title: A Review on 2019 Novel Coronavirus Pneumonia in Ophthalmology.

text: Purpose: To investigate the possibility of ocular involvement in the 2019-novel coronavirus infectious (2019-nCoV) and vital preventive measures in the field of ophthalmology.Methods: All the studies that were most relevant to the 2019-nCoV ocular involvement and routes of transmission, especially in the field of ophthalmology, thoroughly reviewed.Results: From the ocular perspective, conjunctivitis may be the first presenting symptom of 2019-nCoV, so, we as ophthalmologists are at the forefront of exposure with newly infected patients. Although transconjunctival aerosol is a suspected but, the main route of transmission is the known respiratory droplets which will be more significant due to close contact in the field of ophthalmology. This review advise a set of recommendation for preventive care to minimize cross-infection of 2019-nCoV.Conclusions: Ophthalmologists have an essential role in guiding cross-infection control measures between patients and staff. Until a vaccine is created, public health strategies are likely the best weapons against this invisible enemy.


title: Stent strut breakage using high-pressure balloons for bifurcation stenting and subsequent percutaneous pulmonary valve replacement using the Edwards Sapien THV.

text: This report describes the use of the Edwards Sapien THV in a patient who had a short regurgitant/stenotic homograft with early bifurcation stenoses of the pulmonary arteries. A 48-mm AndraStent was positioned in the right pulmonary artery-homograft jailing the left pulmonary artery (LPA). To have an unobstructed access to the LPA, the stent strut leading to the LPA was broken using high-pressure balloon. A 23-mm Edwards Sapien THV was positioned in the stented homograft just proximal to the LPA origin with resolution of the stenosis and regurgitation.


docid: rwziogkd

title: Infrared thermal imaging in medicine.

text: This review describes the features of modern infrared imaging technology and the standardization protocols for thermal imaging in medicine. The technique essentially uses naturally emitted infrared radiation from the skin surface. Recent studies have investigated the influence of equipment and the methods of image recording. The credibility and acceptance of thermal imaging in medicine is subject to critical use of the technology and proper understanding of thermal physiology. Finally, we review established and evolving medical applications for thermal imaging, including inflammatory diseases, complex regional pain syndrome and Raynaud's phenomenon. Recent interest in the potential applications for fever screening is described, and some other areas of medicine where some research papers have included thermal imaging as an assessment modality. In certain applications thermal imaging is shown to provide objective measurement of temperature changes that are clinically significant.


COVID-19 and SIADH relations: impact of the positive pressure ventilation.


title: Long-Term Complications of Appendectomy: A Systematic Review.

text: BACKGROUND AND AIMS Appendectomy is a common surgical procedure, but no overview of the long-term consequences exists. Our aim was to systematically review the long-term complications of appendectomy for acute appendicitis. MATERIALS AND METHODS This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42017064662). The databases PubMed and EMBASE were searched for original reports on appendectomy with n ≥ 500 and follow-up >30 days. The surgical outcomes were ileus and incisional hernia; other outcomes were inflammatory bowel disease, cancer, fertility, and mortality. RESULTS We included 37 studies. The pooled estimate of the ileus prevalence was 1.0% over a follow-up period of 4.6 (range, 0.5-15) years. Regarding incisional hernia, we found a pooled estimate of 0.7% prevalence within a follow-up period of 6.5 (range, 1.9-10) years. Ulcerative colitis had a pooled estimate of 0.15% prevalence in the appendectomy group and 0.19% in controls. The opposite pattern was found regarding Crohn's disease with a pooled estimate of 0.20% prevalence in the appendectomy group and 0.12% in controls. No clear pattern was found regarding most of the examined cancers in appendectomy groups compared with background populations. Pregnancy rates increased after appendicitis compared with controls in most studies. Mortality was low after appendectomy. CONCLUSION Appendectomy had a low prevalence of long-term surgical complications. We did not find any significant other long-term complications, though the prevalence of Crohn's disease was higher and the prevalence of ulcerative colitis was lower after appendectomy than in controls. Appendectomy did not impair fertility.


Shutting down RNA-targeting CRISPR.


Correction: Adenovirus and Herpesvirus Diversity in Free-Ranging Great Apes in the Sangha Region of the Republic of Congo.


title: Psychological therapies for people with borderline personality disorder.

text: BACKGROUND Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006. OBJECTIVES To assess the effects of psychological interventions for borderline personality disorder (BPD). SEARCH METHODS We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011. SELECTION CRITERIA Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data. MAIN RESULTS Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy. AUTHORS' CONCLUSIONS There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.


title: Animal genomics and infectious disease resistance in poultry.

text: Avian pathogens are responsible for major costs to society, both in terms of huge economic losses to the poultry industry and their implications for human health. The health and welfare of millions of birds is under continued threat from many infectious diseases, some of which are increasing in virulence and thus becoming harder to control, such as Marek's disease virus and avian influenza viruses. The current era in animal genomics has seen huge developments in both technologies and resources, which means that researchers have never been in a better position to investigate the genetics of disease resistance and determine the underlying genes/mutations which make birds susceptible or resistant to infection. Avian genomics has reached a point where the biological mechanisms of infectious diseases can be investigated and understood in poultry and other avian species. Knowledge of genes conferring disease resistance can be used in selective breeding programmes or to develop vaccines which help to control the effects of these pathogens, which have such a major impact on birds and humans alike.


Covid-19: Number of Germans infected could be 10 times higher than official estimates.


title: Transport of amino acids in the kidney.

text: Amino acids are the building blocks of proteins and key intermediates in the synthesis of biologically important molecules, as well as energy sources, neurotransmitters, regulators of cellular metabolism, etc. The efficient recovery of amino acids from the primary filtrate is a well-conserved key role of the kidney proximal tubule. Additionally, renal metabolism participates in the whole body disposition of amino acids. Therefore, a wide array of axially heterogeneously expressed transporters is localized on both epithelial membranes. For transepithelial transport, luminal uptake, which is carried out mainly by active symporters, is coupled with a mostly passive basolateral efflux. Many transporters require partner proteins for appropriate localization, or to modulate transporter activity, and/or increase substrate supply. Interacting proteins include cell surface antigens (CD98), endoplasmic reticulum proteins (GTRAP3-18 or 41), or enzymes (ACE2 and aminopeptidase N). In the past two decades, the molecular identification of transporters has led to significant advances in our understanding of amino acid transport and aminoacidurias arising from defects in renal transport. Furthermore, the three-dimensional crystal structures of bacterial homologues have been used to yield new insights on the structure and function of mammalian transporters. Additionally, transgenic animal models have contributed to our understanding of the role of amino acid transporters in the kidney and other organs and/or at critical developmental stages. Progress in elucidation of the renal contribution to systemic amino acid homeostasis requires further integration of kinetic, regulatory, and expression data of amino acid transporters into our understanding of physiological regulatory networks controlling metabolism.


David Oliver: The structural problems highlighted by covid-19.


title: Treatment of osteoid osteoma with CT-guided percutaneous radiofrequency thermoablation.

text: Osteoid osteoma is a benign bone tumor with a male predominance occurring mainly in children and young adults. The most common symptom is intermittent pain that worsens at night and is at least partially relieved by nonsteroidal anti-inflammatory drugs. The purpose of this study was to assess the long-term effectiveness of computed tomography-guided percutaneous radiofrequency thermoablation in patients with a minimum follow-up of 2 years. Twenty patients with osteoid osteoma (15 men and 5 women) with a mean age of 20.7 years (range, 4-61 years; 12 patients aged 20 years or younger) underwent computed tomography-guided percutaneous radiofrequency thermoablation. Lesion sites were the femur (n=9), tibia (n=7), pelvis (n=1), talus (n=1), cuneiform bone (n=1), and humerus (n=1). Mean follow-up was 44 months (range, 3-106 months). Pain relief was significant in 95% of patients; it disappeared within 24 hours in 14 patients, within 3 days in 4, and within 7 days in 1. The patient with persistent symptoms underwent another percutaneous radiofrequency thermoablation procedure that was successful. The difference between pre- and postoperative pain was significant (P ≤ .01). No recurrences occurred. Computed tomography-guided percutaneous radiofrequency thermoablation is a safe, minimally invasive, and economical procedure with high technical and clinical success rates, and it effectively and durably enhances quality of life.


docid: zfsannke

title: Review of new and newly discovered respiratory tract viruses in children.

text: Respiratory tract viral infection continues to be among the most common reasons for emergency department visits and hospitalization of children, particularly infants younger than 1 year, in the United States. Throughout the years, clinicians have considered respiratory syncytial virus followed by influenza as the most common pathogens responsible. Over the past decade, new viruses have been discovered through both more specific testing and the finding of new agents causing infection. This includes human metapneumovirus, which leads to similar but often epidemiologically more severe clinical symptoms than respiratory syncytial virus. Other agents responsible for lower respiratory tract infection include Coronavirus (severe acute respiratory syndrome), Bocavirus, and others. This review serves to focus on some of the recent literature on these agents and the clinical impact they have on pediatric lung infection.


Influenza at the beginning of the 21st century.


Approaches to stimulate clinical reasoning in continuing medical education during the COVID-19 pandemic.


title: Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity?

text: BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is currently being performed with increasing frequency worldwide. It offers an excellent weight loss and resolution of comorbidities in the short term with a very low incidence of complications. However, the ever present risk of a staple line leak is still a major concern. METHODS Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered in an online database and analyzed at the Institute of Quality Assurance in Surgical Medicine. For the current analysis, all patients that had undergone primary sleeve gastrectomy for morbid obesity within a 7-year period were considered. RESULTS Using the GBSR, data from 5.400 LSGs were considered for analysis. Staple line leak rate decreased during the study period from 6.5 to 1.4 %. Male gender, higher BMI, concomitant sleep apnea, conversion to laparotomy, longer operation time, use of both buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate. On multivariate analysis, operation time and year of procedure only had a significant impact on staple line leak rate. CONCLUSIONS The results of the current study demonstrated that there are factors that increase the risk of a leakage which would enable surgeons to define risk groups, to more carefully select patients, and to offer a closer follow-up during the postoperative course with early recognition and adequate treatment. All future efforts should be focused on a further reduction of serious complications to make the LSG a widely accepted and safer procedure.


title: A systematic review of cardiac rehabilitation registries.

text: Introduction Despite cardiac rehabilitation being recommended in clinical practice guidelines internationally these services are underutilised, programmes are not standardised and quality improvement methods and outcomes are rarely published. National registries are an important strategy to characterise service delivery, quality and outcomes, yet the number, type and components of national cardiac rehabilitation registries have not been reported. Aims To identify and describe national and international cardiac rehabilitation registries, and summarise their key features. Methods We systematically reviewed the literature reporting on cardiac rehabilitation registries at a national and international level. A search of four databases was conducted in July 2016, with two reviewers independently screening titles/abstracts and full texts for inclusion. Data were extracted from included studies, independently checked by a second reviewer and synthesised qualitatively. Results Eleven articles were included in the review comprising seven national registries and one international registry (of 12 European countries) for a total sample of 265,608 patients. Data were most commonly provided to the registry by a web-based application, and included individual-level data (i.e. sociodemographic characteristics, medical history, and clinical measurements). When reported, service-level data most commonly included wait times, programme enrolment and completion. The overarching governance, funding modes (e.g. industry ( n = 2), government ( n = 1)), and incentives for registry participation (e.g. benchmarking, financial reimbursement, or mandatory requirement) varied widely. Conclusion The use of national and international registries for characterising cardiac rehabilitation and providing a benchmark for quality improvement is in its early stages but shows promise for national and global benchmarking.


title: We do not need mechanical ventilation any more.

text: Mechanical ventilation is a lifesaving treatment delivered to patients with a wide spectrum of medical and surgical diseases. However, significant limitations of the clinical application of mechanical ventilation in current practice have emerged, prompting the definition of novel therapeutic perspectives, especially concerning the prevention and treatment of acute respiratory failure. In the past few decades, there has been a consistent scientific and technologic effort to develop alternative strategies to avoid the need for mechanical ventilation. In particular, several studies have explored the feasibility and efficacy of extracorporeal oxygenation and carbon dioxide removal. Furthermore, promising results on the prevention of the occurrence of severe acute respiratory failure have been provided by clinical studies on the noninvasive application of continuous positive airway pressure as well as by experimental investigations in basic science. Therefore, further development in this direction will occur only with a permanent integration and exchange of knowledge among industry, clinicians, and scientific investigators.


title: Robotic lobectomy and segmentectomy for lung cancer: results and operating technique.

text: Video-assisted thoracic surgery (VATS) is a minimally invasive approach with several advantages over open thoracotomy for the surgery of lung cancer but also some limitations like rigid instruments and suboptimal vision. Robot technology is an evolution of manual videothoracoscopy introduced to overcome these limitations maintaining the advantages related to low invasiveness. More intuitive movements, greater flexibility and high definition three-dimensional vision are advantages of the robotic approach. Different studies demonstrate that robotic lobectomy and segmentectomy are feasible and safe with long term outcome similar to that of open/VATS approaches, however no randomised comparison are available and benefits in terms of quality of life (QOL) and pain need to be demonstrated yet. Several different robotic techniques are currently employed and differ for number of robotic arms (three versus four), the use of CO2 insufflation, timing of utility incision and the port positioning. The four arms robotic approach with anterior utility incision is the technique described by the authors. Indications to perform robotic lung resections may be more extensive than those of traditional videothoracoscpic approach and includes patients with locally advanced disease after chemotherapy or those requiring anatomical segmentectomy. Learning curve of vats and robotic lung resection is similar. High capital and running costs are the most important disadvantages. Entry of competitor companies should drive down costs.


title: Identification of major histocompatibility complex class I C molecule as an attachment factor that facilitates coronavirus HKU1 spike-mediated infection.

text: Human coronavirus HKU1 (HCoV-HKU1) is a recently discovered human coronavirus associated with respiratory tract infections worldwide. In this study, we have identified the major histocompatibility complex class I C molecule (HLA-C) as an attachment factor in facilitating HCoV-HKU1 spike (S)-mediated infection. HCoV-HKU1 S pseudotyped virus was assembled using a human immunodeficiency virus type 1-derived reporter virus harboring the human codon-optimized spike of HCoV-HKU1. We identified human alveolar epithelial A549 cells as the most susceptible cell line among those tested to infection by HCoV-HKU1 S pseudotypes. A549 cells were shown to bind purified soluble HCoV-HKU1 S(1-600) glycopeptide. To search for the functional receptor for HCoV-HKU1, an A549 cDNA expression library was constructed and transduced into the nonpermissive, baby hamster kidney cells line BHK-21. Transduced cells that bind soluble HCoV-HKU1 S(1-600) glycoprotein with C-terminal FLAG were sorted. Sequencing of two independent clones revealed cDNA inserts encoding HLA-C. Inhibition of HLA-C expression or function by RNAi silencing and anti-HLA-C antibody decreased HCoV-HKU1 S pseudotyped virus infection of A549 cells by 62 to 65%, whereas pretreatment of cells with neuraminidase decreased such infection by only 13%. When HLA-C was constitutively expressed in another nonpermissive cell line, NIH-3T3, quantitative PCR showed that the binding of HCoV-HKU1 S pseudotyped virus to cell surfaces was increased by 200-fold, but the cells remained nonsusceptible to HCoV-HKU1 S pseudotyped virus infection. Our data suggest that HLA-C is involved in the attachment of HCoV-HKU1 to A549 cells and is a potential candidate to facilitate cell entry. However, other unknown surface proteins on A549 cells may be concomitantly utilized by S glycoprotein of HCoV-HKU1 during viral entry. Further studies are required to elucidate other putative receptors or coreceptors for HCoV-HKU1 and the mechanism of HCoV-HKU1 S-mediated cell entry.


title: Computed tomographic-lymphography as a complementary technique for lymph node staging in dogs with malignant tumors of various sites.

text: Locoregional lymph nodes are routinely examined in order to define the spatial extent of neoplastic disease. As draining patterns of certain tumor types can be divergent from expected anatomical distribution, it is critical to sample the lymph nodes truly representing the draining area. The aim of this bicenter prospective pilot study was to describe the technique of computed tomographic (CT)-lymphography for primary draining lymph node mapping in tumor staging in dogs. Forty-five dogs with macro- or microscopic tumors in specified localizations were evaluated. Depending on body weight, 0.8-2 ml contrast agent (iohexol) was injected into four quadrants around the tumor, and CT-images were obtained at 1, 3, 6, 9, and 12 minutes post-injection. Attenuation of chosen regions of interest (Hounsfield units (HU)) and patterns of enhancement were assessed for 284 lymph nodes in the precontrast study with median HUs of 31.1 (Interquartile range (IQR) = 18.4) and for 275 in the intravenous postcontrast study with 104.3 HU (IQR = 31.2) (paired Wilcoxon test, P < 0.001). In the CT-lymphography study, 45 primary draining lymph nodes with a significantly higher median HU value of 348.5 (IQR = 591.4) (one-sample t-test, P < 0.001) were identified. Primary draining lymph nodes were found to be clearly visible after 1-3 minutes after local injection, often concurrent with a good visibility of the lymphatic vessel system. The herein described technique of peritumorally injected CT-contrast agent followed by subsequent CT-lymphography for primary draining lymph node mapping works well in a majority of cases in all investigated sites and warrants further validation for different tumor entities.


title: Retromammary approach for endoscopic resection of benign breast lesions.

text: BACKGROUND One of the merits of endoscopic surgery is that it can be performed through small remote incisions made in inconspicuous areas. To improve cosmetic outcomes of surgical treatment of benign breast lesions, we performed endoscopic surgery through minimally sized axillary incisions with the goal of achieving scar-free breasts. METHODS From August 2007 to August 2008, 18 patients with 20 benign breast lesions underwent endoscopic breast excision in our institution. Endoscopic resection of benign breast lesions was performed via the retromammary route with video assistance. Cosmetic results were evaluated using the five-item, four-step ABNSW scoring system, assessing breast asymmetry, breast shape, nipple shape, skin condition, and wound scars. RESULTS The median age of the patients was 27 years (IQR 23.0, 29.0). Median resected lesion size was 3.3 cm (IQR 2.9, 3.9). Median operative time was 85.0 min (IQR 70.0, 100.0). A marginally significant difference in operative times was noted between fibroadenoma and/or juvenile fibroadenoma cases and mastopathy or benign phyllodes cases (80.0 vs. 100.0; p < 0.06). Median total ABNSW score was 14 points. Postoperatively, 5 patients had mild local subcutaneous emphysema, and one had transient brachial palsy. No breast ecchymosis or deformity was noted. No major complications developed in any patient, and 89% of patients had good or excellent results. CONCLUSIONS Video-assisted endoscopic breast surgery has changed routine breast surgery, manifesting cosmetic effects that cannot be achieved by previous routine surgical techniques. Patients with multiple or large benign tumors who desire excellent cosmetic results are good candidates for this approach.


The president's national security agenda: curtailing Ebola, safeguarding the future.


title: Effect of leak and breathing pattern on the accuracy of tidal volume estimation by commercial home ventilators: a bench study.

text: BACKGROUND New home ventilators are able to provide clinicians data of interest through built-in software. Monitoring of tidal volume (VT) is a key point in the assessment of the efficacy of home mechanical ventilation. OBJECTIVE To assess the reliability of the VT provided by 5 ventilators in a bench test. METHODS Five commercial ventilators from 4 different manufacturers were tested in pressure support mode with the help of a breathing simulator under different conditions of mechanical respiratory pattern, inflation pressure, and intentional leakage. Values provided by the built-in software of each ventilator were compared breath to breath with the VT monitored through an external pneumotachograph. Ten breaths for each condition were compared for every tested situation. RESULTS All tested ventilators underestimated VT (ranges of -21.7 mL to -83.5 mL, which corresponded to -3.6% to -14.7% of the externally measured VT). A direct relationship between leak and underestimation was found in 4 ventilators, with higher underestimations of the VT when the leakage increased, ranging between -2.27% and -5.42% for each 10 L/min increase in the leakage. A ventilator that included an algorithm that computes the pressure loss through the tube as a function of the flow exiting the ventilator had the minimal effect of leaks on the estimation of VT (0.3%). In 3 ventilators the underestimation was also influenced by mechanical pattern (lower underestimation with restrictive, and higher with obstructive). CONCLUSIONS The inclusion of algorithms that calculate the pressure loss as a function of the flow exiting the ventilator in commercial models may increase the reliability of VT estimation.


[In Focus: SARS-CoV-2 and the COVID-19 Pandemic].


title: Clinical Frailty Scale for risk stratification in patients with SARS-CoV-2 infection.

text: Predictive factors for adverse outcomes in patients with COVID-19 are urgently needed. Data related to the applicability of the Clinical Frailty Scale (CFS) for risk stratification in patients with COVID-19 are currently lacking. We investigated the ability of CFS to predict need for mechanical ventilation and the duration of hospital stays in European patients with COVID-19. In total, 42 patients with confirmed COVID-19 infection admitted to the University Medical Center Mainz between March 3 and April 15 2020 were included into this validation study and data were retrospectively analyzed. CFS was assessed at admission in all patients. Patients were followed for need for mechanical ventilation and time to hospital discharge. At admission, the median CFS was 3 (range: 1-7) and 14 (33.3%) patients were considered as at least pre-frail (CFS >3). 24 (57.1%) patients were discharged from hospital after a median time of 7 days (IQR 4-8). 12 (28.6%) patients developed acute respiratory distress syndrome and required mechanical ventilation. In multivariable Cox regression analyses, higher CFS scores (HR 1.659, 95% CI 1.090 to 2.525, p=0.018) were an independent predictor for a higher risk of mechanical ventilation after adjusting for age, Charlson Comorbidity Index and quick sepsis-related organ failure score. Additionally, lower CFS scores (HR 0.554, 95% CI 0.312 to 0.983, p=0.043) were associated with earlier discharge from hospital. In conclusion, this report demonstrates the usefulness of the CFS for risk stratification at hospital admission in patients with COVID-19.


Nasal ACE2 Levels and COVID-19 in Children.


title: An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: A supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II): The TASC steering committee.

text: The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.


title: Probiotics in animal nutrition and health.

text: The use of probiotics for farm animals has increased considerably over the last 15 years. Probiotics are defined as live microorganisms which can confer a health benefit for the host when administered in appropriate and regular quantities. Once ingested, the probiotic microorganisms can modulate the balance and activities of the gastrointestinal microbiota, whose role is fundamental to gut homeostasis. It has been demonstrated that numerous factors, such as dietary and management constraints, can strongly affect the structure and activities of the gut microbial communities, leading to impaired health and performance in livestock animals. In this review, the most important benefits of yeast and bacterial probiotics upon the gastrointestinal microbial ecosystem in ruminants and monogastric animals (equines, pigs, poultry, fish) reported in the recent scientific literature are described, as well as their implications in terms of animal nutrition and health. Additional knowledge on the possible mechanisms of action is also provided.


title: Herd immunity or suppression strategy to combat COVID-19.

text: Some months ago, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) broke out in Wuhan, China, and spread rapidly around the world. Some states, such as the Netherlands, Germany, Great Britain, Sweden and the USA initially focused on keeping the restrictions for economy and society as low as possible. The responsible authorities were of the opinion - and still are e.g. in Sweden - that it is sufficient enough to protect particularly vulnerable persons such as the elderly or people with pre-existing conditions. The idea behind this is that as soon as 60 to 70 percent of the population is infected with a pathogen, a so-called "herd immunity" has developed. However, the increasing numbers of deaths and modelling studies showed the expected overload of the hospitals. Therefore, most countries decided for a temporary lockdown with the exception of Sweden.Based on the number of the total population, three times more people died from COVID-19 in Sweden (2679 deaths per 10 million inhabitants) compared to Germany (6848 deaths per 80 million inhabitants). The comparison Sweden versus Taiwan is even worse because 1072 times more people died in Sweden based on the number of the population (6 deaths per 24 million inhabitants).In the face of the lack of an antiviral treatment and the lack of a protective vaccine one must state Taiwan has made the best out of the pandemic situation whereas Sweden failed completely.


title: Early Effects of COVID-19 on Oral and Maxillofacial Surgery Residency Training-Results From a National Survey.

text: PURPOSE The coronavirus disease 2019 (COVID-19) pandemic has had an immense impact on the healthcare industry. Oral and maxillofacial surgery (OMS) clinical practice uniquely exposes providers to COVID-19. The purpose of the present study was to understand the effect of the COVID-19 pandemic on OMS residency training programs (OMSRTPs): 1) training and education; 2) availability and use of personal protective equipment (PPE); 3) experience with, and use of, screening and viral testing; 4) resident experience; and 5) program director (PD) experience and observations of the immediate and future effects on OMSRTPs. MATERIALS AND METHODS OMS residents and PDs in OMSRTPs in the United States were invited to participate in the present cross-sectional study from April 1, 2020 to May 1, 2020. A 51-question survey was used to evaluate the effects of COVID-19 on OMSRTPs and to assess the 5 specific aims of the present study. RESULTS A total of 160 residents and 13 PDs participated in the survey, representing 83% of US states or territories with OMSRTPs. Almost all residents (96.5%) reported modifications to their training program, and 14% had been reassigned to off-service clinical rotations (eg, medicine, intensive care unit). The use of an N95 respirator mask plus standard PPE precautions during aerosol-generating procedures varied by procedure location, with 36.8% reporting limited access to these respirators. Widespread screening practices were in use, with 83.6% using laboratory-based viral testing. Residents scheduled to graduate in 2022 were most concerned with the completion of the graduation requirements and with decreased operative experience. Most residents (94.2%) had moved to web-based didactics, and a plurality (47%) had found increased value in the didactics. CONCLUSIONS Sweeping alterations to OMS clinical practice have occurred for those in OMSRTPs during the COVID-19 pandemic. Although the overall OMSRTP response has been favorable, residents' concerns regarding the ubiquitous availability of appropriate PPE, operative experience, and completion of graduation requirements requires further deliberation.


title: Robotic Liver Resection: A Case-Matched Comparison.

text: BACKGROUND In recent years, increasingly sophisticated tools have allowed for more complex robotic surgery. Robotic hepatectomy, however, is still in its infancy. Our goals were to examine the adoption of robotic hepatectomy and to compare outcomes between open and robotic liver resections. METHODS The robotic hepatectomy experience of 64 patients was compared to a modern case-matched series of 64 open hepatectomy patients at the same center. Matching was according to benign/malignant diagnosis and number of segments resected. Patient data were obtained retrospectively. The main outcomes and measures were operative time, estimated blood loss, conversion rate (robotic to open), Pringle maneuver use, single non-anatomic wedge resection rate, resection margin size, complication rates (infectious, hepatic, pulmonary, cardiac), hospital stay length, ICU stay length, readmission rate, and 90-day mortality rate. RESULTS Sixty-four robotic hepatectomies were performed in 2010-2014. Forty-one percent were segmental and 34 % were wedge resections. There was a 6 % conversion rate, a 3 % 90-day mortality rate, and an 11 % morbidity rate. Compared to 64 matched patients who underwent open hepatectomy (2004-2012), there was a shorter median OR time (p = 0.02), lower median estimated blood loss (p < 0.001), and shorter median hospital stay (p < 0.001). Eleven of the robotic cases were isolated resections of tumors in segments 2, 7, and 8. CONCLUSIONS Robotic hepatectomy is safe and effective. Increasing experience in more centers will allow definition of which hepatectomies can be performed robotically, and will enable optimization of outcomes and prospective examination of the economic cost of each approach.


title: Long-term balancing selection at the antiviral gene OAS1 in Central African chimpanzees.

text: Oligoadenylate synthetases (OAS) are interferon-induced enzymes that participate in the first line of defense against a wide range of viral infection in animals. Upon activation by viral double-stranded RNA, OAS synthesizes (2-5) oligoadenylates, which activate RNase L, leading to the nonspecific degradation of cellular and viral RNA. Some association studies in humans suggest that variation at one of the OAS genes, OAS1, could be influencing host susceptibility to viral infection. We assessed the diversity of OAS1 in hominoid primates with a focus on chimpanzees. We found that the OAS1 gene is extremely polymorphic in Central African chimpanzee and exhibits levels of silent and replacement diversity much higher than neutral regions of the chimpanzee genome. This level of variation strongly suggests that balancing selection is acting on OAS1, and indeed, this conclusion was validated by several tests of neutrality. We further demonstrated that balancing selection has been acting at this locus since the split between chimpanzees, humans, and gorillas (~8.6 Ma) and caused the persistence of two deeply divergent allelic lineages in Central African chimpanzees. These two groups of OAS1 alleles differ by a large number of amino acids (a.a.), including several a.a. putatively involved in RNA binding. It is therefore very likely that variation at the OAS1 locus affects the innate immune response of individuals to specific viral infection. Our data strongly suggest that interactions between viral RNA and OAS1 are responsible for the maintenance of ancestral polymorphisms at this locus for at least 13.2 My.


Minimising the environmental impact of inhaled therapies.


title: Renin-angiotensin system inhibitors in COVID-19.

text: Concerns have been raised about the potential for renin-angiotensin system (RAS) inhibitors to upregulate expression of angiotensin-converting enzyme 2 (ACE2) and thus increase susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) entry. Currently, there is no evidence that even if RAS inhibitors increase expression and activity of ACE2, that they would increase the risk of SARS-CoV-2 infection by facilitating greater viral entry or worsen outcomes in patients with COVID-19. At this time, there is no clinical evidence to suggest that treatment with RAS inhibitors should be discontinued in stable patients with COVID-19. In hospitalized patients with severe COVID-19, decisions about these medications should be based on clinical condition, including hemodynamic status and renal function.


title: COVID-19 Control: Can Germany Learn From China?

text: The coronavirus disease 2019 (COVID-19) outbreak started in China in December 2019 and has developed into a pandemic. Using mandatory large-scale public health interventions including a lockdown with locally varying intensity and duration, China has been successful in controlling the epidemic at an early stage. The epicentre of the pandemic has since shifted to Europe and The Americas. In certain cities and regions, health systems became overwhelmed by high numbers of cases and deaths, whereas other regions continue to experience low incidence rates. Still, lockdowns were usually implemented country-wide, albeit with differing intensities between countries. Compared to its neighbours, Germany has managed to keep the epidemic relatively well under control, in spite of a lockdown that was only partial. In analogy to many countries at a similar stage, Germany is now under increasing pressure to further relax lockdown measures to limit economic and psychosocial costs. However, if this is done too rapidly, Germany risks facing tens of thousands more severe cases of COVID-19 and deaths in the coming months. Hence, it could again follow China's example and relax measures according to local incidence, based on intensive testing.


title: Malaria and Parasitic Neglected Tropical Diseases: Potential Syndemics with COVID-19?

text: The COVID-19 pandemic, caused by SARS-CoV-2, have surpassed 5 million cases globally. Current models suggest that low- and middle-income countries (LMICs) will have a similar incidence but substantially lower mortality rate than high-income countries. However, malaria and neglected tropical diseases (NTDs) are prevalent in LMICs, and coinfections are likely. Both malaria and parasitic NTDs can alter immunologic responses to other infectious agents. Malaria can induce a cytokine storm and pro-coagulant state similar to that seen in severe COVID-19. Consequently, coinfections with malaria parasites and SARS-CoV-2 could result in substantially worse outcomes than mono-infections with either pathogen, and could shift the age pattern of severe COVID-19 to younger age-groups. Enhancing surveillance platforms could provide signals that indicate whether malaria, NTDs, and COVID-19 are syndemics (synergistic epidemics). Based on the prevalence of malaria and NTDs in specific localities, efforts to characterize COVID-19 in LMICs could be expanded by adding testing for malaria and NTDs. Such additional testing would allow the determination of the rates of coinfection and comparison of severity of outcomes by infection status, greatly improving the understanding of the epidemiology of COVID-19 in LMICs and potentially helping to mitigate its impact.


docid: xhpggtcf

title: Assessing the utility of autofluorescence-based pulmonary optical endomicroscopy to predict the malignant potential of solitary pulmonary nodules in humans.

text: Solitary pulmonary nodules are common, often incidental findings on chest CT scans. The investigation of pulmonary nodules is time-consuming and often leads to protracted follow-up with ongoing radiological surveillance, however, clinical calculators that assess the risk of the nodule being malignant exist to help in the stratification of patients. Furthermore recent advances in interventional pulmonology include the ability to both navigate to nodules and also to perform autofluorescence endomicroscopy. In this study we assessed the efficacy of incorporating additional information from label-free fibre-based optical endomicrosopy of the nodule on assessing risk of malignancy. Using image analysis and machine learning approaches, we find that this information does not yield any gain in predictive performance in a cohort of patients. Further advances with pulmonary endomicroscopy will require the addition of molecular tracers to improve information from this procedure.


title: Sacral osteomyelitis after laparoscopic sacral colpopexy performed after a recent dental extraction: a case report.

text: BACKGROUND Sacral osteomyelitis and subsequent discitis is a rare complication after laparoscopic sacral colpopexy to repair apical vaginal prolapse. CASE We present a patient who developed Bacteroides fragilis sacral osteomyelitis and discitis after laparoscopic sacrocolpopexy with synthetic monofilament mesh and sacral titanium coil fixation. The patient had undergone dental extraction of 3 infected teeth approximately 2 weeks before sacrocolpopexy for stage IV apical vaginal prolapse. Computed tomography and magnetic resonance imaging (MRI) confirmed sacral osteomyelitis and discitis along with Bacteroides fragilis bacteremia approximately a week and a half after the original surgery. The patient was followed up with serial MRIs of the spine which revealed degeneration at the sacral promontory. The patient underwent successful removal of the entire mesh and sacral titanium coils with resolution of her symptoms. Follow-up MRI of the spine revealed resolution of her sacral osteomyelitis. CONCLUSIONS Sacral osteomyelitis is a rare complication after sacrocolpopexy for pelvic organ prolapse repair. There should be a high index of suspicion for patients presenting with disproportionate low back pain and vague symptoms after surgery. Recent oral surgery may increase the risk of bacteremia and subsequent infectious morbidity after sacrocolpopexy with the use of synthetic mesh for prolapse repair.


title: Synovial fluid interleukin-6 as a predictor of periprosthetic shoulder infection.

text: BACKGROUND Diagnosis of periprosthetic joint infection (PJI) in patients undergoing revision shoulder arthroplasty is challenging because of the low virulence of the most common infecting organisms. The goal of this study was to evaluate the diagnostic utility of measuring synovial fluid interleukin-6 (IL-6) levels for identifying PJI of the shoulder. METHODS Thirty-two consecutive patients evaluated for pain at the site of a shoulder arthroplasty were prospectively enrolled from November 2012 to September 2013 and underwent revision surgery (thirty-five procedures during which samples were obtained for synovial fluid IL-6 analysis). Cases were categorized into infection (n = 15) and no-infection (n = 20) groups on the basis of objective preoperative and intraoperative findings. Twenty patients treated with arthroscopic rotator cuff repair were also enrolled to serve as a non-infected control group. Synovial fluid was obtained through aspiration intraoperatively for all patients, as well as preoperatively for some. Synovial fluid IL-6 levels were measured with use of a cytokine immunoassay that utilizes electrochemiluminescent detection. A receiver operating characteristic curve was used to determine the diagnostic utility of synovial fluid IL-6 analysis. RESULTS Based on receiver operating characteristic curve analysis, synovial fluid IL-6 measurement had an area under the curve of 0.891 with an ideal cutoff value of 359.3 pg/mL. The sensitivity, specificity, and positive and negative likelihood ratios were 87%, 90%, 8.45, and 0.15, respectively. Seven patients who underwent a single-stage revision had negative results on standard perioperative testing, including the erythrocyte sedimentation rate and C-reactive protein levels, but multiple positive intraoperative tissue cultures. The level of synovial fluid IL-6 was elevated in five of these seven patients, with a median value of 1400 pg/mL. Intraoperative synovial fluid IL-6 values correlated well with preoperative IL-6 synovial fluid values (correlation = 0.61; p = 0.025) and frozen-section histologic findings (p < 0.001). Synovial fluid IL-6 levels were also significantly elevated in patients with Propionibacterium acnes infection (p = 0.01). CONCLUSIONS Measurement of synovial fluid IL-6 levels is more sensitive and specific than current preoperative testing for predicting positive cultures for patients undergoing revision shoulder arthroplasty. This diagnostic accuracy can lead to improved decision-making in the management of PJI.


title: Should we monitor with bispectral index in all patients at high risk for seizures in the operating room?

text: We report the case of a patient with a cerebral aneurysm, located in the left middle cerebral artery. During the clipping of this aneurysm, the bispectral index (BIS) increased for no apparent reason. This was then interpreted as intraoperative non-convulsive status epilepticus. This clinical condition may have negative impact in the prognosis of the patient, so it is very important to be able to detect this conditions as early as possible. Measuring the BIS while the patient is anaesthetised could be useful in this situation, considering that an increase in values greater than 60, associated with acidosis and without any other peri-anaesthetic explanation, may provide evidence of a convulsive equivalent state, allowing appropriate action to be taken.


title: Long-term quality of life and outcomes following robotic assisted TAPP inguinal hernia repair.

text: Laparoscopic TAPP inguinal hernia repair is an established alternative to open hernia repair, which offers equivalent outcomes with less postoperative pain and faster recovery. Unfortunately, it remains technically challenging, requiring advanced laparoscopic skills which have limited its popularity among surgeons. The robotic platform has the potential to overcome these challenges. The objective of this study was to examine the long-term quality of life and outcomes following robotic assisted TAPP inguinal hernia repair, since these data have not been reported up to now. From October 2012 to October 2015, 159 inguinal hernias in 82 consecutive patients were repaired with 3D mesh (BARD) using da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). The patients' demographics and intraoperative data were documented. Patients were seen 2 and 6 weeks after the surgery and the complications were recorded. Patients were assessed 6 weeks after the surgery by a survey using a universal pain assessment tool to document their post-operative pain, narcotic use and time of return to work and exercise. A modified short form 12 (SF 12) was also sent out to the patients 12-36 months after the surgery to measure their health-related quality of life prior to surgery and at the 12- to 36-month follow-up, and to document any evidence of recurrence. Postoperative health-related quality of life scores were compared to the pre-operative baseline quality of life scores using the unpaired t test. Over the course of 3 years, 159 robotic assisted TAPP inguinal hernia repair were performed in 82 patients, 73 men and 9 women by one surgeon as an outpatient basis. The mean age was 53 and mean body mass index was 26. There were no intraoperative complications or conversions. The average operative time was 99 min. Four patients developed urinary retention post-operatively and one patient developed postoperative bowel obstruction requiring laparoscopic lysis of adhesion with no long-term complications. All patients completed the pain assessment survey and the median pain score, 3 days after the surgery was 3. Narcotics were used for an average of 3.1 days. The modified SF 12 survey assessing for quality of life before and 12-36 months after surgery was completed and returned by 29 patients (response rate of 35.4% and median follow-up of 32 months). Only one recurrence was reported which was repaired with open technique. The analysis of the SF 12 survey that evaluated patient's quality of life, pain score and the ability to perform activities of daily living before and after surgery revealed a significant improvement in those measures 12-36 months after the surgery compare to their baseline. Hernia recurrence, chronic pain and physical impairment are the major long-term concerns after any type of inguinal hernia repair. Our results demonstrate that robotic assisted TAPP inguinal hernia repair appears to be a technically feasible, reproducible and safe minimally invasive alternative with low recurrence, low chronic pain and high health-related quality of life in the long term.


title: Contained Morcellation: Review of Current Methods and Future Directions.

text: Power morcellation of surgical specimen during laparoscopic surgery is a practical technology that provides the opportunity to perform several minimally invasive procedures. However, this technology brought forward additional risks and complications associated with dissemination of both benign and malignant tissues inside the abdominal cavity. Based on startling cases, Food and Drug Administration (FDA) announced a discouraging statement on the use of power morcellators that decreased the number of minimally invasive approaches in the following period. As a response to these concerns and negative impacts of the FDA statement, researchers developed several new approaches resulting in contained or in-bag morcellation methods. In this review, we aimed to discuss these current methods and provide an insight for future developments.


title: Active Therapy with Passive Immunotherapy May Be Effective in the Fight against Covid-19.

text: Passive immunity against pathogens in epidemics has historical roots. Convalescent plasma (CP), plasma collected from individuals who have recovered from an infectious disease, has been used to confer therapeutic benefits in previous epidemics, including measles, mumps, and influenza, and remains the first line passive immunotherapy in emerging diseases, including the H1N1 influenza pandemic (2009) and now Covid-19 (1). Over the last several decades, as technology has developed to purify and manufacture plasma-derived immunoglobulin (IG) as a drug therapy, hyperimmune globulin (H-IG) formulations have been used as the second line of passive immunotherapies against these diseases.


title: Antigen presenting cells in a non-mammalian model system, the chicken.

text: The chicken has a different repertoire of tissues, cells and genes of the immune response compared to mammals, yet generally survives infection with viral, bacterial, protozoal and fungal pathogens, and also worms and ectoparasites, just like mammals. Poultry are also probably the most heavily vaccinated group of farmed animals. Antigen presentation to the adaptive immune response therefore obviously normally occurs efficiently in birds. Although comparatively much is known about macrophages and B cells in the chicken, there is as yet little work on the other, professional, antigen-presenting cells, the dendritic cells (DC). Birds also have at least two other sets of phagocytic cells, heterophils and thrombocytes, which may also have the ability to present antigen. Here we review the current state of knowledge about antigen presenting cells in the chicken, concentrating mainly on recent advances in our knowledge of DC.


docid: msldawjj

title: Experimental study of the characteristics of a novel mesh suture.

text: BACKGROUND The failure of sutures to maintain tissue in apposition is well characterized in hernia repairs. A mesh suture designed to facilitate tissue integration into and around the filaments may improve tissue hold and decrease suture pull-through. METHODS In vitro, the sutures were compared for resistance to pull-through in ballistics gel. In vivo, closure of midline laparotomy incisions was done with both sutures in 11 female pigs. Tissue segments were subsequently subjected to mechanical and histological testing. RESULTS The mesh suture had tensile characteristics nearly identical to those of 0-polypropylene suture. Mesh suture demonstrated greater resistance to pull-through than standard suture (mean(s.d.) 4.27(0.42) versus 2.23(0.48) N; P < 0.001) in vitro. In pigs, the ultimate tensile strength for repaired linea alba at 8 days was higher with mesh suture (320(57) versus 160(56) N; P < 0.001), as was the work to failure (24.6(14.2) versus 7.3(3.7) J; P < 0.001) and elasticity (128(9) versus 72(7) N/cm; P < 0.001) in comparison with 0-polypropylene suture. Histological examination at 8 and 90 days showed complete tissue integration of the mesh suture. CONCLUSION The novel mesh suture structure increased the strength of early wound healing in an experimental model. Surgical relevance Traditional sutures have the significant drawback of cutting and pulling through tissues in high-tension closures. A new mesh suture design with a flexible macroporous outer wall and a hollow core allows the tissues to grow into the suture, improving early wound strength and decreasing suture pull-through. This technology may dramatically increase the reliability of high-tension closures, thereby preventing incisional hernia after laparotomy. As suture pull-through is a problem relevant to all surgical disciplines, numerous additional indications are envisioned with mesh suture formulations of different physical properties and materials.


title: [Analysis of the pregnancy outcomes in pregnant women with COVID-19 in Hubei Province].

text: Objective: To study the effect of COVID-19 on pregnancy outcomes and neonatal prognosis in Hubei Province. Methods: A retrospective comparison of the pregnancy outcomes was done between 16 women with COVID-19 and 45 women without COVID-19. Also, the results of laboratory tests, imaging examinations, and the 2019-nCoV nucleic acid test were performed in 10 cases of neonatal deliverd from women with COVID-19. Results: (1) Of the 16 pregnant women with COVID-19, 15 cases were ordinary type and 1 case was severe type. No one has progressed to critical pneumonia. The delivery method of the two groups was cesarean section, and the gestational age were (38.7±1.4) and (37.9±1.6) weeks, there was no significant difference between the two groups (P> 0.05). Also, there wee no significant differences in the intraoperative blood loss and birth weight of the newborn between the two groups (all P>0.05). (2) Ten cases of neonates delivered from pregnant women with COVID-19 were collected. The 2019-nCoV nucleic acid test were all negative. There were no significant differences in fetal distress, meconium-stained amniotic fluid, preterm birth, and neonatal asphyxia between the two groups (all P>0.05). (3) In the treatment of uterine contraction fatigue, carbetocin or carboprost tromethamine was used more in cesarean section for pregnant women with COVID-19 (1.3±0.6), compared with Non-COVID-19 group (0.5±0.7), the difference was statistically significant (P=0.001). Conclusions: If there is an indication for obstetric surgery or critical illness of COVID-19 in pregnant women, timely termination of pregnancy will not increase the risk of premature birth and asphyxia of the newborn, but it is beneficial to the treatment and rehabilitation of maternal pneumonia. Preventive use of long-acting uterotonic agents could reduce the incidence of postpartum hemorrhage during surgery. 2019-nCoV infection has not been found in neonates deliverd from pregnant women with COVID-19.


Social distancing in covid-19: what are the mental health implications?


title: Transanal Hartmann reversal: a new technique.

text: BACKGROUND Hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. However, the stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be, at least, considered in any case. Open restoration has been associated with significant morbidity and mortality; therefore, many authors have described the advantages of laparoscopic Hartmann reversal. We want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique. METHODS Patients with an end colostomy due to an emergency Hartmann procedure are selected for this intervention. This approach is performed simultaneously laparoscopically and transanally, with single-port devices, through the colostomy wound in the first case and trough anal canal in the second one. The previous stapler line is resected transanally and the proximal rectum and mesorectum are dissected until the peritoneal reflexion, where both teams work together to complete the adhesiolysis. Finally an end-to-end anastomosis is performed under laparoscopic control. RESULTS As in patients with rectal cancer, dissection of the stump in Hartmann reversal procedure may be better and associated with shorter operative time. CONCLUSIONS As with any new surgical procedure, it is probably too early to draw conclusions, but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a Hartmann reversal.


title: The technique of endovascular intracranial revascularization.

text: Intracranial atherosclerosis was traditionally believed to carry a risk of stroke of 8% to 22% per annum. The annualized stroke rate in the recent stenting and aggressive medical management for preventing stroke in intracranial stenosis (SAMMPRIS) trial medical management arm was 12.2%. This trial was halted due to excessive periprocedural events in the stent arm. This stroke rate is still unacceptably, high and a treatment strategy is still needed. SAMMPRIS has no bearing on angioplasty alone. Angioplasty alone has always been our primary intervention for intracranial atherosclerosis and remains so to this day due to its relative simplicity, low complication rate, and efficacy. We have, however, made adjustments to our patient management regimen based on the results of SAMMPRIS. This paper outlines our current patient selection, procedural technique, and post-procedure management. The complications we have encountered while developing our technique are described along with how to avoid them and how to manage them. Our most recent results (since previous publications) are also discussed.


A complication with an intubating introducer and a double-lumen tube: tip of the iceberg?


title: Intrinsic innate immunity fails to control herpes simplex virus and vesicular stomatitis virus replication in sensory neurons and fibroblasts.

text: UNLABELLED Herpes simplex virus 1 (HSV-1) establishes lifelong latent infections in the sensory neurons of the trigeminal ganglia (TG), wherein it retains the capacity to reactivate. The interferon (IFN)-driven antiviral response is critical for the control of HSV-1 acute replication. We therefore sought to further investigate this response in TG neurons cultured from adult mice deficient in a variety of IFN signaling components. Parallel experiments were also performed in fibroblasts isolated concurrently. We showed that HSV-1 replication was comparable in wild-type (WT) and IFN signaling-deficient neurons and fibroblasts. Unexpectedly, a similar pattern was observed for the IFN-sensitive vesicular stomatitis virus (VSV). Despite these findings, TG neurons responded to IFN-β pretreatment with STAT1 nuclear localization and restricted replication of both VSV and an HSV-1 strain deficient in γ34.5, while wild-type HSV-1 replication was unaffected. This was in contrast to fibroblasts in which all viruses were restricted by the addition of IFN-β. Taken together, these data show that adult TG neurons can mount an effective antiviral response only if provided with an exogenous source of IFN-β, and HSV-1 combats this response through γ34.5. These results further our understanding of the antiviral response of neurons and highlight the importance of paracrine IFN-β signaling in establishing an antiviral state. IMPORTANCE Herpes simplex virus 1 (HSV-1) is a ubiquitous virus that establishes a lifelong latent infection in neurons. Reactivation from latency can cause cold sores, blindness, and death from encephalitis. Humans with deficiencies in innate immunity have significant problems controlling HSV infections. In this study, we therefore sought to elucidate the role of neuronal innate immunity in the control of viral infection. Using neurons isolated from mice, we found that the intrinsic capacity of neurons to restrict virus replication was unaffected by the presence or absence of innate immunity. In contrast, neurons were able to mount a robust antiviral response when provided with beta interferon, a molecule that strongly stimulates innate immunity, and that HSV-1 can combat this response through the γ34.5 viral gene. Our results have important implications for understanding how the nervous system defends itself against virus infections.


title: Hope, quality of life, and benefit from treatment in women having chemotherapy for platinum-resistant/refractory recurrent ovarian cancer: the gynecologic cancer intergroup symptom benefit study.

text: Chemotherapy for platinum-resistant/refractory ovarian cancer is motivated by the hope of benefit. We sought to determine the relationships between: (a) trait hope, expectation of symptom benefit from chemotherapy, and anxiety and depression; (b) hope and perceived efficacy of chemotherapy; and (c) unfulfilled hope (where expectations for benefit are not fulfilled) and depression. Methods. Adult patients enrolled within stage 1 of the Gynecologic Cancer Intergroup Symptom Benefit Study were included. Patient. Reported outcomes were collected from 126 women with predominantly platinum-resistant ovarian cancer at baseline, prior to the first four treatment cycles (12-16 weeks), and four weeks after completing chemotherapy or at disease progression, whichever came first. Associations were assessed with Spearman rank correlation coefficient (r) and odds ratio. Results. Trait hope and expectation of symptom benefit from chemotherapy were weakly correlated with each other (r = 0.25). Trait hope, but not expectation of symptom benefit, was negatively correlated with anxiety (r = -0.43) and depression (r = -0.50). The smaller the discrepancy between perceived and expected symptom benefit, the less likely the patient was to have scores indicative of depression (odds ratio: 0.68; 95% confidence interval: 0.49-0.96; p = .026). Conclusion. Trait hope and expectation of symptom benefit from chemotherapy appear to be distinct and independent of the aspects of quality of life and scores for depression. Hope did not appear to affect perceived efficacy of chemotherapy in alleviating symptoms, but women whose expectation of symptom benefit from chemotherapy was not fulfilled were more likely to have scores indicative of depression. It may be preferable to encourage hope toward achievable goals rather than toward benefits from chemotherapy.


Journal Flexibility in the Troubling Times of COVID-19.


title: Association between serum levels of C-reactive protein and personality traits in women.

text: BACKGROUND While low-grade inflammation has consistently been observed in subjects with depression, studies on the possible relationship between inflammation and other aspects of brain function are as yet sparse. In this study, we aimed to investigate the possible association between serum levels of the inflammation marker C-reactive protein (CRP) and personality traits. METHODS In this study, serum levels of high-sensitivity CRP were determined by ELISA in a population of 270 42-year-old women recruited from the population registry who had been assessed using the Temperament and Character Inventory. Self-reported previous or ongoing depression was also recorded. Unpaired two-tailed t-tests were used for comparison between two groups and correlations were evaluated by the calculation of Pearson's r-coefficient. RESULTS The temperament trait harm avoidance was positively (r = 0.227, p < 0.05) and the character trait self-directedness was negatively (r = -0.261, p < 0.01) associated with serum levels of CRP (p-values corrected for multiple comparisons). The correlations between the personality traits and CRP were observed also after exclusion of subjects reporting ongoing depression (n = 26). Whereas women reporting ongoing depression showed significantly increased levels of CRP as compared to non-depressed women (n = 155), women reporting a history of depression displayed no significant difference in CRP levels as compared to women that reported that they had never been depressed. CONCLUSION Serum levels of CRP in women was found to be associated with the personality traits harm avoidance and self-directedness. In addition, moderately elevated levels may be a state dependent marker of depression.


title: Sedation assessment in a mobile intensive care unit: a prospective pilot-study on the relation of clinical sedation scales and the bispectral index.

text: INTRODUCTION The critically-ill undergoing inter-hospital transfers commonly receive sedatives in continuation of their therapeutic regime or to facilitate a safe transfer shielded from external stressors. While sedation assessment is well established in critical care in general, there is only little data available relating to the special conditions during patient transport and their effect on patient sedation levels. The aim of this prospective study was to investigate the feasibility and relationship of clinical sedation assessment (Richmond Agitation-Sedation Scale (RASS)) and objective physiological monitoring (bispectral index (BIS)) during patient transfers in our Mobile-ICU. METHODS The levels of sedation of 30 pharmacologically sedated patients were evaluated at 12 to 17 distinct measurement points spread strategically over the course of a transfer by use of the RASS and BIS. To investigate the relation between the RASS and the BIS, Spearman's squared rank correlation coefficient (ρ(2)) and the Kendall's rank correlation coefficient (τ) were calculated. The diagnostic value of the BIS with respect to the RASS was investigated by its sensitivity and positive predictive value for possible patient awakening. Therefore, measurements were dichotomized considering a clinically sensible threshold of 80 for BIS-values and classifying RASS values being nonnegative. RESULTS Spearman's rank correlation resulted to ρ(2) = 0.431 (confidence interval (CI) = 0.341 to 0.513). The Kendall's correlation coefficient was calculated as τ = 0.522 (CI = 0.459 to 0.576). Awakening of patients (RASS ≥ 0) was detected by a BIS value of 80 and above with a sensitivity of 0.97 (CI = 0.89 to 1.00) and a positive predictive value of 0.59 (CI = 0.45 to 0.71). CONCLUSIONS Our study demonstrates that the BIS-Monitor can be used for the assessment of sedation levels in the intricate environment of a Mobile-ICU, especially when well-established clinical scores as the RASS are impracticable. The use of BIS is highly sensitive in the detection of unwanted awakening of patients during transfers.


Minimally invasive mitral valve repair.


Covid-19: NHS Test and Trace releases first figures, with experts calling for improvements.


docid: ahymosul

title: Transmural Myocardial Scar Assessed by Cardiac Computed Tomography: Predictor of Echocardiographic Versus Clinical Response to Cardiac Resynchronization Therapy?

text: OBJECTIVES Before cardiac resynchronization therapy (CRT) implantation, cardiac computed tomography (CT) can provide assessment of cardiac venous anatomy and visualize left ventricular (LV) myocardial scar. We hypothesized that localization and burden of transmural myocardial scar verified by cardiac CT are associated with echocardiographic and clinical response to CRT. METHODS We prospectively included 140 CRT recipients undergoing preimplant cardiac CT. We assessed transmural scar, defined as hypoperfusion involving more than one-half of the myocardial wall in each LV segment using a 17-segment model. Echocardiographic nonresponse was defined as less than 5% absolute improvement in LV ejection fraction at 6 months' follow-up. Clinical nonresponse was defined as 1 or more of the following at 6 months' follow-up: death, heart failure hospitalization, or no improvement in New York Heart Association class and less than 10% increase in 6-minute walk-test distance. RESULTS Higher burden of myocardial scar was associated with echocardiographic nonresponse (adjusted odds ratio, 3.02; 95% confidence interval, 1.03-8.91; P = 0.045). Scar concordant or adjacent to LV pacing site was associated with echocardiographic nonresponse (adjusted odds ratio, 8.2; 95% confidence interval, 1.51-44.27; P = 0.015). No association between scar and clinical nonresponse was demonstrated. CONCLUSIONS Higher scar burden and scar in proximity to the LV pacing site assessed by cardiac CT are associated with echocardiographic nonresponse to CRT. Burden and location of scar were not associated with clinical nonresponse. Further large-scale studies are needed to assess the potential association between myocardial scar detected by cardiac CT and clinical CRT outcome.


title: Cerebral aneurysm treatment: modern neurovascular techniques.

text: Endovascular treatment of cerebral aneurysm continues to evolve with the development of new technologies. This review provides an overview of the recent major innovations in the neurointerventional space in recent years.


Missed Opportunities on Emergency Remdesivir Use.


title: Expert opinion of the Working Group on Heart Failure of the Polish Cardiac Society: the patient with heart failure facing the COVID-19 pandemic.

text: New coronavirus (SARS-CoV-2, severe acute respiratory syndrome coronavirus) acute respiratory failure is the cause of the rapidly spreading coronavirus disease 2019 (COVID-19, coronavirus disease 2019), affecting thousands of people around the world. Due to the limited information on heart dysfunction in patients with COVID-19, a synthetic summary of current knowledge is needed to help clinicians who care for patients with cardiovascular disease, especially heart failure (HF) patients. We present the expert opinion of the Polish Cardiac Society - Working Group of Heart Failure (PCS - HF).


Another Day in Dystopia. Italy in the Time of COVID-19.


title: Decreased Levels of Circulating Cancer-Associated Protein Biomarkers Following Bariatric Surgery.

text: BACKGROUND Epidemiological studies have identified obesity as a major risk factor for cancer in humans, and trials have demonstrated a significant reduction in the incidence of cancer after bariatric surgery. The rapidity of weight loss after bariatric surgery provides an opportunity to identify the molecular changes associated with effective obesity treatment. Indirectly, this may provide some insights into the mechanisms that drive the association between obesity and cancer. We sought to measure circulating cancer-associated proteins before and after laparoscopic sleeve gastrectomy (LSG). METHODS We prospectively enrolled 15 patients undergoing LSG. Thirty-four plasma protein biomarkers thought to be associated with cancer processes were analyzed at baseline and following successful weight loss at 12 weeks using a multiplex bead-based assay. RESULTS Mean excess body weight loss was 44 % at 12-week follow-up. After LSG, a significant reduction in circulating plasma levels was observed for half (17/34) of the proteins assessed: VEGF-A, VEGF-C, VEGF-D, endoglin, PLGF, sFASL, IGFBP-1, IL-18, prolactin, EGF, TGFα, sCD40L, IL-18, TNFα, IL-6, HB-EGF, and PAI-1. Nonsignificant decreases were found for the remaining proteins. CONCLUSIONS Circulating cancer-related biomarker levels were reduced by surgical weight loss, and this benefit was achieved as early as 3 months after operation. The observed reduction in cancer biomarkers may be related to the reported decrease in cancer incidence following bariatric surgery.


title: Futile Recanalization With Poor Clinical Outcome Is Associated With Increased Edema Volume After Ischemic Stroke.

text: PURPOSE Futile recanalization with poor clinical outcome after endovascular treatment of acute ischemic stroke is poorly understood. Recently, vessel recanalization has been associated with reduced ischemic brain edema in patients with good clinical outcome. As edema volume (EV) may be quantified in computed tomography (CT), we hypothesized that higher EV after revascularization predicts futile recanalization with poor outcome. METHODS In this observational study, 67 ischemic stroke patients with M1 middle cerebral artery occlusion fulfilled all inclusion criteria and were analyzed. All patients received successful endovascular recanalization (thrombolysis in cerebral infarction scale 2b/3) and subsequent follow-up CT 24 hours later. Edema volume within the infarct lesion was calculated in follow-up CT applying lesion water uptake quantification and was used to predict clinical outcome (Modified Rankin Scale [mRS] after 90 days) compared with infarct volume. RESULTS The median EV after thrombectomy was 1.6 mL (interquartile range, 0.2-4.2 mL) in patients with mRS 0 to 4 and 8.6 mL (interquartile range, 2.0-49.8 mL) in patients with mRS 5 to 6 (P = 0.0008). In regression analysis, an EV increase of 1 mL was associated with an 8.0% increased likelihood of poor outcome (95% confidence interval, 2.8%-15.4%; P = 0.008). Based on univariate receiver operating characteristic curve analysis, absolute EV over 4.2 mL predicted poor outcome (mRS 5-6) with good discriminative power (area under curve, 0.74; 95% confidence interval, 0.62-0.84; specificity, 77%; sensitivity, 68%). In comparison, the area under curve for infarct volume was 0.68. CONCLUSIONS Elevated EV after endovascular thrombectomy was associated with poor clinical outcome and may indicate futile recanalization.


Coordinated outreach for Veterans in long-term care facilities by an integrated Veterans Affairs healthcare system during the COVID-19 pandemic.


docid: hflxxnls

title: Constitutive expression of hypoxia-inducible factor-1 α in keratinocytes during the repair of skin wounds in horses.

text: As a transient hypoxic state exists within skin wounds in horses and may be important for the healing process, this study sought to identify a molecular hypoxia response occurring in horse limb and body wounds healing by second intention. Hypoxia-inducible factor 1α (HIF1α) protein expression was studied throughout repair by Western blotting and immunofluorescence. Paradoxically, HIF1α was strongly expressed in intact skin and its expression decreased dramatically following wounding (p<0.01), despite the expected hypoxic state within the wounded tissue. HIF1α levels reincreased in parallel with the epithelialization process, and more rapidly in body wounds than in limb wounds (p<0.01). HIF1α localized predominantly to the keratinocyte layer, in which it was constitutively expressed throughout healing. The HIF1α target gene cyclin-dependent kinase inhibitor 1A (CDKN1A) showed a pattern of expression similar to HIF1α throughout the healing process and also localized to the keratinocyte layer, suggesting that HIF1α may regulate its constitutive expression. The HIF1α target genes vascular endothelial growth factor A (VEGFA) and solute carrier family 2 (facilitated glucose transporter) member 1 (SLC2A1) however did not have a pattern of expression similar to HIF1α, at the mRNA level. We conclude that HIF1α is expressed in a continuous and hypoxia-independent manner in equine keratinocytes in both intact and wounded skin, and may regulate the expression of CDKN1A in this cell type.


title: No Resistance to Penicillin, Cefuroxime, Cefotaxime, or Vancomycin in Pneumococcal Pneumonia.

text: OBJECTIVES Group B Streptococcus is a primary source of pneumonia, which is a leading cause of death worldwide. During the last few decades, there has been news of growing antibiotic resistance in group B streptococci to penicillin and different antibiotic agents. This clinical study retrospectively analyzes antimicrobial resistance in inpatients who were diagnosed with group B streptococcal pneumonia. METHODS All of the required information from inpatients who were identified to have group B streptococcal pneumonia was sourced from the database at the Department of Internal Medicine of HELIOS Clinic Wuppertal, Witten/Herdecke University, in Germany, from 2004-2014. Antimicrobial susceptibility testing was performed for the different antimicrobial agents that were regularly administered to these inpatients. RESULTS Sixty-six inpatients with a mean age of 63.3 ± 16.1 years (45 males [68.2%, 95% CI 60.0%-79.4%] and 21 females [31.8%, 95% CI 20.6%-43.0%]) were detected to have group B streptococcal pneumonia within the study period from January 1, 2004, to August 12, 2014. Group B Streptococcus had a high resistance rate to gentamicin (12.1%), erythromycin (12.1%), clindamycin (9.1%), and co-trimoxazole (3.0%), but it was not resistant to penicillin, cefuroxime, cefotaxime, or vancomycin (P < 0.0001). CONCLUSION No resistance to penicillin, cefuroxime, cefotaxime, or vancomycin was detected among inpatients with pneumonia caused by group B streptococci.


title: Embolotherapy for Neuroendocrine Tumor Liver Metastases: Prognostic Factors for Hepatic Progression-Free Survival and Overall Survival.

text: PURPOSE The purpose of the study was to evaluate prognostic factors for survival outcomes following embolotherapy for neuroendocrine tumor (NET) liver metastases. MATERIALS AND METHODS This was a multicenter retrospective study of 155 patients (60 years mean age, 57 % male) with NET liver metastases from pancreas (n = 71), gut (n = 68), lung (n = 8), or other/unknown (n = 8) primary sites treated with conventional transarterial chemoembolization (TACE, n = 50), transarterial radioembolization (TARE, n = 64), or transarterial embolization (TAE, n = 41) between 2004 and 2015. Patient-, tumor-, and treatment-related factors were evaluated for prognostic effect on hepatic progression-free survival (HPFS) and overall survival (OS) using unadjusted and propensity score-weighted univariate and multivariate Cox proportional hazards models. RESULTS Median HPFS and OS were 18.5 and 125.1 months for G1 (n = 75), 12.2 and 33.9 months for G2 (n = 60), and 4.9 and 9.3 months for G3 tumors (n = 20), respectively (p < 0.05). Tumor burden >50 % hepatic volume demonstrated 5.5- and 26.8-month shorter median HPFS and OS, respectively, versus burden ≤50 % (p < 0.05). There were no significant differences in HPFS or OS between gut or pancreas primaries. In multivariate HPFS analysis, there were no significant differences among embolotherapy modalities. In multivariate OS analysis, TARE had a higher hazard ratio than TACE (unadjusted Cox model: HR 2.1, p = 0.02; propensity score adjusted model: HR 1.8, p = 0.11), while TAE did not differ significantly from TACE. CONCLUSION Higher tumor grade and tumor burden prognosticated shorter HPFS and OS. TARE had a higher hazard ratio for OS than TACE. There were no significant differences in HPFS among embolotherapy modalities.


title: Minimally invasive total gastrectomy for gastric cancer: a pilot series.

text: BACKGROUND Minimally invasive surgery for select gastrointestinal disease has gained worldwide acceptance. However, laparoscopic total gastrectomy for cancer remains controversial. The purpose of this study was to examine an initial experience with laparoscopic total gastrectomy. METHODS Medical records of 16 consecutive patients who underwent laparoscopic total gastrectomy between September 2007 and December 2009 were reviewed in a retrospective manner. Esophagojejunostomy was completed using a transorally delivered anvil, with double-stapled esophageal anastomosis. RESULTS There were no conversions to open procedures. Two patients (12.5%) required extended resections with en bloc distal pancreatectomy and splenectomy, one of whom also underwent transverse colectomy. The median lymph node count for patients who underwent D2 lymphadenectomy (n = 12) for gastric adenocarcinoma was 31. There were no perioperative deaths and the median length of stay was 8 days. There were no anastomotic leaks, but three patients developed anastomotic strictures amenable to dilatation. CONCLUSIONS Minimally invasive total gastrectomy can be performed safely and with adequate lymphadenectomy. The procedure provides an excellent short-term outcome with potential for improved patient outcome.


title: Ultrasonographic Detection of Airway Obstruction in a Model of Obstructive Sleep Apnea.

text: Purpose Obstructive sleep apnea (OSA) is a common clinical disorder characterized by repetitive airway obstruction during sleep. The gold standard for diagnosis of OSA, polysomnogram (PSG), cannot anatomically localize obstruction. Precise identification of obstruction has potential to improve outcomes following surgery. Current diagnostic modalities that provide this information require anesthesia, involve ionizing radiation or disrupt sleep. To mitigate these problems, we conceived that ultrasound (US) technology may be adapted (i) to detect, quantify and localize airway obstruction and (ii) for translational application to home-based testing for OSA. Materials and Methods Segmental airway collapse was induced in 4 fresh cadavers by application of negative pressure. Following visualization of airway obstruction, a rotary US probe was used to acquire transcervical images of the airway before and after induction of obstruction. These images (n=800) were analyzed offline using image processing algorithms. Results Our results show that the non-obstructed airway consistently demonstrated the presence of a US air-tissue interface. Importantly, automated detection of the air-tissue interface strongly correlated with manual measurements. The algorithm correctly detected an air-tissue interface in 90% of the US images while incorrectly detecting it in 20% (area under the curve=0.91). Conclusion The non-invasive detection of airway obstruction using US represents a major step in expanding OSA diagnostics beyond PSG. The preliminary data obtained from our model could spur further research in non-invasive localization of obstruction. US offers the benefit of precise localization of the site of obstruction, with potential for improving outcomes in surgical management.


title: The Ripple Effects of the Pandemic.

text: Societal disruptions pose threats to safety, mental health, and family stability.


title: Immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes.

text: BACKGROUND Immediate delivery of the preterm fetus with suspected compromise may decrease the risk of damage due to intrauterine hypoxia. However, it may also increase the risks of prematurity. OBJECTIVES To assess the effects of immediate versus deferred delivery of preterm babies with suspected fetal compromise on neonatal, maternal and long-term outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing a policy of immediate delivery with deferred delivery or expectant management in preterm fetuses with suspected in utero compromise. Quasi-randomised trials and trials employing a cluster-randomised design were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS We included one trial of 548 women (588 babies) in the review. Women with pregnancies between 24 and 36 weeks' gestation took part. The study took place in 13 European countries, between 1993 and 2001. The difference in the median randomisation to delivery interval between immediate delivery and deferred delivery was four days (median: 0.9 (inter-quartile range (IQR) 0.4 to 1.3) days for immediate delivery, median: 4.9 (IQR 2.0 to 10.8) days in the delay group).There was no clear difference in the primary outcomes of extended perinatal mortality (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.67 to 2.04, one trial, 587 babies, moderate-quality evidence) or the composite outcome of death or disability at or after two years of age (RR 1.22, 95% CI 0.85 to 1.75, one trial, 573 babies, moderate-quality evidence) with immediate delivery compared to deferred delivery. The results for these outcomes are consistent with both appreciable benefit and harm. More babies in the immediate delivery group were ventilated for more than 24 hours (RR 1.54, 95% CI 1.20 to 1.97, one trial, 576 babies). There were no differences between the immediate delivery and deferred delivery groups in any other infant mortality outcome (stillbirth, neonatal mortality, postneonatal mortality > 28 days to discharge), individual neonatal morbidity or markers of neonatal morbidity (cord pH less than 7.00, Apgar less than seven at five minutes, convulsions, interventricular haemorrhage or germinal matrix haemorrhage, necrotising enterocolitis and periventricular leucomalacia or ventriculomegaly).Some important outcomes were not reported, in particular infant admission to neonatal intensive care or special care facility, and respiratory distress syndrome. We were not able to calculate composite rates of serious neonatal morbidity, even though individual morbidities were reported, due to the risk of double counting infants with more than one morbidity.More children in the immediate delivery group had cerebral palsy at or after two years of age (RR 5.88, 95% CI 1.33 to 26.02, one trial, 507 children). There were, however, no differences in neurodevelopment impairment at or after two years (RR 1.72, 95% CI 0.86 to 3.41, one trial, 507 children), death at or after two years of age (RR 1.04, 95% CI 0.66 to 1.63, one trial, 573 children), or death or disability in childhood (six to 13 years of age) (RR 0.82, 95% CI 0.48 to 1.40, one trial, 302 children). More women in the immediate delivery group had caesarean delivery than in the deferred delivery group (RR 1.15, 95% CI 1.07 to 1.24, one trial, 547 women, high-quality evidence). Data were not available on any other maternal outcomes.There were several methodological weaknesses in the included study, and the level of evidence for the primary outcomes was graded high for caesarean section and moderate for extended perinatal mortality and death or disability at or after two years. The evidence was downgraded because the CIs for these outcomes were wide, and were consistent with both appreciable benefit and harm. Bias may have been introduced by several factors: blinding was not possible due to the nature of the intervention, data for childhood follow-up were incomplete due to attrition, and no adjustment was made in the analysis for the non-independence of babies from multiple pregnancies (39 out of 548 pregnancies). This study only included cases of suspected fetal compromise where there was uncertainty whether immediate delivery was indicated, thus results must be interpreted with caution. AUTHORS' CONCLUSIONS Currently there is insufficient evidence on the benefits and harms of immediate delivery compared with deferred delivery in cases of suspected fetal compromise at preterm gestations to make firm recommendations. There is a lack of trials addressing this question, and limitations of the one included trial means that caution must be used in interpreting and generalising the findings. More research is needed to guide clinical practice.Although the included trial is relatively large, it has insufficient power to detect differences in neonatal mortality. It did not report any maternal outcomes other than mode of delivery, or evaluate maternal satisfaction or economic outcomes. The applicability of the findings is limited by several factors: Women with a wide range of obstetric complications and gestational ages were included, and subgroup analysis is currently limited. Advances in Doppler assessment techniques may diagnose severe compromise more accurately and help make decisions about the timing of delivery. The potential benefits of deferring delivery for longer or shorter periods cannot be presumed.Where there is uncertainty whether or not to deliver a preterm fetus with suspected fetal compromise, there seems to be no benefit to immediate delivery. Deferring delivery until test results worsen or increasing gestation favours delivery may improve the outcomes for mother and baby.There is a need for high-quality randomised controlled trials comparing immediate and deferred delivery where there is suspected fetal compromise at preterm gestations to guide clinical practice. Future trials should report all important outcomes, and should be adequately powered to detect differences in maternal and neonatal morbidity and mortality.


title: Prognosis of untreated strokes due to anterior circulation proximal intracranial arterial occlusions detected by use of computed tomography angiography.

text: IMPORTANCE Limited data exist regarding the natural history of proximal intracranial arterial occlusions. OBJECTIVE To investigate the outcomes of patients who had an acute ischemic stroke attributed to an anterior circulation proximal intracranial arterial occlusion. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study at 2 university-based hospitals from 2003 to 2005 in which nonenhanced computed tomography scans and computed tomography angiograms were obtained at admission of all adult patients suspected of having an ischemic stroke in the first 24 hours of symptom onset. EXPOSURE Anterior circulation proximal intracranial arterial occlusion. MAIN OUTCOMES AND MEASURES Frequency of good outcome (defined as a modified Rankin Scale score of ≤ 2) and mortality at 6 months. RESULTS A total of 126 patients with a unilateral complete occlusion of the intracranial internal carotid artery (ICA; 26 patients: median National Institutes of Health Stroke Scale [NIHSS] score, 11 [interquartile range, 5-17]), of the M1 segment of the middle cerebral artery (MCA; 52 patients: median NIHSS score, 13 [interquartile range, 6-16]), or of the M2 segment of the MCA (48 patients: median NIHSS score, 7 [interquartile range, 4-15]) were included. Of these 3 groups of patients, 10 (38.5%), 20 (38.5%), and 26 (54.2%) with ICA, MCA-M1, and MCA-M2 occlusions, respectively, achieved a modified Rankin Scale score of 2 or less, and 6 (23.1%), 12 (23.1%), and 10 (20.8%) were dead at 6 months. Worse outcomes were seen in patients with a baseline NIHSS score of 10 or higher, with a modified Rankin Scale score of 2 or less achieved in only 7.1% (1 of 14), 23.5% (8 of 34), and 22.7% (5 of 22) of patients and mortality rates of 35.7% (5 of 14), 32.4% (11 of 34), and 40.9% (9 of 22) among patients with ICA, MCA-M1, and MCA-M2 occlusions, respectively. Age (odds ratio, 0.94 [95% CI, 0.91-0.98]), NIHSS score (odds ratio, 0.73 [95% CI, 0.64-0.83]), and strength of leptomeningeal collaterals (odds ratio, 2.37 [95% CI, 1.08-5.20]) were independently associated with outcome, whereas the level of proximal intracranial arterial occlusion (ICA vs MCA-M1 vs MCA-M2) was not. CONCLUSIONS AND RELEVANCE The natural history of proximal intracranial arterial occlusion is variable, with poor outcomes overall. Stroke severity and collateral flow appear to be more important than the level of proximal intracranial arterial occlusion in determining outcomes. Our results provide useful data for proper patient selection and sample size calculations in the design of new clinical trials aimed at recanalization therapies.