title: The effect of iodinated contrast agent properties on renal kinetics and oxygenation.

text: OBJECTIVE We analyzed renal kinetics and renal oxygenation in rats after administration of several classes and formulations of contrast agents (CAs) with a focus on the influence of osmolality and substance-specific properties. MATERIALS AND METHODS We investigated the renal kinetics of a nonionic, dimeric CA (iodixanol) formulated in 3 different osmolalities (hypo-osmolar, iso-osmolar, low-osmolar) and compared it to nonionic, low-osmolar (iopromide), and ionic, low-osmolar CAs (ioxaglate) using computed tomography for a period of 24 hours. The CAs were administered intravenously at a dosage of 4 g iodine/kg body weight. The average exposure was calculated, and urine viscosities were compared before the injection and during the time intervals of 0 to 60 minutes and 60 to 120 minutes after the injection. Renal oxygenation levels of the renal cortex and medulla were estimated using blood-oxygen-level-dependent magnetic resonance imaging. We used histologic methods to systematically analyze the gravity of vacuole formation based on the physicochemical and substance-specific properties of each CA. RESULTS Iso-osmolar and hypo-osmolar iodixanol and, to a lesser extent, iodixanol/mannitol accumulated rapidly in the kidneys during the first 5 minutes of the injection and remained higher 2, 4, 6, and 24 hours after the injection compared with iopromide and ioxaglate, which showed fast iodine excretion. Similarly, lower renal blood oxygen levels were estimated for all iodixanol formulations as compared with ioxaglate and iopromide. The incidence of vacuole formation was high for all iodixanol formulations and for ioxaglate (6 of 6 rats) and low for iopromide (1 of 6 rats). Moderate severity of vacuoles was determined for the iodixanol solutions; minimal severity, for ioxaglate and iopromide. CONCLUSIONS We identified a superior profile for the low-osmolar CAs compared with the iso-osmolar CAs regarding rapid excretion, short-term renal exposure, and renal oxygenation.


Simple physical interventions such as handwashing and wearing masks can reduce spread of epidemic respiratory viruses.


title: Epidemiological and Clinical Predictors of COVID-19.

text: BACKGROUND Rapid identification of COVID-19 cases, which is crucial to outbreak containment efforts, is challenging due to the lack of pathognomonic symptoms and in settings with limited capacity for specialized nucleic acid-based reverse transcription polymerase chain reaction (PCR) testing. METHODS This retrospective case-control study involves subjects (7 to 98 years) presenting at the designated national outbreak screening centre and tertiary care hospital in Singapore for SARS-CoV-2 testing from January 26 to February 16, 2020. COVID-19 status was confirmed by PCR testing of sputum, nasopharyngeal swabs or throat swabs. Demographic, clinical, laboratory and exposure-risk variables ascertainable at presentation were analyzed to develop an algorithm for estimating the risk of COVID-19. Model development used Akaike's information criterion in a stepwise fashion to build logistic regression models, which were then translated into prediction scores. Performance was measured using receiver operating characteristics curves, adjusting for over-confidence using leave-out-one cross validation. RESULTS The study population included 788 subjects, of whom 54 (6.9%) were SARS-CoV-2 positive and 734 (93.1%) were SARS-CoV-2 negative. The median age was 34 years and 407 (51.7%) were female. Using leave-out-one cross validation, all the models incorporating clinical tests (Models 1, 2 and 3) performed well with areas under the receiver operating characteristics curve (AUC) of 0.91, 0.88 and 0.88 respectively. In comparison, Model 4 had an AUC of 0.65. CONCLUSIONS Rapidly ascertainable clinical and laboratory data could identify individuals at high risk of COVID-19 and enable prioritization of PCR-testing and containment efforts. Basic laboratory test results were crucial to prediction models.


title: Obesity and COVID-19 Severity in a Designated Hospital in Shenzhen, China.

text: OBJECTIVE Patients with obesity are at increased risk of exacerbations from viral respiratory infections. However, the association of obesity with the severity of coronavirus disease 2019 (COVID-19) is unclear. We examined this association using data from the only referral hospital in Shenzhen, China. RESEARCH DESIGN AND METHODS A total of 383 consecutively hospitalized patients with COVID-19 admitted from 11 January 2020 to 16 February 2020 and followed until 26 March 2020 at the Third People's Hospital of Shenzhen were included. Underweight was defined as a BMI <18.5 kg/m2, normal weight as 18.5-23.9 kg/m2, overweight as 24.0-27.9 kg/m2, and obesity as ≥28 kg/m2. RESULTS Of the 383 patients, 53.1% were normal weight, 4.2% were underweight, 32.0% were overweight, and 10.7% were obese at admission. Obese patients tended to have symptoms of cough (P = 0.03) and fever (P = 0.06) compared with patients who were not obese. Compared with normal weight patients, those who were overweight had 1.84-fold odds of developing severe COVID-19 (odds ratio [OR] 1.84, 95% CI 0.99-3.43, P = 0.05), while those who were obese were at 3.40-fold odds of developing severe disease (OR 3.40, 95% CI 1.40-2.86, P = 0.007), after adjusting for age, sex, epidemiological characteristics, days from disease onset to hospitalization, presence of hypertension, diabetes, cardiovascular disease, chronic obstructive pulmonary disease, liver disease and cancer, and drug used for treatment. Additionally, after similar adjustment, men who were obese versus those who were normal weight were at increased odds of developing severe COVID-19 (OR 5.66, 95% CI 1.80-17.75, P = 0.003). CONCLUSIONS In this study, obese patients had increased odds of progressing to severe COVID-19. As the severe acute respiratory syndrome coronavirus 2 may continue to spread worldwide, clinicians should pay close attention to obese patients, who should be carefully managed with prompt and aggressive treatment.


A half-billion-dollar bid to head off emerging diseases.


title: Scoping Review and Meta-analysis of Hyperbaric Oxygen Therapy for Radiation-Induced Hemorrhagic Cystitis.

text: PURPOSE OF REVIEW To critically review and summarize existing literature assessing the effectiveness of hyperbaric oxygen therapy (HBOT) for the treatment of radiation-induced urologic injury. RECENT FINDINGS Though 5 of the included 13 studies were published in the last 2-3 years, the only randomized controlled study was performed in 2012. Recent studies have confirmed the safety and efficacy of HBOT as well as identified risk factors for success vs. failure of HBOT for hemorrhagic radiation cystitis (HRC). Of the 602 patients that received HBOT for HRC, 84% had a partial or complete resolution. In the 7 studies that utilized RTOG/EORTC, 75% of patients saw an improvement in hematuria of at least one grade (out of possible 5 total). Of the 499 patients with documented follow-up, 14% experienced recurrence, with a median time to recurrence of 10 months (6 to 16.5 months).


title: Treatment options in people with COVID19: Selecting the best armamentarium against the novel virus.

text: Novel coronavirus disease (COVID-19) infection is a global pandemic, of high infectivity, variable mortality, with currently no established treatment. This review summarizes different molecules which are being evaluated for COVID19 treatment. PubMed and Medline, search for articles published to March 2020 was done using terms "COVID19" OR "corona-virus 2019" OR "2019-nCoV" or "severe acute respiratory syndrome coronavirus" AND "treatment". As of today, we have >350 RCTs happening with different agents. COVID19 treatment agents can be broadly classified into immuno-modulators (prevent hyperimmune-activation and cytokine storm) and anti-viral therapies (prevent virus entry, replication or viricidal). Hydroxychloroquine/chloroquine, Interferon-l, glucocorticoids, interleukin antagonists, Ulinastatin, intravenous immunoglobulins, plasmapheresis are main immunomodulators showing initial positive outcomes. Umifenovir. Lopinavir/Ritonavir, Ribavirin, remdesivir and Ravipiravir are some of the major antiviral agents showing initial encouraging results. It may be concluded that the most successful regimen is going to be multi-drug therapy, a combination of immunomodulatory agent with anti-viral agent.


title: Evaluation of peracetic acid fog for the inactivation of Bacillus anthracis spore surrogates in a large decontamination chamber.

text: The purpose of this study was to evaluate the sporicidal (inactivation of bacterial spores) effectiveness and operation of a fogging device utilizing peracetic acid/hydrogen peroxide (PAA). Experiments were conducted in a pilot-scale 24 m(3) stainless steel chamber using either biological indicators (BIs) or bacterial spores deposited onto surfaces via aerosolization. Wipe sampling was used to recover aerosol-deposited spores from chamber surfaces and coupon materials before and after fogging to assess decontamination efficacy. Temperature, relative humidity, and hydrogen peroxide vapor levels were measured during testing to characterize the fog environment. The fog completely inactivated all BIs in a test using a 60 mL solution of PAA (22% hydrogen peroxide/4.5% peracetic acid). In tests using aerosol-deposited bacterial spores, the majority of the post-fogging spore levels per sample were less than 1 log colony forming units, with a number of samples having no detectable spores. In terms of decontamination efficacy, a 4.78 log reduction of viable spores was achieved on wood and stainless steel. Fogging of PAA solutions shows potential as a relatively easy to use decontamination technology in the event of contamination with Bacillus anthracis or other spore-forming infectious disease agents, although additional research is needed to enhance sporicidal efficacy.


title: Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy.

text: OBJECTIVE To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS). SUMMARY BACKGROUND DATA LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other. METHODS A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes. RESULTS A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18-0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27-0.76), wound occurrences (OR: 0.37, 95% CI: 0.11-0.79), and sepsis (OR: 0.52, 95% CI: 0.26-0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS. CONCLUSIONS LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patient's clinical status.


title: Dying still matters in the age of COVID-19.

text: The ongoing COVID-19 pandemic is having a significant impact on people with palliative care needs.


title: Pregnancy promotes tolerance to future offspring by programming selective dysfunction in long-lived maternal T cells.

text: Fetal antigen available during pregnancy induces the proliferation of maternal T cells. It is unknown, however, whether these antigen-activated T cells differentiate into long-lived memory T cells that are capable of mediating rapid-recall responses to tissue antigens. To test the hypothesis that pregnancy induces an alternative fate in fetal-specific maternal T cells, we used a murine model to track longitudinally fetal-specific T cells in pregnant and postpartum animals and test the response of these cells when challenged with the same antigen during sequential pregnancy or skin transplantation. Fetal-specific CD8+ T cells were robustly primed during pregnancy but failed to acquire robust effector functions. These primed cells persisted long term in postpartum animals, frequently maintained a programmed death 1 (PD-1)+ phenotype, and failed to expand or produce cytokines robustly in response to second pregnancy or skin transplantation. However, whereas there was no impact on second pregnancy as a result of the persistence of fetal-primed memory CD8+ T cells in the mother, skin grafts bearing the same antigen were rejected more rapidly. Altogether, our data suggest that fetal antigen exposure during pregnancy induces the differentiation of long-lived maternal CD8+ T cells with context-dependent, selective effector dysfunction. This programmed effector dysfunction provides temporal and systemic restraint of maternal anti-fetal alloreactivity to promote reproductive fitness efficiently, while preserving potentially protective effector T cell responses.


title: Step-wise integration of single-port laparoscopic surgery into routine colorectal surgical practice by use of a surgical glove port.

text: INTRODUCTION The cost associated with single-port laparoscopic access devices may limit utilisation of single-port laparoscopic surgery by colorectal surgeons. This paper describes a simple and cheap access modality that has facilitated the widespread adoption of single-port technology in our practice both as a stand-alone procedure and as a useful adjunct to traditional multiport techniques. METHODS A surgical glove port is constructed by applying a standard glove onto the rim of the wound protector/retractor used during laparoscopic resectional colorectal surgery. To illustrate its usefulness, we present our total experience to date and highlight a selection of patients presenting for a range of elective colorectal surgery procedures. RESULTS The surgical glove port allowed successful completion of 25 single-port laparoscopic procedures (including laparoscopic adhesiolysis, ileo-rectal anastomosis, right hemicolectomy, total colectomy and low anterior resection) and has been used as an adjunct in over 80 additional multiport procedures (including refashioning of a colorectal anastomosis made after specimen extraction during a standard multiport laparoscopic anterior resection). CONCLUSIONS This simple, efficient device can allow use of single-port laparoscopy in a broader spectrum of patients either in isolation or in combination with multiport surgery than may be otherwise possible for economic reasons. By separating issues of cost from utility, the usefulness of the technical advance inherent within single-port laparoscopy for colorectal surgery can be better appreciated. We endorse the creative innovation inherent in this approach as surgical practice continues to evolve for ever greater patient benefit.


title: Mechanical revascularization of acute iatrogenic anterior cerebral artery occlusions: use of a new coaxial dual-lumen balloon catheter results in rapid access and flow restoration.

text: Acute iatrogenic occlusion of cerebral vessels is a risk during the performance of neuroendovascular procedures. Most commonly this is a result of thrombus formation within the vessel, thromboembolism or an acute vasospastic response. There are several options for flow restoration including pharmacological, mechanical and microsurgical. Mechanical flow restoration, usually by thrombectomy, is typically performed in large cerebral vessels. Current mechanical thrombectomy devices have limited utility in smaller vessels that are more difficult to access, such as the anterior cerebral artery (ACA). We present two cases where successful flow restoration of an intraoperative acutely occluded or thrombotic ACA was rapidly achieved by balloon dilation using a new coaxial dual-lumen balloon catheter. The time elapsed from the decision to use the balloon catheter until revascularization for each patient was 5 min and 46 s (case 1) and 10 min and 25 s (case 2).


title: NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen.

text: HYPOTHESIS Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option. MATERIAL AND METHODS We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally. RESULTS The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day. CONCLUSIONS Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.


title: Postoperative fever in the time of COVID-19.

text: Summary Postoperative fever is common following orthopedic trauma surgery. As the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases in the community, migration into the acute care hospital setting intensifies, creating confusion when fever develops postoperatively. The transmission dynamics of SARS-CoV-2 make it difficult to adequately gauge and pinpoint risk groups with questionnaires at the time of hospital admission. This is particularly problematic when asymptomatic or presymptomatic patients infected with SARS-CoV-2 require urgent surgery and cannot be screened effectively. One approach is to treat every patient as though they were SARS-CoV-2-positive in preparation for surgery, but doing so could exacerbate shortages of personal protective equipment and staffing limitations. Uncertainty regarding the etiology of postoperative fever could be significantly reduced by universal SARS-CoV-2 testing of all surgical patients at the time of hospital admission in addition to routine screening, but testing capacity and a rapid turnaround time would be required.


title: A systematic review of trials evaluating success factors of interventions with computerised clinical decision support.

text: BACKGROUND Computerised clinical decision support (CDS) can potentially better inform decisions, and it can help with the management of information overload. It is perceived to be a key component of a learning health care system. Despite its increasing implementation worldwide, it remains uncertain why the effect of CDS varies and which factors make CDS more effective. OBJECTIVE To examine which factors make CDS strategies more effective on a number of outcomes, including adherence to recommended practice, patient outcome measures, economic measures, provider or patient satisfaction, and medical decision quality. METHODS We identified randomised controlled trials, non-randomised trials, and controlled before-and-after studies that directly compared CDS implementation with a given factor to CDS without that factor by searching CENTRAL, MEDLINE, EMBASE, and CINAHL and checking reference lists of relevant studies. We considered CDS with any objective for any condition in any healthcare setting. We included CDS interventions that were either displayed on screen or provided on paper and that were directed at healthcare professionals or targeted at both professionals and patients. The reviewers screened the potentially relevant studies in duplicate. They extracted data and assessed risk of bias in independent pairs or individually followed by a double check by another reviewer. We summarised results using medians and interquartile ranges and rated our certainty in the evidence using the GRADE system. RESULTS We identified 66 head-to-head trials that we synthesised across 14 comparisons of CDS intervention factors. Providing CDS automatically versus on demand led to large improvements in adherence. Displaying CDS on-screen versus on paper led to moderate improvements and making CDS more versus less patient-specific improved adherence modestly. When CDS interventions were combined with professional-oriented strategies, combined with patient-oriented strategies, or combined with staff-oriented strategies, then adherence improved slightly. Providing CDS to patients slightly increased adherence versus CDS aimed at the healthcare provider only. Making CDS advice more explicit and requiring users to respond to the advice made little or no difference. The CDS intervention factors made little or no difference to patient outcomes. The results for economic outcomes and satisfaction outcomes were sparse. CONCLUSION Multiple factors may affect the success of CDS interventions. CDS may be more effective when the advice is provided automatically and displayed on-screen and when the suggestions are more patient-specific. CDS interventions combined with other strategies probably also improves adherence. Providing CDS directly to patients may also positively affect adherence. The certainty of the evidence was low to moderate for all factors. TRIAL REGISTRATION PROSPERO, CRD42016033738.


Thanks to reviewers.


title: COVID-19 in Singapore - a case series from primary care.

text: As the coronavirus disease 2019 (COVID-19) pandemic worsens, early case detection is vital to limiting community spread. We describe our experiences with four COVID-19 cases at the polyclinics in January and February 2020. This retrospective case series highlights the challenges primary care clinicians face in the early identification of suspect cases based on clinical criteria only. To improve case detection, clinicians can sharpen their clinical acumen by keeping abreast with the latest COVID-19 developments and by maintaining a high state of vigilance.


title: Maternal vaccination: moving the science forward.

text: BACKGROUND Infections remain one of the leading causes of morbidity in pregnant women and newborns, with vaccine-preventable infections contributing significantly to the burden of disease. In the past decade, maternal vaccination has emerged as a promising public health strategy to prevent and combat maternal, fetal and neonatal infections. Despite a number of universally recommended maternal vaccines, the development and evaluation of safe and effective maternal vaccines and their wide acceptance are hampered by the lack of thorough understanding of the efficacy and safety in the pregnant women and the offspring. METHODS An outline was synthesized based on the current status and major gaps in the knowledge of maternal vaccination. A systematic literature search in PUBMED was undertaken using the key words in each section title of the outline to retrieve articles relevant to pregnancy. Articles cited were selected based on relevance and quality. On the basis of the reviewed information, a perspective on the future directions of maternal vaccination research was formulated. RESULTS Maternal vaccination can generate active immune protection in the mother and elicit systemic immunoglobulin G (IgG) and mucosal IgG, IgA and IgM responses to confer neonatal protection. The maternal immune system undergoes significant modulation during pregnancy, which influences responsiveness to vaccines. Significant gaps exist in our knowledge of the efficacy and safety of maternal vaccines, and no maternal vaccines against a large number of old and emerging pathogens are available. Public acceptance of maternal vaccination has been low. CONCLUSIONS To tackle the scientific challenges of maternal vaccination and to provide the public with informed vaccination choices, scientists and clinicians in different disciplines must work closely and have a mechanistic understanding of the systemic, reproductive and mammary mucosal immune responses to vaccines. The use of animal models should be coupled with human studies in an iterative manner for maternal vaccine experimentation, evaluation and optimization. Systems biology approaches should be adopted to improve the speed, accuracy and safety of maternal vaccine targeting.


Twitter storm forces Chimerix's hand in compassionate use request.


title: "Acute intrathoracic stomach!" How should we deal with complicated type IV paraesophageal hernias?

text: PURPOSE Management of emergently admitted patients due to a complicated large paraesophageal hernia with acute symptoms of an "intrathoracic stomach" is controversial. The aim of this study was to clarify whether emergency surgery in such cases should be the procedure of choice. METHODS The retrospective analysis of patients who were hospitalized due to emerging acute symptoms of an "intrathoracic stomach" between January 2009 and May 2013 was used as method. Patients were categorized into three groups: emergency operation within 24 h after admission, semi-elective operation within the first 7 days after admission and elective operation. RESULTS Twenty-four patients were identified. Only three (12.5 %) patients required laparoscopic emergency surgery and two incurred a perioperative complication. In consequence of persistent or early recurrent complaints a laparoscopic operation was required prior to discharge semi-elective in 6/24 (25 %) patients without complications. The remaining 15/24 (62.5 %) patients were free of complaints after conservative therapy, but all of them decided upon elective operation after informed consent. One minor complication occurred. CONCLUSION The majority of patients with acute symptoms due to an intrathoracic stomach can primarily be treated conservatively and timing of elective repair should be performed after resuscitation in a center of laparoscopic antireflux surgery.


title: Updated European Association of Urology Guidelines Recommendations for the Treatment of First-line Metastatic Clear Cell Renal Cancer.

text: The randomised phase III clinical trial Checkmate-214 showed a survival superiority for the combination of ipilimumab and nivolumab when compared with the previous standard of care in first-line metastatic/advanced clear cell renal cell carcinoma (RCC) (Escudier B, Tannir NM, McDermott DF, et al. CheckMate 214: efficacy and safety of nivolumab plus ipilimumab vs sunitinib for treatment-naïve advanced or metastatic renal cell carcinoma, including IMDC risk and PD-L1 expression subgroups. LBA5, ESMO 2017, 2017). These results change the frontline standard of care for this disease and have implications for the selection of subsequent therapies. For this reason the European Association of Urology RCC guidelines have been updated. PATIENT SUMMARY The European Association of Urology guidelines will be updated based on the results of the phase III Checkmate-214 clinical trial. The trial showed superior survival for a combination of ipilimumab and nivolumab (IN), compared with the previous standard of care, in intermediate- and poor-risk patients with metastatic clear cell renal cell carcinoma. When IN is not safe or feasible, alternative agents such as sunitinib, pazopanib, and cabozantinib should be considered. Furthermore, at present, the data from the trial are immature in favourable-risk patients. Therefore, sunitinib or pazopanib remains the favoured agent for this subgroup of patients.


Mounting evidence suggests coronavirus is airborne - but health advice has not caught up.


title: Evaluation of Lung Radiofrequency Ablation With Dual-Energy Computed Tomography: Analysis of Tumor Composition and Lung Perfusion.

text: OBJECTIVE The aim of this study was to evaluate radiofrequency ablation (RFA) of lung tumors with dual-energy computed tomography while focusing on tumor composition and lung perfusion. METHODS The 36 tumors in 25 patients were included. Dual-energy computed tomography was performed before RFA and at 2 days and 1, 3, and 6 months thereafter. The effective atomic number (Zeff) of the tumors before RFA was compared with the Zeff at each follow-up using the paired t test. Lung perfusion was evaluated by iodine map images. When decreased perfusion was suspected after RFA, lung perfusion scintigraphy was performed. RESULTS The mean Zeff of the tumors significantly (P < 0.001) decreased at each follow-up, compared with that before RFA. Lung perfusion in the parenchyma peripheral to the tumors appeared to decrease at 2 days in 9 tumors, which was confirmed by scintigraphy in 7 tumors. CONCLUSIONS Dual-energy computed tomography was useful by providing additional information on tumor composition and lung perfusion.


Interpreting Diagnostic Tests for SARS-CoV-2.


title: Chest wall reconstruction with MatrixRib system: avoiding pitfalls.

text: Reconstructions of the chest wall using commercially available artificial metallic rib systems are gaining in popularity. The MatrixRib system involves use of plates and screws to bridge any defect and provide support for the chest wall following resection. So far, there has been no publication focusing on describing the use of this new technology in a step-by-step approach. We describe our technique and discuss potential pitfalls and difficulties of using the system.


title: Minimally invasive adrenal surgery: an update.

text: PURPOSE OF REVIEW To summarize the recent developments in minimally invasive adrenal surgery. RECENT FINDINGS Modern adrenal surgery continues to evolve with new techniques. Both the laparoscopic transabdominal and retroperitoneoscopic approaches are now the standard of care for the removal of nonmalignant adrenal tumors. Other recent developments include robotic retroperitoneal adrenalectomy, single-incision laparoendoscopic surgery, and ambulatory adrenalectomy. SUMMARY Here, we review the literature of minimally invasive adrenal surgery over the last year to highlight new developments and technical refinements.


title: Timing of Community Mitigation and Changes in Reported COVID-19 and Community Mobility - Four U.S. Metropolitan Areas, February 26-April 1, 2020.

text: Community mitigation activities (also referred to as nonpharmaceutical interventions) are actions that persons and communities can take to slow the spread of infectious diseases. Mitigation strategies include personal protective measures (e.g., handwashing, cough etiquette, and face coverings) that persons can use at home or while in community settings; social distancing (e.g., maintaining physical distance between persons in community settings and staying at home); and environmental surface cleaning at home and in community settings, such as schools or workplaces. Actions such as social distancing are especially critical when medical countermeasures such as vaccines or therapeutics are not available. Although voluntary adoption of social distancing by the public and community organizations is possible, public policy can enhance implementation. The CDC Community Mitigation Framework (1) recommends a phased approach to implementation at the community level, as evidence of community spread of disease increases or begins to decrease and according to severity. This report presents initial data from the metropolitan areas of San Francisco, California; Seattle, Washington; New Orleans, Louisiana; and New York City, New York* to describe the relationship between timing of public policy measures, community mobility (a proxy measure for social distancing), and temporal trends in reported coronavirus disease 2019 (COVID-19) cases. Community mobility in all four locations declined from February 26, 2020 to April 1, 2020, decreasing with each policy issued and as case counts increased. This report suggests that public policy measures are an important tool to support social distancing and provides some very early indications that these measures might help slow the spread of COVID-19.


title: Covid-19 and co-morbidities: a role for Dipeptidyl Peptidase 4 (DPP4) in disease severity?

text: The Covid-19 pandemic is caused by a novel betacoronavirus, SARS-CoV-2, similar to SARS-CoV and MERS-CoV, which cause acute respiratory distress syndrome and case fatalities. Covid-19 disease severity is worse in older obese patients with comorbidities such as diabetes, hypertension, cardiovascular disease and chronic lung disease. Cell binding and entry of betacoronaviruses is via their surface spike glycoprotein; SARS-CoV binds to the metalloprotease angiotensin-converting enzyme 2, abbreviated hereafter to ACE2, MERS-CoV utilises dipeptidyl peptidase 4, abbreviated hereafter to DPP4, and recent modelling of the structure of SARS-CoV-2 spike glycoprotein predicts that it can interact with human DPP4 in addition to ACE2. DPP4 is a ubiquitous membrane-bound aminopeptidase that circulates in plasma; it is multifunctional with roles in nutrition, metabolism, immune and endocrine systems. DPP4 activity differentially regulates glucose homeostasis and inflammation via its enzymatic activity and non-enzymatic immunomodulatory effects. The importance of DPP4 for the medical community has been highlighted by the approval of DPP4 inhibitors, or gliptins, for the treatment of Type 2 diabetes mellitus. This review discusses the dysregulation of DPP4 in Covid-19 comorbid conditions; DPP4 activity is higher in older individuals and increased plasma DPP4 is a predictor of the onset of metabolic syndrome. DPP4 upregulation may be a determinant of Covid-19 disease severity, which creates interest regarding the use of gliptins in management of Covid-19. Also, knowledge of the chemistry and biology of DPP4 could be utilised to develop novel therapies to block viral entry of some betacoronaviruses, potentially including SARS-CoV-2. This article is protected by copyright. All rights reserved.


title: Development of a potent DOTA-conjugated bombesin antagonist for targeting GRPr-positive tumours.

text: PURPOSE Radiolabelled somatostatin-based antagonists show a higher uptake in tumour-bearing mouse models than agonists of similar or even distinctly higher receptor affinity. Very similar results were obtained with another family of G protein-coupled receptor ligands, the bombesin family. We describe a new conjugate, RM2, with the chelator DOTA coupled to D-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH(2) via the cationic spacer 4-amino-1-carboxymethyl-piperidine for labelling with radiometals such as (111)In and (68)Ga. METHODS RM2 was synthesized on a solid support and evaluated in vitro in PC-3 cells. IC(50) and K(d) values were determined. The antagonist potency was evaluated by immunofluorescence-based internalization and Ca(2+) mobilization assays. Biodistribution studies were performed in PC-3 and LNCaP tumour-bearing mice with (111)In-RM2 and (68)Ga-RM2, respectively. PET/CT studies were performed on PC-3 and LNCaP tumour-bearing nude mice with (68)Ga-RM2. RESULTS RM2 and (111)In-RM2 are high-affinity and selective ligands for the GRP receptor (7.7 ± 3.3 nmol/l for RM2; 9.3 ± 3.3 nmol/l for (nat)In-RM2). The potent antagonistic properties were confirmed by an immunofluorescence-based internalization and Ca(2+) mobilization assays. (68)Ga- and (111)In-RM2 showed high and specific uptake in both the tumour and the pancreas. Uptake in the tumour remained high (15.2 ± 4.8%IA/g at 1 h; 11.7 ± 2.4%IA/g at 4 h), whereas a relatively fast washout from the pancreas and the other abdominal organs was observed. Uptake in the pancreas decreased rapidly from 22.6 ± 4.7%IA/g at 1 h to 1.5 ± 0.5%IA/g at 4 h. CONCLUSION RM2 was shown to be a potent GRPr antagonist. Pharmacokinetics and imaging studies indicate that (111)In-RM2 and (68)Ga-RM2 are ideal candidates for clinical SPECT and PET studies.


title: Transanal total mesorectal excision for restorative coloproctectomy in an obese high-risk patient with colitis-associated carcinoma.

text: Transanal total mesorectal excision (TaTME) offers great potential for the treatment of malign and benign diseases. However, laparoscopic-assisted TaTME in ulcerative colitis has not been described in more than a handful of patients. We present a 47-year-old highly comorbid female patient with an ulcerative colitis-associated carcinoma of the ascending colon and steroid- refractory pancolitis. A two-stage restorative coloproctectomy including right-sided complete mesocolic excision was conducted. The second step consisted of a successful nerve-sparing TaTME and a handsewn ileal pouch-anal anastomosis. TaTME may extend the possible treatment options in inflammatory bowel disease, especially for high-risk patients.


title: Reversible locoregional lymph node enlargement after radiofrequency ablation of lung tumors.

text: OBJECTIVE The objective of our study was to assess the characteristics of locoregional lymph node enlargement after successful radiofrequency ablation (RFA) in the treatment of malignant lung tumors. MATERIALS AND METHODS Follow-up CT examinations of 14 patients (seven men, seven women; age range, 30-90 years) who underwent 16 RFA sessions for the treatment of primary (n = 9) or metastatic (n = 5) lung tumors with a mean follow-up of 35 +/- 15 (SD) months (range, 7-60 months) were retrospectively reviewed by two thoracic radiologists. The site and size of hilar and mediastinal lymph nodes were recorded at baseline and at follow-up 1, 3, and 6 months after RFA sessions. In addition, the size, type, and location of the ablated lesion or lesions were recorded. All complications from RFA were recorded. Data were analyzed using the Fisher's exact test. RESULTS An increase in lymph node size was detected after 10 of 16 (62.5%) RFA sessions at 1-month follow-up. In four of 10 patients, only one node had enlarged, and in the remaining six patients, more than one nodal region had enlarged. The average increase in nodal size was 3 mm in the short-axis diameter and 4 mm in the long-axis diameter. Twenty-eight percent of RFA sessions were associated with enlargement of at least one lymph node to greater than 10 mm in short-axis diameter at 1-month follow-up. CT showed that nodes had decreased in size at 3- and 6-month follow-ups. Lesion size, location, and complications were not shown to be significantly associated with mediastinal lymph node enlargement (p > 0.05). CONCLUSION Recognition of reversible locoregional lymph node enlargement after RFA is important to prevent misdiagnosis of nodal metastatic disease.


title: Outcomes after toxic alcohol poisoning: a systematic review protocol.

text: BACKGROUND Toxic alcohols have been implicated in accidental ingestions and intentional exposures. Recognition of toxic alcohol poisoning is challenging. The main treatment modalities include antidotes with alcohol dehydrogenase inhibitors and dialysis. Current guidelines exist for both methanol and ethylene glycol intoxication. However, treatment consensus related to other toxic alcohols is limited. Furthermore, uncertainties regarding thresholds for when to initiate antidotes and dialysis persist. As a consequence, variations exist in the interventions utilized for management of all toxic alcohol poisonings. To our knowledge, no prior systematic review of clinical outcomes of toxic alcohols exists. The objective of this study is to summarize existing evidence on short- and long-term outcomes of patients following toxic alcohol poisonings, including methanol, ethylene glycol, isopropanol, propylene glycol, and diethylene glycol. METHODS A literature search in PubMed, MEDLINE, and EMBASE will be performed based on pre-determined criteria. There will be no restrictions on publication dates or languages. The search will be supplemented by manual scan of bibliographies of eligible studies and gray literature assessment. Observational studies and clinical trials will be included in this review. Once eligible studies have been selected based on pre-specified criteria, two investigators will extract relevant data independently and perform quality assessment per validated tools. A pooled analysis of mortality and short- and long-term secondary outcomes will be performed. Pre-specified subgroup analyses will be performed according to the type of toxic alcohol intoxication, mode of renal replacement therapy, and medical interventions received. A meta-analysis will be performed if three or more studies with similar populations, type of toxic alcohol poisoning, and outcome measures, as well as adequate quality, are identified. This review will be reported according to the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Statement. DISCUSSION This systematic review aims to synthesize current evidence in the short- and long-term outcomes of post-toxic alcohol poisoning. The results will enhance the understanding of patient morbidity and mortality after toxic alcohol poisoning, help inform uniform concrete management guideline development, identify gaps in the current state of knowledge, and provide evidence to help implement post-treatment follow-up. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018101955.


title: Prevalence of Respiratory Protective Devices in U.S. Health Care Facilities: Implications for Emergency Preparedness.

text: An online questionnaire was developed to explore respiratory protective device (RPD) prevalence in U.S. health care facilities. The survey was distributed to professional nursing society members in 2014 and again in 2015 receiving 322 and 232 participant responses, respectively. The purpose of this study was to explore if the emergency preparedness climate associated with Ebola virus disease changed the landscape of RPD use and awareness. Comparing response percentages from the two sampling time frames using bivariate analysis, no significant changes were found in types of RPDs used in health care settings. N95 filtering facepiece respirators continue to be the most prevalent RPD used in health care facilities, but powered air-purifying respirators are also popular, with regional use highest in the West and Midwest. Understanding RPD use prevalence could ensure that health care workers receive appropriate device trainings as well as improve supply matching for emergency RPD stockpiling.


title: Comparative Outcome Analysis of Enterprise and Neuroform Stent-Assisted Coiling of Cerebral Aneurysms: A Review of the Literature.

text: Introduction One of the popular treatment strategies for complex cerebral aneurysms with wide necks or low dome-to-neck ratios is stent-assisted coiling. The most widely used intracranial stents for stent-assisted coiling are Neuroform (NF) and Enterprise (EP) stents. The purposes of this study are to review the recent literature of the past 5 years to compare outcomes between the EP and NF stent-assist coiling systems so as to comment on the safety, efficacy, complications, and recurrence rate of stent-assisted coiling in general. Methods PubMed was used to search for all published literature of NF or EP stent-assisted coiling of unruptured cerebral aneurysms from January 2014 to August 2019 with the search terms of "Enterprise stent-assisted coiling," "Neuroform stent," and "Neuroform vs. Enterprise stent." Results Twenty two publications met the inclusion criteria which encompass 1764 patients and 1873 aneurysms. Out of these 1873 aneurysms, 1007 aneurysms were treated with EP stent and 866 aneurysms were treated with NF stent. The overall outcome was low rates of thromboembolic complications (4.37%) and intracranial hemorrhage (1.13%), low permanent morbidity (1.70%) and mortality (0.40%), and lower rate of recanalization (11%). Data analysis shows an overall higher rate of complication and recurrence of aneurysm and lower overall rate of aneurysmal occlusion in the patients where EP stent was used in comparison to NF stent. However, this difference was not statistically significant. Conclusions The review of two stent-assisted coiling devices using EP and NF stents including 1873 aneurysms in 1764 patients revealed that overall, it is safe and effective with comparable outcomes.


title: A comparison of technologies used for estimation of body temperature.

text: Body temperature measurement is an important clinical parameter. The performance of a number of non-invasive thermometers was measured by comparing intra- and inter-operator variability (n = 100) and clinical accuracy (n = 61). Variability was elevated in febrile compared to normothermic subjects for axillary and oral electronic contact thermometer measures and a temporal artery thermometer (p < 0.001 for both). Temporal artery thermometry and one mode of an infrared tympanic thermometer demonstrated significant clinical inaccuracy (p < 0.001 for both). Electronic contact thermometer repeatability and reproducibility are highly variable in febrile adults both in the axilla and oral cavity. Infrared thermometry of the skin over the superficial temporal artery is unreliable for measuring core body temperature, particularly in febrile subjects and patients in theatre. The infrared tympanic thermometers tested are acceptable for clinical practice; however, care should be exercised with the different modes of operation offered.


title: Burnout among medical and health sciences information professionals who support systematic reviews: an exploratory study.

text: Objective The aim of this exploratory study was to assess personal, work-related, and client-related burnout among information professionals who support systematic review (SR) work. Methods The Copenhagen Burnout Inventory, a validated tool for assessing burnout, was administered to information professionals who support SR work. A broad range of health sciences or medical librarians and information professionals were targeted via professional email discussion lists and news outlets. Questionnaire responses were captured electronically using Qualtrics Survey Software and quantitatively analyzed. Results Respondents experienced an average personal burnout score of 48.6, work-related score of 46.4, and client-related score of 32.5 out of 100. Respondents who reported spending >80% of their job duties on SR work had significantly lower personal burnout scores than those who reported spending <10% of their job duties on SR work (average, 31.5 versus 50.9, respectively). Also, respondents who reported using an SR support tool had significantly lower personal burnout scores than those who reported sometimes using a tool (average, 43.7 versus 54.7, respectively). Conclusion The results suggest that information professionals who dedicate more time to SR work or who consistently use an SR support tool experience less burnout. This study provides groundwork for further investigation with the aim of developing approaches to prevent or combat SR-related burnout among information professionals.


title: Shewanella algae: a rare cause of necrotizing fasciitis.

text: BACKGROUND The genus Shewanella consists of motile, gram-negative, facultative anaerobes found in marine environments. Shewanella putrefaciens and Shewanella algae are the two species with documented pathogenicity in human beings. Most documented cases of S. algae infection worldwide have been reported in the context of bacteremia, cellulitis, and acute exacerbations of chronic otitis media in predisposed individuals. We report a rare case of necrotizing soft tissue infection by S. algae in an immunocompetent individual. The infection followed exposure to S. algae in contaminated water in New York City, New York. METHODS We reviewed the English-language literature on similar cases of soft tissue infection using PubMed. Search terms included "Shewanella algae" and "Shewanella putrefaciens" in conjunction with "necrotizing" and "infection." Cognizant that this search method may not have yielded early (pre-1985) reports about Shewanella because of changes in classification and nomenclature, we also searched for "Pseudomonas putrefaciens." RESULTS After prompt surgical debridement and culture-directed antibiotic therapy, the patient recovered from his infection without the need for re-intervention. CONCLUSIONS This case may reflect the geographic spread and emergence of S. algae infection in the United States. Clinicians should be aware of the virulence of S. algae and potential for the rapid clinical deterioration of persons it infects even among immunocompetent individuals.


title: Effective nurse leadership in times of crisis.

text: The emergence of coronavirus disease 2019 (COVID-19) has meant that nurse leaders need to respond rapidly and decisively to the demands and challenges of a pandemic in a context of increased staff shortages and limited resources. This article suggests essential leadership skills and characteristics that nurses can use to underpin effective leadership in a crisis, emphasising the importance of decision-making and emotional intelligence. It also addresses two important questions: 'what do leaders in a crisis need to do that differs from any other time?' and 'what does effective leadership look like in a crisis?'


Transanal total mesorectal excision: the new kid on the block or a false dawn?


Pandemic and the PCMR.


Median arcuate ligament release.


title: Perioperative and oncological outcomes of laparoscopic anatomical hepatectomy for hepatocellular carcinoma introduced gradually in a single center.

text: BACKGROUND Anatomical hepatectomy is an ideal curative treatment for hepatocellular carcinoma (HCC). We have standardized our laparoscopic anatomical hepatectomy (LAH) procedure, gradually extending its indications. In the present study, we describe our experience and the perioperative and oncological outcomes of LAH for HCC compared to those of open anatomical hepatectomy (OAH) during the gradual introduction of LAH. METHODS Seventy patients with primary HCC underwent anatomical hepatectomy in our institution from November 2008 to April 2014. As we gained experience with LAH, our indications for choosing LAH over OAH gradually expanded. Ultimately, 40 and 30 patients underwent LAH and OAH, respectively. Perioperative and oncological outcomes were compared between the two groups. RESULTS There were no significant differences in age, sex, background of liver disease, liver function, tumor size, tumor number, or type of liver resection between the two groups. Major complications and mortality rates were similar between the LAH and OAH groups (12.5% vs. 20%; p = 0.582, and 0% vs. 3.3%; p = 0.429, respectively). The median follow-up time after surgery was 40.5 months in the LAH group and 32.9 months in the OAH group (p = 0.835). The 1-, 3-, and 5-year overall survival rates were 89.9, 84.7, and 70.9%, in the LAH group, and 89.8, 68.0, and 63.1% in the OAH group, respectively (p = 0.255). The 1-, 3-, and 5-year disease-free survival rates were 79.5, 58.0, and 42.5%, in the LAH group, and 72.4, 56.1, and 50.4% in the OAH group, respectively (p = 0.980). CONCLUSIONS Through gradual introduction of LAH, we obtained comparable results to those achieved with OAH. LAH can be a feasible surgical treatment for primary HCC, with good oncological outcomes.


title: Detection of enterovirus 68 as one of the commonest types of enterovirus found in patients with acute respiratory tract infection in China.

text: Human enterovirus 68 (HEV-68) is an enterovirus associated with respiratory illness. In China, no information about HEV-68 is available for children yet. This study aimed to investigate the presence of HEV-68 in mainland China between 2009 and 2012 and to explore the migration events of HEV-68 across the world. Among 1565 samples tested from children, 41 (2.6%) were positive for HEV and 223 (14.3%) for human rhinovirus (HRV). Seven (17.1%) of 41 HEVs were HEV-68. Two HEV-68- and five HRV-positive samples were detected in 585 adult samples. HEV-68 is the predominant type of enterovirus in children with acute respiratory tract infection (ARTI), followed by HEV-71 and coxsackievirus A6. Three HEV-68-infected children presented with severe pneumonia and one presented with a severe asthma attack. The viruses were attributed to two novel distinct sublineages of HEV-68 based on phylogenetic analysis of partial VP1 gene sequences. Migration events analysis showed that the USA and the Netherlands were possible geographical sources of HEV-68, from where three strains migrated to China. In conclusion, HEV-68 may play a predominant role among the enteroviruses associated with ARTI in children. Additional surveillance is needed to clarify the reason why HEV-68 causes such a wide spectrum of disease, from asymptomatic to severe respiratory disease and even death.


title: New dog, new tricks: trends in performance on the Fundamentals of Laparoscopic Surgery simulator for incoming surgery residents.

text: BACKGROUND Exposure to laparoscopic surgery during medical school has increased over recent years. The Fundamentals of Laparoscopic Surgery (FLS) simulator allows for objective assessment of laparoscopic skills. This study aimed to determine whether the fundamental laparoscopic skills of incoming surgery residents have improved. METHODS The initial FLS performance of first-year residents between 2003 and 2008 was identified from a prospective database. Linear regression was used to determine the effect of incoming year on performance of the five FLS simulator tasks (peg transfer, pattern cut, endoloop placement, suture with an extracorporeal knot [EC], suture with an intracorporeal knot [IC]) and the total score. Statistical significance was defined as a p value less than 0.05. RESULTS A total of 63 first-year residents were identified from the database. The total FLS scores improved over time (r = 0.39; p = 0.001). The scores for peg transfer did not change significantly, but the scores for pattern cutting (r = 0.37; p = 0.002), endoloop placement (r = 0.36; p = 0.004), suture with EC (r = 0.32; p = 0.02), and suture with IC (r = 0.26; p = 0.03) all improved significantly over the 5 years. CONCLUSION The baseline fundamental laparoscopic skills of incoming surgery residents appear to have improved over time. This may be due to increased clinical laparoscopic exposure and availability of laparoscopic simulation in medical school.


Association of Black Race with Outcomes in COVID-19 Disease: A Retrospective Cohort Study.


title: A career in sport does not eliminate risk of cardiovascular disease: A systematic review and meta-analysis of the cardiovascular health of field-based athletes.

text: OBJECTIVES To determine the prevalence of cardiovascular disease (CVD) risk factors in current field-based athletes. DESIGN Meta-analysis. METHODS This review was conducted and reported in accordance with PRISMA and pre-registered with PROSPERO. Articles were retrieved via online database search engines, with no date or language restriction. Studies investigating current field-based athletes (>18years) for CVD risk factors according to the European Society of Cardiology and American Heart Association were screened. Full texts were screened using Covidence and Cochrane criteria. Eligible articles were critically appraised using the AXIS tool. Individual study estimates were assessed by random-effect meta-analyses to examine the overall effect. RESULTS This study was ascribed a 1b evidence level, according to the Oxford Centre for Evidence-based Medicine. 41 studies were identified, including 5546 athletes from four sports; American football; soccer; rugby and baseball mean ages: 18-28. Despite participation in sport, increased body mass was associated with increased total cholesterol, low-density lipoprotein, triglycerides, hypertension, systolic blood pressure, and decreased high-density lipoprotein. Linemen had increased prevalence of hypertension compared to non-athletes. Conflicting findings on fasting glucose were prevalent. There were inconsistencies in screening and reporting of CVD risk factors. Sport specific anthropometric demands were associated with elevated prevalence of CVD risk factors, most notably: elevated body mass; dyslipidemia; elevated systolic blood pressure and; glucose. CONCLUSIONS There are elevated levels of risk for CVD in some athletes, primarily football players. Lifestyle behaviours associated with elite athleticism, particularly football linemen potentially expose players to greater metabolic and CVD risk, which is not completely offset by sport participation.


title: Medicoeconomic analysis of lobectomy using thoracoscopy versus thoracotomy for lung cancer: a study protocol for a multicentre randomised controlled trial (Lungsco01).

text: INTRODUCTION In the last decade, video-assisted thoracoscopic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) has had a major effect on thoracic surgery. Retrospective series have reported benefits of VATS when compared with open thoracotomy in terms of postoperative pain, postoperative complications and length of hospital stay. However, no large randomised control trial has been conducted to assess the reality of the potential benefits of VATS lobectomy or its medicoeconomic impact. METHODS AND ANALYSIS The French National Institute of Health funded Lungsco01 to determine whether VATS for lobectomy is superior to open thoracotomy for the treatment of NSCLC in terms of economic cost to society. This trial will also include an analysis of postoperative outcomes, the length of hospital stay, the quality of life, long-term survival and locoregional recurrence. The study design is a two-arm parallel randomised controlled trial comparing VATS lobectomy with lobectomy using thoracotomy for the treatment of NSCLC. Patients will be eligible if they have proven or suspected lung cancer which could be treated by lobectomy. Patients will be randomised via an independent service. All patients will be monitored according to standard thoracic surgical practices. All patients will be evaluated at day 1, day 30, month 3, month 6, month 12 and then every year for 2 years thereafter. The recruitment target is 600 patients. ETHICS AND DISSEMINATION The protocol has been approved by the French National Research Ethics Committee (CPP Est I: 09/06/2015) and the French Medicines Agency (09/06/2015). Results will be presented at national and international meetings and conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02502318.


Left atrioesophageal fistula following catheter ablation for atrial fibrillation: off-bypass, primary repair using an extrapericardial approach.


title: Fistulizing Crohn's disease: Diagnosis and management.

text: Fistulizing Crohn's disease represents an evolving, yet unresolved, issue for multidisciplinary management. Perianal fistulas are the most frequent findings in fistulizing Crohn's disease. While enterocutaneous fistulas are rare, they are associated with considerable morbidity and mortality. Detailed evaluation of the fistula tract by advanced imaging techniques is required to determine the most suitable management options. The fundamentals of perianal fistula management are to evaluate the complexity of the fistula tract, and exclude proctitis and associated abscess. The main goals of the treatment are abscess drainage, which is mandatory, before initiating immunosuppressive medical therapy, resolution of fistula discharge, preservation of continence and, in the long term, avoidance of proctectomy with permanent stoma. The management of enterocutaneous fistulas comprises of sepsis control, skin care, nutritional optimization and, if needed, delayed surgery.


title: Effect of Diameter of Saphenous Vein on Stump Length after Radiofrequency Ablation for Varicose Vein.

text: PURPOSE Radiofrequency ablation (RFA) has gained popularity for treatment of varicose veins. The diameter of the saphenous vein should be considered before RFA because occlusion of the vein may differ depending on its diameter. Until now, however, there have been few data about the correlation between the diameter of the saphenous vein and the stump length after RFA. The purpose of our study was to investigate its correlation. MATERIALS AND METHODS A retrospective review was performed from prospectively collected data of RFA patients between March 2009 and December 2011. Preoperatively, the saphenous vein diameter was measured. Ablation was initiated 2 cm distal from the junction. Postoperatively, stump length was measured at 1 week and 6 months. After 2 years, we measured the length from the saphenofemoral junction to the leading point of occlusion for great saphenous vein, and length from the saphenopopliteal junction to the leading point of occlusion for small saphenous vein. The paired t-test, independent t-test, and correlation analysis were used for statistical analysis. P-value <0.05 was considered statistically significant. RESULTS During the study period, RFA was performed in 201 patients. Endovenous heat-induced thrombosis developed in 3 patients (1.5%). After 2 years, the stump length was obtained in 74 limbs. The mean diameter and stump length of the saphenous vein were 6.7±1.8 mm and 12.5±8.5 mm, respectively. Correlation analysis showed that the Pearson correlation coefficient of these factors was -0.017. CONCLUSION There was no correlation between the diameter of saphenous vein and stump length.


Air pollution and SARS-CoV-2 in the Po Valley: possible environmental persistence?


title: Robotic en bloc first-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results.

text: OBJECTIVE First-rib resection is a key component of the treatment of Paget-Schroetter disease. There are many controversies regarding the management of this disease. We report a safe, effective, minimally invasive robotic transthoracic approach for resection of the first rib. METHODS Over an 8-month period, five patients underwent robotic first-rib resection. Preoperative assessment included physical examination and bilateral venous angiography. On a thoracoscopic platform using three 2-cm incisions and one 1-cm incision, the robot was used to dissect the first rib and divide the scalene muscles. Success of the first-rib resection was assessed by postoperative venous angiography. RESULTS There were four men and one woman. Mean age was 34.6 ± 10 years. Mean operative time was 195 ± 24.6 minutes. There were no complications and no mortality. All patients had a patent subclavian vein on the postoperative venogram and were anticoagulated with warfarin for 3 months. At a median follow-up of 12 months, all patients had an open subclavian vein for a patency rate of 100%. CONCLUSIONS Robotic thoracoscopic first-rib resection represents a feasible minimally invasive approach to en bloc resection of the first rib. This technique minimizes the risk of neurovascular complications that are associated with conventional techniques.


title: Retzius-sparing robotic-assisted laparoscopic radical prostatectomy: racial considerations for 250 consecutive cases.

text: Our objective is to report the functional and oncologic outcomes of a cohort of 250 consecutive prostate cancer patients undergoing a Retzius-sparing approach and to assess for racial differences in continence outcomes. This was a prospective, single-center, case series of 250 consecutive prostate cancer patients who underwent a Retzius-sparing robotic-assisted laparoscopic radical prostatectomy by a single surgeon between May 2015 and April 2019. Our primary objective was to report post-operative continence outcomes of patients undergoing this technique. Continence was defined as using zero or one precautionary pad per day. Median follow-up was 24.0 months [interquartile range (IQR) 18.0-30.0 months]. Median age and body mass index were 62.0 years (IQR 57.0-67.0) and 29.0 kg/m2 (IQR 26.0-33.0), respectively. Median PSA was 8.22 ng/ml (IQR 5.74-13.31). 84.8% of patients were intermediate risk or high risk pre-operatively, as per AUA/ASTRO/SUO guidelines. 96.0% had Gleason Score 7 or worse disease on final pathologic analysis. Positive margin incidence was 18.1% and 44.4% in patients with pT2 and pT3 disease, respectively, of which 75.4% were unifocal. Immediate continence (i.e., continence achieved within 1 month post-operatively) was achieved in 45.2% of patients. Three-month and 1-year continence rates were 70.0% and 92.0%, respectively. Caucasian patients experienced earlier return of continence (77% versus 65% at 3 months) compared to African American patients. IPSS scores gradually improved from 8.0 pre-operatively to 4.0 1-year later. Median PSA level was 0.01 ng/ml (IQR 0.01-9.01) post-operatively. Retzius-sparing robotic-assisted laparoscopic radical prostatectomy is an oncologically safe surgical technique with excellent short- and long-term continence outcomes. Caucasian patients may have earlier return of continence compared to African Americans.


title: Retroperitoneal and retrograde total laparoscopic hysterectomy as a standard treatment in a community hospital.

text: OBJECTIVE To report our experience with a modified procedure for total laparoscopic hysterectomy based on a retrograde and retroperitoneal technique. This surgical approach is analyzed on a consecutive series of patients in a community hospital and theoretical educational advantages are proposed. STUDY DESIGN All patients undergoing hysterectomy from January 2012 to April 2013 were included in the study. A detailed description of the technique is given. As main outcome measures we evaluated: the number and rate of patients excluded from laparoscopic approach, the rate of late complications need readmission, the rate of transfusions, the rate of conversion to laparotomy and the number of minor complications. The main concern of the study was ureteral complications. RESULTS Overall 174 patients underwent hysterectomy in our unit. The rate of patients submitted to laparoscopic hysterectomy was 97.5%. The number of complications needing re-admission was three (2%). The rate of conversion was 2.7%. In the study period, two (1.2%) ureteral complications were observed (late fistulae). There were four bladder lesions but the patients were released on the same day as the patients with no lesion. CONCLUSIONS Opening the retroperitoneum allows rapid control of the main uterine vessels by coagulation, and constant checks on the ureter. Difficult benign situations can be managed. Even in a non-referral center about 94% of hysterectomies can be performed by laparoscopic surgery. This approach is helpful and may be reproducible in gynecological procedures.


Modeling SARS-CoV-2 infection in mice.


title: The LEVANT I (Lutonix paclitaxel-coated balloon for the prevention of femoropopliteal restenosis) trial for femoropopliteal revascularization: first-in-human randomized trial of low-dose drug-coated balloon versus uncoated balloon angioplasty.

text: OBJECTIVES This study sought to evaluate the safety and efficacy of the Lutonix drug-coated balloon (DCB) coated with 2 μg/mm(2)paclitaxel and a polysorbate/sorbitol carrier for treatment of femoropopliteal lesions. BACKGROUND Percutaneous treatment of peripheral vascular disease is associated with a high recurrence. Paclitaxel-coated balloons at 3 μg/mm(2) formulated differently have shown promising results with reduced restenosis. Methods Subjects at 9 centers with Rutherford class 2 to 5 femoropopliteal lesions were randomized between June 2009 and December 2009 to treatment with Lutonix DCB (n = 49) versus uncoated balloons (control group [n = 52]), stratified by whether balloon-only treatment (n = 75) or stenting (n = 26) was intended. The primary endpoint was angiographic late lumen loss at 6 months. Secondary outcomes included adjudicated major adverse events (death, amputation, target lesion thrombosis, reintervention), functional outcomes, and pharmacokinetics. RESULTS Demographic, peripheral vascular disease, and lesion characteristics were matched, with mean lesion length of 8.1 3.8 cm and 42% total occlusions. At 6 months, late lumen loss was 58% lower for the Lutonix DCB group (0.46 1.13 mm) than for the control group (1.09 1.07 mm; p = 0.016). Composite 24-month major adverse events were 39% for the DCB group, including 15 target lesion revascularizations, 1 amputation, and 4 deaths versus 46% for uncoated balloon group, with 20 target lesion revascularizations, 1 thrombosis, and 5 deaths. Pharmacokinetics showed biexponential decay with peak concentration (Cmax) of 59 ng/ml and total observed exposure (AUC(all)) of 73 ng h/ml. For successful DCB deployment excluding 8 malfunctions, 6-month late lumen loss was 0.39 mm and the 24-month target lesion revascularization rate was 24%. CONCLUSIONS Treatment of femoropopliteal lesions with the low-dose Lutonix DCB reduced late lumen loss with safety comparable to that of control angioplasty. (LEVANT I, The Lutonix Paclitaxel-Coated Balloon for the Prevention of Femoropopliteal Restenosis; NCT00930813)


title: An in vitro study assessing the effect of mesh morphology and suture fixation on bacterial adherence.

text: PURPOSE Prosthetic infections, although relatively uncommon in hernia surgery, are a source of considerable morbidity and cost. The aims of this experimental study were to assess the influence of the morphological properties of the mesh on bacterial adherence in vitro. The morphological properties assessed were the polymer type, filament type, filament diameter, mesh weight, mean pore size, and the addition of silver chlorhexidine and titanium coatings. In addition, the study assessed the effect on bacterial adherence of adding a commonly used suture to the mesh and compared adherence rates to self-gripping mesh that does not require suture fixation. METHODS Eight commercially sourced flat hernia meshes with different material characteristics were included in the study. These were Prolene(®) (Ethicon(®)), DualMesh(®) (Gore(®)), DualMesh(®) Plus (Gore(®)), Parietex™ ProGrip (Covidien™), TiMesh(®) Light (GfE Medical), Bard(®) Soft Mesh (Bard(®)), Vypro(®) (Ethicon(®)), and Omyra(®) (Braun(®)). Individual meshes were inoculated with Staphylococcus epidermidis and Staphylococcus aureus with a bacterial inoculum of 10(2) bacteria. To assess the effect of suture material on bacterial adhesion, a sterile piece of commonly used monofilament suture material (2.0 Prolene(®), ZB370 Ethicon(®)) was sutured to selected meshes (chosen to represent different commonly used polymers and/or the presence of an antibacterial coating). Inoculated meshes were incubated for 18 h in tryptone soy broth and then analysed using scanning electron microscopy. A previously validated method for enumeration of bacteria using automated stage movement electron microscopy was used for direct bacterial counting. The final fraction of the bacteria adherent to the mesh was compared between the meshes and for each morphological variable. One-way analysis of variance (ANOVA) was performed on the bacterial counts. Tukey's test was used to determine the difference between the different biomaterials in the event the ANOVA was significant. RESULTS Properties that significantly increased the mean bacterial adherence were the expanded polytetrafluoroethylene polymer (P < 0.001); multifilament meshes (P < 0.001); increased filament diameter (P < 0.001); increased mesh weight (P < 0.001); and smaller mean pore size (P < 0.001). In contrast, mesh coating with antibacterial silver chlorhexidine significantly reduced bacterial adhesion (S. epidermidis mean bacterial count 140.7 ± 19.1 SE with DualMesh(®) vs. 2.3 ± 1.2 SE with DualMesh(®) Plus, P < 0.001; S. aureus mean bacterial count 371.7 ± 22.7 SE with DualMesh(®) vs. 19.3 ± 4.7 SE with DualMesh(®) Plus, P = 0.002). The addition of 2.0 Prolene suture material significantly increased the mean number of adherent bacteria independent of the mesh polymer or mesh coating (P = 0.04 to <0.001). CONCLUSION The present study demonstrates the significant influence of the prosthetic load on bacterial adherence. In patients at increased risk of infection, low prosthetic load materials, i.e., lightweight meshes with large pores, may be beneficial. Furthermore self-fixing meshes, which avoid increasing the prosthetic load and antibacterial impregnated meshes, may have an advantage in this setting.


title: Comparison of the long-term outcomes of the self-expandable metallic stent and transanal decompression tube for obstructive colorectal cancer.

text: Aim Endoscopic decompression using the self-expandable metallic colonic stent (SEMS) or transanal decompression tube (TDT) can convert emergency surgery into elective one-stage surgery for obstructive colorectal cancer (OCRC). The aim of the present study was to clarify the effect of SEMS and TDT on long-term oncological outcomes. Methods We retrospectively analyzed 76 consecutive pathological stage II and III OCRC patients who were inserted with SEMS or TDT as a bridge to curative surgery between 2009 and 2018. Results There were 53 SEMS cases and 23 TDT cases. The tumor was located in the left colon in 58 cases and in the right colon in 18 cases. The interval between the decompression and the surgery was 16.5 days in the SEMS group and 13.0 days in the TDT group (P = 0.09). Technical and clinical success rates were 100% and 100% for SEMS, and 95% and 91% for TDT, respectively. Stoma was created in four patients in the SEMS group, and in five in the TDT group (P = 0.08). Three-year overall survival rates of the SEMS and TDT groups were 82% and 86% (P = 0.94), and disease-free survival rates were 68% and 62% (P = 0.79), respectively. The recurrence pattern was not significantly different. Conclusion This study found no statistically significant differences between the effects of SEMS and TDT for OCRC as a bridge to surgery on long-term outcomes.


title: Prospective evaluation of adhesion characteristics to intraperitoneal mesh and adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair.

text: BACKGROUND The purpose of this study was to characterize the adhesion characteristics of absorbable- and nonabsorbable-barrier-coated meshes and to report adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair. METHODS Under an IRB-approved protocol, patients undergoing laparoscopic re-exploration after prior intraperitoneal mesh placement were prospectively graded intraoperatively for adhesion tenacity (0-4), adhesion surface area (0 = 0%, 10 = 100%), and ratio of adhesiolysis time to mesh surface area (min/cm(2)). Adhesiolysis-related complications were also recorded. Data are given as mean ± SD. Statistical significance (P < 0.05) was determined using the t test and Fisher's exact test. RESULTS From March 2006 to March 2009, 69 patients underwent laparoscopic surgery after prior intraperitoneal mesh placement for ventral hernia repair. Previous meshes were absorbable-barrier-coated mesh (n = 18), permanent-barrier composite mesh [Composix® (n = 17)], permanent-barrier noncomposite mesh [DualMesh® (n = 14)], uncoated polypropylene mesh (n = 12), and biologic mesh (n = 8). Indications for laparoscopic re-exploration were recurrent ventral hernia (n = 58), chronic pain (n = 3), cholecystectomy (n = 3), parastomal hernia (n = 2), small bowel obstruction (n = 1), nephrectomy (n = 1), and Nissen fundoplication (n = 1). Adhesions to DualMesh were less tenacious (P < 0.05) compared to all other meshes. Surface area of adhesions to DualMesh were less (P < 0.05) than to Composix and to uncoated polypropylene mesh, but not to absorbable-barrier-coated and biologic meshes. Adhesiolysis time:mesh surface area was less (P < 0.05) for DualMesh compared to Composix, uncoated polypropylene, and biologic mesh, but not to absorbable-barrier-coated mesh. Adhesiolysis-related complications occurred in two (16.7%) (P = ns) patients with uncoated polypropylene mesh, one cystotomy and one enterotomy; both were repaired laparoscopically. There were two (16.7%) (P = ns) conversions to an open procedure: one converted patient had Composix (6.7%) and one had absorbable-barrier-coated mesh (5.9%). There were no adhesiolysis-related complications with these meshes. There were no adhesiolysis-related complications or conversions to open in the DualMesh or biologic mesh groups. CONCLUSIONS Adhesion characteristics of mesh placed intraperitoneally and adhesiolysis-related complications during laparoscopic re-exploration after ventral hernia repair are associated with unique properties of the mesh and/or barrier.


title: Robot-assisted partial nephrectomy: early unclamping technique.

text: Robot-assisted partial nephrectomy (RAPN) is emerging as a viable minimally invasive surgical technique for small renal tumors. The warm ischemia time (WIT) during laparoscopic partial nephrectomy has been reduced using an early unclamping (EU) technique. We present our technique of EU technique in RAPN. From November 2009 to June 2010, 12 consecutive RAPNs were performed by a single surgeon (A.W.) using EU technique. The median operative time was 227 minutes (176-315); median WIT, 16 minutes (11-25). Median estimated blood loss was 150 mL (50-500) and length of stay 2 days. There were no intraoperative or postoperative complications. RAPN using EU technique is a safe and feasible option in experienced hands, allowing for a shorter WIT without increasing blood loss. This approach requires a highly skilled bedside assistant who is imminently familiar with the robotic system and advanced laparoscopic techniques.


title: Update on Postsurgical Scar Management.

text: Postoperative scar appearance is often a significant concern among patients, with many seeking advice from their surgeons regarding scar minimization. Numerous products are available that claim to decrease postoperative scar formation and improve wound healing. These products attempt to create an ideal environment for wound healing by targeting the three phases of wound healing: inflammation, proliferation, and remodeling. With that said, preoperative interventions, such as lifestyle modifications and optimization of medical comorbidities, and intraoperative interventions, such as adherence to meticulous operative techniques, are equally important for ideal scarring. In this article, the authors review the available options in postoperative scar management, addressing the benefits of multimodal perioperative intervention. Although numerous treatments exist, no single modality has been proven superior over others. Therefore, each patient should receive a personalized treatment regimen to optimize scar management.


title: One-staged in situ embolization combined with surgical resection for eloquence protection of AVM: technical note.

text: Brain arteriovenous malformations (AVMs) near/within eloquent areas are challenging to treat surgically. The insufficient lesion-to-eloquence distance (LED) is related to poor neurological outcomes. This paper reports the use of in situ embolization combined with surgical resection in a one-staged hybrid operation for eloquent area protection. Nine patients who underwent one-staged in situ embolization combined with surgical resection were selected from the database of a prospective clinical trial (NCT03774017). Nidus got partial in situ embolization in the parts located near/within the eloquence. The rest of nidus was removed via a microsurgical procedure in the same operation. The in situ embolization ensured a sufficient LED to prevent eloquent areas and tracts from being damaged in the subsequent resection. All of the patients achieved complete obliteration with no neurological deficits or complications. One-staged hybrid operation initiates closer cooperation between surgical and endovascular treatments and proposes an integrative therapeutic mode for AVMs. The in situ embolization combined with surgical resection is safe and effective for improving the functional outcome of AVMs with eloquence and tracts involved. The clinical trial is registered at ClinicalTrials.gov (NCT03774017, https://clinicaltrials.gov/ct2/show/NCT03774017).


title: Comparative quantitative survey of patient experience in Barrett's oesophagus and other gastrointestinal disorders.

text: Objective To assess health-related quality of life in patients with non-dysplastic Barrett's oesophagus (NDBO) and endoscopically treated dysplastic Barrett's oesophagus (DBO). Design This quantitative, self-administered questionnaire study was conducted across three National Health Service hospitals. Data were collected from three other cohorts; gastro-oesophageal reflux disease (GORD), colonic polyp surveillance and healthy individuals. Fisher's exact and Spearman's rank correlation tests were used for analysis. Propensity score matching adjusted for age, sex and comorbidities. Results 687 participants were eligible for analysis (NDBO n=306, DBO n=49, GORD n=132, colonic polyps n=152 and healthy n=48). 53% of NDBO participants reported similarly high cancer worry, comparable to DBO (50%, p=0.933) and colonic polyp participants (51%, p=0.355). Less cancer worry was reported in GORD participants (43.4%, p=0.01 vs NDBO). NDBO participants reported anxiety in 15.8% and depression in 8.6% of cases, which was similar to the other disease cohorts. Moderate or severe heartburn or acid regurgitation was found in 11% and 10%, respectively, in the NDBO cohort, comparable to DBO participants (heartburn 2% p=0.172, acid regurgitation 4% p=0.31) but lower (better) than GORD participants (heartburn 31% p=<0.001, acid regurgitation 25% p=0.001). NDBO participants with moderate or severe GORD symptoms were associated with higher rates of anxiety (p=<0.001), depression (p=<0.001) and cancer worry (p=<0.001). NDBO patients appropriately perceiving their cancer risk as low had lower rates of cancer worry (p=<0.001). Conclusion This study provides insight into the problems Barrett's oesophagus patients may face. Future care pathways must be more patient focussed to address misconceptions of cancer risk, oesophageal cancer related worry and GORD symptom control.


title: Intra-aneurysmal flow rates are reduced by two flow diverters: an experiment using tomographic particle image velocimetry in an aneurysm model.

text: BACKGROUND Limitations on treating large, giant, and wide-necked aneurysms with coiling have made flow diverters a promising alternative to current practice by supporting reconstruction of the parent artery. OBJECTIVE To assess the changes to fluid dynamics within an aneurysm by studying two different endoluminal flow diverters on a simple aneurysm model, using tomographic particle image velocimetry to determine which device would better minimize fluid flow into an aneurysm and observe any significant changes in aneurysm fluid structures. METHODS Steady velocity fields of the model's aneurysm dome and neck were measured at three inlet velocities (18, 39, and 59 cm/s) for two flow diverter diameters with different porosities and compared against a baseline case with no flow diverter. RESULTS In the baseline case a large vortex was present inside the dome for all flow rates. However, both devices eliminated this main vortex at all flow rates and reduced the peak aneurysmal velocities by about 90%. A strong correlation between flow diverter porosity and flow reduction was found. In each case the inflow to the aneurysm shifted from the distal neck to the mid- or proximal neck after flow diverter placement. CONCLUSIONS Even with this relatively simple experimental setup, we were able to observe the major flow field changes, which occurred immediately after the deployment of each flow diverter. Limitations of the study included a simplified geometry and steady-state flow. Constraints included model making and limited availability of flow diverters.


title: Analysis of threshold stenosis by multiplanar venogram and intravascular ultrasound examination for predicting clinical improvement after iliofemoral vein stenting in the VIDIO trial.

text: BACKGROUND Selecting patients for iliofemoral vein stenting has traditionally relied on the identification and quantification of stenotic lesions with imaging such as multiplanar venography. Recently, intravascular ultrasound (IVUS) imaging has become more available. However, to date, the usefulness of these imaging modalities using the customary >50% treatment threshold for diameter (multiplanar venography) and area (IVUS) stenosis of iliofemoral veins has not been validated prospectively within the context of clinical improvement. METHODS The multicenter Venogram Versus Intravascular Ultrasound for Diagnosing and Treating Iliofemoral Vein Obstruction (VIDIO) trial prospectively enrolled 100 symptomatic patients (Clinical Etiologic Anatomic Pathophysiologic [CEAP] classification of 4-6) with suspected iliofemoral venous outflow disease. Venous stenting for presumed significant iliofemoral vein stenosis, based on imaging and clinical findings, was performed on 68 patients. Based on imaging, stenosis was characterized as nonthrombotic in 48 patients and post-thrombotic in 20 patients. Each underwent baseline and poststenting venography and IVUS to compare the diagnostic and clinical usefulness of the tests. The revised Venous Clinical Severity Score was used to assess clinical patient outcome. A >4-point reduction in the revised Venous Clinical Severity Score between baseline and 6 months was used as an indicator of clinically meaningful improvement. Receiver operating characteristic curve analysis was used to determine the optimal diameter and area thresholds for prediction of clinical improvement. RESULTS Clinical improvement after stenting was best predicted by IVUS baseline measurement of area stenosis (area under the curve, 0.64; P = .04), with >54% estimated as the optimal threshold of stenosis indicating interventional treatment. With measurement of lumen gain from baseline to after the procedure, the optimal reduction in vein stenosis correlative of later clinical improvement was >41%; IVUS measurement of area stenosis was most predictive (area under the curve, 0.70; P = .004). Venographic measurements of baseline stenosis and stenotic change were not predictive of later improvement. In a 48-patient nonthrombotic subset analysis, IVUS diameter rather than area measurements of baseline stenosis were significantly predictive of clinical success, but indicated a higher optimal threshold of stenosis (>61%) may be necessary. CONCLUSIONS This study suggests that IVUS shows significant usefulness at predicting when stenting iliofemoral vein stenosis in patients clinical-etiologic-anatomic-pathophysiologic classification of 4-6 will result in significant symptom improvement. Our findings corroborate the conventional >50% cross-sectional area threshold by IVUS as defining a clinically significant iliofemoral stenosis that, when stented, has significant predictive value for symptom improvement. In nonthrombotic patients, however, a threshold of >61% diameter stenosis by IVUS may better predict clinical improvement.


Cutaneous Clinico-Pathological Findings in three COVID-19-Positive Patients Observed in the Metropolitan Area of Milan, Italy.


title: Culturing the unculturable: human coronavirus HKU1 infects, replicates, and produces progeny virions in human ciliated airway epithelial cell cultures.

text: Culturing newly identified human lung pathogens from clinical sample isolates can represent a daunting task, with problems ranging from low levels of pathogens to the presence of growth suppressive factors in the specimens, compounded by the lack of a suitable tissue culture system. However, it is critical to develop suitable in vitro platforms to isolate and characterize the replication kinetics and pathogenesis of recently identified human pathogens. HCoV-HKU1, a human coronavirus identified in a clinical sample from a patient with severe pneumonia, has been a major challenge for successful propagation on all immortalized cells tested to date. To determine if HCoV-HKU1 could replicate in in vitro models of human ciliated airway epithelial cell cultures (HAE) that recapitulate the morphology, biochemistry, and physiology of the human airway epithelium, the apical surfaces of HAE were inoculated with a clinical sample of HCoV-HKU1 (Cean1 strain). High virus yields were found for several days postinoculation and electron micrograph, Northern blot, and immunofluorescence data confirmed that HCoV-HKU1 replicated efficiently within ciliated cells, demonstrating that this cell type is infected by all human coronaviruses identified to date. Antiserum directed against human leukocyte antigen C (HLA-C) failed to attenuate HCoV-HKU1 infection and replication in HAE, suggesting that HLA-C is not required for HCoV-HKU1 infection of the human ciliated airway epithelium. We propose that the HAE model provides a ready platform for molecular studies and characterization of HCoV-HKU1 and in general serves as a robust technology for the recovery, amplification, adaptation, and characterization of novel coronaviruses and other respiratory viruses from clinical material.


Death, Dying, and Dignity in the Time of the COVID-19 Pandemic.


Subphenotyping ARDS in COVID-19 Patients: Consequences for Ventilator Management.


Face masks for the public during the covid-19 crisis.


title: Influenza A Virus Reassortment Is Limited by Anatomical Compartmentalization following Coinfection via Distinct Routes.

text: Exchange of gene segments through reassortment is a major feature of influenza A virus evolution and frequently contributes to the emergence of novel epidemic, pandemic, and zoonotic strains. It has long been evident that viral diversification through reassortment is constrained by genetic incompatibility between divergent parental viruses. In contrast, the role of virus-extrinsic factors in determining the likelihood of reassortment has remained unclear. To evaluate the impact of such factors in the absence of confounding effects of segment mismatch, we previously reported an approach in which reassortment between wild-type (wt) and genetically tagged variant (var) viruses of the same strain is measured. Here, using wt/var systems in the A/Netherlands/602/2009 (pH1N1) and A/Panama/2007/99 (H3N2) strain backgrounds, we tested whether inoculation of parental viruses into distinct sites within the respiratory tract limits their reassortment. Using a ferret (Mustella putorius furo) model, either matched parental viruses were coinoculated intranasally or one virus was instilled intranasally whereas the second was instilled intratracheally. Dual intranasal inoculation resulted in robust reassortment for wt/var viruses of both strain backgrounds. In contrast, when infections were initiated simultaneously at distinct sites, strong compartmentalization of viral replication was observed and minimal reassortment was detected. The observed lack of viral spread between upper and lower respiratory tract tissues may be attributable to localized exclusion of superinfection within the host, mediated by innate immune responses. Our findings indicate that dual infections in nature are more likely to result in reassortment if viruses are seeded into similar anatomical locations and have matched tissue tropisms.IMPORTANCE Genetic exchange between influenza A viruses (IAVs) through reassortment can facilitate the emergence of antigenically drifted seasonal strains and plays a prominent role in the development of pandemics. Typical human influenza infections are concentrated in the upper respiratory tract; however, lower respiratory tract (LRT) infection is an important feature of severe cases, which are more common in the very young, the elderly, and individuals with underlying conditions. In addition to host factors, viral characteristics and mode of transmission can also increase the likelihood of LRT infection: certain zoonotic IAVs are thought to favor the LRT, and transmission via small droplets allows direct seeding into lower respiratory tract tissues. To gauge the likelihood of reassortment in coinfected hosts, we assessed the extent to which initiation of infection at distinct respiratory tract sites impacts reassortment frequency. Our results reveal that spatially distinct inoculations result in anatomical compartmentalization of infection, which in turn strongly limits reassortment.


title: Influence of preoperative septic peritonitis and anastomotic technique on the dehiscence of enterectomy sites in dogs: A retrospective review of 210 anastomoses.

text: OBJECTIVE To determine the influence of preoperative septic peritonitis (PSP) and stapled versus hand-sewn anastomoses on the dehiscence of intestinal resection and anastomosis (IRA). We hypothesized that the incidence of IRA dehiscence would be greater (1) when performed with PSP and (2) for hand-sewn anastomoses. STUDY DESIGN Retrospective. ANIMAL POPULATIONS Client-owned dogs at Michigan State University Veterinary Teaching Hospital. METHODS Records of dogs surviving 72 hours after IRAs between 2003 and 2013 were reviewed for age, gender, neuter status, weight, presence of PSP, preoperative albumin, IRA indication and location, anastomotic technique, suture type, postoperative dehiscence and timing, duration of hospitalization, last follow-up, and other complications. Univariate logistic regression and chi-square analysis were used to screen prognostic factors; factors with P < .3 were included in a multivariate analysis. RESULTS Two hundred and ten IRAs in 198 dogs fulfilled the inclusion criteria. Dehiscence was diagnosed in 11.4% cases, 6.6% without PSP, and 21.1% with PSP (P = .01). Indication for IRA did not influence the risk of dehiscence. No association was detected between anastomotic technique and IRA dehiscence in dogs without PSP (stapled 4.2%, hand-sewn 8.1%); however, stapled anastomoses were less likely to dehisce in dogs with PSP (stapled 9.7%, hand-sewn 28.9%). Risk factors for dehiscence included PSP (P = .005) and hand-sewn technique (P = .02). CONCLUSION Our results confirmed that PSP is a risk factor for dehiscence of IRA and suggest that patients with PSP may be a unique surgical population, in which stapling may be preferred over hand-sewn anastomoses after enterectomies.


Convalescent serum lines up as first-choice treatment for coronavirus.


Quality of Ribonucleic Acid Extraction for Real-Time Reverse Transcription-PCR (rRT-PCR) of SARS-CoV-2: Importance of Internal Control Monitoring.


title: Resting-state connectivity identifies distinct functional networks in macaque cingulate cortex.

text: Subregions of the cingulate cortex represent prominent intersections in the structural networks of the primate brain. The relevance of the cingulate to the structure and dynamics of large-scale networks ultimately requires a link to functional connectivity. Here, we map fine-grained functional connectivity across the complete extent of the macaque (Macaca fascicularis) cingulate cortex and delineate subdivisions pertaining to distinct identifiable networks. In particular, we identified 4 primary networks representing the functional spectrum of the cingulate: somatomotor, attention-orienting, executive, and limbic. The cingulate nodes of these networks originated from separable subfields along the rostral-to-caudal axis and were characterized by positive and negative correlations of spontaneous blood oxygen level-dependent activity. These findings represent a critical component for understanding how the anterior and midcingulate cortices integrate and shape information processing during task performance. The connectivity patterns also suggest future electrophysiological targets that may reveal new functional representations including those involved in conflict monitoring.


title: Patient-ventilator interaction during noninvasive ventilation.

text: There is arguably more evidence to support the use of noninvasive ventilation (NIV) than any other practice related to the care of patients with acute respiratory failure. Despite this strong evidence base, NIV seems to be under-utilized and the failure rate (need for intubation) may be as high as 40%. Some of these failures potentially relate to asynchrony, although the relationship between asynchrony and NIV failure has not been well studied. Good NIV tolerance has been associated with success of NIV, and improved comfort has been associated with better synchrony. In one study a high rate of asynchrony occurred in 43% of patients during NIV. Asynchrony is commonly associated with leaks. Thus, reducing the leak related to the interface and using a ventilator with good leak compensation should reduce the rate of asynchrony. Asynchronies can also be related to the underlying disease process. This paper reviews issues related to asynchrony during NIV and suggests strategies that might be used to correct asynchrony when it occurs.