title: The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities.

text: PURPOSE The purpose of this review is to describe the epidemiology of out-of-hospital cardiac arrest (OHCA), disparities in organisation and outcome, recent advances in treatment and ongoing controversies. We also outline the standard of care that should be provided by the critical care specialist and propose future directions for cardiac arrest research. METHODS Narrative review with contributions from international resuscitation experts. RESULTS Although it is recognised that survival rates from OHCA are increasing there is considerable scope for improvement and many countries have implemented national strategies in an attempt to achieve this goal. More resources are required to enable high-quality randomised trials in resuscitation. CONCLUSIONS Increasing international collaboration should facilitate resuscitation research and knowledge translation. The International Liaison Committee on Resuscitation (ILCOR) has adopted a continuous evidence review process, which facilitate the implementation of resuscitation interventions proven to improve patient outcomes.


title: Measles virus induces cell-type specific changes in gene expression.

text: Measles virus (MV) causes various responses including the induction of immune responses, transient immunosuppression and establishment of long-lasting immunity. To obtain a comprehensive view of the effects of MV infection on target cells, DNA microarray analyses of two different cell-types were performed. An epithelial (293SLAM; a 293 cell line stably expressing SLAM) and lymphoid (COBL-a) cell line were inoculated with purified wild-type MV. Microarray analyses revealed significant differences in the regulation of cellular gene expression between these two different cells. In 293SLAM cells, upregulation of genes involved in the antiviral response was rapidly induced; in the later stages of infection, this was followed by regulation of many genes across a broad range of functional categories. On the other hand, in COBL-a cells, only a limited set of gene expression profiles was modulated after MV infection. Since it was reported that V protein of MV inhibited the IFN signaling pathway, we performed a microarray analysis using V knockout MV to evaluate V protein's effect on cellular gene expression. The V knockout MV displayed a similar profile to that of parental MV. In particular, in COBL-a cells infected with the virus, no alteration of cellular gene expression, including IFN signaling, was observed. Furthermore, IFN signaling analyzed in vitro was completely suppressed by MV infection in the COBL-a cells. These results reveal that MV induces different cellular responses in a cell-type specific manner. Microarray analyses will provide us useful information about potential mechanisms of MV pathogenesis.


title: Recommendations of the Main Board of the Polish Society of Otorhinolaryngologists, Head and Neck Surgeons for providing services during the COVID-19 pandemic for outpatient and hospital practices.

text: Recommendations of the Main Board of the Polish Society of Otorhinolaryngologists, Head and Neck Surgeons for providing services during the COVID-19 pandemic constitute the guidance to outpatient and hospital practices in all cases where contact with a patient whose status of COVID-19 is unknown. They have been created based on world publications and recommendations due to the current state of the COVID-19 pandemic. Justification for suspension of planned provision of services in the first phase of a pandemic was presented. The indication of the best medical practices for the time of stabilization, but with the persistence of the risk of COVID-19 infection in the population are discussed. The possibility of providing services in the following months of the pandemic is important. We provide the rationale for launching medical activities and indicate optimal practices until the consolidation of SARS COV-2 prevention and treatment methods.


title: Role of ICU-acquired weakness on extubation outcome among patients at high risk of reintubation.

text: BACKGROUND Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired weakness on extubation failure and the relation between limb weakness and cough strength. METHODS A secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-not-reintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semi-quantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation. RESULTS Among 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission. CONCLUSION ICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.


Letter to the Editor. COVID-19 and chronic pain.


title: Ergonomic factors on task performance in laparoscopic surgery training.

text: This paper evaluates the effect of ergonomic factors on task performance and trainee posture during laparoscopic surgery training. Twenty subjects without laparoscopic experience were allotted into 2 groups. Group 1 was trained under the optimal ergonomic simulation setting according to current ergonomic guidelines (Condition A). Group 2 was trained under non-optimal ergonomic simulation setting that can often be observed during training in a skills lab (Condition B). Posture analysis showed that the subjects held a much more neutral posture under Condition A than under Condition B (p<0.001). The subjects had less joint excursion and experienced less discomfort in their neck, shoulders, and arms under Condition A. Significant difference in task performance between Conditions A and B (p<0.05) was found. This study shows that the optimal ergonomic simulation setting leads to better task performance. In addition, no significant differences of task performance, for Groups 1 and 2 using the same test setting were found. However, better performance was observed for Group 1. It can be concluded that the optimal and non-optimal training setting have different learning effects on trainees' skill learning.


title: Influences of Fructus evodiae pretreatment on the pharmacokinetics of Rhizoma coptidis alkaloids.

text: ETHNOPHARMACOLOGICAL RELEVANCE Rhizoma coptidis is a traditional Chinese medicine with pharmacological properties. It is usually prescribed with Fructus evodiae as traditional Chinese medicine (TCM) formulas. Here we report the influences of Fructus evodiae on the pharmacokinetics of the Rhizoma coptidis alkaloids and propose possible mechanisms. MATERIALS AND METHODS Pharmacokinetic experiments were performed in rats. In vitro absorption experiments were performed in everted rat gut sacs, while in vitro metabolism experiments and determination of hepatic UDP-glucuronosyltransferase (UGT) 1A1 mRNA expression were performed in rat liver microsomes. RESULTS Pretreatment with Fructus evodiae extract for two weeks decreased the systemic exposure of the Rhizoma coptidis alkaloids. This effect was not due to inhibition of absorption or enhanced hepatic phase I metabolism of the Rhizoma coptidis alkaloids. However, Fructus evodiae pretreatment enhanced both the activity and expression of hepatic UGT1A1. CONCLUSIONS The results showed that Fructus evodiae pretreatment decreased the systemic exposure of the Rhizoma coptidis alkaloids by inducing hepatic UGT1A1.


title: "Protection of Healthcare Professionals during an Epidemic: Medical, Ethical and Legal Ramifications".

text: UNSTRUCTURED The welfare of health care professionals working in hazardous environments is concerning. Personal protective wear such as face masks, disposable gowns, hair covers , gloves and shoe covers are often used to prevent contamination by contact and droplets. This is especially relevant during an epidemic during which health care professionals are at an elevated risk of being infected. Not providing adequate protection during such epidemics has medical, ethical and legal ramifications.


title: Direct carotid-cavernous fistula: A complication of, and treatment with, flow diversion.

text: Direct carotid-cavernous fistulas (CCFs) are rare complications of flow diversion and have typically been documented in a subacute time frame after treatment. We present the first reported case of an intraprocedural direct CCF that developed immediately after flow diversion for treatment of a symptomatic paraclinoid right internal carotid artery aneurysm with a neck involving the cavernous segment. Endovascular treatment of such direct fistulas typically involves either transarterial obliteration of the fistulous site or transvenous embolization of the cavernous sinus. Our case was successfully treated with further immediate flow diversion without additional transvenous intervention. There are few reports on the use of flow diversion for treatment of such direct CCFs, and in all but one of these cases, flow diversion was combined with concomitant transvenous embolization. Thus, the presented case is not only the first reported case of an immediate CCF after flow diversion, but it is also only the second reported case of a direct fistula to be successfully treated using solely flow diversion, without additional transvenous intervention. We review the literature of direct CCFs after flow diversion, the pathophysiology of development of CCFs after flow diversion, the literature on treatment of CCFs with flow diversion as well as all other current treatment options.


title: Fetal echocardiography and pulsed-wave Doppler ultrasound in a rabbit model of intrauterine growth restriction.

text: Fetal intrauterine growth restriction (IUGR) results in abnormal cardiac function that is apparent antenatally due to advances in fetoplacental Doppler ultrasound and fetal echocardiography. Increasingly, these imaging modalities are being employed clinically to examine cardiac function and assess wellbeing in utero, thereby guiding timing of birth decisions. Here, we used a rabbit model of IUGR that allows analysis of cardiac function in a clinically relevant way. Using isoflurane induced anesthesia, IUGR is surgically created at gestational age day 25 by performing a laparotomy, exposing the bicornuate uterus and then ligating 40-50% of uteroplacental vessels supplying each gestational sac in a single uterine horn. The other horn in the rabbit bicornuate uterus serves as internal control fetuses. Then, after recovery at gestational age day 30 (full term), the same rabbit undergoes examination of fetal cardiac function. Anesthesia is induced with ketamine and xylazine intramuscularly, then maintained by a continuous intravenous infusion of ketamine and xylazine to minimize iatrogenic effects on fetal cardiac function. A repeat laparotomy is performed to expose each gestational sac and a microultrasound examination (VisualSonics VEVO 2100) of fetal cardiac function is performed. Placental insufficiency is evident by a raised pulsatility index or an absent or reversed end diastolic flow of the umbilical artery Doppler waveform. The ductus venosus and middle cerebral artery Doppler is then examined. Fetal echocardiography is performed by recording B mode, M mode and flow velocity waveforms in lateral and apical views. Offline calculations determine standard M-mode cardiac variables, tricuspid and mitral annular plane systolic excursion, speckle tracking and strain analysis, modified myocardial performance index and vascular flow velocity waveforms of interest. This small animal model of IUGR therefore affords examination of in utero cardiac function that is consistent with current clinical practice and is therefore useful in a translational research setting.


title: Repeat laparoscopic totally extraperitoneal hernia repair after primary laparoscopic totally extraperitoneal hernia repair for inguinal hernia.

text: INTRODUCTION Although laparoscopic totally extraperitoneal hernia repair (TEP) is reported to have a low recurrence rate, few reports address treatment for contralateral occurrence after primary TEP. Most studies on surgical treatment for recurrent inguinal hernia reported on laparoscopic transabdominal preperitoneal repair. The aim of this study was to evaluate the efficacy of repeat TEP for contralateral occurrence after primary TEP for unilateral inguinal hernia. METHODS We retrospectively reviewed the medical charts of 215 patients undergoing TEP performed between April 2003 and May 2009. We employed a similar approach to that of standard TEP for primary hernia. RESULTS Twenty eight of 215 patients who underwent unilateral TEP also underwent repeat TEP for contralateral-side hernia occurring after primary TEP. The initial hernia was on the right side in 15 patients and on the left side in 13. The initial hernia was indirect in 26 patients and direct in 2. Mean duration of primary TEP to contralateral occurrence was 54.4 months. Mean operation time for the contralateral occurrence was 73.3 minutes, and there was little intraoperative blood loss. Three patients were converted to an anterior approach because of insufficient surgical field due to injury of the peritoneum. Although the inferior epigastric artery and vein were divided in 4 patients, there were no difficulties during surgery. The postoperative course in all patients was uneventful. CONCLUSIONS TEP after primary TEP for contralateral occurrence is feasible. Repeat TEP might be an alternative technique for new occurrence of contralateral inguinal hernia after primary TEP.


title: Ablation of Programmed -1 Ribosomal Frameshifting in Venezuelan Equine Encephalitis Virus Results in Attenuated Neuropathogenicity.

text: The alphaviruses Venezuelan equine encephalitis virus (VEEV), eastern equine encephalitis virus (EEEV), and western equine encephalitis virus (WEEV) are arthropod-borne positive-strand RNA viruses that are capable of causing acute and fatal encephalitis in many mammals, including humans. VEEV was weaponized during the Cold War and is recognized as a select agent. Currently, there are no FDA-approved vaccines or therapeutics for these viruses. The spread of VEEV and other members of this family due to climate change-mediated vector range expansion underscores the need for research aimed at developing medical countermeasures. These viruses utilize programmed -1 ribosomal frameshifting (-1 PRF) to synthesize the viral trans-frame (TF) protein, which has previously been shown to be important for neuropathogenesis in the related Sindbis virus. Here, the alphavirus -1 PRF signals were characterized, revealing novel -1 PRF stimulatory structures. -1 PRF attenuation mildly affected the kinetics of VEEV accumulation in cultured cells but strongly inhibited its pathogenesis in an aerosol infection mouse model. Importantly, the decreased viral titers in the brains of mice infected with the mutant virus suggest that the alphavirus TF protein is important for passage through the blood-brain barrier and/or for neuroinvasiveness. These findings suggest a novel approach to the development of safe and effective live attenuated vaccines directed against VEEV and perhaps other closely related -1 PRF-utilizing viruses. IMPORTANCE Venezuelan equine encephalitis virus (VEEV) is a select agent that has been weaponized. This arthropod-borne positive-strand RNA virus causes acute and fatal encephalitis in many mammals, including humans. There is no vaccine or other approved therapeutic. VEEV and related alphaviruses utilize programmed -1 ribosomal frameshifting (-1 PRF) to synthesize the viral trans-frame (TF) protein, which is important for neuropathogenesis. -1 PRF attenuation strongly inhibited VEEV pathogenesis in mice, and viral replication analyses suggest that the TF protein is critical for neurological disease. These findings suggest a new approach to the development of safe and effective live attenuated vaccines directed against VEEV and other related viruses.


Sudden olfactory and gustatory dysfunctions: Important red flags in COVID-19.


title: The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair.

text: OBJECTIVE This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre. STUDY DESIGN Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application. RESULTS The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%). CONCLUSION Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.


title: Peak oil, urban form, and public health: exploring the connections.

text: We assessed the relationships between peak oil and urban form, travel behavior, and public health. Peak oil will affect the general economy, travel behavior, and urban form through income and substitution effects; however, because of the wide range of substitution possibilities, the impacts are likely to be gradual and relatively small. Furthermore, we suggest that changes in travel behavior and increases in urban density will have both favorable and unfavorable effects on public health. To mitigate the adverse impacts and to maximize the positive effects of peak oil, we recommend that careful attention should be paid to urban design and public health responses for a range of urbanization patterns.


title: Separating NOM from salts in ion exchange brine with ceramic nanofiltration.

text: In drinking water treatment, natural organic matter (NOM) is effectively removed from surface water using ion exchange (IEX). A main drawback of using IEX for NOM removal is the production of spent IEX regeneration brine, a polluting waste that is expensive to discharge. In this work, we studied ceramic nanofiltration as a treatment for the spent NOM-rich brine, with the aim to reduce the volume of this waste and to recycle salt. Compared to polymeric nanofiltration, the fouling was limited. When NOM is rejected and concentrated, a clean permeate with the regeneration salt (NaCl) could be produced and reused in the IEX regeneration process. Bench scale studies revealed that NOM could be effectively separated from the NaCl solution by steric effects. However, the separation of NaCl from other salts present in the brine, such as Na2SO4, was not sufficient for reuse purposes. The low sulphate rejection was mainly due to the low zeta potential of the membrane at the high ionic strength of the brine. The permeate of the ceramic nanofiltration should be treated further to obtain a sodium chloride quality that can be recycled as a regenerant solution for ion exchange. Further treatment steps will benefit from the removal of NOM from the brine.


title: Flaviviral RNAs: weapons and targets in the war between virus and host.

text: Flaviviruses are a genus of (+)ssRNA (positive ssRNA) enveloped viruses that replicate in the cytoplasm of cells of diverse species from arthropods to mammals. Many are important human pathogens such as DENV-1-4 (dengue virus types 1-4), WNV (West Nile virus), YFV (yellow fever virus), JEV (Japanese encephalitis virus) and TBEV (tick-borne encephalitis). Given their RNA genomes it is not surprising that flaviviral life cycles revolve around critical RNA transactions. It is these we highlight in the present article. First, we summarize the mechanisms governing flaviviral replication and the central role of conserved RNA elements and viral protein-RNA interactions in RNA synthesis, translation and packaging. Secondly, we focus on how host RNA-binding proteins both benefit and inhibit flaviviral replication at different stages of their life cycle in mammalian hosts. Thirdly, we cover recent studies on viral non-coding RNAs produced in flavivirus-infected cells and how these RNAs affect various aspects of cellular RNA metabolism. Together, the article puts into perspective the central role of flaviviral RNAs in modulating both viral and cellular functions.


title: Therapeutic hypothermia after cardiac arrest: a retrospective comparison of surface and endovascular cooling techniques.

text: OBJECTIVES Therapeutic hypothermia (32-34 degrees C) is recommended for comatose survivors of cardiac arrest; however, the optimal technique for cooling is unknown. We aimed to compare therapeutic hypothermia using either surface or endovascular techniques in terms of efficacy, complications and outcome. DESIGN Retrospective cohort study. SETTING Thirty-bed teaching hospital intensive care unit (ICU). PATIENTS All patients (n=83) undergoing therapeutic hypothermia following cardiac arrest over a 2.5-year period. The mean age was 61+/-16 years; 88% of arrests occurred out of hospital, and 64% were ventricular fibrillation/tachycardia. INTERVENTIONS Therapeutic hypothermia was initiated in the ICU using iced Hartmann's solution, followed by either surface (n=41) or endovascular (n=42) cooling; choice of technique was based upon endovascular device availability. The target temperature was 32-34 degrees C for 12-24 h, followed by rewarming at a rate of 0.25 degrees Ch(-1). MEASUREMENTS AND MAIN RESULTS Endovascular cooling provided a longer time within the target temperature range (p=0.02), less temperature fluctuation (p=0.003), better control during rewarming (0.04), and a lower 48-h temperature load (p=0.008). Endovascular cooling also produced less cooling-associated complications in terms of both overcooling (p=0.05) and failure to reach the target temperature (p=0.04). After adjustment for known confounders, there were no differences in outcome between the groups in terms of ICU or hospital mortality, ventilator free days and neurological outcome. CONCLUSION Endovascular cooling provides better temperature management than surface cooling, as well as a more favorable complication profile. The equivalence in outcome suggested by this small study requires confirmation in a randomized trial.


title: Cross-Protection by Infectious Bronchitis Viruses Under Controlled Experimental Conditions.

text: Infectious bronchitis virus (IBV) cross-protection trials were performed in healthy chickens maintained under controlled environmental conditions. Chickens primed or primed and boosted with a Massachusetts (Mass)-type attenuated vaccine were subsequently challenged with either IBV Arkansas (Ark) or GA13-type virulent strains. In addition, Ark-vaccinated chickens were challenged with IBV GA13. Spike protein 1 (S1) amino acid identities between IBV vaccine and challenge strains varied from 76.0% to 77.3%. Contrary to expectations, assessments of clinical signs, viral load, and histopathology indicated a significant level of cross-protection among these antigenically distant IBV strains. Moreover, prime and booster vaccination with Mass protected against GA13 and improved protection against Ark when compared with Mass single vaccination. These results emphasize the need to include both single vaccination control groups and control groups primed and boosted with a single serotype when testing the efficacy of IBV protectotypes and/or novel IBV vaccine combinations against heterologous serotypes under controlled experimental conditions. Such controls are of distinct importance in experiments supporting the introduction of attenuated IBV vaccine strains exotic to regions, since these exotic strains may provide new genetic material for recombination and emergence of novel IBV strains.


title: Recent Endovascular Stroke Trials and Their Impact on Stroke Systems of Care.

text: Five recently published randomized trials of endovascular therapy versus medical management, including intravenous thrombolysis, demonstrated strong positive data in support of intra-arterial thrombectomy procedures. The American Heart Association/American Stroke Association released a focused update of the 2013 guidelines on the early management of acute ischemic strokes to specifically incorporate the findings of the 5 "positive" trials. In this review, we examine the key results of those trials and the principal changes in the updated guidelines. We discuss the ongoing and future changes in stroke systems of care, with an emphasis on the role of pre-hospital stroke triage, interhospital transfer, and the 2 main levels of stroke center certification (primary and comprehensive).


Protect Indigenous peoples from COVID-19.


title: Targeting frameshifting in the human immunodeficiency virus.

text: INTRODUCTION HIV-1 uses a programmed –1 ribosomal frameshift to generate Gag-Pol, the precursor of its enzymes, when its full-length mRNA is translated by the ribosomes of the infected cells. This change in the reading frame occurs at a so-called slippery sequence that is followed by a specific secondary structure, the frameshift stimulatory signal. This signal controls the frameshift efficiency. The synthesis of HIV-1 enzymes is critical for virus replication and therefore, the –1 ribosomal frameshift could be the target of novel antiviral drugs. AREAS COVERED Various approaches were used to select drugs interfering with the –1 frameshift of HIV-1. These include the selection and modification of chemical compounds that specifically bind to the frameshift stimulatory signal, the use of antisense oligonucleotides targeting this signal and the selection of compounds that modulate HIV-1 frameshift, by using bicistronic reporters where the expression of the second cistron depends upon HIV-1 frameshift. EXPERT OPINION The most promising approach is the selection and modification of compounds specifically targeting the HIV-1 frameshift stimulatory signal. The use of antisense oligonucleotides binding to the frameshift stimulatory signal is still questionable. The use of bicistronic reporters preferentially selects compounds that modulate the frameshift by targeting the ribosomes, which is less promising.


title: Image-guided radiofrequency ablation for the treatment of early-stage non-small cell lung neoplasm in high-risk patients.

text: Lung cancer is the most common cause of cancer-related mortality in the United States. Surgical resection with a lobectomy is the standard treatment for stage I non-small cell lung cancer. With an aging population, however, there are a significant number of patients who have other comorbidities that preclude surgical resection. Image-guided radiofrequency ablation is a new emerging modality of treatment which may be applicable in this high-risk group of patients. In this article, we review the principles of radiofrequency ablation, the common devices in use, the results of ablate and resect studies, future directions, and the results of treatment for stage I non-small cell lung neoplasm.


title: Cellular immune responses to severe acute respiratory syndrome coronavirus (SARS-CoV) infection in senescent BALB/c mice: CD4+ T cells are important in control of SARS-CoV infection.

text: We characterized the cellular immune response to severe acute respiratory syndrome coronavirus (SARS-CoV) infection in 12- to 14-month-old BALB/c mice, a model that mimics features of the human disease. Following intranasal administration, the virus replicated in the lungs, with peak titers on day 2 postinfection. Enhanced production of cytokines (tumor necrosis factor alpha [TNF-alpha] and interleukin-6 [IL-6]) and chemokines (CXCL10, CCL2, CCL3, and CCL5) correlated with migration of NK cells, macrophages, and plasmacytoid dendritic cells (pDC) into the lungs. By day 7, histopathologic evidence of pneumonitis was seen in the lungs when viral clearance occurred. At this time, a second wave of enhanced production of cytokines (TNF-alpha, IL-6, gamma interferon [IFN-gamma], IL-2, and IL-5), chemokines (CXCL9, CXCL10, CCL2, CCL3, and CCL5), and receptors (CXCR3, CCR2, and CCR5), was detected in the lungs, associated with an influx of T lymphocytes. Depletion of CD8(+) T cells at the time of infection did not affect viral replication or clearance. However, depletion of CD4(+) T cells resulted in an enhanced immune-mediated interstitial pneumonitis and delayed clearance of SARS-CoV from the lungs, which was associated with reduced neutralizing antibody and cytokine production and reduced pulmonary recruitment of lymphocytes. Innate defense mechanisms are able to control SARS-CoV infection in the absence of CD4(+) and CD8(+) T cells and antibodies. Our findings provide new insights into the pathogenesis of SARS, demonstrating the important role of CD4(+) but not CD8(+) T cells in primary SARS-CoV infection in this model.


title: Patients prone to recurrence after endovascular treatment: periprocedural results of the PRET randomized trial on large and recurrent aneurysms.

text: BACKGROUND AND PURPOSE Some patients with large or recurrent aneurysms may be at increased risk of recurrence postcoiling. The Patients Prone to Recurrence after Endovascular Treatment (PRET) trial was designed to assess whether hydrogel coils were superior to platinum coils in these high-risk patients. This article reports periprocedural safety and operator-assessed angiographic results from the PRET trial. MATERIALS AND METHODS PRET was a pragmatic, multicenter, randomized controlled trial. Patients had ≥10-mm aneurysms (PRET-1) or a major recurrence after coiling of an aneurysm of any size (PRET-2). Patients were randomly allocated to hydrogel or control arms (any platinum coil) by using concealed allocation with minimization. Assist devices could be used as clinically required. Aneurysms could be unruptured or recently ruptured. Analyses were on an intent-to-treat basis. RESULTS Four hundred forty-seven patients were recruited (250 PRET-1; 197 PRET-2). Aneurysms were recently ruptured in 29% of PRET-1 and 4% of PRET-2 patients. Aneurysms were ≥10 mm in all PRET-1 and in 50% of PRET-2 patients. They were wide-neck (≥4 mm) in 70% and in the posterior circulation in 24% of patients. Stents were used in 28% of patients (35% in PRET-2). Coiling was successful in 98%. Adverse events occurred in 28 patients with hydrogel and 23 with platinum coils. Mortality (n=2, unrelated to treatment) and morbidity (defined as mRS>2 at 1 month) occurred in 25 patients (5.6%; 12 hydrogel, 13 platinum), related to treatment in 10 (4 hydrogel; 6 platinum) (or 2.3% of 444 treated patients). No difference was seen between hydrogel and platinum for any of the indices used to assess safety up to at least 30 days after treatment. At 1 month, 95% of patients were home with a good outcome (mRS≤2 or unchanged). Operator-assessed angiographic outcomes were satisfactory (complete occlusion or residual neck) in 339 of 447 or 76.4% of patients, with no significant difference between groups. CONCLUSIONS Endovascular treatment of large and recurrent aneurysms can be performed safely with platinum or hydrogel coils.


title: Fresh versus elective frozen embryo transfer in IVF/ICSI cycles: a systematic review and meta-analysis of reproductive outcomes.

text: BACKGROUND Elective freezing of all good quality embryos and transfer in subsequent cycles, i.e. elective frozen embryo transfer (eFET), has recently increased significantly with the introduction of the GnRH agonist trigger protocol and improvements in cryo-techniques. The ongoing discussion focuses on whether eFET should be offered to the overall IVF population or only to specific subsets of patients. Until recently, the clinical usage of eFET was supported by only a few randomized controlled trials (RCT) and meta-analyses, suggesting that the eFET not only reduced ovarian hyperstimulation syndrome (OHSS), but also improved reproductive outcomes. However, the evidence is not unequivocal, and recent RCTs challenge the use of eFET for the general IVF population. OBJECTIVE AND RATIONALE This systematic review and meta-analysis aimed at evaluating whether eFET is advantageous for reproductive, obstetric and perinatal outcomes compared with fresh embryo transfer in IVF/ICSI cycles. Additionally, we evaluated the effectiveness of eFET in comparison to fresh embryo transfer in different subgroups of patients undergoing IVF/ICSI cycles. SEARCH METHODS We conducted a systematic review, using PubMed/Medline and EMBASE to identify all relevant RCTs published until March 2018. The participants included infertile couples undergoing IVF/ICSI with or without preimplantation genetic testing for aneuploidy (PGT-A). The primary outcome was the live birth rate (LBR), whereas secondary outcomes were cumulative LBR, implantation rate, miscarriage, OHSS, ectopic pregnancy, preterm birth, pregnancy-induced hypertension, pre-eclampsia, mean birthweight and congenital anomalies. Subgroup analyses included normal and hyper-responder patients, embryo developmental stage on the day of embryo transfer, freezing method and the route of progesterone administration for luteal phase support in eFET cycles. OUTCOMES Eleven studies, including 5379 patients, fulfilling the inclusion criteria were subjected to qualitative and quantitative analysis. A significant increase in LBR was noted with eFET compared with fresh embryo transfer in the overall IVF/ICSI population [risk ratio (RR) = 1.12; 95% CI: 1.01-1.24]. Subgroup analyses indicated higher LBRs by eFET than by fresh embryo transfer in hyper-responders (RR = 1.16; 95% CI: 1.05-1.28) and in PGT-A cycles (RR = 1.55; 95% CI: 1.14-2.10). However, no differences were observed for LBR in normo-responders (RR = 1.03; 95% CI: 0.91-1.17); moreover, the cumulative LBR was not significantly different in the overall population (RR = 1.04; 95% CI: 0.97-1.11). Regarding safety, the risk of moderate/severe OHSS was significantly lower with eFET than with fresh embryo transfer (RR = 0.42; 95% CI: 0.19-0.96). In contrast, the risk of pre-eclampsia increased with eFET (RR = 1.79; 95% CI: 1.03-3.09). No statistical differences were noted in the remaining secondary outcomes. WIDER IMPLICATIONS Although the use of eFET has steadily increased in recent years, a significant increase in LBR with eFET was solely noted in hyper-responders and in patients undergoing PGT-A. Concerning safety, eFET significantly decreases the risk of moderate and severe OHSS, albeit at the expense of an increased risk of pre-eclampsia.


title: Effects of fentanyl administration on locomotor response in horses with the G57C μ-opioid receptor polymorphism.

text: OBJECTIVE To determine the locomotor response to the administration of fentanyl in horses with and without the G57C polymorphism of the μ-opioid receptor. ANIMALS 20 horses of various breeds and ages (10 horses heterozygous for the G57C polymorphism and 10 age-, breed-, and sex-matched horses that did not have the G57C polymorphism). PROCEDURES The number of steps each horse took was counted over consecutive 2-minute periods for 20 minutes to determine a baseline value. The horse then received a bolus of fentanyl (20 μg/kg, IV), and the number of steps was again counted during consecutive 2-minute periods for 60 minutes. The mean baseline value was subtracted from each 2-minute period after fentanyl administration; step counts with negative values were assigned a value of 0. Data were analyzed by use of a repeated-measures ANOVA. RESULTS Data for 19 of 20 horses (10 horses with the G57C polymorphism and 9 control horses without the G57C polymorphism) were included in the analysis. Horses with the G57C polymorphism had a significant increase in locomotor activity, compared with results for horses without the polymorphism. There was a significant group-by-time interaction. CONCLUSIONS AND CLINICAL RELEVANCE Horses heterozygous for the G57C polymorphism of the μ-opioid receptor had an increased locomotor response to fentanyl administration, compared with the response for horses without this polymorphism. The clinical impact of this finding should be investigated.


title: Vision rehabilitation interventions following mild traumatic brain injury: a scoping review.

text: Purpose: To broadly examine the literature to identify vision interventions following mild traumatic brain injury. Objectives are to identify: (1) evidence-informed interventions for individuals with visual dysfunction after mild traumatic brain injury; (2) professions providing these interventions; (3) gaps in the literature and areas for further research. Methods: A scoping review was conducted of four electronic databases of peer-reviewed literature from the databases earliest records to June 2017. Articles were included if the study population was mild traumatic brain injury/concussion and a vision rehabilitation intervention was tested. Two independent reviewers screened articles for inclusion, extracted data, and identified themes. Results: The initial search identified 3111 records. Following exclusions, 22 articles were included in the final review. Nine studies evaluated optical devices, such as corrective spectacles, contact lenses, prisms, or binasal occlusion. Two studies assessed vision therapy. Ten studies examined vision therapy using optical devices. One study investigated hyperbaric oxygen therapy. Optometrists performed these interventions in most of the studies. Future research should address quality appraisal of this literature, interventions that include older adult and pediatric populations, and interdisciplinary interventions. Conclusions: There are promising interventions for vision deficits following mild traumatic brain injury. However, there are multiple gaps in the literature that should be addressed by future research. Implications for Rehabilitation Mild traumatic brain injury may result in visual deficits that can contribute to poor concentration, headaches, fatigue, problems reading, difficulties engaging in meaningful daily activities, and overall reduced quality of life. Promising interventions for vision rehabilitation following mild traumatic brain injury include the use of optical devices (e.g., prism glasses), vision or oculomotor therapy (e.g., targeted exercises to train eye movements), and a combination of optical devices and vision therapy. Rehabilitation Professionals (e.g., optometrists, occupational therapists, physiotherapists) have an important role in screening for vision impairments, recommending referrals appropriately to vision specialists, and/or assessing and treating functional vision deficits in individuals with mild traumatic brain injury.


title: Laparoscopic repair of Morgagni hernia with composite mesh in an elderly woman: Report of a case.

text: A 78-year-old woman was admitted to another hospital with vomiting. Chest X-ray showed an abnormal shadow in the lower right lung field, and CT indicated a Morgagni hernia containing the stomach and transverse colon. The patient was transferred to our hospital and underwent laparoscopic surgery. After the hernia contents were repositioned into the abdominal cavity, we repaired the hernia orifice with a prosthetic mesh to achieve a tension-free repair. There were no complications after the surgery, and there has been no recurrence. The patient has remained free of clinical symptoms since 10 months after the surgery. Laparoscopic repair with a prosthetic mesh for Morgagni hernia is a simple and safety procedure for elderly patients.


title: Enterovirus 71 antagonizes the antiviral activity of host STAT3 and IL-6R with partial dependence on virus-induced miR-124.

text: Enterovirus 71 (EV71) has caused major outbreaks of hand, foot and mouth disease. EV71 infections increase the production of many host cytokines and pro-inflammatory factors, including interleukin (IL)-6, IL-10 and COX-2. Some of these molecules could stimulate the signal transducer and activator of transcription 3 (STAT3), which plays a key role in regulating host immune responses and several viral diseases. However, the role of STAT3 in EV71 infection remains unknown. This study found that the phosphorylation levels of STAT3 (pY705-STAT3) are closely related to EV71 infection. Further experiments revealed that STAT3 exerts an anti-EV71 activity. However, the antiviral activity of STAT3 is partially antagonized by EV71-induced miR-124, which directly targets STAT3 mRNA. Similarly, IL-6R, the α-subunit of the IL-6 receptor complex, exhibits anti-EV71 activity and is directly targeted by the virus-induced miR-124. These results indicate that EV71 can evade host IL-6R- and STAT3-mediated antiviral activities by EV71-induced miR-124. This suggests that controlling miR-124 and the downstream targets, IL-6R and STAT3, might benefit the antiviral treatment of EV71 infection.


title: Open direct carotid artery access for coiling of an intracranial aneurysm under conscious sedation.

text: We describe the case of a 61-year-old patient with significant medical co-morbidities and tortuous vascular anatomy presenting with a large middle cerebral artery aneurysm. To avoid the risks of general anesthesia and circumvent a majority of the tortuous vessels, the aneurysm was accessed by direct open exposure of the common carotid artery under conscious sedation and local anesthesia. We were able to achieve complete endovascular occlusion of the aneurysm and the patient tolerated the procedure well with no intra- or post-operative complications. Use of conscious sedation is possible and safe for direct open common carotid artery access in patients with significant vascular tortuosity that makes the standard trans-femoral approach difficult or impossible.


Call of duty: neuro-oncology outpatient management during the COVID-19 pandemic in Milan, ITALY.


title: Effect of stabilization exercise on back pain, disability and quality of life in adults with scoliosis: a systematic review.

text: INTRODUCTION Adult scoliosis (AS) is the most common spine deformity in adults. Back pain is the main symptom leading patients to seek medical consultation. Stabilization exercise has been shown effective for reducing back pain. No literature review has examined the effects of such exercises in adults with scoliosis. The objective was to systematically review the effects of stabilization exercises on back pain, disability and quality of life in adults with scoliosis. EVIDENCE ACQUISITION We systematically searched the following databases from inception to March 2017: Medline, CINAHL, Embase, SportDiscus and Cochrane Register of Controlled Trials. Selection criteria included: controlled clinical trials that compare core stabilization exercise to placebo, no treatment or another treatment in participants diagnosed with AS over 18 years old. Studies with participants presenting torso or lower extremity surgery, injection in the last six months, comorbidity that could affect the spine, red flags signs or with a history of spine trauma were excluded. We extracted information about participants, treatments, and results on pain, function and quality of life. We appraised quality using Cochrane risk of bias. We formulated level of evidence summary statements using a priori rules based on quality and consistency of results. EVIDENCE SYNTHESIS We found 630 unique articles and screened the full-text of 98 articles retrieved. Only one article met all selection criteria and was included in this review. Studies were mainly excluded for study design and patient population. The included study presented a low risk of bias for all criteria except for blinding and reporting if the timing of assessments was similar between groups. The literature provides limited evidence from one study with high risk of bias that stabilization exercises in the form of 20 weeks of active self-correction, task-oriented exercises and cognitive-behavioral therapy significantly improves pain, disability and quality of life. CONCLUSIONS Despite the high prevalence of AS, there is an important gap in the literature with limited evidence reporting the effect of exercise on back pain in adults with scoliosis. This review suggest further experimental research is needed and formulates research recommendations.


title: Subcutaneous Administration of Low-Molecular-Weight Heparin to Horses Inhibits Ex Vivo Equine Herpesvirus Type 1-Induced Platelet Activation.

text: Equine herpesvirus type 1 (EHV-1) is a major cause of infectious respiratory disease, abortion and neurologic disease. Thrombosis in placental and spinal vessels and subsequent ischemic injury in EHV-1-infected horses manifests clinically as abortion and myeloencephalopathy. We have previously shown that addition of heparin anticoagulants to equine platelet-rich plasma (PRP) can abolish ex vivo EHV-1-induced platelet activation. The goal of this study was to test whether platelets isolated from horses treated with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) were resistant to ex vivo EHV-1-induced activation. In a masked, block-randomized placebo-controlled cross-over trial, 9 healthy adult horses received 4 subcutaneous injections at q. 12 h intervals of one of the following treatments: UFH (100 U/kg loading dose, 3 maintenance doses of 80 U/kg), 2 doses of LMWH (enoxaparin) 80 U/kg 24 h apart with saline at the intervening 12 h intervals, or 4 doses of saline. Blood samples were collected before treatment and after 36 h, 40 h (4 h after the last injection) and 60 h (24 h after the last injection). Two strains of EHV-1, Ab4 and RacL11, were added to PRP ex vivo and platelet membrane expression of P selectin was measured as a marker of platelet activation. Drug concentrations were monitored in a Factor Xa inhibition (anti-Xa) bioassay. We found that LMWH, but not UFH, inhibited platelet activation induced by low concentrations (1 × 106 plaque forming units/mL) of both EHV-1 strains at 40 h. At this time point, all horses had anti-Xa activities above 0.1 U/ml (range 0.15-0.48 U/ml) with LMWH, but not UFH. By 60 h, a platelet inhibitory effect was no longer detected and anti-Xa activity had decreased (range 0.03 to 0.07 U/ml) in LMWH-treated horses. Neither heparin inhibited platelet activation induced by high concentrations (5 × 106 plaque forming units/mL) of the RacL11 strain. We found substantial between horse variability in EHV-1-induced platelet activation at baseline and after treatment. Minor injection site reactions developed in horses given either heparin. These results suggest that LMWH therapy may prevent thrombotic sequelae of EHV-1, however further evaluation of dosage regimens is required.


COVID-19 virus case fatality rate: How to avoid errors in calculation of data during the outbreak?


Efficacy of face masks depends on spatial relation between host and recipient and who is being protected.


title: Use of the outreach distal access catheter as an intracranial platform facilitates coil embolization of select intracranial aneurysms: technical note.

text: OBJECTIVE The Outreach distal access catheter (DAC; Concentric Medical, Mountain View, California, USA) has been designed to assist the Merci device (Concentric Medical) with clot retrieval in the setting of acute stroke. Its application for coil embolization of intracranial aneurysms was investigated. METHODS Between December 2008 and January 2010, 150 aneurysms were treated with endovascular methods. In 18 cases of small aneurysms and/or increased parent vessel tortuosity, the DAC was used for additional support. Merits and complications related to the use of this catheter are reviewed. RESULTS The mean aneurysm size was 7.1 mm (range 3.5-25). In each case, the DAC was used as an intracranial platform catheter in close proximity to the target aneurysm. This catheter (outer diameter 3.9 or 4.3 French) increased the stability and reduced the redundancy of the microcatheter. As a result, handling and control of the microcatheter were improved. In three cases, the coiling procedure could not be completed because of difficulties not related to the DAC. Aneurysms in the remaining patients were treated successfully with complete (n=12) or near complete (n=3) angiographic occlusion. CONCLUSION For smaller or distal intracranial aneurysms with difficult access, use of the DAC as an additional platform in close proximity to the target aneurysm subjectively enhanced microcatheter control and safety.


title: Influenza: One Health in action.

text: Influenza highlights the relevance of One Health, where experts in animal, human and environmental health combine to solve inter-related problems. Human disease due to pandemic (H1N1) 2009 influenza and avian and human disease due to influenza A/H5N1 are recent examples of new zoonoses with significant global impact. Management and prevention of influenza and other emerging infectious diseases requires the expansion and continuing support of collaborations between human and animal health experts at the clinical, diagnostic laboratory, public health, research and training levels.


title: Cost-effectiveness of adding FDG-PET or CT to the diagnostic work-up of patients with stage III melanoma.

text: OBJECTIVE The aim of this prospective study was to assess predictive value of fludeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) and to analyze their cost-effectiveness in several diagnosis-treatment combinations. BACKGROUND The incidence of melanoma continues to rise. A proportion will present or recur with lymph node metastases (American Joint Committee on Cancer/Union for International Cancer Control stage III). To detect distant metastases, CT and/or FDG-PET are available. However, few studies have assessed their value and costs in stage III. METHODS All consecutive patients with melanoma with palpable, proven lymph node metastases (2003-2008) referred for examination with FDG-PET and CT were prospectively included. Sensitivity, specificity, and accuracy, and positive predictive value (PPV) and negative predictive value (NPV) were calculated. In economic evaluation, the costs of diagnostic work-up with and without FDG-PET and CT were compared. RESULTS Overall, 253 patients with melanoma were included. FDG-PET showed a higher sensitivity than CT: 86.1% compared with 78.2%. Specificity was higher for CT (93.7%) compared with FDG-PET (93.1%). Overall, FDG-PET showed a higher PPV and NPV. Cost-consequence analysis showed that adding CT (True-Positive upstaging in 61 patients) to diagnostic work-up decreased cost by 5.5%, adding FDG-PET (True-Positive upstaging in 68 patients) increased cost by 7.2%, and adding both (True-Positive upstaging in 78 patients) increased cost by 15.1%. CONCLUSIONS In this study, FDG-PET had higher sensitivity and predictive value, whereas CT had a higher specificity. Adding one of these diagnostic tools improved the staging of stage III patients with less than 10% cost increase. A proposal for stage-specific use of imaging modalities for clinicians caring for patients with melanoma is presented.


title: A retrospective study on the relationship between altered native acetabular angle and vertical implant malpositioning.

text: PURPOSE Acetabular cup positioning in extreme angles of vertical position affects both stability and long-term survivorship of total hip arthroplasty. The purpose of this study is to determine whether native Sharp's angle is associated with an increased abduction angle of the acetabular component. METHODS Consecutive patients who underwent primary total hip replacement between February 2012 and August 2015 were included. Vertical positioning of acetabular implant in the antero-posterior post-operative radiographs were measured. The proportion of implants positioned outside the safe zone (40° ± 10°) was calculated and through a multivariate analysis, Sharp's angle and other factors possibly associated with cup malpositioning were evaluated. RESULTS Five hundred twenty-eight hip arthroplasties were analyzed. Prevalence of cup malpositioning was 7.6% and 25 patients had an altered native acetabular angle. An altered pre-operative Sharp's angle was associated with a higher risk of vertical malpositioning of the acetabular component (OR 2.51 IC 95%: 1.17-5.39) (p = 0.02). Body mass index, surgeon's volume, size of the implant, gender, pre-operative diagnose and age, were not associated with the position of the cup. CONCLUSIONS The alteration of the Sharp's angle as an indicator of hip dysplasia in native hips increases the odds of acetabular cup malpositioning. Other factors explored did not correlate with the position of the acetabular prosthesis. Systematic assessment of Sharp's angle should be included in the pre-operative planning of primary hip arthroplasty.


title: Monitoring tissue oxygenation by near infrared spectroscopy (NIRS): background and current applications.

text: Conventional cardiovascular monitoring may not detect tissue hypoxia, and conventional cardiovascular support aiming at global hemodynamics may not restore tissue oxygenation. NIRS offers non-invasive online monitoring of tissue oxygenation in a wide range of clinical scenarios. NIRS monitoring is commonly used to measure cerebral oxygenation (rSO(2)), e.g. during cardiac surgery. In this review, we will show that tissue hypoxia occurs frequently in the perioperative setting, particularly in cardiac surgery. Therefore, measuring and obtaining adequate tissue oxygenation may prevent (postoperative) complications and may thus be cost-effective. NIRS monitoring may also be used to detect tissue hypoxia in (prehospital) emergency settings, where it has prognostic significance and enables monitoring of therapeutic interventions, particularly in patients with trauma. However, optimal therapeutic agents and strategies for augmenting tissue oxygenation have yet to be determined.


title: Lymph node harvest in single incision laparoscopic surgery for colorectal malignancy.

text: AIM Single incision laparoscopic surgery (SILS) has not been sufficiently evaluated with respect to its oncological equivalence to conventional laparoscopic or open surgery. METHOD Of 507 patients who had SILS for colorectal diseases in our institution, 87 had segmental resection for colorectal adenocarcinoma. For each of the surgical specimens the number of lymph nodes which can be expected to be identified by the pathologist was calculated using the ACPGBI lymph node harvest model, which was developed from a nationwide database of 5845 surgical specimens. The predicted number of lymph nodes was compared with the number identified in our SILS specimens. RESULTS The median predicted number of lymph nodes was 11 (4.5-14.8) compared with 18 (5-44) in the SILS specimens (P < 0.001). In all subgroups analysed for various operations, the lymph node harvest in the SILS specimens was significantly higher than predicted. CONCLUSION In terms of lymph node harvest SILS seems to be comparable to conventional open or laparoscopic surgery.


title: A randomized trial of antibiotic prophylaxis for the prevention of surgical site infection after open mesh-plug hernia repair.

text: BACKGROUND The efficacy of antibiotic prophylaxis for the prevention of surgical-site infection (SSI) after open tension-free inguinal hernia repair remains controversial. METHODS A double-blind, randomized, placebo-controlled trial was conducted. Patients who underwent elective open mesh-plug hernia repair were eligible for randomization. In the antibiotic prophylaxis group, 1.0 g cefazolin was intravenously administrated 30 minutes before the incision. In the placebo group, an equal volume of sterile saline was administered. The primary end point was the incidence of SSI. RESULTS A total of 200 patients were enrolled. SSI developed in 2 of 100 patients (2%) in the antibiotic prophylaxis group and 13 of 100 patients (13%) in the placebo group, indicating a significant difference between the 2 groups (relative risk ratio, 0.25; 95% confidence interval, 0.070 to 0.92; P = .003). Other complications occurred in 23 patients: 7 (7%) in the antibiotic prophylaxis group and 16 (16%) in the placebo group (P = .046). CONCLUSIONS This study indicates that antibiotic prophylaxis is effective for the prevention of SSI after open mesh-plug hernia repair.


title: Addressing the Impact of COVID-19 on the Residency Application Process Through a Virtual Subinternship.

text: Senior medical students are facing an unparalleled experiential gap left by COVID-19 restrictions. Due to a shared commitment to safety, equity, and well-being, away rotations are actively being discouraged or even prohibited. As a result, students transitioning to residency encounter reduced clinical training experiences and decreased access to advising, mentorship, and research opportunities. In addition, limited exposure to residency life across subspecialties and institutions poses unique challenges during the current residency application cycle. The otolaryngology-head and neck surgery community has met these unprecedented challenges by producing diverse electronic resources for specialty-specific clinical education, as well as discussing ways to increase access to advising. In this commentary, we review these initiatives and propose an institutional virtual event as a platform for meeting goals previously achieved by visiting subinternships.


title: Mentality and behavior in COVID-19 emergency status in Japan: Influence of personality, morality and ideology.

text: The COVID-19 pandemic began in December 2019 and severely influenced society. In response, the Japanese government declared a state of emergency on 7th April in seven prefectures. The study conducted an immediate survey on 8th April to record the response of the general public to the first emergency status due to epidemics. The study hypothesized that personality traits, moral foundation, and political ideology can influence people's mentality, cognition, and behavior toward COVID-19. Based on a nationwide dataset of 1856 respondents (male = 56.3%, Mage = 46.7, emergency regions = 49.9%), the study found that personality, morality, and ideology altered mental health status and motivated behaviors toward COVID-19. Neuroticism and avoiding harm involved cognition and behavior through various means. The study also found significant differences among demographic groups. Results are informative and contributive to the governance and management of, and aid for, individual responses to the COVID-19 pandemic.


title: The effects of preoperative oral antibiotic use on the development of surgical site infection after elective colorectal resections: A retrospective cohort analysis in consecutively operated 90 patients.

text: PURPOSE The influence of oral antibiotic use together with mechanical bowel preparation (MBP) on surgical site infection (SSI) rate, length of hospital stay and total hospital costs in patients undergoing elective colorectal surgery were evaluated in this study. METHODS Data from 90 consecutive patients undergoing elective colorectal resection between October 2006 and September 2009 was analyzed retrospectively. All patients received MBP. Patients in group A were given oral antibiotics (a total 480 mg of gentamycin, 4 gr of metronidazole in two divided doses and 2 mg of bisacodyl PO), whereas patients in group B received no oral antibiotics. Exclusion criteria were emergent operations, laparoscopic operations, preoperative chemoradiotherapy, intraoperative colonoscopy prior to the creation of an anastomosis or antibiotic use within the previous 10 days. SSI, length of hospital stays and total hospital charges were evaluated. RESULTS Patients in both study groups, group A (n = 45) and group B (n = 45), were similar in terms of age, BMI, diverting ileostomy creation, localization and stage of the disease. Patients receiving oral antibiotics demonstrated a lower rate of wound infections (36% vs. 71%, p < 0.001), shorter hospital stay (8.1 ± 2.4 days vs. 14.2 ± 10.9 days, respectively, p < 0.001) and similar rates for anastomotic leakage (2% vs. 11%, p = 0.20). The mean ± SD total hospital charges were significantly lower in Group A (2.699 ± 0.892$) than that in Group B (4.411 ± 4.995$, p = 0.029). CONCLUSION Preoperative oral antibiotic use with MBP may provide faster recovery with less SSI and hospital charges.


title: An autophagy-independent role for LC3 in equine arteritis virus replication.

text: Equine arteritis virus (EAV) is an enveloped, positive-strand RNA virus. Genome replication of EAV has been associated with modified intracellular membranes that are shaped into double-membrane vesicles (DMVs). We showed by immuno-electron microscopy that the DMVs induced in EAV-infected cells contain double-strand (ds)RNA molecules, presumed RNA replication intermediates, and are decorated with the autophagy marker protein microtubule-associated protein 1 light chain 3 (LC3). Replication of EAV, however, was not affected in autophagy-deficient cells lacking autophagy-related protein 7 (ATG7). Nevertheless, colocalization of DMVs and LC3 was still observed in these knockout cells, which only contain the nonlipidated form of LC3. Although autophagy is not required, depletion of LC3 markedly reduced the replication of EAV. EAV replication could be fully restored in these cells by expression of a nonlipidated form of LC3. These findings demonstrate an autophagy-independent role for LC3 in EAV replication. Together with the observation that EAV-induced DMVs are also positive for ER degradation-enhancing α-mannosidase-like 1 (EDEM1), our data suggested that this virus, similarly to the distantly-related mouse hepatitis coronavirus, hijacks the ER-derived membranes of EDEMosomes to ensure its efficient replication.


title: Effect of Body Mass Index, Metabolic Health and Adipose Tissue Inflammation on the Severity of Non-alcoholic Fatty Liver Disease in Bariatric Surgical Patients: a Prospective Study.

text: BACKGROUND Non-alcoholic fatty liver disease (NAFLD), driven by the obesity epidemic, has become the most common form of liver disease. Despite this, there is controversy regarding the prevalence and severity of NAFLD in obesity. Obesity-related factors, such as increasing adiposity, metabolic disease and inflammation, may influence prevalence. We therefore prospectively measured NAFLD prevalence in obesity and studied factors associated with NAFLD. MATERIALS AND METHODS We recruited consecutive bariatric patients. Intraoperative liver biopsies were taken. The liver, adipose tissue and serum were collected to measure inflammation. Adipocyte cell size was measured. NAFLD severity was correlated to body mass index (BMI), metabolic health and adipose characteristics. RESULTS There were 216 participants; BMI 45.9 ± 8.9 kg/m2, age 44.4 ± 12.1 years, 75.5% female. Overall NAFLD prevalence was 74.1%, with 17.1% having non-alcoholic steatohepatitis (NASH) and/or steatofibrosis. Odds of NASH/steatofibrosis increased independently with BMI category (odds ratio (OR) 2.28-3.46, all p < 0.05) and metabolic disease (OR 3.79, p = 0.003). These odds markedly increased when both super obesity (BMI > 50) and metabolic disease were present (OR 9.71, p < 0.001). NASH/steatofibrosis prevalence was significantly greater with diabetes, hypertension and dyslipidemia. Although greater visceral adipocyte hypertrophy was evident in NASH/steatofibrosis, there was no significant association between adipose inflammation and NASH/steatofibrosis. CONCLUSION NAFLD remains endemic in obesity; however, NASH/steatofibrosis are less common than previously reported. Worsening obesity and metabolic disease increase odds of NAFLD independently, with substantially compounded effect with both. These observations may help with risk stratification in obese populations. We were unable to delineate clear associations between adipose inflammation and NASH/steatofibrosis in this obese population. TRIAL REGISTRATION Australian Clinical Trials Registry ( ACTRN12615000875505 ).


title: A rare gallbladder ciliated foregut cyst in chronic cholecystitis.

text: INTRODUCTION Ciliated foregut cysts (CFC) are rare anomalies due to aberrant embryological development. It is thought to arise from a remnant of the embryologic foregut. The solitary cysts are characterised by ciliated pseudostratified columnar epithelium. They are usually located above the diaphragm but they can also arise in relation to the liver, gallbladder and pancreas. PRESENTATION OF CASE We present the first ciliated foregut cyst of the gallbladder case reported in Australia, and the ninth known case to be reported worldwide. A 61-year-old male with chronic cholecystitis and cholelithiasis underwent an elective laparoscopic cholecystectomy and intraoperative cholangiogram. Intraoperatively, 'out-pouching' was noted on the lateral border of the gallbladder. Microscopically the histopathology showed that the cyst was lined by ciliated columnar epithelium the characteristic feature of a ciliated foregut cyst. DISCUSSION To date only 8 cases of these ciliated foregut cysts in the gallbladder have been reported in literature. Our case is the first reported in Australia. It is unique in that the patient was an older male as opposed to most other previous cases, which were younger females. These cysts can be difficult to distinguish from neoplasms clinically and radiographically. Reports have shown that these cysts may become dysplastic and is best excised when discovered. CONCLUSION Despite the rarity of CFCs and their potential to mimic malignancy, we propose awareness and understanding of the management for them-being excision and hopefully not cause any confusion or devastatingly allow it to become malignant.


title: Comparing Reinforcement Options for the Staple Line of Laparoscopic Sleeve Gastrectomy.

text: OBJECTIVE To compare three reinforcement options (suture, fibrin glue, and no reinforcement) for staple line reinforcement of patients undergoing laparoscopic sleeve gastrectomy. STUDY DESIGN An experimental study. PLACE AND DURATION OF STUDY Ortadogu Hospital, Adana, Turkey, from 2013 to 2017. METHODOLOGY The inclusion criteria were patients with BMI > 40 Kg/m² or >35 Kg/m² (if there were comorbid diseases associated with obesity). The exclusion criteria were patients who were older than 65 years or had a bariatric procedure earlier. The patients were placed in three groups. Group 1 had no staple line reinforcement, group 2 had fibrin glue on the staple line, and group 3 had barbed continued suture on the staple line. The primary endpoints included stenosis, bleeding, and postoperative leaks. The secondary outcomes included total operation time and time for staple line reinforcement. Values of p<0.05 were deemed significant for all statistical tests. RESULTS The mean time to perform the staple line reinforcement was significantly higher in group 3 (22.05 ± 2.83 minutes) than in group 2 (fibrin glue, 10.86 ± 2.15 minutes, p<0.001). The mean total operation times were significantly different between all three groups; 70.8 ± 5.4 minutes for group 1, 74.7 ± 6.2 minutes for group 2, and 81.2 ± 3.0 minutes for group 3 (p<0.001). The groups had no statistical differences regarding complications. CONCLUSION The use of fibrin glue and barbed continuous suture for staple line reinforcement during laparoscopic sleeve gastrectomy had no effect on post- or per-operative hemorrhage and leakage; however, these procedures significantly extended the operation time.


Challenges in evaluating SARS-CoV-2 vaccines during the COVID-19 pandemic.


title: Transvaginal NOTES hybrid cholecystectomy.

text: BACKGROUND Initial reports confirm the safety and feasibility of natural orifice transluminal eendoscopic surgery (NOTES) transvaginal hybrid cholecystectomy (TVC). Benefits of TVC include no visible scars, less pain, and shorter recovery. The authors describe a single surgeon's initial experience with TVC through his first 20 cases. METHOD Under direct visualization from a 5-mm umbilical trochar, a 12-mm trocar, or in 2 cases a SILS port was introduced through the posterior vagina into the cul-de-sac. The gallbladder was visualized using an endoscope introduced through the vaginal port. Using extracorporeal stay sutures for retraction, the cystic duct and artery were dissected free, clipped, and divided. The gallbladder was then removed through the vaginal port. RESULTS Twenty patients underwent a successful TVC. The average age was 34.9 years (21-55 years), average body mass index was 29.9 kg/m2 (18.3-38.1 kg/m2), and the mean operative time was 71.4 minutes (42-116 minutes). CONCLUSION TVC is a safe, feasible, and attractive alternative to traditional 4-port laparoscopic cholecystectomy.


Trailblazing cancer-physics project accused of losing ambition.


title: Public health physician specialty training in Canada and the United States.

text: Today's interconnected world has produced a distinct need for physician specialists in public health and preventive medicine. As the industrialized world confronts aging populations, rising health care costs, and a growing epidemic of chronic disease, it is clear that the focus of health care must become more preventive than curative.Although public health and preventive medicine exists in various forms worldwide, the literature has not yet examined different national strategies for postgraduate medical training in this unique specialty. This examination of present-day public health physician training in Canada and the United States represents a first step in addressing this gap.Using a standardized template for review, the authors compare key aspects of public health physician specialty training in both countries, including the definition and scope of the specialty; oversight and location of training; length of postgraduate training; specific clinical, academic, and practicum requirements; residency program funding; availability of residency positions; certification; and the roles of specialists.The authors explore similarities and differences between public health physician specialists in Canada and the United States in an effort to highlight training improvements for incorporation into each country's training program and to identify potential avenues of collaboration and cooperation across the border.


title: Duration of Antimicrobial Treatment for Bacteremia in Canadian Critically Ill Patients.

text: OBJECTIVES The optimum duration of antimicrobial treatment for patients with bacteremia is unknown. Our objectives were to determine duration of antimicrobial treatment provided to patients who have bacteremia in ICUs, to assess pathogen/patient factors related to treatment duration, and to assess the relationship between treatment duration and survival. DESIGN Retrospective cohort study. SETTINGS Fourteen ICUs across Canada. PATIENTS Patients with bacteremia and were present in the ICU at the time culture reported positive. INTERVENTIONS Duration of antimicrobial treatment for patients who had bacteremia in ICU. MEASUREMENTS AND MAIN RESULTS Among 1,202 ICU patients with bacteremia, the median duration of treatment was 14 days, but with wide variability (interquartile range, 9-17.5). Most patient characteristics were not associated with treatment duration. Coagulase-negative staphylococci were the only pathogens associated with shorter treatment (odds ratio, 2.82; 95% CI, 1.51-5.26). The urinary tract was the only source of infection associated with a trend toward lower likelihood of shorter treatment (odds ratio, 0.67; 95% CI, 0.42-1.08); an unknown source of infection was associated with a greater likelihood of shorter treatment (odds ratio, 2.14; 95% CI, 1.17-3.91). The association of treatment duration and survival was unstable when analyzed based on timing of death. CONCLUSIONS Critically ill patients who have bacteremia typically receive long courses of antimicrobials. Most patient/pathogen characteristics are not associated with treatment duration; survivor bias precludes a valid assessment of the association between treatment duration and survival. A definitive randomized controlled trial is needed to compare shorter versus longer antimicrobial treatment in patients who have bacteremia.


Assessment of Treatment response to Sirolimus in pulmonary lymphangioleiomyomatosis by longitudinal quantification of cystic changes using automated post-processing of chest CT-data.


title: Osteonecrosis in patients after severe acute respiratory syndrome (SARS): possible role of anticardiolipin antibodies.

text: OBJECTIVES This study examined the anticardiolipin antibodies in post-SARS (severe acute respiratory syndrome) osteonecrosis patients to investigate the etiology of post-SARS osteonecrosis, and to eventually provide valuable information for the early diagnosis of nontraumatic osteonecrosis and for the susceptible population screening. METHODS This study recruited 62 post-SARS osteonecrosis patients and 52 age- and gender-matched healthy controls. Fasting blood samples were collected from all the subjects through cubital veins. Immunoglobulins A, G and M (IgA, G and M) types of anticardiolipin antibodies were examined by enzyme-linked immunosorbent assay. The routine examinations of prothrombin time, thrombin time, prothrombin activity, and international normalized ratio were also performed. RESULTS There were 21 of 62 post-SARS osteonecrosis patients (33.9%) who showed at least one type of anticardiolipin antibodies. The titers of specific IgA, IgG, and IgM were 11.33 +/- 11.209 APL, 5.127 +/- 5.927 GPL, and 17.821 +/- 10.606 MPL, respectively. There were only 4 of 52 subjects in the control group (7.7%) who showed positive anticardiolipin antibody with titers of IgA at 10.702 +/- 3.126 APL, IgG at 5.184 +/- 4.780 GPL, and IgM at 14.684 +/- 5.516 MPL. There were significant differences between the 2 groups confirmed by t-Test and chi(2) test (P < 0.05), while no significant differences were observed in prothrombin time, thrombin time, prothrombin activity, and international normalized ratio results between the 2 groups. CONCLUSIONS The incidences of anticardiolipin antibodies were increased in the post-SARS osteonecrosis patients and anticardiolipin antibodies may play a role in the pathogenesis of post-SARS osteonecrosis.


title: Short and long-term outcomes after esophagectomy for cancer in elderly patients.

text: BACKGROUND As worldwide life expectancy rises, the number of candidates for surgical treatment of esophageal cancer over 70 years will increase. This study aims to examine outcomes after esophagectomy in elderly patients. METHODS This study is a retrospective review of 474 patients undergoing esophagectomy for cancer during 2002 to 2011. A total of 334 (70.5%) patients were less than 70 years old (group A), 124 (26.2%) 70 to 79 years (group B), and 16 (3.4%) 80 years or greater (group C). We analyzed the effect of age on outcome variables including overall and disease specific survival. RESULTS Major morbidity was observed to occur in 115 (35.6%) patients of group A, 58 (47.9%) of group B, and 10 (62.5%) of group C (p = 0.010). Mortality, both 30-day and 90-day was observed in 2 (0.6%) and 7 (2.2%) of group A, 4 (3.2%) and 7 (6.1%) of group B, and 1 (6.3%) and 2 (14.3%) of group C, respectively (p = 0.032 and p = 0.013). Anastomotic leak was observed in 16 (4.8%) patients of group A, 6 (4.8%) of group B, and 0 (0%) of group C (p = 0.685). Anastomotic stricture (defined by the need for ≥ 2 dilations) was observed in 76 (22.8%) of group A, 13 (10.5%) of group B, and 1 (6.3%) of group C (p = 0.005). Five-year overall and disease specific survival was 64.8% and 72.4% for group A, 41.7% and 53.4% for group B, 49.2% and 49.2% for group C patients (p = 0.0006), respectively. CONCLUSIONS Esophagectomy should be carefully considered in patients 70 to 79 years old and can be justified with low mortality. Outcomes in octogenarians are worse suggesting esophagectomy be considered on a case by case basis. Stricture rate is inversely associated to age.


title: Molecular diagnosis of respiratory virus infections.

text: The appearance of eight new respiratory viruses, including the SARS coronavirus in 2003 and swine-origin influenza A/H1N1 in 2009, in the human population in the past nine years has tested the ability of virology laboratories to develop diagnostic tests to identify these viruses. Nucleic acid based amplification tests (NATs) for respiratory viruses were first introduced two decades ago and today are utilized for the detection of both conventional and emerging viruses. These tests are more sensitive than other diagnostic approaches, including virus isolation in cell culture, shell vial culture (SVC), antigen detection by direct fluorescent antibody (DFA) staining, and rapid enzyme immunoassay (EIA), and now form the backbone of clinical virology laboratory testing around the world. NATs not only provide fast, accurate and sensitive detection of respiratory viruses in clinical specimens but also have increased our understanding of the epidemiology of both new emerging viruses such as the pandemic H1N1 influenza virus of 2009, and conventional viruses such as the common cold viruses, including rhinovirus and coronavirus. Multiplex polymerase chain reaction (PCR) assays introduced in the last five years detect up to 19 different viruses in a single test. Several multiplex PCR tests are now commercially available and tests are working their way into clinical laboratories. The final chapter in the evolution of respiratory virus diagnostics has been the addition of allelic discrimination and detection of single nucleotide polymorphisms associated with antiviral resistance. These assays are now being multiplexed with primary detection and subtyping assays, especially in the case of influenza virus. These resistance assays, together with viral load assays, will enable clinical laboratories to provide physicians with new and important information for optimal treatment of respiratory virus infections.


European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary.


Human Immunodeficiency Virus Phylogenetics in the United States-and Elsewhere.


title: Serologic evidence of flavivirus infection in bats in the Yucatan Peninsula of Mexico.

text: We captured 140 bats of seven species in Merida City in the Yucatan Peninsula of Mexico in 2010. Serum was collected from each bat and assayed by plaque reduction neutralization test (PRNT) using six flaviviruses: West Nile virus, St. Louis encephalitis virus, and dengue viruses 1-4. Flavivirus-specific antibodies were detected in 26 bats (19%). The antibody-positive bats belonged to three species: the Pallas's long-tongued bat (Glossophaga soricina), Jamaican fruit bat (Artibeus jamaicensis), and great fruit-eating bat (Artibeus lituratus), and their flavivirus antibody prevalences were 33%, 24%, and 9%, respectively. The PRNT titers were usually highest for dengue virus 2 or dengue virus 4, but none of the titers exceeded 80. These data could indicate that most of the antibody-positive bats had been infected with dengue virus. However, because all titers were low, it is possible that the bats had been infected with another (perhaps unrecognized) flavivirus not included in the PRNT analysis, possibly a virus more closely related to dengue virus than to other flaviviruses. Each serum sample was assayed for flavivirus RNA by reverse transcription PCR, but all were negative.


Restoration to normal physiology without the use of excessive fluids.


title: Zinc Salts Block Hepatitis E Virus Replication by Inhibiting the Activity of Viral RNA-Dependent RNA Polymerase.

text: Hepatitis E virus (HEV) causes an acute, self-limiting hepatitis in healthy individuals and leads to chronic disease in immunocompromised individuals. HEV infection in pregnant women results in a more severe outcome, with the mortality rate going up to 30%. Though the virus usually causes sporadic infection, epidemics have been reported in developing and resource-starved countries. No specific antiviral exists against HEV. A combination of interferon and ribavirin therapy has been used to control the disease with some success. Zinc is an essential micronutrient that plays crucial roles in multiple cellular processes. Zinc salts are known to be effective in reducing infections caused by few viruses. Here, we investigated the effect of zinc salts on HEV replication. In a human hepatoma cell (Huh7) culture model, zinc salts inhibited the replication of genotype 1 (g-1) and g-3 HEV replicons and g-1 HEV infectious genomic RNA in a dose-dependent manner. Analysis of a replication-defective mutant of g-1 HEV genomic RNA under similar conditions ruled out the possibility of zinc salts acting on replication-independent processes. An ORF4-Huh7 cell line-based infection model of g-1 HEV further confirmed the above observations. Zinc salts did not show any effect on the entry of g-1 HEV into the host cell. Furthermore, our data reveal that zinc salts directly inhibit the activity of viral RNA-dependent RNA polymerase (RdRp), leading to inhibition of viral replication. Taken together, these studies unravel the ability of zinc salts in inhibiting HEV replication, suggesting their possible therapeutic value in controlling HEV infection.IMPORTANCE Hepatitis E virus (HEV) is a public health concern in resource-starved countries due to frequent outbreaks. It is also emerging as a health concern in developed countries owing to its ability to cause acute and chronic infection in organ transplant and immunocompromised individuals. Although antivirals such as ribavirin have been used to treat HEV cases, there are known side effects and limitations of such therapy. Our discovery of the ability of zinc salts to block HEV replication by virtue of their ability to inhibit the activity of viral RdRp is important because these findings pave the way to test the efficacy of zinc supplementation therapy in HEV-infected patients. Since zinc supplementation therapy is known to be safe in healthy individuals and since high-dose zinc is used in the treatment of Wilson's disease, it may be possible to control HEV-associated health problems following a similar treatment regimen.


title: Embolization of a spinal dural arteriovenous fistula with ethylene-vinyl alcohol copolymer (Onyx) using a dual-lumen microballoon catheter and buddy wire technique.

text: BACKGROUND N-butyl 2-cyanoacrylate (NBCA) remains the standard embolic agent for spinal dural arteriovenous fistula (SDAVF) treatment. Treatment of SDAVF with ethylene-vinyl alcohol copolymer (Onyx, ev3-Covidien, Irvine CA, USA) is currently not well established. Although several cases have reported the use of Onyx to embolize an intracranial dural arteriovenous fistula using a dual-lumen microballoon catheter, Onyx embolization of an SDAVF using a dual-lumen microballoon catheter has not been reported. CASE DESCRIPTION We treated a 57-year-old man with an SDAVF using a dual-lumen microballoon catheter and buddy wire technique to perform transarterial Onyx embolization via the left sixth intercostal artery. CONCLUSIONS Onyx embolization using a dual-lumen microballoon catheter was effective. Furthermore, the buddy wire technique was useful for providing rigid support of the microcatheter in a narrow and tortuous intercostal artery.


People power: How India is attempting to slow the coronavirus.


Cephalic and digital pulse oximetry in cardiac surgery: a comparative pilot study with arterial oximetry.


title: Operating during COVID-19: Is there a risk of viral transmission from surgical smoke during surgery?

text: Summary The World Health Organization declared a pandemic when coronavirus disease 2019 (COVID-19) started to sweep the globe. Growing concerns for the safety of health care workers was raised when up to 80% of people with COVID-19 showed mild or no symptoms at all. Some surgical procedures will be inevitable during the pandemic, and proper safety measures must be in place to avoid transmission risks. Surgical smoke is a common by-product from the use of energy devices in the operating room. The effects of surgical smoke have been studied for more than 40 years, and potential health hazards have been reported. Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. To ensure the safety of operating room personnel, we must consider whether there is any concern of viral transmission from the inhalation of surgical smoke.


title: Tinidazole: Another Therapeutic Option for Syphilis?

text: After the incidental observation of an almost complete resolution of maculopapular eruption in a patient having simultaneously secondary syphilis and trichomonas vaginalis infection, we extended the treatment with tinidazole (500 mg 4 times daily for 7 days) to 10 other early syphilis patients before the start of the conventional penicillin treatment. All patients showed marked improvement of their lesions in a few days. After the introduction of the conventional penicillin regimen, the lesions further improved and VDRL titers declined at least 4-fold within 6 months in all patients. Tinidazole is a 5-nitroimidazole derivative as well as metronidazole but with a longer plasma half-life. It is activated intracellularly by bacterial/parasitic enzymes to a redox cytotoxic intermediate that damages large protein molecules and inhibits repair and transcription of DNA affecting also the cell wall. With this action, tinidazole might also have a synergic action with penicillin and doxycycline, facilitating the entry of such drugs. It is possible that tinidazole has the same bactericidal action on spirochetes other than Borrelia, such as Treponema pallidum, explaining its rapid therapeutic action on the lesions of early syphilis. Whether this action could be confirmed by studies on larger series of patients, tinidazole might be considered in case of allergy to penicillin or other antibiotics usually prescribed in syphilis.


title: Financial Conflicts of Interest and Stance on Tobacco Harm Reduction: A Systematic Review.

text: Background. Tobacco companies have actively promoted the substitution of cigarettes with purportedly safer tobacco products (e.g., smokeless tobacco, e-cigarettes) as tobacco harm reduction (THR). Given the tobacco, e-cigarette, and pharmaceutical industries' substantial financial interests, we quantified industry influence on support for THR. Objectives. To analyze a comprehensive set of articles published in peer-reviewed journals assessing funding sources and support for or opposition to substitution of tobacco or nicotine products as harm reduction. Search Methods. We searched PubMed, Embase, Web of Science, and PsycINFO with a comprehensive search string including all articles, comments, and editorials published between January 1, 1992, and July 26, 2016. Selection Criteria. We included English-language publications published in peer-reviewed journals addressing THR in humans and excluded studies on modified cigarettes, on South Asian smokeless tobacco variants, on pregnant women, on animals, not mentioning a tobacco or nicotine product, on US Food and Drug Administration-approved nicotine replacement therapies, and on nicotine vaccines. Data Collection and Analysis. We double-coded all articles for article type; primary product type (e.g., snus, e-cigarettes); themes for and against THR; stance on THR; THR concepts; funding or affiliation with tobacco, e-cigarette, pharmaceutical industry, or multiple industries; and each author's country. We fit exact logistic regression models with stance on THR as the outcome (pro- vs anti-THR) and source of funding or industry affiliation as the predictor taking into account sparse data. Additional models included article type as the outcome (nonempirical or empirical) and industry funding or affiliation as predictor, and stratified analyses for empirical and nonempirical studies with stance on THR as outcome and funding source as predictor. Main Results. Searches retrieved 826 articles, including nonempirical articles (21%), letters or commentaries (34%), editorials (5%), cross-sectional studies (15%), systematic reviews and meta-analyses (3%), and randomized controlled trials (2%). Overall, 23.9% disclosed support by industry; 49% of articles endorsed THR, 42% opposed it, and 9% took neutral or mixed positions. Support from the e-cigarette industry (odds ratio [OR] = 20.9; 95% confidence interval [CI] = 5.3, 180.7), tobacco industry (OR = 59.4; 95% CI = 10.1, +infinity), or pharmaceutical industry (OR = 2.18; 95% CI = 1.3, 3.7) was significantly associated with supportive stance on THR in analyses accounting for sparse data. Authors' Conclusions. Non-industry-funded articles were evenly divided in stance, while industry-funded articles favored THR. Because of their quantity, letters and comments may influence perceptions of THR when empirical studies lack consensus. Public Health Implications. Public health practitioners and researchers need to account for industry funding when interpreting the evidence in THR debates.


title: No visible scar (NVIS) colectomy: a new approach to minimal access surgery to the colon.

text: INTRODUCTION Minimally invasive surgery continues to revolutionize surgical standards with trends toward further minimalization and improved cosmesis. Approaches such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) have thus emerged. The authors devised an alternative method for a more efficient approach to minimally invasive surgery called no visible scar (NVIS). This study describes NVIS and its ability to provide operative capacity and outcomes similar to other minimal access techniques, but with improved cosmesis and possibly decreased associated complications. METHODS This is a retrospective analysis of patients undergoing colectomy between June 2009 and March 2010 to evaluate our outcomes with the NVIS technique (surgical approach via a 4-5 cm suprapubic site for inserting trocars/multiport and specimen extraction, with a 5-mm umbilical incision for a single trocar). Outcome measures included intraoperative complications, postoperative morbidity, and cosmetic outcome. RESULTS Ten patients with a mean age of 60.3 years underwent NVIS colectomy. The average operating time was 161.3 minutes with a mean blood loss of 56.5 mL. There were no conversions to open surgery. One patient required additional trocar placement. No perioperative complications were encountered. On follow-up, no wound complications were noted and all patients appeared satisfied with their cosmetic outcome. One patient was readmitted for a low-grade fever, but the NVIS technique was not identified as a contributor. CONCLUSION NVIS is a safe and feasible minimal access alternative, which improves cosmesis and may decrease complications associated with other minimally invasive techniques. Further analysis in a larger patient population is warranted to support our findings.


title: Clinical features, laboratory characteristics, and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19): Early report from the United States.

text: Background Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV2), is an ongoing pandemic that has already affected millions of patients worldwide, and is associated with significant morbidity and mortality burden. Although the clinical and laboratory characteristics of this illness have been reported in patients from China and Europe, data are scant in the United States. Methods We extracted data regarding all patients hospitalized at our hospital with COVID-19 infection between March 1 and April 4, 2020. Presenting signs and symptoms, laboratory and imaging findings, treatment, and complications were recorded from electronic medical records (EMRs). The primary composite endpoint was admission to intensive care unit (ICU), shock, or death. Results We had a total of 43 patients tested for COVID-19 at the emergency room (ER) or during hospitalization, 16 (37%) of whom were admitted with COVID-19 infection. The mean age was 65.5 years and 75% were males. The most common presenting symptoms were fever (94%), cough (88%), and dyspnea (81%). A loss of smell and taste sensations were reported by three (19%) patients. Low oxygen saturation was present in 38% of patients, whilst 31% were hypotensive on admission. Hyponatremia (50%), elevated C-reactive protein (CRP; 100%), and lactate dehydrogenase (LDH; 80%) were common. Acute renal failure, myocardial injury, and elevation in aminotransferases occurred in 69%, 19%, and 38% patients, respectively. The primary composite endpoint occurred in 50% of patients. A total of three patients died; all were aged 70 years or older. Conclusions Laboratory abnormalities and acute renal failure were common in hospitalized patients with SARS-CoV2 infection in our center. Admission to ICU and mechanical ventilation were common.


Is it time for airway management education to be mandatory?


UK preparedness for children with Ebola infection.


title: Weighing in on Body Mass Index and Infection After Total Joint Arthroplasty: Is There Evidence for a Body Mass Index Threshold?

text: BACKGROUND Although morbid obesity is considered a modifiable risk factor for periprosthetic joint infection (PJI), there is no consensus regarding an appropriate threshold for body mass index (BMI) above which a high risk for infection may outweigh the benefits of surgery. QUESTIONS/PURPOSES (1) Is there a BMI cutoff threshold that is associated with increased risk for PJI? (2) Is the risk of PJI increased in higher obesity classes? METHODS A retrospective study was conducted of all primary THAs and TKAs performed at one institution between 2006 and 2015. Overall 19,226 patients were eligible to be included in the study; 1053 patients were excluded as a result of incomplete data, resulting in a final cohort of 18,173 patients (8757 TKAs and 9416 THAs). PJI was defined using the International Consensus Meeting criteria. To ensure accurate followup, and because there is evidence to support the association between obesity and early infection, we identified PJI within 90 days of the index surgery. This relationship was examined separately for BMI as a continuous variable and for each BMI category as defined by the Centers for Disease Control and Prevention (underweight ≤ 18.49 kg/m; normal 18.5-24.9 kg/m; overweight 25-29.9 kg/m; obese class I 30-34.9 kg/m; obese class II 35-39.9 kg/m; obese class III ≥ 40 kg/m). Analyses were performed with logistic regression, accounting for both patient and surgical risk factors. A BMI threshold was evaluated with a receiver operating characteristic (ROC) curve and the Youden index. RESULTS The area under the ROC curve for BMI and risk of PJI within 90 days was only 0.58 (confidence interval [CI], 0.52-0.63) suggesting such a cutoff was not much better than random chance. Among the BMI classes, patients with class III obesity (≥ 40 kg/m) were the only ones showing a higher risk for PJI within 90 days (odds ratio [OR], 3.09 [1.46-6.54]; p = 0.003). The risk of developing PJI was not greater for overweight (OR, 0.72; 95% CI, 0.38-1.4), class I obese (OR, 1.06; 95% CI, 0.57-2.0), or class II obese (OR, 1.08; 95% CI, 0.52-2.2) patients. Underweight patients also demonstrated no increased risk for PJI (OR, 1.80; 95% CI, 0.23-13.9). CONCLUSIONS The risk for infection increases gradually throughout the full range of BMI, but no threshold exists. Weight reduction before surgery may mitigate risk for infection for all patients with a BMI above normal. Of note, patients with a BMI > 40 kg/m carried a threefold higher risk for PJI and for these patients, the risks of surgery must be carefully weighed against its benefits. LEVEL OF EVIDENCE Level III, therapeutic study.


Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China.