after the onset of neuromuscular block in both monitors, to values as low as 44 and 47, and did not return to pre-test levels until after the return of movement. The BIS showed a two-stage decrease, with an immediate reduction to values around 80, and then several minutes later, a sharp decrease to lower values. In some subjects, there were periods where the BIS was <60 for several minutes. The response was similar for both suxamethonium and rocuronium. Neither monitor was consistently superior in reporting the true state of awareness. CONCLUSIONS These results suggest that the BIS monitor requires muscle activity, in addition to an awake EEG, in order to generate values indicating that the subject is awake. Consequently, BIS may be an unreliable indicator of awareness in patients who have received neuromuscular blocking drugs. CLINICAL TRIAL REGISTRY NUMBER ACTRN12613000587707.


The Bothrops legacy: vasoactive peptides from Brazil.


title: Williamwhitmania taraxaci gen. nov., sp. nov., a proteolytic anaerobe with a novel type of cytology from Lake Untersee in Antarctica, description of Williamwhitmaniaceae fam. nov., and emendation of the order Bacteroidales Krieg 2012.

text: The proteolytic bacterium strain A7P-90mT was isolated from Lake Untersee, Antarctica. The anoxic water was collected from a perennially sealed (~100 millennia) glacial ice lake. Gram-stain-negative cells were 0.18-0.3×8.0-25.0 µm in size, straight, slender rods with unusual gliding motility by external, not previously reported, organelles named here as antiae. At the end of stationary phase of growth, spheroplasts were terminally formed and the cells resembled dandelions. After death, cells were helical. The isolate was an athalassic, strictly anaerobic and catalase-negative proteolytic chemoorganotroph. It was moderately psychrophilic with a temperature range for growth of 3-26 °C and an optimum at 22-23 °C. The pH range for growth was 5.5-7.8 with an optimum at 6.9. Major cellular fatty acids were branched pentadecanoic and tridecanoic acids, and saturated tetradecanoic acids. The quinone system comprised menaquinone MK-7. The strain was sensitive to all checked antibiotics and ascorbic acid. The G+C content of the genomic DNA was 42.6 mol%. Based on average nucleotide identity, average amino acid identity and phylogenetic analyses, the novel isolate was placed within a unique phylogenetic cluster distant from all eight families in the order Bacteroidales and formed a novel family with the proposed name Williamwhitmaniaceae fam. nov. The description of the order Bacteroidales was emended accordingly. The name Williamwhitmania taraxaci gen. nov., sp. nov. is proposed for the new genus and novel species with the type strain A7P-90mT (=DSM 100563T=JCM 30888T). The complete draft genome sequence was deposited at the Joint Genomes Institute (JGI) under number IMG OID 2654588148 and in SRA listed as SRP088197.


title: Patient-reported outcomes after single-incision versus traditional laparoscopic cholecystectomy: a randomized prospective trial.

text: BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) is a newer approach that may be a safe alternative to traditional laparoscopic cholecystectomy (TLC) based on retrospective and small prospective studies. As the demand for single-incision surgery may be driven by patient perceptions of benefits, we designed a prospective randomized study using patient-reported outcomes as our end points. METHODS Patients deemed candidates for either SILC or TLC were offered enrollment in the study. After induction of anesthesia, patients were randomized to SILC or TLC. Preoperative characteristics and operative data were recorded, including length of stay (LOS). Pain scores in recovery and for 48 h and satisfaction with wound appearance at 2 and 4 weeks were reported by patients. We used the gastrointestinal quality of life index (GIQLI) survey preoperatively and at 2 and 4 weeks postoperatively to assess recovery. Procedural and total hospital costs per case were abstracted from hospital billing systems. RESULTS Mean age of the study group was 44.1 years (±14.8), 87% were Caucasian, and 77% were female, with no difference between groups. Operative times were longer for SILC (median = 57 vs. 47 min, p = 0.008), but mean LOS was similar (6.8 ± 4.2 h SILC vs. 6.2 ± 4.8 h TLC, p = 0.59). Operating room cost and encounter cost were similar. GIQLI scores were not significantly different preoperatively or at 2 or 4 weeks postoperatively. Patients reported higher satisfaction with wound appearance at 2 weeks with SILC. There were no differences in pain scores in recovery or in the first 48 h, although SILC patients required significantly more narcotic in recovery (19 mg morphine equivalent vs. 11.5, p = 0.03). CONCLUSIONS SILC is a longer operation but can be done at the same cost as TLC. Recovery and pain scores are not significantly different. There may be an improvement in patient satisfaction with wound appearance. Both procedures are valid approaches to cholecystectomy.


title: Potential for the use of the Solitaire stent for recanalization of middle cerebral artery occlusion without a susceptibility vessel sign.

text: BACKGROUND AND PURPOSE Absence of the MCA susceptibility vessel sign (negative MCA susceptibility vessel sign) on gradient recalled-echo MR imaging in acute stroke is commonly associated with in situ stenosis and thrombotic occlusion. We evaluated the effectiveness and safety of the Solitaire stent as the first-line device for the recanalization of MCA occlusion with a negative MCA susceptibility vessel sign. MATERIALS AND METHODS Thirty-eight consecutive patients presenting with acute ischemic stroke due to MCA occlusion were treated by using the Solitaire AB stent alone or combined with thrombolytic drugs. Among these patients, 11 (7 men and 4 women; median age, 70 years; range, 49-89 years) who underwent multimodal stroke MR imaging before the endovascular procedure and had no MCA susceptibility vessel sign on the initial gradient recalled-echo MR imaging were included in this study. The primary end point was the recanalization of the occluded artery evaluated by the arterial occlusive lesion score. Clinical outcome was assessed at discharge and 90 days, as was the degree of residual MCA stenosis or reocclusion. RESULTS Successful recanalization (arterial occlusive lesion score ≥ II) without balloon angioplasty was obtained in 9 patients (81.8%). Six patients (54.5%) had an mRS score of ≤2 at 90 days. After a median of 147 days, no patient showed reocclusion on follow-up imaging. There were no symptomatic intracerebral hemorrhages. CONCLUSIONS The Solitaire stent is a feasible tool as the first-line device for multimodal endovascular recanalization therapy in acute ischemic stroke with a negative MCA susceptibility vessel sign. It has a good rate of successful and complete recanalization and is a fast yet safe procedure.


title: Evaluation of the proximal coronary arteries in suspected pulmonary embolism: diagnostic images in 51% of patients using non-gated, dual-source CT pulmonary angiography.

text: PURPOSE This retrospective study reports the frequency and severity of coronary artery motion on dual-source high-pitch (DSHP), conventional pitch single-source (SS), and dual-source dual-energy (DE) CT pulmonary angiography (CTPA) studies. METHODS Two hundred eighty-eight consecutive patients underwent CTPA scans for suspected pulmonary embolism between September 1, 2013 and January 31, 2014. One hundred ninety-four at DSHP scans, 57 SS scans, and 37 DE scans were analyzed. Coronary arteries were separated into nine segments, and coronary artery motion was qualitatively scored using a scale from 1 to 4 (non-interpretable to diagnostic with no motion artifacts). Signal intensity, noise, and signal to noise ratio (SNR) of the aorta, main pulmonary artery, and paraspinal muscles were also assessed. RESULTS DSHP CTPA images had significantly less coronary artery motion, with 30.1% of coronary segments being fully evaluable compared to 4.2% of SS segments and 7.9% of DE segments (p < 0.05 for all comparisons). When imaging with DSHP, the proximal coronary arteries were more frequently evaluable than distal coronary arteries (51% versus 11.3%, p < 0.001). Without ECG synchronization and heart rate control, the distal left anterior descending coronary artery and mid right coronary artery remain infrequently interpretable (7% and 9%, respectively) on DSHP images. CONCLUSIONS DSHP CTPA decreases coronary artery motion artifacts and allows for full evaluation of the proximal coronary arteries in 51% of cases. The study highlights the increasing importance of proximal coronary artery review when interpreting CTPA for acute chest pain.


Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy.


title: Natural Orifice-Assisted Laparoscopic Meckel Diverticulectomy Incidentally Found During Para-Aortic Mass Resection.

text: STUDY OBJECTIVE To show a surgical video in which an incidentally found Meckel diverticulum was resected with a natural orifice-assisted laparoscopic approach during para-aortic resection of a retroperitoneal schwannoma. DESIGN Case report (Canadian Task Force classification III). SETTING Tertiary referral center in New Haven, Connecticut. INTERVENTIONS This is a step-by-step illustration for resection of a retroperitoneal para-aortic schwannoma and of an incidentally found Meckel diverticulum. The patient was a 39-year-old white woman diagnosed with stage IV choriocarcinoma with metastasis to the lungs and left para-aortic area. She received chemotherapy in the form of etoposide, methotrexate, actinomycin-D, cyclophosphamide, oncovine (EMA-CO) and had an excellent clinical response with resolution of all metastatic disease except for the para-aortic mass. Therefore, she was taken to the operating room for laparoscopic resection of the persistent left para-aortic mass. After placement of four 5-mm abdominal ports, the pelvis and abdomen were explored and revealed an incidental Meckel diverticulum as well as the 5 cm left para-aortic mass. The peritoneum overlying the para-aortic mass was incised and the retroperitoneum explored. Given the proximity to the mass, left ureterolysis was performed. The retroperitoneal attachments were resected, and the left para-aortic mass was removed without any complications. At this point attention was turned to the Meckel diverticulum. In order not to extend the abdominal incisions, a posterior colpotomy was performed in the cul-de-sac equidistant from the uterosacral ligaments. Endo-GIA (Covidien, New Haven CT) was introduced through the 10-mm port site at the posterior colpotomy. Meckel diverticulum was resected without narrowing the lumen of the distal ileum. The specimen was removed in a contained manner through posterior colpotomy. MEASUREMENTS AND MAIN RESULTS The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home on postoperative day 0. Pathology revealed a retroperitoneal schwannoma with negative margins and benign Meckel diverticulum without ectopic gastric or pancreatic tissue. The patient has been disease-free since the completion of surgery. CONCLUSION Laparoscopic resection of the retroperitoneal schwannoma and Meckel diverticulum were successfully performed in this patient with history of stage IV choriocarcinoma. To our knowledge, this is the first report describing a natural orifice-assisted laparoscopic approach for resection of Meckel diverticulum. Natural orifice-assisted laparoscopy should be considered when the surgeon needs to remove a large specimen and/or to introduce >5-mm diameter instruments into the peritoneal cavity without having to extend the abdominal incisions.


title: Fruit Juice and Change in BMI: A Meta-analysis.

text: CONTEXT Whether 100% fruit juice consumption causes weight gain in children remains controversial. OBJECTIVE To determine the association between 100% fruit juice consumption and change in BMI or BMI z score in children. DATA SOURCES PubMed, Embase, CINAHL, and Cochrane databases. STUDY SELECTION Longitudinal studies examining the association of 100% fruit juice and change in BMI measures were included. DATA EXTRACTION Two independent reviewers extracted data using a predesigned data collection form. RESULTS Of the 4657 articles screened, 8 prospective cohort studies (n = 34 470 individual children) met the inclusion criteria. Controlling for total energy intake, 1 daily 6- to 8-oz serving increment of 100% fruit juice was associated with a 0.003 (95% CI: 0.001 to 0.004) unit increase in BMI z score over 1 year in children of all ages (0% increase in BMI percentile). In children ages 1 to 6 years, 1 serving increment was associated with a 0.087 (95% confidence interval: 0.008 to 0.167) unit increase in BMI z score (4% increase in BMI percentile). 100% fruit juice consumption was not associated with BMI z score increase in children ages 7 to 18 years. LIMITATIONS All observational studies; studies differed in exposure assessment and covariate adjustment. CONCLUSIONS Consumption of 100% fruit juice is associated with a small amount of weight gain in children ages 1 to 6 years that is not clinically significant, and is not associated with weight gain in children ages 7 to 18 years. More studies are needed in children ages 1 to 6 years.


title: Viral infections and asthma: an inflammatory interface?

text: Asthma is a chronic inflammatory disease of the airways in which the majority of patients respond to treatment with corticosteroids and β₂-adrenoceptor agonists. Acute exacerbations of asthma substantially contribute to disease morbidity, mortality and healthcare costs, and are not restricted to patients who are not compliant with their treatment regimens. Given that respiratory viral infections are the principal cause of asthma exacerbations, this review article will explore the relationship between viral infections and asthma, and will put forward hypotheses as to why virus-induced exacerbations occur. Potential mechanisms that may explain why current therapeutics do not fully inhibit virus-induced exacerbations, for example, β₂-adrenergic desensitisation and corticosteroid insensitivity, are explored, as well as which aspects of virus-induced inflammation are likely to be attenuated by current therapy.


title: Reporting and Handling of Indeterminate Bone Scan Results in the Staging of Prostate Cancer: A Systematic Review.

text: Bone scintigraphy is key in imaging skeletal metastases in newly diagnosed prostate cancer. Unfortunately, a notable proportion of scans are not readily classified as positive or negative but deemed indeterminate. The extent of reporting of indeterminate bone scans and how such scans are handled in clinical trials are not known. A systematic review was conducted using electronic databases up to October 2016. The main outcome of interest was the reporting of indeterminate bone scans, analyses of how such scans were managed, and exploratory analyses of the association of study characteristics and the reporting of indeterminate bone scan results. Seventy-four eligible clinical trials were identified. The trials were mostly retrospective (85%), observational (95%), large trials (median 195 patients) from five continents published over four decades. The majority of studies had university affiliation (72%), and an author with imaging background (685). Forty-five studies (61%) reported an indeterminate option for the bone scan and 23 studies reported the proportion of indeterminate scans (median 11.4%). Most trials (44/45, 98%) reported how to handle indeterminate scans. Most trials (n = 39) used add-on supplementary imaging, follow-up bone scans, or both. Exploratory analyses showed a significant association of reporting of indeterminate results and number of patients in the study (p = 0.024) but failed to reach statistical significance with other variables tested. Indeterminate bone scan for staging of prostate cancer was insufficiently reported in clinical trials. In the case of indeterminate scans, most studies provided adequate measures to obtain the final status of the patients.


title: Heterologous immunity between viruses.

text: Immune memory responses to previously encountered pathogens can sometimes alter the immune response to and the course of infection of an unrelated pathogen by a process known as heterologous immunity. This response can lead to enhanced or diminished protective immunity and altered immunopathology. Here, we discuss the nature of T-cell cross-reactivity and describe matrices of epitopes from different viruses eliciting cross-reactive CD8(+) T-cell responses. We examine the parameters of heterologous immunity mediated by these cross-reactive T cells during viral infections in mice and humans. We show that heterologous immunity can disrupt T-cell memory pools, alter the complexity of the T-cell repertoire, change patterns of T-cell immunodominance, lead to the selection of viral epitope-escape variants, alter the pathogenesis of viral infections, and, by virtue of the private specificity of T-cell repertoires within individuals, contribute to dramatic variations in viral disease. We propose that heterologous immunity is an important factor in resistance to and variations of human viral infections and that issues of heterologous immunity should be considered in the design of vaccines.


title: The role of 68Ga-DOTATATE PET/CT in suspected neuroendocrine tumors.

text: UNLABELLED In patients with suspected but yet not localized neuroendocrine tumors (NETs), early diagnosis or reliable exclusion is crucial for optimal individual prognosis and therapy. Despite recourse to several imaging modalities, the definite diagnosis of NET can be challenging. Therefore, we tested (68)Ga-DOTATATE PET/CT as a tool for improved diagnosis in a cohort of patients with suspected, nonlocalized NET. METHODS (68)Ga-DOTATATE PET/CT recordings were obtained in 104 consecutive patients meeting at least one of the following criteria: clinical suspicion of NET (n = 70), elevated blood levels of tumor markers (n = 49), and image-based suspicion of NET (n = 53). The presence of NET was validated by histopathology (n = 49) or clinical follow-up of 107 ± 59 wk (n = 55). RESULTS In 36 of 104 patients (35%), NET was histologically verified, most frequently located in the small bowel (10/36), pancreas (8/36), lung (5/36), and stomach (2/36). Twelve patients had tumors of nonneuroendocrine origin, and 7 patients had benign tumors. (68)Ga-DOTATATE PET/CT identified NET in 29 of the 36 cases and excluded the presence of a NET in 61 of the 68 non-NET patients, indicating a sensitivity of 81% and specificity of 90%. The PET/CT gave a false-positive result in 7 patients and a false-negative in another 7 patients, indicating positive and negative predictive values of 81% and 90%, respectively, and an accuracy of 87%. Chromogranin A levels were significantly higher in both PET-positive patients (1,841 vs. 342 ng/mL; P < 0.05) and patients with verified NET (2,214 vs. 524 ng/mL; P < 0.05). CONCLUSION In patients with suspected NETs due to clinical symptoms, elevated levels of tumor markers, or indeterminate tumors suggestive of NET, (68)Ga-DOTATATE PET/CT is highly accurate, thus supporting its use in clinical routine diagnostics.


title: Laparoscopic ventral rectopexy for faecal incontinence: equivalent benefit is seen in internal and external rectal prolapse.

text: AIM An external rectal prolapse (ERP) is often associated with faecal incontinence, and surgery is the recommended therapy. It has been suggested that correction of a high grade internal rectal prolapse (HIRP) is also worthwhile for patients with faecal incontinence. The aim of the present study is to compare the results of laparoscopic ventral rectopexy (LVR) in patients with faecal incontinence associated with either an ERP or a HIRP. METHOD Consecutive patients suffering from faecal incontinence, who underwent a LVR between June 2010 and October 2012, were identified from a prospective database. All patients underwent preoperative defaecating proctography, anorectal manometry and ultrasound. Symptoms were assessed preoperatively and at 1 year after operation using a standardized questionnaire incorporating the Faecal Incontinence Severity Index (FISI; range 0-61) and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS LVR was performed in 50 incontinent patients with a HIRP, and in 41 patients with an ERP. Preoperatively, the FISI was higher in patients with HIRP (HIRP 42 versus ERP 30, P < 0.01). The recurrence rate at 1 year was similar in both groups (HIRP 6 % versus ERP 2 %, P = 0.156). The FISI scores were significantly reduced in both groups (HIRP 48 % versus ERP 50 %, both P < 0.01). GIQLI was equally improved in both groups (HIRP 17 % versus ERP 18 %, both P < 0.01). CONCLUSION Laparoscopic ventral rectopexy for the treatment of faecal incontinence achieves equivalent outcomes in both patients with an external rectal prolapse or high grade internal rectal prolapse.


title: Immunohistochemical evaluation of the effects of paraffin section storage on biomarker stability.

text: Environmental stresses can alter immunoreactivity of biomarkers in stored tissue sections. The effect of temperature and lighting on 49 cellular or microbial antigens was evaluated in 4 serial paraffin sections, cut 12 months, 10 months, 8 months, 5 months, 3 months, 1 month, 3 days, and 1 day before immunohistochemistry. Slides were stored at room temperature (RT) in the dark, at 4°C in the dark, at RT under fluorescent light, or at RT with windowpane exposure to sunlight. Immunohistochemistry was performed simultaneously in an automated immunostainer. Immunoreactivity was compared with that in the corresponding 1-day-old section and scored as 4 (<10% reduction), 3 (10%-25% reduction), 2 (26%-60% reduction), 1(>60% reduction), or 0 (no reactivity). Any loss of immunoreactivity was proportional to the tissue section age and was least in sections stored in the dark. Immunoreactivity was only completely lost in light-exposed sections and as early as 1 month for CD45. Other markers with complete loss of immunoreactivity were bovine viral diarrhea virus, CD18 (only with fluorescent light), CD31, CD68, canine parvovirus, chromogranins, and thyroid transcription factor-1. Markers with complete loss after light exposure also had reduced immunoreactivity when stored in the dark, as early as day 3. Eight markers (Bartonella spp, CD11d, high molecular weight cytokeratins, feline coronavirus, GATA-4, insulin, p63, progesterone receptor) had minimal decrease in immunoreactivity, regardless of treatment. In conclusion, light-induced antigen decay (tissue section aging) is antigen dependent and could explain unexpectedly weak or negative immunohistochemical reactions in stored paraffin sections.


title: Diversity and Evolutionary Histories of Human Coronaviruses NL63 and 229E Associated with Acute Upper Respiratory Tract Symptoms in Kuala Lumpur, Malaysia.

text: The human alphacoronaviruses HCoV-NL63 and HCoV-229E are commonly associated with upper respiratory tract infections (URTI). Information on their molecular epidemiology and evolutionary dynamics in the tropical region of southeast Asia however is limited. Here, we analyzed the phylogenetic, temporal distribution, population history, and clinical manifestations among patients infected with HCoV-NL63 and HCoV-229E. Nasopharyngeal swabs were collected from 2,060 consenting adults presented with acute URTI symptoms in Kuala Lumpur, Malaysia, between 2012 and 2013. The presence of HCoV-NL63 and HCoV-229E was detected using multiplex polymerase chain reaction (PCR). The spike glycoprotein, nucleocapsid, and 1a genes were sequenced for phylogenetic reconstruction and Bayesian coalescent inference. A total of 68/2,060 (3.3%) subjects were positive for human alphacoronavirus; HCoV-NL63 and HCoV-229E were detected in 45 (2.2%) and 23 (1.1%) patients, respectively. A peak in the number of HCoV-NL63 infections was recorded between June and October 2012. Phylogenetic inference revealed that 62.8% of HCoV-NL63 infections belonged to genotype B, 37.2% was genotype C, while all HCoV-229E sequences were clustered within group 4. Molecular dating analysis indicated that the origin of HCoV-NL63 was dated to 1921, before it diverged into genotype A (1975), genotype B (1996), and genotype C (2003). The root of the HCoV-229E tree was dated to 1955, before it diverged into groups 1-4 between the 1970s and 1990s. The study described the seasonality, molecular diversity, and evolutionary dynamics of human alphacoronavirus infections in a tropical region.


Clinical Characteristics of Covid-19 in China.


title: Consolidating malignant pleural and peritoneal services during the COVID-19 response.

text: Delivery of routine and established medical care has been significantly disrupted by the COVID-19 pandemic. Acutely unwell patients are being prioritised, and large numbers of doctors and inpatient beds are required to deliver this care. We have recognised the impact that this disruption will have on patients with presumed and/or confirmed pleural and/or peritoneal malignancies. We present our service transformation and hope that the learning from this reconfiguration can be adopted by other organisations.


title: The challenge of COVID-19 and hematopoietic cell transplantation; EBMT recommendations for management of hematopoietic cell transplant recipients, their donors, and patients undergoing CAR T-cell therapy

text: The new coronavirus SARS-CoV-2 has rapidly spread over the world causing the disease by WHO called COVID-19. This pandemic poses unprecedented stress on the health care system including programs performing allogeneic and autologous hematopoietic cell transplantation (HCT) and cellular therapy such as with CAR T cells. Risk factors for severe disease include age and predisposing conditions such as cancer. The true impact on stem cell transplant and CAR T-cell recipients in unknown. The European Society for Blood and Marrow Transplantation (EBMT) has therefore developed recommendations for transplant programs and physicians caring for these patients. These guidelines were developed by experts from the Infectious Diseases Working Party and have been endorsed by EBMT’s scientific council and board. This work intends to provide guidelines for transplant centers, management of transplant candidates and recipients, and donor issues until the COVID-19 pandemic has passed.


title: Reduction in delayed gastric emptying following non-pylorus preserving pancreaticoduodenectomy by addition of a Braun enteroenterostomy.

text: CONTEXT Delayed gastric emptying is a major cause of morbidity following pancreaticoduodenectomy. OBJECTIVE The impact of a Braun enteroenterostomy on delayed gastric emptying, used in reconstruction following classic pancreaticoduodenectomy, was assessed. PATIENTS Forty-four consecutive patients undergoing non-pylorus preserving pancreaticoduodenectomy from 2009 to 2011 by a single surgeon were included in this study. INTERVENTIONS The first 20 patients had a standard antecolic gastroenterostomy and the subsequent 24 had the addition of a Braun enteroenterostomy. RESULTS Patient characteristics, the extent of surgery, surgical findings and tumor characteristics were similar between the two groups. The delayed gastric emptying rate in the Braun enteroenterostomy (1/24, 4.2%) was significantly lower (P=0.008) than the standard reconstruction group (7/20, 35.0%). In the standard group, 6 of 7 cases (85.7%) of delayed gastric emptying were class C in nature. After exclusion of 8 total pancreatectomy patients, the pancreatic fistula rate in the Braun enteroenterostomy group (4/19, 21.1%) was similar (0.706) to the standard reconstruction group (5/17, 29.4%) as was the median length of hospital stay (10 days vs. 15 days; P=0.291). Braun enteroenterostomy technique was the only significant independent factor associated with reduced delayed gastric emptying with an odds ratio of 0.08 (95% confidence interval: 0.01-0.73; P=0.025). CONCLUSION The use of Braun enteroenterostomy following non-pylorus preserving pancreaticoduodenectomy appears to result in a significant reduction in delayed gastric emptying.


title: Transforaminal approach for cerebral dural arteriovenous fistula embolization.

text: A transverse sinus dural arteriovenous fistula (DAVF) not easily accessible by standard transfemoral (transarterial or transvenous) endovascular approaches is presented. An enlarged transosseous retromastoid foramen harboring the occipital artery branch feeding the lesion was identified on CT angiogram (CTA). Curative Onyx embolization was achieved via percutaneous CT-guided direct puncture of the transosseous occipital arterial branch followed by microcatheter navigation through the needle distally towards the site of the fistula.


title: [Work flow of clinical microbiology laboratory under the outbreak of the novel coronavirus disease 2019].

text: The burn microbiology laboratory of the author's unit is a second-level biosafety laboratory, which is mainly responsible for handling clinical microbial samples from our department and other departments in the hospital. Since the outbreak of the coronavirus disease 2019, in order to ensure the normal development of daily work and the safety of medical staff, the microbiology laboratory has actively adjusted the daily work flow. The specific work flow is summarized as follows to provide reference for the safety protection of peer in clinical microbiology laboratory.


title: Laparoscopic incisionless stoma creation for patients with colorectal malignant stricture.

text: BACKGROUND Minimally invasive techniques have been applied with increasing frequency to stoma creation. A recent focus in the field of minimally invasive surgery is laparoscopic single-site surgery. The aim of this study was to assess whether this procedure is a feasible option compared with other techniques of stoma creation. MATERIALS AND METHODS We introduced laparoscopic surgery to fecal diversion in April 2010 at the Cancer Institute Hospital of the Japanese Foundation for Cancer Research. This technique was performed on 53 patients, including 15 laparoscopic single-site surgeries, from April 2010 to December 2011. RESULTS Of these 15 cases, 8 ileostomies and 7 colostomies were created. The mean operative time was 65.9 minutes (range, 32 to 93 min). The estimated volume of blood loss was small in all cases. There were no intraoperative complications. All patients started an oral diet on the second postoperative day with the exception of 1 patient who suffered from prolonged paralytic ileus. CONCLUSIONS A laparoscopic single-site approach to stoma creation may be a feasible option in fecal diversion.


title: A prospective double-blind randomized controlled trial of radiofrequency versus laser treatment of the great saphenous vein in patients with varicose veins.

text: BACKGROUND Endovenous ablation of varicose veins using radiofrequency ablation (RFA) and endovenous laser therapy (EVLT) has reported advantages over traditional open surgical treatment. There is little evidence comparing the efficacy and patient-reported outcomes between the 2 endovenous solutions. This study compares the RFA and EVLT strategies in a prospective double-blind clinical trial. METHODS Consecutive patients with primary unilateral great saphenous vein (GSV) reflux undergoing endovenous treatment were randomized to RFA (VNUS ClosureFAST) or EVLT (810-nm diode laser). The primary outcome measure was GSV occlusion at 3 months after treatment. Secondary outcome measures were occlusion at 7 days, postoperative pain, analgesic requirement, and bruising, assessed at day 7 after surgery. Quality of life (QoL) was assessed preoperatively and 3 months after surgery using the Aberdeen Varicose Vein Questionnaire (AVVQ) and EQ-5D. RESULTS A total of 159 patients were randomized to RFA (79 patients) or EVLT (80 patients). Groups were well matched for demographics, disease extent, severity, and preoperative QoL. Duplex scanning confirmed 100% vein occlusion at 1 week in both groups. At 3 months, occlusion was 97% for RFA and 96% for EVLT; P = 0.67. Median (interquartile range) percentage above-knee bruise area was greater after EVLT 3.85% (6.1) than after RFA 0.6% (2); P = 0.0001. Postoperative pain assessed at each of the first 7 postoperative days was less after RFA (P = 0.001). Changes in the AVVQ (P = 0.12) and EQ-5D (P = 0.66) at 3 months were similar in both groups. CONCLUSIONS RFA and EVLT offer comparable venous occlusion rates at 3 months after treatment of primary GSV varices; with neither modality proving superior. RFA is associated with less periprocedural pain, analgesic requirement, and bruising. REGISTRATION NUMBER ISRCTN63135694 (http://www.controlled-trials.com).


title: Laparoscopic parenchymal preserving hepatic resections in semiprone position for tumors located in the posterosuperior segments.

text: INTRODUCTION All patients who underwent laparoscopic liver resections in the posterosuperior segments (LPSS) at our center were positioned in semiprone since August 2011. The aims of this study were to assess differences in perioperative outcomes between laparoscopic left lateral sectionectomies (LLLS) performed in supine position and LPSS in semiprone position. METHODS We reviewed our prospectively collected database of all liver resections performed between January 2012 and January 2015. LLLS and LPSS were compared with respect to demographics and perioperative outcomes. RESULTS Forty-five patients underwent LLLS (n = 20) or LPSS (n = 25). There were no differences in patient demographics or tumor diameter (p = 0.946). There were no conversions. Pringle maneuver was not used in both groups. There was no difference in peroperative central venous pressure (p = 0.511). The median operative time in the LLLS group was 100 min (60-260) and 160 min (95-270) in the LPSS group (p = 0.002) with median intraoperative blood loss in the LLLS group of 50 ml (0-550) versus a larger 150 ml (50-700) (p = 0.010) for patients receiving LPSS. No patients required transfusion. Intraoperative and postoperative complication rates were similar in both groups. Median hospital stay was 6 days in both groups (p = 0.554). CONCLUSION LPSS in semiprone can be performed with similar clinical outcomes as a minor laparoscopic liver resection except for longer operative time and larger intraoperative blood loss without the need for transfusion.


A reply to Dr. Pan's and Dr. Wu's response: "Wuhan COVID-19 data - An example to show the importance of public health interventions to fight against the pandemic".


title: Biodistribution study of nanometric hybrid gadolinium oxide particles as a multimodal SPECT/MR/optical imaging and theragnostic agent.

text: Nanometric hybrid gadolinium oxide particles (Gado-6Si-NP) for diagnostic and therapeutic applications (mean diameter 3-4 nm) were obtained by encapsulating Gd(2)O(3) cores within a polysiloxane shell, which carries organic fluorophore (Cy 5) and is derivatized by a hydrophilic carboxylic layer. As residency time in the living body and methods of waste elimination are crucial to defining a good nanoparticle candidate and moving forward with steps for validation, this study was aimed at evaluating the biodistribution of these multimodal Gado-6Si-NP in rodents. Gado-6Si-NP were imaged following intravenous injection in control Wistar rats and mice using MRI (7 T), optical fluorescent imaging, and SPECT. A clear correlation was observed among MRI, optical imaging, and SPECT regarding the renal elimination. Quantitative biodistribution using gamma-counting of each sampled organ confirmed that these nanoparticles circulated freely in the blood pool and were rapidly cleared by renal excretion without accumulation in liver and RES uptake. These results demonstrate that Gado-6Si-NP display optimal biodistribution properties, enabling them to be developed as multimodal agents for in vivo imaging and theragnostics, especially in oncological applications.


Preventing iatrogenic pandemics of panic. Do it in a NICE way.


Seven days in medicine: 22-28 April 2020.


title: Perfusion fixation in brain banking: a systematic review.

text: BACKGROUND Perfusing fixatives through the cerebrovascular system is the gold standard approach in animals to prepare brain tissue for spatial biomolecular profiling, circuit tracing, and ultrastructural studies such as connectomics. Translating these discoveries to humans requires examination of postmortem autopsy brain tissue. Yet banked brain tissue is routinely prepared using immersion fixation, which is a significant barrier to optimal preservation of tissue architecture. The challenges involved in adopting perfusion fixation in brain banks and the extent to which it improves histology quality are not well defined. METHODOLOGY We searched four databases to identify studies that have performed perfusion fixation in human brain tissue and screened the references of the eligible studies to identify further studies. From the included studies, we extracted data about the methods that they used, as well as any data comparing perfusion fixation to immersion fixation. The protocol was preregistered at the Open Science Framework: https://osf.io/cv3ys/ . RESULTS We screened 4489 abstracts, 214 full-text publications, and identified 35 studies that met our inclusion criteria, which collectively reported on the perfusion fixation of 558 human brains. We identified a wide variety of approaches to perfusion fixation, including perfusion fixation of the brain in situ and ex situ, perfusion fixation through different sets of blood vessels, and perfusion fixation with different washout solutions, fixatives, perfusion pressures, and postfixation tissue processing methods. Through a qualitative synthesis of data comparing the outcomes of perfusion and immersion fixation, we found moderate confidence evidence showing that perfusion fixation results in equal or greater subjective histology quality compared to immersion fixation of relatively large volumes of brain tissue, in an equal or shorter amount of time. CONCLUSIONS This manuscript serves as a resource for investigators interested in building upon the methods and results of previous research in designing their own perfusion fixation studies in human brains or other large animal brains. We also suggest several future research directions, such as comparing the in situ and ex situ approaches to perfusion fixation, studying the efficacy of different washout solutions, and elucidating the types of brain donors in which perfusion fixation is likely to result in higher fixation quality than immersion fixation.


title: Influence of blood vessel on the thermal lesion formation during radiofrequency ablation for liver tumors.

text: PURPOSE The major obstacles of radiofrequency ablation (RFA) heat treatments are nonuniform heating in the thermal lesion and heat sinks caused by large blood vessels during treatments which could lead to high tumor recurrence in patients. The objective of this study is to help comprehend RFA heat treatment through thermal lesion formation using computer simulation, and thus to provide helpful assistance in planning RFA. METHODS RFA heat treatment is a popular "minimally invasive" treatment method for both primary and metastatic liver tumors, and the heat treatment is studied by numerical calculation. A finite difference model is used to solve all partial differential equations for a simple three-dimensional cubic geometry model. Maximum tissue temperature is used as a critical index for reaching thermal lesion during RFA. Cylindrical RF cool-tip electrode is internally cooled at constant water temperature. RFA thermal lesion is studied at various impacts by single and countercurrent blood vessel(s) traversing the thermal lesion. Several factors are considered, such as location, diameter, and orientation of the blood vessel(s) to the electrode. RESULTS Results show the thermal lesion size decreases as the lesion blood perfusion rate increases. And, single large blood vessel which is orthogonal to RF electrode will cause less undercooled volume in the thermal lesion than one which is parallel to RF electrode. Furthermore, convective energy may easily damage parallel vessel and its surrounding normal tissues during RFA. Small blood vessels (or larger vessels with slow blood flow rate) during RFA could form "tail-like" thermal lesion formation, which could damage vessel downstream spots. CONCLUSIONS Studies suggested that incomplete RF tumor ablation still exists within 1 cm distance between large blood vessel and RF electrode in a liver. This could have significant impact on local tumor recurrence rates. Second, if thermally significant vessel existed inevitably within the lesion, avoiding the RF cool-tip electrode placement next to the parallel large blood vessel would have a better heat treatment during RF heating. Additionally, reduced blood flow rate could help reduce significant cooling by large blood vessel.


title: Single incision laparoscopic surgery transabdominal pre-peritoneal hernia repair - case report.

text: Single incision laparoscopic surgery (SILS) minimizes perioperative trauma and allows surgical procedures without a visible scar. Here we present a case in which the transabdominal pre-peritoneal method was used in inguinal hernioplasty using a SILS port. The presented case is part of a new trend in surgery to minimize operative trauma. In 2009, when the operation was conducted, it was an innovative procedure.


title: A metabolomic study on early detection of steroid-induced avascular necrosis of the femoral head.

text: The early and accurate diagnosis of steroid-induced avascular necrosis of the femoral head (SANFH) is appealing considering its irreversible progression and serious consequence for the patients. The purpose of this study was to investigate the metabolic change of SANFH for its early detection. Two stages were designed in this study, namely discovery and verification. Except the biochemical index anomaly and the accidental death, 30 adult healthy adult Japanese white rabbits were used for screening out the potential metabolites in discovery experiment and 13 rabbits were used in verification experiment. The femoral heads were assessed with magnetic resonance imaging and transmission electron microscopy. The metabolomic profiling of serum samples were analysis by UHPLC-MS/MS. Metabolomic cluster analysis enable us to differentiate the rabbits without and with injection of the glucocorticoid in 1 week even when there is no obvious abnormal symptom in behaviors or imaging diagnosis. The majority of differential metabolites were identified as phospholipids which were observed significant change after injection of glucocorticoid in 1, 2, 3 weeks. And the results obtained in verification experiment of 6 weeks showed that these differential metabolites exhibited consistent trends in late progression with that in early-stage. At the end of 6 weeks the damage of SANFH could be verified by pathological imaging. Therefore the finding of serum metabolite profile links to the progression of SANFH and provides the potential of early detection of SANFH.


title: Iliopsoas tendon insertion footprint with surgical implications in lesser trochanterplasty for treating ischiofemoral impingement: an anatomic study.

text: The objective of this study was to describe the footprint location of the iliopsoas tendon on the lesser trochanter to clarify the surgical implications of the lesser trochanterplasty for treating ischiofemoral impingement. Ten non-matched, fresh-frozen, cadaveric hemipelvis specimens (average age, 62.4 years; range, 48-84 years; 7 male and 3 female) were included. Registered measures included bony parameters of the lesser trochanter (lesser trochanteric area, distances from the tip to the base in a coordinate system, height and area) and tendinous iliopsoas footprint descriptions (areas and detailed location). The mean height of the lesser trochanter was 13.1 (SD ± 1.8) mm, with female having a smaller lesser trochanter on average (11.3, SD ± 2.0). A double tendinous footprint was found in 7 (70%) specimens. The average area of the single- and double-footprint was 211.2 mm(2) and 187.9 mm(2), respectively. An anterior cortical area with no tendinous insertion on the anterior aspect of lesser trochanter was present in all specimens and measured 4.9 mm (SD ± 0.6) on average. The mean ratio between the bald anterior wall and the lesser trochanter height was 38% (SD ± 0.05). The iliopsoas tendon footprint is double (psoas and iliacus) in most cases and is located on the anteromedial tip of the lesser trochanter. A bald anterior wall on the bottom of the lesser trochanter indicates that a partial or total lesser trochanterplasty for increasing the ischiofemoral space without detaching partially or entirely the iliopsoas tendon is improbable.


title: Recommendations on basic requirements for intensive care units: structural and organizational aspects.

text: OBJECTIVE To provide guidance and recommendations for the planning or renovation of intensive care units (ICUs) with respect to the specific characteristics relevant to organizational and structural aspects of intensive care medicine. METHODOLOGY The Working Group on Quality Improvement (WGQI) of the European Society of Intensive Care Medicine (ESICM) identified the basic requirements for ICUs by a comprehensive literature search and an iterative process with several rounds of consensus finding with the participation of 47 intensive care physicians from 23 countries. The starting point of this process was an ESICM recommendation published in 1997 with the need for an updated version. RESULTS The document consists of operational guidelines and design recommendations for ICUs. In the first part it covers the definition and objectives of an ICU, functional criteria, activity criteria, and the management of equipment. The second part deals with recommendations with respect to the planning process, floorplan and connections, accommodation, fire safety, central services, and the necessary communication systems. CONCLUSION This document provides a detailed framework for the planning or renovation of ICUs based on a multinational consensus within the ESICM.


title: Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive-a Laboratory and Clinical Perspective.

text: Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care.


title: Decrease in cuff pressure during the measurement procedure: an experimental study.

text: BACKGROUND To prevent endotracheal tube (ETT)-related complications during mechanical ventilation, ETT cuff pressure should be kept within proper range. In clinical settings, cuff pressure often decreases from target values. METHODS We performed an experimental study to investigate the effects of measuring devices and endotracheal tubes on change in cuff pressure. We continuously measured cuff pressure by inserting a three-way stopcock in the middle of an ETT pilot balloon system. After adjusting the cuff pressure to 24 cmH2O, we disconnected and reconnected each cuff inflator to the inflation valve of the ETT and measured the changes in the cuff pressure. We measured the change in cuff pressure with different ETT sizes, cuff shapes, brands of cuff inflator, and with and without added extension tubes. RESULTS The cuff pressure decreased, on average, by 6.6 cmH2O (standard deviation 1.9), when connecting the cuff inflator to the pilot balloon. The measured cuff pressure was less than 20 cmH2O in 67% of the tests. The cuff pressure decreased more when an extension tube was used. The brand of cuff inflator made no difference to the pressure loss. The cuff pressure decreased more with ETTs of smaller size and with ETTs with pyriform cuffs. CONCLUSIONS Procedures to connect cuff inflators to inflation valves resulted in the loss of cuff pressure by 6.6 cmH2O on average.


title: Mental health and primary dysmenorrhea: a systematic review.

text: Several factors including demographic, reproductive, lifestyle, psychological and social factors can affect incidence and severity of primary dysmenorrhea. This study aimed to systematically review the psychological risk factors associated with primary dysmenorrhea. Embase, ISI web of knowledge, ProQuest, Science Direct, Scopus and PubMed central were searched using keywords related to risk factors and primary dysmenorrhea. Observational studies, published in English after 2000, focusing solely on psychological factors affecting primary dysmenorrhea were included. The search process retrieved 11,928 potential related articles. Thirty three articles met inclusion criteria and were assessed for final synthesis. The STROBE checklist was used to quality assessment of studies. Results of study showed that few studies had investigated relationship between dysmenorrhea and most psychological disorders. Most studies have investigated the relationship between dysmenorrhea and depression, anxiety, stress, alcohol abuse and somatic disorders. So, further studies are needed to investigate relation between most psychological disorders with primary dysmenorrhea. Significant relationship between some mental health components such as depression, anxiety and stress with primary dysmenorrhea shows the importance of psychological assessment before the choice of therapeutic methods. Also, the feasibility of designing and evaluating the effectiveness of the use of psychotherapy interventions for the treatment of primary dysmenorrhea as alternative therapies can be considered.


Mild or Moderate Covid-19.


title: Single-access retroperitoneoscopic adrenalectomy (SARA) versus conventional retroperitoneoscopic adrenalectomy (CORA): a case-control study.

text: BACKGROUND Stimulated by the concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES), minimizing the access even further has become a new trend in minimally invasive surgery. We compare our recently described new method of endoscopic single-access adrenalectomy with the conventional retroperitoneoscopic approach in a matched-pairs study. METHODS Fifty single-access retroperitoneoscopic adrenalectomies (SARA) were performed in 47 selected patients suffering from Conn's adenomas (n = 20), pheochromocytomas (n = 15), Cushing's adenomas (n = 6), and other diseases (n = 6). For SARA, a single 2-cm skin incision beneath the 12th rib was used. Following creation of the retroperitoneal space with the rigid endoscope, dissection was carried out single-handed. Another 47 patients served as control group; they were treated by the traditional retroperitoneoscopic three-port approach (CORA). Patients were matched with respect to gender, body mass index, diagnoses, tumor size, and tumor site. RESULTS Mortality was zero and no major complications occurred in both groups. SARA was completed in 41 cases (86%). The overall complication rate was 8.5% in SARA and 6.4% in CORA. Operative time was longer for SARA (56 +/- 28 min) than for CORA (40 +/- 12 min) (P < 0.05). Postoperatively, pain medication was administered in 47% of SARA patients and in 75% of CORA patients (P = 0.01). Mean hospital stay was 2.4 +/- 0.7 days (SARA) and 3.1 +/- 1.2 days (CORA) (P < 0.01). CONCLUSIONS Because feasibility and safety of SARA could be demonstrated in a large group of selected patients, this surgical technique may represent a new milestone in minimally invasive endocrine surgery.


Piecemeal mucosectomy, submucosal dissection or transanal microsurgery for large colorectal neoplasm.


title: Far from Standardized: Using Surgical Videos to Identify Variation in Technique for Laparoscopic Sleeve Gastrectomy.

text: BACKGROUND Video assessment is an emerging tool for understanding variation in surgical technique. METHODS Representative videos of laparoscopic sleeve gastrectomy (LSG) were voluntarily submitted by 20 surgeons who participated in a statewide quality improvement collaborative. The amount of time required to complete the salient steps of the operation was measured and variations in the tasks performed during each step were captured. RESULTS Twenty-two videos of LSG were submitted and 11 videos included concurrent hiatal hernia repair. Data obtained from video analysis identified variation in time to complete each step of the procedure: prestapling dissection of stomach (5-25 minutes), gastric stapling (8-20 minutes), and management of the staple line (1-25 minutes). Time required to perform a hiatal hernia repair also varied (1-26 minutes), as did the type of repair: 55% were performed with a posterior cruropexy, 27% were performed with an anterior cruropexy, and 18% were performed with both. Ten different permutations of staple heights and buttressing material were used during division of the stomach with a gastric stapler. Management of the staple line included use of buttressing (64%), fibrin sealant (36%), oversewing (9%), surgical clips (18%), imbrication of the staple line (36%), and omentoplasty (55%). CONCLUSIONS LSG technique is not uniform. Video analysis identified variation in (1) time to complete each step of the procedure, (2) hiatal hernia repair technique, (3) stapling technique, and (4) post-transection staple line management. Future efforts linking video analysis with clinical outcomes can provide objective evidence to support best practices.


title: The neurogenic bladder and incontinent urinary diversion.

text: Management of the neurogenic bladder with an incontinent stoma is necessary in situations in which intermittent catheterization via the urethra or a continent stoma is not feasible. Cutaneous ureterostomy, vesicostomy, ileal conduit, and ileovesicostomy have all been used for this purpose. Vesicostomy is most commonly used as a temporizing measure in the pediatric neurogenic population. Both ileal conduit, with or without cystectomy, and ileovesicostomy have contemporary roles in the management of the neurogenic bladder.


title: Efficacy of auditory evoked potential follow-up in viral meningitis of infants.

text: PURPOSE To examine the rate of occurrence of hearing impairments among the infants who had recovered from viral meningitis under 1 year of age through auditory evoked potential (AEP) test and to investigate the efficacy of the follow-up AEP test in viral meningitis infants. METHODS Two hundred twenty infants (440 ears) were examined through AEP test once, and 47 (94 ears) of them went back for a second examination and were diagnosed with viral meningitis. The first AEP tests were compared with the second results in 47 infants. I latency, V latency, I-III interpeak latency (IPL), and III-V IPL were checked. RESULTS In the first AEP test conducted on 440 ears, the average values of I and V latency and I-III IPL were delayed as compared with normal values. The second AEP results were conducted on 47 infants 92.36 days after the first exam. I latency and V latency of second exam were improved significantly (p < 0.05), but I-III and III-V IPL showed no significant changes. Two hearing impaired patients (4 ears) were confirmed through chart reviews. CONCLUSION The AEP test is a helpful study for early detection of hearing problem. However, in this study, AEP test was too sensitive in acute period, and later, the incidence rate of hearing impairment was relatively low. Therefore, age of onset, severity of neurologic symptom, and clinical examination must be considered before the AEP test.


title: A Piglet Model of Neonatal Hypoxic-Ischemic Encephalopathy.

text: Birth asphyxia, which causes hypoxic-ischemic encephalopathy (HIE), accounts for 0.66 million deaths worldwide each year, about a quarter of the world's 2.9 million neonatal deaths. Animal models of HIE have contributed to the understanding of the pathophysiology in HIE, and have highlighted the dynamic process that occur in brain injury due to perinatal asphyxia. Thus, animal studies have suggested a time-window for post-insult treatment strategies. Hypothermia has been tested as a treatment for HIE in pdiglet models and subsequently proven effective in clinical trials. Variations of the model have been applied in the study of adjunctive neuroprotective methods and piglet studies of xenon and melatonin have led to clinical phase I and II trials(1,2). The piglet HIE model is further used for neonatal resuscitation- and hemodynamic studies as well as in investigations of cerebral hypoxia on a cellular level. However, it is a technically challenging model and variations in the protocol may result in either too mild or too severe brain injury. In this article, we demonstrate the technical procedures necessary for establishing a stable piglet model of neonatal HIE. First, the newborn piglet (< 24 hr old, median weight 1500 g) is anesthetized, intubated, and monitored in a setup comparable to that found in a neonatal intensive care unit. Global hypoxia-ischemia is induced by lowering the inspiratory oxygen fraction to achieve global hypoxia, ischemia through hypotension and a flat trace amplitude integrated EEG (aEEG) indicative of cerebral hypoxia. Survival is promoted by adjusting oxygenation according to the aEEG response and blood pressure. Brain injury is quantified by histopathology and magnetic resonance imaging after 72 hr.


title: Effects of totally extraperitoneal and lichtenstein hernia repair on men's sexual function and quality of life.

text: BACKGROUND In the literature, there have been scant studies that compare the effects of totally extraperitoneal (TEP) and Lichtenstein hernia (LH) repairs on men's sexual function and quality of life. Our aim in this study was to study the sexual function of men after TEP and LH repair according to SF 36 (Health Survey Scoring Demonstration) and IIEF (The International Index of Erectile Function). METHODS A total of 176 men with unilateral inguinal hernia were randomized into two groups. Group T (n = 88) received TEP hernia repair, and Group L (n:88) received LH repair. Patients' demographics and perioperative findings were recorded. For all patients, the preoperative as well as postoperative 7th, 30th and 90th day SF 36 and IIEF were recorded. RESULTS A total of 176 operations consisting of 88 TEP and 88 LH repairs were evaluated. There were no differences in demographics, hernia type, and complications except for body mass index (BMI). The operative time was higher in Group T (29.6 ± 5.8 vs. 43.5 ± 5.7 min; p = 0.001). The averages of the SF 36-Vitality and Social Function for Postoperative (PO) 30th day scores were higher in Group T. The averages of the SF 36-Bodily Pain, General Health, Physical Role, Emotional Role for PO 7-30th days SF36- Mental Health for PO 7th day and SF 36 Physical Function for PO 30-90th days scores were statistically higher in Group T. The averages of the IIEF- Erectile Function for PO 30th day, IIEF- Orgasmic Function, Sexual Desire, Intercourse Satisfaction, and Intercourse Satisfaction for PO 7th and 30th days scores were higher in Group T. CONCLUSIONS TEP and LH repairs have similar results for recurrence, complications, and hospital stay; otherwise, TEP repair yields better results than the LH repair in the postoperative course at the 7th and 30th day evaluation, concerning sexual function and quality of life, but this benefit is no longer apparent at the 90th day. Although the short-term differences were statistically significant, they were moderate and might have a limited impact from the clinical point of view.


title: Atopic eczema and major cardiovascular outcomes: A systematic review and meta-analysis of population-based studies.

text: BACKGROUND Atopic eczema is a common inflammatory skin disease. Various inflammatory conditions have been linked to cardiovascular disease, a major cause of global mortality and morbidity. OBJECTIVE We sought to systematically review and meta-analyze population-based studies assessing associations between atopic eczema and specific cardiovascular outcomes. METHODS MEDLINE, Embase, and Global Health were searched from inception to December 2017. We obtained pooled estimates using random-effects meta-analyses. We used a multivariate Bayesian meta-regression model to estimate the slope of effect of increasing atopic eczema severity on cardiovascular outcomes. RESULTS Nineteen relevant studies were included. The effects of atopic eczema reported in cross-sectional studies were heterogeneous, with no evidence for pooled associations with angina, myocardial infarction, heart failure, or stroke. In cohort studies atopic eczema was associated with increased risk of myocardial infarction (n = 4; relative risk [RR], 1.12; 95% CI, 1.00-1.25), stroke (n = 4; RR, 1.10; 95% CI, 1.03-1.17), ischemic stroke n = 4; RR, 1.17; 95% CI, 1.14-1.20), angina (n = 2; RR, 1.18; 95% CI, 1.13-1.24), and heart failure (n = 2; RR, 1.26; 95% CI, 1.05-1.51). Prediction intervals were wide for myocardial infarction and stroke. The risk of cardiovascular outcomes appeared to increase with increasing severity (mean RR increase between severity categories, 1.15; 95% credibility interval, 1.09-1.21; uncertainty interval, 1.04-1.28). CONCLUSION Significant associations with cardiovascular outcomes were more common in cohort studies but with considerable between-study heterogeneity. Increasing atopic eczema severity was associated with increased risk of cardiovascular outcomes. Improved awareness among stakeholders regarding this small but significant association is warranted.


title: Heritable thrombophilia-hypofibrinolysis and osteonecrosis of the femoral head.

text: We hypothesized that inherited thrombophilia and hypofibrinolysis were risk factors for osteonecrosis of the femoral head. We compared measures of thrombophilia and hypofibrinolysis in referred new adult patients with idiopathic osteonecrosis (n = 71) or secondary osteonecrosis (n = 62) with the same measures in sex- and race-matched healthy control subjects. Heritable thrombophilic Factor VIII and hypofibrinolytic Lp(a) were more frequently high in the 71 patients with idiopathic osteonecrosis than in control subjects. High Factor VIII, Factor V Leiden heterozygosity, and resistance to activated protein C, all heritable thrombophilias, were more frequently present in the 62 patients with secondary osteonecrosis than in control subjects. Our data suggest inherited thrombophilia and hypofibrinolysis are risk factors for both idiopathic and secondary osteonecrosis of the head of the femur.