title: Improvements in Patient Monitoring for the Intensive Care Unit: Survey Study.

text: BACKGROUND Due to demographic change and, more recently, the Coronavirus Disease 2019 (COVID-19), the importance of modern intensive care units (ICU) is becoming apparent. One of the key components of an ICU is the continuous monitoring of patients' vital parameters. However, existing advances in informatics, signal processing, or engineering that could alleviate the burden on ICUs have not yet been applied. This could be related to the lack of user involvement in research and development. OBJECTIVE This study focused on satisfaction of ICU staff with the current patient monitoring and their suggestions for future improvements. We aimed to identify aspects disturbing patient care, display devices for remote monitoring, use cases for artificial intelligence (AI), and whether ICU staff is willing to improve their digital literacy or contribute to the improvement of patient monitoring. We further desired to uncover differences in the responses of the professional groups. METHODS This survey study was realized with ICU staff from four ICUs of a German university hospital between November 2019 and January 2020. We developed a web-based 36-item survey questionnaire by analyzing a preceding qualitative interview study with ICU staff about clinical requirements of future patient monitoring. Statistical analyses of questionnaire results included median values with their bootstrapped 95% confidence intervals, and Chi-square tests to compare the distributions of item responses of the professional groups. RESULTS Eighty-six of the 270 ICU physicians and nurses completed the survey questionnaire. The majority stated to feel confident using the patient monitoring, but high rates of false positive alarms and the many sensor cables were considered to disturb patient care. Wireless sensors, reduction of false positive alarms and hospital standard operating procedures (SOP) for alarm management were demanded. Responses to the display devices proposed for remote patient monitoring were split. Regarding its use, most respondents indicated responsibility for multiple wards or earlier alerting. AI for ICUs would be useful for early detection of complications and increased risk of mortality, as well as to have guidelines for therapy and diagnostics proposed. Transparency, interoperability, usability, and staff training were essential to promote usage of an AI. The majority wanted to learn more about new technologies for ICU and desired more time for it. Physicians had fewer reservations than nurses about using mobile phones for remote monitoring, and AI-based intelligent alarm management. CONCLUSIONS This survey study among ICU staff revealed key improvements for patient monitoring in intensive care medicine. Hospital providers and medical device manufacturers should focus on reducing false alarms, implementing hospital alarm SOPs, introducing wireless sensors, preparing for the use of AI, and enhancing digital literacy of ICU staff. Our results may contribute to the user-centered transfer of digital technologies into practice to alleviate challenges in intensive care medicine. CLINICALTRIAL ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT03514173.


title: What settings have been linked to SARS-CoV-2 transmission clusters?

text: Background: Concern about the health impact of novel coronavirus SARS-CoV-2 has resulted in widespread enforced reductions in people's movement ("lockdowns"). However, there are increasing concerns about the severe economic and wider societal consequences of these measures. Some countries have begun to lift some of the rules on physical distancing in a stepwise manner, with differences in what these "exit strategies" entail and their timeframes. The aim of this work was to inform such exit strategies by exploring the types of indoor and outdoor settings where transmission of SARS-CoV-2 has been reported to occur and result in clusters of cases. Identifying potential settings that result in transmission clusters allows these to be kept under close surveillance and/or to remain closed as part of strategies that aim to avoid a resurgence in transmission following the lifting of lockdown measures. Methods: We performed a systematic review of available literature and media reports to find settings reported in peer reviewed articles and media with these characteristics. These sources are curated and made available in an editable online database. Results: We found many examples of SARS-CoV-2 clusters linked to a wide range of mostly indoor settings. Few reports came from schools, many from households, and an increasing number were reported in hospitals and elderly care settings across Europe. Conclusions: We identified possible places that are linked to clusters of COVID-19 cases and could be closely monitored and/or remain closed in the first instance following the progressive removal of lockdown restrictions. However, in part due to the limits in surveillance capacities in many settings, the gathering of information such as cluster sizes and attack rates is limited in several ways: inherent recall bias, biased media reporting and missing data.


Dozens of coronavirus drugs are in development - what happens next?


title: Metaphoric language and the articulation of emotions by people affected by motor neurone disease.

text: OBJECTIVE To explore the use of metaphoric language to convey emotion in interviews with people affected by motor neurone disease, a progressive neurological condition that sits between chronic and terminal illness. METHODS Secondary analysis of 46 interviews with people affected by motor neurone disease in the United Kingdom (35 individuals with the condition, 11 carers). RESULTS Metaphor and figurative language was used to communicate the intensely emotional experiences of being diagnosed with and living with motor neurone disease. We focus on three pervasive themes that were threaded throughout the interviews: battling and fighting; the self under attack and journeying through a physical and emotional landscape. DISCUSSION This secondary analysis of qualitative research interviews enriches our understanding of the articulation of emotion in motor neurone disease and adds to the literature on metaphor in chronic illness. Of particular interest is how the metaphors used contrasted with other conditions in the relative absence of metaphors of 'fighting' the disease. Furthermore, we analyse the ways in which participants used metaphors to give voice to emotions that are extremely difficult to articulate in 'literal' language, and how, in doing so, they blurred the distinction between 'physical' symptoms and 'emotional' states. Sensitivity to metaphors may help professionals communicate with people affected by motor neurone disease.


The Psychiatry Institute for Medical Students: a decade of success.


title: In vitro performance of prefilled CO2 absorbers with the Zeus®.

text: Low fresh gas flows (FGFs) decrease the use of anesthetic gases, but increase CO2 absorbent usage. CO2 absorbent usage remains poorly quantified. The goal of this study is to determine canister life of 8 commercially available CO2 absorbent prepacks with the Zeus®. Pre-packed CO2 canisters of 8 different brands were tested in vitro: Amsorb Plus, Spherasorb, LoFloSorb, LithoLyme, SpiraLith, SpheraSorb, Drägersorb 800+, Drägersorb Free, and CO2ntrol. CO2 (160 mL min- 1) flowed into the tip of a 2 L breathing bag that was ventilated with a tidal volume of 500 mL, a respiratory rate of 10/min, and an I:E ratio of 1:1 using the controlled mechanical ventilation mode of the Zeus® (Dräger, Lubeck, Germany). In part I, canister life of 5 canisters each of 2 different lots of each brand was determined with a 350 mL min- 1 FGF. Canister life is the time it takes for the inspired CO2 concentration (FICO2) to rise to 0.5%. In part II, canister life was measured accross a FGF range of 0.25 to 4 L min- 1 for Drägersorb 800+ (2 lots) and SpiraLith (1 lot). In part III, the calculated canister life per 100 g fresh granule content of the different brands was compared between the Zeus and (previously published data for) the Aisys. In vitro canister life of prefilled CO2 absorber canisters differed between brands, and depended on the amount of CO2 absorbent and chemical composition. Canister life expressed as FCU0.5 (the fraction of the canister used per hour) was proportional to FGF over 0.2-2 L min-1 range only, but was non-linear with higher FGF: FCU0.5 was larger than expected with FGF > 2 L min-1, and even with FGF > minute ventilation FCU0.5 did not become zero, indicating some CO2 was being absorbed. Canister life on a per weight basis of the same brand is higher with the Zeus than the Aisys. Canister life of prefilled CO2 absorber canisters differs between brands. The FCU0.5-FGF relationship is not linear across the entire FGF range. Canister life of prepacks of the same brand for the Zeus and Aisys differs, the exact etiology of which is probably multifactorial, and may include differences in the absolute amount of absorbent and different rebreathing characteristics of the machines.


title: Diagnosis of a naturally occurring dual infection of layer chickens with fowlpox virus and gallid herpesvirus 1 (infectious laryngotracheitis virus).

text: An outbreak of acute respiratory disease in layers was diagnosed as being of dual nature due to fowlpox and infectious laryngotracheitis using a multidisciplinary approach including virus isolation, histopathology, electron microscopy and polymerase chain reaction (PCR). The diagnosis was based on virus isolation of gallid herpesvirus 1 (GaHV-1) in chicken kidney cells and fowlpox virus (FWPV) in 9-day-old chicken embryonated eggs inoculated via the chorioallantoic membrane. The histopathology of tracheas from dead birds revealed intra-cytoplasmic and intra-nuclear inclusions suggestive of poxvirus and herpesvirus involvement. The presence of FWPV was further confirmed by electron microscopy, PCR and histology. All FWPV isolates contained the long terminal repeats of reticuloendotheliosis virus as demonstrated by PCR. GaHV-1 isolates were detected by PCR and were shown to have a different restriction fragment length polymorphism pattern when compared with the chicken embryo origin SA2 vaccine strain; however, they shared the same pattern with the Intervet chicken embryo origin vaccine strain. This is a first report of dual infection of chickens with GaHV-1 and naturally occurring FWPV with reticuloendotheliosis virus insertions. Further characterization of the viruses was carried out and the results are reported here.


title: Systematic mapping of existing tools to appraise methodological strengths and limitations of qualitative research: first stage in the development of the CAMELOT tool.

text: BACKGROUND Qualitative evidence synthesis is increasingly used alongside reviews of effectiveness to inform guidelines and other decisions. To support this use, the GRADE-CERQual approach was developed to assess and communicate the confidence we have in findings from reviews of qualitative research. One component of this approach requires an appraisal of the methodological limitations of studies contributing data to a review finding. Diverse critical appraisal tools for qualitative research are currently being used. However, it is unclear which tool is most appropriate for informing a GRADE-CERQual assessment of confidence. METHODOLOGY We searched for tools that were explicitly intended for critically appraising the methodological quality of qualitative research. We searched the reference lists of existing methodological reviews for critical appraisal tools, and also conducted a systematic search in June 2016 for tools published in health science and social science databases. Two reviewers screened identified titles and abstracts, and then screened the full text of potentially relevant articles. One reviewer extracted data from each article and a second reviewer checked the extraction. We used a best-fit framework synthesis approach to code checklist criteria from each identified tool and to organise these into themes. RESULTS We identified 102 critical appraisal tools: 71 tools had previously been included in methodological reviews, and 31 tools were identified from our systematic search. Almost half of the tools were published after 2010. Few authors described how their tool was developed, or why a new tool was needed. After coding all criteria, we developed a framework that included 22 themes. None of the tools included all 22 themes. Some themes were included in up to 95 of the tools. CONCLUSION It is problematic that researchers continue to develop new tools without adequately examining the many tools that already exist. Furthermore, the plethora of tools, old and new, indicates a lack of consensus regarding the best tool to use, and an absence of empirical evidence about the most important criteria for assessing the methodological limitations of qualitative research, including in the context of use with GRADE-CERQual.


Pediatric Hospital Medicine Management, Staffing, and Well-being in the Face of COVID-19.


title: Laparoscopic resection of large gastric gastrointestinal stromal tumours.

text: INTRODUCTION Gastrointestinal stromal tumours (GISTs) are a rare class of neoplasms that are seen most commonly in the stomach. Due to their malignant potential, surgical resection is the recommended method for management of these tumours. Many reports have described the ability to excise small and medium sized GISTs laparoscopically, but laparoscopic resection of GISTs greater than 5 cm is still a matter of debate. AIM To investigate the feasibility and effectiveness of laparoscopic surgical techniques for management of large gastric GISTs greater than 4 cm and to detail characteristics of this type of tumour. MATERIAL AND METHODS The study cohort consisted of 11 patients with suspected gastric GISTs who were treated from 2011 to April 2014 in a single institution. All patients underwent laparoscopic resection of a gastric GIST. RESULTS Eleven patients underwent laparoscopic resection of a suspected gastric GIST between April 2011 and April 2014. The cohort consisted of 6 males and 5 females. Mean age was 67 years (range: 43-92 years). Sixty-four percent of these patients presented with symptomatic tumours. Four (36.4%) patients underwent laparoscopic transgastric resection (LTR), 3 (27.3%) laparoscopic sleeve gastrectomy (LSG), 3 (27.3%) laparoscopic wedge resection (LWR) and 1 (9%) laparoscopic distal gastrectomy (LDG). The mean operative time was 215 min. The mean tumour size was 6 cm (range: 4-9 cm). The mean tumour size for LTR was 5.5 cm (range: 4-6.3 cm), for LWR 5.3 cm (range: 4.5-7 cm), for LSG 6.5 cm (range: 4-9 cm) and for LDG 9 cm. We experienced only minor postoperative complications. CONCLUSIONS Laparoscopic procedures can be successfully performed during management of large gastric GISTs, bigger than 4 cm, and should be considered for all non-metastatic cases. The appropriate approach can be determined by assessing the anatomical location of each tumour.


title: Pain treatment in arthritis-related pain: beyond NSAIDs.

text: Managing pain from chronic conditions, such as, but not limited to, osteoarthritis and rheumatoid arthritis, requires the clinician to balance the need for effective analgesia against safety risks associated with analgesic agents. Osteoarthritis and rheumatoid arthritis pain is incompletely understood but involves both nociceptive and non-nociceptive mechanisms, including neuropathic mechanisms. Prevailing guidelines for arthritis-related pain do not differentiate between nociceptive and non-nociceptive pain, sometimes leading to recommendations that do not fully address the nature of pain. NSAIDs are effective in treating the nociceptive arthritis-related pain. However, safety concerns of NSAIDs may cause clinicians to undertreat arthritis-related pain. In this context, combination therapy may be more appropriate to manage the different pain mechanisms involved. A panel convened in November 2010 found that among the currently recommended analgesic products for arthritis-related pain, fixed-low-dose combination products hold promise for pain control because such products allow lower doses of individual agents resulting in decreased toxicity and acceptable efficacy due to synergy between the individual drugs. Better evidence and recommendations are required to improve treatment of chronic arthritis-related pain.


GI symptoms and fever increase the risk of severe illness and death in patients with COVID-19.


title: Behind the (Virtual) Mirror: Online Live Supervision in Couple and Family Therapy.

text: Online therapy and supervision, a rapidly rising practice in couple and family therapy, has been the subject of a growing body of literature. From its early days, family therapy training has included live supervision, which has typically been conducted by a supervisor and a team of trainees situated on the other side of a one-way mirror. To the best of our knowledge, the literature has yet to address online live supervision including a family, a therapist, a supervisor, and a team all online. With the outbreak of the COVID-19 global pandemic, we - the staff of supervisors at the Barcai Institute in Tel Aviv, Israel - were compelled to find solutions to continue meeting with clients and to provide supervision for family therapy trainees. To this end, we have shifted our live supervision courses ("practicums") to the virtual arena, adapting the popular application "Zoom" into what we call "PractiZoom." Based on over 100 PractiZoom sessions conducted between March and May 2020, involving 14 supervisors and 28 therapists-in-training and their clients, the article reflects on this pioneering on-line practicum for the online live supervision of therapists with geographically-distributed participants. In this article, we outline our operational methods and adaptations for conducting live behind-the-mirror supervision online. Following a short theoretical background, we outline the process of online live supervision, discuss our reflections and those of our trainees on the challenges and possibilities it poses, and offer a number of preliminary conclusions and recommendations.


title: Global socio-economic losses and environmental gains from the Coronavirus pandemic.

text: On 3 April 2020, the Director-General of the WHO stated: "[COVID-19] is much more than a health crisis. We are all aware of the profound social and economic consequences of the pandemic (WHO, 2020)". Such consequences are the result of counter-measures such as lockdowns, and world-wide reductions in production and consumption, amplified by cascading impacts through international supply chains. Using a global multi-regional macro-economic model, we capture direct and indirect spill-over effects in terms of social and economic losses, as well as environmental effects of the pandemic. Based on information as of May 2020, we show that global consumption losses amount to 3.8$tr, triggering significant job (147 million full-time equivalent) and income (2.1$tr) losses. Global atmospheric emissions are reduced by 2.5Gt of greenhouse gases, 0.6Mt of PM2.5, and 5.1Mt of SO2 and NOx. While Asia, Europe and the USA have been the most directly impacted regions, and transport and tourism the immediately hit sectors, the indirect effects transmitted along international supply chains are being felt across the entire world economy. These ripple effects highlight the intrinsic link between socio-economic and environmental dimensions, and emphasise the challenge of addressing unsustainable global patterns. How humanity reacts to this crisis will define the post-pandemic world.


title: Distal pancreatectomy and splenectomy: a robotic or LESS approach.

text: INTRODUCTION The role and application of robotic surgery are debated, particularly given the expansion of laparoscopy, especially laparoendoscopic single-site (LESS) surgery. This cohort study was undertaken to delineate differences in outcomes between LESS and robotic distal pancreatectomy and splenectomy. METHODS With Institutional Review Board approval, patients undergoing LESS or robotic distal pancreatectomy and splenectomy from September 1, 2012, through December 31, 2014, were prospectively observed, and data were collected. The results are expressed as the median, with the mean ± SD. RESULTS Thirty-four patients underwent a minimally invasive distal pancreatectomy and splenectomy: 18 with robotic and 16 with LESS surgery. The patients were similar in sex, age, and body mass index. Conversions to open surgery and estimated blood loss were similar. There were two intraoperative complications in the group that underwent the robotic approach. Time spent in the operating room was significantly longer with the robot (297 vs 254 minutes, P = .03), although operative duration (i.e., incision to closure) was not longer (225 vs 190 minutes; P = .15). Of the operations studied, 79% were undertaken for neoplastic processes. Tumor size was 3.5 cm for both approaches; R0 resections were achieved in all patients. Length of stay was similar in the two study groups (5 vs 4 days). There was one 30-day readmission after robotic surgery. CONCLUSIONS Patient outcomes are similar with LESS or robotic distal pancreatectomy and splenectomy. Robotic operations require more time in the operating room. Both are safe and efficacious minimally invasive operations that follow similar oncologic principles for similar tumors, and both should be in the surgeon's armamentarium for distal pancreatectomy and splenectomy.


Covid-19: We need to be open about rationing ventilators.


title: Head-of-bed elevation and early outcomes of gastric reflux, aspiration and pressure ulcers: a feasibility study.

text: BACKGROUND Guidelines recommending head of bed (HOB) elevation greater than 30º to prevent ventilator-associated pneumonia conflict with guidelines to prevent pressure ulcers, which recommend HOB elevation less than 30º. OBJECTIVES To examine the feasibility of 45º HOB elevation and describe and compare the occurrence of reflux, aspiration, and pressure ulcer development at 30º and 45º HOB elevation. METHODS A randomized 2-day crossover trial was conducted. HOB angle was measured every 30 seconds. Oral and tracheal secretions were analyzed for pepsin presence. Skin was assessed for pressure ulcers. Wilcoxon signed rank tests and Kendall τ correlations were conducted. RESULTS Fifteen patients were enrolled; 11 completed both days. Patients were maintained at 30º (mean, 30º) for 96% of minutes and at 45º (mean, 39º) for 77% of minutes. No patients showed signs of pressure ulcers. A total of 188 oral secretions were obtained, 82 (44%) were pepsin-positive; 174 tracheal secretions were obtained, 108 (62%) were pepsin-positive. The median percentage of pepsin-positive oral secretions was not significantly higher (P = .11) at 30º elevation (54%) than at 45º elevation (20%). The median percentage of pepsin-positive tracheal secretions was not significantly higher (P = .37) at 30º elevation (71%) than 45º elevation (67%). Deeper sedation correlated with increased reflux (P = .03). CONCLUSIONS HOB elevation greater than 30º is feasible and preferred to 30º for reducing oral secretion volume, reflux, and aspiration without pressure ulcer development in gastric-fed patients receiving mechanical ventilation. More deeply sedated patients may benefit from higher HOB elevations.


title: Evidence-Based Abdominal Wall Reconstruction: The Maxi-Mini Approach.

text: Complex abdominal wall reconstruction is a high-risk procedure, but it can be performed safely if a systematic approach is followed. In this article, the authors present their evidence-based technique for abdominal wall reconstruction. This approach aims at reducing rates of complications and hernia recurrence, starting with critical patient selection; preoperative patient optimization; adherence to intraoperative principles including preservation of vascular perforators through maintenance of composite tissue with limited undermining; direct supported mesh reinforcement of midline musculofascial reapproximation; use of percutaneous transfascial suture mesh fixation; careful attention to dead space obliteration in any plane; and aggressive soft-tissue resection of marginal, undermined, or tenuous skin and subcutaneous tissue. Postoperative strategies to decrease complications are also used. The authors' surgical technique is described in detail, and pilot data are presented to support the authors' approach.


Stem cell-based treatment of kidney diseases.


docid: fgnrujsf

title: Clinical and Ethical Considerations in Allocation of Ventilators in an Influenza Pandemic or Other Public Health Disaster: A Comparison of the 2007 and 2015 New York State Ventilator Allocation Guidelines.

text: OBJECTIVE During an influenza or COVID-19 pandemic that results in acute respiratory distress, available ventilators will not meet demand. In 2007, the NYS Task Force on Life and the Law and Department of Health released draft Guidelines for ethical allocation of ventilators for adults. In 2015, updated guidelines were released to ensure that: (1) revisions reflect the public's values and (2) the triage protocol is substantiated by evidence-based clinical data. We summarize the development and content of the 2015 Guidelines compared to the 2007 version, emphasizing new/revised aspects of the ethical considerations and clinical protocol. METHODS We compared the 2007 and 2015 guidelines, with particular emphasis on the ethical issues and clinical protocols. RESULTS The 2015 Guidelines retained much of the ethical and clinical framework of the 2007 draft. The triage protocol was revised using evidence-based clinical data. Patients with the highest likelihood of short-term survival with ventilator therapy have priority access. Protocol consists of exclusion criteria, the sequential organ failure assessment (SOFA) score, and periodic clinical assessments. Guidance is provided on secondary triage criteria. Other forms of medical intervention/palliative care and review of triage decisions are discussed. CONCLUSIONS The 2015 Guidelines reflect advances in medicine and societal values and provide an evidenced-based framework to save the most lives. The framework could be adapted in other emergencies, such as the COVID-19 pandemic, that require ventilators.


title: Risk Assessment and Mitigation of the Mycotoxin Content in Medicinal Plants by the Infusion Process.

text: Medicinal plants are often consumed as infusions with boiled water. Scarce information is available in the literature about the migration of mycotoxins into the resulting beverage and/or the effects of the infusion procedure on the final mycotoxin contents. The aim of the present study was to investigate the impact of the infusion process on mycotoxin contents during medicinal plant preparation. For this purpose, the contents of aflatoxins (AFs) [aflatoxin B1 (AFB1), aflatoxin B2 (AFB2), aflatoxin G1 (AFG1), aflatoxin G2 (AFG2)], zearalenone (ZEA), enniatins (ENNs) [enniatin B (ENNB), enniatin B1 (ENNB1), enniatin A (ENNA), enniatin A1 (ENNA1)] and beauvericin (BEA) were analyzed in 224 samples of medicinal plants and in their resulting beverages. The quick, easy, cheap, effective, rugged and safe extraction method (QuEChERS) was applied to the medicinal plants while the dispersive liquid-liquid microextraction procedure (DLLME) was applied to their infusions, and the mycotoxins were determined by liquid chromatography coupled to ion trap tandem mass spectrometry (LC-MS/MS-IT). The results revealed that ZEA, ENNB, ENNB1, AFB2, AFG1 and AFG2 were detected in the beverages with incidences of ≤6% and at concentrations from less than the limit of quantification (LOQ) to 82.2 μg/L. Mycotoxins reduction ranged from 74 to 100% after the infusion process. The risk assessment revealed that the estimated daily intakes (EDIs) obtained for ZEA, ENNB and ENNB1 were far below the tolerable daily intakes (TDIs) established.


title: Size of ruptured intracranial aneurysms: a systematic review and meta-analysis.

text: BACKGROUND There is wide variation in the reported size of ruptured intracranial aneurysms and methods of size estimation. There is widespread belief that small aneurysms < 7 mm do not rupture. Therefore, we performed a systematic review and meta-analysis of the literature to determine the size of ruptured aneurysms according to aneurysm locations and methods of size estimation. METHODS We searched PubMed, Cochrane, CINAHL, and EMBASE databases using a combination of Medical Subject Headings (MeSH) terms. We included articles that reported mean aneurysm size in consecutive series of ruptured intracranial. We excluded studies limited to a specific aneurysm location or type. The random-effects model was used to calculate overall mean size and location-specific mean size. We performed meta-regression to explain observed heterogeneity and variation in reported size. RESULTS The systematic review included 36 studies and 12,609 ruptured intracranial aneurysms. Overall mean aneurysm size was 7.0 mm (95% confidence interval [CI 6.2-7.4]). Pooled mean size varied with location. Overall mean size of 2145 ruptured anterior circulation aneurysms was 6.0 mm (95% CI 5.6-6.4, residual I2 = 86%). Overall mean size of 743 ruptured posterior circulation aneurysms was 6.2 mm (95% CI 5.3-7.0, residual I2 = 93%). Meta-regression identified aneurysm location and definition of size (i.e., maximum dimension vs. aneurysm height) as significant determinants of aneurysm size reported in the studies. CONCLUSIONS The mean size of ruptured aneurysms in most studies was approximately 7 mm. The general wisdom that aneurysms of this size do not rupture is incorrect. Location and size definition were significant determinants of aneurysm size.


title: COVID-19, Australia: Epidemiology Report 19 (Fortnightly reporting period ending 21 June 2020).

text: Notified cases of COVID-19 and associated deaths reported to the National Notifiable Diseases Surveillance System (NNDSS) to 21 June 2020. Confirmed cases in Australia notified up to 7 June 2020: notifications = 7,491; deaths = 102. The incidence of COVID-19 has markedly reduced since a peak in mid-March. A combination of early case identification, physical distancing, public health measures and a reduction in international travel have been effective in slowing the spread of disease in Australia. Of the 215 cases notified between 8 and 21 June, 75% (163 cases) were notified from Victoria. Most of these cases were acquired locally. In contrast, cases notified from other states (NSW, Qld and WA) over this period were mostly overseas-acquired. Of locally-acquired cases in Victoria in this period, 51% were associated with contacts of a confirmed case or in a known outbreak, while 49% were unable to be linked to another case or were under investigation at the time of reporting. There are several clusters across a range of settings, including extended families, hotel quarantine facilities and a retail store, with most cases limited in geographic spread to a number of Local Government Areas around Melbourne. In response, the Victorian Government has re-introduced restrictions for household and outdoor gatherings, has delayed plans to ease other restrictions and has implemented enhanced public health response activities, particularly with regard to testing and contact tracing. A small proportion of overall cases have experienced severe disease, requiring hospitalisation or intensive care, with some fatalities. The crude case fatality rate amongst Australian cases is 1.4%. People who are older and have one or more comorbidities are more likely to experience severe disease. The highest rate of COVID-19 continues to be among people aged 65-79 years. Three-quarters of all cases in this age group have been associated with overseas travel, including several outbreaks linked to cruise ships. The lowest rate of disease is in children under 18 years, a pattern reflected in international reports. Internationally, as of 21 June 2020, the largest numbers of both cases and deaths have been reported in the United States. Of the confirmed cases reported globally, the case fatality rate is approximately 5.3%. Other countries in the Americas region, such as Brazil and Chile, are seeing rapid growth in case numbers. Case numbers in Europe remain relatively steady, while there is significant growth in the South East Asia region, including in India and Bangladesh. Reported cases are increasing in Africa, although the numbers are much smaller. In the Pacific region there are few new cases reported daily.


title: Seroprevalence of Toxoplasma gondii and concurrent Bartonella spp., feline immunodeficiency virus, and feline leukemia virus infections in cats from Grenada, West Indies.

text: Toxoplasma gondii and Bartonella spp. are zoonotic pathogens of cats. Feline immunodeficiency virus (FIV) and feline leukemia virus (FeLv) are related to human immunodeficiency virus, and human leukemia virus, respectively; all of these viruses are immunosuppressive. In the present study, the prevalence of antibodies to T. gondi, Bartonella spp., FIV, as well as FeLv antigen were determined in sera from 75 domestic and 101 feral cats (Felis catus) from the Caribbean island of Grenada, West Indies. Using a modified agglutination test, antibodies to T. gondii were found in 23 (30.6%) of the 75 pet cats with titers of 1:25 in 1, 1:50 in 3, 1:400 in 4, 1:500 in 12, 1:800 in 2, and 1:1,600 in 1, and 28 (27.7%) of 101 feral cats with titers of 1:25 in 4, 1:50 in 7, 1:200 in 4, 1:400 in 1, 1:500 in 3, 1:800 in 2, 1:1,600 in 3, and 1:3,200 in 4. Overall, in both pet and feral cats, the seroprevalence increased with age. Antibodies to Bartonella spp. were found in 38 (50.6%) of the 75 pet cats and 52.4% of 101 feral cats. Antibodies to FIV were found in 6 domestic and 22 feral cats. None of the 176 cats was positive for FeLv antigen. There was no correlation among T. gondii, Bartonella spp., and FIV seropositivity.


title: Low preoperative cerebral oxygen saturation is associated with longer time to extubation during fast-track cardiac anaesthesia.

text: OBJECTIVES Fast-track cardiac anaesthesia programs aiming at early tracheal extubation have not only been linked to a decrease in intensive care unit and hospital length of stay but also to a decrease in morbidity and mortality as well as a containment of rising medical costs. General recommendations for the inclusion criteria concerning fast-track programs are not available. METHODS The present study determined the factors influencing the time to extubation in patients undergoing a newly implemented fast-track protocol. Seventy-nine patients were retrospectively studied. Successful fast track was defined as time to extubation within 75 min after admission to ICU. RESULTS Sixty patients fulfilled the successful fast-track criteria with a mean time to extubation of 43.9 min (range 15-75 min). Nineteen patients needed more than 75 min to be weaned from the respirator with a mean time to extubation of 135 min (range 90-320 min). Analysis of pre- and intraoperative factors revealed that these groups differed only with respect to preoperative cerebral oxygen saturation levels: 67.7 ± 5.2 versus 60.8 ± 7.4%. CONCLUSIONS Cerebral oxygen saturation assessment prior to cardiac surgery is significantly related to time to extubation and may thus be used to stratify candidates in fast-track programs.


Cultural Perspectives and Nurses Reactions on the Corona Pandemic: A Critical View From Denmark.


title: The Role of Biologic Agents in the Non-operative Management of Elbow Ulnar Collateral Ligament Injuries.

text: PURPOSE OF REVIEW Injuries to the elbow ulnar collateral ligament (UCL) are especially common in the overhead throwing athlete. Despite preventative measures, these injuries are occurring at increasing rates in athletes of all levels. UCL reconstruction techniques generally require a prolonged recovery period and introduce the potential for intraoperative complications prompting investigations into more conservative treatment measures based on specific patient and injury characteristics. The purpose of this review is to describe the current literature regarding the use of biologic augmentation in the management of UCL injuries. Specifically, this review will focus on the basic science background and clinical investigations pertaining to biologic augmentation utilizing platelet-rich plasma (PRP) and autologous stem cells. RECENT FINDINGS Despite some evidence supporting the use of PRP therapy in patients with partial UCL tears, there is no current consensus regarding its true efficacy. Similarly, due to a lack of clinical investigations, no consensus exists regarding the utilization of autologous stem cell treatments in the management of UCL injuries. Management of UCL injuries ranges from non-operative treatment with focused physical therapy protocols to operative reconstruction. The use of biologic augmentation in these injuries continues to be investigated in the orthopedic community. Currently, no consensus exists regarding the efficacy of either PRP or autologous stem cells and further research is needed to further define the appropriate role of these treatments in the management of UCL injuries.


title: Percutaneous Computed Tomography-Guided Thermal Ablation of Pulmonary Osteosarcoma Metastases in Children.

text: INTRODUCTION The role of percutaneous thermal ablation as a minimally-invasive treatment has not been evaluated in children under 18 years of age with pulmonary osteosarcoma metastases. METHODS This was a retrospective review of children treated with percutaneous thermal ablation for pulmonary osteosarcoma metastasis after prior surgical metastasectomy and chemotherapy. Selection criteria included number of pulmonary nodules <5 and nodule size smaller than 2 cm. Indications were discussed at multidisciplinary meetings. The goal was to achieve complete remission using percutaneous thermal ablation, thereby avoiding additional thoracotomies. RESULTS A total of 26 pulmonary nodules (mean size 6.7 mm, range 2-16 mm) were successfully treated by percutaneous computed tomography (CT)-guided thermal ablation in 11 children with osteosarcoma between the ages of 7 and 17 years (median 12.5). Patients denied post-procedure pain. Complications were limited to three pneumothoraxes (two minor, one major), and median hospitalization duration was 2.0 days. One patient died of rapidly progressive lumbar metastasis discovered 20 days post-ablation. Of the remaining 10 patients, local control at the ablation site was achieved, with median follow up of 16.7 months (range 4.1-41.8). Five patients remained in complete remission after median follow-up of 37.5 months, and five patients developed new metastases (one osseous, four pulmonary), of which two are in remission after subsequent treatment. CONCLUSION Percutaneous thermal ablation is a safe and effective minimally-invasive curative local treatment alternative for children with oligometastatic pulmonary osteosarcoma in whom surgical intervention is clinically contraindicated or unappealing.


title: Upper airway obstruction in Norwich Terriers: 16 cases.

text: BACKGROUND Norwich Terriers have grown increasingly popular as show animals and pets, and awareness of respiratory problems within the breed is growing. OBJECTIVE To describe components of obstructive upper airway syndrome in a nonbrachycephalic terrier breed. ANIMALS Sixteen Norwich Terriers; 12 with and 4 without clinical signs of respiratory disease. METHODS Prospective case series. Physical and laryngoscopic examinations were performed by 1 investigator in all dogs. Medical and surgical interventions were summarized and results of follow-up examination or owner reports were recorded. RESULTS The study population was comprised of 9 females (6 intact) and 7 males (5 intact). Median age was 3.0 years (range, 0.5-11 years). Of 12 dogs presented for a respiratory complaint, physical examination was normal in 4 dogs. Laryngoscopic examination was abnormal in 11/12 dogs with redundant supra-arytenoid folds, laryngeal collapse, everted laryngeal saccules, and a narrowed laryngeal opening in most. Of 4 dogs lacking clinical signs, all had normal physical examination; however, 3/4 dogs had similar appearance of the larynx to dogs with clinical signs. Response to surgical intervention was minimal to moderate in all dogs. CONCLUSIONS AND CLINICAL IMPORTANCE Norwich Terriers suffer from an upper airway obstructive syndrome that differs from that encountered in brachycephalic breeds. Affected dogs are difficult to identify without laryngoscopic examination because of the lack of clinical signs and abnormalities in physical examination findings, despite severe airway obstruction. Care is warranted when anesthetizing Norwich Terriers because of the small size of the laryngeal opening.


title: In-vitro anti-viral screening and cytotoxicity evaluation of copper-curcumin complex.

text: Multiple therapeutic activities attributed to curcumin deliver a challenge to explore its hidden qualities. Structural features set an opportunity to chelate metal ions and enhance the therapeutics in a specified direction. A metallo-herbal complex (MHco) of curcumin with copper (Cu(2+)) ions was synthesized and characterized by various spectroscopy techniques. It was screened for its antiviral activity and cytotoxicity. Studies revealed that the synthesized compound has good microbicidal activity and would be utilized for the development of vaginal microbicidal gel against viral infections.


title: Simultaneous double hemodialysis for the control of refractory hyperammonemia.

text: INTRODUCTION In adults, hyperammonemia is generally associated with hepatic dysfunction or as a complication of urinary diversions when infected or obstructed. Hyperammonemia has also rarely been reported in association with multiple myeloma. With modest elevations, hyperammonemia often leads to encephalopathy. However, when ammonia reaches extreme levels cerebral edema and herniation may occur leading to coma, seizures, or death. CASE We describe a 72-year-old Caucasian male with a history of end-stage renal disease (ESRD) and multiple myeloma who developed profound encephalopathy and eventual obtundation. He was found to have severe hyperammonemia that was not due to any identified hepatic impairment. His hyperammonemia proved to be refractory to medical therapy with cathartics and antibiotics, prolonged high-flux hemodialysis, and even continuous venovenous hemodialysis (CVVHD). This metabolic derangement as well as encephalopathy was eventually reversed with simultaneous CVVHD and extended daily hemodialysis (EDD). A more durable response was achieved after vincristine and dexamethasone were administered, which allowed the patient to resume his previous intermittent hemodialysis (IHD) schedule. The patient regained his full sensorium and was eventually discharged to home. CONCLUSIONS Simultaneous double hemodialysis may be used as an important adjunct in treating refractory hyperammonemia.


title: Clinical Course of Asymptomatic and Mildly Symptomatic Patients with Coronavirus Disease Admitted to Community Treatment Centers, South Korea.

text: We evaluated the clinical course of asymptomatic and mildly symptomatic patients with laboratory-confirmed coronavirus disease (COVID-19) admitted to community treatment centers (CTCs) for isolation in South Korea. Of 632 patients, 75 (11.9%) had symptoms at admission, 186 (29.4%) were asymptomatic at admission but developed symptoms during their stay, and 371 (58.7%) remained asymptomatic during their entire clinical course. Nineteen (3.0%) patients were transferred to hospitals, but 94.3% (573/613) of the remaining patients were discharged from CTCs upon virologic remission. The mean virologic remission period was 20.1 days (SD + 7.7 days). Nearly 20% of patients remained in the CTCs for 4 weeks after diagnosis. The virologic remission period was longer in symptomatic patients than in asymptomatic patients. In mildly symptomatic patients, the mean duration from symptom onset to virologic remission was 11.7 days (SD + 8.2 days). These data could help in planning for isolation centers and formulating self-isolation guidelines.


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title: Initial Experience Using the 5MAX™ ACE Reperfusion Catheter in Intra-arterial Therapy for Acute Ischemic Stroke.

text: OBJECTIVES The 5MAX ACE is a new large bore aspiration catheter available for vessel recanalization for treatment of acute ischemic stroke (AIS). We report our initial experience with its use. METHODS A retrospective analysis of patients undergoing intra-arterial therapy for AIS using the 5MAX ACE reperfusion catheter at our institution was performed. Patient demographics, clinical characteristics and procedural data were obtained from chart review. Successful recanlization was defined as achievement of Thrombolysis in Cerebral Infarction score (TICI) 2b-3 and time to recanalization was defined as time from groin puncture to achievement of at least TICI 2b recanalization. RESULTS The 5MAX ACE was used in 15 patients from July-October 2013. Direct aspiration was used as the primary technique in 10/15 (67%) patients. Out of these, aspiration alone was sufficient for recanalization in 3 (20%) patients. In the remaining 7 (47%) patients, additional devices were used. In 5/15 (33%) patients, combined aspiration/stentriever thrombectomy using Solitaire™ (3/5 patients) and Penumbra 3D Separator™ (2/5 patients) were used as the primary technique. Successful recanlization (TICI 2b-3) was achieved in 11/15 (73%) patients. Average time from groin puncture to successful recanalization was 46 +/- 30 minutes (range 14-98 minutes). There were no procedural complications. CONCLUSION The 5MAX ACE is a useful recanalization tool, either by direct aspiration or combined stentriever/aspiration. It may be most advantageous with large clots in the internal carotid artery. The potential for effective and faster recanalization using this device alone or in combination may be a good topic for future study.


title: Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture.

text: Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03-0.07), coronal plane malunion (5%, CI: 0.03-0.08), deep (5%, CI: 0.03-0.11) and superficial (6%, CI: 0.03-0.11) infections, and secondary procedures (8%, CI: 0.04-0.18).When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits. Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040.


title: Novel Polydioxanone Multifilament Scaffold Device for Tissue Regeneration.

text: BACKGROUND Facial aging is the result of intrinsic and extrinsic factors that lead to gradual reduction of dermal extracellular components and skin elasticity and wrinkle formation. A novel stent-shaped biodegradable and biocompatible scaffold device braided with absorbable polydioxanone (PDO) multifilaments was recently marketed for tissue suturing and augmentation. OBJECTIVE To explore tissue regeneration profiles following implantation of the stent-shaped hollow scaffold in rats and mini-pigs. MATERIALS AND METHODS The scaffold device was implanted under the panniculus carnosus of rat dorsal skin and in the subcutaneous layer of mini-pig dorsal skin. Tissue samples were harvested and histologically evaluated after 3 days and 1, 2, 4, and 12 weeks for rats and after 1, 2, 4, 8, and 12 weeks for mini-pigs. RESULTS Type III collagen was slowly replaced by Type I collagen in the scaffold. Cells from the surrounding tissue infiltrated the hollow space of the scaffold, which induced de novo tissue regeneration in this space. CONCLUSION The novel stent-shaped scaffold used here may be useful for stimulated tissue remodeling of aged skin, collagen synthesis, and partial restoration of dermal matrix components. The cosmetic purpose of this novel soft tissue augmentation device should be clinically investigated in long-term studies.


How fake news about coronavirus became a second pandemic.


title: Outcomes after Tracheostomy in COVID-19 Patients.

text: OBJECTIVE To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients as well as the risk of transmission to providers through this highly aerosolizing procedure. METHODS A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy following acute respiratory failure secondary to COVID-19. RESULTS Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ± 6.9 days. The most common indication for tracheostomy was ARDS, followed by failure to wean ventilation and post-ECMO decannulation. 30 patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ± 6.9 days (range 2 - 32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients appears safe for both patients and healthcare workers performing the procedure.


title: Cell-type specific expression of constitutively-active Rheb promotes regeneration of bulbospinal respiratory axons following cervical SCI.

text: Damage to respiratory neural circuitry and consequent loss of diaphragm function is a major cause of morbidity and mortality in individuals suffering from traumatic cervical spinal cord injury (SCI). Repair of CNS axons after SCI remains a therapeutic challenge, despite current efforts. SCI disrupts inspiratory signals originating in the rostral ventral respiratory group (rVRG) of the medulla from their phrenic motor neuron (PhMN) targets, resulting in loss of diaphragm function. Using a rat model of cervical hemisection SCI, we aimed to restore rVRG-PhMN-diaphragm circuitry by stimulating regeneration of injured rVRG axons via targeted induction of Rheb (ras homolog enriched in brain), a signaling molecule that regulates neuronal-intrinsic axon growth potential. Following C2 hemisection, we performed intra-rVRG injection of an adeno-associated virus serotype-2 (AAV2) vector that drives expression of a constitutively-active form of Rheb (cRheb). rVRG neuron-specific cRheb expression robustly increased mTOR pathway activity within the transduced rVRG neuron population ipsilateral to the hemisection, as assessed by levels of phosphorylated ribosomal S6 kinase. By co-injecting our novel AAV2-mCherry/WGA anterograde/trans-synaptic axonal tracer into rVRG, we found that cRheb expression promoted regeneration of injured rVRG axons into the lesion site, while we observed no rVRG axon regrowth with AAV2-GFP control. AAV2-cRheb also significantly reduced rVRG axonal dieback within the intact spinal cord rostral to the lesion. However, cRheb expression did not promote any recovery of ipsilateral hemi-diaphragm function, as assessed by inspiratory electromyography (EMG) burst amplitudes. This lack of functional recovery was likely because regrowing rVRG fibers did not extend back into the caudal spinal cord to synaptically reinnervate PhMNs that we retrogradely-labeled with cholera toxin B from the ipsilateral hemi-diaphragm. Our findings demonstrate that enhancing neuronal-intrinsic axon growth capacity can promote regeneration of injured bulbospinal respiratory axons after SCI, but this strategy may need to be combined with other manipulations to achieve reconnection of damaged neural circuitry and ultimately recovery of diaphragm function.


title: Economics of public health programs for underserved populations: a review of economic analysis of the National Breast and Cervical Cancer Early Detection Program.

text: PURPOSE The purpose of this paper is to provide a brief overview of economic analysis methods used in estimating the costs and benefits of public health programs and systematically review the application of these methods to the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS Published literature on economic analyses of the NBCCEDP was systematically reviewed. The Consensus on Health Economic Criteria checklist was used to assess methodological quality of the included studies. RESULTS Methods available for economic analysis of public health programs include program cost, cost-effectiveness, cost-utility, cost-benefit analysis, and budget impact analysis. Of these, program cost analysis, cost-effectiveness analysis, and cost-utility analysis have been applied to the NBCCEDP in previously published literature. CONCLUSION While there have been multiple program cost analyses, there are relatively fewer cost-effectiveness and cost-utility studies and no cost-benefit and budget impact analysis studies to evaluate the NBCCEDP. Addressing these gaps will inform implementation of effective public health programs with equitable resource allocation to all population subgroups.


title: Perceptions of healthcare professionals about the adoption and use of EHR in Gulf Cooperation Council countries: a systematic review.

text: INTRODUCTION Electronic health records (EHRs) can improve the quality and safety of care. However, the adoption and use of the EHR is influenced by several factors, including users' perception. OBJECTIVES To undertake a systematic review of the literature to understand healthcare professionals' perceptions about the adoption and use of EHRs in Gulf Cooperation Council (GCC) countries in order to influence the implementation strategies, training programme and policy development in the GCC region. METHOD A systematic literature search was undertaken on seven online databases to identify articles published between January 2006 and December 2017 examining healthcare professionals' perception towards the adoption and use of EHR in the Gulf context. RESULTS The fourteen articles included in this review identified both positive and negative perceptions of the role of EHR in healthcare. The positive perceptions included EHR benefits, such as improvements to work efficiency, quality of care, communication and access to patient data. Conversely, the negative perceptions were associated with challenges or risks of adopting an EHR, such as disruption of provider-patient communication, privacy and security concerns and high initial costs. The perceptions were influenced by personal factors (eg, age, occupation and computer literacy) and system factors (perceived usefulness and perceived ease of use). CONCLUSION Positive perceptions of EHRs by the healthcare professionals could facilitate the adoption of this technology in the Gulf region, particularly when barriers are addressed early. Negative perceptions may inform change management strategies during adoption and implementation. The perceptions should be further evaluated from a technology acceptance perspective.


title: Considerations for STI Clinics during the COVID-19 pandemic.

text: Coronavirus disease (COVID-19) is responsible for a global pandemic. It is important to balance the need for access to healthcare services, including testing and treatment for sexually transmitted infections (STIs). STI programs must consider how to use limited resources and implement novel approaches to provide continued access to care.


title: Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees.

text: Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions. Objective: Our hypothesis was that over the past decade the rate of procedures performed by Pediatric Critical Care Medicine Fellowship trainees decreased. Methods: Retrospective review at a single institution, tertiary, academic, children's hospital of patients admitted from July 1, 2007-June 30, 2017 to the Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit. A Poisson regression model with a scale adjustment for over-dispersion estimated by the square root of Pearson's Chi-Square/DOF was applied. Results: There has been a statistically significant decrease in the average rate of central venous lines (p = 0.004; -5.72; 95% CI: -9.45, -1.82) and arterial lines (p = 0.02; -7.8; 95% CI: -13.90, -1.25) per Fellow per years in Fellowship over the last 10 years. There was no difference in the rate of intubations per Fellow per years in Fellowship (p = 0.27; 1.86; 95% CI:-1.38, 5.24). Conclusions: There has been a statistically significant decrease in the rate of central venous lines and arterial lines performed by Pediatric Critical Care Medicine Fellowship trainees per number of years in Fellowship over the last 10 years. Educators need to be constantly reassessing the clinical landscape in an effort to make sure that trainees are receiving adequate educational experiences as this has the potential for an impact on the education of trainees and the safety of the patients that they care for.


title: Device-Based Therapy for Drug-Resistant Hypertension: An Update.

text: Drug-resistant hypertension (RH) remains a significant and common cardiovascular risk despite the availability of multiple potent antihypertensive medications. Uncontrolled resistant hypertension contributes substantially to excessive cardiovascular and renal morbidity and mortality. Clinical and experimental evidence suggest that sympathetic nervous system over-activity is the main culprit for the development and maintenance of drug-resistant hypertension. Both medical and interventional strategies, targeting the sympathetic over-activation, have been designed in patients with hypertension over the past few decades. Minimally invasive, catheter-based, renal sympathetic denervation (RDN) and carotid baroreceptor activation therapy (BAT) have been extensively evaluated in patients with RH in clinical trials. Current trial outcomes, though at times impressive, have been mostly uncontrolled trials in need of validation. Device-based therapy for drug-resistant hypertension has the potential to provide alternative treatment options to certain groups of patients who are refractory or intolerant to current antihypertensive medications. However, more research is needed to prove its efficacy in both animal models and in humans. In this article, we will review the evidence from recent renal denervation, carotid baroreceptor stimulation therapy, and newly emerged central arteriovenous anastomosis trials to pinpoint the weak links, and speculate on potential alternative approaches.


title: Single-cell-level screening method for migratory cancer cells and its potential feasibility in high-throughput manner.

text: High-throughput screening (HTS) is a well-established approach for tumor-specific drug development because of its high efficiency and customizable selection of antineoplastic drugs. However, there is still a lack of an appropriate cell-based HTS specific for migratory cancer cells. In the study presented here, we created a novel assay (mHTS): a single-cell-level screening method targeting migratory cancer cells and can be applied in a high-throughput manner. This mHTS platform is based on microchannel devices (providing physical confinement during cell migration and limit migrating cells' proliferation rate) assembled 96-well plate (fitting to HTS manner). To determine the feasibility of this assay, we quantified the anti-migratory and anti-viability effects of several molecules (Cytochalasin D, Doxorubicin and AZD-6244) on migrating (creeping inside microchannel) glioblastoma multiforme (GBM) cells. After analyzing migration screening data that was collected on a single-cell-level, we were able to compare those drug's effects on cancer cells' migration velocity and uncovered the migration inhibiting potential of AZD (500nM and 1000nM). Viability data based on single-cell-level screening also allowed us to further understand the same drug's different lethality toward migrating and normal 2D cultured cancer cells. The Pre-classification of subpopulations enables us to study the heterogeneity of cancer and ensures our method's feasibility for a high-throughput manner. All these results proved our mHTS platform is suitable for single-cell-level anti-migration drug screening and has potential feasibility in promoting the development of anti-migratory-cancer-drug in a high-throughput manner.


title: Image-guided microwave thermoablation of hepatic tumours using novel robotic guidance: an early experience.

text: OBJECTIVE To evaluate and compare novel robotic guidance and manual approaches based on procedural accuracy, procedural time, procedural performance, image quality as well as patient dose during image-guided microwave thermoablation. METHOD The study was prospectively performed between June 2013 and December 2013 using 70 patients. Forty randomly selected patients (group 1) were treated with manual guidance and 30 patients (group 2) were treated using a novel robotic guidance. Parameters evaluated were procedural accuracy, total procedural time, procedural performance, quantitative/qualitative image quality and patient dose. Two-sided Student's t test and Wilcoxon rank-sum test were used to test the significance of the data and p values less than 0.05 were considered statistically significant. RESULT Accuracy parameters were significantly higher in group 2 (all p < 0.05). Total procedural time showed a mean time difference of 3 min (group 2 > group 1; p = 0.0008). Volume CT dose index and dose-length product were significantly lower for group 2 compared to group 1 (all p < 0.05) for CT fluoroscopy imaging. Total procedural performance score was higher for group 2 compared to group 1 (p = 0.0001). Image quality parameters were insignificant between examined groups. CONCLUSION The novel robotic guided approach improved the accuracy of targeting the target tumour, reduced patient dose and increased procedural performance (which influences the procedural safety) during ablation. KEY POINTS • Few reports are available in the literature regarding robotic-assisted liver microwave ablation. • The robotic guided approach improved accuracy of localizing the target tumour. • Radiation dose on patients was reduced with the robotic guidance. • Numbers of insertions and readjustments were reduced, lowering chances of complications.


title: Ilio-Iliac Arteriovenous Fistulae-An Unusual Diagnosis with an Even More Unusual Clinical Presentation.

text: BACKGROUND Major pelvic ilio-iliac arteriovenous fistula (AVF) is an exceedingly rare diagnosis with only a few described cases in the literature, most of them related to congenital defects or trauma. In this case report, we aim to present a case of an ilio-iliac AVF with an atypical clinical presentation. METHODS Relevant medical data were collected from hospital database. RESULTS The patient is a 77-year-old woman, with a relevant medical history of a temporally remote hysterectomy. She developed an exuberant unilateral right leg edema and was diagnosed with a femoro-iliac deep vein thrombosis (DVT) and started on anticoagulation and daily use of elastic compression stockings. No improvement in leg edema was evident, and she reported painful complaints refractory to medication. She also progressively developed right foot numbness and foot drop. A computed tomography angiography (CTA) was performed to exclude any compressive or paraneoplastic syndrome, with no remarkable findings other than common iliac vein (CIV) occlusion. As the patient's symptoms continued to worsen, a new CTA was performed 5 months later, which revealed an ilio-iliac AVF that was confirmed by angiography. After 2 ineffective attempts to embolize AVF afferents, we chose to completely embolize the arterial component of the AVF with Helix EV3 coils and Onyx glue (Covidien, Irvine, CA, USA). CIV recanalization and deployment of a Venovo stent (Bard Inc, Tempe, AZ, USA) was also performed. The final angiograms showed exclusion of the AVF and rapid venous flow through the stent. There was progressive improvement of edema and pain but little improvement of foot drop. CONCLUSION AVF etiology and mechanism of neurologic deficits are controversial, with multiple possible explanations. Endovascular treatment modalities are promising a safer and more efficient approach when compared with open surgery. Our experience in this case was encouraging, but long-term results are currently lacking.


title: Reconstruction of the gastric passage by a side-to-side gastrogastrostomy after failed vertical-banded gastroplasty: a case report.

text: INTRODUCTION Vertical-banded gastroplasty, a technique that is commonly performed in the treatment of morbid obesity, represents a nonadjustable restrictive procedure which reduces the volume of the upper stomach by a vertical stapler line. In addition, a textile or silicone band restricts food passage through the stomach. CASE PRESENTATION A 71-year-old woman presented with a severe gastric stenosis 11 years after vertical gastroplasty. We describe a side-to-side gastrogastrostomy as a safe surgical procedure to restore the physiological gastric passage after failed vertical-banded gastroplasty. CONCLUSION Occasionally, restrictive procedures for morbid obesity cannot be converted into an alternative bariatric procedure to maintain weight control. This report demonstrates that a side-to-side gastrogastrostomy is a feasible and safe procedure.


title: Predicting regression of Barrett's esophagus: results from a retrospective cohort of 1342 patients.

text: INTRODUCTION Barrett's esophagus (BE) is the most predictive risk factor for development of esophageal adenocarcinoma (EAC), a malignancy with the fastest increasing incidence in the US. The aim of this study was to investigate differences in exposures, demographics, and comorbidities between regressing and non-regressing patients. METHODS AND PROCEDURES We retrospectively collected and analyzed data from a cohort of BE patients participating in a single-center study comprised of all patients diagnosed with BE over a 10-year period. We collected information from the patient's electronic medical records regarding demographic data, endoscopic findings, histological findings, exposures, and history of antireflux surgery. RESULTS This study included 1,342 BE patients, 505 (37.6%) of which experienced regression. The regressed group was 52.3% male, while the non-regressing group was 68.3% male (p < 0.001). Mean age was 65.2 ± 12.8 and 62.0 ± 13.1 years for non-regressing and regressing patients, respectively (p < 0.001). No difference was seen in BMI between regressing and non-regressing groups (27.5 ± 5.7 vs. 27.7 ± 5.4, p = 0.52). No difference was seen between groups with respect to PPI use (93.5% non-regressing vs. 94.1% regressed patients, p = 0.70), but regressed patients were more likely to take vitamin D than non-regressing patients (34.1 vs. 42.1%, p = 0.003). Regressed patients had an average segment length of 1.48 cm (±1.58 cm), in contrast to those not regressing (3.58 ± 3.09 cm (p < 0.001)). Interestingly, one patient in the regression group progressed to dysplasia, while 101 of the non-regressing patients progressed to dysplasia/EAC, a result found to be independent of segment length on multivariate analysis (p < 0.001). CONCLUSIONS Currently, several studies have shown risk factors that can predict progression of non-dysplastic BE, but few investigate predictors for regression. Our study reports several factors that can be used to predict patients who will regress from BE and those who likely will not, tools that will be useful in tailoring therapeutic and surveillance strategies.


NK cells join the anti-cancer armory.


title: Clinical evaluation of pneumonia-associated rhabdomyolysis with acute renal failure.

text: This study aims to evaluate the clinical features, diagnosis, and treatment efficacy in patients with pneumonia-associated rhabdomyolysis and acute renal failure. The subjects included six patients who had presented with rhabdomyolysis and acute renal failure due to bacterial or viral pneumonia on admission to our university hospital and the Yokohama Social Insurance Central Hospital between 2004 and 2005. The causative organisms were identified as Legionella pneumophila (N = 1), Staphylococcus epidermidis (N = 2), Staphylococcus aureus (N = 1), and Unknown (N = 2). For anuric or oliguric patients (N = 4), a blood purification therapy was performed, while conservative therapy was administered to those with a normal urine volume (N = 2). The patient suffering from L. pneumophila pneumonia did not survive, while the other patients regained full kidney function. It is important to identify, evaluate, and treat patients with bacterial or viral pneumonia-associated rhabdomyolysis and acute renal failure.


title: Single incision laparoscopic ventral hernia repair.

text: BACKGROUND AND OBJECTIVES Laparoscopic ventral hernia repair (LVH) requires several skin incisions for trocar placement. We have developed a single incision approach to LVH repair. The technique was introduced in clinical practice to any consenting patients who were candidates for a standard multi-port laparoscopic hernia repair. A consecutive series of patients was then followed to evaluate feasibility. METHODS Over an 8-month period, 14 patients (9 females, 5 males) underwent LVH repair by an academic surgeon. One of 2 access methods was used in each patient through a single 1.5-cm to 2-cm skin incision. One technique utilized two 5-mm ports with a temporarily placed 11-mm port for mesh insertion. The second technique utilized the SILS port (Covidien, Norwalk, CT). Standard or roticulating laparoscopic instruments were used with both techniques. RESULTS Range (mean) BMI: 23 to 59 (38), Age: 26 to 73 years (53), DURATION: 37 to 87 minutes (57), Defect size: 1cm to 8cm (2), 3 with Swiss-cheese defect hernias. The procedure was successfully performed in all patients. No conversions to a multiple-port approach or to an open procedure were necessary. There were no mortalities, major complications, or recurrences during the mean follow-up period of 4 weeks. CONCLUSION Single incision ventral hernia repair is technically feasible, effective, and reproducible. The technique is easy to master, and safe for any patient who is a candidate for laparoscopic ventral hernia repair. Further data collection with long-term follow-up will be needed to ensure equivalent outcomes. There will be demand for this approach by patients for cosmetic reasons, and it may serve as a bridge to natural orifice techniques.


title: Protocol for a systematic review and qualitative synthesis of information quality frameworks in eHealth.

text: INTRODUCTION Electronic health (eHealth) applications have become a very large repository of health information which informs critical decisions relating to the diagnosis, treatment and prognosis of patients. Poor information quality (IQ) within eHealth may compromise patient safety. Evaluation of IQ in eHealth is therefore necessary to promote patient safety. An IQ framework specifies what aspects of information to assess and how to conduct the assessment. This systematic review aims to identify dimensions within existing IQ frameworks in eHealth and develop a new IQ framework for the assessment of eHealth. METHOD AND ANALYSIS We will search Embase, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature, Maternity and Infant Care, PsycINFO (American Psychological Association), Global Health, Scopus, ProQuest Dissertations and Theses Global, Health Management Information Consortium and reference lists of relevant publications for articles published in English until November 2018. Studies will be selected by two independent reviewers based on prespecified eligibility criteria. Two reviewers will independently extract data in each eligible study using a prepiloted Microsoft Excel data extraction form. Thematic synthesis will be employed to define IQ dimensions and develop a new IQ framework for eHealth. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review as primary data will not be collected. The result of the review will be disseminated through publication in an academic journal and scientific conferences. PROSPERO REGISTRATION NUMBER CRD42018097142.


title: Ceftriaxone versus ceftriaxone plus a macrolide for community-acquired pneumonia in hospitalized patients with HIV/AIDS: a randomized controlled trial.

text: OBJECTIVES To evaluate if treatment with ceftriaxone and a macrolide, improved patient outcome when compared with monotherapy with ceftriaxone, in hospitalized patients with human immunodeficiency virus/acquired immunodeficient syndrome (HIV/AIDS) with community-acquired pneumonia (CAP). METHODS Adult patients with HIV hospitalized due to suspected CAP were randomized to receive one of two regimens, ceftriaxone plus macrolide or ceftriaxone plus placebo, at a 1:1 proportion (Brazilian Clinical Trials Registry: RBR-8wtq2b). The primary outcome was in-hospital mortality and the secondary outcomes were mortality within 14 days, need for vasoactive drugs, need for mechanical ventilation, time to clinical stability and length of hospitalization. RESULTS A total of 227 patients were randomized, two were excluded after randomization; 225 patients were analysed (112 receiving ceftriaxone plus placebo and 113 receiving ceftriaxone plus macrolide). The frequency of the primary outcome, in-hospital mortality, was not statistically different between the regimens: 12/112 (11%) patients who received ceftriaxone plus placebo and 17/113 (15%) who received ceftriaxone plus macrolide died during hospitalization (hazard ratio 1.22, 95% CI 0.57-2.59). We did not find differences between the regimens for any of the secondary outcomes, including mortality within 14 days, which occurred in 5/112 (4%) patients with ceftriaxone plus placebo and in 12/113 (11%) patients with ceftriaxone plus macrolide (relative risk 2.38, 95% CI 0.87-6.53). CONCLUSIONS Among hospitalized patients with HIV/AIDS with CAP, treatment with ceftriaxone and a macrolide did not improve patient outcomes, when compared with ceftriaxone monotherapy.


title: A survey of the clinicopathological and molecular characteristics of patients with suspected Lynch syndrome in Latin America.

text: BACKGROUND Genetic counselling and testing for Lynch syndrome (LS) have recently been introduced in several Latin America countries. We aimed to characterize the clinical, molecular and mismatch repair (MMR) variants spectrum of patients with suspected LS in Latin America. METHODS Eleven LS hereditary cancer registries and 34 published LS databases were used to identify unrelated families that fulfilled the Amsterdam II (AMSII) criteria and/or the Bethesda guidelines or suggestive of a dominant colorectal (CRC) inheritance syndrome. RESULTS We performed a thorough investigation of 15 countries and identified 6 countries where germline genetic testing for LS is available and 3 countries where tumor testing is used in the LS diagnosis. The spectrum of pathogenic MMR variants included MLH1 up to 54%, MSH2 up to 43%, MSH6 up to 10%, PMS2 up to 3% and EPCAM up to 0.8%. The Latin America MMR spectrum is broad with a total of 220 different variants which 80% were private and 20% were recurrent. Frequent regions included exons 11 of MLH1 (15%), exon 3 and 7 of MSH2 (17 and 15%, respectively), exon 4 of MSH6 (65%), exons 11 and 13 of PMS2 (31% and 23%, respectively). Sixteen international founder variants in MLH1, MSH2 and MSH6 were identified and 41 (19%) variants have not previously been reported, thus representing novel genetic variants in the MMR genes. The AMSII criteria was the most used clinical criteria to identify pathogenic MMR carriers although microsatellite instability, immunohistochemistry and family history are still the primary methods in several countries where no genetic testing for LS is available yet. CONCLUSION The Latin America LS pathogenic MMR variants spectrum included new variants, frequently altered genetic regions and potential founder effects, emphasizing the relevance implementing Lynch syndrome genetic testing and counseling in all of Latin America countries.


title: Economic evaluation of HIV pre-exposure prophylaxis strategies: protocol for a methodological systematic review and quantitative synthesis.

text: BACKGROUND Pre-exposure prophylaxis (PrEP) with antiretrovirals is an efficacious and effective intervention to decrease the risk of HIV (human immunodeficiency virus) acquisition. Yet drug and delivery costs prohibit access in many jurisdictions. In the absence of guidelines for the synthesis of economic evaluations, we developed a protocol for a systematic review of economic evaluation studies for PrEP by drawing on best practices in systematic reviews and the conduct and reporting of economic evaluations. We aim to estimate the incremental cost per health outcome of PrEP compared with placebo, no PrEP, or other HIV prevention strategies; assess the methodological variability in, and quality of, economic evaluations of PrEP; estimate the incremental cost per health outcome of different PrEP implementation strategies; and quantify the potential sources of heterogeneity in outcomes. METHODS We will systematically search electronic databases (MEDLINE, Embase) and the gray literature. We will include economic evaluation studies that assess both costs and health outcomes of PrEP in HIV-uninfected individuals, without restricting language or year of publication. Two reviewers will independently screen studies using predefined inclusion criteria, extract data, and assess methodological quality using the Philips checklist, Second Panel on the Cost-effectiveness of Health and Medicines, and the International Society for Pharmacoeconomics and Outcomes Research recommendations. Outcomes of interest include incremental costs and outcomes in natural units or utilities, cost-effectiveness ratios, and net monetary benefit. We will perform descriptive and quantitative syntheses using sensitivity analyses of outcomes by population subgroups, HIV epidemic settings, study designs, baseline intervention contexts, key parameter inputs and assumptions, type of outcomes, economic perspectives, and willingness to pay values. DISCUSSION Findings will guide future economic evaluation of PrEP strategies in terms of methodological and knowledge gaps, and will inform decisions on the efficient integration of PrEP into public health programs across epidemiologic and health system contexts. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016038440 .


title: A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression.

text: BACKGROUND Ethnic minorities with depression are more likely to seek mental health care through primary care providers (PCPs) than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limited time to address mental health, and limited referral options for mental health care. Patient-specific challenges include stigma around mental health issues and reluctance to seek mental health treatment. To address these issues, we implemented a multi-component intervention for Asian American and Latino American primary care patients with depression at Massachusetts General Hospital (MGH). METHODS/DESIGN We propose a randomized controlled trial to evaluate a culturally appropriate intervention to improve the diagnosis and treatment of depression in our target population. Our goals are to facilitate a) primary care providers' ability to provide appropriate, culturally informed care of depression, and b) patients' knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American and Latino American adult (18 years of age or older) primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturally focused psychiatric (CFP) consultation. Patients will meet with a study clinician and receive toolkits that include psychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation, patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility and cost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFP service. Exploratory aims will describe the study population at screening, recruitment, and enrollment and identify which variables influenced patient participation in the program. DISCUSSION The study involves an innovative yet practical intervention that builds on existing resources and strives to improve quality of care for depression for minorities. Additionally, it complements the current movement in psychiatry to enhance the treatment of depression in primary care settings. If found beneficial, the intervention will serve as a model for care of Asian American and Latino American patients.


title: Avian metapneumovirus infection of chicken and turkey tracheal organ cultures: comparison of virus-host interactions.

text: Avian metapneumovirus (aMPV) is a pathogen with worldwide distribution, which can cause high economic losses in infected poultry. aMPV mainly causes infection of the upper respiratory tract in both chickens and turkeys, although turkeys seem to be more susceptible. Little is known about virus-host interactions at epithelial surfaces after aMPV infection. Tracheal organ cultures (TOC) are a suitable model to investigate virus-host interaction in the respiratory epithelium. Therefore, we investigated virus replication rates and lesion development in chicken and turkey TOC after infection with a virulent aMPV subtype A strain. Aspects of the innate immune response, such as interferon-α and inducible nitric oxide synthase mRNA expression, as well as virus-induced apoptosis were determined. The aMPV-replication rate was higher in turkey (TTOC) compared to chicken TOC (CTOC) (P < 0.05), providing circumstantial evidence that indeed turkeys may be more susceptible. The interferon-α response was down-regulated from 2 to 144 hours post infection in both species compared to virus-free controls (P < 0.05); this was more significant for CTOC than TTOC. Inducible nitric oxide synthase expression was significantly up-regulated in aMPV-A-infected TTOC and CTOC compared to virus-free controls (P < 0.05). However, the results suggest that NO may play a different role in aMPV pathogenesis between turkeys and chickens as indicated by differences in apoptosis rate and lesion development between species. Overall, our study reveals differences in innate immune response regulation and therefore may explain differences in aMPV - A replication rates between infected TTOC and CTOC, which subsequently lead to more severe clinical signs and a higher rate of secondary infections in turkeys.


TMPRSS2 and ACE2 Coexpression in SARS-CoV-2 Salivary Glands Infection.


title: 12-year old adolescent with super morbid obesity, treated with laparoscopic one anastomosis gastric bypass (LOAGB/BAGUA): A case report after 5-year follow-up.

text: The prevalence of morbid obesity among adolescents has being on the increased in the recent decades specifically in developed countries around the world. In Europe, Spain has the highest prevalence of obese adolescents with more than 18% of the population of children and adolescents. There is evidence that the only effective and permanent treatment for morbid obesity and the comorbidities is surgical treatment, however there exists many controversies about which treatment is the best for obese adolescents. We report a case of a 12 year old patient with super obesity (58.5 kg/m(2) of BMI) and metabolic syndrome who underwent LOAGB/BAGUA and monitored during the last 5 year. The patient after five years follow-up maintains a 22.4 kg/m(2) of BMI. We consider that LOAGB/ BAGUA could be an effective and safe procedure as a treatment of obesity and comorbidities as well, for adolescent patients.


title: Overcoming the innate immune response to small interfering RNA.

text: Many types of nucleic acid, including canonical small interfering RNA (siRNA) duplexes, are potent activators of the mammalian innate immune system. Synthetic siRNA duplexes can induce high levels of inflammatory cytokines and type I interferons, in particular interferon-alpha, after systemic administration in mammals and in primary human blood cell cultures. These responses are greatly potentiated by the use of delivery vehicles that facilitate cellular uptake of the siRNA. Although the immunomodulatory effects of nucleic acids may be harnessed therapeutically, for example, in oncology and allergy applications, in many cases immune activation represents a significant undesirable side effect due to the toxicities associated with excessive cytokine release and associated inflammatory syndromes. The potential for siRNA-based drugs to be rendered immunogenic is also a cause for concern because the establishment of an antibody response may severely compromise both safety and efficacy. Clearly, there are significant implications both for the development of siRNA-based drugs and in the interpretation of gene-silencing effects elicited by siRNA. This review provides the background information required to anticipate, manage, and abrogate the immunological effects of siRNA and will assist the reader in the successful in vivo application of siRNA-based drugs.


title: Glucose 6-phosphate dehydrogenase deficient subjects may be better "storers" than donors of red blood cells.

text: Storage of packed red blood cells (RBCs) is associated with progressive accumulation of lesions, mostly triggered by energy and oxidative stresses, which potentially compromise the effectiveness of the transfusion therapy. Concerns arise as to whether glucose 6-phosphate dehydrogenase deficient subjects (G6PD(-)), ~5% of the population in the Mediterranean area, should be accepted as routine donors in the light of the increased oxidative stress their RBCs suffer from. To address this question, we first performed morphology (scanning electron microscopy), physiology and omics (proteomics and metabolomics) analyses on stored RBCs from healthy or G6PD(-) donors. We then used an in vitro model of transfusion to simulate transfusion outcomes involving G6PD(-) donors or recipients, by reconstituting G6PD(-) stored or fresh blood with fresh or stored blood from healthy volunteers, respectively, at body temperature. We found that G6PD(-) cells store well in relation to energy, calcium and morphology related parameters, though at the expenses of a compromised anti-oxidant system. Additional stimuli, mimicking post-transfusion conditions (37°C, reconstitution with fresh healthy blood, incubation with oxidants) promoted hemolysis and oxidative lesions in stored G6PD(-) cells in comparison to controls. On the other hand, stored healthy RBC units showed better oxidative parameters and lower removal signaling when reconstituted with G6PD(-) fresh blood compared to control. Although the measured parameters of stored RBCs from the G6PD deficient donors appeared to be acceptable, the results from the in vitro model of transfusion suggest that G6PD(-) RBCs could be more susceptible to hemolysis and oxidative stresses post-transfusion. On the other hand, their chronic exposure to oxidative stress might make them good recipients, as they better tolerate exposure to oxidatively damaged long stored healthy RBCs.


title: Clinical and Patient-Centered Outcomes in Obese Patients With Type 2 Diabetes 3 Years After Randomization to Roux-en-Y Gastric Bypass Surgery Versus Intensive Lifestyle Management: The SLIMM-T2D Study.

text: OBJECTIVE To compare the effect of Roux-en-Y gastric bypass (RYGB) surgery versus intensive medical diabetes and weight management (IMWM) on clinical and patient-reported outcomes in obese patients with type 2 diabetes. RESEARCH DESIGN AND METHODS We prospectively randomized 38 obese patients with type 2 diabetes (15 male and 23 female, with mean ± SD weight 104 ± 16 kg, BMI 36.3 ± 3.4 kg/m2, age 52 ± 6 years, and HbA1c 8.5 ± 1.3% [69 ± 14 mmol/mol]) to laparoscopic RYGB (n = 19) or IMWM (n = 19). Changes in weight, HbA1c, cardiovascular risk factors (UKPDS risk engine), and self-reported health status (the 36-Item Short-Form [SF-36] survey, Impact of Weight on Quality of Life [IWQOL] instrument, and Problem Areas in Diabetes Survey [PAID]) were assessed. RESULTS After 3 years, the RYGB group had greater weight loss (mean -24.9 kg [95% CI -29.5, -20.4] vs. -5.2 [-10.3, -0.2]; P < 0.001) and lowering of HbA1c (-1.79% [-2.38, -1.20] vs. -0.39% [-1.06, 0.28] [-19.6 mmol/mol {95% CI -26.0, -13.1} vs. -4.3 {-11.6, 3.1}]; P < 0.001) compared with the IMWM group. Changes in cardiometabolic risk for coronary heart disease and stroke were all more favorable in RYGB versus IMWM (P < 0.05 to P < 0.01). IWQOL improved more after RYGB (P < 0.001), primarily due to subscales of physical function, self-esteem, and work performance. SF-36 and PAID scores improved in both groups, with no difference between treatments. A structural equation model demonstrated that improvement in overall quality of life was more strongly associated with weight loss than with improved HbA1c and was manifest by greater improvements in IWQOL than with either SF-36 or PAID. CONCLUSIONS Three years after randomization to RYGB versus IMWM, surgery produced greater weight loss, lower HbA1c, reduced cardiovascular risk, and improvements in obesity-related quality of life in obese patients with type 2 diabetes.


title: Recombinase polymerase amplification as a promising tool in hepatitis C virus diagnosis.

text: Hepatitis C virus (HCV) infection represents a significant health problem and represents a heavy load on some countries like Egypt in which about 20% of the total population are infected. Initial infection is usually asymptomatic and result in chronic hepatitis that give rise to complications including cirrhosis and hepatocellular carcinoma. The management of HCV infection should not only be focus on therapy, but also to screen carrier individuals in order to prevent transmission. In the present, molecular detection and quantification of HCV genome by real time polymerase chain reaction (PCR) represent the gold standard in HCV diagnosis and plays a crucial role in the management of therapeutic regimens. However, real time PCR is a complicated approach and of limited distribution. On the other hand, isothermal DNA amplification techniques have been developed and offer molecular diagnosis of infectious dieses at point-of-care. In this review we discuss recombinase polymerase amplification technique and illustrate its diagnostic value over both PCR and other isothermal amplification techniques.


title: Genetic Dissection of the Host Tropism of Human-Tropic Pathogens.

text: Infectious diseases are the second leading cause of death worldwide. Although the host multitropism of some pathogens has rendered their manipulation possible in animal models, the human-restricted tropism of numerous viruses, bacteria, fungi, and parasites has seriously hampered our understanding of these pathogens. Hence, uncovering the genetic basis underlying the narrow tropism of such pathogens is critical for understanding their mechanisms of infection and pathogenesis. Moreover, such genetic dissection is essential for the generation of permissive animal models that can serve as critical tools for the development of therapeutics or vaccines against challenging human pathogens. In this review, we describe different experimental approaches utilized to uncover the genetic foundation regulating pathogen host tropism as well as their relevance for studying the tropism of several important human pathogens. Finally, we discuss the current and future uses of this knowledge for generating genetically modified animal models permissive for these pathogens.


title: Adnexal Masses Treated Using a Combination of the SILS Port and Noncurved Straight Laparoscopic Instruments: Turkish Experience and Review of the Literature.

text: Objective. To report our experience treating adnexal masses using a combination of the SILS port and straight nonroticulating laparoscopic instruments. Study Design. This prospective feasibility study included 14 women with symptomatic and persistent adnexal masses. Removal of adnexal masses via single-incision laparoscopic surgery using a combination of the SILS port and straight nonroticulating laparoscopic instruments was performed. Results. All of the patients had symptomatic complex adnexal masses. Mean age of the patients was 38.4 years (range: 21-61 years) and mean duration of surgery was 71 min (range: 45-130 min). All surgeries were performed using nonroticulating straight laparoscopic instruments. Mean tumor diameter was 6 cm (range: 5-12 cm). All patient pathology reports were benign. None of the patients converted to laparotomy. All the patients were discharged on postoperative d1. Postoperatively, all the patients were satisfied with their incision and cosmetic results. Conclusion. All 14 patients were successfully treated using standard, straight nonroticulating laparoscopic instruments via the SILS port. This procedure can reduce the cost of treatment, which may eventually lead to more widespread use of the SILS port approach. Furthermore, concomitant surgical procedures are possible using this approach. However, properly designed comparative studies with single port and classic laparoscopic surgery are urgently needed.


Microwave ablation.


SARS-CoV-2 Rates in BCG-Vaccinated and Unvaccinated Young Adults.


title: Identity in lockdown: supporting primary care professional identity development in the COVID-19 generation.

text: The current COVID-19 pandemic has dramatically impacted undergraduate medical studies. Whilst challenges for knowledge and clinical skills are being actively addressed, wider considerations such as the impact on professional identity development have been mostly neglected thus far. A robust professional identity is linked to professional behaviour and has been shown to reduce burnout and be an important factor for general practice career choice amongst medical students. The Communities of Practice Model is a sociocultural approach that conceptualises the formation of professional identity through student engagement within a community. We argue the current suspension of clinical placements holds the potential to negatively influence such identity acquisition. In this commentary we explore how the Communities of Practice Model may inform professional identity development of medical students within the COVID-19 environment, considering digital communities and volunteering roles within primary care. We further encourage educators and institutions to consider professional identity in future planning to address the challenges posed by the current situation, both in terms of placement loss but also changes in the way primary care is delivered. Such considerations will be essential if we are to avoid problems relating to poor medical student professional identity development in future.