title: Robotic-Assisted Surgery Improves the Quality of Total Mesorectal Excision for Rectal Cancer Compared to Laparoscopy: Results of a Case-Controlled Analysis.

text: BACKGROUND The use of a robotic surgical system is claimed to allow precise traction and counter-traction, especially in a narrow pelvis. Whether this translates to improvement of the quality of the resected specimen is not yet clear. The aim of the study was to compare the quality of the TME and the short-term oncological outcome between robotic and laparoscopic rectal cancer resections. METHODS 20 consecutive robotic TME performed in a single institution for rectal cancer (Rob group) were matched 1:2 to 40 laparoscopic resections (Lap group) for gender, body mass index (BMI), and distance from anal verge on rigid proctoscopy. The quality of TME was assessed by 2 blinded and independent pathologists and reported according to international standardized guidelines. RESULTS Both samples were well matched for gender, BMI (median 25.9 vs. 24.2 kg/m(2), p = 0.24), and level of the tumor (4.1 vs. 4.8 cm, p = 0.20). The quality of the TME was better in the Robotic group (complete TME: 95 vs. 55 %; p = 0.0003, nearly complete TME 5 vs. 37 %; p = 0.04, incomplete TME 0 vs. 8 %, p = 0.09). A trend for lower positive circumferential margin was observed in the Robotic group (10 vs. 25 %, p = 0.1). CONCLUSIONS These results suggest that robotic-assisted surgery improves the quality of TME for rectal cancer. Whether this translates to better oncological outcome needs to be further investigated.


title: Xenograft biologic mesh in parietal and general surgery: Technical assessment and review of clinical effectiveness and safety data.

text: STUDY AIM To describe the main technical characteristics of biologic prostheses used for parietal reinforcement and to present the state of the art on their risk/benefit ratio. METHODS We conducted a technical analysis of manufacturer specifications of the biologic prostheses that are currently available in France accompanied by a literature review by selecting meta-analyses and systematic reviews, randomized controlled trials and publications of health technology rating agencies. RESULTS Biological implants for parietal reinforcement are mainly intended for use in a contaminated environment where the use of synthetic prostheses is contra-indicated. We identified fourteen systematic reviews and meta-analyses and one randomized controlled trial. Six ongoing clinical trials were identified as well as two clinical trials that had been interrupted. In the current state of knowledge, there are no high-level evidence data on the therapeutic contribution of biologic prostheses that allow prioritization of the various biologic prostheses according to their characteristics or their different manufacturing processes. CONCLUSION Pending the results of current randomized controlled trials to validate the indications and an eventual specific reimbursement, indications for the use of biologic parietal reinforcement prostheses seems to be limited to rare clinical situations and only after collegial discussion.


title: The dynamic nature of contact networks in infectious disease epidemiology.

text: Although contact network models have yielded important insights into infectious disease transmission and control throughout the last decade, researchers have just begun to explore the dynamic nature of contact patterns and their epidemiological significance. Most network models have assumed that contacts are static through time. Developing more realistic models of the social interactions that underlie the spread of infectious diseases thus remains an important challenge for both data gatherers and modelers. In this article, we review some recent data-driven and process-driven approaches that capture the dynamics of human contact, and discuss future challenges for the field.


title: Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling.

text: BACKGROUND Diaphragmatic muscle contractions triggered by ventilator insuffl ations constitute a form of patient-ventilator interaction referred to as “entrainment,” which is usually unrecognized in critically ill patients. Our objective was to review tracings, which also included muscular activity, obtained in sedated patients who were mechanically ventilated to describe the entrainment events and their characteristics. The term “reverse triggering” was adopted to describe the ventilator-triggered muscular efforts. METHODS Over a 3-month period, recordings containing fl ow, airway pressure, and esophageal pressure or electrical activity of the diaphragm were reviewed. Recordings were obtained from a series of consecutive heavily sedated patients ventilated with an assist-control mode of ventilation for ARDS. The duration of entrainment, the entrainment ratio, and the phase difference elapsing between the commencement of the ventilator and neural breaths were evaluated. RESULTS The tracings of eight consecutive patients with ARDS were reviewed; they all showed different forms of entrainment. Reverse triggering occurred over a portion varying from 12% to 100% of the total recording period. Seven patients had a 1:1 mechanical insuffl ation to diaphragmatic contractions ratio; this coexisted with a 1:2 ratio in one patient and 1:2 and 1:3 ratios in another. One patient exhibited only a 1:2 ratio. The frequency of reverse-triggered breaths had a mean coeffi cient of variability of , 5%, very close to the variability of mechanical breaths. CONCLUSIONS To our knowledge, this is the fi rst time that the presence of respiratory entrainment in sedated, critically ill adult patients who are mechanically ventilated has been documented. The “reverse-triggered” breaths illustrate a new form of neuromechanical coupling with potentially important clinical consequences.


title: A review of reviews: Sedentary behaviour and cardiovascular disease specific to older people.

text: BACKGROUND The incidence of sedentary behaviour and cardiovascular disease impacts the health of older people, potentially leading to serious and negative health consequences. AIM The purpose of this umbrella review was to identify the systematic reviews that explore the association between sedentary behaviour and cardiovascular disease specific to older people. METHODS An umbrella review was undertaken to systematically search five databases. Papers included were published between 2011 and 2015. RESULTS A search yielded 2,163 results. Six reviews met the inclusion criteria. While all six systematic reviews included older people in the overall sample, only one systematic review focused on an entirely older person population. Three of the six systematic reviews provided a meta-analysis, but none of the reviews reported a separate subgroup analysis for a discrete sample of older people CONCLUSION: This umbrella review demonstrates that while sedentary behaviour is associated with cardiovascular disease, a gap exists in the analysis on the relationship specific to older persons. IMPLICATIONS FOR PRACTICE Interventions aimed at reducing sedentary behaviour may improve cardiovascular health and well-being among older people.


title: Traumatic abdominal wall hernias: an emerging trend in handlebar injuries.

text: Handlebar injuries are well described in pediatric patients and are frequently associated with internal injuries, including the "classic" duodenal hematoma and solid organ injuries. Before this report, traumatic handlebar hernias were considered rare. They occur when the end of the handlebar (often bare or lacking protective equipment) applies a significant force to a focal area of the abdomen leading to a disruption in the underlying muscle fibers and fascia while sparing the overlying skin. Such nonpenetrating injuries may present with subtle clinical signs and should always be considered in the differential diagnosis. Imaging, with the use of computed tomographic scan or ultrasound will confirm the diagnosis as well as identify any associated injuries. The management plan usually requires surgical exploration and repair of the defect. The prognosis is favorable presuming that there is no significant underlying injury. In this report, we present a series of 5 patients with traumatic handlebar hernia-the most frequently-occurring injury in our series-and review concurrent associated injuries.


title: Opioid-induced respiratory depression: reversal by non-opioid drugs.

text: The human body is critically dependent on the ventilatory control system for adequate uptake of oxygen and removal of carbon dioxide (CO2). Potent opioid analgesics, through their actions on μ-opioid receptor (MOR) expressed on respiratory neurons in the brainstem, depress ventilation. Opioid-induced respiratory depression (OIRD) is potentially life threatening and the cause of substantial morbidity and mortality. One possible way of prevention of OIRD is by adding a respiratory stimulant to the opioid treatment, which through activation of non-opioidergic pathways will excite breathing and consequently will offset OIRD and should not affect analgesia. Various new respiratory stimulants are currently under investigation including (a) potassium channel blockers acting at the carotid bodies, and (b) ampakines and (c) serotonin receptor agonists acting within the brainstem. (a) GAL-021 targets BKCa-channels. Initial animal and human experimental evidence indicates that this potassium channel blocker is a potent respiratory stimulant that reverses OIRD without affecting antinociception. GAL021 is safe and better tolerated than the older K(+)-channel blocker doxapram and more efficacious in its effect on respiration. (b) Ampakines modulate glutamatergic respiratory neurons in brainstem respiratory centers. Various ampakines have been studied showing their ability to increase respiratory drive during OIRD by increasing respiratory rate. Currently, CX717 is the most promising ampakine for use in humans as it is safe and does not affect opioid analgesia. (c) While animal studies show that serotonin receptor agonists increase respiratory drive via activation of serotonin receptors in brainstem respiratory centers, human studies are without success. Further clinical studies are required to improve our care of patients that are treated with potent opioid analgesics. The use of non-opioid adjuvants may reduce the probability of OIRD but does never relieve us of our duty to continuously monitor these patients, irrespective whether they are treated in-house or in an ambulatory setting.


title: Venous thromboembolism following elbow, wrist and hand surgery: a review of the literature and prophylaxis guidelines.

text: This review summarizes the literature regarding venous thromboembolism and examines the prophylaxis guidelines with relation to hand, wrist and elbow surgery. We performed an extensive literature search identifying any relevant case reports or outcome studies. Of 680 potential articles, only four contained data relevant to thrombosis after elbow, wrist and hand surgery. No isolated deep vein thromboses and only nine pulmonary embolisms were identified suggesting that the rate of venous thromboembolism is extremely low following this subset of upper limb surgery. We identified nine guidelines, of which only two (the British Society for Surgery of the Hand and the National Institute of Health and Clinical Excellence) addressed the upper limb. We present a set of recommendations based on the results of this review.


title: [Conventional respiratory support therapy for Severe Acute Respiratory Infections (SARI): Clinical indications and nosocomial infection prevention and control].

text: Severe acute respiratory infection (SARI) diseases (such as SARS, MERS, pH1N1) can rapidly progress to acute respiratory failure with high lethality. The outbreak of a novel coronavirus infection can lead to 15% ~ 30% patients developing into acute respiratory distress syndrome (ARDS). Respiratory support is the most important therapy for SARI patients with respiratory failure. However, respiratory support is a high skilled technology, which means inappropriate application may bring related complications and cross infection of SARI pathogens among medical staff and non-medical personnel in hospital. Therefore, it is meaningful to established a standardized indication of respiratory support and to prevent related nosocomial transmission in SARI patients.


title: Alpaca (Vicugna pacos), the first nonprimate species with a phosphoantigen-reactive Vγ9Vδ2 T cell subset.

text: Vγ9Vδ2 T cells are a major γδ T cell population in the human blood expressing a characteristic Vγ9JP rearrangement paired with Vδ2. This cell subset is activated in a TCR-dependent and MHC-unrestricted fashion by so-called phosphoantigens (PAgs). PAgs can be microbial [(E)-4-hydroxy-3-methyl-but-2-enyl pyrophosphate, HMBPP] or endogenous (isopentenyl pyrophosphate, IPP) and PAg sensing depends on the expression of B7-like butyrophilin (BTN3A, CD277) molecules. IPP increases in some transformed or aminobisphosphonate-treated cells, rendering those cells a target for Vγ9Vδ2 T cells in immunotherapy. Yet, functional Vγ9Vδ2 T cells have only been described in humans and higher primates. Using a genome-based study, we showed in silico translatable genes encoding Vγ9, Vδ2, and BTN3 in a few nonprimate mammalian species. Here, with the help of new monoclonal antibodies, we directly identified a T cell population in the alpaca (Vicugna pacos), which responds to PAgs in a BTN3-dependent fashion and shows typical TRGV9- and TRDV2-like rearrangements. T cell receptor (TCR) transductants and BTN3-deficient human 293T cells reconstituted with alpaca or human BTN3 or alpaca/human BTN3 chimeras showed that alpaca Vγ9Vδ2 TCRs recognize PAg in the context of human and alpaca BTN3. Furthermore, alpaca BTN3 mediates PAg recognition much better than human BTN3A1 alone and this improved functionality mapped to the transmembrane/cytoplasmic part of alpaca BTN3. In summary, we found remarkable similarities but also instructive differences of PAg-recognition by human and alpaca, which help in better understanding the molecular mechanisms controlling the activation of this prominent population of γδ T cells.


title: Chemoattractant receptor-homologous molecule expressed on Th2 cells (CRTH2) antagonists in asthma: a systematic review and meta-analysis protocol.

text: INTRODUCTION More than 20 orally bioavailable chemoattractant receptor-homologous molecule expressed on Th2 cells (CRTH2) antagonists have moved forward to clinical development in recent years for the treatment of asthma. However, evidence from individual randomised controlled trials (RCTs) has demonstrated inconsistent results in their efficacy and safety. METHODS AND ANALYSIS PubMed/Medline, Embase, Web of Science, Cochrane Database of Systematic Reviews, Global Index Medicus, Cochrane Central Register of Controlled Trials and Scopus will be searched from inception to 30 December 2017 for eligible RCTs, with additional studies being identified by manual searches. The study eligibility, data extraction and quality appraisal will be performed by two independent reviewers. Studies deemed fit for inclusion will be assessed using Cochrane Collaboration risk of bias tool. To generate more accurate analyses, Grading of Recommendations Assessment, Development and Evaluation will be used to grade the evidence. We will use the χ2 test and the I2 statistic to assess heterogeneity. The metaregression and subgroup analyses will be undertaken in the presence of heterogeneity. The potential for publication bias will be examined using funnel plots. ETHICS AND DISSEMINATION The current study is based on published data, thus ethical approval is not a requirement. The results of this study will be reported in an open-access peer-reviewed publication or will be disseminated as conference proceedings. This systematic review will increase the understanding of the application of CRTH2 antagonists in patients with asthma, which may help to establish and identify specific gaps in the evidence informing a future agenda for asthma research, policy and practice. TRIAL REGISTRATION NUMBER CRD42017079342.


title: Isoproternenol increases vascular volume expansion and urinary output after a large crystalloid bolus in healthy volunteers.

text: BACKGROUND The primary goal of fluid therapy is to maintain fluid homeostasis. Commonly used isotonic crystalloids are only marginally effective and contribute to fluid excess syndrome. In patients with decreased cardiovascular reserve, fluid therapy alone is not sufficient to maintain end-organ perfusion. Therefore, inotropes or vasoactive drugs are used to supplement fluid infusion. Recent animal data suggest that coinfusion of adrenergic agents modulate the distribution of fluid between the vascular and extravascular/interstitial compartments after a fluid bolus. We sought to determine if this effect would translate in humans by coadministering a β-adrenergic agonist with fluid. METHODS Nine healthy volunteers (aged 21-50 years) were randomly paired and received either a continuous isoproterenol infusion (ISO: 0.05 μg/kg per minute) or 0.9% saline (control [CON]) 30min prior to a 25 mL/kg 0.9% NaCl fluid bolus. Hemodynamics, ventricular volume and function, and microcirculatory determinants (capillary filtration coefficient and oncotic pressure) were measured. Vascular and extravascular volume and fluid balance were determined. RESULTS Compared with CON, ISO significantly increased heart rate (CON: 64.2 ± 4.1 beats/min vs. ISO: 97.4 ± 5.7 beats/min) and cardiac output (CON: 4.4 ± 0.7 L/min vs. ISO: 10.2 ± 0.9) before fluid bolus. Isoproterenol significantly increased urinary output (ISO: 10.86 ± 1.95 vs. control: 6.53 ± 1.45 mL/kg) and reduced extravascular volume (7.98 ± 2.0 vs. 14.15 ± 1.1mL/kg). Isoproterenol prevented an increase in capillary filtration coefficient (1.74 ± 0.4 vs. 3.21 ± 0.4 mL/min per mmHg · 10). CONCLUSIONS Isoproterenol, a nonselective β-adrenergic agonist, augments vascular volume expansion and eliminates extravascular volume via enhanced diuresis, which may in part be due to enhanced endothelial barrier function.


Dual antiplatelet therapy.


Therapeutic implications of the vasoprotective axis of the renin-angiotensin system in cardiovascular diseases.


title: Robotic hysterectomy strategies in the morbidly obese patient.

text: BACKGROUND AND OBJECTIVES The purpose of this study was to present strategies for performing computer-enhanced telesurgery in the morbidly obese patient. METHODS This was a prospective, institutional review board-approved, descriptive feasibility study (Canadian Task Force classification II-2) conducted at a university-affiliated hospital. Twelve class III morbidly obese women with a body mass index of 40 kg/m(2) or greater were selected to undergo robotic-assisted total laparoscopic hysterectomy. Robotic-assisted total laparoscopic hysterectomy, classified as type IVE, with complete detachment of the cardinal-uterosacral ligament complex, unilateral or bilateral, with entry into the vagina was performed. RESULTS The median estimated blood loss was 146.3 mL (range, 15-550 mL), the mean length of stay in the hospital was 25.3 hours (range, 23- 48 hours), and the complication rate was 0%. The rate of conversion to laparotomy was 8%. The median surgical time was 109.6 minutes (range, 99 -145 minutes). CONCLUSION Robotic-assisted total laparoscopic hysterectomy can be a safe and effective method of performing hysterectomies in select morbidly obese patients, allowing them the opportunity to undergo minimally invasive surgery without increased perioperative complications.


title: Reaching older adults during the COVID-19 pandemic through social networks and Social Security Schemes in Ghana: Lessons for considerations.

text: Throughout the world, the outbreak of the novel Coronavirus disease (COVID-19) has exposed the older population to health, social and financial risks. With the effects of COVID-19 pandemic on social security schemes and individuals' income, dependent older people's needs are critically at stake. Like other developing countries, older people in Ghana need to rely on their social networks through family ties, friends and social organisations for support. Also, there is the need for social security institutions, including the Social Security and National insurance Trust, to make provisions for older people aged 50+ to receive part of their pension package to meet their basic needs during the pandemic. In a period like this, social services are required as older people may need practical support in terms of having someone to run errands for them. However, government should improve social intervention package, particularly the livelihood empowerment against poverty grant for older adults with very low income in order to enhance their living conditions.


title: Effects of somatostatin analogs on a growth hormone-releasing hormone secreting bronchial carcinoid, in vivo and in vitro studies.

text: CONTEXT A 56-yr-old woman presented with acromegaly, a pulmonary mass, and elevated levels of GHRH, GH, and IGF-I. Histological examination revealed a bronchial carcinoid with positive staining for GHRH. Somatostatin analogs (SAs) can play an important role in the treatment of neuroendocrine tumors, dependent on the somatostatin receptor subtype (sst) expression pattern. The sst pattern in bronchial carcinoids and effects of SAs have not been extensively investigated, particularly not for the recently developed universal SA SOM230 (Pasireotide) that has high affinity for sst1, 2, 3, and 5. OBJECTIVE Our objective was to investigate the in vivo response of a GHRH-producing bronchial carcinoid to octreotide (OCT), its sst-expression profile, and in vitro responses to different SAs, including SOM230. METHODS In vivo, 50 microg OCT was administered, and plasma GH and GHRH responses were determined. In vitro, the expression of ssts was analyzed by quantitative PCR. Furthermore, the effects of SOM230 and OCT on GHRH secretion were evaluated in primary cell cultures of the carcinoid tissue. RESULTS In vivo, OCT administration fully suppressed GH and GHRH levels. In vitro, sst1 mRNA was most abundant, followed by sst2 and sst5. Both SOM230 and OCT inhibited GHRH production dose dependently (SOM230 100 nm vs. control, P = 0.01; OCT 110 nm vs. control, P = 0.05). CONCLUSIONS In this case of a GHRH-producing bronchial carcinoid, we demonstrated that SOM230 was a potent inhibitor of GHRH production in vitro and was at least equally potent compared with OCT. Therefore, SOM230 may be a potential therapeutic agent to control GHRH secretion in ectopic acromegaly.


title: Successful penetration and bougie dilatation with Brockenbrough needle for severely calcified occlusion in superficial femoral artery.

text: A 75-year-old hemodialysis patient with right critical limb ischemia received endovascular therapy for a chronic total occlusion (CTO) in a diffusely calcified superficial femoral artery (SFA). During a retrograde approach, a Brockenbrough needle (BN) was able to penetrate the calcified hard plaque formed in the middle segment of the CTO. Moreover, bougie dilatation with the BN allowed balloon crossing and stent deployment, even after failure to pass a 2.0-mm monorail balloon across the plaque. These results suggest that the BN offers a new therapeutic option in the penetration and modification of severely calcified CTO in SFA.


docid: sxlbcbdj

title: Feasibility of Hepatology-directed Microwave Ablation in Management of Hepatocellular Carcinoma in North America: A Pilot Project.

text: In North America, the role of Hepatologists in treatment of hepatocellular carcinoma is limited. We conducted a pilot project wherein a Hepatologist participated directly in microwave ablation of HCC at an academic center in the United States (n=14). The pilot project shows promising outcomes, with complete remission rate of 93%.


title: Comparison of outcomes of laparoscopy-assisted and open proximal gastrectomy with jejunal interposition for early gastric cancer in the upper third of the stomach: A retrospective observational study.

text: INTRODUCTION Laparoscopy-assisted proximal gastrectomy with jejunal interposition (LAPG-JI) is not yet widely used because the three anastomotic procedures involved in this operation are technically complicated. This study aimed to describe our surgical procedure for LAPG-JI and assess its feasibility and safety. METHODS This was a retrospective study of 70 patients who had undergone proximal gastrectomy with jejunal interposition for gastric cancer in the upper third of the stomach between July 2007 and October 2016. Of these patients, 32 underwent LAPG-JI, and 38 underwent open proximal gastrectomy with jejunal interposition. Clinical characteristics and both surgical and postoperative outcomes were compared between LAPG-JI and open proximal gastrectomy with jejunal interposition. RESULTS The operation time was longer in the LAPG-JI group (189 vs 154 min, P < 0.001) and estimated blood loss was lower (30 vs 180 mL, P < 0.001). There were no differences in the rates of early (9.4% vs 13.2%) or late postoperative complications (12.5% vs 10.5%). No anastomotic leakage was observed in either group. In the LAPG-JI group, the time to first eating was shorter, and the white blood cell counts on postoperative days 1 and 7 and body temperature on postoperative day 3 were lower. The number of additional doses of postoperative analgesia was lower in the LAPG-JI group. Reflux esophagitis graded C according to the Los Angeles classification was observed in only one patient (3.1%) in the LAPG-JI group. CONCLUSION Although the operation time was longer in the LAPG-JI group, the procedure seemed to be feasible and safe. Also, it offered the advantages of laparoscopic surgery, including less invasiveness and quicker recovery.


title: Vertical transumbilical incision versus left lower transverse incision for specimen retrieval during laparoscopic colorectal surgery.

text: BACKGROUND This study compared the short-term surgical outcomes of the vertical transumbilical incision with the left lower transverse incision for specimen retrieval in laparoscopic colorectal cancer surgery. METHODS One hundred forty-seven consecutive patients scheduled for laparoscopic surgery for sigmoid colon and rectal cancer between April 2010 and December 2010 were classified into one of the two groups according to the site of the minilaparotomy: a transumbilical incision group (n = 92) and a left lower transverse incision group (n = 55). RESULTS Demographic data, operation time, estimated blood loss, frequency of transfusion, size of the tumor, number of harvested lymph nodes, distal resection margins, time to first flatus, and length of hospital stay were similar between the two groups. Postoperative pain scores were also similar between the two groups. The length of the minilaparotomy incision was shorter in the transumbilical group than the left lower transverse group at operation (mean, 4.6 vs. 6.2 cm, p = 0.000). The postoperative mean satisfaction score was higher in the transumbilical group, but this was not statistically significant (7.6 vs. 7.1, p = 0.224). Fourteen patients in the transumbilical group and 7 patients in the left lower transverse group developed wound-related complications (p = 0.810), including two cases of incisional hernia, both in the transumbilical group. High body mass index (≥25 kg/m(2)) and longer operative time (≥180 min) were risk factors for wound complications on univariate analysis. CONCLUSIONS Transumbilical minilaparotomy in laparoscopic colorectal surgery is a good alternative approach with acceptable wound complications.


How the erosion of our public health system hobbled England's covid-19 response.


title: Haitian Immigrants and Type 2 Diabetes: An Integrative Review.

text: Type 2 diabetes (T2D) is a complex, lifelong condition that is disproportionately prevalent among minority populations. Haitian immigrants (HIs) living in the US with T2D have unique factors that influence diagnosis, treatment, and self-management. The purpose of this integrative review was to provide a synthesis of the research on T2D in the HI population. In a systematic literature search, 14 studies met the inclusion criteria. Three themes were identified: risk factors for less self-management and/or worse metabolic control; protective factors for better self-management and/or metabolic control; and mixed results. HIs had higher HbA1c, yet better self-management, different genetic profiles, and lower levels of vitamin D and hemoglobin concentration compared to other ethnic groups. HIs also reported better dietary quality, less healthcare utilization, and higher perceived emotional/psychological stress compared to other ethnic groups. This study has implications for practice for integrating the unique cultural factors when assessing and intervening with HIs.


docid: kywotchg

title: Paravalvular Leak: An Interesting Interplay of Acquired vWF-Disease and Late Bleeding After TAVR.


title: Is Sport Activity Possible After Arthroscopic Meniscal Allograft Transplantation? Midterm Results in Active Patients.

text: BACKGROUND Meniscal allograft transplantation (MAT) has produced good to excellent results in the general population; however, few investigations have examined MAT in athletes and sport-related outcomes. PURPOSE To report midterm clinical outcomes of MAT and the rate of return to sport in a physically active population. STUDY DESIGN Case series; Level of evidence, 4. METHODS The study included all physically active patients who underwent arthroscopic MAT without bone plugs and had a minimum of 2 years of follow-up at a single institution. Clinical evaluation was performed with the Knee injury and Osteoarthritis Outcome Score (KOOS), the Tegner activity scale, and a 0- to 100-point subjective scale for knee function and satisfaction. Outcomes evaluated included ability to return to sport, time to return to sport, level of sport activity upon return compared with preinjury level, and level of decrease in sport participation or reasons for not returning to sport participation. Comparisons were made between patients who did or did not return to sport and between patients who returned to the same level or a decreased level. Regression analysis was performed to determine the variables affecting the outcomes. RESULTS Eighty-nine patients, whose mean ± SD age at surgery was 38.5 ± 11.2 years, were evaluated to a mean follow-up of 4.2 ± 1.9 years. Total KOOS improved from a mean ± SD of 39.5 ± 18.5 preoperatively to 84.7 ± 14.8 at the latest follow-up (P < .001). The Tegner score improved significantly from a median of 2 (interquartile range [IQR], 1-4) preoperatively to a median of 4 (IQR, 3-6) at the latest follow-up (P < .001), although it did not reach the preinjury level of 6 (IQR, 5-7) (P < .001). Older age at surgery was correlated with the worst clinical results. Sixty-six patients (74%) were able to return to sport after 8.6 ± 4.1 months. Forty-four (49%) returned to the same level as preinjury. Patients who did not return to sport activity and those who reduced their activity level at follow-up had inferior subjective outcomes compared with those who returned to sport and those who returned to their preinjury levels, respectively. Only 11 patients (12%) underwent a surgical procedure during the follow-up period. CONCLUSION Arthroscopic MAT without bone plugs improved knee function and reduced pain, allowing sport resumption in 74% of patients and return to the preinjury activity level in 49% of patients at midterm follow-up. Of all the demographic and surgical variables, only age at surgery seemed to affect outcomes.


title: Pretargeted radioimmunoscintigraphy in patients with primary colorectal cancer using a bispecific anticarcinoembryonic antigen CEA X anti-di-diethylenetriaminepentaacetic acid F(ab')2 antibody.

text: BACKGROUND Antibody-based imaging agents are available commercially, but their success has been limited, mainly because of low contrast and the emergence of 2-fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) scanning. In pretargeting, administration of the radionuclide is separated from the antibody, thereby enhancing image contrast and allowing detection at earlier time points after injection. METHODS The authors conducted an open-label, single-arm trial that assessed a pretargeting procedure in which an anticarcinoembryonic antigen x (anti-CEA x) anti-diethylenetriaminepentaacetic acid (anti-DTPA)-indum (In) antibody was used in combination with a (111)In-labeled di-DTPA peptide for the diagnostic imaging of CEA-expressing colorectal cancer. Three patients received the (111)In peptide alone to investigate tumor targeting, organ distribution, and clearance of the peptide. Thereafter, 11 patients received the bispecific antibody (bsAb) (5 mg) to pretarget the tumor. After 3 to 5 days, patients were injected with 185 megabecquerels of (111)In-labeled peptide to assess the optimal interval for best image quality. RESULTS Fourteen patients with primary colorectal cancer were enrolled. One of 3 patients who received (111)In peptide alone had low-level tumor uptake. In 9 of 11 other patients, tumors were observed. In 1 patient, FDG-PET-positive lymph nodes were observed clearly with pretargeted immunoscintigraphy. Peptide pharmacokinetics revealed enhanced circulating levels of (111)In-labeled peptide in patients in the 3-day interval cohort compared with the other cohorts. Tumor-to-background ratios ranged from 3.5 to 6.4 in the 3-day interval group, from 5.1 to 14.2 in the 4-day interval group, and from 3.5 to 3.9 in the 5-day interval group. The best images were acquired with a 4-day interval at 24 hours after injection of the radiolabeled peptide. Grade 1 adverse events were observed in 2 patients. CONCLUSIONS Imaging of colorectal cancer using a 2-step, pretargeting system produced the best imaging results 24 hours after peptide administration using a 4-day interval between injection of the bsAb and the peptide.


Editorial: Discipline and training.


Dentistry: Time for a New Meaning?


title: Respiratory therapies for amyotrophic lateral sclerosis: a primer.

text: Respiratory complications are a common cause of morbidity and mortality in amyotrophic lateral sclerosis (ALS). Treatment of respiratory insufficiency with noninvasive ventilation (NIV) improves ALS patients' quality of life and survival. Evidence-based practice guidelines for the management of ALS patients recommend treatment of respiratory insufficiency with NIV as well as consideration of insufflation/exsufflation to improve clearance of airway secretions. Despite these recommendations respiratory therapies remain underused. In this review we provide a practical guide for the clinician to prescribe and manage respiratory therapies for the patient with ALS.


title: Prognostic Value of the 24-Hour Neurological Examination in Anterior Circulation Ischemic Stroke: A post hoc Analysis of Two Randomized Controlled Stroke Trials.

text: BACKGROUND Early prognostication of long-term outcomes following ischemic stroke can facilitate medical decision-making. We hypothesized that the 24-hour National Institute of Health Stroke Scale (NIHSS) predicts 3-month clinical outcomes in anterior circulation stroke. METHODS Secondary analyses of the Interventional Management of Stroke 3 (IMS3) and intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke [National Institute of Neurological Diseases and Stroke (NINDS) IV tPA] trials were performed. In participants with documented 24-hour NIHSS and 3-month Modified Rankin Scale (mRS), the predictive power of the 24-hour NIHSS and 24-hour NIHSS improvement for 3-month outcomes [mRS 0-2 and Barthel Index (BI) ≥95] was assessed. Percentages of good outcome (mRS 0-2 or BI ≥95) at 3, 6, and 12 months and mean quality of life (EQ5D™) index at 3 months across 24-hour NIHSS quartiles were compared. RESULTS The majority of the study participants were included (IMS3 n = 587/656, NINDS IV tPA n = 619/624). The 24-hour NIHSS was correlated with 3-month mRS (R = 0.73) with excellent predictive power for mRS 0-2 [area under the curve (AUC) = 0.91] and BI ≥95 (AUC = 0.9) in both cohorts. A model with the 24-hour NIHSS alone correctly classified 82-84% of patients in both cohorts. The percentages of good outcomes at 3-12 months across 24-hour NIHSS quartiles were similar in both cohorts. mRS 0-2 was achieved by 75.6-77.7% of patients with 24-hour NIHSS ≤11 but by only 1.4-3.6% with 24-hour NIHSS ≥20. The EQ5D index at 3 months varied among NIHSS 0-4 (mean 0.86 ± 0.16), 5-11 (0.77 ± 0.18), and 12-19 (0.59 ± 0.26) quartiles. CONCLUSIONS The 24-hour NIHSS strongly predicts long-term stroke outcomes and is associated with quality of life. Its easy availability, reliability, and validity support its use as an early prognostic marker and surrogate of clinical outcome in ischemic stroke.


title: A randomized controlled feasibility trial of paracetamol during febrile neutropenia in hemato-oncology patients.

text: The efficacy of paracetamol (acetaminophen) as an antipyretic during febrile neutropenia (FN) has not previously been established. We conducted a randomized double-blind placebo-controlled feasibility trial: hemato-oncology patients at high FN risk were randomly assigned to six hourly oral paracetamol (1 g) or placebo during the first 42 hours of FN. Fifty-three participants were screened, thirty-seven enrolled; 22 developed FN and commenced treatment (13 paracetamol; 9 placebo); recruitment rates were below, and retention rates met, pre-defined feasibility criteria. During the first 24 hours of FN, paracetamol recipients had significantly lower peak temperature than placebo: mean 38.2 (standard deviation 0.8) °C versus 38.9 (0.4) °C; difference -0.78 °C (95% CI -1.38 to -0.18); p = .013. Bacterial load measurement was not informative. Paracetamol lowers body temperature during FN, and definitive trials to determine its impact on FN outcomes are needed. Australian New Zealand Clinical Trials Registry reference ACTRN12613000601730; funded by Health Research Council of New Zealand.


title: Rapid and sensitive detection of Feline immunodeficiency virus using an insulated isothermal PCR-based assay with a point-of-need PCR detection platform.

text: Feline immunodeficiency virus (FIV) is an important infectious agent of cats. Clinical syndromes resulting from FIV infection include immunodeficiency, opportunistic infections, and neoplasia. In our study, a 5' long terminal repeat/gag region-based reverse transcription insulated isothermal polymerase chain reaction (RT-iiPCR) was developed to amplify all known FIV strains to facilitate point-of-need FIV diagnosis. The RT-iiPCR method was applied in a point-of-need PCR detection platform--a field-deployable device capable of generating automatically interpreted RT-iiPCR results from nucleic acids within 1 hr. Limit of detection 95% of FIV RT-iiPCR was calculated to be 95 copies standard in vitro transcription RNA per reaction. Endpoint dilution studies with serial dilutions of an ATCC FIV type strain showed that the sensitivity of lyophilized FIV RT-iiPCR reagent was comparable to that of a reference nested PCR. The established reaction did not amplify any nontargeted feline pathogens, including Felid herpesvirus 1, feline coronavirus, Feline calicivirus, Feline leukemia virus, Mycoplasma haemofelis, and Chlamydophila felis. Based on analysis of 76 clinical samples (including blood and bone marrow) with the FIV RT-iiPCR, test sensitivity was 97.78% (44/45), specificity was 100.00% (31/31), and agreement was 98.65% (75/76), determined against a reference nested-PCR assay. A kappa value of 0.97 indicated excellent correlation between these 2 methods. The lyophilized FIV RT-iiPCR reagent, deployed on a user-friendly portable device, has potential utility for rapid and easy point-of-need detection of FIV in cats.


title: Castration-resistant prostate cancer: AUA Guideline.

text: PURPOSE This Guideline is intended to provide a rational basis for the management of patients with castration-resistant prostate cancer based on currently available published data. MATERIALS AND METHODS A systematic review and meta-analysis of the published literature was conducted using controlled vocabulary supplemented with keywords relating to the relevant concepts of prostate cancer and castration resistance. The search strategy was developed and executed by reference librarians and methodologists to create an evidence report limited to English-language, published peer-reviewed literature. This review yielded 303 articles published from 1996 through 2013 that were used to form a majority of the guideline statements. Clinical Principles and Expert Opinions were used for guideline statements lacking sufficient evidence-based data. RESULTS Guideline statements were created to inform clinicians on the appropriate use of observation, androgen-deprivation and antiandrogen therapy, androgen synthesis inhibitors, immunotherapy, radionuclide therapy, systemic chemotherapy, palliative care and bone health. These were based on six index patients developed to represent the most common scenarios encountered in clinical practice. CONCLUSIONS As a direct result of the significant increase in FDA-approved therapeutic agents for use in patients with metastatic CRPC, clinicians are challenged with a multitude of treatment options and potential sequencing of these agents that, consequently, make clinical decision-making more complex. Given the rapidly evolving nature of this field, this guideline should be used in conjunction with recent systematic literature reviews and an understanding of the individual patient's treatment goals. In all cases, patients' preferences and personal goals should be considered when choosing management strategies.


title: Porphyromonas gingivalis enzymes enhance infection with human metapneumovirus in vitro.

text: Relatively recently discovered, human metapneumovirus (HMPV) is a human pathogen with worldwide prevalence, accounting for a substantial percentage of respiratory tract diseases. Concurrent viral and bacterial infections enable intricate mechanisms of cooperation between pathogens, which complicate the symptoms and outcome of the disease. Such bilateral interactions are based on the modulation of bacterial growth on epithelium pathologically altered during viral illness and the modulation of immune responses, as well as the enhancement of virus replication by bacterial virulence factors. This study showed that proteases produced by Porphyromonas gingivalis, a Gram-negative bacterium implicated in the development of periodontitis, named gingipains, facilitated HMPV replication in LLC-MK2 cells and may contribute to HMPV pathogenicity in patients with periodontitis. Gingipains at low nanomolar concentrations enabled HMPV replication and allowed virus propagation in vitro. In contrast to previously published data for influenza virus, however, Staphylococcus aureus proteases and human neutrophil elastase did not affect virus replication.


title: Differentiation of Tomato yellow leaf curl virus and Tomato yellow leaf curl Sardinia virus using real-time TaqMan PCR.

text: During the past four decades, Tomato yellow leaf curl disease has become one of the major constraints in tomato production worldwide. In the Mediterranean basin, several isolates from two major Begomovirus species are involved in outbreaks and persistent epidemics. A real-time TaqMan PCR assay was developed and evaluated for the rapid and multiplex detection and differentiation of two begomoviruses often found in mixed infections in the region, Tomato yellow leaf curl virus (TYLCV) and Tomato yellow leaf curl Sardinia virus (TYLCSV). This assay was 1000-fold more sensitive than conventional PCR assays described previously, allowing the use of simple template preparation methods and eliminating the need for total nucleic acid purification. The viral DNA template was obtained by spotting sap extract derived from TYLCV or TYLCSV infected tissues on a nylon membrane or by directly using crude plant extracts in the real-time reaction cocktail. Preliminary results showed that this method can successfully detect and discriminate virus species from infected tomato, bean, pepper and different weed species obtained from the Mediterranean basin, the USA and Japan, allowing the simple, fast and cost-effective testing of a large number of samples in certification schemes. The assay can also be used for the detection of these two begomovirus species in their whitefly vector biotypes of the Bemisia tabaci (Gennadius) species group.


title: Quantitative Analysis of EEG Power Spectrum and EMG Median Power Frequency Changes after Continuous Passive Motion Mirror Therapy System.

text: Robotic mirror therapy (MT), which allows movement of the affected limb, is proposed as a more effective method than conventional MT (CMT). To improve the rehabilitation effectiveness of post-stroke patients, we developed a sensory stimulation-based continuous passive motion (CPM)-MT system with two different operating protocols, that is, asynchronous and synchronous modes. To evaluate their effectiveness, we measured brain activation through relative and absolute power spectral density (PSD) changes of electroencephalogram (EEG) mu rhythm in three cases with CMT and CPM-MT with asynchronous and synchronous modes. We also monitored changes in muscle fatigue, which is one of the negative effects of the CPM device, based on median power frequency (MPF) and root mean square (RMS). Relative PSD was most suppressed when subjects used the CPM-MT system under synchronous control: 22.11%, 15.31%, and 16.48% on Cz, C3, and C4, respectively. The absolute average changes in MPF and RMS were 1.59% and 9.78%, respectively, with CPM-MT. Synchronous mode CPM-MT is the most effective method for brain activation, and muscle fatigue caused by the CPM-MT system was negligible. This study suggests the more effective combination rehabilitation system for MT by utilizing CPM and magnetic-based MT task to add action execution and sensory stimulation compared with CMT.


title: Wheezing rhinovirus illnesses in early life predict asthma development in high-risk children.

text: RATIONALE Virus-induced wheezing episodes in infancy often precede the development of asthma. Whether infections with specific viral pathogens confer differential future asthma risk is incompletely understood. OBJECTIVES To define the relationship between specific viral illnesses and early childhood asthma development. METHODS A total of 259 children were followed prospectively from birth to 6 years of age. The etiology and timing of specific viral wheezing respiratory illnesses during early childhood were assessed using nasal lavage, culture, and multiplex reverse transcriptase-polymerase chain reaction. The relationships of these virus-specific wheezing illnesses and other risk factors to the development of asthma were analyzed. MEASUREMENTS AND MAIN RESULTS Viral etiologies were identified in 90% of wheezing illnesses. From birth to age 3 years, wheezing with respiratory syncytial virus (RSV) (odds ratio [OR], 2.6), rhinovirus (RV) (OR, 9.8), or both RV and RSV (OR , 10) was associated with increased asthma risk at age 6 years. In Year 1, both RV wheezing (OR, 2.8) and aeroallergen sensitization (OR, 3.6) independently increased asthma risk at age 6 years. By age 3 years, wheezing with RV (OR, 25.6) was more strongly associated with asthma at age 6 years than aeroallergen sensitization (OR, 3.4). Nearly 90% (26 of 30) of children who wheezed with RV in Year 3 had asthma at 6 years of age. CONCLUSIONS Among outpatient viral wheezing illnesses in infancy and early childhood, those caused by RV infections are the most significant predictors of the subsequent development of asthma at age 6 years in a high-risk birth cohort.


title: Screening of deceased organ donors: no easy answers.

text: Transmission of infection to recipients of solid organs is uncommon but well documented. Improved technologies for the diagnosis of infectious diseases suggest possible changes to paradigms used in the screening of organ donors to prevent disease transmission with transplantation. Available microbiologic assays, including molecular tests, are generally designed for use as diagnostic tools in individuals believed to have a specific infection based on clinical or epidemiological criteria. By contrast, these assays often lack the performance characteristics required for screening of deceased organ donors. This challenge is apparent with the analysis of assays for human T-cell lymphotropic virus-I and -II in low-risk populations. Changing epidemiologic patterns associated with the spread of novel pathogens or altered patterns of immigration will necessitate flexibility in the "list" of potential pathogens. Individual benefits from transplantation generally outweigh the risk of transmission of infection. However, this favorable experience will not obviate the need to continuously improve screening practices.


title: Pre-pubertal presentation of peritoneal inclusion cyst associated with congenital lower extremity venous valve agenesis.

text: Peritoneal inclusion cysts are uncommon lesions that usually occur in the pelvis of reproductive-age females. The case of a 7-year-old girl with an inflamed peritoneal inclusion cyst with unusual right paracolic localization and congenital lower extremity superficial and deep venous valve agenesis is presented. Inflammation of the peritoneal inclusion cyst was responsible for the signs of acute abdomen and subsequent presentation at our center. The cystic structure was initially diagnosed using ultrasonography, and its complete extent (8cm x 6.5cm x 4cm) was evident after magnetic resonance imaging. The minimal access approach was opted for to resect the entire cyst from the lateral border of the ascending colon. Afterwards, the cyst was punctured to reduce its size and to retrieve the cyst wall using an endoscopic specimen retrieval bag. Minimal access surgery precautions in this patient with congenital lower extremity venous valve agenesis are discussed.


title: Surveillance of diarrhoea in small animal practice through the Small Animal Veterinary Surveillance Network (SAVSNET).

text: Using the Small Animal Veterinary Surveillance Network (SAVSNET), a national small animal disease-surveillance scheme, information on gastrointestinal disease was collected for a total of 76 days between 10 May 2010 and 8 August 2011 from 16,223 consultations (including data from 9115 individual dogs and 3462 individual cats) from 42 premises belonging to 19 UK veterinary practices. During that period, 7% of dogs and 3% of cats presented with diarrhoea. Adult dogs had a higher proportional morbidity of diarrhoea (PMD) than adult cats (P <0.001). This difference was not observed in animals <1 year old. Younger animals in both species had higher PMDs than adult animals (P < 0.001). Neutering was associated with reduced PMD in young male dogs. In adult dogs, miniature Schnauzers had the highest PMD. Most animals with diarrhoea (51%) presented having been ill for 2-4 days, but a history of vomiting or haemorrhagic diarrhoea was associated with a shorter time to presentation. The most common treatments employed were dietary modification (66% of dogs; 63% of cats) and antibacterials (63% of dogs; 49% of cats). There was variability in PMD between different practices. The SAVNET methodology facilitates rapid collection of cross-sectional data regarding diarrhoea, a recognised sentinel for infectious disease, and characterises data that could benchmark clinical practice and support the development of evidence-based medicine.


title: Does the compromised sleep and circadian disruption of night and shiftworkers make them highly vulnerable to 2019 coronavirus disease (COVID-19)?

text: Rotating and permanent night shiftwork schedules typically result in acute and sometimes chronic sleep deprivation plus acute and sometimes chronic disruption of the circadian time structure. Immune system processes and functionalities are organized as circadian rhythms, and they are also strongly influenced by sleep status. Sleep is a vital behavioral state of living beings and a modulator of immune function and responsiveness. Shiftworkers show increased risk for developing viral infections due to possible compromise of both innate and acquired immunity responses. Short sleep and sleep loss, common consequences of shiftwork, are associated with altered integrity of the immune system. We discuss the possible excess risk for COVID-19 infection in the context of the common conditions among shiftworkers, including nurses, doctors, and first responders, among others of high exposure to the contagion, of sleep imbalance and circadian disruption.Abbreviations: ACE2: Angiotensin-converting enzyme 2; APC: Antigen-presenting cells; CCL: Chemokine (C-C motif) ligand; CD+: Adhesion molecule expression; COVID-19: 2019 coronavirus disease; DCs: Dendritic cells; GH: Growth hormone; HPA: Hypothalamic-pituitary-adrenal; HSF: Heat shock factor; HSP70: Heat shock protein 70; HSP90: Heat shock protein 90; IL: Interleukin; INFγ: Interferon-gamma; LT/LB: T/B lymphocytes; MHC: Major histocompatibility complex; NK: Natural killer; RAAS: renin-angiotensin-aldosterone system; SARS: Severe acute respiratory syndrome; SCN: Suprachiasmatic nucleus;SD: Sleep deprivation; SNS: Sympathetic nervous system; Th1/Th2: T helper lymphocytes 1/2; TLR2/TLR4: Toll-like receptor 2/4; TNF-α: Tumor necrosis factor alpha; VEGF: Vascular endothelial growth factor.


title: Incidence and mechanisms of stroke after permanent carotid artery occlusion following temporary occlusion testing.

text: BACKGROUND AND PURPOSE Patients who require sacrifice of the internal carotid artery (ICA) have a substantial risk of stroke, despite preoperative testing with temporary balloon occlusion (TBO). The purpose of this study is to examine the incidence and mechanisms of stroke after permanent carotid artery occlusion in this population. METHODS Consecutive patients undergoing TBO testing from March 2002 to December 2011 were identified. The protocol included 30 min of balloon occlusion, continuous intraprocedural neurological assessment, angiographic imaging of collateral flow during the occlusion, and perfusion imaging. Clinical records were reviewed for procedure results, procedural complications, and the incidence and causes of stroke, transient ischemic attack (TIA) and death over 6 months. Strokes were categorized as thromboembolic or hypoperfusion based on available clinical and imaging data. RESULTS One hundred and fifty carotid occlusion tests were performed during the study period, including 84 women and 66 men. No procedural strokes were recorded. Thirty-seven patients (25%) had permanent occlusion of the tested ICA. Six of the 37 patients had ipsilateral stroke (16.2%) and three experienced TIA (8.1%). Two strokes occurred in the immediate postoperative period (thromboembolic), two strokes occurred within days of ICA occlusion (hypoperfusion), and two strokes occurred at least 30 days from the time of ICA occlusion (thromboembolic). CONCLUSIONS The rate of ischemic stroke following carotid sacrifice remains high and most strokes are thromboembolic in nature. Our testing protocol did not eliminate the risk of hypoperfusion-related stroke. Delayed venous phase by angiography may be a better indicator of hemodynamic tolerance than perfusion imaging.


title: Self-Direction of Home and Community-Based Services in the Time of COVID-19.

text: During the COVID-19 pandemic, nursing homes and assisted living facilities have accounted for over 20% of all infections, adult day care and other congregate sites have closed, and traditional home care agencies are facing staff shortages. In this environment, self-direction of home and community-based services, where the participant can hire their own staff and manage a budget that can be used for a broad range of goods and services including home modifications and assistive devices, is seen as a promising intervention. Using self-direction participants can minimize the number of people who enter their homes and pay close family and friends who were already providing many hours of informal care, and now may be unemployed. The Center for Medicare and Medicaid Services is encouraging this approach. This commentary presents information on how states have responded using the new CMS Toolkit by expanding who can be a paid caregiver, increasing budgets and broadening the kinds of items that can be purchased with budgets to include items like personal protective equipment and supports for telehealth. This Commentary concludes with policy and research questions regarding how the delivery of long-term services and supports (LTSS) may change as the world returns to"normal".


title: Robot-assisted thoracoscopic lymphadenectomy along the left recurrent laryngeal nerve for esophageal squamous cell carcinoma in the prone position: technical report and short-term outcomes.

text: BACKGROUND Meticulous mediastinal lymphadenectomy frequently induces recurrent laryngeal nerve palsy (RLNP). Surgical robots with impressive dexterity and precise dissection skills have been developed to help surgeons perform operations. The objective of this study was to determine the impact on short-term outcomes of robot-assisted thoracoscopic radical esophagectomy performed on patients in the prone position for the treatment of esophageal squamous cell carcinoma, including its impact on RLNP. METHODS A single-institution nonrandomized prospective study was performed. The patients (n = 36) with resectable esophageal squamous cell carcinoma were divided into two groups: patients who agreed to robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy performed in the prone position (n = 16, robot-assisted group) without insurance reimbursement, and those who agreed to undergo the same operation without robot assistance but with health insurance coverage (n = 20, control group). These patients were observed for 30 days following surgery to assess short-term surgical outcomes, including the incidence of vocal cord palsy, hoarseness, and aspiration. RESULTS Robot assistance significantly reduced the incidence of vocal cord palsy (p = 0.018) and hoarseness (p = 0.015) and the time on the ventilator (p = 0.025). There was no in-hospital mortality in either group. There were no significant differences between the two groups with respect to patient background, except for the use of preoperative therapy (robot-assisted group <control, p = 0.003). There were no significant differences in estimated blood loss, operating time, number of dissected lymph nodes, completeness of resection, or the incidence of the other complications, except for anastomotic leakage (p = 0.038). CONCLUSION Robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy is feasible and safe. This method shows promise in preventing RLNP.


Chronic liver disease is not associated with severity or mortality in Coronavirus disease 2019 (COVID-19): a pooled analysis.


title: Microwave ablation for hepatic malignancies: a multiinstitutional analysis.

text: OBJECTIVE This study hypothesized that tumor size, number of tumors, surgical approach, and tumor histology significantly affected microwave ablation (MWA) success and recurrence-free survival. BACKGROUND Although many hepatobiliary centers have adopted MWA, the factors that influence local control are not well described. METHODS Consecutive patients with hepatic malignancy treated by MWA were included from 4 high-volume institutions (2003-2011) and grouped by histology: hepatocellular carcinoma (HCC), colorectal liver metastases, neuroendocrine liver metastases, and other cancers. Independent significance of outcome variables was established with logistic regression and Cox proportional hazards models. RESULTS Four hundred fifty patients were treated with 473 procedures (139 HCC, 198 colorectal liver metastases, 61 neuroendocrine liver metastases, and 75 other) for a total of 875 tumors. Median follow-up was 18 months. Concurrent hepatectomy was performed in 178 patients (38%), and when performed was associated with greater morbidity. Complete ablation was confirmed for 839 of 865 tumors (97.0%) on follow-up cross-sectional imaging (10 were unevaluable). A surgical approach (open, laparoscopic, or percutaneous) had no significant impact on complication rates, recurrence, or survival. The local recurrence rate was 6.0% overall and was highest for HCC (10.1%, P = 0.045) and percutaneously treated lesions (14.1%, P = 0.014). In adjusted models, tumor size 3 cm or more predicted poorer recurrence-free survival (hazard ratio: 1.60, 95% CI: 1.02-2.50, P = 0.039). CONCLUSIONS In this large data set, patients with 3 cm or more tumors showed a propensity for early recurrence, regardless of histology. Higher rates of local recurrence were noted in HCC patients, which may reflect underlying liver disease. There were no significant differences in morbidity or survival based on the surgical approach; however, local recurrence rates were highest for percutaneously ablated tumors.


title: Concentric Malar Lift in the Management of Lower Eyelid Rejuvenation or Retraction: A Clinical Retrospective Study on 342 Cases, 13 Years After the First Publication.

text: BACKGROUND Lower eyelid rejuvenation can, unfortunately, induce scleral show even if the lower eyelid procedure is limited. This study was designed to assess the effectiveness and reliability of the concentric malar lift technique in two scenarios: the first, in rejuvenation of the mid-face and, the second, in reconstructive surgery for correction of congenital or acquired eyelids malposition. METHODS The concentric malar lift technique was first published by Le Louarn (Aesthet Plast Surg 28(6):359-372, 2004). This retrospective study was carried out by analyzing data on patients operated on between January 2010 and January 2016. Patients operated on before 2010 were excluded because barbed thread sutures were not used in the first version of the technique. Patients after January 2016 were excluded to ensure adequate follow-up, and so 342 patients are included in the study. A total of 256 cases (75%) were for aesthetic mid-face lifting, and 86 cases (25%) were reconstructive surgeries for lower eyelid retraction. A spacer graft was used in 30 of these reconstructive cases (35%). The mean follow-up time was 13.6 months. All the concentric malar lifting procedures included strengthening the lateral canthus, which is a key element of the procedure. RESULTS None of the patients developed secondary eyelid malposition, and all the cases of lower eyelid retraction displayed marked improvement both functionally and aesthetically. Two patients experienced loss of sensitivity of part in the infra-orbital nerve distribution for 4 months after the procedure. CONCLUSION The concentric malar lift procedure enables the recruitment of a significant amount of skin into the lower eyelid: between 10 and 30 mm. It ensures better rejuvenation of the mid-face with minimal risk of lower eyelid malposition. In reconstruction of the lower eyelid lid, the concentric malar lift is able to reduce the need for skin grafting and a skin flap reducing the risks of visible scarring. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .


title: Culture-Competent SARS-CoV-2 in Nasopharynx of Symptomatic Neonates, Children, and Adolescents.

text: Children do not seem to drive transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We isolated culture-competent virus in vitro from 12 (52%) of 23 SARS-CoV-2-infected children; the youngest was 7 days old. Our findings show that symptomatic neonates, children, and teenagers shed infectious SARS-CoV-2, suggesting that transmission from them is plausible.


title: Steam ablation versus radiofrequency and laser ablation: an in vivo histological comparative trial.

text: OBJECTIVE There is an increasing use of minimal invasive techniques to treat saphenous vein reflux. Among these radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and foam sclerotherapy are frequently used. A new method of thermal ablation is the steam vein sclerosing (SVS) system. This study evaluates the histological changes after ablation of the saphenous veins in goats with RFA, EVLA, and SVS. METHODS Twelve saphenous veins in six goats were treated with one of the three treatment modalities: four veins with RFA, four with EVLA, four with SVS. Seven days after treatment occlusion and diameter changes were evaluated by ultrasound imaging and histological changes were examined microscopically. RESULTS Vein length, mean diameter, and the amount of tumescence was comparable between the three groups. Histological examination showed extensive vein wall destruction, the least in the outer layer of the vein wall. The total vein wall damage was 9.2/15 (SD 3.5) for EVLA, 13.3/15 (SD 3.3) for RFA, and 11.2/15 (SD 2.8) for SVS group. There was no significant difference among the three groups. Perivenous tissue damage was low. No extrafascial damage was seen. CONCLUSION Histological findings after steam ablation are similar to the RFA and EVLA with a low perivenous tissue destruction score and a high vein wall destruction score.


title: The economic impact of SARS in Beijing, China.

text: OBJECTIVE To document the impact of the severe acute respiratory syndrome (SARS) outbreak in Beijing on indicators of social and economic activity. METHODS Associations between time series of daily and monthly SARS cases and deaths and volume of public train, airplane and cargo transport, tourism, household consumption patterns and gross domestic product growth in Beijing were investigated using the cross-correlation function. RESULTS Significant correlation coefficients were found for all indicators except wholesale accounts and expenditures on necessities, with the most significant correlations occurring with a delay of 1 day to 1 month. CONCLUSIONS Especially leisure activities, local and international transport and tourism were affected by SARS particularly in May 2003. Much of this consumption was merely postponed; but irrecoverable losses to the tourist sector alone were estimated at about US$ 1.4 bn, or 300 times the cost of treatment for SARS cases in Beijing.


Making a Difference for Patients with Peripheral Artery Disease by Advocating Together as One.


title: Recent advances in the angiotensin-converting enzyme 2-angiotensin(1-7)-Mas axis.

text: In the past few years, the classical concept of the renin-angiotensin system (RAS) has experienced substantial conceptual changes. The identification of: the renin/prorenin receptor; the angiotensin-converting enzyme homologue, ACE2, as an angiotensin peptide-processing enzyme and a virus receptor for severe acute respiratory syndrome, the Mas as a receptor for angiotensin (1-7) [Ang(1-7)], and the possibility of signaling through ACE have contributed to switch our understanding of the RAS from the classical limited-proteolysis linear cascade to a cascade with multiple mediators, multiple receptors and multifunctional enzymes. With regard to Ang(1-7), the identification of ACE2 and of Mas as a receptor implicated in its actions contributed to decisively establish this heptapeptide as a biologically active member of the RAS cascade. In this review, we will focus on the recent findings related to the ACE2-Ang(1-7)-Mas axis and, in particular, on its putative role as an ACE-Ang II-AT(1) receptor counter-regulatory axis within the RAS.


title: Frequency of diarrhoea-associated viruses in swine of various ages in Hungary.

text: Enteric viral diseases of swine are one of the most frequent disorders causing huge economic losses in pork production. After the reappearance of an emerging enteropathogen, porcine epidemic diarrhoea virus (PEDV) in Hungary in 2016, an extensive survey was initiated in an attempt to identify diarrhoea-related porcine viruses, including adeno-, astro-, boca-, calici-, circo-, corona-, kobu-, rota- and Torque teno viruses. A total of 384 faecal samples collected during a twoyear period from diarrhoeic and asymptomatic pigs of various ages in 17 farms were screened by conventional and real-time PCR methods. Half of the samples contained at least one examined virus with the dominance of kobuvirus (55.1%) followed by bocaviruses (33.2%) and rotavirus groups A and C together (20.9%), while coronaviruses including PEDV were not found in this set of samples. Statistical analysis showed a highly significant difference (P < 0.0001) in the frequency of single infections compared to mixed ones with the exception of weaned pigs, in which group additionally most viruses were detected. The results of this study suggest that the complexity of this disease may vary with age, which makes the prevention of diarrhoea a challenge, especially in weaned pigs.


title: Flow Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre Experience.

text: BACKGROUND Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms. MATERIALS AND METHODS We retrospectively reviewed our prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, we recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up. RESULTS Our search identified 13 patients (7 males) with an average age of 61.7 years (47-74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5-10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic. CONCLUSION In our series, 91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible.


title: No extensive experience in open procedures is needed to learn lobectomy by video-assisted thoracic surgery.

text: OBJECTIVES Lobectomies done by video-assisted thoracic surgery (VATS) result in fewer complications and less pain and save total costs compared with the traditional approach. However, the majority of procedures are still performed via open thoracotomies, because VATS lobectomy is considered difficult to learn, requiring experience in open surgery, and causing complications in the initial phase of the learning curve. The aim of this study was to describe a training model appreciating patient safety during training and to explore the initial learning curve for a trainee rather inexperienced in open surgery. METHODS A trainee who had performed 14 lobectomies by thoracotomy was enrolled in a training programme at a high-volume VATS centre. The training model included courses and simulations followed by the selection of suitable patients operated on during close expert supervision. Data regarding time, a variety of quality indicators and complications were collected prospectively and compared with experts' performance. RESULTS Over 12 months, 29 of 214 VATS lobectomies were performed by the trainee. Twice, the supervisor had to finish the procedure due to technical difficulties. None of the operations were converted to open thoracotomy. Compared with experts, the trainee operated significantly slower [median 120 (range 74-160) vs 100 (range 42-255) min, P = 0.04]; had similar perioperative bleeding [median 100 (range 10-500) vs 50 (range 5-2500) ml, P = 0.79]; had earlier chest tube removal [median 1 (range 1-6) vs 2 (range 1-32) postoperative days, P < 0.001]; and reduced hospital stay [median 3 (range 1-10) vs 4 (range 1-41) days, P < 0.001]. Twenty-three (79%) patients had no complications, while 2 had atrial fibrillation. Pneumothorax after chest tube removal, incisional infection, prolonged pain and need for pleuracentesis were each seen once. CONCLUSIONS With thorough preparation of trainees and training on selected patients under close supervision, the learning curve can be overcome with good results even if the trainee has limited prior experience in open surgery.


title: Porcine epidemic diarrhea virus nucleocapsid protein antagonizes beta interferon production by sequestering the interaction between IRF3 and TBK1.

text: UNLABELLED Porcine epidemic diarrhea virus (PEDV), a porcine enteropathogenic coronavirus, causes lethal watery diarrhea in piglets and results in large economic losses in many Asian and European countries. A large-scale outbreak of porcine epidemic diarrhea occurred in China in 2010, and the virus emerged in the United States in 2013 and spread rapidly, posing significant economic and public health concerns. Previous studies have shown that PEDV infection inhibits the synthesis of type I interferon (IFN), and viral papain-like protease 2 has been identified as an IFN antagonist. In this study, we found that the PEDV-encoded nucleocapsid (N) protein also inhibits Sendai virus-induced IFN-β production, IFN-stimulated gene expression, and activation of the transcription factors IFN regulatory factor 3 (IRF3) and NF-κB. We also found that N protein significantly impedes the activation of the IFN-β promoter stimulated by TBK1 or its upstream molecules (RIG-I, MDA5, IPS-1, and TRAF3) but does not counteract its activation by IRF3. A detailed analysis revealed that the PEDV N protein targets TBK1 by direct interaction and that this binding sequesters the association between TBK1 and IRF3, which in turn inhibits both IRF3 activation and type I IFN production. Together, our findings demonstrate a new mechanism evolved by PEDV to circumvent the host's antiviral immunity. IMPORTANCE PEDV has received increasing attention since the emergence of a PEDV variant in China and the United States. Here, we identify nucleocapsid (N) protein as a novel PEDV-encoded interferon (IFN) antagonist and demonstrate that N protein antagonizes IFN production by sequestering the interaction between IRF3 and TBK1, a critical step in type I IFN signaling. This adds another layer of complexity to the immune evasion strategies evolved by this economically important viral pathogen. An understanding of its immune evasion mechanism may direct us to novel therapeutic targets and more effective vaccines against PEDV infection.


docid: edacaqan

title: Endovascular Rescue Therapies for Refractory Vasospasm After Subarachnoid Hemorrhage: A Prospective Evaluation Study Using Multimodal, Continuous Event Neuromonitoring.

text: BACKGROUND Critical hypoperfusion and metabolic derangement are frequently encountered with refractory vasospasm. Endovascular rescue therapies (ERT) have proven beneficial in selected cases. However, angioplasty (AP) and intraarterial lysis (IAL) are measures of last resort and prospective, quantitative results regarding the efficacy (cerebral oxygenation, metabolism) are largely lacking. OBJECTIVE To evaluate the efficacy of ERTs for medically refractory vasospasm using multimodal, continuous event neuromonitoring. METHODS To detect cerebral compromise in a timely fashion, sedated patients with aneurysmal subarachnoid hemorrhage received continuous neuromonitoring (p ti O 2 measurement, intraparenchymal microdialysis). ERT (AP and/or IAL) was considered in cases of clinically relevant vasospasm refractory to conservative treatment measures. Oxygen saturation and cerebral and systemic metabolism before and after events of ERT was recorded. RESULTS We prospectively included 13 consecutive patients and recorded a total of 25 ERT events: AP (n = 10), IAL (n = 11), or both (AP + IAL, n = 4). Average cerebral p ti O 2 was 10 ± 11 torr before and 49 ± 22 torr after ERT ( P < .001), with a lactate-pyruvate ratio decreasing from 146.6 ± 119.0 to 27.9 ± 10.7 after ERT ( P < .001). Comparable improvement was observed for each type of intervention (AP, IAL, or both). No significant alterations in systemic metabolism could be detected after ERT. CONCLUSION Multimodal event neuromonitoring is able to quantify treatment efficacy in subarachnoid hemorrhage-related vasospasm. In our small cohort of highly selected cases, ERT was associated with improvement in cerebral oxygenation and metabolism with reasonable outcome. Event neuromonitoring may facilitate individual and timely optimization of treatment modality according to the individual clinical course.


title: EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2.

text: The provisional EULAR recommendations address several aspects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus, and the disease caused by SARS-CoV-2, COVID-19 and are meant for patients with rheumatic and musculoskeletal diseases (RMD) and their caregivers. A task force of 20 members was convened by EULAR that met several times by videoconferencing in April 2020. The task force finally agreed on five overarching principles and 13 recommendations covering four generic themes: (1) General measures and prevention of SARS-CoV-2 infection. (2) The management of RMD when local measures of social distancing are in effect. (3) The management of COVID-19 in the context of RMD. (4) The prevention of infections other than SARS-CoV-2. EULAR considers this set of recommendations as a 'living document' and a starting point, which will be updated as soon as promising new developments with potential impact on the care of patients with RMD become available.


title: Somatostatin-receptor-based imaging and therapy of gastroenteropancreatic neuroendocrine tumors.

text: Somatostatin receptor imaging (SRI) with [(111)In-DTPA(0)]octreotide has proven its role in the diagnosis and staging of gastroenteropancreatic neuroendocrine tumors (GEPNETs). Newer radiolabeled somatostatin analogs which can be used in positron emission tomography (PET) imaging, and which have a higher affinity for the somatostatin receptor, especially receptor subtype-2, have been developed. It would be desirable, however, if one radiolabeled analog became the new standard for PET imaging, because the current application of a multitude of analogs implies a fragmented knowledge on the interpretation of the images that are obtained in clinical practice. In our view, the most likely candidates for such a universal PET tracer for SRI are [(68)Ga-DOTA(0),Tyr(3)]octreotate or [(68)Ga-DOTA(0),Tyr(3)]octreotide. Treatment with radiolabeled somatostatin analogs is a promising new tool in the management of patients with inoperable or metastasized neuroendocrine tumors. Symptomatic improvement may occur with all (111)In-, (90)Y-, or (177)Lu-labeled somatostatin analogs that have been used for peptide receptor radionuclide therapy (PRRT). The results that were obtained with [(90)Y-DOTA(0),Tyr(3)]octreotide and [(177)Lu-DOTA(0),Tyr(3)]octreotate are very encouraging in terms of tumor regression. Also, if kidney protective agents are used, the side effects of this therapy are few and mild, and the median duration of the therapy response for these radiopharmaceuticals is 30 and 40 months respectively. The patients' self-assessed quality of life increases significantly after treatment with [(177)Lu-DOTA(0),Tyr(3)]octreotate. Lastly, compared to historical controls, there is a benefit in overall survival of several years from the time of diagnosis in patients treated with [(177)Lu-DOTA(0),Tyr(3)]octreotate. These data compare favorably with the limited number of alternative treatment approaches. If more widespread use of PRRT can be guaranteed, such therapy may well become the therapy of first choice in patients with metastasized or inoperable GEPNETs.


title: Metagenomic identification of a novel anellovirus in Pacific harbor seal (Phoca vitulina richardsii) lung samples and its detection in samples from multiple years.

text: To investigate viral pathogens potentially involved in a mortality event of 21 Pacific harbor seals (Phoca vitulina richardsii) in California in 2000, viral metagenomics was performed directly on lung samples from five individuals. Metagenomics revealed a novel seal anellovirus (SealAV), which clusters phylogenetically with anelloviruses from California sea lions and domestic cats. Using specific PCR, SealAV was identified in lung tissue from two of five animals involved in the 2000 mortality event, as well as one of 20 harbor seal samples examined post-mortem in 2008. The identification of SealAV in multiple years demonstrates that this virus is persistent in the harbor seal population. SealAV is the second anellovirus reported in the lungs of pinnipeds, suggesting that anellovirus infections may be common amongst marine mammals and that more research is needed to understand the roles of these viruses in marine mammal health and disease.


title: Laparoscopic repair of traumatic abdominal wall hernia from handlebar injury.

text: A 14-year-old boy was seen at an outside hospital after falling over the handlebar of his bicycle and was discharged home. He was subsequently seen in our emergency department with complaints of persistent abdominal pain. A computed tomography scan of the abdomen revealed disruption of the muscles of the upper right abdominal wall containing the hepatic flexure of the colon, with a small amount of intraperitoneal free fluid noted. The patient underwent laparoscopic exploration using 3 ports (2-5 mm and 1-12 mm) and 2 separate stab incisions. The traumatic abdominal wall hernia was repaired with interrupted sutures placed with an ENDO CLOSE (Covidien, Mansfield, MA) device, and a mesenteric defect in the colon was approximated with intracorporeal sutures. The trocar sites were sutured closed. The patient recovered well and was discharged home. Follow-up examination revealed no abdominal wall defect and resolution of his symptoms. Laparoscopic repair of a traumatic abdominal wall defect and exploratory laparoscopy after trauma is feasible and safe in the pediatric patient. It should be considered as an alternative approach with potentially less morbidity than an exploratory laparotomy for handlebar injuries in a stable patient.


Bariatric surgery: To bypass or switch? That is the question in obesity surgery.


title: Development of a minimally invasive, injectable, shape memory suture and delivery system.

text: Suturing in space-confined surgical settings encountered during microsurgical procedures can be technically complex and time intensive. This paper presents the development of a new injector and new shape-memory alloy clip that can replace conventional suture. Engineering and surgical assessments of the injector and clips were performed. A prototype of the delivery system was tested in simulated surgical settings and compared to conventional suturing techniques for surgical time and wound strength. In various micro-surgical scenarios, the new injectable system proved to be 5 to 20-times more efficient and to have wound strengths over three-times that of conventional suturing. Further, the wounds closed by the shape-memory alloy clips could be forced to open and then recover to a watertight state, unlike conventional sutures which break upon failure. This new injector and shape-memory alloy clips proved to be quicker, stronger, and technically easier than conventional suturing. Future work is underway to test the injectable delivery system and the shape-memory alloy clips using a real-time, in vivo porcine model.


title: Chest wall reconstruction using implantable cross-linked porcine dermal collagen matrix (Permacol).

text: BACKGROUND/PURPOSE Chest wall reconstruction in children is typically accomplished with either primary tissue repair or synthetic mesh prostheses. Primary tissue repair has been associated with high rates of scoliosis, whereas synthetic prostheses necessitate the placement of a permanent foreign body in growing children. This report describes the use of biologic mesh (Permacol; Covidien, Mansfield, MA) as an alternative to both tissue repair and synthetic prostheses in pediatric chest wall reconstruction. METHODS A retrospective chart review was performed identifying patients undergoing chest wall reconstruction with biologic mesh at our tertiary referral children's hospital between 2007 and 2011. Data collection included patient demographics, indication for chest wall resection, number of ribs resected, the administration of postoperative radiation, length of follow-up, postoperative complications, and the degree of spinal angulation (preoperatively and at most recent follow-up). RESULTS Five patients (age, 9.0-21.7 years; mean, 15.4 years) underwent resection for primary chest wall malignancy followed by reconstruction with biologic mesh (Permacol) during the study period. There were no postoperative mesh-related complications, and none of the patients developed clinically significant scoliosis (follow-up, 1.1-2.6 years; mean 1.9 years). CONCLUSION Biologic mesh offers a safe and dependable alternative to both primary tissue repair and synthetic mesh in pediatric patients undergoing chest wall reconstruction.


title: Covid-19: Refracting decision-making through the prism of resource allocation.

text: Medical decision-making has, across the history of the NHS, made a transitional journey from a model characterised by paternalism to one which places emphasis on partnership and patient autonomy. This article assesses the extent to which the circumstances generated by the Covid-19 pandemic affect the mode of critical care decision-making. It observes that clinical judgment influenced by protocols, algorithms and resource constraints do not lend themselves to full identification with either of the two frameworks familiar to the NHS. The unique mode of decision-making engendered can only be understood on its own terms.


title: Community-acquired pneumonia.

text: PURPOSE OF REVIEW Community-acquired pneumonia (CAP) is the most common infectious disease cause of death. We summarize recent findings regarding the epidemiology of CAP in adults, efficacy of vaccines against Streptococcus pneumoniae, diagnostics, and discuss the current controversy between CAP and healthcare-associated pneumonia (HCAP). RECENT FINDINGS The emergence of the Middle East respiratory syndrome coronavirus and the avian influenza A strain H7N9 are of concern but still these are infrequent causes of CAP. Recent data indicate that vaccinating children also protects adults against CAP by generating significant herd immunity, and that the conjugated pneumococcal vaccine in adults may offer some efficacy in preventing CAP caused by vaccine serotypes. The immunochromotagraphic urinary antigen test has improved the diagnostic yield for the aetiology of CAP, and initial data demonstrate that a novel multiplex urinary antigen test will further increase the sensitivity for detection of S. pneumoniae. There has been significant concern that a relatively recently described pneumonia category, HCAP, requires empirical treatment for potentially multidrug-resistant organisms (MDRO). However, new evidence shows that (at least in Europe) pneumonia caused by MDRO remains uncommon even in HCAP category patients. SUMMARY CAP remains a major cause of morbidity and mortality. Advances in vaccination and diagnosis should help reduce the amount of disease due to S. pneumoniae, the commonest cause of CAP. Outside of the United States, MDRO are relatively uncommon causes of CAP, and the increased mortality of HCAP category patients seems to be related to their comorbidities and age rather than microbial aetiology.


docid: pxcyseps

title: Surgical versus percutaneous coronary revascularization for multivessel disease in diabetic patients with non-ST-segment-elevation acute coronary syndrome: analysis from the Acute Catheterization and Early Intervention Triage Strategy trial.

text: BACKGROUND The preferred revascularization strategy for diabetic patients with acute coronary syndromes and multivessel coronary artery disease is uncertain. We evaluated the outcomes of diabetic patients with moderate and high-risk acute coronary syndrome and multivessel disease managed with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). METHODS AND RESULTS Among 13 819 moderate and high-risk acute coronary syndrome patients enrolled in the Acute Catheterization and Early Intervention Triage Strategy (ACUITY) trial, 1772 diabetic patients had multivessel disease with left anterior descending artery involvement and were managed by PCI (n=1349) or CABG (n=423). Propensity scoring was applied to adjust for differences in baseline clinical and angiographic characteristics, yielding a total of 326 matched patients (163 managed by PCI and 163 managed by CABG). At 30 days, treatment with PCI compared with CABG was associated with lower rates of major bleeding (15.3% versus 55.6%; P<0.0001), blood transfusions (9.2% versus 43.2%; P<0.0001), and acute kidney injury (13.4% versus 33.6%; P<0.0001), but more unplanned revascularization procedures (6.9% versus 1.9%; P=0.03). At 1 year PCI was associated with higher rates of repeat revascularization procedures (19.5% versus 5.2%; P=0.0001), with nonsignificantly different rates of myocardial infarction, stroke, and death at either 30 days or 1 year. CONCLUSIONS In the large-scale ACUITY trial, diabetic patients with acute coronary syndrome and multivessel disease treated with PCI rather than CABG had less bleeding and acute kidney injury, greater need for repeat revascularization procedures, and comparable rates of myocardial infarction, stroke, and death through 1-year follow-up. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.


title: Novel technique for full-thickness resection of gastric malignancy: feasibility of nonexposed endoscopic wall-inversion surgery (news) in porcine models.

text: Full-thickness resection for gastric malignancy carries a risk of peritoneal dissemination due to opening of the gastric lumen. We evaluated the feasibility and safety a novel method of full-thickness resection without transmural communication, called nonexposed endoscopic wall-inversion surgery in ex vivo and in vivo porcine models. Six explanted porcine stomachs and 6 live pigs were used for this study. After marking and submucosal injection around 3 cm simulated lesions, the seromuscular layer was laparoscopically cut and sutured with the lesion inverted to the inside. Consecutively, a mucosubmucosal incision was made endoscopically. Three pigs used for the survival study were monitored for 7 days. All 12 lesions were successfully resected en bloc without perforation. The 3 pigs survived for 1 week without adverse events, and necropsy revealed neither leakage nor abscess formation related to the operation. We demonstrated nonexposed endoscopic wall-inversion surgery to be technically feasible and safe in both ex vivo and in vivo porcine studies.


Helen Salisbury: Fear in the time of covid.


title: Compacting a Single Flow Diverter versus Overlapping Flow Diverters for Intracranial Aneurysms: A Computational Study.

text: BACKGROUND AND PURPOSE Locally compacting the mesh of a flow diverter by a dynamic push-pull technique can accelerate intracranial aneurysm healing. We asked how this deployment strategy compares with overlapping 2 flow diverters for aneurysmal flow reduction. MATERIALS AND METHODS Using a high-fidelity virtual stent placement method, we simulated 3 flow-diverter strategies (single noncompacted, 2 overlapped, and single compacted) in 3 aneurysms (fusiform, large saccular, and medium saccular). Computational fluid dynamics analysis provided posttreatment hemodynamic parameters, including time-averaged inflow rate, aneurysm-averaged velocity, wall shear stress, total absolute circulation, and turnover time. We examined the relationship between the achieved degree of compaction and aneurysm orifice area. RESULTS Flow-diverter compaction resulted in a compaction coverage of 57%, 47%, and 22% over the orifice of the fusiform, large, and medium saccular aneurysm, respectively. Compaction coverage increased linearly with orifice area. In the fusiform aneurysm, the single compacted flow diverter accomplished more aneurysmal flow reduction than the other 2 strategies, as indicated by all 5 hemodynamic parameters. In the 2 saccular aneurysms, the overlapped flow diverters achieved the most flow reduction, followed by the single compacted and the noncompacted flow diverter. CONCLUSIONS Compacting a single flow diverter can outperform overlapping 2 flow diverters in aneurysmal flow reduction, provided that the compaction produces a mesh denser than 2 overlapped flow diverters and this denser mesh covers a sufficient portion of the aneurysm orifice area, for which we suggest a minimum of 50%. This strategy is most effective for aneurysms with large orifices, especially fusiform aneurysms.


title: Influence of time delay on the estimated lung shunt fraction on 99mTc-labeled MAA scintigraphy for 90Y microsphere treatment planning.

text: 90Y-microspheres therapy is used to treat selected patients with primary or metastatic liver tumors in a safe and effective way. As a preparation for 90Y-microspheres treatment, a 99mTc-macroaggregated albumin (99mTc-MAA) simulation procedure is essential to evaluate particle shunting to the lung or gastrointestinal tract. We investigated the effect of interval between injection of 99mTc-MAA and time of scanning on the lung shunt fraction (LSF). In 4 patients with secondary hepatic malignancies who underwent repeated whole-body scintigraphy up to 5 hours after injection of 99mTc-MAA, a marked change in LSF was observed. It appears that tracer degradation leads to an important overestimation of LSF at later time points. An overestimation of LSF can lead to dose reduction or canceling of the planned 90Y-microspheres treatment. It is concluded that the interval between injection and scanning should be kept as short as possible.


Complement Activation During Critical Illness: Current Findings and an Outlook in the Era of COVID-19.


title: Diagnosis of insulinoma in a Maine Coon cat.

text: Case summary A 14-year-old male neutered Maine Coon cat presented with a 6-month history of polyphagia and one recent episode of tremors and weakness. Blood work revealed profound hypoglycemia and results of a paired insulin glucose test were consistent with an insulinoma. Abdominal ultrasound revealed a solitary pancreatic mass, and results of a fine-needle aspirate (FNA) gave further support for the location of the neuroendocrine tumor. After unsuccessful medical management of the hypoglycemia, the mass was surgically removed. Immunohistochemistry confirmed that it was an insulinoma. At the time of writing, the patient had been in clinical remission for 9 months. Relevance and novel information Feline insulinomas are rare and there is very little information on their behavior, clinical course and histologic characteristics. This is the first reported case of an insulinoma in a Maine Coon cat and the first to describe results of an ultrasound-guided FNA of the mass. In addition, the progression of disease, histopathology and immunohistochemistry results add to the currently minimal database for feline insulinomas.


title: Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey.

text: OBJECTIVE During the past two decades, professional associations, accrediting bodies, and payors have made post-surgical pain treatment a high priority. In light of the disappointing findings in previous surveys, a survey was conducted to assess patient perceptions and characterize patient experiences/levels of satisfaction with post-surgical pain management. RESEARCH DESIGN AND METHODS Survey included a random sample of US adults who had undergone surgery within 5 years from the survey date. Participants were asked about their concerns before surgery, severity of perioperative pain, pain treatments, perceptions about post-surgical pain and pain medications, and satisfaction with treatments they received. RESULTS Of the 300 participants, ∼86% experienced pain after surgery; of these, 75% had moderate/extreme pain during the immediate post-surgical period, with 74% still experiencing these levels of pain after discharge. Post-surgical pain was the most prominent pre-surgical patient concern, and nearly half reported they had high/very high anxiety levels about pain before surgery. Approximately 88% received analgesic medications to manage pain; of these, 80% experienced adverse effects and 39% reported moderate/severe pain even after receiving their first dose. STUDY LIMITATIONS Key study limitations include the relatively small population size, potential for recall bias associated with the 14-month average time delay from surgery date to survey date, and the inability to account for influences of type of surgery and intraoperative anesthetic/analgesic use on survey results. CONCLUSIONS Despite heightened awareness and clinical advancements in pain management, there has been little improvement in post-surgical analgesia as measured by this survey of post-surgical patients.


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