title: Determining the Impact of a Cancer Diagnosis on Diabetes Management: A Systematic Literature Review.

text: OBJECTIVES Cancer patients with comorbid diabetes have a 50% increased risk of all-cause mortality compared with cancer patients without diabetes. Less attention to diabetes management (glucose control, medication adherence, and diabetes self-management behaviors) during active cancer treatment is hypothesized as an explanation for worse outcomes among diabetic cancer patients. The objective of this systematic review is to determine and quantify how a cancer diagnosis impacts diabetes management. METHODS Quantitative and qualitative studies evaluating diabetes management among patients were identified by searching 4 databases: MEDLINE, EMBASE, The Cochrane Library, and Web of Science. Two independent reviewers extracted data and summarized results from eligible studies. Study quality was formally assessed. RESULTS Thirty-six studies met all inclusion criteria. We observed heterogeneity across studies in terms of study design, sample size, cancer site, type of diabetes management evaluated, and quality. Numerous articles discussed that overall, glucose control, medication adherence, and diabetes self-management behaviors declined following a cancer diagnosis. However, findings were inconsistent across studies. CONCLUSIONS Although the effects of a cancer diagnosis on diabetes management are mixed, when results across studies were synthesized together, diabetes management appeared to generally decline after a cancer diagnosis. Declines in diabetes management seem to be primarily due to shifts in the priority of care from diabetes management to cancer. A next critical step in this line of work is to identify patient and provider level predictors of better or worse diabetes management to design and test interventions aimed at improving effective diabetes management for cancer patients.


title: Uniportal thoracoscopic lobectomy for intralobar pulmonary sequestration.

text: BACKGROUND Pulmonary sequestration is an uncommon congenital condition for which surgical resection is usually indicated - either via open thoracotomy or conventional multi-port Video-Assisted Thoracoscopic Surgery (VATS). Of the two types of sequestration, intralobar sequestration is technically more challenging to resect. CASE PRESENTATION We report the management of a 34 year old male patient with a long history of respiratory symptoms, and an extensively diseased right lower lobe. A diagnosis of sequestration was confirmed by CT scanning, showing three separate anomalous feeding vessels arising from the abdominal aorta. A right lower lobectomy using a Uniportal VATS approach was performed, and the patient discharged home on the fourth post-operative day. CONCLUSION This is the first report to our knowledge demonstrating the safety and feasibility of the Uniportal approach for the resection of a relatively challenging intralobar sequestration.


title: Identification of irrigation potential areas, using multi-criteria analysis in Khyber District, Pakistan.

text: This study explores the opportunities for irrigated agriculture in Khyber District of Former Federally Administered Tribal Area (FATA). Agriculture continues to be most important economic activity in Pakistan and former FATA is no exception. However, agriculture in the semi-arid Khyber District continues to suffer a decline due to excessive reliance on rainfall, which is drastically insufficient. Khyber District have large expanses of fertile land; however, farmers depend on unpredictable rain-fed agriculture, which has low productivity and food insecurity. There are a number of rivers in the region where great prospects exist for irrigated farming. Geographical information systems (GIS)-based multi-criteria analysis can be used to map areas with irrigation potential. The current study focused on different variables including soil texture, perennial rivers, land cover, topography, and dams. For this study, data was collected from diverse sources which include Google earth images, top sheets, land use land cover, soil texture map of FATA, and SRTM 30 Meter. The collected data was analyzed by using multi-criteria analysis in Arc GIS 10.2.2 by using MIF technique. The results of this research indicate that there is great potential for irrigated farming in the study area. Potential land for this purpose were divided into three categories, i.e., highly suitable which consisted of 678 km2, or 26% of the total area; 1044 km2 representing 40% were moderately suitable to irrigation; while the remaining 698 km2 representing 27% were considered least suitable for irrigation. Likewise, 204 km2 representing 7% were deemed unsuitable for irrigated agriculture mostly consisting of barren rocks. The results also illustrate how GIS as a tool can be used in the exploration of water resources in a scientific approach, thus making decision-making easier and more accurate.


Rebuttal to letter "Is thromboprophylaxis with high-dose enoxaparin really necessary for COVID-19 patients? A new "prudent" randomised clinical trial".


title: Potential benefits of single-port compared to multiport laparoscopic inguinal herniorraphy: a prospective randomized controlled study.

text: BACKGROUND Multiple prospective studies have confirmed safety and efficacy of laparoscopic inguinal herniorraphy with single-port compared to multiport surgery. This prospective randomized controlled trial aimed to assess safety, efficacy and potential benefits of single-port total extraperitoneal inguinal herniorraphy beyond the learning curve. METHODS All referred patients with inguinal/femoral hernias were enrolled from December 2011 to February 2013. Exclusion criteria included workers compensation cases. Identical balloon dissector, light-weight mesh and non-absorbable tacks were used in all cases. For single-port cases Triport™ was used while structural balloon trocar/inflation bulb for multiport cases. Results were analyzed with IBM(®) SPSS(®) version 22 for Windows. RESULTS Participation rate was 100 % with 157 inguinal/femoral hernias in 100 patients: 51 randomized to single-port and 49 to multiport group. There was no conversion to open surgery/need for additional ports. There were no statistical differences between single-port and multiport groups with respect to age, sex, body mass index, American Society of Anesthesiologists scores, preoperative pain, hernia defect sizes and length of hospital stay. Operation times were equivalent for single-port and multiport 60.0 vs 61.0 min, P = 0.23, respectively. Significantly, single-port patients ingested fewer pain killers: 6 tablets vs 14 Dextropropoxyphene tablets, P < 0.001, experienced less pain (visual analog scores) on day 1 and 7 post-op op: 2.5 and 0, P < 0.001 compared to 4.5 and 2.5, P < 0.001, respectively, returned to work/normal physical activities 7 days quicker: 7.0 vs 14.0, P < 0.001 and had higher cosmetic scar scores at 6-week follow-up: 24 vs 21, P < 0.001, compared to multiport patients. There were no mortalities, morbidities or recurrences after follow-up of 6-21 months. CONCLUSIONS Compared to multiport, single-port laparoscopic total extraperitoneal inguinal herniorraphy, when performed by a high-volume and highly dedicated hernia surgeon, resulted in significantly reduced postoperative pain, analgesic requirements, quicker return to work/normal activities, improved cosmesis, and equivalent safety and efficacy.


title: Rhenium and technetium tricarbonyl, {M(CO)3} (+) (M = Tc, Re), binding to mammalian metallothioneins: new insights into chemical and radiopharmaceutical implications.

text: This paper deals with the binding of the four mammalian metallothioneins (MTs) to the organometallic metal fragment {fac-M(CO)3}(+) (M = (99)Tc, Re), which is highly promising for the preparation of second-generation radiopharmaceuticals. The study of the transmetallation reaction between zinc and rhenium in Zn7-MT1 by means of UV-vis and CD spectroscopy demonstrated the incorporation of the {fac-Re(CO)3}(+) fragment to the MTs. This reaction should be performed at 70 °C to accelerate the reaction rate, a result that is consistent with the reported reactivity of the rhenium fragment. ESI-TOF MS demonstrated the formation of mixed-metal species as Zn6,{Re(CO)3}-MT, Zn6,{Re(CO)3}2-MT, and Zn5,{Re(CO)3}3-MT, as well as the different reactivity of the four MT isoforms. Hence, Zn-MT3 showed the highest reactivity, in agreement with its high Cu-thionein character, whereas Zn-MT2 exhibited the lowest reactivity, in line with its high Zn-thionein character. The reactivity of the Zn-loaded forms of MT1 and MT4 is intermediate between those of MT3 and MT2. The study of the binding of the {fac-(99)Tc(CO)3}(+) fragment to MTs showed a significant and very interesting different reactivity in relation to rhenium. The transmetallation reaction is much more effective with technetium than with rhenium and significant amounts of mixed Zn x ,{(99)Tc(CO)3} y -MT species were formed with the four MT isoforms whereas only MT3 rendered similar amounts of rhenium derivatives. The results obtained in this study support the possible use of technetium for labelling mammalian metallothioneins and also for possible radiopharmaceutical applications.


title: Response to COVID-19: Minimizing Risks, Addressing Challenges and Maintaining Operations in a Complex Academic Radiology Department.

text: The coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid response plans to minimize risks of infection in the workforce while ensuring maintenance of essential functions of radiology departments. Plan adoption is, however, challenged by the need to coordinate with institutional efforts, a rapidly expanding number of patients, and the diversity of clinical and administrative functions in the department. Here, we describe the implementation of a response plan in an academic radiology department, challenges encountered, and tactics used to address these challenges.


Estimation of Coronavirus Disease 2019 Burden and Potential for International Dissemination of Infection From Iran.


title: Rickettsia typhi as Cause of Fatal Encephalitic Typhus in Hospitalized Patients, Hamburg, Germany, 1940-1944.

text: We evaluated formalin-fixed paraffin-embedded tissue specimens from 7 patients who died with encephalitic typhus in Hamburg, Germany, during World War II. The archived specimens included only central nervous system tissues >70 years old that had been stored at room temperature. We demonstrated successful detection of Rickettsia typhi DNA by a nested qPCR specific to prsA in 2 patients. These results indicate that R. typhi infections contributed to typhus outbreaks during World War II. Immunohistochemical analyses of brain tissue specimens of R. typhi DNA-positive and -negative specimens showed perivascular B-cell accumulation. Around blood vessels, nodular cell accumulations consisted of CD4-positive and CD8-positive T cells and CD68-positive microglia and macrophages; neutrophils were found rarely. These findings are similar to those of previously reported R. prowazekii tissue specimen testing. Because R. typhi and R. prowazekii infections can be clinically and histopathologically similar, molecular analyses should be performed to distinguish the 2 pathogens.


docid: lroknanr

title: Partha Kar: What will come after the covid-19 crisis?


title: Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage.

text: BACKGROUND Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. METHOD A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string "colorectal anastomotic ("leak" OR "bleed"), "endoscopy", endoscopic management". Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. RESULTS A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. CONCLUSION Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.


Pandemic: Looking Back and Thinking Ahead.


title: Same day discharge, surgical training and early complications after open and laparoscopic repair of primary paraumbilical hernia.

text: AIMS The aims of this study were to compare same day discharges and early complications after open and laparoscopic primary paraumbilical hernia (PUH) repair, including the procedures performed by surgical trainees (STs). METHODS All patients who had open (suture or mesh) and laparoscopic repair of primary PUH in the Day Surgery Unit (DSU) between January 2007 and June 2009 were identified from the hospital database. The database was questioned regarding the grade of operating surgeon, type of surgical repair, day of admission and discharge from the DSU, and a patient's return to surgical services. Data were stored in Microsoft Excel(®) (TM 2007). Statistical significance was determined using Fisher's exact test. RESULTS PUH was repaired in 337 patients: 252/337 (74.8 %) had open and 85/337 (25.2 %) had laparoscopic repair. Significantly, more patients were discharged home on the day of surgery after an open repair compared to the laparoscopic repair: open repair 187/252 (74.2 %), laparoscopic repair 35/85 (41.17 %), P = 0.0001. Overall early complications such as wound complications and hospital re-visits were similar in both groups: open repair 6.3 % (16/252), laparoscopic repair 11.7 % (10/85), P = 0.1554. STs performed 142/337 (42.1 %) of the PUH repairs with similar same day discharges from the DSU: STs 64.7 % (92/142), consultant surgeons 66.7 % (130/195), P = 0.7285. The difference in hernia recurrence between open repair 7/252 (2.78 %) and laparoscopic group 0/85 was not significant (P = 0.1985). CONCLUSION Patients with PUH repair were more likely to go home on the day of surgery after open than after laparoscopic repair. This was not affected by the grade of the operating surgeon. Early complications were similar following open and laparoscopic repair of primary PUH.


title: Combined pharmacomechanical thrombolysis of complete portomesenteric thrombosis in a liver transplant recipient.

text: Treatment options for portomesenteric venous thrombosis range from anticoagulation to surgery, depending on chronicity, severity of symptoms, extent of thrombosis, and the availability of local expertise. For acute and subacute cases, a variety of endovascular options have been described in limited published series and case reports, including thrombolysis and mechanical thrombectomy. We report what is to our knowledge the first case in which the Trellis pharmacomechanical thrombolysis device was used successfully to treat complete acute thrombosis of the entire superior mesenteric vein and the entire portal vein with extension into all segmental intrahepatic portal branches in a young adult after liver transplantation. This device, coupled with adjunctive techniques using balloon catheters, facilitated complete restoration of flow, resulting in graft salvage and long-term patency.


title: Interplay between SIRT1 and hepatitis B virus X protein in the activation of viral transcription.

text: Hepatitis B virus (HBV) genome is organized into a minichromosome known as covalently closed circular DNA (cccDNA), which serves as the template for all viral transcripts. SIRT1 is an NAD+-dependent protein deacetylase which activates HBV transcription by promoting the activity of cellular transcription factors and coactivators. How SIRT1 and viral transactivator X protein (HBx) might affect each other remains to be clarified. In this study we show synergy and mutual dependence between SIRT1 and HBx in the activation of HBV transcription. All human sirtuins SIRT1 through SIRT7 activated HBV gene expression. The steady-state levels of SIRT1 protein were elevated in HBV-infected liver tissues and HBV-replicating hepatoma cells. SIRT1 interacted with HBx and potentiated HBx transcriptional activity on precore promoter and covalently closed circular DNA (cccDNA) likely through a deacetylase-independent mechanism, leading to more robust production of cccDNA, pregenomic RNA and surface antigen. SIRT1 and HBx proteins were more abundant when both were expressed. SIRT1 promoted the recruitment of HBx as well as cellular transcriptional factors and coactivators such as PGC-1α and FXRα to cccDNA. Depletion of SIRT1 suppressed HBx recruitment. On the other hand, SIRT1 recruitment to cccDNA was compromised when HBx was deficient. Whereas pharmaceutical agonists of SIRT1 such as resveratrol activated HBV transcription, small-molecule inhibitors of SIRT1 including sirtinol and Ex527 exhibited anti-HBV activity. Taken together, our findings revealed not only the interplay between SIRT1 and HBx in the activation of HBV transcription but also new strategies and compounds for developing antivirals against HBV.


Case Image: Endovascular coil treatment of a right coronary artery aneurysm related to atherosclerosis.


title: CODE FAST: a quality improvement initiative to reduce door-to-needle times.

text: BACKGROUND Rapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions. OBJECTIVE To start a quality improvement project called CODE FAST in order to reduce DTN times at our institution. MATERIALS AND METHODS We retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol. RESULTS A total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8 min (p<0.0001) and DTN time with a reduction in the median from 62 to 25 min (p<0.0001). In logistic regression modeling, there was a trend towards more discharges to home in patients treated during the CODE FAST era. CONCLUSIONS We present a quality improvement project that has been overwhelmingly successful in reducing DTN time to <30 min. The template we present may be helpful to other institutions looking to reduce their DTN times and may also reduce costs as we note a trend towards more discharges to home.


title: COVID-19 Molecular Testing in Korea: Practical Essentials and Answers From Experts Based on Experiences of Emergency Use Authorization Assays.

text: Coronavirus disease 2019 (COVID-19) is a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Early detection of COVID-19 and immediate isolation of infected patients from the naive population are important to prevent further pandemic spread of the infection. Real-time reverse transcription (RT)-PCR to detect SARS-CoV-2 RNA is currently the most reliable diagnostic method for confirming COVID-19 worldwide. Guidelines for clinical laboratories on the COVID-19 diagnosis have been recently published by Korean Society for Laboratory Medicine and the Korea Centers for Disease Control and Prevention. However, these formal guidelines do not address common practical laboratory issues related to COVID-19 real-time RT-PCR testing and their solutions. Therefore, this guideline is intended as a practical and technical supplement to the "Guidelines for Laboratory Diagnosis of COVID-19 in Korea".


Peginesatide for anemia in chronic kidney disease.


title: Comparative study on immediate versus delayed meniscus allograft transplantation: 4- to 6-year follow-up.

text: BACKGROUND Meniscus allograft transplantation (MAT) is generally used for patients who sustain symptoms after meniscectomy, which could be called delayed MAT. Meniscus allograft transplantation for patients immediately after meniscectomy has not been reported. HYPOTHESIS Compared with the conventional delayed MAT, immediate MAT might provide better clinical results and reduce joint degeneration. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study was performed with 18 transplanted menisci (6 medial, 12 lateral) from 16 patients. Eight menisci were transplanted immediately after meniscectomy (IM group); 10 menisci, from patients who complained of knee symptoms at a mean time of 35 months (range, 9-92 months) after total meniscectomy, underwent delayed transplantation (DE group). Fourteen patients undergoing meniscectomy during the same period were included as controls (ME group). Degenerative changes in knee joints were evaluated by plain radiographs and magnetic resonance imaging (MRI). Allograft extrusion and relative percentage of extrusion were measured on MRI. Other outcome assessments included preoperative and postoperative International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores; visual analog scale (VAS) for pain; and range of motion and isokinetic muscle strength evaluation. RESULTS The mean length of follow-up was 50.8 months (range, 44-62 months) for the IM group, 72.0 months (range, 44-94 months) for the DE group, and 54.3 months (range, 45-62 months) for the ME group. A statistically significant difference in favor of the IM and ME groups was found on the VAS (0.4 [IM group] vs 1.1 [ME group] vs 2.5 [DE group]) and muscle strength (P < .05). The mean IKDC score in the IM group was significantly higher than that in the DE group (93 [range, 85-99] vs 74 [range, 38-95], respectively; P < .05). The IM group showed significantly less preoperative to postoperative cartilage degeneration changes on radiographs and MRI when compared with the DE and ME groups (Kellgren-Lawrence score changes: 0.25 [IM group] vs 1.0 [DE group] vs 1.7 [ME group]; Yulish score changes: 0.25 [IM group] vs 1.0 [DE group] vs 1.1 [ME group]; P < .05). Extrusion of the allograft was observed in the body of the menisci in all patients. No significant difference was found in terms of the Lysholm score, Tegner score, joint narrowing, or meniscus extrusion (P > .05). CONCLUSION Compared with delayed MAT, immediate MAT led to more satisfactory subjective results, less joint degeneration, and less muscle strength deficits. The short-term results of delayed meniscus transplantation were close to those of meniscectomy.


title: New-onset atrial fibrillation in adult critically ill patients: a scoping review.

text: PURPOSE New-onset atrial fibrillation (NOAF) is common and associated with increased morbidity and mortality. However, its clinical importance and management in critically ill patients are not well described. The aim of this scoping review is to assess the epidemiology and management strategies of NOAF during critical illness. METHOD The review was conducted in accordance with the PRISMA extension for scoping reviews. We searched PubMed, EMBASE and the Cochrane Library for studies assessing the incidence, outcome and management strategies of NOAF in adult critically ill patients. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS A total of 99 studies were included, of which 79 were observational and 20 were interventional. The incidence of NOAF varied from 1.7% to 43.9% with considerable inter-population variation (very low quality of evidence). Commonly identified risk factors for NOAF included higher age, cardiovascular comorbidities and sepsis. The occurrence of NOAF was associated with adverse outcomes, including stroke, prolonged length of stay and mortality (very low quality of evidence). We found limited data on the optimal management strategy with no evidence for firm benefit or harm for any intervention (very low/low quality of evidence). CONCLUSIONS The definition and incidence of NOAF in critically ill patients varied considerably and many risk factors were identified. NOAF seemed to be associated with adverse outcomes, but data were very limited and current management strategies are not evidence-based.


MERS coronavirus has low pandemic potential, so far.


title: Autophagy and role in asthma.

text: PURPOSE OF REVIEW Asthma is a common worldwide respiratory illness with significant morbidity and mortality. The disease is characterized by airway inflammation with involvement of multiple biological pathways. Genetic predisposition and increased susceptibility to severe respiratory viral infections are well known clinical features of asthma. Autophagy is an evolutionarily conserved cellular degradation process with significant impact on immunity and antiviral response. In this review we have described the role of autophagy in immune cell survival, proliferation and function. Autophagy has complex effects on immune response involved in inflammation, specifically Th2 immune response. Common respiratory viruses are associated with increased morbidity and mortality in asthmatic patients. RECENT FINDINGS We describe recent studies showing the effect of autophagy on replication and immune response to common respiratory viruses. The role of autophagy in asthma has recently been investigated. Two studies have been published describing the association of autophagy with asthma. Genetic polymorphism in specific autophagy genes is associated with asthma and influences gene expression in an experimental in-vivo model. SUMMARY These studies provide us with a window into the possible role of autophagy in asthma and offer new clues to pathogenesis. Modulation of autophagy has the potential to develop into a new therapeutic avenue to treat this common respiratory ailment.


title: Saliva as an Alternate Specimen Source for Detection of SARS-CoV-2 in Symptomatic Patients Using Cepheid Xpert Xpress SARS-CoV-2.

text: Among the many facets of the SARS-CoV-2 pandemic is the unprecedented pressure it has placed on different points of the supply chain for hospital systems worldwide such as collection devices for the diagnosis of COVID-19.….


title: Small bowel obstructions following the use of barbed suture: a review of the literature and analysis of the MAUDE database.

text: BACKGROUND Barbed suture has been adopted across all surgical specialties. One of the infrequent complications seen with the use of barbed suture is small bowel obstructions (SBOs). In this study, we perform a review of the literature and the Manufacturer and User Facility Device Experience Database (MAUDE) to characterize SBOs after the use of barbed sutures in a variety of operative procedures. METHODS A review of the literature was performed by searching PubMed and Ovid. We used the search terms: "barbed," "suture," "bowel," and "obstructions." For each case report, we examined the initial surgical procedure, type of barbed suture used, the type of complication, the time to complication, the presentation, and the type of operative interventions required. We did the same with the MAUDE database. RESULTS Our review of the literature revealed 18 different cases of SBO secondary to the use of barbed suture. The four most common procedures, with a total of four cases each, were inguinal hernia procedures, myomectomy, hysterectomy, and pelvic floor reconstructive procedures. The average time of presentation to SBO was found to be 26.3 days post-op (1-196 days). A total of 16 patients (88.9%) presented with abdominal pain. Other common complaints included vomiting (33.3%), abdominal distension (27.8%), oral intolerance (22.2%), and constipation (16.7%). A total of 5 cases were also found to have a possible volvulus on computed tomography (CT), and 2 cases were reported to have strangulation. The MAUDE database had 14 cases reporting on obstruction. CONCLUSIONS Surgeons should have a high index of suspicion for SBO if a patient presents with obstructive symptoms after a surgery that used barbed suture. This will often present as a mesenteric volvulus on CT. These particular SBOs require operative exploration, with laparoscopy being successful in the majority of cases.


title: Pulmonary neuroendocrine (carcinoid) tumors: European Neuroendocrine Tumor Society expert consensus and recommendations for best practice for typical and atypical pulmonary carcinoids.

text: BACKGROUND Pulmonary carcinoids (PCs) are rare tumors. As there is a paucity of randomized studies, this expert consensus document represents an initiative by the European Neuroendocrine Tumor Society to provide guidance on their management. PATIENTS AND METHODS Bibliographical searches were carried out in PubMed for the terms 'pulmonary neuroendocrine tumors', 'bronchial neuroendocrine tumors', 'bronchial carcinoid tumors', 'pulmonary carcinoid', 'pulmonary typical/atypical carcinoid', and 'pulmonary carcinoid and diagnosis/treatment/epidemiology/prognosis'. A systematic review of the relevant literature was carried out, followed by expert review. RESULTS PCs are well-differentiated neuroendocrine tumors and include low- and intermediate-grade malignant tumors, i.e. typical (TC) and atypical carcinoid (AC), respectively. Contrast CT scan is the diagnostic gold standard for PCs, but pathology examination is mandatory for their correct classification. Somatostatin receptor imaging may visualize nearly 80% of the primary tumors and is most sensitive for metastatic disease. Plasma chromogranin A can be increased in PCs. Surgery is the treatment of choice for PCs with the aim of removing the tumor and preserving as much lung tissue as possible. Resection of metastases should be considered whenever possible with curative intent. Somatostatin analogs are the first-line treatment of carcinoid syndrome and may be considered as first-line systemic antiproliferative treatment in unresectable PCs, particularly of low-grade TC and AC. Locoregional or radiotargeted therapies should be considered for metastatic disease. Systemic chemotherapy is used for progressive PCs, although cytotoxic regimens have demonstrated limited effects with etoposide and platinum combination the most commonly used, however, temozolomide has shown most clinical benefit. CONCLUSIONS PCs are complex tumors which require a multidisciplinary approach and long-term follow-up.


title: Surgical treatment of a Morgagni hernia causing intermittent gastric outlet obstruction.

text: A Morgagni hernia is a rare diaphragmatic hernia which develops through a congenital defect in the retrosternal area, usually on the right hand side. Because of its congenital aetiology, Morgagni hernias are rarely considered in the differential diagnosis of gastric outlet obstruction symptoms in adults. We present a patient with an incarcerated Morgagni hernia who presented with gastric outlet obstruction. A 77-year-old woman presented with symptoms and signs of gastric outlet obstruction, dehydration and acute renal impairment. She was treated by fluid resuscitation and nasogastric tube insertion. Radiological imaging showed a Morgagni hernia containing stomach, omentum and colon. This was treated surgically via an abdominal approach and the defect was closed with mesh. The patient recovered well from this procedure and was discharged. We discuss the anatomy, clinical presentation and surgical treatment of this rare diaphragmatic hernia to raise awareness among surgeons and surgical trainees.


Smoking, ACE-2, and COVID-19: Ongoing Controversies.


title: Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review.

text: BACKGROUND Although many case series have been published on the treatment of shoulder periprosthetic joint infection (PJI), few provide direct comparison of outcomes. This systematic review synthesizes the available English literature on shoulder PJI to quantify treatment effectiveness. METHODS The PubMed and Embase databases were searched in April 2014. Keywords included "shoulder replacement infection" and "shoulder arthroplasty infection." Of 663 titles, 55 manuscripts underwent full-text review after application of exclusion criteria. Thirty articles were finally included. RESULTS Propionibacterium acnes was most commonly reported, representing 38.9% of infections, followed by Staphylococcus species. Risk factors for shoulder PJI include previous surgery, increased age, male gender, increased body mass index, and diabetes mellitus. The average white blood cell count in 13 studies was 7472 cells/µL. Ten studies reported a mean erythrocyte sedimentation rate of 27.6 mm/h, whereas 14 studies reported a mean C-reactive protein level of 2.6 mg/dL. P. acnes in intraoperative culture specimens was an independent risk factor for failed treatment for shoulder PJI. When outcomes were pooled, no statistical difference was found in the success rates of 1-stage, 2-stage, or resection arthroplasty revision; each displayed a success rate >90%. However, single-stage revision produced the highest mean Constant score; implant retention resulted in the best range of motion. CONCLUSIONS Our data suggest that single-stage revision can be as effective as 2-stage or resection treatments; however, the retrospective nature of these data precluded our ability to control for confounding variables. Future studies on shoulder PJI should involve direct comparisons of 1-stage vs. 2-stage treatment while comparing cost, morbidity, and functional outcomes.


title: Comparison of Short-term and Long-term Clinical Outcomes Between Laparoscopic and Open Total Gastrectomy for Patients With Gastric Cancer.

text: BACKGROUND AND PURPOSE Validation of laparoscopic total gastrectomy (LTG) for patients with gastric cancer has not been fully investigated. In particular, the technique for esophagojejunostomy remains controversial. We performed 103 cases of LTG for patients with gastric cancer between 2007 and 2013, in which all esophagojejunostomy reconstruction was performed with intracorporeal circular stapling esophagojejunostomy using the OrVil system except for the first 3 cases. The purpose of this study is to retrospectively analyze the clinical usefulness of LTG with intracorporeal circular stapling esophagojejunostomy using the OrVil system and oncological feasibility of LTG as compared with open total gastrectomy (OTG). PATIENTS AND METHOD We retrospectively analyzed clinical course of consecutive 100 operations with LTG in comparison with consecutive 53 operations with OTG for patients with gastric cancer. As an estimation of short-term outcome, operative time, blood loss, postoperative hospital days and postoperative data of blood and drain examination were included. Moreover, relapse-free survival time and overall survival time stratified by each stage were calculated by log-rank test as an estimation of prognostic relevance. RESULTS Blood loss and postoperative hospital stay of LTG were significantly less than that of OTG. Postoperative complications were equivalent between the 2 groups and no patient died within 1 month post-LTG. Only 1 patient had recurrence and died for carcinomatosa peritonitis 50 months after LTG (median follow-up period: 44 mo). CONCLUSIONS Our experience revealed that LTG with intracorporeal circular stapling esophagojejunostomy using the OrVil system could be performed safely and with acceptable oncological outcome for patients with gastric cancer.


title: Thermo-sensitive hydrogel for preventing bowel injury in percutaneous renal radiofrequency ablation.

text: PURPOSE Percutaneous radiofrequency ablation (PRFA) has been used to ablate renal neoplasms with good outcome. However, if bowel lies adjacent to a tumor, ablation increases the risk of thermal bowel injury, and the consequences could be fatal. We describe the technique, effectiveness and safety of using thermo-sensitive hydrogel as insulation to displace the bowel away during PRFA. MATERIALS AND METHODS The study was divided into two main parts: the in vitro and in vivo studies. In in vitro study, to explore the heat insulation of hydrogel, the rabbit kidney was entirely embedded in hydrogel, and then radiofrequency ablation was performed; the temperature on the gel-air and gel-kidney interfaces was measured. In in vivo study, hydrogel of poloxamer 407, 25 % concentration (w/v), was instilled into the perinephric space of 10 rabbits under CT guidance to separate the kidney from adjacent bowel before PRFA performed in the targeted parenchyma in the gel group. For the control group, PRFA was performed in similar portions of 10 rabbits without instillation of hydrogel. Some parameters were recorded such as kidney-to-bowel and electrode-to-bowel distance. Immediately after PRFA, distribution of hydrogel was evaluated and the dimension of radiofrequency ablation zone was measured; bowel thermal injury was compared between the gel and control groups by gross anatomy and histopathological examination. To assess safety, two additional follow-up groups with 10 rabbits in each were set; after PRFA, CT scan was performed every 2 days; gel absorption, thermal damage and some other complications were evaluated during the period. RESULTS AND CONCLUSIONS In in vitro study, temperature was significantly lower at the gel-air than gel-kidney interface (P < .05), and the temperature gradient was positively associated with gel thickness. In in vivo study, hydrogel was instilled successfully in all rabbits in the gel group. The kidney-to-bowel and electrode-to-bowel distances were larger in the gel than control group [(1.1 ± 0.6 cm vs 0.1 ± 0.0 cm, P < .01), (1.8 ± 0.4 cm vs 0.5 ± 0.1 cm, P < .01), respectively]. The gel and control groups did not differ in size of the ablation zones (0.80 ± 0.2 cm vs 0.75 ± 0.3 cm, P > .05). Thermal injury in adjacent bowel was more serious in the control than gel group (P < .01). As for the follow-up, rabbits with gel instillation showed good condition and gel was absorbed gradually within 5 days. Those rabbits with no bowel displacement by gel got significantly lower survival rate and high complication rate (P < .01). CONCLUSION Hydrogel-dissection by means of thermo-sensitive hydrogel instillation is valuable for protecting the bowel adjacent to ablation area against thermal injury during PRFA.


title: [Ethics of clinical trials].

text: L’éthique des essais thérapeutiques. La pandémie de COVID-19 a conduit certains acteurs reconnus de la médecine à renoncer aux méthodes codifiées de la recherche médicale au profit d’affirmations établies dans l’urgence et sans réelle évaluation scientifique. Autant l’on peut comprendre que certains praticiens recourent à ce qui leur est ainsi proposé, autant cette confusion entre action dans l’urgence et recherche scientifique serait lourde de conséquences si elle venait à se généraliser, et cela à de multiples points de vue : image et rôle de la science, qualité et éthique de la recherche médicale et en fin de compte sort des malades soumis à des traitements mal évalués. Ce sont ces questions qui motivent la mise au point qui suit sur les questions d’éthique associées de longue date aux « essais thérapeutiques », cette procédure rationnelle d’acquisition dans les meilleurs délais d’informations fiables sur les avantages et les risques des traitements dont on envisage l’éventuelle utilisation.


title: A diagnostic cohort study on the accuracy of 18-fluorodeoxyglucose (18FDG) positron emission tomography (PET)-CT for evaluation of malignancy in anterior mediastinal lesions: the DECiMaL study.

text: OBJECTIVES The aim of this study is to collate multi-institutional data to determine the value by defining the diagnostic performance of fluorodeoxyglucose positron emission tomography (FDG PET)/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass in order to ascertain the clinical utility of PET/CT to differentiate malignant from benign aetiologies in patients presenting with an anterior mediastinal mass SETTING: DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK surgical sites. PARTICIPANTS Between January 2002 and June 2015, a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. We included all patients undergoing surgery who presented with an anterior mediastinal mass and underwent PET/CT. PET/CT was considered positive for any reported avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria. PRIMARY AND SECONDARY OUTCOME MEASURES Sensitivity, specificity, positive and negative predicted values of [18F]-FDG PET in determining malignant aetiology for an anterior mediastinal mass. RESULTS The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (95% CI 37 to 78). The positive and negative predictive values were 90% (95% CI 83% to 95%) and 42% (95% CI 26% to 61%). CONCLUSIONS The results of our study suggest reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign diseases of the anterior mediastinum.


docid: xxwpbtbb

title: Lessons from the front lines: the prehospital experience of the 2009 novel H1N1 outbreak in Victoria, Australia.

text: The H1N1 (swine influenza) 2009 outbreak in Victoria, Australia, provided a unique opportunity to review the prehospital response to a public health emergency. As part of Ambulance Victoria's response to the outbreak, relevant emergency response plans and pandemic plans were instigated, focused efforts were aimed at encouraging the use of personal protective equipment (PPE), and additional questions were included in the call-taking script for telephone triage of emergency calls to identify potential cases of H1N1 from the point of call. As a result, paramedics were alerted to all potential cases of H1N1 influenza or any patient who met the current case definition before their arrival on the scene and were advised to use appropriate PPE. During the period of May 1 to July 2, Ambulance Victoria telephone triaged 1598 calls relating to H1N1 (1228 in metropolitan areas and 243 in rural areas) and managed 127 calls via a referral service that provides specific telephone triage for potential H1N1 influenza cases based on the national call-taking script. The referral service determines whether a patient requires an emergency ambulance or can be diverted to other resources such as flu clinics. Key lessons learned during the H1N1 outbreak include a focused need for continued education and communication regarding infection control and the appropriate use of PPE. Current guidelines regarding PPE use are adequate for use during an outbreak of infectious disease. Compliance with PPE needs to be addressed through the use of intra-agency communications and regular information updates early in the progress of the outbreak.


title: The effect of xenon-augmented sevoflurane anesthesia on intraoperative hemodynamics and early postoperative neurocognitive function in children undergoing cardiac catheterization: A randomized controlled pilot trial.

text: BACKGROUND In adults, xenon has only minimal hemodynamic side effects when compared with other anesthetics. Moreover, in preclinical experiments, xenon has been demonstrated to possess cardio- and neuroprotective properties. Altogether, the favorable hemodynamic profile combined with its potential for organ-protection could render xenon an attractive option for anesthesia in children with cardiovascular compromise. AIMS The aim of this study was to explore safety and feasibility of sevoflurane-augmented xenon anesthesia in school-aged children and to assess early postoperative neurocognitive effects of xenon-sevoflurane and sevoflurane anesthesia when compared to a control group that did not have anesthesia. METHODS Forty children aged 4-12 years, suffering from congenital heart disease, undergoing diagnostic or interventional cardiac catheterization were randomized to either xenon-augmented sevoflurane anesthesia or sevoflurane alone. Safety was assessed by the incidence of intraprocedural hemodynamic instability and feasibility by anesthetic depth and respiratory profile. In addition, neurocognitive performance was assessed preoperatively, 2 hours after discharge from PACU and at 24 hours after anesthesia using the Amsterdam Neuropsychological Tasks system. A healthy control group of 22 age- and gender-matched children not exposed to anesthesia underwent an identical neurocognitive test battery, at comparable time intervals. RESULTS Overall hemodynamics did not differ between groups. Xenon-sevoflurane anesthesia resulted in decreased intraoperative ephedrine requirements (median [IQR]) (0.00 mg/kg [0.00-0.00] vs 0.00 mg/kg [0.00-0.01], P = 0.047). Only neurocognitive tests in the domain of alertness were significantly impaired 2 hours postoperatively in both anesthesia groups in comparison with the control group (alertness variability: P = 0.02, odds ratio 5.8), but recovered at 24 hours. For working memory, inhibition, cognitive flexibility, and motor coordination tasks, no significant interaction effects of anesthesia were found in the early postoperative period. CONCLUSION In this pilot trial, xenon-augmented sevoflurane anesthesia in school-aged children was feasible, and associated with decreased ephedrine requirements. All children exposed to anesthesia showed impaired neurocognitive performance in the immediate postoperative period when compared to control children; however, without significant differences between both treatment groups.


title: Adaptive human behavior in epidemiological models.

text: The science and management of infectious disease are entering a new stage. Increasingly public policy to manage epidemics focuses on motivating people, through social distancing policies, to alter their behavior to reduce contacts and reduce public disease risk. Person-to-person contacts drive human disease dynamics. People value such contacts and are willing to accept some disease risk to gain contact-related benefits. The cost-benefit trade-offs that shape contact behavior, and hence the course of epidemics, are often only implicitly incorporated in epidemiological models. This approach creates difficulty in parsing out the effects of adaptive behavior. We use an epidemiological-economic model of disease dynamics to explicitly model the trade-offs that drive person-to-person contact decisions. Results indicate that including adaptive human behavior significantly changes the predicted course of epidemics and that this inclusion has implications for parameter estimation and interpretation and for the development of social distancing policies. Acknowledging adaptive behavior requires a shift in thinking about epidemiological processes and parameters.


docid: oiibnccx

title: Conservative treatment for anal fistula: collagen matrix injection.


title: Ventrally dislocated attachment of the ovarian suspensory ligament, a risk factor for tubal occlusion as a postoperative complication of inguinal hernia repair: efficacy of laparoscopic inguinal hernia repair for preventing tubal damage.

text: PURPOSE Although the traditional cutdown inguinal hernia repair in children is well established, tubal occlusion has been reported as a complication in girls. The purpose was to investigate the mechanism of this complication and the efficacy of laparoscopic repair for preventing tubal occlusion. METHODS Between October 2006 and May 2010, we performed laparoscopic hernia repair in 100 girls (54 with a right hernia, including 2 with an inguinal ovarian hernia, 40 with a left hernia, including 3 with an inguinal ovarian hernias, and 6 with bilateral hernias). During laparoscopic repair we examined the anatomical relationship between the ovary, ovarian suspensory ligament, internal inguinal ring, and round ligament on both sides. RESULTS In 17 cases, 5 with an inguinal ovarian hernia and 12 without, the suspensory ligaments were ventrally dislocated and attached around the internal inguinal ring, and the ovary and fallopian tube were positioned near the internal inguinal ring and above the pelvic brim on the side of the original hernia. CONCLUSION This ventrally dislocated attachment may facilitate sliding of the ovaries and tubes into the hernial sac and induce tubal occlusion as a postoperative complication of inguinal hernia repair. The laparoscopic procedure makes it easy to prevent this complication.


title: Association of Padua prediction score with in-hospital prognosis in COVID-19 patients.

text: BACKGROUND Nearly 20% novel coronavirus disease 2019 (COVID-19) patients have abnormal coagulation function. Padua prediction score (PPS) is a validated tools for venous thromboembolism (VTE) risk assessment. However, its clinical value in COVID-19 patients evaluation was unclear. METHODS We prospectively evaluated the VTE risk of COVID-19 patients using PPS. Demographic and clinical data were collected. Association of PPS with 28-days mortality was analyzed by multivariate logistic regression and Kaplan-Meier analysis. RESULTS 274 continuous patients were enrolled, with total mortality of 17.2%. Patients in high PPS group, with significantly abnormal coagulation, have a higher levels of interleukin 6 (25.27 pg/ml vs.2.55 pg/ml, P < 0.001), prophylactic anticoagulation rate (60.7% vs. 6.5%, P<0.001) and mortality (40.5% vs. 5.9%, P<0.001) as compared with that in low PPS group. Critical patients showed higher PPS (6 score vs. 2 score, P<0.001) than that in severe patients. Multivariate logistic regression revealed the independent risk factors of in-hospital mortality included high PPS (OR: 7.35, 95%CI: 3.08 - 16.01), increased interleukin-6 (OR: 11.79, 95%CI: 5.45 - 26.20) and elevated d-dimer (OR: 4.65, 95%CI: 1.15 - 12.15). Kaplan-Meier analysis indicated patients with higher PPS had a significant survival disadvantage. Prophylactic anticoagulation in higher PPS patients show a mild advantage of mortality but without statistical significance (37.1% vs. 45.7%, P=0.42). CONCLUSION Higher PPS associated with in-hospital poor prognosis in COVID-19 patients. Prophylactic anticoagulation showed a mild advantage of mortality in COVID-19 patients with higher PPS, but it remain need further investigation.


title: Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization.

text: BACKGROUND Endovascular treatment of wide-necked aneurysms is challenging. Stent-assisted coiling (SAC) is associated with increased complications and requires dual antiplatelet therapy. OBJECTIVE To compare treatment of unruptured, wide-necked aneurysms with a dual-microcatheter technique (DMT) versus SAC. METHODS Between 2006 and 2011, 100 patients with unruptured wide-necked intracranial aneurysms were treated with DMT and 160 with SAC. Over time there was a significant decrease in the use of SAC and a corresponding increase in DMT. The investigators matched 60 patients treated with DMT blinded to outcome in a 1:2 fashion based on maximal aneurysm dome diameter with 120 patients treated with SAC. Outcomes were determined with conditional (matched) multivariate analysis. RESULTS There were no significant differences in patient or aneurysm characteristics between cohorts, including aneurysm diameter, neck width, or volume. Overall packing density and coil volume achieved was not significantly different between cohorts. There were higher rates of overall complications in those receiving SAC (19.2%) compared with DMT (5.0%; p=0.012), but no significant difference in major complications (8.3% vs 1.7%, respectively; p=0.103). At a mean follow-up of 27.0 ± 18.9 months, rates of retreatment did not differ between DMT (15.1%) and SAC (17.7%). Delayed in-stent stenosis occurred in five patients and in-stent thrombosis in four patients treated with SAC. There was no difference in favorable functional outcome (modified Rankin score 0-2) between those treated with DMT (90.6%) compared with SAC (91.2%). CONCLUSIONS DMT and SAC are effective endovascular approaches for unruptured, wide-necked aneurysms; however, DMT may result in less morbidity. Further long-term studies are necessary to determine the optimal indications for these treatment options.


title: A Case of Ruptured Blood Blister-like Aneurysm Treated with Pipeline Embolization Device: Clinical Significance of Fetal-type Posterior Communicating Artery.

text: Blood-blister like aneurysms (BBAs) are challenging lesions because of their wide fragile neck. Flow-diverting stents (FDSs), such as the Pipeline Embolization Device (PED), have been applied to treat BBAs less amenable to more established techniques of treatment. However, the use of FDSs, including the PED, in acute subarachnoid hemorrhage (SAH) still remains controversial. We report a case of aneurysm regrowth following PED application for a ruptured BBA that overlapped the origin of the dominant posterior communicating artery (PCoA), which was successfully treated after coil trapping of the origin of the fetal-type PCoA. And, we discuss the clinical significance of the fetal-type PCoA communicating with a BBA in terms of PED failure.


title: Retroperitoneal Laparoscopic Radical Nephrectomy for Large (>7 cm) Solid Renal Tumors: Comparison of Perioperative Outcomes with the Transperitoneal Approach.

text: PURPOSE To describe our technique for retroperitoneal laparoscopic radical nephrectomy (LRN) and to present the perioperative outcomes of our retroperitoneal LRN series for large (>7 cm) solid renal tumors and to compare them with those of the transperitoneal approach. MATERIALS AND METHODS A retrospective chart review was performed for patients who had undergone LRN for a solid renal tumor greater than 7 cm in size on computed tomography (CT) scans between June 2008 and January 2016. Perioperative outcomes were compared between transperitoneal and retroperitoneal approaches. RESULTS There were 30 cases in the transperitoneal approach group and 34 cases in the retroperitoneal group. The mean tumor size was 9.0 cm in the transperitoneal approach group and 10.3 cm in the retroperitoneal group (P = .494). In the retroperitoneal approach group, the operation time was shorter, estimated blood loss (EBL) was lower, and time to start diet was shorter (P < .001, P = .037, and P = .002, respectively). The complication rate was comparable between the two approaches. CONCLUSIONS Retroperitoneal LRN for a large (>7 cm) solid renal tumor demonstrated a superior result in terms of operation time, estimated blood loss, and time to start diet than transperitoneal LRN. Other perioperative outcomes and complication rate were comparable between the two approaches. We believe that with sufficient experience, retroperitoneal LRN may be an effective and safe procedure for large (>7 cm) solid renal tumors.


title: Effects of intracanal mineral trioxide aggregate and calcium hydroxide during four weeks on pH changes in simulated root surface resorption defects: an in vitro study using matched pairs of human teeth.

text: INTRODUCTION Diffusion of hydroxyl ions from intracanal calcium hydroxide (CH) through dentin is used to arrest external inflammatory root resorption. However, long-term and short-term CH placement has been associated with an increased risk of root fracture. Intracanal mineral trioxide aggregate (MTA) might provide an alternative to CH as a source of hydroxyl ions. This in vitro study compared the effects of intracanal MTA and CH on hydroxyl ion diffusion through dentin by measuring pH changes over time in simulated root surface resorption defects prepared in matched pairs of teeth; the null hypothesis tested was that there is no difference. METHODS Root surface cavities were prepared 5 mm from the apex in extracted human permanent anterior teeth (21 matched pairs) and 7 additional teeth (controls). Root canals were instrumented to size 50/.04 and filled with either tooth-colored MTA (ProRoot) or CH (UltraCal XS); control teeth were filled with saline. The pH in root surface cavities was measured at 3 hours, 24 hours, 1 week, 2 weeks, 3 weeks, and 4 weeks. RESULTS In controls, pH readings did not differ significantly during the 4 weeks (P > .05, repeated-measures analysis of variance [ANOVA]). For the experimental intragroup effects, significant pH changes occurred over time in the MTA group (P = .005, repeated-measures ANOVA) and the CH group (P < .0001). For the experimental intergroup effects, the overall mean pH was higher in the MTA group (8.66; standard error [SE], 0.07) compared with the CH group (8.46; SE, 0.07) (P = .014, paired t test). At 4 weeks pH was higher in the MTA group (8.30; SE, 0.16) compared with the CH group (7.90; SE, 0.11) (P = .011); at all other time points intergroup differences were insignificant. The null hypothesis was rejected. CONCLUSIONS Intracanal MTA and CH groups differed in their overall effect on pH measured in simulated root surface resorption defects. At 4 weeks intracanal placement of MTA compared with CH resulted in a small but significantly higher pH.


title: The global experience of digital health interventions in COVID-19 management.

text: Digital health interventions are globally playing a significant role to combat coronavirus disease 2019 (COVID-19), which is an infectious disease caused by Severe Acute Respiratory Syndrome coronavirus 2. Here, we present a very brief overview of the multifaceted digital interventions, globally, and in India, for maintaining health and health-care delivery, in the context of the Covid-19 pandemic.


We practised for a pandemic, but didn't brace.


title: Relationship between inflammation and sex hormone profile in female patients receiving different types of renal replacement therapy.

text: BACKGROUND Patients with end-stage renal disease (ESRD) experience female sexual dysfunction (FSD). The purpose of this study was to compare FSD in different types of renal replacement therapy and control patients. METHODS The study was consisted of 47 renal transplantation (RT), 46 hemodialysis (HD), and 28 continuous ambulatory peritoneal dialysis (CAPD) patients and 36 healthy control subjects. All groups were evaluated with the following scales: Female Sexual Function Index (FSFI) questionnaire, Short Form (SF)-36 questionnaires, and Beck Depression Inventory (BDI). Demographic data, laboratory values, and hormone levels were obtained. The patients with FSFI score <26.55 were accepted as experiencing sexual dysfunction. RESULTS Overall, total FSFI scores in RT, HD, CAPD, and control were 22 (range, 2-35), 22.4 (4-34), 18.35 (2-34), and 29.6 (2-35), respectively. The mean total FSFI score was not different in patients receiving different kinds of renal replacement therapy (P > .05) although they were significantly worse then the control group (P < .001). On regression analysis, age was significantly associated with FSD (β = -0.14; P = .001). In addition, the physiologic health domain of SF-36 was significantly better in control groups (P < .001). The difference in terms of mean of BDI score did not reach statistical significance among patient groups (P > .05). Female sexual dysfunction score was negatively correlated with BDI (r = -0.371; P < .001) and positively correlated with the mental-physical components score of SF-36 (r = 0.423 [P < .001] and r = 0.494 [P < .001], respectively) in all patients groups. Regarding the hormones of the patients, there was a significant difference between RT and the HD and CAPD groups in dihydroepiandrosterone sulfate (DHEAS; P < .001), RT and HD in prolactin (P < .001), and RT and CAPD in free testesterone (P < .001). CONCLUSIONS Renal transplantation, hemodialysis, and peritoneal dialysis patients were at more risk of developing sexual dysfunction and lower quality of life scores than healthy subjects. Notably, the mode of renal replacement therapy had no impact on female sexual function.


title: Community eye-health and vision center guidelines during COVID-19 pandemic in India.

text: The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has disrupted our society on an unprecedented scale since its inception in December 2019. As the health-care system is finally re-organizing to mitigate the impact of the pandemic, it was necessary to re-structure primary eye care (PEC) activities as well on the same lines. A consensus meeting was held with leading eye-care experts on 2nd May 2020 to prepare a roadmap for PEC in the days to come. Guidelines are needed for PEC activities like vision testing, refraction, optical dispensing, counseling, etc., Some of the activities at vision centers (VCs) may be postponed or modified in light of the current pandemic situation. PEC workers need to strictly follow social distancing norms (minimum 3 feet) for minimizing risk of exposure and need access to appropriate personal protective equipment (PPE), like gloves, masks and shields while examining beneficiaries. For optometrists, sterilization of instruments and encouraging the people to remain silent during the examination is recommended. Because conjunctivitis may be an early sign which can present at VCs, extra precautions in the form of PPE has to be ensured while examining such patients. This is also an opportunity to start running telemedicine clinics for all emergent cases that cannot be managed at the primary level. The guidelines also need to be updated based on the context of the working environment and changes in government directives from time to time.


title: Systematic Review Looking at the Use of Technology to Measure Free-Living Symptom and Activity Outcomes in Parkinson's Disease in the Home or a Home-like Environment.

text: BACKGROUND The emergence of new technologies measuring outcomes in Parkinson's disease (PD) to complement the existing clinical rating scales has introduced the possibility of measurement occurring in patients' own homes whilst they freely live and carry out normal day-to-day activities. OBJECTIVE This systematic review seeks to provide an overview of what technology is being used to test which outcomes in PD from free-living participant activity in the setting of the home environment. Additionally, this review seeks to form an impression of the nature of validation and clinimetric testing carried out on the technological device(s) being used. METHODS Five databases (Medline, Embase, PsycInfo, Cochrane and Web of Science) were systematically searched for papers dating from 2000. Study eligibility criteria included: adults with a PD diagnosis; the use of technology; the setting of a home or home-like environment; outcomes measuring any motor and non-motor aspect relevant to PD, as well as activities of daily living; unrestricted/unscripted activities undertaken by participants. RESULTS 65 studies were selected for data extraction. There were wide varieties of participant sample sizes (<10 up to hundreds) and study durations (<2 weeks up to a year). The metrics evaluated by technology, largely using inertial measurement units in wearable devices, included gait, tremor, physical activity, bradykinesia, dyskinesia and motor fluctuations, posture, falls, typing, sleep and activities of daily living. CONCLUSIONS Home-based free-living testing in PD is being conducted by multiple groups with diverse approaches, focussing mainly on motor symptoms and sleep.


title: Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy as a definitive surgical procedure for morbid obesity. Mid-term results.

text: BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has been gaining acceptance because it has shown good short- and mid-term results as a single procedure for morbid obesity. The aim of this study was to compare short- and mid-term results between laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG. METHODS Observational retrospective study from a prospective database of patients undergoing LRYGB and LSG between 2004 and 2011, where 249 patients (mean age 44.7 years) were included. Patients were followed at 1, 3, 6, 12, and 18 months, and annually thereafter. Short- and mid-term weight loss, comorbidity improvement or resolution, postoperative complications, re-interventions, and mortality were evaluated. RESULTS One hundred thirty-five LRYGB and 114 LSG were included. Significant statistical differences between LRYGB and LSG were found in operative time (153 vs. 93 min. p < 0.001), minor postoperative complications (21.5 % vs. 4.4 %, p = 0.005), blood transfusions (8.8 % vs. 1.7 %, p = 0.015), and length of hospital stay (4 vs. 3 days, p < 0.001). There were no differences regarding major complications and re-interventions. There was no surgery-related mortality. The percentage of excess weight loss up to 4 years was similar in both groups (66 ± 13.7 vs. 65 ± 14.9 %). Both techniques showed similar results in comorbidities improvement or resolution at 1 year. CONCLUSIONS There is a similar short- and mid-term weight loss and 1-year comorbidity improvement or resolution between LRYGB and LSG, although minor complication rate is higher for LRYGB. Results of LSG as a single procedure need to be confirmed after a long-term follow-up.


title: Measurement and State-Dependent Modulation of Hypoglossal Motor Excitability and Responsivity In-Vivo.

text: Motoneurons are the final output pathway for the brain's influence on behavior. Here we identify properties of hypoglossal motor output to the tongue musculature. Tongue motor control is critical to the pathogenesis of obstructive sleep apnea, a common and serious sleep-related breathing disorder. Studies were performed on mice expressing a light sensitive cation channel exclusively on cholinergic neurons (ChAT-ChR2(H134R)-EYFP). Discrete photostimulations under isoflurane-induced anesthesia from an optical probe positioned above the medullary surface and hypoglossal motor nucleus elicited discrete increases in tongue motor output, with the magnitude of responses dependent on stimulation power (P < 0.001, n = 7) and frequency (P = 0.002, n = 8, with responses to 10 Hz stimulation greater than for 15-25 Hz, P < 0.022). Stimulations during REM sleep elicited significantly reduced responses at powers 3-20 mW compared to non-rapid eye movement (non-REM) sleep and wakefulness (each P < 0.05, n = 7). Response thresholds were also greater in REM sleep (10 mW) compared to non-REM and waking (3 to 5 mW, P < 0.05), and the slopes of the regressions between input photostimulation powers and output motor responses were specifically reduced in REM sleep (P < 0.001). This study identifies that variations in photostimulation input produce tunable changes in hypoglossal motor output in-vivo and identifies REM sleep specific suppression of net motor excitability and responsivity.


title: Caring for Infectious Disease in the Prehospital Setting: A Qualitative Analysis of EMS Providers Experiences and Suggestions for Improvement.

text: OBJECTIVE The purpose of this study was to examine the attitudes and behaviors of emergency medical technicians (EMTs) and Paramedics when faced with the decision to care for patients with suspected Ebola Virus Disease (EVD) and to illicit suggestions for improvement of infectious disease (ID) preparedness. METHODS A convenience sample of 22 EMT/Paramedics were recruited from an emergency department at one of the designated Ebola centers. Each provider participated in one of three on-site focus groups. Participants answered questions about how they gained their knowledge, felt about caring for EVD patients, made decisions about caring for EVD patients, and suggestions for improvement of ID preparedness. Focus groups were recorded, transcribed, and coded using inductive content analysis. RESULTS Analysis revealed five prominent themes: reactions to scare, education/training, danger, decision making, and suggestions for future responses. Overall, first responders were excited to be a part of the response to EVD. They were more comfortable caring for EVD patients if they received adequate education and transparency from the administration. This resulted in a decreased perceived danger of the disease and decreased hesitancy when caring for EVD patients. However, those that expressed the most hesitancy also expressed the most emotional distress. Suggestions for improvement of ID preparedness included continuing education, tiered training models, peer training models, collaboration between emergency medical services (EMS) systems, better communication between departments, and the development of an infectious disease response team. CONCLUSIONS Although first responders were excited to be a part of the response to EVD, this did not come without hesitation and emotional distress. Some of these concerns may be mitigated by first providing a clear definition of "duty to care," followed by interventions such as the development of clear and consistent ID preparedness training and interventions that address the emotional distress experienced by these providers.


title: Focal middle cerebral artery ischemia in rats via a transfemoral approach using a custom designed microwire.

text: OBJECTIVES The aim of this study was to develop a reliable and repeatable method of inducing focal middle cerebral artery occlusion (MCAo) in rats without ligation of the external carotid artery (ECA), while reducing the risk of subarachnoid hemorrhage. METHODS We prototyped microwires with different diameters (0.0120 inch, 0.0115 inch, 0.0110 inch), materials, and construction methods (coil-on-core, extruded polymer jacket-on-core). Under fluoroscopic guidance and using femoral artery access, the microwires were navigated into the internal carotid artery of male Wistar rats (n=50, weight 376±64 g) to induce MCAo for 1 or 2 h. We performed neurological assessments at baseline, and at 3, 24, 72, and 168 h after MCAo. MRI measurements were performed on a 9.4 T scanner at 1 and 7 days post-injury. RESULTS The 0.0115 inch microwire with polymer jacket-on-core provided the most successful outcome. At 1 and 7 days post-injury, we observed similar infarction volumes for 1 and 2 h MCAo in the MRI study. Infarcted lesion volumes in both MCAo groups were significantly reduced at 7 days compared with 1 day post-injury. The trend in longitudinal changes for the scores of different neurological assessments was confirmed to be significant after the injury, but both groups showed a similar trend of neurological deficits over the course of the study. CONCLUSIONS We have developed a reliable and repeatable MCAo method in rats, allowing for precise occlusion of the MCA under direct fluoroscopic visualization without alteration of the cerebral hemodynamics associated with ECA ligation. The custom designed microwire can also be sized for targeted focal ischemia in larger animals.


docid: jmyfyoqj

title: Update on baculovirus as an expression and/or delivery vehicle for vaccine antigens.

text: After three decades of development, the baculovirus/insect cell expression system is now recognized as a powerful platform for recombinant protein production. With a number of distinct advantages, the baculovirus/insect cell expression system has been extensively used for the production of various vaccine candidates, and several human and veterinary vaccine products have been commercially available. In addition to insect cells, baculovirus is capable of entering a broad range of mammalian cells, lending itself to a promising gene delivery vehicle for antigen expression and display in vivo. The use of baculovirus for antigen expression and delivery has been reviewed in 2008. Rather than a critical evaluation, this paper aims to provide an update of the applications of baculovirus as an in vitro or in vivo antigen expression/delivery vehicle, with special focuses on developments and advances after 2008.


Illustrating health inequalities in Glasgow.


Clare Gerada: What to do with appraisal.


title: Form follows function: lymphoid tissue microarchitecture in antimicrobial immune defence.

text: Secondary lymphoid organs (SLOs) are tissues that facilitate the induction of adaptive immune responses. These organs capture pathogens to limit their spread throughout the body, bring antigen-presenting cells into productive contact with their cognate lymphocytes and provide niches for the differentiation of immune effector cells. Therefore, the microanatomy of SLOs defines the ability of an organism to respond to pathogens. SLO microarchitecture is, at the same time, extremely adaptable to environmental changes. In this Review, we discuss recent insights into the function and plasticity of the SLO microenvironment with regards to antimicrobial immune defence.


title: Effectiveness, training and quality assurance of colonoscopy screening for colorectal cancer.

text: Screening for colorectal cancer has been proven to be effective in reducing colorectal cancer incidence and mortality. While the precise benefit of screening exclusively by colonoscopy is not yet known, unarguably, the exam is central to the success of any screening programme. The test affords the opportunity to detect and resect neoplasia across the entire large bowel and is the definitive examination when other screening tests are positive. However, colonoscopy is invasive and often requires sedation as well as extensive bowel preparation, all of which puts the patient at risk. Furthermore, the test can technically be demanding and, unarguably, there is variation in how it is performed. This variation in performance has now been definitively linked to important outcome measures. For example, interval cancers are more common in low adenoma detectors as compared with high adenoma detectors. This review outlines the most current thinking regarding the effectiveness of colonoscopy as a screening tool. It also outlines key concepts to optimise its performance through robust quality assurance programmes and high-quality training.


title: NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.

text: BACKGROUND The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases. METHODS Transanal endoscopic rectal resection with total mesorectal excision using the TEM platform was performed in a 76-year-old woman with a T2N2 rectal cancer treated with preoperative chemoradiation. Laparoscopic visualization and assistance with retraction and exposure during rectosigmoid mobilization was provided through one 5-mm port, which was later used as the stoma site, and 2-mm needle ports, one of which was used as a drain site. The specimen was transected transanally followed by handsewn coloanal anastomosis. RESULTS The procedure was completed successfully with an operative time of 4 hours and 30 minutes. Mesorectal excision was complete. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology demonstrated pT1N0 with 23 negative lymph nodes and negative proximal, distal, and radial margins. CONCLUSIONS NOTES transanal endoscopic rectosigmoid resection using TEM and laparoscopic assistance is feasible and safe. Careful patient selection and improvement in NOTES instrumentation are critical to optimize this approach before widespread clinical application.


title: Psychological impact of anti-Asian stigma due to the COVID-19 pandemic: A call for research, practice, and policy responses.

text: The COVID-19 pandemic is linked to a rise in stigma and discrimination against Chinese and other Asians, which is likely to have a negative impact on mental health, especially when combined with additional outbreak-related stressors. We discuss the need to consider the potential harms of these anti-Asian sentiments during both the height of the pandemic and longer-term recovery through (a) research-examining how it affects mental health and recovery; (b) practice-implementing evidence-based stigma reduction initiatives; and (c) policy-coordinating federal response to anti-Asian racism including investment in mental health services and community-based efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Augmentation of Fracture Healing Using Soft Callus.

text: OBJECTIVES This study sought to investigate the effect of soft callus removal and reapplication in a rat closed femur fracture model. We hypothesized that removing soft callus will impair fracture healing, whereas reapplication will facilitate healing. METHODS A closed midshaft femur fracture was created in 78 rats and stabilized with an intramedullary wire. Seven days later, rats were equally divided and fractures surgically exposed. In the control group, no callus was removed, whereas in the callus removal group CR(-) group, the callus was removed and in the callus replaced group CR(+), callus was removed and replaced. Half of the rats were killed at 4 and 7 weeks. Fracture healing was graded with radiographs and callus volume measured with micro-CT. Mechanical torsion properties were measured, and histologic analysis was conducted. RESULTS At both end points, evidence of delayed healing was found on radiographs and micro-CT in CR(-) rats (P = 0.0001), whereas CR(+) rats showed normal fracture healing compared with controls. The normalized callus volume was similar in all groups at both end points. At 7 weeks, the maximum stiffness in CR(-) rats was 68% less than control (P = 0.0001). Stiffness increased 55% in CR(+) rats from CR(-) rats (P = 0.0017). Histology supported our findings with complete endochondral ossification in CR(+) rats but wide areas of hyaline cartilage in CR(-) rats at 7 weeks. CONCLUSIONS Removal of soft callus in a rat model delays fracture healing at early and late time points, whereas replacement mitigates these negative consequences. Replacing the soft callus should be considered in all osteosynthesis procedures.


Bleeding and Bleeding Risk in COVID-19.


title: One stage functional end-to-end stapled intestinal anastomosis and resection performed by nonexpert surgeons for the treatment of small intestinal obstruction in 30 dogs.

text: OBJECTIVES To describe stapled 1-stage functional end-to-end intestinal anastomosis for treatment of small intestinal obstruction in dogs and evaluate outcome when the technique is performed by nonexpert surgeons after limited training in the technique. STUDY DESIGN Case series. ANIMALS Dogs (n=30) with intestinal lesions requiring an enterectomy. METHODS Stapled 1-stage functional end-to-end anastomosis and resection using a GIA-60 and a TA-55 stapling devices were performed under supervision of senior residents and faculty surgeons by junior surgeons previously trained in the technique on pigs. Procedure duration and technical problems were recorded. Short-term results were collected during hospitalization and at suture removal. Long-term outcome was established by clinical and ultrasonographic examinations at least 2 months after surgery and from written questionnaires, completed by owners. RESULTS Mean±SD procedure duration was 15±12 minutes. Postoperative recovery was uneventful in 25 dogs. One dog had anastomotic leakage, 1 had a localized abscess at the transverse staple line, and 3 dogs developed an incisional abdominal wall abscess. No long-term complications occurred (follow-up, 2-32 months). CONCLUSION Stapled 1-stage functional end-to-end anastomosis and resection is a fast and safe procedure in the hand of nonexpert but trained surgeons.


title: Pharmacokinetics of Colistin Methansulphonate (CMS) and Colistin after CMS Nebulisation in Baboon Monkeys.

text: PURPOSE The objective of this study was to compare two different nebulizers: Eflow rapid® and Pari LC star® by scintigraphy and PK modeling to simulate epithelial lining fluid concentrations from measured plasma concentrations, after nebulization of CMS in baboons. METHODS Three baboons received CMS by IV infusion and by 2 types of aerosols generators and colistin by subcutaneous infusion. Gamma imaging was performed after nebulisation to determine colistin distribution in lungs. Blood samples were collected during 9 h and colistin and CMS plasma concentrations were measured by LC-MS/MS. A population pharmacokinetic analysis was conducted and simulations were performed to predict lung concentrations after nebulization. RESULTS Higher aerosol distribution into lungs was observed by scintigraphy, when CMS was nebulized with Pari LC® star than with Eflow Rapid® nebulizer. This observation was confirmed by the fraction of CMS deposited into the lung (respectively 3.5% versus 1.3%).CMS and colistin simulated concentrations in epithelial lining fluid were higher after using the Pari LC star® than the Eflow rapid® system. CONCLUSIONS A limited fraction of CMS reaches lungs after nebulization, but higher colistin plasma concentrations were measured and higher intrapulmonary colistin concentrations were simulated with the Pari LC Star® than with the Eflow Rapid® system.


docid: worxwfpo

title: Putting the Public Back in Public Health - Surveying Symptoms of Covid-19.


title: Training Standards in Neuroendovascular Surgery: Program Accreditation and Practitioner Certification.

text: BACKGROUND AND PURPOSE Neuroendovascular surgery is a medical subspecialty that uses minimally invasive catheter-based technology and radiological imaging to diagnose and treat diseases of the central nervous system, head, neck, spine, and their vasculature. To perform these procedures, the practitioner needs an extensive knowledge of the anatomy of the nervous system, vasculature, and pathological conditions that affect their physiology. A working knowledge of radiation biology and safety is essential. Similarly, a sufficient volume of clinical and interventional experience, first as a trainee and then as a practitioner, is required so that these treatments can be delivered safely and effectively. METHODS This document has been prepared under the aegis of the Society of Neurological Surgeons and its Committee for Advanced Subspecialty Training in conjunction with the Joint Section of Cerebrovascular Surgery for the American Association of Neurological Surgeons and Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery, and the Society of Vascular and Interventional Neurology. RESULTS The material herein outlines the requirements for institutional accreditation of training programs in neuroendovascular surgery, as well as those needed to obtain individual subspecialty certification, as agreed on by Committee for Advanced Subspecialty Training, the Society of Neurological Surgeons, and the aforementioned Societies. This document also clarifies the pathway to certification through an advanced practice track mechanism for those current practitioners of this subspecialty who trained before Committee for Advanced Subspecialty Training standards were formulated. CONCLUSIONS Representing neuroendovascular surgery physicians from neurosurgery, neuroradiology, and neurology, the above mentioned societies seek to standardize neuroendovascular surgery training to ensure the highest quality delivery of this subspecialty within the United States.


docid: rtuqrhmf

title: Feasibility of asymmetric stretch assessment in the ascending aortic wall with DENSE cardiovascular magnetic resonance.

text: BACKGROUND Vessel diameter is the principal imaging parameter assessed clinically for aortic disease, but adverse events can occur at normal diameters. Aortic stiffness has been studied as an additional imaging-based risk factor, and has been shown to be an independent predictor of cardiovascular morbidity and all-cause mortality. Reports suggest that some aortic pathology is asymmetric around the vessel circumference, a feature which would not be identified with current imaging approaches. We propose that this asymmetry may be revealed using Displacement Encoding with Stimulated Echoes (DENSE). The objective of this study is to investigate the feasibility of assessing asymmetric stretch in healthy and diseased ascending aortas using DENSE. METHODS Aortic wall displacement was assessed with DENSE cardiovascular magnetic resonance (CMR) in 5 volunteers and 15 consecutive patients. Analysis was performed in a cross-sectional plane through the ascending aorta at the pulmonary artery. Displacement data was used to determine the wall stretch between the expanded and resting states of the aorta, in four quadrants around the aortic circumference. RESULTS Analysis of variance (ANOVA) did not only show significant differences in stretch between groups of volunteers (p<0.001), but also significant differences in stretch along the circumference of the aorta (p<0.001), indicating an asymmetric stretch pattern. Furthermore, there is a significant difference in the asymmetry between volunteers and different groups of patients (p<0.01). CONCLUSIONS Evaluation of asymmetric stretch is feasible in the ascending aorta with DENSE CMR. Clear differences in stretch are seen between patients and volunteers, with asymmetric patterns demonstrated around the aortic circumference.


title: Jejunal varices diagnosed by capsule endoscopy in patients with post-liver transplant portal hypertension.

text: Portal hypertension secondary to portal vein obstruction following liver transplant occurs in 5%-10% of children. Jejunal varices are uncommon in this group. We present a case series of children with significant GI blood loss, negative upper endoscopy, and jejunal varices detected by CE. Case series of patients who had CE for chronic GI blood loss following liver transplantation. Three patients who had their initial transplants at a median age of 7 months were identified at our institution presenting at a median age of 8 years (range 7-16 years) with a median Hgb of 2.8 g/dL (range 1.8-6.8 g/dL). Upper endoscopy was negative for significant esophageal varices, gastric varices, and bleeding portal gastropathy in all three children. All three patients had significant jejunal varices noted on CE in mid-jejunum. Jejunal varices were described as large prominent bluish vessels underneath visualized mucosa, one with evidence of recent bleeding. The results led to venoplasty of the portal vein in two patients and a decompressive shunt in one patient with resolution of GI bleed and anemia. CE is useful to diagnose intestinal varices in children with portal hypertension and GI bleeding following liver transplant.


Impact of COVID-19 on academic mothers.


title: Maternal and newbornnewborn outcomes of antenatal breastmilk expression: a scoping review protocol.

text: INTRODUCTION Mothers with diabetes face unique challenges associated with breastfeeding initiation and maintenance. Antenatal breastmilk expression (BME) may be suggested to mothers, including mothers with diabetes, to improve breastfeeding, maternal, and infant outcomes postpartum. However, there have been few evaluations of the potential harms and benefits of this practice. The objective of our scoping review will be to broadly examine the literature describing maternal and infant outcomes of antenatal BME. METHODS AND ANALYSIS This scoping review will address the research question: 'Among women who engaged in antenatal BME, what maternal and infant outcomes have been evaluated?' A search of published and unpublished studies available in English will be conducted in February 2020 using the following databases: Medline (OVID), Embase (OVID), CINAHL (EBSCOHost), and Cochrane Database of Systematic Reviews (OVID). A search of the British Library E-Theses Online Services (EThOS) database and OpenGrey will be conducted to identify relevant grey literature. This scoping review will use a five-step framework to guide the selection, extraction, and analysis of eligible studies. Clinical consultation will be included as a sixth step to our methodology. Literature reporting on the effect of antenatal BME on maternal and infant outcomes, breastfeeding initiation and duration, and the experiences of women who have engaged in the practice will be considered. The data will be summarised with attention paid to high-risk obstetrical populations such as women with diabetes. Our results will be reported as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. ETHICS AND DISSEMINATION Research ethics board approval will not be required due to the nature of the study's methodology. The results of this review will be disseminated through peer-reviewed publication and presentation at relevant conferences. TRAIL REGISTRATION NUMBER Open Science Framework (osf.io/gfp2q).


title: The Feasibility of LigaSure to Create Intestinal Anastomosis: Results of Ex Vivo Study.

text: OBJECTIVE To evaluate the feasibility and the effectiveness of LigaSure Forced Triad to create intestinal anastomosis in an ex vivo porcino model. METHODS Colon samples (n = 100) were prospectively randomized into 2 groups: LigaSure group (n = 90) and Stapler group (n = 10). The LigaSure group was divided into 9 subgroups, each of 10 samples, according to the different power levels of the LigaSure system (Bar 1, Bars 2, and Bars 3) and radiofrequency application (1 application, 2 applications, and 3 applications) used. All anastomoses were tested for early burst pressure. The LigaSure subgroup having the highest burst pressure was compared with the Stapler group. Finally, the specimen was reviewed by the same pathologist. RESULTS The burst pressures of the 9 subgroups of LigaSure segments were the following: 29.7 ± 4.5 (Subgroup a); 27.4 ± 3.1 (Subgroup b); 25.3 ± 4 (Subgroup c); 32.9 ± 2.3 (Subgroup d); 30.7 ± 3.8 (Subgroup e); 25.7 ± 4.8 (Subgroup f); 42 ± 4.7 (Subgroup g); 31.8 ± 3.8 (Subgroup h); and 28.5 ± 3 (Subgroup j). Subgroup g (3 bars-power levels/1 frequency application) had the highest burst pressure (P < .001; ANOVA test). No significant difference was found between burst pressure of Subgroup g and Stapler group (42 ± 4.7 vs 42 ± 4.3, respectively, P = .9). On histological view, the LigaSure anastomosis was formed by collagen sealed without cavitation defects. CONCLUSIONS Our study seems to confirm the feasibility of creating intestinal anastomosis using LigaSure. However, further researches in in vivo models are mandatory before recommending its clinical usage in such settings.


title: Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy.

text: BACKGROUND This study reports the short- and long-term results for a prospective rectal cancer management program using laparoscopic radical transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis (TATA) after neoadjuvant therapy. METHODS A prospective database included 102 rectal cancer patients treated with laparoscopic TATA from 1998 to 2008. Patients with distant metastasis at presentation, patients with a tumor more than 3 cm from the anorectal ring, and patients not undergoing neoadjuvant therapy were excluded, leaving 79 patients (54 men and 25 women) with a mean age of 59.2 years (range, 22-85 years) for this study. 13 patients completed neoadjuvant therapy before the original evaluation, and they are excluded from the report of initial clinical assessment. Before treatment, 50 patients were staged as T3 and 16 patients as T2. The mean level in the rectum superior to the anorectal ring was 1.2 cm (range, -0.5 to 3 cm). In terms of fixity, 31 of the tumors were mobile, 27 were tethered, and 8 showed early fixation. Ulceration was absent in 8 cases, minimal in 12 cases, superficial in 7 cases, moderate in 22 cases, and deep in 17 cases. The mean pretreatment tumor size tumor was 4.8 cm (range, 1.5-12 cm). The median external beam radiation was 5,400 cGy (range, 3,000-8,040 cGy), and 77 patients underwent chemotherapy. RESULTS The mean follow-up period was 34.2 months (range, 1.9-113.9 months). There were no perioperative mortalities. The conversion rate was 2.5%, and the mean largest incision length was 4.3 cm (range, 1.2-21 cm). For 84% of the patients, the incision was less than 6.0 cm, and 46% of the patients had no abdominal incision for delivery of the specimen. The mean estimated blood loss was 367 ml (range, 75-2,200 ml). All the patients had a temporary diverting stoma. The major morbidity rate was 11%, and the minor morbidity rate was 19%. The major complications included four full-thickness rectal prolapses with repair, one ischemic neorectum with successful reanastomosis, two bowel obstructions, and two failed anastomoses requiring stoma. The ypT stages included 22 complete responses, 12 cases of ypT1, 22 cases of ypT2, 23 cases of ypT3; 65 cases of ypN0, and 14 cases of ypN + (T3 = 7, T2 = 4, T1 = 3). The local recurrence rate was 2.5% (2/79), and the distant metastases rate was 10.1% (8/79). The KM5YAS rate was 97%. Overall, 90% of the patients lived without a stoma. Neorectal loss was due to positive margins or recurrence and was followed by abdominoperineal resection in three cases and ischemia in two cases. The condition of two patients was not reversed due to comorbidities, and one patient had a stoma secondary to bowel obstruction. CONCLUSION The study results indicate excellent local recurrence (2.7%) and 5-year survival rates without the need for permanent colostomy in patients with cancers in the distal one-third of the rectum. Laparoscopic total mesorectal excision (TME) with the TATA approach is safe and can be performed laparoscopically. Multi-institutional studies are required to establish the reproducibility of this promising approach.


title: Pain and recovery are comparable after either uniportal or multiport video-assisted thoracoscopic lobectomy: an observation study.

text: OBJECTIVES Uniportal approaches to video-assisted thoracoscopic surgery (VATS) lobectomy have been described in significant series. Few comparison studies between the two techniques exist. The aim was to determine whether the uniportal technique had more favourable postoperative outcomes than the multiport technique. METHODS All VATS lobectomies undertaken at a single university hospital during August 2012 to December 2013 were studied. Patients with preoperative opiate use or chronic pain were excluded. Patients were divided into those with uniportal and multiport approaches for analysis. All continuous data were assessed for normality, and analysed with the Mann-Whitney U-tests or t-tests as appropriate. Categorical data were analysed by Fisher's exact or χ(2) test for trend as appropriate. RESULTS One hundred and twenty-nine VATS lobectomies were completed. Six were excluded and data were incomplete for 13, leaving 110 (15 uniportal, 95 multiport) for analysis. The demographics of the two groups were similar. There was no significant difference in the Thoracoscore or American Society of Anesthesiologists grades. The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group, P = 0.84. The median visual analogue pain score in the first 24 h was 0 in the uniportal group and 0 in the multiport group, P = 0.65. There was no difference in the duration of patient-controlled analgesia (P = 0.97), chest drain duration (P = 0.67) or hospital length of stay (P = 0.54). There was no inpatient mortality and no unplanned admission to critical care in either group. CONCLUSIONS Uniportal VATS lobectomy is safe, and there is no appreciable negative impact on the hospital stay or morbidity. Patient-reported pain and morphine use in the first 24 h was low with either technique. Larger prospective studies are needed to quantify any benefit to a particular approach for VATS lobectomy.