title: News in wound healing and management.

text: PURPOSE OF REVIEW Nonhealing wounds are a significant problem in the healthcare system all over the world. The present review focuses on some recent developments and promising clinical progresses in wound management. RECENT FINDINGS New findings have increased our knowledge in several wound areas. In the treatment of wounds, the new trend in the wound device marked is to produce dressings containing compounds or drugs. This could be local antiseptics (silver, other antiseptics, honey) and pain relieving drugs such as ibuprofen and morphine. New treatments such as anti-tumor necrosis factor alfa (anti-TNFalpha) and Lactobacillus plantarum cultures have also been successfully used in hard to heal, atypical wounds. Knowledge on influencing factors as smoking and biofilm on the healing process has also been improved. Smoking results in delayed healing and increased risk of postoperative infection, whereas the role of biofilm is still at an exploratory level. Organizing models for optimal wound management are constantly being developed and refined. SUMMARY Recent knowledge on the importance of new dressing materials containing active substances, new treatments for atypical wounds, influencing factors on the healing process and organization in the wound area are increasingly been launched. This may in the coming years significantly improve the treatment outcome of problem wounds.


title: Detection of herpesviruses 1-6 and community-acquired respiratory viruses in patients with chronic rhinosinusitis with nasal polyposis.

text: OBJECTIVE To evaluate the prevalence of human herpesviruses (HHV) 1-6 and community-acquired respiratory viruses (CARVs) in specimens from patients with nasal polyposis undergoing functional endoscopic sinus surgery (FESS) and investigate the potential clinical role. METHODS Viral occurrence was evaluated by molecular methods in polyp, turbinate mucosa, and pre- and postoperative scraping specimens from 35 consecutive patients at different time points in relation to FESS. RESULTS Overall, 21 patients (60%) were positive to at least one virus in at least one specimen; in particular, 12.1% of all specimens for HHV-6 (3/35 polyps, 11/31 turbinates, 1 presurgical scraping) and 10.5% for Epstein-Barr virus (EBV) (8/35 polyps, 3/31 turbinates, 1/29 pre- and 1/29 postsurgical scraping), followed by CMV and HSV-1 (both 1.6%; 1/35 polyps, 1/29 postsurgical scraping and 2/35 polyps, respectively). EBV positivity tended to be higher in polyps, as well as HHV-6 in adjacent healthy turbinate mucosa, although no significant association was found. Only one preoperative cytological specimen was positive to parainfluenza virus-1. CONCLUSION No association between the development of nasal polyps, herpesviruses and CARVs seems to exist. However, the higher EBV frequency in polyps could suggest a causative role or persistence in the inflammatory lymphoid tissue.


Repair of a anastomotic-vaginal fistula with biological mesh (Permacol™) after surgery for low rectal cancer.


title: Thromboinflammatory response in SARS-CoV-2 sepsis.

text: Viral sepsis is rare, and its real incidence is not known. SARS-CoV-2 infection causes the release of a significant amount of pro-inflammatory cytokines that aggravates interstitial pneumonia and evolves in viral sepsis with prominent hypercoagulability. We believe it is useful and advisable to establish early immunomodulator therapy and the prophylaxis anticoagulant therapy should be rethought.


title: Impact of Casting and Splinting Manipulations on Below-Dressing Pressures: An Experimental Model.

text: BACKGROUND We tested how different applications of casts and splints affect underlying below-dressing pressures and how these dressings respond to swelling. METHODS A 3-in polyvinyl chloride pipe with an attached 100 mL saline bag to the outer surface was used to simulate a human forearm. A pressure transducer was attached to the bag and connected to a monitor providing continuous pressure measurements. Either a circumferential fiberglass cast or single-sided plaster splint was applied around the bag. To simulate the dressing's compliance to soft tissue swelling, change in pressure was measured after 25 mL of saline was injected into the bag. Compliance was determined by calculating change in volume over change in pressure as volume was added. RESULTS In our 150 mL model, cast bivalving reduced pressure up to 28%, and splitting the cotton padding of a splint reduced pressures up to 33%. The mean compliance (ability to accommodate swelling) across all volume intervals was 182% greater in a bivalved cast versus a cast and 21% greater in a cotton-split splint versus a splint. Below-dressing pressure of a tightly wrapped elastic bandage was up to 2.76× greater than a medium tension bandage and up to 6.44× greater than a loosely applied bandage. A splint with real cotton padding had a 28% greater pressure than a splint with synthetic soft-roll padding. CONCLUSIONS Splitting a dressing, utilizing synthetic cotton padding, and applying an elastic bandage cautiously can help reduce surface pressures and allow the construct to be more accommodating to soft tissue swelling.


title: Gene expression comparison of flow diversion and coiling in an experimental aneurysm model.

text: BACKGROUND AND PURPOSE Mechanisms of both healing and complications, including spontaneous aneurysm rupture, remain unclear following flow diverter treatment. The aim of this study was to compare gene expression of various key molecules involved in the healing of aneurysms, between aneurysms treated with microcoils and flow diverters. METHODS Saccular aneurysms were created in rabbits. Aneurysms were treated with coils (n=6) or flow diverters (n=6). Aneurysms were harvested at 4 weeks following treatment and used for gene expression and zymography experiments. Genes with a fold change of 1.2 or more were considered upregulated whereas those with a fold change of 0.8 or less were considered downregulated. RESULTS All coil embolized aneurysms were completely occluded at follow-up. Two aneurysms were occluded and the remaining four samples were incompletely occluded in the flow diverter treated group. The following genes were expressed at lower levels in the flow diverter group compared with the coiled aneurysm group: proteinases (matrix metalloproteinases 2 and 9), cellular markers (endothelial nitric oxide synthase and smooth muscle actin), and structural proteins (collagens and fibronectin). Genes related to inflammation (tumor necrosis factor α and monocyte chemoattractant protein 1) were upregulated in flow diverter treated aneurysms compared with coil embolized aneurysms. Notably, the enzymatic activity of active matrix metalloproteinase 9 was high in aneurysms treated with flow diverters. CONCLUSIONS Our findings may provide improved understanding of rupture risk and healing following aneurysm treatment and inform development of therapies aimed at lowering rupture risk and accelerating healing.


title: Giant hepatocellular carcinoma with bone metastasis in a young adult, emerged from pigmented adenoma with beta-Catenin activation: A case report.

text: INTRODUCTION Hepatocellular carcinomas (HCC) that are very large in size are a very rare finding in young adult. The malignant transformation of a pigmented hepatocellular adenoma (HCA) with beta-Catenin activation is a possible cause for appearance of HCC. PRESENTATION OF CASE We present the case of a 33-year-old male with a huge HCC with bone metastasis, emerged from pigmented HCA with beta-Catenin activation. As a two-stage surgical procedure, a left hepatectomy followed by a partial rib resection was performed. DISCUSSION Giant hepatocellular carcinomas mostly develop in non-cirrhotic livers and at time of diagnosis an extrahepatic spread occurs in up to 15%. In the present case, the progression from a benign HCA to malignant HCC was documented, as a unique finding. Surgical resection is the only curative treatment and was successfully performed in this case. CONCLUSION Hepatobiliary surgery with resection of metastases is the treatment with best long-term survival for patients with huge HCC. Molecular characterization as well as pigmentation analysis is useful tools for risk assessment of HCA.


title: Campylobacteriosis in dogs and cats: a review.

text: Campylobacter species are commonly isolated from faecal samples collected from dogs and cats, with the most prevalent species being C. upsaliensis, C. helveticus, and C. jejuni. Although the majority of dogs and cats are subclinically infected, some will develop mild to moderate enteritis. Immature animals, animals from intensive housing backgrounds, and animals with concurrent disease are especially predisposed to infection and the development of clinical signs. Bacterial culture methods applied in diagnostic laboratories remain biased to C. jejuni and C. coli detection, but molecular methods to diagnose Campylobacter spp. infections in dogs and cats have become widely available and can aid rapid and accurate diagnosis. Multilocus sequence typing has also been developed for subtyping different strains and has been used in epidemiological investigations. In the majority of cases, clinical signs are self-limiting and antimicrobial treatment is not warranted. Campylobacter spp. isolated from dogs and cats have shown resistance to commonly used antimicrobials, so antimicrobial therapy should only be administered where this is justified. Contact with dogs and cats is a recognised risk factor for human campylobacteriosis, thus people living or working in close contact with cats and dogs should be made aware of the zoonotic organisms these animals can shed.


title: [Colorectal anastomosis using a compression device].

text: BACKGROUND The most severe complication following an intestinal anastomosis is the dehiscence with the consequent development of sepsis, fistulas, stenosis, and death. For this reason the compression anastomosis (NiTi) system was developed, with the aim of reducing these complications. MATERIAL AND METHODS A retrospective study was conducted, from 1 June 2012 to 30 August 2014, on total of 14 patients operated on the Humanitas Hospital Medical Group Coyoacán, the ASMED, and Clínica Médica Sur. The subjects were predominantly male 65%, a mean age of 58 years, with range 30-79 years. RESULTS A total of 14 patients were included. The indication for surgery was complicated diverticular disease Hinchey II-III (36%), and the procedures performed were: 6 (43%) left hemicolectomy with primary end to end compression anastomosis, 2 (14%) major complications (dehiscence wall and anastomosis), 1 (7%) minor complication (infection of the soft tissues). There was a mean 98ml (range 20-300ml) of intraoperative bleeding, with start of oral feeding on the second day, a mean hospital stay of 4 days (range 2-10), one patient with ileo-rectal anastomosis dehiscence presented on the 4th post-operative day, and performing anastomosis with stapling device and loop ileostomy. Stenosis developed in 7% during follow-up and was resolved with a new anastomosis stapler. CONCLUSIONS The NiTi device is an additional alternative for colorectal anastomosis, mainly in low anastomosis, obtaining good results in this study without major complications.


title: Short-term outcomes after transanal and laparoscopic total mesorectal excision for rectal cancer.

text: BACKGROUND Transanal total mesorectal excision (taTME) has potential benefits of better visual control, especially in male patients with a high body mass index and low rectal cancer. However, this method has not yet been validated in clinical trials. The aim of this study was to compare the short-term outcomes of transanal and laparoscopic (lap) TME. METHODS From October 2013 to January 2015, consecutive patients undergoing transanal or laparoscopic TME for biopsy-proven mrT1-4aN0-2M0 rectal cancer were included in a prospective database. Patients with Eastern Cooperative Oncology Group performance status 2 and higher and patients undergoing partial mesorectal excision were excluded. This analysis focused on short-term surgical outcomes. RESULTS From October 2013 to January 2015, 22 taTME procedures and 23 laparoscopic TME procedures were performed. Patient characteristics were comparable between groups, but more patients in the taTME group underwent neoadjuvant (chemo) radiotherapy (87 vs. 48 %, p = 0.006). Median operative time was 320 min in the taTME group and 305 min in the lapTME group. There was one conversion in each group, but the transanal procedure was converted to laparoscopic resection. Transanal specimen extraction was performed in 86 versus 48 % patients in taTME and lapTME groups accordingly (p = 0.021). There was no post-operative mortality and post-operative morbidity in the taTME and lapTME groups was similar (27 vs. 26 %). One patient in the taTME group had positive circumferential resection margins. Oncologic results from resected specimens were comparable. CONCLUSIONS Our initial experience demonstrates comparable short-term results for taTME and lap TME. Further investigation is necessary to assess long-term functional and oncologic outcomes.


title: Clinical and histologic tissue responses of skin incisions closed with glycomer 631 and lactomer 9-1 using a subcuticular technique in pigs.

text: BACKGROUND Glycomer 631 and lactomer 9-1 are absorbable suture materials indicated for soft tissue approximation in non-infected wounds. Pigs are often used as surgical models in translational research; however, reports of tissue reactions to both suture materials in pigs are limited. The aim of this study was to assess clinical and histologic responses of skin incisions closed with a subcuticular technique using glycomer 631 and lactomer 9-1 in pigs. RESULTS Skin incisions on 17 pigs were closed with glycomer 631 and lactomer 9-1, and a clinical reactive score (CRS) including erythema, swelling, discharge and dehiscence was calculated on postoperative days 7 and 14. Subcuticular tissue reaction was assessed histologically on postoperative day 14 (the presence of extravascular neutrophils, macrophages, multinucleated giant cells, lymphocytes, fibroblasts, bacterial colonies and the overall severity of the inflammatory response to the suture material), and the cumulative score of the variables was calculated as an aggregate tissue irritation score (ATIS). Tissue samples were examined for suture extrusion and evaluated microbiologically. The clinical reactive score did not differ between the suture materials. Only one ATIS variable, namely the overall severity of the inflammatory response, was lower (p = 0.029) when glycomer 631 was used. Suture extrusion was found in 10/17 of the incisions closed by glycomer 631 and in 7/13 of the incisions closed by lactomer 9-1. Trueperella pyogenes was isolated from the skin and from the area of tissue reaction in six pigs. CONCLUSIONS No difference in CRS between the suture materials was observed, and thus both materials may be used for the subcuticular technique in pigs. Glycomer 631 induced less tissue reaction only in terms of the overall severity of the inflammatory response. Suture extrusion was observed in more than 50% of incisions regardless of the suture material, possibly due to a large amount of suture material in the wound. Trueperella pyogenes was the only pathogen isolated from the tissue surrounding the suture material.


title: Individualizing Management of Complex Esophageal Pathology Using Three-Dimensional Printed Models.

text: PURPOSE In complex esophageal cases, conventional two-dimensional imaging is limited in demonstrating anatomic relationships. We describe the utility of three-dimensional (3D) printed models for complex patients to individualize care. DESCRIPTION Oral effervescent agents, with positive enteric contrast, distended the esophagus during computed tomography (CT) scanning to facilitate segmentation during post-processing. The CT data were segmented, converted into a stereolithography file, and printed using photopolymer materials. EVALUATION In 1 patient with a left pneumonectomy, aortic bypass, and esophageal diversion, 3D printing enabled visualization of the native esophagus and facilitated endoscopic mucosal resection, followed by hiatal dissection and division of the gastroesophageal junction as treatment. In a second patient, 3D printing allowed enhanced visualization of multiple esophageal diverticula, allowing for optimization of the surgical approach. CONCLUSIONS Printing of 3D anatomic models in patients with complex esophageal pathology facilitates planning the optimal surgical approach and anticipating potential difficulties for the multidisciplinary team. These models are invaluable for patient education.


title: Flexible versus rigid single-port peritoneoscopy: a randomized controlled trial in a live porcine model followed by initial experience in human cadavers.

text: INTRODUCTION We compared single incision laparoscopic surgery with flexible endoscope ("flexible SILS") and with rigid optic ("rigid SILS") for access to 11 elective sites of peritoneal carcinomatosis. MATERIALS AND METHODS Back-to-back flexible and rigid SILS peritoneoscopy were performed in ten live pigs. SILS peritoneoscopy was performed using a flexible endoscope or a rigid optic, in random order, together with two rigid 5-mm laparoscopic forceps. Primary endpoint was access success rate to 11 elective sites of peritoneal carcinomatosis. Findings for the most favorable option were then assessed in four human cadavers. RESULTS In the porcine model, the overall rate of access to targets was 98% with flexible SILS and 87% with rigid SILS (p < 0.001). Both flexible and rigid SILS allowed a 100% access rate to diaphragmatic domes, paracolic gutters, splenic and hepatic hilum, pelvic floor, and trigonal bladder. The rates of access to other sites by flexible versus rigid SILS, respectively, were: root of the mesentery (90 vs. 50%), origin of the inferior mesenteric vein (90 vs. 50%), inferior vena cava (100 vs. 90%), and cul-de-sac of Douglas (100 vs. 50%). No complications were observed. Procedures were performed in mean time of 26 and 24 min, respectively. These findings were confirmed for flexible SILS in four human cadavers. CONCLUSIONS Flexible SILS is superior to rigid SILS to evaluate the peritoneal cavity in a timely manner. This suggests a need for flexible instrumentation or other technical solutions to perform thorough minimally invasive surgical evaluation of peritoneal carcinomatosis.


title: Do Complications Alter Postoperative Weight Loss 1 Year After Primary and Revisional Roux-en-Y Gastric Bypass?

text: BACKGROUND Around 10 % of the bariatric surgery patients experience postoperative complications (<30 days). It could be hypothesized that complications influence postoperative weight loss, which is one of the most important endpoints of bariatric surgery. Therefore, this study inventoried the effect of complications on postoperative weight loss. METHODS A consecutive database including patients who were operated from November 2007 onwards was retrospectively reviewed. All short-term complications were classified according to the Clavien-Dindo classification. Weight loss was assessed at 6 and 12 months postoperatively. RESULTS A total of 1130 patients underwent either primary (n = 907, 80.3 %) or revisional (n = 233, 19.7 %) surgery till October 2013. Short-term complications occurred in 115 (10.2 %) patients, of whom 48 (41.7 %) had a severe (Clavien-Dindo ≥ 3) complication. One year post surgery, 184 patients (16.3 %) were lost to follow-up. Patients with a short-term complication had a higher percentage of excess weight loss (%EWL) at 6 months (58.6 (SD 16.6) versus 52.9 (SD 17.6), p = 0.003) and 1 year (71.9 (SD 22.3) versus 65.9 (SD 21.3), p = 0.017) of follow-up. Although a trend was seen toward higher BMI loss and total weight loss (TWL) after 6 months, no effect was seen 1 year postoperatively. In multivariable linear regression analysis, complications were not a significant predictor for 1-year %EWL. CONCLUSIONS Although short-term complications alter 1-year %EWL, no effect was seen on BMI loss and TWL. In addition, complications were not a predictor in a multivariable linear regression model for 1-year %EWL. It can be concluded that short-term complications do not impair weight loss after Roux-en-Y gastric bypass.


title: Qivas Therapy for Treatment of Implant Associated MDR Bacterial Infection.

text: INTRODUCTION Orthopedic implant-associated infections are difficult to treat, both physically and psychologically, for the patient and the surgeon as well. Organisms capable of forming biofilms tend to be more virulent and have ability of causing chronic infections. Chronic implant associated infections are very difficult to treat, requires a lot of time, money and other resources. Chronic infections produce a lot of morbidity and sometimes mortality to the patient. CASE REPORT A 40-year-old male treated for bilateral acetabular fracture sustained after fall from height due to an episode of seizure. After acetabular surgery, he developed surgical site infection unresponsive to wound wash and intravenous antibiotics. After two weeks, we started treatment with Qurion solution and Vacuum assisted suction (QiVAS) to which patient responded very well and his infection was cured. We are not aware of any study or case report using QiVAS therapy for treatment of infection associated with orthopaedic implant. CONCLUSION Orthopaedic implant related infection can be difficult to treat especially if caused by multidrug resistant organisms capable of forming biofilm. QiVAS therapy is a new method which can be used in such difficult situations to treat infection without removal of implant within short period of time thus reducing morbidity for patients.


title: Bilateral Adrenalectomy: Differences between Cushing Disease and Ectopic ACTH-Producing Tumors.

text: BACKGROUND Bilateral adrenalectomy (BA) is a curative treatment for hypercortisolism in patients with corticotropin (ACTH)-dependent Cushing syndrome. Indications include refractory Cushing's disease (CD) following failed pituitary surgery, and occult or unresectable ectopic ACTH-producing neoplasms (EA). METHODS This was a single-center, retrospective review (1995-2017) of patients undergoing BA for CD or EA. Demographics, laboratory findings, and intraoperative and postoperative variables were analyzed. RESULTS Of 137 patients, 83 (61%) had CD and 54 (39%) had EA; 87% of CD patients were female versus 46% of EA patients (p < 0.0001). Mean age at diagnosis was 40 ± 15 years for CD and 49 ± 18 years for EA (p = 0.004). Preoperative serum cortisol concentrations were higher in the EA cohort (63 ± 40 μg/dL) versus the CD cohort (33 ± 19 μg/dL) [p < 0.001], with no significant differences in serum ACTH. Time from diagnosis until adrenalectomy was 54 ± 69 months for CD versus 4 ± 13 for EA (p = 0.002). Most patients underwent minimally invasive surgery (MIS; 86% CD vs. 75% EA; p = 0.19). There was no difference between the rates of conversion to an open approach, intraoperative blood loss, or operative time between groups, and no difference between complications in CD versus EA (p = 1.0). Five-year survival was significantly shorter among the EA cohort (30% for EA vs. 80% for CD; p < 0.001). CONCLUSION Patients with EA presented with higher serum cortisol levels compared with patients with CD. EA patients were more likely to require intraoperative transfusion and postoperative intensive care. BA in patients with CD and EA can be performed safely in an MIS fashion, with similar morbidity; however, survival at 5 years was significantly less in the EA cohort.


title: Ethicists, doctors and triage decisions: who should decide? And on what basis?

text: We report here an emerging dispute in Italy concerning triage criteria for critically ill covid-19 patients, and how best to support doctors having to make difficult decisions in a context of insufficient life saving resources. The dispute we present is particularly significant as it juxtaposes two opposite views of who should make triage decisions, and how doctors should best be supported. There are both empirical and normative questions at stake here. The empirical questions pertain to the available level of evidence that healthcare professionals would rather not be left alone with their 'clinical judgments' to make triage decisions, and to the accounts of distributive justice that doctors and healthcare professionals rely on, when making triage decisions. The normative questions pertain to how this empirical evidence should inform guidelines on how prioritisation decisions are made in a context of emergency, and who gets to have the authority to do so. This debate goes beyond the discussion of the care of critically ill patients with COVID-19 and has broader implications beyond the national context for the discussion of how to relieve moral distress in contexts of imbalances between healthcare resources and clinical needs of a population.


title: Individualized treatment based on CYP3A5 single-nucleotide polymorphisms with tacrolimus in ulcerative colitis.

text: BACKGROUND/AIMS The pharmacokinetics of tacrolimus (TAC) is known to be largely influenced by single-nucleotide polymorphisms (SNPs) in CYP3A5. Patients starting TAC require careful dose adjustment, owing to the wide range of optimal dosages, depending on their CYP3A5 expression status. Here, we evaluated whether individualization of TAC dosages based on CYP3A5 SNPs would improve its therapeutic efficacy in ulcerative colitis. METHODS Twenty-one patients were prospectively treated, with their initial dosage adjusted according to their CYP3A5 status (0.1, 0.15, and 0.2 mg/kg/day for CYP3A5*3/*3, CYP3A5*1/*3, and CYP3A5*1/*1, respectively). Their clinical outcomes were compared with those of patients treated with a fixed dose (0.1 mg/kg/day). RESULTS The first blood trough level of CYP3A5 expressors, CYP3A5*1/*3 or CYP3A5*1/*1, and the overall rate in achieving the target blood trough level within a week in the individualized-dose group were significantly higher than those in the fixed-dose group (5.15±2.33 ng/mL vs. 9.63±0.79 ng/mL, P=0.035 and 12.5% vs. 66.7%, P=0.01). The remission rate at 2 weeks in the expressors was as high as that in the nonexpressors, CYP3A5*3/*3, in the individualized-dose group. CONCLUSIONS Individualized TAC treatment is effective against ulcerative colitis regardless of the CYP3A5 genotype.


title: A New Video Tumorial by Young Cancer Patients Dedicated to COVID-19 Pandemic and Lockdown (Re: J Adolesc Young Adult Oncol. [Epub ahead of print]; DOI: 10.1089/jayao.2020.0008).

text: After the video tutorials created a few months ago and published in the Journal of Adolescent and Young Adult Oncology, Milan's Youth Project young cancer patients decided to record another video: a "special issue" dedicated to the coronavirus disease 2019 pandemic. The video addresses critical issues of the social isolation imposed by the lockdown and the fear the patients face in addition to their actual worries related to the disease. When many people across the world are forced to social distance for the imposed lockdown, the positive attitude and the advice of young cancer patients who experience social isolation regularly may be of great support and a fine example.


title: Muscle mass, strength, and physical performance predicting activities of daily living: a meta-analysis.

text: Background Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are essential for independent living and are predictors of morbidity and mortality in older populations. Older adults who are dependent in ADLs and IADLs are also more likely to have poor muscle measures defined as low muscle mass, muscle strength, and physical performance, which further limit their ability to perform activities. The aim of this systematic review and meta-analysis was to determine if muscle measures are predictive of ADL and IADL in older populations. Methods A systematic search was conducted using four databases (MEDLINE, EMBASE, Cochrane, and CINAHL) from date of inception to 7 June 2018. Longitudinal cohorts were included that reported baseline muscle measures defined by muscle mass, muscle strength, and physical performance in conjunction with prospective ADL or IADL in participants aged 65 years and older at follow-up. Meta-analyses were conducted using a random effect model. Results Of the 7760 articles screened, 83 articles were included for the systematic review and involved a total of 108 428 (54.8% female) participants with a follow-up duration ranging from 11 days to 25 years. Low muscle mass was positively associated with ADL dependency in 5/9 articles and 5/5 for IADL dependency. Low muscle strength was associated with ADL dependency in 22/34 articles and IADL dependency in 8/9 articles. Low physical performance was associated with ADL dependency in 37/49 articles and with IADL dependency in 9/11 articles. Forty-five articles were pooled into the meta-analyses, 36 reported ADL, 11 reported IADL, and 2 reported ADL and IADL as a composite outcome. Low muscle mass was associated with worsening ADL (pooled odds ratio (95% confidence interval) 3.19 (1.29-7.92)) and worsening IADL (1.28 (1.02-1.61)). Low handgrip strength was associated with both worsening ADL and IADL (1.51 (1.34-1.70); 1.59 (1.04-2.31) respectively). Low scores on the short physical performance battery and gait speed were associated with worsening ADL (3.49 (2.47-4.92); 2.33 (1.58-3.44) respectively) and IADL (3.09 (1.06-8.98); 1.93 (1.69-2.21) respectively). Low one leg balance (2.74 (1.31-5.72)), timed up and go (3.41 (1.86-6.28)), and chair stand test time (1.90 (1.63-2.21)) were associated with worsening ADL. Conclusions Muscle measures at baseline are predictors of future ADL and IADL dependence in the older adult population.


title: Adhesions after abdominal surgery: a systematic review of the incidence, distribution and severity.

text: Abdominal adhesions are associated with increased postoperative complications, cost and workload. We performed a systematic review with statistical pooling to estimate the formation rate, distribution and severity of postoperative adhesions in patients undergoing abdominal surgery. A literature search was carried out for all articles reporting on the incidence, distribution and severity of adhesions between January 1990 and July 2011. Twenty-five articles fulfilled the inclusion criteria. The weighted mean formation rate of adhesions after abdominal surgery was 54 % (95 % confidence interval [CI] 40-68 %), and was 66 % (95 % CI 38-94 %) after gastrointestinal surgery, 51 % (95 % CI 40-63 %) after obstetric and gynaecological surgery and 22 % (95 % CI 7-38 %) after urological surgery. The mean overall severity score was 1.11 ± 0.98 according to the Operative Laparoscopy Study Group classification. Laparoscopic surgery reduced the adhesion formation rate by 25 % and decreased the adhesion severity score (laparoscopic; 0.36 ± 0.69 vs. open; 2.14 ± 0.84) for gastrointestinal surgery. Our results demonstrate that the incidence and severity of abdominal adhesions varies between surgical specialties and procedures. An increased awareness of adhesions can help in identifying the underlying mechanisms of adhesion formation and novel therapeutic approaches, while also improving the surgical consent process.


Parosmia as an Early Symptom of Acute SARS-CoV-2 Infection.


title: Protection against cholera from killed whole-cell oral cholera vaccines: a systematic review and meta-analysis.

text: BACKGROUND Killed whole-cell oral cholera vaccines (kOCVs) are becoming a standard cholera control and prevention tool. However, vaccine efficacy and direct effectiveness estimates have varied, with differences in study design, location, follow-up duration, and vaccine composition posing challenges for public health decision making. We did a systematic review and meta-analysis to generate average estimates of kOCV efficacy and direct effectiveness from the available literature. METHODS For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and the Cochrane Review Library on July 9, 2016, and ISI Web of Science on July 11, 2016, for randomised controlled trials and observational studies that reported estimates of direct protection against medically attended confirmed cholera conferred by kOCVs. We included studies published on any date in English, Spanish, French, or Chinese. We extracted from the published reports the primary efficacy and effectiveness estimates from each study and also estimates according to number of vaccine doses, duration, and age group. The main study outcome was average efficacy and direct effectiveness of two kOCV doses, which we estimated with random-effect models. This study is registered with PROSPERO, number CRD42016048232. FINDINGS Seven trials (with 695 patients with cholera) and six observational studies (217 patients with cholera) met the inclusion criteria, with an average two-dose efficacy of 58% (95% CI 42-69, I2=58%) and effectiveness of 76% (62-85, I2=0). Average two-dose efficacy in children younger than 5 years (30% [95% CI 15-42], I2=0%) was lower than in those 5 years or older (64% [58-70], I2=0%; p<0·0001). Two-dose efficacy estimates of kOCV were similar during the first 2 years after vaccination, with estimates of 56% (95% CI 42-66, I2=45%) in the first year and 59% (49-67, I2=0) in the second year. The efficacy reduced to 39% (13 to 57, I2=48%) in the third year, and 26% (-46 to 63, I2=74%) in the fourth year. INTERPRETATION Two kOCV doses provide protection against cholera for at least 3 years. One kOCV dose provides at least short-term protection, which has important implications for outbreak management. kOCVs are effective tools for cholera control. FUNDING The Bill & Melinda Gates Foundation.


Reply: 68Ga-DOTATATE PET/CT Versus MRI: Why the Comparison of 68Ga-DOTATATE PET/CT to an Appropriate MRI Protocol Is Essential.


title: Extended 3D approach for quantification of abnormal ascending aortic flow.

text: BACKGROUND Flow displacement quantifies eccentric flow, a potential risk factor for aneurysms in the ascending aorta, but only at a single anatomic location. The aim of this study is to extend flow displacement analysis to 3D in patients with aortic and aortic valve pathologies. METHODS 43 individuals were studied with 4DFlow MRI in 6 groups: healthy, tricuspid aortic valve (TAV) with aortic stenosis (AS) but no dilatation, TAV with dilatation but no AS, and TAV with both AS and dilatation, BAV without AS or dilatation, BAV without AS but with dilation. The protocol was approved by our institutional review board, and informed consent was obtained. Flow displacement was calculated for multiple planes along the ascending aorta, and 2D and 3D analyses were compared. RESULTS Good correlation was found between 2D flow displacement and both maximum and average 3D values (r>0.8). Healthy controls had significantly lower flow displacement values with all approaches (p<0.05). The highest flow displacement was seen with stenotic TAV and aortic dilation (0.24±0.02 with maximum flow displacement). The 2D approach underestimated the maximum flow displacement by more than 20% in 13 out of 36 patients (36%). CONCLUSIONS The extended 3D flow displacement analysis offers a more comprehensive quantitative evaluation of abnormal systolic flow in the ascending aorta than 2D analysis. Differences between patient subgroups are better demonstrated, and maximum flow displacement is more reliably assessed.


Laying straw men to rest: author's reply to "Urgency and uncertainty: covid-19, face masks, and evidence informed policy".


Biobanking During the COVID-19 Pandemic.


title: Acute chloroquine poisoning: A comprehensive experimental toxicology assessment of the role of diazepam.

text: BACKGROUND AND PURPOSE Resurgence in the use of chloroquine as a putative treatment for COVID-19 has seen recent cases of fatal toxicity due to unintentional overdoses. Protocols for the management of poisoning recommend diazepam, although there are uncertainties in its pharmacology and efficacy in this context. The aim was to assess the effects of diazepam in experimental models of chloroquine cardiotoxicity. EXPERIMENTAL APPROACH In vitro experiments involved cardiac tissues isolated from rats and incubated with chloroquine, alone, or in combination with diazepam. In vivo models of toxicity involved chloroquine administered intravenously to pentobarbitone-anaesthetised rats and rabbits. Randomised, controlled interventional studies in rats assessed diazepam, clonazepam and Ro5-4864 administered: (i) prior, (ii) during, and (iii) after chloroquine; and the effects of diazepam: (iv) at high dose, (v) in urethane-anaesthetised rats, and (vi) co-administered with adrenaline. KEY RESULTS Chloroquine decreased the developed tension of left atria, prolonged the effective refractory period of atria, ventricular tissue and right papillary muscles, and caused dose-dependent impairment of haemodynamic and electrocardiographic parameters. Cardiac arrhythmias indicated impairment of atrioventricular conduction. Studies (i), (ii) and (v) showed no differences between interventions and control. Diazepam increased heart rate in study (iv) and, as with clonazepam, also prolonged the QTc interval in study (iii). Combined administration of diazepam and adrenaline in study (vi) improved cardiac contractility but caused hypokalaemia. CONCLUSION AND IMPLICATIONS Neither diazepam, nor other ligands for benzodiazepine binding sites, protect against or attenuate chloroquine cardiotoxicity. However, diazepam may augment the effe cts of positive inotropes in reducing chloroquine cardiotoxicity.


title: Effects of interferons α/β on the proliferation of human micro- and macrovascular endothelial cells.

text: Synthetic interferons (IFNs) are used in the treatment of several types of cancer. In addition to an antitumor effect, IFNs show antiangiogenic activity. The aim of this study was to investigate the effects of IFN-α and IFN-β on human micro- and macrovascular endothelial cells in vitro [human micro vascular lung endothelial cells (HMVEC-L) and human umbilical cord endothelial cells (HUVEC)]. By immunohistochemical staining and quantitative reverse transcriptase (RT)-polymerase chain reaction, we studied expression of type I IFN receptors. We evaluated the effects of IFN-α and IFN-β on the proliferation (DNA content), apoptosis (DNA fragmentation by enzyme-linked immunosorbent assay), and cell cycle distribution (flow-cytometric analysis) of endothelial cells. HUVEC and HMVEC-L cells show comparable expression level of the distinct IFN receptor subtypes. Proliferation of HMVEC-L and HUVEC was inhibited by IFN-β (the half maximal inhibitory concentration [IC(50)] = 60 and 90 IU/mL, respectively), but not by IFN-α at a dose up to 1,000 IU/mL. An interesting and unexpected observation was an inhibition of apoptosis by IFN-β. After 72 h of treatment with IFN-β. Cell cycle inhibition occurs in late S-phase in both cell lines. In conclusion, only IFN-β, not IFN-α (10-1,000 IU/mL), has an inhibitory activity on endothelial cell proliferation. Surprisingly, apoptosis was decreased by IFN treatment, whereas inhibition of proliferation is caused by cell cycle arrest in late S-phase.


title: Selecting coronavirus disease 2019 patients with negligible risk of progression: early experience from non-hospital isolation facility in Korea.

text: Background/Aims As the novel coronavirus (coronavirus disease 2019 [COVID-19]) outbreak progresses rapidly, staying home is recommended for suspected patients; however, the safety of this recommendation is uncertain. In Korea, non-hospital facilities called "living and treatment centers (LTCs)" have been established since 5 March 2020. The LTCs provided a unique opportunity to evaluate the safety of selection criteria for low-risk groups. Methods Between 5 March and 9 April 2020, patients with COVID-19 who met the following criteria were admitted to the LTC; alert, age below 65 years old, no underlying disease or well-controlled underlying disease, body temperature below 38.0°C, whether taking antipyretics or not, and no dyspnea. Patients were closely observed by doctors or nurses' interviews twice a day and transferred to hospitals when symptoms worsened. Results A total of 113 patients were admitted to the LTC; 52.2% were female, with a median age of 25 years (interquartile range, 21.5 to 39.5). Of 113 patients, 54 (47.8%) were asymptomatic at diagnosis, and 15 (13.3%) had no symptoms until they were released from isolation. During the follow-up period, two (1.8%) patients were transferred to a hospital but did not progress to severe status during hospitalization. Conclusions The risk of progression was negligible in COVID-19 patients who met the admission criteria for LTC at the time of diagnosis. LTCs could be a safe alternative considering shortage of hospital beds.


title: Pre-intervention cerebral blood volume predicts outcomes in patients undergoing endovascular therapy for acute ischemic stroke.

text: BACKGROUND Pre-intervention perfusion imaging is increasingly becoming part of stroke triage. Small studies supporting imaging based patient selection have been published. The goal of this larger study was to determine if perfusion imaging could impact on functional outcomes in patients undergoing stroke interventions. METHODS All patients who had undergone endovascular therapy for anterior circulation strokes over a 7 year period were retrospectively analyzed. The pre-intervention perfusion imaging was assessed for size of cerebral blood volume (CBV), cerebral blood flow and mean transit time (MTT) abnormalities. A perfusion mismatch for irreversible versus reversible ischemia was based on CBV and MTT. Clinical outcome and mortality were based on the 90 day modified Rankin Scale. An analysis of the pre-intervention perfusion parameters was then performed to determine any impact on functional outcomes. RESULTS 110 patients underwent endovascular therapy for anterior circulation strokes. A younger age and lower National Institutes of Health Stroke Scale score were important clinical predictors of favorable outcome (modified Rankin Scale ≤ 2). The extent of the CBV abnormality and percentage of CBV/MTT mismatch were the strongest imaging predictors of outcome and mortality. A CBV area of 229.5 mm(2) (± 290) was seen for favorable outcomes versus 968 mm(2) (± 1173) for poor outcomes (p<0.0001). A CBV/MTT mismatch of 91% (± 10.7) was seen for favorable outcomes versus 72.5% (± 31.6) for poor outcomes (p=0.0001). The CBV area was 273 mm(2) (± 392) in patients without mortality versus 1401.1 mm(2) (± 1310) in patients with mortality (p<0.0001). Patients who survived had a mean CBV/MTT mismatch of 90.2% (± 12.5) versus 61.1% (± 35.2) for those who did not (p<0.0001). A CBV lesion approximately greater than one-third of the middle cerebral artery distribution predicted a poor outcome and mortality. CONCLUSION The extent of pre-intervention CBV abnormality is a strong predictor of functional outcomes following endovascular stroke therapy. This information can aid in patient selection and improve procedure efficacy.


title: Evaluation of the COVID-19 pandemic using an algorithm based on the Bateman function: Prediction of disease progression using observational data for the city of Heidelberg, Germany .

text: The COVID-19 pandemic has been evaluated using an algorithm based on the Bateman function in a modified SIR/SIZ-Model. Prediction of the number of persons carrying the live COVID-19 coronavirus (I) in a susceptible population (S) was achieved using two rate constants describing the rate of increase and decrease in the number of infectious persons on a daily basis. The model was verified using observational data for the city of Heidelberg, Germany. Three hypothetical scenarios, having their counterparts in practice were considered, namely Scenario A - No restrictions on the population; Scenario B - Assumption of a 10-fold higher number of infections than observed; Scenario C - Protective measures introduced only for elderly persons. It could be demonstrated using the model that the lockdown measures introduced prevented a major medical emergency and possibly a near catastrophe in the region. It was further demonstrated that the prospective application of the model can facilitate realtime decisions on pandemic management strategy for the population. This is achieved by curve-fitting for the rate constants, determinants for the number of infectious persons. The calculated maximum numbers of infected and infectious persons daily increased in proportion to the number of persons initially susceptible to the infection. After appearance of the first two infections in Heidelberg, the calculated maximum number of persons carrying live virus was 2,291 at Day 102 (Scenario B), 18,936 infectious persons at Day 139 (Scenario C) and 22,535 infectious at Day 142 (Scenario A). In Scenario A, high values would have persisted for 6 months during which a total of 124,301 persons would have been infected in Heidelberg. The model predicted that the virus would have disappeared within 1 year after being first detected. A disease catastrophe of this magnitude would not be expected provided the rate constant (α) for the rate of increase in the number of infectious persons remained lower than the rate constant (β) for the fall in number of infectious persons. .


title: Another nightmare after SARS: knowledge perceptions of and overcoming strategies for H1N1 influenza among chronic renal disease patients in Hong Kong.

text: In this article I demonstrate the knowledge perceptions of and the preventive health behaviors toward the influenza A H1N1 pandemic, or "human swine flu," among the chronic renal disease patients in Hong Kong. Based on ethnographic data from participant observation in a chronic renal disease patient self-help alliance and semistructured interviews with its 30 members, I demonstrate that the participants' knowledge perceptions of and the adoption of the preventive health behaviors against H1N1 were greatly influenced by their past experiences of being stigmatized in the 2003 severe acute respiratory syndrome (SARS) outbreak. In addition, the past experiences in the SARS outbreak not only led the participants to remember their stigmatization experiences in this H1N1 pandemic, but also aroused the memory of the general Hong Kong population that chronic renal disease patients were "dangerous" and "polluted," which could further contribute to their stigmatization in this H1N1 pandemic.


title: Incidence of venous thromboembolism in different ethnic groups: a regional direct comparison study.

text: BACKGROUND There are few studies that directly compare the variation in incidence of venous thromboembolism (VTE) according to ethnicity. OBJECTIVE The aim of this study was to compare the rates of VTE, deep venous thrombosis (DVT) and pulmonary embolism (PE) among different ethnic groups. METHOD The cases diagnosed with VTE, DVT and PE for a period between March 2004 and June 2009 were identified through the hospital-based database system. The 2006 New Zealand Census data were used to calculate the rate of diagnosis. RESULTS The observed annual incidence of VTE during this period was 81.6 per 100000 population. The relative risks of VTE when comparing European subjects with Maori, Pacific Island and Asian subjects after age standardization were 1.98 (95% confidence interval [CI], 1.63-2.41), 3.22 (95% CI, 2.60-3.99) and 4.02 (95% CI, 3.34-4.84), respectively. Relative risks of DVT after age standardization when comparing European subjects with Maori, Pacific Island and Asian subjects, were 2.14 (95% CI, 1.72-2.66), 3.20 (95% CI, 2.46-4.17) and 4.75 (95% CI, 3.80-5.94), respectively. Indirect age standardization was used for comparison of the diagnosis of PE. The ratio between the calculated expected number of cases and the actual number of cases was 1.32 (95% CI, 0.89-1.75) for Maori subjects, 2.96 (95% CI, 1.89-4.03) for Pacific Islanders and 3.89 (95% CI, 3.00-4.78) for Asians. CONCLUSION Europeans have a significantly higher incidence of VTE compared with Maori, Pacific Island and Asian populations.


title: A Novel Method for Segmentation-Based Semiautomatic Quantitative Evaluation of Metal Artifact Reduction Algorithms.

text: OBJECTIVES The aim of this study was to establish an objective segmentation-based evaluation of metal artifact reduction algorithms in the context of percutaneous microwave ablation in a porcine model. MATERIALS AND METHODS Five computed tomography acquisitions from a previous animal study on computed tomography-guided percutaneous applicator positioning for microwave antenna were reconstructed with 6 different algorithms (30 image series total): standard filtered backprojection (B30f) and iterative reconstruction (ADMIRE-I30-1, ADMIRE-I30-3), all with and without metal artifact reduction. For artifact quantification, 3-dimensional segmentation of liver parenchyma without visible artifacts (VLiverReference) and liver volume surrounding the antenna (VLiverVOI) was performed, determining thresholds for artifact segmentation and calculating volume of voxels influenced by artifacts. Objective image analysis was based on relative volume of artifacts, and subjective image quality (ie, metal artifact extent) was evaluated by 2 independent observers. Correlation between objective and subjective evaluation was calculated. RESULTS Both objective and subjective evaluations showed a significant reduction in metal artifacts when using dedicated metal artifact reduction algorithms (both P < 0.05). No significant reduction in metal artifacts was found when using iterative reconstruction (both P > 0.05). A good correlation between subjective and objective image quality was found (Spearman rank correlation coefficient rs = 0.65; P < 0.05). Interreader agreement was substantial (κ = 0.67). CONCLUSIONS Segmentation-based objective evaluation of metal artifacts shows good agreement with conventional subjective evaluations and offers a promising quantitative and precise approach with limited time expenditure.


title: SARS-CoV-2, Testosterone and frailty in males (PROTEGGIMI): A multidimensional research project.

text: Preliminary published data depicts a much greater prevalence of malewith laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) referred for intensive care unit admission and severe sequelae in several countries. In this context, males seem to not only be more susceptible to the infection compared to female subjects, at least in western countries, but their case fatality rate attributable to SARS-CoV-2 infection is also highest. Therefore, we may speculate that the different hormonal milieu could have a more profound pathophysiological role in association with SARS-CoV-2, with endogenous testosterone leaving men more prone to develop more serious complications related to the SARS-CoV-2 infection. Another option is that SARS-CoV-2 infection per se causes an acute stage of male hypogonadism, the depletion of androgenic action triggering serious or an even fatal course of the disease. Therefore, we stongly advocate the development of a prospective multidimensional andrological translational research project in men, which we called the PROTEGGIMI study. In this Opinion Article we will not only highlight novel research activity in this area but also invite other researchers and learned scientific societies to join us in our efforts to understand an important and very newly discovered gap in knowledge, which may have serious implications for the lives of millions of men.


title: A randomized controlled trial to evaluate an antimicrobial dressing with silver alginate powder for the management of chronic wounds exhibiting signs of critical colonization.

text: OBJECTIVE The primary objective of this study was to evaluate if a topical silver dressing that consists of silver alginate powder is effective in managing chronic wounds that exhibit signs of critical colonization and promoting wound healing. METHOD This was a prospective, open-label, 4-week randomized controlled trial. The primary end points of the study were changes in signs associated with critical colonization and in wound surface areas. All subjects were evaluated at weeks 0, 2, and 4 at the end of the study. SUBJECT AND SETTINGS: Participants between 18 and 85 years of age were recruited from 2 wound care clinics in Canada. The study was reviewed and approved by research ethics boards. DATA ANALYSIS Analyses of this study were carried out based on intent-to-treat principle; t tests were used to determine if the means were statistically different between treatment groups. RESULTS Thirty-four subjects participated and completed in the study. In the control group, the mean infection checklist score was 2.2 at baseline and 2.3 at week 4 (t9 = -0.36, P = .73). In the silver alginate powder group, the infection score reduced from 3.3 at baseline to 1.3 at week 4; the result was significant (t23 = 7.62, P < .00). The difference in average surface reduction over time between the 2 groups was statistically significant (t32 = 3.56, P < .001). Subjects randomized to the silver group achieved a greater surface reduction than those who were randomized to the use of foam dressing as the control. CONCLUSION Silver alginate powder is an effective treatment option for wounds with increased bacterial burden.


title: Clinical factors related to false-positive rates of patency capsule examination.

text: BACKGROUND Retention is the most common complication of capsule endoscopy (CE), and is reported to occur in 0-13% of cases. To avoid retention, a PillCam patency capsule (PC) is used in patients with suspected intestinal stenosis. However, a relatively low positive predictive value of the PC examination has been reported previously. The aims of this study were to clarify the accuracy of PC examination and to evaluate clinical factors related to cases of false-positive detection. METHODS We performed a retrospective single-center study of 282 consecutive patients referred for PC examination. Patients in which the PC could not pass through the small bowel within 33 h were classified into the 'no patency' group. The 'no patency' group was investigated for evidence of significant stenosis upon further examinations, including CE, double-balloon endoscopy, and small bowel follow-through after PC examination. Clinical factors related to small bowel patency and false-positive cases were evaluated. RESULTS We included 161 male (57.1%) and 121 female (42.9%) patients with a mean age of 47.5 ± 17.7 years. Of the 282 patients enrolled, 27 patients exhibited 'no patency' upon PC examination. Multivariate analysis showed that clinical factors related to 'no patency' included Crohn's disease, abdominal symptoms, stenosis upon imaging, and previous abdominal surgery. Upon further examination, nine cases in the 'no patency' group had significant stenosis. Sensitivity, specificity, and negative and positive predictive values of PC examination for detecting small bowel stenosis were 93.8%, 96.6%, 99.6%, and 62.5%, respectively, and the only clinical factor related to false-positive cases was constipation (p < 0.05). CONCLUSION We found a relatively low positive predictive value of PC examination and that constipation was related to false-positive results. To extend the implications of CE indications, clinical study focusing on these results is expected.


title: Trends of hospitalized acute stroke care in Germany from clinical trials to bedside. Comparison of nation-wide administrative data 2008-2012.

text: Promising advances in stroke medicine have been reported recently regarding specialized stroke unit (SU) care, expansion of the time window of iv thrombolysis (IVT), mechanical thrombectomy (MT), and decompressive hemicraniectomy (DHC) for malignant brain infarction. It remains unclear to what extent new evidence of therapeutic procedures is transferred to the "real-world" of everyday hospital care. We analyzed epidemiologic and procedural therapeutic trends of hospitalized acute stroke patients in Germany by the comparison of administrative hospital data of the years 2008 (n=219,359) and 2012 (n=239,394). Proportion of specialized SU care rose from 43.4% to 56.9%. Even in age-matched analysis women were less likely to obtain this procedure. Rate of IVT increased from 5.6% to 10.2%. 32% of IVT therapies in 2012 were performed in patients over 80 years. Number of MT increased exponentially from 298 to 3906 procedures. Number of DHC did not increase significantly (2008=636; 2011=796). A strong momentum in transferring scientific insights to the "real-world" stroke care in Germany was documented. Increase of IVT therapy is largely due to the increase of off-label treatment. Almost every 46 th patient <80 years was treated by MT in 2012. Despite proven benefits in selected patients, utilization of DHC remained almost stable.


title: Team interventions in acute hospital contexts: a systematic search of the literature using realist synthesis.

text: BACKGROUND Research on team effectiveness in healthcare has focussed on whether effective teams yield positive outcomes for patients and on the effectiveness of team interventions to improve performance. Limited understanding exists of what works for whom within an effective team, or how and why the context in which the team operates enables team members both as individuals and as a collective to enact behaviours that promote positive outcomes. METHODS This realist synthesis of the literature explores the relationship between team interventions, underlying teamwork mechanisms generated by those interventions, and the resultant impact on patient outcomes in an acute hospital context. A systematic search of five healthcare and healthcare management academic databases: PubMed, PsychINFO, CINAHL, ABInform, Emerald Management and three grey literature databases: ERIC, OpenDOAR and Open Grey was undertaken. Five experts in the field were also contacted to source relevant literature. Using PRISMA guidelines, relevant studies published between January 2006 and January 2017 were systematically searched by a team of three people. Drawing on realist methodology, data were synthesised using context, mechanism and outcome configurations as the unit of analysis to identify enablers and barriers to effective team interventions. RESULTS Out of 3347 papers retrieved, 18 were included in the final synthesis. From these, five contextual enablers were identified: an inter-disciplinary focus and flattened hierarchy; effective communication; leadership support and alignment of team goals with organisational goals; credibility of intervention; and appropriate team composition with physician involvement. Ten recurring mechanisms were identified, the most frequently occurring of which was shared responsibility. CONCLUSIONS The advantage of using realist synthesis to extrapolate data from the literature is that it considers the context and mechanisms that will impact effectiveness of healthcare team interventions. This methodological approach provides a different perspective to other types of syntheses and offers insight as to why certain contextual elements may yield more success than others. Findings therefore tend to have more practical implications. Specificity of detail in terms of how external drivers impact on healthcare team interventions was limited in the articles extracted for analysis. This broader perspective is therefore an important consideration for future research.


Clinical trials suspended in UK to prioritise covid-19 studies and free up staff.


Extracorporeal Co2 removal for chronic obstructive pulmonary disease: too risky or ready for a trial?.


Frozen cells and empty cages: researchers struggle to revive stalled experiments after the lockdown.


title: Oncologic outcome of fertility-sparing radical trachelectomy versus radical hysterectomy for stage IB1 cervical carcinoma.

text: OBJECTIVE To compare the oncologic outcomes of women who underwent a fertility-sparing radical trachelectomy (RT) to those who underwent a radical hysterectomy (RH) for stage IB1 cervical carcinoma. METHODS We performed a case-control study of all patients with stage IB1 cervical carcinoma who underwent a vaginal or abdominal RT between 11/01 and 6/07. The control group consisted of patients with stage IB1 disease who underwent an RH between 11/91 and 6/07 and who would be considered candidates for fertility-sparing surgery. Information was extracted from a prospectively acquired database. Recurrence-free and disease-specific survival (RFS and DSS) were estimated using Kaplan-Meier estimates and compared with the log-rank test where indicated. Multivariate analysis was performed using the Cox regression method. RESULTS Forty stage IB1 patients underwent an RT and 110 patients underwent an RH. There were no statistical differences between the two groups for the following prognostic variables: histology, median number of lymph nodes removed, node positive rate, lymph-vascular space involvement (LVSI), or deep stromal invasion (DSI). The median follow-up for the entire group was 44 months. The 5-year RFS rate was 96% (for the RT group compared to 86% for the RH group (P=NS). On multivariate analysis in this group of stage IB1 lesions, tumor size <2 cm was not an independent predictor of outcome, but both LVSI and DSI retained independent predictive value (P=0.033 and 0.005, respectively). CONCLUSION For selected patients with stage IB1 cervical cancer, fertility-sparing radical trachelectomy appears to have a similar oncologic outcome to radical hysterectomy. LVSI and DSI appear to be more valuable predictors of outcome than tumor diameter in this subgroup of patients.


title: Public Discourses of Ebola Contagion and Courtesy Stigma: The Real Risk to International Health Care Workers Returning Home From the West Africa Ebola Outbreak?

text: This article explores the homecoming experiences of international health care workers who responded to the 2014 to 2016 West African Ebola outbreak. Interviews with 11 frontline international medical staff were undertaken and data thematically analyzed. It was found that international health care workers faced an unforeseen risk of stigmatization upon their return home, related to others' fears of their infectious status. Media representations of the disease appear to have played a significant role in heightening societal perceptions of the risks associated with the returning health care workers, resulting in public hostility toward them. For participants, these social risks overtook concerns about biological risks during the immediate postmission period. The participants developed different strategies to cope with courtesy stigma, by rationalizing stigmatizing attitudes, educating people, or simply through an avoidance of others.


title: Control of airborne infectious diseases in ventilated spaces.

text: We protect ourselves from airborne cross-infection in the indoor environment by supplying fresh air to a room by natural or mechanical ventilation. The air is distributed in the room according to different principles: mixing ventilation, displacement ventilation, etc. A large amount of air is supplied to the room to ensure a dilution of airborne infection. Analyses of the flow in the room show that there are a number of parameters that play an important role in minimizing airborne cross-infection. The air flow rate to the room must be high, and the air distribution pattern can be designed to have high ventilation effectiveness. Furthermore, personalized ventilation may reduce the risk of cross-infection, and in some cases, it can also reduce the source of infection. Personalized ventilation can especially be used in hospital wards, aircraft cabins and, in general, where people are in fixed positions.


title: Esophagogastric separation and abdominal esophagostomy via jejunal interposition: a new operation for extreme forms of pathologic aerophagia.

text: Pathologic aerophagia is sometimes seen in patients with neurologic disorders. It rarely causes massive bowel distention, ileus, and volvulus. Here, we report the use of esophagogastric separation and abdominal esophagostomy via jejunal interposition to prevent bowel distention caused by severe aerophagia in 2 patients with neurologic disorders in whom the usual nonoperative methods of management failed. In both cases, swallowed air was evacuated via the jejunostomy, eliminating bowel distention. This operation may be useful in patients with neurologic disorders associated with severe aerophagia.


title: Intraoperative positive end-expiratory pressure evaluation using the intratidal compliance-volume profile.

text: BACKGROUND Lung-protective mechanical ventilation during general surgery including the application of PEEP can reduce postoperative pulmonary complications. In a prospective clinical observation study, we evaluated volume-dependent respiratory system compliance in adult patients undergoing ear-nose-throat surgery with ventilation settings chosen empirically by the attending anaesthetist. METHODS In 40 patients, we measured the respiratory variables during intraoperative mechanical ventilation. All measurements were subdivided into 5 min intervals. Dynamic compliance (CRS) and the intratidal volume-dependent CRS curve was calculated for each interval and classified into one of the six specific compliance profiles indicating intratidal recruitment/derecruitment, overdistension or all. We retrospectively compared the occurrences of the respective compliance profiles at PEEP levels of 5 cm H2O and at higher levels. RESULTS The attending anaesthetists set the PEEP level initially to 5 cm H2O in 29 patients (83%), to 7 cm H2O in 5 patients (14%), and to 8 cm H2O in 2 patients (6%). Across all measurements the mean CRS was 61 (11) ml cm H2O(-1) (40-86 ml cm H2O(-1)) and decreased continuously during the procedure. At PEEP of 5 cm H2O the compliance profile indicating strong intratidal recruitment/derecruitment occurred more often (18.6%) compared with higher PEEP levels (5.5%, P<0.01). Overdistension was practically never observed. CONCLUSIONS In most patients, a PEEP of 5 cm H2O during intraoperative mechanical ventilation is too low to prevent intratidal recruitment/derecruitment. The analysis of the intratidal compliance profile provides the rationale to individually titrate a PEEP level that stabilizes the alveolar recruitment status of the lung during intraoperative mechanical ventilation. TRIAL REGISTRATION NUMBER DRKS00004286.


title: Sevoflurane attenuates platelets activation of patients undergoing lung cancer surgery and suppresses platelets-induced invasion of lung cancer cells.

text: STUDY OBJECTIVE Platelets play a pivotal role in metastasis of tumor cells. The aim of this study is to explore the effects of sevoflurane and isoflurane on platelets activation of patients undergoing lung cancer surgery, and the effects of sevoflurane and isoflurane on platelets-induced invasion of lung cancer cells. DESIGN Prospective and randomized study, and in vitro experiment. SETTING University-affiliated teaching hospital and laboratory. PATIENTS Forty-six patients scheduled for lung cancer radical surgery. INTERVENTIONS Patients were randomized to two groups of 23 patients each and were received sevoflurane (group SEV) or isoflurane (group ISO) during surgery, respectively. In vitro, lung cancer cells were treated with platelets in the presence or absence anesthetics. MEASUREMENTS Platelets activation were determined by detecting glycoproteinIIb/IIIa (GPIIb/IIIa), CD62P, and platelets aggregation rate (PAR) pre-, intra-, and postoperatively. Invasion ability of lung cancer cells were evaluated by Transwell assay. RESULTS The levels of GPIIb/IIIa, CD62P, and PAR were reduced markedly in group SEV during perioperative period compared with group ISO. In vitro, activated platelets contributed profoundly to the invasive ability of lung cancer cells. Sevoflurane, but not isoflurane, inhibited platelets-induced invasion of lung cancer cells. Furthermore, sevoflurane suppressed the platelets activity in vitro. CONCLUSION Sevoflurane attenuates platelets activation of patients undergoing lung cancer surgery. In vitro, sevoflurane suppresses platelets-induced invasion of lung cancer cells via decreasing platelets activity.


title: Impact of closed minimal extracorporeal circulation on microvascular tissue perfusion during surgical aortic valve replacement: intravital imaging in a prospective randomized study.

text: OBJECTIVES Closed minimal extracorporeal circulation (MECC) systems currently do not represent the standard of surgical care for open-heart surgery. Yet, considering the beneficial results reported for coronary artery bypass graft (CABG) surgery, we used an MECC system in aortic valve replacement (AVR) and analysed the effects on intraoperative microvascular perfusion in comparison with conventional open extracorporeal circulation (CECC). METHODS In the current study, we analysed alterations in microvascular perfusion at 4 predefined time points (T1-T4) during surgical AVR utilizing orthogonal polarization spectral (OPS) imaging. Twenty patients were randomized for being operated on utilizing either MECC or CECC. Changes in functional capillary density (FCD, cm/cm(2)), mircovascular blood flow velocity (mm/s) and vessel diameter (μm) were analysed by a blinded investigator. RESULTS After the start of extracorporeal circulation and aortic cross-clamping (T2), both groups showed a significant drop in FCD, but with a significantly higher FCD in the MECC group (153.1 ± 15.0 cm/cm² in the CECC group vs 160.8 ± 12.2 cm/cm² in the MECC group, P = 0.034). During the late phase of the cardiopulmonary bypass (CPB) (T3), the FCD was still significantly depressed in both treatment groups (153.5 ± 14.6 cm/cm² in the CECC group, P <0.05 vs 'T1'; 159.5 ± 12.4 cm/cm² in the MECC group, P <0.05 versus 'T1'). After termination of CPB (T4), the FCD recovered in both groups to baseline values. Microvascular blood flow velocity tended to remain at a higher level in the MECC group, whereas haemodilution during CPB was significantly reduced in the MECC group. CONCLUSIONS The use of MECC in AVR did not affect procedural safety and, resulted in beneficial preservation of microvascular blood flow velocity and significantly reduced haemodilution during CPB. In contrast to CABG surgery, the use of MECC did not improve FCD during surgical AVR. Clinical advantages possibly resulting from attenuated haemodilution and preservation of microvascular blood flow velocity require further validation in larger patient cohorts.


Novel relapsing fever spirochete in bat tick.


title: SARS-CoV-2 Phylogenetic Analysis, Lazio Region, Italy, February-March 2020.

text: We report phylogenetic and mutational analysis of severe acute respiratory syndrome coronavirus 2 virus strains from the Lazio region of Italy and provide information about the dynamics of virus spread. Data suggest effective containment of clade V strains, but subsequently, multiple waves of clade G strains were circulating widely in Europe.


title: Induced Pluripotent Stem Cell-Derived Hematopoietic Embryoid Bodies Improve Mouse Status in Septic Peritonitis.

text: We examined the efficacy of embryoid bodies from 6-day induced pluripotent stem cells an in vivo sepsis model. Injection of embryoid bodies to septic mice improved the condition of their lungs and significantly increased their survival rate. Although embryoid bodies secretedsphingosine-1-phosphate in vitro, its serum levels in mouse plasma were significantly reduced compared to that in the control (untreated mice receiving PBS). Low concentrations of sphingosine-1-phosphate protected endothelial cells, while high concentrations disrupted endothelial barrier integrity. Therefore, exogenous sphingosine-1-phosphate secreted by embryoid bodies during early stage of sepsis might down regulate endogenous production of sphingosine-1-phosphate. Inhibition of excessive sphingosine-1-phosphate release protects against endothelial injury and suppresses a vicious cycle of inflammatory reactions. The obtained results open new prospects in induced pluripotent stem cells-based therapy for sepsis.


title: Type III Endoleak of a Disconnected Stent-graft Limb.

text: A 70-year-old man, who had undergone the placement of an endovascular aneurysm repair graft for an abdominal aortic aneurysm 7 years previously, presented to our facility with the separation of a left iliac stent-graft limb from the main-body stent-graft, resulting in a type III endoleak. An attempt was made to repair the disconnected stent-graft limb with endovascular intervention. An extension stent-graft was successfully deployed using a pulled-through technique to connect the main-body stent-graft with the disconnected stent-graft limb. Endovascular intervention may be an acceptable treatment for type III endoleaks.


title: pCONus Device for the Endovascular Treatment of Wide-Neck Middle Cerebral Artery Aneurysms.

text: BACKGROUND AND PURPOSE Endovascular treatment of bifurcation middle cerebral artery aneurysms with a wide neck could be challenging, and many lesions are still treated by a surgical approach. The pCONus is a newly emerging device for wide-neck bifurcation intracranial aneurysms. To date, a single report on the treatment of intracranial aneurysms including all locations has been published. We report our experience with pCONus in the treatment of wide-neck MCA aneurysms. MATERIALS AND METHODS MCA aneurysms treated with pCONus in 4 European centers were retrospectively reviewed. RESULTS Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) were treated in 40 patients (mean age, 62 years). Aneurysm coiling was performed after deployment of 1 pCONus in 95% (38/40) of cases and after deployment of 2 pCONus devices in 5% (2/40). No procedural angiographic complications were observed. Reversible neurologic complications were noted in 5% (2/40), and permanent neurologic complication, in 2.5% (1/40) at 1 month. There was no mortality. No aneurysms bled or rebled after treatment. Immediate angiographic results were complete aneurysm occlusion in 25% (10/40), neck remnant in 47.5% (19/40), and aneurysm remnant in 27.5% (11/40). Follow-up (mean, 6.8 months) was available for 33 aneurysms (82.5%). Stable or improved results were observed in all except 3 cases, including 48.5% complete occlusions (16/33), 30.3% neck remnants (10/33), and 21.2% aneurysm remnants (7/33). There was no in-stent stenosis or jailed branch occlusion. There was no angiographic recurrence of initially totally occluded aneurysms. CONCLUSIONS MCA aneurysms with a wide neck are amenable to treatment with pCONus.


title: Development and characterization of an equine infectious anemia virus Env-pseudotyped reporter virus.

text: We developed a replication-defective reporter virus pseudotyped with the envelope glycoprotein of equine infectious anemia virus (EIAV). The in vitro host range and neutralization phenotype of EIAV Env-pseudotyped virus were similar to those of replication-competent virus. An EIAV Env pseudovirus will improve antigenic characterization of viral variants and evaluation of lentivirus vaccines.


title: Acute surgical vs non-surgical management for ocular and peri-ocular burns: a systematic review and meta-analysis.

text: Background Burn-related injury to the face involving the structures of the eyes, eyelids, eyelashes, and/or eyebrows could result in multiple reconstructive procedures to improve functional and cosmetic outcomes, and correct complications following poor acute phase management. The objective of this article was to evaluate if non-surgical or surgical interventions are best for acute management of ocular and/or peri-ocular burns. Methods This systematic review and meta-analysis compared 272 surgical to 535 non-surgical interventions within 1 month of patients suffering burn-related injuries to 465 eyes, 253 eyelids, 90 eyelashes, and 0 eyebrows and evaluated associated outcomes and complications. The PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical and medical interventions, outcomes, and complications were recorded. Results Eight of the 14,927 studies queried for this study were eligible for the systematic review and meta-analysis, with results from 33 of the possible 58 outcomes and complications using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. Surgery was associated with standard mean differences (SMD) 0.44 greater visual acuity on follow-up, SMD 1.63 mm shorter epithelial defect diameters on follow-up, SMD 1.55 mm greater changes in epithelial diameters from baseline, SMD 1.17 mm2 smaller epithelial defect areas on follow-up, SMD 1.37 mm2 greater changes in epithelial defect areas from baseline, risk ratios (RR) 1.22 greater numbers of healed epithelial defects, RR 11.17 more keratitis infections, and a 2.2 greater reduction in limbal ischemia compared to no surgical intervention. Conclusions This systematic review and meta-analysis found that compared to non-surgical interventions, acute surgical interventions for ocular, eyelid, and/or eyelash burns were found to have greater visual acuity on follow-up, shorter epithelial defect diameters on follow-up, greater changes in epithelial diameters from baseline, smaller epithelial defect areas on follow-up, greater changes in epithelial defect areas from baseline, greater numbers of healed epithelial defects, more keratitis infections, and a greater reduction in limbal ischemia, possibility preventing the need of a future limbal stem cell transplantation.


title: The effects of barbed suture on watertightness after knee arthrotomy closure: a cadaveric study.

text: BACKGROUND Wound closure is one of the crucial aspects of total knee arthroplasty (TKA) for patients who perform high-flexion activities of daily living, because the joint capsule is highly stretched and integrity of the arthrotomy closure must be maintained. Watertightness of the knee joint is a different aspect of the repair integrity of arthrotomy closure and is being noticed with increasing usage of the drain clamp method for blood management after TKA. Recently, the barbed knotless suture has been growing in popularity as a strong, secure closure appropriate for high-tension areas, such as the fascia and joint capsule. The purpose of this study was to compare the barbed knotless suture with simple interrupted suture in cadaveric knees. METHODS Nine fresh-frozen cadaveric lower extremities were used. After placing a parapatellar incision and setting a closed suction drain, arthrotomies were closed randomly using three suture materials: simple interrupted absorbable suture (No. 0 PDS, group C); or a single running knotless barbed suture Stratafix with 8N (group BS-8N) or 15N (group BS-15N) of tension. After arthrotomy closure, saline was injected in a retrograde manner into the joint through a drain until saline started to leak from the joint. Peak values for intra-articular pressure and infusion volume in each group were recorded and compared. RESULTS Mean infusion volumes were 13.0 ± 7.2 ml, 38.6 ± 10.7 ml, and 5.1 ± 2.5 ml in groups BS-8N, BS-15N, and C, respectively. Mean intra-articular pressures were 0.67 ± 0.47 kPa, 9.44 ± 4.55 kPa, and 0.56 ± 0.44 kPa in groups BS-8N, BS-15N, and C, respectively. Infusion volume and joint internal pressure were significantly higher in group BS-15N than in groups BS-8N (p = 0.008) or C (p = 0.04). CONCLUSIONS Barbed suture with 15N appears appropriate for maintaining maximal watertightness after knee joint capsule closure, offering successful drain clamping, higher resistance to early mobilization protocols, and subsequent achievement of early deep knee flexion after TKA.


title: An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes.

text: The emergence of a novel coronavirus, termed SARS-CoV-2, and the potentially life-threating respiratory disease that it can produce, COVID-19, has rapidly spread across the globe creating a massive public health problem. Previous epidemics of many emerging viral infections have typically resulted in poor obstetrical outcomes including maternal morbidity and mortality, maternal-fetal transmission of the virus, and perinatal infections and death. This communication reviews the effects of two previous coronavirus infections - severe acute respiratory syndrome (SARS) caused by SARS-CoV and Middle East respiratory syndrome (MERS) caused by MERS-CoV - on pregnancy outcomes. In addition, it analyzes literature describing 38 pregnant women with COVID-19 and their newborns in China to assess the effects of SARS-CoV-2 on the mothers and infants including clinical, laboratory and virologic data, and the transmissibility of the virus from mother to fetus. This analysis reveals that unlike coronavirus infections of pregnant women caused by SARS and MERS, in these 38 pregnant women COVID-19 did not lead to maternal deaths. Importantly, and similar to pregnancies with SARS and MERS, there were no confirmed cases of intrauterine transmission of SARS-CoV-2 from mothers with COVID-19 to their fetuses. All neonatal specimens tested, including in some cases placentas, were negative by rt-PCR for SARS-CoV-2. At this point in the global pandemic of COVID-19 infection there is no evidence that SARS-CoV-2 undergoes intrauterine or transplacental transmission from infected pregnant women to their fetuses. Analysis of additional cases is necessary to determine if this remains true.


title: Soy-based infant formula feeding and menstrual pain in a cohort of women aged 23-35 years.

text: STUDY QUESTION Is soy formula feeding during infancy associated with menstrual pain in reproductive-age women? SUMMARY ANSWER Our data suggest that soy formula feeding during infancy is associated with several indicators of severe menstrual pain in reproductive-age women. WHAT IS KNOWN ALREADY A prior study observed greater severity of menstrual pain in young women who as infants participated in feeding studies and were assigned to soy-based formula feeding. STUDY DESIGN, SIZE, DURATION We used data from the Study of Environment, Lifestyle & Fibroids (SELF), a cohort of 1696 African-American women ages 23-35 years at enrollment. PARTICIPANTS/MATERIALS, SETTINGS, METHODS Data on infant soy formula feeding was ascertained by self-administered questionnaire for 1553 participants, with 89% of participants receiving assistance from their mothers. Information on menstrual pain indicators was collected by web- and telephone-interview. We estimated the relative risk (RR) and 95% confidence interval (CI) using log-binomial regression, or log-multinomial regression, adjusting for participant age and maternal education. MAIN RESULTS AND THE ROLE OF CHANCE Women ever fed soy formula as infants were more likely than unexposed women to report ever use of hormonal contraception for menstrual pain (RR 1.4, CI: 1.1-1.9) and moderate/severe menstrual discomfort/pain with 'most periods', but not 'every period', during early adulthood (ages 18-22 when not using hormonal contraception) (RR 1.5, CI: 1.1-2.0). LIMITATIONS, REASONS FOR CAUTION We relied on retrospective recall to ascertain infant exposure to soy formula feeding and data on menstrual pain indicators. WIDER IMPLICATIONS OF THE FINDINGS Our observations add to the growing body of literature from animal and human studies on the reproductive health consequences of early-life exposure to soy formula. STUDY FUNDING/COMPETING INTEREST(S) This research was supported by the Intramural Research Program of the NIH, National Institute of Environmental Health Sciences and, in part, by funds allocated for health research by the American Recovery and Reinvestment Act. This research was also supported by grant K99NR017191 (KU). None of the authors has a conflict of interest. TRIAL REGISTRATION NUMBER Not applicable.


title: Host-response biomarkers for diagnosis of late-onset septicemia and necrotizing enterocolitis in preterm infants.

text: Preterm infants are highly susceptible to life-threatening infections that are clinically difficult to detect, such as late-onset septicemia and necrotizing enterocolitis (NEC). Here, we used a proteomic approach to identify biomarkers for diagnosis of these devastating conditions. In a case-control study comprising 77 sepsis/NEC and 77 nonsepsis cases (10 in each group being monitored longitudinally), plasma samples collected at clinical presentation were assessed in the biomarker discovery and independent validation phases. We validated the discovered biomarkers in a prospective cohort study with 104 consecutively suspected sepsis/NEC episodes. Proapolipoprotein CII (Pro-apoC2) and a des-arginine variant of serum amyloid A (SAA) were identified as the most promising biomarkers. The ApoSAA score computed from plasma apoC2 and SAA concentrations was effective in identifying sepsis/NEC cases in the case-control and cohort studies. Stratification of infants into different risk categories by the ApoSAA score enabled neonatologists to withhold treatment in 45% and enact early stoppage of antibiotics in 16% of nonsepsis infants. The negative predictive value of this antibiotic policy was 100%. The ApoSAA score could potentially allow early and accurate diagnosis of sepsis/NEC. Upon confirmation by further multicenter trials, the score would facilitate rational prescription of antibiotics and target infants who require urgent treatment.


Virus detection in patients with severe pneumonia: still more questions than answers?


title: Spontaneous Chronic Pain After Experimental Thoracotomy Revealed by Conditioned Place Preference: Morphine Differentiates Tactile Evoked Pain From Spontaneous Pain.

text: Chronic pain after surgery limits social activity, interferes with work, and causes emotional suffering. A major component of such pain is reported as resting or spontaneous pain with no apparent external stimulus. Although experimental animal models can simulate the stimulus-evoked chronic pain that occurs after surgery, there have been no studies of spontaneous chronic pain in such models. Here the conditioned place preference (CPP) paradigm was used to reveal resting pain after experimental thoracotomy. Male Sprague Dawley rats received a thoracotomy with 1-hour rib retraction, resulting in evoked tactile hypersensitivity, previously shown to last for at least 9 weeks. Intraperitoneal injections of morphine (2.5 mg/kg) or gabapentin (40 mg/kg) gave equivalent 2- to 3-hour-long relief of tactile hypersensitivity when tested 12 to 14 days postoperatively. In separate experiments, single trial CPP was conducted 1 week before thoracotomy and then 12 days (gabapentin) or 14 days (morphine) after surgery, followed the next day by 1 conditioning session with morphine or gabapentin, both versus saline. The gabapentin-conditioned but not the morphine-conditioned rats showed a significant preference for the analgesia-paired chamber, despite the equivalent effect of the 2 agents in relieving tactile allodynia. These results show that experimental thoracotomy in rats causes spontaneous pain and that some analgesics, such as morphine, that reduce evoked pain do not also relieve resting pain, suggesting that pathophysiological mechanisms differ between these 2 aspects of long-term postoperative pain. Perspective: Spontaneous pain, a hallmark of chronic postoperative pain, is demonstrated here in a rat model of experimental postthoracotomy pain, further validating the use of this model for the development of analgesics to treat such symptoms. Although stimulus-evoked pain was sensitive to systemic morphine, spontaneous pain was not, suggesting different mechanistic underpinnings.


title: Management of subclavian artery in-stent restenosis.

text: Stenotic and occlusive diseases of the subclavian and brachiocephalic arteries can cause a significant morbidity as it can lead to symptomatic ischemia affecting the upper extremities, brain and, in some cases, the heart. An endovascular approach with primary stenting or provisional stenting has become the primary modality of revascularization of subclavian artery stenosis. In-stent restenosis can be treated with percutaneous transluminal angioplasty or repeat stenting and although stents offer superior long-term patency over balloon angioplasty alone for de novo lesions, there are no data regarding primary versus provisional stenting in subclavian in-stent restenosis. Here we describe a case of subclavian in-stent restenosis treated with just balloon angioplasty and demonstrate that provisional stenting with angioplasty alone when the percutaneous transluminal angioplasty results are excellent is a reasonable alternative to primary stent placement for subclavian in-stent restenosis.


title: Receiving the Unwanted Gift: Infection Transmission through Organ Transplantation.

text: BACKGROUND Infections are common in the general U.S. population, so it is inevitable that some persons with a potentially transmissible disease will become organ donors. There are numerous reports of viral, parasitic, fungal, and bacterial transmission through transplantation. At the same time, immunosuppression increases the risk of infection in organ recipients, so attribution of infectious diseases to the transplanted organ is often difficult. METHOD Review of the English-language literature. RESULTS The Organ Procurement and Transplantation Network states that all potential deceased organ donors must be assessed for conditions that may influence donor acceptance. The infections most often transmitted knowingly to organ recipients are cytomegalovirus and hepatitis C virus. There was a 43% increase in the number of potential donor-derived transmission events between 2012 and 2013, but this affected only 3% of transplants; and the patterns of unexpected infection transmissions have remained fairly constant. The 2013 recognition of a case of raccoon rabies in a kidney recipient brought the risk of untested pathogens back into the general discussion of disease transmission. Also, unexpected transmissions of parasitic infection have resulted in highly visible recipient deaths. CONCLUSIONS Organ transplantation has been an enormous advance in the treatment of chronic diseases, but the risk of unanticipated disease transmission has been gaining attention. The task for the organ donation community is to assess risk of transmission of clinically relevant diseases accurately without substantially diminishing organ availability.


Extracorporeal Membrane Oxygenation for Critically Ill Patients with COVID-19 Related Acute Respiratory Distress Syndrome: Worth the Effort?


The Toughest Triage - Allocating Ventilators in a Pandemic.


Is Canada ready for the second wave of COVID-19?


title: Sleepiness, quality of life, and sleep maintenance in REM versus non-REM sleep-disordered breathing.

text: RATIONALE The impact of REM-predominant sleep-disordered breathing (SDB) on sleepiness, quality of life (QOL), and sleep maintenance is uncertain. OBJECTIVE To evaluate the association of SDB during REM sleep with daytime sleepiness, health-related QOL, and difficulty maintaining sleep, in comparison to their association with SDB during non-REM sleep in a community-based cohort. METHODS Cross-sectional analysis of 5,649 Sleep Heart Health Study participants (mean age 62.5 [SD = 10.9], 52.6% women, 22.6% ethnic minorities). SDB during REM and non-REM sleep was quantified using polysomnographically derived apnea-hypopnea index in REM (AHI(REM)) and non-REM (AHI(NREM)) sleep. Sleepiness, sleep maintenance, and QOL were respectively quantified using the Epworth Sleepiness Scale (ESS), the Sleep Heart Health Study Sleep Habit Questionnaire, and the physical and mental composites scales of the Medical Outcomes Study Short Form (SF)-36. MEASUREMENTS AND MAIN RESULTS AHI(REM) was not associated with the ESS scores or the physical and mental components scales scores of the SF-36 after adjusting for demographics, body mass index, and AHI(NREM) x AHI(REM) was not associated with frequent difficulty maintaining sleep or early awakening from sleep. AHI(NREM) was associated with the ESS score (beta = 0.25; 95% confidence interval [CI], 0.16 to 0.34) and the physical (beta = -0.12; 95% CI, -0.42 to -0.01) and mental (beta = -0.20; 95% CI, -0.20 to -0.01) components scores of the SF-36 adjusting for demographics, body mass index, and AHI(REM). CONCLUSIONS In a community-based sample of middle-aged and older adults, REM-predominant SDB is not independently associated with daytime sleepiness, impaired health-related QOL, or self-reported sleep disruption.


title: High-Efficiency Particulate Air Filters in the Era of COVID-19: Function and Efficacy.

text: Aerosol-generating procedures in the office represent a major concern for health care-associated infection of patients and health care providers by SARS-CoV-2, the causative agent for coronavirus disease 2019 (COVID-19). Although the Centers for Disease Control and Prevention has not yet provided any recommendations for the use of portable air purifiers, air purifiers with high-efficiency particulate air (HEPA) filters have been discussed as an adjunctive means for decontamination of SARS-CoV-2 aerosols in health care settings. This commentary discusses HEPA filter mechanisms of action, decontamination time based on efficiency and flow rate, theoretical application to SARS-CoV-2, and limitations. HEPA filter functionality and prior guidance from the Centers for Disease Control and Prevention for SARS-CoV-1 suggest theoretical efficacy for HEPA filters to decontaminate airborne SARS-CoV-2, although direct studies for SARS-CoV-2 have not been performed. Any portable HEPA purifier utilization for SARS-CoV-2 should be considered an adjunctive infection control measure and undertaken with knowledge of HEPA filter functionality and limitations in mind.


Tropical Medicine & International Health March 2020.


title: Inexperienced nurses and doctors are equally efficient in managing the airway in a manikin model.

text: OBJECTIVE The aim of the present study was to investigate whether minimally trained medical and nursing school graduates would be equally efficient in placing a laryngeal mask airway (LMA) and in intubating the trachea with the Macintosh blade or a videolaryngoscope in a manikin model. Airway management is an essential skill for both physicians and nurses who may be confronted with a critically ill patient, because in the emergency department the airway is not exclusively managed by medical personnel. Several studies have shown that other healthcare professionals are not any less efficient in securing the airway. METHODS Ninety-six graduates from medical and nursing faculties comprised our study population. After a brief educational session, participants were randomly allocated into 3 groups to secure the airway in manikins with 3 techniques: LMA (The Laryngeal Mask Company Limited, Buckinghamshire, UK) insertion and intubation with the Macintosh blade and with a videolaryngoscope (GlideScope, Verathon Inc, Bothell, WA). The number of attempts until the first successful intubation, time required for the first successful attempt, and severity of dental trauma were assessed. RESULTS No statistically significant difference was observed between physicians and nurses in the number of attempts and in the time required for the first successful attempt with any of the 3 techniques studied. From the 3 techniques studied, LMA placement was the fastest (P < .001). No significant difference was observed between physicians and nurses in the severity of dental trauma. CONCLUSION Nurses are as efficient as physicians in managing the airway safely and adequately with the 3 different techniques in manikins.


title: [Anesthesia recovery comparison between remifentanil-propofol and remifentanil-desflurane guided by Bispectral Index® monitoring].

text: BACKGROUND AND OBJECTIVES There is a strong demand for fast and predictable anesthesia recovery with few side effects. Choice of the hypnotic agent could impact on that. This study investigated the differences between recoveries after remifentanil-propofol and remifentanil-desflurane anesthesias guided by bispectral index (BIS®). METHODS Forty patients were randomly assigned into 2 groups according to the anesthesia technique applied: remifentanil-propofol (REM-PRO) and remifentanil-desflurane (REM-DES). After the discontinuation of the anesthetics, the times to extubation, to obey commands and to recover the airway protection reflex were recorted. In the post-anesthetic recovery room (PACU) it was recorded the occurrence of nausea and vomiting (PONV), scores of Ramsay sedation scale and of numeric pain scale (NPS), morphine dose and length of stay in the unit. RESULTS Data from 38 patients were analyzed: 18 from REM-PRO and 20 from REM-DES group. Anesthesia times were similar (REM-PRO=193min, SD 79.9 vs. 175.7min, SD 87.9 REM-DES; p=0.5). REM-DES had shorter times than REM-PRO group: time to follow command (8.5min; SD 3.0 vs. 5.6min; SD 2.5; p=0.0) and extubation time (6.2 minutes; 3.1-8.5 vs. 9.5 minutes; 4.9-14.4; p=0.0). Times to recover airway protective reflex were similar: 16 patients from REM-PRO (88.9%) restored the airway protective reflex 2min after extubation vs. 17 from REM-DES (89.5%); and 2 patients from REM-PRO (11.1%) vs. 2 from REM-DES (10.5%) 6min after extubation, p=1. Ramsay sedation score, NPS, PONV incidents, morphine dose and PACU stay of length PACU were also similar. CONCLUSION Remifentanil-desflurane-based anesthesia has a faster extubation time and to follow command than remifentanil-propofol-based anesthesia when both guided by BIS®.