title: Trends in Early Morbidity and Mortality after Sleeve Gastrectomy in Patients over 60 Years : Retrospective Review and Data Analysis of the German Bariatric Surgery Registry.

text: BACKGROUND The population are getting older and obesity is growing. Laparoscopic sleeve gastrectomy (LSG) is increasingly used worldwide but is still used with skepticism in the elderly. The purpose of our analysis is to judge the security of LSG in patients older than 60 years compared to patients younger than 60 years. METHODS This retrospective review included data of all patients in Germany who underwent LSG between January 2005 and December 2016.The data were published online in the German Bariatric Surgery Registry. A total of 21,571 operations were gathered and divided into two groups: group I, patients < 60 years old; and group II, patients ≥ 60 years old. RESULTS The total number of patients and the mean body mass index of group I and group II was 19,786, 51.7 ± 9.5 kg/m2 and 1771, 49.2 ± 8.1 kg/m2, respectively. Regarding comorbidities, group II suffered statistically significantly more comorbidities than group I (p < 0.001). The general postoperative complications were 4.9% in group I and 7.8% in group II (p < 0.001). There was no significant difference in special postoperative complications (p = 0.048) and a slightly higher intraoperative complication rate in group II (2.2% vs. 1.6%, p = 0.048). Thirty-day mortality rate for group I versus II was 0.22% and 0.23% (p = 0.977), respectively. CONCLUSIONS LSG is a low-risk operation and safe surgical method with acceptable, not elevated perioperative morbidity and mortality rates in patients ≥ 60 years of age.


title: Tourniquet use in lower limb fracture surgery: a systematic review and meta-analysis.

text: BACKGROUND Tourniquets are commonly used in today's orthopaedic surgical practice, but little evidence is available regarding the links between the use of a tourniquet and the amount of post-operative pain and other complications. The aim of the study was to conduct a systematic review and meta-analysis comparing tourniquet versus non-tourniquet use during fracture surgery of the lower limb in adult patients. METHOD A search was performed using the keyword "tourniquet" in EmBase and as a MeSH term in PubMed, and no limitations (including language) were applied. Available studies were screened using the Covidence software, and demographic as well as outcome data were extracted from the final studies. Critical appraisal was performed according to Cochrane Risk of Bias guidelines. Pooled data were assessed for heterogeneity using Chi-squared and I2 tests. RESULTS Five studies were included, and no statistically significant difference was found in the amount of pain and post-operative complications between tourniquet and non-tourniquet groups. Length of in-hospital stay was longer in the tourniquet groups. An overall high risk of bias was found in the included studies. CONCLUSION Although the validity and statistical strength of our results are not strong enough to suggest a change in practice in tourniquet use, the operating surgeon should still carefully consider his or her decision to use a tourniquet in lower limb fracture surgery, as there are indeed complications associated with it and no current evidence to support its continued use. LEVEL OF EVIDENCE Level I, systematic review of randomized controlled trials.


title: The effect of anterosuperior rotator cuff tears on glenohumeral translation.

text: PURPOSE The purpose of this study was to sequentially investigate the biomechanical effects of anterosuperior rotator cuff tear size on superior and anterosuperior translation, including tears interrupting the anterior cable attachment and the anterior force couple. METHODS Five cadaveric shoulders were subjected to different loading conditions in both the superior and anterosuperior directions in the intact state, with the supraspinatus cut and with sequentially larger anterosuperior rotator cuff tears. RESULTS Isolated tears of the supraspinatus had no significant biomechanical consequences under any condition tested. Anterosuperior translation was greater than superior translation in the intact specimen and for every combination of anterosuperior rotator cuff defect. With the supraspinatus and the superior half of the subscapularis (i.e., the anterior cable attachment) released, there was no significant increase in anterosuperior or superior glenohumeral translation in response to lower loading conditions (10 to 20 N). At higher loading conditions (40 to 50 N), tears of the supraspinatus and superior half of the subscapularis led to significantly increased translation in both directions. CONCLUSIONS Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis significantly alter shoulder biomechanics and lead to increased anterosuperior and superior glenohumeral translation under higher loads. The anterior attachment of the rotator cuff cable is therefore an important determinant of the biomechanics of anterosuperior rotator cuff tears at higher loads but not at lower loads. Preserving the inferior half of the subscapularis was sufficient to maintain relatively normal shoulder kinematics under lower loading conditions. Tears of the entire subscapularis altered glenohumeral kinematics at essentially all loads. CLINICAL RELEVANCE Knowledge of the biomechanics of anterosuperior rotator cuff tears enhances our understanding of how to best treat these lesions.


title: Tissue engineering of acellular vascular grafts capable of somatic growth in young lambs.

text: Treatment of congenital heart defects in children requiring right ventricular outflow tract reconstruction typically involves multiple open-heart surgeries because all existing graft materials have no growth potential. Here we present an 'off-the-shelf' vascular graft grown from donor fibroblasts in a fibrin gel to address this critical unmet need. In a proof-of-concept study, the decellularized grafts are implanted as a pulmonary artery replacement in three young lambs and evaluated to adulthood. Longitudinal ultrasounds document dimensional growth of the grafts. The lambs show normal growth, increasing body weight by 366% and graft diameter and volume by 56% and 216%, respectively. Explanted grafts display physiological strength and stiffness, complete lumen endothelialization and extensive population by mature smooth muscle cells. The grafts also show substantial elastin deposition and a 465% increase in collagen content, without signs of calcification, aneurysm or stenosis. Collectively, our data support somatic growth of this completely biological graft.


docid: cmzwmmhv

title: The evolving role of a gynaecologic oncologist in a tertiary hospital.

text: INTRODUCTION Whilst the prime role of a gynaecologic oncologist is the comprehensive management of women with a gynaecologic cancer, their surgical skills are increasingly utilised for general gynaecological and obstetric surgery. Within tertiary centres, there is increasing provision of support by gynaecologic oncologists for both emergency and complex elective cases. AIM The aim of the study was to investigate and define the expanding role of the gynaecologic oncologist within obstetrics and gynaecology. METHOD A retrospective analysis of all nongynaecological oncology unit cases from 2006 to 2012 which required the presence of a gynaecologic oncologist in the operating theatre. RESULTS A wide variety of cases that required the involvement of a gynaecologic oncologist were identified. These ranged from complications such as bowel injuries and haemorrhage to gynaecological surgeries in complicated patients, and obstetric patients with placenta accreta and intra-operative diagnosis of unexpected malignancy. CONCLUSION The role of the gynaecologic oncologist within a tertiary centre is expanding to include the provision of support to general gynaecologists and obstetricians. There is increasing utilisation of the gynaecologic oncologist whereby their attendance is often pre-arranged prior to the surgery. However, emergency cases requiring their assistance are not uncommon.


title: Update on rhinovirus and coronavirus infections.

text: Rhinoviruses and coronaviruses cause significant morbidity in immunocompetent people of all ages and in patients with underlying chronic medical or immunosuppressed conditions. Newer diagnostic tests, such as polymerase chain reaction (PCR), have expanded our understanding of these respiratory viruses in clinical infections. These sensitive diagnostic tests have been used to describe new members of these virus families, such as human rhinovirus C (HRVC) and human coronavirus NL-63 (HCoV-NL63). The epidemiology of these newly described viruses will help us develop better intervention strategies.


title: Feasibility of liquid nitrogen cryotherapy after failed radiofrequency ablation for Barrett's esophagus.

text: BACKGROUND AND AIM Radiofrequency ablation (RFA) for dysplastic Barrett's esophagus (BE) is highly effective. RFA failures are infrequent but can be a challenging cohort to manage. There are limited data on the feasibility of liquid nitrogen cryospray ablation for complete eradication of dysplasia (CE-D) and/or intestinal metaplasia (CE-IM) after RFA has failed to achieve CE-IM in patients with dysplastic BE. METHODS This is a retrospective review from two medical centers of prospectively maintained databases looking at patients that underwent liquid nitrogen cryospray ablation for refractory intestinal metaplasia post failed RFA. RESULTS Eighteen patients were identified that met inclusion criteria. Eleven patients had persistent dysplasia and IM following RFA and seven had persistent non-dysplastic IM. More than 80% of patients were male with long-segment BE (median length 8 cm). Seventy two percent of patients with dysplasia achieved CE-D after cryotherapy. Fifty percent (9/18) of all RFA failures achieved CE-IM with cryotherapy. In comparison, RFA has a CE-IM of 78% in a less challenging treatment naïve cohort from a large-scale meta-analysis of 3802 patients. No adverse events occurred in our cohort. CONCLUSION Cryospray ablation is feasible and safe for achieving CE-D and CE-IM after RFA failure. The CE-D rates are high with cryotherapy in this population. CE-IM with cryotherapy is acceptable in this difficult-to-treat cohort when compared to CE-IM rates with RFA in dysplastic BE treatment naïve patients (50% vs 78%).


Covid-19: Why Germany's case fatality rate seems so low.


Middle East Respiratory Syndrome Coronavirus and Children.


title: Endoscopic pyloromyotomy: a new concept of minimally invasive surgery for pyloric stenosis.

text: BACKGROUND AND STUDY AIMS Pyloric stenosis is currently managed using open or laparoscopic pyloromyotomy. However, with recent improvements in flexible endoscopic instrumentation and techniques, totally peroral endoscopic approaches could reduce the invasiveness of myotomic procedures. The aim of the study was to establish the feasibility and efficacy of endoscopic submucosal pyloromyotomy in a porcine model. METHODS Four pigs were included in a preliminary study and a 2-week survival study was performed in another four pigs. An esophagogastroduodenoscope was inserted perorally into the stomach. Saline solution was injected into the submucosal space proximal to the pylorus. The gastric mucosa was incised and a 5-cm submucosal tunnel was created. After exposure of the muscular layer in a submucosal tunnel, myotomy of the circular muscle layer was performed until the longitudinal muscular layer was reached. Once myotomy was completed, endoscopic clips were used to re-approximate the mucosal incision. RESULTS Submucosal dissection, identification of the circular muscular layer, and pyloromyotomy were achieved in all animals. Acute complications such as bleeding and perforation were not observed in any cases. Median pyloric resting pressure was reduced from 16.5 mmHg to 6.1 mmHg immediately after myotomy and 8.4 mmHg at 14 days after myotomy. CONCLUSION Peroral endoscopic submucosal pyloromyotomy appears to be technically feasible and effective. Potential clinical applications, such as for infantile hypertrophic pyloric stenosis or delayed gastric emptying after esophagectomy, could be considered after confirmation of safety in additional survival studies.


title: Blood Glucose and Cerebral Tissue Oxygenation Immediately after Birth-An Observational Study.

text: OBJECTIVE To assess a possible association of blood glucose concentration with cerebral regional oxygen saturation (crSO2) and cerebral fractional tissue oxygen extraction (cFTOE) in neonates born at term and preterm 15 minutes after birth. STUDY DESIGN A post-hoc analysis of secondary outcome measures of 2 prospective observational studies was performed. Neonates born at term and preterm via cesarean delivery were included if cerebral near-infrared spectroscopy measurements were performed during the immediate transition after birth and blood glucose concentrations were measured at 15-20 minutes after birth. Arterial oxygen saturation and heart rate were measured with pulse oximetry. cFTOE was calculated from arterial oxygen saturation and crSO2 values. crSO2 and cFTOE 15 minutes after birth were correlated with blood glucose concentrations. RESULTS Seventy-five infants were included. In 50 neonates born at term, crSO2 and cFTOE 15 minutes after birth were 83 ± 7.7% and 0.14 ± 0.08, respectively. In 25 neonates born preterm, crSO2 and cFTOE 15 minutes after birth were 80.2 ± 12.1%, and 0.15 ± 0.1, respectively. crSO2 and cFTOE correlated significantly with blood glucose concentrations in neonates born at term and preterm. Increasing blood glucose concentrations were associated with decreasing crSO2 in neonates born at term (q = -0.35, P = .01) and neonates born preterm (q = -0.69, P = .01) and with increasing cFTOE in neonates born at term (q = 0.31, P = .03) and neonates born preterm (q = 0.67, P = .01). CONCLUSIONS Blood glucose concentration was associated with cerebral oxygenation during the immediate transition after birth in neonates born at term and preterm.


Have we found the panacea to COVID-19 with remdesivir, an old but newly packaged drug?


title: The treatment of female stress urinary incontinence: an evidenced-based review.

text: OBJECTIVE To review the literature on the surgical and nonsurgical treatment options for stress urinary incontinence in women, focusing exclusively on randomized clinical trials and high quality meta-analyses. MATERIALS AND METHODS A computer-aided and manual search for published randomized controlled trials and high quality meta-analyses investigating both conservative and surgical treatment options for stress urinary incontinence. In the case of a treatment that is not studied in these formats large case series have been used. RESULTS Articles were reviewed and the results summarized on pelvic floor physical therapy, pharmacotherapy, bulking agents, and surgery (open and minimally invasive). CONCLUSION There are numerous high quality studies in the literature. It can be difficult to make definitive conclusions on the most appropriate treatment options due to the variability in the outcomes used to define success in these articles. There is also a dire lack of studies evaluating and comparing the surgical options for patients with intrinsic sphincter deficiency.


Amiodarone as a possible therapy for coronavirus infection.


title: Laparoscopic Single-Site Inguinal Hernia Repair Using a Self-Fixating Mesh.

text: BACKGROUND AND OBJECTIVES Every year ∼20 million inguinal hernia repairs are completed worldwide. Increased patient access to medical information and education has elicited interest in minimally invasive surgical techniques that obtain improved surgical outcomes and cosmesis. Because of these factors, there is a growing interest in single-incision surgery. Laparoscopic totally extraperitoneal (TEP) single-incision hernia repair technique has been reported with different meshes used in a tack fixation system. Recently, self-fixating mesh technology has offered the possibility of avoiding tack fixation and potentially avoiding chronic postoperative pain. Self-fixating mesh technology employs monofilament polylactic acid (PLA) creating a microgrip system that provides self-adherence of the mesh to adjacent tissue. This tack-free fixation system provides coverage over the entire myopectineal orifice and surrounding areas where traditional tacks cannot be placed. Self-fixating mesh has also been safely applied in laparoscopic TEP procedures, but this mesh has not been described in single site TEP surgery; possibly because of the potential difficulty with mesh deployment. We sought to determine the technical feasibility of a single-site laparoscopic TEP repair of inguinal hernias and to discuss our techniques and patient short-term outcomes. METHODS Review of a prospectively maintained database of patients who received single-site laparoscopic TEP herniorrhaphy from August 2012 through August 2015. Patient characteristics and demographics and perioperative and postoperative data were analyzed. RESULTS Thirty-four patients (aged 55.2 ±14.2; 17.6% women) with a mean body mass index of 26.2 ± 3.9 were analyzed. Mean operative time was 99.5 ± 30.5 minutes, 41.2% were left-side repairs, and 50% were bilateral. Estimated blood loss was 18.4 ± 14.1 mL. Recurrent hernias accounted for 14.7% of cases; 32.4% of cases were combination surgeries, most commonly a concurrent umbilical hernia repair. The most common short-term postoperative complication was urinary retention (4 patients). The median length of follow-up was 25 days (IQR 18.75-61.75). Complications occurring at >30 days included hydrocele (2 patients) and stitch abscess (1 patient). Eight (23.5%) patients had complications (surgical or during follow-up). No recurrences or deaths were reported. CONCLUSIONS With comparable operative times, perioperative outcomes, and safety profile, SS-TEP appears to be a safe and effective surgical approach for the management of inguinal hernias in the short term. Furthermore, SS-TEP with a self-fixating mesh is a feasible approach.


title: Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomised multicentre study, 1-year results.

text: PURPOSE Laparoscopic incisional ventral hernia repair (LIVHR) is often followed by seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence, chronic pain and poor quality of life (QoL). We aimed to evaluate whether LIVHR combined with defect closure (hybrid) follows as a diminished seroma formation and thereby has a lower rate of hernia recurrence and chronic pain compared to standard LIVHR. METHODS This study is a multicentre randomised controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomised to either a laparoscopic (LG) or a hybrid (HG) repair group. The main outcome measure was hernia recurrence, evaluated clinically and radiologically at a 1-year follow-up visit. At the same time, chronic pain scores and QoL were also measured. RESULTS At the 1-year-control visit, we found no difference in hernia recurrence between the study groups. Altogether, 11 recurrent hernias were found in ultrasound examination, producing a recurrence rate of 6.4%. Of these recurrences, 6 (6.7%) were in the LG group and 5 (6.1%) were in the HG group (p > 0.90). The visual analogue scores for pain were low in both groups; the mean visual analogue scale (VAS) was 1.5 in LG and 1.4 in HG (p = 0.50). QoL improved significantly comparing preoperative status to 1 year after operation in both groups since the bodily pain score increased by 7.8 points (p < 0.001) and physical functioning by 4.3 points (p = 0.014). CONCLUSION Long-term follow-up is needed to demonstrate the potential advantage of a hybrid operation with fascial defect closure. Both techniques had low hernia recurrence rates 1 year after operation. LIVHR reduces chronic pain and physical impairment and improves QoL. TRIAL REGISTRY Clinical trial number NCT02542085.


title: ATP1A1-mediated Src signaling inhibits coronavirus entry into host cells.

text: UNLABELLED In addition to transporting ions, the multisubunit Na(+),K(+)-ATPase also functions by relaying cardiotonic steroid (CTS)-binding-induced signals into cells. In this study, we analyzed the role of Na(+),K(+)-ATPase and, in particular, of its ATP1A1 α subunit during coronavirus (CoV) infection. As controls, the vesicular stomatitis virus (VSV) and influenza A virus (IAV) were included. Using gene silencing, the ATP1A1 protein was shown to be critical for infection of cells with murine hepatitis virus (MHV), feline infectious peritonitis virus (FIPV), and VSV but not with IAV. Lack of ATP1A1 did not affect virus binding to host cells but resulted in inhibited entry of MHV and VSV. Consistently, nanomolar concentrations of the cardiotonic steroids ouabain and bufalin, which are known not to affect the transport function of Na(+),K(+)-ATPase, inhibited infection of cells with MHV, FIPV, Middle East respiratory syndrome (MERS)-CoV, and VSV, but not IAV, when the compounds were present during virus inoculation. Cardiotonic steroids were shown to inhibit entry of MHV at an early stage, resulting in accumulation of virions close to the cell surface and, as a consequence, in reduced fusion. In agreement with an early block in infection, the inhibition of VSV by CTSs could be bypassed by low-pH shock. Viral RNA replication was not affected when these compounds were added after virus entry. The antiviral effect of ouabain could be relieved by the addition of different Src kinase inhibitors, indicating that Src signaling mediated via ATP1A1 plays a crucial role in the inhibition of CoV and VSV infections. IMPORTANCE Coronaviruses (CoVs) are important pathogens of animals and humans, as demonstrated by the recent emergence of new human CoVs of zoonotic origin. Antiviral drugs targeting CoV infections are lacking. In the present study, we show that the ATP1A1 subunit of Na(+),K(+)-ATPase, an ion transporter and signaling transducer, supports CoV infection. Targeting ATP1A1 either by gene silencing or by low concentrations of the ATP1A1-binding cardiotonic steroids ouabain and bufalin resulted in inhibition of infection with murine, feline, and MERS-CoVs at an early entry stage. Infection with the control virus VSV was also inhibited. Src signaling mediated by ATP1A1 was shown to play a crucial role in the inhibition of virus entry by ouabain and bufalin. These results suggest that targeting the Na(+),K(+)-ATPase using cardiotonic steroids, several of which are FDA-approved compounds, may be an attractive therapeutic approach against CoV and VSV infections.


title: A novel flexible endoluminal stapling device for use in NOTES colotomy closure: a feasibility study using an ex vivo porcine model.

text: BACKGROUND With advances in endoscopic diagnosis of early-stage gastrointestinal pathology, the need to offer minimally invasive treatment is attracting significant interest. It is essential that secure and consistent closure of full-thickness colonic resections and colotomy access be provided in natural orifice translumenal surgery (NOTES). This ex vivo porcine study aimed to evaluate a novel prototype flexible endoscopic stapler device for use in closure of full-thickness colonic defects. METHODS A feasibility study using ex vivo porcine colon was undertaken to explore the potential of the prototype stapler to close and seal a colotomy. A standardized linear colotomy was created in 30 colons. The novel flexible endostapler was used to close 20, interrupted hand-sewn sutures to close 5, and a well-validated linear stapler to close 5 of these colotomies. The colons were subsequently subjected to leak pressure testing. RESULTS The colotomy closure using the prototype stapler endoluminally required a median time of 280 s. No statistically significant difference in leak pressures between the stapler and the other techniques was described. Although the endostapler without any colotomy was found to have the highest median leak pressures and the interrupted sutures the lowest pressures, no significant difference could be demonstrated (p = 0.52). Furthermore, no significant difference was demonstrated when the closure integrity created by the flexible stapler was compared with that created by the well-validated linear stapler. CONCLUSION The results suggest that the flexible endoscopic stapler is an effective device for the safe closure of a visceral defect, which in this feasibility study was equivalent to other well-established techniques. Further studies will focus on in vivo application of the prototype stapling device in the setting of full-thickness colonic resection.


title: Longitudinal dialysis adequacy and clinical performance of the VectorFlow hemodialysis catheter: a prospective study.

text: PURPOSE To report clinical performance and longitudinal assessment of hemodialysis adequacy with the Arrow-Clark VectorFlow catheter, a symmetrical-tip device with a distal lumen configuration designed to reduce platelet shear stress and catheter thrombosis. METHODS AND MATERIALS We prospectively enrolled patients who required de novo placement of a chronic tunneled catheter for hemodialysis or exchange of a dysfunctional catheter as part of an Institutional Review Board (IRB)-approved protocol. Catheter patency, Kt/V, mean blood-flow (Qb), and pump pressures were obtained at baseline and at monthly intervals to 90 days. RESULTS Forty-six subjects were enrolled into the study. During the 90-day observation period, maximum blood-flow rate averaged 355-398 mL/minute; mean Qb averaged 333-392 mL/minute. Mean Kt/V values were consistently ≥1.5. Dwell-time was 15-114 days, for a total of 2997 catheter days (mean 71.4 days). Excluding patients who died during the study and those receiving surgical access, overall intervention-free catheter patency rate was 94.9%, 92.2% and 88.8% at days 30, 60, 90, respectively. There were no acute complications. During the follow-up period, three patients developed complications (6.5%). Two catheter infections occurred (0.7/1000 catheter days) and one catheter malfunctioned; a rate of 1.0/ 1000 catheter days for all complications. CONCLUSIONS The VectorFlow catheter produced safe, effective hemodialysis with Kt/V ≥1.5. A single catheter occlusion occurred and a low rate of infection was seen. Results support the hypothesis that the VectorFlow design reduces thrombogenic risk during clinical performance.


docid: accjjxhy

title: Affordable medicines facility for malaria.


docid: cvymwavt

title: Laparoscopic transhiatal resection of a large mid-esophageal diverticulum: a case report.

text: This is a description of transhiatal laparoscopic approach for mid-esophageal diverticulum. Traditionally mid-esophageal diverticula are approached by thoracotomy or thoracoscopy, with the laparoscopic technique being reserved for epiphrenic diverticula. A 78-year-old Caucasian female with a secondary dilatative ischemic cardiomyopathy presented with dysphagia, tenderness in the epigastrium and a considerable weight loss. A large mid-esophageal diverticulum was found on barium swallow and confirmed by CT scan. Underlying achalasia was recorded on manometry. The patient underwent diverticulectomy via transhiatal approach, followed by Heller myotomy and Dor fundoplication. Throughout the procedure auxiliary, esophagoscopic image was provided by interventional gastroenterologist due to a very narrow operating field and lack of orientation points. Based on our experience with this case, we propose transhiatal approach as a feasible alternative to thoracoscopy, in particular with patients who suffer from cardiac or pulmonary co-morbidities which make traditional techniques of high risk.


docid: gpxxdebo

title: Estimation of COVID-19-induced depletion of hospital resources in Ontario, Canada.

text: BACKGROUND The global spread of coronavirus disease 2019 (COVID-19) continues in several jurisdictions, causing substantial strain to health care systems. The purpose of our study was to predict the effect of the COVID-19 pandemic on patient outcomes and use of hospital resources in Ontario, Canada. METHODS We developed an individuallevel simulation to model the flow of patients with COVID-19 through the hospital system in Ontario. We simulated different combined scenarios of epidemic trajectory and hospital health care capacity. Our outcomes included the number of patients who needed admission to the ward or to the intensive care unit (ICU) with or without the need for mechanical ventilation, number of days to resource depletion, number of patients awaiting resources and number of deaths. RESULTS We found that with effective early public health measures, hospital system resources would not be depleted. For scenarios with late or ineffective implementation of physical distancing, hospital resources would be depleted within 14-26 days, and in the worst case scenario, 13 321 patients would die while waiting for needed resources. Resource depletion would be avoided or delayed with aggressive measures to increase ICU, ventilator and acute care hospital capacities. INTERPRETATION We found that without aggressive physical distancing measures, the Ontario hospital system would have been inadequately equipped to manage the expected number of patients with COVID-19 despite a rapid increase in capacity. This lack of hospital resources would have led to an increase in mortality. By slowing the spread of the disease using public health measures and by increasing hospital capacity, Ontario may have avoided catastrophic stresses to its hospitals.


Reply: Vitamin C as a Possible Therapy for COVID-19.


title: Quality of life and nutritional consequences after aboral pouch reconstruction following total gastrectomy for gastric cancer: randomized controlled trial CCG1101.

text: BACKGROUND Total gastrectomy has detrimental effects on postoperative nutritional status and quality of life (QOL), but it is often unavoidable in the treatment of gastric cancer. Roux-en-Y (RY) is the most common reconstruction method following total gastrectomy. Trials to explore other means of reconstruction have been conducted but have failed to identify a method that is globally accepted. METHODS Aboral pouch reconstruction (AP), in which an anisoperistaltic jejunal pouch is created in the Y limb of the RY reconstruction, is considered effective and technically feasible. A prospective randomized trial was conducted to compare AP with RY. Gastric cancer patients requiring total gastrectomy for R0 resection were randomly assigned during surgery to receive either RY (n = 51) or AP (n = 49). Postoperative QOL as assessed by the EORTC QLQ-C30 and STO22, body composition, and morbidity were compared between the two reconstruction methods. The physical functioning score of the QLQ-C30 was selected as the primary endpoint. RESULTS The incidences of postoperative complications were similar between the two groups (29 % in the RY group and 27 % in the AP group). No significant difference was observed in the physical functioning score, and the superiority of AP was demonstrated only for the nausea and vomiting score at 12 months (p = 0.041) and the reflux score at 1 month (p = 0.036). No significant differences were observed in body composition or serum biochemistry. CONCLUSIONS Although AP was safely implemented, no increased benefits in nutritional or QOL-related parameters were observed for this method over RY within 12 months postoperatively.


Clinical features of discharged COVID-19 patients with an extended SARS-CoV-2 RNA positive signal in respiratory samples.


title: Induction of DNA damage signaling upon Rift Valley fever virus infection results in cell cycle arrest and increased viral replication.

text: Rift Valley fever virus (RVFV) is a highly pathogenic arthropod-borne virus infecting a wide range of vertebrate hosts. Of particular interest is the nonstructural NSs protein, which forms large filamentous fibril bundles in the nucleus. Past studies have shown NSs to be a multifaceted protein important for virulence through modulation of the interferon response as well acting as a general inhibitor of transcription. Here we investigated the regulation of the DNA damage signaling cascades by RVFV infection and found virally inducted phosphorylation of the classical DNA damage signaling proteins, ataxia-telangiectasia mutated (ATM) (Ser-1981), Chk.2 (Thr-68), H2A.X (Ser-139), and p53 (Ser-15). In contrast, ataxia-telangiectasia mutated and Rad3-related kinase (ATR) (Ser-428) phosphorylation was decreased following RVFV infection. Importantly, both the attenuated vaccine strain MP12 and the fully virulent strain ZH548 showed strong parallels in their up-regulation of the ATM arm of the DNA damage response and in the down-regulation of the ATR pathway. The increase in DNA damage signaling proteins did not result from gross DNA damage as no increase in DNA damage was observed following infection. Rather the DNA damage signaling was found to be dependent on the viral protein NSs, as an NSs mutant virus was not found to induce the equivalent signaling pathways. RVFV MP12-infected cells also displayed an S phase arrest that was found to be dependent on NSs expression. Use of ATM and Chk.2 inhibitors resulted in a marked decrease in S phase arrest as well as viral production. These results indicate that RVFV NSs induces DNA damage signaling pathways that are beneficial for viral replication.


title: Tumor size correlates with malignancy in nonfunctioning pancreatic endocrine tumor.

text: BACKGROUND Tumor size is a criterion of staging in nonfunctioning pancreatic endocrine tumors as well as a predictor of outcome after curative resection. This study analyzes the correlation between tumor size and malignancy in patients with nonfunctioning pancreatic endocrine tumors. METHODS All patients with nonfunctioning pancreatic endocrine tumors who underwent curative resection (R0) at our institution between 1990 and 2008 were considered. Their clinicopathologic characteristics were compared among 3 different groups according to tumor size. Univariate and multivariable analyses were performed. RESULTS Over the study period, 177 patients were identified. Overall, 90 patients (51%) had a tumor size ≤2 cm (group 1), 46 (26%) had tumor size between >2 cm and ≤4 cm (group 2), and 41 (23%) had tumor size >4 cm (group 3). Tumors ≤2 cm were more frequently incidentally discovered (group 1, 57% vs group 2, 51% vs group 3, 32%; P = .014) and benign (group 1, 81% vs group 2, 65% vs group 3, 5%; P < .0001). The presence of a nonfunctioning pancreatic endocrine tumor >2 cm and a nonincidental diagnosis of the tumor were independent predictors of malignancy at multivariable analysis. None of the 51 patients (29%) with a pancreatic endocrine tumor ≤2 cm that was incidentally diagnosed died of disease. CONCLUSION A strict correlation between tumor size and malignancy in nonfunctioning pancreatic endocrine tumors was demonstrated. A nonoperative management could be advocated for tumors ≤2 cm when discovered incidentally.


Covid-19: experts question analysis suggesting half UK population has been infected.


title: Relationship between ABO blood group distribution and clinical characteristics in patients with COVID-19.

text: OBJECTIVE To explore ABO blood group distribution and clinical characteristics in patients with COVID-19. METHODS The clinical data of 187 patients with COVID-19 seen between January 20, 2020 and March 5, 2020 at the First Hospital of Changsha were retrospectively analyzed. The differences in the ABO blood group distribution between COVID-19 patients and the control group (1,991 cases) were analyzed. The relationship between blood type and clinical characteristics was analyzed. RESULTS Of the 187 patients with COVID-19, 69 had type A (36.90%), 63 had type B (33.69%), 41 had type O (21.92%), and 14 had type AB blood (7.49%). The proportion of patients with type A blood in the COVID-19 group was significantly higher than that in the control group (36.90% vs. 27.47%, P =0.006), while the proportion of patients with type O blood in the COVID-19 group was significantly lower than that in the control group (21.92% vs. 30.19%, P= 0.018). The risk of COVID-19 was higher for individuals with blood group A than for those with blood group O (OR = 1.849, 95% CI = 1.228-2.768, P= 0.003). The risk of COVID-19 was higher for patients with blood group A than for those with a blood group other than A (OR = 1.544, 95% CI = 1.122-2.104, P= 0.006). Patients with blood group O had a lower risk of COVID-19 than non-O blood group patients (OR = 0.649, 95% CI = 0.457-0.927, P= 0.018). The ABO blood group distribution was related to COVID-19 status. CONCLUSIONS Patients with blood group A had an increased risk for infection with SARS-CoV-2, whereas blood group O was associated with a decreased risk, indicating that certain ABO blood groups were correlated with SARS-CoV-2 susceptibility. Blood type was related to some clinical characteristics of patients with COVID-19.


title: A double-inactivated severe acute respiratory syndrome coronavirus vaccine provides incomplete protection in mice and induces increased eosinophilic proinflammatory pulmonary response upon challenge.

text: Severe acute respiratory syndrome coronavirus (SARS-CoV) is an important emerging virus that is highly pathogenic in aged populations and is maintained with great diversity in zoonotic reservoirs. While a variety of vaccine platforms have shown efficacy in young-animal models and against homologous viral strains, vaccine efficacy has not been thoroughly evaluated using highly pathogenic variants that replicate the acute end stage lung disease phenotypes seen during the human epidemic. Using an adjuvanted and an unadjuvanted double-inactivated SARS-CoV (DIV) vaccine, we demonstrate an eosinophilic immunopathology in aged mice comparable to that seen in mice immunized with the SARS nucleocapsid protein, and poor protection against a nonlethal heterologous challenge. In young and 1-year-old animals, we demonstrate that adjuvanted DIV vaccine provides protection against lethal disease in young animals following homologous and heterologous challenge, although enhanced immune pathology and eosinophilia are evident following heterologous challenge. In the absence of alum, DIV vaccine performed poorly in young animals challenged with lethal homologous or heterologous strains. In contrast, DIV vaccines (both adjuvanted and unadjuvanted) performed poorly in aged-animal models. Importantly, aged animals displayed increased eosinophilic immune pathology in the lungs and were not protected against significant virus replication. These data raise significant concerns regarding DIV vaccine safety and highlight the need for additional studies of the molecular mechanisms governing DIV-induced eosinophilia and vaccine failure, especially in the more vulnerable aged-animal models of human disease.


title: Beyond malaria--causes of fever in outpatient Tanzanian children.

text: BACKGROUND As the incidence of malaria diminishes, a better understanding of nonmalarial fever is important for effective management of illness in children. In this study, we explored the spectrum of causes of fever in African children. METHODS We recruited children younger than 10 years of age with a temperature of 38°C or higher at two outpatient clinics--one rural and one urban--in Tanzania. Medical histories were obtained and clinical examinations conducted by means of systematic procedures. Blood and nasopharyngeal specimens were collected to perform rapid diagnostic tests, serologic tests, culture, and molecular tests for potential pathogens causing acute fever. Final diagnoses were determined with the use of algorithms and a set of prespecified criteria. RESULTS Analyses of data derived from clinical presentation and from 25,743 laboratory investigations yielded 1232 diagnoses. Of 1005 children (22.6% of whom had multiple diagnoses), 62.2% had an acute respiratory infection; 5.0% of these infections were radiologically confirmed pneumonia. A systemic bacterial, viral, or parasitic infection other than malaria or typhoid fever was found in 13.3% of children, nasopharyngeal viral infection (without respiratory symptoms or signs) in 11.9%, malaria in 10.5%, gastroenteritis in 10.3%, urinary tract infection in 5.9%, typhoid fever in 3.7%, skin or mucosal infection in 1.5%, and meningitis in 0.2%. The cause of fever was undetermined in 3.2% of the children. A total of 70.5% of the children had viral disease, 22.0% had bacterial disease, and 10.9% had parasitic disease. CONCLUSIONS These results provide a description of the numerous causes of fever in African children in two representative settings. Evidence of a viral process was found more commonly than evidence of a bacterial or parasitic process. (Funded by the Swiss National Science Foundation and others.).


Prolonged air leak following lung resection - does Tri-staplerTM technology improve the incidence?


title: Care for Patients with Musculoskeletal Pain During the COVID-19 Pandemic: Physical Therapy and Rehabilitation Suggestions for Pain Management.

text: Coronavirus disease 2019 has severely affected public health. Under social distancing and lockdown policies, patients with musculoskeletal pain have fewer opportunities than usual to receive routine medical care for pain management in hospitals. Therefore, we provided some suggestions for such patients to manage musculoskeletal pain and techniques that may be performed at home during this period.


docid: woalynuo

title: Oligonucleotide-based biosensors for in vitro diagnostics and environmental hazard detection.

text: Oligonucleotide-based biosensors have drawn much attention because of their broad applications in in vitro diagnostics and environmental hazard detection. They are particularly of interest to many researchers because of their high specificity as well as excellent sensitivity. Recently, oligonucleotide-based biosensors have been used to achieve not only genetic detection of targets but also the detection of small molecules, peptides, and proteins. This has further broadened the applications of these sensors in the medical and health care industry. In this review, we highlight various examples of oligonucleotide-based biosensors for the detection of diseases, drugs, and environmentally hazardous chemicals. Each example is provided with detailed schematics of the detection mechanism in addition to the supporting experimental results. Furthermore, future perspectives and new challenges in oligonucleotide-based biosensors are discussed.


Introduction: "COVID-19: Politics, Inequalities, and Pandemic".


title: [CoViD-19: we knew everything but we didn't understand anything.]

text: The CoViD-19 and its consequences could perhaps have been foreseen. Above all, this pandemic force us to review what is essential and really necessary in term of priorities and regulatory process for clinical pharmacological research. It is evident, among other things, the difficulty to deal with therapeutic uncertainties.Not proven specific therapies are available for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2, the cause of CoViD-19), other than supportive care. However, several clinical centres decided to use off label drugs as a standard of care in the absence of efficacy and safety data. The national regulatory body (AIFA) has set up a process in a short time to transparently govern the approval of new trials and to regulate the use of medicines that are not indicated. In this context, the communication of risk associated with experimental therapies was also very important. The lessons we will learn from this emergency may result crucial in redesigning a better way of conducting clinical trials and information on drugs.


title: Phrenic nerve injury after radiofrequency ablation of lung tumors: retrospective evaluation of the incidence and risk factors.

text: PURPOSE To retrospectively investigate the incidence of and risk factors for phrenic nerve injury after radiofrequency (RF) ablation of lung tumors. MATERIALS AND METHODS The study included 814 RF ablation procedures of lung tumors. To evaluate the development of phrenic nerve injury, chest radiographs obtained before and after the procedure were examined. Phrenic nerve injury was assumed to have developed if the diaphragmatic level was elevated after the procedure. To identify risk factors for phrenic nerve injury, multiple variables were compared between cases of phrenic nerve injury and randomly selected controls by using univariate analyses. Multivariate analysis was then performed to identify independent risk factors. RESULTS Evaluation of phrenic nerve injury from chest radiographs was possible after 786 procedures. Evidence of phrenic nerve injury developed after 10 cases (1.3%). Univariate analysis revealed that larger tumor size (≥ 20 mm; P = .014), proximity of the phrenic nerve to the tumor (< 10 mm; P < .001), the use of larger electrodes (array diameter or noninsulated tip length ≥ 3 cm; P = .001), and higher maximum power applied during ablation (≥ 100 W; P < .001) were significantly associated with the development of phrenic nerve injury. Multivariate analysis demonstrated that the proximity of the phrenic nerve to the tumor (< 10 mm; P < .001) was a significant independent risk factor. CONCLUSIONS The incidence of phrenic nerve injury after RF ablation was 1.3%. The proximity of the phrenic nerve to the tumor was an independent risk factor for phrenic nerve injury.


title: Is There a Role for Environmental and Metabolic Factors Predisposing to Severe COVID-19?

text: The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic affects people around the world. However, there have been striking differences in the number of infected individuals and deaths in different countries. Particularly, within Central Europe in countries that are similar in ethnicity, age, and medical standards and have performed similar steps of containment, such differences in mortality rates remain inexplicable. We suggest to consider and explore environmental factors to explain these intriguing variations. Countries like Northern Italy, France, Spain, and UK have suffered from 5 times more deaths from the corona virus infection than neighboring countries like Germany, Switzerland, Austria, and Denmark related to the size of their respective populations. There is a striking correlation between the level of environmental pollutants including pesticides, dioxins, and air pollution such as NO2 known to affect immune function and healthy metabolism with the rate of mortality in COVID-19 pandemic in these European countries. There is also a correlation with the use of chlorination of drinking water in these regions. In addition to the improvement of environmental protective programs, there are possibilities to lower the blood levels of these pollutants by therapeutic apheresis. Furthermore, therapeutic apheresis might be an effective method to improve metabolic inflammation, altered vascular perfusion, and neurodegeneration observed as long-term complications of COVID-19 disease.


title: Restrictive versus liberal transfusion strategies for older mechanically ventilated critically ill patients: a randomized pilot trial.

text: OBJECTIVES To compare hemoglobin concentration (Hb), RBC use, and patient outcomes when restrictive or liberal blood transfusion strategies are used to treat anemic (Hb≤90 g/L) critically ill patients of age≥55 years requiring≥4 days of mechanical ventilation in ICU. DESIGN Parallel-group randomized multicenter pilot trial. SETTING Six ICUs in the United Kingdom participated between August 2009 and December 2010. PATIENTS One hundred patients (51 restrictive and 49 liberal groups). INTERVENTIONS Patients were randomized to a restrictive (Hb trigger, 70 g/L; target, 71-90 g/L) or liberal (90 g/L; target, 91-110 g/L) transfusion strategy for 14 days or the remainder of ICU stay, whichever was longest. MEASUREMENTS AND MAIN RESULTS Baseline comorbidity rates and illness severity were high, notably for ischemic heart disease (32%). The Hb difference among groups was 13.8 g/L (95% CI, 11.5-16.0 g/L); p<0.0001); mean Hb during intervention was 81.9 (SD, 5.1) versus 95.7 (6.3) g/L; 21.6% fewer patients in the restrictive group were transfused postrandomization (p<0.001) and received a median 1 (95% CI, 1-2; p=0.002) fewer RBC units. Protocol compliance was high. No major differences in organ dysfunction, duration of ventilation, infections, or cardiovascular complications were observed during intensive care and hospital follow-up. Mortality at 180 days postrandomization trended toward higher rates in the liberal group (55%) than in the restrictive group (37%); relative risk was 0.68 (95% CI, 0.44-1.05; p=0.073). This trend remained in a survival model adjusted for age, gender, ischemic heart disease, Acute Physiology and Chronic Health Evaluation II score, and total non-neurologic Sequential Organ Failure Assessment score at baseline (hazard ratio, 0.54 [95% CI, 0.28-1.03]; p=0.061). CONCLUSIONS A large trial of transfusion strategies in older mechanically ventilated patients is feasible. This pilot trial found a nonsignificant trend toward lower mortality with restrictive transfusion practice.


Critical Care in Resource-Restricted Settings.


title: Bariatric surgery and cardiovascular outcomes: a systematic review.

text: PURPOSE To quantify the impact of bariatric surgery on cardiovascular (CV) risk factors, and on cardiac structure and function. DATA SOURCES Three major databases (PubMed, Medline and Cochrane) were searched for original studies written in English. STUDY SELECTION Original articles reporting CV risk factors or non-invasive imaging parameters for patients undergoing bariatric surgery, from January 1950 to June 2012. DATA EXTRACTION Data extraction from selected studies was based on protocol-defined criteria that included study design, methods, patient characteristics, surgical procedures, weight loss, changes in CV risk factors, cardiac structure and cardiac function postoperatively. DATA SYNTHESIS 73 CV risk factor studies involving 19 543 subjects were included (mean age 42 years, 76% female). Baseline prevalence of hypertension, diabetes and hyperlipidaemia were 44%, 24%, and 44%, respectively. Mean follow-up was 57.8 months (range 3-176) and average excess weight loss was 54% (range 16-87%). Postoperative resolution/improvement of hypertension occurred in 63% of subjects, of diabetes in 73% and of hyperlipidaemia in 65%. Echocardiographic data from 713 subjects demonstrated statistically significant improvements in left ventricular mass, E/A ratio, and isovolumic relaxation time postoperatively. LIMITATIONS Diagnostic criteria, CV risk factor reporting, and imaging parameters were not uniform across all studies. Study groups were heterogeneous in their demographics, operative technique and follow-up period. CONCLUSIONS This systematic review highlights the benefits of bariatric surgery in reducing risk factors for CV disease. There is also evidence for left ventricular hypertrophy regression and improved diastolic function. These observations provide further evidence that bariatric surgery enhances future CV health for obese individuals.


Covid-19: Indian government vows to protect healthcare workers from violence amid rising cases.


title: Characteristics of electroencephalogram signatures in sedated patients induced by various anesthetic agents.

text: Devices that monitor the depth of hypnosis based on the electroencephalogram (EEG) have long been commercialized, and clinicians use these to titrate the dosage of hypnotic agents. However, these have not yet been accepted as standard monitoring devices for anesthesiology. The primary reason is that the use of these monitoring devices does not completely prevent awareness during surgery, and the development of these devices has not taken into account the neurophysiological mechanisms of hypnotic agents, thus making it possible to show different levels of unconsciousness in the same brain status. An alternative is to monitor EEGs that are not signal processed with numerical values presented by these monitoring devices. Several studies have reported that power spectral analysis alone can distinguish the effects of different hypnotic agents on consciousness changes. This paper introduces the basic concept of power spectral analysis and introduces the EEG characteristics of various hypnotic agents that are used in sedation.


title: Global factors driving emerging infectious diseases.

text: The extinction of species across the globe is accelerating directly or indirectly from human activities. Biological impoverishment, habitat fragmentation, climate change, increasing toxification, and the rapid global movement of people and other living organisms have worked synergistically to diminish ecosystem function. This has resulted in unprecedented levels of disease emergence driven by human-induced environmental degradation, which poses a threat to the survival and health of biodiversity. What is often overlooked in the discussion of the health consequences to humans is that critically endangered wildlife species are at grave risk of extinction by disease outbreaks. As habitat becomes more compressed and with migration routes cut off, gene pools of small species are stranded in isolated habitat fragments. Species now are vulnerable to encroachment, malnutrition, environmental pollutants, and epidemics from domestic animals and humans. Furthermore, the continuous degradation of ecosystems is leading to increased stress, immunosuppression, and greater susceptibility to disease. Disease can be catastrophic to a diminished stressed population, becoming in some instances the leading factor of local, regional, and global extinctions. The strategies of the new field of conservation medicine include long-term monitoring, health assessment, and interventions to protect species at risk. We particularly must minimize the threat of any potentially catastrophic disease outbreaks resulting from anthropogenic changes to the environment. Current and future diagnostic molecular techniques offer new opportunities to identify tools for the management and possible treatment of diseases in imperiled species.


title: Pregnancy serum facilitates hepatitis E virus replication in vitro.

text: Hepatitis E virus (HEV) infection causes high mortality in pregnant women. However, the pathogenic mechanisms of HEV infection in pregnant women remain unknown. In this study, the roles of pregnancy serum in HEV infection were investigated using an efficient cell culture system. HEV infection was exacerbated by supplementing with pregnancy serum, especially theat in third trimester of pregnancy. Oestrogen receptors (ER-α and ER-β) were activated in cells supplemented with pregnancy serum and were significantly inhibited during HEV infection. Type I IFN, especially IFN-β, showed delayed upregulation in HEV-infected cells supplemented with the serum in the third trimester of pregnancy, which indicated that delayed IFN-β expression may facilitate viral replication. Results suggested that pregnancy serum accelerated HEV replication by suppressing oestrogen receptors and type I IFN in the early stage of infection.


title: [Analysis of CT features of 15 children with 2019 novel coronavirus infection].

text: Objective: To explore imaging characteristics of children with 2019 novel coronavirus (2019-nCoV) infection. Methods: A retrospective analysis was performed on clinical data and chest CT images of 15 children diagnosed with 2019-nCoV infection. They were admitted to the Third People's Hospital of Shenzhen from January 16 to February 6, 2020. The distribution and morphology of pulmonary lesions on chest CT images were analyzed. Results: Among the 15 children, 5 were males and 10 females, aged from 4 to 14 years. Five of the 15 children were febrile and 10 were asymptomatic on the first visit. The first nasal or pharyngeal swab samples in all the 15 cases were positive for 2019-nCoV nucleic acid. For their first chest CT images, 6 patients had no lesions, while 9 patients had pulmonary inflammatory lesions. Seven cases had small nodular ground glass opacities and 2 cases had speckled ground glass opacities. After 3 to 5 days of treatment, 2019-nCoV nucleic acid in a second respiratory sample turned negative in 6 cases. Among them, chest CT images showed less lesions in 2 cases, no lesion in 3 cases, and no improvement in 1 case. The remaining 9 cases were still positive in a second nucleic acid test. Six patients showed similar chest CT inflammation, while 3 patients had new lesions, which were all small nodular ground glass opacities. Conclusions: The early chest CT images of children with 2019-nCoV infection are mostly small nodular ground glass opacities. The clinical symptoms of children with 2019-nCoV infection are nonspecific. Dynamic reexamination of chest CT and nucleic acid are important.


Risk of COVID-19 Transmission During Autopsy.


COVID-19 and rheumatology: first steps towards a different future?


title: Prone extralevator abdominoperineal excision of the rectum with porcine collagen perineal reconstruction (Permacol™): high primary perineal wound healing rates.

text: PURPOSE Extralevator abdominoperineal excision of the rectum (elAPER) is arguably the modern surgical approach to low rectal cancer and yet results in large defects that may necessitate plastic surgical reconstruction. This study aims to evaluate the quality of prone elAPER surgery with Permacol™ repair of the perineum. The primary end point studied was the rate of primary perineal wound healing. METHODS Data were prospectively collected for consecutive patients having prone elAPER at a single institution to assess surgical morbidity together with pathological and cancer-specific outcomes. RESULTS Between 2006 and 2012, 48 patients had prone elAPER with median age of 63 (40-86). Thirty-four patients (72.3%) received neoadjuvant treatment. Median length of stay was 9 days (6-66). With a prone approach, three patients had specimen perforation (6.4%) and seven patients had circumferential margin involvement (14.9%). Complete perineal wound healing was achieved in 34 patients (73.9%) at 4 weeks. Four patients (8.3%) were unhealed at 6 months; one patient required a perineal sinus to be laid open, and another patient required plastic surgical reconstruction. No perineal wound herniae have been identified during follow-up. CONCLUSIONS Acceptable oncological outcomes are achieved with the prone extralevator approach. The technique achieves high rates of primary healing, making it an attractive option in centres without access to plastic reconstructive expertise.


title: Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program.

text: Importance Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation. Objective To evaluate the association of the ERIN pilot with LOS after colectomy. Design, Setting, and Participants Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals. Interventions Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration. Main Outcomes and Measures The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite. Results There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P < .001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P < .001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P < .001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P < .001). Conclusions and Relevance Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot may inform efforts to scale this effective and evidence-based intervention.


title: Changes in glucose-6-phosphate dehydrogenase expression results in altered behavior of HBV-associated liver cancer cells.

text: Hepatocellular carcinoma (HCC) is regarded as a major global health care issue, and chronic hepatitis B virus (HBV) infection is considered to be involved in pathogenesis of HCC. To increase knowledge of HCC pathogenesis, as well as discover potential novel molecules for anti-cancer therapy, mass spectrometry and isobaric tag for relative and absolute quantitation (iTARQ) were employed. The differences between nine HBV-related HCC and adjacent non-HCC tissue specimens were studied. In total, 222 proteins were analyzed for differential expression in the two types of samples. Among these proteins, several were further confirmed by immunohistochemical, immunoblotting, and real-time RT-PCR analysis. RNA interference induced downregulation of glucose-6-phosphate dehydrogenase (G6PD) and decreased HBV replication by fivefold by the IFN pathway. Decreased G6PD expression resulted in decreased hepatoma cell migration and invasion in cell culture. In summary, the investigation provides new information on pathogenesis of HBV infection and suggests G6PD as a novel anti-HCC target. G6PD suppression may contribute to treatment strategies for inhibiting tumor progression.


title: The prevalence and radiological findings of pulmonary embolism in HIV-positive patients referred for computed tomography pulmonary angiography in the Western Cape of South Africa.

text: AIM To provide imaging data and report associations between human immunodeficiency virus (HIV), tuberculosis (TB) and pulmonary embolism (PE) in a South African population that underwent computed tomography pulmonary angiography (CTPA) for suspected PE. METHODS A validated Qanadli severity scoring system for PE was used for 164 CTPA scans, and parenchymal, pleural and cardiovascular complications were reported. Serological confirmation of HIV testing and microbiological confirmation of TB were recorded. RESULTS Prevalence of PE in the CTPA population was 26% (95% CI: 19.67-33.65%). HIV-positive prevalence in patients with PE was 67% (95% CI: 48.17-82.04%), however it was not statistically significantly different when compared with the patients without PE (p = 1). HIV-positive patients had more extensive partial thrombus in the right middle lobe (p = 0.045), but no other differences when compared with HIV-negative patients. TB prevalence in patients with PE was 57% (95% CI: 34.49-76.81%). This was statistically significantly different when compared with the patients without PE (p = 0.073 at the 10% level). Prevalence of TB co-morbidity in the HIV-positive group with proven PE was 71% (95% CI: 41.90- 91.61%), however there was no statistically significant difference in comparison with the HIV-negative patients with TB and PE (p= 0.305). CONCLUSION The high number of patients presenting for CTPA who were HIV infected (and also infected with TB) highlights that PE evaluation should include severity/extent of the disease, as these patients may have more severe disease in specific lung lobes. The use of a validated scoring system, such as the Qanadli score, when reporting PE may have a profound effect on patient risk stratification, management and prognosis and would also provide a system for collecting larger volumes of data for analysis.


title: Dalteparin versus unfractionated heparin in critically ill patients.

text: BACKGROUND The effects of thromboprophylaxis with low-molecular-weight heparin, as compared with unfractionated heparin, on venous thromboembolism, bleeding, and other outcomes are uncertain in critically ill patients. METHODS In this multicenter trial, we tested the superiority of dalteparin over unfractionated heparin by randomly assigning 3764 patients to receive either subcutaneous dalteparin (at a dose of 5000 IU once daily) plus placebo once daily (for parallel-group twice-daily injections) or unfractionated heparin (at a dose of 5000 IU twice daily) while they were in the intensive care unit. The primary outcome, proximal leg deep-vein thrombosis, was diagnosed on compression ultrasonography performed within 2 days after admission, twice weekly, and as clinically indicated. Additional testing for venous thromboembolism was performed as clinically indicated. Data were analyzed according to the intention-to-treat principle. RESULTS There was no significant between-group difference in the rate of proximal leg deep-vein thrombosis, which occurred in 96 of 1873 patients (5.1%) receiving dalteparin versus 109 of 1873 patients (5.8%) receiving unfractionated heparin (hazard ratio in the dalteparin group, 0.92; 95% confidence interval [CI], 0.68 to 1.23; P=0.57). The proportion of patients with pulmonary emboli was significantly lower with dalteparin (24 patients, 1.3%) than with unfractionated heparin (43 patients, 2.3%) (hazard ratio, 0.51; 95% CI, 0.30 to 0.88; P=0.01). There was no significant between-group difference in the rates of major bleeding (hazard ratio, 1.00; 95% CI, 0.75 to 1.34; P=0.98) or death in the hospital (hazard ratio, 0.92; 95% CI, 0.80 to 1.05; P=0.21). In prespecified per-protocol analyses, the results were similar to those of the main analyses, but fewer patients receiving dalteparin had heparin-induced thrombocytopenia (hazard ratio, 0.27; 95% CI, 0.08 to 0.98; P=0.046). CONCLUSIONS Among critically ill patients, dalteparin was not superior to unfractionated heparin in decreasing the incidence of proximal deep-vein thrombosis. (Funded by the Canadian Institutes of Health Research and others; PROTECT ClinicalTrials.gov number, NCT00182143.).


title: Proteomic analysis of membrane proteins of vero cells: exploration of potential proteins responsible for virus entry.

text: Vero cells are highly susceptible to many viruses in humans and animals, and its membrane proteins (MPs) are responsible for virus entry. In our study, the MP proteome of the Vero cells was investigated using a shotgun LC-MS/MS approach. Six hundred twenty-seven proteins, including a total of 1839 peptides, were identified in MP samples of the Vero cells. In 627 proteins, 307 proteins (48.96%) were annotated in terms of biological process of gene ontology (GO) categories; 356 proteins (56.78%) were annotated in terms of molecular function of GO categories; 414 proteins (66.03%) were annotated in terms of cellular components of GO categories. Of 627 identified proteins, seventeen proteins had been revealed to be virus receptor proteins. The resulting protein lists and highlighted proteins may provide valuable information to increase understanding of virus infection of Vero cells.


title: Elasticity and breaking strength of synthetic suture materials incubated in various equine physiological and pathological solutions.

text: REASONS FOR PERFORMING STUDY Selection of suture material in equine surgery is often based on costs or subjective factors, such as the surgeon's personal experience, rather than objective facts. The amount of objective data available on durability of suture materials with regard to specific equine physiological conditions is limited. OBJECTIVES To evaluate the effect of various equine physiological and pathological fluids on the rate of degradation of a number of commonly used suture materials. STUDY DESIGN In vitro material testing. METHODS Suture materials were exposed in vitro to physiological fluid, followed by biomechanical analysis. Three absorbable suture materials, glycolide/lactide copolymer, polyglactin 910 and polydioxanone were incubated at 37°C for 7, 14 or 28 days in phosphate-buffered saline, equine serum, equine urine and equine peritoneal fluid from an animal with peritonitis. Five strands of each suture material type were tested to failure in a materials testing machine for each time point and each incubation medium. Yield strength, strain and Young's modulus were calculated, analysed and reported. RESULTS For all suture types, the incubation time had a significant effect on yield strength, percentage elongation and Young's modulus in all culture media (P<0.0001). Suture type was also shown significantly to influence changes in each of yield strength, percentage elongation and Young's modulus in all culture media (P<0.0001). While the glycolide/lactide copolymer demonstrated the highest Day 0 yield strength, it showed the most rapid degradation in all culture media. For each of the 3 material characteristics tested, polydioxanone showed the least variation across the incubation period in each culture medium. CONCLUSIONS The duration of incubation and the type of fluid have significant effects on the biomechanical properties of various suture materials. These findings are important for evidence-based selection of suture material in clinical cases.


title: Comparison of the Antibacterial Efficacy of Commiphora molmol and Sodium Hypochlorite as Root Canal Irrigants against Enterococcus faecalis and Fusobacterium nucleatum.

text: Objective The investigation aims to compare antimicrobial efficacy of the extract of Commiphora molmol, against Enterococcus faecalis and Fusobacterium nucleatum, with sodium hypochlorite (NaOCl). Design T he dehydrated oleo-gum resin of Commiphora molmol was extracted by using 70% ethanol and was suspended in 99.8% dimethyl sulfoxide (DMSO) as a dissolving agent in a 1:2 volume to produce an aqueous solution at room temperature. Agar-well diffusion and broth microdilution methods assay were utilized to determine both the antimicrobial activity and minimum inhibitory concentration, of alcoholic extract of Commiphora molmol against E. faecalis and F. nucleatum. The values of the inhibition zones were determined based on the concentration of the investigated material. One hundred and forty extracted human premolar teeth were instrumented and immersed in bacterial suspension of E. faecalis or F. nucleatum (70 teeth in each species suspension). Prepared teeth were then immersed in the myrrh extract solution, 2.5% NaOCl, DMSO, or Cefotaxime and incubated for 30 and 60 minutes. Results The largest inhibition zone diameter for both bacterial species was obtained by the 100mg/100μL concentration. The minimum inhibitory concentration (MIC) was 0.03mg/300μL for both E. faecalis and F. nucleatum. The minimum bactericidal concentration (MBC) results showed that 0.03mg/μL myrrh extract and 2.5% sodium hypochlorite significantly reduced bacterial growth at both 30 and 60 minutes of different treatments of root canals, compared to DMSO group (negative control) and the antibiotic group (positive group). Conclusion Myrrh extract was proven to have considerable antibacterial activity against both F. nucleatum and E. faecalis.


title: The Role of Surgeons' Colposcopic Experience in Obtaining Adequate Samples by Large Loop Excision of the Transformation Zone in Women of Reproductive Age.

text: Introduction: There is insufficient reporting on the level of colposcopic training for the safe use of large loop excision of the transformation zone. The aim of this study was to perform a quality assessment of large loop excision of the transformation zone in women of reproductive age by evaluating the surgeons' colposcopic experience. Materials and Methods: A retrospective cohort study was performed on diagnostic or therapeutic large loop excision of the transformation zone. The following variables were analyzed: age, parity, indications for surgery, level of surgeon's colposcopic experience, definitive histological diagnosis, margin involvement, and the presence and type of artifacts interfering with the pathological interpretation. Patients were divided into three groups: group A - 75 patients treated by junior colposcopists; group B - 74 patients treated by experienced colposcopists, and group C - 117 patients treated by expert colposcopists. Results: Regarding the presence and diagnostic significance of the artifacts the groups were significantly different. Inadequate samples were the least frequent in group C. Artifacts precluding histological diagnosis were the most common in group A. The margins were predominantly inconclusive in group A. Conclusions: A high rate of artifacts is a disadvantage of the large loop excision of the transformation zone performed by surgeons less skilled for colposcopy. Although large loop excision of the transformation zone is considered to be a minor surgery, skills in colposcopy are an essential prerequisite for optimal results.


title: Better together: the role of IFIT protein-protein interactions in the antiviral response.

text: The interferon-induced proteins with tetratricopeptide repeats (IFITs) are a family of antiviral proteins conserved throughout all vertebrates. IFIT1 binds tightly to non-self RNA, particularly capped transcripts lacking methylation on the first cap-proximal nucleotide, and inhibits their translation by out-competing the cellular translation initiation apparatus. This exerts immense selection pressure on cytoplasmic RNA viruses to maintain mechanisms that protect their messenger RNA from IFIT1 recognition. However, it is becoming increasingly clear that protein-protein interactions are necessary for optimal IFIT function. Recently, IFIT1, IFIT2 and IFIT3 have been shown to form a functional complex in which IFIT3 serves as a central scaffold to regulate and/or enhance the antiviral functions of the other two components. Moreover, IFITs interact with other cellular proteins to expand their contribution to regulation of the host antiviral response by modulating innate immune signalling and apoptosis. Here, we summarize recent advances in our understanding of the IFIT complex and review how this impacts on the greater role of IFIT proteins in the innate antiviral response.


title: Comparison of perioperative outcomes following open versus minimally invasive Ivor Lewis oesophagectomy at a single, high-volume centre.

text: OBJECTIVES With the increasing popularity of minimally invasive oesophageal resections, equivalence, if not superiority, to open techniques must be demonstrated. Here we compare our open and minimally invasive Ivor Lewis oesophagectomy (MIE) experience. METHODS A prospective database of all oesophagectomies performed at Massachusetts General Hospital in Boston, MA between November 2007 and January 2011 was analysed. A total of 38 MIE and 76 open Ivor Lewis (OIE) oesophagectomies were performed for oesophageal carcinoma. Sixty-day surgical, oncological and postoperative outcomes were examined between the two groups. RESULTS Groups had similar demographics in terms of age, gender, tumour histology, clinical stage, preoperative comorbidities and neoadjuvant therapy. No difference was found with respect to adequacy of oncological resections. The median number of lymph nodes retrieved (OIE: 21, inter-quartile range (IQR): (16, 27) versus MIE: 19, IQR: (15, 28)), resection margins (OIE: 6.6% positive versus MIE: no positive margins) and 60-day mortality (OIE: 2.6% versus MIE: no deaths) were comparable. However, rates of pulmonary complications were significantly lower in the MIE group (OIE: 43.4 versus MIE: 2.6%, P < 0.001). Additionally, the median length of ICU and hospital stay, intraoperative blood loss and amount of intravenous fluids infused intraoperatively were also significantly decreased with MIE, while median operative times and the requirement for intraoperative blood transfusion were not significantly different between the two groups. Multivariate logistic regression analysis identified MIE as the only variable associated with a significant reduction in the rate of pulmonary complications in our study, while pre-existing pulmonary comborbidity was associated with an increased risk of pulmonary complications. CONCLUSIONS Open and MIE appear equivalent with regard to early oncological outcomes. A minimally invasive approach, however, appears to lead to a significant reduction in the rate of postoperative pulmonary complications. Length of ICU and hospital stay, as well as intraoperative blood loss and intravenous fluid requirements are also reduced in the setting of MIE. Long-term survival data will need to be followed closely. A large, multi-centred, randomized, controlled trial is warranted to confirm these results.


title: Ethical considerations during the COVID-19 pandemic.

text: The care of patients during the COVID-19 pandemic has added many layers of complexity to ethical issues. Our response emphasizes the importance of having an ethically sound framework to inform our decisions, requiring caregivers to consider what is ethically optimal and feasible for the patient. It is increasingly important to understand the ethical principles and to appropriately apply them to both patient management decisions and guide scarce resource allocation. If we are to be prepared to face the many challenges of this pandemic, we must prioritize the ethical demands to our treatment and management concerns.


title: Interval Colorectal Cancer After Colonoscopy: Exploring Explanations and Solutions.

text: There is good evidence that colorectal cancer (CRC) screening has been successful at reducing both CRC incidence and death. Colonoscopy, utilized as either a primary screening tool or a follow-up exam when other screening tests are positive, has significantly contributed to these encouraging trends. However, it is well recognized that colonoscopy is not perfectly sensitive for the detection of neoplasia and that CRC can be diagnosed within a short interval following a colonoscopy that did not detect one. The literature surrounding these cases has rapidly expanded over the last decade. Specifically, studies aimed at understanding the frequency of these events and the likely explanations for their occurrence have been performed. This review will highlight current knowledge around the epidemiology of interval post colonoscopy CRC (PCCRC). The common explanations for these cancers including missed lesions, new lesions, and incompletely resected lesions will be reviewed and their contribution to interval PCCRC estimated. Finally, the relationship of these putative explanations to potential opportunities to prevent interval PCCRC will be explored. Current approaches to prevention largely center on consistent adherence to quality colonoscopy standards. Future approaches include advances in technology to better visualize the colon and adequately resect detected neoplasia. Finally, improvement in training as well as development of a culture of continuous quality improvement will be essential to maximize the benefits of colonoscopy in daily clinical practice.


title: Distress and anxiety associated with COVID-19 among Jewish and Arab pregnant women in Israel.

text: INTRODUCTION The fact that little is yet known about the possible implications of COVID-19 for pregnancy, puts pregnant women at greater risk of heightened anxiety and psychological distress. In this study, we sought to explore the psychological distress and COVID-19-related anxiety of pregnant women during the crisis. METHODS Israeli Jewish and Arab pregnant women (n = 336) aged 20-47 completed a set of questionnaires during the COVID-19 pandemic in March 2020. RESULTS The levels of all COVID-19-related anxieties were quite high (much or very much), with the highest regarding public places and transportation (87.5%, 70%, respectively), followed by concerns over the possible infection of other family members and the health of the foetus (71.7%, 70%, respectively), going for pregnancy check-ups (68.7%,), being infected themselves, and the delivery (59.2%, 55.4%, respectively). Although COVID-19-related anxieties were shared by pregnant women characterised by diverse sociodemographic variables, with very small nuances, Arab women were more anxious about each of the issues than Jewish women. DISCUSSION Our findings highlight the importance of assessing anxiety and distress in pregnant women during the COVID-19 pandemic, as well as the need to be attentive to the double stress of pregnant women in times of crisis and to the potential vulnerability of subgroups, such as cultural minorities.


docid: tlvrnsae

title: Osteochondromas after total-body irradiation.


Interpreting a covid-19 test result.


title: THROMBOELASTOGRAPHY IN THE HEALTHY ASIAN ELEPHANT ( ELEPHAS MAXIMUS): REFERENCE INTERVALS AND EFFECTS OF STORAGE.

text: Hemorrhagic disease associated with elephant endotheliotropic herpesvirus infection is the most-frequent cause of mortality in captive Asian elephants ( Elephas maximus). Survival relies on intensive monitoring of hemostatic status. Thromboelastography (TEG) utilizes whole blood samples containing all the blood components of hemostasis and is therefore a sensitive indicator of the clinical status in the patient. This study was performed to assess the practicability of TEG in Asian elephants in a zoo environment. Citrated stabilized whole blood samples were obtained from 44 healthy Asian elephants. Kaolin-activated TEG was performed on whole blood at 60 min and 24 hr postsampling (to replicate shipment to an external laboratory) as well as on freeze-thawed plasma samples, 12-14 mo postsampling. Reference intervals were calculated for fresh whole blood and freeze-thawed plasma samples. In the 24-hr analysis, storage artifacts, likely due to cellular degeneration, resulted in a hypercoagulable thromboelastogram and thus reduced sensitivity for detecting coagulopathies. Therefore, delayed analysis of whole blood samples is not recommended.


title: An Unusual Case of an Ethmoidal Arteriovenous Fistula Draining Into the Superior Ophthalmic Vein: Technical Case Report.

text: BACKGROUND AND IMPORTANCE Ethmoidal arteriovenous fistulae (AVF) are uncommon and are characterized by an aggressive clinical course. Typical venous drainage is into the frontal cortical veins. We present the case of a 76-year-old male patient who was found to have a right ethmoidal AVF draining directly into the superior ophthalmic vein (SOV), with no cavernous sinus involvement and an associated SOV aneurysm and was successfully treated using surgical cutdown of the SOV followed by endovascular embolization. CLINICAL PRESENTATION A 76-year-old man presented with chemosis, proptosis, and lid lag with occasional diplopia. Based on the clinical presentation, there was a suspicion of a carotid cavernous fistula. Cerebral angiography demonstrated a right ethmoidal to SOV fistula, without any involvement of the cavernous sinus, and a SOV aneurysm. Transarterial embolization of the fistula was attempted but was unsuccessful. An SOV approach was performed using SOV cutdown followed by endovascular embolization of the fistula from a transocular route using coils and Onyx embolic agent. There was complete obliteration of the fistula and associated venous aneurysm. The patient had a remarkable recovery. CONCLUSION In rare cases, ethmoidal AVFs can present with an unusual venous drainage. Clinical presentation may be similar to carotid cavernous fistulae, and proper identification of the lesion using an angiogram is essential to guide treatment. In cases in which other approaches fail to treat the fistula, direct surgical exposure of the SOV followed by embolization using coiling and Onyx may be successful in achieving AVF occlusion.


Guidance needed for singlehanded GPs to deal with covid-19 pandemic.


title: Obesity and SARS-CoV-2: a population to safeguard.

text: Evidence has lately emerged regarding an increased risk of SARS-CoV-2 with worse prognosis in patients with obesity, especially among the young. Weight excess is a well-established respiratory disease risk factor, and the newly reported correlation is therefore unsurprising. The underlying pathophysiology is likely multi-stranded, ranging from complement system hyperactivation, increased Interleukin-6 secretion, chronic inflammation, presence of comorbidities such as diabetes and hypertension, and a possible local, detrimental effect within the lung. Further understanding the link between obesity and SARS-CoV-2 is crucial, as this could aid proper tailoring of immunomodulatory treatments, together with improving stratification among those possibly requiring critical care. This article is protected by copyright. All rights reserved.


Triage of patients with COVID-19.


title: Potential of the ovine brain as a model for anesthesia-induced neuroapoptosis.

text: PURPOSE This study aimed to determine the feasibility of the fetal ovine model for anesthesia-induced neuroapoptosis detection and effect of dexmedetomidine on neuroapoptosis. METHODS Brains of fetal lambs that underwent tracheal occlusion for congenital diaphragmatic hernia were studied following anesthetic exposure. The brains of nine fetuses from six pregnant sheep were studied. Seven of these fetuses underwent surgery for tracheal balloon insertion at 118-120 days gestational age (GA) under 1.5-2.0% isoflurane for 2-3 h. Two weeks afterward, at balloon retrieval, a repeat anesthetic: 1.5-2% isoflurane for 6 h was administered. Five of these fetuses were also exposed to dexmedetomidine concurrently. Immunohistochemistry of fetal brains for apoptotic neurons using activated caspase-3 antibodies was compared to that of an unexposed control group at GA 109 and 122 days. RESULTS Neuroapoptosis was detected in the ovine fetus with GA- dependent variation observed in the hippocampus. Increased neuroapoptosis occurred in the isoflurane-only group. Fetuses with isoflurane-dexmedetomidine exposure exhibited decreased neuroapoptosis compared to isoflurane-only group. CONCLUSION The fetal ovine model is a suitable option for neuroapoptosis analysis. Isoflurane use appears to be associated with additional neuroapoptosis in ovine fetuses undergoing surgical stimulation. Possible amelioration of isoflurane-induced neuroapoptosis by dexmedetomidine deserves further study. Further studies of the effect of gestational age, dose, duration of anesthesia and surgical stimulation on neuroapoptosis are needed.


title: Influenza vaccines: time for a rethink.

text: Officials and professional societies treat influenza as a major public health threat for which the annual vaccine offers a safe and effective solution. In this article, I challenge these basic assumptions. I show that there is no good evidence that vaccines reduce serious complications of influenza, the outcomes the policy is meant to address. Moreover, promotional messages conflate "influenza" (disease caused by influenza viruses) with "flu" (a syndrome with many causes, of which influenza viruses appear to be a minor contributor). This lack of precision causes physicians and potential vaccine recipients to have unrealistic assumptions about the vaccine's potential benefit, and impedes dissemination of the evidence on nonpharmaceutical interventions against respiratory diseases. In addition, there are potential vaccine-related harms, as unexpected and serious adverse effects of influenza vaccines have occurred. I argue that decisions surrounding influenza vaccines need to include a discussion of these risks and benefits.


title: Abuse-deterrent and tamper-resistant opioids: how valuable are novel formulations in thwarting non-medical use?

text: INTRODUCTION In recent years, attention has been given to the development of abuse-deterrent and tamper-resistant opioid formulations in light of concern over the growing misuse and abuse of opioids prescribed for the treatment of chronic pain. AREAS COVERED This critical review discusses abuse-deterrent and tamper-resistant formulations, which may help to overcome concerns of misuse in using opioids for pain management. The role and utility of these novel formulations in clinical practice are outlined, as well as the risks and benefits associated with formulations that are currently available or under development. EXPERT OPINION Numerous concerns with the integration of these formulations into clinical practice remain, as no product is intended or capable of addressing all types of misuse or abuse. As a result, these formulations should not necessarily be considered preferred agents once available in clinical practice. Moreover, before initiating therapy with abuse-deterrent and tamper-resistant formulations, proper patient assessment to identify risk factors for misuse and abuse should be implemented and optimized. With screening and monitoring in place, it would then be sensible to consider these formulations in patients who appear to be at high risk of misuse, abuse and/or diversion.


title: Follow-up of skin lesions during the evolution of COVID-19: a case report.

text: The disease caused by the new coronavirus (COVID-19) has many systemic manifestations affecting the upper airways, lungs, gastrointestinal tract and inducing hematological repercussions. With the evolution of the pandemic, skin lesions were observed. However, there is little information about the evolution of the lesions at this moment. The authors report a case of a patient who had more than one exposure to the coronavirus during the evolution of the disease and manifested different types of edematous lesions. The lesions started in the prodromal period and changed their presentation and localization during the evolution of COVID-19. The lesions regressed quickly with the use of corticoid cream and antihistamine. Viral skin lesions are frequent causes of exanthema. However, viral etiology is not always investigated in acute urticarial and atypical erythematous-edematous conditions. The immunological basis of acute urticaria has points in common with COVID-19, justifying the appearance of lesions. Investigation of viral etiology should always be remembered in acute urticarial and edematous conditions.


title: Analysis and Prevention of Microplastics Pollution in Water: Current Perspectives and Future Directions.

text: The analysis, prevention, and removal of microplastics (MPs) pollution in water is identified as one major problem the world is currently facing. MPs can be directly released to water or formed by the degradation of bigger plastics. Nowadays, it is estimated that annually between 4 and 12 million tonnes of plastic go into the seas and oceans-with a forecast for them to outweigh the amount of fish in 2050. Based on the existing studies, the characterization of MPs in waters is still one of the remaining challenges because they can be easily confused with organic or other types of matter. Consequently, there is an urgent necessity to establish pathways for the chemical identification of the MP nature. In this perspective, the recent techniques and instrumentation for MP characterization (Raman and Fourier-transform infrared spectroscopies and microscopies, pyrolysis and thermal desorption gas chromatography, imaging techniques, etc.) are discussed including considerations to the multidimensionality of the problem. This perspective also summarizes and provides updated data on the sources and occurrence, transport and fate of MPs in aquatic ecosystems, as well as influencing conditions and factors affecting dispersal. Additionally, how engineering and biotechnological tools, such as advanced water treatments, would help to control, reduce, or even eliminate MP pollution in the near future is outlined.


title: Comprehensive assessment of disability post-stroke using the newly developed miFUNCTION scale.

text: BACKGROUND AND PURPOSE The modified Rankin Scale (mRS) is the most widely used primary outcome measure in acute stroke trials. However, substantial interobserver variability impairs outcome assessment as well as reduces power of clinical trials. Guided by the International Classification of Functioning, Disability and Health, we developed a comprehensive, hierarchical assessment tool (miFUNCTION) to address the shortcomings of the modified Rankin Scale and deliver a more thorough understanding of disability following stroke. METHODS The initial construct validity of miFUNCTION was established in a pilot study of patients at an outpatient stroke prevention clinic that had been diagnosed with stroke within 60 days. To further assess criterion validity, miFUNCTION was compared against the modified Rankin Scale and other outcome measures within the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial. Logistic regression analysis with miFUNCTION as an outcome was used to demonstrate the beneficial effect of endovascular treatment. RESULTS The pilot study showed moderate inter-observer agreement (k = 0.585, p < 0.005) but near perfect correlation between miFUNCTION and modified Rankin Scale (ρ = 0.821, p < 0.05). The correlation of miFUNCTION and modified Rankin Scale was near perfect again in the ESCAPE trial (ρ = 0.944). Effect size of the multivariable models using modified Rankin Scale (adjusted odds ratio: 3.45, 95% confidence interval: 2.05-5.78) and miFUNCTION (adjusted odds ratio: 3.32, 95% confidence interval: 1.99-5.55) as an outcome measure for the ESCAPE trial patients was similar. CONCLUSIONS miFUNCTION is strongly associated with the degree of disability following stroke both in an outpatient setting and a clinical trial. Further work remains to assess sensitivity to change and to improve the inter-observer reliability of the scale.


title: Intracorporeal Esophagojejunostomy Using a Circular or a Linear Stapler in Totally Laparoscopic Total Gastrectomy: a Propensity-Matched Analysis.

text: Purpose There is no consensus on the optimal method for intracorporeal esophagojejunostomy (EJ) in laparoscopic total gastrectomy (LTG). This study aims to compare 2 established methods of EJ anastomosis in LTG. Materials and Methods A total of 314 patients diagnosed with gastric cancer that underwent LTG in the period from January 2013 to October 2016 were enrolled in the study. In 254 patients, the circular stapler with purse-string "Lap-Jack" method was used, and in the other 60 patients the linear stapling method was used for EJ anastomosis. After propensity score matching, 58 were matched 1:1, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed. Results The 2 groups showed no significant difference in age, body mass index, or other clinicopathological characteristics. After propensity score matching analysis, the linear group had shorter operating time than the circular group (200.3±62.0 vs. 244.0±65.5, P≤0.001). Early postoperative complications in the circular and linear groups occurred in 12 (20.7%) and 15 (25.9%, P=0.660) patients, respectively. EJ leakage occurred in 3 (5.2%) patients from each group, with 1 patient from each group needing intervention of Clavien-Dindo grade III or more. Late complications were observed in 3 (5.1%) patients from the linear group only, including 1 EJ anastomosis stricture, but there was no statistical significance. Conclusions Both circular and linear stapling techniques are feasible and safe in performing intracorporeal EJ anastomosis during LTG. The linear group had shorter operative time, but there was no difference in anastomosis complications.


title: Hydrated silica exterior produced by biomimetic silicification confers viral vaccine heat-resistance.

text: Heat-lability is a key roadblock that strangles the widespread applications of many biological products. In nature, archaeal and extremophilic organisms utilize amorphous silica as a protective biomineral and exhibit considerable thermal tolerance. Here we present a bioinspired approach to generate thermostable virus by introducing an artificial hydrated silica exterior on individual virion. Similar to thermophiles, silicified viruses can survive longer at high temperature than their wild-type relatives. Virus inactivation assays showed that silica hydration exterior of the modified virus effectively prolonged infectivity of viruses by ∼ 10-fold at room temperature, achieving a similar result as that obtained by storing native ones at 4 °C. Mechanistic studies indicate that amorphous silica nanoclusters stabilize the inner virion structure by forming a layer that restricts molecular mobility, acting as physiochemical nanoanchors. Notably, we further evaluate the potential application of this biomimetic strategy in stabilizing clinically approved vaccine, and the silicified polio vaccine that can retain 90% potency after the storage at room temperature for 35 days was generated by this biosilicification approach and validated with in vivo experiments. This approach not only biomimetically connects inorganic material and living virus but also provides an innovative resolution to improve the thermal stability of biological agents using nanomaterials.