title: Modulation of corticospinal output in agonist and antagonist proximal arm muscles during motor preparation.

text: Previous studies have shown modulation of corticospinal output of the agonist muscle when a known-movement is prepared but withheld until a response signal appearance, reflecting motor preparation processes. However, modulation in the antagonist muscles has not been described, despite the fact that reaching movements require precise coordination between the activation of agonist and antagonist muscles. In this study, participants performed an instructed-delay reaction time (RT) task, with randomized elbow flexion and extension movements. The aim was to assess the time course modulation of corticospinal output in two antagonist muscles, by simultaneously quantified the amplitude of motor evoked potentials (MEPs) in biceps brachii and triceps brachii, and the amplitude and direction of elbow movements evoked by transcranial magnetic stimulation (TMS). Depending on the prepared movement direction, a specific modulation of corticospinal output was observed, MEPs and TMS-evoked movements amplitude being relatively greater for extension compared to flexion. At the end of motor preparation, a decrease in MEPs amplitude was observed for both biceps brachii and triceps brachii, regardless of the prepared movement direction. In contrast, the probability of evoking movement in the flexion direction and the amplitude of TMS-evoked movement decreased at the end of preparation for flexion, but not for extension. Together, these results confirm the existence of inhibitory processes at the end of the motor preparation, probably to avoid a premature motor response. Moreover, they provide evidence of differences in the corticospinal control of elbow flexor and extensor muscles with patterns of modulation that are not necessarily reciprocal during motor preparation.


Engaging students during the COVID-19 pandemic.


title: The use of Integra™ in rhinoplasty.

text: Different biosynthesized materials and autologous grafts have been used for many years to increase the size or to change the shape of the nasal dorsum in augmentation rhinoplasty. To avoid the undesirable effects of these materials, such as reabsorption, intolerance, granulomas, visualization of the graft's edges, and the migration of the implant, a new technique is proposed that uses a dermic regeneration template (Integra™). The authors have performed 56 surgeries for patients with different indications, and 30 of these patients have been followed up for a minimum of 12 months. The advantage of using this template, a sheet comprising a porous matrix of collagen fibers and glycosaminoglycans, is that it provides a structure for autologous dermic tissue regeneration. Its handling versatility once the silicone sheet is removed allows it to be folded over itself until the needed thickness is obtained as well as the desired aesthetic results. The authors believe that the dermic regeneration template (Integra™) is a good alternative filler material because it is completely reabsorbed and replaced by autologous dermis. The action is not to replace but to help the development of the patient's own tissue, avoiding a possible intolerance because it does not act as a foreign body. The volume remains stable throughout time, and overcorrection is not necessary.


title: A Novel Strategy to Identify Placebo Responders: Prediction Index of Clinical and Biological Markers in the EMBARC Trial.

text: BACKGROUND One in three clinical trial patients with major depressive disorder report symptomatic improvement with placebo. Strategies to mitigate the effect of placebo responses have focused on modifying study design with variable success. Identifying and excluding or controlling for individuals with a high likelihood of responding to placebo may improve clinical trial efficiency and avoid unnecessary medication trials. METHODS Participants included those assigned to the placebo arm (n = 141) of the Establishing Moderators and Biosignatures for Antidepressant Response in Clinical Care (EMBARC) trial. The elastic net was used to evaluate 283 baseline clinical, behavioral, imaging, and electrophysiological variables to identify the most robust yet parsimonious features that predicted depression severity at the end of the double-blind 8-week trial. Variables retained in at least 50% of the 100 imputed data sets were used in a Bayesian multiple linear regression model to simultaneously predict the probabilities of response and remission. RESULTS Lower baseline depression severity, younger age, absence of melancholic features or history of physical abuse, less anxious arousal, less anhedonia, less neuroticism, and higher average theta current density in the rostral anterior cingulate predicted a higher likelihood of improvement with placebo. The Bayesian model predicted remission and response with an actionable degree of accuracy (both AUC > 0.73). An interactive calculator was developed predicting the likelihood of placebo response at the individual level. CONCLUSION Easy-to-measure clinical, behavioral, and electrophysiological assessments can be used to identify placebo responders with a high degree of accuracy. Development of this calculator based on these findings can be used to identify potential placebo responders.


title: Patient flow in the largest French psychiatric emergency centre in the context of the COVID-19 pandemic.

text: To date, we have no French data about the psychiatric consequences of the Covid-19 pandemic and the confinement. In the largest French psychiatric emergency centre, we compared the average number of consultations per day during the confinement with the same period preceding the confinement and with the same periods of previous years, and we observed a significant drop in attendance. Our team had to adapt promptly to these changes in public mental health services, and we set up a telephone hotline dedicated to psychiatric patients and their families, in order to prevent a secondary psychiatric crisis.


title: Impact of COVID-19 on dental education in the United States.

text: Dental institutions in the United States are reeling from the consequences of the novel SARS-CoV2 coronavirus, the causative agent of CODIV-19. As oral health care providers, we have been trained on prevention of aerosol transmissible diseases, but we are still grappling with many unknown factors regarding COVID-19. While the Centers for Disease Control and Prevention (CDC), American Dental Association (ADA), and local state agencies are releasing updates on guidelines for dentists and patients, no official information exists for dental institutions on how to effectively follow the recommended guidelines including "shelter in place" with social distancing to protect students, faculty, staff, and patients, and still ensure continuity of dental education. This article discusses the challenges that we face currently and offers some simple strategies to bridge the gaps in dental education to overcome this emergency.


title: Acute Ischemic Stroke Treatment, Part 2: Treatment "Roles of Capillary Index Score, Revascularization and Time".

text: Due to recent results from clinical intra-arterial treatment for acute ischemic stroke (IAT-AIS) trials such as the interventional management of stroke III, IAT-AIS and the merit of revascularization have been contested. Even though intra-arterial treatment (IAT) has been shown to improve revascularization rates, a corresponding increase in good outcomes has only recently been noted. Even though a significant percentage of patients achieve good revascularization in a timely manner, results do not translate into good clinical outcomes (GCOs). Based on a review of the literature, the authors suspect limited GCOs following timely and successful revascularization are due to poor patient selection that led to futile and possibly even harmful revascularization. The capillary index score (CIS) is a simple angiography-based scale that can potentially be used to improve patient selection to prevent revascularization being performed on patients who are unlikely to benefit from treatment. The CIS characterizes presence of capillary blush related to collateral flow as a marker of residual viable tissue, with absence of blush indicating the tissue is no longer viable due to ischemia. By only selecting patients with a favorable CIS for IAT, the rate of GCOs should consistently approach 80-90%. Current methods of patient selection are primarily dependent on time from ischemia. Time from cerebral ischemia to irreversible tissue damage seems to vary from patient to patient; so focusing on viable tissue based on the CIS rather than relying on an artificial time window seems to be a more appropriate approach to patient selection.


title: Combined surgical and endovascular treatment with arch preservation of acute DeBakey type I aortic dissection.

text: BACKGROUND DeBakey type I aortic dissection is a catastrophic event that presents a formidable challenge to cardiovascular surgeon. Here, we evaluate a new combined surgical and endovascular technique for acute condition. METHODS Between December 2011 and December 2015, 12 patients with type I aortic dissection concomitant involving supra-aortic vessels underwent ascending aortic replacement and simultaneous stent grafts inserted into the descending aorta, left subclavian, and left carotid arteries, and into the innominate artery when possible, without arch replacement. The stent grafts, Gore TAG thoracic endoprosthesis and Viabahn, were deployed under visual guidance through opened aortic arch into the true lumen, with the techniques of circulatory arrest, moderate hypothermia, and bilateral antegrade cerebral perfusion. RESULTS Operation was performed smoothly in all patients. There was one death, and the other 11 recovered without any neurological deficits. Follow-up computed tomography scans showed that the true lumen expanded and false lumen regressed in both arch and descending aortic segments in 1 year. The diameter did not increase in either arch or descending aortic segments. CONCLUSION Ascending aortic replacement and stent graft for supra-aortic arteries and the descending aorta without arch replacement are feasible options for type I aortic dissection with satisfactory short-term aortic remodeling.


title: Localized BIA identifies structural and pathophysiological changes in soft tissue after post-traumatic injuries in soccer players.

text: Localized bioimpedance (BIA) was measured with a single frequency phase-sensitive analyzer at 50 kHz in three post-traumatic types of injuries on four professional soccer players: (1) myositis ossificans, (2) intramuscular seroma and (3) trochanteric (hip) bursitis. Normal reference value (no injury) was obtained from the contra lateral not injured limb at a mirror-like location of the injury. The relative variations resistance (R) and reactance (Xc) at the time of injury was confronted with the not injured values. Relative variations between acute measurements and post medication ones on intramuscular seroma and bursitis have been computed. In intramuscular seroma and trochanteric bursitis we have obtained a percent of change between injury data and after medical intervention. On myositis ossificans, localized BIA showed a 7-8 % decrease in Xc whereas the percent of change of R was negligible (1 %). These percent of changes are in concordance with histological evidence. In the case of a presence of seroma or the lower thigh and trochanteric bursitis, the soft tissue cavity accumulates fluid. Post-injury localized BIA, relative with respect to non-injured side, confirmed sizeable soft tissue destruction evidenced by 50 % decrease of Xc and 24-31 % decrease of R due to interstitial fluid accumulation. Once the seroma and the blood in the bursitis was removed the localized the immediate post-injury BIA parameters increased as follows: a) intramuscular seroma + 10 % on R and + 74 % of Xc; b) trochanteric bursitis + 20 % of R and +24 % of Xc. Localized BIA other than classifying soft tissue injuries, can be useful to understand the pathophysiology and structural impairments of other kind of injuries and to understand their behavior.


title: Systematic review of the neurocognitive outcomes used in studies of paediatric anaesthesia neurotoxicity.

text: BACKGROUND Neurotoxicity of anaesthetics in developing brain cells is well documented in preclinical studies, yet results are conflicting in humans. The use of many and different outcome measures in human studies may contribute to this disagreement. METHODS We conducted a systematic review to identify all measures used to assess long-term neurocognitive outcomes following general anaesthesia (GA) and surgery in children. The quality of studies was assessed according to the Newcastle-Ottawa Scale (NOS) for observational studies. PubMed/MEDLINE, EMBASE, Cinahl, Web of Science, and the Cochrane Library were searched for studies investigating neurocognitive outcome after GA in children <18 yr. RESULTS Sixty-seven studies were identified from 19 countries during 1990-2017. Most assessments were performed within cognition, sensory-motor development, academic achievement or neuropsychological diagnosis. Few studies assessed other outcomes (magnetic resonance imaging, serum-biomarkers, mortality, neurological examination, measurement of head circumference, impairment of vision). Rating according to the NOS rewarded a mean of six stars out of nine. Some concerns prevail regarding potential inter-rater variability because of equivocal description of rating criteria. Specific features such as stability over lifetime and inter-relations of outcomes (e.g. prediction of subsequent development or diagnosis of neuropsychological conditions) are discussed. The importance of validity and reliability of the various test instruments are described. The studies vary immensely in important characteristics. CONCLUSIONS Future observational studies should be more consistent in the choice of study population, age at exposure, follow-up, indication for and type of surgery, and outcomes. Assessment of sensory-motor development seems feasible in young children (age <4 yr), and intelligence/cognition in older children.


title: Cost-effectiveness analysis of orbital atherectomy plus balloon angioplasty vs balloon angioplasty alone in subjects with calcified femoropopliteal lesions.

text: INTRODUCTION As cost considerations become increasingly critical when selecting optimal endovascular treatment strategies, a cost-benefit analysis was conducted comparing the Diamondback 360°® Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc., St Paul, MN, USA) and balloon angioplasty (BA) vs BA alone for treatment of calcified femoropopliteal lesions. PATIENTS AND METHODS The clinical outcomes from COMPLIANCE 360°, a prospective, multicenter, randomized study comparing OAS+BA vs BA alone for treatment of calcified femoropopliteal lesions, were correlated with cost data and previously published quality of life data. Site of service, hospital charges, and associated medical resource utilization were obtained from Uniform Billing statements for index treatments and associated revascularizations out to 1 year. Hospital costs were estimated using hospital-specific, procedure-specific cost-to-charge ratios. Length of stay and procedural data were collected from participating study sites. RESULTS Twenty-five subjects with 38 lesions and 25 subjects with 27 lesions were randomized to the OAS+BA and BA-alone groups, respectively. Mean hospital charges (US$51,755 vs US$39,922) and estimated hospital costs (US$15,100 vs US$11,016) were higher for OAS+BA compared with BA alone (not statistically significant). Stent utilization was statistically significantly higher with BA-alone treatment for all subjects (1.1 vs 0.1, P=0.001) and in the subset of subjects with one lesion (1.0 vs 0.1, P<0.00001). There was a significant difference in cost for single-lesion versus multiple-lesion treatment. Using costs and quality-adjusted life years (QALYs) for the single-lesion cohort, the 1-year incremental cost of OAS+BA vs BA alone was US$549, and incremental QALY was 0.16. This results in an incremental cost-effectiveness ratio of US$3,441, well below the US$50,000 threshold. CONCLUSION One-year index procedure cost and cost-effectiveness were comparable for OAS+BA vs BA alone. This study provides compelling cost-effectiveness data for using atherectomy for treatment of calcified femoropopliteal lesions, a longstanding challenge for peripheral artery disease interventionalists.


title: MR imaging techniques for pancreas.

text: Pancreatic magnetic resonance (MR) imaging has become a useful tool in evaluating pancreatic disorders. Technical innovations in MR imaging have evolved over the last decade, with most sequences being performed in one or a few breath-holds. Three-dimensional sequences with thin, contiguous slices allow for improved spatial resolution on the postgadolinium images and MR cholangiopancreatography (MRCP). The diagnostic potential of MRCP is equivalent to endoscopic retrograde pancreatography, particularly when intravenous secretin is used to enhance the pancreatic duct assessment. This article highlights the advantages and disadvantages of state-of-the-art and emerging pulse sequences and their application to imaging pancreatic diseases.


title: Characterizing the spatiotemporal envelope of the human visual system through the visibility of temporal aliasing artifacts.

text: Previous studies have demonstrated that the onset of temporal aliasing artifacts occurs when the spatial displacement between samples reaches a critical distance, and that subsequently a linear relationship exists between stimulus speed and critical sampling rates. In this paper, we carry out further experimentation using a novel experimental setup, in which a strobe light is used to emulate impulsive temporal sampling, in order to investigate the spatiotemporal envelope of the human visual system and the effect of a stimulus. For non-periodic stimuli, experimental results show that critical sampling rates increase with motion speed and decrease with stimulus width. These interactions can be described using simple log-linear models, and characterized using the temporal aliasing visibility function, where maximum critical frame rates up to 1500 Hz are predicted. For periodic stimuli, we demonstrate that both perceptible temporal aliasing artifacts and stimulus aliasing can cause stroboscopic effects.


title: The effect of the jaw-thrust manoeuvre on the ability to advance a tracheal tube over a bronchoscope during oral fibreoptic intubation.

text: During fibreoptic intubation, it is often difficult to advance a tracheal tube over the fibreoptic bronchoscope. We performed a prospective randomised study to investigate the effect of the jaw-thrust manoeuvre on the ability to advance a tracheal tube during oral fibreoptic intubation. After placing the bronchoscope in the trachea, an assistant randomly applied a jaw-thrust manoeuvre (jaw-thrust group) or sham manoeuvre (control group) in 82 patients during tube advancement. The jaw-thrust group had a higher success rate on the first attempt (70.7% vs 34.1%, p = 0.002), required fewer attempts (median (IQR [range]) 1 (1-2 [1-3]) vs 2 (1-3 [1-4]), p < 0.001), and took less time [6 (4-8 [2-16]) s vs 10 (7-15 [3-40]) s, p < 0.001] for tube advancement compared with the control group. The jaw-thrust manoeuvre facilitates the advancement of a tracheal tube over the bronchoscope during oral fibreoptic intubation.


title: Brain Imaging Use and Findings in COVID-19: A Single Academic Center Experience in the Epicenter of Disease in the United States.

text: Coronavirus disease 2019 (COVID-19) is a serious public health crisis and can have neurologic manifestations. This is a retrospective observational case series performed March 1-31, 2020, at New York University Langone Medical Center campuses. Clinical and imaging data were extracted, reviewed, and analyzed. Two hundred forty-two patients with COVID-19 underwent CT or MRI of the brain within 2 weeks after the positive result of viral testing (mean age, 68.7 ± 16.5 years; 150 men/92 women [62.0%/38.0%]). The 3 most common indications for imaging were altered mental status (42.1%), syncope/fall (32.6%), and focal neurologic deficit (12.4%). The most common imaging findings were nonspecific white matter microangiopathy (134/55.4%), chronic infarct (47/19.4%), acute or subacute ischemic infarct (13/5.4%), and acute hemorrhage (11/4.5%). No patients imaged for altered mental status demonstrated acute ischemic infarct or acute hemorrhage. White matter microangiopathy was associated with higher 2-week mortality (P < .001). Our data suggest that in the absence of a focal neurologic deficit, brain imaging in patients with early COVID-19 with altered mental status may not be revealing.


title: Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature.

text: CONTEXT Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery. OBJECTIVE To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology. EVIDENCE ACQUISITION A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology. EVIDENCE SYNTHESIS In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES. CONCLUSIONS NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.


title: Docking Screens for Novel Ligands Conferring New Biology.

text: It is now plausible to dock libraries of 10 million molecules against targets over several days or weeks. When the molecules screened are commercially available, they may be rapidly tested to find new leads. Although docking retains important liabilities (it cannot calculate affinities accurately nor even reliably rank order high-scoring molecules), it can often can distinguish likely from unlikely ligands, often with hit rates above 10%. Here we summarize the improvements in libraries, target quality, and methods that have supported these advances, and the open access resources that make docking accessible. Recent docking screens for new ligands are sketched, as are the binding, crystallographic, and in vivo assays that support them. Like any technique, controls are crucial, and key experimental ones are reviewed. With such controls, docking campaigns can find ligands with new chemotypes, often revealing the new biology that may be docking's greatest impact over the next few years.


Advantages of delayed sequence intubation in selected patients with coronavirus disease (COVID-19).


Treatment of patients with nonsevere and severe coronavirus disease 2019: an evidence-based guideline.


title: Improving Bariatric Patient Aftercare Outcome by Improved Detection of a Functional Vitamin B12 Deficiency.

text: BACKGROUND Vitamin B12 deficiency is common after bariatric surgery. Vitamin B12 is a poor predictor of functional vitamin B12 status, since deficiencies might even occur within the reference limits. Therefore, vitamin B12 deficiencies with serum vitamin B12 levels are between 140 and 200 pmol/L remain undetected. Methylmalonic acid (MMA), however, will detect these deficiencies as accumulates due to functional intracellular vitamin B12 deficiencies. MMA is a relative expensive analysis and is therefore not generally available. To lower the costs, we only request MMA when vitamin B12 levels are between these levels. As a result, more biochemical deficiencies are found. However, it was not known whether bariatric patients with vitamin B12 levels between 140 and 200 pmol/L would benefit from supplementation. METHOD Bariatric patients with vitamin B12 levels between 140 and 200 pmol/L with (n = 45) and without (n = 45) intramuscular hydroxocobalamin injections were compared. RESULTS Treated patients showed a significant increase of vitamin B12 levels (P < 0.001) and a significant decrease in MMA levels (P < 0.001). Biochemical improvement occurs in both patients with and without clinical symptoms. The control group showed a significant increase of MMA levels (P < 0.001). To examine whether biochemical benefits of vitamin B12 supplementation are correlated with clinical improvement, patient records were checked for complaints. Complaints were disappeared after treatment, while no improvement was seen in untreated patients. CONCLUSION This study shows that all bariatric patients with vitamin B12 levels between 140 and 200 pmol/L benefit clinical and biochemical from vitamin B12 supplementation, regardless the MMA levels.


title: Serial Imaging Surveillance for Patients With a History of Intracranial Aneurysm: Risk of De Novo Aneurysm Formation.

text: BACKGROUND Although rare, de novo intracranial aneurysms (DNIAs) may develop in patients with a history of intracranial aneurysms (IAs). OBJECTIVE To evaluate the benefit of routine radiographic screening for DNIAs. METHODS Data for 2153 patients with IAs were retrospectively analyzed. A total of 185 patients underwent screening for DNIAs at frequent intervals. RESULTS Overall, DNIAs were detected in 26 patients (1.2%). Of the 185 patients with surveillance, DNIAs developed in 9 (4.9%). The risk of DNIA detection was 1.14% per person-year of follow-up (95% confidence interval: 0.6%-2.2%). Patients with imaging follow-up had a significantly higher rate of DNIA detection compared with patients without regular imaging surveillance (4.9% vs 0.86%; P < .001), but surveillance was associated with smaller lesions (with surveillance: 3.8 ± 1.8 mm, without: 7.0 ± 4.4 mm, mean ± standard deviation; P = .026). A unimodal distribution of time to detection was found in those with surveillance, with a peak between 0 and 2 years. There was a trend toward an association of cigarette smoking and DNIA detection within 10 years (P = .06); 6 of the 26 patients (23.1%) with DNIAs had a history of cigarette smoking, with all 6 patients continuing to smoke up to the detection of the DNIAs, which were detected in 2.5 ± 1.8 years. CONCLUSION The low 1.14% per-person year risk of DNIA detection and small DNIA size at detection cannot justify routine screening for DNIAs in all patients with a personal history of IAs. If imaging follow-up is considered for selected patients, early screening will likely yield the most benefit in patients who continue to smoke cigarettes.


title: Radioembolization dosimetry: the road ahead.

text: Methods for calculating the activity to be administered during yttrium-90 radioembolization (RE) are largely based on empirical toxicity and efficacy analyses, rather than dosimetry. At the same time, it is recognized that treatment planning based on proper dosimetry is of vital importance for the optimization of the results of RE. The heterogeneous and often clustered intrahepatic biodistribution of millions of point-source radioactive particles poses a challenge for dosimetry. Several studies found a relationship between absorbed doses and treatment outcome, with regard to both toxicity and efficacy. This should ultimately lead to improved patient selection and individualized treatment planning. New calculation methods and imaging techniques and a new generation of microspheres for image-guided RE will all contribute to these improvements. The aim of this review is to give insight into the latest and most important developments in RE dosimetry and to suggest future directions on patient selection, individualized treatment planning, and study designs.


title: Hospital Inpatient Admissions With Dehydration and/or Malnutrition in Medicare Beneficiaries Receiving Enteral Nutrition: A Cohort Study.

text: BACKGROUND Enteral nutrition (EN) supports many older and disabled Americans. This study describes the frequency and cost of acute care hospitalization with dehydration and/or malnutrition of Medicare beneficiaries receiving EN, focusing on those receiving home EN. METHODS Medicare 5% Standard Analytic Files were used to determine Medicare spending for EN supplies and the proportion and cost of beneficiaries receiving EN, specifically home EN, admitted to the hospital with dehydration and/or malnutrition. RESULTS In 2013, Medicare paid $370,549,760 to provide EN supplies for 125,440 beneficiaries, 55% of whom were also eligible for Medicaid. Acute care hospitalization with dehydration and/or malnutrition occurred in 43,180 beneficiaries receiving EN. The most common principal diagnoses were septicemia (21%), aspiration pneumonitis (9%), and pneumonia (5%). In beneficiaries receiving EN at home, >one-third (37%) were admitted with dehydration and/or malnutrition during a mean observation interval of 231 ± 187 days. Admitted patients were usually hospitalized more than once with dehydration and/or malnutrition (1.73 ± 1.30 admissions) costing $23,579 ± 24,966 per admitted patient, totaling >$129,685,622 during a mean observation interval of 276 ± 187 days. Mortality in the year following enterostomy tube placement was significantly higher for admitted compared with nonadmitted patients (40% vs 33%; P = .05). CONCLUSION Acute care hospitalizations with dehydration and/or malnutrition in Medicare beneficiaries receiving EN were common and expensive. Additional strategies to reduce these, with particular focus on vulnerable populations such as Medicaid-eligible patients, are needed.


title: Optical trocar access for initial trocar placement in laparoscopic gastrointestinal surgery: A propensity score-matching analysis.

text: INTRODUCTION Optical trocar access is a technique to place the initial trocar in laparoscopic surgery. With optical trocar access, each tissue layer can be visualized before insertion, which can help prevent organ injury, and air leaks at the trocar site can be minimized even in obese patients. The aim of this study was to compare the time needed for trocar insertion using optical trocar access and an open method in patients who underwent laparoscopic gastrointestinal surgery. METHODS We reviewed our prospectively collected database and identified 384 patients who underwent laparoscopic gastrointestinal surgery involving initial trocar insertion near the umbilicus by either the optical trocar access or the open method. Before the two methods were compared, propensity score matching was used to adjust for essential variables between the optical trocar access and open groups. RESULTS Patients categorized in the optical trocar access and open groups were matched one-to-one by propensity score matching, and 137 pairs of patients were generated. The time needed for trocar insertion was significantly shorter in the optical trocar access group than in the open group (36.6 vs 209.8 s, P < 0.01). The multivariable analysis identified an inexperienced surgeon as the only independent risk factor for prolonged time for initial trocar insertion using the optical trocar access. CONCLUSIONS This study indicated that optical trocar access may be recommended for inserting the initial trocar in laparoscopic gastrointestinal surgery.


Abdominoplasty access for desmoid tumor resection in the rectus abdominis muscle.


docid: eeyaahcg

title: Procedural changes to decrease complications in laparoscopic gastric bypass.

text: BACKGROUND AND OBJECTIVES Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a complex procedure performed in a patient population with significant medical comorbidities. Evaluation and modification of surgical techniques can minimize the complications associated with the lengthy learning curve for this procedure. The purpose of this study was to evaluate a single surgeon's decade-long experience with LRYGB, to determine whether complications decreased with experience and surgical modifications improved perioperative outcomes. METHODS A retrospective review of all procedures performed by a fellowship-trained surgeon (MK) from December 1, 2000, to October 31, 2013, identified patients who underwent LRYGB. We evaluated perioperative outcomes in 1117 patients and examined the impact of modification of surgical techniques on complications. The patients were divided into 4 groups: cases 1-100 (group 1), cases 101-400 (group 2), cases 401-700 (group 3), and cases 701-1117 (group 4). RESULTS Operating time decreased significantly after the initial 100 cases, from 179.1 minutes for group 1 to 122.1 minutes for group 4. With experience, early complication rates improved from 25.0% to 5.0%, but the rates of early reoperation increased from 1.0% to 2.2% over the 4 case groups. Late complication and reoperation rates increased from 4.0% to 10.5%. However, rates of bleeding, early stricture, internal hernia, and wound infection all decreased after the modification of surgical techniques. CONCLUSIONS Operating time and early complication rates decreased with operative experience, but late complication and early and late reoperation rates increased. However, after modifications of surgical technique, common complications of LRYGB decreased to rates lower than those reported in several gastric bypass case series in the literature. The findings in this study will be helpful to fellow bariatric surgeons who are refining their strategies for reducing morbidity related to LRGYB.


title: Adjuvant Human Papillomavirus Vaccine to Reduce Recurrent Cervical Dysplasia in Unvaccinated Women: A Systematic Review and Meta-analysis.

text: OBJECTIVE To perform a systematic review and meta-analysis evaluating the efficacy of adjuvant human papillomavirus (HPV) vaccination in preventing recurrent cervical intraepithelial neoplasia (CIN) 2 or greater after surgical excision. DATA SOURCES Electronic databases (Cochrane, PubMed, EMBASE, MEDLINE, Scopus, and ClinicalTrials.gov) were searched for studies comparing surgical excision alone to surgical excision with adjuvant HPV vaccination for CIN 2 or greater. Studies published from January 1990 to January 2019 were included. METHODS A total of 5,901 studies were reviewed. The primary outcomes evaluated included: recurrence of CIN 2 or greater, CIN 1 or greater, and HPV 16,18 associated CIN within 6-48 months. We used Covidence software to assist with screening, and meta-analysis was performed using Review Manager. TABULATION, INTEGRATION, AND RESULTS Six studies met inclusion criteria and were included in the final analysis. In total 2,984 women were included; 1,360 (45.6%) received adjuvant HPV vaccination after surgical excision, and 1,624 (54.4%) received either placebo or surgical management alone for CIN 2 or greater. Recurrence of CIN 2 or greater occurred within 6-48 months in 115 women (3.9%) overall; however, recurrence was significantly lower for vaccinated women: 26 of 1,360 women (1.9%) vs 89 of 1,624 unvaccinated women (5.9%) (relative risk [RR] 0.36 95% CI 0.23-0.55). The risk of CIN 1 or greater was also significantly lower with adjuvant HPV vaccination, occurring in 86 of 1,360 vaccinated women (6.3%) vs 157 of 1,624 unvaccinated women (9.7%) (RR 0.67 95% CI 0.52-0.85). Thirty-five women developed recurrent CIN 2 or greater lesions specific to HPV 16,18; nine received adjuvant vaccination (0.9%) vs 26 who were unvaccinated (2.0%) (RR 0.41 95% CI 0.20-0.85). CONCLUSION Adjuvant HPV vaccination in the setting of surgical excision for CIN 2 or greater is associated with a reduced risk of recurrent cervical dysplasia overall and a reduction in the risk of recurrent lesions caused by the most oncogenic strains (HPV 16,18). Human papillomavirus vaccination should therefore be considered for adjuvant treatment in patients undergoing surgical excision for CIN 2 or greater. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019123786.


title: A prospective randomized trial comparing subatmospheric wound therapy with a sealed gauze dressing and the standard vacuum-assisted closure device.

text: OBJECTIVE Two methods of subatmospheric pressure wound therapy--wall suction applied to a sealed gauze dressing (GSUC) and the vacuum-assisted closure device (VAC)--were compared in hospitalized patients at University of Chicago Medical Center. SUMMARY OF BACKGROUND DATA VAC therapy is widely used, but can be expensive and difficult to apply; it also fails in some patients. METHODS A randomized prospective study of 87 patients (N = 45 in the GSUC arm and N = 42 in the VAC arm) was undertaken between October 2006 and May 2008. The study comprised patients with acute wounds resulting from trauma, dehiscence, or surgery. RESULTS Demographics and wound characteristics were similar in both groups. There were significant reductions in wound surface area and volume in each group. In the GSUC group, the reductions in wound surface area and volume were 4.5%/day and 8.4%/day, respectively (P < 0.001 for both), and in the VAC group, this was 4.9%/day and 9.8%/day, respectively (P < 0.001 for both). The reductions in wound surface area and volume were similar in both groups (P = 0.60 and 0.19, respectively, for the group-by-time interaction). The estimated difference (VAC - GSUC) was 0.4% (95% confidence interval: -1.0, 1.7) for wound surface area and 1.4% (95% confidence interval: -0.7, 3.5) for volume. The mean cost per day for GSUC therapy was $4.22 versus $96.51 for VAC therapy (P < 0.01) and the average time required for a GSUC dressing change was 19 minutes versus 31 minutes for a VAC dressing change (P < 0.01). The sum of pain intensity differences was 0.50 in the GSUC group compared with 1.73 for the VAC group (P = 0.02). CONCLUSIONS GSUC is noninferior to VAC with respect to changes in wound volume and surface area in an acute care setting. In addition, GSUC dressings were easier to apply, less expensive, and less painful.


Sodium-Glucose Cotransporter 2 Inhibitors in the Era of COVID-19 Pandemic: Is the Benefit to Risk Ratio Still Favorable?


docid: plxitpzz

title: Targeted long-term venous occlusion using pulsed high-intensity focused ultrasound combined with a pro-inflammatory agent.

text: Esophageal and gastric varices are associated with significant morbidity and mortality for cirrhotic patients. The current modalities available for treating bleeding esophageal and gastric varices, namely endoscopic band ligation and sclerotherapy, require frequent sessions to obtain effective thrombosis and are associated with significant adverse effects. A more effective therapy that results in long-term vascular occlusion has the potential to improve patient outcomes. In this study, we investigated a new potential method for inducing long-term vascular occlusion by targeting segments of a rabbit's auricular vein in vivo with low-duty-cycle, high-peak-rarefaction pressure (9 MPa), pulsed high-intensity focused ultrasound in the presence of intravenously administered ultrasound microbubbles followed by local injection of fibrinogen and a pro-inflammatory agent (ethanol, cyanoacrylate or morrhuate sodium). The novel method introduced in this study resulted in acute and long-term complete vascular occlusions when injecting a pro-inflammatory agent with fibrinogen. Future investigation and translational studies are needed to assess its clinical applicability.


title: Frailty Is Associated With Postoperative Delirium But Not With Postoperative Cognitive Decline in Older Noncardiac Surgery Patients.

text: BACKGROUND Postoperative cognitive dysfunction (POCD) and delirium are the most common perioperative cognitive complications in older adults undergoing surgery. A recent study of cardiac surgery patients suggests that physical frailty is a risk factor for both complications. We sought to examine the relationship between preoperative frailty and postoperative delirium and preoperative frailty and POCD after major noncardiac surgery. METHODS We performed a prospective cohort study of patients >65 years old having major elective noncardiac surgery with general anesthesia. Exclusion criteria were preexisting dementia, inability to consent, cardiac, intracranial, or emergency surgery. Preoperative frailty was determined using the FRAIL scale, a simple questionnaire that categorizes patients as robust, prefrail, or frail. Delirium was assessed with the Confusion Assessment Method for the intensive care unit (CAM-ICU) twice daily, starting in the recovery room until hospital discharge. All patients were assessed with neuropsychological tests (California Verbal Learning Test II, Trail Making Test, subtests from the Wechsler Adult Intelligence Scale, Logical Memory Story A, Immediate and Delayed Recall, Animal and Vegetable verbal fluency, Boston Naming Test, and the Mini-Mental Status Examination) before surgery and at 3 months afterward. RESULTS A total of 178 patients met inclusion criteria; 167 underwent major surgery and 150 were available for follow-up 3 months after surgery. The median age was 70 years old. Thirty-one patients (18.6%) tested as frail, and 72 (43.1%) prefrail before surgery. After adjustment for baseline cognitive score, age, education, surgery duration, American Society of Anesthesiologists (ASA) physical status, type of surgery, and sex, patients who tested frail or prefrail had an estimated 2.7 times the odds of delirium (97.5% confidence interval, 1.0-7.3) when compared to patients who were robust. There was no significant difference between the proportion of POCD between patients who tested as frail, prefrail, or robust. CONCLUSIONS After adjustment for baseline cognition, testing as frail or prefrail with the FRAIL scale is associated with increased odds of postoperative delirium, but not POCD after noncardiac surgery.


title: Contrast-enhanced spectral mammography: comparison with conventional mammography and histopathology in 152 women.

text: OBJECTIVE The goal of the study was to compare conventional mammography (MG) and contrast-enhanced spectral mammography (CESM) in preoperative women. MATERIALS AND METHODS The study was approved by the local Ethics Committee and all participants provided informed consent. The study included 152 consecutive patients with 173 breast lesions diagnosed on MG or CESM. All MG examinations and consults were conducted in one oncology centre. Non-ionic contrast agent, at a total dose of 1.5 mL/kg body weight, was injected intravenous. Subsequently, CESM exams were performed with a mammography device, allowing dual-energy acquisitions. The entire procedure was done within the oncology centre. Images from low and high energy exposures were processed together and the combination provided an "iodine" image which outlined contrast up-take in the breast. RESULTS MG detected 157 lesions in 150 patients, including 92 infiltrating cancers, 12 non-infiltrating cancers, and 53 benign lesions. CESM detected 149 lesions in 128 patients, including 101 infiltrating cancers, 13 non-infiltrating cancers, and 35 benign lesions. CESM sensitivity was 100% (vs. 91% for MG), specificity was 41% (vs. 15% for MG), area under the receiver operating characteristic curve was 0.86 (vs. 0.67 for MG), and accuracy was 80% (vs. 65% for MG) for the diagnosis of breast cancer. Both MG and CESM overestimated lesion sizes compared to histopathology (p < 0.001). CONCLUSION CESM may provide higher sensitivity for breast cancer detection and greater diagnostic accuracy than conventional mammography.


title: Level of Evidence in Facial Plastic Surgery Research: A Procedure-Level Analysis.

text: BACKGROUND As evidence-based medicine has taken hold across medical specialties, the level of evidence within the facial plastic surgery literature has risen, but remains weak in comparison. There has not yet been a systematic, critical appraisal of the relative strength of evidence among subsets of the practice of facial plastic surgery. METHODS The current study is a systematic review, designed to evaluate the level of evidence observed in the facial plastic surgery literature. Five journals were queried using facial plastic surgery terms for four selected years over a 10-year period. Following screening, articles were assigned to a category regarding subject matter, assessed for the presence of various methodological traits, and evaluated for overall level of evidence. Comparisons were made in regard to level of evidence across the breadth of facial plastic surgery subject matter. RESULTS A total of 826 articles were included for final review. Studies on operative facial rejuvenation and rhinoplasty had significantly fewer authors on average than studies on cancer reconstruction or craniofacial topics. Craniofacial studies demonstrated higher levels of evidence relative to all other categories, with the exception of facial paralysis and facial trauma studies, from which there was no significant difference. In general, reconstructive studies had significantly more authors and higher levels of evidence than did articles with an aesthetic focus. CONCLUSION Level of evidence in facial plastic surgery remains relatively weak overall. Reconstructive and particularly craniofacial studies demonstrate higher mean level of evidence, relative to other subsets of facial plastic surgery. LEVEL OF EVIDENCE III 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: A Novel Dual-Phase Activation-Dependent Foot-Switch Mechanism for Surgical Energy Devices as an Asset in Early Surgical Training: A Proof of Concept Study.

text: Introduction. Many processes exist that limit or eliminate the incidence of adverse events in general surgery including the World Health Organization safety checklist. Technology and device advancement has a potentially expanding role in the context of surgical safety. Materials and Methods. A dual controlled accessory electrical diathermy footswitch (Permissive diathermy foot switch device or PDf) device concept was developed in an effort to improve patient safety in theatre and enhance opportunities in training. Electrical diathermy is only activated if the senior supervising surgeon and the novice surgeon simultaneously activate their interconnected footswitches. The activation of the PDf accessory footswitch device allows a senior surgeon to exert control on "initiation" of activation of diathermy devices operated by a novice surgeon (foot on pedal) as well as when desiring to deactivate the device (foot off pedal). Results. A process of designing and prototyping was initiated to define the purpose and the functionality of the PDf device up till the stage of a fully functioning prototype. The PDf device was constructed as a final working and tested prototype in association with the local medical engineering department at the Cumberland Infirmary in Carlisle. The device was on a nonbiological model to determine efficacy and safety and passed its laboratory testing phase and was deemed ready for clinical use. Conclusion. We demonstrated the feasibility and functionality of the PDf device and propose a positive role in surgical training in the context of early surgical training and specific circumstances where more control is needed.


Meaningful Engagement of Older Adults in Long-Term Care: A Call for Action.


title: Lower serum calcium level is associated with hemorrhagic transformation after thrombolysis.

text: BACKGROUND AND PURPOSE We aim to investigate whether lower admission serum calcium levels are associated with hemorrhagic transformation (HT) after intravenous thrombolysis (IVT). METHODS A total of 362 patients treated with IVT was divided into 4 quartiles based on admission serum calcium levels (Q1[<2.16], Q2[2.16, 2.23], Q3[2.24, 2.31], and Q4[>2.31] mmol/L). HT was classified as hemorrhagic infarction and parenchymal hemorrhage. Logistic regression was applied to assess the association between serum calcium levels and the incidence of HT. RESULTS Compared with Q4, HT was more common in Q1 (odds ratio, 2.580; 95% CI, [1.258-5.292]; P=0.010), Q2 (odds ratio, 2.382; 95% CI, [1.163-4.877]; P=0.018), and Q3 (odds ratio, 2.293; 95% CI, [1.133-4.637]; P=0.021). Hemorrhagic infarction was more common in Q1 (P=0.037), and Q2 (P=0.018), compared with Q4, and parenchymal hemorrhage was more common in Q1 (P=0.029) than Q4. CONCLUSIONS Lower admission serum calcium level is independently associated with HT after IVT, and this hypothesis needs larger confirmatory trials.


title: A repeated carpal tunnel syndrome due to tophaceous gout in flexor tendon: A case report.

text: RATIONALE Gouty tophi is a rare cause of CTS. We first report a unique case of repeated CTS with gouty tophi in flexor tendon. In the previous literature, the symptoms cases of CTS were gradually increased. PATIENT CONCERNS We report a 44-year-old male porter presented with mass on his left distal forearm combined a repeated carpal tunnel syndrome for 5 years. He felt numbness in fingers and his left palmar. The CTS symptoms had been eased through rest and dugs medication. It recurred twice. DIAGNOSES Monosodium urate crystal deposits were found in surgery. Histologic findings confirmed the diagnosis of gout. INTERVENTIONS We removed partial of gouty tophus and retained the integrity of the tendon. OUTCOMES Two years after the surgery, the patient had not experienced any symptom recurrence. LESSONS Early diagnosis and control of gout are necessary to avoid irreversible complications. The surgery combined with decreasing trioxypurine treatment can improve the treatment outcome of gouty tophus.


title: Pharmacodynamic Analysis of a Fluid Challenge.

text: OBJECTIVE This study aims to describe the pharmacodynamics of a fluid challenge over a 10-minute period in postoperative patients. DESIGN Prospective observational study. SETTING General and cardiothoracic ICU, tertiary hospital. PATIENTS Twenty-six postoperative patients. INTERVENTION Two hundred and fifty-milliliter fluid challenge performed over 5 minutes. Data were recorded over 10 minutes after the end of fluid infusion MEASUREMENTS AND MAIN RESULTS Cardiac output was measured with a calibrated LiDCOplus (LiDCO, Cambridge, United Kingdom) and Navigator (Applied Physiology, Sydney, Australia) to obtain the Pmsf analogue (Pmsa). Pharmacodynamics outcomes were modeled using a Bayesian inferential approach and Markov chain Monte Carlo estimation methods. Parameter estimates were summarized as the means of their posterior distributions, and their uncertainty was assessed by the 95% credible intervals. Bayesian probabilities for groups' effect were also derived. The predicted maximal effect on cardiac output was observed at 1.2 minutes (95% credible interval, -0.6 to 2.8 min) in responders. The probability that the estimated area under the curve of central venous pressure was smaller in nonresponders was 0.12. (estimated difference, -4.91 mm Hg·min [95% credible interval, -13.45 to 3.3 mm Hg min]). After 10 minutes, there is no evidence of a difference between groups for any hemodynamic variable. CONCLUSIONS The maximal change in cardiac output should be assessed 1 minute after the end of the fluid infusion. The global effect of the fluid challenge on central venous pressure is greater in nonresponders, but not the change observed 10 minutes after the fluid infusion. The effect of a fluid challenge on hemodynamics is dissipated in 10 minutes similarly in both groups.


docid: yntclqsl

title: Microwave ablation therapy: clinical utility in treatment of pulmonary metastases.

text: PURPOSE To prospectively evaluate the safety and efficacy of microwave ablation therapy of unresectable pulmonary metastases. MATERIALS AND METHODS All patients provided informed consent for this prospective institutional review board-approved study. Eighty patients (30 men, 50 women; mean age, 59.7 years ± 6.4; range, 48-68 years) underwent computed tomography-guided percutaneous microwave ablation of pulmonary metastatic lesions in 130 sessions. The tumors represented metastases from colorectal carcinoma, breast carcinoma, hepatocellular carcinoma, renal cell carcinoma, and bronchogenic carcinoma; there was no evidence of extrapulmonary metastasis for any tumor. Logistic regression analysis was used for evaluation of the statistical significance of factors affecting the end result of microwave ablation therapy. The Kaplan-Meier method was used for estimation of survival rates. RESULTS Complete, successful ablation was achieved in 95 (73.1%) of 130 lesions. Successful tumor ablation was significantly more frequent for lesions with a maximal axial diameter of 3 cm or smaller (90 of 110) than for lesions greater than 3 cm in maximal axial diameter (five of 20) (P < .0001) and for peripheral lesions (80 [80%] of 100) than for centrally located lesions (15 [50%] of 30) (P = .002). The histopathologic type of the metastasis did not significantly correlate with the ablation result (P > .3). The 12- and 24-month survival rates were 91.3% and 75%, respectively. There was no intraprocedural death, and the overall 60-day mortality rate after ablation was 0%. Higher survival rates were observed in patients with tumor-free states after successful ablation than in patients with failed ablation (P = .001). The incidence of pneumothorax was 8.5% (11 of 130). An intercostal chest tube was applied in one (0.8%) of the 11 sessions. Pulmonary hemorrhage developed in eight (6.2%) of 130 sessions. CONCLUSION Microwave ablation therapy may be safely and effectively used as a therapeutic tool for treatment of pulmonary metastases. The efficacy of the treatment is primarily determined by preablation tumor size and location in relation to the hilum.


title: Thoracoscopy in the management of congenital lung diseases in infancy.

text: BACKGROUND This study aimed to compare the results of thoracoscopic surgery for congenital lung diseases between infants younger than 6 months and those older than 6 months at the time of surgery in terms of operation duration, surgical complications, chest tube duration, and hospital stay. METHODS The charts of 30 thoracoscopic resections for congenital lung diseases were retrospectively reviewed. This study compared 17 children younger than 6 months (mean, 3.94 months; range, 0.37-5.7 months; group 1) with 13 children older than 6 months (mean, 12.05 months; range, 6.2-24.63 months; group 2) at the time of surgery. The median follow-up period was 9 months (range, 1-41 months). RESULTS Lobectomy was performed in 27 cases, bilobectomy in 1 case, and nonanatomic excision in 2 cases. The mean operating time for group 1 (176±54 min) was similar to that for group 2 (160±46 min). The difference is not significant. The mean duration of chest tube drainage was similar in the two groups (4.4 days; range, 1-9 days for group 1 vs. 4.1 days; range, 3-8 days for group 2). The complications included 1 major and 10 minor complications, with no statistically significant difference between the two groups. Three surgical procedures in each group were converted. The hospital stay was not statistically different between the two groups (8 days; range, 3-20 days for group 1 vs. 6 days; range, 4-10 days for group 2). CONCLUSIONS The study findings showed no statistically significant difference between the two groups in terms of operation time, complication rate, conversion rate, or hospital stay. Lobectomy can be safely and successfully performed by thoracoscopy even for children younger than 6 months.


title: Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses.

text: AIMS The aim of this study was to investigate the relationships between depressive symptoms, burnout and perceptions of patient safety. A mediation model was proposed whereby the association between symptoms of depression and patient safety perceptions was mediated by burnout. BACKGROUND There is growing interest in the relationships between depressive symptoms and burnout in healthcare staff and the safety of patient care. Depressive symptoms are higher in healthcare staff than the general population and overlap conceptually with burnout. However, minimal research has investigated these variables in nurses. Given the conceptual overlap between depressive symptoms and burnout, there is also a need for an explanatory model outlining the relative contributions of these factors to patient safety. DESIGN A cross-sectional questionnaire was distributed at three acute NHS Trusts. METHOD Three-hundred and twenty-three hospital nursing staff completed measures of depressive symptoms, burnout and patient safety perceptions (including measures at the level of the individual and the work area/unit) between December 2015 - February 2016. RESULTS When tested in separate analyses, depressive symptoms and burnout facets were each associated with both patient safety measures. Furthermore, the proposed mediation model was supported, with associations between depressive symptoms and patient safety perceptions fully mediated by burnout. CONCLUSION These results suggest that symptoms of depression and burnout in hospital nurses may have implications for patient safety. However, interventions to improve patient safety may be best targeted at improving burnout in particular, with burnout interventions known to be most effective when focused at both the individual and the organisational level.


docid: ucxuljwr

title: COVID-19, interferons, and depression: A commentary.

text: An option currently being explored for the treatment of COVID-19 is the use of interferons (INFs), either alone or in combination with other antiviral agents. INFs are known to shift the metabolism of tryptophan (TRP) away from its role as a precursor of serotonin. For some patients, reduction in TRP levels may either expose an underlying vulnerability to depression or trigger a de novo episode of depression. This Commentary discusses the pathway involved and recommends in-hospital augmentation with foods or supplements that increase TRP levels for COVID-19 patients treated with INFs. Selective serotonin reuptake inhibitors may also be tried if the depressive symptomatology is not short-lived.


title: Seoul Virus Infection in Humans, France, 2014-2016.

text: We report detection of Seoul virus in 3 patients in France over a 2-year period. These patients accounted for 3 of the 4 Seoul virus infections among 434 hantavirus infections (1.7%) reported during this time. More attention should be given to this virus in Europe where surveillance has been focused mostly on Puumala and Dobrava-Belgrade hantaviruses.


docid: hdvimxzb

title: Flow diverter stent for treatment of cerebral aneurysms: A report of 130 patients with 134 aneurysms.

text: Background This study aims to report our experience with cerebral aneurysms, which may improve in the treatment with the flow-diverter stent and follow up. Methods This study was conducted in a consecutive series of 130 patients. 134 procedures were performed for treating these patients in Hanoi Medical University Hospital and Bach Mai Hospital from January 2012 to April 2017. 143 flow diverter stents (Pipeline, FRED and SILK) were used. Aneurysm morphology, stent patency and cerebral parenchyma before and after intervention were analyzed on images of digital subtraction angiography (DSA), computed tomography (CT) and magnetic resonance (MR). The follow-up data after 3-6 months and 12 months were recorded. Results In 130 patients (31 men, 99 women), aneurysms of internal carotid artery were mostly common (92.6%), especially in cavernous (35.1%) and in para-ophthalmic (40.3%) segments. 83 cases (61.9%) had wide-neck aneurysms, and 16 cases (11.9%) had multiple aneurysms, and only 5 cases (3.7%) had blister-liked aneurysms. Endovascular treatment was successfully performed at rate of 94.8%. In 3 patients, the stent could not be delivered. Mortality and morbidity rates were 1.5% and 3.7%, respectively. MRI and MSCT follow-up at 3 months showed complete or incomplete occlusions of aneurysms was 7.4% or 17.5%, respectively. 3 patients experienced a thromboembolic event (4.3%). Conclusions Intracranial aneurysms of cavernous and para-ophthalmic segments of internal carotid artery are mostly common with wide-neck and multi aneurysms. Deployment of flow diverter stent is safe and effective with high rate of successful and low procedural complications.


title: Co-digestion of food waste in a municipal wastewater treatment plant: Comparison of batch tests and full-scale experiences.

text: The effects of co-digestion of food waste in a municipal wastewater treatment plant (WWTP) were studied in batch tests. The results obtained were compared with the mass balance of a digester at a full-scale WWTP for a one-year period without and with the addition of co-substrate. The specific methane yield calculated from the balance was 18% higher than the one in the batch tests, suggesting a stimulation of methane generation by co-digestion. It was hypothesized that this increase was caused by shifting the C/N ratio of raw sludge (8.8) to a more favourable ratio of the added food waste (17.7). In addition, potential benefits by adding food waste for energy autarky was investigated. While just 25% of the total energy demand of the plant could be recovered by biogas generation when no co-substrate was fed, this percentage has more than doubled when food waste was added at a ratio of 10% (w/w).


title: Use of the ACTH challenge test to identify the predominant glucocorticoid in the southern sea otter (Enhydra lutris nereis).

text: After nearly being hunted to extinction during the fur trade of the late 20th Century, sea otter (Enhydra lutris) populations have recovered to varying degrees of their historical range. While overall population numbers and range have increased, there are regions in which expansion has occurred at a slower rate and/or animal numbers have decreased, which may be a result of chronic stress from a variety of sources. Some have employed glucocorticoid analysis in their attempts to validate these explanations. Our goal was to conduct a controlled study using sea otters managed under human care to validate the use of serum glucocorticoid analysis to monitor stress physiology in the sea otter. We used a standard ACTH challenge test to compare cortisol and corticosterone responses, thereby identifying the primary glucocorticoid in the sea otter. Fourteen sea otters of both sexes (five males, nine females), including juveniles, sub-adults and adults, participated in the study. The results of the testing supported cortisol as the primary glucocorticoid in the sea otter. Sex and age did not affect how the individual responded to the ACTH or saline injection. Interestingly, the saline injection not only confirmed the effects of the ACTH on glucocorticoid release from the adrenal glands but also provided information on how long it takes the sea otter's glucocorticoid levels to return to baseline after capture and sedation. The insight gained from this study will aid in future efforts to better understand the role of stress in free-ranging sea otter populations. Recognition of the primary glucocorticoid will facilitate evaluation of more stable biological material, such as fur or whiskers, which tend to be less affected by the diurnal cycling of glucocorticoids.


Annals On Call - Disparities and COVID-19.


title: Impact to spinal cord stimulator lead integrity with direct suture loop ties.

text: BACKGROUND Lead migration of spinal cord stimulators (SCS) is a significant problem, and experience suggests that anchoring sutures directly around the SCS lead may reduce migration. Such practices have been limited by concerns about potential damage to the lead and impairment of performance. OBJECTIVE This study sought to determine the extent of overt damage following maximal tension from tying sutures directly around SCS leads. DESIGN Twenty-eight SCS leads were prospectively exposed to 56 suture knots that were tightened under controlled conditions to the suture's breaking point. OUTCOME MEASURES Lead damage was evaluated by high power microscopy and assessment of lead impedance. RESULTS None of the leads had evidence of substantial physical damage or electrical impairment. CONCLUSIONS This small study suggests that anchoring directly to the lead appears to produce minimal damage, but these preliminary data must be confirmed and expanded.


docid: gdjmhjkb

title: The sheeping technique or how to avoid exchange maneuvers.

text: INTRODUCTION The arteries of bifurcation aneurysms are sometimes so angulated or tortuous that an exchange maneuver is necessary to catheterize them with a balloon or stent delivery catheter. Because of the risk of distal wire perforation associated with exchange maneuvers, we sought to find an alternative technique. METHODS Our experience shows that a microcatheter tends to preferentially follow a previously placed microcatheter, even if the initial catheterization might be challenging. Accessing an artery with two microcatheters simultaneously may thus be an alternative to an exchange maneuver. Because of this tendency for catheters to behave like sheep following one another, we named this method the sheeping technique (ST). The ST consists of (a) first placing a 1.7 French microcatheter into the division branch requiring balloon or stent protection to straighten the course of the arteries in order to facilitate and (b) positioning in the same artery of a larger and stiffer balloon or stent microcatheter. Once the second balloon or stent microcatheter is in place, the first microcatheter can be pulled back and used to coil the aneurysm. RESULTS Between January 2009 and December 2012, The ST was successfully used in 208/246 procedures (85%). Conversion to an exchange maneuver was necessary in 38/246 (15%). There were no arterial perforations or ischemic events related to the handling of both microcatheters. CONCLUSION The sheeping technique may improve safety by replacing the need for an exchange maneuver during difficult balloon- or stent-assisted coiling.


The Island.


title: Multidisciplinary treatment of T1a adenocarcinoma in Barrett's esophagus: contemporary comparison of endoscopic and surgical treatment in physiologically fit patients.

text: BACKGROUND Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC). METHODS Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed. RESULTS Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable. CONCLUSION In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.


Covid-19 and air pollution: communicating the results of geographic correlation studies.


title: Outcomes and predictors of mortality and stoma formation in surgical management of colonoscopic perforations: a multicenter review.

text: OBJECTIVES To perform a retrospective review of all patients with colonoscopic perforations managed in hospitals within the Eastern New Territories region of Hong Kong and to determine the predictors of mortality and stoma formation in patients with colonoscopic perforations. DESIGN Retrospective computer-based review. SETTING Multicenter (1 university teaching hospital and 2 district hospitals). METHODS We reviewed the outcomes of patients with colonoscopic perforations surgically managed between January 1, 1998, and December 31, 2005. Predictors of mortality and stoma formation were identified with multivariable analysis. MAIN OUTCOME MEASURES Mortality and stoma rates and their predictors. RESULTS A total of 37,971 colonoscopies were performed during the study period, and 43 colonoscopic perforations were identified. The overall perforation rate was 0.113% and represented a decreasing trend. There was no significant difference in the perforation rate between gastroenterologists (0.148%) and surgeons (0.091%) (P = .15). Perforations that occurred during diagnostic colonoscopies were significantly larger than those that occurred during therapeutic colonoscopies (P = .04), and the patients presented earlier (P = .02). Surgical intervention was performed in 39 patients. The overall morbidity and mortality rate was 48.7% and 25.6%, respectively. The stoma rate was 38.5%. The predictors of stoma formation include moderate to severe peritoneal contamination and the presence of malignant colonic neoplasms (P = .01 and P = .008, respectively). The predictors of mortality include American Society of Anesthesiologists class 3 or higher and antiplatelet therapy (P = .009 and P = .001, respectively). CONCLUSIONS Colonoscopic perforations were in a decreasing trend. Patients with predictors of mortality should not be treated conservatively. Other options of large bowel investigations should be considered in high-risk patients when the potential diagnostic yield is low.


docid: bydmccjp

title: Could vets manage Covid-19 better?


title: To Protect Health Care Workers Better, To Save More Lives With COVID-19

text: The Coronavirus Disease 2019 (COVID-19) pandemic has thus far caused a total of 81,747 confirmed cases with 3283 deaths in China and more than 370,000 confirmed cases including over 16,000 deaths around the world by March 24, 2020. This issue has received extensive attention from the international community and has become a major public health priority. As the pandemic progresses, it is regrettable to know the health care workers, including anesthesiologists, are being infected constantly. Therefore, we would like to share our firsthand practical experience and perspective in China, focusing on the personal protection of health care workers and the risk factors related to their infection, based on the different stages of the COVID-19 epidemic in China.


title: [Non-pharmacological prevention of ventilator-associated pneumonia].

text: Ventilator-associated pneumonia (VAP) is the first cause of mortality due to nosocomial infections in the intensive care unit. Its incidence ranges from 9% to 67% of patients on mechanical ventilation. Risk factors are multiple and are associated with prolonged stays in hospital and intensive care units. Additional costs for each episode of VAP range from 9,000 euro to 31,000 euro. Thus, its prevention should be considered as a priority. This prevention could decrease associated morbidity, mortality, costs, and increase patient safety.


Outcomes of the Seventh International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion and Second Annual Meeting of the International Society for Pediatric Mechanical Cardiopulmonary Support.


title: Fluorescent Inhibitors as Tools To Characterize Enzymes: Case Study of the Lipid Kinase Phosphatidylinositol 4-Kinase IIIβ (PI4KB).

text: The lipid kinase phosphatidylinositol 4-kinase IIIβ (PI4KB) is an essential host factor for many positive-sense single-stranded RNA (+RNA) viruses including human pathogens hepatitis C virus (HCV), Severe acute respiratory syndrome (SARS), coxsackie viruses, and rhinoviruses. Inhibitors of PI4KB are considered to be potential broad-spectrum virostatics, and it is therefore critical to develop a biochemical understanding of the kinase. Here, we present highly potent and selective fluorescent inhibitors that we show to be useful chemical biology tools especially in determination of dissociation constants. Moreover, we show that the coumarin-labeled inhibitor can be used to image PI4KB in cells using fluorescence-lifetime imaging microscopy (FLIM) microscopy.


title: Cordless ultrasonic dissector versus advanced bipolar vessel sealing device for laparoscopic ovariectomy in dogs.

text: OBJECTIVE To compare Sonicision cordless ultrasonic dissector (SCUD) to LigaSure vessel sealing device (LVSD) for laparoscopic ovariectomy (Lap OVE) in dogs. STUDY DESIGN Randomized, paired prospective clinical trial. ANIMALS Client-owned dogs (n = 22) presented for elective Lap OVE. METHODS Dogs were randomly assigned to one of two protocols: protocol 1 required the left ovary resected using SCUD and the right ovary using LVSD; protocol 2 required the left ovary resected using LVSD and the right ovary using SCUD. Duration of ovary excision, complications, surgical smoke production, and collateral thermal damage were compared between SCUD and LVSD. Total surgery duration, postoperative convalescence, obesity, mesovarial fat score, and technique-associated costs were also recorded. RESULTS Ovary excision was significantly faster with LVSD than SCUD. Surgical smoke production was significantly greater for SCUD than LVSD. Minor pedicle hemorrhage occurred 3 times with SCUD and one time with LVSD (not significantly different) and was easily corrected intraoperative. Presence of hemorrhage significantly increased ovary excision time. Technique-associated costs were lower for SCUD than LVSD. No significant differences were found in collateral thermal damage between SCUD and LVSD. Total surgery duration and convalescence time were similar to previous reports of Lap OVE in dogs at the authors' institution. CONCLUSIONS SCUD is a cost-effective alternative for Lap OVE, taking into account differences in technique and user preference.


title: Outcomes of manual aspiration thrombectomy for acute ischemic stroke refractory to stent-based thrombectomy.

text: BACKGROUND AND PURPOSE The optimal treatment for patients with acute stroke refractory to stent-based thrombectomy (SBT) is unclear. This study aimed to report clinical outcomes of manual aspiration thrombectomy (MAT) for the treatment of acute ischemic stroke refractory to SBT. METHODS We retrospectively analyzed clinical and angiographic data of 30 patients who underwent MAT with a Penumbra reperfusion catheter because of refractory occlusion after SBT with a Solitaire stent as first-line endovascular therapy. Refractory occlusion was defined by a lack of successful revascularization (defined as Thrombolysis In Cerebral Infarction ≥2b) after five retrieval attempts. A good outcome was defined as a modified Rankin scale score of ≤2 at 3 months. RESULTS Successful revascularization was achieved in 83.3% (25/30) of the patients who underwent MAT after failed SBT. There was no arterial rupture or dissection or symptomatic intracranial hemorrhage. Two embolic occlusions in a new arterial territory and five subarachnoid hemorrhages occurred, neither of which caused neurological worsening. At the 3-month follow-up, 36.7% (11/30) of patients exhibited a good outcome. The mortality rate was 6.7% (2/30) at 3 months. CONCLUSIONS This study suggests that MAT with the Penumbra reperfusion catheter can further increase the revascularization rate without serious complications in patients with acute stroke with refractory occlusions after SBT with a Solitaire stent.


title: Dynamic physostigmine effects on hippocampus perfusion.

text: PURPOSE To characterize the dynamic response of hippocampus blood flow to physostigmine infusion and to determine an infusion duration sufficiently long for robust detection of effects with arterial spin labeling (ASL) and sufficiently short to avoid peripheral side effects of physostigmine. MATERIALS AND METHODS Two female (49 ± 15 years) and nine male (53 ± 13 years) subjects were studied to determine the time course of the physostigmine effect on hippocampus blood flow with ASL perfusion imaging during 20 minutes of baseline, 30 minutes of physostigmine infusion at 1.0 mg/hr, and 70 minutes of recovery. RESULTS Hippocampus perfusion decreased steadily over the course of the infusion, with the reduction in flow becoming significant after 20 minutes of infusion, reaching lowest levels near the end of infusion, and remaining significantly low and stable in the 70-minute recovery period. Percentage changes of hippocampus perfusion were -13.3%, -13.4%, and -13.4% for left, right, and bilateral hippocampus, respectively, at the end of infusion. CONCLUSION At a dose rate of 1.0 mg/hr it is feasible to use an infusion time as short as 20 minutes, performing perfusion imaging up to an hour after physostigmine infusion is discontinued, to minimize chances for adverse side effects.


title: Structure, space and size: competing drivers of variation in urban and rural measles transmission.

text: A key concern in public health is whether disparities exist between urban and rural areas. One dimension of potential variation is the transmission of infectious diseases. In addition to potential differences between urban and rural local dynamics, the question of whether urban and rural areas participate equally in national dynamics remains unanswered. Specifically, urban and rural areas may diverge in local transmission as well as spatial connectivity, and thus risk for receiving imported cases. Finally, the potential confounding relationship of spatial proximity with size and urban/rural district type has not been addressed by previous research. It is rare to have sufficient data to explore these questions thoroughly. We use exhaustive weekly case reports of measles in 954 urban and 468 rural districts of the UK (1944-1965) to compare both local disease dynamics as well as regional transmission. We employ the time-series susceptible-infected-recovered model to estimate disease transmission, epidemic severity, seasonality and import dependence. Congruent with past results, we observe a clear dependence on population size for the majority of these measures. We use a matched-pair strategy to compare proximate urban and rural districts and control for possible spatial confounders. This analytical strategy reveals a modest difference between urban and rural areas. Rural areas tend to be characterized by more frequent, smaller outbreaks compared to urban counterparts. The magnitude of the difference is slight and the results primarily reinforce the importance of population size, both in terms of local and regional transmission. In sum, urban and rural areas demonstrate remarkable epidemiological similarity in this recent UK context.


A COVID-19 Rapid-Response Research Agenda.


title: Control of massive hemoptysis via a "back-door" approach through the pulmonary artery.

text: Bronchial artery embolization is an effective nonsurgical therapy for massive hemoptysis. Routine selection of the bronchial arteries from the aorta usually enables the interventionalist full interrogation and embolization of the culprit vascular abnormality. In problematic cases where bronchial artery access is difficult, a systemic-to-pulmonary arterial shunt can be exploited as a retrograde means of vascular intervention. A case is presented where inaccessibility of a tortuous left bronchial artery was circumvented by accessing the left pulmonary artery, leading to successful embolization and control of hemoptysis.


title: Efficacy of intravenous ketamine treatment in anxious versus nonanxious unipolar treatment-resistant depression.

text: OBJECTIVE To examine the effect of high baseline anxiety on response to ketamine versus midazolam (active placebo) in treatment-resistant depression (TRD). METHODS In a multisite, double-blind, placebo-controlled trial, 99 subjects with TRD were randomized to one of five arms: a single dose of intravenous ketamine 0.1, 0.2, 0.5, 1.0 mg/kg, or midazolam 0.045 mg/kg. The primary outcome measure was change in the six-item Hamilton Rating Scale for Depression (HAMD6). A linear mixed effects model was used to examine the effect of anxious depression baseline status (defined by a Hamilton Depression Rating Scale Anxiety-Somatization score ≥7) on response to ketamine versus midazolam at 1 and 3 days postinfusion. RESULTS N = 45 subjects had anxious TRD, compared to N = 54 subjects without high anxiety at baseline. No statistically significant interaction effect was found between treatment group assignment (combined ketamine treatment groups versus midazolam) and anxious/nonanxious status on HAMD6 score at either days 1 or 3 postinfusion (Day 1: F(1, 84) = 0.02, P = 0.88; Day 3: F(1, 82) = 0.12, P = 0.73). CONCLUSION In contrast with what is observed with traditional antidepressants, response to ketamine may be similar in both anxious and nonanxious TRD subjects. These pilot results suggest the potential utility of ketamine in the treatment of anxious TRD.


title: An electroencephalographic signature predicts antidepressant response in major depression.

text: Antidepressants are widely prescribed, but their efficacy relative to placebo is modest, in part because the clinical diagnosis of major depression encompasses biologically heterogeneous conditions. Here, we sought to identify a neurobiological signature of response to antidepressant treatment as compared to placebo. We designed a latent-space machine-learning algorithm tailored for resting-state electroencephalography (EEG) and applied it to data from the largest imaging-coupled, placebo-controlled antidepressant study (n = 309). Symptom improvement was robustly predicted in a manner both specific for the antidepressant sertraline (versus placebo) and generalizable across different study sites and EEG equipment. This sertraline-predictive EEG signature generalized to two depression samples, wherein it reflected general antidepressant medication responsivity and related differentially to a repetitive transcranial magnetic stimulation treatment outcome. Furthermore, we found that the sertraline resting-state EEG signature indexed prefrontal neural responsivity, as measured by concurrent transcranial magnetic stimulation and EEG. Our findings advance the neurobiological understanding of antidepressant treatment through an EEG-tailored computational model and provide a clinical avenue for personalized treatment of depression.


title: MiR-210-3p Inhibits Proliferation and Migration of C6 Cells by Targeting Iscu.

text: Glioma is the most common primary brain tumor and the most malignant type of glioma is glioblastoma with the character of high mortality, high recurrence rate and poor prognosis. MicroRNAs act as an important component in glioma development and thus may be a potential target for the treatment of glioma. There were some researches indicated that miR-210-3p played a role in glioma development, but if it can inhibit glioma growth, as well as the underlying mechanism, is still uncertain. In the present study, we investigated the effects of miR-210-3p and its potential target gene Iscu on glioma (C6) cells proliferation and migration in vitro as well as the influence of miR-210-3p on glioma growth in vivo. The results showed that miR-210-3p inhibited the proliferation and migration of C6 cells by regulating the expression of its target gene Iscu in vitro. We also demonstrated that glioma growth was suppressed in immunodeficient mice when they were implanted with C6 cells overexpressing miR-210-3p. Our data indicated that miR-210-3p played an important role in the prevention of glioma growth by targeting Iscu and so miR-210-3p/Iscu axis might be a potential target for the treatment of glioma.


title: BEHRT: Transformer for Electronic Health Records.

text: Today, despite decades of developments in medicine and the growing interest in precision healthcare, vast majority of diagnoses happen once patients begin to show noticeable signs of illness. Early indication and detection of diseases, however, can provide patients and carers with the chance of early intervention, better disease management, and efficient allocation of healthcare resources. The latest developments in machine learning (including deep learning) provides a great opportunity to address this unmet need. In this study, we introduce BEHRT: A deep neural sequence transduction model for electronic health records (EHR), capable of simultaneously predicting the likelihood of 301 conditions in one's future visits. When trained and evaluated on the data from nearly 1.6 million individuals, BEHRT shows a striking improvement of 8.0-13.2% (in terms of average precision scores for different tasks), over the existing state-of-the-art deep EHR models. In addition to its scalability and superior accuracy, BEHRT enables personalised interpretation of its predictions; its flexible architecture enables it to incorporate multiple heterogeneous concepts (e.g., diagnosis, medication, measurements, and more) to further improve the accuracy of its predictions; its (pre-)training results in disease and patient representations can be useful for future studies (i.e., transfer learning).


title: Self-care of medical staff in primary care: An issue that needs attention during the COVID-19 outbreak.

text: Self-care is essential for primary care professionals who are at risk of COVID-19.


title: Evaluation of Patient's Perceptions, Healing, and Reattachment After Conventional and Diode Laser Frenectomy: A Three-Arm Randomized Clinical Trial.

text: Objective: The aim of this study is to compare the conventional and diode laser techniques in terms of patient's perceptions, epithelization, reattachment, and periodontal clinical parameters in the treatment of abnormal papillary frenum. Materials and methods: Forty-eight patients with abnormal papillary frenum were enrolled in the study. Patients were randomly assigned into three groups; conventional frenectomy operation (C group), diode laser-assisted frenectomy (L group), and diode laser-assisted frenectomy with conventional horizontal incision on the periosteum (L + P group). Post-operative pain, discomfort in speaking, and chewing scores were assessed with visual analogue scale (VAS) at post-operative 3rd hour and on days 1, 7, 14, 21, and 45. Epithelialization process of the wound surface was evaluated by hydrogen peroxide solution applied to the wound on days 7, 14, 21, and 45 following operations. The distance between the frenum attachment point and mucogingival junction (FMGJ) was recorded at baseline, post-operative 45th day, and 6th month to assess the reattachment of the frenum. Plaque index, gingival index, bleeding on probing, and probing depth were recorded at baseline and post-operative 7th, 14th, 21st, and 45th days. Results: On the 1st and 7th day after operation, VAS pain score in the C group was significantly higher than in the L and L + P groups (p < 0.017). Difficulty in speaking and chewing scores were significantly lower in the L and L + P groups compared to the C group at post-operative 3rd hour and 7th day (p < 0.017). The FMGJ and epithelization period demonstrated no difference among the groups at any time point (p > 0.05). Conclusions: Our results suggest that diode laser provides better post-operative patient's perceptions than the conventional technique in frenectomy operation. In addition, both conventional and laser-assisted frenectomy surgeries prevent the frenum reattachment regardless of periosteal horizontal incision.


title: The Lateral Antebrachial Neurocutaneous Flap: A Cadaveric Study and Clinical Applications.

text: BACKGROUND The neurocutaneous flap is an axial pattern flap that receives a vascular supply from a vessel along its cutaneous nerve and has favorable outcomes when used for soft tissue reconstruction in the upper extremities. The neurocutaneous flap depends on the lateral antebrachial cutaneous nerve (LACN) and its retrograde-flow has been studied via cadaveric dissection. The aim of this study is to prove the vascularity of the lateral antebrachial neurocutaneous (LABN) flap. METHODS The distally based LABN flap was created in 18 upper limbs (12 cadavers). The skin flap was dissected at the proximal half of the forearm and then diluted methylene blue was injected through the brachial artery. The pedicle of the flap on the distal half of the forearm was dissected along the LACN for the anatomical study of the perforating branches, paraneural vessels, and flap territory. RESULTS The mean age of cadavers was 74.1 years (nine males). The mean distance of most distal and proximal perforating branches from the radial styloid process were 2.32 ± 0.59 and 11.17 ± 1.72 cm, respectively. The mean total number of perforating branches was 7.4, which abundantly appeared approximately 4 to 5 cm from the radial styloid process. The mean flap territory was 8.64 ± 0.82 cm in width and 10.50 ± 1.90 cm in length. The mean forearm circumference was 24.84 ± 1.52 cm, and mean forearm length was 24.74 ± 1.8 cm. CONCLUSION This study ensured that retrograde-flow via the neurocutaneous artery could be provided through the vascularity of the LABN flap, which suggests that the pivot point of the flap should not extend beyond 5 cm proximal to the radial styloid process. The LABN flap is a useful alternative method for performing soft tissue reconstruction in hand and wrist defects without sacrificing the major vessels.


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title: Hospital Pharmacy Service: Facing the logistics of medicines procurement.

text: COVID crisis has abruptly broken into our hospitals, and many difficulties have emerged, including those related to supply logistics. A huge number of new patients, a fast internal reorganization process and many other changes were suddenly established. These circumstances revealed the need to increase stocks of drugs, both for basic treatment as well as for specific SARS-CoV-2 infection management. At the same time, other problems (shortages, new and complex purchasing procedures, etc.) surfaced, so they could risk safety along the pharmacotherapeutic process. The main objective was to develop and implement all the necessary measures within the logistics circuit in order to ensure the availability of medicines for patients, as safely and effectively as possible, during the Coronavirus crisis. Firstly, two pharmacists were appointed to coordinate the whole process, and a preliminary analysis of the following aspects was carried out an estimation of needs to make an initial drug provisioning, a storage feasibility study and a global analysis of the logistics process to detect critical points. Three different circuits for medicines supply were established as some drugs were operated by Agencia Española de Medicamentos y Productos Sanitarios (AEMPS) or Servicio Madrileño de Salud (SERMAS), and others were under no restrictions. For stocks control, inventory was frequently reviewed and monitoring of prescription trends was implemented. For all new medicinal products, compliance with security standards was reviewed and relabeling was carried out if necessary. Criteria were defined for the storage of overstocks and it was placed an isolated area for quarantined drugs. Shortages inevitably occurred but their effects were partly mitigated by AEMPS and SERMAS. After all, we consider that the implemented procedure for logistics management may be reproducible, and the key points we have identified are the following: to enhance our quality management system, to develop an Action Plan for Healthcare Emergencies and to ensure the adequate training for all pharmacy staff. Furthermore, we also should address other aspects: to establish storage optimization strategies, to focus on a more advanced logistics management model, as well as to take advantage of the extraordinary multidisciplinary network, which has been consolidated during this COVID pandemic.


title: Prevention and diminished expression of experimental autoimmune encephalomyelitis by low dose naltrexone (LDN) or opioid growth factor (OGF) for an extended period: Therapeutic implications for multiple sclerosis.

text: Endogenous opioids inhibit the onset and progression of experimental autoimmune encephalomyelitis (EAE) with 30days of treatment. This study examined the long term effects of the opioid growth factor (OGF, [Met(5)]-enkephalin) and a low dose of the opioid antagonist naltrexone (LDN) on expression of myelin oligodendrocyte glycoprotein (MOG)-induced EAE. C57BL/6 mice began receiving daily injections of 10mg/kg OGF (MOG+OGF), 0.1mg/kg naltrexone (MOG+LDN), or saline (MOG+Vehicle) at the time of EAE induction and continuing for 60days. In contrast to 100% of the MOG+Vehicle group with behavioral symptoms of EAE, 63% and 68% of the MOG+OGF and MOG+LDN mice expressed disease. Both severity and disease indices of EAE in OGF- and LDN-treated mice were notably decreased from MOG+Vehicle cohorts. By day 60, 6- and 3-fold more animals in the MOG+OGF and MOG+LDN groups, respectively, had a remission compared to MOG+Vehicle mice. Neuropathological studies revealed i) astrocyte activation and neuronal damage as early as day 10 (prior to behavioral symptoms) in all MOG-injected groups, ii) a significant reduction of activated astrocytes in MOG+OGF and MOG+LDN groups compared to MOG+Vehicle mice at day 30, and iii) no demyelination on day 60 in mice treated with OGF or LDN and not displaying disease symptoms. These results indicate that treatment with OGF or LDN had no deleterious long-term repercussions and did not exacerbate EAE, but i) halted progression of disease, ii) reversed neurological deficits, and iii) prevented the onset of neurological dysfunction across a considerable span of time.


title: Comparison of speed of inhalational induction in children with and without congenital heart disease.

text: BACKGROUND Conduct of stable inhalational anesthetic induction in children with congenital heart disease (CHD) presents special challenges. It requires in-depth understanding of the effect of congenital shunt lesions on the uptake, delivery, and equilibration of anesthetic drugs. Intracardiac shunts can alter the induction time and if delivery of anesthetic agent is not carefully titrated, can lead to overdosing and undesirable myocardial depression. AIMS To study the effect of congenital shunt lesions on the speed of inhalational induction and also the impact of inhalational induction on hemodynamics in the presence of congenital shunt lesions. SETTING Tertiary care hospital. DESIGN A prospective, single-center clinical study. MATERIALS AND METHODS Ninety-three pediatric patients undergoing elective surgery were segregated into three equal groups, namely, Group 1: no CHD, Group 2: acyanotic CHD, and Group 3: cyanotic CHD. General anesthesia was induced with 8% sevoflurane in 6 L/min air-oxygen. The time to induction was noted at loss of eyelash reflex and decrease in bispectral index (BIS) value below 60. End-tidal sevoflurane concentration, minimum alveolar concentration, and BIS were recorded at 15 s intervals for the 1 st min followed by 30 s interval for another 1 min during induction. Hemodynamic data were recorded before and after induction. RESULTS Patients in Group 3 had significantly prolonged induction time (99 ± 12.3 s; P < 0.001), almost twice that of the patients in other two groups (51 ± 11.3 s in Group 1 and 53 ± 12.0 s in Group 2). Hypotension occurred after induction in Group 1. No other adverse hemodynamic perturbations were observed. CONCLUSION The time to inhalational induction of anesthesia is significantly prolonged in patients with right-to-left shunt, compared to patients without CHD or those with left-to-right shunt, in whom it is similar. Sevoflurane is safe and maintains stable hemodynamics in the presence of CHD.


Patient´s perspective: psychological burden of the COVID-19 pandemic in 146 psoriatic patients treated with biological drugs and small molecules in real clinical practice.