title: Ventilatory support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference.

text: OBJECTIVE To describe the recommendations of the Pediatric Acute Lung Injury Consensus Conference for mechanical ventilation management of pediatric patients with acute respiratory distress syndrome. DESIGN Consensus Conference of experts in pediatric acute lung injury. METHODS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 27 recommendations focused on the optimal mechanical ventilation approach of the patient with pediatric acute respiratory distress syndrome. Topics included ventilator mode, tidal volume delivery, inspiratory plateau pressure, high-frequency ventilation, cuffed endotracheal tubes, and gas exchange goals. When experimental data were lacking, a modified Delphi approach emphasizing the strong professional agreement was used. RESULTS There were 17 recommendations with strong agreement and 10 recommendations with weak agreement. There were no recommendations with equipoise or disagreement. There was weak agreement on recommendations concerning approach to tidal volume and inspiratory pressure limitation (88% to 72% agreement, respectively), whereas strong agreement could be achieved for accepting permissive hypercapnia. Using positive end-expiratory pressure levels greater than 15 cm H2O in severe pediatric acute respiratory distress syndrome, under the condition that the markers of oxygen delivery, respiratory system compliance, and hemodynamics are closely monitored as positive end-expiratory pressure is increased, is strongly recommended. The concept of exploring the effects of careful recruitment maneuvers during conventional ventilation met an agreement level of 88%, whereas the use of recruitment maneuvers during rescue high-frequency oscillatory ventilation is highly recommended (strong agreement). CONCLUSIONS The Consensus Conference developed pediatric-specific recommendations regarding mechanical ventilation of the patient with pediatric acute respiratory distress syndrome as well as future research priorities. These recommendations are intended to initiate discussion regarding optimal mechanical ventilation management for children with pediatric acute respiratory distress syndrome and identify areas of controversy requiring further investigation.


title: The seroprevalence of canine respiratory coronavirus and canine influenza virus in dogs in New Zealand.

text: AIM To determine whether canine respiratory coronavirus (CRCoV) and canine influenza virus (CIV) are present in dogs in New Zealand. METHODS Serum samples from 251 dogs of varying age, breed and clinical histories were tested for the presence of antibodies to CRCoV and CIV, using indirect fluorescent antibody (IFA) analysis. The population sampled represented a wide geographic area but principally encompassed the central and lower North Island of New Zealand. RESULTS Seventy-three of the 251 samples (29%) were seropositive for CRCoV. Dogs <2 years old were less likely to be seropositive for CRCoV than older dogs. None was seropositive for CIV. CONCLUSIONS This study revealed the presence of antibodies to CRCoV in dogs in New Zealand. Young dogs are less likely to be seropositive than older dogs, probably due to increased opportunity for exposure to CRCoV over time. Serum antibodies to CIV were not detected in any of the dogs sampled, suggesting that this virus is unlikely to be present in dogs in New Zealand. CLINICAL RELEVENCE: Canine respiratory coronavirus is present in New Zealand. Although the role of this virus in canine infectious tracheobronchitis has not been fully elucidated, evidence suggests that it may have a causal role in this disease. Veterinarians should consider CRCoV as a differential diagnosis in cases of respiratory disease in dogs in New Zealand. While CIV appears not to be currently present in New Zealand, veterinarians should consider infection with this virus as a differential diagnosis in dogs presenting with respiratory signs.


title: A Patient with COVID-19 Disease in a Referral Hospital in Iran: A Typical Case.

text: After the initial Wuhan outbreak in the end of December 2019, many new cases were found in other provinces of China and also many other countries over the world, including South Korea, Italy, Iran, Japan, and 68 other countries. We presented a 61-year-old woman with a history of diabetes mellitus was referred to the emergency department of a referral hospital in Tehran, Iran. The patient presented with fever, chills, and myalgia within three days. Laboratory analysis showed increased levels of erythrocyte sedimentation rate (ESR), and mild leukopenia. SARSCoV-2 PCR test -under Iran Ministry of Health and Medical Education (MoH&ME) guidelines - result was positive and the chest X-ray shows bilateral ground glass opacity. O2 saturation was 87% (without O2 therapy). The patient was hospitalized and treated with Oseltamivir 75 mg every 12 hours, Lopinavir/Ritonavir (Kaletra) 400/100 mg every 12 hours and hydroxychloroquine 400 mg stat. The patient last O2 saturation measured was 93% and had no fever in the 10th day of hospitalization. So she has been discharged from hospital and homeisolated according to Iran Ministry of Health protocol.


title: Using open-source intelligence to detect early signals of COVID-19 in China, Descriptive study.

text: BACKGROUND COVID-19 in China was first reported to the World Health Organization on December 31st 2019. The first cases were officially identified around December 8th 2019. The origin of COVID-19 is not confirmed, but half the early cases were linked to a seafood market in Wuhan. The first two documented cases did not attend the seafood market. News reports, social media and informal sources may contain information about outbreaks prior to formal notification. OBJECTIVE To identify early signals of pneumonia and/or severe acute respiratory illness (SARI) in China, prior to official recognition of the COVID 19 outbreak in December 2019, using open source data. METHODS In order to capture early reports we searched an open source epidemic observatory, Epiwatch from 1st October2019 in China, for severe acute respiratory illness (SARI) or pneumonia related illnesses. Google and Chinese search engine Baidu were used. RESULTS There was an increase in reports following the official notification of COVID 19 to WHO on December 31 2019, and a retracted report on December 26th 2019. A report of severe pneumonia was identified on November 22 2019 in Xiangyang, Index patient was retrospectively identified on 17 November. CONCLUSIONS The lack of reports of a SARI outbreaks prior to December 31st, with a retracted report on December 26th suggests media censorship, given formal reports that cases began on December 8th. However, the findings also support relatively recent origin of COVID-19 in November 2019. The case reported on November 22nd was transferred to Wuhan approximately 1 incubation period before the first reported cases on December 8th, and should be further investigated, as only half of the early cases had exposure to the seafood market. It has since been reported that another case of COVID 19 has been retrospectively identified in Hubei on November 17th, confirming that the infection was present prior to December. CLINICALTRIAL


title: Textually mediated discourses in Canadian news stories: Situating nurses' salaries as the problem.

text: The aim of this article is to elucidate how nurses are positioned in Canadian news stories regarding their salaries. While the image of nursing in mass media has been widely studied, few studies explore how nurses are constructed in news stories. Drawing on ideas from institutional ethnography together with discourse analysis, this discussion highlights public textual discourses about nurses' salaries in Canadian news stories. The media discourse was found to distort the issues by focusing attention on nurses. Recognizing how these textual distortions mediate and construct messages is important in understanding how nurses and their work are constructed in the media. This discussion seeks to inform readers about how nurses are situated within commonly circulated discourses in the media. It also seeks to contribute to the literature about the nurse's image and how nurses and their work are portrayed in the public realm. It concludes by recommending increased awareness about how nurses are talked about in mass communication and the need to disrupt these messages and their underlying assumptions.


title: Outcomes of Endovascular Thrombectomy Performed 6-24 h after Acute Stroke from Extracranial Internal Carotid Artery Occlusion.

text: Thrombectomy has demonstrated clinical efficacy against acute ischemic stroke caused by intracranial occlusion of the internal carotid artery (ICA), even if performed 6-24 h after onset. This study investigated the outcomes of thrombectomy performed 6-24 h after stroke onset caused by extracranial ICA occlusion. Of 586 stroke patients receiving thrombectomy during the past 3 years and registered in the Tama Registry of Acute Endovascular Thrombectomy database, 24 were identified with ICA occlusion (14 extracranial and 10 intracranial), known to be well 6-24 h before presentation, and with pre-stroke modified Rankin Scale (mRS) score of 0 or 1. Clinical outcomes measured were the rate of functional independence at 90 days according to mRS score of 0-2 and 90 day mortality rate. Of patients with extracranial ICA occlusion, two received additional carotid stenting with thrombectomy. The median interval between the last time the patient was known to be well and hospital arrival was 601 (interquartile range, 476-729 min). Both the rate of functional independence at 90 days and 90 day mortality were comparable between patients with extracranial or intracranial ICA occlusion (36% vs. 40% and 7% vs. 10%, respectively). No symptomatic intracranial hemorrhages occurred within 24 h following treatment of extracranial ICA occlusion. Thrombectomy performed 6-24 h after extracranial ICA results in acceptable functional outcome. Further clinical study is warranted to better define the temporal window of thrombectomy for acceptable functional outcome in patients with extracranial ICA occlusion.


Noninvasive hemodynamic monitoring: can we have it all?


title: Detection and management of dyspnea in mechanically ventilated patients.

text: PURPOSE OF REVIEW In ICU patients, dyspnea is one of the most prominent and distressing symptom. We sought to summarize current data on the prevalence and prognostic influence of dyspnea in the ICU setting and to provide concise and useful information for dyspnea detection and management. RECENT FINDINGS As opposed to pain, dyspnea has been a neglected symptom with regard to detection and management. Many factors contribute to the pathogenesis of dyspnea. Among them, ventilator settings seem to play a major role. Dyspnea affects half of mechanically ventilated patient and causes immediate intense suffering [median dyspnea visual analog scale of 5 (4-7)]. In addition, it is associated with delayed extubation and with an increased risk of intubation and mortality in those receiving noninvasive ventilation. However, one-third of critically ill patients are noncommunicative, and therefore, at high risk of misdiagnosis. Heteroevaluation scales based on physical and behavioral signs of respiratory discomfort are reliable and promising alternatives to self-report. SUMMARY Dyspnea is frequent and severe in critically ill patients. Implementation of observational scale will help physicians to access to noncommunicative patient's respiratory suffering and tailor its treatment. Further studies on the prognostic impact and management strategies are needed.


title: Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage.

text: BACKGROUND AND PURPOSE By 2010 there had been 14 published trials of surgery for intracerebral hemorrhage reported in systematic reviews or to the authors, but the role and timing of operative intervention remain controversial and the practice continues to be haphazard. This study attempted to obtain individual patient data from each of the 13 studies published since 1985 to better define groups of patients that might benefit from surgery. METHODS Authors of identified published articles were approached by mail, e-mail, and at conferences and invited to take part in the study. Data were obtained from 8 studies (2186 cases). Individual patient data included patient's age, Glasgow Coma Score at presentation, volume and site of hematoma, presence of intraventricular hemorrhage, method of evacuation, time to randomization, and outcome. RESULTS Meta-analysis indicated that there was improved outcome with surgery if randomization was [corrected] undertaken within 8 hours of ictus (P=0.003), or the volume of the hematoma was 20 to 50 mL (P=0.004), or the Glasgow Coma Score was between 9 and 12 (P=0.0009), or the patient was aged between 50 and 69 years (P=0.01). In addition, there was some evidence that more superficial hematomas with no intraventricular hemorrhage might also benefit (P=0.09). CONCLUSIONS There is evidence that surgery is of benefit if undertaken early before the patient deteriorates. This work identifies areas for further research. Ongoing studies in subgroups of patients such as the Surgical Trial in Lobar Intracerebral Hemorrhage (STICH II) will confirm whether these interpretations can be replicated.


The friendly use of chloroquine in the COVID-19 disease: a warning for the G6PD-deficient males and for the unaware carriers of pathogenic alterations of the G6PD gene.


title: Oxygen supplementation in noninvasive home mechanical ventilation: the crucial roles of CO2 exhalation systems and leakages.

text: BACKGROUND When supplemental oxygen is added to noninvasive ventilation using a non-ICU ventilator, it is usually introduced with a preset flow into the circuit near the ventilator; however, the impact of different CO2 exhalation systems and leaks on the actual FIO2 and gas exchange has not been elucidated. METHODS In a randomized, open-label, 4-treatment (2-by-2), 4-period crossover design, 4 daytime measurements (60 min each) were performed in 20 subjects receiving home mechanical noninvasive ventilation plus supplemental oxygen (≥ 2 L/min) inserted near the ventilator: active valve circuit or leak port circuit with or without artificial leakage (4 mm inner diameter). Oxygen concentration near the ventilator, oxygen concentration at the mask, and blood gases were measured. RESULTS Overall, oxygen concentration at the mask (29 ± 5%) was lower than oxygen concentration at the ventilator (34 ± 4%), with a mean difference of 5.1% (95% CI 4.2-5.9%, P < .001)%. With the leak port circuit, oxygen concentration at the mask decreased by 3.2% (95% CI 2.6 to 3.9%, P < .001), compared to the active valve circuit. When artificial leakage was introduced into the circuit, oxygen concentration at the mask decreased by 5.7% (95% CI 5.1 to 6.4%, P < .001)%, PaO2 by 10.4 mm Hg (95% CI 3.1 to 17.7 mm Hg, P = .006), and PaCO2 increased by 1.8 mm Hg (95% CI 0.5 to 3.1 mm Hg, P = .008). CONCLUSIONS The use of a leak port circuit and the occurrence of leak around the interface significantly reduced oxygen concentration at the mask and negatively impacted gas exchange in subjects receiving home noninvasive ventilation and supplemental oxygen. (German Clinical Trials Registry, www.drks.de, DRKS00000449).


What's the psychiatrist's role in the COVID-19 outbreak?


Face masks can be devastating for people with hearing loss.


title: A systematic review of existing ageism scales.

text: Ageism has been shown to have a negative impact on older people's health and wellbeing. Though multiple scales are currently being used to measure this increasingly important issue, syntheses of the psychometric properties of these scales are unavailable. This means that existing estimates of ageism prevalence may not be accurate. We conducted a systematic review aimed at identifying available ageism scales and evaluating their scope and psychometric properties. A comprehensive search strategy was used across fourteen different databases, including PubMed and CINAHL. Independent reviewers extracted data and appraised risk of bias following the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. Of the 29,664 records identified, 106 studies, assessing 11 explicit scales of ageism, were eligible for inclusion. Only one scale, the 'Expectations Regarding Aging' met minimum requirements for psychometric validation (i.e., adequate content validity, structural validity and internal consistency). Still, this scale only assesses the 'stereotype' dimension of ageism, thus failing to evaluate the other two ageism dimensions (prejudice and discrimination). This paper highlights the need to develop and validate a scale that accounts for the multidimensional nature of ageism. Having a scale that can accurately measure ageism prevalence is key in a time of increasing and rapid population ageing, where the magnitude of this phenomenon may be increasing.


Journal Watch.


title: Study design and rationale of the 'Balloon-Expandable Cobalt Chromium SCUBA Stent versus Self-Expandable COMPLETE-SE Nitinol Stent for the Atherosclerotic ILIAC Arterial Disease (SENS-ILIAC Trial) Trial': study protocol for a randomized controlled trial.

text: BACKGROUND The self-expandable COMPLETE™ stent (Medtronic) has greater elasticity, allowing it to regain its shape after the compression force reduces, and has higher trackability, thus is easier to maneuver through tortuous vessels, whereas the balloon-expandable SCUBA™ stent (Medtronic) has higher radial stiffness and can afford more accurate placement without geographic miss, which is important in aortoiliac bifurcation lesions. To date, there have been no randomized control trials comparing efficacy and safety between the self-expanding stent and balloon-expandable stent in advanced atherosclerotic iliac artery disease. METHODS/DESIGN The purpose of our study is to examine primary patency (efficacy) and incidence of stent fracture and geographic miss (safety) between two different major representative stents, the self-expanding nitinol stent (COMPLETE-SE™) and the balloon-expanding cobalt-chromium stent (SCUBA™), in stenotic or occlusive iliac arterial lesions. This trial is designed as a prospective, randomized, multicenter trial to demonstrate a noninferiority of SCUBA™ stent to COMPLETE-SE™ stent following balloon angioplasty in iliac arterial lesions, and a total of 280 patients will be enrolled. The primary end point of this study is the rate of primary patency in the treated segment at 12 months after intervention as determined by catheter angiography, computed tomography angiography, or duplex ultrasound. DISCUSSION The SENS-ILIAC trial will give powerful insight into whether the stent choice according to deployment mechanics would impact stent patency, geographic miss, or stent fracture in patients undergoing stent implantation in iliac artery lesions. TRIAL REGISTRATION National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier: NCT01834495 ), registration date: May 8, 2012.


title: Five-step Correction of Congenital Symmastia.

text: Congenital symmastia is distressing and difficult to treat, and traditional surgical modalities have met with limited success. We present a novel approach for a patient that failed all traditional surgical options. The anatomic deformity is analyzed using a modified version of Blondeel's 3-step analysis (conus, footprint, and skin envelope, to which we added a fourth element "intermammary web"). Combining operative principles from breast cancer reconstruction, we describe 5 operative steps that help correct the deformity, followed by a new postoperative splinting regimen that addresses the common pitfalls that could lead to recurrence.


Aspirin for Lynch syndrome: a legacy of prevention.


title: The host protease TMPRSS2 plays a major role in in vivo replication of emerging H7N9 and seasonal influenza viruses.

text: UNLABELLED Proteolytic cleavage of the hemagglutinin (HA) protein is essential for influenza A virus (IAV) to acquire infectivity. This process is mediated by a host cell protease(s) in vivo. The type II transmembrane serine protease TMPRSS2 is expressed in the respiratory tract and is capable of activating a variety of respiratory viruses, including low-pathogenic (LP) IAVs possessing a single arginine residue at the cleavage site. Here we show that TMPRSS2 plays an essential role in the proteolytic activation of LP IAVs, including a recently emerged H7N9 subtype, in vivo. We generated TMPRSS2 knockout (KO) mice. The TMPRSS2 KO mice showed normal reproduction, development, and growth phenotypes. In TMPRSS2 KO mice infected with LP IAVs, cleavage of HA was severely impaired, and consequently, the majority of LP IAV progeny particles failed to gain infectivity, while the viruses were fully activated proteolytically in TMPRSS2+/+ wild-type (WT) mice. Accordingly, in contrast to WT mice, TMPRSS2 KO mice were highly tolerant of challenge infection by LP IAVs (H1N1, H3N2, and H7N9) with ≥1,000 50% lethal doses (LD50) for WT mice. On the other hand, a high-pathogenic H5N1 subtype IAV possessing a multibasic cleavage site was successfully activated in the lungs of TMPRSS2 KO mice and killed these mice, as observed for WT mice. Our results demonstrate that recently emerged H7N9 as well as seasonal IAVs mainly use the specific protease TMPRSS2 for HA cleavage in vivo and, thus, that TMPRSS2 expression is essential for IAV replication in vivo. IMPORTANCE Influenza A virus (IAV) is a leading pathogen that infects and kills many humans every year. We clarified that the infectivity and pathogenicity of IAVs, including a recently emerged H7N9 subtype, are determined primarily by a host protease, TMPRSS2. Our data showed that TMPRSS2 is the key host protease that activates IAVs in vivo through proteolytic cleavage of their HA proteins. Hence, TMPRSS2 is a good target for the development of anti-IAV drugs. Such drugs could also be effective for many other respiratory viruses, including the recently emerged Middle East respiratory syndrome (MERS) coronavirus, because they are also activated by TMPRSS2 in vitro. Consequently, the present paper could have a large impact on the battle against respiratory virus infections and contribute greatly to human health.


title: Robot-Assisted Laparoscopic Partial Colpectomy and Intracorporeal Ileal Conduit Urinary Diversion (Bricker) for Cervical Adenocarcinoma Recurrence.

text: Ileal conduit urinary diversion (Bricker) is a standard surgical open procedure. The Da Vinci robot allowed precision for this surgical procedure, especially for intracorporeal suturing. Meanwhile, few reports of robot-assisted laparoscopic ileal conduit diversion (Bricker) are described in the literature. We report the case of a 69-year-old patient with a vaginal recurrence of cervical adenocarcinoma associated with vesicovaginal fistula treated by robot-assisted laparoscopic partial colpectomy and ileal conduit urinary diversion (Bricker). The robot-assisted laparoscopic procedure followed all surgical steps of the open procedure. Postoperative period was free of complications.


title: Helicobacter pylori Does not Affect Postoperative Outcomes After Sleeve Gastrectomy.

text: BACKGROUND The effect of Helicobacter pylori (HP) colonization of the stomach of patients undergoing laparoscopic sleeve gastrectomy (LSG) is unclear. OBJECTIVE The objective of this study is to evaluate the effect of HP colonization on postoperative outcomes of LSG. SETTING The setting of this study is in University Hospital. METHODS This study was a retrospective cohort study of prospectively maintained database of all patients who underwent LSG at Jordan University Hospital from 2008 to 2015. RESULTS Five hundred patients were included (362 females and 138 males). The mean preoperative weight was 124.5 ± 23.8 kg. The mean preoperative body mass index (BMI) was 45.5 ± 6.9 kg/m2. Two hundred sixteen (43.2%) patients were found to be HP positive. The differences between the HP positive and negative groups in respect of sex, baseline weight, and BMI were not statistically significant. However, patients who were HP positive were significantly older. All patients were followed for at least 3 months. We had an overall complication rate of 2.6%. Differences in the complication rate between the two groups were not statistically significant. Follow-up was 61% at 1 year. The mean percent total weight loss (%TWL) was 32.9 ± 7.9, and the mean percent excess weight loss (%EWL) was 76.9 ± 21.1. The decrease in BMI was 15.2 ± 5.2. The difference between the two groups was not statistically significant. CONCLUSION There is no clear association between HP infection at the time of surgery and postoperative complications, especially leaks.


China's air quality dilemma: reconciling economic growth with environmental protection.


Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response.


title: SARS Cov2 infection in a renal transplanted patients. A case report.

text: The clinical manifestation of COVID-19 can vary from an asymptomatic course to ARDS requiring invasive mechanical ventilation and extracorporeal membrane oxygenation. A kidney transplanted patient infected with SARS CoV2 infection showed a mild disease despite immune suppression. It is possible that Immunosuppression can "be protective" as the cytokine storm is an important factor in the disease story. Despite the good outcome reported in the present case report, is remains of vital importance the solid organ transplant patients use precautions in order to avoid the infection.


title: The Impact of Peripheral Artery Disease in Chronic Total Occlusion Percutaneous Coronary Intervention (Insights From PROGRESS-CTO Registry).

text: The impact of peripheral artery disease (PAD) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We reviewed 3999 CTO PCIs performed in 3914 patients between 2012 and 2018 at 25 centers, 14% of whom had a history of PAD. We compared the clinical and angiographic characteristics and procedural outcomes of patients with versus without history of PAD. Patients with PAD were older (67 ± 9 vs 64 ± 10 years, P < .001) and had a higher prevalence of cardiovascular risk factors. They also had more complex lesions as illustrated by higher Japanese CTO score (2.7 ± 1.2 vs 2.4 ± 1.3, P < .001). In patients with PAD, the final crossing technique was less often antegrade wire escalation (40% vs 51%, P < .001) and more often the retrograde approach (23 vs 20%, P < .001) and antegrade dissection/reentry (20% vs 16%, P < .001). Technical success was similar between the 2 study groups (84% vs 87%, P = .127), but procedural success was lower for patients with PAD (81% vs 85%, P = .015). The incidence of in-hospital major adverse cardiac events was higher among patients with PAD (3% vs 2%, P = .046). In conclusion, patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions, and lower procedural success.


title: Brominated flame retardants (BFRs): A review on environmental contamination in China.

text: Brominated flame retardants (BFRs) which were detected extensively in environmental and biota samples worldwide, have raised significant concerns during past decades for their persistence, bioaccumulation and potential toxicity to ecological environment and human health. In this paper, we have compiled and reviewed existing literature on the contamination status of BFRs in abiotic and biotic environments in China, including polybrominated diphenyl ethers (PBDEs), hexabromocyclododecane, tetrabromobisphenol A and new BFRs. Temporal trends were also summarized and evaluated. Based on this review, it has been concluded that (1) high concentrations of PBDEs were generally related to the e-waste disposal processing, while the spatial distribution pattern of other BFRs was not necessarily in accordance with this; (2) extremely high concentrations of BFRs in indoor dust emphasized the importance of indoor contamination to human body burdens, while more work need to be done to confirm its contribution; (3) PBDEs in electronics dismantling workers were higher compared to the general population, indicating the occupational exposure should be of particular concern; (4) more data are now becoming available for BFRs in aquatic and terrestrial organisms not previously studied, while studies that consider the occurrence of BFRs in organisms of different trophic levels are still of urgent need for evaluating the fate of BFRs in the food web; and (5) limited data showed a decreasing trend for PBDEs, while more data on time trends of BFR contamination in various matrices and locations are still needed before the impact of regulation of BFRs can be assessed.


title: Immunity-Boosting Spices and the Novel Coronavirus.

text: Although there is no reported genetic predisposition in contracting coronavirus disease 2019 (COVID-19), the mortality rate varies among different ethnic groups. Here we determined potential correlation between COVID-19 and spice consumption. The data from 163 countries including total cases, total deaths, and total recovered were analyzed. It was observed that there is a clear interrelated prevalence between the total number of COVID-19 cases per million population tested and the gram of spice supply per capita per day. Nations with lower consumptions of spices per capita showed greater number of COVID-19 cases per million population. This is not surprising as herbs and spices are well-known to boost immunity. Although the precise molecular mechanisms associated with spices and immunity are not completely understood, our findings led us to hypothesize that spice consumption plays a role in our ability to fight COVID-19; however, intensive research is needed to determine the translational value of these findings.


title: Metagenomic analysis of viruses from bat fecal samples reveals many novel viruses in insectivorous bats in China.

text: Increasing data indicate that bats harbor diverse viruses, some of which cause severe human diseases. In this study, sequence-independent amplification and high-throughput sequencing (Solexa) were applied to the metagenomic analysis of viruses in bat fecal samples collected from 6 locations in China. A total of 8,746,417 reads with a length of 306,124,595 bp were obtained. Among these reads, 13,541 (0.15%) had similarity to phage sequences and 9,170 (0.1%) had similarity to eukaryotic virus sequences. A total of 129 assembled contigs (>100 nucleotides) were constructed and compared with GenBank: 32 contigs were related to phages, and 97 were related to eukaryotic viruses. The most frequent reads and contigs related to eukaryotic viruses were homologous to densoviruses, dicistroviruses, coronaviruses, parvoviruses, and tobamoviruses, a range that includes viruses from invertebrates, vertebrates, and plants. Most of the contigs had low identities to known viral genomic or protein sequences, suggesting that a large number of novel and genetically diverse insect viruses as well as putative mammalian viruses are transmitted by bats in China. This study provides the first preliminary understanding of the virome of some bat populations in China, which may guide the discovery and isolation of novel viruses in the future.


title: Angiotensin-Converting Enzyme 2 as a Versatile Player in the Management of Coronavirus Disease 2019.

text: In view of the global coronavirus disease 2019 (COVID-19) pandemic, there are ongoing efforts aimed at predicting potential factors causing clinical exacerbation of COVID-19 and at seeking effective therapies for COVID-19.Recent studies have indicated that severe acute respiratory coronavirus 2 (SARS-CoV-2) uses angiotensin-converting enzyme 2 (ACE2) as a receptor for cellular invasion and subsequent replication.


title: Histomorphometric and histologic evaluation of titanium-zirconium (aTiZr) implants with anodized surfaces.

text: The choice of implant surface has a significant influence on osseointegration. Modification of TiZr surface by anodization is reported to have the potential to modulate the osteoblast cell behaviour favouring more rapid bone formation. The aim of this study is to investigate the effect of anodizing the surface of TiZr discs with respect to osseointegration after four weeks implantation in sheep femurs. Titanium (Ti) and TiZr discs were anodized in an electrolyte containing DL-α-glycerophosphate and calcium acetate at 300 V. The surface characteristics were analyzed by scanning electron microscopy, electron dispersive spectroscopy, atomic force microscopy and goniometry. Forty implant discs with thickness of 1.5 and 10 mm diameter (10 of each-titanium, titanium-zirconium, anodized titanium and anodized titanium-zirconium) were placed in the femoral condyles of 10 sheep. Histomorphometric and histologic analysis were performed 4 weeks after implantation. The anodized implants displayed hydrophilic, porous, nano-to-micrometer scale roughened surfaces. Energy dispersive spectroscopy analysis revealed calcium and phosphorous incorporation into the surface of both titanium and titanium-zirconium after anodization. Histologically there was new bone apposition on all implanted discs, slightly more pronounced on anodised discs. The percentage bone-to-implant contact measurements of anodized implants were higher than machined/unmodified implants but there was no significant difference between the two groups with anodized surfaces (P > 0.05, n = 10). The present histomorphometric and histological findings confirm that surface modification of titanium-zirconium by anodization is similar to anodised titanium enhances early osseointegration compared to machined implant surfaces.


title: Hemodynamic-morphologic discriminants for intracranial aneurysm rupture.

text: BACKGROUND AND PURPOSE the purpose of this study was to identify significant morphological and hemodynamic parameters that discriminate intracranial aneurysm rupture status using 3-dimensional angiography and computational fluid dynamics. METHODS one hundred nineteen intracranial aneurysms (38 ruptured, 81 unruptured) were analyzed from 3-dimensional angiographic images and computational fluid dynamics. Six morphological and 7 hemodynamic parameters were evaluated for significance with respect to rupture. Receiver operating characteristic analysis identified area under the curve (AUC) and optimal thresholds separating ruptured from unruptured aneurysms for each parameter. Significant parameters were examined by multivariate logistic regression analysis in 3 predictive models-morphology only, hemodynamics only, and combined-to identify independent discriminants, and the AUC receiver operating characteristic of the predicted probability of rupture status was compared among these models. RESULTS morphological parameters (size ratio, undulation index, ellipticity index, and nonsphericity index) and hemodynamic parameters (average wall shear stress [WSS], maximum intra-aneurysmal WSS, low WSS area, average oscillatory shear index, number of vortices, and relative resident time) achieved statistical significance (P<0.01). Multivariate logistic regression analysis demonstrated size ratio to be the only independently significant factor in the morphology model (AUC, 0.83; 95% CI, 0.75 to 0.91), whereas WSS and oscillatory shear index were the only independently significant variables in the hemodynamics model (AUC, 0.85; 95% CI, 0.78 to 0.93). The combined model retained all 3 variables, size ratio, WSS, and oscillatory shear index (AUC, 0.89; 95% CI, 0.82 to 0.96). CONCLUSIONS all 3 models-morphological (based on size ratio), hemodynamic (based on WSS and oscillatory shear index), and combined-discriminate intracranial aneurysm rupture status with high AUC values. Hemodynamics is as important as morphology in discriminating aneurysm rupture status.


title: [Practical Aspects of Anesthesia and Perioperative Care in COVID-19 Infected Patients].

text: he care of those affected by the coronavirus pandemic that erupted in December 2019 places a significant burden on health. Not only because some patients require intensive therapeutic care, but because patients with any severity of the disease may also need surgical treatment. And solving this poses a significant challenge to anesthesiologists. This summary is intended to present the practical aspects of anesthesiological and perioperative care for patients requiring surgical treatment. Orv Hetil. 2020; 161 (17): 692-695.


title: Methicillin-Susceptible, Vancomycin-Resistant Staphylococcus aureus, Brazil.

text: We report characterization of a methicillin-susceptible, vancomycin-resistant bloodstream isolate of Staphylococcus aureus recovered from a patient in Brazil. Emergence of vancomycin resistance in methicillin-susceptible S. aureus would indicate that this resistance trait might be poised to disseminate more rapidly among S. aureus and represents a major public health threat.


title: Multiphasic Regulation of Systemic and Peripheral Organ Metabolic Responses to Cardiac Hypertrophy.

text: BACKGROUND Reduced fat oxidation in hypertrophied hearts coincides with a shift of carnitine palmitoyl transferase I from muscle to increased liver isoforms. Acutely increased carnitine palmitoyl transferase I in normal rodent hearts has been shown to recapitulate the reduced fat oxidation and elevated atrial natriuretic peptide message of cardiac hypertrophy. METHODS AND RESULTS Because of the potential for reduced fat oxidation to affect cardiac atrial natriuretic peptide, and thus, induce adipose lipolysis, we studied peripheral and systemic metabolism in male C57BL/6 mice model of transverse aortic constriction in which left ventricular hypertrophy occurred by 2 weeks without functional decline until 16 weeks (ejection fraction, -45.6%; fractional shortening, -22.6%). We report the first evidence for initially improved glucose tolerance and insulin sensitivity in response to 2 weeks transverse aortic constriction versus sham, linked to enhanced insulin signaling in liver and visceral adipose tissue (epididymal white adipose tissue [WAT]), reduced WAT inflammation, elevated adiponectin, mulitilocular subcutaneous adipose tissue (inguinal WAT) with upregulated oxidative/thermogenic gene expression, and downregulated lipolysis and lipogenesis genes in epididymal WAT. By 6 weeks transverse aortic constriction, the metabolic profile reversed with impaired insulin sensitivity and glucose tolerance, reduced insulin signaling in liver, epididymal WAT and heart, and downregulation of oxidative enzymes in brown adipose tissue and oxidative and lipogenic genes in inguinal WAT. CONCLUSIONS Changes in insulin signaling, circulating natriuretic peptides and adipokines, and varied expression of adipose genes associated with altered insulin response/glucose handling and thermogenesis occurred prior to any functional decline in transverse aortic constriction hearts. The findings demonstrate multiphasic responses in extracardiac metabolism to pathogenic cardiac stress, with early iWAT browning providing potential metabolic benefits.


title: Procedures Performed by Advanced Practice Providers Compared With Medical Residents in the ICU: A Prospective Observational Study.

text: To assess the frequency and safety of procedures performed by advanced practice providers and medical residents in a mixed-bed ICU. Design A prospective observational study where consecutive invasive procedures were studied over a period of 1 year and 8 months. The interventions were registered anonymously in an online database. Endpoints were success rate at first attempt, number of attempts, complications, level of supervision, and teamwork. Setting A 33-bedded mixed ICU. Subjects Advanced practice providers and medical residents. Interventions Registration of the performance of tracheal intubation, central venous and arterial access, tube thoracostomies, interhospital transportation, and electrical cardioversion. Measurement and Main Results A full-time advanced practice provider performed an average of 168 procedures and a medical resident an average of 68. The advanced practice provider inserted significant more radial, brachial, and femoral artery catheters (66% vs 74%, p = 0.17; 15% vs 12%, p = 0.14; 18% vs 14%, p = 0.14, respectively). The median number of attempts needed to successfully insert an arterial catheter was lower, and the success rate at first attempt was higher in the group treated by advanced practice providers (1.30 [interquartile range, 1-1.82] vs 1.53 [interquartile range, 1-2.27], p < 0.0001; and 71% vs 54%, p < 0.0001). The advanced practice providers inserted more central venous catheters (247 vs 177) with a lower median number of attempts (1.20 [interquartile range, 1-1.71] vs 1.33 [interquartile range, 1-1.86]) and a higher success rate at first attempt (81% vs 70%; p < 0.005). The number of intubations by advanced practice providers was 143 and by medical residents was 115 with more supervision by the advanced practice provider (10% vs 0%; p = 0.01). Team performance, as reported by nursing staff, was higher during advanced practice provider procedures compared with medical resident procedures (median, 4.85 [interquartile range, 4.85-5] vs 4.73 [interquartile range, 4.22-5]). Other procedures were also more often performed by advanced practice providers. The complication rate in the advanced practice provider-treated patient group was lower than that in the medical resident group. Conclusions Advanced practice providers in critical care performed procedures safe and effectively when compared with medical residents. Advanced practice providers appear to be a valuable addition to the professional staff in critical care when it comes to invasive procedures.


title: Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials.

text: BACKGROUND Aggressive fluid resuscitation in trauma promotes deleterious effects such as clot disruption, dilutional coagulopathy and hypothermia. Animal studies suggest that permissive hypotension maintains appropriate organ perfusion, reduces bleeding and improves mortality. This review assesses the efficacy and safety of permissive hypotension in adult trauma patients with hemorrhagic shock. METHODS We searched the MEDLINE and EMBASE databases from inception to May 2017 for randomized controlled trials comparing permissive hypotension vs. conventional resuscitation following traumatic injury. We included preoperative and intraoperative resuscitation strategies. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included blood product utilization, estimated blood loss and in-hospital complications. Pooling was performed with a random-effects model. RESULTS We screened 722 abstracts, from which five randomized trials evaluating 1,158 patients were included. Blood pressure targets in the intervention arms varied from systolic BP 50 mm Hg to 70 mm Hg or mean arterial pressure of 50 mm Hg or higher as compared to systolic BP 65 mm Hg to 100 mm Hg or mean arterial pressure of 65 or higher in the control arms. Two studies evaluated only patients with penetrating injury while the remaining three additionally included blunt injuries. Four trials suggested a survival benefit for 30-day or in-hospital mortality with hypotensive resuscitation, although three studies were insufficiently powered to find statistical significance. Studies were of poor to moderate quality due to poor protocol reporting and lack of blinding. The pooled odds ratio was 0.70 (95% confidence interval, 0.53-0.92), suggesting a survival benefit for permissive hypotension. Those patients received fewer blood products and had lesser estimated blood loss. CONCLUSION Permissive hypotension may offer a survival benefit over conventional resuscitation for patients with hemorrhagic injury. It may additionally reduce blood loss and blood product utilization. However, the majority of studies were underpowered, thus reflecting a need for high quality, adequately powered trials. PROSPERO REGISTRATION Systematic Review, level II.CRD42017070526.


title: Smoking Does Not Affect Occlusion Rates and Morbidity-Mortality after Pipeline Embolization for Intracranial Aneurysms.

text: BACKGROUND AND PURPOSE Smoking is a major risk factor for patients with intracranial aneurysms, yet the effects of smoking on outcomes of aneurysm with flow-diverter treatment remain unknown. We studied the impact of smoking on long-term angiographic and clinical outcomes after flow-diverter treatment of intracranial aneurysms. MATERIALS AND METHODS We retrospectively reviewed data from patients treated with the Pipeline Embolization Device and included in the International Retrospective Study of the Pipeline Embolization Device, the Pipeline for Uncoilable or Failed Aneurysms Study, and the Aneurysm Study of Pipeline in an Observational Registry. Patients were stratified according to smoking status into 3 groups: 1) never smoker, 2) current smoker, and 3) former smoker. We studied angiographic and clinical outcomes. Outcomes were compared by using χ(2) and Student t tests. A multivariate analysis was performed to determine whether smoking was independently associated with poor outcomes. RESULTS Six hundred sixteen patients with 694 aneurysms were included. Current smokers had a smaller mean aneurysm size compared with the other 2 groups (P = .005) and lower rates of multiple Pipeline Embolization Device use (P = .015). On multivariate analysis, former smokers (OR, 1.08; 95% CI, 0.43-2.71; P = .57) and current smokers (OR, 0.70; 95% CI, 0.27-1.77; P = .38) had similar odds of long-term angiographic incomplete occlusion compared with never smokers. Former smokers (OR, 1.27; 95% CI, 0.64-2.52; P = .25) and current smokers (OR, 0.74; 95% CI, 0.37-1.46; P = .22) had similar odds of major morbidity and neurologic mortality compared with never smokers. CONCLUSIONS These results suggest that smoking is not associated with angiographic and clinical outcomes among patients treated with the Pipeline Embolization Device. Nonetheless, patients with intracranial aneurysms should continue to be counseled about the risks of tobacco smoking.


title: In vitro characteristics of a gelling PEGDA-QT polymer system with model drug release for cerebral aneurysm embolization.

text: A liquid-to-solid gelling polymer system, such as the poly(ethylene glycol) diacrylate-pentaerythritol tetrakis (3-mercaptopropionate) (PEGDA-QT) system, can fill cerebral aneurysms more completely than current embolization materials, reducing the likelihood of aneurysm recurrence. PEGDA-QT gels were formulated using PEGDA of different molecular weights (PEGDA575 and PEGDA700), and their characteristics were examined in vitro. Experiments examined gel time, mass change, crosslink integrity, cytotoxicity, and protein release capabilities. In general, PEGDA575-QT gels were more hydrophobic, requiring an initiating solution with a higher pH (pH 9.5) to achieve a gel time comparable to PEGDA700-QT gels, which used an initiating solution at pH 9.19. The mass change and crosslink integrity of gels were analyzed over time after gels were submerged in 150 mM phosphate buffered saline. After 380 days, PEGDA575-QT gels achieved a maximum mass increase of 72% due to water uptake, while PEGDA700-QT gels doubled their initial mass (100% increase) by 165 days. Compression tests showed that PEGDA700-QT gels hydrolyzed more quickly than PEGDA575-QT gels. Cytotoxicity assays showed that in general, PEGDA575-QT negatively affected cell growth, while PEGDA700-QT gels promoted cell viability. Sustained, controlled release of lysozyme, a 14.3 kDa protein, was achieved over an 8-week period when loaded into PEGDA700-QT gels, but PEGDA575-QT gels did not show sustained release. These studies show that although they are similar in composition, these PEGDA-QT gel formulations behave considerably differently. Although PEGDA700-QT gels swell more and degrade faster than PEGDA575-QT gels, their cytocompatibility and protein release characteristics may prove to be more beneficial for in vivo aneurysm treatment.


title: Validation of a thoracoscopic lobectomy simulator.

text: OBJECTIVES Although simulation is considered integral to general surgery training, its role has only recently been recognized in thoracic surgical education, perhaps due to a lack of widely available, validated simulators for advanced thoracic procedures. This study evaluates the construct, content and face validity of an inexpensive, easily reproducible simulator for teaching thoracoscopic lobectomy. METHODS Construct validity (ability of the simulator to discriminate between users of different skill levels) was assessed by having surgical trainees perform a lobectomy on the simulator. Participants were divided into three groups (experienced, intermediate and novice) based on self-reported experience with minimally invasive surgery. After instruction and practice time to limit the effect of any simulator-specific learning curve, each performed a left upper lobectomy that was scored using a standardized assessment tool incorporating total time plus weighted penalty minutes assigned for errors. Content validity (simulator requires same steps and decision-making as a clinical lobectomy) was assessed using a Likert scale by those participants who had previously seen a thoracoscopic lobectomy in a patient. RESULTS Thirty-one residents participated in the study (12 experienced, 6 intermediate and 13 novice). All 12 experienced participants completed the lobectomy. The other groups were less successful with 4 of 6 in the intermediate group and 5 of 13 in the novice group completing the lobectomy (P = 0.004). The mean times for lobectomy + penalty minutes were 35 + 6.8 (experienced), 50 + 13 (intermediate) and 54 + 20 (novice). Differences between groups were statistically significant for experienced vs. novice (P < 0.001) and experienced vs. intermediate (P < 0.04). Content validity was assessed by the 18 participants who had previously seen a thoracoscopic lobectomy with a mean of 9.2 of 10 possible points. CONCLUSIONS The thoracoscopic lobectomy simulator used in this study demonstrates acceptable validity and can be a useful tool for teaching thoracoscopic lobectomy to trainees or experienced surgeons.


title: Flow Diverter Therapy of a Giant Fusiform Vertebrobasilar Junction Aneurysm in a Child: Case Report.

text: The management of giant vertebrobasilar junction (VBJ) aneurysms is extremely challenging. Flow diverter (FD) therapy has become an important alternative to treat difficult intracranial aneurysms for both open surgery and conventional endovascular therapy. Herein, we report a rare case of a giant fusiform VBJ aneurysm in a child that is successfully treated with FD therapy.


title: Osteonecrosis of the femoral head in SARS patients: seven years later.

text: This study is aimed to explore the progression of osteonecrosis of the femoral head (OFNH) in severe acute respiratory syndrome patients 7 years after steroid administration and to analyze factors affecting the prognosis. One-hundred and ninety hips in 117 patients with more than 7 years of follow-up were studied. The prevalence of progression to symptoms and collapse was determined. The total dose of steroid, gender, age, stage, lesion location, volume of necrosis, viable lateral column and bone marrow edema were analyzed and correlated with progression. During the 7 years of follow-up, 66 hips progressed to symptoms, 50 hips collapsed and 10 hips showed complete regression. Fifty-seven hips (86.36 %) caused pain and 32 (64.00 %) collapsed within 3 years of steroid administration. The lesion was relatively larger, and there was relatively less viable lateral column in hips that exhibited symptoms or collapsed. Mechanical failure of the necrotic segment of bone principally occurred within 3 years after the administration of steroids. Larger lesions and less viable lateral column were the main risk factors for progression. Small ONFH lesions seldom collapsed.


title: Flow Diversion and Outcomes of Vertebral Fusiform Aneurysms After Stent-Only Treatment: A Hemodynamic Study.

text: BACKGROUND The aim of this study was to determine the effectiveness of treating vertebral fusiform aneurysms (VFAs) only with stents. Using computational fluid dynamics, we evaluated the hemodynamic patterns of VFAs after stent-only treatment (SOT) and monitored hemodynamic changes in the side branches. METHODS Between September 2014 and December 2015, we enrolled 10 consecutive patients with VFAs who underwent SOT. Successful aneurysm reconstruction is defined as perfect reconstruction of the parent artery and complete or nearly complete occlusion of the aneurysm. Otherwise, the reconstruction was considered unsuccessful. After SOT, we used computational fluid dynamics to assess hemodynamic changes in aneurysmal velocity, wall shear stress, and relative residual time (RRT) as well as velocity in side branches. RESULTS Ten patients were studied. At follow-up after initial treatment, 7 of the 10 reconstructions were successful. Compared with the 3 unsuccessful reconstructions, successful reconstructions showed a significantly greater increase in the mean RRT (1185.1% vs. 204.8%; P = 0.030) and a greater reduction in mean velocity (44.5% vs. 34.7%; P = 0.053) and wall shear stress (49.2% vs. 27.9%; P = 0.087). The average velocity in the branches decreased by 10.0% after SOT. There was also a significant difference between the mean reduction in the rate of flow velocity in the aneurysm and the side branches (42.1% vs. 10.0%; P < 0.001). CONCLUSIONS We found a significant increase in RRT of successful reconstruction of aneurysms. There may be less effect on the flow in branches arising from VFAs after SOT, whether the aneurysms showed complete occlusion or not.


title: Glidescope(®) videolaryngoscope improves intubation success rate in cardiac arrest scenarios without chest compressions interruption: a randomized cross-over manikin study.

text: AIM The aim of this study was to assess the performance of the Glidescope(®) in a manikin cardiopulmonary resuscitation (CPR) scenario. METHODS Following a brief didactic session, 45 volunteer doctors inexperienced with airway management, attempted to intubate a manikin using a Macintosh laryngoscope and Glidescope(®) with uninterrupted and without chest compressions. Primary endpoints were intubation times and success rate with each device. Dental compression and level of self-confidence in using each device were also assessed. RESULTS In the scenario without chest compressions the cumulative success rate related to time to intubation was significantly higher with the Macintosh blade than with the Glidescope(®) (p<0.001). On the contrary, in the scenario with continuous chest compressions, the cumulative rate related to time to intubation was significantly higher with the Glidescope(®) (p=0.035). Significantly fewer attempts were required for the first successful intubation with the Macintosh blade in the non-CPR scenario versus the CPR scenario (p=0.007). Moreover, the number of attempts for the first successful intubation was significantly lower for the Glidescope(®) in the non-CPR (p=0.001) and the CPR scenario (p<0.001). Dental compression was significantly lower with the Glidescope(®) in both scenarios (p<0.001). CONCLUSIONS Using the GlideScope(®) in a manikin CPR scenario provides extremely high intubation success rates in short times with the first attempt, in medical practitioners inexperienced in intubation.


title: Ribosomal proteins as a possible tool for blocking SARS-COV 2 virus replication for a potential prospective treatment.

text: Coronavirus disease (COVID-19) is caused by SARS-COV2 and has resulted in more than four million cases globally and the death cases exceeded 300,000. Normally, a range of surviving and propagating host factors must be employed for the completion of the infectious process including RPs. Viral protein biosynthesis involves the interaction of numerous RPs with viral mRNA, proteins which are necessary for viruses replication regulation and infection inside the host cells. Most of these interactions are crucial for virus activation and accumulation. However, only small percentage of these proteins is specifically responsible for host cells protection by triggering the immune pathway against virus. This research proposes RPs extracted from bacillus sp. and yeast as new forum for the advancement of antiviral therapy. Hitherto, antiviral therapy with RPs-involving viral infection has not been widely investigated as critical targets. Also, exploring antiviral strategy based on RPs could be a promising guide for more potential therapeutics.


title: ICU early mobilization: from recommendation to implementation at three medical centers.

text: OBJECTIVE To compare and contrast the process used to implement an early mobility program in ICUs at three different medical centers and to assess their impact on clinical outcomes in critically ill patients. DESIGN Three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement framework of Plan-Do-Study-Act. INTERVENTION Each of the three ICU early mobilization programs required an interprofessional team-based approach to plan, educate, and implement the ICU early mobility program. Champions from each profession-nursing, physical therapy, physician, and respiratory care-were identified to facilitate changes in ICU culture and clinical practice and to identify and address barriers to early mobility program implementation at each institution. SETTING The medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center. RESULTS Establishing an ICU early mobilization quality improvement program resulted in a reduced ICU and hospital length of stay at all three institutions and decreased rates of delirium and the need for sedation for the patients enrolled in the Johns Hopkins ICU early mobility program. CONCLUSION Instituting a planned, structured ICU early mobility quality improvement project can result in improved outcomes and reduced costs for ICU patients across healthcare systems.


title: Massive hematemesis after radiofrequency ablation of metastatic liver tumor with successful hemostasis achieved through transarterial embolization.

text: Hemorrhagic complications are the most common major complications that occur after radiofrequency ablation, but hematemesis as a complication after radiofrequency ablation for hepatic tumor has not been mentioned before. A hepatogastric fistula as a delayed complication is also rare. We present the case of a 77-year-old man with severe hematemesis that occurred 2 months after radiofrequency ablation of a liver metastasis of gastric cancer. A ruptured hepatic artery pseudoaneurysm and a hepatogastric fistula were confirmed through serial imaging examinations. The current case is reported in combination with 2 rare major complications after radiofrequency ablation of a liver tumor.


Doctors' wellbeing: self-care during the covid-19 pandemic.


title: An evaluation of total disintegration time for three different doses of sublingual fentanyl tablets in patients with breakthrough pain.

text: INTRODUCTION Breakthrough pain is common among patients with cancer and presents challenges to effective pain management. Breakthrough pain is characterized by rapid onset, severe intensity, and duration typically lasting <1 h. Thus, optimal relief from breakthrough pain is best attained by administering analgesics with dissolution times and bioavailabilities that closely match the onset and duration of breakthrough pain. The objective of this study was to assess complete disintegration time of three different doses of sublingual fentanyl tablets in opioid-tolerant patients. METHODS This was a single-center, non-randomized, open-label study. Opioid-tolerant adult patients (N = 30) with chronic pain were assigned to one of three dose groups and self-administered a single 100, 200, or 300 μg sublingual fentanyl tablet (Abstral(®), Galena Biopharma, Portland, OR, USA). Time to complete disintegration was measured by each patient with a stopwatch and independently verified by study personnel. RESULTS Disintegration time (mean ± SD) for sublingual fentanyl tablets (all doses) was 88.2 ± 55.1 s. Mean disintegration times tended to be slightly longer for the 200 μg (96.7 ± 57.9 s) and 300 μg doses (98.6 ± 64.8 s) compared to the 100 μg dose (69.5 ± 40.5 s). Differences were not statistically significant. Disintegration time was not significantly different between men and women and was not affected by age. CONCLUSION Sublingual fentanyl tablets dissolved rapidly (average time <2 min) in all patients, with the higher doses taking slightly more time to dissolve.


docid: kjlboizg

title: Predictors of successful separation from high-flow nasal oxygen therapy in patients with acute respiratory failure: a retrospective monocenter study.

text: BACKGROUND High-flow nasal oxygen therapy (HFOT) is a promising first-line therapy for acute respiratory failure. However, its weaning has never been investigated and could lead to unnecessary prolonged intensive-care unit (ICU) stay. The aim of this study is to assess predictors of successful separation from HFOT in critically ill patients. We performed a retrospective monocenter observational study over a 2-year period including all patients treated with HFOT for acute respiratory failure in the ICU. Those who died or were intubated without prior HFOT separation attempt, who were treated with non-invasive ventilation at the time of HFOT separation, or who received HFOT as a preventive treatment during the post-extubation period were excluded. RESULTS From the 190 patients analyzed, 168 (88%) were successfully separated from HFOT at the first attempt. Patients who failed separation from HFOT at the first attempt had longer ICU length of stay than those who succeeded: 10 days (7-12) vs. 5 (4-8), p < 0.0001. Fraction of inspired oxygen (FiO2) ≤ 40% and a respiratory rate-oxygenation (ROX) index (calculated as the ratio of SpO2/FiO2 to the respiratory rate) ≥ 9.2 predicted successful separation from HFOT with sensitivity of 85% and 84%, respectively. CONCLUSIONS FiO2 ≤ 40% and ROX index ≥ 9.2 were two predictors of successful separation from HFOT at the bedside. Prospective multicenter studies are needed to confirm these results.


title: Cerebral oximetry: the standard monitor of the future?

text: PURPOSE OF REVIEW There is an increasing interest in the application of near-infrared spectroscopy (NIRS) as a monitoring tool in noncardiac surgery. This review summarizes the latest developments and current evidence for the use of NIRS in the noncardiac intraoperative setting. RECENT FINDINGS Unanticipated intraoperative physiological disturbances and a substantial interpatient variability in the limits of cerebral autoregulation, pose our patients at risk for adverse cerebral outcome, if the brain is not monitored specifically. In addition to a means to monitor the brain, NIRS has been shown to allow an estimate of overall organ oxygenation. Preliminary data suggest a relationship between cerebral desaturation and both neurologic and major organ morbidity. SUMMARY NIRS offers noninvasive monitoring of cerebral and overall organ oxygenation in a wide range of clinical scenarios. There is an increasing evidence that the optimized cerebral oxygenation is associated with improved outcomes in both neurologic and major organ morbidity in a variety of surgical settings.


Single-incision laparoscopic hernioplasty for obturator hernia.


Rhinitis associated with allergic nasal granuloma in Jersey cattle.


title: Efficacy of oral meloxicam suspension for prevention of pain and inflammation following band and surgical castration in calves.

text: BACKGROUND Castration is one of the most common procedures performed on beef and dairy cattle. The objective of the study was to determine the efficacy of meloxicam oral suspension in reducing pain and inflammation in calves following band or surgical castration. METHODS Two identical trials with the exception of the method of castration (Band Castration Study 1 and Surgical Castration Study 2) were conducted. Sixty (60) healthy Holstein calves 4 to 5 months of age (138-202 Kg) were used. Animals received either Meloxicam Oral Suspension at a dose of 1 mg/kg BW (n = 15 Study 1 and 15 Study 2) or Saline (n = 15 Study 1 and 15 Study 2) 2 h before castration. Physiological (Heart Rate, Plasma Cortisol and Plasma Substance P) and Behavioral (Visual Analog Scale (VAS), Accelerometers and tail Pedometers) evaluations were conducted before (day -1) and after Castration (Day 0, 1, 2, 3). Inflammation was evaluated daily by providing an individual animal score (Study1) or with a measurement of scrotal thickness (Study 2). RESULTS Heart rates were significantly greater in control animals following band and surgical castration. Plasma cortisol and substance P were significantly reduced in animals receiving Meloxicam Oral Suspension. Control animals had significantly greater VAS scores. Accelerometers showed that meloxicam treated animals had a significantly greater motion index and number of steps as well as less % time lying and number of lying bouts. The scrotal inflammation (based on scrotal swelling) was significantly decreased in the meloxicam treated animals compared to the control animals on day 1, day 2 and 3. CONCLUSION Meloxicam Oral Suspension was able to significantly reduce the display of painful behaviors and physiological responses to pain in band castrated and surgical castrated calves for up to 72 h following a single oral treatment of 1 mg/kg body weight. Meloxicam Oral Suspension was able to significantly reduce scrotal inflammation in band castrated and surgical castrated calves.


title: Transcatheter embolization in the management of epistaxis.

text: A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.


title: Patient engagement in research related to dementia: A scoping review.

text: Patient 'engagement' or 'involvement' in health research broadly refers to including people with lived experience (i.e. individuals with personal experience of a health issue and their friends, family and caregivers or carers) in the research process. Although previous reviews have systematically summarized approaches to patient engagement in research, it is unclear whether and how engagement activities have been implemented or adapted for research related to dementia. We conducted a scoping review to describe the extent and nature of patient engagement approaches that have been used to involve persons with dementia and their care partners in research. We then summarized the reported barriers, enablers, and impacts of this engagement. Fifty-four research articles were included in the review and almost all were published after 2010. Persons with dementia and their care partners have been engaged in diverse phases of the research process. The majority of engagement involved both persons with dementia and care partners. Barriers and enablers to engagement included those identified for general patient engagement in research, but some more specific to engaging persons with dementia and their care partners were also reported. Very few studies assessed the impact of patient engagement. While the arguments for patient engagement in research are compelling, research to demonstrate the impact - on the research process and outcomes as well as on persons with dementia, care partners, researchers, research institutions and society - is still needed.


title: Artificial Neural Networks Solve Musical Problems With Fourier Phase Spaces.

text: How does the brain represent musical properties? Even with our growing understanding of the cognitive neuroscience of music, the answer to this question remains unclear. One method for conceiving possible representations is to use artificial neural networks, which can provide biologically plausible models of cognition. One could train networks to solve musical problems, and then study how these networks encode musical properties. However, researchers rarely examine network structure in detail because networks are difficult to interpret, and because many assume that networks capture informal or subsymbolic properties. Here we report very high correlations between network connection weights and discrete Fourier phase spaces used to represent musical sets. This is remarkable because there is no clear mathematical relationship between network learning rules and discrete Fourier analysis. That networks discover Fourier phase spaces indicates that these spaces have an important role to play outside of formal music theory. Finding phase spaces in networks raises the strong possibility that Fourier components are possible codes for musical cognition.


Lessening COVID-19 healthcare burden in dental practice via rapid serological tests.


Middle East respiratory syndrome (MERS-CoV).


title: Gastric band placement for obesity is not associated with increased urinary risk of urolithiasis compared to bypass.

text: PURPOSE Obesity is associated with multiple health risks. Bariatric surgery is a treatment for clinically severe obesity and is known to increase urolithiasis risk. However, trends in risk over time are not well characterized. Moreover little attention has been devoted to laparoscopic gastric band placement. A comparison of urinary risk of urolithiasis after the Roux-en-Y and gastric banding procedures was performed. MATERIALS AND METHODS We evaluated 24-hour urine collections from 39 subjects (11 male and 28 female, mean age 51 years) after bariatric surgery. Of these subjects 27 underwent Roux-en-Y gastric bypass and 12 had gastric banding procedures. Mean time since surgery was 3.4 and 2.1 years for the Roux-en-Y gastric bypass and gastric banding groups, respectively. RESULTS Urine volume was low in both groups (less than 1.5 l daily). Urinary calcium excretion was lower (p = 0.001) in the Roux-en-Y gastric bypass (100 mg daily) vs the gastric banding group (191 mg daily). After Roux-en-Y gastric bypass surgery 48% had a urinary oxalate of 45 mg daily or more compared to 25% after gastric banding. Urinary citrate was less than 370 mg daily for 14 subjects in the Roux-en-Y gastric bypass and 1 in the gastric banding group. All patients were taking calcium supplements. Dietary intake of high oxalate foods did not correlate with urinary oxalate excretion or with hyperoxaluria. CONCLUSIONS Our study confirms the risk of urinary stones following the Roux-en-Y gastric bypass procedure as a result of hyperoxaluria, low urine volume and hypocitraturia. Those with gastric banding placement had low urine volumes. Future studies should elucidate the effect of nutrition and/or pharmacological therapy on stone risk of both surgeries as their incidence increases.


title: Venous thromboembolism after bariatric surgery performed by Bariatric Surgery Center of Excellence Participants: analysis of the Bariatric Outcomes Longitudinal Database.

text: BACKGROUND Venous thromboembolism (VTE) is an uncommon complication of bariatric surgery but a leading cause of postoperative mortality. Studying the factors predictive of low-incidence complications requires the analysis of large cohorts. The Bariatric Outcomes Longitudinal Database, the world's largest prospective database for bariatric surgery, has provided a suitable medium for analyzing low-frequency events. METHODS The data in the Bariatric Outcomes Longitudinal Database from 73,921 research-consented patients who had undergone bariatric surgery by a participant in the American Society for Metabolic and Bariatric Surgery Bariatric Surgery Center of Excellence program before September 22, 2009, were analyzed for VTE events within 90 days after surgery. RESULTS The overall risk of VTE within 90 days after surgery was .42%, and 73% of these events occurred after discharge, most within 30 days after surgery. The risk of VTE was greater in the patients undergoing gastric bypass than in those undergoing adjustable gastric banding (.55% versus .16%). VTE was more frequent when the procedure was performed using an open than a laparoscopic approach (1.54% versus .34%). Patients with a VTE event were older (+4.9 yr), had had a greater preoperative body mass index (+3.9 kg/m(2)), and were more likely to have a history of VTE (16.5% versus 3.7%). The risk of VTE was greater in men (hazard ratio 2.32, 95% confidence interval 1.81-2.98) and in patients with an inferior vena cava filter (hazard ratio 7.66, 95% confidence interval 4.55-12.91). CONCLUSION The overall risk of VTE was low in the population treated by participants in the Bariatric Surgery Center of Excellence program, where clinical pathways to prevent VTE have been mandated. Analysis of this large study population allowed the identification of patient characteristics correlating with increased risk of postoperative VTE and the variable effectiveness of VTE prophylaxis methods.


title: Nonrobotic Total Endoscopic Coronary Artery Bypass Grafting: A Proof-of-Concept Study in 20 Patients.

text: OBJECTIVE At present, minimal invasive direct coronary artery grafting is the least invasive nonrobotic surgical approach to revascularize the left anterior descending artery with the left internal mammary artery. Total endoscopic coronary bypass grafting is performed with the help of a telemanipulator ("robot"). A prospective proof-of-concept study was initiated to investigate a nonrobotic total endoscopic coronary bypass grafting approach. METHODS Twenty patients with significant left anterior descending artery or left main stem lesion were operated on via three or four left thoracic access ports. Under exclusive endoscopic vision, the left internal mammary artery was harvested and anastomosed to the left anterior descending artery manually. Cardiopulmonary bypass and cardioplegic arrest were planned in all cases. RESULTS In 10 patients, the operation was completed successfully as nonrobotic total endoscopic coronary bypass grafting. Reasons for conversions to minimal invasive direct coronary artery grafting or conventional sternotomy were dense pleural adhesions (3 patients), bleeding of the anastomosis (3), diffuse bleeding during left internal mammary artery harvesting (2), identification problems of the target artery (1), or left internal mammary artery failure (1). Postoperative angiography in five primarily successful nonrobotic total endoscopic coronary bypass grafting patients showed patent anastomoses in four cases. One patient was reoperated on for early anastomotic failure in a 1.0-mm target vessel. Until now, a percutaneous coronary intervention of remaining lesions as staged hybrid procedure was performed in three patients (2 nonrobotic total endoscopic coronary bypass grafting, 1 minimal invasive direct coronary artery grafting). CONCLUSIONS With a thoroughly surveyed learning curve, nonrobotic total endoscopic coronary bypass grafting procedure could become an alternative to other available treatment options; however, the value of the procedure has to be further investigated.


docid: lrmaefdl

title: Resequencing microarray for detection of human adenoviruses in patients with community-acquired gastroenteritis: a proof-of-concept study.


title: Multiplex method for simultaneous serological detection of porcine reproductive and respiratory syndrome virus and porcine circovirus type 2.

text: Porcine circovirus type 2 (PCV2) and porcine reproductive and respiratory syndrome virus (PRRSV) are major contributors to the porcine respiratory disease complex (PRDC). Routine serological diagnosis and surveillance play an important role in the prevention of PRDC, as it is a leading cause of economic losses to the swine industry. We herein describe an advanced microsphere-based immunoassay that permits the simultaneous detection of antibodies to PCV2 and PRRSV, thereby reducing the time and effort involved in testing. Recombinant PRRSV nucleoprotein antigen and the PCV2 capsid antigen were coupled to fluorophore-dyed beads with distinct spectral addresses. Weekly serum samples from 72 pigs that were experimentally exposed to either PCV2, PRRSV, or both PCV2 and PRRSV were used to validate the microbead assay (MBA) in comparison with the "gold standard" enzyme-linked immunosorbent assays. The kinetics of the PCV2- and PRRSV-specific antibody responses measured by the microbead assay were comparable to those of the standard assays; Spearman's rank correlations were 0.72 (P < 0.001) for PRRSV and 0.80 (P < 0.001) for PCV2. Diagnostic sensitivity and specificity were determined using field sera whose positive or negative status was determined by the standard tests. The diagnostic sensitivity and specificity were both 98% for PCV2 and were 91% and 93%, respectively, for PRRSV (kappa coefficients, 0.85 and 0.67 for PCV2 and PRRSV, respectively). Multiplexing did not interfere with assay performance or diagnostic sensitivity. Therefore, the described study demonstrates proof of concept for the development of more versatile and economical microbead array-based multiplex serological test panels for veterinary use.


Treatments in the COVID-19 pandemic: an update on clinical trials.


title: Ecology and diversity in upper respiratory tract microbial population structures from a cross-sectional community swabbing study.

text: PURPOSE Respiratory tract infections (RTIs) are responsible for over 2.8 million deaths per year worldwide with pathobiont carriage a required precursor to infection. We sought to determine carriage epidemiology for both bacterial and viral respiratory pathogens as part of a large population-based cross-sectional carriage study. METHODOLOGY Nose self-swab samples were collected in two separate time-points, May to August 2012 (late spring/summer) and February to April 2013 (winter/early spring). The presence of six bacterial species: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, P. aeruginosa and N. meningitidis in addition to respiratory syncytial virus, influenza viruses A and B, rhinovirus/enterovirus, coronavirus, parainfluenza viruses 1-3 and adenovirus was determined using culture and PCR methods.Results/Key findings. Carriage was shown to vary with age, recent RTI and the presence of other species. Spatial structures of microbial communities were more disordered in the 0-4 age group and those with recent RTI. Species frequency distributions were flatter than random expectation in young individuals (X2=20.42, P=0.002), indicating spatial clumping of species consistent with facilitative relationships. Deviations from a neutral model of ecological niches were observed in summer samples and from older individuals but not in the winter or younger individuals (0-4 years), suggesting the presence of seasonal and age-dependent niche processes in respiratory community assembly. CONCLUSION The application of epidemiological methods and ecological theory to respiratory tract samples has yielded novel insights into the factors that drive microbial community composition.


Hematuria Associated With SARS-CoV-2 Infection in a Child.


docid: hsnonydr

title: Postoperative delirium in a substudy of cardiothoracic surgical patients in the BAG-RECALL clinical trial.

text: BACKGROUND Postoperative delirium in the intensive care unit (ICU) is a frequent complication after cardiac or thoracic surgery and is associated with increased morbidity and mortality. METHODS In this single-center substudy of the BAG-RECALL trial (NCT00682825), we screened patients after cardiac or thoracic surgery in the ICU twice daily for delirium using the Confusion Assessment Method for the ICU. The primary outcome was the incidence of delirium in patients who had been randomized to intraoperative Bispectral Index (BIS)-guided and end-tidal anesthetic concentration-guided depth of anesthesia protocols. As a secondary analysis, a Bayesian stochastic search variable selection strategy was used to rank a field of candidate risk factors for delirium, followed by binary logistic regression. RESULTS Of 310 patients assessed, 28 of 149 (18.8%) in the BIS group and 45 of 161 (28.0%) in the end-tidal anesthetic concentration group developed postoperative delirium in the ICU (odds ratio 0.60, 95% confidence interval, 0.35-1.02, P= 0.058). Low average volatile anesthetic dose, intraoperative transfusion, ASA physical status, and European System for Cardiac Operative Risk Evaluation were identified as independent predictors of delirium. CONCLUSIONS A larger randomized study should determine whether brain monitoring with BIS or an alternative method decreases delirium after cardiac or thoracic surgery. The association between low anesthetic concentration and delirium is a surprising finding and could reflect that patients with poor health are both more sensitive to the effects of volatile anesthetic drugs and are also more likely to develop postoperative delirium. Investigation of candidate methods to prevent delirium should be prioritized in view of the established association between postoperative delirium and adverse patient outcomes.


title: Increased Postoperative Glucose Variability Is Associated with Adverse Outcomes Following Total Joint Arthroplasty.

text: BACKGROUND Increased glucose variability during hospitalization has been associated with a longer length of stay in the hospital and a higher mortality rate following non-orthopaedic surgical procedures. Our aim was to investigate the association between glucose variability and postoperative complications following total joint arthroplasty. METHODS We analyzed data on 21,487 patients who had undergone total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a single center from 2001 to 2017. Patients with a minimum of 2 postoperative glucose values per day or >3 values overall were included in the study. Glucose variability was assessed using a coefficient of variation. Adverse outcomes included an increased length of stay in the hospital, 90-day mortality, reoperations, periprosthetic joint infection, and surgical site infection. Periprosthetic joint infection was defined using the Musculoskeletal Infection Society criteria. RESULTS The final cohort included 2,360 patients who had undergone THA and 2,698 who had undergone TKA; 1,007 (19.9%) had diabetes. Higher glycemic variability was associated with an increased length of stay, 90-day mortality, periprosthetic joint infection, and surgical site infection. Adjusted analysis indicated that for every 10-percentage-point increase in the coefficient of variation, the length of stay increased by 6.1% (95% confidence interval [CI], 5.1% to 7.2%; p < 0.001), the risk of mortality increased by 26% (odds ratio [OR] = 1.26, 95% CI = 0.98 to 1.61; p = 0.07), and the risks of periprosthetic joint infection and surgical site infection increased by 20% (OR = 1.20, 95% CI = 1.02 to 1.41; p = 0.03) and 14% (OR = 1.14, 95% CI = 1.00 to 1.31; p = 0.06), respectively. These associations were independent of the year of surgery, age, body mass index, Elixhauser comorbidity index, diagnosis of diabetes, in-hospital use of insulin or steroids, and mean glucose values during hospitalization. CONCLUSIONS Higher glucose variability in the postoperative period is associated with increased rates of surgical site and periprosthetic joint infections and may be a useful predictor of the risk of mortality following THA and TKA. Efforts should be made to control the glucose variability in the early postoperative period, and future studies should examine the role of continuous glucose monitoring in a subset of patients with high glucose fluctuations. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.


title: Endovascular Devices and Revascularization Techniques for Limb-Threatening Ischemia in Individuals With Diabetes.

text: Diabetes mellitus (DM) is a rapidly worsening global epidemic over the last thirty-five years. The increased prevalence of DM has changed the phenotypic expression of atherosclerotic limb threatening ischemia (LTI), resulting in an increase in lesions in the tibial vessels. These patients are also afflicted with peripheral neuropathy, foot deformities, and medial calcification of the vasculature. In response to the evolving phenotype of atherosclerosis, newer minimally invasive tools and techniques have been developed to improve the blood supply in LTI. Arterial access, traditionally obtained from the contralateral common femoral artery (CFA) in a retrograde fashion, is now also frequently being obtained in the ipsilateral limb in an antegrade fashion. Retrograde access of the tibial, pedal, tarsal, or calf collateral vessels is also being utilized to provide a route through which wires, catheters, balloons and stents may be placed. Wires have evolved to have a variety of diameters, materials and coatings providing interventionalists with a wide variety of choices when attempting to traverse blockages in the arteries. When catheters and wires fail to traverse the lesion, newer chronic total occlusion (CTO) devices have been developed to aid in the placement of a wire across the offending lesions. Due to medial calcification associated with DM, atherectomy devices have been developed to debulk the atherosclerotic plaque within the vessel. High pressure balloon angioplasty with or without stents remain the mainstay of intervention, with drug-coated balloons (DCBs) and drug-eluting stents (DESs) now being frequently used to prevent reocclusions of atherosclerotic lesions.


Sibling Grief #394.


title: Shared Ventilation in the Era of COVID-19: A Theoretical Consideration of the Dangers and Potential Solutions.

text: INTRODUCTION The use of shared ventilation, or the simultaneous support of multiple patients connected in parallel to a single mechanical ventilator, is receiving considerable interest for addressing the severe shortage of mechanical ventilators available during the novel coronavirus pandemic (COVID-19). In this paper we highlight the potentially disastrous consequences of naïve shared ventilation, in which patients are simply connected in parallel to a ventilator without any regard to their individual ventilatory requirements. We then examine possible approaches for individualization of mechanical ventilation, using modifications to the breathing circuit that may enable tuning of individual tidal volumes and driving pressures during either volume-controlled ventilation (VCV) or pressure-controlled ventilation (PCV). METHODS Breathing circuit modifications included a PEEP valve on each expiratory limb for both VCV and PCV, an adjustable constriction and one-way valve on the inspiratory limb for VCV, and a pressure relief valve for peak-inspiratory pressure reduction on the inspiratory limb for PCV. The ability to regulate individual tidal volumes using these breathing circuit modifications was tested both theoretically in computer simulations as well as experimentally in mechanical test lungs. RESULTS In both the simulations and experimental measurements, naïve shared ventilation resulted in large imbalances across individual tidal volume delivery, dependent on imbalances across patient mechanical properties. The proposed breathing circuit modifications for shared VCV and shared PCV enabled optimization of tidal volume distributions. Individual tidal volume for one patient during shared VCV was sensitive to changes in the mechanical properties of other patients. By contrast, shared PCV enabled independent control of individual patient received ventilation. CONCLUSIONS Of the shared ventilation strategies considered, shared PCV, with the inclusion of in-line pressure relief valves in the individual inspiratory and expiratory limbs, offers the greatest degree of safety and lowest risk of catastrophic mechanical interactions between multiple patients connected to a single ventilator.


Covid-19: Each discarded face mask is a potential biohazard.


Alemtuzumab in multiple sclerosis during the COVID-19 pandemic: A mild uncomplicated infection despite intense immunosuppression.


title: The effects of food on opioid-induced nausea and vomiting and pharmacological parameters: a systematic review.

text: Opioids remain the standard of care for treating moderate to severe pain resulting from surgery or injury in cases of acute pain, and are recommended for patients who have not responded to nonopioid analgesics. Effective management of pain has an impact on clinical course and often depends on achieving an acceptable balance between opioid efficacy, safety, and tolerability. Common opioid-related adverse events such as nausea and vomiting are associated with an overall lower achievement of effective pain management and patient satisfaction. However, in practice, clinicians employ various strategies to maximize efficacy, minimize these adverse effects, and ensure the careful, judicious, and evidence-based use of opioids for patients who require them. Typical strategies for management and minimization of these types of adverse events include dose reduction, dose titration, opioid rotation, prescription for an antiemetic, and recommending the patient take opioids with food. Overall, the most straightforward approach that clinicians tend to employ that does not require additional visits or adjustment of prescriptions, is to recommend patients take opioids with food. However, given the current climate with opioids, it is critical and imperative that decisions for use of opioids be grounded in a solid and thorough evidence-base. In fact, several opioids are recommended to be taken explicitly with or without food because of interactions with abuse-deterrent technologies that can cause increased adverse events or inadequate analgesia. Therefore, we sought to review, synthesize, and summarize the literature for randomized, controlled trials and other studies to support the hypothesis that taking opioids with food reduces opioid-related events such as nausea and vomiting. Based on the current evidence we surveyed, the recommendation to take opioids with food does not appear to consistently and unequivocally reduce nausea and vomiting and, in many cases, increases the frequency of these adverse events in the studies we examined.


title: Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy.

text: BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium-glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin-angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P = 0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P = 0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P = 0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years. (Funded by Janssen Research and Development; CREDENCE ClinicalTrials.gov number, NCT02065791.).


title: Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke : A Multicenter Analysis.

text: AIM In acute large vessel occlusions, endovascular therapy (EVT) achieves flow restoration in the majority of cases; however, EVT fails to achieve sufficient reperfusion in a substantial minority of patients. This study aimed to identify predictors of failed reperfusion. METHODS In this study 2211 patients from the German Stroke Registry who received EVT for anterior circulation stroke were retrospectively analyzed. Failure of reperfusion was defined as thrombolysis in cerebral infarction (TICI) grades 0/1/2a, and sufficient reperfusion as TICI 2b/3. In 1629 patients with complete datasets, associations between failure of reperfusion and baseline clinical data, comorbidities, location of occlusion, and procedural data were assessed with multiple logistic regression. RESULTS Failure of reperfusion occurred in 371 patients (16.8%) and was associated with the following locations of occlusion: cervical internal carotid artery (ICA, adjusted odds ratio, OR 2.01, 95% confidence interval, CI 1.08-3.69), intracranial ICA without carotid T occlusion (adjusted OR 1.79, 95% CI 1.05-2.98), and M2 segment (adjusted OR 1.86, 95% CI 1.21-2.84). Failed reperfusion was also associated with cervical ICA stenosis (>70% stenosis, adjusted OR 2.90, 95% CI 1.69-4.97), stroke of other determined etiology by TOAST (Trial of ORG 10172 in acute stroke treatment) criteria (e.g. nonatherosclerotic vasculopathies, adjusted OR 2.73, 95% CI 1.36-5.39), and treatment given outside the usual working hours (adjusted OR 1.41, 95% CI 1.07-1.86). Successful reperfusion was associated with higher Alberta stroke program early CT score (ASPECTS) on initial imaging (adjusted OR 0.85, 95% CI 0.79-0.92), treatment with the patient under general anesthesia (adjusted OR 0.72, 95% CI 0.54-0.96), and concomitant ICA stenting in patients with ICA stenosis (adjusted OR 0.20, 95% CI 0.11-0.38). CONCLUSION Several factors are associated with failure of reperfusion, most notably occlusions of the proximal ICA and low ASPECTS on admission. Conversely, stent placement in the proximal ICA was associated with reperfusion success.