title: Webside Manner during the COVID-19 Pandemic: Maintaining Human Connection during Virtual Visits.

text: Background: As the death rate numbers in the United States related to COVID-19 are in the tens of thousands, clinicians are increasingly tasked with having serious illness conversations. However, in the setting of infection control policies, visitor restrictions, social distancing, and a lack of personal protective equipment, many of these important conversations are occurring by virtual visits. Objective: From our experience with a multisite study exploring the effectiveness of virtual palliative care, we have identified key elements of webside manner that are helpful when conducting serious illness conversations by virtual visit. Results: The key elements and components of webside manner skills are proper set up, acquainting the participant, maintaining conversation rhythm, responding to emotion, and closing the visit. Other considerations that may require conversion to phone visits include persistent technical difficulties, lack of prerequisite technology to conduct virtual visits, patients who are too ill to participate, or who find virtual visits too technically challenging. Conclusions: Similar to bedside manner, possessing nuanced verbal and nonverbal webside manner skills is essential to conducting serious illness conversations during virtual visits.


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title: Injection of N‑butyl Cyanoacrylate Through a Dual-Lumen Balloon for Embolization of High-flow Intranidal Fistulas in Brain Arteriovenous Malformations: Technical Note.

text: PURPOSE N-butyl cyanoacrylate (NBCA) glue is a valuable liquid embolic agent for the endovascular treatment of brain arteriovenous malformations (BAVM). The use of NBCA carries a risk of embolic agent reflux and distal migration with ensuing possibility of venous drainage compromise. The aim of this technical note is to describe a single center case series of high-flow intranidal fistulas embolized though a dual lumen balloon under local flow-arrest conditions. METHODS This article presents a retrospective description of a case series including five NBCA injections through a dual lumen balloon performed by a single operator in three patients with BAVM. Demographic, clinical, imaging and procedure-related data are reported. RESULTS The three patients presented with ruptured BAVMs. Of the patients, one underwent proximal flow-related ruptured aneurysm coiling before planned BAVM embolization. In the three patients, staged BAVM embolization as a first line treatment was decided. Preliminary embolization of high-flow BAVM fistulas by NBCA using a dual lumen balloon under local flow-arrest conditions was performed and five separate injections were carried out without any complications. No balloon entrapment or rupture was observed. CONCLUSION High-flow BAVM fistulas can be treated with NBCA embolization using a dual lumen balloon under local flow-arrest conditions.


title: Arterivirus minor envelope proteins are a major determinant of viral tropism in cell culture.

text: Arteriviruses are enveloped positive-strand RNA viruses for which the attachment proteins and cellular receptors have remained largely controversial. Arterivirus particles contain at least eight envelope proteins, an unusually large number among RNA viruses. These appear to segregate into three groups: major structural components (major glycoprotein GP5 and membrane protein [M]), minor glycoproteins (GP2a, GP3, and GP4), and small hydrophobic proteins (E and the recently discovered ORF5a protein). Biochemical studies previously suggested that the GP5-M heterodimer of porcine reproductive and respiratory syndrome virus (PRRSV) interacts with porcine sialoadhesin (pSn) in porcine alveolar macrophages (PAM). However, another study proposed that minor protein GP4, along with GP2a, interacts with CD163, another reported cellular receptor for PRRSV. In this study, we provide genetic evidence that the minor envelope proteins are the major determinant of arterivirus entry into cultured cells. A PRRSV infectious cDNA clone was equipped with open reading frames (ORFs) encoding minor envelope and E proteins of equine arteritis virus (EAV), the only known arterivirus displaying a broad tropism in cultured cells. Although PRRSV and EAV are only distantly related and utilize diversified transcription-regulating sequences (TRSs), a viable chimeric progeny virus was rescued. Strikingly, this chimeric virus (vAPRRS-EAV2ab34) acquired the broad in vitro cell tropism of EAV, demonstrating that the minor envelope proteins play a critical role as viral attachment proteins. We believe that chimeric arteriviruses of this kind will be a powerful tool for further dissection of the arterivirus replicative cycle, including virus entry, subgenomic RNA synthesis, and virion assembly.


Caring for Refugee Children.


title: Comparison of postoperative pain between single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy: prospective case-control study.

text: BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) is an emerging technique used in cholecystectomy. Nevertheless, studies on the difference in postoperative pain between SILC and conventional laparoscopic cholecystectomy are lacking in the literature. PATIENT AND METHODS From August 2009 to July 2010, 20 consecutive patients who underwent SILC (SILC group) were compared with a prospective cohort of 20 patients who underwent conventional 4-port laparoscopic cholecystectomy (LC group) during the same period. Standard postoperative analgesic protocol was applied to all patients. Pain scores were registered before operation and one day after operation using visual analog scale. Satisfactory score was self-assessed by all patients one month after surgery using visual analog scale. RESULTS There was no significant difference in the baseline characteristics, preoperative pain score, and intraoperative opioid usage between the 2 groups. The postoperative pain score was significantly lower in the SILC group (2.9±1.6 in SILC group vs. 4.8±1.5 in LC group, P<0.01). There was also a lower analgesic consumption and a higher satisfactory score in the SILC group although the results did not reach statistical significance. CONCLUSIONS SILC resulted in significantly less postoperative pain than conventional laparoscopic cholecystectomy. It is a safe alternative to conventional laparoscopic cholecystectomy.


title: Pediatric Emergency Department responses to COVID-19: transitioning from surge preparation to regional support.

text: In the midst of a global pandemic, hospitals around the world are working to meet the demand for patients ill with COVID-19 caused by the novel coronavirus first identified in Wuhan, China. As the crisis unfolds, several countries have reported lower numbers as well as less morbidity and mortality for pediatric patients. Thus, pediatric centers find themselves pivoting from preparing for a patient surge to finding ways to support the regional response for adults. This report describes the response from two west coast freestanding academic children's hospitals that were among the first cities in the United States impacted during this pandemic.


title: Torquetenovirus infection and ciliary dysmotility in children with recurrent pneumonia.

text: BACKGROUND The aim of the study was to assess Torquetenovirus (TTV) loads within respiratory ciliated cells and to verify the existence of a correlation between TTV loads and functional or structural ciliary abnormalities, in a group of children with recurrent or persistent pneumonia. METHODS Nasal brushing samples of 55 children (28 male) were evaluated for ciliary motion and ultrastructural assessment, as well as for detection and quantification of TTV. Moreover, presence and load of TTV within ciliated cells, obtained from 5 patients by laser capture microdissection, were determined. RESULTS The nasal samples of 47 (85%) children with persistent or recurrent pneumonia resulted positive for TTV (loads = 2.1-7.3 log10 copies/microg total DNA). TTV were demonstrated also within microdissected ciliated cells. No significant difference between primary (11 subjects) and secondary ciliary dyskinesia (44 subjects) for TTV prevalence and mean loads were found. A significant correlation was observed between nasal TTV loads and ciliary beat frequency score (r = 0.305; P < 0.05), but not between TTV loads and presence of abnormal motion patterns, in patients with secondary ciliary abnormalities. As expected no correlations were found between nasal TTV loads and ciliary motion analysis in primary ciliary dyskinesia. CONCLUSIONS The presence of TTV in nasal samples demonstrates TTV ability to infect respiratory ciliated cells and suggests that these cells are potentially able to support virus replication. Moreover, TTV may behave in respiratory cells in a similar way to other viruses, that is, they disrupt the mucociliary escalator.


title: Antibiotics in acute exacerbations of chronic bronchitis.

text: Acute exacerbations of chronic bronchitis (AECB) are a major contributor to morbidity and mortality in patients with chronic obstructive pulmonary disease, accounting for more than 16 million physician office visits and over 500,000 hospitalizations in the USA each year. Antimicrobials have been recognized by clinical guidelines as an important component in the management of AECB with a bacterial etiology. The challenge of identifying patients most likely to benefit from antimicrobial therapy is difficult in the clinical setting. However, appropriate risk stratification of patients, and the use of antimicrobials within the correct spectrum and for a suitable duration, can improve clinical outcomes while minimizing induction of antimicrobial resistance. With an improved design in pharmacologic and clinical studies, differences can be appreciated among the various antimicrobial agents available to treat AECB. Factors to be considered in antimicrobial agent selection include local tissue penetration, effects on bacteriological eradication, duration of therapy, speed of resolution and prevention or delay of recurrences.


title: Dysphagia in non-traumatic subarachnoid haemorrhage: a scoping review.

text: There is currently limited information regarding dysphagia following non-traumatic subarachnoid haemorrhage (SAH), which impacts upon speech-language pathologists' (SLP) decisions when providing clinical care for this patient cohort. This scoping review aims to summarise the available evidence on the topic and identify gaps in the literature. The scoping review framework as described by Arskey and O'Malley (Soc Res Methodol 8(1):19-32, 2005) was used. Searches were undertaken in six databases. Inclusion criteria included that participants were adults (18+ years), with a primary diagnosis of non-traumatic SAH, and dysphagia occurred as a result of non-traumatic SAH. Data was extracted by the primary author independently and cross-checked by the second author. Data extracted included year of publication, study location, population, aims of the study, study design, method used to identify dysphagia, who completed the assessment, dysphagia incidence, dysphagia type and severity, risk factors, characteristics, and intervention details. Ten studies were included. Dysphagia was diagnosed based on staff reports, screening, clinical swallowing examination, and/or instrumental swallowing assessment with considerable variability identified across studies with regard to incidence (range 0.9-100%). Studies were highly heterogeneous with regard to dysphagia assessment practice, risk factors, characteristics, provision of intervention, and outcomes. The current evidence regarding dysphagia following non-traumatic SAH is insufficient to provide best practice guidelines for assessment and management recommendations. Emerging evidence will inform healthcare professionals managing dysphagia in individuals following non-traumatic SAH. Future research with more rigorous study designs will promote evidence-based clinical care standards for this population.


title: Incidental haemothorax after sublobar resection: did staple line scratch chest wall?

text: We herein report a case of life-threatening haemothorax that occurred 40 days after pulmonary segmentectomy in a 60-year-old man. The patient uneventfully underwent resection of the apical and posterior segments of the right upper lobe by video-assisted thoracic surgery for early-stage lung cancer. An emergency operation of haemostat for active bleeding from the intercostal artery was successful via a right thoracotomy. The bleeding point was in the vicinity of the staple line dividing the intersegmental plane. This case reveals that scratch by staples can cause haemothorax through incidental injury of the intercostal artery.


title: Diagnosis and management of prosthetic joint infection.

text: PURPOSE OF REVIEW Prosthetic joint infection remains a devastating complication of arthroplasty associated with significant patient morbidity. The demand for arthroplasty is rapidly growing with a corresponding increase in the number of infections involving the prosthesis. The diagnosis and treatment of prosthetic joint infections presents a significant challenge to orthopaedic and infectious diseases clinicians. RECENT FINDINGS The underlying pathogenesis of prosthetic joint infections is due to the ability of the microorganisms to form a biofilm. The biofilm provides protection against host immune responses and antimicrobial therapy. In addition, it impedes standard laboratory diagnostic techniques. This review will examine new investigations to improve the diagnostic yield and rapidity of diagnosis of infections, including the use of sonication to disrupt the biofilm, new molecular tests to improve the detection of infecting microorganisms and new imaging techniques such as (18)F-fluoro-deoxyglucose PET. SUMMARY The successful treatment of prosthetic joint infections is dependent on eliminating the biofilm dwelling microorganisms whilst maintaining patient mobility and quality of life. This review will examine current understanding of management approaches for these infections, with a particular focus on antimicrobial therapy with activity against the biofilm, such as rifampicin and fluoroquinolones.


title: Laparoscopic Hepatectomy for Liver Cancer.

text: This chapter covers a range of important topics of laparoscopic hepatectomy as a novel approach toward treatment of liver cancer. Although laparoscopic hepatectomy was performed in a limited number of centers in the 1990s, technological innovations, improvements in surgical techniques and accumulation of experience by surgeons have led to more rapid progress in laparoscopic hepatectomy in the late 2000s for minimally invasive hepatic surgery. Currently, laparoscopic hepatectomy can be performed for all tumor locations and several diseases via several approaches. The laparoscopic approach can be applied to several types of resection, not only for tumors but also for liver transplantation, with equivalent or better results compared with those obtained with open surgery. Therefore, laparoscopic hepatectomy will become a standard procedure for treatment of liver cancer in the near future.


IgA Staining Patterns Differentiate Between IgA Nephropathy and IgA-Dominant Infection-Associated Glomerulonephritis.


title: Major intraoperative complications during video-assisted thoracoscopic anatomical lung resections: an intention-to-treat analysis.

text: OBJECTIVES A multicentre evaluation of the frequency and nature of major intraoperative complications during video-assisted thoracoscopic (VATS) anatomical resections. METHODS Six European centres submitted their series of consecutive anatomical lung resections with the intention to treat by VATS. Conversions to thoracotomy, vascular injuries and major intraoperative complications were studied in relation to surgeons' experience. Major complications included immediate life-threatening complications (i.e. blood loss of more than 2 l), injury to proximal airway or other organs or those leading to unplanned additional anatomical resections. All cases were discussed by a panel and recommendations were drafted. RESULTS A total of 3076 patients were registered. Most resections (90%, n = 2763) were performed for bronchial carcinoma. There were 3 intraoperative deaths, including 1 after conversion for technical reasons. In-hospital mortality was 1.4% (n = 43). Conversion to open thoracotomy was observed in 5.5% (n = 170), of whom 21.8% (n = 37) were for oncological reasons, 29.4% (n = 50) for technical reasons and 48.8% (n = 83) for complications. Vascular injuries were reported in 2.9% (n = 88) patients and led to conversion in 2.2% (n = 70). In 1.5% (n = 46), major intraoperative complications were identified. These consisted of erroneous transection of bronchovascular structures (n = 9); injuries to gastrointestinal organs (n = 5) or proximal airway (n = 6); complications requiring additional unplanned major surgery (n = 9) or immediate life-threatening complications (n = 17). Twenty-three percent of the in-hospital mortalities (n = 10/43) were related to major intraoperative complications. Eight pneumonectomies (five intraoperative and three postoperative at 0.3%) were a consequence of a major complication. Surgeon's experience was related to non-oncological conversions, but not to vascular injuries or major complications in a multivariable logistic regression analysis. CONCLUSION Major intraoperative complications during VATS anatomical lung resections are infrequent, seem not to be related to surgical experience but have an important impact on patient outcome. Constant awareness and a structured plan of action are of paramount importance to prevent them.


title: Safety and efficacy of aneurysm treatment with WEB in the cumulative population of three prospective, multicenter series.

text: BACKGROUND Flow disruption with the WEB is an innovative endovascular approach for treatment of wide-neck bifurcation aneurysms. Initial studies have shown a low complication rate with good efficacy. PURPOSE To report clinical and anatomical results of the WEB treatment in the cumulative population of three Good Clinical Practice (GCP) studies: WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm), French Observatory, and WEBCAST-2. METHODS WEBCAST, French Observatory, and WEBCAST-2 are single-arm, prospective, multicenter, GCP studies dedicated to the evaluation of WEB treatment. Clinical data were independently evaluated. Postoperative and 1-year aneurysm occlusion was independently evaluated using the 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. RESULTS The cumulative population comprised 168 patients with 169 aneurysms, including 112 female subjects (66.7%). The patients' ages ranged between 27 and 77 years (mean 55.5±10.2 years). Aneurysm locations were middle cerebral artery in 86/169 aneurysms (50.9%), anterior communicating artery in 36/169 (21.3%), basilar artery in 30/169 (17.8%), and internal carotid artery terminus in 17/169 (10.1%). The aneurysm was ruptured in 14/169 (8.3%). There was no mortality at 1 month and procedure/device-related morbidity was 1.2% (2/168). At 1 year, complete aneurysm occlusion was observed in 81/153 aneurysms (52.9%), neck remnant in 40/153 aneurysms (26.1%), and aneurysm remnant in 32/153 aneurysms (20.9%). Re-treatment was carried out in 6.9%. CONCLUSIONS This series is at the moment the largest prospective, multicenter, GCP series of patients with aneurysms treated with WEB. It shows the high safety and good mid-term efficacy of this treatment. CLINICAL TRIAL REGISTRATION French Observatory: Unique identifier (NCT18069); WEBCAST and WEBCAST-2: Unique identifier (NCT01778322).


title: Balancing ischaemia and bleeding risks with novel oral anticoagulants.

text: Vitamin K antagonists (VKAs) have long been the standard of care for treatment of venous thromboembolism (VTE), and thromboprophylaxis in atrial fibrillation (AF). Despite their efficacy, their use requires frequent monitoring and is complicated by drug-drug interactions and the need to maintain a narrow therapeutic window. Since 2009, novel oral anticoagulants (NOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors apixaban, edoxaban, and rivaroxaban, have become alternative options to VKAs owing to their predictable and safe pharmacological profiles. The overall clinical effect of these drugs, which is a balance between ischaemic benefit and bleeding harm, varies according to the clinical scenario. As adjunctive therapy to dual antiplatelet therapy in patients with acute coronary syndrome, NOACs are associated with incremental bleeding risks and modest benefits. For treatment of VTE, NOACs have a safer profile than VKAs and a similar efficacy. In thromboprophylaxis in AF, NOACs are associated with the greatest benefits by reducing both ischaemic events and haemorrhagic complications and might reduce mortality compared with VKAs. The role of NOACs continues to evolve as these drugs are evaluated in different patient populations, including those with renal impairment or with AF and undergoing percutaneous coronary intervention.


title: Making the business case for resource recovery.

text: People altered the biophysical environment upon which they depend through the overexploitation of resources and growing waste generation. Action is urgently needed to return the resource economy within planetary boundaries and safeguard human well-being, by realising an increasingly closed-loop system that maintains values of materials and products within a sustainable circular economy. Innovative technologies and business models must be developed and implemented, requiring convincing "business cases" for industry and government; why should they be interested in adopting circular, resource recovery practices? Despite multi-dimensional challenges facing people and their environment, and the ability of resource recovery to contribute to restoring environment, society and economy, arguments for circular practices are often overly focused on economic aspects. Economic growth is not a panacea and this article supports the preparation of better arguments by presenting expert insights on 37 themes to consider for a resource recovery business case. The most important themes cover 1) Economic, social, environmental and technical value of resources and 2) Regulatory change; focusing business cases on these is likely to deliver positive impacts regarding all identified themes. The article synthesises the old "growth will solve it-" with a new "multi-dimensional challenges and solutions" paradigm, suggesting that resource recovery should support multi-dimensional growth to partly redistribute economic benefits to social and environmental values through the preservation of technical, functional value of materials and products. Writing successful business cases for resource recovery requires inter-disciplinary collaboration, and sustained effort to complete and translate business cases into measurable impacts through changed practices outside academia.


title: Robotic-assisted laparoscopic radical cystoprostatectomy and extracorporeal continent urinary diversion: highlight of surgical techniques and outcomes.

text: BACKGROUND We report our technique for robotic-assisted laparoscopic radical cystoprostatectomy (RARCP) and extracorporeal urinary diversion and present their clinical outcomes. METHODS Between October 2003 and December 2008 we performed 58 RARCPs with extracorporeal continent urinary diversion. Preoperative, operative and postoperative data was evaluated. RESULTS Mean patient age was 68 (range 46-89) years, with an average American Society of Anesthesiologists classification of 2.9. Mean operative time was 8 (range 5-11) h. Median blood loss was 450 ml. Thirteen patients received intra-operative blood transfusions and 22 patients received peri-operative blood transfusions. Continent urinary diversions were performed by means of the Studer technique (n = 42) or Indiana pouch (n = 16). Mean number of lymph nodes examined on lymphadenectomy was 27 (range 0-52). CONCLUSIONS Our RARCP and continent diversion technique is a safe and feasible option for primary urothelial carcinoma of the bladder. Oncological and surgical outcomes are comparable to open cystectomy series.


title: Targeting low-normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial.

text: PURPOSE We aimed to determine the feasibility of targeting low-normal or high-normal mean arterial pressure (MAP) after out-of-hospital cardiac arrest (OHCA) and its effect on markers of neurological injury. METHODS In the Carbon dioxide, Oxygen and Mean arterial pressure After Cardiac Arrest and REsuscitation (COMACARE) trial, we used a 23 factorial design to randomly assign patients after OHCA and resuscitation to low-normal or high-normal levels of arterial carbon dioxide tension, to normoxia or moderate hyperoxia, and to low-normal or high-normal MAP. In this paper we report the results of the low-normal (65-75 mmHg) vs. high-normal (80-100 mmHg) MAP comparison. The primary outcome was the serum concentration of neuron-specific enolase (NSE) at 48 h after cardiac arrest. The feasibility outcome was the difference in MAP between the groups. Secondary outcomes included S100B protein and cardiac troponin (TnT) concentrations, electroencephalography (EEG) findings, cerebral oxygenation and neurological outcome at 6 months after cardiac arrest. RESULTS We recruited 123 patients and included 120 in the final analysis. We found a clear separation in MAP between the groups (p < 0.001). The median (interquartile range) NSE concentration at 48 h was 20.6 µg/L (15.2-34.9 µg/L) in the low-normal MAP group and 22.0 µg/L (13.6-30.9 µg/L) in the high-normal MAP group, p = 0.522. We found no differences in the secondary outcomes. CONCLUSIONS Targeting a specific range of MAP was feasible during post-resuscitation intensive care. However, the blood pressure level did not affect the NSE concentration at 48 h after cardiac arrest, nor any secondary outcomes.


title: Systematic review and meta-analysis of iron therapy in anaemic adults without chronic kidney disease: updated and abridged Cochrane review.

text: AIMS Anaemia is increasingly recognized as having an independent impact upon patient outcomes in cardiac disease. The role of novel iron therapies to treat anaemia is increasing. This systematic review and meta-analysis assesses the efficacy and safety of iron therapies for the treatment of adults with anaemia. METHODS AND RESULTS Electronic databases and search engines were searched as per Cochrane methodology. Randomized controlled trials (RCTs) of iron vs. inactive control or placebo, as well as alternative formulations, doses, and routes in anaemic adults without chronic kidney disease or in the peri-partum period were eligible. The primary outcome of interest was mortality at 1 year. Secondary outcomes were blood transfusion, haemoglobin levels, quality of life, serious adverse events, and length of hospital stay. A total of 64 RCTs (including five studies of heart failure patients) comprising 9004 participants were included. None of the studies was at a low risk of bias. There were no statistically significant differences in mortality between iron and inactive control. Both oral and parenteral iron significantly reduced the proportion of patients requiring blood transfusion compared with inactive control [risk ratio (RR) 0.66, 95% confidence interval (CI) 0.48-0.90; and RR 0.84, 95% CI 0.73-0.97, respectively]. Haemoglobin was increased more by both oral and parenteral iron compared with inactive control [mean difference (MD) 0.91 g/dL, 95% CI 0.48 to 1.35; and MD 1.04, 95% CI 0.52 to 1.57, respectively], and parenteral iron demonstrated a greater increase when compared with oral iron (MD 0.53 g/dL, 95% CI 0.31-0.75). In all comparisons, there were no differences in the results comparing patients with and without heart failure. CONCLUSION Both oral and parenteral iron are shown to decrease the proportion of people who require blood transfusion and increase haemoglobin levels, without any benefit on mortality. Further trials at a low risk of bias, powered to measure clinically significant endpoints, are still required.


title: Measles virus infection diminishes preexisting antibodies that offer protection from other pathogens.

text: Measles virus is directly responsible for more than 100,000 deaths yearly. Epidemiological studies have associated measles with increased morbidity and mortality for years after infection, but the reasons why are poorly understood. Measles virus infects immune cells, causing acute immune suppression. To identify and quantify long-term effects of measles on the immune system, we used VirScan, an assay that tracks antibodies to thousands of pathogen epitopes in blood. We studied 77 unvaccinated children before and 2 months after natural measles virus infection. Measles caused elimination of 11 to 73% of the antibody repertoire across individuals. Recovery of antibodies was detected after natural reexposure to pathogens. Notably, these immune system effects were not observed in infants vaccinated against MMR (measles, mumps, and rubella), but were confirmed in measles-infected macaques. The reduction in humoral immune memory after measles infection generates potential vulnerability to future infections, underscoring the need for widespread vaccination.


title: The development and evaluation of an online application to assist in the extraction of data from graphs for use in systematic reviews.

text: Background: The extraction of data from the reports of primary studies, on which the results of systematic reviews depend, needs to be carried out accurately. To aid reliability, it is recommended that two researchers carry out data extraction independently. The extraction of statistical data from graphs in PDF files is particularly challenging, as the process is usually completely manual, and reviewers need sometimes to revert to holding a ruler against the page to read off values: an inherently time-consuming and error-prone process. Methods: To mitigate some of the above problems we developed a new web-based graphical data extraction tool to assist reviewers in extracting data from graphs. This tool aims to facilitate more accurate and timely data extraction through a user interface which can be used to extract data through mouse clicks. We carried out a non-inferiority evaluation to examine its performance in comparison to standard practice. Results: We found that our new graphical data extraction tool is not inferior to users' prior preferred current approaches. Our study was not designed to show superiority, but suggests that there may be a saving in time of around 6 minutes per graph, accompanied by a substantial increase in accuracy. Conclusions: Our study suggests that the incorporation of this type of tool in online systematic review software would be beneficial in facilitating the production of accurate and timely evidence synthesis to improve decision-making.


title: Can early computed tomography angiography after endovascular aortic aneurysm repair predict the need for reintervention in patients with type II endoleak?

text: PURPOSE This study was designed to identify parameters on CT angiography (CTA) of type II endoleaks following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), which can be used to predict the subsequent need for reinterventions. METHODS We retrospectively identified 62 patients with type II endoleak who underwent early CTA in mean 3.7 ± 1.9 days after EVAR. On the basis of follow-up examinations (mean follow-up period 911 days; range, 373-1,987 days), patients were stratified into two groups: those who did (n = 18) and those who did not (n = 44) require reintervention. CTA characteristics, such as AAA, endoleak, as well as nidus dimensions, patency of the inferior mesenteric artery, number of aortic branch vessels, and the pattern of endoleak appearance, were recorded and correlated with the clinical outcome. RESULTS Univariate and receiver operating characteristic curve regression analyses revealed significant differences between the two groups for the endoleak volume (surveillance group: 1391.6 ± 1427.9 mm(3); reintervention group: 3227.7 ± 2693.8 mm(3); cutoff value of 2,386 mm(3); p = 0.002), the endoleak diameter (13.6 ± 4.3 mm compared with 25.9 ± 9.6 mm; cutoff value of 19 mm; p < 0.0001), the number of aortic branch vessels (2.9 ± 1.2 compared with 4.2 ± 1.4 vessels; p = 0.001), as well as a "complex type" endoleak pattern (13.6 %, n = 6 compared with 44.4 %, n = 8; p = 0.02). CONCLUSIONS Early CTA can predict the future need for reintervention in patients with type II endoleak. Therefore, treatment decision should be based not only on aneurysm enlargement alone but also on other imaging characteristics.


title: Effects of Music Therapy During Total Knee Arthroplasty Under Spinal Anesthesia: A Prospective Randomized Controlled Study.

text: Purpose Music therapy is an effective non-pharmacologic intervention that is cost-effective, easy to implement, and customize. It has been shown to significantly alleviate anxiety and improve patient satisfaction. In this study, we aimed to compare music therapy to a control (no music) group with respect to sedation requirements, anxiety levels, and patient satisfaction for patients undergoing total knee arthroplasty under spinal anesthesia. Methods In this randomized controlled study, we compared the effect of music therapy in patients ≥ 18 years old. Patients undergoing total knee arthroplasty were screened for the study to rule out any contraindications for spinal anesthesia. Patients were randomized in a 1:1 ratio for either the "music" or "control" group. Both groups were compared for sedation requirements, preoperative and postoperative anxiety levels, and patient satisfaction. Results Subjects in the music group had a statistically significant lower than average State-Trait Anxiety Inventory (STAI)-State baseline score as compared to the control group (music group 31.00 (standard deviation (SD) 1.44), control group 38.04 (SD 2.35); p = 0.01). Postoperative STAI-State-Trait Anxiety Inventory (STAI)-State scores for the music group were lower for the music group than the control group (music group 28.34 (SD 1.64), control group 32.21 (SD 1.56), p= 0.09). STAI-Trait scores were similar pre-operatively, but significantly less post-operatively in the music group (28.14 SD 1.0) as compared to the control group (34.71 SD 2.31); p = 0.01. Propofol dose per kilogram per surgical minute was similar between the two groups (music group 0.05, control group 0.06; p= 0.264). Patient satisfaction scores with their perioperative experience were higher in the music group (p= 0.009). Conclusions Music therapy may be offered as an alternative to traditional anxiolytics intra-operatively. However further studies are warranted to evaluate whether or not music therapy can decrease sedation and anxiolytic medications during surgery. The type and mode of delivery of music also need to be studied to better understand the impact of music therapy. Clinical trial registry: Clinicaltrials.gov # NCT03569397.


title: Blood pressure variability and the development of early neurological deterioration following acute ischemic stroke.

text: OBJECTIVES Early neurological deterioration (END) is a common condition associated with poor outcome after acute ischemic stroke. We studied association between blood pressure (BP) variability and development of END. METHODS In this retrospective observational study, we studied a consecutive series of patients hospitalized for acute ischemic stroke within 24 h of onset. The primary outcome of interest was the development of END according to predefined criteria within the first 72 h of stroke onset. During this period, the mean, maximum (max), and minimum (min) values for the SBP and DBP were measured. The following parameters of BP variability were calculated for the SBP and DBP: the difference between the maximum and minimum (max-min), the SD, and the coefficient of variation. RESULTS Of the 1161 patients enrolled in the study (mean age, 67.5 ± 13.3 years; 59.6% men), 210 (18.1%) developed END. All of the BP variability parameters were linearly associated with END independent of mean BP and potential clinical variables (P values < 0.05 on likelihood ratio tests for trend), except for SBPmax-min. Among the other BP parameters, SBPmean, SBPmax, DBPmax, and DBPmin were independently associated with END. After adjustments for potential confounders, the odds for END increased 14-21% with each increase of one standard deviation in the BP variability parameter. CONCLUSION BP variability is independently and linearly associated with the development of neurologic deterioration in acute stage of ischemic stroke.


title: Analysis of apoptosis of memory T cells and dendritic cells during the early stages of viral infection or exposure to toll-like receptor agonists.

text: Profound type I interferon (IFN-I)-dependent attrition of memory CD8 and CD4 T cells occurs early during many infections. It is dramatic at 2 to 4 days following lymphocytic choriomeningitis virus (LCMV) infection of mice and can be elicited by the IFN-inducing Toll receptor agonist poly(I:C). We show that this attrition occurs in many organs, indicating that it is due to T cell loss rather than redistribution. This loss correlated with elevated intracellular staining of T cells ex vivo for activated caspases but with only low levels of ex vivo staining with annexin V, probably due to the rapid clearance of apoptotic cells in vivo. Instead, a high frequency of annexin V-reactive CD8alpha(+) dendritic cells (DCs), which are known to be highly phagocytic, accumulated in the spleen as the memory T cell populations disappeared. After short in vitro incubation, memory phenotype T cells isolated from LCMV-infected mice (day 3) or mice treated with poly(I:C) (12 h) displayed substantial DNA fragmentation, as detected by terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling (TUNEL) assay, compared to T cells isolated from uninfected mice, indicating a role for apoptosis in the memory T cell attrition. This apoptosis of memory CD8 T cells early during LCMV infection was reduced in mice lacking the proapoptotic molecule Bim. Evidence is presented showing that high levels of T cell attrition, as found in young mice, correlate with reduced immunodomination by cross-reactive memory cells.


title: Laparoscopic triple neurectomy for intractable groin pain: technical report of 3 cases.

text: BACKGROUND Neuropathic groin pain can be a severely debilitating condition. Triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerves is a viable treatment option. OBJECTIVE To present our initial experience with the laparoscopic retroperitoneal approach to triple neurectomy. METHODS Three patients (33 to 48 years of age) presented with chronic groin pain of 3 to 7 years' duration. The discomfort manifested in the ilioinguinal, iliohypogastric, and genitofemoral nerve distributions and severely affected their lifestyles, resulting in multiple unsuccessful medical and surgical treatments without symptomatic relief. Because the patients failed other modes of treatment, they underwent a laparoscopic retroperitoneal triple neurectomy. RESULTS Three patients underwent a triple neurectomy from November 2006 to May 2009. All patients reported debilitating chronic groin pain and underwent prior treatments ranging from anesthetic blocks to orchiectomy without lasting relief. The first case illustrates the anatomic variation of the genitofemoral nerve and the importance of transecting both branches for adequate symptomatic relief. The remaining cases demonstrate successful transection of all 3 nerves with significant pain relief at 10 months to 3 years of follow-up. No major complications were encountered. CONCLUSION This technique provides several advantages in the treatment of chronic groin pain. The retroperitoneal approach provides a facile method to reach the nerves in 1 stage and provides a dissection field free of previous scars. As a laparoscopic technique, benefits include small incision sites with small scars, less postoperative pain, and shorter hospitalizations and/or same-day discharges with effective relief of groin pain.


A17 Molecular characteristics of hepatitis B virus (HBV) isolated from chronic hepatitis B patients in South Vietnam.


title: Dynamic Thromboembolic Risk Modelling to Target Appropriate Preventative Strategies for Patients with Non-Small Cell Lung Cancer.

text: Prevention of cancer-associated thromboembolism (TE) remains a significant clinical challenge and priority world-wide safety initiative. In this prospective non-small cell lung cancer (NSCLC) cohort, longitudinal TE risk profiling (clinical and biomarker) was undertaken to develop risk stratification models for targeted TE prevention. These were compared with published models from Khorana, CATS, PROTECHT, CONKO, and CATS/MICA. The NSCLC cohort of 129 patients, median follow-up 22.0 months (range 5.6-31.3), demonstrated a hypercoagulable profile in >75% patients and TE incidence of 19%. High TE risk patients were those receiving chemotherapy with baseline fibrinogen ≥ 4 g/L and d-dimer ≥ 0.5 mg/L; or baseline d-dimer ≥ 1.5 mg/L; or month 1 d-dimer ≥ 1.5 mg/L. The model predicted TE with 100% sensitivity and 34% specificity (c-index 0.67), with TE incidence 27% vs. 0% for high vs. low-risk. A comparison using the Khorana, PROTECHT, and CONKO methods were not discriminatory; TE incidence 17⁻25% vs. 14⁻19% for high vs. low-risk (c-index 0.51⁻0.59). Continuous d-dimer (CATS/MICA model) was also not predictive of TE. Independent of tumour stage, high TE risk was associated with cancer progression (HR 1.9, p = 0.01) and mortality (HR 2.2, p = 0.02). The model was tested for scalability in a prospective gastrointestinal cancer cohort with equipotency demonstrated; 80% sensitivity and 39% specificity. This proposed TE risk prediction model is simple, practical, potent and can be used in the clinic for real-time, decision-making for targeted thromboprophylaxis. Validation in a multicentre randomised interventional study is underway (ACTRN12618000811202).


title: AngioJet-assisted transvenous-transhepatic mechanical thrombectomy in the portal vein.

text: Purpose To evaluate AngioJet-assisted transvenous portal vein (PV) thrombectomy for non-cirrhotic patients with total portal vein and mesenteric vein thrombosis (PVMVT). Material and methods From 2015 to 2016 four patients (3 male, mean 43.9 years, range 33-52 years) with acute (3 cases) and acute-on-chronic (1 case) PVMVT underwent transvenous thrombolysis. All patients received initial AngioJet (Boston Scientific, Natick, MA, USA) thrombectomy followed by continuous catheter directed thrombolysis with Urokinase (Medac, Wedel, Germany) for 22-52 hours. Transjugular intrahepatic portosystemic shunts (TIPS), using Viatorr stent grafts (W.L. Gore and Associates, AZ, USA; mean diameter: 10 mm, length: 60-80 mm), were implanted in all patients. Patients were followed clinically and with imaging (mean 646 days, range 392 to 936 days). Results Technical success was 100%. Therapeutic success was achieved in 75% of cases. AngioJet-assisted thrombectomy substantially reduced thrombus load in the acute cases, while only slight improvement was achieved in the acute-on-chronic case. Continuous thrombolysis subtotally re-established PV flow in the acute cases, while only minimal improvement was seen in the acute-on-chronic case. Following TIPS implantation complete PV recanalisation could be achieved in all acute cases. In the acute-on-chronic case initial stagnant PV flow was seen; however, PV and TIPS re-occluded 10 days after implantation. During follow-up PV remained patent in acute cases. Conclusions AngioJet-assisted thrombectomy was technically feasible and uncomplicated in all of our patients. The initial results suggest that AngioJet-assisted thrombectomy facilitates recanalisation in acute and severe cases of PVMVT.


title: Imaging RAGE expression in atherosclerotic plaques in hyperlipidemic pigs.

text: BACKGROUND Receptor for advanced glycated end product (RAGE) expression is a prominent feature of atherosclerosis. We have previously shown in apoE null mice uptake of a radiolabeled anti-RAGE antibody in atherosclerotic plaque and now evaluate RAGE-directed imaging to identify advanced plaques in a large animal model. METHODS Nine hyperlipidemic (HL) pigs were injected with 603.1 ± 129.5 MBq of (99m)Tc-anti-RAGE F(ab')2, and after 6 h (blood pool clearance), they underwent single-photon emission computed tomography/computed tomography (SPECT/CT) imaging of the neck, thorax, and hind limbs. Two HL pigs received (99m)Tc non-immune IgG F(ab')2, and three farm pigs were injected with (99m)Tc-anti-RAGE F(ab')2. After imaging, the pigs were euthanized. The aorta from the root to bifurcation was dissected, and the innominates, proximal carotids, and coronaries were dissected and counted, stained for H&E and RAGE, and AHA-classified. RESULTS On pathology, 24% of the arterial segments showed AHA class III or IV lesions, and these lesions were confined almost exclusively to coronaries and carotids with % stenosis from 15% to 65%. Scatter plots of %ID/g for class III/IV vs. I/II lesions showed almost complete separation. Focal vascular uptake of tracer visualized on SPECT scans corresponded to class III/IV lesions in the coronary and carotid vessels. In addition, uptake in the hind limbs was noted in the HL pigs and corresponded to RAGE staining of small arteries in the muscle sections. Correlations for the vascular lesions were r = 0.747, P = 0.001 for %ID vs. %ID/g and r = 0.83, P = 0.002 for %ID/g vs. % RAGE staining. CONCLUSIONS Uptake of radiolabeled anti-RAGE antibody in coronary and carotid fibroatheroma and in the small arteries of the hind limbs in a relevant large animal model of atherosclerosis supports the important role of RAGE in atherosclerosis and peripheral artery disease as a target for imaging and treatment.


title: Clinical benefit of remdesivir in rhesus macaques infected with SARS-CoV-2.

text: Effective therapeutics to treat COVID-19 are urgently needed. While many investigational, approved, and repurposed drugs have been suggested, preclinical data from animal models can guide the search for effective treatments by ruling out treatments without in vivo efficacy. Remdesivir (GS-5734) is a nucleotide analog prodrug with broad antiviral activity1,2, that is currently investigated in COVID-19 clinical trials and recently received Emergency Use Authorization from the US Food and Drug Administration3,4. In animal models, remdesivir treatment was effective against MERS-CoV and SARS-CoV infection.2,5,6 In vitro, remdesivir inhibited replication of SARS-CoV-2.7,8 Here, we investigated the efficacy of remdesivir treatment in a rhesus macaque model of SARS-CoV-2 infection9. In contrast to vehicle-treated animals, animals treated with remdesivir did not show signs of respiratory disease and had reduced pulmonary infiltrates on radiographs and reduced virus titers in bronchoalveolar lavages 12hrs after the first treatment administration. Virus shedding from the upper respiratory tract was not reduced by remdesivir treatment. At necropsy, lung viral loads of remdesivir-treated animals were lower and there was a reduction in damage to the lungs. Thus, therapeutic remdesivir treatment initiated early during infection had a clinical benefit in SARS-CoV-2-infected rhesus macaques. Although the rhesus macaque model does not represent the severe disease observed in a proportion of COVID-19 patients, our data support early remdesivir treatment initiation in COVID-19 patients to prevent progression to pneumonia.


title: Automated CT Perfusion Ischemic Core Volume and Noncontrast CT ASPECTS (Alberta Stroke Program Early CT Score): Correlation and Clinical Outcome Prediction in Large Vessel Stroke.

text: BACKGROUND AND PURPOSE The semiquantitative noncontrast CT Alberta Stroke Program Early CT Score (ASPECTS) and RAPID automated computed tomography (CT) perfusion (CTP) ischemic core volumetric measurements have been used to quantify infarct extent. We aim to determine the correlation between ASPECTS and CTP ischemic core, evaluate the variability of core volumes within ASPECTS strata, and assess the strength of their association with clinical outcomes. METHODS Review of a prospective, single-center database of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions with pretreatment CTP between September 2010 and September 2015. CTP was processed with RAPID software to identify ischemic core (relative cerebral blood flow<30% of normal tissue). RESULTS Three hundred and thirty-two patients fulfilled inclusion criteria. Median age was 66 years (55-75), median ASPECTS was 8 (7-9), whereas median CTP ischemic core was 11 cc (2-27). Median time from last normal to groin puncture was 5.8 hours (3.9-8.8), and 90-day modified Rankin scale score 0 to 2 was observed in 54%. The correlation between CTP ischemic core and ASPECTS was fair (R=-0.36; P<0.01). Twenty-six patients (8%) had ASPECTS <6 and CTP core ≤50 cc (37% had modified Rankin scale score 0-2, whereas 29% were deceased at 90 days). Conversely, 27 patients (8%) had CTP core >50 cc and ASPECTS ≥6 (29% had modified Rankin scale 0-2, whereas 21% were deceased at 90 days). Moderate correlations between ASPECTS and final infarct volume (R=-0.42; P<0.01) and between CTP ischemic core and final infarct volume (R=0.50; P<0.01) were observed; coefficients were not significantly influenced by the time from stroke onset to presentation. Multivariable regression indicated ASPECTS ≥6 (odds ratio 4.10; 95% confidence interval, 1.47-11.46; P=0.01) and CTP core ≤50 cc (odds ratio 3.86; 95% confidence interval, 1.22-12.15; P=0.02) independently and comparably predictive of good outcome. CONCLUSIONS There is wide variability of CTP-derived core volumes within ASPECTS strata. Patient selection may be affected by the imaging selection method.


title: FGF 19 and Bile Acids Increase Following Roux-en-Y Gastric Bypass but Not After Medical Management in Patients with Type 2 Diabetes.

text: BACKGROUND This study aims to quantify changes in fibroblast growth factor 19 (FGF19) and bile acids (BAs) in patients with uncontrolled type 2 diabetes randomized to Roux-en-Y gastric bypass (RYGB) vs intensive medical management (IMM) and matched for similar reduction in HbA1c after 1 year of treatment. METHODS Blood samples were drawn from patients who underwent a test meal challenge before and 1 year after IMM (n = 15) or RYGB (n = 15). RESULTS Mean HbA1c decreased from 9.7 to 6.4% after RYGB and from 9.1 to 6.1% in the IMM group. At 12 months, the number of diabetes medications used per subject in the RYGB group (2.5 ± 0.5) was less than in the IMM group (4.6 ± 0.3). After RYGB, FGF19 increased in the fasted (93 ± 15 to 152 ± 19 pg/ml; P = 0.008) and postprandial states (area under the curve (AUC), 10.8 ± 1.9 to 23.4 ± 4.1 pg × h/ml × 10(3); P = 0.006) but remained unchanged following IMM. BAs increased after RYGB (AUC ×10(3), 6.63 ± 1.3 to 15.16 ± 2.56 μM × h; P = 0.003) and decreased after IMM (AUC ×10(3), 8.22 ± 1.24 to 5.70 ± 0.70; P = 0.01). No changes were observed in the ratio of 12α-hydroxylated/non-12α-hyroxylated BAs. Following RYGB, FGF19 AUC correlated with BAs (r = 0.54, P = 0.04) and trended negatively with HbA1c (r = -0.44; P = 0.09); these associations were not observed after IMM. CONCLUSIONS BA and FGF19 levels increased after RYGB but not after IMM in subjects who achieved similar improvement in glycemic control. Further studies are necessary to determine whether these hormonal changes facilitate improved glucose homeostasis.


title: A multicentre randomized pilot trial on the effectiveness of different levels of cooling in comatose survivors of out-of-hospital cardiac arrest: the FROST-I trial.

text: PURPOSE To obtain initial data on the effect of different levels of targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA). METHODS We designed a multicentre pilot trial with 1:1:1 randomization to either 32 °C (n = 52), 33 °C (n = 49) or 34 °C (n = 49), via endovascular cooling devices during a 24-h period in comatose survivors of witnessed OHCA and initial shockable rhythm. The primary endpoint was the percentage of subjects surviving with good neurologic outcome defined by a modified Rankin Scale (mRS) score of ≤ 3, blindly assessed at 90 days. RESULTS At baseline, different proportions of patients who had received defibrillation administered by a bystander were assigned to groups of 32 °C (13.5%), 33 °C (34.7%) and 34 °C (28.6%; p = 0.03). The percentage of patients with an mRS ≤ 3 at 90 days (primary endpoint) was 65.3, 65.9 and 65.9% in patients assigned to 32, 33 and 34 °C, respectively, non-significant (NS). The multivariate Cox proportional hazards model identified two variables significantly related to the primary outcome: male gender and defibrillation by a bystander. Among the 43 patients who died before 90 days, 28 died following withdrawal of life-sustaining therapy, as follows: 7/16 (43.8%), 10/13 (76.9%) and 11/14 (78.6%) of patients assigned to 32, 33 and 34 °C, respectively (trend test p = 0.04). All levels of cooling were well tolerated. CONCLUSIONS There were no statistically significant differences in neurological outcomes among the different levels of TTM. However, future research should explore the efficacy of TTM at 32 °C. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov unique identifier: NCT02035839 ( http://clinicaltrials.gov ).


docid: wiaierdi

title: Emergency abdominal surgery in a patient anticoagulated with dabigatran.

text: Dabigatran is a newer oral anticoagulant, indicated for chronic atrial fibrillation anticoagulation. Experience with an emergent laparotomy in a patient on dabigatran is presented. Difficulties of this medication and strategies to deal with the coagulopathy from this direct thrombin inhibitor are described.


title: Resolvin D1, a metabolite of omega-3 polyunsaturated fatty acid, decreases post-myocardial infarct depression.

text: We hypothesized that inflammation induced by myocardial ischemia plays a central role in depression-like behavior after myocardial infarction (MI). Several experimental approaches that reduce inflammation also result in attenuation of depressive symptoms. We have demonstrated that Resolvin D1 (RvD1), a metabolite of omega-3 polyunsaturated fatty acids (PUFA) derived from docosahexaenoic acid, diminishes infarct size and neutrophil accumulation in the ischemic myocardium. The aim of this study is to determine if a single RvD1 injection could alleviate depressive symptoms in a rat model of MI. MI was induced in rats by occlusion of the left anterior descending coronary artery for 40 min. Five minutes before ischemia or after reperfusion, 0.1 μg of RvD1 or vehicle was injected in the left ventricle cavity. Fourteen days after MI, behavioral tests (forced swim test and socialization) were conducted to evaluate depression-like symptoms. RvD1 reduced infarct size in the treated vs. the vehicle group. Animals receiving RvD1 also showed better performance in the forced swim and social interaction tests vs. vehicle controls. These results indicate that a single RvD1 dose, given 5 min before occlusion or 5 min after the onset of reperfusion, decreases infarct size and attenuates depression-like symptoms.


title: Structural basis of a shared antibody response to SARS-CoV-2.

text: Molecular understanding of neutralizing antibody responses to SARS-CoV-2 could accelerate vaccine design and drug discovery. We analyzed 294 anti-SARS-CoV-2 antibodies and found that IGHV3-53 is the most frequently used IGHV gene for targeting the receptor-binding domain (RBD) of the spike protein. Co-crystal structures of two IGHV3-53 neutralizing antibodies with RBD, with or without Fab CR3022, at 2.33 to 3.20 Å resolution revealed that the germline-encoded residues dominate recognition of the ACE2 binding site. This binding mode limits the IGHV3-53 antibodies to short CDR H3 loops, but accommodates light-chain diversity. These IGHV3-53 antibodies show minimal affinity maturation and high potency, which is promising for vaccine design. Knowledge of these structural motifs and binding mode should facilitate design of antigens that elicit this type of neutralizing response.


title: [Delirium and multimorbidity in the elderly].

text: Delirium is an acute confusion state of multifactorial genesis, commonly seen in the elderly with multimorbidity. Age and dementia, followed by infections and polypharmacy, are known as the most important risk factors. Increased disease interactions and medication use in the multimorbid elderly might precipitate delirium. Serious consequences of multimorbidity often are psychiatric diseases such as depression. Also anxiety and schizoprenia show a high comorbidity with somatic diseases. The therapy of elderly multimorbid patients is risky and must be preceded by profound assessment of all pathogenic factors. Pharmacotherapy needs an ongoing screening for side effects and indication.


title: A novel liver parenchyma transection technique using locking straight rigid ties. An experimental study in pigs.

text: INTRODUCTION Technological advances have led to the development of many devices used in liver resections. However, no single transection tool is uniformly considered to be better than the others. This study aimed to develop an effective, fast, and cost-efficient technique for hepatic parenchymal transection. MATERIALS AND METHODS A liver parenchyma compression device in the form of a locking straight rigid tie (LoStRiT) was newly developed. Twelve pigs were distributed into two groups. The control group ( n = 6) comprised animals that underwent hepatectomy using the standard Kelly-clysis technique. The study group (n = 6) comprised animals that underwent hepatectomy using sequential LoStRiT mechanisms. The transection speed, blood loss, and biloma formation were recorded. RESULTS The mean parenchymal transection speed was 1.27 ± 0.27 cm(2)/min for the control group and 2.39 ± 0.56 cm(2)/min for the LoStRiT group ( p = .003). The mean blood loss per kilogram of body weight was 9.8 ± 5.2 ml/kg for the control group and 3.9 ± 0.9 ml/kg for the LoStRiT group ( p = .040). No bilomas were identified. CONCLUSION LoStRiT hepatectomy appears to be effective, fast, and reproducible in a porcine model of liver resection. Further development of this novel and potentially cost-efficient technique includes construction of the device using absorbable materials.


title: Mechanical thrombectomy with the Solitaire stent: is there a learning curve in achieving rapid recanalization times?

text: METHODS In acute ischemic stroke, good outcome following successful recanalization is time dependent. In patients undergoing endovascular therapy at our institution, recanalization times with the Solitaire stent were retrospectively evaluated to assess for the presence of a learning curve in achieving rapid recanalization. METHODS We reviewed patients who presented to our stroke center and achieved successful recanalization with the Solitaire stent exclusively. Time intervals were calculated (CT to angiography arrival, angiography arrival to groin puncture, groin puncture to first deployment, and deployment to recanalization) from time stamped images and angiography records. Patients were divided into three sequential groups, with overall CT to recanalization time and subdivided time intervals compared. RESULTS 83 patients were treated with the Solitaire stent from May 2009 to February 2012. Recanalization (Thrombolyis in Cerebral Infarction score 2A) occurred in 75 (90.4%) patients. CT to recanalization demonstrated significant improvement over time, which was greatest between the first 25 and the most recent 25 cases (161-94 min; p<0.01). The maximal contribution to this was from improvements in first stent deployment to recanalization time (p=0.001 between the first and third groups), with modest contributions from moving patients from CT to the angiography suite faster (p=0.02 between the first and third groups) and from groin puncture to first stent deployment (p=0.02 between the first and third groups). CONCLUSIONS There is a learning curve involved in the efficient use of the Solitaire stent in endovascular acute stroke therapy. Along with improvements in patient transfer to angiography and improved efficiency with intracranial access, mastering this device contributed significantly towards reducing recanalization times.


title: A lesson in treating the whole patient: Todd Nicholson's story.

text: The authors present a patients story to demonstrate the usefulness of a complete patient approach, incorporating V.A.C. therapy, to achieving clinical success from the patients perspective. The article discusses why a total patient approach is important and therapeutic flexibility increases the chance of a successful outcome for all involved.


title: CT colonography: performance and program outcome measures in an older screening population.

text: PURPOSE To evaluate computed tomographic (CT) colonography performance and program outcome measures in an older cohort (65-79 years) of an established large-scale colorectal cancer screening program. MATERIALS AND METHODS This HIPAA-compliant study was approved by the institutional review board; informed consent waived. Retrospective analysis of the 65-79-year-old cohort (n = 577) from the University of Wisconsin CT colonography screening program (n = 5176) was undertaken. Performance and outcome measures including advanced neoplasia prevalence and colonoscopy referral, extracolonic finding, extracolonic work-up, and complication rates were obtained by using a CT colonography database and review of medical records. Comparisons between the older cohort and the general screening population were made by using the Student t, Pearson chi(2), and Fisher exact tests. A P value <or= .05 was considered to indicate a significant difference. RESULTS With a 6-mm threshold for positivity, the overall referral rate to optical colonoscopy was 15.3% (88 of 577), leading to 277 polypectomies and the removal of 103 nondiminutive adenomas. For adenomas, the per-patient positivity rates were 10.9% (63 of 577) and 6.8% (39 of 577) at the 6- and 10-mm thresholds, respectively. The prevalence of advanced neoplasia was 7.6% (44 of 577). Fifty-four adenomas met advanced status, and five unsuspected cancers were detected. The advanced neoplasias identified were typically large, with a mean size of 21 mm. Potentially important extracolonic findings were seen in 15.4% (89 of 577) of patients, with a work-up rate of 7.8% (45 of 577). The majority of important extracolonic diagnoses were vascular aneurysms (n = 18). No major complications were encountered. CONCLUSION CT colonography is a safe and effective screening modality for the older population.


title: Differential Ventilation Using Flow Control Valves as a Potential Bridge to Full Ventilatory Support during the COVID-19 Crisis: From Bench to Bedside.

text: BACKGROUND During the COVID-19 pandemic, ventilator sharing was suggested to increase availability of mechanical ventilation. The safety and feasibility of ventilator sharing is unknown. METHODS A single ventilator in pressure control mode was used with flow control valves to simultaneously ventilate two patients with different lung compliances. The system was first evaluated using high-fidelity human patient simulator mannequins and then tested for 1 h in two pairs of COVID-19 patients with acute respiratory failure. Patients were matched on positive end-expiratory pressure, fractional inspired oxygen tension, and respiratory rate. Tidal volume and peak airway pressure (PMAX) were recorded from each patient using separate independent spirometers and arterial blood gas samples drawn at 0, 30, and 60 min. The authors assessed acid-base status, oxygenation, tidal volume, and PMAX for each patient. Stability was assessed by calculating the coefficient of variation. RESULTS The valves performed as expected in simulation, providing a stable tidal volume of 400 ml each to two mannequins with compliance ratios varying from 20:20 to 20:90 ml/cm H2O. The system was then tested in two pairs of patients. Pair 1 was a 49-yr-old woman, ideal body weight 46 kg, and a 55-yr-old man, ideal body weight 64 kg, with lung compliance 27 ml/cm H2O versus 35 ml/cm H2O. The coefficient of variation for tidal volume was 0.2 to 0.6%, and for PMAX 0 to 1.1%. Pair 2 was a 32-yr-old man, ideal body weight 62 kg, and a 56-yr-old woman, ideal body weight 46 kg, with lung compliance 12 ml/cm H2O versus 21 ml/cm H2O. The coefficient of variation for tidal volume was 1.4 to 7.7%, and for PMAX 0 to 2.1%. CONCLUSIONS Differential ventilation using a single ventilator is feasible. Flow control valves enable delivery of stable tidal volume and PMAX similar to those provided by individual ventilators. : WHAT WE ALREADY KNOW ABOUT THIS TOPIC: In previous mass casualty situations where intensive care unit or emergency room surge conditions have resulted, the use of ventilator splitting to ventilate two or more patients has been proposed.The concept has received renewed attention with the global COVID-19 pandemic.The impaired respiratory mechanics similar to the acute respiratory distress syndrome seen in COVID-19 patients pose significant engineering challenges to optimally ventilate one patient while preventing damage to a paired patient. WHAT THIS ARTICLE TELLS US THAT IS NEW Custom designed three-dimensional printed inspiratory flow control valves designed to allow individualized setting of tidal volume and airway pressure were evaluated using high-fidelity simulator mannequins with similar or different lung compliance and were found to perform as expected with stable tidal volumes delivered to each mannequin.Testing for 60 min in two pairs of volunteer COVID-19 patients with acute respiratory failure, matched on positive end-expiratory pressure level, fractional inspired oxygen tension level, and respiratory rate, demonstrated stable system performance. Continuous assessment of tidal volume and peak airway pressure in each patient during the study allowed for dynamic alteration of tidal volume in response to respiratory acidosis.This study suggests that custom designed flow control valves may facilitate the use of split ventilation techniques in a surge setting.


title: Pringle Maneuver in Extended Liver Resection: A propensity score analysis.

text: Despite the ongoing decades-long controversy, Pringle maneuver (PM) is still frequently used by hepatobiliary surgeons during hepatectomy. The aim of this study was to investigate the effect of PM on intraoperative blood loss, morbidity, and posthepatectomy hemorrhage (PHH). A series of 209 consecutive patients underwent extended hepatectomy (EH) (≥5 segment resection). The association of PM with perioperative outcomes was evaluated using multivariate analysis with a propensity score method to control for confounding. Fifty patients underwent PM with a median duration of 19 minutes. Multivariate analysis revealed that risk of excessive intraoperative bleeding (≥1500 ml; odds ratio [OR] 0.27, 95%-confidence interval [CI] 0.10-0.70, p = 0.007), major morbidity (OR 0.41, 95%-CI 0.18-0.97, p = 0.041), and PHH (OR 0.22, 95%-CI 0.06-0.79, p = 0.021) were significantly lower in PM group after EH. Furthermore, there was no significant difference in 3-year recurrence-free-survival between groups. PM is associated with lower intraoperative bleeding, PHH, and major morbidity risk after EH. Performing PM does not increase posthepatectomy liver failure and does not affect recurrence rate. Therefore, PM seems to be justified in EH.


title: Development of subunit vaccines against severe acute respiratory syndrome.

text: Severe acute respiratory syndrome (SARS) is a novel infectious disease caused by SARS coronavirus (SARS-CoV). Although SARS appears to have been successfully contained, there is still a risk for its reemergence due to sporadic laboratory accidents or the presence of a natural reservoir for SARS-CoV-like virus. Therefore, the development of effective vaccines against SARS-CoV continues to be the current focus of SARS research. This review will first describe the rationale for developing safe and effective SARS vaccines, followed by elucidating viral antigens that could be used as potential vaccine components. After comparing current vaccine categories against SARS, this article will demonstrate the advantages of subunit vaccines, describe the current situation of developing subunit vaccines, and point out the possibility for further improvement of subunit SARS vaccines. This suggests that recombinant protein/peptide-based subunit vaccines containing the spike protein, especially the receptor-bind domain of SARS-CoV, could be developed as safe and effective SARS vaccines.


Preventing dementia beyond treating hypertension.


title: COVID-19 in the Shadows of MERS-CoV in the Kingdom of Saudi Arabia.

text: Middle East Respiratory Syndrome Coronavirus (MERS-CoV) has plagued the Middle East since it was first reported in 2012. Recently, at the end of December 2019, a cluster of pneumonia cases were reported from Wuhan city, Hubei Province, China, linked to a wet seafood market with a new coronavirus identified as the etiologic agent currently named SARS-CoV-2. Most cases are in Mainland China with international spread to 25 countries. The novelty of the virus, the rapid national and international spread, and the lack of therapeutic and preventative strategies have led the WHO International Health Regulation emergency committee to declare the disease as Public Health Emergency of International Concern (PHEIC) on January 30, 2020. As it relates to countries with the ongoing MERS-CoV community cases and hospital acquired infections, there will be a huge challenge for HCWs to deal with both coronaviruses, especially with the lack of standardized and approved point of care testing. This challenge will now be faced by the whole global health community dealing with COVID-19 since both coronaviruses have similar presentation. Those patients should now be tested for both MERS-CoV and SARS-CoV-2 simultaneously, and with the continuing wide international spread of SARS-CoV-2, the travel history to China in the last 14 days will be of less significance.


title: Novel hemagglutinin-based influenza virus inhibitors.

text: Influenza virus has caused seasonal epidemics and worldwide pandemics, which caused tremendous loss of human lives and socioeconomics. Nowadays, only two classes of anti-influenza drugs, M2 ion channel inhibitors and neuraminidase inhibitors respectively, are used for prophylaxis and treatment of influenza virus infection. Unfortunately, influenza virus strains resistant to one or all of those drugs emerge frequently. Hemagglutinin (HA), the glycoprotein in influenza virus envelope, plays a critical role in viral binding, fusion and entry processes. Therefore, HA is a promising target for developing anti-influenza drugs, which block the initial entry step of viral life cycle. Here we reviewed recent understanding of conformational changes of HA in protein folding and fusion processes, and the discovery of HA-based influenza entry inhibitors, which may provide more choices for preventing and controlling potential pandemics caused by multi-resistant influenza viruses.


title: Assessment of helical interfaces in protein-protein interactions.

text: Herein we identify and analyze helical protein interfaces as potential targets for synthetic modulators of protein-protein interactions.


title: Stochastic two-group models with transmission dependent on host infectivity or susceptibility.

text: Stochastic epidemic models with two groups are formulated and applied to emerging and re-emerging infectious diseases. In recent emerging diseases, disease spread has been attributed to superspreaders, highly infectious individuals that infect a large number of susceptible individuals. In some re-emerging infectious diseases, disease spread is attributed to waning immunity in susceptible hosts. We apply a continuous-time Markov chain (CTMC) model to study disease emergence or re-emergence from different groups, where the transmission rates depend on either the infectious host or the susceptible host. Multitype branching processes approximate the dynamics of the CTMC model near the disease-free equilibrium and are used to estimate the probability of a minor or a major epidemic. It is shown that the probability of a major epidemic is greater if initiated by an individual from the superspreader group or by an individual from the highly susceptible group. The models are applied to Severe Acute Respiratory Syndrome and measles.


title: Assessing Quality of Syndesmotic Reduction in Surgically Treated Acute Syndesmotic Injuries: A Systematic Review.

text: There is no universal method with cutoff values for the assessment of distal tibiofibular joint reduction in acute syndesmotic injuries. It is important to detect malreductions because they may lead to impaired functional outcome and may demand reoperations. The aim of this study was to systematically review the literature to evaluate the appropriateness of different image techniques in determining syndesmotic malalignment. A literature search was conducted in Medline, Embase, and the Cochrane Library to search for articles assessing syndesmotic reduction. Excluded were articles where no criteria and/or measurements for syndesmotic reduction were provided, only normative values were provided and reviews. In total, 2157 articles were found, of which 1421 studies were screened for title and abstract after exclusion of duplicates. One hundred ten studies were eligible for full-text analysis. Of these, 61 were excluded. Three studies where added after screening the included references. Fifty-two studies were included, of which 32 were original publications and 20 were publications referring to the original publications. From the original publications, 14 used plains radiographs, 19 computed tomographic (CT) scans, and 5 used 3-dimensional CT scans (some authors used >1 modality in their study). For each modality, a large number of parameters and different cutoff values were reported. CT scanning is superior to plain radiography in the assessment of the quality of joint reduction. Parameters used the most were fibular position in the incisura and fibular rotation. The criteria for adequate reduction should at least include the position of the fibula in the incisura and rotation of the fibula, while ensuring adequate fibular length, all equaling or at least approaching the values of the uninjured contralateral side.


title: Vessel sealing comparison: old school is still hip.

text: BACKGROUND Ligation with either absorbable or non-absorbable sutures has been the traditional state of the art, but a proliferation of technology now offers a host of methods to close and divide vessels. Only limited data are available that objectively compare different vessel sealing methods. The objective of this study was to compare a broad variety of methods of surgical vessel closure in a reproducible, independent, standardized test-to-failure ex vivo pressure challenge. METHODS Ten of the most common surgical sealing devices were represented in this study, including both mechanical and energy devices. Unfixed porcine carotid arteries were selected for testing. They were connected to a pump, and automated controlled infusion was initiated. Upon identification of a leak at the source of sealing, the maximum pressure in mmHg was logged. RESULTS There were a total of 184 trials conducted using the 10 vessel sealing methods. The average burst pressure across all trials was 1100 mmHg with a range of 51.3-5171 mmHg. Suture-based methods displayed the highest average pressure until failure. Stapling methods showed the lowest burst pressures. All methods showed mean burst pressures above the "physiologically relevant" level of 250 mmHg. CONCLUSIONS This study presents an independent, reproducible, ex vivo comparison of multiple methods of surgical arterial closure. In these laboratory conditions, tests to failure demonstrated widely varying sealing strength, highly dependent on method. All hemostatic modalities tested are capable of securing vessels safely and well above physiologic blood pressures, while suture-based methods were significantly stronger than other mechanical methods or modern energy devices.


title: Sonic aerosol therapy to target maxillary sinuses.

text: AIM Intranasal aerosol administration of drugs is widely used by ENT specialists. Although clinical evidence is still lacking, intranasal nebulization appears to be an interesting therapeutic option for local drug delivery, targeting anatomic sites beyond the nasal valve. The sonic nebulizer NL11SN associates a 100Hertz (Hz) sound to the aerosolization to improve deposition in the nasal/paranasal sinuses. The aim of the present study was: to evaluate in vivo the influence of associating a 100Hz sound on sinus ventilation and nasal and pulmonary aerosol deposition in normal volunteers, and; to quantify in vitro aerosol deposition in the maxillary sinuses in a plastinated head model. MATERIAL AND METHODS Scintigraphic analysis of (81m)Kr gas ventilation and of sonic aerosol ((99m)Tc-DTPA) deposition using the NL11SN was performed in vivo in seven healthy volunteers. In parallel, NL11SN gentamicin nebulization was performed, with or without associated 100Hz sound, in a plastinated human head model; the gross amount of gentamicin delivered to the paranasal sinuses was determined by fluorescence polarization immunoassay. RESULTS Associating the 100Hz sound to (81m)Kr gas ensured paranasal sinus ventilation in healthy volunteers. (99m)Tc-DTPA particles nebulized with the NL11SN were deposited predominantly in the nasal cavities (2/3, vs 1/3 in the lungs). In vitro, the use of NL11SN in sonic mode increased gentamicin deposition threefold in the plastinated model sinuses (P<0.002); the resulting antibiotic deposit would be sufficient to induce a local therapeutic effect. CONCLUSION The NL11SN nebulizer ensured preferential nasal cavity aerosol deposition and successfully targeted the maxillary sinuses.


title: Nesiritide following maze and mitral valve surgery.

text: BACKGROUND Fluid retention following "maze" and mitral valve surgery has been associated with diminished levels of atrial natriuretic peptide (ANP). We hypothesized prophylactic administration of nesiritide (human recombinant brain natriuretic peptide, NES, Natrecor, Scios, Fremont, CA, USA), which has similar physiologic properties to ANP and would promote diuresis in maze and mitral patients postoperatively. METHODS Randomized, blinded, prospective pilot study comparing patients undergoing maze and mitral surgery including excision of the left atrial appendage. Three hours after cardiopulmonary bypass, patients received either a 72-hour infusion of NES at 0.01 mcg/kg/min (n = 9) or placebo (n = 10). Diuresis, diuretics, time to extubation, oxygenation, ANP, and serum Endothelin-1 levels were measured. Nonparametric analysis with Mann-Whitney test was performed with SPSS (SPSS Inc., Chicago, IL, USA). RESULTS In both groups, postoperative ANP levels fell from baseline (NES 330 to 280 ng/mL and control 220 to 150 ng/mL). There were no significant differences in patients receiving NES compared to controls in diuresis (1.33 mL/kg/hour urine output NES vs. 1.68 mL/kg/hour controls, p = 0.14); furosemide dosage (0.04 mg/kg/hour NES vs. 0.04 mg/kg/hour controls, p = 0.08); time to extubation (17.5 hours NES vs. 19.5 control, p = 0.42) or PaO2/FiO2 ratio at 48 hours (NES 200 vs. 273 control, p > 0.05). Endothelin-1 levels were higher at baseline with NES but not at 1 and 72 hours after cardiopulmonary bypass (NES 3.1, 3.8, 2.9 pg/mL vs. control 1.85, 4.05, 2.75 pg/mL; p = 0.01, 0.77, 0.47). CONCLUSIONS This pilot study did not demonstrate additional diuresis with nesiritide in postoperative mitral/maze patients already following a loop diuretic protocol.


title: Intraoperative use of transcranial motor/sensory evoked potential monitoring in the clipping of intracranial aneurysms: evaluation of false-positive and false-negative cases.

text: OBJECTIVESomatosensory and motor evoked potentials (SEPs and MEPs) are often used to prevent ischemic complications during aneurysm surgeries. However, surgeons often encounter cases with suspicious false-positive and false-negative results from intraoperative evoked potential (EP) monitoring, but the incidence and possible causes for these results are not well established. The aim of this study was to investigate the efficacy and reliability of EP monitoring in the microsurgical treatment of intracranial aneurysms by evaluating false-positive and false-negative cases.METHODSFrom January 2012 to April 2016, 1514 patients underwent surgery for unruptured intracranial aneurysms (UIAs) with EP monitoring at the authors' institution. An EP amplitude decrease of 50% or greater compared with the baseline amplitude was defined as a significant EP change. Correlations between immediate postoperative motor weakness and EP monitoring results were retrospectively reviewed. The authors calculated the sensitivity, specificity, and positive and negative predictive values of intraoperative MEP monitoring, as well as the incidence of false-positive and false-negative results.RESULTSEighteen (1.19%) of the 1514 patients had a symptomatic infarction, and 4 (0.26%) had a symptomatic hemorrhage. A total of 15 patients showed motor weakness, with the weakness detected on the immediate postoperative motor function test in 10 of these cases. Fifteen false-positive cases (0.99%) and 8 false-negative cases (0.53%) were reported. Therefore, MEP during UIA surgery resulted in a sensitivity of 0.10, specificity of 0.94, positive predictive value of 0.01, and negative predictive value of 0.99.CONCLUSIONSIntraoperative EP monitoring has high specificity and negative predictive value. Both false-positive and false-negative findings were present. However, it is likely that a more meticulously designed protocol will make EP monitoring a better surrogate indicator of possible ischemic neurological deficits.


title: Maturation mechanism of severe acute respiratory syndrome (SARS) coronavirus 3C-like proteinase.

text: The 3C-like proteinase (3CL(pro)) of the severe acute respiratory syndrome (SARS) coronavirus plays a vital role in virus maturation and is proposed to be a key target for drug design against SARS. Various in vitro studies revealed that only the dimer of the matured 3CL(pro) is active. However, as the internally encoded 3CL(pro) gets matured from the replicase polyprotein by autolytic cleavage at both the N-terminal and the C-terminal flanking sites, it is unclear whether the polyprotein also needs to dimerize first for its autocleavage reaction. We constructed a large protein containing the cyan fluorescent protein (C), the N-terminal flanking substrate peptide of SARS 3CL(pro) (XX), SARS 3CL(pro) (3CLP), and the yellow fluorescent protein (Y) to study the autoprocessing of 3CL(pro) using fluorescence resonance energy transfer. In contrast to the matured 3CL(pro), the polyprotein, as well as the one-step digested product, 3CLP-Y-His, were shown to be monomeric in gel filtration and analytic ultracentrifuge analysis. However, dimers can still be induced and detected when incubating these large proteins with a substrate analog compound in both chemical cross-linking experiments and analytic ultracentrifuge analysis. We also measured enzyme activity under different enzyme concentrations and found a clear tendency of substrate-induced dimer formation. Based on these discoveries, we conclude that substrate-induced dimerization is essential for the activity of SARS-3CL(pro) in the polyprotein, and a modified model for the 3CL(pro) maturation process was proposed. As many viral proteases undergo a similar maturation process, this model might be generally applicable.


title: Accelerated induction regimens of TNF-alpha inhibitors in patients with inflammatory bowel disease: a scoping review protocol.

text: INTRODUCTION Tumour necrosis factor (TNF)-alpha inhibitors are commonly used to treat inflammatory bowel disease (IBD). In patients with IBD who are unresponsive to their first induction dose, the implementation of an 'accelerated' induction dose schedule (doses more frequent than recommended in product monographs) is becoming increasingly common. It is unclear whether this practice results in favourable patient outcomes, such as avoidance of surgery and disease remission. As such, there is a need to identify and map the current evidence base on accelerated induction schedules of these medications in the treatment of IBD. METHODS AND ANALYSIS A scoping review will be employed to systematically identify and characterise the nature of scientific literature on accelerated induction regimens of TNF-alpha inhibitors. MEDLINE, Embase, International Pharmaceutical Abstracts and grey literature will be searched to identify relevant studies. The titles/abstracts of all records and full text of potentially relevant articles will be independently screened for inclusion by two reviewers. Data will be abstracted from included studies by one reviewer and verified for accuracy by another. The findings will be synthesised descriptively. ETHICS AND DISSEMINATION We intend to report the findings of this scoping review in a peer-reviewed journal and a scientific conference. TRIAL REGISTRATION This research was registered prospectively with the Open Science Framework (https://osf.io/z7n2d/).


title: Hand Awareness.

text: The concept of Hand Awareness affects a more comprehensive respiratory infection prevention plan than vaccine immunization alone, as most respiratory infections do not have a vaccine solution. Additionally, the resurgence of measles, mumps, and pertussis in those who have been vaccinated is a good reminder that we must improve our approach to respiratory infection prevention. Weak links exist in the vaccine production and administration chain. It is not the panacea we once hoped. Changing behavior, while very difficult, is critical in order to have a greater impact on reducing all respiratory infections. Hand Awareness is defined as an integrated approach of hand hygiene, respiratory etiquette, and cross-contamination awareness practices or, in lay terms, knowing where your hands are and what they are doing at all times. Teaching strategies and resources are explored to assist with student understanding and application of desired behaviors that will achieve the greatest impact of both student and staff productivity and wellness.


title: Mechanical Recanalization for Acute Embolic Occlusion at the Origin of the Superior Mesenteric Artery.

text: PURPOSE We report a combined technique consisting of thrombectomy and thromboaspiration for the treatment of acute embolic occlusion of the superior mesenteric artery (SMA) at the origin. CASE A 90-year-old female with chronic atrial fibrillation had a sudden onset of abdominal pain and hematochezia due to acute embolic occlusion at the origin of the SMA. Computed tomographic findings showed reversible bowel wall ischemia. We performed mechanical thrombectomy using the Solitaire FR revascularization device, a self-expanding and fully retrievable stent-based thrombectomy system for acute intracranial large artery occlusion, combined with manual aspiration through a 6F guiding sheath placed at the SMA origin via a right brachial approach. Prompt and complete recanalization of the SMA was obtained without distal embolism, and intestinal necrosis was avoided. CONCLUSION Combined endovascular procedures of mechanical thrombectomy using the Solitaire FR with thromboaspiration may allow prompt recanalization, clot removal, and prevention of distal embolism and therefore would be a new therapy for acute embolic occlusion at the origin of the SMA.


title: Using optogenetics to tackle systems-level questions of multicellular morphogenesis.

text: Morphogenesis of multicellular systems is governed by precise spatiotemporal regulation of biochemical reactions and mechanical forces which together with environmental conditions determine the development of complex organisms. Current efforts in the field aim at decoding the system-level principles underlying the regulation of developmental processes. Toward this goal, optogenetics, the science of regulation of protein function with light, is emerging as a powerful new tool to quantitatively perturb protein function in vivo with unprecedented precision in space and time. In this review, we provide an overview of how optogenetics is helping to address system-level questions of multicellular morphogenesis and discuss future directions.


title: Does COVID-2019 have an Impact on the Purchase Intention of Commercial Long-Term Care Insurance among the Elderly in China?

text: PURPOSE As an important measure to alleviate long-term care (LTC) costs for the disabled due to the aging of the population, long-term care insurance (LTCI) system has been paid more attention in China. In addition to the government-led public LTCI system that has been piloted in cities such as Qingdao, Chongqing and Shanghai, health insurers such as the China Life Insurance Company are also experimenting with various types of commercial LTCI in the private market. However, the commercial LTCI market is developing very slowly due to public awareness and other reasons. On the other hand, COVID-2019 has had an impact on the cognition of the importance of long-term care for the elderly due to the fact that the death cases of COVID-2019 have been mainly concentrated in the elderly population with chronic diseases such as hypertension. Therefore, the purpose of this study is to explore the differences in the purchase intention of commercial LTCI among the elderly in two different periods: before and after the outbreak of COVID-2019. METHODS By using the Andersen behavioral model and two investigations in two different periods before and after the outbreak of COVID-2019, this study explores the impacts of COVID-2019 on the purchase intention of commercial LTCI. RESULTS Some significant discoveries were found. For example, 25.8% of interviewees showed purchase intention in LTCI in the time before the COVID-2019 outbreak, while this proportion increased to 37.6% after the COVID-2019 outbreak. People who were younger (OR = 2.128, before COVID-2019; OR = 1.875, after COVID-2019) or who had more education (OR = 1.502, before COVID-2019; OR = 2.218, after COVID-2019) were more interested in commercial LTCI. CONCLUSION This study shows that COVID-2019 has had an obvious impact on the purchase intention of commercial LTCI, which provides some enlightenment for China to improve the LTCI system in the future, especially to accelerate the development of commercial LTCI. For example, it is essential to promote the importance of long-term care among the elderly in a focused and targeted way. In terms of the key target audience, it can be developed gradually from the groups with higher education levels and the middle elderly aged 45-64 years old.


COVID-19: Getting ahead of the epidemic curve by early implementation of social distancing.


title: Polyester vs polypropylene, do mesh materials matter? A meta-analysis and systematic review.

text: Purpose Controversy exists regarding the outcomes following ventral hernia repair with polypropylene (PP) or polyester (PET) mesh. Monofilament PP less frequently requires extraction in the setting of contamination compared to multifilament PET mesh. The purpose of this systematic review and meta-analysis was to analyze the clinical outcomes of ventral hernia repair with PP and PET mesh. Patients and methods A comprehensive literature search was performed using the Ovid search platform. Criteria included ventral hernia repair publications using either PP or PET mesh with a minimum follow-up duration of one year. Included studies were subject to data extraction including mesh position, weight, recurrence rates, infection, and complications. Random effect meta-analysis was run to provide pooled event rate and 95% CI. Results Ninety-seven studies including a total of 10,022 patients were included in the final analysis. Hernia recurrence rates are similar (4.8%, 95% CI [3.5-6.5] vs 4.7%, 95% CI [3.7-6.0]) as well as mesh infection rates (3.5%, 95% CI [2.5-4.9] vs 5.0%, 95% CI [3.9-6.3]) between PET and PP, respectively. Mesh infections occurred less frequently in laparoscopic repair compared to open (1.6%, 95% CI [0.9-2.6] vs 5.2%, 95% CI [4.3-6.3]). Conclusion This study suggests that mesh material does not affect recurrence or infection in ventral hernia repair and that surgery can be safely performed with both PP and PET mesh. A laparoscopic approach is associated with a decreased infection rate compared to open repair independent of mesh type.


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title: Effects of collagen prosthesis cross-linking on long-term tissue regeneration following the repair of an abdominal wall defect.

text: Collagen prostheses used to repair abdominal wall defects, depending on their pretreatment (noncross-linked vs. cross-linked), besides repair may also achieve tissue regeneration. We assessed the host tissue incorporation of different bioprostheses using a new tool that combines immunofluorescence confocal microscopy with differential interference contrast images, making it possible to distinguish newly formed collagen. Partial hernial defects in the abdominal wall of rabbits were repaired using cross-linked/noncross-linked bioprostheses. Expanded polytetrafluoroethylene (ePTFE) was used as control. After 14/30/90/180 days of implant, specimens were taken for microscopy, immunohistochemistry, and quantitative-reverse transcription-polymerase chain reaction to determine host tissue ingrowth and collagen I/III protein and 1a1/3a1 gene expression. Shrinkage and stress resistance were also examined. At 14 days, cross-linked prostheses had suffered significantly less shrinkage than ePTFE or noncross-linked prostheses. Significantly higher shrinkage was recorded for ePTFE in the longer term. Microscopy revealed encapsulation of ePTFE by neoformed tissue, while the bioprostheses became gradually infiltrated by host tissue. Noncross-linked prosthesis showed better tissue ingrowth, more intense inflammatory reaction and more rapid degradation than the cross-linked prostheses. At 14 days, cross-linked prostheses induced up-regulated collagen 1a1 and 3a1 gene expression, while noncross-linked only showed increased collagen III protein expression at 90 days postimplant. At 6 months, the tensile strengths of cross-linked prostheses were significantly greater compared with ePTFE. Our findings demonstrate that despite the cross-linked collagen prostheses promoting less tissue ingrowth than the noncross-linked meshes, they became gradually replaced by good quality host tissue and were less rapidly degraded, leading to improved stress resistance in the long term.


title: Use of a HEHEHE purification tag instead of a hexahistidine tag improves biodistribution of affibody molecules site-specifically labeled with (99m)Tc, (111)In, and (125)I.

text: Affibody molecules are a class of small (∼7 kDa) robust scaffold proteins suitable for radionuclide molecular imaging in vivo. The attachment of a hexahistidine (His(6))-tag to the Affibody molecule allows facile purification by immobilized metal ion affinity chromatography (IMAC) but leads to high accumulation of radioactivity in the liver. Earlier, we have demonstrated that replacement of the His(6)-tag with the negatively charged histidine-glutamate-histidine-glutamate-histidine-glutamate (HEHEHE)-tag permits purification of Affibody molecules by IMAC, enables labeling with [(99m)Tc(CO)(3)](+), and provides low hepatic accumulation of radioactivity. In this study, we compared the biodistribution of cysteine-containing Affibody molecules site-specifically labeled with (111)In, (99m)Tc, and (125)I at the C-terminus, having a His(6)-tag at the N- or C-terminus or a HEHEHE-tag at the N-terminus. We show that the use of a HEHEHE-tag provides appreciable reduction of hepatic radioactivity, especially for radiometal labels. We hope that this information can also be useful for development of other scaffold protein-based imaging agents.


title: A novel approach to endobronchial closure of a bronchial pleural fistula.

text: Bronchopleural fistula presents an important and challenging management problem after lung parenchymal resection. The mainstay of treatment has been surgical revision of the bronchial stump, however increasingly endobronchial therapies are being employed. We report the novel use of a liquid embolic agent with an Amplatzer vascular plug to seal a chronic bronchopleural fistula. Using rigid bronchoscopy, fluoroscopy, radio opaque liquid embolic agent, and the Amplatzer vascular plug, we were able to demonstrate not only feasibility but also safety and a marked reduction in symptoms consistent with successful closure of the bronchopleural fistula.


title: [Nurses: A Voice to Lead, Nursing the World to Health-Viewing COVID-19 Epidemic Prevention Efforts in Light of Nightingale's Perspective on Infection Control].

text: Florence Nightingale (1820-1910), extolled as the founder of modern nursing, contributed greatly to the advancement of modern public health. Written 150 years ago, Nightingale's advice on infection control, addressing the importance of hand washing, environmental sanitation, ventilation, sunshine, statistical data, and health literacy, remains highly relevant in today's global fight against the coronavirus. In honor of Florence Nightingale's 200th birthday, World Health Organization declared 2020 the International Year of the Nurse and Midwife. The era of "Nurses: A Voice to Lead - Nursing the World to Health" is drawing near. This article addresses the profound impact of Nightingale's infection control and public health perspectives on measures currently being taken to contain coronavirus disease 2019 (COVID-19). Furthermore, we call on governments throughout the world to invest proactively in nursing to assure the safety of patients and promote public health in order to achieve the pledge of the United Nations' sustainable development goals to leave no one behind.