bluuebunny/crossref_metadata_2025 huggingface dataset:
Discrimination and the Church of England: To What Extent does the Equality Act 2010 Adequately Protect Church of England Clergy?
Authors: Grout Christopher
Published: August 2020

The extent to which members of the clergy are considered ‘employees’ for the purposes of secular employment and equality legislation has been the subject of much discussion, but essentially remains a fact sensitive question. The Equality Act 2010 (‘the 2010 Act’) seeks to prevent discrimination on the basis of nine ‘protected characteristics’. While recognizing that the application of the 2010 Act to the variety of clergy offices is ‘not straightforward’, the Church of England (‘the Church’) has opined that an equitable approach to clergy appointments is to proceed as if they were subject to the provisions of the 2010 Act. What follows is in`tended to be a thorough review of the eligibility criteria for clergy appointment in the Church to assess their compatibility with the requirements of the 2010 Act. In addition, particular consideration will be given to Schedule 9(2) to the 2010 Act which makes specific provision relating to religious requirements concerning the protected characteristics of sex, sexual orientation, and marriage and civil partnership. In short, where the employment is for the purposes of an organized religion, such as the Church, requirements which relate to these protected characteristics will not constitute discrimination where they engage the ‘compliance or non-conflict principle’. What these principles mean and how they might operate in practice is discussed below, taking into account the likely canonical and theological justifications for discriminating against certain individuals. Whether the law strikes the right balance between, on the one hand protecting clergy and, on the other, providing the Church with the autonomy to act in accordance with its established doctrine, will be explored in the final analysis.
Shame and the Scope of Moral Accountability
Authors: Wang Shawn Tinghao
Published: August 2020

It is widely agreed that reactive attitudes play a central role in our practices concerned with holding people responsible. However, it remains controversial which emotional attitudes count as reactive attitudes such that they are eligible for this central role. Specifically, though theorists near universally agree that guilt is a reactive attitude, they are much more hesitant on whether to also include shame. This paper presents novel arguments for the view that shame is a reactive attitude. The arguments also support the view that shame is a reactive attitude in the sense that concerns moral accountability. The discussion thereby challenges both the view that shame is not a reactive attitude at all, suggested by philosophers such as R. Jay Wallace and Stephen Darwall, and the view that shame is a reactive attitude but does not concern moral accountability, recently defended by Andreas Carlsson and Douglas Portmore.
Safety and Ethics in Endoscopic Studies in Children: Evidence From the BEECH Study in Zambia
Authors: Chandwe Kanta , Amadi Beatrice , Chipunza Miyoba , Zyambo Masuzyo , Kelly Paul
Published: August 2020

Background

Environmental enteropathy is an example of a poorly-understood intestinal disorder affecting millions of children worldwide, characterized by malabsorption and stunting. Although there is increasing interest in non-invasive means of assessing intestinal structure and function, the potential value of intestinal biopsy for histology, immunostaining, RNA sequencing and epigenetic work means that endoscopic biopsy remains extremely valuable. We here report our experience in the BEECH (Biomarkers of Environmental Enteropathy in CHildren) study of stunting in Zambia, in the belief that it may help address the knowledge gap regarding the safety of endoscopic biopsy in vulnerable young children.

Methods

We report our experience of safety in 119 children undergoing endoscopic biopsy in the BEECH study in Lusaka Children’s Hospital, Lusaka, and discuss ethical considerations in this light.

Results

Upper gastrointestinal endoscopy was performed on children with stunting (length-for-age z score -2 or less) not responsive to nutritional interventions. Conscious sedation was provided by anaesthetists. Of 119 children, 5 (4%) developed transient desaturation, but no serious adverse events were experienced; no clinical, demographic or anaesthetic characteristics were identified as predictive of desaturation. Two children derived clinically useful information from the endoscopy, one life-saving. Of 105 lactase tests, 59 (54%) showed hypolactasia.

Discussion

Children with stunting underwent endoscopy safely, and some derived clinical benefit. Safety and the possibility of clinical benefit are usually felt to be preconditions for the ethical justification for endoscopy for research in children, and we believe that these conditions were met in this study.
Inference of Nipah virus evolution, 1999–2015
Authors: Whitmer Shannon L M , Lo Michael K , Sazzad Hossain M S , Zufan Sara , Gurley Emily S , Sultana Sharmin , Amman Brian , Ladner Jason T , Rahman Mohammed Ziaur , Doan Stephanie , Satter Syed M , Flora Meerjady S , Montgomery Joel M , Nichol Stuart T , Spiropoulou Christina F , Klena John D
Published: August 2020

Despite near-annual human outbreaks of Nipah virus (NiV) disease in Bangladesh, typically due to individual spillover events from the local bat population, only twenty whole-genome NiV sequences exist from humans and ten from bats. NiV whole-genome sequences from annual outbreaks have been challenging to generate, primarily due to the low viral load in human throat swab and serum specimens. Here, we used targeted enrichment with custom NiV-specific probes and generated thirty-five additional unique full-length genomic sequences directly from human specimens and viral isolates. We inferred the temporal and geographic evolutionary history of NiV in Bangladesh and expanded a tool to visualize NiV spatio-temporal spread from a Bayesian continuous diffusion analysis. We observed that strains from Bangladesh segregated into two distinct clades that have intermingled geographically in Bangladesh over time and space. As these clades expanded geographically and temporally, we did not observe evidence for significant branch and site-specific selection, except for a single site in the Henipavirus L polymerase. However, the Bangladesh 1 and 2 clades are differentiated by mutations initially occurring in the polymerase, with additional mutations accumulating in the N, G, F, P, and L genes on external branches. Modeling the historic geographical and temporal spread demonstrates that while widespread, NiV does not exhibit significant genetic variation in Bangladesh. Thus, future public health measures should address whether NiV within in the bat population also exhibits comparable genetic variation, if zoonotic transmission results in a genetic bottleneck and if surveillance techniques are detecting only a subset of NiV.
Making the Case for a Rome V Regulation on the Law Applicable to Companies
Authors: Gerner-Beuerle Carsten , Mucciarelli Federico , Schuster Edmund , Siems Mathias
Published: August 2020

There is significant legal variation and uncertainty in the conflict of laws rules applicable to companies in the EU. While the case law of the Court of Justice on the freedom of establishment has clarified some questions, it is evident that case law cannot provide for an adequate level of legal certainty. The main recommendation of this article is that private international company law in the EU should be harmonized. The article discusses the main challenges that a future regulation to this effect—called here ‘Rome V Regulation on the Law Applicable to Companies’—would have to overcome. Some of those are of a political nature: for instance, countries may fear that it may become easier for companies to evade domestic company law (eg, rules of employee co-determination), and there are specific considerations that concern companies established in third countries. Another challenge is that a future regulation on the law applicable to companies has to be consistent with existing EU conflict of laws rules as regards, for example, insolvency and tort law, while also complying with the freedom of establishment of the Treaty. It is the aim of this article to discuss these questions in detail, notably the general considerations for harmonisation in this field, a potential harmonization based on the ‘incorporation theory’, how it may be possible to overcome some contentious issues such as the definition of the lex societatis or the relationship between the lex societatis and other areas of law, and the prospects for future international harmonization.
Top 100 Cited Articles on Spinal Disc Arthroplasty Research
Authors: Zhao Tingxiao , Shen Jianjian , Zhang Jun , Hu Xueyu , Morizane Kazuaki , Huang Yazeng , Shao Haiyu , Riew Grant J. , Riew Daniel K.
Published: August 2020

Study Design.

A bibliometric review of current literature.

Objective.

The purpose of this study was to identify and analyze the 100 most cited articles in spinal disc arthroplasty (SDA) research.

Summary of Background Data.

In the last several decades, SDA has been widely performed all over the world, with increasing popularity of cervical disc arthroplasty (CDA). While there is a large number of articles on this topic, to our knowledge, there is no bibliometric analysis yet.

Methods.

All databases from the Web of Science were searched in a three-step approach. The information of the 100 most cited studies was collected, including title, first and last author, year of publication, journal, total citations, geographic origin, subspecialty, and types of artificial intervertebral disc for further analysis.

Results.

The 100 most-cited articles were published from 1966 to 2015 in 9 different journals and were cited from 66 to 346 times. A total of 11 countries contributed to the 100 articles and the United States topped the list, with 54 articles, followed by Germany and France, with 10 and nine articles, respectively. There were more studies in CDA (n = 53) than lumbar disc arthroplasty (n = 35). Most of the studies reported clinical and radiographic outcomes (n = 33). The most productive periods were from 2006 to 2010. The majority of publications were in Spine, which published 43 articles. In total, 12 authors published more than two articles on the list.

Conclusion.

Of the top 100 most cited articles on SDA, cervical papers outnumbered lumbar articles and the United States had 55 articles, with no other countries having more than 10. Our paper can help readers determine which of the thousands of articles on this topic are the most impactful and important ones to be familiar with.

Level of Evidence: 3
Historical Perspective: Thomas E. Whitesides, Jr.
Authors: Lockey Stephen D. , Kalantar Seyed Babak , Heller John G.
Published: August 2020

Dr. Thomas Whitesides was a pioneer in general orthopedics and spine surgery. He brought the anterior approach to the United States in the management of thoracolumbar trauma, a revolutionary step at the time. At Emory, he taught 100s of residents and fellows using the Socratic method. Dr. Whitesides remains a valuable consultant for complex spine cases to this day.
The Outcomes of Patients With Neck Pain Following ACDF
Authors: Stull Justin D. , Goyal Dhruv K. C. , Mangan John J. , Divi Srikanth N. , McKenzie James C. , Casper David S. , Okroj Kamil , Kepler Christopher K. , Vaccaro Alexander R. , Schroeder Gregory D. , Hilibrand Alan S.
Published: August 2020

Study Design.

Retrospective cohort study.

Objective.

The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy.

Summary of Background Data.

Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF.

Methods.

Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain.

Results.

Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P < 0.001) reduction in VAS neck pain, (ΔVAS neck; R group: −2.9, M: −2.5, MR: −2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (P = 0.011), RR (P = 0.006), and % minimum clinically important difference (P = 0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (P = 0.025).

Conclusion.

Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements.

Level of Evidence: 3
Pedicle Screw System May Not Control Severe Spinal Rotational Instability
Authors: Kasai Yuichi , Paholpak Permsak , Nabudda Kriengkrai , Wisanuyotin Taweechok , Sirichativapee Winai , Kosuwon Weerachai , Mizuno Tetsutaro , Kato Takaya
Published: August 2020

Study Design.

An in vitro biomechanical study.

Objective.

The purpose of this study is to discuss whether pedicle screw systems can control spinal rotational instability in a functional spinal unit of lumbar spine on human cadaver.

Summary of Background Data.

Rotational experiments using deer lumbar cadaveric models showed that rotational range of motion (ROM) of the model fixed by a pedicle screw system with crosslinking after total facetectomy for both the sides was larger than that in the intact model, and stated that spinal rotational instability could not be controlled using a pedicle screw system.

Methods.

A rotation experiment using 10 functional spinal units (L3–4) of lumbar spine on human cadavers was performed by preparing the four models (intact model, damaged model, pedicle screw model, and crosslink (CL) model) in stages, then calculating and comparing rotational ROM among the four models.

Results.

Rotational ROM in the CL model was still larger than that of the intact model in all the samples. And, rotational ROM decreased in the order of damaged model >> pedicle screw model > CL model > intact model. Statistical analysis revealed significant differences between all models (P < 0.001).

Conclusions.

Pedicle screw systems may not control severe spinal rotational instability in human lumbar cadaveric models with total facetectomy on both the sides. This may represent a major biomechanical drawback to the pedicle screw system.

Level of Evidence: N/A
Extracorporeal Membrane Oxygenation to Support Life-Threatening Drug-Refractory Electrical Storm
Authors: Baudry Guillaume , Sonneville Romain , Waintraub Xavier , Lebreton Guillaume , Deguillard Camille , Mertens Emilie , Bouadma Lila , Demondion Pierre , Bréchot Nicolas , Luyt Charles-Edouard , Extramiana Fabrice , Hékimian Guillaume , Dupuis Claire , Para Marylou , Pisani Angelo , Braham Wael , Gandjbakhch Estelle , Leenhardt Antoine , Timsit Jean-François , Leprince Pascal , Combes Alain , Schmidt Matthieu
Published: August 2020

Objectives:

Despite rapid implementation of anti-arrhythmic treatment and sedation and controlling the triggering event, rare patients develop treatment-refractory electrical storm and their hemodynamic instability prevents emergency catheter ablation. In that context, venoarterial extracorporeal membrane oxygenation could rapidly restore hemodynamics and tissue perfusion and reduce myocardial oxygen consumption, until adequate anti-arrhythmic drug levels are reached to safely perform catheter ablation.

Design:

Retrospective, multicenter study over an 8-year period.

Setting:

Two French tertiary care centers.

Patients:

Eighty-three consecutive adults with venoarterial extracorporeal membrane oxygenation-supported treatment-refractory electrical storm (median [interquartile range] age, 55 yr [48–63 yr]).

Measurements and Main Results:

Fifty-nine percent of these patients had acute ischemic cardiomyopathy and 66% underwent cardiopulmonary resuscitation prior to venoarterial extracorporeal membrane oxygenation initiation, with 18% cannulated during it. Fifty patients (60%) had ventricular tachycardia and/or ventricular fibrillation alternating with short periods of sinus rhythm and 33 (40%) had refractory ventricular tachycardia and/or ventricular fibrillation. Twelve patients (15%) underwent safe catheter ablation under venoarterial extracorporeal membrane oxygenation. After a median of 3 days (1–13 d) on extracorporeal membrane oxygenation support, 37 patients (45%) were successfully weaned off and 42% were alive 6 months post-ICU admission. Multivariable analysis retained ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm (odds ratio, 0.18; 95% CI, 0.06–0.52; p = 0.002) and age less than 50 years (odds ratio, 0.32; 95% CI, 0.18–0.89; p = 0.002) as being independent protective factors with 6-month survival, regardless of the underlying electrical storm cause.

Conclusions:

Among venoarterial extracorporeal membrane oxygenation-supported drug-refractory electrical storm patients, 42% survived 6 months post-ICU admission. Ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm and age less than 50 years were independently associated with better survival.
The Development and Validation of a Machine Learning Model to Predict Bacteremia and Fungemia in Hospitalized Patients Using Electronic Health Record Data
Authors: Bhavani Sivasubramanium V. , Lonjers Zachary , Carey Kyle A. , Afshar Majid , Gilbert Emily R. , Shah Nirav S. , Huang Elbert S. , Churpek Matthew M.
Published: August 2020

Objectives:

Bacteremia and fungemia can cause life-threatening illness with high mortality rates, which increase with delays in antimicrobial therapy. The objective of this study is to develop machine learning models to predict blood culture results at the time of the blood culture order using routine data in the electronic health record.

Design:

Retrospective analysis of a large, multicenter inpatient data.

Setting:

Two academic tertiary medical centers between the years 2007 and 2018.

Subjects:

All hospitalized patients who received a blood culture during hospitalization.

Interventions:

The dataset was partitioned temporally into development and validation cohorts: the logistic regression and gradient boosting machine models were trained on the earliest 80% of hospital admissions and validated on the most recent 20%.

Measurements and Main Results:

There were 252,569 blood culture days—defined as nonoverlapping 24-hour periods in which one or more blood cultures were ordered. In the validation cohort, there were 50,514 blood culture days, with 3,762 cases of bacteremia (7.5%) and 370 cases of fungemia (0.7%). The gradient boosting machine model for bacteremia had significantly higher area under the receiver operating characteristic curve (0.78 [95% CI 0.77–0.78]) than the logistic regression model (0.73 [0.72–0.74]) (p < 0.001). The model identified a high-risk group with over 30 times the occurrence rate of bacteremia in the low-risk group (27.4% vs 0.9%; p < 0.001). Using the low-risk cut-off, the model identifies bacteremia with 98.7% sensitivity. The gradient boosting machine model for fungemia had high discrimination (area under the receiver operating characteristic curve 0.88 [95% CI 0.86–0.90]). The high-risk fungemia group had 252 fungemic cultures compared with one fungemic culture in the low-risk group (5.0% vs 0.02%; p < 0.001). Further, the high-risk group had a mortality rate 60 times higher than the low-risk group (28.2% vs 0.4%; p < 0.001).

Conclusions:

Our novel models identified patients at low and high-risk for bacteremia and fungemia using routinely collected electronic health record data. Further research is needed to evaluate the cost-effectiveness and impact of model implementation in clinical practice.
Nationwide Incidence and Outcomes of Patients With Coronavirus Disease 2019 Requiring Intensive Care in Iceland
Authors: Kristinsson Bjarki , Kristinsdottir Linda B. , Blondal Asbjorn T. , Thormar Katrin M. , Kristjansson Mar , Karason Sigurbergur , Sigvaldason Kristinn , Sigurdsson Martin I.
Published: August 2020

Objectives:

To determine the nationwide demographics and hospital mortality of patients with severe acute respiratory syndrome coronavirus 2 infection requiring admission to the ICU for coronavirus disease 2019 in Iceland.

Design:

Prospective observational study.

Setting:

All ICUs in Iceland (Landspitali University Hospital and Akureyri Regional Hospital).

Patients:

All patients admitted to the ICU for management of coronavirus disease 2019 between March 14, 2020, and April 13, 2020, with follow-up through May 5, 2020.

Interventions:

None.

Measurements and Main Results:

A total of 27 patients were admitted to the ICU for coronavirus disease 2019 out of 1,788 severe acute respiratory syndrome coronavirus 2 positive cases, rendering an overall admission ratio of 1.5% (95% CI, 1.0–2.2%). The population rate of ICU admission for coronavirus disease 2019 was 7.4 (95% CI, 4.9–10.8) admissions per 100,000 individuals. The hospital mortality of patients admitted to the ICU was 15% (95% CI, 4–34%), and the mortality of patients receiving mechanical ventilation was 19% (95% CI, 4–46%).

Conclusions:

We report a lower overall ratio of ICU admissions for coronavirus disease 2019 among severe acute respiratory syndrome coronavirus 2 positive patients and a lower hospital mortality for patients treated in the ICU for coronavirus disease 2019 compared with initial reports from Italy and China. Our results could be explained by the early adoption of widespread testing and a successful national response to the pandemic.
Transpelvic Oblique Rectus Abdominis Myocutaneous Flap With Preservation of the Rectus Sheath
Authors: Canessa César E. , Cal Fernando Bonilla , Viglione Noelia Brito , Jalda Ricardo Misa
Published: August 2020

BACKGROUND:

Perineal reconstructive surgery is an effective procedure to decrease the morbidity associated with extensive abdominoperineal resection in the treatment of advanced low rectal and anal malignancies. Rectus abdominis myocutaneous flaps are often utilized in perineal reconstruction with excellent results. However, the main disadvantages are donor-site morbidity and the need for an open procedure after laparoscopic resection, requiring larger incisions with a resultant increase in postoperative pain. Herein, we describe a modified oblique rectus abdominis myocutaneous flap technique that allows sparing of the rectus sheath and the linea alba.

TECHNIQUE:

We followed the 3 stages regularly described for the procedure: 1) abdominoperineal resection with simultaneous abdominal and perineal team approach, and removal of the specimen through the perineal wound; 2) right oblique rectus abdominis myocutaneous flap with inferior epigastric pedicle, and release of the rectus muscle from its aponeurotic sheath through the skin paddle incision and transposition of the oblique rectus abdominis myocutaneous flap through an incision in the transversalis fascia; and 3) perineal reconstruction by sutures of the skin paddle to the perineal wound skin edges.

RESULTS:

Release of the rectus muscle within its sheath through the incision in the skin paddle turned out to be a simple surgical procedure, without the need of specialized surgical instruments or additional incisions. There were no complications during the postoperative recovery. Our patient was pain-free 1 month after the surgery, with a well-healed flap and abdominal scar.

CONCLUSION:

Performance of an oblique rectus abdominis myocutaneous flap that is specifically fitted for the perineal defect after abdominoperineal resection, with muscle dissection performed through the skin paddle incision and transposition into the pelvis through the transversalis fascia, offers good functional outcome while minimizing damage to the abdominal wall.
Robotic Harvest of a Rectus Abdominis Muscle Flap After Abdominoperineal Resection
Authors: Hammond Jacob B. , Howarth Ashley L. , Haverland Rachael A. , Rebecca Alanna M. , Yi Johnny , Bryant Lyndsey A. , Polveroni Thomas M. , Mishra Nitin
Published: August 2020

INTRODUCTION:

As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits.

TECHNIQUE:

After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect.

RESULTS:

After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap.

CONCLUSIONS:

This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.
Current Advances in Colorectal Surgery in Latin America
Authors: Valente Michael , Silva-Velazco Jorge , Ortega Adrian E.
Published: August 2020

The Latin American Association of Coloproctology (ALACP) held its 26th biennial congress in conjunction with the 44th annual meeting of the Mexican Society of Surgeons of the Rectum, Colon, and Anus (SMCRCA). The meeting took place October 2 to 5, 2019, in Cancun, Mexico. Twenty-eight international professors from North America, Europe, and Asia participated alongside 62 speakers from all of Latin America and the Caribbean. More than 400 participants converged from North, Central, and South America; the Caribbean; Europe; and Asia. Participants included 63 residents from Latin America, Europe, and Asia who contributed an unprecedented number of poster presentations. The meeting was highly interactive, consisting of 1 day of 5 highly dynamic workshops and 3 days of plenary sessions covering a broad spectrum of topics within colorectal surgery. Authoritative lectures by world leaders were punctuated by debates, panel discussions, and presentations of problem cases that delighted the audience. ALACP accomplished transformative changes in its general assembling meetings set into motion by its 26th presidency. These accomplishments included the first reformation of its bylaws in over a quarter century, an official affiliation with Diseases of the Colon & Rectum, and the relocation of the ALACP Secretariat General from Rio de Janeiro to Mexico City.
Organ Preservation in the Treatment of Stage II and III Rectal Cancer
Authors: Hagen Edward R. , Cleary Robert K.
Published: August 2020

CASE SUMMARY:

A 65-year-old man underwent colonoscopy to evaluate rectal bleeding and was found to have a low rectal mass. Biopsy revealed moderately differentiated microsatellite stable adenocarcinoma. The tumor was palpable at the fingertip in the anterior rectum with the inferior border 5 cm from the anal verge by rigid proctoscopy. CEA was 0.8 ng/mL. CT imaging of the chest, abdomen, and pelvis showed no evidence of distant metastases. MRI confirmed a 5-cm mass with one 8-mm mesorectal lymph node metastasis and no extramural venous invasion. The tumor penetrated the mesorectal fat to a depth of 4 mm, and the circumferential margin was estimated to be 1 mm from the tumor (Fig. 1). He was presented at the multidisciplinary tumor board conference and interviewed and examined at the multidisciplinary clinic. He was dismayed at the prospect of his surgical options, a low anterior resection versus abdominoperineal resection, and wished to keep the options for organ preservation available. Standard long-course chemoradiation was initiated, with resolution of his bleeding after 2 weeks. He then completed 6 cycles of folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy (consolidation total neoadjuvant therapy (TNT)). The tumor was no longer palpable on office examination. A complete clinical response (cCR) was confirmed by flexible sigmoidoscopy (Fig. 2) and MRI (Fig. 3). He was entered into the nonoperative management program with intense surveillance scheduling and has no evidence of recurrent disease almost 2 years after completion of TNT.
Complications After Mohs Micrographic Surgery in Patients Aged 85 and Older
Authors: Nemer Kathleen M. , Ko James J. , Hurst Eva A.
Published: August 2020

BACKGROUND

As the US population ages, safe surgical procedures are necessary for treatment of cutaneous neoplasms in very elderly patients.

OBJECTIVE

To determine the incidence of complications associated with Mohs micrographic surgery (MMS) in patients aged 85 and older, and the risk factors that predispose to complications.

METHODS

A 9-year retrospective chart review of patients aged 85 and older who underwent MMS at our institution between 07/2007 and 11/2016 was performed. Six types of complications associated with scalpel-based cutaneous surgery were recorded, as well as patient, tumor, and repair characteristics.

RESULTS

This study included 949 patients totaling in 1683 MMS cases. There were 30 complications: infection (N = 11), wound dehiscence (N = 6), hematoma (N = 6), hemorrhage (N = 5), flap necrosis (N = 1), and graft necrosis (N = 1), resulting in an overall complication rate of 1.78%. Independent risk factors associated with a statistically higher incidence of complications were anticoagulant use (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26–6.13; p = .012), extremity location (OR, 2.80; 95% CI, 1.19–6.54; p = .018), greater than 2 MMS stages (OR, 2.43; 95% CI, 1.08–5.46; p = .032), and flap repair (OR, 2.27; 95% CI, 1.05–4.90; p = .036).

CONCLUSION

Mohs micrographic surgery is a safe procedure for treatment of cutaneous neoplasms in the very elderly.
Dermoscopic Findings in the Presurgical Evaluation of Basal Cell Carcinoma. A Prospective Study
Authors: Conforti Claudio , Giuffrida Roberta , Zalaudek Iris , Guarneri Fabrizio , Cannavò Serafinella Patrizia , Pizzichetta Maria Antonietta , Bonin Serena , Corneli Paola , Bussani Rossana , Bazzacco Giulia , Di Meo Nicola
Published: August 2020

BACKGROUND

Surgery is the best treatment for basal cell carcinoma (BCC); however, incomplete excisions are possible.

OBJECTIVE

Assessment of the accurateness of dermoscopy and clinical evaluation in the detection of borders of BCC and description of dermoscopic findings in clinically healthy tissue surrounding BCC.

MATERIALS AND METHODS

Eighty-eight lesions with clinical dermoscopic diagnosis of BCC were examined clinically and dermoscopically, to delineate the correct site of surgical incision, demarcating the respective margins with colred dermographic pencils. Specific dermoscopic features were searched in the skin adjacent to the demarcated clinical margin.

RESULTS

In 29 of 88 lesions, clinical and dermoscopic margins of the tumor coincided. In the remaining 59 (67%), 10 (16.9%) presented, in the lesion area identified under dermoscopy, classical criteria for BCC and 57 (96.6%) nonclassical criteria. Differences between clinical and dermoscopic margins were significantly more frequent in superficial BCCs (p = .006). The frequency was not significantly different (p = .85) in relation to body sites.

CONCLUSION

Dermoscopy improves the identification of margins for surgical excision in BCC. The observation of nontraditional dermoscopic criteria of BCC, mainly pink–white areas and short telangiectasias in the area between clinically and dermoscopically detected margins, helps to define the actual tumoral margins and to achieve a really radical excision.
Trimethoprim-sulfamethoxazole-induced hyponatremia in an elderly lady with Achromobacter xylosoxidans pneumonia
Authors: Ghali Michael George Zaki , Kim Marc J.
Published: August 2020

Rationale:

Hyponatremia occurs frequently in the hospital setting and may be attributable to a host of etiologies. Drugs are frequently implicated. Trimethoprim-sulfamethoxazole (TMP/SMX) represents a well-recognized pharmacologic precipitant of drug-induced hyponatremia, with several reports extant in the retrievable literature. Nephrologists thus debate the mechanisms giving rise to TMP/SMX-induced hyponatremia and the precise mechanism by which treatment with TMP/SMX generates reductions of serum sodium concentration remain controversial. The agent has a well-known effect of antagonizing the effects of aldosterone upon the distal nephron. Renal salt wasting and the syndrome of inappropriate antidiuretic hormone secretion represent implicated mechanistic intermediaries in TMP/SMX-induced hyponatremia.

Patient concerns:

The patient endorsed no explicit concerns.

Diagnoses:

We describe the case of an 83-year-old female clinically diagnosed with pneumonia found to have an initial serum sodium in the range of 130 to 134 mEq/L consistent with mild hyponatremia upon admission. Sputum cultures grew Achromobacter xylosoxidans susceptible to TMP/SMX. The patient's serum sodium concentration precipitously decline following institution of treatment with TMP/SMX to 112 to 114 mEq/L during the course of 5 days.

Interventions:

Severe hyponatremia proved recalcitrant to initial therapy with supplemental salt tabs and standard doses of the vasopressin receptor antagonist tolvaptan.

Outcomes:

Escalating doses of tolvaptan increased the patient's sodium to 120 to 124 mEq/L. The patient was transferred to another hospital for further management. During her stay, the patient did not exhibit frank or obvious clinical features consistent with hyponatremia nor readily appreciable evidence of volume depletion.

Lessons:

TMP/SMX represents a frequent, though underreported cause of hyponatremia in the hospital setting several authors believe natriuresis may represent the most common mechanism underlying TMP/SMX-induced hyponatremia. Evidence implicating natriuresis to be mechanistic in TMP/SMX-induced hyponatremia include clinically appreciable hypovolemia and resolution of hyponatremia with oral or intravenous salt repletion. Salt repletion failed to monotherapeutically enhance our patient's hyponatremiadisfavoring renal salt wasting as originately mechanistic. Contemporaneous refractoriness of serum sodium to fluid restriction nor standard doses of tolvaptan confounded our initial attempts to mechanistically attribute the patient's hyponatremia to a specific cause. Clinical euvolemia and rapid response of hyponatremia to exceptionally high doses of tolvaptan strongly favors syndrome of inappropriate antidiuretic hormone to represent the chief mechanism by which TMP/SMX exacerbates hyponatremia.
Anterior cervical discectomy and fusion vs posterior laminoplasty for the treatment of myelopathy due to two-level localized ossification of the posterior longitudinal ligament
Authors: Noh Sung Hyun , Kim Kyung Hyun , Park Jeong Yoon , Kuh Sung Uk , Chin Dong Kyu , Kim Keun Su , Cho Yong Eun
Published: August 2020

We conducted a retrospective study to compare the clinical and radiological results of anterior cervical discectomy and fusion (ACDF) and posterior laminoplasty for two-level localized ossification of the posterior longitudinal ligament (OPLL).

ACDF and posterior laminoplasty are performed for localized OPLL at the disc and vertebral body levels, respectively.

Eighty six patients with two-level localized OPLL who underwent surgery from January 2011 to December 2016 were retrospectively investigated (41, ACDF group; 45, laminoplasty group). Clinical outcomes were reviewed, and radiologic results such as occupying ratio (OR), space available in the spinal cord, cranial and caudal OPLL-to-disc distance (ODD)/posterior body height (PBH) ratios, segmental angle, C2–C7 Cobb angle, T1 slope, C2–C7 sagittal vertical axis (SVA), and range of motion were investigated.

Patients were followed-up for an average of 42.7 ± 10.5 months. Clinical outcomes, postoperative OR, and space available in the spinal cord were significantly improved at the final follow-up in both groups. Preoperatively, the OR and cranial and caudal ODD/PBH ratios were not significantly different between the groups. Compared to pre-operative values, differences in the segmental and C2–C7 Cobb angles at the final follow-up were statistically significant for the ACDF group (P < .05). The mean operative time, bleeding volume, and the duration of hospitalization were significantly lower in the ACDF group than in the laminoplasty group (P < .05). Complications occurred in 1 ACDF case and in 5 laminoplasty cases.

Both ACDF and laminoplasty provided satisfactory clinical and radiologic outcomes for two-level localized OPLL. However, ACDF was associated with a lower operation time, bleeding loss, duration of hospitalization, and complications.
Nodes staging score to quantify lymph nodes for examination in gastric cancer
Authors: Sun Liping , Liu Qiaohong , Ren He , Li Ping , Liu Gang , Sun Lining
Published: August 2020

The lymph nodal invasion diagnosis is critical for therapeutic-decision and follows up in gastric cancer. However, the number of nodes to be examined for nodal invasion diagnosis is still under controversy, and the model for quantifying risk of missing positive node is currently not reported yet. We analyzed the nodal invasion status of 13,857 gastric cancer samples with records of primary tumor stage, the number of examined and positive lymph nodes in the surveillance, epidemiology, and end results (SEER) database, fitting a beta-binomial model. The nodes need to be examined with different primary tumor stage were determined based on the model. Overall, examining 11 lymph nodes reduces the probability of missing positive nodes to <10%, and the currently median nodes dissected is adequate (12 nodes). While the number of nodes demands to be dissected for T1, T2, T3, and T4 subgroups are 6, 19, 40, and 66, respectively. The currently implemented median value for these samples was 12, 12, 13, and 16, separately. It implies that the number of nodes to be examined is sufficient for early gastric cancer (T1), but it is inadequate for middle and advanced gastric cancer (T2–T3). The clinical significance of nodal staging score was validated with survival information. In summary, we first quantified the lymph nodes to be examined during surgery using a beta-binomial model, and validated with survival information.
Treatment of atrial fibrillation with third-degree atrioventricular block by pacing His bundle and left bundle branch
Authors: Zhang Denghong , Huang Xiaoming
Published: August 2020

Introduction:

Substantial advances in cardiac pacing technology have been developed in the past decades. However, efforts to improve pacing technology to achieve physiological electrical activity, such as with cardiac resynchronization therapy, are underway. Permanent His bundle pacing, which directly stimulates the His-Purkinje network and electrically activates both ventricles, simulates physiological electric activity in the heart, and has been considered an ideal pacing strategy to treat arrhythmias. For patients with atrial fibrillation complicated by third-degree atrioventricular block (AVB), permanent His bundle pacing is a better option than conventional right ventricular apical or septal pacing, the latter of which may be associated with risks, such as heart failure. However, His bundle pacing exhibits some shortcomings, including elevated pacing threshold, dislocation, and abnormal sensing.

Case presentation:

A 69-year-old female patient who had atrial fibrillation (AF) complicated by third-degree AVB and who was treated with permanent His bundle pacing combined with left bundle branch pacing.

Diagnosis:

AF complicated by third-degree AVB.

Interventions:

We used the left bundle branch as a backup pacing site to overcome any shortcomings related to permanent His bundle pacing.

Outcomes:

The patient recovered well without any events.

Conclusion:

We selected His bundle pacing as the primary pacing, but also used left bundle branch pacing as a backup approach. If His bundle pacing results in an increased sensing threshold, pacing threshold changes, or dislocations, left bundle branch pacing can compensate for dysfunction of permanent deficiencies in His bundle pacing, preserving physiological pacing.
First neonates with severe acute respiratory syndrome coronavirus 2 infection in Romania
Authors: Dima Mirabela , Enatescu Ileana , Craina Marius , Petre Izabella , Iacob Emil Radu , Iacob Daniela
Published: August 2020

Rationale:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, which quickly spread throughout the world, has been putting medical workers all over the world in difficulty because of the high number of cases combined with the lack of information about the disease. Although pediatric cases are rare, the group age under 12 months has been in general more susceptible to develop severe forms of the disease compared with the patients in the age interval of 1 to 18 years.

Patient concerns:

Three newborns have been tested positive for SARS-CoV-2 infection. One of them presented bilateral decreased air entry, while the other 2 had no respiratory symptomatology. All 3 developed diaper erythema and oral candidiasis.

Diagnosis:

For building up the report, newborns that were positive for coronavirus disease 2019 (COVID-19) infection were included in the case series. The chest X-ray of the symptomatic patient revealed a medium degree of hilar parenchymal infiltration and a slight infiltration of the visceral pleura.

Interventions:

The patients were admitted in our isolated neonatology ward. All of them received antifungal treatment for the oral candidiasis and topic cream for diaper erythema. The symptomatic patient also received prophylactic antibiotherapy, human immunoglobulins, aminophylline, and parenteral nutrition.

Outcomes:

All 3 neonates were discharged after 2 consecutive negative tests for SARS-CoV-2. Patients 1 and 2 fully recovered, whereas the condition of patient 3 improved.

Lessons:

Even if there are only a few reported cases of neonates infected with COVID-19 and most of them present mild manifestations, newborns need a more careful insight because of the nonspecific symptomatology.
Association between liver cirrhosis and estimated glomerular filtration rates in patients with chronic HBV infection
Authors: Wang Dexin , Yan Xiuping , Zhang Min , Ren Cuicui , Wang Lili , Ma Jiewen , Guo Lu
Published: August 2020

To investigate the estimated glomerular filtration rates of chronic hepatitis B (CHB) patients with or without liver cirrhosis, and to explore the related risk factors.

A total of 559 CHB patients were enrolled. Liver cirrhosis was diagnosed with ultrasound. The Child-Pugh scoring system was used to stage patients with liver cirrhosis. The Modification of Diet in Renal Disease (MDRD) formula was used to calculate the estimated glomerular filtration rate (eGFR).

A total of 296 patients were involved. The results showed that the incidence of renal impairment in patients with liver cirrhosis was 8.45% (25/296). The incidence of renal impairment in Child-Pugh C patients was significantly higher than that in Child-Pugh B and Child-Pugh Grade A patients (i.e., 17.2% [17/99] vs 6.67% [7/105] vs 1.09% [1/92], respectively, P < .001); age, hyperuricemia, and Child-Pugh score are all risk factors for impaired renal function.

With the deterioration of liver function in patients with cirrhosis, the incidence of impaired renal function has increased significantly, and renal function should be closely monitored to guide patients in clinical medication.
Humanistic care and psychological counseling on psychological disorders in medical students after COVID-19 outbreak
Authors: Tian Hao , Xue Yu , Yao Rong-rong , Yan Yu , Xue Yong , Chen Da-yin , Wang Fan-bo , Li Chun-feng , Ji Qing-hui
Published: August 2020

Background:

The objective of this study is to investigate the effects of humanistic care and psychological counseling (HCPC) on psychological disorders (PD) in medical students after coronavirus disease 2019 (COVID-19) outbreak.

Methods:

We will search randomized controlled trials or case-controlled studies of HCPC on PD in medical students after COVID-19 outbreak in the following electronic databases: PUBMED/MEDLINE, EMBASE, Cochrane Library, CINAHL, AMED, WANGFANG, and CNKI. The time is restricted from the construction of each database to the present. All process of study selection, data collection, and study quality evaluation will be carried out by two independent authors. Any different opinions will be solved by a third author through discussion. We will employ RevMan 5.3 software to conduct statistical analysis.

Results:

This study will provide a better understanding of HCPC on PD in medical students after COVID-19 outbreak.

Conclusions:

This study may offer strong evidence for clinical practice to treat PD in medical students after COVID-19 outbreak.

Study registration:

CRD42020193199.