title: Colorectal anastomosis facilitated by the use of the LigaSure(®) sealing device: comparative study in an animal model.

text: BACKGROUND Recently, there has been speculation about the possibility of fusing intestinal tissue using bipolar sealing devices. In this study we compare in a porcine model the anastomoses created using the LigaSure(®) device with those created with a stapler after section and closure of a rectal stump. METHODS Thirty pigs underwent laparoscopic colorectal anastomosis. In group A (n = 15), the division of the intestine and distal stump closure were done with a 10-mm LigaSure Atlas(®) device. In group B, these steps were carried out using an endoscopic stapler. Subsequently, the colorectal anastomosis was performed using circular stapling in both groups. The 4-week follow-up included health status, weight gain, blood tests, X-rays, and colonoscopy. Anastomotic tissue was processed to study the mechanical tensile strength and histopathology. RESULTS There was no difference in the rate of conversion to open surgery or in average operating time between the groups. In the sealing device group, there was a significantly higher rate of failure in rectal stump closure (p = 0.042). There was one death in group B due to anastomotic leak. There was no difference in adhesion formation or stenosis. Mid-section anastomosis area was 89.7 mm(2) in group A compared with 100 mm(2) in group B (p = 0.52). In tensile strength studies, the maximum load resisted by the sample was 13.8 ± 4.9 N (group A) versus 15.7 ± 4.4 N (group B) (p = 0.17). There was no difference between the groups in degree of reepithelialization, number of inflammatory cells, or the presence of microabscesses. CONCLUSIONS Division and sealing of the rectal stump with the LigaSure(®) device is feasible in the proposed experimental model, but it is less reliable than conventional closure with a stapler, since it has a significantly greater failure rate. Therefore, The LigaSure(®) device should not be used for this purpose in the clinical setting as this could lead to serious and dramatic complications.


title: Bilateral migration of open-cell design carotid stents in the early post-procedure period: a rare complication.

text: We describe migration of bilateral carotid stents in a 63-year-old man shortly after stenting. Carotid stent migration was found four days post-procedure on the right side and one day post-procedure on the left side on angiography and duplex ultrasound, respectively. This is the first reported case of bilateral carotid artery stenting complicated by bilateral proximal migration of open-cell design stents in the early post-procedure period.


title: Endovascular treatment of iliac and common femoral arteries disease by the transradial access: A prospective, feasibility study.

text: AIM To report feasibility and safety of endovascular interventions on iliac and common femoral arteries, using the transradial access (TRA). METHODS 100 consecutive patients (19 women; mean age 71, range 37-90years) with critical limb ischemia (30%) or claudication, and TASC A-D lesions in iliac or common femoral arteries, were prospectively enrolled, from January 2013 to June 2015, to be treated via the TRA. Exclusion criteria included no palpable radial arteries (RA) and the presence of a fistula for hemodialysis. Patients were evaluated for procedural technical success, in-hospital complications, and 30days clinical success (defined as improvement of at least one grade in the Rutherford classification of symptoms). RESULTS A total of 131 iliac and common femoral arteries lesions were treated (58 in common iliac arteries, 38 in external iliac arteries and 35 in common femoral arteries). Ninety-two stents were deployed in 58 patients. Procedural technical success was achieved in 91% of the lesions; with 95% technical success rate in common iliac arteries, 87% in external iliac arteries and 89% in common femoral arteries; with 72% technical success rate in occlusions and 98% in stenosis. No in-hospital complications were observed. At 30days, 93 patients (93%) had an improvement of at least one category in the Rutherford classification of symptoms (clinical success rate 93%); 12 patients (12%) had an asymptomatic occlusion of the RA. CONCLUSIONS TRA can be used to treat iliac and common femoral arteries lesions with a high grade of technical success and a low rate of complications.


Teaching neuroimages: combined retinal and cerebral hyperperfusion syndrome after carotid thromboendarterectomy.


docid: qqngyxrs

title: Why the Use of Angiotensin II May Be a Fatal Mistake in Covid-19.


title: Dialysis outcomes in those aged ≥65 years.

text: BACKGROUND The number of elderly people over the age of 65 commencing dialysis in NZ has increased by almost 400% in the past decade. Few data are available about health related outcomes and survival on dialysis in the elderly to help the individual, their family, clinicians and health planners with decision-making. METHODS/DESIGN This study will provide the first comprehensive longitudinal survey of health-related quality of life (HRQOL) and other patient centred outcomes for individuals aged ≥65 years on, or eligible for, dialysis therapy and will link these data to survival outcomes. Data collected by yearly structured interviews with participants will be linked to co-morbidity data, health service use, and laboratory information collected from health records, and analysed with respect to HRQOL and survival. The information obtained will inform the delivery of dialysis services in New Zealand and facilitate improved decision-making by individuals, their family and clinicians, about the appropriateness and impact of dialysis therapy on subsequent health and survival. DISCUSSION Results from this study will make possible more informed decision-making by future elderly patients and their families as they contemplate renal replacement therapy. Results will also allow health professionals to more accurately describe the impact of dialysis therapy on quality of life and outcomes for patients. TRIAL REGISTRATION ACTRN12611000024943.


title: Probing the HIV gp120 envelope glycoprotein conformation by NMR.

text: The HIV envelope glycoprotein gp120 plays a critical role in virus entry, and thus, its structure is of extreme interest for the development of novel therapeutics and vaccines. To date, high resolution structural information about gp120 in complex with gp41 has proven intractable. In this study, we characterize the structural properties of gp120 in the presence and absence of gp41 domains by NMR. Using the peptide probe 12p1 (sequence, RINNIPWSEAMM), which was identified previously as an entry inhibitor that binds to gp120, we identify atoms of 12p1 in close contact with gp120 in the monomeric and trimeric states. Interestingly, the binding mode of 12p1 with gp120 is similar for clades B and C. In addition, we show a subtle difference in the binding mode of 12p1 in the presence of gp41 domains, i.e. the trimeric state, which we interpret as small differences in the gp120 structure in the presence of gp41.


title: Perforation of the cecum by a toothpick: report of a case and review of the literature.

text: BACKGROUND Ingesting a foreign body (FB) is not an uncommon occurrence. Most pass through the gastrointestinal (GI) tract uneventfully and rarely cause complications. However, long, sharp, slender, and hard objects such as fish bones, chicken bones, and toothpicks may lead to perforation of the GI tract, which is a potentially life-threatening complication. CASE REPORT We report the case of a 50-year-old woman who presented to the Emergency Department of our hospital complaining of right lower quadrant abdominal pain of 2 days' duration. Ultrasound imaging and computed tomography scan demonstrated the presence of a foreign body protruding from the lateral cecal wall and surrounded by an area of inflammation. The patient was taken to the operating room, where a toothpick was found to have perforated the cecum. The FB was removed and the defect of the intestinal wall was closed using a TA linear stapler (Covidien, Mansfield, MA). The patient was discharged on the 8(th) postoperative day. We also conducted a literature search for reports on injuries caused by ingested FBs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Perforation of the GI tract by an ingested FB in the adult population is most commonly secondary to accidental ingestion. Patients rarely recall the episode of the ingestion, or may remember the incident only after a diagnosis is made. We present this case to increase awareness of the diagnosis.


Audio Interview: The Impact of Covid-19 on Minority Communities.


title: Surgical management of 58 patients with placenta praevia percreta.

text: OBJECTIVE The aim of this study is to present our experience with surgical management of placenta praevia percreta. METHODS This study was conducted from January 2009 through March 2014 at Harran University Hospital and was a chart review of all patients who underwent caesarean hysterectomy with the placenta left in situ for placenta praevia percreta. RESULTS The study group comprised 58 patients. All of the patients underwent ultrasound mapping of the placental area before surgery. Emergent caesarean hysterectomy was only performed in 9 patients; 49 patients underwent planned caesarean hysterectomy. Bilateral internal iliac artery ligation was performed in all cases. Four patients (6.9 %) had bladder damage, one patient (1.7 %) required cystotomy, and one patient (1.7 %) required re-operation because of postoperative hemorrhage. The mean operative time was 141.6 (range: 95-355) minutes. Only 17 (29.3 %) patients were administered more than four units of red blood cells. There was no ureteral damage or maternal death. Furthermore, there were no complications in 42 (72.4 %) patients. CONCLUSIONS Caesarean hysterectomy for placenta praevia percreta is associated with increased maternal morbidity. However, preoperative diagnosis of placenta praevia percreta, ultrasound mapping of the placenta, and the presence of a multidisciplinary experienced team may decrease maternal morbidity and mortality. Moreover, the urinary system may be protected in the patients with placenta praevia percreta without serious morbidity.


docid: bkdvgfwy

title: China: clamp down on violations of wildlife trade ban.


title: Systematic review of reporting benefits and harms of surgical interventions in randomized clinical trials.

text: BACKGROUND Standardized reporting methods facilitate comparisons between studies. Reporting of data on benefits and harms of treatments in surgical RCTs should support clinical decision-making. Correct and complete reporting of the outcomes of clinical trials is mandatory to appreciate available evidence and to inform patients properly before asking informed consent. METHODS RCTs published between January 2005 and January 2017 in 15 leading journals comparing a surgical treatment with any other treatment were reviewed systematically. The CONSORT checklist, including the extension for harms, was used to appraise the publications. Beneficial and harmful treatment outcomes, their definitions and their precision measures were extracted. RESULTS Of 1200 RCTs screened, 88 trials were included. For the differences in effect size of beneficial outcomes, 68 per cent of the trials reported a P value only but not a 95 per cent confidence interval. For harmful effects, this was 67 per cent. Only five of the 88 trials (6 per cent) reported a number needed to treat, and no study a number needed to harm. Only 61 per cent of the trials reported on both the beneficial and harmful outcomes of the intervention studied in the same paper. CONCLUSION Despite CONSORT guidelines, current reporting of benefits and harms in surgical trials does not facilitate clear communication of treatment outcomes with patients. Researchers, reviewers and journal editors should ensure proper reporting of treatment benefits and harms in trials.


title: Concussion Guidelines Step 2: Evidence for Subtype Classification.

text: BACKGROUND Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments. OBJECTIVE To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury. METHODS A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD). RESULTS The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI = 0.37, 0.67) and cognitive (0.40; 95% CI = 0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI = 0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P < .05). Children and adults with concussion showed significantly more cognitive symptoms than their respective controls (SMD = 0.66 and 0.24; P < .001). Furthermore, ocular-motor in adult patients (SMD = 0.72; P < .001) and vestibular symptoms in both pediatric and adult patients (SMD = 0.18 and 0.36; P < .05) were significantly worse in concussion patients than in controls. CONCLUSION Five concussion subtypes with varying prevalence within 3 d following injury are commonly seen clinically and identifiable upon systematic literature review. Sleep disturbance, a concussion-associated condition, is also common. There was insufficient information available for analysis of cervical strain. A comprehensive acute concussion assessment defines and characterizes the injury and, therefore, should incorporate evaluations of all 5 subtypes and associated conditions.


Diagnosing rhinitis: viral and allergic characteristics.


title: Adenosine deaminase acts as a natural antagonist for dipeptidyl peptidase 4-mediated entry of the Middle East respiratory syndrome coronavirus.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) replicates in cells of different species using dipeptidyl peptidase 4 (DPP4) as a functional receptor. Here we show the resistance of ferrets to MERS-CoV infection and inability of ferret DDP4 to bind MERS-CoV. Site-directed mutagenesis of amino acids variable in ferret DPP4 thus revealed the functional human DPP4 virus binding site. Adenosine deaminase (ADA), a DPP4 binding protein, competed for virus binding, acting as a natural antagonist for MERS-CoV infection.


title: CT-Guided Percutaneous Radiologic Gastrostomy for Patients with Head and Neck Cancer: A Retrospective Evaluation in 177 Patients.

text: PURPOSE The purpose of this study was to assess the technical success rate and adverse events (AEs) associated with computed tomography (CT)-guided percutaneous gastrostomy for patients with head and neck cancer (HNC). MATERIALS AND METHODS This retrospective study included patients with HNC who had undergone CT-guided percutaneous gastrostomy between February 2007 and December 2013. Information regarding the patients' backgrounds, CT-guided percutaneous gastrostomy techniques, technical success rate, and AEs were obtained from the medical records. In all patients, the stomach was punctured under CT fluoroscopy with a Funada gastropexy device. RESULTS During the study period, 177 patients underwent CT-guided percutaneous gastrostomy. The most common tumor location was the oral cavity, followed by the pharynx and maxilla. The indication for CT-guided percutaneous gastrostomy were tumor obstruction in 78 patients, postoperative dysphagia in 55 patients, radiation edema in 43 patients, and cerebral infarction in 1 patient. The technical success rate was 97.7 %. The overall mean procedure time was 25.3 min. Major AEs occurred in seven patients (4.0 %), including bleeding (n = 4), colonic injury (n = 1), gastric tear (n = 1), and aspiration pneumonia (n = 1). Minor AEs occurred in 15 patients (8.5 %), which included peristomal leakage (n = 6), irritation (n = 4), inadvertent removal (n = 2), peristomal hemorrhage (n = 1), peristomal infection (n = 1), and wound granulation (n = 1). The mean follow-up period was 111 days (range 1-1106 days). CONCLUSION Our study suggests that CT-guided gastrostomy may be suitable in patients with HNC.


title: Effect of PEEP, blood volume, and inspiratory hold maneuvers on venous return.

text: According to Guyton's model of circulation, mean systemic filling pressure (MSFP), right atrial pressure (RAP), and resistance to venous return (RVR) determine venous return. MSFP has been estimated from inspiratory hold-induced changes in RAP and blood flow. We studied the effect of positive end-expiratory pressure (PEEP) and blood volume on venous return and MSFP in pigs. MSFP was measured by balloon occlusion of the right atrium (MSFPRAO), and the MSFP obtained via extrapolation of pressure-flow relationships with airway occlusion (MSFPinsp_hold) was extrapolated from RAP/pulmonary artery flow (QPA) relationships during inspiratory holds at PEEP 5 and 10 cmH2O, after bleeding, and in hypervolemia. MSFPRAO increased with PEEP [PEEP 5, 12.9 (SD 2.5) mmHg; PEEP 10, 14.0 (SD 2.6) mmHg, P = 0.002] without change in QPA [2.75 (SD 0.43) vs. 2.56 (SD 0.45) l/min, P = 0.094]. MSFPRAO decreased after bleeding and increased in hypervolemia [10.8 (SD 2.2) and 16.4 (SD 3.0) mmHg, respectively, P < 0.001], with parallel changes in QPA Neither PEEP nor volume state altered RVR (P = 0.489). MSFPinsp_hold overestimated MSFPRAO [16.5 (SD 5.8) vs. 13.6 (SD 3.2) mmHg, P = 0.001; mean difference 3.0 (SD 5.1) mmHg]. Inspiratory holds shifted the RAP/QPA relationship rightward in euvolemia because inferior vena cava flow (QIVC) recovered early after an inspiratory hold nadir. The QIVC nadir was lowest after bleeding [36% (SD 24%) of preinspiratory hold at 15 cmH2O inspiratory pressure], and the QIVC recovery was most complete at the lowest inspiratory pressures independent of volume state [range from 80% (SD 7%) after bleeding to 103% (SD 8%) at PEEP 10 cmH2O of QIVC before inspiratory hold]. The QIVC recovery thus defends venous return, possibly via hepatosplanchnic vascular waterfall.


title: A stepwise approach based on a rational use of components separation and double mesh prosthesis for incisional hernia repair.

text: PURPOSE We aimed to evaluate the results of a protocol for a tension-free reconstruction of the abdominal wall in midline incisional hernia repair, based on the rational association of components separation and prosthesis, independently of the hernia size. METHODS A total of 100 consecutive patients with midline incisional hernias were prospectively included in the study. Three groups according to the transverse diameter of the defect [group A (<4 cm, N = 18), group B (4-10 cm, N = 59), and group C (>10 cm, N = 23)] were identified. RESULTS Components separation was necessary in 54% of the patients: 16.7% (3/18) in group A, 59.3% (35/59) in group B, and 69.6% (16/23) in group C. Complete tension-free reconstruction was achieved in 87% of the patients: 94.4% (17/18) in group A, 91.5% (54/59) in group B, and 69.6% (16/23) in group C. Overall morbidity rate was 21% (21/100) [group A 16.7% (3/18), group B 22% (13/59), and group C 21.7% (5/23)]. Hospital length of stay was 3.7 ± 3.3 days (group A 1.83 ± 1.43 days, group B 3.05 ± 2.11 days, and group C 6.91 ± 4.45 days). Median follow-up was 25 months (interquartile range 12.25-55.25) with overall recurrence of 2%. CONCLUSION A tension-free abdominal wall reconstruction can be achieved in most cases of small and large midline incisional hernia repair, by a stepwise approach based on a rational association of components separation and double mesh prosthesis, with a low morbidity and recurrence rates.


title: Genetic mutations in live infectious bronchitis vaccine viruses following single or dual in vitro infection of tracheal organ cultures.

text: Despite regular co-vaccination of two different strains of live infectious bronchitis vaccine viruses, little is known about possible mutations in these viruses following vaccination. As an alternative to chicks, this study used an in vitro infection model to identify single-nucleotide polymorphisms (SNPs) within the part-S1 gene of two live infectious bronchitis virus vaccine strains (793B and Massachusetts) following single or dual inoculation onto tracheal organ cultures. Results indicate that viral titres reduced over the duration of the study; conversely, the amount of detected infectious bronchitis virus genome increased. Results demonstrate a greater number of non-synonymous SNPs in both vaccine strains when they are co-inoculated, compared with the single inoculations. The influence of the increased SNP and hydrophobic properties of the translated proteins on the vaccine viruses' virulence is unknown.


title: Acute pancreatitis secondary to a prolapsed gastric fundal GIST.

text: INTRODUCTION Gastrointestinal stromal tumours (GISTs) account for less than 3% of all gastrointestinal tract tumours and 5.7% of all sarcomas, and the majority of these tumours are gastric in origin. Patients commonly present with gastrointestinal bleeding or abdominal pain with 10-30% of patients presenting with symptoms of gastrointestinal obstruction. PRESENTATION OF A CASE We present a case of a 65-year-old gentleman who presented with symptomatic iron deficiency anaemia. Gastroscopy revealed a large submucosal lesion originating from the gastric fundus, consistent with a GIST. The patient developed acute epigastric pain, vomiting with raised inflammatory markers. A CT of the abdomen revealed the GIST to be causing gastric outlet obstruction as result of a prolapse of the tumour through the pylorus into the duodenum. This also resulted in compression of the distal common bile duct and was associated with the radiological appearance of acute pancreatitis. This responded to conservative management. The GIST was resected subsequently using a laparoscopic technique. DISCUSSION Only one similar case has previously been reported in the literature. Several surgical approached have been described in the management of gastric GISTs including open, laparoscopic, hand assisted, ultrasound assisted and a combined endoscopic and laparoscopic approach. A laparosopic 'eversion' techinque was preferred in our case due to the close proximity of the tumour to the gastro-oesophageal junction. CONCLUSION Pancreatitis secondary to a prolapsed gastric GIST is a rare entity. Laparoscopic wedge resection of these tumours can be safely performed with a satisfactory oncological outcome.


docid: molveggi

title: [Comment on Gender-Specific Aspects in Obesity and Metabolic Surgery--Analysis of Data from the German Bariatric Surgery Registry].

text: BACKGROUND The current situation in obesity and metabolic surgery since January 2005 has been investigated with the help of the quality assurance study on surgical therapy for obesity = German Bariatric Surgery Registry (GBSR). The data were acquired and analysed in cooperation with the Institute for Quality Assurance in Surgical Medicine at the Otto-von-Guericke University. METHODS Data acquisition was done with the help of an online database. On a voluntary basis, all obesity and metabolic surgical interventions since 2005 have been recorded. In addition to the surgical data, the findings of the yearly follow-up investigations were recorded. RESULTS Since 2005 there have been 1,263 gastric balloon procedures, 11,840 sleeve gastrectomies, 13,722 Roux-en-Y gastric bypasses and 3999 gastric banding operations. The average age of the male patients in all interventions was significantly higher. The average BMI of female patients who received a gastric banding or a gastric balloon procedure was significantly lower than that of the male patients. Men exhibited a higher incidence of comorbidities than women. CONCLUSION The number of obesity and metabolic surgical interventions in Germany is continuously increasing. The results of the study on surgical therapy for obesity (GBSR) reveal significant differences in the gender-specific incidence of preoperative comorbidities. postoperative complications and mortality. Further studies on gender-specific aspects are necessary in order to optimise patient selection and reduce the incidence of postoperative complications.


Covid-19: PHE upgrades PPE advice for all patient contacts with risk of infection.


[Cardiac rehabilitation and secondary prevention programs during the COVID-19 pandemic: what's "COVID on"?]


title: Microwave Thermoablation of Colorectal Liver Metastases Close to Large Hepatic Vessels Under Pringle Maneuver Minimizes the "Heat Sink Effect".

text: BACKGROUND Liver resection and thermoablation are the mainstay of the surgical management of colorectal liver metastases (CRLM). The main limitation of thermoablation is the "heat-sink" effect for nodules next to large vessels. Herein, we report the preliminary results of microwave ablation (MWA) with associated Pringle maneuver to overcome this flaw. METHODS From November 2017, we performed intraoperative MWA with Pringle maneuver for nodules ≤3 cm with immediate proximity to large vessels (distance ≤ 5 mm, diameter ≥ 3 mm). We collected characteristics of nodules, surgical procedures and postoperative morbidity. Diameter of the ablation area, especially the ablative minimal margin, was calculated for each nodule. Recurrence was also evaluated. RESULTS Nineteen patients underwent MWA with Pringle maneuver for 23 nodules. Nineteen (83%) ablated nodules were located in segments VI, VII and VIII, and one nodule was in segment I. Median size of nodules was 15 mm (10-21). No deaths occurred. Six patients (38%) experienced complications, among them only one was subsequent to the thermal ablation. Ablative minimal margin was ≥5 mm for 19 (83%) nodules. Margin was not sufficient for four nodules, among them only 2/23 cases (8.7%) of in situ recurrence occurred after 12 months of median follow-up. CONCLUSIONS In this preliminary study, MWA with Pringle maneuver was associated with a low related morbidity rate and favorable oncological outcome, especially when the radiological minimal margin was sufficient.


title: Transmission of Zika virus through breast milk and other breastfeeding-related bodily-fluids: A systematic review.

text: BACKGROUND Zika virus (ZIKV) infection is an emerging mosquito-borne disease, which is associated with an increase in central nervous system malformations and newborn microcephaly cases. This review investigated evidence of breastfeeding transmission from ZIKV-infected mothers to their children and the presence of ZIKV infection in breastfeeding-related fluids. METHODOLOGY/PRINCIPAL FINDINGS We conducted a systematic review of observational studies, case studies, and surveillance reports involving breastfeeding women with ZIKV infection in several international databases. Data extraction and analysis were conducted following a PROSPERO-registered protocol. From 472 non-duplicate records, two case reports met criteria for inclusion. We reviewed three cases of ZIKV infection among lactating mothers near the time of delivery. Two of the three (2/3) associated newborns had evidence of ZIKV infection. ZIKV was detected in breast milk of all three mothers. Breast milk detection results were positive in all mothers (3/3) by RT-PCR, one was positive by culture (1/3), and none was tested for ZIKV-specific antibodies. Serum samples were ZIKV positive in all mothers (3/3), and sweat was not tested for ZIKV. CONCLUSIONS/SIGNIFICANCE We describe three cases of ZIKV-infected breastfeeding mothers who were symptomatic within three days of delivery, and two cases with ZIKV-infected newborns. While ZIKV was detected in the breast milk of all three mothers, the data are not sufficient to conclude ZIKV transmission via breastfeeding. More evidence is needed to distinguish breastfeeding transmission from other perinatal transmission routes.


title: Intra-abdominal adhesions: definition, origin, significance in surgical practice, and treatment options.

text: BACKGROUND Intra-abdominal adhesions arise after more than 50% of all abdominal operations and are an important source of postoperative complications. They attach normally separated organs to each other and can cause major problems for the affected patients by giving rise to small bowel obstruction, chronic pelvic pain, dyspareunia, infertility, and higher complication rates in subsequent operations. They are also a frequent source of medicolegal conflict. Thus, every physician should be familiar with their mechanism of origin, their consequences, and the methods by which they can be prevented. METHODS A selective PubMed/Medline search from 1960 onward as well as articles to which these publications referred. The expert consensus position of the European Society for Gynaecological Surgery is also taken into consideration. RESULTS Adhesions arise through aberrant wound healing after peritoneal injury with further influence from a variety of other factors. Preventive measures include minimizing peritoneal injury intraoperatively through the meticulous observance of basic surgical principles, moistening the mesothelium to keep it from drying out, irrigating the peritoneal cavity to remove blood and clot, and keeping the use of intra-abdominal foreign material to a minimum. CONCLUSION Adhesions are an inevitable consequence of intra-abdominal surgery. They can be prevented to some extent with meticulous surgical technique and certain other measures. For operations carrying a high risk of postoperative adhesions, e.g., surgery on the adnexa or bowel, commercially available peritoneal instillates or barrier methods can be used to limit adhesion formation.


docid: xtkpnpxh

title: Hepatitis B virus infection and interferon-inducible protein-10.

text: Interferon (IFN)-inducible protein-10 (IP-10) is a proinflammatory chemokine, binding the chemokine (C-X-C motif) receptor 3 (CXCR3), which is found mainly on activated T cells and natural killer (NK) cells, and plays an important role in T helper (Th) 1 type inflammatory disorders (autoimmune, neoplastic, and infectious diseases). Concerning viral hepatitis, IP-10 appears to be involved on the pathogenesis of liver damage as well as on the extra-hepatic manifestations either protecting or promoting infection, depending on host immune status and genetic background. During chronic hepatitis B, IP-10 is specifically produced by hepatocytes in inflammatory areas. Here, IP-10 leads to recruitment of T cells, production of IFN-gamma by activated NK T cells, and then monokine induced by IFN-gamma (MIG) and IP-10 secretion by parenchymal and non-parenchymal cells, with a final positive feedback, perpetuating the immune cascade. The increased levels of IP-10 and IP-10 mRNA in the peripheral blood of patients with cirrhosis are closely correlated with the load of HBV DNA in serum, and seem to play a key role in the progression of post-hepatitic cirrhosis. Higher pre-treatment IP-10 levels, and dynamic down-regulation, are associated with an increased probability of hepatitis B e antigen (HBeAg) loss after Peg-IFN therapy. Hepatitis B surface antigen (HBsAg) drop in patients treated with nucleos(t)ide analogues (NAs) is associated with higher baseline IP-10.


title: Non-Exposure Endoscopic-Laparoscopic Cooperative Surgery for Stomach Tumors: First Experience from the Czech Republic.

text: BACKGROUND/AIMS The aim of this study was to investigate the use of non-exposure endoscopic wall-inversion surgery (NEWS) and the combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET) in gastric tumors. METHODS We reviewed all cases of NEWS and CLEAN-NET performed in the department of surgery of the Royal Vinohrady Teaching Hospital. RESULTS Our department performed 12 gastric tumor resections (NEWS, n=10 and CLEAN-NET, n=2) between March 2016 and February 2017. The cases chosen for these resections included predominantly submucosal tumors with no signs of dissemination or local invasion and early gastric carcinomas (T1SM1 and T1M), where tumor location made it impossible to use endoscopic submucosal dissection. R0 resection margins were confirmed in all the cases. CONCLUSIONS NEWS and CLEAN-NET allow en bloc non-exposed full-thickness gastric wall resection in a way that uses a "close first, cut later" approach to prevent seeding of the peritoneal cavity with tumor cells. These mini-invasive techniques combine laparoscopic and endoscopic techniques, and preserve the full function of the stomach.


docid: ekqbokym

title: Bilateral osteonecrosis of the navicular and medial cuneiform in a patient with systemic lupus erythematosus: a case report.

text: INTRODUCTION Atraumatic avascular necrosis (AVN) is an unusual pathology to the foot. Risk factors include the use of corticosteroids, smoking, alcohol, rheumatologic disorders, hematologic disorders, and metabolic disorders. To the authors' knowledge, this study presents the first case of bilateral atraumatic AVN to the navicular and medial cuneiform in a patient with systemic lupus erythamatosus (SLE). CASE DESCRIPTION A 40-year-old man presented with a past medical history of SLE in which he developed AVN of the tarsal navicular and medial cuneiform. This occurred first on the subject's right foot and then while recovering from surgical intervention, on his left foot. Talonaviculocuneiform arthrodesis was performed with the use of distal tibial autograft on both extremities. The subject's American Orthopaedic Foot and Ankle Society midfoot score improved from 34 to 80 at 21 months on the right and 37 to 90 at 15 months to the left. DISCUSSION Patients with SLE carry a significant risk of developing AVN. Comorbidities such as vasculitis, corticosteroid use, cytotoxic medication, and peripheral neuropathy are known risk factors in the development of AVN. Unusual features such as multifocal AVN and unusual anatomic locations can occur with SLE. AVN of the foot is generally treated with surgical intervention. Treatments such as core decompression, open reduction and internal fixation, and arthrodesis have been recommended based on the symptoms and presentation. CONCLUSION The authors present a very rare presentation of bilateral osteonecrosis of the tarsal navicular and first cuneiform in a patient with SLE. The patient was treated with bilateral talonaviculocuneiform arthrodesis. The patient demonstrated considerable improvement to both extremities. LEVELS OF EVIDENCE Therapeutic, Level IV.


Readying for a Post-COVID-19 World: The Case for Concurrent Pandemic Disaster Response and Recovery Efforts in Public Health.


title: Integrating health status and survival data: the palliative effect of lung volume reduction surgery.

text: RATIONALE In studies that address health-related quality of life (QoL) and survival, subjects who die are usually censored from QoL assessments. This practice tends to inflate the apparent benefits of interventions with a high risk of mortality. Assessing a composite QoL-death outcome is a potential solution to this problem. OBJECTIVES To determine the effect of lung volume reduction surgery (LVRS) on a composite endpoint consisting of the occurrence of death or a clinically meaningful decline in QoL defined as an increase of at least eight points in the St. George's Respiratory Questionnaire total score from the National Emphysema Treatment Trial. METHODS In patients with chronic obstructive pulmonary disease and emphysema randomized to receive medical treatment (n = 610) or LVRS (n = 608), we analyzed the survival to the composite endpoint, the hazard functions and constructed prediction models of the slope of QoL decline. MEASUREMENTS AND MAIN RESULTS The time to the composite endpoint was longer in the LVRS group (2 years) than the medical treatment group (1 year) (P < 0.0001). It was even longer in the subsets of patients undergoing LVRS without a high risk for perioperative death and with upper-lobe-predominant emphysema. The hazard for the composite event significantly favored the LVRS group, although it was most significant in patients with predominantly upper-lobe emphysema. The beneficial impact of LVRS on QoL decline was most significant during the 2 years after LVRS. CONCLUSIONS LVRS has a significant effect on the composite QoL-survival endpoint tested, indicating its meaningful palliative role, particularly in patients with upper-lobe-predominant emphysema.


title: Upper extremity hemodynamics and sensation with backpack loads.

text: Heavy backpacks are often used in extreme environments, for example by military during combat, therefore completion of tasks quickly and efficiently is of operational relevance. The purpose of this study was to quantify hemodynamic parameters (brachial artery Doppler and microvascular flow by photoplethysmography; tissue oxygenation by near-infrared spectroscopy; arterial oxygen saturation by pulse oximeter) and sensation in upper extremities and hands (Semmes-Weinstein monofilament test and 2-point discrimination test) while wearing a loaded backpack (12 kg) in healthy adults for 10 min. All values were compared to baseline before wearing a backpack. Moderate weight loaded backpack loads significantly decreased upper extremity sensation as well as all macrovascular and microvascular hemodynamic values. Decreased macrovascular and microvascular hemodynamics may produce neurological dysfunction and consequently, probably affect fine motor control of the hands.


title: H1N1 influenza: critical care aspects.

text: During the Northern Hemisphere spring of 2009, a novel H1N1 influenza A virus emerged in Mexico, causing widespread human infection and acute critical respiratory illness. The 2009 H1N1 virus spread initially to the United States and Canada, with subsequent rapid global dissemination, leading the World Health Organization (WHO) to declare "a public health emergency of international concern" in April 2009, and upgrading the viral threat to pandemic status in June 2009. Despite initial fears, the severity of the 2009 H1N1 pandemic overall did not differ significantly from that of seasonal influenza. However, the demographics of those at risk of severe illness did differ (affecting children and young adults, rather than the very young and the very old). The 2009 H1N1 pandemic led to rapid implementation of health care initiatives, including the provision of critical care services, to limit the effect of the influenza outbreak on the community. This review focuses on the critical care response to the H1N1 pandemic and examines whether the implementation of critical care services as planned a priori matched the reality of the clinical workload and the patient burden that transpired during the 2009 H1N1 influenza pandemic.


title: All Feet On Deck-The Role of Podiatry During the COVID-19 Pandemic: Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes.

text: The COVID-19 pandemic is driving significant change in the healthcare system and disrupting the best practices for diabetic limb preservation, leaving large numbers of patients without care. Patients with diabetes and foot ulcers are at increased risk for infections, hospitalization, amputations, and death. Podiatric care is associated with fewer diabetes-related amputations, ER visits, hospitalizations, length-of-stay, and costs. But podiatrists must mobilize and adopt the new paradigm of shifts away from hospital care to community-based care. Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring can help podiatrists manage patients while reducing the COVID-19 risk. The goal of podiatrists during the pandemic is to reduce the burden on the healthcare system by keeping diabetic foot and wound patients safe, functional, and at home.


title: Effect of dexmedetomidine on plasma brain-derived neurotrophic factor: A double-blind, randomized and placebo-controlled study.

text: BACKGROUND Dexmedetomidine (DEX) has neuro-protective effects, but the clinical mechanism remains unclear. METHOD Forty patients were randomly divided into two groups: group A (control) and group B (treated with DEX). Plasma concentrations of brain-derived neurotrophic factor (BDNF) were determined in blood samples using enzyme-linked immunosorbent assays at five time points: T1 (baseline), T2 (15 minutes after intubation and before the surgery was started), T3 (the end of surgery), T4 (10 minutes after extubation in the post-anesthesia care unit), and T5 (24 hours after the surgery). Changes in bispect (BIS) index, heart rates, and doses of anesthetics used for induction were also recorded. RESULTS Baseline plasma concentrations of BDNF did not differ between group A and group B; 15 minutes after induction, concentrations of plasma BDNF were significantly reduced in group A. Twenty-four hours after surgery, the concentration was still higher in group B than in group A. In contrast, plasma concentrations of BDNF at other time points tested did not differ between the two groups. CONCLUSION It appears that DEX could reverse the reduced plasma concentrations of BDNF caused by anesthetics, and this effect lasted for 24 hours after surgery.


Optimum brightness of a new light-emitting diode lightwand device in a cadaveric model - a pilot study.


docid: zgnogygh

title: Prediction of Early Recurrent Thromboembolic Event and Major Bleeding in Patients With Acute Stroke and Atrial Fibrillation by a Risk Stratification Schema: The ALESSA Score Study.

text: BACKGROUND AND PURPOSES This study was designed to derive and validate a score to predict early ischemic events and major bleedings after an acute ischemic stroke in patients with atrial fibrillation. METHODS The derivation cohort consisted of 854 patients with acute ischemic stroke and atrial fibrillation included in prospective series between January 2012 and March 2014. Older age (hazard ratio 1.06 for each additional year; 95% confidence interval, 1.00-1.11) and severe atrial enlargement (hazard ratio, 2.05; 95% confidence interval, 1.08-2.87) were predictors for ischemic outcome events (stroke, transient ischemic attack, and systemic embolism) at 90 days from acute stroke. Small lesions (≤1.5 cm) were inversely correlated with both major bleeding (hazard ratio, 0.39; P=0.03) and ischemic outcome events (hazard ratio, 0.55; 95% confidence interval, 0.30-1.00). We assigned to age ≥80 years 2 points and between 70 and 79 years 1 point; ischemic index lesion >1.5 cm, 1 point; severe atrial enlargement, 1 point (ALESSA score). A logistic regression with the receiver-operating characteristic graph procedure (C statistic) showed an area under the curve of 0.697 (0.632-0.763; P=0.0001) for ischemic outcome events and 0.585 (0.493-0.678; P=0.10) for major bleedings. RESULTS The validation cohort consisted of 994 patients included in prospective series between April 2014 and June 2016. Logistic regression with the receiver-operating characteristic graph procedure showed an area under the curve of 0.646 (0.529-0.763; P=0.009) for ischemic outcome events and 0.407 (0.275-0.540; P=0.14) for hemorrhagic outcome events. CONCLUSIONS In acute stroke patients with atrial fibrillation, high ALESSA scores were associated with a high risk of ischemic events but not of major bleedings.


title: ADHD and Covid-19: Current roadblocks and future opportunities.

text: Attention Deficit Hyperactivity Disorder is the commonest disorder presenting to Child and Adolescent Mental Health Services in Ireland. ADMiRE is a specialist ADHD service in South Dublin that provides assessment and intervention for >200 children and adolescents with ADHD.The first section of this article considers the impact of the Covid-19 pandemic on the provision of mental health services for young people with ADHD with specific reference to the difficulties that have been experienced in ADMiRE since the outbreak of Covid-19 in Ireland. In ADMiRE, there has been a significant reduction of face to face consultations, postponement of new assessments, difficulties with physical monitoring, delays in medication initiation, suspension of medication titration, lack of group interventions and problems with access to controlled drug prescriptions. Current guidelines and alternative ways of ensuring adequate service provision are discussed.Restrictions to mitigate the spread of Covid-19 are likely to continue for many months, and child and adolescent mental health services need to find new ways to provide a sustainable service to young people in Ireland. There is a growing evidence base for telepsychiatry, the use of technology such as video conferencing to deliver mental health care remotely, and this approach may be particularly useful in assessment and management of ADHD. The second section of this article discusses the evidence base for telepsychiatry in ADHD, and outlines factors that should be considered when developing a telepsychiatry service for children and adolescents with ADHD.


title: Time-Dependent Associations Between Actionable Bleeding, Coronary Thrombotic Events, and Mortality Following Percutaneous Coronary Intervention: Results From the PARIS Registry.

text: OBJECTIVES The aim of this study was to examine the independent associations between actionable bleeding (AB) and coronary thrombotic events (CTE) on mortality risk after percutaneous coronary intervention (PCI). BACKGROUND The independent impact of AB and CTE on mortality risk after PCI remains poorly characterized. METHODS A post hoc analysis was conducted of the PARIS (Patterns of Non-Adherence to Dual Antiplatelet Therapy in Stented Patients) registry, a real-world cohort of 5,018 patients undergoing PCI with stent implantation. CTE included definite or probable stent thrombosis or myocardial infarction. AB was defined as Bleeding Academic Research Consortium type 2 or 3. Associations between CTE and AB, both of which were modeled as time-dependent covariates, and 2-year mortality risk were examined using extended Cox regression. RESULTS Over 2 years, the cumulative incidence of CTE, AB, and all-cause mortality was 5.9% (n = 289), 8.1% (n = 391), and 4.7% (n = 227), respectively. Adjusted hazard ratios for mortality associated with CTE and AB were 3.3 (95% confidence interval: 2.2 to 4.9) and 3.5 (95% confidence interval: 2.3 to 5.4), respectively. Temporal gradients in risk after either event were highest in the first 30 days and declined rapidly thereafter. Thrombotic events occurring while patients were on versus off dual-antiplatelet therapy were associated with a higher mortality risk, whereas risk related to AB was not influenced by dual-antiplatelet therapy status at the time of bleeding. CONCLUSIONS Intracoronary thrombosis and AB are associated with mortality risks of comparable magnitude over a 2-year period after PCI, findings that might inform risk/benefit calculations for extension versus discontinuation of dual-antiplatelet therapy.


title: Preliminary experience of sandwich repair technique: a new method of laparoscopic splenorraphy for high-grade splenic injuries.

text: BACKGROUND Laparoscopic splenectomy has been used safely for patients with blunt splenic trauma and failed nonoperative management. Reports of using laparoscopic splenorraphy for spleen salvage were fewer and mainly limited to lower grades of injuries. No study has focused on the role of laparoscopic splenorraphy in the treatment of patients with high grades of splenic injuries. METHODS Medical records of 15 patients with high grades of splenic injuries that required an operation for failed nonoperative management were retrospectively reviewed. They underwent a new technique of sandwich repair laparoscopically for spleen salvage by 3 surgeons who had adequate training in laparoscopy for trauma. Preoperative parameters, sandwich repair technique, perioperative parameters, and postoperative outcomes were evaluated. RESULTS Fourteen of the 15 (93.3%) patients underwent the technique successfully with 1 patient converting to laparotomy. The median (interquartile range) time to reach hemostasis was 30.0 (26.0-40.0) minutes, and the median overall operation time was 135.0 (120.0-165.0) minutes. Median blood loss amount was 1300.0 (750.0-2300.0) mL. The median length of hospital stay was 8.0 (7.0-11.0) days, and the intensive care unit stay was 2.0 (0.0-4.0) days. No mortality was noted. No rebleeding, total splenic infarction, or intra-abdominal abscess was noted during 3-month follow-up after the operation. CONCLUSIONS The preliminary results show that laparoscopic splenorraphy by the "sandwich repair technique" is feasible and safe for patients with high-grade splenic injuries.


Opinion: Sustainable development must account for pandemic risk.


title: Phase 2 and Later of COVID-19 Lockdown: Is it Possible to Perform Remote Diagnosis and Intervention for Autism Spectrum Disorder? An Online-Mediated Approach.

text: COVID-19 is still in phase 2. The lockdown has been significantly reduced compared to phase 1. The centers and institutions that deal with the diagnosis and intervention of children with autism spectrum disorder (ASD) require rapid functional adaptation to respond to patients' needs. The possibility of using technology to activate and manage diagnostic (preliminary diagnosis) and intervention processes should be explored. Two developed telemedicine working models for diagnosis and intervention, including synchronous and asynchronous transmissions, are presented. They are proposals not yet supported by the data. The diagnosis step is composed by two different and consecutives phases: (A) pre-specialistic consultation (PSC) and (B) specialistic assessment. The intervention step implemented well-recognized evidence-based models for preschoolers, school-aged, and older children in an online format. Parents' support is also included. The described working models have the purpose of carrying out preliminary specialistic answers to the families without aiming to replace preferable in-person assessment. Based on previous research findings, the telemedicine approach is accepted by parents, increases their sense of competence, increases the parent intervention adhesion, and improves the social communication competencies for children with ASD. In conclusion, the presented working models must be considered partial responses to the current emergency status and at the same time as possible integrations into traditional approaches.


title: Reference Managers that Support Collaborative Research: Dreaming of the Perfect Fit.

text: Reference or citation managers aid in capturing and managing citations and associated full text, tracking references and citing them properly in manuscripts, and creating bibliographies. With more features than ever, selecting the most appropriate reference manager can be overwhelming for users and librarians. One common situation in which librarians are asked for advice involves building shared libraries of references to support collaborative group work. This project developed a structured evaluation for comparison of several common citation managers and prototypical use cases to help match features with user needs, preferences, and workflows. As products evolve and needs change, is there a "perfect fit"?


title: Treatment of male varicoceles by transcatheter polidocanol foam sclerotherapy: evaluation of clinical success, complications, and patients' satisfaction with regard to alternative techniques.

text: OBJECTIVES We report our experience with polidocanol foam sclerotherapy with no additional coils, evaluating clinical success, patients' satisfaction, and complications. METHODS We conducted a retrospective study of 141 patients with 146 varicoceles (mean age: 29.3 years; range: 13 - 60 years) who underwent foam sclerotherapy with polidocanol 2% (range: 2 - 12 ml) in an outpatient setting between January 2007 and December 2013. For the follow-up, telephone interviews with the patients were conducted (mean follow-up time: 46.4 months, standard deviation: 20.17 months). RESULTS The technical success rate was 91.8%. There was a 55.8% response rate to the telephone interviews. Follow-up revealed a clinical success rate of 83.9% and a persistence or relapse rate of 16.1%. Of the patients, 81.9% were absolutely satisfied with the outcome. In 94.9% of cases, pain or discomfort resolution was reported, and in 97% of cases, aesthetic issues were no longer a problem. Of partners, 63.2% achieved pregnancy, and in 50% of patients with preprocedural testicular atrophy, catch-up growth was observed. One patient with pampiniform plexus phlebitis received inpatient treatment with no long-term damage recorded. CONCLUSIONS Polidocanol foam varicocele sclerotherapy is a safe and effective procedure, with a high rate of patients' satisfaction, clinical and technical success, and considerable catch-up growth and pregnancy achievement. KEY POINTS • Varicocele treatment using polidocanol foam sclerotherapy is a safe and effective procedure. • It is easily feasible in an outpatient setting. • The clinical and technical success rates are high. • It shows a high rate of patients' satisfaction and symptom resolution. • Postinterventional catch-up growth and pregnancy achievement are considerable.


title: Complications of seasonal and pandemic influenza.

text: Influenza is a seasonal viral infection associated with significant morbidity and mortality. In 2009, a novel H1N1 influenza A virus emerged and has been classified as a pandemic. In contrast to seasonal influenza, severe disease from pandemic H1N1 seems concentrated in older children and young adults, with almost no cases reported in patients older than 60 yrs. Although patients with underlying cardiopulmonary disease remain at risk, most complications have occurred among previously healthy individuals, with obesity and respiratory disease as the strongest risk factors. Pulmonary complications are common. Primary influenza pneumonia occurs most commonly in adults and may progress rapidly to acute lung injury requiring mechanical ventilation. Secondary bacterial infection is more common in children. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with a high mortality rate. Treatment of pneumonia should include empirical coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may occur.


Lack of effect of lamivudine on Ebola virus replication.


title: Severity and outcome associated with human coronavirus OC43 infections among children.

text: BACKGROUND Human coronaviruses are known causes of the common cold. Subtype OC43 (HCoV-OC43) is the more prevalent human coronavirus in several parts of the world. Recent studies have suggested these viruses can cause severe lower respiratory tract illnesses in children. OBJECTIVE We sought to determine the epidemiology, clinical characteristics, outcomes and severity of illness associated with HCoV-OC43 infections in a pediatric population. METHODS We retrospectively identified patients with positive HCoV-OC43 respiratory specimens between December 2009 and December 2010 in a pediatric hospital in Montreal. Each case was compared with 2 controls (tested negative for HCoV-OC43). Clinical characteristics, underlying conditions, outcomes and disease severity were reviewed for both groups. Risk factors and independent predictors of disease severity were also assessed. RESULTS During the study period, 68 patients were identified as infected with HCoV-OC43 (1.8% of specimens tested, 4.2% of all respiratory viruses identified by reverse transcription polymerase chain reaction). The majority (77%) occurred in November 2010. Chief symptoms of HCoV-OC43 infection were fever (in 78% of cases), cough (67%) and upper respiratory tract infection symptoms (57%). HCoV-OC43 infection was not more frequent in children with preexisting conditions. Coinfection with other respiratory viruses was associated with lower respiratory tract infections in HCoV-OC43-infected cases, but did not lead to increased rates of hospitalization, admission to intensive care unit or death. CONCLUSIONS In our population, HCoV-OC43 infections generally caused upper respiratory tract infection, but can be associated with lower respiratory tract infection especially in those coinfected with other respiratory viruses.


title: Gastrointestinal, influenza-like illness and dermatological complaints following exposure to floodwater: a cross-sectional survey in The Netherlands.

text: Extreme rainfall events may cause pluvial flooding, increasing the transmission of several waterborne pathogens. However, the risk of experiencing clinically overt infections following exposure to pluvial floodwater is poorly estimated. A retrospective cross-sectional survey was performed to quantify the occurrence of self-reported gastrointestinal, influenza-like illness (ILI) and dermatological complaints, and the frequency of visits to the general practitioner (GP), during a 4-week observation period following pluvial flooding at seven locations in The Netherlands. Questionnaires were sent to 817 flooded households, 149 (17%) of which returned the questionnaire reporting information for 199 participants. Contact with floodwater was significantly associated with increased occurrence of gastrointestinal [odds ratio (OR 4·44)], ILI (OR 2·75) and dermatological (OR 6·67) complaints, and GP visits (OR 2·72). Having hand contact with floodwater was associated with gastrointestinal and dermatological complaints, whereas ILI complaints were associated with being engaged in post-flooding cleaning operations and having walked/cycled through floodwater. This study shows that floodwater-associated diseases occur in urban settings following extreme rainfall events in a high-income country. As pluvial floods are expected to escalate in the future due to global climate change, further research is warranted to determine the disease burden of pluvial flooding and to assess the effect of different interventions, including raising awareness among stakeholders.


title: Novel influenza virus NS1 antagonists block replication and restore innate immune function.

text: The innate immune system guards against virus infection through a variety of mechanisms including mobilization of the host interferon system, which attacks viral products mainly at a posttranscriptional level. The influenza virus NS1 protein is a multifunctional facilitator of virus replication, one of whose actions is to antagonize the interferon response. Since NS1 is required for efficient virus replication, it was reasoned that chemical inhibitors of this protein could be used to further understand virus-host interactions and also serve as potential new antiviral agents. A yeast-based assay was developed to identify compounds that phenotypically suppress NS1 function. Several such compounds exhibited significant activity specifically against influenza A virus in cell culture but had no effect on the replication of another RNA virus, respiratory syncytial virus. Interestingly, cells lacking an interferon response were drug resistant, suggesting that the compounds block interactions between NS1 and the interferon system. Accordingly, the compounds reversed the inhibition of beta interferon mRNA induction during infection, which is known to be caused by NS1. In addition, the compounds blocked the ability of NS1 protein to inhibit double-stranded RNA-dependent activation of a transfected beta interferon promoter construct. The effects of the compounds were specific to NS1, because they had no effect on the ability of the severe acute respiratory syndrome coronavirus papainlike protease protein to block beta interferon promoter activation. These data demonstrate that the function of NS1 can be modulated by chemical inhibitors and that such inhibitors will be useful as probes of biological function and as starting points for clinical drug development.


title: From press release to news: mapping the framing of the 2009 H1N1 A influenza pandemic.

text: Pandemics challenge conventional assumptions about health promotion, message development, community engagement, and the role of news media. To understand the use of press releases in news coverage of pandemics, this study traces the development of framing devices from a government public health agency's press releases to news stories about the 2009 H1N1 A influenza pandemic. The communication management of the H1N1 pandemic, an international news event with local implications, by the Singapore government is a rich locus for understanding the dynamics of public relations, health communication, and journalism. A content analysis shows that the evolution of information from press release to news is marked by significant changes in media frames, including the expansion and diversification in dominant frames and emotion appeals, stronger thematic framing, more sources of information, conversion of loss frames into gain frames, and amplification of positive tone favoring the public health agency's position. Contrary to previous research that suggests that government information subsidies passed almost unchanged through media gatekeepers, the news coverage of the pandemic reflects journalists' selectivity in disseminating the government press releases and in mediating the information flow and frames from the press releases.


title: Characterization of the Mechanical Strength, Resorption Properties, and Histologic Characteristics of a Fully Absorbable Material (Poly-4-hydroxybutyrate-PHASIX Mesh) in a Porcine Model of Hernia Repair.

text: Purpose. Poly-4-hydroxybutyrate (P4HB) is a naturally derived, absorbable polymer. P4HB has been manufactured into PHASIX Mesh and P4HB Plug designs for soft tissue repair. The objective of this study was to evaluate mechanical strength, resorption properties, and histologic characteristics in a porcine model. Methods. Bilateral defects were created in the abdominal wall of n = 20 Yucatan minipigs and repaired in a bridged fashion with PHASIX Mesh or P4HB Plug fixated with SorbaFix or permanent suture, respectively. Mechanical strength, resorption properties, and histologic characteristics were evaluated at 6, 12, 26, and 52 weeks (n = 5 each). Results. PHASIX Mesh and P4HB Plug repairs exhibited similar burst strength, stiffness, and molecular weight at all time points, with no significant differences detected between the two devices (P > 0.05). PHASIX Mesh and P4HB Plug repairs also demonstrated significantly greater burst strength and stiffness than native abdominal wall at all time points (P < 0.05), and material resorption increased significantly over time (P < 0.001). Inflammatory infiltrates were mononuclear, and both devices exhibited mild to moderate granulation tissue/vascularization. Conclusions. PHASIX Mesh and P4HB Plug demonstrated significant mechanical strength compared to native abdominal wall, despite significant material resorption over time. Histological assessment revealed a comparable mild inflammatory response and mild to moderate granulation tissue/vascularization.


title: Acute effects of coffee consumption on self-reported gastrointestinal symptoms, blood pressure and stress indices in healthy individuals.

text: BACKGROUND It has been suggested that coffee may affect the gut-brain axis with conflicting outcomes. Moreover, there is insufficient evidence to determine whether the type or temperature of coffee consumed will have a different impact on the gut-brain axis. The purpose of this study was to investigate the effects of acute coffee consumption on the following: 1. self-reported GI symptoms and salivary gastrin, 2. stress indices [salivary cortisol and alpha-amylase (sAA)] and psychometric measures, and 3. blood pressure (BP), in healthy, daily coffee consuming individuals in non-stressful conditions. METHODS This was a randomized, double blind, crossover clinical trial, in which 40 healthy individuals (20 men, 20 women), 20-55 years of age, randomly consumed four 200 ml coffee beverages containing 160 mg caffeine (hot and cold instant coffee, cold espresso, hot filtered coffee), 1 week apart. Salivary samples and psychometric questionnaires were collected at baseline and post-coffee consumption at 15,30, and 60 min for salivary gastrin and sAA measurements and at 60,120, and 180 min for cortisol measurements. BP was measured at beginning and end of each intervention. ClinicalTrials.gov ID: NCT02253628 RESULTS: Coffee consumption significantly increased sAA activity (P = 0.041), with significant differences only between cold instant and filter coffee at 15 and 30 min post-consumption (P < 0.05). Coffee temporarily increased salivary gastrin, without differences between coffee types. Coffee did not affect salivary cortisol or self-reported anxiety levels. Coffee consumption significantly increased BP, within the healthy physiological levels, in a gender specific manner at the end of the experimental periods, without differences between coffee types. CONCLUSION Acute coffee consumption in non-stressful conditions activated sAA and BP but not salivary cortisol, indicating activation of the sympathetic nervous system. Post-coffee sAA increase without a concomitant cortisol increase may also indicate that coffee may have some anti-stress properties.


Middle East Respiratory Syndrome: A Global Health Challenge.


title: Ligation of the internal jugular vein increased regional cerebral oxygen saturation but decreased the bispectral index in a 72-year-old man: a case report.

text: Regional cerebral oxygen saturation (rSO2) and the bispectral index (BIS) are used to detect cerebral perfusion abnormalities. However, whether rSO2 and BIS values change during ligation of the internal jugular vein (IJV) is unknown. We report a case in which BIS values were decreased, despite increased rSO2 during ligation of the IJV. A 72-year-old man was diagnosed with metastasis of renal cancer to the thyroid associated with tumor embolism in the right IJV. Thyroidectomy with total laryngectomy was performed. After right IJV ligation, right rSO2 was increased from 73 to 78 %, while the right BIS value was decreased from 40 to 27. Contralateral rSO2 and BIS values were unchanged. Right rSO2 and BIS values returned to pre-ligation values in 10 min. Ligation of the IJV might increase cerebral blood flow and ipsilateral rSO2. Physicians should use BIS values with caution during IJV ligation because a sudden decrease in the BIS value is not always associated with cerebral hypoperfusion.


Covid-19: Gilead withdraws orphan drug designation from potential treatment after criticism.


title: Dressings and topical agents for treating venous leg ulcers.

text: BACKGROUND Venous leg ulcers are open skin wounds on the lower leg which can be slow to heal, and are both painful and costly. The point prevalence of open venous leg ulcers in the UK is about 3 cases per 10,000 people, and many people experience recurrent episodes of prolonged ulceration. First-line treatment for venous leg ulcers is compression therapy, but a wide range of dressings and topical treatments are also used. This diversity of treatments makes evidence-based decision-making challenging, and a clear and current overview of all the evidence is required. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents. OBJECTIVES To assess the effects of (1) dressings and (2) topical agents for healing venous leg ulcers in any care setting and to rank treatments in order of effectiveness, with assessment of uncertainty and evidence quality. SEARCH METHODS In March 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We updated this search in March 2018; as a result several studies are awaiting classification. SELECTION CRITERIA We included published or unpublished randomised controlled trials (RCTs) that enrolled adults with venous leg ulcers and compared the effects of at least one of the following interventions with any other intervention in the treatment of venous leg ulcers: any dressing, or any topical agent applied directly to an open venous leg ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factors and other biological agents, larval therapy and treatments such as laser, heat or ultrasound. Studies were required to report complete wound healing to be eligible. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We conducted this NMA using frequentist meta-regression methods for the efficacy outcome; the probability of complete healing. We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals (CIs) for individual treatments focusing on comparisons with widely used dressing classes, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole. MAIN RESULTS We included 78 RCTs (7014 participants) in this review. Of these, 59 studies (5156 participants, 25 different interventions) were included in the NMA; resulting in 40 direct contrasts which informed 300 mixed-treatment contrasts.The evidence for the network as a whole was of low certainty. This judgement was based on the sparsity of the network leading to imprecision and the general high risk of bias in the included studies. Sensitivity analyses also demonstrated instability in key aspects of the network and results are reported for the extended sensitivity analysis. Evidence for individual contrasts was mainly judged to be low or very low certainty.The uncertainty was perpetuated when the results were considered by ranking the treatments in terms of the probability that they were the most effective for ulcer healing, with many treatments having similar, low, probabilities of being the best treatment. The two most highly-ranked treatments both had more than 50% probability of being the best (sucralfate and silver dressings). However, the data for sucralfate was from one small study, which means that this finding should be interpreted with caution. When exploring the data for silver and sucralfate compared with widely-used dressing classes, there was some evidence that silver dressings may increase the probability of venous leg ulcer healing, compared with nonadherent dressings: RR 2.43, 95% CI 1.58 to 3.74 (moderate-certainty evidence in the context of a low-certainty network). For all other combinations of these five interventions it was unclear whether the intervention increased the probability of healing; in each case this was low- or very low-certainty evidence as a consequence of one or more of imprecision, risk of bias and inconsistency. AUTHORS' CONCLUSIONS More research is needed to determine whether particular dressings or topical agents improve the probability of healing of venous leg ulcers. However, the NMA is uninformative regarding which interventions might best be included in a large trial, largely because of the low certainty of the whole network and of individual comparisons.The results of this NMA focus exclusively on complete healing; whilst this is of key importance to people living with venous leg ulcers, clinicians may wish to take into account other patient-important outcomes and factors such as patient preference and cost.


docid: fkqkbail

title: Rocuronium pharmacokinetics and pharmacodynamics in the adductor pollicis and masseter muscles.

text: BACKGROUND The aim of this study was to characterize the dose-effect relationship of rocuronium at the adductor pollicis and masseter muscles. METHODS Ten, ASA I, adult patients, received a bolus dose of rocuronium 0.3 mg/kg during propofol based anesthesia. Train-of-four (TOF) was simultaneously monitored at the masseter and the adductor pollicis muscles until recovery. Rocuronium arterial serum concentrations were measured during 120 min. The first twitch of the TOF response was used to characterize the time-effect profile of both muscles using pharmacokinetic-pharmacodynamic analysis in NONMEM. A decrease in NONMEM objective function (∆OFV) of 3.84 points for an added parameter was considered significant at the 0.05 level. RESULTS Onset time at the masseter (mean ± SD, 1.5 ± 0.9 min) was faster than at the adductor pollicis (2.7 ± 1.4 min, P < 0.05). Recovery, measured as the time to TOF ratio = 0.9 was similar between muscles 29.9 ± 6.7 (adductor pollicis) vs. 29.3 ± 8.1 (masseter). (P = 0.77). The estimated pharmacodynamic parameters [mean (95% CI)] of the adductor pollicis muscle and the masseter muscle were; plasma effect-site equilibration half-time (teq) 3.25 (2.34, 3.69) min vs. 2.86 (1.83, 3.29) min, (∆OFV 383.665); Ce50 of 1.24 (1.13, 1.56) mg/l vs. 1.19 (1.00, 1.21) mg/l, (∆OFV 184.284); Hill coefficient of 3.97 (3.82, 5.62) vs. 4.68 (3.83, 5.71), (∆OFV 78.906). CONCLUSIONS We found that the masseter muscle has faster onset of blockade and similar recovery profile than adductor pollicis muscle. These findings were best, explained by a faster plasma effect-site equilibration of the masseter muscle to rocuronium.


title: Colorectal surgery in Parkinson's disease--outcomes and predictors of mortality.

text: PURPOSE Although diseases of the lower gastrointestinal tract are common in patients with Parkinson's disease, there is a paucity of data regarding postoperative outcomes after colorectal surgery. METHODS The Nationwide Inpatient Sample database (2007-2011) was utilized to analyze outcomes in patients with Parkinson's disease (PD) undergoing colorectal surgery. Main outcomes were risk-adjusted inpatient morbidity, mortality, hospital charge, and length of hospital stay. RESULTS A total of 6490 patients were identified. Utilization of laparoscopic surgery in Parkinson's patients has progressively increased in frequency over the latest 5 years analyzed. The most common diagnoses were colorectal malignancy (39 %) and intestinal obstruction (20 %). Right hemicolectomy (37 %) and sigmoidectomy (30 %) were the most common operations. Laparoscopy was used in 18 % of Parkinson's patients and most commonly in the elective setting. 54.3 % of Parkinson's patients had emergency surgery compared to 38.6 % in non-Parkinson's. Overall morbidity and mortality were significantly lower after laparoscopic surgery compared to open (20 vs. 25 % and 2.1 vs. 6.6 %, respectively). Length of stay was significantly shorter (OR -1.86; p < 0.01) for laparoscopic operations, but there were no significant differences in risk-adjusted outcomes between laparoscopic and open groups. CONCLUSION PD patients have high rates of morbidity and mortality after colorectal surgery; this may be because more than half of all patients in this population undergo emergent surgery. The laparoscopic approach appears to have short-term benefits in this patient population.


title: Cytokines transcript levels in lung and lymphoid organs during genotype 1 Porcine Reproductive and Respiratory Syndrome Virus (PRRSV) infection.

text: Porcine Reproductive and Respiratory Syndrome (PRRS) is one of the most economically important diseases of swine. PRRS virus (PRRSV) infection in the pig is characterized by a weak or absent host innate immune response. The underlying mechanisms of PRRSV pathogenesis are still unclear. The analysis of transcript levels represents an alternative to immunoassays for the detection of cytokines that sometimes are difficult to detect due to their low amounts. This study sets out to determine the differences in pathogenesis and the immune response between lung, tonsil, tracheobronchial lymph node (Tb-LN) and retropharyngeal LN (Rf-LN) of PRRSV 2982 strain infected pigs. PRRSV strain 2982 avoided the onset of an effective innate immune response, especially in PRRSV main target (lung) and reservoir (tonsil) organs. PRRSV lead to an impaired expression of IFN-α and TNF-α gene expression, which finally induced a weak and delayed adaptive immune response through an inefficient IL-12 and IFN-γ expression. Finally, PRRSV replication favored the expression of the anti-inflammatory IL-10 cytokine in infected pigs.


title: Technique or technology? Evaluating leaks after gastric bypass.

text: OBJECTIVE To assess the relationship between technique and surgical devices on anastomotic and staple-line leaks after laparoscopic Roux-en-Y gastric bypass. BACKGROUND Leaks after bariatric surgery remain a major source of morbidity and mortality. The association of surgical technique and devices with leaks after gastric bypass is poorly understood. SETTING Multi-centered study that included teaching and non-teaching hospitals that participate in a statewide consortium for quality improvement using a payer-funded outcome registry. METHODS We analyzed data from the Michigan Bariatric Surgery Collaborative and performed a case-control study comparing patients who sustained a leak with those who did not after primary laparoscopic Roux-en-Y gastric bypass. A total of 71 (.44%) patients with leaks were identified between January 2007 and December 2011. The leak group was matched 1:2 to a control group (nonleak) based on procedure type, age, body mass index, sex, and the year in which the procedure was performed. Technique-specific case characteristics and device-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. RESULTS The rate of leak decreased during the study period, and there was a significant downward trend (slope estimate: -.19961%, P = .0372). After performing multivariate analysis, the type of anastomosis (circular stapler, hand-sewn, or linear stapler) and stapler manufacturer were not associated with leaks. The use of buttressing material was associated with a higher rate of leaks (odds ratio: 8.79 [95% confidence interval: 2.49-31.01], P = .0007), whereas the use of fibrin sealant was associated with a lower rate of leaks (odds ratio .11 [95% confidence interval: .03-.41], P = .0013). These findings could not be explained by differences in measures of surgeon performance. CONCLUSION Leak rates after laparoscopic gastric bypass have fallen in Michigan despite variations in technique and device utilization. Although the type of anastomosis and stapler manufacturer do not appear to be significantly associated with leaks, it appears that the use of buttressing material was more common in cases in which leaks occurred, whereas the use of fibrin sealant was not. Given the complex interplay of multiple variables that affect surgical outcomes, future studies justifying the benefits of operative devices should be evaluated prospectively in the context of surgeon technique and skill.


title: Rapid and sensitive detection of rare cancer cells by the coupling of immunomagnetic nanoparticle separation with ELISA analysis.

text: This study presents a rapid and sensitive method for detecting cancer cells occurring at low concentration. The method involves the simultaneous detection of two biomarkers of T helper cancer cells. One biomarker conjugates with immunofunctionalized magnetic nanoparticles (MNPs), enabling the separation of the T helper cells from a mixed population of cells. The other biomarker is used for detection during enzyme-linked immunosorbent assay (ELISA) analysis. The specific T helper cells can be quantified according to their ELISA absorbance values following magnetic separation. The experimental results demonstrate that immunofunctionalized MNPs can function as magnetic sensors and separate specific T helper cells from a mixed population with high efficiency and high specificity. Coupled with the ELISA technique, the immunofunctionalized MNPs can simultaneously detect rare cells. Results indicated increasing absorbance with increasing T cell number (from 10 to 10(6)). The total detection time was less than 15 minutes, even at a low T cell count. The advantages of the proposed method for detecting specific cells at low concentration include ease of preparation, low cost, rapid detection, and high sensitivity. The proposed system can be adopted to detect circulating tumor cells in early tumor stages for diagnostic or prognostic purposes.


title: Analyses of evolutionary dynamics in viruses are hindered by a time-dependent bias in rate estimates.

text: Time-scales of viral evolution and emergence have been studied widely, but are often poorly understood. Molecular analyses of viral evolutionary time-scales generally rely on estimates of rates of nucleotide substitution, which vary by several orders of magnitude depending on the timeframe of measurement. We analysed data from all major groups of viruses and found a strong negative relationship between estimates of nucleotide substitution rate and evolutionary timescale. Strikingly, this relationship was upheld both within and among diverse groups of viruses. A detailed case study of primate lentiviruses revealed that the combined effects of sequence saturation and purifying selection can explain this time-dependent pattern of rate variation. Therefore, our analyses show that studies of evolutionary time-scales in viruses require a reconsideration of substitution rates as a dynamic, rather than as a static, feature of molecular evolution. Improved modelling of viral evolutionary rates has the potential to change our understanding of virus origins.


The COVID-19 Pandemic and Pediatric Graduate Medical Education.


title: Hepatitis C Virus Envelope Glycoprotein E1 Forms Trimers at the Surface of the Virion.

text: UNLABELLED In hepatitis C virus (HCV)-infected cells, the envelope glycoproteins E1 and E2 assemble as a heterodimer. To investigate potential changes in the oligomerization of virion-associated envelope proteins, we performed SDS-PAGE under reducing conditions but without thermal denaturation. This revealed the presence of SDS-resistant trimers of E1 in the context of cell-cultured HCV (HCVcc) as well as in the context of HCV pseudoparticles (HCVpp). The formation of E1 trimers was found to depend on the coexpression of E2. To further understand the origin of E1 trimer formation, we coexpressed in bacteria the transmembrane (TM) domains of E1 (TME1) and E2 (TME2) fused to reporter proteins and analyzed the fusion proteins by SDS-PAGE and Western blotting. As expected for strongly interacting TM domains, TME1-TME2 heterodimers resistant to SDS were observed. These analyses also revealed homodimers and homotrimers of TME1, indicating that such complexes are stable species. The N-terminal segment of TME1 exhibits a highly conserved GxxxG sequence, a motif that is well documented to be involved in intramembrane protein-protein interactions. Single or double mutations of the glycine residues (Gly354 and Gly358) in this motif markedly decreased or abrogated the formation of TME1 homotrimers in bacteria, as well as homotrimers of E1 in both HCVpp and HCVcc systems. A concomitant loss of infectivity was observed, indicating that the trimeric form of E1 is essential for virus infectivity. Taken together, these results indicate that E1E2 heterodimers form trimers on HCV particles, and they support the hypothesis that E1 could be a fusion protein. IMPORTANCE HCV glycoproteins E1 and E2 play an essential role in virus entry into liver cells as well as in virion morphogenesis. In infected cells, these two proteins form a complex in which E2 interacts with cellular receptors, whereas the function of E1 remains poorly understood. However, recent structural data suggest that E1 could be the protein responsible for the process of fusion between viral and cellular membranes. Here we investigated the oligomeric state of HCV envelope glycoproteins. We demonstrate that E1 forms functional trimers after virion assembly and that in addition to the requirement for E2, a determinant for this oligomerization is present in a conserved GxxxG motif located within the E1 transmembrane domain. Taken together, these results indicate that a rearrangement of E1E2 heterodimer complexes likely occurs during the assembly of HCV particles to yield a trimeric form of the E1E2 heterodimer. Gaining structural information on this trimer will be helpful for the design of an anti-HCV vaccine.


title: Evaluation of ventilators for mouthpiece ventilation in neuromuscular disease.

text: BACKGROUND Daytime mouthpiece ventilation is a useful adjunct to nocturnal noninvasive ventilation (NIV) in patients with neuromuscular disease. The aims of the study were to analyze the practice of mouthpiece ventilation and to evaluate the performance of ventilators for mouthpiece ventilation. METHODS Practice of mouthpiece ventilation was assessed by a questionnaire, and the performance of 6 home ventilators with mouthpiece ventilation was assessed in a bench test using 24 different conditions per ventilator: 3 mouthpieces, a child and an adult patient profile, and 4 ventilatory modes. RESULTS Questionnaires were obtained from 30 subjects (mean age 33 ± 11 y) using NIV for 12 ± 7 y. Fifteen subjects used NIV for > 20 h/day, and 11 were totally ventilator-dependent. The subject-reported benefits of mouthpiece ventilation were a reduction in dyspnea (73%) and fatigue (93%) and an improvement in speech (43%) and eating (27%). The bench study showed that none of the ventilators, even those with mouthpiece ventilation software, were able to deliver mouthpiece ventilation without alarms and/or autotriggering in each condition. Alarms and/or ineffective triggering or autotriggering were observed in 135 of the 198 conditions. The occurrence of alarms was more common with a large mouthpiece without a filter compared to a small mouthpiece with a filter (P < .001), but it was not related to the patient profile, the ventilatory mode, or the type of ventilator. CONCLUSIONS Subjects are satisfied with mouthpiece ventilation. Alarms are common with home ventilators, although less common in those with mouthpiece ventilation software. Improvements in home ventilators are needed to facilitate the expansion of mouthpiece ventilation.


title: A phase 3 study of nivolumab in previously treated advanced gastric or gastroesophageal junction cancer (ATTRACTION-2): 2-year update data.

text: BACKGROUND Nivolumab showed improvement in overall survival (OS) in ATTRACTION-2, the first phase 3 study in patients with gastric/gastroesophageal junction (G/GEJ) cancer treated with ≥ 2 chemotherapy regimens. The 2-year follow-up results of ATTRACTION-2 are presented herein. METHODS ATTRACTION-2 was a randomized, double-blind, placebo-controlled, phase 3 trial (49 sites; Japan, South Korea, and Taiwan). The median (min-max) follow-up period was 27.3 (24.1-36.3) months. The primary endpoint was OS. A subanalysis of OS was performed based on best overall response and tumor-programmed death ligand-1 (PD-L1) expression status. RESULTS Overall, 493 of 601 screened patients were randomized (2:1) to receive nivolumab (330) or placebo (163). OS (median [95% confidence interval; CI]) was significantly longer in the nivolumab group (5.26 [4.60-6.37] vs 4.14 [3.42-4.86] months in placebo group) at the 2-year follow-up (hazard ratio [95% CI], 0.62 [0.51-0.76]; P < 0.0001). A higher OS rate was observed in the nivolumab vs placebo group at 1 (27.3% vs 11.6%) and 2 years (10.6% vs 3.2%). The OS benefit was observed regardless of tumor PD-L1 expression. Among patients with a complete or partial response (CR or PR) in the nivolumab group, the median OS (95% CI) was 26.6 (21.65-not applicable) months; the OS rates at 1 and 2 years were 87.1% and 61.3%, respectively. No new safety signals were identified. CONCLUSIONS Nivolumab treatment resulted in clinically meaningful long-term improvements in OS in patients with previously treated G/GEJ cancer. The long-term survival benefit of nivolumab was most evident in patients with a CR or PR.


title: Emergence times and airway reactions during general anaesthesia with remifentanil and a laryngeal mask airway: A multicentre randomised controlled trial.

text: BACKGROUND Avoidance of airway complications and rapid emergence from anaesthesia are indispensable for the use of a laryngeal mask airway (LMA). Evidence from adequately powered randomised studies with a low risk of bias for the optimal anaesthetic in this context is limited. OBJECTIVE We tested the hypothesis that when using remifentanil-based intra-operative analgesia, desflurane would be the most suitable anaesthetic: with noninferiority in the occurrence of upper airway complications and superiority in emergence times compared with sevoflurane or propofol. DESIGN A randomised, multicentre, partially double-blinded, three-arm, parallel-group study. SETTING Two university and two regional German hospitals, from February to October 2015. PATIENTS A total of 352 patients (age 18 to 75 years, ASA physical status I to III, BMI less than 35 kg m and fluent in German) were enrolled in this study. All surgery was elective with a duration of 0.5 to 2 h, and general anaesthesia with a LMA was feasible. INTERVENTION The patients were randomised to receive desflurane, sevoflurane or propofol anaesthesia. MAIN OUTCOME MEASURES This study was powered for the primary outcome 'time to state date of birth' and the secondary outcome 'intra-operative cough'. Time to emergence from anaesthesia and the incidence of upper airway complications were assessed on the day of surgery. RESULTS The primary outcome was analysed for 343 patients: desflurane (n=114), sevoflurane (n=111) and propofol (n=118). The desflurane group had the fastest emergence. The mean (± SD) times to state the date of birth following desflurane, sevoflurane and propofol were 8.1 ± 3.6, 10.1 ± 4.0 and 9.8 ± 5.1 min, respectively (P < 0.01). There was no difference in upper airway complications (cough and laryngospasm) across the groups, but these complications were less frequent than in previous studies. CONCLUSION When using a remifentanil infusion for intra-operative analgesia in association with a LMA, desflurane was associated with a significantly faster emergence and noninferiority in the incidence of intra-operative cough than either sevoflurane or Propofol. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02322502; EudraCT identifier: 2014-003810-96.


title: Control of hemorrhage through the osteotomy gap during tibial plateau leveling osteotomy: 9 cases.

text: OBJECTIVE To describe a new technique to control intraoperative hemorrhage during tibial plateau leveling osteotomy (TPLO) and report subsequent short-term and long-term complications. STUDY DESIGN Retrospective case series. ANIMALS Nine dogs with arterial hemorrhage during TPLO. METHODS Medical records of dogs with hemorrhage controlled through the osteotomy gap of a TPLO were reviewed at 2 institutions over 8 years. Inclusion criteria included diagnosis of single cranial cruciate ligament rupture, intraoperative arterial hemorrhage during the radial osteotomy controlled with bipolar electrocautery or hemostatic clips placed along the cranial tibial artery through the osteotomy, complete medical records, radiographic follow-up for at least 8 weeks postoperatively, and completion of long-term follow-up questionnaire by the owner. RESULTS Dogs were 4.6 ± 1.8 years old and weighed 36.6 ± 9.7 kg. In total, 3 ± 1 hemostatic clips were placed per stifle. Intraoperative hemostasis was achieved in all cases. One of the first dogs received a blood transfusion during the procedure and had a postoperative packed cell volume of 37%. The only complication consisted of fibular fracture, which was noticed on radiographs of 1 dog 8 weeks after TPLO. CONCLUSION Arterial hemorrhage during the radial osteotomy of a TPLO can be controlled by occlusion of the compromised artery through distraction of the osteotomy gap. This technique was not associated with long-term complications.


title: COVID-19 in Pregnant Women: Case Series from One Large New York City Obstetrical Practice.

text: OBJECTIVE This study aimed to report a case series of pregnant women in New York City with confirmed or presumed coronavirus disease (COVID-19) infection. STUDY DESIGN Beginning March 22, 2020, all pregnant women from one large obstetrical practice in New York City were contacted regularly to inquire about symptoms of COVID-19 (fever, cough, shortness of breath, malaise, anosmia), or sick contacts. A running log was kept of these patients, as well as all patients who underwent COVID-19 testing. For this report, we included every patient with suspected COVID-19 infection, which was defined as at least two symptoms, or a positive COVID-19 nasopharyngeal polymerase chain reaction test. RESULTS From March 22, 2020 until April 30, 2020, 757 pregnant women in our practice were evaluated and 92 had known or suspected COVID-19 (12.2%, 95% confidence interval [CI]: 10.0-14.7%). Of these 92 women, 33 (36%) had positive COVID-19 test results. Only one woman required hospital admission for 5 days due to COVID-19 (1.1%, 95% CI: 0.2-5.9%). One other woman received home oxygen. No women required mechanical ventilation and there were no maternal deaths. One woman had an unexplained fetal demise at 14 weeks' gestation around the time of her COVID-19 symptoms. Twenty one of the 92 women have delivered, and all were uncomplicated. CONCLUSIONS Among 92 women with confirmed or presumed COVID-19, the overall morbidity was low. These preliminary results are encouraging for pregnant women during the COVID-19 pandemic. KEY POINTS · Coronavirus disease (COVID-19) is prevalent in New York City.. · In this case series, COVID-19 in pregnant women had a very low morbidity and no mortality.. · This preliminary data is reassuring for pregnant women at risk of COVID-19..


title: Xenon as an adjuvant to sevoflurane anesthesia in children younger than 4 years of age, undergoing interventional or diagnostic cardiac catheterization: A randomized controlled clinical trial.

text: BACKGROUND Xenon has repeatedly been demonstrated to have only minimal hemodynamic side effects when compared to other anesthetics. Moreover, in experimental models, xenon was found to be neuroprotective and devoid of developmental neurotoxicity. These properties could render xenon attractive for the anesthesia in neonates and infants with congenital heart disease. However, experience with xenon anesthesia in children is scarce. AIMS We hypothesized that in children undergoing cardiac catheterization, general anesthesia with a combination of sevoflurane with xenon results in superior hemodynamic stability, compared to sevoflurane alone. METHODS In this prospective, randomized, single-blinded, controlled clinical trial, children with a median age of 12 [IQR 3-36] months undergoing diagnostic/interventional cardiac catheterization were randomized to either general anesthesia with 50-65vol% xenon plus sevoflurane or sevoflurane alone. The primary outcome was the incidence of intraprocedural hemodynamic instability, defined as the occurrence of: (i) a heart rate change >20% from baseline; or (ii) a change in mean arterial blood pressure >20% from baseline; or (iii) the requirement of vasopressors, inotropes, chronotropes, or fluid boluses. Secondary endpoints included recovery characteristics, feasibility criteria, and safety (incidence of emergence agitation and postoperative vomiting. RESULTS After inclusion of 40 children, the trial was stopped as an a priori planned blinded interim analysis revealed that the overall rate of hemodynamic instability did not differ between groups [100% in both the xenon-sevoflurane and the sevoflurane group. However, the adjuvant administration of xenon decreased vasopressor requirements, preserved better cerebral oxygen saturation, and resulted in a faster recovery. Xenon anesthesia was feasible (with no differences in the need for rescue anesthetics in both groups). CONCLUSION Our observations suggest that combining xenon with sevoflurane in preschool children is safe, feasible, and facilitates hemodynamic management. Larger and adequately powered clinical trials are warranted to investigate the impact of xenon on short- and long-term outcomes in pediatric anesthesia.