title: High frequency of rheumatic regional pain syndromes in first-degree relatives of patients with rheumatoid arthritis.

text: First-degree relatives (FDR) of patients with rheumatoid arthritis (RA) have a higher risk for the development of RA. In the stages prior to the development of arthritis, nonspecific musculoskeletal (MSK) manifestations may occur. The aim of the study is to describe the frequency of rheumatic regional pain syndromes (RRPS) in FDR of RA patients. A cross-sectional study was carried out from July 2016 to September 2018. Parents, offspring, and siblings of RA patients completed the Community Oriented Program in the Rheumatic Diseases (COPCORD) questionnaire. Rheumatoid factor (RF) IgG, IgM, and IgA; anticitrullinated peptide antibodies (ACPAs); C-reactive protein (CRP); and erythrocyte sedimentation rate (ESR) were determined. All subjects with a positive COPCORD (defined by the presence of musculoskeletal pain) were evaluated and classified. Three hundred thirty-five FDRs participated, 75.8% were female, mean age of 44.15 years; 138 (41.2%) were diagnosed with at least one RRPS; 72 (21.5%) had rotator cuff tendinitis, 51 (15.2%) pes anserine bursitis, and 39 (11.6) lateral epicondylitis; RA was diagnosed in 24 (7.16%) subjects, undifferentiated arthritis (UA) in 30 (8.9%) and inflammatory arthralgia (AI) in 104 (31%). We found anti-CCP positivity in 6.8%, RF IgA in 22.3%, RF IgM in 48.6%, and RF IgG in 8.9%. The presence of RRPS was higher in this RA-FDR group compared to general population. Clinical evaluation of this risk group should include screening for RRPS.


What we can learn from COVID-19 outbreak in Iran about the importance of alcohol use education.


title: Patterns of Illness and Injury on Antarctic Research Cruises, 2004-2019: a descriptive analysis.

text: BACKGROUND Prior to the impact of the Covid 19 pandemic, cruise travel had experienced exponential growth in the preceding decade. Travel medicine practitioners were increasingly called upon to provide pre-cruise travel advice and medical clearance. Demand for these services will return at some time in the future. METHODS The clinical conditions seen in those presenting for care on 6 small vessel scientific cruises to Antarctica were analyzed. RESULTS Personnel presented on 196 occasions resulting in 257 consultations (when initial plus all follow up consultations were included). Personnel presented with a clinical condition at a rate of 17.9 per 1000 person days at sea. The total consultation rate was 23.5 per 1000 person days at sea. Injury accounted for 24% of all presentations at a rate of 4.3 per 1000 person days at sea. Dermatological, soft tissue and musculoskeletal, general malaise and motion sickness were the four most common presentations. CONCLUSIONS Pre-cruise advice for travelers planning small vessel cruises to polar regions needs to include skin care, prevention and management of sea sickness and how to reduce the risk of injury. Those providing medical care on such cruises should be prepared to manage a wide range of clinical presentations.


Clinical course and outcome of COVID-19 in patients with rheumatic diseases: are all biological disease-modifying antirheumatic drugs alike? Response to: 'Increased risk for severe COVID-19 in patients with inflammatory rheumatic diseases treated with rituximab' by Schulze-Koops et al.


title: [Advanced organ support and life-sustaining therapies in critically ill COVID-19 infected patients].

text: In critically ill patients with COVID-19 infection, the cardiorespiratory system may collapse by the following mechanisms: (1) cytokine storm, haemophagocytosis - septic shock, (2) uncontrollable hypoxaemia, (3) specific organ failure or multiple organ failure. In this summary, we review the currently available therapeutic options for the treatment and prevention of the above conditions. Removal of cytokines by CytoSorb haemoperfusion has been used more and more frequently and with encouraging success in recent years to treat septic shock. In the case of hypoxaemia, which can no longer be treated with conventional mechanical ventilation, inhaled nitric oxide (iNO), inhaled epoprostenol and venovenous extracorporeal membrane oxygenation (VV-ECMO) are considered. A common component of mostly late-stage organ failure is acute renal failure, which requires the initiation of one of the available continuous renal replacement therapies. Orv Hetil. 2020; 161 (17): 704-709.


title: Cognitive Communication Impairments in Children With Traumatic Brain Injury: A Scoping Review.

text: OBJECTIVE This scoping review synthesizes the scholarly literature on cognitive communication impairments in traumatic brain injury (TBI) sustained during childhood to identify gaps in research, and make recommendations that will further the field of cognitive communication in pediatric TBI. METHODS MEDLINE, PsycINFO, CINAHL, and EMBASE were searched to identify peer-reviewed studies that examined cognitive communication impairments in children who sustained a TBI between 3 months to 18 years of age. RESULTS Twenty-eight studies met inclusion criteria with 3 main categories identified in relation to cognitive communication: (1) impairments according to TBI severity, (2) impairments according to age at injury, and (3) trends in recovery according to TBI severity. CONCLUSIONS The results of this scoping review suggest that (1) TBI severity is not the sole predictor of performance; other factors contribute to cognitive communication outcome and recovery; (2) developing skills at time of injury are most susceptible to impairment; and (3) standard, norm-referenced language assessments are not sensitive in detecting language impairments that are secondary to cognitive impairments found in TBI. Directions for future research and suggestions for clinical practice are proposed.


title: A comprehensive process for disclosing and managing conflicts of interest on perceived bias at the SAGES annual meeting.

text: INTRODUCTION The relationship between the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and its industry partners has been longstanding, productive technologically, and beneficial to patient care and education. In order to both maintain this important relationship to honor its responsibility to society for increasing transparency, SAGES established a Conflict of Interest Task Force (CITF) and charged it with identifying and managing potential conflicts of interest (COI) and limiting bias at the SAGES Annual Scientific Meetings. The CITF developed and implemented a comprehensive process for reporting, evaluating, and managing COI in accordance with (and exceeding) Accreditation Council for Continuing Medical Education guidelines. METHODS From 2011 to 2013, all presenters, moderators, and session chairs received proactive and progressively increasing levels of education regarding the CITF rationale and processes and were required to disclose all relationships with commercial interests. Disclosures were reviewed and discussed by multiple layers of reviewers, including moderators, chairs, and CITF committee members with tiered, prescribed actions in a standardized, uniform fashion. Meeting attendees were surveyed anonymously after the annual meeting regarding perceived bias. The CITF database was then analyzed and compared to the reports of perceived bias to determine whether the implementation of this comprehensive process had been effective. RESULTS In 2011, 68 of 484 presenters (14 %) disclosed relationships with commercial interests. In 2012, 173 of 523 presenters (33.5 %) disclosed relationships, with 49 having prior review (9.4 %), and eight required alteration. In 2013, 190 of 454 presenters disclosed relationships (41.9 %), with 93 presentations receiving prior review (20.4 %), and 20 presentations were altered. From 2008 to 2010, the perceived bias among attendees surveyed was 4.7, 6.2, and 4.4 %; and in 2011-2013, was 2.2, 1.2, and 1.5 %. CONCLUSION It is possible to have a surgical meeting that includes participation of speakers that have industry relationships, and minimize perceived bias.


title: Use of Intravascular Imaging During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry.

text: BACKGROUND Intravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention. METHODS AND RESULTS We examined the frequency of use and outcomes of intravascular imaging among 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers. Mean age was 65.4±10 years and 85% of the patients were men. Intravascular imaging was used in 38%: intravascular ultrasound in 36%, optical coherence tomography in 3%, and both in 1.45%. Intravascular imaging was used for stent sizing (26.3%), stent optimization (38.0%), and CTO crossing (35.7%, antegrade in 27.9%, and retrograde in 7.8%). Intravascular imaging to facilitate crossing was used more frequently in lesions with proximal cap ambiguity (49% versus 26%, P<0.0001) and with retrograde as compared with antegrade-only cases (67% versus 31%, P<0.0001). Despite higher complexity (Japanese CTO score: 2.86±1.19 versus 2.43±1.19, P=0.001), cases in which imaging was used for crossing had similar technical and procedural success (92.8% versus 89.6%, P=0.302 and 90.1% versus 88.3%, P=0.588, respectively) and similar incidence of major cardiac adverse events (2.7% versus 3.2%, P=0.772). Use of intravascular imaging was associated with longer procedure (192 minutes [interquartile range 130, 255] versus 131 minutes [90, 192], P<0.0001) and fluoroscopy (71 minutes [44, 93] versus 39 minutes [25, 69], P<0.0001) time. CONCLUSIONS Intravascular imaging is frequently performed during CTO percutaneous coronary intervention both for crossing and for stent selection/optimization. Despite its use in more complex lesion subsets, intravascular imaging was associated with similar rates of technical and procedural success for CTO percutaneous coronary intervention. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436.


title: The Great Exhale: Using Breath Analysis to Detect Disease.

text: Your breath gives away a lot of information. Besides betraying that you've had garlic or onions for lunch, it also contains volatile organic compounds (VOCs) that provide quite telling biomarkers of disease. Building on the potential capability of VOCs to detect illness, the U.K. company Owlstone Medical is now developing a testing platform called Breath Biopsy [1] as a noninvasive diagnostic method and is collaborating with clinicians, researchers, and other biomedical companies around the world on its potential application for early detection of various cancers, respiratory illnesses, and immune diseases.


title: Surface electromyography before and after orthognathic surgery and condylectomy in active laterognathia: a case report.

text: BACKGROUND Condylar hyperplasia is a rare bone disease characterised by excessive development of mandibular condyle, which can lead to the development of asymmetric facial deformity together with malocclusion, mandibular deviation, TMJ and masticatory musculoskeletal system dysfunction. There is not a treatment protocol universally accepted. In order to determine the correct management, treatment and intervention timing of these patients, morphological examinations should be coupled with functional assessments. CASE REPORT In the present case report, morphological (bone scintigraphy; orthopantomography; posteroanterior and lateral cephalograms; 3D facial photographs) and functional (surface electromyography of masseter and temporalis muscles) quantitative data of a 20-year-old male patient affected by unilateral condylar hyperplasia are presented. The patient underwent a surgical treatment with high unilateral condylectomy associated to a maxillary Le Fort I osteotomy; as well as orthodontic treatment before and after surgery. Facial morphology and masticatory muscles activity were assessed before surgery and followed-up 6, 12 and 24 months after surgery. Twenty-four months after surgery, all electromyographic values were normal, and soft-tissue facial asymmetry was negligible at 3D assessment. CONCLUSION Surface electromyography joins a set of clinical and morphological diagnostic tests that help the surgeon in planning the operation and managing the post-surgical patient.


title: Infrared laser thermal fusion of blood vessels: preliminary ex vivo tissue studies.

text: Suture ligation of blood vessels during surgery can be time-consuming and skill-intensive. Energy-based, electrosurgical, and ultrasonic devices have recently replaced the use of sutures and mechanical clips (which leave foreign objects in the body) for many surgical procedures, providing rapid hemostasis during surgery. However, these devices have the potential to create an undesirably large collateral zone of thermal damage and tissue necrosis. We explore an alternative energy-based technology, infrared lasers, for rapid and precise thermal coagulation and fusion of the blood vessel walls. Seven near-infrared lasers (808, 980, 1075, 1470, 1550, 1850 to 1880, and 1908 nm) were tested during preliminary tissue studies. Studies were performed using fresh porcine renal vessels, ex vivo, with native diameters of 1 to 6 mm, and vessel walls flattened to a total thickness of 0.4 mm. A linear beam profile was applied normal to the vessel for narrow, full-width thermal coagulation. The laser irradiation time was 5 s. Vessel burst pressure measurements were used to determine seal strength. The 1470 nm laser wavelength demonstrated the capability of sealing a wide range of blood vessels from 1 to 6 mm diameter with burst strengths of 578 ± 154, 530 ± 171, and 426 ± 174 mmHg for small, medium, and large vessel diameters, respectively. Lateral thermal coagulation zones (including the seal) measured 1.0 ± 0.4 mm on vessels sealed at this wavelength. Other laser wavelengths (1550, 1850 to 1880, and 1908 nm) were also capable of sealing vessels, but were limited by lower vessel seal pressures, excessive charring, and/or limited power output preventing treatment of large vessels (>4 mm outer diameter).


title: Using public health law to contain the spread of COVID-19.

text: Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers what powers are available to ministers, health and local authorities to minimise the spread of the novel coronavirus and the disease it causes.


title: Indication for radioiodine remnant ablation in differentiated thyroid cancer patients: does 2018 Italian consensus change anything?

text: PURPOSE We speculated that radioiodine remnant ablation (RRA) could be performed less frequently in differentiated thyroid cancer (DTC) patients, if the recommendations of the 2018 Italian Consensus (ITA) were applied in clinical practice. Therefore, we compared the ITA indications for RRA with the recommendations by the 2015 American Thyroid Association guidelines (ATA). METHODS We retrospectively evaluated 380 consecutive DTC patients treated with surgery and RRA, followed at the Section of Endocrinology, University of Siena, Italy from January 2006 to December 2019. RESULTS Using ITA a significant increase of DTC patients classified as low or high risk and a significant decrease of patients defined at intermediate risk were observed (p < 0.0001). Consequently, the percentage of patients without routinary indication for RRA (47.4%, versus 38.2%, p < 0.0001) and those with a definite indication for RRA (8.2 versus 1.8%, p < 0.0001) was significantly higher compared to ATA. Moreover, using ITA the percentage of patients with a selective use of RRA was lower in comparison to ATA (44.7% versus 60%, p < 0.0001). Nevertheless, the prevalence of distant metastases, at post-ablative whole body scan, in patients without indication for RRA, was not different using either ATA or ITA (2.1% and 1.1% respectively, p = 0.37). CONCLUSION The use of ITA Consensus, in clinical practice, increases significantly the number of patients for whom RRA is not routinely indicated in comparison to ATA guidelines but without differences in delaying the diagnosis of distant metastatic disease.


Retraction. Short interfering RNA (siRNA) as a novel therapeutic.


title: Battery life of portable home ventilators: effects of ventilator settings.

text: BACKGROUND The battery life (BL) of portable home ventilator batteries is reported by manufacturers. The aim of this study was to evaluate the effects of ventilator mode, breathing frequency, PEEP, and leaks on the BL of 5 commercially available portable ventilators. METHODS The effects of the ventilator mode (volume controlled-continuous mandatory ventilation [VC-CMV] vs pressure support ventilation [PSV]), PEEP 5 cm H2O, breathing frequency (10, 15, and 20 breaths/min), and leaks during both volume-targeted ventilation and PSV on the BL of 5 ventilators (Elisée 150, Monnal T50, PB560, Vivo 50, and Trilogy 100) were evaluated. Each ventilator was ventilated with a test lung at a tidal volume of 700 ml and an inspiratory time of 1.2 s in the absence of leaks. RESULTS Switching from PSV to VC-CMV or the addition of PEEP did not significantly change ventilator BL. The increase in breathing frequency from 10 to 20 breaths/min decreased the BL by 18 ± 11% (P = .005). Leaks were associated with an increase in BL during the VC-CMV mode (18 ± 20%, P = .04) but a decrease in BL during the PSV mode (-13 ± 15%, P = .04). CONCLUSIONS The BL of home ventilators depends on the ventilator settings. BL is not affected by the ventilator mode (VC-CMV or PSV) or the addition of PEEP. BL decreases with an increase in breathing frequency and during leaks with a PSV mode, whereas leaks increase the duration of ventilator BL during VC-CMV.


title: A step toward NOTES total mesorectal excision for rectal cancer: endoscopic transanal proctectomy.

text: BACKGROUND Previous publications have suggested that endoscopic transanal proctectomy (ETAP) is a promising technique and may be an alternative to conventional low anterior resection for rectal cancer. The aim of this study was to evaluate the technical feasibility of ETAP, with a particular focus on postoperative and oncological results and on functional outcomes. METHODS This study was a multicenter prospective study of unselected consecutive patients with low rectal cancer requiring proctectomy and coloanal anastomosis. All patients underwent a standardized procedure. The study endpoints were the safety and adequacy of the oncological resection criteria. All patients were evaluated with the Wexner Fecal Incontinence Questionnaire after stoma closure. RESULTS Fifty-six consecutive patients (41 men) underwent ETAP between February 2010 and June 2012. The median age was 65 years (39-83), and the median body mass index was 27 (20-42). No intraoperative complications were encountered. There was no postoperative mortality, and the morbidity rate was 26%. The mesorectum was complete in 47 cases (84%) and nearly complete in 9 cases (16%). The median number of lymph nodes retrieved was 12 (range, 7-29) per patient. The median radial and distal margins were 8 mm (0-20) and 10 mm (3-40), respectively. R0 resection was achieved in 53 patients (94.6%). The median Wexner score was 4 (3-12). Thirteen (28%) patients reported stool fragmentation and difficult evacuation. CONCLUSIONS ETAP is a feasible alternative surgical option to conventional laparoscopy for rectal resection and may represent a promising step toward rectal natural orifice transluminal endoscopic surgery (NOTES).


title: Sodium Nitroprusside-Enhanced Cardiopulmonary Resuscitation Improves Blood Flow by Pulmonary Vasodilation Leading to Higher Oxygen Requirements.

text: Sodium nitroprusside-enhanced cardiopulmonary resuscitation has shown superior resuscitation rates and neurologic outcomes in large animal models supporting the need for a randomized human clinical trial. This study is the first to show nonselective pulmonary vasodilation as a potential mechanism for the hemodynamic benefits. The pulmonary shunting that is created requires increased oxygen treatment, but the overall improvement in blood flow increases minute oxygen delivery to tissues. In this context, hypoxemia is an important safety endpoint and a 100% oxygen ventilation strategy may be necessary for the first human clinical trial.


title: Intensive care sedation: the past, present and the future.

text: Despite the universal prescription of sedative drugs in the intensive care unit (ICU), current practice is not guided by high-level evidence. Landmark sedation trials have made significant contributions to our understanding of the problems associated with ICU sedation and have promoted changes to current practice. We identified challenges and limitations of clinical trials which reduced the generalizability and the universal adoption of key interventions. We present an international perspective regarding current sedation practice and a blueprint for future research, which seeks to avoid known limitations and generate much-needed high-level evidence to better guide clinicians' management and therapeutic choices of sedative agents.


title: The KEEP SIMPLEST Study: Improving In-House Delays and Periinterventional Management in Stroke Thrombectomy-A Matched Pair Analysis.

text: BACKGROUND AND PURPOSE Although the treatment window for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) has been extended in recent years, it has been proven that recanalizing treatment must be administered as soon as possible. We present a new standard operating procedure (SOP) to reduce in-house delay, standardize periinterventional management and improve patient safety during MT. METHODS KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment (KEEP SIMPLEST) was a prospective, single-center observational study aimed to compare aspects of periinterventional management in AIS patients treated according to our new SOP using a combination of esketamine and propofol with patients having been randomized into conscious sedation (CS) in the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial. Primary outcome was early neurological improvement at 24h using the National Institutes of Health Stroke Scale, and secondary outcomes were door-to-recanalization, recanalization grade, conversion rate and modified Rankin Scale (mRS) at 3 months. RESULTS Door-to-recanalization time (128.6 ± 69.47 min vs. 156.8 ± 75.91 min; p = 0.02), mean duration of MT (92.01 ± 52 min vs. 131.9 ± 64.03 min; p < 0.001), door-to-first angiographic image (51.61 ± 31.7 min vs. 64.23 ± 21.53 min; p = 0.003) and computed tomography-to-first angiographic image time (31.61 ± 20.6 min vs. 44.61 ± 19.3 min; p < 0.001) were significantly shorter in the group treated under the new SOP. There were no differences in early neurological improvement, mRS at 3 months or other secondary outcomes between the groups. Conversion rates of CS to general anesthesia were similar in both groups. CONCLUSION An SOP using a novel sedation regimen and optimization of equipment and procedures directed at a leaner, more integrative and compact periinterventional management can reduce in-house treatment delays significantly in stroke patients receiving thrombectomy in light sedation and demonstrated the safety and feasibility of our improved approach.


title: Saving time stitching thick biological mesh during laparoscopic ventral rectopexy.

text: We present a trick to save time at stitching of thick biological mesh during laparoscopic ventral mesh rectopexy by the use of a belt hole puncher.


title: Meningeal γδ T cell-derived IL-17 controls synaptic plasticity and short-term memory.

text: The notion of "immune privilege" of the brain has been revised to accommodate its infiltration, at steady state, by immune cells that participate in normal neurophysiology. However, the immune mechanisms that regulate learning and memory remain poorly understood. Here, we show that noninflammatory interleukin-17 (IL-17) derived from a previously unknown fetal-derived meningeal-resident γδ T cell subset promotes cognition. When tested in classical spatial learning paradigms, mice lacking γδ T cells or IL-17 displayed deficient short-term memory while retaining long-term memory. The plasticity of glutamatergic synapses was reduced in the absence of IL-17, resulting in impaired long-term potentiation in the hippocampus. Conversely, IL-17 enhanced glial cell production of brain-derived neurotropic factor, whose exogenous provision rescued the synaptic and behavioral phenotypes of IL-17-deficient animals. Together, our work provides previously unknown clues on the mechanisms that regulate short-term versus long-term memory and on the evolutionary and functional link between the immune and nervous systems.


title: Recent advances in vaccines and diagnostics against Middle East respiratory syndrome coronavirus.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) is an RNA virus that causes severe respiratory disease. Since it was identified in 2012, approximately 2500 MERS cases with high mortality have been confirmed in 27 countries. Although most cases have occurred in the Middle East, an outbreak in South Korea in 2015 showed that MERS could be a global threat via human-to-human transmission. There is no licensed vaccine against MERS. Thus, early detection is the best way to limit the spread of this fatal disease. In this review, we focus on transmission, the infection process, and scientific efforts in vaccine development and diagnostics for MERS-CoV. Keywords: Middle East respiratory syndrome coronavirus; epidemiology; virology; vaccine; diagnostics.


title: Identification of novel porcine and bovine parvoviruses closely related to human parvovirus 4.

text: Human parvovirus 4 (PARV4), a recently discovered parvovirus found exclusively in human plasma and liver tissue, was considered phylogenetically distinct from other parvoviruses. Here, we report the discovery of two novel parvoviruses closely related to PARV4, porcine hokovirus (PHoV) and bovine hokovirus (BHoV), from porcine and bovine samples in Hong Kong. Their nearly full-length sequences were also analysed. PARV4-like viruses were detected by PCR among 44.4 % (148/333) of porcine samples (including lymph nodes, liver, serum, nasopharyngeal and faecal samples), 13 % (4/32) of bovine spleen samples and 2 % (7/362) of human serum samples that were sent for human immunodeficiency virus and hepatitis C virus antibody tests. Three distinct parvoviruses were identified, including two novel parvoviruses, PHoV and BHoV, from porcine and bovine samples and PARV4 from humans, respectively. Analysis of genome sequences from seven PHoV strains, from three BHoV strains and from one PARV4 strain showed that the two animal parvoviruses were most similar to PARV4 with 61.5-63 % nt identities and, together with PARV4 (HHoV), formed a distinct cluster within the family Parvoviridae. The three parvoviruses also differed from other parvoviruses by their relatively large predicted VP1 protein and the presence of a small unique conserved putative protein. Based on these results, we propose a separate genus, Hokovirus, to describe these three parvoviruses. The co-detection of porcine reproductive and respiratory syndrome virus, the agent associated with the recent 'high fever' disease outbreaks in pigs in China, from our porcine samples warrants further investigation.


title: Pandemic management in a pediatric hospital.

text: OBJECTIVES To describe our experiences in the management of the second wave of influenza A H1N1 (pH1N1) pandemic in a tertiary-care children's hospital. METHODS An autoethnographic study of the pandemic planning and management committee members involved in managing the second wave of pH1N1 was conducted. RESULTS Staffing, surge capacity, communications and emergency operations planning by adding leaders of frontline workers and other key operational roles to the incident management team, and creating a tactical response team emerged as important factors in pandemic management in our hospital. The emergency department visits increased by 50%, necessitating increased staffing of the emergency department. Communications using existing chains of command had to be used to reach frontline staff during the pandemic. CONCLUSIONS Incident management teams managing pandemics and other disasters have to be dynamic and create tactical teams to ensure implementation and facilitate bidirectional communication with frontline workers.


title: Polyinosine-polycytidylic acid enhances cellular adherence of Streptococcus pneumoniae.

text: OBJECTIVES/HYPOTHESIS Viral upper respiratory tract infections (URIs) are often followed by secondary bacterial infections. To better understand this phenomenon, we examined the impact of the viral agent polyinosine-polycytidylic acid [Poly (I:C)] on the adherence of Streptococcus pneumoniae (Spn) to pharyngeal epithelial cells. STUDY DESIGN In vitro model of cultured human pharyngeal epithelial cells. METHODS Detroit 562 cells, a human pharyngeal carcinoma cell line, were pretreated with Poly (I:C). Poly (I:C)-induced expression of platelet-activating factor receptor (PAF-R) was assayed using real-time polymerase chain reaction, flow cytometry, and immunofluorescence microscopy. Bacterial adhesion to these epithelial cells was assessed using immunofluorescence microscopy and colony formation assays. RESULTS Pretreatment with Poly (I:C) increased mRNA and protein expression of PAF-R in Detroit 562 cells and enhanced the adherence of Spn to these epithelial cells. CONCLUSIONS RNA viral infection can enhance PAF-R expression in epithelial cells and increase the adherence of Spn. These findings might explain in part the mechanisms that underlie the increase in bacterial infection following URIs.


Combined HawkOne directional atherectomy and paclitaxel-coated balloon angioplasty for isolated calcified popliteal artery lesion: a no-stent approach to lower extremity endovascular revascularization.


title: Medical education engagement during the COVID-19 era - A student parents perspective.

text: The COVID-19 pandemic has affected the delivery of medical education and has limited the ability of student parents to fully engage with their studies. Student parents have been faced with additional challenges such as increased childcare roles and home-schooling responsibilities, splitting their focus. Identifying the issues student parents face and adopting workable solutions at all levels, will ensure the best outcomes for these students and better preparedness for the future.


title: Experiences of children exposed to parental post-traumatic stress disorder while growing up in military and veteran families: a systematic review protocol.

text: REVIEW QUESTION/OBJECTIVE The objective of this review is to understand how parental Post-Traumatic Stress Disorder (PTSD) might impact children growing up in military and veteran families. The following question will guide and inform the review: What is the experience of children growing up in military families where the military or veteran parent is living with post-traumatic stress disorder?


title: Multidrug-Resistant Organisms in the Setting of Periprosthetic Joint Infection-Diagnosis, Prevention, and Treatment.

text: BACKGROUND Periprosthetic joint infection (PJI) is a rare yet challenging problem in total hip and knee arthroplasties. The management of PJI remains difficult primarily due to the evolution of resistance by the infecting organisms. METHODS This review profiles acquired mechanisms of bacterial resistance and summarizes established and emerging techniques in PJI diagnosis, prevention, and treatment. RESULTS New techniques in PJI diagnosis and prevention continue to be explored. Antibiotics combined with 1 or 2-stage revision are associated with the higher success rates and remain the mainstay of treatment. CONCLUSION With higher prevalence of antibiotic-resistant organisms, novel antibiotic implant and wound care materials, improved methods for organism identification, and well-defined organism-specific treatment algorithms are needed to optimize outcomes of PJI.


title: Manual aspiration thrombectomy with a Penumbra catheter for acute anterior cerebral artery occlusion.

text: Purpose The purpose of this article is to assess the efficacy and safety of manual aspiration thrombectomy (MAT) using a Penumbra catheter in patients with anterior cerebral artery (ACA) occlusions. Materials and methods From January 2012 to March 2016, 16 patients underwent MAT with Penumbra catheters using a proximal and distal supporting technique to treat ACA occlusions. We evaluated immediate angiographic results and clinical outcomes by reviewing patient electrical medical records. Results Of these patients, 11 had a complete obstruction of the distal internal carotid artery (ICA) and five had ACA and middle cerebral artery (MCA) occlusions. All patients achieved successful recanalization of the distal ICA or MCA (Thrombolysis in Cerebral Infarction (TICI) grade ≥2b). Overall the recanalization rate for ACA occlusions (TICI grade≥2b) was 93.7% (15/16). The median procedure time was 45 minutes (range: 35-65 minutes). No patients were observed to have a procedure-related subarachnoid hemorrhage. Four patients (25.0%) died during hospitalization because of massive symptomatic hemorrhage, brain edema, or herniation. At discharge, the median NIHSS score for surviving patients was 6 (range: 1-17). Five patients had favorable clinical outcomes (modified Rankin scale ≤2). Conclusion MAT appears to be safe and successfully achieves recanalization in patients with ACA occlusions.


title: Polyetheretherketone Versus Titanium Cages for Posterior Lumbar Interbody Fusion: Meta-Analysis and Review of the Literature.

text: OBJECTIVE Lumbar fusion with implantation of interbody cage is a common procedure for treatment of lumbar degenerative disease. This study aims to compare the fusion and subsidence rates of titanium (Ti) versus polyetheretherketone (PEEK) interbody cages after posterior lumbar interbody fusion and investigate the effect of clinical and radiological outcomes following fusion on patient-reported outcomes. METHODS A systematic search strategy of 4 electronic databases (MEDLINE, Embase, Web of Science, and Cochrane) was conducted using different MeSH (medical subject headings) terms until January 2020. Pooled odds ratios (ORs) with 95% confidence intervals (CI) were calculated using fixed and random-effect models based upon the heterogeneity (I2) to estimate the association between interbody cages and the measured outcomes. RESULTS A total of 1,094 patients from 11 studies were reviewed. The final analysis included 421 patients (38.5%) who had lumbar surgery using a Ti and/or a Ti-coated interbody cage and 673 patient (61.5%) who had lumbar surgery using a PEEK cage. Overall, PEEK interbody devices were associated with a significantly lower fusion rate compared with Ti interbody devices (OR, 0.62; 95% CI, 0.41-0.93; p = 0.02). There was no difference in subsidence rates between Ti and PEEK groups (OR, 0.91; 95% CI, 0.54-1.52; p = 0.71). Also, there were no statistically significant differences in visual analogue scale (VAS)-low back pain (p = 0.14) and Japanese Orthopedic Association scale (p = 0.86) between the 2 groups. However, the PEEK group had lower odds of leg pain after surgery compared to the Ti group (OR [VAS-leg], 0.61; 95% CI, 0.28-0.94; p = 0.003). CONCLUSION Ti and Ti-coated PEEK cages used for posterior lumbar interbody fusion are associated with similar rates of subsidence, but a higher rate of fusion compared to PEEK interbody cages. Randomized controlled trials are needed to better assess the effect of cage materials and potential factors that could influence the outcomes of interbody lumbar fusion.


NHS Test and Trace: it didn't have to be this way.


title: Deadeye: A Novel Preattentive Visualization Technique Based on Dichoptic Presentation.

text: Preattentive visual features such as hue or flickering can effectively draw attention to an object of interest - for instance, an important feature in a scientific visualization. These features appear to pop out and can be recognized by our visual system, independently from the number of distractors. Most cues do not take advantage of the fact that most humans have two eyes. In cases where binocular vision is applied, it is almost exclusively used to convey depth by exposing stereo pairs. We present Deadeye, a novel preattentive visualization technique based on presenting different stimuli to each eye. The target object is rendered for one eye only and is instantly detected by our visual system. In contrast to existing cues, Deadeye does not modify any visual properties of the target and, thus, is particularly suited for visualization applications. Our evaluation confirms that Deadeye is indeed perceived preattentively. We also explore a conjunction search based on our technique and show that, in contrast to 3D depth, the task cannot be processed in parallel.


Risks to Bangladeshi children and young people during covid-19 outbreak.


title: The unwanted third wheel in the Calot's triangle: Incidence and surgical significance of caterpillar hump of right hepatic artery with a systematic review of the literature.

text: Background Caterpillar hump of the right hepatic artery is a rare variation increasing the risk of vascular and biliary injuries during hepatobiliary surgery. The aim of this study is to record the cases of the right hepatic artery forming caterpillar hump in a cohort of patients underwent laparoscopic cholecystectomy and to report a review of the literature systematically conducted. Methods We reviewed clinical and surgical video data of 230 patients with symptomatic cholelithiasis treated with laparoscopic cholecystectomy between January 2016 and August 2017. A systematic literature search in PubMed, Medline, Cochrane and Ovid databases until 30th June 2017 was also performed in accordance with the PRISMA statement. Results Our institutional data indicated that 1.3% of 230 patients presented caterpillar hump right hepatic artery. The systematic review included 16 studies reporting data from a total of 498 human cadavers and 579 patients submitted to cholecystectomy. The overall proportion of surgical patients with the caterpillar hump right hepatic artery was 6.9%. Conclusions Variations of the cystic artery are not just an anatomical dissertation, assuming a very crucial role in surgical strategies to avoid uncontrolled vascular lesions. A meticulous knowledge of the hepatobiliary triangle in association with all elements of 'Culture of Safety in Cholecystectomy' is mandatory for surgeons facing more than two structures within Calot's triangle.


A dialogue between the editor-in-chief and a deputy editor of a cardiology journal during the coronavirus outbreak: Take-home messages from the Italian experience.


title: An assessment of opportunities to dissect host genetic variation in resistance to infectious diseases in livestock.

text: This paper reviews the evidence for host genetic variation in resistance to infectious diseases for a wide variety of diseases of economic importance in poultry, cattle, pig, sheep and Atlantic salmon. Further, it develops a method of ranking each disease in terms of its overall impact, and combines this ranking with published evidence for host genetic variation and information on the current state of genomic tools in each host species. The outcome is an overall ranking of the amenability of each disease to genomic studies that dissect host genetic variation in resistance. Six disease-based assessment criteria were defined: industry concern, economic impact, public concern, threat to food safety or zoonotic potential, impact on animal welfare and threat to international trade barriers. For each category, a subjective score was assigned to each disease according to the relative strength of evidence, impact, concern or threat posed by that particular disease, and the scores were summed across categories. Evidence for host genetic variation in resistance was determined from available published data, including breed comparison, heritability studies, quantitative trait loci (QTL) studies, evidence of candidate genes with significant effects, data on pathogen sequence and on host gene expression analyses. In total, 16 poultry diseases, 13 cattle diseases, nine pig diseases, 11 sheep diseases and three Atlantic salmon diseases were assessed. The top-ranking diseases or pathogens, i.e. those most amenable to studies dissecting host genetic variation, were Salmonella in poultry, bovine mastitis, Marek's disease and coccidiosis, both in poultry. The top-ranking diseases or pathogens in pigs, sheep and Atlantic salmon were Escherichia coli, mastitis and infectious pancreatic necrosis, respectively. These rankings summarise the current state of knowledge for each disease and broadly, although not entirely, reflect current international research efforts. They will alter as more information becomes available and as genome tools become more sophisticated for each species. It is suggested that this approach could be used to rank diseases from other perspectives as well, e.g. in terms of disease control strategies.


Planet hunters plot course for habitable worlds.


title: Transanal minimally invasive surgery: initial experience and short-term functional results.

text: BACKGROUND Currently, the preferred method for local excision of rectal polyps is transanal endoscopic microsurgery, avoiding rectal resection. Transanal minimally invasive surgery is a relatively new technique using a disposable port in combination with conventional laparoscopic instruments. This method is less expensive as compared with transanal endoscopic microsurgery, relatively easy to learn, and available. Despite wide adoption of transanal minimally invasive surgery, to date only a few series on the implementation and use of this technique are reported, and detailed information on the effect of transanal minimally invasive surgery on fecal continence is not available. OBJECTIVE The purpose of this work was to prospectively assess the functional outcome after transanal minimally invasive surgery using the Fecal Incontinence Severity Index preoperatively and postoperatively. DESIGN This was a prospective cohort study. SETTINGS The study was conducted at a large teaching hospital. PATIENTS Patients included those who underwent transanal minimally invasive surgery between October 2011 and September 2013. INTERVENTIONS Transanal minimally invasive surgery was studied. MAIN OUTCOME MEASURES We measured postoperative surgical and functional results. RESULTS A total of 37 patients underwent transanal minimally invasive surgery during our study period. Short-term morbidity rate was 14%, and positive resection margins were reported in 6 cases (16%); in 1 of these patients, a local recurrence was observed. Overall, there was a significant decline in preoperative and postoperative Fecal Incontinence Severity Index scores (p = 0.02), indicating an improvement in anorectal function after transanal minimally invasive surgery for patients with impaired preoperative continence. Seventeen patients (49%) had impaired continence before transanal minimally invasive surgery (mean Fecal Incontinence Severity Index score = 21). Continence improved in 15 (88%) of these patients after surgery; no change was observed in 1 patient (6%), and continence further decreased in another. In addition, 18 patients (51%) had normal preoperative continence (Fecal Incontinence Severity Index score = 0), of which 83% had no change in functionality, and continence decreased in 3. LIMITATIONS No quality of life was measured. CONCLUSIONS Short-term functional results of transanal minimally invasive surgery for rectal polyps are excellent and comparable to functional results using the dedicated transanal endoscopic microsurgery equipment. More research on outcome after transanal minimally invasive surgery is needed to assess morbidity rates and oncologic clearance.


title: In vitro security of 3 surgical knots placed by novice veterinary students.

text: OBJECTIVE To determine the most secure knot when tied by veterinary students in a ligation model. STUDY DESIGN Prospective study. SAMPLE POPULATION Sixteen first-year veterinary students. METHODS Veterinary students were taught 3 knots: surgeon's, Miller's, and strangle. After having demonstrated competence, students tied each knot twice in a vascular ligation model at physiologic pressure. The system was tested for completeness of occlusion and volume of fluid lost over 10 seconds. Time, reattempts, repositioning, correctness, and difficulty score were documented. Students were surveyed before and after training regarding their experience. RESULTS Students correctly tied 75% of all knots and achieved complete occlusion of the model with 56% of knots. No difference was identified among knot types in correctness, difficulty, complete occlusion, or time to construct the knot. The first surgeon's knot placed by students had more fluid loss than the Miller's knot, but this was not true of the second knot. CONCLUSION Incomplete occlusion was common among all knot types, but students generally achieved similar knot security when placing surgeon's, Miller's, and strangle knots on a model. More surgeon's knots failed catastrophically during the first attempt, evidenced by a greater volume of fluid loss. CLINICAL SIGNIFICANCE This study does not provide evidence to recommend any of the 3 tested knots as superior to the others to improve the security of ligatures during surgeries performed by students. The prevalence of incomplete occlusion among student knots illustrates the requirement for education regarding knot security and vigilant monitoring of students performing live animal surgeries.


title: A Remotely Conducted Pediatric Boot Camp for 4th Year Medical Students.

text: Boot camp style courses for graduating students provide intensive, timely training to help improve and polish clinical and communication skills before transitioning to the intern role. At our institution, we offer an annual two-week pediatric boot camp elective for graduating medical students entering into pediatric residencies each spring that uses a combination of simulation, patient encounters and classroom-based sessions. However, medical students graduating in 2020 were removed from all patient care activities for their final quarter because of the COVID-19 pandemic, limiting many planned "just in time" experiences.


title: Application of Biosafety Principles in Laboratory Analysis of Clinical Samples from Patients with COVID-19.

text: COVID-19 poses a great challenge to clinical and diagnostic services around the world. The need of biosafety practices can never be emphasised more than under current circumstances. The four pillars of biosafety namely, leadership, standard operating procedures, personal protective equipment (PPE) and engineering controls must be employed for effective and safe practices in the clinical setting in general and laboratory settings in particular. Risk assessment must be carried out before meeting up the diagnostic challenge for COVID-19 and essential biorisk management measures are required to be taken. In our resource-poor settings, we need to adapt safe but cost-effective and improvised solutions to ensure safe handling of clinical samples from COVID-19 patients in the laboratories. The correct use of PPE and their suitable alternatives are available for selection and use. Disinfection of the lab areas and safe disposal of the clinical samples from such patients is also of paramount importance.


title: Loneliness, isolation, and social support factors in post-COVID-19 mental health.

text: Social support plays a key role in well-being, yet one of the major preventative efforts for reducing the spread of COVID-19 involves social distancing. During times of crisis, social support is emphasized as a coping mechanism. This requires many people to change their typical ways of connectedness and assumes that people have existing healthy relationships or access to technology. The purpose of this article was to explore the potential impact of COVID-19 on loneliness and well-being. Social support is an important consideration for understanding the impact of COVID-19 Psychological First Aid and Skills for Psychological Recovery, which are tools used to inform response methods to help people connect during isolation and are interventions that could be adapted to COVID-specific needs for what may be a prolonged isolation and postisolation. Given the many unknowns of COVID-19, studies are needed to understand the larger behavioral health impact to ensure resources are available, current, and evidence informed. Future studies are also needed to understand how access to technology may help buffer loneliness and isolation and thus improve the social outcomes of the current pandemic. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Supraspinatus tendon overuse results in degenerative changes to tendon insertion region and adjacent humeral cartilage in a rat model.

text: The etiology of rotator cuff tendon overuse injuries is still not well understood. Furthermore, how this overuse injury impacts other components of the glenohumeral joint, including nearby articular cartilage, is also unclear. Therefore, this study sought to better understand the time course of tendon protease activity in a rat model of supraspinatus overuse, as well as determine effects of 10 weeks of overuse on humeral head articular cartilage. For these studies, multiplex gelatin zymography was used to characterize protease activity profiles in tendon and cartilage, while histological scoring/mechanical testing and micro-computed tomography (μCT) imaging were used to quantify structural damage in the supraspinatus tendon insertion and humeral articular cartilage, respectively. Histological scoring of supraspinatus tendon insertions revealed tendinopathic cellular and collagen fiber changes after 10 weeks of overuse when compared to controls, while mechanical testing revealed no significant differences between tensile moduli (overuse: 24.5 ± 11.5 MPa; control: 16.3 ± 8.7 MPa). EPIC-μCT imaging on humeral articular cartilage demonstrated significant cartilage thinning (overuse: 119.6 ± 6.34 μm; control: 195.4 ± 13.4μm), decreased proteoglycan content (overuse: 2.1 ± 0.18 cm-1 ; control: 1.65 ± 0.14 cm-1 ), and increased subchondral bone thickness (overuse: 216.2 ± 10.9 μm; control: 192 ± 17.8μm) in the overuse animals. Zymography results showed no significant upregulation of cathepsins or matrix metalloproteinases in tendon or cartilage at 2 or 10 weeks of overuse compared to controls. These results have further elucidated timing of protease activity over 10 weeks and suggest that damage occurs to other tissues in addition to the supraspinatus tendon in this overuse injury model. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1910-1918, 2017.


Blood transfusion: friend or foe?


title: SCAI expert consensus statement for femoral-popliteal arterial intervention appropriate use.

text: Successful endovascular intervention for femoral-popliteal (FP) arterial disease provides relief of claudication and offers limb-salvage in cases of critical limb ischemia. Technologies and operator technique have evolved to the point where we may now provide effective endovascular therapy for a spectrum of lesions, patients, and clinical scenarios. Endovascular treatment of this segment offers a significant alternative to surgical revascularization, and may confer improved safety for a wide range of patients, not solely those deemed high surgical risk. Although endovascular therapy of the FP segment has historically been hampered by high rates of restenosis, emerging technologies including drug-eluting stents, drug-coated balloons, and perhaps bio-absorbable stent platforms, provide future hope for more durable patency in complex disease. By combining lessons learned from clinical trials, international trends in clinical practice, and insights regarding emerging technologies, we may appropriately tailor our application of endovascular therapy to provide optimal care to our patients. This document was developed to guide physicians in the clinical decision-making related to the contemporary application of endovascular intervention among patients with FP arterial disease.


title: Characterization of epitopes recognized by monoclonal antibodies: experimental approaches supported by freely accessible bioinformatic tools.

text: Monoclonal antibodies (mAbs) have been used successfully both in research and for clinical purposes. The possible use of protective mAbs directed against different microbial pathogens is currently being considered. The fine definition of the epitope recognized by a protective mAb is an important aspect to be considered for possible development in epitope-based vaccinology. The most accurate approach to this is the X-ray resolution of mAb/antigen crystal complex. Unfortunately, this approach is not always feasible. Under this perspective, several surrogate epitope mapping strategies based on the use of bioinformatics have been developed. In this article, we review the most common, freely accessible, bioinformatic tools used for epitope characterization and provide some basic examples of molecular visualization, editing and computational analysis.


title: The global proliferation of high-containment biological laboratories: understanding the phenomenon and its implications.

text: Disease-causing pathogens have been with humanity for as long as the species has existed, but the world has changed. The human population is increasing and becoming more globalised. Meanwhile, the international system remains unstable and biotechnology is advancing at a breakneck speed. Humans are coming into contact with new and re-emerging pathogens as they spread into previously uninhabited environments. Pathogens play an increasingly global role, and infectious disease is becoming less confined by geographical or climatic boundaries. In order to meet these new challenges, both states and the private sector have been building an increasing number of high-containment biological laboratories(HCBLs) that work with biosafety level (BSL) 3 and 4 pathogens. This rate has increased sharply since 11 September 2011, and most states that have the means to build such laboratories do so. Pathogens do not stop at borders, and the more prepared a state is to deal with them, the better for its national security. Although there is information available on the world's BSL-4 laboratories, none of it includes the proliferation of BSL-3 laboratories. This paper attempts to create a working database of the state of global HCBL proliferation. It seeks to analyse the data and to understand how we are dealing with this phenomenon, the risks involved, and the possible measures to be taken. The information is inevitably complex and certainly far from complete, but it is the author's hope that it will provide a sufficient basis from which to make useful, actionable inferences.


VACCINES. Ebola virus vaccines--preparing for the unexpected.


title: EUS-guided sutured gastropexy for transgastric ERCP (ESTER) in patients with Roux-en-Y gastric bypass: a novel, single-session, minimally invasive approach.

text: BACKGROUND AND STUDY AIMS Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) is a challenging procedure. Available techniques are hampered by limited success, need for a separate delayed session for ERCP, potential complications,and/or invasiveness. This paper reports on a novel technique that involves endoscopic ultrasound(EUS)-guided access into the remnant stomach and sutured gastropexy for transgastric ERCP in a single combined session. PATIENTS AND METHODS A total of 10 patients with RYGB underwent transgastric ERCP using the novel technique. EUS was used to puncture the excluded stomach through the gastric pouch or jejunum,the stomach was insufflated, and a direct percutaneous gastrostomy puncture followed by sutured gastropexy was performed. ERCP was performed by passing a duodenoscope through the gastrostomy. RESULTS Technical success of EUS-assisted sutured gastropexy was achieved in nine patients (90 %),with immediate, same-session ERCP in all nine.There were no adverse events. CONCLUSIONS EUS-assisted, fluoroscopically guided sutured gastropexy is a safe and effective method to obtain access into the excluded gastric remnant for same-session transgastric ERCP inpatients with Roux-en-Y gastric bypass anatomy.


Some reflections on organizational profiles in Italy in the time of COVID-19.


title: Prohemostatic interventions in liver surgery.

text: Surgical procedures of the liver, such as partial liver resections and liver transplantation, are major types of abdominal surgery. Liver surgery can be associated with excessive intraoperative blood loss, not only because the liver is a highly vascularized organ, but also because it plays a central role in the hemostatic system. Intraoperative blood loss and transfusion of blood products have been shown to be negatively associated with postoperative outcome after liver surgery. Dysfunction of the liver is frequently accompanied with a dysfunctional hemostatic system. However, in general, there is a poor correlation between preoperative coagulation tests and the intraoperative bleeding risk in patients undergoing liver surgery. Strategies to avoid excessive blood loss in liver surgery have been an active field of research and include three different areas: surgical methods, anesthesiological methods, and pharmacological agents.Surgeons can minimize blood loss by clamping the hepatic vasculature, by using specific dissection devices, and by using topical hemostatic agents. Anesthesiologists play an important role in minimizing blood loss by avoiding intravascular fluid overload. Maintaining a low central venous pressure has shown to be very effective in reducing blood loss during partial liver resections. Prophylactic transfusion of blood products such as fresh frozen plasma (FFP) has not been shown to reduce intraoperative bleeding and even seems counterproductive as it results in an increase of the intravascular filling status, which may enhance the bleeding risk. In patients with liver cirrhosis, there is increasing evidence that factors such as portal hypertension and the hyperdynamic circulation play a more important role in the bleeding tendency than changes in the coagulation system. Therefore, intravenous fluid restriction rather than prophylactic administration of large volumes of blood products (i.e., FFP) is recommended in patients undergoing major liver surgery. Pharmacological agents such as antifibrinolytic drugs or recombinant factor VIIa may be indicated in selected individual patients, but these agents do not have a routine role in the management of patients undergoing liver surgery.


title: Systems biology and systems genetics - novel innovative approaches to study host-pathogen interactions during influenza infection.

text: Influenza represents a serious threat to public health with thousands of deaths each year. A deeper understanding of the host-pathogen interactions is urgently needed to evaluate individual and population risks for severe influenza disease and to identify new therapeutic targets. Here, we review recent progress in large scale omics technologies, systems genetics as well as new mathematical and computational developments that are now in place to apply a systems biology approach for a comprehensive description of the multidimensional host response to influenza infection. In addition, we describe how results from experimental animal models can be translated to humans, and we discuss some of the future challenges ahead.


title: Coronavirus S protein-induced fusion is blocked prior to hemifusion by Abl kinase inhibitors.

text: Enveloped viruses gain entry into host cells by fusing with cellular membranes, a step that is required for virus replication. Coronaviruses, including the severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV) and infectious bronchitis virus (IBV), fuse at the plasma membrane or use receptor-mediated endocytosis and fuse with endosomes, depending on the cell or tissue type. The virus spike (S) protein mediates fusion with the host cell membrane. We have shown previously that an Abelson (Abl) kinase inhibitor, imatinib, significantly reduces SARS-CoV and MERS-CoV viral titres and prevents endosomal entry by HIV SARS S and MERS S pseudotyped virions. SARS-CoV and MERS-CoV are classified as BSL-3 viruses, which makes experimentation into the cellular mechanisms involved in infection more challenging. Here, we use IBV, a BSL-2 virus, as a model for studying the role of Abl kinase activity during coronavirus infection. We found that imatinib and two specific Abl kinase inhibitors, GNF2 and GNF5, reduce IBV titres by blocking the first round of virus infection. Additionally, all three drugs prevented IBV S-induced syncytia formation prior to the hemifusion step. Our results indicate that membrane fusion (both virus-cell and cell-cell) is blocked in the presence of Abl kinase inhibitors. Studying the effects of Abl kinase inhibitors on IBV will be useful in identifying the host cell pathways required for coronavirus infection. This will provide an insight into possible therapeutic targets to treat infections by current as well as newly emerging coronaviruses.


title: Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications.

text: The purpose of this investigation was to investigate the association between first attempt success and intubation-related complications in the Intensive Care Unit after the widespread adoption of video laryngoscopy. We further sought to characterize and identify the predictors of complications that occur despite first attempt success. This was a prospective observational study of consecutive intubations performed with video laryngoscopy at an academic medical Intensive Care Unit. Operator, procedural, and complication data were collected. Multivariable logistic regression was used to examine the relationship between the intubation attempts and the occurrence of one or more complications. A total of 905 patients were intubated using a video laryngoscope. First attempt success occurred in 739 (81.7 %), whereas >1 attempt was needed in 166 (18.3 %). One or more complications occurred in 146 (19.8 %) of those intubated on the first attempt versus 107 (64.5 %, p < 0.001) of those requiring more than one attempt. Logistic regression analysis shows that >1 attempt is associated with 6.4 (95 % CI 4.4-9.3) times the adjusted odds of at least one complication. Pre-intubation predictors of at least one complication despite first attempt success include vomit or edema in the airway as well as the presence of hypoxemia or hypotension. There are increased odds of complications with even a second attempt at intubation in the Intensive Care Unit. Complications occur frequently despite a successful first attempt, and as such, the goal of airway management should not be simply first attempt success, but instead first attempt success without complications.


title: Type 1 Phototherapeutic Agents. 2. Cancer Cell Viability and ESR Studies of Tricyclic Diarylamines.

text: Type 1 phototherapeutic agents based on diarylamines were assessed for free radical generation and evaluated in vitro for cell death efficacy in the U937 leukemia cancer cell line. All of the compounds were found to produce copious free radicals upon photoexcitation with UV-A and/or UV-B light, as determined by electron spin resonance (ESR) spectroscopy. Among the diarylamines, the most potent compounds were acridan (4) and 9-phenylacridan (5), with IC50 values of 0.68 μM and 0.17 μM, respectively.


title: Carotid artery stenting: what you need to know.

text: Carotid stenting has become an accepted alternative in patients with carotid stenosis. The purpose of this article is to review the relevant trials, describe the different devices available for stenting, the devices for cerebral protection, as well as describe techniques and tricks for successful carotid artery stenting. Understanding how to appropriately preoperatively evaluate patients and intra- and postoperative procedures, carotid artery stenting can be a safe procedure.


title: Video. Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy.

text: Enthusiasm for natural orifice transluminal endoscopic surgery (NOTES) has been partly tempered by the reality that most NOTES procedures to date have been laparoscopically assisted. After safely performing transvaginal cholecystectomy in an IACUC-approved porcine model, the authors embarked on an institution review board (IRB)-approved protocol for ultimate performance of pure NOTES cholecystectomy in humans. They describe their experience performing a true NOTES transvaginal cholecystectomy after safely accomplishing three laparoscopically assisted or hybrid procedures in humans. One of the patients was a 35-year-old woman presenting with symptoms of biliary colic. Ultrasound confirmed gallstones, and her liver enzymes were normal. Pneumoperitoneum to 15 mmHg was obtained via a transvaginal trocar placed through a colpotomy made under direct vision. A double-channel endoscope then was advanced into the abdomen. To overcome the retracting limitations of currently available endoscopes, the authors used an extra-long 5-mm articulating retractor placed into the abdomen via a separate colpotomy made under direct vision using the flexible endoscope in a retroflexed position. Endoscopically placed clips were used for control of both the cystic duct and the artery. These techniques obviated the need for any transabdominally placed instruments or needles. This patient was the first to undergo a completely NOTES cholecystectomy at the authors' institution, and to their knowledge, in the United States. She was discharged on the day of surgery and at this writing has not experienced any complication after 1 month of follow-up evaluation. Performance of NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe for humans. Additional experience with this technique are required before studies comparing it with standard laparoscopy and hybrid techniques are appropriate.


title: A classification of clinical fat grafting: different problems, different solutions.

text: BACKGROUND Fat grafting has reemerged from a highly variable procedure to a technique with vast reconstructive and cosmetic potential. Largely because of a more disciplined and scientific approach to fat grafting as a transplantation event, early adopters of fat transplantation have begun to approach fat grafting as a process, using sound surgical transplantation principles: recipient preparation, controlled donor harvest, time-efficient transplantation, and proper postoperative care. Despite these principles, different fat grafting techniques yield impressive clinical outcomes. METHODS The essential variables of four types of fat grafting cases were identified and compared: harvesting, methods of cell processing, methods of transplantation, and management of the recipient site. RESULTS Each case differed for most of the variables analyzed. The two clinical drivers that most impacted these differences were the volume demands of the recipient site and whether the recipient site was healthy tissue or pathologic tissue. After these two drivers, a matrix classification of small-volume versus large-volume and regenerative versus nonregenerative cases yields four distinct categories. CONCLUSIONS Not all fat grafting is the same. Fat grafting, once thought to be a simple technique with variable results, is a much more complex procedure with at least four definable subtypes. By defining the essential differences in the recipient site, the key driver in fat transplantation, the proper selection of technique can be best chosen. In fat transplantation, different problems require different solutions.


title: Neuroendovascular clinical trials disruptions due to COVID-19 potential future challenges and opportunities.

text: To assess the impact of COVID-19 on neurovascular research and deal with the challenges imposed by the pandemic. METHODS A survey-based study focused on randomized controlled trials (RCTs) and single-arm studies for acute ischemic stroke and cerebral aneurysms was developed by a group of senior neurointerventionalists and sent to sites identified through the clinical trials website (https://clinicaltrials.gov/), study sponsors, and physician investigators. RESULTS The survey was sent to 101 institutions, with 65 responding (64%). Stroke RCTs were being conducted at 40 (62%) sites, aneurysm RCTs at 22 (34%) sites, stroke single-arm studies at 37 (57%) sites, and aneurysm single-arm studies at 43 (66%) sites. Following COVID-19, enrollment was suspended at 51 (78%) sites-completely at 21 (32%) and partially at 30 (46%) sites. Missed trial-related clinics and imaging follow-ups and protocol deviations were reported by 27 (42%), 24 (37%), and 27 (42%) sites, respectively. Negative reimbursements were reported at 17 (26%) sites. The majority of sites, 49 (75%), had put new trials on hold. Of the coordinators, 41 (63%) worked from home and 20 (31%) reported a personal financial impact. Remote consent was possible for some studies at 34 (52%) sites and for all studies at 5 (8%) sites. At sites with suspended trials (n=51), endovascular treatment without enrollment occurred at 31 (61%) sites for stroke and 23 (45%) sites for aneurysms. A total of 277 patients with acute ischemic stroke and 184 with cerebral aneurysms were treated without consideration for trial enrollment. CONCLUSION Widespread disruption of neuroendovascular trials occurred because of COVID-19. As sites resume clinical research, steps to mitigate similar challenges in the future should be considered.


title: Practical aspects of high resolution esophageal manometry.

text: High resolution esophageal manometry (HRM) is currently under development as can be seen in the various Chicago classifications. In order to standardize criteria in certain practical aspects with limited scientific evidence, the First National Meeting for Consensus in High Resolution Manometry of the Spanish Digestive Motility Group took place, bringing together a wide group of experts. The proposals were based on a prior survey composed of 47 questions, an exhaustive review of the available literature and the experience of the participants. Methodological aspects relating to the poorly defined analysis criteria of certain new high resolution parameters were discussed, as well as other issues previously overlooked such as spontaneous activity or secondary waves. Final conclusions were drawn with practical applications.


Diaphragmatic hernia after percutaneous radiofrequency ablation of lung tumor.


title: Clinical Implications of 5 Cases of Middle East Respiratory Syndrome Coronavirus Infection in a South Korean Outbreak.

text: The Korea Middle East respiratory syndrome coronavirus (MERS-CoV) was first confirmed on May 20, 2015, with a subsequent outbreak in South Korea. Five patients with suspected MERS-CoA infection were admitted to our hospital during this outbreak. One patient had no major symptoms upon admission, but pneumonia was identified upon chest radiography. Two patients progressed rapidly to acute respiratory failure and required ventilator-assisted respiration. One patient required extracorporeal membrane oxygenation to treat refractory hypoxemia, and one patient died of shock with multiorgan failure. All the patients had fever, myalgia, leucopenia, normal procalcitonin level, and pneumonia. Importantly, clinicians should test for pneumonia in all suspected patients with MERS-CoV infection, even in the absence of respiratory symptoms. The pneumonia usually affected the lower lobes. A shorter incubation period was associated with more severe disease and greater risk of mortality, and the severity of fever predicted the prognosis of MERS-CoV infection-related pneumonia. Therefore, in cases of lower-lobe pneumonia that occur during an MERS-CoV outbreak and are unesponsive to antibiotics, clinicians should consider the possibility of MERS-CoV infection.


title: Contained Power Morcellation Versus Transvaginal Extraction for Retrieval of Laparoscopically Removed Myomas: A Comparison of Perioperative Outcomes.

text: OBJECTIVE To evaluate clinical and operative outcomes of transvaginal extraction (TVE) and contained power morcellation (CPM) for myoma retrieval after laparoscopic myomectomy. MATERIALS AND METHODS Prospective data from 35 consecutive cases using CPM were compared with retrospective data of all cases using TVE from December 2014 to January 2017. Patients were matched 1:1 based on myoma diameter. A total of 62 women were included in the final analysis. Specimen retrieval was performed using the TVE or CPM within an insufflated isolation bag. RESULTS Age, body mass index, mode of prior obstetric delivery, history of previous abdominal surgery, indication for myomectomy, and the myoma(s) characteristics were similar between groups. Retrieval time was significantly shorter in the TVE group compared with the CPM group: 10 minutes (3-15 minutes) versus 17 minutes (14-42 minutes); P < .001. Time required for placement of the instruments was 9.7 minutes for the isolation bag and 0.5 minutes for the vaginal extractor. Additional analgesic administration for pain relief was necessary in 13 patients (42%) in the TVE group and 23 patients (72%) in the CPM group ( P = .01). Total cost of the hospital stay was significantly higher in the CPM group compared with the TVE group ( P < .001). Estimated blood loss and duration of hospital stay were similar between groups. CONCLUSION Both CPM and TVE can be used for safe retrieval of large myomas that are removed laparoscopically. Compared with CPM, TVE was associated with a shorter retrieval time, less postoperative pain, and less hospital costs.


title: Entry and Release of Hepatitis C Virus in Polarized Human Hepatocytes.

text: Hepatitis C virus (HCV) primarily infects hepatocytes, which are highly polarized cells. The relevance of cell polarity in the HCV life cycle has been addressed only in distantly related models and remains poorly understood. Although polarized epithelial cells have a rather simple morphology with a basolateral and an apical domain, hepatocytes exhibit complex polarization structures. However, it has been reported that some selected polarized HepG2 cell clones can exhibit a honeycomb pattern of distribution of the tight-junction proteins typical of columnar polarized epithelia, which can be used as a simple model to study the role of cell polarization in viral infection of hepatocytes. To obtain similar clones, HepG2 cells expressing CD81 (HepG2-CD81) were used, and clones were isolated by limiting dilutions. Two clones exhibiting a simple columnar polarization capacity when grown on a semipermeable support were isolated and characterized. To test the polarity of HCV entry and release, our polarized HepG2-CD81 clones were infected with cell culture-derived HCV. Our data indicate that HCV binds equally to both sides of the cells, but productive infection occurs mainly when the virus is added at the basolateral domain. Furthermore, we also observed that HCV virions are released from the basolateral domain of the cells. Finally, when polarized cells were treated with oleic acid and U0126, a MEK inhibitor, to promote lipoprotein secretion, a higher proportion of infectious viral particles of lower density were secreted. This cell culture system provides an excellent model to investigate the influence of cell polarization on the HCV life cycle.IMPORTANCE Hepatitis C is a major health burden, with approximately 170 million persons infected worldwide. Hepatitis C virus (HCV) primarily infects hepatocytes, which are highly polarized cells with a complex organization. The relevance of cell polarity in the HCV life cycle has been addressed in distantly related models and remains unclear. Hepatocyte organization is complex, with multiple apical and basolateral surfaces. A simple culture model of HepG2 cells expressing CD81 that are able to polarize with unique apical and basolateral domains was developed to study HCV infection. With this model, we demonstrated that HCV enters and exits hepatocytes by the basolateral domain. Furthermore, lower-density viral particles were produced under conditions that promote lipoprotein secretion. This cell culture system provides a useful model to study the influence of cell polarization on HCV infection.


title: EEG Findings in Coronavirus Disease.

text: PURPOSE Neurologic manifestations of coronavirus disease (COVID-19) such as encephalopathy and seizures have been described. To our knowledge, detailed EEG findings in COVID-19 have not yet been reported. This report adds to the scarce body of evidence. METHODS We identified eight COVID-19 positive patients who underwent EEG monitoring in our hospital system. RESULTS EEGs were most commonly ordered for an altered level of consciousness, a nonspecific neurologic manifestation. We observed generalized background slowing in all patients and generalized epileptiform discharges with triphasic morphology in three patients. Focal electrographic seizures were observed in one patient with a history of focal epilepsy and in another patient with no such history. Five of eight patients had a previous diagnosis of epilepsy, suggesting that pre-existing epilepsy can be a potential risk factor for COVID-19-associated neurological manifestations. Five of eight patients who underwent EEG experienced a fatal outcome of infection. CONCLUSIONS Our findings underscore previous observations that neurologic manifestations are common in severe cases. COVID-19 patients with epilepsy may have an increased risk of neurological manifestations and abnormal EEG.


title: Estrogen-based hormone therapy in women with primary ovarian insufficiency: a systematic review.

text: PURPOSE Sex hormones play a role in bone density, cardiovascular health, and wellbeing throughout reproductive lifespan. Women with primary ovarian insufficiency (POI) have lower estrogen levels requiring hormone therapy (HT) to manage symptoms and to protect against adverse long-term health outcomes. Yet, the effectiveness of HT in preventing adverse outcomes has not been systematically assessed. We summarize the evidence regarding effects of HT on bone and cardiovascular health in women with POI. METHODS A comprehensive search of the electronic databases MEDLINE, EMBASE, and Scopus was conducted by a medical reference librarian from database inception to January 2016. Randomized trials and observational cohort studies with an estrogen-based HT intervention in women with POI under the age of 40 were included. Reviewers worked independently and in duplicate to assess eligibility and risk of bias, and extract data of interest from each study. RESULTS The search identified 1670 articles; 12 met inclusion criteria. Four randomized clinical trials and eight cohort studies at high risk of bias enrolled 806 women with POI. The most common HT formulations were transdermal estradiol and oral conjugated equine estrogen combined with medroxyprogesterone acetate. Bone mineral density was the most frequent outcome, with three out of eight studies showing HT associated increase benefits. Only one study reported effects on fractures or vasomotor symptoms and none on cardiovascular mortality. Results regarding lipid profiles were inconsistent. CONCLUSIONS Evidence supporting bone and cardiovascular benefits of HT in women with POI is limited by high risk of bias, reliance on surrogate outcomes, and heterogeneity of trials regarding the formulation, dose, route of administration, and regimen of HT. Further research addressing patient important outcomes such as fractures, stroke, and cardiovascular mortality are crucial to optimize benefits of this therapy.


Diagnosing and Treating Systemic Racism.


Coronavirus: online GP bookings should be stopped because of safety risks, warns BMA.


title: [Evaluation of Seeplex Pneumobacter multiplex PCR kit for the detection of respiratory bacterial pathogens in pediatric patients].

text: BACKGROUND Rapid identification of the causative agent among potential bacterial and viral pathogens is important for the management of acute respiratory disease. In this study, we evaluated the analytical performance and clinical usefulness of a recently-introduced multiplex PCR assay, Seeplex Pneumobacter detection kit (Seegene Inc., Korea) for the identification of respiratory bacterial pathogens. METHODS One hundred and eighty one nasopharyngeal aspirates were collected from pediatric patients with respiratory symptoms and analysed by multiplex PCR for the detection of Streptococcus pneumoniae (S.P), Haemophilus influenzae (H.I), Mycoplasma pneumoniae (M.P), Chlamydophila pneumoniae (C.P), Bordetella pertussis (B.P) and Legionella pneumophila (L.P). A comparison of multiplex PCR with conventional culture for the isolation of S.P and H.I was performed on 112 specimens. The cross reactivity of multiplex PCR was also evaluated. RESULTS Of 181 cases, 81 cases were positive by multiplex PCR (44.8%): 52 cases for S.P (28.7%), 47 cases for H.I (26.0%), 9 cases for M.P (5.0%), 3 cases for B.P (1.7%) and 1 case for C.P (0.6%) including multiple infection cases. The agreement rates between multiplex PCR and culture for S.P and H.I were 92.9% (kappa index=0.84, P<0.001) and 91.1% (kappa index=0.75, P<0.001), respectively. There was no cross reactivity with common bacterial and viral pathogens. CONCLUSIONS Seeplex Pneumobacter detection kit could be a useful screening tool for the rapid detection of respiratory bacterial pathogens. Further studies with lower respiratory tract specimens would be needed for the clinical evaluation of S. pneumoniae and H. influenzae detected by multiplex PCR.


The Role of Spine Surgeons in the Era of COVID-19 Outbreak.


title: Vaginal cuff closure during robotic-assisted total laparoscopic hysterectomy: comparing vicryl to barbed sutures.

text: BACKGROUND AND OBJECTIVES Empirical evidence is needed to assess clinical appropriateness of any new surgical device or material. Differences in surgical outcomes between Vicryl figure-of-8 and V-Loc barbed sutures for vaginal cuff closure during robotic hysterectomy were assessed. METHODS We examined the electronic medical records of 202 patients who underwent scheduled robotic-assisted total laparoscopic hysterectomy for benign indications, without concomitant urogynecologic procedures, between January 2008 and November 2010 at the Henry Ford Health System academic medical center. Cuff closure approach was selected by the surgeon. Data on demographics, vaginal cuff suture type, body mass index (BMI), estimated blood loss (EBL), perioperative hemoglobin change, procedure duration, hospital length of stay (LOS), specimen weight, and postoperative complications were obtained. RESULTS The average age was 46 y (SD = 8.0 y). Women with Vicryl figure-of-8 closures (n = 133) were more likely than women with V-Loc barbed suture closures (n = 69) to have had a LOS > 1 d (48/133, 36.1% vs. 12/69, 17.4%; chi square P < .006), greater EBL (median 75 vs. 50 mL, Wilcoxon Rank Sum WRS P < .001), and longer procedure durations (175 vs. 135 min, WRS P < .001). These differences persisted even after considering uterine weight, BMI, smoking status, and concomitant oophorectomy. No differences with respect to the frequency of major (2 in each closure type) or minor complications were observed (P < .36). CONCLUSIONS There were no differences in complications between the Vicryl figure-of-8 and V-Loc barbed sutures in our sample. However, the latter had lower EBL and shorter procedure duration and LOS.


title: Surfactant-modified nanoclay exhibits an antiviral activity with high potency and broad spectrum.

text: UNLABELLED Nanomaterials have the characteristics associated with high surface-to-volume ratios and have been explored for their antiviral activity. Despite some success, cytotoxicity has been an issue in nanomaterial-based antiviral strategies. We previously developed a novel method to fully exfoliate montmorillonite clay to generate the most fundamental units of nanoscale silicate platelet (NSP). We further modified NSP by capping with various surfactants and found that the surfactant-modified NSP (NSQ) was less cytotoxic. In this study, we tested the antiviral potentials of a series of natural-clay-derived nanomaterials. Among the derivatives, NSP modified with anionic sodium dodecyl sulfate (NSQc), but not the pristine clay, unmodified NSP, a silver nanoparticle-NSP hybrid, NSP modified with cationic n-octadecanylamine hydrochloride salt, or NSP modified with nonionic Triton X-100, significantly suppressed the plaque-forming ability of Japanese encephalitis virus (JEV) at noncytotoxic concentrations. NSQc also blocked infection with dengue virus (DEN) and influenza A virus. Regarding the antiviral mechanism, NSQc interfered with viral binding through electrostatic interaction, since its antiviral activity can be neutralized by Polybrene, a cationic polymer. Furthermore, NSQc reduced the lethality of JEV and DEN infection in mouse challenge models. Thus, the surfactant-modified exfoliated nanoclay NSQc may be a novel nanomaterial with broad and potent antiviral activity. IMPORTANCE Nanomaterials have being investigated as antimicrobial agents, yet their antiviral potential is overshadowed by their cytotoxicity. By using a novel method, we fully exfoliated montmorillonite clay to generate the most fundamental units of nanoscale silicate platelet (NSP). Here, we show that the surfactant-modified NSP (NSQ) is less cytotoxic and that NSQc (NSP modified with sodium dodecyl sulfate) could potently block infection by dengue virus (DEN), Japanese encephalitis virus (JEV), and influenza A virus at noncytotoxic concentrations. For the antiviral mechanism, we find that the electrostatic interaction between the negatively charged NSQc and the positively charged virus particles blocks viral binding. Furthermore, we used mouse challenge models of JEV and DEN to demonstrate the in vivo antiviral potential of NSQc. Thus, NSQc may function as a potent and safe antiviral nanohybrid against several viruses, and our success in synthesizing surfactant-modified NSP with antiviral activity may shed some light on future antiviral development.


title: Treatment of unruptured intracranial aneurysms: a review.

text: INTRODUCTION Unruptured brain aneurysms (UIAs) present a challenge due to the lack of definitive understanding of their natural history and treatment outcomes. As the treatment of UIAs is aimed at preventing the possibility of rupture, the immediate risk of treatment must be weighed against the risk of rupture in the future. As such, treatment for a large proportion of UIAs is currently individualized. AREAS COVERED In this article, we discuss the important natural history studies of UIAs and discuss the existing scientific evidence and recent advances that help identify the rupture risk guide management of UIAs. We also address the recent advances in pharmacological therapy of UIAs. Expert commentary: In the recent years, there have been great advances in understanding the pathophysiology of UIAs and determining the rupture risk going beyond the traditional parameter of aneurysm size. Aneurysm morphology and hemodynamics play a pivotal role in growth and rupture. A true randomized trial for the management of UIAs is the need of the hour.


title: Endovascular treatment of complex aneurysms at the vertebrobasilar junction with flow-diverting stents: initial experience.

text: BACKGROUND Large or giant complex vertebrobasilar junction aneurysms have a dismal natural history and are often challenging to treat with standard endovascular or neurosurgical techniques. OBJECTIVE To report initial experience with endovascular treatment of these aneurysms using flow-diverting stents (FDS). METHODS Ten patients with FDS treatment of complex vertebrobasilar junction aneurysms were collected from 4 large cerebrovascular centers. Clinical/angiographic presentation and outcome were retrospectively analyzed. RESULTS Of 10 aneurysms, 7 presented with brainstem compression, 2 with ischemia, and 1 with subarachnoid hemorrhage, and 3 were recurrent after stent-assisted treatments. Eight were giant. Morphology was fusiform in 5, fusiform dissecting in 1, and multilobulated saccular in 4. Six were partially thrombosed. In addition to FDS (mean number of devices, 3.9; range, 1-9), contralateral vertebral artery sacrifice and adjunctive coiling were performed in 9 and 5 of the 10 patients, respectively. At follow-up, 5 of 10 were completely occluded, 4 showed minimal residual filling, and 1 was retreated with an additional FDS. Postinterventionally, worsening mass effect and ischemic complications were seen in 2 and 4 of 10, respectively. Clinical outcome was good in 6 (modified Rankin Scale score, 0-2). Four fatalities were related to sequelae of subarachnoid hemorrhage, late FDS thrombosis, progressive mass effect, and delayed intracranial hemorrhage. CONCLUSION FDS may be used to treat complex vertebrobasilar junction aneurysms with overall good angiographic outcome. A combined reconstructive/deconstructive approach appears useful to avoid endoleaks. FDS strategies, like other endovascular and neurosurgical approaches to these lesions, are associated with significant risk and therefore should be reserved for those cases in which alternative approaches either are deemed unsafe or are likely to be ineffective. ABBREVIATIONS FDS, flow-diverting stentPED, Pipeline Embolization DeviceSAH, subarachnoid hemorrhageVA, vertebral arteryVBJ, vertebrobasilar junction.


title: Pharmacologic and Pharmacomechanical Thrombolysis for Acute Deep Vein Thrombosis: Focus on ATTRACT CME.

text: Systemically delivered pharmacologic thrombolysis for acute deep vein thrombosis long ago gave way to catheter delivery of plasminogen activators within the clot. This simple concept resulted in markedly improved efficacy and safety. In an effort to accelerate thrombus dissolution or extraction, mechanical methods were developed, but the initial techniques left substantial residual thrombus that required subsequent catheter-directed thrombolysis (CDT). It was soon observed that combined pharmacomechanical thrombolysis was more effective than either one alone. Randomized trials of catheter-based strategies for thrombus removal have documented objective benefit, including improved patency, preserved valve function, and reduced post-thrombotic syndrome. The largest randomized study is the ATTRACT trial published at the end of 2017. Although mild post-thrombotic syndrome (PTS) was no different between the pharmacomechanical catheter-directed thrombolysis (PCDT) and control groups, acute pain and swelling and moderate-to-severe PTS were reduced with PCDT. Additional analyses from this robust data set are forthcoming.


title: Health advice and education given to overweight patients by primary care doctors and nurses: A scoping literature review.

text: Health advice for overweight patients in primary care has been a focus of obesity guidelines. Primary care doctors and nurses are well placed to provide evidence based preventive health advice. This literature review addressed two research questions: 'When do primary care doctors and nurses provide health advice for weight management?' and 'What health advice is provided to overweight patients in primary care settings?' The study was conducted in the first half of 2018 and followed Arksey and O'Malley (2005) five stage framework to conduct a comprehensive scoping review. The following databases were searched: Emcare, Ovid, Embase, The Cochrane library, Proquest family health, Health source (nursing academic), Joanna Briggs Institute EBP database, Medline, PubMed, Rural and remote, Proquest (nursing and allied health) and TRIP using search term parameters. Two hundred and forty-eight (248) articles were located and screened by two reviewers. Twenty-three research papers met the criteria and data were analysed using a content analysis method. The results show that primary care doctors and nurses are more likely to give advice as BMI increases and often miss opportunities to discuss weight with overweight patients. Body Mass Index (BMI) is often wrongly categorised as overweight, when in fact it is in the range of obese, or not recorded and when health advice is given, it can be of poor quality. Few studies on this topic included people under 40 years, practice nurses as the focus and those with a BMI of 25-29.9 without a risk factor. A 'toolkit' approach to improve advice and adherence to evidence based guidelines should be explored in future research.


title: Implementing recommended screening for critical congenital heart disease.

text: BACKGROUND AND OBJECTIVE Critical congenital heart disease (CCHD) is endorsed by the US Secretary of Health and Human Services as part of the recommended uniform screening panel for newborns. Although initial recommendations for implementation exist, as states and hospitals have moved forward with implementation of screening, new challenges and areas for additional focus have been identified. The objective of this study was to develop recommendations to address current challenges and areas of focus surrounding CCHD newborn screening. METHODS A workgroup of experts and stakeholders was convened in Washington, District of Columbia, for a 1-day meeting in February 2012. At the beginning of the meeting, the stakeholders held a brainstorming session to identify areas of main priority based on their experience. After this, stakeholders broke into small groups to refine recommendations, which were then finalized by consensus. RESULTS Recommendations to address selection of screening equipment, standards for reporting of screening outcomes to stakeholders, training of health care providers and educating families, future research priorities, payment for screening, follow-up diagnostic testing, and public health oversight, and advocacy to facilitate effective and comprehensive screening were proposed. Suggestions for future work were developed. CONCLUSIONS Screening for CCHD presents novel challenges and opportunities; however, addressing these will strengthen newborn screening and newborn care networks, and ultimately improve health outcomes.


title: Significant reduction in systolic blood pressure following renal artery stenting in patients with uncontrolled hypertension: results from the HERCULES trial.

text: BACKGROUND Atherosclerotic renal artery stenosis (ARAS) causes hypertension (HTN) and threatens renal function (RF). The HERCULES Trial is a prospective, multicenter trial of renal stenting in patients with uncontrolled HTN and ARAS evaluating the safety and effectiveness of the RX Herculink Elite Renal Stent System (Abbott Vascular, Santa Clara, CA). METHODS A total of 202 patients (241 total lesions; 78 bilateral lesions) were enrolled between August 2007 and October 2009. The primary endpoint was 9-month binary restenosis determined by duplex ultrasound and/or angiography. Secondary endpoints included changes in blood pressure, antihypertensive medications, and RF between baseline and 9 months. Brain natriuretic peptide (BNP) was measured at baseline, 24 hr and 30 days postprocedure. RESULTS Mean systolic blood pressure (SBP) at baseline was 162 mm Hg. Nearly 70% of patients were receiving three or more antihypertensive medications (mean 3.4 medications per patient). Baseline serum creatinine was 1.2 ± 0.4 and 61.5% of subjects had estimated glomerular filtration <60. The restenosis rate was 10.5% at 9 months. The study device, procedure, and clinical success rates were 96.0, 99.2, and 98.0%, respectively. Freedom from major adverse events was 94.8%. At 9 months, the mean SBP significantly decreased (mean 145, paired t test P < 0.0001) after stenting with no change in medications. There was no correlation between SBP reduction and baseline BNP or BNP reduction. CONCLUSIONS HERCULES demonstrates clinically and statistically significant SBP reduction in patients with uncontrolled HTN, low in-stent restenosis, and complication rates. This study highlights that when appropriate patients are selected for renal artery stenting, impressive reductions in blood pressure may be anticipated. Although the magnitude of absolute reduction in SBP was related to baseline SBP, elevated baseline BNP levels were not predictive of reduction in SBP. Further studies for predictors of clinical response following percutaneous renal revascularization are needed.