title: Molecular survey of RNA viruses in Hungarian bats: discovering novel astroviruses, coronaviruses, and caliciviruses.

text: UNLABELLED Background: Bat-borne viruses pose a potential risk to human health and are the focus of increasing scientific interest. To start gaining information about bat-transmitted viruses in Hungary, we tested multiple bat species for several virus groups between 2012 and 2013. MATERIALS AND METHODS Fecal samples were collected from bats across Hungary. We performed group-specific RT-PCR screening for astro-, calici-, corona-, lyssa-, othoreo-, paramyxo-, and rotaviruses. Positive samples were selected and sequenced for further phylogenetic analyses. RESULTS A total of 447 fecal samples, representing 24 European bat species were tested. Novel strains of astroviruses, coronaviruses, and caliciviruses were detected and analyzed phylogenetically. Out of the 447 tested samples, 40 (9%) bats were positive for at least one virus. Bat-transmitted astroviruses (BtAstV) were detected in eight species with a 6.93% detection rate (95% confidence interval [CI] 4.854, 9.571). Coronaviruses (BtCoV) were detected in seven bat species with a detection rate of 1.79% (95% CI 0.849, 3.348), whereas novel caliciviruses (BtCalV) were detected in three bat species with a detection rate of 0.67% (95% CI 0.189, 1.780). Phylogenetic analyses revealed a great diversity among astrovirus strains, whereas the Hungarian BtCoV strains clustered together with both alpha- and betacoronavirus strains from other European countries. One of the most intriguing findings of our investigation is the discovery of novel BtCalVs in Europe. The Hungarian BtCalV did not cluster with any of the calcivirus genera identified in the family so far. CONCLUSIONS We have successfully confirmed BtCoVs in numerous bat species. Furthermore, we have described new bat species harboring BtAstVs in Europe and found new species of CalVs. Further long-term investigations involving more species are needed in the Central European region for a better understanding on the host specificity, seasonality, phylogenetic relationships, and the possible zoonotic potential of these newly described viruses.


title: Leukoencephalopathy Associated with Severe COVID-19 Infection: Sequela of Hypoxemia?

text: There is increasing evidence to suggest that complications of coronavirus disease 2019 (COVID-19) infection are not only limited to the pulmonary system but can also involve the central nervous system. Here, we report 6 critically ill patients with COVID-19 infection and neuroimaging findings of leukoencephalopathy. While these findings are nonspecific, we postulate that they may be a delayed response to the profound hypoxemia the patients experienced due to the infection. No abnormal enhancement, hemorrhage, or perfusion abnormalities were noted on MR imaging. In addition, Severe Acute Respiratory Syndrome coronavirus 2 was not detected in the CSF collected from the 2 patients who underwent lumbar puncture. Recognition of COVID-19-related leukoencephalopathy is important for appropriate clinical management, disposition, and prognosis.


title: Adapting 'Sunshine,' A Socially Assistive Chat Robot for Older Adults with Cognitive Impairment: A Pilot Study.

text: The COVID-19 pandemic challenges us to think outside of the box to respond to this unprecedented global crisis. In this letter, we propose a pilot study to use a socially assistive robot to help meet social needs for older adults with cognitive impairment residing in long-term care facilities.


title: Antiviral Activities of Different Interferon Types and Subtypes against Hepatitis E Virus Replication.

text: Hepatitis E virus (HEV) is the causative agent of hepatitis E in humans and a member of the genusOrthohepevirusin the familyHepeviridae HEV infections are the common cause of acute hepatitis but can also take chronic courses. Ribavirin is the treatment of choice for most patients, and type I interferon (IFN) has been evaluated in a few infected transplant patientsin vivo In this study, the antiviral effects of different exogenously administered interferons were investigated by using state-of-the-art subgenomic replicon and full-length HEV genome cell culture models. Hepatitis C virus (HCV) subgenomic replicons based on the genotype 2a JFH1 isolate served as the reference. The experiments revealed that HEV RNA replication was inhibited by the application of all types of IFN, including IFN-α (type I), IFN-γ (type II), and IFN-λ3 (type III), but to a far lesser extent than HCV replication. Simultaneous determination of interferon-stimulated gene (ISG) expression levels for all IFN types demonstrated efficient downregulation by HEV. Furthermore, different IFN-α subtypes were also able to block viral replication in combination with ribavirin. The IFN-α subtypes 2a and 2b exerted the strongest antiviral activity against HEV. In conclusion, these data demonstrate for the first time moderate anti-HEV activities of types II and III IFNs and different IFN-α subtypes. As HEV employed a potent anti-interferon mechanism by restricting ISG expression, exogenous application of IFNs as immunotherapy should be carefully assessed.


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title: An alternative approach to minimize the risk of coronavirus (Covid-19) and similar infections.

text: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new strain that was discovered in 2019 and has not been previously identified in humans. On December 31st 2019 World Health Organization (WHO) was informed of a cluster of cases with pneumonia of unknown origin from Wuhan City, Hubei province of China. The WHO announced in February 2020 that COVID-19 is the official name of the coronavirus diseases. A total of 519,899 confirmed cases with 23,592 deaths linked to this pathogen as on March 27, 2020 have been reported. Due to increasing number of infected people across the continents and huge loss to human life, the WHO has declared the novel COVID-19 outbreak a pandemic. A pandemic is defined as the "worldwide spread" of a new disease. Currently, no COVID-19 specific treatments have been approved by the United States Food and Drug Administration (US-FDA). However, the current treatment options include hydroxychloroquine, tocilizumab, remdesivir, lopinavir-ritonavir (Kaletra®), and nitazoxanide. In recent past, some natural herbal compounds have demonstrated encouraging anti-viral properties. This article attempted to summarize available information on the reported anti-viral activity of some natural products.


title: Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance.

text: OBJECTIVES Spinal cord protection during thoracoabdominal aortic surgery is challenging for surgeons. We performed thoracoabdominal replacement using a strategy for maintaining spinal cord perfusion pressure. Here, we report our experience with this procedure and the surgical outcomes. METHODS Between January 2000 and December 2014, 130 patients [male: 91 (74.6%), female: 39 (25.4%); mean age: 66.6 ± 12.8 years] underwent thoracoabdominal replacement using cardiopulmonary bypass at Hiroshima Shimin Hospital, Japan. The surgical outcomes of these patients were analysed. RESULTS The in-hospital mortality rate of all patients was 2.5%. The incidence of postoperative paraplegia was 3.8%. Aortic event-free survival rates at 1, 3 and 5 years were 98.2%, 93.9% and 80.7%, respectively. CONCLUSIONS The present study suggests that our strategy for maintaining spinal cord perfusion pressure provides acceptable outcomes.


title: Subarachnoid haemorrhage secondary to traumatic intracranial aneurysm of the posterior cerebral circulation: case series and literature review.

text: BACKGROUND To identify the clinical features, rebleed risk, timing and method of diagnosis, complications and outcome for subarachnoid haemorrhage (SAH) from traumatic intracranial aneurysm (TICA) of the posterior circulation. Subjects included 26 patients aged 3-54 (mean 24.8). METHODS Case series and literature search to identify all reported cases. RESULTS In our series, two of three cases were fatal as a result of rebleed, and one case had a good outcome with no deficit, following prompt diagnosis and embolisation. Our key findings from the literature review were: 30.7 % of patients were age 16 and under; 88 % had an acute drop in consciousness, 46 % in a delayed manner; the mean time to diagnosis was 7.5 days; initial cerebrovascular imaging was normal in 23 %; the rebleed rate was 23 %; 61 % required emergency diversion of cerebrospinal fluid; 11 % developed vasospasm requiring treatment; 19.2 % had deficits that rendered them unable to live independently. The mortality rate was 27 %. CONCLUSIONS SAH from ruptured posterior circulation TICA is associated with significant morbidity and mortality. A high index of suspicion as well as prompt diagnosis, repeat imaging in selected cases, and treatment of any associated TICA can be crucial to a favourable outcome.


title: Single incision versus reduced port splenectomy--searching for the best alternative to conventional laparoscopic splenectomy.

text: BACKGROUND Laparoscopic splenectomy (LS) is a well accepted approach for the treatment of multiple hematologic diseases. Single port access splenectomy (SPAS) emphasizes the concept of surgery through one small incision. The reduced port access splenectomy (RPAS) entails the use of fewer trocars of smaller sizes. The aim of this study was to compare the clinical outcomes after LS, SPAS, and RPAS, and to analyze the aesthetic result and patient satisfaction. METHODS We included patients who underwent LS (group 1, n = 15), SPAS (group 2, n = 8), and RPAS (group 3, n = 10) between June 2008 and February 2012, whose final spleen weight was less of 500 g. The outcome parameters analyzed were operative time, need of additional trocars, blood loss, blood transfusion, weight of the spleen, postoperative complications, and duration of hospital stay. To evaluate the cosmetic result, patients were asked to take the Body Image Questionnaire. RESULTS Patients in group 3 were younger than group 1. Operative time was significantly longer in group 2 compared to groups 1 and 3 (83 ± 19 vs. 131 ± 43 vs. 81 ± 22 min, p = 0.01). There was no need to convert to open surgery in any group, nor were there differences in intra- or postoperative outcome. There were no differences between the groups in relation to the analgesic requirements. Twenty-two out of the 33 patients answered the questionnaire. There was a significant advantage in group 2 and 3 in the body image index with respect to group 1. There were no differences between groups 2 and 3 (7.3 ± 2.8 vs. 5.8 ± 1.3 vs. 5.1 ± 0.4, p < 0.02). CONCLUSIONS RPAS is a good alternative to LS and SPAS. It improves the aesthetic results as compared to LS, whereas minimizes the technical challenges faced with SPAS.


title: The effect of captopril on lipopolysaccharide-induced lung inflammation.

text: PURPOSE As an angiotensin converting enzyme (ACE) inhibitor, the effects of captopril on inflammation has been previously examined. Captopril has been shown to have anti-inflammatory and antioxidant effects. Imbalance in the oxidant/antioxidant system is one of the major causes of inflammation. In the present study, the effects of captopril on total and differential white blood cells (WBC), oxidative stress andlung histopathological changes produced by lipopolysaccharide (LPS) were investigated in rat. MATERIALS AND METHOD The rats were divided into: control (saline-treated), LPS (1 mg/kg), 12.5, 25 or 50 mg/kg captopril-treated before LPS administration (LPS+Cap12.5, LPS+Cap25 and LPS+Cap50) and Cap-treated, 50 mg/kg before saline administration (as positive control group)groups. The levels of total and percentage of differential WBC in blood, and the oxidative stress index in the serum were evaluated. Lung histopathological changes were also examined. RESULTS In the LPS group, total WBC count, percentage of neutrophils, basophils, eosinophils, and monocytes in the blood, oxidative stress indices in serum, lung pathological changes were significantly higher than the control group (p < 0.05 to p < 0.001). Pathological changes of lung, serum oxidative stress indices of LPS+Cap50 group, total WBC counts of LPS+Cap25 and LPS+Cap50 groups, as well as percentage of neutrophils, monocytes, and basophils in LPS+Cap50 group and percentage of eosinophils in LPS+Cap50 and LPS+Cap25 groups, were significantly decreased compared to the LPS group (p < 0.05 to p < 0.001). CONCLUSION The results of this study showed that captopril dose-dependently reduced total and differential WBC counts, while it improved serum oxidant/antioxidant biomarkers and histopathological changes in LPS-treated rats. These results indicate a therapeutic potential for captopril on systemic inflammation and oxidative stress against LPS-induced lung injuries.


title: Mutations in Influenza A Virus Neuraminidase and Hemagglutinin Confer Resistance against a Broadly Neutralizing Hemagglutinin Stem Antibody.

text: Influenza A virus (IAV), a major cause of human morbidity and mortality, continuously evolves in response to selective pressures. Stem-directed, broadly neutralizing antibodies (sBnAbs) targeting the influenza virus hemagglutinin (HA) are a promising therapeutic strategy, but neutralization escape mutants can develop. We used an integrated approach combining viral passaging, deep sequencing, and protein structural analyses to define escape mutations and mechanisms of neutralization escape in vitro for the F10 sBnAb. IAV was propagated with escalating concentrations of F10 over serial passages in cultured cells to select for escape mutations. Viral sequence analysis revealed three mutations in HA and one in neuraminidase (NA). Introduction of these specific mutations into IAV through reverse genetics confirmed their roles in resistance to F10. Structural analyses revealed that the selected HA mutations (S123G, N460S, and N203V) are away from the F10 epitope but may indirectly impact influenza virus receptor binding, endosomal fusion, or budding. The NA mutation E329K, which was previously identified to be associated with antibody escape, affects the active site of NA, highlighting the importance of the balance between HA and NA function for viral survival. Thus, whole-genome population sequencing enables the identification of viral resistance mutations responding to antibody-induced selective pressure.IMPORTANCE Influenza A virus is a public health threat for which currently available vaccines are not always effective. Broadly neutralizing antibodies that bind to the highly conserved stem region of the influenza virus hemagglutinin (HA) can neutralize many influenza virus strains. To understand how influenza virus can become resistant or escape such antibodies, we propagated influenza A virus in vitro with escalating concentrations of antibody and analyzed viral populations by whole-genome sequencing. We identified HA mutations near and distal to the antibody binding epitope that conferred resistance to antibody neutralization. Additionally, we identified a neuraminidase (NA) mutation that allowed the virus to grow in the presence of high concentrations of the antibody. Virus carrying dual mutations in HA and NA also grew under high antibody concentrations. We show that NA mutations mediate the escape of neutralization by antibodies against HA, highlighting the importance of a balance between HA and NA for optimal virus function.


title: Surviving a life-threatening crisis: Taiwan's nurse leaders' reflections and difficulties fighting the SARS epidemic.

text: AIM This study explored Taiwan's nurse leaders' reflections and experiences of the difficulties they encountered and survival strategies they employed fighting the severe acute respiratory syndrome epidemic and the background context framing these phenomena. BACKGROUND On several continents in 2002-2003, the highly infectious severe acute respiratory syndrome overwhelmed health care systems and health professionals who had to provide care in situations involving high personal risk and stress, some becoming infected and dying. Nurse leaders in Taiwan had to develop new strategies and support systems for nursing care. DESIGN A two-step within-method qualitative triangulation research design. METHODS Focus group in-depth interviews held with 70 nurse leaders from four Northern Taiwan hospitals involved in the severe acute respiratory syndrome epidemic. Participants then completed an open ended questionnaire. Content analysis was undertaken with data and stages and themes generated. Data were then analysed using Hobfall's concepts of conservation of resources to further discuss participants' reactions and actions in the severe acute respiratory syndrome crisis. RESULTS Participants worked under incredible stress to lead the profession through a period of crisis. Five stages arose in the participants' involvement against severe acute respiratory syndrome over 12 weeks: facing shock and chaos; searching for reliable sources to clarify myths; developing and adjusting nursing care; supporting nurses and their clients; and rewarding nurses. CONCLUSION Nurse leaders become important executors of intervention in this health disaster, requiring emotional intelligence to manage their internal conflicts and interpersonal relationships effectively. They developed sociopolitical and analytical abilities and crucial requirements for planning and implementing strategies in areas where none previously existed. Building support systems was an important resource for managing conflicts between familial and professional roles. Relevance to clinical practice. Findings will assist nurse leaders to prepare themselves and the profession to better deal with disaster management in similar infectious outbreaks in the future.


title: Venous thromboembolism in COVID-19: systematic review of reported risks and current guidelines.

text: AIMS OF THE STUDY Many centres have noticed a high number of venous thromboembolism (VTE) events among critically ill inpatients with COVID-19 pneumonia. The aims of this study were (1) to summarise the reported risk of VTE associated with COVID-19 infections and (2) to summarise guidance documents on thromboprophylaxis in COVID-19 patients, in a systematic review. METHODS We systematically searched for peer-reviewed evidence on the risk of VTE in patients with COVID-19, in PubMed, Embase and Twitter, and for guidelines or guidance documents for thromboprophylaxis, from international or national societies relevant to the field of thrombosis and haemostasis, up to April 30 2020. RESULTS We found 11 studies (1 clinical trial, 7 retrospective cohorts and 3 prospective cohorts), which included a range of 16 to 388 in patients with COVID-19 (total of 1369 inpatients). The diagnoses of COVID-19 and VTE were of high quality, but the follow-up was often unclear. Most studies reported universal in-hospital thromboprophylaxis. Among all inpatients and among intensive care unit (ICU) inpatients with COVID-19, reported risks of VTE were 4.4–8.2% (three studies) and 0–35.3% (six studies), respectively. Two studies at least partially screened for VTE in ICU inpatients with COVID-19, and found risks of 24.7–53.8%. We found 12 guidelines for thromboprophylaxis of COVID-19 patients. The majority suggested universal pharmacological thromboprophylaxis in all COVID-19 inpatients, but there was heterogeneity in the suggested intensity of thromboprophylaxis: seven advised considering intensified doses of heparin according to the clinical or biological severity of the disease, especially in the ICU setting. CONCLUSIONS Venous thromboembolism very commonly complicates the clinical course of inpatients with COVID-19, despite thromboprophylaxis. The risk appears highest among critically ill inpatients. We found no estimates of risks among outpatients. Many questions remain unresolved, as delineated by the heterogeneity of national and international guidelines. This situation calls for fast randomised clinical trials, comparing different schemes of thromboprophylaxis in COVID-19 inpatients.


title: Yield of sputum for viral detection by reverse transcriptase PCR in adults hospitalized with respiratory illness.

text: Diagnostic tests for respiratory viral infections have traditionally been performed on nasopharyngeal swabs or washings. Reverse transcriptase PCR (RT-PCR) is rapid, sensitive, and specific for viral infection diagnosis but is rarely applied to sputum samples. Thus, we evaluated the diagnostic yield of RT-PCR for detection of nine virus types by the use of nose and throat swabs (NTS) and sputum samples from patients admitted to the hospital with acute respiratory tract illnesses. Adults hospitalized with acute respiratory tract illnesses were recruited during the winters of 2008 and 2009. At enrollment, combined nose and throat swabs and sputum samples were collected for RT-PCR for detection of nine common respiratory virus types. A total of 532 subjects admitted for 556 respiratory illnesses were enrolled. A total of 189 virus strains were identified. The diagnostic yields for detection of any virus were 23% (126/556) for NTS RT-PCR and 36% (146/404) for sputum RT-PCR. A total of 83 (44%) of 189 viral detections were positive by both methods, 43 (23%) were positive by NTS alone, and 63 (33%) were positive only with sputum samples. The inclusion of RT-PCR performed with sputum samples significantly increased the diagnostic yield for respiratory viral infections in adults. Further studies designed to adapt the use of sputum samples for commercial RT-PCR respiratory virus assays are needed.


title: Laparoscopic robotic liver surgery: the Henri Mondor initial experience of 20 cases.

text: Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in the hands of trained surgeons. The introduction of robotics into surgery represents progression in the field of minimally invasive surgery but has seen a slow uptake in the hepatopancreaticobiliary subspeciality. We report our initial experience in 20 cases of laparoscopic robotic liver resection (LRLR). From March 2011 to April 2013 patients with lesions within the liver were assessed and consented for laparoscopic robotic liver surgery. This is a retrospective analysis of a prospectively kept database on preoperative details and intraoperative and postoperative outcomes. During the time period there were 20 LRLRs. The median age was 62 years (range 39-80 years) with a male to female ratio of 14:6. Ten patients had left lateral sectionectomies, 10 patients had atypical segmental resections; 14 patients had resections for malignancies, 6 patients had resections for benign disease. One case was converted to open resection. The mean operating time was 176.4 ± 74.6 min (range 60-300 min), the mean blood loss was 107 ± 106 ml (range 50-700 ml) and the mean hospital stay was 6.5 ± 3.7 days (range 2-16 days). Two patients required blood transfusions. The incidence of postoperative complications was 10 % (n = 2). LRLR overcomes some of the disadvantages of conventional laparoscopic surgery. It is a technically feasible and safe approach for wedge resections and left lateral sectionectomy of the liver without oncological compromise. However, this surgical technique requires advanced laparoscopic skills and there is an associated steep learning curve. Further studies are needed to determine the potential advantages of this technique for the patient compared to the traditional laparoscopic approach.


title: Elucidating the Pivotal Role of Immune Players in the Management of COVID-19: Focus on Mesenchymal Stem Cells and Inflammation.

text: The world is currently engulfed with a viral disease with no cure. So, far, millions of people are infected with the virus across the length and breadth of world with thousand losing their lives each passing day. The WHO is February 2020 classified the virus as a coronavirus and the name Coronavirus-19 (CoV-19) was offered to the virus. The disease caused by the virus was termed coronavirus disease-19 (COVID-19). The pathogenesis of COVID-19 is associated with elevation of several immune plays as well as inflammatory factors which contributes to cytokine storms. Currently, the detection of CoV-19 RNA is through reverse transcriptase polymerase chain reaction (RT-PCR). Mesenchymal stem cells (MSCs) are capable of suppressing several kinds of cytokines via the paracrine secretion system. Therefore, MSCs therapy could be game charges in the treatment of the current COVID-19 pandemic. Also, intravenous IG may be capable of suppressing the high expression of IL-6 by the CoV-19 resulting in lessen disease burden. Anti-inflammatory medications like, corticosteroids, tocilizumab, glycyrrhetinic acid, as well as etoposide may be very advantageous in decreasing the COVID-19 burden because, their mode of action targets the cytokine storms initiated by the CoV-19. It is important to indicate that, these medication does not target the virus itself. Therefore, potent CoV-19 anti-viral medications are needed to completely cure patients with COVID-19. Also, a vaccine is urgently needed to stop the spread of the virus. This review therefore elucidates the immune players in the management of COVID-19; focusing principally on MSCs and inflammatory mediators.


Covid-19: Indian doctors criticise directive to expedite vaccine trials.


title: Clinical and radiological characteristics of e-cigarette or vaping product use associated lung injury.

text: PURPOSE E-cigarette or vaping product use associated lung injury (EVALI) has received national attention as an epidemic resulting in cases of significant morbidity and mortality. We aim to present the clinical and imaging findings in adolescents with pulmonary symptoms from suspected EVALI. METHODS Chest radiographs and CTs of adolescents (< 19 years) with acute pulmonary symptoms and history of vaping were reviewed by two radiologists in consensus. Clinical presentation and laboratory data were derived from the electronic medical records including pulmonary function tests (PFTs). RESULTS Eleven patients were identified (9 male, mean 16.6 years). The most common presentation was progressive, subacute respiratory distress with abdominal pain. All but one of the patients tested positive for tetrahydrocannabinol. Chest radiograph features were notable for interstitial pattern of opacities (91%) and basilar abnormalities (82%). CT features were notable for ground-glass opacities (89%), interstitial opacities (78%), and subpleural sparing (67%). Eight patients underwent PFTs. Six had diffusing capacity measurement, which demonstrated impaired diffusion in 3 (50%). All patients received supportive treatment with supplemental oxygen and corticosteroids. CONCLUSION Adolescents with suspected EVALI commonly present with subacute respiratory distress with abdominal pain. Imaging findings include ground-glass opacities, subpleural sparing, and basilar opacities, most consistent with organizing pneumonia or hypersensitivity pneumonitis. Recognition of the common imaging findings may have significant patient management implications, especially if the diagnosis is not suspected clinically. The lung function effects of vaping are consistent with mildly reduced airflow, which improves on follow-up testing, and reduced diffusion capacity, which, concerningly, does not improve.


title: Design and integration of an all-in-one biomicrofluidic chip.

text: We demonstrate a highly integrated microfluidic chip with the function of DNA amplification. The integrated chip combines giant electrorheological-fluid actuated micromixer and micropump with a microheater array, all formed using soft lithography. Internal functional components are based on polydimethylsiloxane (PDMS) and silvercarbon black-PDMS composites. The system has the advantages of small size with a high degree of integration, high polymerase chain reaction efficiency, digital control and simple fabrication at low cost. This integration approach shows promise for a broad range of applications in chemical synthesis and biological sensinganalysis, as different components can be combined to target desired functionalities, with flexible designs of different microchips easily realizable through soft lithography.


title: In vivo measurements of regional hemoglobin oxygen saturation values and limb-to-arm ratios of near-infrared spectroscopy for tissue oxygenation monitoring of lower extremities in healthy subjects.

text: OBJECTIVE Near-infrared spectroscopy (NIRS) is a noninvasive technique that allows monitoring of regional hemoglobin oxygen saturation (rSO2) values and might have a role in the diagnosis of peripheral arterial disease. We assessed the reproducibility and inter-subject variability of rSO2 values and rSO2 limb-to-arm ratios (LARs) in lower extremities of healthy subjects. METHODS The rSO2 values and rSO2 LARs were calculated in eight healthy subjects without peripheral arterial disease. The rSO2 values were measured at rest at six fixed spots at each lower limb and a reference spot at each upper arm. NIRS provided the rSO2 values without involvement of any other processing technique. After measurements were completed, rSO2 LARs were calculated by dividing the rSO2 value of a lower extremity spot by the rSO2 value of the arm. Measurements were performed twice on 1 day and repeated on 4 different days. RESULTS Mean coefficients of variation of measurements of rSO2 values and rSO2 LARs at the same spot in the same subject were respectively less than 6% and 8% for every measurement spot over time. Coefficients of variation of measurements at the same spot between different subjects were less than 15% and 19% for every measurement spot respectively. CONCLUSION NIRS is an easily applicable, noninvasive tool for measurement of tissue oxygenation of lower extremities in healthy subjects. The reproducibility of rSO2 values and rSO2 LARs at the same measurement spot in the same subject is good.


title: China upgrades surveillance and control measures of Middle East respiratory syndrome (MERS).

text: Three years after the identification of Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia, the first case of MERS in China was reported on May 29, 2015. Although the Chinese government issued the MERS Prevention and Control Plan in 2013, a novel edition was released on June 5, 2015 to better cope with the current epidemic situation. The revised Plan refines the descriptions in case-finding and establishment of case-monitoring systems. In addition, tougher regulations on close contacts of confirmed patients and suspected cases are introduced in this new Plan. It is expected these countermeasures will play a greater role in surveilling and controlling MERS in China.


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title: A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries.

text: Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.


title: Modeling the impact of twitter on influenza epidemics.

text: Influenza remains a serious public-health problem worldwide. The rising popularity and scale of social networking sites such as Twitter may play an important role in detecting, affecting, and predicting influenza epidemics. In this paper, we develop a simple mathematical model including the dynamics of ``tweets'' --- short, 140-character Twitter messages that may enhance the awareness of disease, change individual's behavior, and reduce the transmission of disease among a population during an influenza season. We analyze the model by deriving the basic reproductive number and proving the stability of the steady states. A Hopf bifurcation occurs when a threshold curve is crossed, which suggests the possibility of multiple outbreaks of influenza. We also perform numerical simulations, conduct sensitivity test on a few parameters related to tweets, and compare modeling predictions with surveillance data of influenza-like illness reported cases and the percentage of tweets self-reporting flu during the 2009 H1N1 flu outbreak in England and Wales. These results show that social media programs like Twitter may serve as a good indicator of seasonal influenza epidemics and influence the emergence and spread of the disease.


title: Image-guided thermal ablation of tumors increases the plasma level of interleukin-6 and interleukin-10.

text: PURPOSE To identify changes in plasma cytokine levels after image-guided thermal ablation of human tumors and to identify the factors that independently predict changes in plasma cytokine levels. MATERIALS AND METHODS Whole-blood samples were collected from 36 patients at three time points: before ablation, after ablation (within 48 hours), and at follow-up (1-5 weeks after ablation). Plasma levels of interleukin (IL)-1α, IL-2, IL-6, IL-10, and tumor necrosis factor (TNF)-α were measured using a multiplex immunoassay. Univariate and multivariate analyses were performed using cytokine level as the dependent variable and sample collection, time, age, sex, primary diagnosis, metastatic status, ablation site, and ablation type as the independent variables. RESULTS There was a significant increase in the plasma level of IL-6 after ablation compared with before ablation (9.6-fold ± 31-fold, P<.002). IL-10 also showed a significant increase after ablation (1.9-fold ± 2.8-fold, P<.02). Plasma levels of IL-1α, IL-2, and TNF-α were not significantly changed after ablation. Cryoablation resulted in the largest change in IL-6 level (>54-fold), whereas radiofrequency ablation and microwave ablation showed 3.6-fold and 3.4-fold changes, respectively. Ablation of melanomas showed the largest change in IL-6 48 hours after ablation (92×), followed by ablation of kidney (26×), liver (8×), and lung (6×) cancers. Multivariate analysis revealed that ablation type (P<.0003) and primary diagnosis (P<.03) were independent predictors of changes to IL-6 after ablation. Age was the only independent predictor of IL-10 levels after ablation (P< .019). CONCLUSIONS Image-guided thermal ablation of tumors increases plasma levels of IL-6 and IL-10, without increasing plasma levels of IL-1α, IL-2, or TNF-α.


title: Prenatal stress-induced increases in hippocampal von Willebrand factor expression are prevented by concurrent prenatal escitalopram.

text: Prenatal stress has been linked to deficits in neurological function including deficient social behavior, alterations in learning and memory, impaired stress regulation, and susceptibility to adult disease. In addition, prenatal environment is known to alter cardiovascular health; however, limited information is available regarding the cerebrovascular consequences of prenatal stress exposure. Vascular disturbances late in life may lead to cerebral hypoperfusion which is linked to a variety of neurodegenerative and psychiatric diseases. The known impact of cerebrovascular compromise on neuronal function and behavior highlights the importance of characterizing the impact of stress on not just neurons and glia, but also cerebrovasculature. Von Willebrand factor has previously been shown to be impacted by prenatal stress and is predictive of cerebrovascular health. Here we assess the impact of prenatal stress on von Willebrand factor and related angiogenic factors. Furthermore, we assess the potential protective effects of concurrent anti-depressant treatment during in utero stress exposure on the assessed cerebrovascular endpoints. Prenatal stress augmented expression of von Willebrand factor which was prevented by concurrent in utero escitalopram treatment. The functional implications of this increase in von Willebrand factor remain elusive, but the presented data demonstrate that although prenatal stress did not independently impact total vascularization, exposure to chronic stress in adulthood decreased blood vessel length. In addition, the current study demonstrates that production of reactive oxygen species in the hippocampus is decreased by prenatal exposure to escitalopram. Collectively, these findings demonstrate that the prenatal experience can cause complex changes in adult cerebral vascular structure and function.


title: Associations between drugs and small-bowel mucosal bleeding: Multicenter capsule-endoscopy study.

text: BACKGROUND AND AIM Although several drugs may induce small-bowel mucosal injuries, it is unclear whether these injuries contribute to overt small-bowel bleeding. This study was designed to evaluate the associations between drug use and small-bowel mucosal injury and between these mucosal injuries and overt bleeding in a disease-relevant population. METHODS We retrospectively studied patients with suspected small-bowel diseases who underwent capsule endoscopy between 2010 and 2013. Drug exposure, Charlson Comorbidity Index, smoking, and alcohol consumption were assessed before capsule endoscopy. Adjusted odds ratios (AOR) and confidence intervals (CI) were estimated for small-bowel mucosal injury and small-bowel overt bleeding. RESULTS In total, 850 patients were analyzed during the study period. Median age was 64 years, and 544 patients (64.0%) were men. Among the patients with small-bowel mucosal injury (n = 60) and without mucosal injury (n = 705), use of non-steroidal anti-inflammatory drugs (NSAIDs) (AOR 1.8, 95% CI 1.01-3.31) was significantly associated with an increased risk of small-bowel mucosal injury compared with non-use. Patients with small-bowel mucosal injury with overt bleeding (n = 85) and without overt bleeding (n = 60) were compared, and no significant difference between the groups in the usage rates for NSAIDs, thienopyridine, other antiplatelets, anticoagulants, acetaminophen, tramadol hydrochloride, or steroids was revealed, even after adjusting for confounders. CONCLUSION Although the use of NSAIDs was significantly associated with an increased risk of small-bowel mucosal injury, no significant associations were observed between the use of such drugs and small-bowel overt bleeding.


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title: PDC1, a pyruvate/α-ketoacid decarboxylase, is involved in acetaldehyde, propanal and pentanal biosynthesis in melon (Cucumis melo L.) fruit.

text: Plant pyruvate decarboxylases (PDC) catalyze the decarboxylation of pyruvate to form acetaldehyde and CO2 and are well known to play a key role in energy supply via fermentative metabolism in oxygen-limiting conditions. In addition to their role in fermentation, plant PDCs have also been hypothesized to be involved in aroma formation although, to date, there is no direct biochemical evidence for this function. We investigated the role of PDCs in fruit volatile biosynthesis, and identified a melon pyruvate decarboxylase, PDC1, that is highly expressed in ripe fruits. In vitro biochemical characterization of the recombinant PDC1 enzyme showed that it could not only decarboxylate pyruvate, but that it also had significant activity toward other straight- and branched-chain α-ketoacids, greatly expanding the range of substrates previously known to be accepted by the plant enzyme. RNAi-mediated transient and stable silencing of PDC1 expression in melon showed that this gene is involved in acetaldehyde, propanal and pentanal production, while it does not contribute to branched-chain amino acid (BCAA)-derived aldehyde biosynthesis in melon fruit. Importantly, our results not only demonstrate additional functions for the PDC enzyme, but also challenge the long standing hypothesis that PDC is involved in BCAA-derived aldehyde formation in fruit.


title: Extracranial internal carotid artery pseudoaneurysm associated with neurofibromatosis type 1 treated with endovascular stenting and coil embolization.

text: An internal carotid artery (ICA) pseudoaneurysm associated with neurofibromatosis type 1 (NF-1) is rare. We report the first case of unruptured extracranial pseudoaneurysm of the ICA in a patient with NF-1 successfully treated with endovascular stenting and coil embolization.A 66-year-old woman diagnosed with NF-1 had sudden left neck pain and massive swelling 3 years earlier. Radiological examination showed a ruptured pseudoaneurysm of the left internal thoracic artery (ITA). The posttreatment computed tomography (CT) scan revealed complete obliteration of the aneurysm of the left ITA and an unruptured pseudoaneurysm of the right ICA. After 3 years of follow-up, a CT scan revealed the enlargement of the pseudoaneurysm of the right extracranial ICA. Endovascular stenting and coil embolization were performed to prevent rupture, and the lesion was completely obliterated. Follow-up angiography at 6 months revealed good flow of the ICA through the stent without any filling of the aneurysm.


title: Roux-en-Y gastrojejunal bypass using a hybrid NOTES-12 mm trocar technique in a porcine model.

text: AIMS To evaluate the feasibility and safety of Roux-en-Y gastrojejunal bypass procedure using a hybrid NOTES-12 mm trocar technique in a survival porcine model. MATERIAL AND METHODS The procedure was carried out on ten pigs. Two gastroscopes were introduced through the mouth and through a 12 mm trocar, respectively. A mechanical circular gastro-jejunal anastomosis was created by introducing a stapler after the trocar incision was enlarged. A 21 mm EEA OrVil circular stapler was utilized in the first six pigs and a 25 mm one was used in the other four. All pigs were fed beginning 24 hours after the procedure and were euthanized three weeks later. RESULTS The procedure was successfully completed in all ten animals. The mean length of the skin incision was 2.5 cm. All pigs survived without complications. Endoscopic inspection detected anastomotic strictures in 5/6 of the 21 mm-stapler and in 0/4 of the 25 mm-stapler anastomoses (p < 0.05). CONCLUSION Roux-en-Y gastrojejunal bypass using a hybrid NOTES-single 12 mm trocar access technique is a simple and safe procedure in a survival porcine model. Functional results need to be evaluated by further studies.


title: Usefulness of a Telemedicine Tool TELEA in the Management of the COVID-19 Pandemic.

text: Background: The usefulness of telemedicine in the management of the coronavirus disease 2019 (COVID-19) pandemic has not been evaluated. Methods: We conducted a descriptive study of the process of recruitment and follow-up of patients using a telemedicine tool (TELEA) in the management of patients at risk, in a rural environment with a dispersed population in Lugo in north western Spain. Results: A large number of patients diagnosed with COVID-19 infection (N = 545) were evaluated. Of this group, 275 had comorbidities and were enrolled in the program, with a mean age of 57.6 ± 16.3 years, 43.1% male. The risk factors were hypertension (38%), diabetes (16%), asthma (9.5%), heart disease (8.8%), and immunosuppression (5.1%). Patients were followed through the platform with daily control of symptoms and vital signs. Only 8% were admitted to the hospital, 5.1% on a scheduled basis and 2.9% through the emergency room. Conclusion: The telemedicine tool TELEA is useful for the management of high-risk patients with COVID-19.


title: Measuring women's experiences of maternity care: protocol for a systematic review of self-report survey instruments.

text: BACKGROUND The use of survey instruments to measure women's experiences of their maternity care is regarded internationally as an indicator of the quality of care received. To ensure the credibility of the data arising from these instruments, the methodological quality of development must be high. This paper reports the protocol for a systematic review of self-report instruments used to measure women's experiences of their maternity care. METHODS Citation databases CINAHL, Ovid MEDLINE and EMBASE will be searched from 2002 to 2018 using keywords including women, experience, maternity care, questionnaires, surveys, and self-report. Citations will be screened by two reviewers, in two rounds, for inclusion as per predetermined inclusion and exclusion criteria. Data extraction forms will be populated with data, extracted from each study, to evaluate the methodological quality of each survey instrument and the criteria for good measurement properties using quality criteria. Data will also be extracted to categorise the items included in each survey instrument. A combination of a structured narrative synthesis and quantitate summaries in tabular format will allow for recommendations to be made on the use, adaptation and development of future survey instruments. DISCUSSION The value of survey instruments that evaluate women's experiences of their maternity care, as a marker of quality care, has been recognised internationally with many countries employing the use of such instruments to inform policy and practice. The development of these instruments must be methodologically sound and the instrument itself fit for the purpose and context in which it is used. This protocol describes the methods that will be used to complete a systematic review that will serve as a guide for choosing the most appropriate existing instruments to use or adapt so that they are fit for purpose, in addition to informing the development of new instruments. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018105325.


title: Practical strategies to manage cancer patients during the COVID-19 pandemic: Saudi Oncology Pharmacy Assembly Experts recommendations.

text: PURPOSE During COVID-19 pandemic, cancer patients are considered one of the most vulnerable to infection since they tend to have advanced age, multiple comorbidities, and are often immunosuppressed by their cancer or therapy. Hence, the Saudi Oncology Pharmacy Assembly has issued recommendations to reduce the frequency of cancer patients' visits to oncology centers during the pandemic while maintaining the access to cancer therapy and minimize the risk of exposure to coronavirus disease. MATERIALS AND METHODS A qualitative methodological approach was conducted in April 2020 using a virtual panel discussion for collection of recommendations. RESULTS A total of 12 expert oncology pharmacy practitioners shared their knowledge and experiences in managing oncology patients during the COVID-19 pandemic. The participants recognized many fundamental recommendations that were already applied in many cancer centers since the start of the COVID-19 outbreak. On that basis, the panelists developed eight practice-related recommendations for action, with a main focus on cancer treatment modification. CONCLUSIONS In conclusion, delivering cancer care during the COVID-19 pandemic carries significant challenges. This paper addressed suggestions to properly manage cancer patients during difficult times. Implementing changes in practice mandates a national collaborative effort from different sectors to guarantee the quality and continuity of care. The SOPA expert panel developed these recommendations, to ultimately contribute in maintaining access to cancer therapy while minimizing the risk of COVID-19 exposure.


COVID-19 Clinical Trials: Unravelling a Methodological Gordian Knot.


docid: gtqxijcs

title: Laparoscopic gastrectomy for gastric cancer.

text: BACKGROUND Surgery in gastric cancer (GC) aims to achieve resection of the primary tumor and its lymphatic drain, with a minimal adverse effect on morbidity and mortality, and the best possible quality of life. METHODS From June 1993 to May 2008, 113 patients with a preoperative diagnosis of the GC were considered for laparoscopic gastrectomy at our institution. There was a predominance of males and mean age was 60 years. After peritoneal cavity inspection, laparoscopic ultrasound was used to determine the presence of deep liver metastasis. Total gastrectomy and Roux-en-Y reconstruction were performed in upper and middle-third tumors, and subtotal gastrectomy, either with Billroth II or Roux-en-Y reconstruction, in tumors affecting the lower third of the stomach. D2 lymphadenectomy was performed in both cases. RESULTS There were 21 cases (18.5%) with distant metastases and/or an unresectable tumor due to the invasion of adjacent organs. In these patients the procedure was limited to laparoscopic biopsy in 16 cases and laparoscopic gastrojejunostomy in 5 cases. Laparoscopic gastrectomy was performed in 92 patients with a mean surgical time of 162 minutes and a mortality rate of 5.4%. Conversion was necessary in 7 cases (7.6%). CONCLUSIONS The benefits and safety of laparoscopic gastrectomy are evident, with similar outcomes to conventional surgery and all the advantages of minimally invasive access. The learning curve is long. Laparoscopic gastrectomy is a safe and effective option for the treatment of GC, avoiding nontherapeutic laparotomy in patients with advanced disease. Comparative prospective studies evaluating the long-term survival of these patients are still necessary.


title: Receptor usage and cell entry of porcine epidemic diarrhea coronavirus.

text: Porcine epidemic diarrhea coronavirus (PEDV) has significantly damaged America's pork industry. Here we investigate the receptor usage and cell entry of PEDV. PEDV recognizes protein receptor aminopeptidase N from pig and human and sugar coreceptor N-acetylneuraminic acid. Moreover, PEDV infects cells from pig, human, monkey, and bat. These results support the idea of bats as an evolutionary origin for PEDV, implicate PEDV as a potential threat to other species, and suggest antiviral strategies to control its spread.


title: Endovascular management of posttraumatic and iatrogenic large pelvic pseudoaneurysms following biopsy: case report.

text: Pelvic traumatic and iatrogenic pseudoaneurysms supplied by the internal iliac artery are very rare but can present with pain, nerve compression, and rupture. Particularly with more chronic pseudoaneurysms, their imaging appearance can be confusing and they can be mistaken for tumors. We present two cases of pelvic pseudoaneurysms supplied by the superior gluteal artery that were initially mistaken for masses and subsequently biopsied. We report the subsequent successful endovascular embolization technique subsequently utilized for both of these cases. A high index of suspicion should be maintained to avoid biopsy of these lesions. In the appropriately selected patient, an endovascular approach may be safely used to perform embolization.


title: Acute Necrotizing Pancreatitis in a Yellow-naped Amazon Parrot ( Amazona auropalliata).

text: A 25-year-old female yellow-naped Amazon parrot ( Amazona auropalliata) was presented for an acute onset of lethargy, ptyalism, and regurgitation. Results of hematologic testing and plasma biochemical analysis revealed severe leukopenia and heteropenia with toxic heterophils and marked hyperamylasemia and hypoproteinemia, consistent with gastrointestinal dysfunction. Survey radiograph findings were suggestive of coelomic effusion. Results of a contrast-enhanced computed tomography (CT) scan revealed a tubular, irregularly marginated structure along the medial aspect of the duodenum, consistent with an inflamed pancreas. The bird died soon after CT imaging, and acute necrotizing pancreatitis and pancreatic coagulative necrosis were observed at necropsy. This report describes the use of a less-invasive modality such as CT to aid in the antemortem diagnosis of acute pancreatitis in a psittacine bird. Pancreatitis should be considered a differential diagnosis in birds with gastrointestinal signs and coelomic effusion visualized on radiography, and the observation of an enlarged inflamed pancreas in the absence of a defined pancreatic mass on CT.


title: Transanal Endoscopic Operation for Benign Rectal Lesions and T1 Carcinoma.

text: BACKGROUND AND OBJECTIVES Transanal endoscopic operation (TEO) is a minimally invasive technique used for local excision of benign and selected malignant rectal lesions. The purpose of this study was to investigate the feasibility, safety, and oncological outcomes of the procedure and to report the experience in 3 centers. METHODS Retrospective review of a prospectively collected database was performed of all patients with benign lesions or ≤cT1N0 rectal cancer who underwent TEO with curative intent at 3 Belgian centers (2012 through 2014). RESULTS Eighty-three patients underwent 84 TEOs for 89 rectal lesions (37 adenomas, 43 adenocarcinomas, 1 gastrointestinal stromal tumor, 1 lipoma, 2 neuroendocrine tumors, and 5 scar tissues). Operative time was associated with lesion size (P < .001). Postoperative complications occurred in 13 patients: 7 hemorrhages, 1 urinary tract infection, 1 urinary retention, 2 abscesses, 1 anastomotic stenosis, and 1 entrance into the peritoneal cavity. Median hospital stay was 3 days (range, 1-8). During a median follow-up of 13 months (range, 2-27), there was 1 recurrence. CONCLUSION Although longer follow-up is still necessary, TEO appears to be an effective method of excising benign tumors and low-risk T1 carcinomas of the rectum. However, TEO should be considered as part of the diagnostic work-up. Furthermore, the resected specimen of a TEO procedure allows adequate local staging in contrast to an endoscopic piecemeal excision. Nevertheless, definitive histology must be appreciated, and in case of unfavorable histology, radical salvage resection still has to be performed.


title: BMP tests of source selected OFMSW to evaluate anaerobic codigestion with sewage sludge.

text: The aim of this study is to characterize different types of source selected organic fraction of municipal solid waste (SS-OFMSW) in order to optimize the upgrade of a sewage sludge anaerobic digestion unit by codigestion. Various SS-OFMSW samples were collected from canteens, supermarkets, restaurants, households, fruit-vegetable markets and bakery shops. The substrates characterization was carried out getting traditional chemical-physical parameters, performing elemental analysis and measuring fundamental anaerobic digestion macromolecular compounds such as carbohydrates, proteins, lipids and volatile fatty acids. Biochemical methane potential (BMP) tests were conducted at mesophilic temperature both on single substrates and in codigestion regime with different substrates mixing ratios. The maximum methane yield was observed for restaurant (675 NmlCH4/gVS) and canteens organic wastes (571 and 645 NmlCH4/gVS). The best codigestion BMP test has highlighted an increase of 47% in methane production respect sewage sludge digestion.


title: Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care.

text: PURPOSE Speaking valves (SV) are used infrequently in tracheostomised ICU patients due to concerns regarding their putative effect on lung recruitment. A recent study in cardio-thoracic population demonstrated increased end-expiratory lung volumes during and post SV use without examining if the increase in end-expiratory lung impedance (EELI) resulted in alveolar recruitment or potential hyperinflation in discrete loci. MATERIALS AND METHODS A secondary analysis of Electrical Impedance Tomography (EIT) data from a previous study was conducted. EELI distribution and tidal variation (TV) were assessed with a previously validated tool. A new tool was used to investigate ventilated surface area (VSA) and regional ventilation delay (RVD) as indicators of alveolar recruitment. RESULTS The increase in EELI was found to be uniform with significant increase across all lung sections (p<0.001). TV showed an initial non-significant decrease (p=0.94) with subsequent increase significantly above baseline (p<0.001). VSA and RVD showed non-significant changes during and post SV use. CONCLUSIONS These findings indicate that hyperinflation did not occur with SV use, which is supported by previously published data on respiratory parameters. These data along with obvious psychological benefits to patients are encouraging towards safe use of SVs in this critically ill cardio-thoracic patient population. TRIAL REGISTRATION Anna-Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN ACTRN12615000589583. 4/6/2015.


title: State-specific gating of salient cues by midbrain dopaminergic input to basal amygdala.

text: Basal amygdala (BA) neurons guide associative learning via acquisition of responses to stimuli that predict salient appetitive or aversive outcomes. We examined the learning- and state-dependent dynamics of BA neurons and ventral tegmental area (VTA) dopamine (DA) axons that innervate BA (VTADA→BA) using two-photon imaging and photometry in behaving mice. BA neurons did not respond to arbitrary visual stimuli, but acquired responses to stimuli that predicted either rewards or punishments. Most VTADA→BA axons were activated by both rewards and punishments, and they acquired responses to cues predicting these outcomes during learning. Responses to cues predicting food rewards in VTADA→BA axons and BA neurons in hungry mice were strongly attenuated following satiation, while responses to cues predicting unavoidable punishments persisted or increased. Therefore, VTADA→BA axons may provide a reinforcement signal of motivational salience that invigorates adaptive behaviors by promoting learned responses to appetitive or aversive cues in distinct, intermingled sets of BA excitatory neurons.


title: The comparison between propofol and dexmedetomidine infusion on perioperative anxiety during regional anesthesia

text: Background/aim Regional anesthesia for surgery is associated with increased anxiety for patients. This study aimed to compare the effect of propofol and dexmedetomidine infusion on perioperative anxiety during regional anesthesia. Materials and methods Eighty-four patients were randomly divided into two groups receiving either study drug infusion. Anxiety score, level of sedation using the Bispectral Index and Observer’s Assessment of Alertness and Sedation, hemodynamic stability, and overall patient’s feedback on anxiolysis were assessed. Results Both groups showed a significant drop in mean anxiety score at 10 and 30 min after starting surgery. Difference in median anxiety scores showed a significant reduction in anxiety score at the end of the surgery in the dexmedetomidine group compared to the propofol group. Dexmedetomidine and propofol showed a significant drop in mean arterial pressure in the first 30 min and first 10 min respectively. Both drugs demonstrated a significant drop in heart rate in the first 20 min from baseline after starting the drug infusion. Patients in the dexmedetomidine group (76.20%) expressed statistically excellent feedback on anxiolysis compared to patients in the propofol group (45.20%). Conclusion Dexmedetomidine infusion was found to significantly reduce anxiety levels at the end of surgery compared to propofol during regional anesthesia.


title: In vivo enzyme inhibition improves the targeting of [177Lu]DOTA-GRP(13-27) in GRPR-positive tumors in mice.

text: INTRODUCTION Gastrin-releasing peptide receptors (GRPR) and GRP-derived analogs have attracted attention due to high receptor expression in frequently occurring human neoplasia. The authors recently synthesized a series of GRPR-affine peptide analogs based on the 27-mer GRP and derivatized with the DOTA chelator at the N-terminus for (111)In-labeling. In this study, the authors evaluated the most promising from these series, DOTA-GRP(13-27), after radiolabeling with (177)Lu for future therapeutic applications. In addition, to improve in vivo stability of the peptide against in vivo degradation by the protease neutral endopeptidase (NEP), the authors coinjected [(177)Lu]DOTA-GRP(13-27) with the potent NEP inhibitor phosphoramidon (PA). The authors also aimed at reducing renal uptake by coadministration of lysine. METHODS In vivo stability studies were performed in Swiss albino mice. Biodistribution studies were conducted in NMRI nu/nu mice bearing prostate cancer (PC)-3 xenografts. Ex vivo autoradiography was performed using frozen sections from PC-3 xenografts and kidneys. RESULTS AND DISCUSSION Coadministration of PA significantly increased the percentage of intact radiopeptide in the mouse circulation. From biodistribution and ex vivo autoradiography studies, coadministration of both lysine and PA with [(177)Lu]DOTA-GRP(13-27) appeared to induce a clear improvement of tumor uptake as well as lower levels of renal radioactivity, causing a promising ninefold increase in tumor/kidney ratios.


title: Respiratory viral infections during the first 28 days after transplantation in pediatric hematopoietic stem cell transplant recipients.

text: Respiratory viruses (RVs) are a known cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). In this retrospective study, we focused on the first 28 d after transplantation in pediatric HSCT recipients and showed that a multiplex PCR assay significantly increased RV detection compared with a viral culture method. Among 176 pediatric HSCT recipients, 84 with respiratory symptoms within one yr after HSCT were tested by viral culture or multiplex PCR. Within 28 d after HSCT, nine patients were infected with RVs; the incidence of a first episode of RV infection within 28 d after HSCT was 5.1%. Eight patients recovered without complications. However, one patient died of adenovirus (AdV) pneumonia with pulmonary hemorrhage; the mortality rate of RV infection within 28 d after HSCT was 0.57%. In the nine patients with RV infection, five different types of RV were identified, either alone or with another RV. These were corona virus (CoV), rhinovirus (RhV) and respiratory syncytial virus combined with CoV; AdV combined with RhV; and parainfluenza virus. Viral culture detected only one case of RV infection, while multiplex PCR detected eight, suggesting that screening of respiratory infections using multiplex PCR is better than the conventional culture method.


docid: zqafcwcu

title: Assuring the quality, safety, and efficacy of DNA vaccines.

text: Scientists in academia whose research is aimed at the development of a novel vaccine or approach to vaccination may not always be fully aware of the regulatory process by which a candidate vaccine becomes a licensed product. This chapter will provide an overview of the regulatory process and will discuss in more detail the quality and pre-clinical safety issues of plasmid DNA vaccines intended for human use. It is useful for research scientists to be aware of these processes as the development of a novel vaccine could be problematic due to the starting material often being developed in a research laboratory under ill-defined conditions.


title: A Prospective Randomized Crossover Study on the Comparison of Cotton Versus Waterproof Cast Liners.

text: BACKGROUND Many fractures are treated with casting which can cause complications likely from inability to wash the extremity. Gore-Tex-based waterproof cast liner has been compared with cotton liner and shown to be superior in physician and patient scoring but also has high cost and difficult application. The purpose of this study is to compare newer generation waterproof liners with traditional cotton liner. It is the first study to compare this new waterproof liner and cotton liner in a crossover model, allowing patients to swim in the pool with the cast. METHODS Twenty patients (ages 3-30) with upper extremity injuries were randomized to waterproof-liner or cotton-liner casts made of fiberglass. Patients would switch cast liners halfway between their treatments to fulfill crossover criteria. All fractures were within a 2-week period from original incident. At each clinic visit, patients evaluated comfort parameters through questionnaires, and physicians rated skin condition. Patients were also asked which cast liner they preferred at the end of the study. RESULTS There were no unscheduled cast changes. The waterproof-liner group had better scores for odor (P = .041), sweat (P = .016), and overall physician-rated score (P = .038). There was no significant difference in other patient-rated parameters. Seventy-five percent of patients preferred waterproof casting to the cotton liner. CONCLUSIONS This new waterproof cast liner, compared with cotton cast liner, had better odor, sweat, and overall physician scores. The waterproof liners allow patients to rinse casts daily, and the majority of patients prefer waterproof to cotton liner.


docid: jbeugnyz

title: The Potential Effects of Coronavirus on National Health Expenditures.


title: Nebivolol in preventing atrial fibrillation following coronary surgery in patients over 60 years of age.

text: OBJECTIVE Postoperative atrial fibrillation is a common complication after cardiac surgery, with an incidence as high as 20-50%. Increased age is associated with a significant increase in postoperative atrial fibrillation risk. This common complication is associated with higher morbidity and mortality rates. The aim of this study was to assess the efficacy of nebivolol in preventing atrial fibrillation following coronary artery bypass surgery in patients over 60 years of age. METHODS In this prospective randomized study, 200 patients who were candidates for elective coronary artery bypass surgery were divided into two groups. The first group was administered with nebivolol and the second group was administered with metoprolol. Treatment was initiated four days prior to surgery, and patients were monitored for atrial fibrillation until discharge. Forty-one patients received 50 mg metoprolol succinate daily, which was initiated minimum 4 days before surgery. RESULTS Demographic data were similar in both groups. The incidence of postoperative atrial fibrillation in both groups was similar, with no significant difference being identified [n=20 (20%); n=18 (18%), P=0.718; respectively]. There were not any mortality at both groups during study. Inotropic agent requirement at ICU was similar for both groups [n=12 (12%), n=18 (18%), P=0.32]. CONCLUSION We compared the effectiveness of nebivolol and metoprolol in decreasing the incidence of postoperative atrial fibrillation, and determined that nebivolol was as effective as metoprolol in preventing postoperative atrial fibrillation at patients. Nebivolol may be the drug of choice due to its effects, especially after elective coronary artery bypass surgery.


docid: fwgkpiex

title: Serological evidence of Toxoplasma gondii infection in five species of bats in China.

text: Toxoplasma gondii is an obligate intracellular protozoan parasite that can infect almost all warm-blooded animals and humans with a worldwide distribution. Bats are reservoirs for an increasing number of emerging zoonotic viruses, such as henipaviruses and severe acute respiratory syndrome coronavirus (SARS-CoV). However, little is known of T. gondii infection in bats. The objective of the present study was to determine the seroprevalence of T. gondii infection in bats in China. A total of 217 serum samples from 5 species of bats were collected between April, 2010, and August, 2011, from 4 provinces in China. Antibodies to T. gondii were determined using the modified agglutination test (MAT, 1:25 or higher). Antibodies to T. gondii were found in 26.5% (18/68) Megaderma lyra, 13.6% (12/88) Rousettus leschenaulti, 13.6% (3/22) Cynopterus sphinx, 20% (4/20) Vespertilio superaus, and 15.8% (3/19) Pipistrellus javanicus. Antibody titers ranged from 1:25 to 1:400, with titers of 1:200 detected in 4 of the 5 bat species. The present study suggests the likely occurrence of T. gondii infection in bats in China, and these bats are new putative hosts for T. gondii, which may pose a threat to human health.


title: Paramyxovirus V Proteins Interact with the RIG-I/TRIM25 Regulatory Complex and Inhibit RIG-I Signaling.

text: Paramyxovirus V proteins are known antagonists of the RIG-I-like receptor (RLR)-mediated interferon induction pathway, interacting with and inhibiting the RLR MDA5. We report interactions between the Nipah virus V protein and both RIG-I regulatory protein TRIM25 and RIG-I. We also observed interactions between these host proteins and the V proteins of measles virus, Sendai virus, and parainfluenza virus. These interactions are mediated by the conserved C-terminal domain of the V protein, which binds to the tandem caspase activation and recruitment domains (CARDs) of RIG-I (the region of TRIM25 ubiquitination) and to the SPRY domain of TRIM25, which mediates TRIM25 interaction with the RIG-I CARDs. Furthermore, we show that V interaction with TRIM25 and RIG-I prevents TRIM25-mediated ubiquitination of RIG-I and disrupts downstream RIG-I signaling to the mitochondrial antiviral signaling protein. This is a novel mechanism for innate immune inhibition by paramyxovirus V proteins, distinct from other known V protein functions such as MDA5 and STAT1 antagonism.IMPORTANCE The host RIG-I signaling pathway is a key early obstacle to paramyxovirus infection, as it results in rapid induction of an antiviral response. This study shows that paramyxovirus V proteins interact with and inhibit the activation of RIG-I, thereby interrupting the antiviral signaling pathway and facilitating virus replication.


title: Critically Ill Patients With the Middle East Respiratory Syndrome: A Multicenter Retrospective Cohort Study.

text: OBJECTIVES To describe patient characteristics, clinical manifestations, disease course including viral replication patterns, and outcomes of critically ill patients with severe acute respiratory infection from the Middle East respiratory syndrome and to compare these features with patients with severe acute respiratory infection due to other etiologies. DESIGN Retrospective cohort study. SETTING Patients admitted to ICUs in 14 Saudi Arabian hospitals. PATIENTS Critically ill patients with laboratory-confirmed Middle East respiratory syndrome severe acute respiratory infection (n = 330) admitted between September 2012 and October 2015 were compared to consecutive critically ill patients with community-acquired severe acute respiratory infection of non-Middle East respiratory syndrome etiology (non-Middle East respiratory syndrome severe acute respiratory infection) (n = 222). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Although Middle East respiratory syndrome severe acute respiratory infection patients were younger than those with non-Middle East respiratory syndrome severe acute respiratory infection (median [quartile 1, quartile 3] 58 yr [44, 69] vs 70 [52, 78]; p < 0.001), clinical presentations and comorbidities overlapped substantially. Patients with Middle East respiratory syndrome severe acute respiratory infection had more severe hypoxemic respiratory failure (PaO2/FIO2: 106 [66, 160] vs 176 [104, 252]; p < 0.001) and more frequent nonrespiratory organ failure (nonrespiratory Sequential Organ Failure Assessment score: 6 [4, 9] vs 5 [3, 7]; p = 0.002), thus required more frequently invasive mechanical ventilation (85.2% vs 73.0%; p < 0.001), oxygen rescue therapies (extracorporeal membrane oxygenation 5.8% vs 0.9%; p = 0.003), vasopressor support (79.4% vs 55.0%; p < 0.001), and renal replacement therapy (48.8% vs 22.1%; p < 0.001). After adjustment for potential confounding factors, Middle East respiratory syndrome was independently associated with death compared to non-Middle East respiratory syndrome severe acute respiratory infection (adjusted odds ratio, 5.87; 95% CI, 4.02-8.56; p < 0.001). CONCLUSIONS Substantial overlap exists in the clinical presentation and comorbidities among patients with Middle East respiratory syndrome severe acute respiratory infection from other etiologies; therefore, a high index of suspicion combined with diagnostic testing is essential component of severe acute respiratory infection investigation for at-risk patients. The lack of distinguishing clinical features, the need to rely on real-time reverse transcription polymerase chain reaction from respiratory samples, variability in viral shedding duration, lack of effective therapy, and high mortality represent substantial clinical challenges and help guide ongoing clinical research efforts.


title: Comparison of Harmonic scalpel and monopolar cautery for capsulectomy at the second stage of expander/implant breast reconstruction.

text: Background Capsular contracture is a common complication of two-stage expander/implant breast reconstruction. To minimize the risk of this complication, capsulectomy is performed using monopolar cautery or ultrasonic surgical instrumentation, the latter of which can be conducted with a Harmonic scalpel. To date, there is disagreement regarding which of the two methods is superior. The purpose of this study was to compare postoperative outcomes between a group of patients who underwent surgery using a Harmonic scalpel and another group treated with monopolar cautery. Methods A retrospective chart review was conducted of patients who underwent capsulectomy as part of two-stage breast reconstruction between January 2018 and February 2019 and who received at least 1 month of follow-up after surgery. Operative time and postoperative outcomes, including drainage duration, were analyzed. Results In total, 36 female patients underwent capsulectomy. The monopolar group consisted of 18 patients and 22 breasts, while the Harmonic scalpel group consisted of 18 patients and 21 breasts. There was no statistically significant difference in demographics between the two groups. The Harmonic scalpel group had a significantly shorter mean drainage duration (6.65 days vs. 7.36 days) and a smaller mean total drainage volume (334.69 mL vs. 433.54 mL) than the monopolar cautery group (P<0.05). No statistically significant difference was observed with regard to seroma or hematoma formation. Conclusions The Harmonic scalpel approach for capsulectomy reduced the total drainage volume and drainage duration compared to the monopolar cautery approach. Therefore, this approach could serve as a good alternative to electrocautery.


Assessing the adequacy of past antidepressant trials: a clinician's guide to the antidepressant treatment response questionnaire.


title: Multicenter clinical experience in over 125 patients with the Penumbra Separator 3D for mechanical thrombectomy in acute ischemic stroke.

text: BACKGROUND The aim of this study was to assess reperfusion and clinical outcome of treatment with the self-expanding retrievable Separator 3D in revascularization of acute ischemic stroke. The three-dimensional (3D) device secures thrombus with direct aspiration and supports debulking of the clot. METHODS At two centers, 129 consecutive stroke patients with National Institutes of Health Stroke Scale (NIHSS) scores ≥5 were treated with mechanical thrombectomy using the Separator 3D as a component of the Penumbra System within 8 h of symptom onset; modified Treatment in Cerebral Infarction (mTICI) revascularization scores, NIHSS score on admission and discharge, mortality rates, and modified Rankin Scale (mRS) outcomes at 90 days were evaluated. RESULTS A total of 129 vessels in 129 patients were treated. Occlusions were located in the middle cerebral artery (MCA, 48%), internal carotid artery (ICA, 33%), cervical ICA-MCA (3%), and vertebrobasilar arteries (16%). Intravenous thrombolytic therapy with recombinant tissue plasminogen activator was given to 78% of patients. Median NIHSS was 15 prior to treatment. Reperfusion to mTICI 2b or 3 was successful in 96/129 (74%) target arterial lesions, with more than half of cases (51%) achieving mTICI 3. The mean time from arterial puncture to revascularization was 65 min. At 90 days, the symptomatic intracranial hemorrhage rate was 4%, all cause mortality was 32%, and 43/99 patients (43%) achieved functional independence with an mRS score of ≤2. CONCLUSIONS The results suggest that the Separator 3D enables safe and effective revascularization of occluded large arteries in acute stroke intervention, leading to a high rate of functional independence at 90 days.


title: Complications of Flat Bed Rest After Incidental Durotomy.

text: STUDY DESIGN Retrospective case series. OBJECTIVE To determine whether bed rest is a risk factor for specific medical complications. SUMMARY OF BACKGROUND DATA Flat bed rest after incidental durotomy is commonly used to reduce the risk of CSF leakage and associated complications. METHODS Retrospective case series of consecutive patients after lumbar laminectomy were identified. Medical records were reviewed for duration of bed rest and complications (pulmonary, wound, neurological, gastrointestinal, and urinary) in the chart notes, repair methods, subfascial drain placement, consultant notes, imaging reports, and discharge summaries. Patients were compared with duration of bed rest >24 hours versus duration of bed rest ≤24 hours. The incidence of complications was compared between groups using the Fisher exact test. RESULTS There were a total of 42 patients with incidental durotomy. There were 18 patients in the bed rest ≤24 hours group and 24 patients in the bed rest >24 hours group. Comparing the bed rest ≤24 hours to bed rest >24 hours patients, there was no statistically significant difference in the incidence of postdurotomy-related neurological complications, wound complications, and need for revision surgery. There was a statistically significant decrease in the incidence of total medical complications in the ≤24-hour group (0% vs. 50%, P=0.0003). CONCLUSION There was an increased incidence of medical complications in the bed rest group >24 hours. Flat bed rest after modern dural repair method may not be a necessity in all cases and may be associated with a higher incidence of medical complications.


title: Clinical Characteristics and Outcomes of Patients With Diabetes and COVID-19 in Association With Glucose-Lowering Medication.

text: OBJECTIVE Diabetes is one of the most distinct comorbidities of COVID-19. Here, we describe the clinical characteristics of and outcomes in patients with diabetes in whom COVID-19 has been confirmed or clinically diagnosed (with typical features on lung imaging and symptoms), and their association with glucose-lowering or blood pressure-lowering medications. RESEARCH DESIGN AND METHODS In this retrospective study involving 904 patients with COVID-19 (136 with diabetes, mostly type 2 diabetes), clinical and laboratory characteristics were collected and compared between the group with diabetes and the group without diabetes, and between groups taking different medications. Logistic regression was used in order to explore risk factors associated with mortality or poor prognosis. RESULTS The proportion of comorbid diabetes is similar between cases of confirmed and of clinically diagnosed COVID-19. Risk factors for higher mortality of patients with diabetes and COVID-19 were older age (adjusted odds ratio [aOR] 1.09 [95% CI 1.04, 1.15] per year increase; P = 0.001) and elevated C-reactive protein (aOR 1.12 [95% CI 1.00, 1.24]; P = 0.043). Insulin usage (aOR 3.58 [95% CI 1.37, 9.35]; P = 0.009) was associated with poor prognosis. Clinical outcomes of those who use an ACE inhibitor (ACEI) or angiotensin II type-I receptor blocker (ARB) were comparable with those of patients who do not use ACEI/ARB among patients with diabetes and hypertension who have COVID-19. CONCLUSIONS C-reactive protein may help to identify patients with diabetes who are at greater risk of dying during hospitalization. Older patients with diabetes were prone to death related to COVID-19. Attention needs to be paid to patients with diabetes and COVID-19 who use insulin. ACEI/ARB use showed no significant impact on patients with diabetes and hypertension who have COVID-19.


title: Transcutaneous Drainage of Gel-Like Substance after Application of Hydrogel Dural Sealant: Report of Two Cases.

text: Study Design Case report. Objective Incidental durotomy (IDT) is a common complication of spinal surgery. The use of collagen matrix graft along with hydrogel dural sealant is a common method of IDT repair. With this method, there have been several reported cases of detrimental dural sealant expansion in the literature. One case study reported an expansion rate greater than 300%; many report neurologic damage. This article reports the clinical course of two patients who developed postoperative transcutaneous drainage of a gel-like substance after the use of a dural sealant, which is a previously unreported complication. Methods The clinical course and treatment outcome of two patients is presented. Results Both patients experienced postoperative transcutaneous drainage of a gel-like substance at the surgical site. Case one began draining this substance on postoperative day 14. This patient required no further intervention, and the drainage ended after 3 mL of a gel-like substance was expressed from his incision while in the clinic. Case two began draining the gel on postoperative day 16. This patient underwent two washout procedures and resolution of the drainage. No infection was ever detected. Conclusions To our knowledge, our patients are the first reported cases of transcutaneous drainage of expanded dural sealant. It is important to take into consideration the unexpected expansion of a dural sealant when using it for the repair of IDT.


Ending systemic racism in medicine.


title: Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture.

text: A patient with a giant symptomatic vertebrobasilar aneurysm was treated by endoscopic third ventriculostomy for obstructive hydrocephalus followed by treatment of the aneurysm by flow diversion using a Pipeline Embolization Device. After an uneventful procedure and initial periprocedural period, the patient experienced an unexpected fatal subarachnoid hemorrhage 1 week later. Autopsy demonstrated extensive subarachnoid hemorrhage and aneurysm rupture (linear whole wall rupture). The patent Pipeline Embolization Device was in its intended location, as was the persistent coil occlusion of the distal left vertebral artery. The aneurysm appeared to rupture in a linear manner and contained a thick large expansile clot that seemed to disrupt or rupture the thin aneurysm wall directly opposite the basilar artery/Pipeline Embolization Device. We feel the pattern of aneurysm rupture in our patient supports the idea that the combination of flow diversion and the resulting growing intra-aneurysmal thrombus can create a mechanical force with the potential to cause aneurysm rupture.


title: The new coronavirus that came from the East: analysis of the initial epidemic in Mexico.

text: Introduction As of March 23, 2020, suspension of non-essential activities was declared in Mexico throughout the country in order to mitigate the spread of the COVID-19 pandemic. Objective To analyze data on the first 1,510 laboratory-confirmed cases of COVID-19 in Mexico, and to describe the geographical distribution of the disease and its transmission dynamics. Method Description of the first COVID-19 cases with real-time RT-PCR-positive test, as well as evaluation of epidemiological measures, cumulative incidence, rate of transmission, and mortality and lethality rates during the first month of the epidemic. Results Average age was 43 years, and 58 % were males; 44 % of initial cases were imported. Lethality in the population during the first month went from 1.08 to 3.97 per 100 cases; however, the trend is linear and similar to that observed in Europe. Conclusions In Mexico, social distancing is being applied, but studies are still required on the dynamics of the epidemic, person-to-person transmission, incidence of subclinical infections, and patient survival.


title: Daily vancomycin dose requirements as a continuous infusion in obese versus non-obese SICU patients.

text: BACKGROUND Limited data are available assessing vancomycin concentrations in obese critically ill patients. Currently, there are no studies evaluating dosing requirements in this population who receive vancomycin administered as a continuous infusion (CI). The aim of this study was to assess whether there was a difference in the weight-based maintenance dose required to reach a therapeutic vancomycin concentration at 24 hours when given as a CI in obese versus non-obese critically ill patients. METHODS A retrospective cohort study of adult obese patients admitted to the SICU between 2013 and 2015 receiving a vancomycin CI (CIV), and with 24-hour serum measurements were included. Obese patients (body mass index (BMI) ≥35 kg/m(2)) were matched with non-obese patients (BMI <30 kg/m(2)) based on renal function, age and acute physiology and chronic health evaluation (APACHE)-II score at admission. All patients in this study received a loading dose of 25 mg/kg then a maintenance dose based on renal function according to the protocol. The study was approved by the Institutional Review Board. The primary outcome was the weight-based total daily maintenance dose required to achieve a vancomycin level of 20 mg/L. The secondary endpoints included the achievement of a therapeutic level at 24 hours. RESULTS Twenty-six matched pairs of patients met the inclusion criteria. Of these, 17 pairs had preserved renal function and 9 pairs required continuous venovenous hemofiltration. Mean BMI was 40.9 kg/m(2) in obese and 24.8 kg/m(2) in non-obese patients. To achieve a vancomycin concentration of 20 mg/L, the weight-based daily maintenance dose in obese patients was 25.6 mg/kg versus 43.8 mg/kg in non-obese patients (p <0.01). Therapeutic 24-hour levels were achieved in 24/26 obese versus 23/26 no-obese patients (p = 0.63). Mean 24-hour vancomycin level was 20.3 ± 3.81 mcg/ml in obese compared to 20.03 ± 3.79 mcg/ml in non-obese patients (p = 0.77). Mean daily maintenance doses required to achieve a level of 20 mcg/ml were 2961 ± 1670 mg in obese compared to 3189 ± 1600.69 mg in non-obese (p = 0.61). CONCLUSIONS The results of our study suggest that critically ill obese patients treated with CIV required a significantly lower maintenance dose per unit of body weight than non-obese patients to achieve the same target level.


Balancing effectiveness and equality of opportunity in organ allocation.


title: Technical considerations in laparoscopic total proctocolectomy.

text: Total proctocolectomy, whether restorative or terminating with an end ileostomy, is an advanced laparoscopic procedure. The goal of this publication is to address specific techniques unique to the operation of laparoscopic total proctocolectomy and review the basics of laparoscopic colon and rectal resections. As in all complex operations, proficiency and efficiency in performing the laparoscopic total proctocolectomy comes with a step-wise approach. Respectable operating room times and true patient benefits may take more than safe reliable, technique; however, and only after a significant experience has been gained will the learning curve plateau.


Not Just the Flu.


title: Transformative learning as pedagogy for the health professions: a scoping review.

text: CONTEXT Transformative learning (TL) has been described as learning that challenges established perspectives, leading to new ways of being in the world. As a learning theory it has resonated with educators globally, including those in the health professions. Described as a complex metatheory, TL has evolved over time, eliciting divergent interpretations of the construct. This scoping review provides a comprehensive synthesis of how TL is currently represented in the health professions education literature, including how it influences curricular activities, to inform its future application in the field. METHODS Arksey and O'Malley's six-step framework was adopted to review the period from 2006 to May 2018. A total of 10 bibliographic databases were searched, generating 1532 potential studies. After several rounds of review, first of abstracts and then of full texts, 99 studies were mapped by two independent reviewers onto the internally developed data extraction sheet. Descriptive information about included studies was aggregated. Discursive data were subjected to content analysis. RESULTS A mix of conceptual and empirical research papers, which used a range of qualitative methodologies, were included. Studies from the USA, the UK and Australia were most prevalent. Insights relating to how opportunities for TL were created, how it manifests and influences behaviour, as well as how it is experienced, demonstrated much congruency. Conceptions of TL were seen to be clustered around the work of key theorists. CONCLUSIONS The training of health professionals often takes place in unfamiliar settings where students are encouraged to be active participants in providing care. This increases the opportunity for exposure to learning experiences that are potentially transformative, allowing for a pedagogy of uncertainty that acknowledges the complexity of the world we live in and questions what we believe we know about it. TL provides educators in the health professions with a theoretical lens through which they can view such student learning.


title: Montelukast as an episodic modifier for acute viral bronchiolitis: a randomized trial.

text: This study was designed to evaluate the effect of once-daily montelukast therapy on the clinical progress and the cytokine profile of patients with acute viral bronchiolitis. A randomized, double-blind, placebo-controlled trial included 85 patients (mean age, 3.5 +/- 2.35 months), clinically diagnosed as first-episode acute bronchiolitis in addition to 10 healthy controls of matched age and sex. Patients were randomly assigned to receive either montelukast (4-mg sachets; n = 47) or placebo (n = 38) daily from the time of admission until discharge. The primary outcome measure was the length of hospital stay (LOS), and clinical severity scores (CSs) and changes in plasma levels of interferon gamma and interleukin-4 were secondary outcomes. LOS for the montelukast group was found to be significantly lower than that of the placebo group (p < 0.05). This effect was also found at nonsignificant levels among patients with a positive family history of asthma or allergy. Moreover, cases receiving montelukast showed lower CSs all through the hospital stay that were significant in the first 24 hours (p < 0.05). Montelukast is probably of benefit as an episodic modifier in infants with acute viral bronchiolitis.


title: Cellular remodeling during plant virus infection.

text: This review focuses on the extensive membrane and organelle rearrangements that have been observed in plant cells infected with RNA viruses. The modifications generally involve the formation of spherules, vesicles, and/or multivesicular bodies associated with various organelles such as the endoplasmic reticulum and peroxisomes. These virus-induced organelles house the viral RNA replication complex and are known as virus factories or viroplasms. Membrane and organelle alterations are attributed to the action of one or two viral proteins, which additionally act as a scaffold for the assembly of a large complex of proteins of both viral and host origin and viral RNA. Some virus factories have been shown to align with and traffic along microfilaments. In addition to viral RNA replication, the factories may be involved in other processes such as viral RNA translation and cell-to-cell virus transport. Confining the process of RNA replication to a specific location may also prevent the activation of certain host defense functions.


title: Dual-lumen balloon catheters may improve liquid embolization of vascular malformations: an experimental study in Swine.

text: BACKGROUND AND PURPOSE Liquid embolic agents are increasingly used to treat vascular malformations. We sought to assess embolization with these agents by using a dual-lumen balloon catheter in an experimental setting. MATERIALS AND METHODS Eighteen injections of liquid embolic agents were performed in the rete mirabile of swine. We used 3 methods to control liquid embolic agent reflux: 1) dual-lumen balloon-catheter (group A, n = 8); 2) injection of liquid embolic agent after proximal n-BCA plug formation through a second microcatheter (group B, n = 4); and 3) standard liquid embolic agent injection (group C, controls, n = 6). The following outcomes were graded by using ordinal scales by angiography, macrophotography, and radiography of retia after euthanasia: 1) angiographic and pathologic extent of liquid embolic agent embolization of the rete, 2) reflux of liquid embolic agents in the parent artery, and 3) density of liquid embolic agents in the proximal rete. Technical complications were also recorded. A successful injection was defined as an embolization that reached the contralateral rete without reflux into proximal external branches. Exact logistic regression analyses were performed to compare groups. RESULTS There were significant differences among groups for reflux (P = .029) and liquid embolic agent density in the proximal rete (P = .014), while extension to the contralateral rete did not reach statistical significance (P = .07). Injections differed among groups (P = .004), with dual-lumen balloon-catheter injections more frequently successful compared with control injections (P = .019). CONCLUSIONS Dual-lumen balloon catheters allowed better liquid embolic agent injections than standard injections.


title: Superselective Provocative Test with Propofol Using Motor-Evoked Potential Monitoring for Managing Cerebral Arteriovenous Malformations Fed by the Anterior Choroidal Artery.

text: When feeder artery obliteration is performed via an endovascular procedure to treat cerebral arteriovenous malformation (AVM), it is important to prevent the ischemic complications that are associated with feeder occlusion. A provocative test may be beneficial in some cases to protect against ischemic complications. We report the case of a 57-year-old man who developed an intracerebral hematoma in the left internal temporal lobe and who had an AVM with a varix in the ambient cistern, which was primarily fed by a branch of the left anterior choroidal artery (AChA) and the posterior lateral choroidal artery, and drained into the basal vein. Therefore, we planned endovascular obliteration of the AChA, followed by gamma knife radiosurgery for the residual posterior component. The patient underwent a superselective provocative test with a 3 mg of propofol under general anesthesia using motor-evoked potential monitoring. The feeder embolization was performed as planned after the provocative test, and the patient exhibited no neurological deficits, such as hemiparesis, during the procedure.


title: Aerosolization During Common Ventilation Scenarios.

text: Otolaryngologists are at increased risk for exposure to suspected aerosol-generating procedures during the ongoing coronavirus disease 2019 (COVID-19) pandemic. In the present study, we sought to quantify differences in aerosol generation during common ventilation scenarios. We performed a series of 30-second ventilation experiments on porcine larynx-trachea-lung specimens. We used an optical particle sizer to quantify the number of 1- to 10-µm particles observed per 30-second period (PP30). No significant aerosols were observed with ventilation of intubated specimens (10.8 ± 2.4 PP30 vs background 9.5 ± 2.1, P = 1.0000). Simulated coughing through a tracheostomy produced 53.5 ± 25.2 PP30, significantly more than background (P = .0121) and ventilation of an intubated specimen (P = .0401). These data suggest that undisturbed ventilation and thus intubation without stimulation or coughing may be safer than believed. Coughing increases aerosol production, particularly via tracheostomy. Otolaryngologists who frequently manage patient airways and perform tracheostomy are at increased risk for aerosol exposure and require appropriate personal protective equipment, especially during the ongoing COVID-19 pandemic.


title: Exchange of the coronavirus replicase polyprotein cleavage sites alters protease specificity and processing.

text: Coronavirus nonstructural proteins 1 to 3 are processed by one or two papain-like proteases (PLP1 and PLP2) at specific cleavage sites (CS1 to -3). Murine hepatitis virus (MHV) PLP2 and orthologs recognize and cleave at a position following a p4-Leu-X-Gly-Gly-p1 tetrapeptide, but it is unknown whether these residues are sufficient to result in processing by PLP2 at sites normally cleaved by PLP1. We demonstrate that exchange of CS1 and/or CS2 with the CS3 p4-p1 amino acids in engineered MHV mutants switches specificity from PLP1 to PLP2 at CS2, but not at CS1, and results in altered protein processing and virus replication. Thus, the p4-p1 residues are necessary for PLP2 processing but require a specific protein or cleavage site context for optimal PLP recognition and cleavage.