title: Image-based monitoring of magnetic resonance-guided thermoablative therapies for liver tumors.

text: Minimally invasive treatment options for liver tumor therapy have been increasingly used during the last decade because their benefit has been proven for primary and inoperable secondary liver tumors. Among these, radiofrequency ablation has gained widespread consideration. Optimal image-guidance offers precise anatomical information, helps to position interventional devices, and allows for differentiation between already-treated and remaining tumor tissue. Patient safety and complete ablation of the entire tumor are the overriding objectives of tumor ablation. These may be achieved most elegantly with magnetic resonance (MR)-guided therapy, where monitoring can be performed based on precise soft-tissue imaging and additional components, such as diffusion-weighted imaging and temperature mapping. New MR scanner types and newly developed sequence techniques have enabled MR-guided intervention to move beyond the experimental phase. This article reviews the current role of MR imaging in guiding radiofrequency ablation. Signal characteristics of primary and secondary liver tumors are identified, and signal alteration during therapy is described. Diffusion-weighted imaging (DWI) and temperature mapping as special components of MR therapy monitoring are introduced. Practical information concerning coils, sequence selection, and parameters, as well as sequence gating, is given. In addition, sources of artifacts are identified and techniques to decrease them are introduced, and the characteristic signs of residual tumor in T1-, T2-, and DWI are described. We hope to enable the reader to choose MR sequences that allow optimal therapy monitoring depending on the initial signal characteristics of the tumor as well as its size and location in the liver.


title: Middle East Respiratory Syndrome Coronavirus epidemic impact on healthcare workers' risk perceptions, work and personal lives.

text: INTRODUCTION Middle East respiratory syndrome coronavirus (MERS-CoV) continues to cause frequent outbreaks in hospitals in Saudi Arabia. Since healthcare workers (HCWs) have a higher risk of acquiring and spreading MERS-CoV, we aimed to evaluate the perceived risk and anxiety level of HCWs in Saudi Arabia regarding MERS. METHODOLOGY An anonymous, self-administered questionnaire was sent online to HCWs at King Khalid University Hospital in Saudi Arabia. The total knowledge and anxiety scores were calculated. Logistic regression analyses were used to identify predictors of high anxiety scores. RESULTS Of 591 (70%) HCWs that responded, 284 (55%), 164 (32%), and 68 (13.2%) were physicians, nurses, and technicians, respectively. Physicians obtained a lower median knowledge score (6/9) compared to other professions (7/9). The mean anxiety score was similar for physicians and other HCWs (3/5); however, non-physicians expressed higher levels of anxiety toward the risk of transmitting MERS-CoV to their families, with an anxiety score of 4/5. The ability of the virus to cause severe disease or death was the most frequently reported reason for worry by physicians (89.7%) and non-physicians (87.2%). Overall, 80% of physicians and 90% of non-physicians reported improvement in adherence to hand hygiene and standard precautions while in hospital (p = 0.002). Concern over transmitting MERS-CoV to family members was the most predictive factor for anxiety among non-physician HCWs. CONCLUSION A significant proportion of HCWs expressed anxiety about the risk of acquiring MERS-CoV infection. Healthcare institutions need to develop an integrated psychological response for HCWs to the occupational and psychological challenge of MERS-CoV outbreaks.


title: Incidence and effects of subacute ruminal acidosis and subclinical ketosis with respect to postpartum anestrus in grazing dairy cows.

text: Subclinical Ruminal Acidosis (SARA) and Subclinical Ketosis (SCK) are two of the most prevalent metabolic diseases of dairy cows, with impacts on reproductive performance. There is scarce literature about these diseases in dairy regions in Colombia. In 29 randomly selected herds in Pasto, Colombia, 249 dairy cows were followed weekly for two months postpartum to determine: 1) incidence risk of SARA and SCK; and 2) effects of SARA and SCK on the occurrence of postpartum anestrus (PA) at two months. Samples from ruminal liquor and blood were obtained one time per cow during the first week postpartum to determine presence of SARA (pH < 5.6) and SCK (1.0-2.9 mmol/L of blood Beta-Hydroxy-Butyrate), respectively. PA diagnosis was determined with ultrasound. Pregnancy risks at 30 and 60 days post-breeding (and assumed embryo losses between these days) were determined. Risk factors associated with PA were estimated through a mixed multi-level multivariable logistic regression model, adjusting for clustering of cows within herds. The incidence risks of SARA and SCK were 23.3% and 46.2%, respectively. Simultaneous occurrence of SCK and SARA (SCASCK) was present in 5.2% of the cows. In the final multivariable model, the occurrence of SARA (Odds Ratio: OR = 39.4), SCK (OR = 47.4) and SCASCK (OR = 68.5) was associated with increased odds of PA. Feeding a transition period diet was associated with reduced odds of PA (OR = 0.15). Second parity cows had significantly lower odds of PA than first parity cows (OR = 0.21). In conclusion, inadequate pre-partum and postpartum nutritional management of the herds increased the occurrence of SARA and SCK, which had adverse effects on reproductive performance.


title: Introduction to Modern Climate Change. Andrew E. Dessler: Cambridge University Press, 2011, 252 pp, ISBN-10: 0521173159

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title: Detection of human adenoviruses in organic fresh produce using molecular and cell culture-based methods.

text: The consumption of organic fresh produce has increased in recent years due to consumer demand for healthy foods without chemical additives. However, the number of foodborne outbreaks associated with fresh produce has also increased. Contamination of food with enteric viruses is a major concern because the viruses have a low infectious dose and high persistence in the environment. Human adenovirus (HAdV) has been proposed as a good marker of faecal contamination. Therefore, the aim of this study was to evaluate the efficiency of the plaque assay (PA), real time PCR (qPCR) and integrated cell culture-RT-qPCR (ICC-RT-qPCR) for the recovery of HAdV from artificially and naturally contaminated fresh produce. Organic lettuce, strawberries and green onions were selected because these fresh products are frequently associated with foodborne outbreaks. The virus extraction efficiencies from artificially contaminated samples varied from 2.8% to 32.8% depending on the food matrix and the quantification method used. Although the HAdV recoveries determined by qPCR were higher than those determined by PA and ICC-RT-qPCR, PA was defined as the most reproducible method. The qPCR assays were more sensitive than the PA and ICC-RT-qPCR assays; however, this technique alone did not provide information about the viability of the pathogen. ICC-RT-qPCR was more sensitive than PA for detecting infectious particles in fresh produce samples. HAdV genome copies were detected in 93.3% of the analysed naturally contaminated samples, attesting to the common faecal contamination of the fresh produce tested. However, only 33.3% of the total samples were positive for infectious HAdV particles based on ICC-RT-qPCR. In conclusion, this study reported that HAdV can be an efficient viral marker for fresh produce contamination. Good detection of infectious HAdV was obtained with the ICC-RT-qPCR and PA assays. Thus, we suggest that the ICC-RT-qPCR and PA assays should be considered when quantitative microbial risk assessment (QMRA) studies are required and to establish reliable food safety guidelines.


ASGE EndoVators Summit: Defining the role and value of endoscopic therapies in obesity management.


Cautious Interpretation of Antiphospholipid Antibodies in COVID-19.


title: Mechanical Ventilation for ARDS During Extracorporeal Life Support: Research and Practice.

text: Ventilator-induced lung injury remains a key contributor to the morbidity and mortality of the acute respiratory distress syndrome. Efforts to minimize this injury are typically limited by the need to preserve adequate gas exchange. In the most severe forms of the syndrome, extracorporeal life support is increasingly being deployed for severe hypoxemia or hypercapnic acidosis refractory to conventional ventilator management strategies. Data from a recent randomized controlled trial, a post-hoc analysis of that trial, a meta-analysis, and a large, international, multicenter observational study, all suggest that extracorporeal life support, when combined with lower tidal volumes and airway pressures than the current standard of care, may improve outcomes compared with conventional management in patients with the most severe forms of the acute respiratory distress syndrome. These findings raise important questions not only about the optimal ventilator strategies for patients receiving extracorporeal support, but how various mechanisms of lung injury in the acute respiratory distress syndrome may potentially be mitigated by ultra-lung-protective ventilation strategies when gas exchange is sufficiently managed with the extracorporeal circuit. Additional studies are needed to more precisely delineate the best strategies for optimizing invasive mechanical ventilation in this patient population.


title: NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model.

text: BACKGROUND We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure. METHODS We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy. RESULTS We studied 12 dogs: 8 had subphrenic balloon implants and 4 had interbowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the "abscess" in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications. CONCLUSION Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.


title: Rat respiratory coronavirus infection: replication in airway and alveolar epithelial cells and the innate immune response.

text: The rat coronavirus sialodacryoadenitis virus (SDAV) causes respiratory infection and provides a system for investigating respiratory coronaviruses in a natural host. A viral suspension in the form of a microspray aerosol was delivered by intratracheal instillation into the distal lung of 6-8-week-old Fischer 344 rats. SDAV inoculation produced a 7 % body weight loss over a 5 day period that was followed by recovery over the next 7 days. SDAV caused focal lesions in the lung, which were most severe on day 4 post-inoculation (p.i.). Immunofluorescent staining showed that four cell types supported SDAV virus replication in the lower respiratory tract, namely Clara cells, ciliated cells in the bronchial airway and alveolar type I and type II cells in the lung parenchyma. In bronchial alveolar lavage fluid (BALF) a neutrophil influx increased the population of neutrophils to 45 % compared with 6 % of the cells in control samples on day 2 after mock inoculation. Virus infection induced an increase in surfactant protein SP-D levels in BALF of infected rats on days 4 and 8 p.i. that subsided by day 12. The concentrations of chemokines MCP-1, LIX and CINC-1 in BALF increased on day 4 p.i., but returned to control levels by day 8. Intratracheal instillation of rats with SDAV coronavirus caused an acute, self-limited infection that is a useful model for studying the early events of the innate immune response to respiratory coronavirus infections in lungs of the natural virus host.


The SNM practice guideline for somatostatin receptor scintigraphy 2.0.


Correction: Should Clinicians Use Chloroquine or Hydroxychloroquine Alone or in Combination With Azithromycin for the Prophylaxis or Treatment of COVID-19?


title: Single-port cholecystectomy in a patient with situs inversus totalis presenting with cholelithiasis: a case report.

text: INTRODUCTION Situs inversus totalis (mirror image organs) is a rare condition and may affect the intra-abdominal viscera as well as the intrathoracic organs. Cholelithiasis is not more common in these conditions, but the diagnosis may be more difficult. CASE PRESENTATION We present the case of a 59-year-old African woman with gallstones and situs inversus totalis. A single-port cholecystectomy was performed using a single trocar access device (SITRACC). CONCLUSIONS The procedure was uneventful, showing that this approach may be an option for this kind of surgery even in patients with situs inversus totalis.


title: The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery.

text: PURPOSE Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery. MATERIALS AND METHODS In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups. RESULTS Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis. CONCLUSIONS The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.


title: Increase of mtDNA number and its mutant copies in rat brain after exposure to 150 MeV protons.

text: Proton beam therapy is widely used for treating brain tumor. Despite the efficacy of treatment, the use of this therapy has met some limitations associated with possible damage to normal brain tissues located beyond the tumor site. In this context, the exploration of the harmful effects of protons on the normal brain tissues is of particular interest. We have investigated changes in the total mitochondrial DNA (mtDNA) copy number and identified mtDNA mutant copies in three brain regions (the hippocampus, cortex and cerebellum) of rats after irradiation their whole-head with 150 MeV protons at doses of 3 and 5 Gy. The study was performed in 2-months old male Spraque Dawley rats (n = 5 each group). The mtDNA copy numbers were determined by real-time PCR. The level of mtDNA heteroplasmy was estimated using Surveyor nuclease technology. Our results show that after head exposure to protons, levels of mtDNA copy number in three rat brain regions increase significantly as the levels of mtDNA mutant copies increase. The most significant elevation is observed in the hippocampus. In conclusion, an increase in mtDNA mutant copies may contribute to mitochondrial dysfunction accompanied by increased oxidative stress in different brain regions and promote the development of neurodegenerative diseases and the induction of carcinogenesis.


title: Severe acute respiratory syndrome coronavirus nucleocapsid protein does not modulate transcription of the human FGL2 gene.

text: Among the structural and nonstructural proteins of severe acute respiratory syndrome coronavirus (SARS-CoV), the nucleocapsid (N) protein plays pivotal roles in the biology and pathogenesis of viral infection. N protein is thought to dysregulate cell signalling and the transcription of cellular genes, including FGL2, which encodes a prothrombinase implicated in vascular thrombosis, fibrin deposition and pneumocyte necrosis. Here, we showed that N protein expressed in cultured human cells was predominantly found in the cytoplasm and was competent in repressing the transcriptional activity driven by interferon-stimulated response elements. However, the expression of N protein did not influence the transcription from the FGL2 promoter. More importantly, N protein did not modulate the expression of FGL2 mRNA or protein in transfected or SARS-CoV-infected cells. Taken together, our findings did not support the model in which SARS-CoV N protein specifically modulates transcription of the FGL2 gene to cause fibrosis and vascular thrombosis.


title: Embolisation of a proximal type I endoleak post-Nellix aortic aneurysm repair complicated by reflux of Onyx into the Nellix endograft limb.

text: We report the first case of intervention for a proximal type 1 endoleak following Nellix endovascular aneurysm sealing repair of an aortic aneurysm. This was complicated by migration of Onyx into one of the Nellix graft limbs causing significant stenosis. Subsequent placement of a covered stent to affix the Onyx between the stent and the wall of the Nellix endograft successfully restored stent patency.


title: Outcomes with drug-coated balloons in small-vessel coronary artery disease.

text: BACKGROUND Percutaneous coronary intervention (PCI) of small-vessel coronary artery disease (SVD) is associated with increased risk of restenosis. The use of drug-coated balloons (DCBs) in SVD has received limited study. OBJECTIVES To assess the outcomes of DCB in the treatment of SVD compared with the standard of care. METHODS We performed a meta-analysis of all studies published between January 2000 and September 2018 reporting the outcomes of DCB versus other modalities in the treatment of de novo SVD. RESULTS Seven studies with 1,824 patients (1,938 lesions) were included (four randomized controlled trials and three observational studies). During a mean follow-up of 14.5 ± 10 months, DCBs were associated with a similar risk of target lesion revascularization (TLR) (OR: 0.99, 95% CI: 0.54, 1.84, P = 97) and major adverse cardiovascular events (MACE) (OR: 0.86, 95% CI: 0.51, 1.45, P = 0.57) compared with drug-eluting stents (DES). During a mean follow-up of 7 ± 1.5 months, DCBs were associated with a significantly lower risk of TLR (OR: 0.19, 95% CI 0.04-0.88, P = 0.03) and binary restenosis (OR: 0.17, 95% CI 0.08-0.37, P = <0.00001) compared with noncoated balloon angioplasty. CONCLUSION The use of DCBs in SVD is associated with comparable outcomes when compared with DES and favorable outcomes when compared with balloon angioplasty.


title: Pancreatic surgery: a multidisciplinary assessment of the value of intraoperative US.

text: PURPOSE To assess the value of intraoperative ultrasonography (US) for different types of pancreatic surgery. MATERIALS AND METHODS An institutional review board-approved, HIPAA-compliant retrospective review with waiver of informed consent was performed to evaluate all cases of pancreatic surgery with intraoperative US or laparoscopic US that occurred at a single institution during a 10-year period. Surgical notes, radiologic images, and clinical data for each surgical procedure and subsequent clinical course were reviewed by pancreatic surgeons and radiologists. Presumptive diagnosis, type of surgical procedure performed, and final pathologic data were recorded. A relative value score was established by consensus and assigned to each case with a grade of 0-3, which indicated the value of the intraoperative or laparoscopic US. The type of operation and pathologic data were compared in each of the value score groups. Categoric variables were compared by using either χ(2) or Fisher exact test. RESULTS One hundred ninety-three intraoperative or laparoscopic US procedures were performed in 189 patients. Of the patients, there were 102 men and 87 women. The mean age was 57.8 years (range, 18-86 years). Intraoperative or laparoscopic US value scores were as follows: value score 0, 3.6%; value score 1, 11.9%; value score 2, 31.1%; and value score 3, 53.4%. The most common contribution that resulted in a high score (value score 3) was facilitation of technical performance of the surgery (n = 60). High value score was significantly associated with performance of pancreatitis-related surgery (P < .001). The surgical indication that most commonly resulted in a low value score of 0 or 1 was staging of pancreatic cancers. All cases that received a score of 0 occurred in the laparoscopic adenocarcinoma surgical setting (staging or pancreatic biopsy). CONCLUSION Intraoperative or laparoscopic US can be a valuable procedure in multiple types of surgical procedures that involve the pancreas and shows clear patterns of value in the different types of surgery.


title: Robotic transduodenal ampullectomy: A novel minimally invasive approach for ampullary neoplasms.

text: BACKGROUND The adoption of minimally invasive surgery for transduodenal ampullectomy has been slow because of special characteristics and complexity of this procedure. METHODS Six patients underwent robotic transduodenal ampullectomy. We employed novel methods to facilitate exposure of the ampulla. RESULTS All patients completed robotic transduodenal ampullectomy, but one patient was immediately converted to robotic pancreaticoduodenectomy because of presence of invasive carcinoma on frozen biopsy. The final pathologic report revealed high-grade dysplasia in four patients, low-grade dyplasia in one, and T2N0 in one patient who converted to pancreaticoduodenectomy. There was no immediate postoperative complication or mortality. One patient was readmitted after 3 months because of stricture of the bile duct outlet. There was no recurrence over a median follow-up period of 20 months. CONCLUSION An appropriate combination of patient positioning and retraction method helps the robot surgical system to provide competent performance for sophisticated and precise manipulation of ampullary lesions.


title: Maternal health care management during the outbreak of coronavirus disease 2019 (COVID-19).

text: Coronavirus disease 2019 (COVID-19) is a novel type of highly contagious pneumonia caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite the strong efforts taken to control the epidemic, hundreds of thousands of people were infected worldwide by Mar. 11th , and was characterized as a pandemic by World Health Organization. Pregnant women are more susceptible to the virus due to immune and anatomic alteration, though hospital visits may increase the chance of infection, the lack of medical care during pregnancy may do more harm. Hence, a well-managed system that allows pregnant women to access maternal health care with minimum exposure risk is desired during the outbreak. Here, we present the managing processes of three pregnant women that had a fever during hospitalization at gynecology or obstetrics department, then further summarize and demonstrate our maternal health care management strategies including antenatal care planning, patient triage based on risk level, admission control, and measures counteracting emergencies and newly discovered high risk cases at in-patient department. In the meantime, we will explain the alterations we have done throughout different stages of the epidemic, and also review relative articles in both Chinese and English to compare our strategies with those of other areas. Although tens of COVID-19 cases were confirmed in our hospital, no nosocomial infection has occurred and none of the pregnant woman registered in our hospital was reported to be infected. This article is protected by copyright. All rights reserved.


title: Laparoscopic Roux-en-Y gastric bypass with ileal transposition - an alternative surgical treatment for type 2 diabetes mellitus and gastroesophageal reflux.

text: Currently, type 2 diabetes mellitus (T2DM) is considered as a gastrointestinal disease. Numerous studies have demonstrated that bariatric operations ameliorate T2DM significantly. The laparoscopic Roux-en-Y gastric bypass (L-RYGB) is considered as the gold standard procedure. We aimed to evaluate the feasibility and impact of L-RYGB with ileal transposition (or interposition) on diabetes resolution in a patient who has not benefited from any medical therapy, with its additional effect on the amelioration of gastroesophageal reflux disease. The patient was a 38-year-old diabetic woman with uncontrolled blood glucose despite medical treatment, with additional gastroesophageal reflux disease. Following the procedure, her biochemical parameters and reflux symptoms improved significantly within 10 months. We think that L-RYGB with ileal transposition may be easily employed to gain a maximum effect in diabetics with adverse prognosis. This technique may be an alternative in the treatment of type 2 diabetic patients with gastroesophageal reflux.


Ensuring continuity of care for children with inherited metabolic diseases at the time of COVID-19: the experience of a metabolic unit in Italy.


title: Diagnostic modalities for the evaluation of small bowel disorders.

text: PURPOSE OF REVIEW This review summarizes the recent developments in the evaluation of small bowel disorders using videocapsule endoscopy (VCE) and serological and breath-test biomarkers. RECENT FINDINGS The ability to visualize the small bowel was revolutionized with the introduction of VCE technology. VCE allows for accurate, noninvasive visualization of the small bowel mucosa. This device is invaluable in the investigation of obscure gastrointestinal bleeding (OGIB), occult bleeding with iron deficiency anaemia, small bowel Crohn's disease (CD), small bowel neoplasms and other mucosal disorders. Recent studies underscored the utility of VCE for documenting the extent and severity of small bowel CD as well as monitoring activity after therapy. The accuracy of the discrimination between small bowel tumours and benign bulges has been improved by a novel endoscopic algorithm. The accuracy of VCE was also evaluated as a potential noninvasive alternative to small bowel biopsies in suspected celiac disease. New findings have been made using breath tests and other biomarkers for the diagnosis of celiac disease, irritable bowel syndrome and bacterial overgrowth. SUMMARY VCE as well as breath-test biomarkers play a major and expanding role in the diagnosis and monitoring of various small bowel disorders.


title: Ethics for laboratory professionals during the Covid pandemic.

text: It is not wrong to say that ethical issues have been given limited attention by professionals in laboratory medicine as compared to other fields of medicine (1). The most ethically problematic laboratory examinations are those dealing with genetic testing, autopsies, prenatal and HIV examinations and now, testing microbial agents in epidemics or pandemics, like Covıd-19..


title: Public health, global surveillance, and the "emerging disease" worldview: a postcolonial appraisal of PEPFAR.

text: Drawing upon a postcolonial lens, this project looks at how meanings of HIV/AIDS are discursively constructed within the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which was launched in 2003 under the presidency of George W. Bush and has been heralded as the largest global public health intervention program in history. Building on existing literature that theorizes the interrelationships of public health and national security, global surveillance, and transnational hegemony, the postcolonial theoretical standpoint interrogates how such meanings are constructed within PEPFAR. A postcolonial deconstruction of the 2009 PEPFAR report to the Congress revealed three meanings of HIV/AIDS that were discursively constructed in such policy documents: (a) the "Third World" as a site of intervention, (b) U.S. altruism as "lifting" the burden of the soul, and (c) AIDS, economics, and security. The themes put forth the linkages among the symbolic representations in neocolonial configurations and the politics of material disparities across the globe, thus issuing a call for the creation of participatory and dialogic spaces for engaging subaltern voices that are typically treated as targets of policy and intervention discourses.


title: Catalytic stereoselective synthesis of diverse oxindoles and spirooxindoles from isatins.

text: A strategy for the efficient two-step synthesis of triazole derivatives of oxindoles and spirooxindoles is presented. Using a common set of N-propargylated isatins, a series of mechanistically distinct stereoselective reactions with different combinations of nucleophiles and catalysts provide access to diverse hydroxy-oxindoles, spiroindolones, and spirocyclic oxazoline structures. The resulting N-propargylated oxindoles are then converted to triazoles using copper-catalyzed azide-alkyne cycloaddition (CuAAC) reactions. Overall, this strategy affords a 64-member pilot-scale library of diverse oxindoles and spirooxindoles.


title: Detection and genomic characterization of new avian-like hepatitis E virus in a sparrow in the United States.

text: Hepatitis E virus (HEV) is a nonenveloped, positive-sense, single-stranded RNA virus that has been detected in a wide variety of animals. In 2017, an avian-like HEV was identified in sparrow feces sampled from around a pig farm in the midwestern United States. Sequence analysis revealed that the sparrow isolate represents a novel HEV that is distantly related to chicken and little egret HEVs.


title: Long-term outcome of colectomy and ileorectal anastomosis for Crohn's colitis.

text: BACKGROUND Ileorectal anastomosis is an important surgical option for patients with Crohn's colitis with relative rectal sparing. OBJECTIVE This study aimed to audit outcomes of ileorectal anastomosis for Crohn's and factors associated with proctectomy and reoperation. DESIGN This retrospective study involved a chart review and contacting patients. SETTINGS Patients with Crohn's colitis who had an ileorectal anastomosis were identified from the Mount Sinai Hospital Inflammatory Bowel Disease Database. PATIENTS Demographics, operative and perioperative outcomes, and reoperative data were collected. MAIN OUTCOME MEASURES Five- and 10-year Kaplan-Meier survival estimates and 95% confidence intervals were calculated for survival from proctectomy and Crohn's-related revisional surgery. Cox proportional hazards models were used to model the hazards of proctectomy and Crohn's-related revision on the clinical characteristics of patients. RESULTS Eighty-one patients had an ileorectal anastomosis for Crohn's disease from 1982 to 2010. The most common indications for surgery were failed medical management (60/81, 74.1%) and a stricture causing obstruction (14/81, 17.3%). Seventy-seven percent (n = 62) had a 1-stage procedure, whereas 23% (n = 19) had a 2-stage procedure (colectomy followed by ileorectal anastomosis). The overall anastomotic leak rate was 7.4% (n = 6). Fifty-six patients had a functioning ileorectal anastomosis at the time of follow-up. At 5 and 10 years, 87% (95% CI: 75.5-93.3) and 72.2% (95% CI: 55.8-83.4) of individuals had a functioning ileorectal anastomosis. Eighteen patients required proctectomy for poor symptom control, whereas 11 patients required a small-bowel resection plus redo-ileorectal anastomosis. The mean time to proctectomy from the original ileorectal anastomosis was 88.3 months (SD = 62.1). Smoking was associated with both proctectomy (HR 3.93 (95% CI: 1.46-10.55)) and reoperative surgery (HR 2.12 (95% CI: 0.96-4.72)). LIMITATIONS : This study was retrospective. CONCLUSIONS Ileorectal anastomosis is an appropriate operation for selected patients with Crohn's colitis with sparing of the rectum. However, patients must be counseled that the reoperation rate and/or proctectomy rate is approximately 30%.


title: Delayed thromboembolic events more than 30 days after self expandable intracranial stent-assisted embolization of unruptured intracranial aneurysms.

text: OBJECTIVE The Enterprise stent is used for endovascular treatment of complex intracranial aneurysms. The purpose of this study was to evaluate delayed thromboembolic events (DTEs) that developed more than 30 days after Enterprise stent-assisted embolization (SAC) and its associated risk factors. METHODS There were 125 consecutive patients (90 women and 35 men; mean age, 56.1 years) who received endovascular treatment for 126 complex intracranial aneurysms using the Enterprise stent during December 2008 to May 2011. A DTE was defined as a symptomatic or asymptomatic ischemic stroke with positive findings on brain magnetic resonance imaging in the territory of the treated aneurysm and transient ischemic attack. Asymptomatic in-stent stenosis and occlusion were excluded. RESULTS During a mean follow-up of 32.4 months, DTEs occurred in 10 patients (7.93%). DTEs occurred on antiplatelet therapy (dual medication, n = 2, 2 months after embolization; single medication, n = 6, 10-20 months after SAC) or after discontinuation of antiplatelet therapy (n = 2, 14 months after embolization). Multivariate analysis showed that current smoking (p = 0.005) and maximum parent artery diameter >4.5mm (p = 0.003) were associated with DTE. CONCLUSIONS SAC with the Enterprise stent poses a considerable risk of DTE. Our results suggest that a longer duration of antiplatelet therapy and clinical follow-up may be warranted for cases with suggested risk factors. The protocol for antiplatelet therapy after SAC should be determined in a large prospective trial.


Editorial commentary: Respiratory viruses and otitis media in young children.


COVID-19 in India: Moving from containment to mitigation.


COVID-19 Research in Brief: 28 March to 3 April, 2020.


title: Procedural outcomes with use of the flash ostial system in aorto-coronary ostial lesions.

text: BACKGROUND The Flash Ostial system (Ostial Corporation, Sunnyvale, CA) was designed to optimize implantation of aorto-ostial coronary stents by flaring the proximal stent struts against the aortic wall. METHODS We retrospectively reviewed the medical record, angiograms, and intravascular ultrasound images of 22 aorto-ostial percutaneous coronary interventions performed at our institution between March and September 2015. The Flash Ostial system was used in 13 cases (59%). RESULTS Mean age was 67 ± 8 years and all patients were men. The target vessel was the right coronary artery (59%), left main (27%), or a saphenous vein graft (14%); 59% of the lesions had moderate/severe calcification. The mean number of predilation balloons was 1.8 ± 1.6, mean Flash ostial balloon diameter was 3.3 ± 0.5 mm and mean inflation pressure was 13.1 ± 4.0 atmospheres. Intravascular ultrasonography (available for 19 patients) revealed mean ostial minimum lumen cross-sectional area (MLA) of 9.2 ± 3.0 mm2 and reference MLA of 8.5 ± 2.7 mm2 . The percent difference between ostial and reference MLA was higher in cases in which the Flash Ostial system was used versus those where it was not (9.6 ± 5.5% vs. 4.0 ± 2.8%, P = 0.03). All stent struts were well apposed. Technical success was 100%. One patient developed a left groin pseudoaneurysm treated with thrombin injection and one patient had a periprocedural myocardial infarction. Median contrast, fluoroscopy time, and procedure time were 235 mL, 33 min, and 118 min, respectively. CONCLUSIONS The Flash Ostial system can be successfully used in aorto-ostial stenting, resulting in large ostial vessel MLA. © 2016 Wiley Periodicals, Inc.


title: Chest wall reconstruction for sternal dehiscence after open heart surgery.

text: BACKGROUND Sternal dehiscence is a grave complication after open heart surgery. Sternal debridement and flap coverage are the mainstays of therapy, but no consensus exists regarding the appropriate level of debridement. More recently, the use of vacuum-assisted closure devices has been advocated as a bridge to definitive closure, but indications for use remain incompletely defined. MATERIALS AND METHODS A retrospective review of all chest wall reconstructions performed from January 2000 to December 2010 was conducted. The type of operative management was evaluated to assess morbidity, mortality, and length of hospital stay. RESULTS Fifty-four patients underwent chest wall reconstruction for poststernotomy mediastinitis. Of these patients, 24 underwent conservative sternal debridement with flap closure, 24 underwent radical sternectomy including resection of the costal cartilages followed by flap closure, and 6 underwent radical sternectomy with vacuum-assisted closure therapy followed by flap closure in a delayed fashion. There were 15 patients in the conservative group and 8 patients in the radical sternectomy group who developed postoperative complications (62.5% vs 33.3%, P < 0.05). The conservative sternectomy group had more serious complications requiring reoperation compared to the radical sternectomy group (86.7% vs 25.0%, P < 0.05). The most common complication in the former group was flap dehiscence (8/15, 53.3%), whereas that in the latter group was a superficial wound infection (6/8, 75.0%). There was no significant difference in mortality (25.0% vs 25.0%, P > 0.05%) or length of hospital stay. CONCLUSIONS Radical sternectomy including the costal cartilages is associated with lower rates of surgical morbidity and reoperation, but not mortality.


Foreword: 10-year special edition.


title: Safe management of anastomotic leakage after gastric cancer surgery with enteral nutrition via a nasointestinal tube.

text: PURPOSE Anastomotic leakage is a serious complication after gastric cancer surgery. Despite the superiority of enteral nutrition (EN), total parenteral nutrition (PN) remains the standard therapy for anastomotic leakage. After introduction of EN via a nasointestinal tube for patients with anastomotic leakage in our institution in 2006, standard nutritional therapy was shifted gradually from PN to EN. The present preliminary study evaluates the safety and feasibility of EN via a nasointestinal tube for anastomotic leakage after gastric cancer surgery. METHODS Retrospective review of all gastric cancer surgeries from 2005 to 2009 (n = 2,588) revealed 53 patients (2.0%) who developed anastomotic leakage and were treated conservatively. EN was performed via a nasointestinal tube inserted using a guidewire under X-ray fluoroscopy. Clinical outcomes and complications following EN were compared with those in patients treated with PN (historical control group). The severity of complications was evaluated according to the Clavien-Dindo classification. RESULTS Fifty patients were included in the final analysis (three patients died): 29 patients managed by EN and 21 managed by PN. There were no significant differences in clinical outcomes and the frequency of total complications between the two groups; however, there were fewer tube/catheter-related complications in the EN compared with the PN group (1 vs. 7, respectively; P < 0.01). There was one epistaxis (3.4%; grade I) in the EN group and seven catheter infections (33.3%; grade II) in the PN group. The risk of grade II or higher complications was greater in the PN than the EN group (11 vs. 4, respectively; P < 0.01), with the greatest difference seen in the incidence of catheter infections. On days 7, 10, and 15 after diagnosis of leakage, the white blood cell count and C-reactive protein levels were higher in the PN than in the EN group. The PN group required prolonged intravenous antibiotic infusion (P < 0.01). CONCLUSIONS Nasointestinal tube insertion with EN can be performed safely for patients with anastomotic leakage. A major advantage of EN is fewer infectious complications. Because EN was not inferior to PN in terms of clinical outcome, we recommended that it is used in patients with anastomotic leakage after gastric cancer surgery.


title: Estimating the effectiveness and cost-effectiveness of establishing additional endovascular Thrombectomy stroke Centres in England: a discrete event simulation.

text: BACKGROUND We have previously modelled that the optimal number of comprehensive stroke centres (CSC) providing endovascular thrombectomy (EVT) in England would be 30 (net 6 new centres). We now estimate the relative effectiveness and cost-effectiveness of increasing the number of centres from 24 to 30. METHODS We constructed a discrete event simulation (DES) to estimate the effectiveness and lifetime cost-effectiveness (from a payer perspective) using 1 year's incidence of stroke in England. 2000 iterations of the simulation were performed comparing baseline 24 centres to 30. RESULTS Of 80,800 patients admitted to hospital with acute stroke/year, 21,740 would be affected by the service reconfiguration. The median time to treatment for eligible early presenters (< 270 min since onset) would reduce from 195 (IQR 155-249) to 165 (IQR 105-224) minutes. Our model predicts reconfiguration would mean an additional 33 independent patients (modified Rankin scale [mRS] 0-1) and 30 fewer dependent/dead patients (mRS 3-6) per year. The net addition of 6 centres generates 190 QALYs (95%CI - 6 to 399) and results in net savings to the healthcare system of £1,864,000/year (95% CI -1,204,000 to £5,017,000). The estimated budget impact was a saving of £980,000 in year 1 and £7.07 million in years 2 to 5. CONCLUSION Changes in acute stroke service configuration will produce clinical and cost benefits when the time taken for patients to receive treatment is reduced. Benefits are highly likely to be cost saving over 5 years before any capital investment above £8 million is required.


Chest CT imaging of an early Canadian case of COVID-19 in a 28-year-old man.


title: Impact of the introduction of pneumococcal conjugate vaccination on pneumonia in The Gambia: population-based surveillance and case-control studies.

text: BACKGROUND Pneumococcal conjugate vaccines (PCVs) are used in many low-income countries but their impact on the incidence of pneumonia is unclear. The Gambia introduced PCV7 in August, 2009, and PCV13 in May, 2011. We aimed to measure the impact of the introduction of these vaccines on pneumonia incidence. METHODS We did population-based surveillance and case-control studies. The primary endpoint was WHO-defined radiological pneumonia with pulmonary consolidation. Population-based surveillance was for suspected pneumonia in children aged 2-59 months (minimum age 3 months in the case-control study) between May 12, 2008, and Dec 31, 2015. Surveillance for the impact study was limited to the Basse Health and Demographic Surveillance System (BHDSS), whereas surveillance for the case-control study included both the BHDSS and Fuladu West Health and Demographic Surveillance System. Nurses screened all outpatients and inpatients at all health facilities in the surveillance area using standardised criteria for referral to clinicians in Basse and Bansang. These clinicians recorded clinical findings and applied standardised criteria to identify patients with suspected pneumonia. We compared the incidence of pneumonia during the baseline period (May 12, 2008, to May 11, 2010) and the PCV13 period (Jan 1, 2014, to Dec 31, 2015). We also investigated the effectiveness of PCV13 using case-control methods between Sept 12, 2011, and Sept 31, 2014. Controls were aged 90 days or older, and were eligible to have received at least one dose of PCV13; cases had the same eligibility criteria with the addition of having WHO-defined radiological pneumonia. FINDINGS We investigated 18 833 children with clinical pneumonia and identified 2156 cases of radiological pneumonia. Among children aged 2-11 months, the incidence of radiological pneumonia fell from 21·0 cases per 1000 person-years in the baseline period to 16·2 cases per 1000 person-years (23% decline, 95% CI 7-36) in 2014-15. In the 12-23 month age group, radiological pneumonia decreased from 15·3 to 10·9 cases per 1000 person-years (29% decline, 12-42). In children aged 2-4 years, incidence fell from 5·2 to 4·1 cases per 1000 person-years (22% decline, 1-39). Incidence of all clinical pneumonia increased by 4% (-1 to 8), but hospitalised cases declined by 8% (3-13). Pneumococcal pneumonia declined from 2·9 to 1·2 cases per 1000 person-years (58% decline, 22-77) in children aged 2-11 months and from 2·6 to 0·7 cases per 1000 person-years (75% decline, 47-88) in children aged 12-23 months. Hypoxic pneumonia fell from 13·1 to 5·7 cases per 1000 person-years (57% decline, 42-67) in children aged 2-11 months and from 6·8 to 1·9 cases per 1000 person-years (72% decline, 58-82) in children aged 12-23 months. In the case-control study, the best estimate of the effectiveness of three doses of PCV13 against radiological pneumonia was an adjusted odds ratio of 0·57 (0·30-1·08) in children aged 3-11 months and vaccine effectiveness increased with greater numbers of doses (p=0·026). The analysis in children aged 12 months and older was underpowered because there were few unvaccinated cases and controls. INTERPRETATION The introduction of PCV in The Gambia was associated with a moderate impact on the incidence of radiological pneumonia, a small reduction in cases of hospitalised pneumonia, and substantial reductions of pneumococcal and hypoxic pneumonia in young children. Low-income countries that introduce PCV13 with reasonable coverage can expect modest reductions in hospitalised cases of pneumonia and a marked impact on the incidence of severe childhood pneumonia. FUNDING GAVI's Pneumococcal vaccines Accelerated Development and Introduction Plan, Bill & Melinda Gates Foundation, and UK Medical Research Council.


title: Expanding immunization coverage in rural India: a review of evidence for the role of community health workers.

text: Poor routine immunization coverage in India has led to a large burden of vaccine-preventable diseases borne by children under 5 years of age. Despite efforts to strengthen infrastructure and service delivery in the past decade, immunization coverage rates have reached a plateau. To meet the formidable needs of India's growing population and address the shortcomings of health services for rural populations, the country is now turning toward a new national community health worker (CHW) plan. This article reviews the effectiveness of CHWs in expanding immunization coverage in developing countries and examines the potential contribution of CHWs toward strengthening immunization services in rural India. While the limited number and quality of available studies make it difficult to directly compare CHW interventions to other strategies for improving immunization coverage, it is clear that CHWs make diverse contributions toward strengthening immunization programs. Incorporation of evidence-based strategies for CHW selection, retention, and training is critical for success of India's immunization program. In addition, there is growing need to develop efficient mechanisms for monitoring children's vaccination status to generate actionable feedback and identify cost-effective strategies.


title: Development of a model for investigation of perennial ryegrass toxicosis in sheep.

text: AIMS To develop a clinical model of perennial ryegrass toxicosis (PRGT) based on feeding a known dose of lolitrem B and ergotamine, and to produce a consistent clinical presentation for assessment of disease pathophysiology, neurological changes and neurohistopathology. METHODS Male lambs, aged between 10-12 months, were randomly assigned to either Treatment (n=9) or Control (n=9) groups. Lambs in the Treatment group received feed containing a novel endophyte-infested perennial ryegrass seed, commencing on Day 0 of the Feeding phase with a low induction dose, then increasing after 3 days to provide 0.16 mg/kg live bodywight (LBW)/day of lolitrem B and 0.054 mg/kg LBW/day ergotamine. Lambs were examined daily and when defined signs of PRGT were observed they were transferred to the Testing phase. Neurological examinations, assessment of gait, surface electromyography (EMG) and mechanosensory nociceptive threshold testing were carried out and blood samples collected during both phases of the trial, with a full necropsy, histopathological examination and measurement of faecal cortisol metabolites (FCM) performed on Day 2 of the Testing phase. RESULTS Typical clinical signs of PRGT, including ataxia of vestibulocerebellar origin leading to stumbling, were observed in all Treatment lambs. The median interval from the start of the Feeding phase to entry into the Testing phase was 21 (min 18, max 34) days. Histopathological characterisation of neurological lesions included the presence of Purkinje cell vacuolation, pyknotic granular layer neurons and proximal axonal Purkinje cell spheroids. Lesions were most apparent within the vestibulocerebellum. Mean root-mean-square voltages from triceps EMG increased in Treatment lambs between Feeding phase Day 0 and Testing phase Day 2 (p<0.001). Daily water intake during the Testing phase for the Treatment group was less than in Control group lambs (p=0.002), and concentrations of FCM at necropsy were higher in Treatment compared to Control lambs (p=0.02). CONCLUSIONS AND CLINICAL RELEVANCE Lolitrem B and ergotamine dosing in feed on a live weight basis combined with neurological/gait assessment provides an effective model for investigation of PRGT and potential therapeutics. Assessment of gait changes using defined criteria and RMS voltages from EMG appear to be useful tools for the assessment of the severity of neurological changes.


title: A transorbital approach to the maxillary nerve block in dogs: a cadaver study.

text: OBJECTIVE To describe a transorbital approach to the maxillary nerve block in dogs and compare it with a traditional approach. STUDY DESIGN Prospective, randomized controlled study. ANIMALS Heads from 17 euthanized dogs (10 Greyhounds, three Border Collies and four of mixed breed). METHODS A volume of 1 mL of methylene blue dye was injected by each of two techniques, a traditional percutaneous approach and a transorbital approach to the maxillary nerve block. Both techniques were used on each head, alternating the left and right sides after random assignment to the first head. The heads were dissected to reveal the maxillary nerve and the length of nerve stained was measured. RESULTS There was no significant difference (p = 0.67) in the proportion of nerves stained for a length >6 mm by either technique (88.2% transorbital versus 82.3% percutaneous). The mean length of nerve stained did not differ significantly between the techniques (p = 0.26). CONCLUSIONS AND CLINICAL RELEVANCE The transorbital approach to the maxillary nerve block described here presents a viable alternative to the traditional percutaneous approach. Further study is required to confirm its efficacy and safety under clinical conditions.


Ovarian cancer in obese women: risk and optimal medical and surgical treatment options.


title: Acute bovine viral diarrhea associated with extensive mucosal lesions, high morbidity, and mortality in a commercial feedlot.

text: In 2008, a northwest Texas feedlot underwent an outbreak of Bovine viral diarrhea virus (BVDV) causing high morbidity and mortality involving 2 lots of calves (lots A and B). Severe mucosal surface lesions were observed grossly in the oral cavity, larynx, and esophagus. Mucosal lesions varied from small (1-3 mm) infrequent mucosal ulcerations to large (5 mm to 1 cm) and coalescing ulcerations. Necrotic debris was present in ulcerations of some mortalities with some having plaque-like debris, but other mortalities presented more proliferative lesions. A calf persistently infected with BVDV arrived with one lot and the isolated virus was genotyped as BVDV-1b. Identical BVDV-1b strains were isolated from 2 other mortalities. A BVDV-2a genotype was also isolated in this outbreak. This genotype was identical to all BVDV-2a strains isolated in both lots. Serum samples were collected from exposed and unexposed animals and tested for antibodies for multiple viral pathogens. Seropositivity ranged from zero percent for calicivirus to 100% positive to Pseudocowpox virusx. At the end of the feeding period, the morbidity and mortality for the 2 lots involved was 76.2% and 30.8%, respectively, for lot A, and 49.0% and 5.6%, respectively, for lot B. Differential diagnoses included vesicular stomatitis viruses, Bovine papular stomatitis virus, and Foot-and-mouth disease virus. Based on the present case, acute BVDV should be considered when mucosal lesions are observed grossly.


title: Patterns of intravenous contrast material use and corticosteroid premedication in children--a survey of Society of Chairs of Radiology in Children's Hospitals (SCORCH) member institutions.

text: BACKGROUND There are few data available concerning the use of intravenous contrast materials in children. OBJECTIVE To assess patterns of intravenous iodinated/gadolinium-based contrast material (ICM/GBCM) use in children. MATERIALS AND METHODS Society of Chairs of Radiology in Children's Hospitals (SCORCH) members were invited to complete a Web-based survey regarding intravenous contrast material use at their institutions. RESULTS Sixty-six percent (42/64) of SCORCH member institutions responded, 76% of which are academic hospitals. Ioversol and gadopentetate dimeglumine are the most commonly used ICMs and GBCMs (52% and 81%, respectively). Premedication policies to mitigate risk of allergic-like contrast reactions are more common for ICMs than GBCMs (71% vs. 32%). For both ICMs and GBCMs, most institutions premedicate or avoid contrast material in the setting of a prior allergic-like contrast reaction of any severity. Policies regarding ICM and GBCM use in children with renal insufficiency are in place at 74% and 88% of institutions, respectively, but are variable. CONCLUSION Policies concerning premedication for prevention of allergic-like contrast agent reactions and administration of contrast materials in children with renal insufficiency are variable and not consistently present at all pediatric institutions. This highlights the need for standardization of practice patterns and pediatric-specific research on these topics.


title: The effect of mannitol on intraoperative brain relaxation in patients undergoing supratentorial tumor surgery: study protocol for a randomized controlled trial.

text: BACKGROUND The risk of brain swelling after dural opening is high in patients with midline shift undergoing supratentorial tumor surgery. Brain swelling may result in increased intracranial pressure, impeded tumor exposure, and adverse outcomes. Mannitol is recommended as a first-line dehydration treatment to reduce brain edema and enable brain relaxation during neurosurgery. Research has indicated that mannitol enhanced brain relaxation in patients undergoing supratentorial tumor surgery; however, these results need further confirmation, and the optimal mannitol dose has not yet been established. We propose to examine whether different doses of 20% mannitol improve brain relaxation in a dose-dependent manner when administered at the time of incision. We will examine patients with preexisting mass effects and midline shift undergoing elective supratentorial brain tumor surgery. METHODS This is a single-center, randomized controlled, parallel group trial that will be carried out at Beijing Tiantan Hospital, Capital Medical University. Randomization will be achieved using a computer-generated table. The study will include 220 patients undergoing supratentorial tumor surgery whose preoperative computed tomography/magnetic resonance imaging results indicate a brain midline shift. Patients in group A, group B, and group C will receive dehydration treatment at incision with 20% mannitol solutions of 0.7, 1.0, and 1.4 g/kg, respectively, at a rate of 600 mL/h. The patients in the control group will not receive mannitol. The primary outcome is an improvement in intraoperative brain relaxation and dura tension after dehydration with mannitol. Secondary outcomes are postoperative outcomes and the incidence of mannitol side effects. DISCUSSION The aim of this study is to determine the optimal dose of 20% mannitol for intraoperative infusion. We will examine brain relaxation and outcome in patients undergoing supratentorial tumor surgery. If our results are positive, the study will indicate the optimal dose of mannitol to improve brain relaxation and avoid side effects during brain tumor surgery. TRIAL REGISTRATION The study is registered with the registry website http://www.chictr.org with the registration number ChiCTRTRC13003984 (17 December 2013).


The Differential Outcomes of Coronavirus Disease 2019 in Low- and Middle-Income Countries vs High-Income Countries.


title: Invest in health and uphold rights to "build back better" after COVID-19.

text: The COVID-19 pandemic is not just a health crisis - it is a full-blown economic and social crisis that is impacting the lives and livelihoods of billions of people. This commentary examines the mutually dependent relationship between health security and universal health coverage (UHC), and how the longstanding underinvestment in both renders us all vulnerable. It also discusses the vulnerability of services for sexual and reproductive health and rights (SRHR) in times of crisis, which is compounded when these services are not included and well integrated into national UHC packages. It concludes with a call for stronger political leadership for UHC and SRHR as the global community strives to "build back better" after COVID-19. Résumé La pandémie de COVID-19 n'est pas seulement une crise sanitaire, c'est une véritable crise économique et sociale qui a des conséquences sur la vie et les moyens d'existence de milliards de personnes. Ce commentaire examine la relation mutuellement dépendante entre sécurité sanitaire et couverture santé universelle (CSU) et de quelle manière le sous-investissement chronique dans ces deux domaines nous rend tous vulnérables. Il aborde aussi la vulnérabilité des services de santé et droits sexuels et reproductifs en temps de crise, une vulnérabilité qui est aggravée quand ces services ne sont pas inclus et bien intégrés dans les paniers nationaux de la CSU. Il se termine par un appel pour un leadership politique plus énergique autour de la CSU ainsi que de la santé et des droits sexuels et reproductifs, tandis que la communauté internationale s'efforce de « se reconstruire en mieux » après le COVID-19. Resumen La pandemia de COVID-19 no es solo una crisis de salud, sino también una crisis económica y social generalizada, que está impactando la vida y el sustento de miles de millones de personas. Este comentario examina la relación mutuamente dependiente entre la seguridad de salud y la cobertura universal de salud (CUS), y cómo la subinversión de larga data en ambas hace vulnerables a todas las personas. Además, discute la vulnerabilidad de los servicios de salud y derechos sexuales y reproductivos (SDSR) en tiempos de crisis, que es agravada cuando estos servicios no son incluidos y bien integrados en los paquetes nacionales de CUS. Concluye con un llamado a mejor liderazgo político para la CUS y SDSR, a medida que la comunidad mundial lucha por 'reconstruir mejor' después de COVID-19.


COVID-19 Research in Brief: 18 April to 24 April, 2020.


title: Plasma Erythropoietin, IL-17A, and IFNγ as Potential Biomarkers of Motor Function Recovery in a Canine Model of Spinal Cord Injury.

text: Traumatic spinal cord injury (SCI) is a devastating neurological disease for which an accurate, cost-effective prediction of motor function recovery is in pressing need. A plethora of neurochemical changes involved in the pathophysiological process of SCI may serve as a new source of biomarkers for patient outcomes. Five dogs were included in this study. We characterized the plasma cytokine profiles in acute phase (0, 1, and 3 days after SCI) and subacute phase (7, 14, and 21 days after SCI) with microarray analysis. The motor function recovery following SCI was monitored by Olby scores. The expression level of differentially expressed proteins (DEPs) was measured with enzyme-linked immunosorbent assay (ELISA). Then, correlations with the Olby scores and receiver operating characteristic curve (ROC) analysis were performed. We identified 12 DEPs including 10 pro-inflammatory and 2 anti-inflammatory cytokines during the 21-day study period. Among those, the expression levels of erythropoietin (EPO), IL-17A, and IFNγ significantly correlated with the Olby scores with R2 values of 0.870, 0.740, and 0.616, respectively. The results of the ROC analysis suggested that plasma EPO, IL-17A, and IFNγ exhibited a significant predictive power with an area under the curve (AUC) of 0.656, 0.848, and 0.800 for EPO, IL-17A, and IFNγ, respectively. Our results provide a longitudinal description of the changes in plasma cytokine expression in the acute and subacute stages of canine SCI. These data reveal novel panels of inflammation-related cytokines which have the potential to be evaluated as biomarkers for predicting motor function prognosis after SCI.


title: Detection of canine pneumovirus in dogs with canine infectious respiratory disease.

text: Canine pneumovirus (CnPnV) was recently identified during a retrospective survey of kenneled dogs in the United States. In this study, archived samples from pet and kenneled dogs in the United Kingdom were screened for CnPnV to explore the relationship between exposure to CnPnV and the development of canine infectious respiratory disease (CIRD). Within the pet dog population, CnPnV-seropositive dogs were detected throughout the United Kingdom and Republic of Ireland, with an overall estimated seroprevalence of 50% (n = 314/625 dogs). In the kennel population, there was a significant increase in seroprevalence, from 26% (n = 56/215 dogs) on the day of entry to 93.5% (n = 201/215 dogs) after 21 days (P <0001). Dogs that were seronegative on entry but seroconverted while in the kennel were 4 times more likely to develop severe respiratory disease than those that did not seroconvert (P < 0.001), and dogs with preexisting antibodies to CnPnV on the day of entry were significantly less likely to develop respiratory disease than immunologically naive dogs (P < 0.001). CnPnV was detected in the tracheal tissues of 29/205 kenneled dogs. Detection was most frequent in dogs with mild to moderate respiratory signs and histopathological changes and in dogs housed for 8 to 14 days, which coincided with a significant increase in the risk of developing respiratory disease compared to the risk of those housed 1 to 7 days (P < 0.001). These findings demonstrate that CnPnV is present in the United Kingdom dog population; there is a strong association between exposure to CnPnV and CIRD in the kennel studied and a potential benefit in vaccinating against CnPnV as part of a wider disease prevention strategy.


'Put on your own oxygen mask before helping others': mitigating health care worker risk from COVID-19.


title: My Family Didn't Sign Up for This.

text: "Will buddies." That was an unfortunate phrase a friend of mine and I coined together during a shift early in the pandemic. He was a resident in our program just a couple of years ago and is now one of my attendings. While we were working a shift in the ED swarming with critically ill COVID patients, it came up in the "doc box" that we were both drafting our wills.


title: Innate immunity in the central nervous system.

text: Immune responses in the CNS are common, despite its perception as a site of immune privilege. These responses can be mediated by resident microglia and astrocytes, which are innate immune cells without direct counterparts in the periphery. Furthermore, CNS immune reactions often take place in virtual isolation from the innate/adaptive immune interplay that characterizes peripheral immunity. However, microglia and astrocytes also engage in significant cross-talk with CNS-infiltrating T cells and other components of the innate immune system. Here we review the cellular and molecular basis of innate immunity in the CNS and discuss what is known about how outcomes of these interactions can lead to resolution of infection, neurodegeneration, or neural repair depending on the context.


title: Rapid identification of uropathogens by combining Alfred 60 system with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry technology.

text: Rapid identification of uropathogens is needed to determine appropriate antimicrobial therapy. This study evaluated performance of the Alfred 60 system combined with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS) technology for rapid identification of uropathogens. The Alfred 60 system was used to screen urine cultures, followed by identifying the microbial pathogen in positive cultures using MALDI-TOF MS. The Alfred 60 detected positive cultures by measuring the turbidity of urine samples, which were transferred automatically to vials containing liquid medium and incubated for 3.5 h at 35 °C in the Alfred 60 system. Vials that showed growth were removed and centrifuged. The pellet was subjected to MALDI-TOF MS identification. In parallel, positive urine samples were inoculated onto agar plates for identification by conventional culture. The time required to detect positive urine cultures with Alfred 60 and identify the uropathogens with MALDI-TOF MS ranged from 15 min to 3.5 h. Among 146 positive urine samples tested, conventional cultures showed three culture groups: group 1 included 101 samples with growth of a single type of microorganism; group 2 included 34 samples with 2 types of microorganisms; and group 3 included 11 samples with ≥ 3 types of microorganisms. Direct identification by MALDI-TOF MS was concordant with 95% of the samples in group 1, 100% of the principal microorganism in group 2, but could not identify microorganisms in group 3. This combination of methods provides rapid, reliable microbial identification for most positive urine cultures.


title: Comparison of a novel lycra endotracheal tube cuff to standard polyvinyl chloride cuff and polyurethane cuff for fluid leak prevention.

text: BACKGROUND A high-volume low-pressure endotracheal tube (ETT) cuff forms folds along its contact with the trachea, allowing mucus leakage into the lungs. We developed a thin-walled ETT cuff made of Lycra polyurethane. METHODS In vitro, we tested 6 of each of the new prototype Lycra cuff, the Mallinkrodt Hi-Lo ETT (polyvinyl chloride cuff), and the Kimberly-Clark Microcuff ETT (polyurethane cuff), for leakage, in an acrylic mock trachea (inner diameter 20-mm), with a cuff inflation pressure of 20 cm H(2)O. We poured 15 mL of methylene-blue colored water into the acrylic tube above the cuff and observed for leakage for 24 hours. RESULTS The Lycra cuffs had no folds upon inflation in the mock trachea and completely prevented fluid leakage for 24 hours (P < .001 vs the Hi-Lo and the Microcuff). The average leakage past the Hi-Lo was 1,182 ± 1,321 mL/h. The average leakage past the Microcuff was 1.2 ± 0.4 mL/h (P < .001 vs the Hi-Lo). CONCLUSIONS Our Lycra cuff provided complete tracheal sealing in vitro.


Seven days in medicine: 18-24 March.


title: Evaluation of Performance Characteristics of Panther Fusion Assays for Detection of Respiratory Viruses from Nasopharyngeal and Lower Respiratory Tract Specimens.

text: Accurate and rapid diagnosis is needed for timely intervention and clinical management of acute respiratory infections. This study evaluated performance characteristics of the Panther Fusion assay for the detection of influenza A virus (Flu A), influenza B virus (Flu B), respiratory syncytial virus (RSV), parainfluenza viruses 1 to 3 (Para 1 to 3), human metapneumovirus (hMPV), rhinovirus (RV), and adenovirus (Adeno) targets in comparison to those of the eSensor and Lyra assays using 395 nasopharyngeal (NP) and 104 lower respiratory tract (LRT) specimens. Based on the consensus positive result established (positive result in 2 of the 3 assays), the NP specimens for the Fusion and eSensor assays had 100% positive percent agreement (PPA) for all the analytes and the Lyra assays had 100% PPA for Flu A and Adeno analytes. A 100% negative percent agreement (NPA) was observed for all the Lyra analytes, whereas those for the Fusion targets ranged from 98.4 to 100% and those for the eSensor ranged from 99.4 to 100% for all the analytes except RV. For the LRT specimens, Fusion had 100% PPA and 100% NPA for all the targets except hMPV. There was a 100% PPA for eSensor analytes; the NPA ranged from 98 to 100%, except for RV. For the Lyra assays, the PPA ranged between 50 and 100%, while the NPA was 100% for all the targets except Adeno. The Fusion assay performed similarly to the eSensor assay for majority of the targets tested and provides laboratories with a fully automated random-access system to test for a broad array of viral respiratory pathogens.


title: Treatment of a dissecting vertebral artery aneurysm with angioplasty and the pipeline embolisation device.

text: A 49-year-old woman was admitted with Hunt and Hess grade 1 subarachnoid haemorrhage. A cerebral aneurysm of the intracranial left vertebral artery (VA) distal to the left posterior inferior cerebellar artery (PICA) was found and treated using parent vessel occlusion with coils. The PICA was preserved. Angiography at three time points during her hospitalisation showed a normal right VA. Eight months later, angiography demonstrated a new 14 mm right VA dissecting aneurysm with 90% outflow stenosis and recurrence of the left VA aneurysm distal to the coils. A Marksman microcatheter would not traverse the stenosis despite the use of two intraluminal wires. Following Gateway balloon (1.5 mm × 9 mm) angioplasty, the Marksman passed easily. The pipeline embolisation device (PED) was successfully deployed across the aneurysm and 11 coils placed through a trapped microcatheter. The patient was discharged home 2 days later. Eighteen-month follow-up has revealed complete resolution of both aneurysms.


title: Responsible data sharing in international health research: a systematic review of principles and norms.

text: BACKGROUND Large-scale linkage of international clinical datasets could lead to unique insights into disease aetiology and facilitate treatment evaluation and drug development. Hereto, multi-stakeholder consortia are currently designing several disease-specific translational research platforms to enable international health data sharing. Despite the recent adoption of the EU General Data Protection Regulation (GDPR), the procedures for how to govern responsible data sharing in such projects are not at all spelled out yet. In search of a first, basic outline of an ethical governance framework, we set out to explore relevant ethical principles and norms. METHODS We performed a systematic review of literature and ethical guidelines for principles and norms pertaining to data sharing for international health research. RESULTS We observed an abundance of principles and norms with considerable convergence at the aggregate level of four overarching themes: societal benefits and value; distribution of risks, benefits and burdens; respect for individuals and groups; and public trust and engagement. However, at the level of principles and norms we identified substantial variation in the phrasing and level of detail, the number and content of norms considered necessary to protect a principle, and the contextual approaches in which principles and norms are used. CONCLUSIONS While providing some helpful leads for further work on a coherent governance framework for data sharing, the current collection of principles and norms prompts important questions about how to streamline terminology regarding de-identification and how to harmonise the identified principles and norms into a coherent governance framework that promotes data sharing while securing public trust.


title: Serologic Detection of Latent SARS-CoV-2 Infections in Hemodialysis Centers: A Multi-center, Retrospective Study in Wuhan, China.

text: RATIONALE & OBJECTIVE Maintenance hemodialysis (MHD) patients are a population highly vulnerable to infection with SARS-CoV-2. The current study was designed to evaluate the prevalence of SARS-CoV-2 infection based on both nucleic acid testing (NAT) and antibody testing in Chinese MHD patients. STUDY DESIGN Cross-sectional study. SETTING & PARTICIPANTS From Dec 1, 2019 to Mar 31, 2020, 1027 MHD patients in five large hemodialysis centers in Wuhan, China were enrolled. Patients were screened by blood tests, chest computed tomography, NAT and antibody tests for SARS-CoV-2. EXPOSURE NAT and antibody tests for SARS-CoV-2. OUTCOMES Morbidity, clinical features, laboratory and radiologic findings. ANALYTICAL Approach Differences between groups were examined by Student's t-test or Mann-Whitney U test, comparing those not infected to those infected and comparing those with infection detected by NAT to with positive serology tests and negative NAT. RESULTS Of the 1027 MHD patients, 99 cases have been identified as SARS-CoV-2 infection, equivalent to a prevalence of 9.6%. In the 99 cases, 52 (53%) patients were diagnosed with SARS-CoV-2 infection by positive NAT; 47 (48%) patients were identified by positive IgG or IgM antibodies against SARS-CoV-2 with negative NAT. The spectrum of antibody profiles in these 47 patients showed IgM antibodies in 5 (11%), IgG antibodies in 35 (75%), and both positive IgM and IgG antibodies in 7 (15%). 51% of the infected patients were asymptomatic during the epidemic. Patients with hypertensive kidney disease were more often identified with infection by SARS-CoV-2 infection and they tended to be more symptomatic than other patient groups. LIMITATIONS Possibility of false positives and false negatives for both NAT and antibody testing; possible lack of generalizability to other dialysis populations. CONCLUSIONS Half of the SARS-CoV-2 infections in MHD patients were subclinical and unidentified by universal chest CT and selective NAT. Serologic testing may help to evaluate the overall prevalence and understand the diversity of clinical course among MHD patients infected with SARS-CoV-2.


Personal Protective Equipment and Covid-19.


title: Tea tree oil for Demodex blepharitis.

text: BACKGROUND Demodex blepharitis is a chronic condition commonly associated with recalcitrant dry eye symptoms though many people with Demodex mites are asymptomatic. The primary cause of this condition in humans is two types of Demodex mites: Demodex folliculorum and Demodex brevis. There are varying reports of the prevalence of Demodex blepharitis among adults, and it affects both men and women equally. While Demodex mites are commonly treated with tea tree oil, the effectiveness of tea tree oil for treating Demodex blepharitis is not well documented. OBJECTIVES To evaluate the effects of tea tree oil on ocular Demodex infestation in people with Demodex blepharitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We used no date or language restrictions in the electronic search for trials. We last searched the databases on 18 June 2019. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared treatment with tea tree oil (or its components) versus another treatment or no treatment for people with Demodex blepharitis. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts and then full text of records to determine their eligibility. The review authors independently extracted data and assessed risk of bias using Covidence. A third review author resolved any conflicts at all stages. MAIN RESULTS We included six RCTs (1124 eyes of 562 participants; 17 to 281 participants per study) from the US, Korea, China, Australia, Ireland, and Turkey. The RCTs compared some formulation of tea tree oil to another treatment or no treatment. Included participants were both men and women, ranging from 39 to 55 years of age. All RCTs were assessed at unclear or high risk of bias in one or more domains. We also identified two RCTs that are ongoing or awaiting publications. Data from three RCTs that reported a short-term mean change in the number of Demodex mites per eight eyelashes contributed to a meta-analysis. We are uncertain about the mean reduction for the groups that received the tea tree oil intervention (mean difference [MD] 0.70, 95% confidence interval [CI] 0.24 to 1.16) at four to six weeks as compared to other interventions. Only one RCT reported data for long-term changes, which found that the group that received intense pulse light as the treatment had complete eradication of Demodex mites at three months. We graded the certainty of the evidence for this outcome as very low. Three RCTs reported no evidence of a difference for participant reported symptoms measured on the Ocular Surface Disease Index (OSDI) between the tea tree oil group and the group receiving other forms of intervention. Mean differences in these studies ranged from -10.54 (95% CI - 24.19, 3.11) to 3.40 (95% CI -0.70 7.50). We did not conduct a meta-analysis for this outcome given substantial statistical heterogeneity and graded the certainty of the evidence as low. One RCT provided information concerning visual acuity but did not provide sufficient data for between-group comparisons. The authors noted that mean habitual LogMAR visual acuity for all study participants improved post-treatment (mean LogMAR 1.16, standard deviation 0.26 at 4 weeks). We graded the certainty of evidence for this outcome as low. No RCTs provided data on mean change in number of cylindrical dandruff or the proportion of participants experiencing conjunctival injection or experiencing meibomian gland dysfunction. Three RCTs provided information on adverse events. One reported no adverse events. The other two described a total of six participants randomized to treatment with tea tree oil who experienced ocular irritation or discomfort that resolved with re-educating the patient on application techniques and continuing use of the tea tree oil. We graded the certainty of the evidence for this outcome as very low. AUTHORS' CONCLUSIONS The current review suggests that there is uncertainty related to the effectiveness of 5% to 50% tea tree oil for the short-term treatment of Demodex blepharitis; however, if used, lower concentrations may be preferable in the eye care arena to avoid induced ocular irritation. Future studies should be better controlled, assess outcomes at long term (e.g. 10 to 12 weeks or beyond), account for patient compliance, and study the effects of different tea tree oil concentrations.


title: Probing secondary interactions in biomolecular recognition by dynamic combinatorial chemistry.

text: Artificial multivalent recognition systems offer promising perspectives for developing synthetic compounds capable of interacting effectively and selectively with biomolecules in aqueous medium. The identification of multi-point binding ligands requires screening of a large number of complex structures, with different spacers, different ligands, and varying valency. This represents a challenge for rational design approaches. On the other hand, the use of dynamic covalent chemistry enables a target-driven one-pot screening approach for probing secondary interactions, thereby facilitating the identification of multivalent recognition systems that optimally combine multiple fragments. Herein we review the recent developments in the implementation of dynamic combinatorial chemistry for probing secondary interactions and thereby identify multi-point binding ligands of biomolecules.


title: Predicting image properties in penalized-likelihood reconstructions of flat-panel CBCT.

text: PURPOSE Model-based iterative reconstruction (MBIR) algorithms such as penalized-likelihood (PL) methods exhibit data-dependent and shift-variant properties. Image quality predictors have been derived to prospectively estimate local noise and spatial resolution, facilitating both system hardware design and tuning of reconstruction methods. However, current MBIR image quality predictors rely on idealized system models, ignoring physical blurring effects and noise correlations found in real systems. In this work, we develop and validate a new set of predictors using a physical system model specific to flat-panel cone-beam CT (FP-CBCT). METHODS Physical models appropriate for integration with MBIR analysis are developed and parameterized to represent nonidealities in FP projection data including focal spot blur, scintillator blur, detector aperture effect, and noise correlations. Flat-panel-specific predictors for local spatial resolution and local noise properties in PL reconstructions are developed based on these realistic physical models. Estimation accuracy of conventional (idealized) and FP-specific predictors is investigated and validated against experimental CBCT measurements using specialized phantoms. RESULTS Validation studies show that flat-panel-specific predictors can accurately estimate the local spatial resolution and noise properties, while conventional predictors show significant deviations in the magnitude and scale of the spatial resolution and local noise. The proposed predictors show accurate estimations over a range of imaging conditions including varying x-ray technique and regularization strength. The conventional spatial resolution prediction is sharper than ground truth. Using conventional spatial resolution predictor, the full width at half maximum (FWHM) of local point spread function (PSF) is underestimated by 0.2 mm. This mismatch is mostly eliminated in FP-specific prediction. The general shape and amplitude of local noise power spectrum (NPS) FP-specific predictions are consistent with measurement, while the conventional predictions underestimated the noise level by 70%. CONCLUSION The proposed image quality predictors permit accurate estimation of local spatial resolution and noise properties for PL reconstruction, accounting for dependencies on the system geometry, x-ray technique, and patient-specific anatomy in real FP-CBCT. Such tools enable prospective analysis of image quality for a range of goals including novel system and acquisition design, adaptive and task-driven imaging, and tuning of MBIR for robust and reliable behavior.


Patient with coronary stents needs surgery: what to do?


title: Ventral rectopexy with biological mesh: short-term functional results.

text: PURPOSE Ventral mesh rectopexy (VMR) is an established, minimally invasive, nerve-sparing procedure for the treatment of various symptomatic morphological changes in the posterior pelvic compartment. We present the short-term functional outcome and patient satisfaction after laparoscopic and robotic VMR with biological mesh. METHODS We analyzed data from 123 patients who underwent laparoscopic ventral mesh rectopexy (LVMR) or robotic ventral mesh rectopexy (RVMR) from August 2012 to January 2017. Included in these data were patient demographics, intra- and postoperative findings, Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), Cleveland Clinic Incontinence Score (CCIS), and patient satisfaction as measured by visual analog scale (0-10). RESULTS Improvements in CCCS, CCIS, and ODS were statistically significant at 6 and 12 months (p < 0.001). Patient satisfaction was excellent at 6 and 12 months (8.2/10 and 8.3/10, respectively). The overall complication rate was 14%, with a major complication rate of 2%. No mesh-related complications were observed. The need for surgical re-intervention because of relapse, symptom persistence or recurrence, or new symptoms was 3%. Outcome appears to be similar between LVMR and RVMR. CONCLUSIONS Both LVMR and RVMR with biological mesh are safe and effective in reducing symptoms, as measured by CCCS, CCIS, and ODS, and patient satisfaction is high.


title: Autopsy Services and Emergency Preparedness of a Tertiary Academic Hospital Mortuary for the COVID-19 Public Health Emergency: The Yale Plan.

text: Pathology Autopsy and Mortuary Services have been front and center in the severe acute respiratory syndrome coronavirus 2 (SARS-Co-V-2) pandemic. The sheer number of fatalities from the pandemic have been unlike any other in recent memory and needed the rapid creation of new protocols and paradigms to manage the situation. This required rapidly escalating mortuary capacity to manage the increased fatalities from the pandemic with the establishment of lines of communication and networking with governmental entities, institution of new policies for patient flow, and implementation of worker infection control and well-being plans. Autopsies also assumed a crucial role, both to provide insight into the pathomechanisms of a novel disease and to allow tissue retrieval necessary to power research directed towards finding a vaccine. We here outline the plan adopted by the Yale Autopsy and Mortuary Services, in alignment with the institutional mission of high-quality patient care, education, research and health care worker safety and well-being, as the Corona Virus Disease of 2019 (COVID-19) pandemic surged in Connecticut. In the early response phase, ensuring sufficient mortuary capacity necessarily took center stage. As we enter the recovery and plateau phase of the pandemic, setting up a process for a rapid and safe autopsy, that will meet educational and research needs while ensuring the safety of our workforce is being implemented.


Introducing the 21st Century's New Four Horsemen of the Coronapocalypse.


title: Changes in tissue and cerebral oxygenation following spinal anesthesia in infants: a prospective study.

text: Use of spinal anesthesia (SA) in children may address concerns about potential neurocognitive effects of general anesthesia. We used near-infrared spectroscopy (NIRS) to assess the effects of SA on cerebral and tissue oxygenation in 19 patients aged 7 ± 3 months. Prior to SA placement, NIRS monitors were placed on the forehead (cerebral) and the thigh (tissue). Intraoperative cerebral and tissue saturation were 73 ± 7 and 80 ± 11%, respectively, before SA placement. NIRS measurements were monitored every minute for 30 min after SA placement and modeled using mixed-effects linear regression. Regression estimates showed that cerebral saturation remained stable from 67% [95% confidence interval (CI) 63, 71%] after SA placement to 68% (95% CI 65, 72%) at the conclusion of monitoring. After SA placement, tissue saturation was elevated compared to baseline values; but further change [from 91% (95% CI 89, 93%) to 93% (95% CI 91, 95%) at the end of monitoring] was clinically non-significant. All patients breathed spontaneously on room air without changes in oxygen saturation. Blood pressure and heart rate decreased after SA placement, but no changes in hemodynamic parameters required treatment. These data provide further evidence of the neutral effect of SA on cerebral oxygenation 30 min after block placement.


title: The 5% of the Population at High Risk for Severe COVID-19 Infection Is Identifiable and Needs to Be Taken Into Account When Reopening the Economy.

text: The goal of this column is to help mental health care professionals understand coronavirus disease 2019 (COVID-19) so that they can better explain the complexities of the current crisis to their patients. The bottom-line of this column is that, while COVID-19 can infect virtually everyone in the human population, only about 5% are susceptible to severe infection requiring admission to an intensive care unit and/or causing a fatal outcome and this population can be identified on the basis of comorbid medical illness and/or age. These numbers are based on experience in China, the United States, and Europe. Table 1 presents an analysis conducted by the US Centers for Disease Control and Prevention (CDC), which is further supported by several other sources reviewed in the article. The population at risk for severe infection are individuals with comorbid medical illness and those 85 years of age and older. The comorbid medical illnesses identified as risk factors are preexisting respiratory and cardiovascular disease, immunocompromised status, morbid obesity (ie, body mass index ≥40), diabetes mellitus, and possibly significant kidney or liver impairment. Parenthetically, news reports and the literature sometimes cite age 60 years and older as a risk factor but age between 60 and 85 years is likely a surrogate for having 1 or more of these comorbid medical conditions. While 5% may initially seem like a small number, it nevertheless potentially represents 16.5 million people, given the United States population of 330 million. That is a tremendous number of people requiring intensive care unit admission and/or potentially dying, and individuals in this population have overwhelmed the US health care system in some hotspots. For this reason, this column suggests taking this at-risk population into account in mitigation strategies when attempting to open the US economy. The column addresses the following questions: (1) What are the 3 aspects of the race to minimize the damage caused by COVID-19? (2) What data are currently available to help guide decisions to be made? (3) What strategies have been employed to date and how successful have they been? and (4) Might risk stratification of exposure be a viable strategy to minimize the damage caused by the virus? The race to minimize the damage caused by COVID-19 requires that we obtain knowledge about the disease and its treatment or prevention, how to best safeguard public health and avoid overwhelming the health care system, and how to minimize the societal damage caused by substantial disruption of the economy. Data gathered over the past 4 months since the COVID-19 virus emerged as a human pathogen have provided guidance for our decisions going forward. The most widely adopted strategies for dealing with the COVID-19 pandemic to date have involved the epidemiological approach of encouraging good hygiene practices and social distancing, including orders to "shelter in place," quarantine of high-risk individuals, and isolation of infected individuals. The goal of this epidemiological approach has been to "flatten the curve" by reducing the height of the peak of the infection to avoid overwhelming the health care system and society in general, while buying time to learn more about the disease and find more effective ways to deal with it. However, now that more is known about COVID-19 and the portion of the population that is most at risk for serious adverse outcomes including death, it may be possible to move from a shelter-in-place approach for the entire population to focus on those at most risk and thus facilitate a gradual and rational phased reduction of social restrictions to reopen the economy. Such a graduated opening would be based on regions of countries meeting specific criteria in terms of being able to contain the virus, coupled with vigorous monitoring to look for outbreaks, followed by case monitoring, isolation of infected individuals and quarantine of exposed individuals, and increased use of testing for active disease as well as for immunity. Taking the data on high-risk individuals into account would allow for a gradual lifting of restrictions on the majority of the population while maintaining more stringent safeguards to protect the vulnerable portion of the population. Nevertheless, the entire population would need to continue to practice good hygiene and social distancing while simultaneously-and perhaps even more vigorously-focusing on sheltering the vulnerable population until adequate community immunity has been achieved to prevent the spread of the virus, whether that is accomplished through natural exposure alone or with the addition of safe and effective vaccine(s) which may not be available for a year. Continued widespread testing for antibodies will help determine how far or close this country is-and other countries are-from developing effective community immunity.


title: Association between air pollutants and outpatient and emergency hospital visits for childhood asthma in Shenyang city of China.

text: Effects of air pollution on asthma vary in different study areas, and long-term time series research on the effects of air pollution on asthma outpatients and emergency hospital visits has not been conducted in Northeast China. We assessed the impact of air pollutants on the risk of asthma outpatients and emergency hospital visits in Shenyang, China. A distributed lag non-linear model with a Poisson regression was used to assess the short-term effects of air pollutants on asthma outpatient and emergency hospital visits between January 1, 2013 and December 31, 2017. Confounding factors were adjusted using natural cubic splines. Ozone (O3), carbon monoxide (CO), and suspended particulates < 10 μm in aerodynamic diameter (PM10) were positively associated with the number of asthma hospital visits. The largest cumulative effects of O3, CO, and PM10 on hospital visits were on lag day 2 (RR = 1.163, 95% CI 1.051-1.287) for 0-5-year-old childhood asthma, on lag day 3 (RR = 1.386, 95% CI 1.136-1.69) for asthma in winter, and on lag day 10 (RR = 1.148, 95% CI 0.942-1.399) for female asthma, respectively. The cumulative effect of air pollution represented by the air quality index (AQI) was largest on lag day 10 for 0-5-year-old childhood asthma with an increase of 28.6% (95% CI 6.5-55.4) hospital visits every IQR increment of the AQI. CO, O3, and PM10 were the main air pollutants in Shenyang city. Children with bronchitis asthma were more vulnerable to air pollution during the cold season.


title: Intracranial bailout stenting with the Acclino (Flex) Stent/NeuroSpeed Balloon Catheter after failed thrombectomy in acute ischemic stroke: a multicenter experience.

text: BACKGROUND AND PURPOSE To report on the feasibility, safety, and outcome of acute intracranial stenting (ICS) with the Acclino (Flex) Stent and NeuroSpeed Balloon Catheter in cases of failed mechanical thrombectomy (MT) for acute ischemic stroke (AIS). METHODS We retrospectively reviewed the data of patients treated with acute bailout stenting after failed MT in three large neurointerventional centers using exclusively the Acclino (Flex) Stent and the NeuroSpeed Balloon Catheter. Functional outcome was assessed by the rate of major early neurological recovery (mENR) at 24 hours and at 90 days with the modified Rankin Scale (mRS). Safety evaluation included symptomatic intracranial hemorrhage (sICH), mortality, and intervention-related serious adverse events (SAEs). RESULTS 50 patients with a median age of 71 years met the inclusion criteria and 52% (26/50) of the occluded vessels were located within the anterior circulation. mENR was observed in 38.8% and 90-day favorable outcome (mRS ≤2) was 40.6% (13/32). Higher NIH Stroke Scale scores on admission were significantly associated with poor functional outcome (mRS ≥3) at 90 days (adjusted OR 1.28; 95% CI 1.07 to 1.53; p=0.007). sICH occurred in two cases of the study population. There were no intervention-related SAEs. CONCLUSION Intracranial bailout stenting with the Acclino (Flex) Stent and the NeuroSpeed Balloon Catheter after failed MT is a feasible and effective recanalization method for atherosclerotic stenosis-based stroke that is associated especially with low rates of sICH.