title: Assessment of liver tumor response by high-field (3 T) MRI after radiofrequency ablation: short- and mid-term evolution of diffusion parameters within the ablation zone.

text: PURPOSE To compare the apparent diffusion coefficient (ADC) values of malignant liver lesions on diffusion-weighted MRI (DWI) before and after successful radiofrequency ablation (RF ablation). MATERIALS AND METHODS Thirty-two patients with 43 malignant liver lesions (23/20: metastases/hepatocellular carcinomas (HCC)) underwent liver MRI (3.0 T) before (<1 month) and after RF ablation (at 1, 3 and 6 months) using T2-, gadolinium-enhanced T1- and DWI-weighted MR sequences. Jointly, two radiologists prospectively measured ADCs for each lesion by means of two different regions of interest (ROIs), first including the whole lesion and secondly the area with the visibly most restricted diffusion (MRDA) on ADC map. Changes of ADCs were evaluated with ANOVA and Dunnett tests. RESULTS Thirty-one patients were successfully treated, while one patient was excluded due to focal recurrence. In metastases (n=22), the ADC in the whole lesion and in MRDA showed an up-and-down evolution. In HCC (n=20), the evolution of ADC was more complex, but with significantly higher values (p=0.013) at 1 and 6 months after RF ablation. CONCLUSION The ADC values of malignant liver lesions successfully treated by RF ablation show a predictable evolution and may help radiologists to monitor tumor response after treatment.


title: Proteomics of SARS-CoV-2-infected host cells reveals therapy targets.

text: A novel coronavirus was recently discovered and termed SARS-CoV-2. Human infection can cause coronavirus disease 2019 (COVID-19), which has been rapidly spreading around the globe1,2. SARS-CoV-2 shows some similarities to other coronaviruses. However, treatment options and a cellular understanding of SARS-CoV-2 infection are lacking. Here we identify the host cell pathways modulated by SARS-CoV-2 infection and show that inhibition of these pathways prevent viral replication in human cells. We established a human cell culture model for infection with SARS-CoV-2 clinical isolate. Employing this system, we determined the SARS-CoV-2 infection profile by translatome3 and proteome proteomics at different times after infection. These analyses revealed that SARS-CoV-2 reshapes central cellular pathways, such as translation, splicing, carbon metabolism and nucleic acid metabolism. Small molecule inhibitors targeting these pathways prevented viral replication in cells. Our results reveal the cellular infection profile of SARS-CoV-2 and led to the identification of drugs inhibiting viral replication. We anticipate our results to guide efforts to understand the molecular mechanisms underlying host cell modulation upon SARS-CoV-2 infection. Furthermore, our findings provide insight for the development of therapy options for COVID-19.


title: Rapid and sensitive diagnostic procedure for multiple detection of pandemic Coronaviridae family members SARS-CoV-2, SARS-CoV, MERS-CoV and HCoV: a translational research and cooperation between the Phan Chau Trinh University in Vietnam and University of Bari "Aldo Moro" in Italy.

text: OBJECTIVE A new pandemic coronavirus causing coronavirus disease-2019 (COVID-19), initially called 2019-nCoV and successively named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The COVID-19 refers to the disease while the SARS-CoV-2 refers to the virus and is characterized by a rapid contagious capacity able to spread worldwide in a very short time. The rise in the number of infected patients and deaths is of great concern especially because symptoms are vague and similar to other forms of flu infection and corona syndrome infections characterized by fever, fatigue, dry cough, and dyspnea. According to the latest guidelines published by the World Health Organization (WHO), the diagnosis of COVID-19 must be confirmed by quantitative reverse transcription polymerase chain reaction (rRT-PCR) or gene sequencing of specimen obtained from throat, sputum and blood samples. However, the limitations due to logistics, as well as low sensitivity and specificity diagnostic tools currently available have been reported as the main cause of high incidence of either false-negative or positive results. PATIENTS AND METHODS The purpose of the present translational research protocol is to discuss and present the original findings from our research team on new diagnostic technique to detect four Coronaviridae family members (SARS-CoV-2, SARS-CoV, HCoV and MERS-CoV), highlighting the methodology, the procedure and the possible advantages. Moreover, the authors review the current epidemiology, precautions and safety measures for health personnel to manage patients with known or suspected COVID-19 infection. RESULTS Implementation of an effective and rapid plan of diagnosing, screening and checking is a key factor to reduce and prevent further transmission. This procedure based on rRT-PCR could be of great help to decisively validate the results obtained from more conventional diagnostic procedures such as chest computed tomography (CT) imaging and chest ultrasound. CONCLUSIONS This translational diagnostic tool will assist emergency and primary care clinicians, as well as out-of-hospital providers, in effectively managing people with suspected or confirmed SARS-CoV-2.


title: Laparoscopic splenectomy for a wandering spleen causing chronic pelvic pain.

text: Wandering spleen is a rare condition with a reported incidence of less than 0.5% in which the spleen migrates from its normal anatomical location to any other position in the abdomen. Women constitute 80% of cases and one third of the overall patients are children. It has different clinical presentations such as asymptomatic, painless mass in the abdomen, intermittent abdominal pain and acute abdomen due to torsion of the vascular pedicle. Here we present a case of wandering spleen causing chronic pelvic pain. Laparoscopic splenopexy was the treatment choice but it could not be performed due to huge size of the wandering spleen.


title: Application of terahertz spectrum and interval partial least squares method in the identification of genetically modified soybeans.

text: Genetically modified soybeans are the world's most important genetically modified agricultural product. At present, the traditional methods for identifying genetically modified and non-transgenic soybeans are time-consuming, costly, and complicated to operate, which cannot meet the needs of practical applications. Therefore, it is necessary to discover a fast and accurate method for identifying transgenic soybeans. Terahertz (THz) time domain spectra were collected in sequence from 225 transgenic and non-transgenic soybean samples. Fourier transform was used to convert the terahertz time domain spectrum into a THz frequency domain spectrum with a frequency range of 0.1-2.5 THz. Firstly, the interval partial least squares (iPLS) method was used to remove interference spectral bands and select appropriate spectral intervals. Secondly, 168 samples were selected as the calibration set. Discriminant partial least squares (DPLS), Grid Search support vector machine (Grid Search-SVM) and principal component analysis back propagation neural network (PCA-BPNN) were used to establish a qualitative identification model. Afterwards, 57 test set samples were predicted. By comparing the experimental results, it was found that iPLS could effectively screen and remove the interference THz band, which was more helpful to improve the efficiency and accuracy of the identification model. After the iPLS and mean center pre-treatment technology, the Grid Search-SVM identification model had the best identification effect, with a total accuracy rate of 98.25% (transgenic identification rate was 96.15%, non-transgenic identification rate was 100%). This study shows that after selecting spectra from iPLS, THz spectroscopy combined with chemometrics can more accurately, quickly, and efficiently identify transgenic and non-transgenic soybeans.


title: Gut hormones, early dumping and resting energy expenditure in patients with good and poor weight loss response after Roux-en-Y gastric bypass.

text: OBJECTIVE To identify factors contributing to the variation in weight loss after Roux-en-Y gastric bypass (RYGB). DESIGN Cross-sectional study of patients with good (excess body mass index lost (EBL) >60%) and poor weight loss response (EBL <50%) >12 months after RYGB and a lean control group matched for age and gender. MATERIALS AND METHODS Sixteen patients with good weight loss response, 17 patients with poor weight loss response, and eight control subjects were included in the study. Participants underwent dual energy X-ray absorptiometry scan, indirect calorimetry and a 9 h multiple-meal test with measurements of glucose, insulin, total bile acids (TBA), glucagon-like peptide (GLP)-1, peptide YY3-36 (PYY), cholecystokinin (CCK), ghrelin, neurotensin and pancreatic polypeptide (PP) as well as assessment of early dumping and appetite. RESULTS Suppression of hunger was more pronounced in the good than the poor responders in response to the multiple-meal test (P=0.006). In addition, the good responders had a larger release of GLP-1 (P=0.009) and a greater suppression of ghrelin (P=0.037) during the test, whereas the postprandial secretion of CCK was highest in the poor responders (P=0.005). PYY, neurotensin, PP and TBA release did not differ between the RYGB-operated groups. Compared with control subjects, patients had exaggerated release of GLP-1 (P<0.001), PYY (P=0.008), CCK (P=0.010) and neurotensin (P<0.001). Early dumping was comparable in the good and poor responders, but more pronounced than in controlled subjects. Differences in resting energy expenditure between the three groups were entirely explained by differences in body composition. CONCLUSION Favorable meal-induced changes in hunger and gut hormone release in patients with good compared with poor weight loss response support the role of gut hormones in the weight loss after RYGB.


title: Direct carotid cavernous sinus fistulae: vessel reconstruction using flow-diverting implants.

text: PURPOSE Retrospective evaluation of our experience with the use of flow diverters (FD) for the endovascular treatment of direct carotid-cavernous sinus fistulae (diCCF). METHODS Between 2011 and 2015, 14 consecutive patients with 14 diCCF were treated with FD alone or in combination with other implants in a single institution. RESULTS A total of 21 sessions were performed in 14 patients. FD placement was technically successful in all cases without an adverse event. Patients were treated with FD alone (n = 5), FD and covered stents (n = 2), FD and coils (n = 7). A total of 59 FD (24 Pipeline Embolization Device, Medtronic; 35 p64 Flow Modulation Device, phenox), 291 coils, and 3 stent grafts were used. Three of 14 diCCF were completely occluded after the 1st session, a minor residual shunt was found in 7/14, and in the remaining 4/14 patients, the shunt volume was reduced significantly. The mean follow-up period encompassed 20 months. Additional treatment included transvenous coil occlusion (n = 3) and/or further FD deployment (n = 5). An asymptomatic internal carotid artery (ICA) occlusion was encountered in 2 patients, related to an interruption of antiaggregation. At the last follow-up, 10/14 patients were free from ocular symptoms (71 %), 2 had residual exophthalmos, and no patient had clinical deterioration. CONCLUSION The usage of FD for the treatment of diCCF is straightforward. Injury of the cranial nerves can be avoided. In most cases, ocular symptoms improve. Several FD layers and/or an adjunctive venous coil occlusion are required. Complete occlusion of a diCCF may take weeks or months and long-term antiaggregation is required. In the future, a flexible stent graft might be a better solution.


title: Immediate Interventions for Presyncope of Vasovagal or Orthostatic Origin: A Systematic Review.

text: BACKGROUND Syncope is a common condition that may be prevented. There are non-pharmacological interventions that may be of benefit during the acute episode preceding syncope (presyncope), including physical counter-pressure maneuvers (PCM) or change of body position. We performed a systematic review of interventions that may be applied during presyncope as an immediate, first aid tactic. METHODS We searched Medline, Embase, and CINAHL and used the Grading of Recommendations Assessment, Development and Evaluation methods, and risk of bias assessments to determine the certainty of the evidence. We included randomized controlled trials (RCTs), non-randomized studies, and case series investigating adults and children with signs and symptoms of presyncope of suspected vasovagal or orthostatic origin who applied any intervention that could be used as an immediate, first aid intervention. We examined the following outcomes: prevention of syncope, adverse events, symptom improvement, and vital signs. We conducted a sub-group analysis based on the etiology of vasovagal or orthostatic presyncope. RESULTS We screened 5,160 titles and abstracts followed by 81 full text articles. We identified 8 studies meeting inclusion criteria, including 2 RCTs and 6 observational studies. All studies used PCM in adults and all were judged to be of low and very low certainty of evidence. For prevention of syncope, one RCT demonstrated benefit with the use of PCM (RR = 1.80 [1.26-1.89]), while observational studies failed to show benefit (RR = 1.31 [0.98 - 1.75]). Two RCTs showed benefit in symptom improvement (RR = 6.00 [2.21 - 8.61] and (RR = 1.57 [1.06 - 1.93]). Blood pressure (BP) improved with the use of PCM: systolic BP mean difference (MD) 21 mmHg higher (95% CI: 18.25 to 23.41 BPM) and diastolic BP MD 11 mmHg higher (95% CI: 9.39 to 13.10 mmHg higher). No adverse events were reported. CONCLUSION While there is a minimal amount of evidence available and the findings were mixed, PCM may provide benefit for prevention of syncope during acute episodes of presyncope and may be tried in the first aid setting. No evidence was found for other non-pharmacologic interventions or for the use of PCM in children.


title: Mixed infection by Feline astrovirus and Feline panleukopenia virus in a domestic cat with gastroenteritis and panleukopenia.

text: Astroviruses are important pathogens of human beings and animals. Feline astroviruses have been identified by electron microscopy in the feces of either asymptomatic or symptomatic cats, and experimental infection with one isolate was shown to induce enteric clinical signs and virus excretion, thus suggesting a possible role as enteric pathogen. However, due to the lack of specific diagnostic assays, feline astroviruses are not included in the diagnostic algorithms of feline infectious diseases, and their role as feline pathogens remains unclear. The present report describes a dual infection by Feline astrovirus and Feline panleukopenia virus in a 4-month-old cat with severe gastroenteritis and panleukopenia. Upon sequence analysis, the Feline astrovirus strain was found to be genetically related to astroviruses identified in human beings and felids.


COVID-19 outbreak measures may indirectly lead to greater burden on hospitals.


title: The Department of Defense Chemical and Biological Defense Program: An Enabler of the Third Offset Strategy.

text: The US Department of Defense (DOD) established programs to defend against chemical and biological weapons 100 years ago because military leaders understood that the operational capability of the US military is diminished when service member health is compromised. These threats to operational readiness can be from an overt attack using chemical and biological threats but may also arise from natural exposures. In the current era of rapidly emerging technologies, adversaries are not only rediscovering chemical and biological weapons; they are also displaying an increased propensity to employ them to cause strategic instability among deployed forces or nations undergoing conflict. The United States's investments in its Chemical and Biological Defense Program (CBDP) can be a critical enabler of the third offset strategy, which is a DOD initiative that seeks to maximize force capability to offset emerging threats. To realize this vision, the CBDP must make fundamental changes in acquiring and employing effective technologies so that enemy use of chemical and biological agents against US assets is no longer a viable option. Maximization of US force health status will provide a strategic advantage over theater opponents more vulnerable to operational degradation from chemical and biological threats.


title: The need to strengthen Primary Health Care in Brazil in the context of the COVID-19 pandemic.

text: The emergence of severe acute respiratory coronavirus 2 (SARS-CoV-2) and its association with severe pneumonia and deaths has exposed gaps in the health systems of several countries worldwide. Although the necessary focus has been to care for hospitalized patients, the strengthening of Primary Health Care (PHC) actions is necessary. PHC is the gateway to the health system in several countries, including Brazil and it plays a role in preventing, protecting, promoting, and treating individuals and communities. Brazil, like other countries, has faced the SARS-CoV-2 pandemic. As Brazil has a universal and decentralized health system, in which PHC has been the model of health re-organizing the health system; here we reflected the importance of strengthening PHC in Brazil in the times of coronavirus disease 2019 pandemic.


Chronic care management codes: A small step in the right direction.


title: Combined subchronic toxicity of bisphenol A and dibutyl phthalate on male rats.

text: OBJECTIVE To evaluate the combined subchronic toxicity of bisphenol A (BPA) and dibutyl phthalate (DBP) in male Sprague Dawley (SD) rats. METHODS Forty 4-week-old male rats weighing 115-125 g were randomly divided into BPA-treated, DBP-treated group, BPA+DBP-treated and control groups and fed with a soy- and alfalfa-free diet containing 285.4 ppm BPA, 285.4 ppm DBP, 285.4 ppm BPA plus 285.4 ppm DBP, and a control diet, respectively, for 90 consecutive days. At the end of the study, the animals were sacrificed by exsanguination via the carotid artery under diethyl etherane aesthesia and weighed. Organs, including liver, kidneys, spleen, thymus, heart, brain, and testis underwent pathological examination. The androgen receptor (AR), gonadotropin-releasing hormone receptor (GNRHR), and progesterone hormone receptor (PR) genes from the hypothalamus were detected by real-time PCR. The biomedical parameters were analyzed. RESULTS No significant difference was found in food intake, body weight, tissue weight, organ/brain weight ratio, and biomedical parameters among the four groups (P>0.05). However, BPA and DBP up-regulated AR, PR and GNRHR expression levels in rats and showed a synergistic or an additive effect in the BPA+DBP group. CONCLUSION The combined subchronic toxicity of BPA and DBP is synergistic or additive in male SD rats.


title: Spontaneous social distancing in response to a simulated epidemic: a virtual experiment.

text: BACKGROUND Studies of social distancing during epidemics have found that the strength of the response can have a decisive impact on the outcome. In previous work we developed a model of social distancing driven by individuals' risk attitude, a parameter which determines the extent to which social contacts are reduced in response to a given infection level. We showed by simulation that a strong response, driven by a highly cautious risk attitude, can quickly suppress an epidemic. However, a moderately cautious risk attitude gives weak control and, by prolonging the epidemic without reducing its impact, may yield a worse outcome than doing nothing. In real societies, social distancing may arise spontaneously from individual choices rather than being imposed centrally. There is little data available about this as opportunistic data collection during epidemics is difficult. Our study uses a simulated epidemic in a computer game setting to measure the social distancing response. METHODS Two hundred thirty participants played a computer game simulating an epidemic on a spatial network. The player controls one individual in a population of 2500 (with others controlled by computer) and decides how many others to contact each day. To mimic real-world trade-offs, the player is motivated to make contact by being rewarded with points, while simultaneously being deterred by the threat of infection. Participants completed a questionnaire regarding psychological measures of health protection motivation. Finally, simulations were used to compare the experimentally-observed response to epidemics with no response. RESULTS Participants reduced contacts in response to infection in a manner consistent with our model of social distancing. The experimentally observed response was too weak to halt epidemics quickly, resulting in a somewhat reduced attack rate and a substantially reduced peak attack rate, but longer duration and fewer social contacts, compared to no response. Little correlation was observed between participants' risk attitudes and the psychological measures. CONCLUSIONS Our cognitive model of social distancing matches responses to a simulated epidemic. If these responses indicate real world behaviour, spontaneous social distancing can be expected to reduce peak attack rates. However, additional measures are needed if it is important to stop an epidemic quickly.


title: [Information technology and digital health to support health in the time of CoViD-19.]

text: The CoViD-19 pandemic has provided the opportunity for the health care's digital revolution with the unprecedented accelerated expansion of telehealth, telemedicine and other digital health tools. Several tools have been developed and launched at national and international level to face the emergency, including tools to perform online triage, symptoms checking, video visits and remote monitoring, and to conduct local and national epidemiological surveillance studies. Artificial intelligence-based tools have also been developed to diagnose cases of CoViD-19 or to identify patients at risk. Most of these technologies have been endorsed by medical societies such as the American Medical Association and the American Academy of Family Physicians which launched specific guidelines about their use. The growth in telemedicine services and in digital health technologies could not have occurred without important telehealth regulatory changes that have occurred in some countries aimed at promoting their use to face the CoViD-19 emergency, such as the deregulation of the use of video conferencing and video chat systems to carry out video visits, and the payment parity between telehealth and in clinic care. In order to decide whether to continue using these tools even after the pandemic is over, it could be useful to perform validation and efficacy studies of these tools to study their implications on the doctor-patient relationship, to understand if the new features can be integrated with the other technological tools already in use, and if they can improve clinical practice and quality of care.


title: Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese.

text: BACKGROUND The objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients. METHODS One hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45 kg/m(2). These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2 years (range 19-62 years) and average BMI of 38.9 kg/m(2) (range 35.2-44.9 kg/m(2)). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments. RESULTS The mean operative time was 60 min for cholecystectomy, 41 min for TV appendectomy, and 90 min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61 min, p = 0.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered. CONCLUSIONS NOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy.


title: Genomics, Endoscopy, and Control of Gastroesophageal Cancers: A Perspective.

text: In The Cancer Genome Atlas the goals were to define how to treat advanced cancers with targeted therapy. However, the challenges facing cancer interception for early detection and prevention include length bias in which current screening and surveillance approaches frequently miss rapidly progressing cancers that then present at advanced stages in the clinic with symptoms (underdiagnosis). In contrast, many early detection strategies detect benign conditions that may never progress to cancer during a lifetime, and the patient dies of unrelated causes (overdiagnosis). This challenge to cancer interception is believed to be due to the speed at which the neoplasm evolves, called length bias sampling; rapidly progressing cancers are missed by current early detection strategies. In contrast, slowly or non-progressing cancers or their precursors are selectively detected. This has led to the concept of cancer interception, which can be defined as active interception of a biological process that drives cancer development before the patient presents in the clinic with an advanced, symptomatic cancer. The solutions needed to advance strategies for cancer interception require assessing the rate at which the cancer evolves over time and space. This is an essential challenge that needs to be addressed by robust study designs including normal and non-progressing controls when known to be appropriate.


Association of Coronavirus Disease 2019 (COVID-19) With Myocardial Injury and Mortality.


title: Experiences and Insights from the Early US COVID-19 Epicenter: A Rapid Assessment Procedure Informed Clinical Ethnography Case Series.

text: Objective: The Coronavirus disease (COVID-19) outbreak has evolved into a pandemic crisis, with King County in Washington State emerging as the early US epicenter. A literature review revealed few reports providing front-line clinical and research teams guidance related to multilevel, rapidly evolving COVID-19 directives.Method: The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method was used to develop a clinical case series and conduct participant observation during an ongoing comparative effectiveness trial of peer-integrated, patient-centered interventions after traumatic injury. Participants were patients enrolled in the intervention arm of the ongoing trial, as well as front-line clinicians, patient peer interventionists, and clinical research team members implementing the trial. All participants were exposed to the Washington State COVID-19 outbreak.Results: Primary and secondary COVID-19 prevention strategies were feasibly integrated into ongoing care coordination and behavioral interventions for at-risk patients. Beyond the compilation of case studies, as an iterative method, RAPICE data collection naturalistically evolved to include observations of intervention team activity occurring within the larger pandemic epicenter context. A daily clinical research team huddle that flexibly accommodated virtual participation was also feasibly implemented.Conclusions: Primary and secondary COVID-19 prevention strategies can be feasibly integrated into ongoing clinical interventions during the pandemic. Routine, proactive clinical and research team communication that transparently addresses ethical tensions and health-sustaining activities may promote well-being for providers grappling with rapidly evolving pandemic directives. Proactive assessments of individual provider vulnerabilities for severe COVID-19 related respiratory illness may also be a crucial element of the health care system pandemic responses.


title: Activation of proteases and changes in Na+-K+-ATPase subunits in hearts subjected to ischemia-reperfusion.

text: Previous studies have shown that ischemia-reperfusion (I/R) injury is associated with cardiac dysfunction and changes in sarcolemmal Na(+)-K(+)-ATPase subunits and activity. This study was undertaken to evaluate the role of proteases in these alterations by subjecting rat hearts to different times of global ischemia, as well as reperfusion after 45 min of ischemia. Decreases in Na(+)-K(+)-ATPase activity at 30-60 min of global ischemia were accompanied by augmented activities of both calpain and matrix metalloproteinases (MMPs) and depressed protein content of β(1)- and β(2)-subunits, without changes in α(1)- and α(2)-subunits of the enzyme. Compared with control values, the activities of both calpain and MMP-2 were increased, whereas the activity and protein content for all subunits of Na(+)-K(+)-ATPase were decreased upon reperfusion for 5-40 min, except that α(1)- and α(2)-subunit content was not depressed in 5 min I/R hearts. MDL28170, a calpain inhibitor, was more effective in attenuating the I/R-induced alterations in cardiac contracture, Na(+)-K(+)-ATPase activity, and α(2)-subunit than doxycycline, an MMP inhibitor. Incubation of control sarcolemma preparation with calpain, unlike MMP-2, depressed Na(+)-K(+)-ATPase activity and decreased α(1)-, α(2)-, and β(2)-subunits, without changes in the β(1)-subunit. These results support the view that activation of both calpain and MMP-2 are involved in depressing Na(+)-K(+)-ATPase activity and degradation of its subunits directly or indirectly in hearts subjected to I/R injury.


title: Vascular clips versus ligatures in thyroid surgery--results of a multicenter randomized controlled trial (CLIVIT Trial).

text: BACKGROUND New techniques using vascular clips or ultrasonically activated shears have been suggested to shorten operation time without compromising safety. The objective of the CLIVIT Trial was to compare ligatures with vascular clips for hemostasis in elective benign thyroid surgery. METHODS This multicenter, randomized, controlled, parallel group superiority trial was conducted in 13 German surgical centers. Patients scheduled for at least subtotal resection bilaterally were intraoperatively randomized. The primary endpoint was resection time. Secondary endpoints were the amount of postoperative bleeding, reoperation due to bleeding, wound infection, temporary (reversal within 12 months) and permanent (over 1 year) recurrent laryngeal nerve (RLN) paralysis, length of hospital stay, and safety. REGISTRATION ISRCTN 96901396. RESULTS Two hundred fifty patients were treated with ligatures and 241 with vascular clips. No differences in patients' baseline and surgical characteristics were observed. No difference was detected for mean resection time (clip 63.5 min ± 29.6, ligature 66.1 min ± 29.3, P = 0.258). Postoperative bleeding (mean 86 ml ± 93), reoperation due to bleeding (clips 4, ligature 2), wound infections (clips 4, ligature 4), postoperative hospital stay (mean 3.0 ± 1.9), and safety data also did not vary significantly. The rates of temporary and permanent RLN paralysis were 6.9 % (34/491) and 2.9 % (14/491), respectively. Not using a surgical drain (123 patients) was not associated with a higher rate of complications. CONCLUSION Vascular clips did not reduce the resection time. However, a 2.9 % rate of permanent RLN paralysis is of concern. Drains in elective surgery may be of no benefit.


Covid-19: Lack of PPE in care homes is risking spread of virus, leaders warn.


title: [Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia].

text: Definite evidence has shown that the novel coronavirus (COVID-19) could be transmitted from person to person, so far more than 1,700 bedside clinicians have been infected. A lot of respiratory treatments for critically ill patients are deemed as high-risk factors for nosocomial transmission, such as intubation, manual ventilation by resuscitator, noninvasive ventilation, high-flow nasal cannula, bronchoscopy examination, suction and patient transportation, etc, due to its high possibility to cause or worsen the spread of the virus. As such, we developed this consensus recommendations on all those high-risk treatments, based on the current evidence as well as the resource limitation in some areas, with the aim to reduce the nosocomial transmission and optimize the treatment for the COVID-19 pneumonia patients. Those recommendations include: (1) Standard prevention and protection, and patient isolation; (2) Patient wearing mask during HFNC treatment; (3) Using dual limb ventilator with filters placed at the ventilator outlets, or using heat-moisture exchanger (HME) instead of heated humidification in single limb ventilator with HME placed between exhalation port and mask; avoid using mask with exhalation port on the mask; (4) Placing filter between resuscitator and mask or artificial airway; (5) For spontaneous breathing patients, placing mask for patients during bronchoscopy examination; for patients receiving noninvasive ventilation, using the special mask with bronchoscopy port to perform bronchoscopy; (6) Using sedation and paralytics during intubation, cuff pressure should be maintained between 25-30 cmH(2)O; (7) In-line suction catheter is recommended and it can be used for one week; (8) Dual-limb heated wire circuits are recommended and only changed with visible soiled; (9. For patients who need breathing support during transportation, placing an HME between ventilator and patient; (10) PSV is recommended for implementing spontaneous breathing trial (SBT), avoid using T-piece to do SBT. When tracheotomy patients are weaned from ventilator, HME should be used, avoid using T-piece or tracheostomy mask. (11) Avoid unnecessary bronchial hygiene therapy; (12) For patients who need aerosol therapy, dry powder inhaler metered dose inhaler with spacer is recommended for spontaneous breathing patients; while vibrating mesh nebulizer is recommended for ventilated patients and additional filter is recommended to be placed at the expiratory port of ventilation during nebulization.


title: Parathyroid function following total thyroidectomy using energy devices.

text: LigaSure precise (LP) and harmonic scalpel (HS) are two energy-based devices used in thyroidectomy surgery. We aimed to compare the effect of these two devices in patients who had undergone total thyroidectomy, by highlighting the post-operative parathyroid function. A total of 201 consecutive patients for whom total thyroidectomy had been planned were prospectively classified into two groups. There were 104 patients in LP group and 97 patients in HS group. Hypoparathyroidism was followed up by serially measuring the levels of intact parathyroid hormone (iPTH) and serum calcium. The early iPTH level was 29 (8-50) pg/mL in group LP, and 17 (4-43) pg/mL in group HS. The early iPTH level was significantly lower in the HS group (p < 0.001). However, these levels were within the reference interval in both groups. The early iPTH level was lower than 20 pg/mL in 23 (23.1 %) patients in HS group, and 15 (13.7 %) patients in LP group (p < 0.001). Also, the late iPTH levels were not statistically significance between two groups. The early and late serum calcium levels were not statistically significant between groups. However, the amount of calcium replacement was higher in the HS group than the LP group and the duration of treatment was longer in the HS group than the LP group (p < 0.05). In conclusion, although parathyroid hormone levels impaired in the HS group more than LP group in the early period, these levels were in the normal limits in both groups. These levels were not significant between groups in the long time period.


Internet Searches for Unproven COVID-19 Therapies in the United States.


title: A study protocol for a single-blind, randomized controlled trial of adjunctive transcranial direct current stimulation (tDCS) for chronic pain among patients receiving specialized, inpatient multimodal pain management.

text: BACKGROUND Available treatments for chronic pain (CP) are modestly effective or associated with iatrogenic harm. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that may be an effective, adjunctive treatment to non-opioid therapies. In this randomized control trial (RCT), we compare adjunctive active versus sham tDCS among patients in a multimodal inpatient pain management program. The primary objectives of the RCT are to improve pain tolerance and subjective pain experience. METHODS AND DESIGN Patients admitted to the Pain Management Program at The Menninger Clinic in Houston, Texas are eligible for this trial. Eighty-four participants will be randomized (1:1) into a single-blind, 2×12 (group×time) controlled trial. A battery-powered direct and constant current stimulator (Soterix Medical Inc. 2014) delivers anodal stimulation over the left dorsolateral prefrontal cortex (DLPFC) and cathodal stimulation over the right DLPFC. Active tDCS is applied by supplying a 2mA current for 20min/session over 10 sessions. Participants complete self-report and performance-based assessments on a weekly basis just prior to brain stimulation. Self-report assessments are collected via Chronic Pain Tracker version 3.6, an iPad interfaced application. The performance-based pain tolerance task is completed through the cold presser task. DISCUSSION Interventions with cross-symptomatic therapeutic potential are absolutely essential in the context of CP, in which psychiatric comorbidity is the norm. Modalities that can be used in tandem with evidence-based, non-opioid therapies have the potential to have a synergistic effect, resulting in increased effectiveness of what have been modestly effective treatments to date.


First steps in an uncharted territory by WFNMB.


title: Spinal manipulative therapy reduces peripheral neuropathic pain in the rat.

text: Spinal manipulative therapy, including low-velocity variable-amplitude spinal manipulation (LVVA-SM), relieves chronic low back pain, especially in patients with neuropathic radiating leg pain following peripheral nervous system insult. Understanding the underlying analgesic mechanisms requires animal models. The aim of the current study was to develop an animal model for the analgesic actions of LVVA-SM in the setting of peripheral neuropathic pain. Adult male Sprague-Dawley rat sciatic nerve tibial and common peroneal branches were transected, sparing the sural branch (spared nerve injury, SNI). After 15-18 days, rats were assigned randomly to one of three groups (n=9 each group): LVVA-SM at 0.15-or 0.16-Hz or Control. LVVA-SM (20° flexion at the L5 vertebra with an innovative motorized treatment table) was administered in anesthetized rats for 10 min. Control rats were administered anesthesia and positioned on the treatment table. After 10, 25, and 40 min, the plantar skin of the hindpaw ipsilateral to SNI was tested for mechanical sensitivity (paw withdrawal threshold to a logarithmic series of Semmes-Weinstein monofilaments) and cold sensitivity (duration of paw lifting, shaking, and/or licking to topical acetone application). SNI produced behavioral signs of mechanical and cold allodynia. LVVA-SM reduced mechanical, but not cold, hypersensitivity compared with Control (0.15-Hz: P=0.04 at 10 min; 0.16-Hz: P<0.001 at 10 min, P=0.04 at 25 min). The analgesic effect of LVVA-SM in chronic low back pain patients with neuropathic leg pain can be reverse-translated to a rat model Video abstract: http://links.lww.com/WNR/A453.


title: Analysis of a tuberculosis model with a case study in Uganda.

text: We consider a four-compartment tuberculosis model including exogenous reinfection. We derive sufficient conditions, in terms of the parameters of the system, which guarantee the occurrence of backward bifurcation. We also discuss the global stability of the endemic state by using a generalization of the Poincaré-Bendixson criterion. An application is given for the case of Internally Displaced People's Camps in North Uganda. The study suggests how important it is to provide qualitative indications on the threshold value of the population density in the area occupied by the camps, in order to possibly eradicate the disease.


title: Proficiency training on a virtual reality robotic surgical skills curriculum.

text: INTRODUCTION The clinical application of robotic surgery is increasing. The skills necessary to perform robotic surgery are unique from those required in open and laparoscopic surgery. A validated laparoscopic surgical skills curriculum (Fundamentals of Laparoscopic Surgery or FLS™) has transformed the way surgeons acquire laparoscopic skills. There is a need for a similar skills training and assessment tool for robotic surgery. Our research group previously developed and validated a robotic training curriculum in a virtual reality (VR) simulator. We hypothesized that novice robotic surgeons could achieve proficiency levels defined by more experienced robotic surgeons on the VR robotic curriculum, and that this would result in improved performance on the actual daVinci Surgical System™. METHODS 25 medical students with no prior robotic surgery experience were recruited. Prior to VR training, subjects performed 2 FLS tasks 3 times each (Peg Transfer, Intracorporeal Knot Tying) using the daVinci Surgical System™ docked to a video trainer box. Task performance for the FLS tasks was scored objectively. Subjects then practiced on the VR simulator (daVinci Skills Simulator) until proficiency levels on all 5 tasks were achieved before completing a post-training assessment of the 2 FLS tasks on the daVinci Surgical System™ in the video trainer box. RESULTS All subjects to complete the study (1 dropped out) reached proficiency levels on all VR tasks in an average of 71 (± 21.7) attempts, accumulating 164.3 (± 55.7) minutes of console training time. There was a significant improvement in performance on the robotic FLS tasks following completion of the VR training curriculum. CONCLUSIONS Novice robotic surgeons are able to attain proficiency levels on a VR simulator. This leads to improved performance in the daVinci surgical platform on simulated tasks. Training to proficiency on a VR robotic surgery simulator is an efficient and viable method for acquiring robotic surgical skills.


title: Indirect inguinal hernia repair conducted with single conventional port intracorporeal conventional equipment-endoscopic surgery.

text: PURPOSE Laparoscopic or laparoscopy-assisted inguinal hernia repair (IHR) can be performed using one port plus two stab wounds. We herein present our experience with laparoscopic IHR conducted using a single conventional port and a single working instrument. METHODS The records patients who underwent single conventional port intracorporeal IHR during November 2013-December 2018 were evaluated. The main outcome measurements were patient's demographic characteristics, hernia side, presence of incarceration, operative time, and complications. RESULTS A total of 132 inguinal hernias (52 right, 40 left, and 20 bilateral) were repaired in 112 patients (76 boys, 36 girls). The mean ages of the patients were 69.8 ± 53.4 months (3 months to 17 years). In six patients, contralateral processus vaginalis was found to be patent during operation. Incarcerated inguinal hernia was present in two patients. Mean operative time was 17.9 ± 3.8 min (9-30 min) in unilateral hernias and 28.9 ± 6.5 min (24-45 min) in bilateral hernias. No intraoperative and postoperative complications were encountered. The mean hospital stay of the patients was 8.8 ± 5.0 h (4-36 h). Postoperative follow-up was 16.5 ± 5.1 months (6-24 months). No recurrent inguinal hernias were detected during follow-up. CONCLUSION Single conventional port intracorporeal IHR obviates additional stab wounds. Additionally, present technique eliminates the risk of skin puckering, subcutaneous granuloma, infection, nerve, and muscle damage development induced by the subcutaneously placed knot in laparoscopy-assisted IHR. Single conventional port intracorporeal IHR in children is a feasible and safe operative technique with low complication rates.


title: Recurrent Ectopic Variceal Bleed After Pancreas Transplantation With No Portal Hypertension: Case Report and Outcomes of Endovascular Onyx Embolization.

text: A 57-year-old male presented with intermittent gastrointestinal bleeding (GIB) 1 year after a successful simultaneous pancreas and kidney transplant. No source could be found after 5 tagged red blood cell studies, 3 computed tomographies (CTs), 7 endoscopies, and 4 catheter angiograms. Review of CTs showed pathologically enlarged superior mesenteric vein branches near a jejunal segment near pancreas graft. Transhepatic superior mesenteric venogram showed varicosities near jejunum, which were obliterated with ethylene vinyl alcohol (Onyx). Follow-up CTs confirmed complete obliteration, but he had more GIBs and eventually underwent native jejunal and donor duodenal resection. He has remained GIB-free for 12 months.


Spontaneous breathing (SB) using airway pressure-release ventilation (APRV) in patients under extracorporeal-membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS).


title: A scoping review of the role of HIV-related stigma and discrimination in noncommunicable disease care.

text: BACKGROUND People living with HIV are increasingly burdened by noncommunicable diseases (NCDs) as a result of the NCD susceptibility that accompanies increased life expectancy and the rising global prevalence of NCDs. Health systems are being strengthened and programs are being developed to address this burden, often building on HIV care strategies and infrastructure or through integrated care models. HIV remains a stigmatized condition and the role of HIV stigma in the provision of NCD care is not well understood. METHODS We conducted a scoping literature review of both peer reviewed and grey literature to identify evidence of the role of HIV stigma in the NCD-care continuum (prevention, diagnosis, care seeking, retention in care, and adherence to treatment of NCDs). We searched PsychInfo and Pubmed and conducted additional searches of programmatic reports and conference abstracts. Included studies were published in English within the past decade and examined HIV-related stigma as it relates to NCD-care or to integrated NCD-and HIV-care programs. RESULTS Sixteen articles met the inclusion criteria. Findings suggest: fear of disclosure, internalized shame and embarrassment, and negative past experiences with or negative perceptions of health care providers negatively influence engagement with NCD care; HIV stigma can adversely affect not only people living with HIV in need of NCD care, but all NCD patients; some NCDs are stigmatized in their own right or because of their association with HIV; integrating NCD and HIV care can both reduce stigma for people living with HIV and a present a barrier to access for NCD care. CONCLUSION Due to the dearth of available research and the variability in initial findings, further research on the role of HIV stigma in the NCD-care continuum for people living with HIV is necessary. Lessons from the field of HIV-stigma research can serve as a guide for these efforts.


title: The suture retention test, revisited and revised.

text: A systematic investigation of the factors affecting the suture retention test is performed. The specimen width w and the distance a of the suture bite from the specimen free edge emerge as the most influential geometrical parameters. A conservative approach for the quantification of suture retention strength is identified, based on the use of a camera to monitor the incipient failure and detect the instant of earliest crack propagation. The corresponding critical force, called break starting strength, is extremely robust against test parameter variations and its dependence on the specimen geometry becomes negligible when a≥ 2mm and w≥ 10mm. Comparison of suture retention and mode I crack opening tests reveals a linear correlation between break starting strength and tearing energy. This suggests that the defect created by the needle and the load applied by the suture thread lead to a fracture mechanics problem, which dominates the initiation of failure.


title: Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

text: BACKGROUND Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. OBJECTIVE The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. DESIGN Comparative review of patients at 2 institutions in the same metropolitan area were conducted. SETTINGS The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. PATIENTS A total of 350 patients with colorectal cancer from each hospital were evaluated. MAIN OUTCOME MEASURES Overall survival across hospital systems was measured. RESULTS The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). LIMITATIONS This was a retrospective review, reporting from medical charts. CONCLUSIONS Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues. See Video Abstract at http://links.lww.com/DCR/A454.


title: The role of immunohistochemistry in the study of the newborn kidney.

text: The identification of the different cell types involved in human nephrogenesis, when solely based on morphology, may lead to errors in its interpretation, given the complexity of the histological picture of the fetal and of the newborn kidney. In this study, the most recent works utilizing immunohistochemistry for the identification of the multiple cell types involved in human nephrogenesis are reviewed. The role of WT1, MUC1, Thymosin beta 10, Thymosin beta 4, CD10 and CD44 in the different phases of glomerulogenesis and of tubulogenesis is here described, with particular emphasis on their expression in the early phases of nephrogenesis. On the basis of our data, immunohistochemistry appears to be a useful tool in the study of human nephrogenesis, giving new data on the different steps of the differentiation of metanephric mesenchyme towards the multiple cell types characterizing the mature human kidney. Moreover, allowing a better knowledge of the protein products involved in the generation of new nephrons, immunohistochemistry could open new perspectives in the field of renal regenerating medicine, evidencing the factors able to prolong nephrogenesis after birth, helping us to reach our goal: allowing newborn kidneys to restore their nephron endowment, escaping susceptibility to hypertension and renal disease in adulthood.


title: The cortisol response to hypobaric hypoxia at rest and post-exercise.

text: High altitude exposure normally leads to a marked natriuresis and diuresis. Acute mountain sickness is often associated with fluid retention, to which an elevated cortisol may contribute. Most investigators report a rise in resting cortisol with ascent, but little data exist regarding the cortisol response to a day trekking. We therefore measured salivary cortisol during ascent to > 5000 m in a cohort of between 42-45 subjects following a 6-h trek (samples taken between 15:30-16:30 h) and between 15-20 subjects at rest (morning samples taken between 08:00-09:00 h). Morning resting cortisol [nmol/l, mean±sd, (range)] was 5.5±2.9 (2.13-13.61) at 1300 m; 4.7±6.8 (1.4-27.02) at 3400 m, and significantly (p=0.002) rose between 4270 m [3.5±2.1 (1.4-8.34)] and 5150 m [14.5±30.3 (1.9-123.1)]. Post-exercise cortisol [nmol/l, mean±sd, (range)] dropped between 3400 m [7±6 (1.5-33.3)] and 4270 m [4.2±4.8 (1.4-29.5)] (p=0.001) followed by a significant rise in post-exercise cortisol between 4270 m [4.2±4.8 (1.4-29.5)] and 5 150 m [9.2±10.2 (1.4-61.3)] (p<0.001). There were no significant associations between severity of acute mountain sickness and cortisol levels. There was a significant though weak correlation between cortisol post-exercise at 5150 m and oxygen saturation at 5150 m (rho= - 0.451, p=0.004). In conclusion, this is the largest cohort to have their resting and post-exercise cortisol levels ascertained at high altitude. We confirm the previous findings of an elevated resting morning cortisol at > 5000 m, but present the novel finding that the cortisol response to a day trekking at HA appears suppressed at 4270 m.


title: Length of Barrett's segment predicts failure of eradication in radiofrequency ablation for Barrett's esophagus: a retrospective cohort study.

text: BACKGROUND We aim to investigate factors that may contribute to failure of eradication of dysplastic Barrett's Esophagus among patients undergoing radiofrequency ablation treatment. METHODS A retrospective review of patients undergoing radiofrequency ablation for treatment of Barrett's Esophagus was performed. Data analyzed included patient demographics, medical history, length of Barrett's Esophagus, number of radiofrequency ablation sessions, and histopathology. Subsets of patients achieving complete eradication were compared with those not achieving complete eradication. RESULTS A total of 107 patients underwent radiofrequency ablation for Barrett's Esophagus, the majority white, overweight, and male. Before treatment, 63 patients had low-grade dysplasia, and 44 patients had high-grade dysplasia or carcinoma. Complete eradication was achieved in a majority of patients (57% for metaplasia, and 76.6% for dysplasia). Failure of eradication occurred in 15.7% of patients. The median number of radiofrequency ablation treatments in patients achieving complete eradication was 3 sessions, compared to 4 sessions for failure of eradication (p = 0.06). Barrett's esophagus length of more than 5 cm was predictive of failure of eradication (p < 0.001). CONCLUSIONS Radiofrequency ablation for dysplastic Barrett's Esophagus is a proven and effective treatment modality, associated with a high rate of complete eradication. Our rates of eradication from a center starting an ablation program are comparable to previously published studies. Length of Barrett's segment > 5 cm was found to be predictive of failure of eradication in patients undergoing radiofrequency ablation.


title: Early Administration of Azithromycin and Prevention of Severe Lower Respiratory Tract Illnesses in Preschool Children With a History of Such Illnesses: A Randomized Clinical Trial.

text: IMPORTANCE Many preschool children develop recurrent, severe episodes of lower respiratory tract illness (LRTI). Although viral infections are often present, bacteria may also contribute to illness pathogenesis. Strategies that effectively attenuate such episodes are needed. OBJECTIVE To evaluate if early administration of azithromycin, started prior to the onset of severe LRTI symptoms, in preschool children with recurrent severe LRTIs can prevent the progression of these episodes. DESIGN, SETTING, AND PARTICIPANTS A randomized, double-blind, placebo-controlled, parallel-group trial conducted across 9 academic US medical centers in the National Heart, Lung, and Blood Institute's AsthmaNet network, with enrollment starting in April 2011 and follow-up complete by December 2014. Participants were 607 children aged 12 through 71 months with histories of recurrent, severe LRTIs and minimal day-to-day impairment. INTERVENTION Participants were randomly assigned to receive azithromycin (12 mg/kg/d for 5 days; n = 307) or matching placebo (n = 300), started early during each predefined RTI (child's signs or symptoms prior to development of LRTI), based on individualized action plans, over a 12- through 18-month period. MAIN OUTCOMES AND MEASURES The primary outcome measure was the number of RTIs not progressing to a severe LRTI, measured at the level of the RTI, that would in clinical practice trigger the prescription of oral corticosteroids. Presence of azithromycin-resistant organisms in oropharyngeal samples, along with adverse events, were among the secondary outcome measures. RESULTS A total of 937 treated RTIs (azithromycin group, 473; placebo group, 464) were experienced by 443 children (azithromycin group, 223; placebo group, 220), including 92 severe LRTIs (azithromycin group, 35; placebo group, 57). Azithromycin significantly reduced the risk of progressing to severe LRTI relative to placebo (hazard ratio, 0.64 [95% CI, 0.41-0.98], P = .04; absolute risk for first RTI: 0.05 for azithromycin, 0.08 for placebo; risk difference, 0.03 [95% CI, 0.00-0.06]). Induction of azithromycin-resistant organisms and adverse events were infrequently observed. CONCLUSIONS AND RELEVANCE Among young children with histories of recurrent severe LRTIs, the use of azithromycin early during an apparent RTI compared with placebo reduced the likelihood of severe LRTI. More information is needed on the development of antibiotic-resistant pathogens with this strategy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01272635.


title: Hepatitis C virus association with peripheral blood B lymphocytes potentiates viral infection of liver-derived hepatoma cells.

text: Hepatitis C virus (HCV) primarily replicates within the liver, leading to hepatitis, fibrosis, and hepatocellular carcinoma. Infection is also associated with B-cell abnormalities, suggesting an association of the virus with B cells. The infectious JFH-1 strain of HCV can bind primary and immortalized B cells but fails to establish productive infection. However, B cell-associated virus readily infects hepatoma cells, showing an enhanced infectivity compared with extracellular virus. B cells express the viral receptors CD81, SR-BI, and the C-type lectins DC-SIGN and L-SIGN. Antibodies specific for SR-BI and DC-SIGN/L-SIGN reduced B-cell transinfection, supporting a role for these molecules in B-cell association with HCV. Stimulation of B cells with CD40 ligand and interleukin-4 promoted their ability to transinfect hepatoma cells. B cell-associated virus is resistant to trypsin proteolysis and HCV-specific neutralizing antibodies, consistent with particle internalization. HCV promoted the adhesion of primary B cells to Huh-7 hepatomas, providing a mechanism for B-cell retention in the infected liver. In summary, B cells may provide a vehicle for HCV to persist and transmit to the liver.


title: The Ethics of Everyday Life in the Midst of a Pandemic.

text: Elderly individuals are at higher risk of serious illness and death if they become infected by the coronavirus. During the current pandemic, my wife and I, at ages seventy-two and seventy-one, respectively, have been paying a person laid off from a job to purchase groceries-a practice that exposes the shopper to risk of infection for our benefit. In this essay, I examine this practice with respect to the normative concepts of treating another person as a means, coercion, exploitation, and complicity.


title: Open Development and Clinical Validation Of Multiple 3D-Printed Nasopharyngeal Collection Swabs: Rapid Resolution of a Critical COVID-19 Testing Bottleneck.

text: The SARS-CoV-2 pandemic has caused a severe international shortage of the nasopharyngeal swabs that are required for collection of optimal specimens, creating a critical bottleneck blocking clinical laboratories' ability to perform high-sensitivity virological testing for SARS-CoV-2. To address this crisis, we designed and executed an innovative, cooperative, rapid-response translational-research program that brought together healthcare workers, manufacturers, and scientists to emergently develop and clinically validate new swabs for immediate mass production by 3D printing. We performed a multi-step preclinical evaluation on 160 swab designs and 48 materials from 24 companies, laboratories, and individuals, and shared results and other feedback via a public data repository (http://github.com/rarnaout/Covidswab/) We validated four prototypes through an institutional review board (IRB)-approved clinical trial that involved 276 outpatient volunteers who presented to our hospital's drive-through testing center with symptoms suspicious for COVID-19. Each participant was swabbed with a reference swab (the control) and a prototype, and SARS-CoV-2 reverse-transcriptase polymerase chain reaction (RT-PCR) results were compared. All prototypes displayed excellent concordance with the control (κ=0.85-0.89). Cycle-threshold (Ct) values were not significantly different between each prototype and the control, supporting the new swabs' non-inferiority (Mann-Whitney U [MWU] p>0.05). Study staff preferred one of the prototypes over the others and the control swab overall. The total time elapsed between identification of the problem and validation of the first prototype was 22 days. Contact information for ordering can be found at http://printedswabs.org Our experience holds lessons for the rapid development, validation, and deployment of new technology for this pandemic and beyond.


title: Aetiology of upper respiratory tract infections in children in Arak city: a community based study.

text: Viruses are frequent causes of upper respiratory tract infections in children. We investigated the viral aetiology of community-acquired upper respiratory tract infections (URIs) in young children treated as outpatients in community settings. During November 2008, nasal swab specimens were taken from children with recent onset of upper respiratory tract infections. The patients attended day care or primary schools; the specimens were randomly obtained by pediatricians from schools and childcare institutions and sent for identification by PCR method. A total of 300 specimens were collected. From all samples, 40.67% were positive for at least 1 virus, viz. adenovirus 11.76%, rhinovirus 9.8%, respiratory syncytial virus 6.08%, influenza virus 5.56%, parainfluenza virus 4.9%, enterovirus 2.94% and a combination of 2 viruses 2%. Clinical manifestations of the respiratory infections were as follows: 70.7% of the patients had coryza, 69.3% cough, 26% sneezing, 19.7% sore throat, 2.7% headache, 7.7% fever, 2.3% conjunctivitis, 1.3% abdominal pain and 1% hoarseness. The results of this study demonstrate that adenoviruses and rhinoviruses are the two most common viral agents isolated from pediatric outpatients with acute URIs in autumn in Arak City. Coryza and cough were the most common symptoms in children. Sore throat and hoarseness were more prevalent in infections caused by influenza virus, conjunctivitis in parainfluenza, and coryza in rhinovirus infections.


title: Effect of opioid-free anaesthesia on post-operative period in cardiac surgery: a retrospective matched case-control study.

text: BACKGROUND No study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course. METHODS After retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS). RESULTS One hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6-34) vs 5 mg (2-18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66-115) vs 77 mmol/l (IQR: 69-95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1-5) vs 5 (3-6) hours, p = 0.001 and 2 (1-3) vs 3 (2-5) days, p = 0.037). CONCLUSION The use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results. TRIAL REGISTRATION This study was retrospectively registered to ct2 (identifier: NCT03816592 ) on January 25, 2019.


title: The role of lipid rafts in the early stage of Enterovirus 71 infection.

text: BACKGROUND/AIMS Although it has been widely accepted that Enterovirus 71 (EV71) enters permissive cells via receptor-mediated endocytosis, the details of entry mechanism for EV71 still need more exploration. This study aimed to investigate the role of lipid rafts in the early stage of EV71 Infection. METHODS The effect of cholesterol depletion or addition of exogenous cholesterol was detected by immunofluorescence assays and quantitative real-time PCR. Effects of cholesterol depletion on the association of EV71 with lipid rafts were determined by flow cytometry and co-immunoprecipitation assays. Localization and internalization of EV71 and its receptor were assayed by confocal microscpoy and sucrose gradient analysis. The impact of cholesterol on the activation of phosphoinositide 3'-kinase/Akt signaling pathway during initial virus infection was analyzed by Western-blotting. RESULTS Disruption of membrane cholesterol by a pharmacological agent resulted in a significant reduction in the infectivity of EV71. The inhibitory effect could be reversed by the addition of exogenous cholesterol. Cholesterol depletion post-infection did not affect EV71 infection. While virus bound equally to cholesterol-depleted cells, EV71 particles failed to be internalized by cholesterol-depleted cells. EV71 capsid protein co-localized with cholera toxin B, a lipid-raft-dependent internalization marker. CONCLUSION Lipid rafts play a critical role in virus endocytosis and in the activation of PI3K/Akt signaling pathway in the early stage of EV71 infection.


title: The Europeanization of public health: how does it work? The seminal role of the AIDS case.

text: This article analyzes the path that led the European Union from a somewhat accidental involvement in fighting AIDS to a new and sustainable policy of communicable disease control. It responds to three main questions: Why did an unexpected case lead to the organization of a new sustainable policy? How was this achieved despite national competency over the given policy sector? How did the new policy succeed in covering the enlarged EU? The explanation combines political factors and public health issues. European integration and eastern enlargement made transborder disease management a political necessity. Treaties gave legitimacy to EU policy, while the AIDS matrix furnished the practical procedures: networking, data harmonization, peer-conducted policy coaching, and participation. This pattern of public health management is compatible with national competency, and it is consistent with the democratic values the EU promotes throughout and beyond the enlarged EU. From a theoretical point of view, these patterns of activities constitute the empirically grounded content of the much used but less defined concept of cognitive Europeanization.


title: Intestinal obstruction following use of laparoscopic barbed suture: a new complication with new material?

text: Small bowel obstruction is a common pathology. Among the various etiologies, foreign material has been incriminated as a possible but uncommon cause. Recently, barbed suture has been successfully introduced in various surgical fields and has been reported as safe as standard suture. We report herein a case of intestinal obstruction due to the laparoscopic use of barbed suture during a promontofixation. Barbed suture has the risk of entrapping the small bowel. The surgeon should keep in mind this hypothetical problem and a high index of suspicion is needed to diagnose and treat quickly this potentially severe complication.


title: Systemic Bovine herpesvirus 1 infections in neonatal dairy calves.

text: During a 6-year period, 62 out of 2,980 calves examined (2.08%) between 1-30 days of age had lesions consistent with Bovine herpesvirus 1 infection. The mean and median age of affected calves was 14 days of age. Most cases of infection were in calves 12 and 15 days of age, with 34 calves (54.8%) affected; 14 calves (22.6%) were between 16-21 days of age; 11 calves (17.8%) were between 7-11 days of age; and 3 calves (4.8%) were between 22-30 days of age. In 29 of the calves, the adrenal gland was the only organ affected. In 25 calves, the adrenal gland and at least 1 other tissue had lesions consistent with herpes viral infection. Five animals had no adrenal lesions but had 1 or more additional tissue with lesions consistent with herpesvirus. Three animals had no adrenal gland present for examination but had lesions in other tissues. Organs and number of animals affected by Bovine herpesvirus 1 infection were adrenal gland (54), liver (18), lungs (15), kidney (8), small intestines (7), large intestines (7), rumen/omasum (7), trachea/larynx (3), abomasum (2), heart (1), esophagus (1), thymus (1), and lymph node (1).


title: Surveillance for the identification of cases of acute respiratory infection by enterovirus D68 in children in a tertiary level care hospital during 2014-2016.

text: Background The reemergence of enterovirus D68 (EV-D68) infections in the United States was reported from August-October 2014 (691 cases). In Mexico, an outbreak at the National Institute of Respiratory Diseases was reported (24 cases). The results of epidemiological surveillance of Enterovirus sp. (EV) and other respiratory viruses in a national pediatric tertiary care level hospital are presented. Methods Following the alert issued by the reemergence of EV-D68 in 2014, epidemiological surveillance -which only detected respiratory viruses by PCR in patients with influenza-like illness using nasopharyngeal swabs- expanded to include children with asthma exacerbation or acute respiratory distress. Positive samples to EV were confirmed and typed by sequencing. Subsequent sequencing was used to obtain the complete viral genome. Results Of 1705 samples, 13 were positive to EV. Patients with EV presented the following comorbidities: chronic lung disease (7.7%), neoplastic disease (15.4%), allergic asthma/rhinitis (23%), recurrent pneumonia (23%), and other (23%). Of the 13 samples positive for EV, three were positive for EV-D68. These cases required invasive mechanical ventilation, presented no neurological involvement and survived. Conclusions The impact of the population studied by EV-D68 was lower than that reported in Mexico during the same period. Cases of EV-D68 infection had multiple comorbidities, but few pulmonary comorbidities, which could explain the low attack rate. The epidemiological surveillance and infection prevention system may have contained the outbreak.


Fighting COVID-19 in Iran; Economic Challenges Ahead.


title: Endoscopic management of complications after gastrointestinal weight loss surgery.

text: As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.


title: Learning curve for laparoscopic totally extraperitoneal repair of inguinal hernia.

text: BACKGROUND Laparoscopic totally extraperitoneal (TEP) repair has been accepted as a popular procedure for inguinal hernia repair, but surgeons still encounter technical difficulties owing to unfamiliar pelvic anatomy and limited working space. We sought to estimate the learning curve for laparoscopic TEP repair without supervision. METHODS We retrospectively analyzed the medical records of patients scheduled for laparoscopic TEP repair of an inguinal hernia from December 2000 to October 2007. RESULTS We reviewed medical records for 700 patients. The cases were divided into 8 groups: 20 patients each in groups I-V and 200 patients each in groups VI-VIII. No significant difference in demographic characteristics was identified among the groups. The mean duration of surgery significantly decreased (p < 0.001) in relation to experience; it reached a plateau of less than 30 minutes (mean 28 min) after 60 cases. The mean length of stay in hospital was 0.97 days, reaching a plateau after 20 cases. Six patients were converted to other techniques: 1 patient each in groups III and VIII and 4 patients in group VII. Three recurrences were detected; however, 2 were excluded because the patient had bilateral inguinal hernias. CONCLUSION We estimate the learning curve for laparoscopic TEP repair is 60 cases for a beginner surgeon. The presence of an experienced supervisor during the first 60 cases can help prevent unnecessary complications and shorten the duration of surgery.


title: Complete mucosal healing of distal lesions induced by twice-daily budesonide 2-mg foam promoted clinical remission of mild-to-moderate ulcerative colitis with distal active inflammation: double-blind, randomized study.

text: BACKGROUND Budesonide foam is used for the topical treatment of distal ulcerative colitis. This phase III study was performed to confirm mucosal healing and other therapeutic effects of twice-daily budesonide 2-mg foam in patients with mild-to-moderate ulcerative colitis including left-sided colitis and pancolitis. METHODS This was a multicenter, randomized, placebo-controlled, double-blind trial. A total of 126 patients with mild-to-moderate ulcerative colitis with active inflammation in the distal colon were randomized to two groups receiving twice-daily budesonide 2 mg/25 ml foam or placebo foam. The primary endpoint was the percentage of complete mucosal healing of distal lesions (endoscopic subscore of 0) at week 6. Some patients continued the treatment through week 12. Drug efficacy and safety were evaluated. RESULTS The percentages of both complete mucosal healing of distal lesions and clinical remission were significantly improved in the budesonide as compared with the placebo group (p = 0.0003 and p = 0.0035). Subgroup analysis showed similar efficacy of budesonide foam for complete mucosal healing of distal lesions and clinical remission regardless of disease type. The clinical remission percentage tended to be higher in patients achieving complete mucosal healing of distal lesions than in other patients. There were no safety concerns with budesonide foam. CONCLUSIONS This study confirmed for the first time complete mucosal healing with twice-daily budesonide 2-mg foam in mild-to-moderate ulcerative colitis with distal active inflammation. The results also indicated that complete mucosal healing of distal lesions by budesonide foam promotes clinical remission of ulcerative colitis. Clinical trial registration no.: Japic CTI-142704.


title: Evaluation of serum sialic acid level in buffaloes naturally infected with Theileria annulata.

text: Tropical theileriosis, caused by Theileria annulata, is the most economically important disease of domestic buffaloes and causing major losses in livestock production in Iran. Sialic acids are often involved in interaction between the cells and the infectious agents by regulating the molecular relations as well as mediating a variety of cell-cell adhesion processes in the immune response. This study was conducted to assess the effect of T. annulata infection on sialic acid concentration in blood sera in naturally infected buffaloes. T. annulata-infected (n = 22) and uninfected control (n = 20) adult buffaloes were selected. Theileria infection was revealed by Giemsa-stained peripheral blood and was confirmed by nested-PCR using T. annulata-specific primers. Based on the detected parasitemia, the infected animals were subgrouped into low <1 %, moderate 1-3 %, high 3-5 %, and very high >5 %. Hematological parameters and the concentrations of total sialic acid (TSA), lipid-bound sialic acid (LBSA), and protein-bound sialic acid (PBSA) were measured and correlated to parasitemia. The results showed significant differences (P < 0.05) in red blood cells (RBCs), packed cell volume (PCV), hemoglobin (Hb), and sialic acid concentrations between infected and control groups. As the parasitemia increased accordingly, a significant decrease in RBCs, PCV, Hb and increase in the mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), and serum sialic acids was observed. We concluded that T. annulata infection could elevate the serum sialic acid concentrations. The increased levels of serum sialic acid concentrations during parasitemia presumably stimulate the host immune response and influence the parasite-host cell adhesion.


title: Direct RNA nanopore sequencing of full-length coronavirus genomes provides novel insights into structural variants and enables modification analysis.

text: Sequence analyses of RNA virus genomes remain challenging owing to the exceptional genetic plasticity of these viruses. Because of high mutation and recombination rates, genome replication by viral RNA-dependent RNA polymerases leads to populations of closely related viruses, so-called "quasispecies." Standard (short-read) sequencing technologies are ill-suited to reconstruct large numbers of full-length haplotypes of (1) RNA virus genomes and (2) subgenome-length (sg) RNAs composed of noncontiguous genome regions. Here, we used a full-length, direct RNA sequencing (DRS) approach based on nanopores to characterize viral RNAs produced in cells infected with a human coronavirus. By using DRS, we were able to map the longest (∼26-kb) contiguous read to the viral reference genome. By combining Illumina and Oxford Nanopore sequencing, we reconstructed a highly accurate consensus sequence of the human coronavirus (HCoV)-229E genome (27.3 kb). Furthermore, by using long reads that did not require an assembly step, we were able to identify, in infected cells, diverse and novel HCoV-229E sg RNAs that remain to be characterized. Also, the DRS approach, which circumvents reverse transcription and amplification of RNA, allowed us to detect methylation sites in viral RNAs. Our work paves the way for haplotype-based analyses of viral quasispecies by showing the feasibility of intra-sample haplotype separation. Even though several technical challenges remain to be addressed to exploit the potential of the nanopore technology fully, our work illustrates that DRS may significantly advance genomic studies of complex virus populations, including predictions on long-range interactions in individual full-length viral RNA haplotypes.


title: Erroneous Communication Messages on COVID-19 in Africa.

text: Adherence of the population to COVID-19 prevention recommendations is crucial to control the epidemic. However, a study of communication messages around COVID-19 in 15 West African countries showed a number of unfounded messages, as well as a lack of communication on critical information to understand the prevention measures being promoted. Incidents of violence that have taken place recently suggest that general mistrust and hostility could grow, similar to the events that occurred during the previous Ebola epidemics. It is therefore urgent to review and revise the COVID-19 communication messages currently used in sub-Saharan Africa.


title: Laparoscopic transumbilical cholecystectomy: surgical technique.

text: BACKGROUND Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports. METHODS The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval. RESULTS Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m(2). The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours. CONCLUSION Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.


John-Arne Røttingen.


title: Onyx embolization in distal dissecting posterior inferior cerebellar artery aneurysms.

text: BACKGROUND Dissecting aneurysms located along the distal segments of the posterior inferior cerebellar artery (PICA) are extremely rare, accounting for only 0.5-0.7% of all intracranial aneurysms. Treatment of these aneurysms is challenging, both surgically and endovascularly. We present our preliminary experience and clinical data utilizing Onyx as an embolization agent in the treatment of these lesions with proximal parent artery preservation. METHODS 7 consecutive ruptured peripheral PICA aneurysms, in 7 patients, were treated with superselective Onyx embolization at our institutions. According to the anatomical classification of Lister et al, these aneurysms were located in the lateral medullary segment (n=1), tonsillomedullary segment (n=1), and the telovelotonsillary segment (n=5) of the PICA. Technical feasibility, procedure related complications, angiographic results, follow-up diagnostic imaging, and clinical outcome were evaluated. RESULTS In all cases, endovascular treatment was successful, with complete occlusion of the aneurysm with proximal parent artery preservation at the final postprocedural angiogram. Procedure related complications were not observed. One patient with a poor clinical condition at admission died during the initial hospital stay due to extensive subarachnoid and intraventricular hemorrhage. No rebleeding or recanalization was noted during follow-up. Two patients had a residual moderate to severe disability at follow-up. Favorable outcomes, with no or mild disability, were observed in four of the surviving patients. CONCLUSIONS Angiographic, diagnostic imaging, and clinical results of our small series indicate that Onyx embolization of dissecting distal PICA aneurysms with parent artery preservation is an effective option with acceptable morbidity and mortality rate, in those cases in which surgical clipping or endovascular coiling of the aneurysmal sac is not suitable.


title: Oxidative stress-mediated selective antimicrobial ability of nano-VO2 against Gram-positive bacteria for environmental and biomedical applications.

text: Vanadium dioxide (VO2) is a unique thermochromic material as a result of its semiconductor-metal transition, holding great promise for energy-saving intelligent windows. Herein, pure nano-VO2 from discrete nanoparticles to continuous films were successfully deposited on quartz glass by controlling the sputtering parameters. It was demonstrated that, for Gram-positive S. aureus and S. epidermidis, the nano-VO2 could effectively disrupt bacteria morphology and membrane integrity, and eventually cause death. By contrast, the nano-VO2 did not exhibit significant toxicity towards Gram-negative E. coli and P. aeruginosa. To our knowledge, this is the first report on a selective antimicrobial effect of nano-VO2 materials on Gram-positive bacteria. Based on the experimental results, a plausible mechanism was proposed for the antimicrobial selectivity, which might originate from the different sensitivity of Gram-positive and Gram-negative bacteria to intracellular reactive oxygen species (ROS) level. Elevated intracellular ROS levels exceed the threshold that bacteria can self-regulate to maintain cellular redox homeostasis and thus cause oxidative stress, which can be alleviated by the intervention of glutathione (GSH) antioxidant. In addition, nano-VO2 did not produce significant cytotoxicity (hemolysis) against human erythrocytes within 12 h. Meanwhile, potential cytotoxicity against HIBEpiC revealed a time- and dose-dependent behavior that might be controlled and balanced by careful design. The findings in the present work may contribute to understanding the antimicrobial behavior of nano-VO2, and to expanding the new applications of VO2-based nanomaterials in environmental and biomedical fields.


Experience of a small country (Montenegro) in the COVID-19 epidemic and its impact on rehabilitation.


Suprapubic single port ileocaecal resection for complicated Crohn's disease - a video vignette.


ACP Journal Club. In ischemic stroke, early intraarterial treatment plus alteplase improved reperfusion and functional outcome.


title: Developing a percutaneous dilatational tracheostomy service by medical intensivists: experience at one academic institution.

text: PURPOSE Percutaneous dilatational tracheostomy (PDT) is increasingly becoming the preferred method, compared with open surgical tracheostomy, for patients requiring chronic ventilatory assistance. Little is known regarding the process involved to incorporate PDT as a standard service in the medical intensive care unit. In this report, we describe our experience developing a "PDT service" led by medical intensivists. MATERIALS AND METHODS With support from our leadership and surgical colleagues, we developed a credentialing and training process for medical intensivists, formulated a bedside team to perform PDT, refined our technique, and maintained a patient data registry for quality improvement. RESULTS To date, our service includes 4 medical intensivists with PDT privileges. Over a 4-year period, we performed 171 PDTs for patients in the medical intensive care unit after 12.1 ± 8.2 days of mechanical ventilation. Our procedure-related complication rates are similar to other reports. No patient required emergent open surgical tracheostomy, and there were no deaths related to PDT. We required minimal to no backup support from our surgical colleagues in performing PDT. CONCLUSIONS We successfully developed a medical intensivist-driven PDT service, sharing our unique successes and challenges, to facilitate the care of our patients requiring prolonged ventilator support.


title: Pedicled omental flaps in the treatment of complex spinal wounds after en bloc resection of spine tumors.

text: STUDY DESIGN The present paper presents a retrospective study of 5 patients who underwent pedicled omental flap procedure following spine tumor removal. SUMMARY OF BACKGROUND DATA Postoperative wound dehiscence represents a major complication in spinal surgery, particularly after en bloc tumor resection, because of the extended sacrifice of soft tissues and adjuvant radiation therapy and chemotherapy. METHODS Five patients, with a mean age of 52 years (range, 24-71 years), who underwent omental flaps for the treatment of postoperative complication in spine tumor resections were retrospectively evaluated. RESULTS Four of 5 patients underwent omental transposition after a mean of 15 months (range, 4-27) from the previous surgery because of dehiscence of the wound (all of them had cerebrospinal fluid leak: 1 transpleural and in 3 cases, associated with deep infection), whereas one patient underwent the omental flap procedure at the time of elective spinal surgery because of several contemporary risk factors for wound healing. At the time of discharge after a mean of 36 days (range, 23-53), all patients had well-healed surgical wounds with an acceptable structural and aesthetic result. One of the patients had ileus, requiring surgical lysis of abdominal adhesions 3 months after omentum flap procedure. No other complications were observed. CONCLUSION Our data suggest that pedicled omental flap is a viable option for the treatment of complicated spinal wounds, helping in the resolution of the infection and CSF leak.


title: Cardiac Troponin for the Diagnosis and Risk-Stratification of Myocardial Injury in COVID-19: JACC Review Topic of the Week.

text: Increases in cardiac troponin (cTn) indicative of myocardial injury are common in patients with COVID-19 and associated with adverse outcomes such as arrhythmias and death. These increases are more likely to occur in those with chronic cardiovascular conditions and in those with severe COVID-19 presentations. The increased inflammatory, prothrombotic, and procoagulant responses following SARS-CoV-2 infection increase the risk for acute nonischemic myocardial injury and acute myocardial infarction, particularly type 2 myocardial infarction because of respiratory failure with hypoxia and hemodynamic instability in critically ill patients. Myocarditis, stress cardiomyopathy, acute heart failure, and direct injury from SARS-CoV-2 are important etiologies, but primary non-cardiac conditions such as pulmonary embolism, critical illness, and sepsis probably cause more of the myocardial injury. The structured use of serial cTn has the potential to facilitate risk stratification, help make decisions about when to use imaging, and inform stage categorization and disease phenotyping among hospitalized COVID-19 patients.


title: Biomechanical evaluation of three fixation modalities for preperitoneal inguinal hernia repair: a 24-hour postoperative study in pigs.

text: PURPOSE Tacks and sutures ensure a strong fixation of meshes, but they can be associated with pain and discomfort. Less invasive methods are now available. Three fixation modalities were compared: the ProGrip™ laparoscopic self-fixating mesh; the fibrin glue Tisseel™ with Bard™ Soft Mesh; and the SorbaFix™ absorbable fixation system with Bard™ Soft Mesh. MATERIALS AND METHODS Meshes (6 cm ×6 cm) were implanted in the preperitoneal space of swine. Samples were explanted 24 hours after surgery. Centered defects were created, and samples (either ten or eleven per fixation type) were loaded in a pressure chamber. For each sample, the pressure, the mesh displacement through the defect, and the measurements of the contact area were recorded. RESULTS At all pressures tested, the ProGrip™ laparoscopic self-fixating mesh both exhibited a significantly lower displacement through the defect and retained a significantly higher percentage of its initial contact area than either the Bard™ Soft Mesh with Tisseel™ system or the Bard™ Soft Mesh with SorbaFix™ absorbable fixation system. Dislocations occurred with the Bard™ Soft Mesh with Tisseel™ system and with the Bard™ Soft Mesh with SorbaFix™ absorbable fixation system at physiological pressure (,225 mmHg). No dislocation was recorded for the ProGrip™ laparoscopic self-fixating mesh. CONCLUSION At 24 hours after implantation, the mechanical fixation of the ProGrip™ laparoscopic self-fixating mesh was found to be significantly better than the fixation of the Tisseel™ system or the SorbaFix™ absorbable fixation system.


Making treatment recommendations during the COVID-19 pandemic.


Models that work: incorporating quality principles in different clinical settings.


title: Impact of near-infrared angiography on the quality of anatomical resection during video-assisted thoracic surgery segmentectomy.

text: Background The aim of the present study was to assess the impact of near-infrared angiography in guiding intraoperatively sublobar anatomical resection by video-assisted thoracic surgery (VATS). Methods We retrospectively analyzed data from 67 patients who underwent segmentectomy by VATS from November 2014 to November 2017 at the University Hospitals of Geneva, Switzerland. The need to modify arterial or parenchymal resection based on intraoperative near-infrared imaging was considered the primary study outcome. Results A total of 67 patients (28 men, 39 women, mean age 66±10 years) underwent anatomical pulmonary segmentectomy by VATS. Histological analysis revealed a primary lung tumor in 59 patients. The mean ± standard deviation (SD) operation time was 154±51 minutes. Identification of the intersegmental plane (ISP) with near-infrared angiography was achieved in 88% of patients and led to modification of the resection during segmentectomy in 7 patients (10%), avoiding inappropriate resection; 2 patients had distant tumor recurrences (3%). Conclusions Near-infrared angiography during VATS segmentectomy is effective for identifying ISPs, with respect to the oncological margins, as well as for correcting the anatomical resection.


title: Should we consider topical silver nitrate irrigation as a definitive nonsurgical treatment for perianal fistula?

text: BACKGROUND Surgery is currently the sole treatment modality for anal fistulas. However, surgery is associated with complications such as permanent incontinence, which reduces quality of life. OBJECTIVE To determine the rate of complete clinical healing of anal fistulas after irrigation of the fistula tract with silver nitrate solution as a nonsurgical treatment. DESIGN Prospective single arm study. SETTING Tertiary university hospital PATIENTS : Adult patients with symptomatic perianal fistula presenting between June 2012 and January 2013. INTERVENTION Irrigation of the fistula tract with 1% silver nitrate solution. Irrigation was repeated every 2 weeks when necessary. MAIN OUTCOME MEASURES The primary outcome measure was the rate of complete clinical healing. RESULTS Fifty-six consecutive patients with anal fistula were analyzed. Of those, 29 (52%) had complete clinical healing without recurrence for a median of 10 months. The median number of irrigations needed for complete clinical healing was 4 (1-10). The level of satisfaction was excellent in patients with complete clinical healing. The frequency of complaints was the only independent factor that had an impact on healing; patients with intermittent discharge had a significantly higher rate of complete clinical healing (67%) than those with continuous discharge (40%). There were no notable complications. LIMITATIONS Short follow-up, small sample size, and no comparisons. CONCLUSION This study demonstrates that the application of silver nitrate solution often produces a favorable outcome in the treatment of anal fistula. This method may be considered as a first-line treatment for the disease because it is simple, performed on an outpatient basis, minimally invasive, and lacks the complications encountered with current conventional surgical modalities.


title: Are Covid-19-positive mothers dangerous for their term and well newborn babies? Is there an answer?

text: Background The pandemic caused by the new coronavirus SARS-CoV-2 (Covid-19) is quite a challenging experience for the world. At the moment of birth, the fetus is prepared to face the challenge of labor and the exposure to the outside world, meaning that labor and birth represent the first extrauterine major exposure to a complex microbiota. The vagina, which is a canal for reproduction, is by evolution separated (but not far) from the anus and urethra. Passing through the birthing canal is a mechanism for intergenerational transmission of vaginal and gut microorganisms for the vertical transmission of microbiota not only from our mothers and grandmothers but also from earlier ancestors. Methods Many national and international instructions have been developed since the beginning of the Covid-19 outbreak in January 2020 in Wuhan in China. All of them pointed out hygiene measures, social distancing and avoidance of social contacts as the most important epidemiological preventive measures. Pregnancy and neonatal periods are considered as high risk for Covid-19 infection. Results The instructions defined the care for pregnant women in the delivery room, during a hospital stay and after discharge. The controversial procedures in the care of Covid-19-suspected or -positive asymptomatic women in labor were: mode of delivery, companion during birth and labor, skin-to-skin contact, breastfeeding, and visits during a hospital stay. Conclusion There is a hope that instruction on coping with the coronavirus (Covid-19) infection in pregnancy with all proposed interventions affecting mothers, babies and families, besides saving lives, are beneficial and efficient by exerting no harm.