title: Information visualisation as a resource for popularising the technical-biomedical aspects of the last Ebola virus epidemic: The case of the Spanish reference press.

text: This study explores the role that information visualisation played in the popularisation of the technical-biomedical aspects of the last Ebola virus epidemic, the most devastating to date. Applying content analysis methods, the total population of information visualisations ( N = 209) was coded and analysed to identify topics, and to define features and identify patterns in the images. The corpus was based on the record of articles with graphics appearing in five Spanish reference newspapers from 22 March 2014 to 13 January 2016, the start and suppression of the epidemic, respectively. The results suggest that information visualisation was a key factor in the popularisation of the epidemic's technical-biomedical aspects, as well as contributing actively to construct, in the words of Myers, a narrative of nature.


title: Pediatric and Adolescent Extracranial Germ Cell Tumors: The Road to Collaboration.

text: During the past 35 years, survival rates for children with extracranial malignant germ cell tumors (GCTs) have increased significantly. Success has been achieved primarily through the application of platinum-based chemotherapy regimens; however, clinical challenges in GCTs remain. Excellent outcomes are not distributed uniformly across the heterogeneous distribution of age, histologic features, and primary tumor site. Despite good outcomes overall, the likelihood of a cure for certain sites and histologic conditions is less than 50%. In addition, there are considerable long-term treatment-related effects for survivors. Even modest cisplatin dosing can cause significant long-term morbidities. A particular challenge in designing new therapies for GCT is that a variety of specialists use different risk stratifications, staging systems, and treatment approaches for three distinct age groups (childhood, adolescence, and young adulthood). Traditionally, pediatric cancer patients younger than 15 years have been treated by pediatric oncologists in collaboration with their surgical specialty colleagues. Adolescents and young adults with GCTs often are treated by medical oncologists, urologists, or gynecologic oncologists. The therapeutic dilemma for all is how to best define disease risk so that therapy and toxicity can be appropriately reduced for some patients and intensified for others. Further clinical and biologic insights can only be achieved through collaborations that do not set limitations by age, sex, and primary tumor site. Therefore, international collaborations, spanning different cooperative groups and disciplines, have been developed to address these challenges.


title: The future of renal denervation in resistant hypertension.

text: Resistant hypertension, defined as inadequate blood pressure control despite three or more antihypertensive medications at maximally tolerated doses, is strongly linked to increased cardiovascular morbidity and mortality. Increased renal afferent and efferent sympathetic activity carried by nerves which arborize the adventitia of the renal arteries, appears to be central to the pathobiology of resistant hypertension. Historical experience indicates that surgical denervation and/or sympathectomy often dramatically reduced blood pressure in patients with malignant hypertension. Catheter-based radio-frequency renal denervation was developed in the past decade as a percutaneous adaptation of surgical denervation. Percutaneous renal denervation using a variety of systems has demonstrated to date, in non-randomized and unblinded studies, dramatic reductions in office-based blood pressure, but more modest impact on ambulatory blood pressure. The only single, appropriately powered, blinded, sham-controlled study of renal denervation conducted to date, however, failed to meet its primary endpoint, casting doubt on the value of the therapy. Ancillary benefits of renal denervation have been described in such conditions as diabetes mellitus, heart failure, and sleep apnea but require further study. While renal denervation is already widely available outside of the USA for commercial use, its utility in resistant hypertension must be vetted by further rigorous investigation before its use can be routinely recommended.


title: Detection of Human Bocavirus DNA by Multiplex PCR Analysis: Postmortem Case Report.

text: BACKGROUND Human bocavirus (HBoV) is a virus belonging to the Parvoviridae family, which has been newly discovered to be associated with respiratory tract infections in children. There are many reports worldwide on the endemicity of this virus. Since it is relatively new, it is not routinely detected in clinical laboratory investigations. CASE REPORT We demonstrated that HBoV infection caused the death of a 5-month-old girl with a history of high fever and wheezing. Human bocavirus (HBoV 1/2/3/4) was found in a nasopharyngeal swab, paraffin-embedded lung tissue and stool samples by multiplex PCR methods using postmortem microbiological analysis. CONCLUSION This case suggests that lower respiratory tract infections due to HBoV may cause severe and life-threatening diseases. Postmortem microbiology is useful in both clinical and forensic autopsies, and allows a suspected infection to be confirmed. To our knowledge, this report is the first document of a HBoV postmortem case in Turkey.


title: Strengthening China's Public Health Response System: From SARS to COVID-19.

text: Today, the world is experiencing a pandemic caused by a novel coronavirus. COVID-19 is the third disease from a coronavirus to cause a global outbreak, after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), and the second that emerged from China. During the 17 years between the SARS and the COVID-19 outbreaks, China has quadrupled its share of the world economy, lifted hundreds of millions of people out of poverty, and established a national health insurance system covering 95% of its 1.4 billion people. Will China's public heath response to a coronavirus epidemic be different this time? (Am J Public Health. Published online ahead of print March 26, 2020: e1-e2. doi:10.2105/AJPH.2020.305654).


title: Current status of laparoendoscopic single-site surgery in urologic surgery.

text: Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.


Dermatology before, during and after COVID 19.


title: Laparoscopic repeat hepatectomy is a more favorable treatment than open repeat hepatectomy for contralateral recurrent hepatocellular carcinoma cases.

text: BACKGROUND We compared surgical outcomes, with a focus on tumor characteristics, of laparoscopic repeat hepatectomy (LRH) and open repeat hepatectomy (ORH) to identify recurrent hepatocellular carcinoma (HCC) cases where the LRH procedure would be more favorable than ORH. METHODS Eighty-one HCC patients who underwent repeat hepatectomy in our hospital from 2008 to 2019 were retrospectively analyzed in this study. Of these patients, 30 and 51 patients underwent LRH and ORH, respectively. We analyzed surgical outcomes of LRH and ORH, focusing on tumor characteristics such as tumor size, location, distance from major vessels, and contralateral or ipsilateral tumor recurrence to determine what factors could affect surgical outcomes. Subsequently, using a propensity-matched cohort, we compared the impact of those factors on LRH and ORH outcomes. RESULTS In the entire cohort, the LRH operation time was significantly shorter in contralateral recurrent HCC cases than in ipsilateral recurrent HCC cases (252 vs. 398 min, P = 0.008); however, such a difference was not observed in the ORH operation time. We subsequently compared the surgical outcomes, in terms of the location of tumor recurrence, between the LRH and ORH groups in a propensity-matched cohort. In total, 23 patients were included in each of these groups. We found that the LRH procedure had significantly shorter operative time than the ORH procedure in the contralateral recurrent HCC cases (253 vs. 391 min, P = 0.018); however, we did not observe such a difference in the ipsilateral recurrent HCC cases (372 vs. 333 min, P = 0.669). LRH had lower blood loss, similar postoperative complications and shorter hospital stay than ORH in both contralateral and ipsilateral recurrent HCC cases. CONCLUSIONS LRH is likely considered a more favorable approach than ORH in treating patients with contralateral recurrent HCC.


title: A Hemodynamically Significant Patent Ductus Arteriosus Does Not Affect Cerebral or Renal Tissue Oxygenation in Preterm Infants.

text: BACKGROUND Patent ductus arteriosus (PDA) is common in preterm infants and is associated with significant morbidity. To determine whether the PDA is hemodynamically significant (HSDA), several echocardiographic parameters have been suggested, including retrograde diastolic blood flow in the descending aorta (Dao). OBJECTIVE To assess the impact of an HSDA, including retrograde diastolic flow in the Dao, on regional tissue oxygen saturation (rSO2) and extraction measured by near-infrared spectroscopy (NIRS). METHODS This is a prospective observational cohort study in which we included preterm infants (GA <32 weeks) who underwent echocardiographic screening because of clinical signs of an HSDA within 2 weeks after birth. We measured cerebral and renal rSO2 on the day of echocardiography. HSDA was diagnosed if left-to-right shunting through the PDA was accompanied by left atrial-to-aortic root ratio >1.4 and/or left pulmonary artery end-diastolic flow velocity >0.2 m/s and/or retrograde diastolic blood flow in the Dao. RESULTS Forty-nine infants were included, with a median GA of 27.6 weeks (IQR: 26.1-29.0), birth weight of 980 g (IQR: 800-1,200), and postnatal age of 77 h (IQR: 70-107). Infants with a closed duct (n = 11), a non-HSDA (n = 18), and an HSDA (n = 20) had similar cerebral and renal NIRS measurements. Retrograde diastolic blood flow in the Dao, present in 11 infants with PDA, also did not affect cerebral and renal NIRS measurements. CONCLUSION In preterm infants with clinical signs of an HSDA within 2 weeks after birth, cerebral and renal oxygen saturation and extraction are not affected by an HSDA or by retrograde diastolic blood flow in the Dao.


title: Cornual resection for interstitial pregnancy by laparoendoscopic single-site surgery.

text: OBJECTIVE To present two cases of interstitial pregnancy treated successfully by use of laparoendoscopic single-site surgery (LESS). DESIGN Case series. SETTING Department of obstetrics and gynecology at a tertiary health care facility. PATIENT(S) Two women with interstitial pregnancy requiring surgical treatment. INTERVENTION(S) Laparoscopy by use of LESS with the single-incision laparoscopic surgery (SILS) system. MAIN OUTCOME MEASURE(S) Feasibility of LESS with the SILS system. RESULT(S) Two patients were treated successfully by use of LESS with the SILS system. After laparoscopic confirmation of the interstitial pregnancy, a cornual resection was performed with bipolar forceps and scissors for the first patient and with an automatic stapler for the second. CONCLUSION(S) Laparoscopic treatment of interstitial pregnancy by use of LESS seems feasible. Larger series are necessary to confirm these findings.


title: Intra-operative double-stapled colorectal or coloanal anastomotic complications of laparoscopic low anterior resection for rectal cancer: double-stapled anastomotic complication could result in persistent anastomotic leakage.

text: BACKGROUND Laparoscopic surgery for rectal cancer is technically demanding and can be hindered by unexpected intra-operative complications. Among the various intra-operative complications, double-stapled anastomotic complications are more serious and complicated to manage. The purpose of this study is to analyze the impact of intra-operative double-stapled colorectal or coloanal anastomotic complications on short-term surgical outcomes and persistent leak, and risk factors of intra-operative double-stapled anastomotic complication. METHODS Consecutive 363 cases of laparoscopic low anterior resection from August 2004 to November 2012 were analyzed in this study. We retrospectively reviewed intra-operative double-stapled anastomotic complications and compared patient characteristics, surgical data, post-operative clinical data, and pathological data between groups with and without intra-operative double-stapled anastomotic complications. And we analyzed risk factors for double-stapled anastomotic complication. RESULTS There were 20 intra-operative double-stapled anastomotic complications among the patients (5.5 %). Operation time was longer (304.8 ± 122.0 vs. 197.1 ± 87.5 min, p = 0.001) and more diversion ileostomy were made (75 vs. 34.7 %, p < 0.001) in the group with double-stapled anastomotic complications. There were no differences in terms of surgical morbidity, conversion rate, anastomotic leakage, and hospital stay. However, there was more persistent anastomotic leakage (15 vs. 0.9 %, p = 0.003) in the group with double-stapled anastomotic complications. In univariate analysis, risk factors for double-stapled anastomotic complications were male, T4 stage lesion, and three or more stapler firings. CONCLUSIONS The double-stapled anastomotic complications during laparoscopic low anterior resection increased operation time and rate of diversion ileostomy. Although these factors did not adversely affect short-term surgical outcome including post-operative morbidity and anastomotic leakage, double-stapled anastomotic complications could increase persistent anastomotic leakage rate.


Covid-19: Use radiotherapy only if "unavoidable," says NICE.


title: Pilot in vivo study of an absorbable polydioxanone vena cava filter.

text: OBJECTIVE The objectives of this study were to evaluate tensile strength retention of polydioxanone as a function of time in a swine venous system and to assess the feasibility of an absorbable inferior vena cava (IVC) filter made from polydioxanone in a pilot swine study. METHODS Twenty strands (60 cm each) of size 1 polydioxanone absorbable suture (Ethicon, Somerville, NJ) were placed in the central venous system of domestic swine. Strands were harvested at weekly intervals during 10 weeks for tensile strength testing. Results were compared with control samples obtained from an in vitro engineered circulation system containing sodium phosphate buffer solution. Three IVC filters braided from polydioxanone suture were also catheter deployed in three swine to assess absorbable IVC filter feasibility. RESULTS Polydioxanone retained 82% tensile strength in vitro vs 79% in vivo at 35 days (P > .22), the desired prophylactic duration. For IVC filters made from polydioxanone, technical success of placement was achieved in all three filters deployed (100%). Autologous thrombus deployed inferior to the filter remained trapped in the filter until thrombus resorption, with no evidence of pulmonary emboli on follow-up computed tomography. There were no instances of caval penetration, filter-induced IVC thrombosis, filter migration, or tilt >15 degrees with imaging and clinical follow-up carried out to 32 weeks. CONCLUSIONS Strength retention of polydioxanone suture placed in the venous system of swine is similar to earlier in vitro studies out to 10 weeks (P > .06 for all weeks) and is more than sufficient (8.20 ± 0.37 kg mean load at break for size 1) to trap thrombus. Pilot animal study suggests that an absorbable polydioxanone IVC filter can be catheter deployed to capture and to hold iatrogenically administered autologous thrombus through resorption.


title: Totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy using anterior approach in HCC patient with Type II portal vein anomaly: a case report.

text: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gradually developed because of rapid hypertrophy of the future liver remnant volume (FLR) in spite of high morbidity. To minimize the patient's postoperative pain and morbidity including wound complication caused by two consecutive major abdominal operations, we adopted a totally laparoscopic approach and used a composite mesh graft. Also, to maximize the oncologic efficacy, we adopted the "anterior approach" technique. A 44-year-old woman with large hepatitis B-related hepatocellular carcinoma (HCC) in her right lobe was transferred to our hospital for surgical treatment. Preoperatively predicted FLR by a CT scan was 21% and type II portal vein anomaly was detected. A totally laparoscopic approach was planned. During the first stage operation, right anterior and posterior portal veins were meticulously dissected and tied. After parenchymal transection by the "anterior approach" technique, two glissonian pedicles of the right liver were individually isolated. A composite mesh graft was used to prevent severe adhesion on both liver partition surfaces. During the second-stage operation, 9 days after the first stage operation, the two isolated glissonian pedicles were initially transected. After full mobilization of the right lobe, the right hepatic vein was also transected. The right lobe was removed through the Pfannenstiel incision. She was discharged 7 days after the second stage operation. Her postoperative course was uneventful and there was no HCC recurrence for 15 months after hepatectomy. A totally laparoscopic ALPPS procedure can be a feasible technique that ensures patient safety and oncologic superiority, even in patients with complicated anatomical variation.


title: A versatile bifunctional dendritic cell targeting vaccine vector.

text: We have developed an efficient versatile in vivo dendritic cell (DC) targeting vector for delivering different classes of antigens such as proteins, peptide, glycolipids and naked DNA for vaccine applications. A single chain antibody (scFv) that recognizes DEC-205 receptor of DC was fused with a core-streptavidin domain and expressed in Escherichia coli using the T7 expression system. The bifunctional fusion protein (bfFp) was expressed as a periplasmic soluble protein and affinity-purified in its monomeric form. The bifunctional activity against DEC-205 and biotin was characterized by ELISA and Western blot. In vivo DC targeting of a diverse group of biotinylated antigens such as viral and bacterial proteins, a cancer peptide, gangliosides and DNA of certain infectious diseases was conducted in mice. Results show that in the presence of bfFp and costimulatory anti-CD40 mAb, both humoral and cell-mediated responses were augmented in either the single antigen or multiple antigen targeting strategy. Lastly, bfFp based DC targeting of antigens in low doses may be a useful strategy for the design of monovalent or polyvalent vaccines for the masses.


title: Anesthesia and perioperative management of patients who undergo transfemoral transcatheter aortic valve implantation: an observational study of general versus local/regional anesthesia in 125 consecutive patients.

text: OBJECTIVE To describe differences in intra- and postoperative care between general (GA) and local/regional anesthesia (LRA) in consecutive high-risk patients with aortic stenosis who underwent transfemoral transcatheter aortic valve implantation (TAVI). DESIGN A retrospective review of data collected in an institutional registry. SETTING An academic hospital. PARTICIPANTS One hundred twenty-five consecutive patients with severe aortic stenosis who underwent transfemoral TAVI. INTERVENTIONS GA versus LRA followed by postoperative care. Complications were defined by pre-established criteria. MATERIAL AND METHODS Consecutive patients referred for transfemoral TAVI between October 2006 and October 2010 initially underwent GA (n = 91) followed by LRA after March 2010 (n= 34). Results are presented as mean ± standard deviation or median (25-75 percentiles) as appropriate. GA and LRA TAVI patients had similar preoperative characteristics. LRA was associated with a significantly shorter procedure duration (LRA: 80 [67-102]; GA: 120 [90-140 minutes]; p < 0.001), hospital stay (LRA: 8.5 [7-14.5]; GA: 15.5 [10-24] days; p < 0.001), intraoperative requirements of catecholamines (LRA 23%; GA: 90% of patients; p < 0.001), and volume expansion (LRA: 11 [8-16]; GA: 22 [15-36] mL/kg; p < 0.001). There were significant differences in delta creatinine (day 1, preoperative creatinine values; LRA: 0 [-12 to 9]; GA: -15 (-25 to 2.9) μmol, p < 0.004). The frequency of any postoperative complications was 38% (LRA) and 77% (GA) (p = 0.11). Thirty-day mortality was 7% (GA) and 9% (LRA) (p = 0.9). CONCLUSIONS This observational study suggests that LRA was associated with less intraoperative hemodynamic instability and significant shortening of the procedure and hospital stay. Changes in the anesthetic technique adapted to changes in TAVI interventional techniques and did not increase the rate of postoperative complications.


How Academic Health Systems Can Move Forward Once COVID-19 Wanes.


September Updates: People and Places.


title: An allelic variant of Crry in the murine Sle1c lupus susceptibility interval is not impaired in its ability to regulate complement activation.

text: The Sle1c subinterval on distal murine chromosome 1 confers loss of tolerance to chromatin. Cr2, which encodes complement receptors 1 and 2 (CR1/CR2; CD35/CD21), is a strong candidate gene for lupus susceptibility within this interval based on structural and functional alterations in its protein products. CR1-related protein/gene Y (Crry) lies 10 kb from Cr2 and encodes a ubiquitously expressed complement regulatory protein that could also play a role in the pathogenesis of systemic lupus erythematosus. Crry derived from B6.Sle1c congenic mice migrated at a higher m.w. by SDS-PAGE compared with B6 Crry, as a result of differential glycosylation. A single-nucleotide polymorphism in the first short consensus repeat of Sle1c Crry introduced a novel N-linked glycosylation site likely responsible for this structural alteration. Five additional single-nucleotide polymorphisms in the signal peptide and short consensus repeat 1 of Sle1c Crry were identified. However, the cellular expression of B6 and B6.Sle1c Crry and their ability to regulate the classical pathway of complement were not significantly different. Although soluble Sle1c Crry regulated the alternative pathway of complement more efficiently than B6 Crry, as a membrane protein, it regulated the alternative pathway equivalently to B6 Crry. These data fail to provide evidence for a functional effect of the structural alterations in Sle1c Crry and suggest that the role of Cr2 in the Sle1c autoimmune phenotypes can be isolated in recombinant congenic mice containing both genes.


title: Effect of whole-body vibration exercise in preventing falls and fractures: a systematic review and meta-analysis.

text: OBJECTIVE To investigate the effect of whole-body vibration exercise (WBV) on fracture risk in adults ≥50 years of age. DESIGN A systematic review and meta-analysis calculating relative risk ratios, fall rate ratio and absolute weighted mean difference using random effects models. Heterogeneity was estimated using I2 statistics, and the Cochrane Collaboration's risk of bias tool and the GRADE approach were used to evaluate quality of evidence and summarise conclusions. DATA SOURCES The databases PubMed, Embase and the Cochrane Central Register from inception to April 2016 and reference lists of retrieved publications. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials examining the effect of WBV on fracture risk in adults ≥50 years of age. The primary outcomes were fractures, fall rates and the proportion of participants who fell. Secondary outcomes were bone mineral density (BMD), bone microarchitecture, bone turnover markers and calcaneal broadband attenuation (BUA). RESULTS 15 papers (14 trials) met the inclusion criteria. Only one study had fracture data reporting a non-significant fracture reduction (risk ratio (RR)=0.47, 95% CI 0.14 to 1.57, P=0.22) (moderate quality of evidence). Four studies (n=746) showed that WBV reduced the rate of falls with a rate ratio of 0.67 (95% CI 0.50 to 0.89, P=0.0006; I2=19%) (moderate quality of evidence). Furthermore, data from three studies (n=805) found a trend towards falls reduction (RR=0.76, 95% CI 0.48 to 1.20, P=0.24; I2=24%) (low quality of evidence). Finally, moderate to low quality of evidence showed no overall effect on BMD and only sparse data were available regarding microarchitecture parameters, bone turnover markers and BUA. CONCLUSIONS WBV reduces fall rate but seems to have no overall effect on BMD or microarchitecture. The impact of WBV on fractures requires further larger adequately powered studies. This meta-analysis suggests that WBV may prevent fractures by reducing falls. PROSPERO REGISTRATION NUMBER CRD42016036320; Pre-results.


docid: jnugqqvm

title: Extended right hepatectomy for hilar bile duct carcinoma using the modified liver hanging maneuver.

text: To achieve complete extended right hepatectomy or trisectionectomy for a bismuth type IV hilar bile duct carcinoma, we propose the application of Belghiti's liver hanging maneuver (LHM) using a small nasogastric tube. This small nasogastric tube was placed in the cut plane: the top of the tube was placed between the hepatic veins. The tube was placed along the border between the left lateral sector and Spiegel's caudate lobe and the bottom of the tube was placed at the left side of the umbilical Glissonian pedicle. Hepatic parenchyma was transected using a vascular sealing device. Hepatic transection was always targeted to the tube and, eventually, a cut line of left hepatic ducts remained. We report the case of a 76-year-old female and an 83-year-old female with widely extended hilar bile duct carcinomas showing Bismuth type IV. Applying the modified LHM for extended right hepatectomy, the cut planes were easily and adequately obtained in patients with hilar bile duct carcinoma.


The Role of Telehealth in Reducing the Mental Health Burden from COVID-19.


title: Single port laparoscopic surgery for patients with complex and recurrent Crohn's disease.

text: BACKGROUND Single port laparoscopic surgery (SPLS) is a modified access technique allowing grouping of instruments at a single parietal site. It is intuitively appealing specifically for patients with Crohn's disease (CD) as its minimal invasiveness favors cosmesis and facilitates any future (re)operation. METHODS Consecutive patients presenting either electively or urgently for resectional surgery for CD over a 36 month period were considered for SPLS using, by preference, a transumbilical 'Surgical Glove Port'. Standard, straight laparoscopic instrumentation was used without additional resources. RESULTS Of 33 consecutive, unselected patients, 28 (92%) had their procedure initiated by SPLS including those needing urgent intervention (n=15) and those with prior abdominal operation (n=8), obstruction (n=7), mass (n=6), fistula (n=6) and/or abscess (n=4). The median (range) age and BMI of the patients were 31 (17-69) years and 21.3 (18.6-28) kg/m2 respectively. 31 had ileocolonic resection (6 with recurrent disease) while two underwent segmental colectomy. No-one suffered intraoperative or anastomotic complication. Both conversion (15%) and postoperative complication (13 Clavian-Dindo complications - I: 8; II: 2; IIIa: 3) rates were predominantly reflective of patient and disease complexity. Median (range) postoperative day of discharge was 6 (3-33) overall and 5 (3-18) in those completed by SPLS. There was one early readmission (for infectiouscolitis) and median follow-up is now 21 months. CONCLUSIONS Complex and recurrent Crohn's resections can be performed by SPLS in the majority of patients presenting elective or urgently for surgery. The Surgical Glove Port performs capably and, by minimizing cost, can facilitate broad embrace of this approach.


title: Preliminary Data Related to the Effect of Climacostol Produced by the Freshwater Ciliate Climacostomum virens on Human Adenovirus.

text: The new epidemiological scenario has so far focused on the environmental circulation of human viral pathogens. Owing to the side effects of chemical disinfectants, there is an increasing need for knowledge on the use of virucidal compounds, especially those of a natural origin. Climacostol is a molecule produced by a freshwater ciliate and it exhibits activity against bacterial and fungal pathogens. We thus also speculated that there might be an effect on viral viability, which has never been tested. To evaluate such activity, we chose human adenovirus (HAdV), which is representative of waterborne viruses. We conducted experiments using HAdV serotype 5, whose titer was determined by infecting HeLa cell cultures. HAdV5 was shown to be sensitive to climacostol at a concentration of 0.0002 mg/mL, with an approximate 3 Log10 reduction when the initial titer of HAdV5 was approximately 104 and 103 TCID50/mL. These preliminary results could be an important starting point for further research aimed at improving the characterization of climacostol activity under different experimental conditions and against various viruses, including enveloped ones (i.e., the coronavirus). The production of climacostol by a protist living in fresh water also suggests a possible application in the activated sludge of wastewater treatment plants.


docid: zzockvin

title: Covid-19 and mental health: a transformational opportunity to apply an evidence-based approach to clinical practice and research.


title: Self-microemulsifying drug delivery system (SMEDDS)--challenges and road ahead.

text: Self-microemulsifying drug delivery system (SMEDDS) has emerged as a vital strategy to formulate poor water soluble compounds for bioavailability enhancement. However, certain limitations are associated with SMEDDS formulations which include in vivo drug precipitation, formulation handling issues, limited lymphatic uptake, lack of predictive in vitro tests and oxidation of unsaturated fatty acids. These limitations restrict their potential usage. Inclusion of polymers or precipitation inhibitors within lipid based formulations helps to maintain drug supersaturation after dispersion. This, thereby, improves the bioavailability and reduces the variability on exposure. Also, formulating solid SMEDDS helps to overcome liquid handling and stability problems. Usage of medium chain triglycerides (MCT) and suitable antioxidants to minimize oxidation of unsaturated fatty acids are few of the steps to overcome the limitations associated with SMEDDS. The review discussed here, in detail, the limitations of SMEDDS and suitable measures that can be taken to overcome them.


title: Laparoscopic repair of complex ventral hernia facilitated by pre-operative chemical component relaxation using Botulinum Toxin A.

text: PURPOSE The operative management of complex ventral hernia poses a formidable challenge, despite recent advances in surgical techniques. Recurrence rates after complex ventral hernia repair remain high, and increase with each failed attempt. This study examines the effect of pre-operative abdominal wall chemical component relaxation using Botulinum Toxin A (BTA) to induce temporary flaccid paralysis in order to facilitate laparoscopic repair of large complex ventral hernia. METHODS This is a prospective evaluation of 27 patients from January 2013 to August 2015 who underwent ultrasound guided BTA injections to the lateral abdominal wall muscles prior to elective complex ventral hernia repair. Non-contrast serial CT imaging was obtained pre- and post-BTA injection to measure change in fascial defect size and abdominal wall muscle thickness and length. Fascial defects were closed and hernias repaired using laparoscopic or laparoscopic-assisted intra-peritoneal onlay mesh (IPOM) techniques. RESULTS 27 patients received pre-operative BTA injections which were well tolerated with no complications. Comparison of pre-BTA and post-BTA CT imaging demonstrated a significant increase in mean length of the lateral abdominal wall from 15.7 cm pre-BTA to 19.9 cm post-BTA (p < 0.0001), with mean unstretched length gain of 4.2 cm/side (range 0-11.7 cm/side). All hernias were surgically reduced and repaired with mesh, with no early recurrences. CONCLUSION Pre-operative administration of BTA is a safe and effective technique in the pre-operative preparation of patients undergoing elective complex ventral hernia repair. This technique lengthens and relaxes the laterally retracted abdominal muscles and enables laparoscopic closure of large complex ventral hernia.


title: Intrinsic repair of full-thickness articular cartilage defects in the axolotl salamander.

text: OBJECTIVE The ability to fully regenerate lost limbs has made the axolotl salamander (Ambystoma mexicanum) a valuable model for studies of tissue regeneration. The current experiments investigate the ability of these vertebrates to repair large articular cartilage defects and restore normal hyaline cartilage and joint structure independent of limb amputation. METHODS Full-thickness articular cartilage defects were made by resection of the medial femoral condyle to the level of the metaphysis. At 0, 2 days, 1, 2, 3, 4, 6, 8, 12, 18, 24, 36 and 48 weeks post-surgery, the repair process was analyzed on H&E and Safranin-O stained 7 μm tissue sections. Symmetric Kullback-Leibler (SKL) divergences were used to assess proteoglycan staining intensities. Immunohistochemistry was performed for collagen types I and II. RESULTS A fibrous "interzone-like" tissue occupies the intraarticular space of the axolotl femorotibial joint and no evidence of joint cavitation was observed. By 4 weeks post-surgery, cells within the defect site exhibited morphological similarities to those of the interzone-like tissue. At 24 weeks, joint structure and cartilaginous tissue repair were confirmed by immunohistochemistry for collagen types I and II. Quantitation of Safranin-O staining indicated restoration of proteoglycan content by 18 weeks. CONCLUSIONS The axolotl femorotibial joint has morphological similarities to the developing mammalian diarthrodial joint. Cells in the intraarticular space may be homologous to the interzone tissue and contribute to intrinsic repair of full-thickness articular cartilage defects. Taken together, these results suggest that the axolotl may serve as a valuable model for the investigation of cellular and molecular mechanisms that achieve full articular cartilage repair.


title: Prospective randomized comparison of single-incision laparoscopic cholecystectomy with new facilitating maneuver vs. conventional four-port laparoscopic cholecystectomy.

text: OBJECTIVE We aimed to investigate the technical feasibility of single-incision laparoscopic cholecystectomy (SILC) with our new facilitative maneuver and to compare it with the gold standard four-port laparoscopic cholecystectomy (LC). MATERIAL AND METHODS Operation time, cosmetic score and incisional hernia rates between LC (n=20) and SILC-1 (first 20 consecutive operations with the new technique) and 2 (subsequent 20 operations with the new technique) were compared. RESULTS The median operation time for LC, SILC-1 and SILC-2 were; 35 min (12-75), 47.5 min (30-70), and 30 min (12-80), respectively (p=0.005). The operation duration was similar in LC and SILC-2 (p=0.277) groups. Wound seroma rate was higher in SILC-1 (45%) and SILC-2 (30%) groups than LC (5%) group (p=0.010). Cosmetic score was similar between all the groups. Hernia rates were 15.8% and 5.3% in the SILC-1 and SILC-2 groups, respectively, while there was no hernia in the LC group. CONCLUSION SILC with new facilitating maneuver is comparable with classical four-port laparoscopic cholecystectomy in terms of ease, operation time, reproducibility and safety. Besides these advantages, the single-incision access technique must be optimized to provide comparable wound complication and postoperative hernia rates before being recommended to patients.


title: Modeling the spread of Middle East respiratory syndrome coronavirus in Saudi Arabia.

text: Middle East respiratory syndrome coronavirus has been persistent in the Middle East region since 2012. Abundant scientific evidence showed that dromedary camels are the primary host of the virus. Majority of human cases (i.e., 75% or 88%) are due to human-to-human transmission, while the others are due to camel-to-human transmission. Mathematical modeling of Middle East respiratory syndrome coronavirus camel-to-camel transmission was lacking. Using the plug-and-play likelihood-based inference framework, we fitted a susceptible-exposed-infectious-recovered-susceptible model of camels to the reported human cases with a constant proportion of human cases from camels (i.e., either 25% or 12%). We considered two scenarios: (i) the transmission rate among camels is time-varying with a constant spill-over rate from camels to human or (ii) the spill-over rate is time-varying with a constant transmission rate among camels. Our estimated loss-of-immunity rate and prevalence of Middle East respiratory syndrome coronavirus infections among camels largely matched with previous serological or virological studies, shedding light on this issue. We recommended including dromedary camels in animal surveillance and control of Middle East respiratory syndrome coronavirus in Saudi Arabia which could help reduce their sporadic introductions to humans.


title: Serum LL-37 Levels Associated With Severity of Bronchiolitis and Viral Etiology.

text: Background LL-37 is a host defense peptide with antimicrobial and immunomodulatory properties. We examined the relation of serum LL-37 levels to the severity of bronchiolitis and viral etiology. Methods We performed a 17-center prospective cohort study in infants hospitalized with bronchiolitis over 3 winters (2011-2014). Site teams collected clinical data, nasopharyngeal aspirates and serum. We used real-time polymerase chain reaction to test nasopharyngeal aspirates for 16 viruses. We tested serum for LL-37. Severity of bronchiolitis was defined by intensive care use and hospital length of stay. Viral etiology was defined as respiratory syncytial virus (RSV) or rhinovirus (RV), including coinfections with other viruses. Results The median age of the 1005 enrolled infants was 3 months (interquartile range, 2-6 months). After adjustment for 12 variables, LL-37 levels in the lowest quartile, compared with the highest, were associated both with intensive care use (adjusted odds ratio [aOR], 1.97; P = .01) and longer hospital stay (1.34; P < .001). In separate multivariable models, infants with LL-37 levels in the lowest 3 quartiles, compared with the highest, were more likely to have RSV (eg, aOR, 2.6 [lowest quartile]; P < .001 [all quartiles]). By contrast, infants with the lowest 3 LL-37 quartiles were less likely to have RV (eg, aOR, 0.5 [lowest quartile]; Pall quartiles ≤ .03 [all quartiles]). Conclusions In a large multicenter study of infants hospitalized with bronchiolitis, lower levels of serum LL-37 were associated with increased severity of illness. There was also an inverse relationship between LL-37 levels and the most common virus causing bronchiolitis, RSV. These findings highlight the role of LL-37 in the pathogenesis of bronchiolitis.


title: How reliable are sympathetic skin responses in subjects with spinal cord injury?

text: OBJECTIVE To determine the test-retest reliability of sympathetic skin responses (SSR) in individuals with spinal cord injury (SCI). METHODS Fourteen men and four women with traumatic SCI (age: 44 ± 18 years; C2-T11; AIS A-D; 1-383 months post-injury) participated in two electrophysiological testing sessions separated by an average of 1 day. During each session, sudomotor function was tested supine by recordings of SSRs in both hands and feet. Two stimulation approaches were chosen: median nerve stimulation and a deep breath maneuver. SSR recordings were analyzed as SSR scores representing the presence or absence of responses. In addition, SSR amplitude and latencies were calculated. Test-retest reliability for the SSR score was calculated by the intraclass correlation coefficient (ICC) and its confidence interval. Coefficient of variation (CV) was calculated for SSR amplitudes and latencies. RESULTS SSR score to median nerve stimulation demonstrated 'almost perfect' reliability with ICCs of 0.97 and 0.96, for both hands and feet, respectively. The SSR score to deep breath maneuver was slightly lower, such as 0.89 and 0.74 for hands and feet. The CV of SSR amplitudes to median nerve stimulation was 48 and 18% for hands and feet, respectively, and 7 and 12% for the latency. INTERPRETATION The qualitative interpretation of SSR by its presence or absence is a reliable way to assess sudomotor function in individuals with SCI. Although methodical procedures try to standardize SSR testings, quantitative SSR outcomes (amplitude, latency) are still highly variable.


title: Reinforced Stapling Technique for Reconstruction After Laparoscopic Distal Gastrectomy.

text: PURPOSE We outline our reinforced stapling technique for reconstruction after laparoscopic distal gastrectomy (LDG). We also investigated the safety and feasibility of short-term surgical outcomes of this technique for patients with gastric cancer (GC). MATERIALS AND METHODS This is a retrospective study of 24 consecutive patients with GC who underwent reinforced stapling technique for reconstruction after LDG at our institute between 2016 and 2017. We adopted intracorporeal anastomosis, namely delta-shaped Billroth I gastroduodenostomy or Roux-en-Y gastrojejunostomy, using reinforced staples with polyglycolic acid sheets (Neoveil). RESULTS No anastomosis-related complications (anastomotic leakage, anastomotic stricture, postoperative gastrointestinal bleeding) were found in our 24 consecutive patients. CONCLUSIONS Reinforced stapling for reconstruction after LDG is a feasible and safe procedure for GC with regard to short-term surgical outcomes.


Social Media Use During Social Distancing.


title: Does respiratory virus coinfection increases the clinical severity of acute respiratory infection among children infected with respiratory syncytial virus?

text: BACKGROUND Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory infection in children less than 5 years of age. The impact of non-RSV respiratory virus coinfection on the severity of RSV disease is unknown. METHODS This hospital-based prospective study was conducted in Nagasaki, Japan, on all children less than 5 years of age with acute respiratory infection (ARI) who had undergone a rapid RSV diagnostic test between April 2009 and March 2010. Thirteen respiratory viruses were identified from nasopharyngeal swab samples using a multiplex polymerase chain reaction; polymerase chain reaction-positive samples were considered as confirmed respiratory virus infections. The cases were classified into 3 categories (pneumonia, moderate-to-severe nonpneumonic ARI and mild ARI) according to the findings of the chest radiograph and the hospitalization records. RESULTS Among 384 cases enrolled, 371 were eligible for analysis, of whom 85 (23%) were classified as pneumonia cases; 137 (37%) as moderate-to-severe nonpneumonic ARI cases and 162 (40%) as mild ARI cases. RSV was detected in 172 cases (61.6%), and 31 cases (18.0%) had double or triple infections with other respiratory viruses. RSV infection was more frequently observed in pneumonia cases (odds ratio [OR]: 2.3; 95% confidence interval [CI]: 1.31-3.9) and moderate-to-severe nonpneumonic ARI cases (OR: 2.95; 95% CI: 1.82-4.78) than in mild ARI cases. The association with moderate-to-severe nonpneumonic ARI cases was stronger with RSV/non-RSV respiratory virus coinfection (adjusted OR: 4.91; 95% CI: 1.9-12.7) than with RSV single infection (adjusted OR: 2.77; 95% CI: 1.64-4.7). CONCLUSIONS Non-RSV respiratory virus coinfection is not uncommon in RSV-infected children and may increase the severity of RSV disease.


title: Reply to letter to the editor.

text: We congratulate Martín Carreras-Presas et al (2020) for their instructive article presenting cases of oral vesiculobullous lesions associated with SARS-COV-2 infection (Martín Carreras-Presas et al., 2020). Furthermore, an irregular ulcer on the tongue (Chaux-Bodard, Deneuve & Desoutter, 2020) and reactivation of oral herpes simplex virus type-1 were reported as intraoral findings of COVID-19 patients, recently (Tang et al., 2020).


[COVID-19 pandemic: the need to reorganize a Cardiology Department in a hospital of the Lombardy Region, Italy].


title: Diagnosis and surgical management of traumatic cerebrospinal fluid oculorrhea: case report and systematic review of the literature.

text: Background Oculorrhea, or cerebrospinal fluid leakage developing from a cranio-orbital fistula, is a rare development following traumatic injury. Case Report A 22-year-old man involved in a motor vehicle accident developed a blowout fracture of the left orbital roof penetrating the frontal lobe, inducing oculorrhea. He underwent a supraorbital craniotomy for removal of the bony fragment and skull base reconstruction using a pericranial flap. Methods A systematic review of the database was performed to identify all prior cases of traumatic oculorrhea. Results Twenty-two reported cases met inclusion criteria for subsequent analysis. Oculorrhea developed due to blunt and penetrating head injury in 14 (64%) and 8 patients (36%), respectively. The most common mechanisms were car accidents, stab wounds, falls, and gunshot wounds. Ocular signs and symptoms-including visual loss, ophthalmoplegia, and pupillary dysfunction-were commonly associated findings. Initial conservative management was successful in four patients. Thirteen patients underwent initial surgical intervention, and three additional patients required operative intervention following failed conservative treatment. Conclusion Although oculorrhea rarely develops following severe orbital trauma, suspicion should nevertheless be maintained to facilitate more prompt diagnosis and management. The decision for conservative versus surgical management often depends on the severity of the fracture and dural injury.


title: Systemic inflammatory response syndrome as a predictor of anastomotic leakage after esophagectomy.

text: PURPOSE Esophageal anastomotic leakage is still a major cause of morbidity and mortality after esophagectomy. We conducted this study to elucidate how anastomotic leakage affects the systemic inflammatory response syndrome (SIRS) criteria. METHODS The subjects of this retrospective study were 61 patients who underwent esophagectomy. We evaluated their preoperative status, the surgical procedures, and postoperative systemic response, including white blood cell count, heart rate, respiratory rate, body temperature, and laboratory data up to postoperative day (POD) 4. RESULTS Anastomotic leakage developed in nine patients (14.8%) and was found on POD 7 on average. These patients had a significantly longer hospital stay than those without leakage. Although no difference was observed in postoperative changes of any of the SIRS criteria, the postoperative incidence of SIRS was significantly higher in the patients with anastomotic leakage on POD 4. The number of positive criteria for SIRS was also significantly higher in patients with anastomotic leakage than in those without leakage on PODs 3 and 4. CONCLUSIONS The SIRS scoring system is valuable for evaluating the severity of systemic inflammatory response caused by anastomosis leakage, and may serve as an indicator for prompt management.


docid: zpoeogbo

title: Recombinant complement receptor 2 radiolabeled with [99mTc(CO)3]+: a potential new radiopharmaceutical for imaging activated complement.

text: We describe the design and synthesis of a new Tc-99m labeled bioconjugate for imaging activated complement, based on Short Consensus Repeats 1 and 2 of Complement Receptor 2 (CR2), the binding domain for C3d. To avoid non specific modification of CR2 and the potential for modifying lysine residues critical to the CR2/C3d contact surface, we engineered a new protein, recombinant CR2 (rCR2), to include the C-terminal sequence VFPLECHHHHHH, a hexahistidine tag (for site-specific radiolabeling with [(99m)Tc(CO)(3)(OH(2))(3)](+)). The protein was characterized by N-terminal sequencing, SDS-PAGE and size exclusion chromatography. To test the function of the recombinant CR2, binding to C3d was confirmed by enzyme-linked immunosorbent assay (ELISA). The function was further confirmed by binding of rCR2 to C3d(+) red blood cells (RBC) which were generated by deposition of human or rat C3d and analyzed by fluorescence microscopy and flow cytometry. The affinity of rCR2 for C3d(+), in presence of 150 mM NaCl, was measured using surface plasma resonance giving rise to a K(D)≈500 nM. Radiolabeling of rCR2 or an inactive mutant of rCR2 (K41E CR2) or an unrelated protein of a similar size (C2A) with [(99m)Tc(CO)(3)(OH(2))(3)](+) at gave radiochemical yields >95%. Site-specifically radiolabeled rCR2 bound to C3d to C3d(+) RBC. Binding of radiolabeled rCR2 to C3d was inhibited by anti-C3d and the radiolabeled inactive mutant K41E CR2 and C2A did not bind to C3d(+) RBCs. We conclude that rCR2-Tc(99m) has excellent radiolabeling, stability and C3d binding characteristics and warrants in vivo evaluation as an activated complement imaging agent.


title: Skin grafting of the penis.

text: Penile skin loss may occur after trauma, infection, or as a result of surgical resection. This article reviews indications for reconstruction of the penile skin, skin anatomy, and skin graft physiology. Choice of reconstructive options, skin grafting techniques, and complications of skin grafting are also discussed.


title: Antiviral properties from plants of the Mediterranean flora.

text: Natural products are a successful source in drug discovery, playing a significant role in maintaining human health. We investigated the in vitro cytotoxicity and antiviral activity of extracts from 18 traditionally used Mediterranean plants. Noteworthy antiviral activity was found in the extract obtained from the branches of Daphne gnidium L. against human immunodeficiency virus type-1 (EC50 = 0.08 μg/mL) and coxsackievirus B5 (EC50 = 0.10 μg/mL). Other relevant activities were found against BVDV, YFV, Sb-1, RSV and HSV-1. Interestingly, extracts from Artemisia arborescens L. and Rubus ulmifolius Schott, as well as those from D. gnidium L., showed activities against two different viruses. This extensive antiviral screening allowed us to identify attractive activities, offering opportunities to develop lead compounds with a great pharmaceutical potential.


title: Laparoscopic-guided transversus abdominis plane block for colorectal surgery.

text: The transversus abdominis plane block has been used as a component of postoperative analgesia after hysterectomy and open abdominal surgery. This block involves the injection of anesthetic between the internal oblique and transversus abdominis muscles. We demonstrate an improved method by the use of laparoscopic guidance for transversus abdominis plane blocks.Transversus abdominis plane blocks are performed at the conclusion of an elective laparoscopic procedure by an experienced colorectal surgeon. With the use of direct visualization with a laparoscope, a Braun Stimuplex A insulated needle is passed through the skin at the level of the midaxillary line, midway between the iliac crest and the costal margin. The needle is inserted further until 2 distinct "pops" are felt, indicating the correct needle position between the internal oblique and transversus abdominis muscle. The laparoscope confirms a bulge, which signifies the injectate covered by the transversus abdominis muscle. The procedure is performed at a second injection site on the same side and bilaterally.The transversus abdominis plane block is useful as an adjunct to reduce postoperative analgesia in patients undergoing laparoscopic colorectal surgery. Our method for transversus abdominis plane blocks with the use of laparoscopy is easily performed at the conclusion of any laparoscopic procedure. Prospective randomized trials are necessary to assess the significance of these blocks in postoperative pain control, length of stay, and cost benefit.


title: Effects of hemodynamic monitoring using a single-use transesophageal echocardiography probe in critically ill patients - study protocol for a randomized controlled trial.

text: BACKGROUND Hemodynamic instability is one of the leading causes of intensive care unit (ICU) admission. Early stabilization of hemodynamics is associated with improved outcome. The monitoring used to guide hemodynamic support may influence the time needed to achieve stable hemodynamics. Visualization of the heart using echocardiography offers the advantage of direct measurement of cardiac volumes and ventricular function. A miniaturized monoplane transesophageal echocardiography (TEE) probe was developed, allowing for almost continuous qualitative hemodynamic TEE assessment (hTEE) after brief bedside training. The primary objective of the study is to assess whether hemodynamic monitoring using the hTEE technology shortens time to resolution of shock in ICU patients in comparison to standard monitoring using a central venous catheter, pulmonary artery catheter, or conventional echocardiography. METHODS Five hundred consecutive subjects with circulatory shock (low mean arterial blood pressure (MAP) and signs of organ hypoperfusion) at the time of ICU admission are included in the study. The subjects are randomly assigned to one of four groups using a 2 × 2 factorial design stratified by method of hemodynamic monitoring (hTEE vs standard hemodynamic monitoring) and frequency of hemodynamic assessments (minimum every 4 h vs standard of care). The primary study outcome is the time from study inclusion to resolution of circulatory shock, defined as MAP > 60 mmHg for ≥ 4 h after discontinuation of vasopressors and inotropes. The hTEE monitoring consists of the acquisition of three defined echocardiography views: Transgastric mid-esophageal short axis with measurement of fractional area change of left ventricle, mid-esophageal four-chamber view with measurement of the ratio of right to left ventricular area, and mid-esophageal ascending aortic short-axis view with measurement of the superior vena cava collapsibility index. In the control groups, monitoring modalities, including conventional TTE and TEE but not hTEE, are at the discretion of the treating physician. The interpretation of hemodynamic monitoring and the subsequent changes in patient management are recorded after each hemodynamic assessment. Differences in the primary and further secondary time-to-event outcomes will be assessed using a competing risk model accounting for the competing risk of death. DISCUSSION The effect of using echocardiography as a monitoring modality on relevant patient outcomes has not been established so far. The study at hand may be one of the first trials to provide detailed data on effectiveness and safety of echocardiography to guide treatment in patients with circulatory shock. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02048566. Registered on January 29, 2014.


Ultrafast response of the French Society of Pharmacology and Therapeutics to the COVID-19 pandemic.


title: Reactivity of Porcine Epidemic Diarrhea Virus Structural Proteins to Antibodies against Porcine Enteric Coronaviruses: Diagnostic Implications.

text: The development of porcine epidemic diarrhea virus (PEDV) antibody-based assays is important for detecting infected animals, confirming previous virus exposure, and monitoring sow herd immunity. However, the potential cross-reactivity among porcine coronaviruses is a major concern for the development of pathogen-specific assays. In this study, we used serum samples (n = 792) from pigs of precisely known infection status and a multiplex fluorescent microbead-based immunoassay and/or enzyme-linked immunoassay platform to characterize the antibody response to PEDV whole-virus (WV) particles and recombinant polypeptides derived from the four PEDV structural proteins, i.e., spike (S), nucleocapsid (N), membrane (M), and envelope (E). Antibody assay cutoff values were selected to provide 100% diagnostic specificity for each target. The earliest IgG antibody response, mainly directed against S1 polypeptides, was observed at days 7 to 10 postinfection. With the exception of nonreactive protein E, we observed similar antibody ontogenies and patterns of seroconversion for S1, N, M, and WV antigens. Recombinant S1 provided the best diagnostic sensitivity, regardless of the PEDV strain, with no cross-reactivity detected against transmissible gastroenteritis virus (TGEV), porcine respiratory coronavirus (PRCV), or porcine deltacoronavirus (PDCoV) pig antisera. The WV particles showed some cross-reactivity to TGEV Miller and TGEV Purdue antisera, while N protein presented some cross-reactivity to TGEV Miller. The M protein was highly cross-reactive to TGEV and PRCV antisera. Differences in the antibody responses to specific PEDV structural proteins have important implications in the development and performance of antibody assays for the diagnosis of PEDV enteric disease.


title: Serum FABP4 concentrations decrease after Roux-en-Y gastric bypass but not after intensive medical management.

text: BACKGROUND Serum concentrations of fatty acid binding protein 4, an adipose tissue fatty acid chaperone, have been correlated with insulin resistance and cardiovascular risk factors. The objective of this study were to assess relationships among Roux-en-Y gastric bypass, intensive lifestyle modification and medical management protocol, fatty acid binding protein 4, and metabolic parameters in obese patients with severe type 2 diabetes mellitus; and to evaluate the relative contribution of abdominal subcutaneous adipose and visceral adipose to the secretion of fatty acid binding protein 4. METHODS Participants were randomly assigned to intensive lifestyle modification and medical management protocol (n = 29) or to intensive lifestyle modification and medical management protocol augmented with Roux-en-Y gastric bypass (n = 34). Relationships among fatty acid binding protein 4 and demographic characteristics, metabolic parameters, and 12-month changes in these values were examined. Visceral and subcutaneous adipose tissue explants from obese nondiabetic patients (n = 5) were obtained and treated with forskolin to evaluate relative secretion of fatty acid binding protein 4 in the different adipose tissue depots. RESULTS The intensive lifestyle modification and medical management protocol and Roux-en-Y gastric bypass cohorts had similar fasting serum fatty acid binding protein 4 concentrations at baseline. At 1 year, mean serum fatty acid binding protein 4 decreased by 42% in Roux-en-Y gastric bypass participants (P = .002) but did not change significantly in the intensive lifestyle modification and medical management protocol cohort. Percentage of weight change was not a significant predictor of 12-month fatty acid binding protein 4 within treatment arm or in multivariate models adjusted for treatment arm. In adipose tissue explants, fatty acid binding protein 4 was secreted similarly between visceral and subcutaneous adipose tissue. CONCLUSION After Roux-en-Y gastric bypass, fatty acid binding protein 4 is reduced 12 months after surgery but not after intensive lifestyle modification and medical management protocol in patients with type 2 diabetes mellitus. Fatty acid binding protein 4 was secreted similarly between subcutaneous and visceral adipose tissue explants.


title: Ensuring patient access to essential medicines while minimizing harmful use: a revised World Health Organization tool to improve national drug control policy.

text: In 2011, the World Health Organization (WHO) published a series of 21 guidelines to assist governments in improving their national drug control laws, regulations, and administrative procedures to promote the availability of controlled medicines for pain relief and for a variety of acute and chronic diseases and conditions. These guidelines ultimately are designed to encourage the development of policies designed to fulfill a country's dual obligation concerning these medicines: to prevent their abuse, diversion and trafficking while ensuring access for medical and scientific purposes. This article summarizes each guideline and outlines the constituents who can actively participate in making controlled medicines available to the patients who need them. It is hoped that representatives of governments and medical institutions, as well as health care professionals, will commonly and effectively use the revised WHO guidelines as a policy change tool.


title: The threat of a support surface translation affects anticipatory postural control.

text: This study examined how postural threat in the form of a potential perturbation affects an individual's ability to perform a heel raise. Seventeen adults completed three conditions: i) low threat, where participants performed a heel raise in response to a "go" tone, ii) high threat, where participants either heard the same "go" tone, for which they performed a heel raise, or experienced a support surface translation in the medio-lateral direction that disturbed their balance, and iii) choice reaction time task, where participants either completed a heel raise in response to the same "go" tone or a toe raise in response to a lower pitched tone. For all heel raise trials, anticipatory postural adjustments (APAs) were quantified from center of pressure (COP) recordings and electromyographic (EMG) activity from the tibialis anterior (TA) and soleus (SOL). Results indicated that participants exhibited larger APAs, as reflected by the greater backward COP displacement (p=0.038) and velocity (p=0.022) as well as a larger TA EMG amplitude (p=0.045), during the high threat condition. During the execution phase of the heel raise, an earlier (p=0.014) and larger (p=0.041) SOL EMG activation were observed during the high threat condition. These results contrast with previous findings of reduced APAs when the postural threat was evoked through changes in surface height. Therefore, the characteristics of the postural threat must be considered to isolate the effects of threat on anticipatory movement control.


title: Early Recurrent Ischemic Lesions in Patients With Cryptogenic Stroke and Patent Foramen Ovale: An Observational Study.

text: Background: Randomized controlled trials indicate that patent foramen ovale (PFO) closure reduces risk of stroke recurrence in patients with cryptogenic stroke and PFO. However, the optimal time point for PFO closure is unknown and depends on the risk of stroke recurrence. Objective: We aimed to investigate risk of early new ischemic lesions on cerebral magnetic resonance imaging (MRI) in cryptogenic stroke patients with and without PFO. Methods: Cryptogenic stroke patients underwent serial MRI examinations within 1 week after symptom onset to detect early new ischemic lesions. Diffusion-weighted imaging (DWI) lesions were delineated, co-registered, and analyzed visually for new hyperintensities by raters blinded to clinical details. A PFO was classified as stroke-related in patients with PFO and a Risk of Paradoxical Embolism (RoPE) score >5 points. Results: Out of 80 cryptogenic stroke patients, risk of early recurrent DWI lesions was not significantly different in cryptogenic stroke patients with and without PFO. Similar results were observed in patients ≤60 years of age. Patients with a stroke-related PFO even had a significantly lower risk of early recurrent ischemic lesions compared to all other patients with cryptogenic stroke (unadjusted odds ratio 0.23 [95% confidence interval 0.06-0.87], P = 0.030). Conclusion: Our data argue against a high risk of early stroke recurrence in patients with cryptogenic stroke and PFO.


The Death Throes of Mercy - Our Shared Responsibility When Hospitals Close.


title: Fuzziness endows viral motif-mimicry.

text: Motif-mimicry is exploited by viruses to interfere with host regulatory networks and has also been suggested as a prevalent strategy for eukaryotic and prokaryotic pathogens. Using the same peptide motif however does not guarantee more effective interactions with the host. Motif-mediated interactions require a flexible or disordered environment, with structural and dynamic features that should differ between the competing host and viral proteins. Using the eukaryotic linear motif (ELM) database we analyzed the protein regions which contained the eukaryotic and viral motifs, including human and human virus ELMs with common target sites. We found that although the eukaryotic motifs are associated with a lack of structure, they are more stable than their flanking regions and can serve as molecular recognition elements. In contrast, eukaryotic viral motifs are often located in more ordered regions, but have increased local flexibility or disorder compared to their embedding environment. Most viral ELMs are devoid of stable binding elements and remain fuzzy after binding. Fuzziness reduces the entropic cost of binding and imparts versatile interaction modes to increase binding promiscuity and to compete with multiple host peptides. Fuzzy interactions confer further functional benefits such as the combinatorial usage of motifs, and a fine-tuning affinity via post-translational modifications.


Kawasaki disease in a COVID-19-struck region.


REGULATE-PCI trial--Author's reply.


title: Single-Incision, Gasless, Endoscopic Trans-Axillary Total Thyroidectomy: A Feasible and Oncologic Safe Surgery in Patients with Papillary Thyroid Carcinoma.

text: BACKGROUND The aim of this study is to compare the feasibility and oncologic safety of Single-incision, gasless, Endoscopic trans-axillary bilateral Total thyroidectomy (SET) with open cervical total thyroidectomy in patients with papillary thyroid carcinoma (PTC). MATERIALS AND METHODS From March 2008 to December 2012, PTC patients underwent bilateral total thyroidectomy. Conventional, open surgery was performed on 538 patients (Group O) and endoscopic surgery was performed on 200 patients (Group E). We analyzed the patient's clinicopathologic, postoperative complications, and surgical completeness. RESULTS The mean ages of the patients were 48.9 ± 0.5 (range = 24-77) in Group O and 39.5 ± 0.8 (range = 17-73) in Group E with statistical significance (P < .001). Percentage of female patients were 74.3% in Group O and 96.0% in Group E with statistical significance (P < .001). The postoperative hospital stay in Group O was significantly longer than Group E (4.60 ± 0.05 versus 3.30 ± 0.05; P < .001). The operation time in Group E was significantly longer than Group O (93.9 ± 1.3 versus 142.6 ± 3.3; P < .001). More transient hypocalcemia was found in Group O compared to Group E with statistical significance (28.1% versus 22.4%; P < .001). There were no significant differences with respect to permanent hypocalcemia, permanent recurrent laryngeal nerve palsy, seroma, and hematoma. The mean 1 year-stimulated sTg was 0.23 ± 0.03 and 0.18 ± 0.02 in Group O and E, respectively. Tumor recurrence during short-term follow-up at neck ultrasonography (1 year) was detected in 4 patients in Group O. CONCLUSION SET is safe and effective, not only for low-risk patients with early-detected cancer, but also for selected cases of advanced cancer.


title: Evaluation of epidemiological and clinical features of influenza and other respiratory viruses.

text: AIM In our study, we aimed to clinically and epidemiologically evaluate respiratory tract infections the viral agents of which were detected by molecular methods and to compare influenza and other respiratory tract viruses in this context. MATERIAL AND METHODS The records of 178 patients aged above 2 years who presented to pediatric emergency outpatient clinic with fever and respiratory tract infection findings between December 2013 and April 2014 were examined retrospectively. RESULTS At least one respiratory tract pathogen was detected by polymerase chain reaction in 78.6% (n=140) of the patients: influenza A 33.5%, influenza B 16.4%, respiratory syncytial virus 9.2%, adenovirus 7.8%, rhinovirus 7.1%, coronavirus 7.1%, human metapneumovirus 5.7%, human bocavirus 5.7%, parainfluenza virus 3.5%, coinfection 2.8%. The mean age of the patients was 6.3±3.6 years. Sixty-nine patients (49.2%) were aged between 2 and 5 years. Seventy-one patients (50.7%) were aged 5 years and above. Upper respiratory tract infection was found with a rate of 65.7% and lower respiratory tract infection was found with a rate of 34.2%. It was observed that the distribution of respiratory tract viruses showed variance by age groups. Influenza A infection was observed with the highest rate in both age groups. Influenza B was the second leading agent (p=0.008) above the age of 5 years and respiratory syncytial virus was the second leading agent in the 2-5 year age group (p=0.003). Influenza viruses were detected in 55.9% of 118 patients who were found to be compatible with the definition of "influenza-like illness" specified in the Center for Disease Control and Prevention guidelines and other viral agenst were detected in 44%. No difference could be found between the clinical pictures and radiological findings caused by influenza and other respiratory tract viruses. CONCLUSIONS In this study, it was concluded that influenza and other respiratory viruses can not be differentiated definitely by clinical and radiological findings, though there are some differences.


title: Transmission of respiratory tract infections at mass gathering events.

text: PURPOSE OF REVIEW Mass gathering events bring people from across all continents increasing the risk of spread of aerosol transmissible respiratory tract infections. Respiratory tract infections for instance in pilgrims attending the world's largest recurring annual pilgrimage, the Hajj are common. We review recent literature on viral and bacterial infectious diseases with special focus on the Hajj. RECENT FINDINGS The prevalence of bacterial and viral infections continue to increase, because of the acquisition of rhinovirus, coronaviruses (229E, HKU1, OC43), influenza A H1N1, Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus during Hajj. Whilst MERS-CoV continues to circulate in the Middle East, no cases of MERS-CoV have yet been identified in pilgrims during Hajj. SUMMARY Respiratory tract infections are a major cause of morbidity in pilgrims attending mass gathering events. The management of severe respiratory infections should consider investigation and empirical coverage for the most likely agents based on syndromic surveillance data from hosting country and /or other relevant exposure history during events. Pneumococcal and Pertussis vaccines should be recommended for Hajj pilgrims.


Standing open-flank approach for removal of enlarged pathologic ovaries in mares.


title: Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.

text: PURPOSE Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.


title: A registry-based randomized trial comparing radial and femoral approaches in women undergoing percutaneous coronary intervention: the SAFE-PCI for Women (Study of Access Site for Enhancement of PCI for Women) trial.

text: OBJECTIVES This study sought to determine the effect of radial access on outcomes in women undergoing percutaneous coronary intervention (PCI) using a registry-based randomized trial. BACKGROUND Women are at increased risk of bleeding and vascular complications after PCI. The role of radial access in women is unclear. METHODS Women undergoing cardiac catheterization or PCI were randomized to radial or femoral arterial access. Data from the CathPCI Registry and trial-specific data were merged into a final study database. The primary efficacy endpoint was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding or vascular complications requiring intervention. The primary feasibility endpoint was access site crossover. The primary analysis cohort was the subgroup undergoing PCI; sensitivity analyses were conducted in the total randomized population. RESULTS The trial was stopped early for a lower than expected event rate. A total of 1,787 women (691 undergoing PCI) were randomized at 60 sites. There was no significant difference in the primary efficacy endpoint between radial or femoral access among women undergoing PCI (radial 1.2% vs. 2.9% femoral, odds ratio [OR]: 0.39; 95% confidence interval [CI]: 0.12 to 1.27); among women undergoing cardiac catheterization or PCI, radial access significantly reduced bleeding and vascular complications (0.6% vs. 1.7%; OR: 0.32; 95% CI: 0.12 to 0.90). Access site crossover was significantly higher among women assigned to radial access (PCI cohort: 6.1% vs. 1.7%; OR: 3.65; 95% CI: 1.45 to 9.17); total randomized cohort: (6.7% vs. 1.9%; OR: 3.70; 95% CI: 2.14 to 6.40). More women preferred radial access. CONCLUSIONS In this pragmatic trial, which was terminated early, the radial approach did not significantly reduce bleeding or vascular complications in women undergoing PCI. Access site crossover occurred more often in women assigned to radial access. (SAFE-PCI for Women; NCT01406236).


title: Lactic acidosis in patients with hepatitis C virus cirrhosis and combined ribavirin/sofosbuvir treatment.

text: BACKGROUND & AIMS Sofosbuvir (SOF) based interferon-alfa free antiviral therapy has become the treatment of choice for patients with chronic hepatitis C virus (HCV) infection. Little is known about safety of drug combinations using two nucleos(t)ide polymerase inhibitors in patients with HCV associated advanced cirrhosis. Here, we report frequent occurrence of lactic acidosis associated with acute-on-chronic hepatic decompensation during ribavirin (RBV) plus SOF based antiviral therapy. METHODS Thirty-five patients with chronic hepatitis C and advanced fibrosis, compensated cirrhosis, and decompensated cirrhosis without and after liver transplantation were treated with SOF based antiviral therapy with and without RBV. Adverse events including lactic acidosis (pH <7.35, lactate >20 mg/dl) were recorded 24 weeks before and during (mean ±SD, 18±11 weeks) antiviral therapy. Efficacy was determined by assessment of serum HCV RNA. RESULTS We observed severe adverse events in 15/35 (43%) patients before (24 weeks) and in 12/35 (34%) patients during antiviral therapy, the majority in association with acute-on-chronic hepatic decompensation. Lactic acidosis occurred in 5/35 (14%) patients during therapy, while no event of lactic acidosis was observed prior to therapy. Lactic acidosis was associated with hepatic decompensation including renal failure and infection, and was severe (pH <7.3) in two patients. CONCLUSIONS RBV in combination with SOF based antiviral therapy in patients with HCV associated advanced cirrhosis may be associated with the development of lactic acidosis. Impaired renal function, and higher MELD/Child-Pugh scores were identified as potential risk factors.


title: Effect of modified laparoscopic hysterectomy on pelvic floor function: A retrospective observational study.

text: Hysterectomy is a potential risk factor for subsequent surgery for pelvic organ prolapse, especially when the prolapse exists before hysterectomy. Women without prolapse before hysterectomy may also experience prolapse after hysterectomy. This study aimed to describe a surgical modification of laparoscopic colposuspension with round ligaments after hysterectomy in women without preexisting genital prolapse and to evaluate the initial surgical results in these patients.We reviewed data of 54 patients who underwent laparoscopic hysterectomy with colposuspension with unilateral or bilateral round ligaments after hysterectomy at Chia-Yi Chang Gung Memorial Hospital from July 2012 to March 2015. Vaginal length was measured before and after colposuspension after complete hysterectomy. Preoperative characteristics of the patients, perioperative quality, postoperative outcomes, and vaginal length differences were analyzed.Vaginal length increased by a mean of 2.59 cm after colposuspension. The mean extra-operative time needed for laparoscopic colposuspension was about 10 minutes. No severe complications were reported in our patients, and we did not find any cystocele after completing vaginal cuff suspension to the round ligament.The vaginal apex level was maintained in our modified laparoscopic hysterectomy. Therefore, laparoscopic colposuspension with round ligaments is a promising option as a routine, first-line standard procedure in younger women without genital prolapse to maintain an acceptable vaginal length after laparoscopic hysterectomy.


title: Transgraft sac Embolization Combined with Graft Reinforcement for Refractory Mixed-Type Endoleak.

text: An 80-year-old female underwent EVAR 4 years ago. She presented type II endoleak with sac expansion from 68 to 80 mm during 3-year follow-up after EVAR. Although she underwent translumbar percutaneous sac embolization, the AAA sac continued to enlarge, suggesting mixed-type endoleak including type I, II, and III. Transgraft direct sac angiography revealed endoleak cavity without demonstrable feeding vessel. Transgraft sac embolization using n-butyl cyanoacrylate and graft reinforcement was performed concurrently, without complications. The graft reinforcement consisted of graft extension for eliminating occult type I endoleak, and relining for eliminating occult type III endoleak. Six months after the procedure, CT showed no signs of sac expansion. Transgraft sac embolization combined with graft reinforcement is one of the available options for persistent and refractory mixed-type endoleak.


title: Primary dysmenorrhea and self-care strategies among Chinese college girls: a cross-sectional study.

text: OBJECTIVES To explore the prevalence of primary dysmenorrhea (PD), the characteristics of PD and self-care strategies for managing PD among Chinese college girls. DESIGN Cross-sectional study. SETTING Changsha, China. PARTICIPANTS A total of 2555 college girls were recruited using multistage cluster random sampling. OUTCOME MEASURES A self-report questionnaire was used to measure sociodemographic information, characteristics of PD and self-care strategies for managing PD. Additionally, a Visual Analogue Scale was used to measure pain severity. RESULTS Of the 2555 girls, 1306 had experienced PD, representing a 51.1% prevalence. In addition, the prevalence rates of mild, moderate and severe pain in PD were 18.1%, 27.7% and 5.4%, respectively. The most common symptoms associated with PD were cramps (96.9%), weakness (70.0%), backache (65.1%), facial blemishes (55.3%) and irritability (55.3%). Commonly used self-care strategies for managing PD comprised reducing physical activity (94.6%), keeping warm (84.6%), communicating dysmenorrhea with friends or classmates (79.0%), drinking warm beverages (75.7%) and avoiding cold drinks and foods (74.2%). In addition, only 34.8% self-medicated with Western medicine (15.6%), traditional Chinese medicine (8.6%), or both (10.6%). Medical advice was sought by 27.4% of subjects from a Western medical doctor (10.3%), a doctor of traditional Chinese medicine (13.6%), or both (3.5%). Girls who had greater pain severity were more likely to be self-medicated (OR=7.01; 95% CI 4.50 to 10.91), use complementary therapies (OR=2.64; 95% CI 1.70 to 4.10) and seek medical advice (OR=5.93; 95% CI 3.80 to 9.24). CONCLUSIONS PD is highly prevalent among Chinese college girls, with a high burden of symptoms. In addition, these girls are most likely to change their lifestyle, communicate dysmenorrhea with friends or mothers, use heat therapy and engage in self-talk, but less likely to self-medicate or seek medical advice for managing PD.


title: Assessment of Cerebral Autoregulation Patterns with Near-infrared Spectroscopy during Pharmacological-induced Pressure Changes.

text: BACKGROUND Previous work has demonstrated paradoxical increases in cerebral oxygen saturation (ScO2) as blood pressure decreases and paradoxical decreases in ScO2 as blood pressure increases. It has been suggested that these paradoxical responses indicate a functional cerebral autoregulation mechanism. Accordingly, the authors hypothesized that if this suggestion is correct, paradoxical responses will occur exclusively in patients with intact cerebral autoregulation. METHODS Thirty-four patients undergoing elective cardiac surgery were included. Cerebral autoregulation was assessed with the near-infrared spectroscopy-derived cerebral oximetry index (COx), computed by calculating the Spearman correlation coefficient between mean arterial pressure and ScO2. COx less than 0.30 was previously defined as functional autoregulation. During cardiopulmonary bypass, 20% change in blood pressure was accomplished with the use of nitroprusside for decreasing pressure and phenylephrine for increasing pressure. Effects on COx were assessed. Data were analyzed using two-way ANOVA, Kruskal-Wallis test, and Wilcoxon and Mann-Whitney U test. RESULTS Sixty-five percent of patients had a baseline COx less than 0.30, indicating functional baseline autoregulation. In 50% of these patients (n = 10), COx became highly negative after vasoactive drug administration (from -0.04 [-0.25 to 0.16] to -0.63 [-0.83 to -0.26] after administration of phenylephrine, and from -0.05 [-0.19 to 0.17] to -0.55 [-0.94 to -0.35] after administration of nitroprusside). A negative COx implies a decrease in ScO2 with increase in pressure and, conversely, an increase in ScO2 with decrease in pressure. CONCLUSIONS In this study, paradoxical changes in ScO2 after pharmacological-induced pressure changes occurred exclusively in patients with intact cerebral autoregulation, corroborating the hypothesis that these paradoxical responses might be attributable to a functional cerebral autoregulation.


title: Institutional characteristics associated with receipt of emergency care for obstructive pyelonephritis at community hospitals.

text: PURPOSE Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients. MATERIALS AND METHODS We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care. RESULTS Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94-3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01). CONCLUSIONS High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented.


docid: bwymlfos

title: Rivaroxaban for thromboprophylaxis in acutely ill medical patients.

text: BACKGROUND The clinically appropriate duration of thromboprophylaxis in hospitalized patients with acute medical illnesses is unknown. In this multicenter, randomized, double-blind trial, we evaluated the efficacy and safety of oral rivaroxaban administered for an extended period, as compared with subcutaneous enoxaparin administered for a standard period, followed by placebo. METHODS We randomly assigned patients 40 years of age or older who were hospitalized for an acute medical illness to receive subcutaneous enoxaparin, 40 mg once daily, for 10±4 days and oral placebo for 35±4 days or to receive subcutaneous placebo for 10±4 days and oral rivaroxaban, 10 mg once daily, for 35±4 days. The primary efficacy outcomes were the composite of asymptomatic proximal or symptomatic venous thromboembolism up to day 10 (noninferiority test) and up to day 35 (superiority test). The principal safety outcome was the composite of major or clinically relevant nonmajor bleeding. RESULTS A total of 8101 patients underwent randomization. A primary efficacy outcome event occurred in 78 of 2938 patients (2.7%) receiving rivaroxaban and 82 of 2993 patients (2.7%) receiving enoxaparin at day 10 (relative risk with rivaroxaban, 0.97; 95% confidence interval [CI], 0.71 to 1.31; P=0.003 for noninferiority) and in 131 of 2967 patients (4.4%) who received rivaroxaban and 175 of 3057 patients (5.7%) who received enoxaparin followed by placebo at day 35 (relative risk, 0.77; 95% CI, 0.62 to 0.96; P=0.02). A principal safety outcome event occurred in 111 of 3997 patients (2.8%) in the rivaroxaban group and 49 of 4001 patients (1.2%) in the enoxaparin group at day 10 (P<0.001) and in 164 patients (4.1%) and 67 patients (1.7%) in the respective groups at day 35 (P<0.001). CONCLUSIONS In acutely ill medical patients, rivaroxaban was noninferior to enoxaparin for standard-duration thromboprophylaxis. Extended-duration rivaroxaban reduced the risk of venous thromboembolism. Rivaroxaban was associated with an increased risk of bleeding. (Funded by Bayer HealthCare Pharmaceuticals and Janssen Research and Development; MAGELLAN ClinicalTrials.gov number, NCT00571649.).


title: Robot-assisted combined pancreatectomy/hepatectomy for metastatic pancreatic acinar cell carcinoma: case report and review of the literature.

text: Acinar cell carcinoma (ACC) of the pancreas is a rare neoplasm with less aggressive behavior than ductal carcinoma. As a result, surgical resection for metastatic ACC is a therapeutic option which can result in long-term survival. There is a paucity of data describing institutional approaches to these challenging patients, and therefore, we herein describe our institution's approach to a patient with a distal pancreatic ACC and isolated liver metastasis. The patient underwent neoadjuvant chemotherapy (FOLFIRINOX), followed by a robot-assisted distal pancreatectomy/splenectomy and non-anatomic segment 6 resection. He was discharged to home post-operative day 2. Final pathology revealed complete tumor response of the liver metastasis and a margin negative resection of the primary tumor. He remains disease free and without complications at 3 months. We highlight that combined modality therapy for metastatic ACC can yield long-term survival in selected patients. Similarly, the robotic platform enables performance of complex multivisceral resections with rapid recovery. Future research investigating precision medicine for metastatic ACC is warranted given widely variable tumor biology in this disease.


title: Building global health through a center-without-walls: the Vanderbilt Institute for Global Health.

text: The Institute for Global Health at Vanderbilt enables the expansion and coordination of global health research, service, and training, reflecting the university's commitment to improve health services and outcomes in resource-limited settings. Global health encompasses both prevention via public health and treatment via medical care, all nested within a broader community-development context. This has fostered university-wide collaborations to address education, business/economics, engineering, nursing, and language training, among others. The institute is a natural facilitator for team building and has been especially helpful in organizing institutional responses to global health solicitations from the National Institutes of Health (NIH), Centers for Disease Control (CDC), and other funding agencies. This center-without-walls philosophy nurtures noncompetitive partnerships among and within departments and schools. With extramural support from the NIH and from endowment and developmental investments from the school of medicine, the institute funds new pilot projects to nurture global educational and research exchanges related to health and development. Vanderbilt's newest programs are a CDC-supported HIV/AIDS service initiative in Africa and an overseas research training program for health science graduate students and clinical fellows. New opportunities are available for Vanderbilt students, staff, and faculty to work abroad in partnership with international health projects through a number of Tennessee institutions now networked with the institute. A center-without-walls may be a model for institutions contemplating strategic investments to better organize service and teaching opportunities abroad, and to achieve greater successes in leveraging extramural support for overseas and domestic work focused on tropical medicine and global health.


title: Endovascular treatment of middle cerebral artery aneurysms with flow modification with the use of the pipeline embolization device.

text: BACKGROUND AND PURPOSE The Pipeline Embolization Device was reported to be safe and effective in the treatment of sidewall aneurysms, preserving the patency of the vessels covered by the construct. However, to date, the safety and efficacy of this device in treating bifurcation aneurysms remains unknown. We report our preliminary experience with the use of the Pipeline Embolization Device in the management of MCA aneurysms located at the bifurcations, including mid- and long-term follow-up data. MATERIALS AND METHODS Wide-neck MCA aneurysms, which give rise to a bifurcating or distal branch in which other endovascular techniques are thought to be unfeasible or more risky, were included. Data including demographics, aneurysm features, antiplatelet therapy, complications, and angiographic follow-up results for up to 30 months were recorded. RESULTS Twenty-five aneurysms located at the MCA bifurcation (n = 21) or distal (n = 4) were treated. Of these, 22 were small and 3 were large. A single device was used in all but 2. No deaths occurred in the series. All patients had at least 1 control angiographic study, 21 of which were DSA (3-30 months), which showed that 12 of the rising branches were patent whereas 6 were filling in reduced caliber and 3 were occluded asymptomatically. According to the last angiographic follow-up, complete occlusion was revealed in 21 of 25 aneurysms (84%). CONCLUSIONS The Pipeline Embolization Device provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky.


title: Modular training in laparoscopic colorectal surgery maximizes training opportunities without clinical compromise.

text: BACKGROUND Laparoscopic surgery is increasingly proposed as the gold standard technique for colorectal resections and is offered to greater numbers of patients. To meet the rising service demands, more trainees and established consultants need to learn the technique. We sought to establish whether it is feasible and safe to train on a large proportion of patients without adversely affecting clinical outcome or smooth running of clinical service. METHODS Between September 2006 and July 2008, four senior trainees of the Wessex Specialist Registrar training rotation were involved in training in laparoscopic colorectal surgery. Major colorectal resections were separated into clearly defined modules for training purposes. Right and left hemicolectomies each comprised two modules, and low anterior resection comprised three modules. Prospective data on consecutive patients undergoing laparoscopic colorectal surgery were collected. Data included type of surgery, module of procedure performed by trainee or trainer, body mass index (BMI), conversion rates, median operative time, complications, length of hospital stay, and mortality. RESULTS During the study period 227 colorectal resections were attempted laparoscopically. Of these, 216 (96%) proved suitable for training and 97% were completed laparoscopically. Some 23% of patients were American Society of Anesthesiologists score (ASA)≥3; 35% had a BMI≥28; 38% had a history of previous laparotomy. Trainees performed 96% (142/148) of right hemicolectomy modules, 99% (154/156) of left hemicolectomy modules, and 67% (128/192) of rectal resection modules. Each trainee was competent to do right and left hemicolectomy at the end of the training period. Four patients (2%) required further surgery for postoperative complications. Of the procedures completed by the trainees, 155/171 (91%) cancer resections were potentially surgically curative, and R0 resections were achieved in 99%. The readmission rate was 10% (22/216) and median length of hospital stay was 4 days. Postoperative mortality was zero. CONCLUSIONS Using a modular approach it is possible to provide effective training during almost all laparoscopic colorectal resections while achieving good clinical outcomes for the patients.


title: Preoperative embolization of skull base meningiomas: current indications, techniques, and pearls for complication avoidance.

text: Skull base meningiomas are technically challenging tumors to treat because of their deep vascular supply that can preclude early devascularization during resection. Preoperative embolization of these arterial feeders is thought to decrease blood loss and facilitate resection; however, given the complex and varied anatomy of these skull base lesions, preoperative embolization is not without risk. It is essential for both endovascular and skull base neurosurgeons to understand these risks in light of the potential benefits. The authors review the vascular anatomy of skull base meningiomas, indications for preoperative devascularization, endovascular techniques, and published results regarding embolization of these lesions.


Covid-19: doctors must take control of their wellbeing.


Single incision laparoscopic cholecystectomy.


title: Barbed sutures in body surgery.

text: Wound-closing technology continues to evolve with the advent of barbed sutures, which appear to address some of the limitations of traditional sutures (numerous knots and time-consuming insertion, among other things). Advantages of knotless suture devices, specifically in body contouring, have been discussed in the literature over the past decade, with a recent increase over the past several years due to the US Food and Drug Administration (FDA) approval of unidirectional V-Loc (Covidien, Mansfield, Massachusetts) and bidirectional Quill (Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada) barbed sutures for soft tissue approximation. A thorough review of the existing literature and evaluation of the author's personal experience are presented in this article. As with any new surgical device, a learning curve is present that needs to be overcome to realize the full benefits of utilizing barbed sutures in body surgery while minimizing their complications.