title: BMP tests of source selected OFMSW to evaluate anaerobic codigestion with sewage sludge.

text: The aim of this study is to characterize different types of source selected organic fraction of municipal solid waste (SS-OFMSW) in order to optimize the upgrade of a sewage sludge anaerobic digestion unit by codigestion. Various SS-OFMSW samples were collected from canteens, supermarkets, restaurants, households, fruit-vegetable markets and bakery shops. The substrates characterization was carried out getting traditional chemical-physical parameters, performing elemental analysis and measuring fundamental anaerobic digestion macromolecular compounds such as carbohydrates, proteins, lipids and volatile fatty acids. Biochemical methane potential (BMP) tests were conducted at mesophilic temperature both on single substrates and in codigestion regime with different substrates mixing ratios. The maximum methane yield was observed for restaurant (675 NmlCH4/gVS) and canteens organic wastes (571 and 645 NmlCH4/gVS). The best codigestion BMP test has highlighted an increase of 47% in methane production respect sewage sludge digestion.


title: Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care.

text: PURPOSE Speaking valves (SV) are used infrequently in tracheostomised ICU patients due to concerns regarding their putative effect on lung recruitment. A recent study in cardio-thoracic population demonstrated increased end-expiratory lung volumes during and post SV use without examining if the increase in end-expiratory lung impedance (EELI) resulted in alveolar recruitment or potential hyperinflation in discrete loci. MATERIALS AND METHODS A secondary analysis of Electrical Impedance Tomography (EIT) data from a previous study was conducted. EELI distribution and tidal variation (TV) were assessed with a previously validated tool. A new tool was used to investigate ventilated surface area (VSA) and regional ventilation delay (RVD) as indicators of alveolar recruitment. RESULTS The increase in EELI was found to be uniform with significant increase across all lung sections (p<0.001). TV showed an initial non-significant decrease (p=0.94) with subsequent increase significantly above baseline (p<0.001). VSA and RVD showed non-significant changes during and post SV use. CONCLUSIONS These findings indicate that hyperinflation did not occur with SV use, which is supported by previously published data on respiratory parameters. These data along with obvious psychological benefits to patients are encouraging towards safe use of SVs in this critically ill cardio-thoracic patient population. TRIAL REGISTRATION Anna-Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN ACTRN12615000589583. 4/6/2015.


title: State-specific gating of salient cues by midbrain dopaminergic input to basal amygdala.

text: Basal amygdala (BA) neurons guide associative learning via acquisition of responses to stimuli that predict salient appetitive or aversive outcomes. We examined the learning- and state-dependent dynamics of BA neurons and ventral tegmental area (VTA) dopamine (DA) axons that innervate BA (VTADA→BA) using two-photon imaging and photometry in behaving mice. BA neurons did not respond to arbitrary visual stimuli, but acquired responses to stimuli that predicted either rewards or punishments. Most VTADA→BA axons were activated by both rewards and punishments, and they acquired responses to cues predicting these outcomes during learning. Responses to cues predicting food rewards in VTADA→BA axons and BA neurons in hungry mice were strongly attenuated following satiation, while responses to cues predicting unavoidable punishments persisted or increased. Therefore, VTADA→BA axons may provide a reinforcement signal of motivational salience that invigorates adaptive behaviors by promoting learned responses to appetitive or aversive cues in distinct, intermingled sets of BA excitatory neurons.


title: The comparison between propofol and dexmedetomidine infusion on perioperative anxiety during regional anesthesia

text: Background/aim Regional anesthesia for surgery is associated with increased anxiety for patients. This study aimed to compare the effect of propofol and dexmedetomidine infusion on perioperative anxiety during regional anesthesia. Materials and methods Eighty-four patients were randomly divided into two groups receiving either study drug infusion. Anxiety score, level of sedation using the Bispectral Index and Observer’s Assessment of Alertness and Sedation, hemodynamic stability, and overall patient’s feedback on anxiolysis were assessed. Results Both groups showed a significant drop in mean anxiety score at 10 and 30 min after starting surgery. Difference in median anxiety scores showed a significant reduction in anxiety score at the end of the surgery in the dexmedetomidine group compared to the propofol group. Dexmedetomidine and propofol showed a significant drop in mean arterial pressure in the first 30 min and first 10 min respectively. Both drugs demonstrated a significant drop in heart rate in the first 20 min from baseline after starting the drug infusion. Patients in the dexmedetomidine group (76.20%) expressed statistically excellent feedback on anxiolysis compared to patients in the propofol group (45.20%). Conclusion Dexmedetomidine infusion was found to significantly reduce anxiety levels at the end of surgery compared to propofol during regional anesthesia.


title: In vivo enzyme inhibition improves the targeting of [177Lu]DOTA-GRP(13-27) in GRPR-positive tumors in mice.

text: INTRODUCTION Gastrin-releasing peptide receptors (GRPR) and GRP-derived analogs have attracted attention due to high receptor expression in frequently occurring human neoplasia. The authors recently synthesized a series of GRPR-affine peptide analogs based on the 27-mer GRP and derivatized with the DOTA chelator at the N-terminus for (111)In-labeling. In this study, the authors evaluated the most promising from these series, DOTA-GRP(13-27), after radiolabeling with (177)Lu for future therapeutic applications. In addition, to improve in vivo stability of the peptide against in vivo degradation by the protease neutral endopeptidase (NEP), the authors coinjected [(177)Lu]DOTA-GRP(13-27) with the potent NEP inhibitor phosphoramidon (PA). The authors also aimed at reducing renal uptake by coadministration of lysine. METHODS In vivo stability studies were performed in Swiss albino mice. Biodistribution studies were conducted in NMRI nu/nu mice bearing prostate cancer (PC)-3 xenografts. Ex vivo autoradiography was performed using frozen sections from PC-3 xenografts and kidneys. RESULTS AND DISCUSSION Coadministration of PA significantly increased the percentage of intact radiopeptide in the mouse circulation. From biodistribution and ex vivo autoradiography studies, coadministration of both lysine and PA with [(177)Lu]DOTA-GRP(13-27) appeared to induce a clear improvement of tumor uptake as well as lower levels of renal radioactivity, causing a promising ninefold increase in tumor/kidney ratios.


title: Respiratory viral infections during the first 28 days after transplantation in pediatric hematopoietic stem cell transplant recipients.

text: Respiratory viruses (RVs) are a known cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). In this retrospective study, we focused on the first 28 d after transplantation in pediatric HSCT recipients and showed that a multiplex PCR assay significantly increased RV detection compared with a viral culture method. Among 176 pediatric HSCT recipients, 84 with respiratory symptoms within one yr after HSCT were tested by viral culture or multiplex PCR. Within 28 d after HSCT, nine patients were infected with RVs; the incidence of a first episode of RV infection within 28 d after HSCT was 5.1%. Eight patients recovered without complications. However, one patient died of adenovirus (AdV) pneumonia with pulmonary hemorrhage; the mortality rate of RV infection within 28 d after HSCT was 0.57%. In the nine patients with RV infection, five different types of RV were identified, either alone or with another RV. These were corona virus (CoV), rhinovirus (RhV) and respiratory syncytial virus combined with CoV; AdV combined with RhV; and parainfluenza virus. Viral culture detected only one case of RV infection, while multiplex PCR detected eight, suggesting that screening of respiratory infections using multiplex PCR is better than the conventional culture method.


title: Assuring the quality, safety, and efficacy of DNA vaccines.

text: Scientists in academia whose research is aimed at the development of a novel vaccine or approach to vaccination may not always be fully aware of the regulatory process by which a candidate vaccine becomes a licensed product. This chapter will provide an overview of the regulatory process and will discuss in more detail the quality and pre-clinical safety issues of plasmid DNA vaccines intended for human use. It is useful for research scientists to be aware of these processes as the development of a novel vaccine could be problematic due to the starting material often being developed in a research laboratory under ill-defined conditions.


title: A Prospective Randomized Crossover Study on the Comparison of Cotton Versus Waterproof Cast Liners.

text: BACKGROUND Many fractures are treated with casting which can cause complications likely from inability to wash the extremity. Gore-Tex-based waterproof cast liner has been compared with cotton liner and shown to be superior in physician and patient scoring but also has high cost and difficult application. The purpose of this study is to compare newer generation waterproof liners with traditional cotton liner. It is the first study to compare this new waterproof liner and cotton liner in a crossover model, allowing patients to swim in the pool with the cast. METHODS Twenty patients (ages 3-30) with upper extremity injuries were randomized to waterproof-liner or cotton-liner casts made of fiberglass. Patients would switch cast liners halfway between their treatments to fulfill crossover criteria. All fractures were within a 2-week period from original incident. At each clinic visit, patients evaluated comfort parameters through questionnaires, and physicians rated skin condition. Patients were also asked which cast liner they preferred at the end of the study. RESULTS There were no unscheduled cast changes. The waterproof-liner group had better scores for odor (P = .041), sweat (P = .016), and overall physician-rated score (P = .038). There was no significant difference in other patient-rated parameters. Seventy-five percent of patients preferred waterproof casting to the cotton liner. CONCLUSIONS This new waterproof cast liner, compared with cotton cast liner, had better odor, sweat, and overall physician scores. The waterproof liners allow patients to rinse casts daily, and the majority of patients prefer waterproof to cotton liner.


The Potential Effects of Coronavirus on National Health Expenditures.


title: Nebivolol in preventing atrial fibrillation following coronary surgery in patients over 60 years of age.

text: OBJECTIVE Postoperative atrial fibrillation is a common complication after cardiac surgery, with an incidence as high as 20-50%. Increased age is associated with a significant increase in postoperative atrial fibrillation risk. This common complication is associated with higher morbidity and mortality rates. The aim of this study was to assess the efficacy of nebivolol in preventing atrial fibrillation following coronary artery bypass surgery in patients over 60 years of age. METHODS In this prospective randomized study, 200 patients who were candidates for elective coronary artery bypass surgery were divided into two groups. The first group was administered with nebivolol and the second group was administered with metoprolol. Treatment was initiated four days prior to surgery, and patients were monitored for atrial fibrillation until discharge. Forty-one patients received 50 mg metoprolol succinate daily, which was initiated minimum 4 days before surgery. RESULTS Demographic data were similar in both groups. The incidence of postoperative atrial fibrillation in both groups was similar, with no significant difference being identified [n=20 (20%); n=18 (18%), P=0.718; respectively]. There were not any mortality at both groups during study. Inotropic agent requirement at ICU was similar for both groups [n=12 (12%), n=18 (18%), P=0.32]. CONCLUSION We compared the effectiveness of nebivolol and metoprolol in decreasing the incidence of postoperative atrial fibrillation, and determined that nebivolol was as effective as metoprolol in preventing postoperative atrial fibrillation at patients. Nebivolol may be the drug of choice due to its effects, especially after elective coronary artery bypass surgery.


title: Serological evidence of Toxoplasma gondii infection in five species of bats in China.

text: Toxoplasma gondii is an obligate intracellular protozoan parasite that can infect almost all warm-blooded animals and humans with a worldwide distribution. Bats are reservoirs for an increasing number of emerging zoonotic viruses, such as henipaviruses and severe acute respiratory syndrome coronavirus (SARS-CoV). However, little is known of T. gondii infection in bats. The objective of the present study was to determine the seroprevalence of T. gondii infection in bats in China. A total of 217 serum samples from 5 species of bats were collected between April, 2010, and August, 2011, from 4 provinces in China. Antibodies to T. gondii were determined using the modified agglutination test (MAT, 1:25 or higher). Antibodies to T. gondii were found in 26.5% (18/68) Megaderma lyra, 13.6% (12/88) Rousettus leschenaulti, 13.6% (3/22) Cynopterus sphinx, 20% (4/20) Vespertilio superaus, and 15.8% (3/19) Pipistrellus javanicus. Antibody titers ranged from 1:25 to 1:400, with titers of 1:200 detected in 4 of the 5 bat species. The present study suggests the likely occurrence of T. gondii infection in bats in China, and these bats are new putative hosts for T. gondii, which may pose a threat to human health.


title: Paramyxovirus V Proteins Interact with the RIG-I/TRIM25 Regulatory Complex and Inhibit RIG-I Signaling.

text: Paramyxovirus V proteins are known antagonists of the RIG-I-like receptor (RLR)-mediated interferon induction pathway, interacting with and inhibiting the RLR MDA5. We report interactions between the Nipah virus V protein and both RIG-I regulatory protein TRIM25 and RIG-I. We also observed interactions between these host proteins and the V proteins of measles virus, Sendai virus, and parainfluenza virus. These interactions are mediated by the conserved C-terminal domain of the V protein, which binds to the tandem caspase activation and recruitment domains (CARDs) of RIG-I (the region of TRIM25 ubiquitination) and to the SPRY domain of TRIM25, which mediates TRIM25 interaction with the RIG-I CARDs. Furthermore, we show that V interaction with TRIM25 and RIG-I prevents TRIM25-mediated ubiquitination of RIG-I and disrupts downstream RIG-I signaling to the mitochondrial antiviral signaling protein. This is a novel mechanism for innate immune inhibition by paramyxovirus V proteins, distinct from other known V protein functions such as MDA5 and STAT1 antagonism.IMPORTANCE The host RIG-I signaling pathway is a key early obstacle to paramyxovirus infection, as it results in rapid induction of an antiviral response. This study shows that paramyxovirus V proteins interact with and inhibit the activation of RIG-I, thereby interrupting the antiviral signaling pathway and facilitating virus replication.


title: Critically Ill Patients With the Middle East Respiratory Syndrome: A Multicenter Retrospective Cohort Study.

text: OBJECTIVES To describe patient characteristics, clinical manifestations, disease course including viral replication patterns, and outcomes of critically ill patients with severe acute respiratory infection from the Middle East respiratory syndrome and to compare these features with patients with severe acute respiratory infection due to other etiologies. DESIGN Retrospective cohort study. SETTING Patients admitted to ICUs in 14 Saudi Arabian hospitals. PATIENTS Critically ill patients with laboratory-confirmed Middle East respiratory syndrome severe acute respiratory infection (n = 330) admitted between September 2012 and October 2015 were compared to consecutive critically ill patients with community-acquired severe acute respiratory infection of non-Middle East respiratory syndrome etiology (non-Middle East respiratory syndrome severe acute respiratory infection) (n = 222). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Although Middle East respiratory syndrome severe acute respiratory infection patients were younger than those with non-Middle East respiratory syndrome severe acute respiratory infection (median [quartile 1, quartile 3] 58 yr [44, 69] vs 70 [52, 78]; p < 0.001), clinical presentations and comorbidities overlapped substantially. Patients with Middle East respiratory syndrome severe acute respiratory infection had more severe hypoxemic respiratory failure (PaO2/FIO2: 106 [66, 160] vs 176 [104, 252]; p < 0.001) and more frequent nonrespiratory organ failure (nonrespiratory Sequential Organ Failure Assessment score: 6 [4, 9] vs 5 [3, 7]; p = 0.002), thus required more frequently invasive mechanical ventilation (85.2% vs 73.0%; p < 0.001), oxygen rescue therapies (extracorporeal membrane oxygenation 5.8% vs 0.9%; p = 0.003), vasopressor support (79.4% vs 55.0%; p < 0.001), and renal replacement therapy (48.8% vs 22.1%; p < 0.001). After adjustment for potential confounding factors, Middle East respiratory syndrome was independently associated with death compared to non-Middle East respiratory syndrome severe acute respiratory infection (adjusted odds ratio, 5.87; 95% CI, 4.02-8.56; p < 0.001). CONCLUSIONS Substantial overlap exists in the clinical presentation and comorbidities among patients with Middle East respiratory syndrome severe acute respiratory infection from other etiologies; therefore, a high index of suspicion combined with diagnostic testing is essential component of severe acute respiratory infection investigation for at-risk patients. The lack of distinguishing clinical features, the need to rely on real-time reverse transcription polymerase chain reaction from respiratory samples, variability in viral shedding duration, lack of effective therapy, and high mortality represent substantial clinical challenges and help guide ongoing clinical research efforts.


title: Comparison of Harmonic scalpel and monopolar cautery for capsulectomy at the second stage of expander/implant breast reconstruction.

text: Background Capsular contracture is a common complication of two-stage expander/implant breast reconstruction. To minimize the risk of this complication, capsulectomy is performed using monopolar cautery or ultrasonic surgical instrumentation, the latter of which can be conducted with a Harmonic scalpel. To date, there is disagreement regarding which of the two methods is superior. The purpose of this study was to compare postoperative outcomes between a group of patients who underwent surgery using a Harmonic scalpel and another group treated with monopolar cautery. Methods A retrospective chart review was conducted of patients who underwent capsulectomy as part of two-stage breast reconstruction between January 2018 and February 2019 and who received at least 1 month of follow-up after surgery. Operative time and postoperative outcomes, including drainage duration, were analyzed. Results In total, 36 female patients underwent capsulectomy. The monopolar group consisted of 18 patients and 22 breasts, while the Harmonic scalpel group consisted of 18 patients and 21 breasts. There was no statistically significant difference in demographics between the two groups. The Harmonic scalpel group had a significantly shorter mean drainage duration (6.65 days vs. 7.36 days) and a smaller mean total drainage volume (334.69 mL vs. 433.54 mL) than the monopolar cautery group (P<0.05). No statistically significant difference was observed with regard to seroma or hematoma formation. Conclusions The Harmonic scalpel approach for capsulectomy reduced the total drainage volume and drainage duration compared to the monopolar cautery approach. Therefore, this approach could serve as a good alternative to electrocautery.


Assessing the adequacy of past antidepressant trials: a clinician's guide to the antidepressant treatment response questionnaire.


title: Multicenter clinical experience in over 125 patients with the Penumbra Separator 3D for mechanical thrombectomy in acute ischemic stroke.

text: BACKGROUND The aim of this study was to assess reperfusion and clinical outcome of treatment with the self-expanding retrievable Separator 3D in revascularization of acute ischemic stroke. The three-dimensional (3D) device secures thrombus with direct aspiration and supports debulking of the clot. METHODS At two centers, 129 consecutive stroke patients with National Institutes of Health Stroke Scale (NIHSS) scores ≥5 were treated with mechanical thrombectomy using the Separator 3D as a component of the Penumbra System within 8 h of symptom onset; modified Treatment in Cerebral Infarction (mTICI) revascularization scores, NIHSS score on admission and discharge, mortality rates, and modified Rankin Scale (mRS) outcomes at 90 days were evaluated. RESULTS A total of 129 vessels in 129 patients were treated. Occlusions were located in the middle cerebral artery (MCA, 48%), internal carotid artery (ICA, 33%), cervical ICA-MCA (3%), and vertebrobasilar arteries (16%). Intravenous thrombolytic therapy with recombinant tissue plasminogen activator was given to 78% of patients. Median NIHSS was 15 prior to treatment. Reperfusion to mTICI 2b or 3 was successful in 96/129 (74%) target arterial lesions, with more than half of cases (51%) achieving mTICI 3. The mean time from arterial puncture to revascularization was 65 min. At 90 days, the symptomatic intracranial hemorrhage rate was 4%, all cause mortality was 32%, and 43/99 patients (43%) achieved functional independence with an mRS score of ≤2. CONCLUSIONS The results suggest that the Separator 3D enables safe and effective revascularization of occluded large arteries in acute stroke intervention, leading to a high rate of functional independence at 90 days.


title: Complications of Flat Bed Rest After Incidental Durotomy.

text: STUDY DESIGN Retrospective case series. OBJECTIVE To determine whether bed rest is a risk factor for specific medical complications. SUMMARY OF BACKGROUND DATA Flat bed rest after incidental durotomy is commonly used to reduce the risk of CSF leakage and associated complications. METHODS Retrospective case series of consecutive patients after lumbar laminectomy were identified. Medical records were reviewed for duration of bed rest and complications (pulmonary, wound, neurological, gastrointestinal, and urinary) in the chart notes, repair methods, subfascial drain placement, consultant notes, imaging reports, and discharge summaries. Patients were compared with duration of bed rest >24 hours versus duration of bed rest ≤24 hours. The incidence of complications was compared between groups using the Fisher exact test. RESULTS There were a total of 42 patients with incidental durotomy. There were 18 patients in the bed rest ≤24 hours group and 24 patients in the bed rest >24 hours group. Comparing the bed rest ≤24 hours to bed rest >24 hours patients, there was no statistically significant difference in the incidence of postdurotomy-related neurological complications, wound complications, and need for revision surgery. There was a statistically significant decrease in the incidence of total medical complications in the ≤24-hour group (0% vs. 50%, P=0.0003). CONCLUSION There was an increased incidence of medical complications in the bed rest group >24 hours. Flat bed rest after modern dural repair method may not be a necessity in all cases and may be associated with a higher incidence of medical complications.


title: Clinical Characteristics and Outcomes of Patients With Diabetes and COVID-19 in Association With Glucose-Lowering Medication.

text: OBJECTIVE Diabetes is one of the most distinct comorbidities of COVID-19. Here, we describe the clinical characteristics of and outcomes in patients with diabetes in whom COVID-19 has been confirmed or clinically diagnosed (with typical features on lung imaging and symptoms), and their association with glucose-lowering or blood pressure-lowering medications. RESEARCH DESIGN AND METHODS In this retrospective study involving 904 patients with COVID-19 (136 with diabetes, mostly type 2 diabetes), clinical and laboratory characteristics were collected and compared between the group with diabetes and the group without diabetes, and between groups taking different medications. Logistic regression was used in order to explore risk factors associated with mortality or poor prognosis. RESULTS The proportion of comorbid diabetes is similar between cases of confirmed and of clinically diagnosed COVID-19. Risk factors for higher mortality of patients with diabetes and COVID-19 were older age (adjusted odds ratio [aOR] 1.09 [95% CI 1.04, 1.15] per year increase; P = 0.001) and elevated C-reactive protein (aOR 1.12 [95% CI 1.00, 1.24]; P = 0.043). Insulin usage (aOR 3.58 [95% CI 1.37, 9.35]; P = 0.009) was associated with poor prognosis. Clinical outcomes of those who use an ACE inhibitor (ACEI) or angiotensin II type-I receptor blocker (ARB) were comparable with those of patients who do not use ACEI/ARB among patients with diabetes and hypertension who have COVID-19. CONCLUSIONS C-reactive protein may help to identify patients with diabetes who are at greater risk of dying during hospitalization. Older patients with diabetes were prone to death related to COVID-19. Attention needs to be paid to patients with diabetes and COVID-19 who use insulin. ACEI/ARB use showed no significant impact on patients with diabetes and hypertension who have COVID-19.


title: Transcutaneous Drainage of Gel-Like Substance after Application of Hydrogel Dural Sealant: Report of Two Cases.

text: Study Design Case report. Objective Incidental durotomy (IDT) is a common complication of spinal surgery. The use of collagen matrix graft along with hydrogel dural sealant is a common method of IDT repair. With this method, there have been several reported cases of detrimental dural sealant expansion in the literature. One case study reported an expansion rate greater than 300%; many report neurologic damage. This article reports the clinical course of two patients who developed postoperative transcutaneous drainage of a gel-like substance after the use of a dural sealant, which is a previously unreported complication. Methods The clinical course and treatment outcome of two patients is presented. Results Both patients experienced postoperative transcutaneous drainage of a gel-like substance at the surgical site. Case one began draining this substance on postoperative day 14. This patient required no further intervention, and the drainage ended after 3 mL of a gel-like substance was expressed from his incision while in the clinic. Case two began draining the gel on postoperative day 16. This patient underwent two washout procedures and resolution of the drainage. No infection was ever detected. Conclusions To our knowledge, our patients are the first reported cases of transcutaneous drainage of expanded dural sealant. It is important to take into consideration the unexpected expansion of a dural sealant when using it for the repair of IDT.


Ending systemic racism in medicine.


title: Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture.

text: A patient with a giant symptomatic vertebrobasilar aneurysm was treated by endoscopic third ventriculostomy for obstructive hydrocephalus followed by treatment of the aneurysm by flow diversion using a Pipeline Embolization Device. After an uneventful procedure and initial periprocedural period, the patient experienced an unexpected fatal subarachnoid hemorrhage 1 week later. Autopsy demonstrated extensive subarachnoid hemorrhage and aneurysm rupture (linear whole wall rupture). The patent Pipeline Embolization Device was in its intended location, as was the persistent coil occlusion of the distal left vertebral artery. The aneurysm appeared to rupture in a linear manner and contained a thick large expansile clot that seemed to disrupt or rupture the thin aneurysm wall directly opposite the basilar artery/Pipeline Embolization Device. We feel the pattern of aneurysm rupture in our patient supports the idea that the combination of flow diversion and the resulting growing intra-aneurysmal thrombus can create a mechanical force with the potential to cause aneurysm rupture.


title: The new coronavirus that came from the East: analysis of the initial epidemic in Mexico.

text: Introduction As of March 23, 2020, suspension of non-essential activities was declared in Mexico throughout the country in order to mitigate the spread of the COVID-19 pandemic. Objective To analyze data on the first 1,510 laboratory-confirmed cases of COVID-19 in Mexico, and to describe the geographical distribution of the disease and its transmission dynamics. Method Description of the first COVID-19 cases with real-time RT-PCR-positive test, as well as evaluation of epidemiological measures, cumulative incidence, rate of transmission, and mortality and lethality rates during the first month of the epidemic. Results Average age was 43 years, and 58 % were males; 44 % of initial cases were imported. Lethality in the population during the first month went from 1.08 to 3.97 per 100 cases; however, the trend is linear and similar to that observed in Europe. Conclusions In Mexico, social distancing is being applied, but studies are still required on the dynamics of the epidemic, person-to-person transmission, incidence of subclinical infections, and patient survival.


title: Daily vancomycin dose requirements as a continuous infusion in obese versus non-obese SICU patients.

text: BACKGROUND Limited data are available assessing vancomycin concentrations in obese critically ill patients. Currently, there are no studies evaluating dosing requirements in this population who receive vancomycin administered as a continuous infusion (CI). The aim of this study was to assess whether there was a difference in the weight-based maintenance dose required to reach a therapeutic vancomycin concentration at 24 hours when given as a CI in obese versus non-obese critically ill patients. METHODS A retrospective cohort study of adult obese patients admitted to the SICU between 2013 and 2015 receiving a vancomycin CI (CIV), and with 24-hour serum measurements were included. Obese patients (body mass index (BMI) ≥35 kg/m(2)) were matched with non-obese patients (BMI <30 kg/m(2)) based on renal function, age and acute physiology and chronic health evaluation (APACHE)-II score at admission. All patients in this study received a loading dose of 25 mg/kg then a maintenance dose based on renal function according to the protocol. The study was approved by the Institutional Review Board. The primary outcome was the weight-based total daily maintenance dose required to achieve a vancomycin level of 20 mg/L. The secondary endpoints included the achievement of a therapeutic level at 24 hours. RESULTS Twenty-six matched pairs of patients met the inclusion criteria. Of these, 17 pairs had preserved renal function and 9 pairs required continuous venovenous hemofiltration. Mean BMI was 40.9 kg/m(2) in obese and 24.8 kg/m(2) in non-obese patients. To achieve a vancomycin concentration of 20 mg/L, the weight-based daily maintenance dose in obese patients was 25.6 mg/kg versus 43.8 mg/kg in non-obese patients (p <0.01). Therapeutic 24-hour levels were achieved in 24/26 obese versus 23/26 no-obese patients (p = 0.63). Mean 24-hour vancomycin level was 20.3 ± 3.81 mcg/ml in obese compared to 20.03 ± 3.79 mcg/ml in non-obese patients (p = 0.77). Mean daily maintenance doses required to achieve a level of 20 mcg/ml were 2961 ± 1670 mg in obese compared to 3189 ± 1600.69 mg in non-obese (p = 0.61). CONCLUSIONS The results of our study suggest that critically ill obese patients treated with CIV required a significantly lower maintenance dose per unit of body weight than non-obese patients to achieve the same target level.


Balancing effectiveness and equality of opportunity in organ allocation.


title: Technical considerations in laparoscopic total proctocolectomy.

text: Total proctocolectomy, whether restorative or terminating with an end ileostomy, is an advanced laparoscopic procedure. The goal of this publication is to address specific techniques unique to the operation of laparoscopic total proctocolectomy and review the basics of laparoscopic colon and rectal resections. As in all complex operations, proficiency and efficiency in performing the laparoscopic total proctocolectomy comes with a step-wise approach. Respectable operating room times and true patient benefits may take more than safe reliable, technique; however, and only after a significant experience has been gained will the learning curve plateau.


Not Just the Flu.


title: Transformative learning as pedagogy for the health professions: a scoping review.

text: CONTEXT Transformative learning (TL) has been described as learning that challenges established perspectives, leading to new ways of being in the world. As a learning theory it has resonated with educators globally, including those in the health professions. Described as a complex metatheory, TL has evolved over time, eliciting divergent interpretations of the construct. This scoping review provides a comprehensive synthesis of how TL is currently represented in the health professions education literature, including how it influences curricular activities, to inform its future application in the field. METHODS Arksey and O'Malley's six-step framework was adopted to review the period from 2006 to May 2018. A total of 10 bibliographic databases were searched, generating 1532 potential studies. After several rounds of review, first of abstracts and then of full texts, 99 studies were mapped by two independent reviewers onto the internally developed data extraction sheet. Descriptive information about included studies was aggregated. Discursive data were subjected to content analysis. RESULTS A mix of conceptual and empirical research papers, which used a range of qualitative methodologies, were included. Studies from the USA, the UK and Australia were most prevalent. Insights relating to how opportunities for TL were created, how it manifests and influences behaviour, as well as how it is experienced, demonstrated much congruency. Conceptions of TL were seen to be clustered around the work of key theorists. CONCLUSIONS The training of health professionals often takes place in unfamiliar settings where students are encouraged to be active participants in providing care. This increases the opportunity for exposure to learning experiences that are potentially transformative, allowing for a pedagogy of uncertainty that acknowledges the complexity of the world we live in and questions what we believe we know about it. TL provides educators in the health professions with a theoretical lens through which they can view such student learning.


title: Montelukast as an episodic modifier for acute viral bronchiolitis: a randomized trial.

text: This study was designed to evaluate the effect of once-daily montelukast therapy on the clinical progress and the cytokine profile of patients with acute viral bronchiolitis. A randomized, double-blind, placebo-controlled trial included 85 patients (mean age, 3.5 +/- 2.35 months), clinically diagnosed as first-episode acute bronchiolitis in addition to 10 healthy controls of matched age and sex. Patients were randomly assigned to receive either montelukast (4-mg sachets; n = 47) or placebo (n = 38) daily from the time of admission until discharge. The primary outcome measure was the length of hospital stay (LOS), and clinical severity scores (CSs) and changes in plasma levels of interferon gamma and interleukin-4 were secondary outcomes. LOS for the montelukast group was found to be significantly lower than that of the placebo group (p < 0.05). This effect was also found at nonsignificant levels among patients with a positive family history of asthma or allergy. Moreover, cases receiving montelukast showed lower CSs all through the hospital stay that were significant in the first 24 hours (p < 0.05). Montelukast is probably of benefit as an episodic modifier in infants with acute viral bronchiolitis.


title: Cellular remodeling during plant virus infection.

text: This review focuses on the extensive membrane and organelle rearrangements that have been observed in plant cells infected with RNA viruses. The modifications generally involve the formation of spherules, vesicles, and/or multivesicular bodies associated with various organelles such as the endoplasmic reticulum and peroxisomes. These virus-induced organelles house the viral RNA replication complex and are known as virus factories or viroplasms. Membrane and organelle alterations are attributed to the action of one or two viral proteins, which additionally act as a scaffold for the assembly of a large complex of proteins of both viral and host origin and viral RNA. Some virus factories have been shown to align with and traffic along microfilaments. In addition to viral RNA replication, the factories may be involved in other processes such as viral RNA translation and cell-to-cell virus transport. Confining the process of RNA replication to a specific location may also prevent the activation of certain host defense functions.


title: Dual-lumen balloon catheters may improve liquid embolization of vascular malformations: an experimental study in Swine.

text: BACKGROUND AND PURPOSE Liquid embolic agents are increasingly used to treat vascular malformations. We sought to assess embolization with these agents by using a dual-lumen balloon catheter in an experimental setting. MATERIALS AND METHODS Eighteen injections of liquid embolic agents were performed in the rete mirabile of swine. We used 3 methods to control liquid embolic agent reflux: 1) dual-lumen balloon-catheter (group A, n = 8); 2) injection of liquid embolic agent after proximal n-BCA plug formation through a second microcatheter (group B, n = 4); and 3) standard liquid embolic agent injection (group C, controls, n = 6). The following outcomes were graded by using ordinal scales by angiography, macrophotography, and radiography of retia after euthanasia: 1) angiographic and pathologic extent of liquid embolic agent embolization of the rete, 2) reflux of liquid embolic agents in the parent artery, and 3) density of liquid embolic agents in the proximal rete. Technical complications were also recorded. A successful injection was defined as an embolization that reached the contralateral rete without reflux into proximal external branches. Exact logistic regression analyses were performed to compare groups. RESULTS There were significant differences among groups for reflux (P = .029) and liquid embolic agent density in the proximal rete (P = .014), while extension to the contralateral rete did not reach statistical significance (P = .07). Injections differed among groups (P = .004), with dual-lumen balloon-catheter injections more frequently successful compared with control injections (P = .019). CONCLUSIONS Dual-lumen balloon catheters allowed better liquid embolic agent injections than standard injections.


title: Superselective Provocative Test with Propofol Using Motor-Evoked Potential Monitoring for Managing Cerebral Arteriovenous Malformations Fed by the Anterior Choroidal Artery.

text: When feeder artery obliteration is performed via an endovascular procedure to treat cerebral arteriovenous malformation (AVM), it is important to prevent the ischemic complications that are associated with feeder occlusion. A provocative test may be beneficial in some cases to protect against ischemic complications. We report the case of a 57-year-old man who developed an intracerebral hematoma in the left internal temporal lobe and who had an AVM with a varix in the ambient cistern, which was primarily fed by a branch of the left anterior choroidal artery (AChA) and the posterior lateral choroidal artery, and drained into the basal vein. Therefore, we planned endovascular obliteration of the AChA, followed by gamma knife radiosurgery for the residual posterior component. The patient underwent a superselective provocative test with a 3 mg of propofol under general anesthesia using motor-evoked potential monitoring. The feeder embolization was performed as planned after the provocative test, and the patient exhibited no neurological deficits, such as hemiparesis, during the procedure.


title: Aerosolization During Common Ventilation Scenarios.

text: Otolaryngologists are at increased risk for exposure to suspected aerosol-generating procedures during the ongoing coronavirus disease 2019 (COVID-19) pandemic. In the present study, we sought to quantify differences in aerosol generation during common ventilation scenarios. We performed a series of 30-second ventilation experiments on porcine larynx-trachea-lung specimens. We used an optical particle sizer to quantify the number of 1- to 10-µm particles observed per 30-second period (PP30). No significant aerosols were observed with ventilation of intubated specimens (10.8 ± 2.4 PP30 vs background 9.5 ± 2.1, P = 1.0000). Simulated coughing through a tracheostomy produced 53.5 ± 25.2 PP30, significantly more than background (P = .0121) and ventilation of an intubated specimen (P = .0401). These data suggest that undisturbed ventilation and thus intubation without stimulation or coughing may be safer than believed. Coughing increases aerosol production, particularly via tracheostomy. Otolaryngologists who frequently manage patient airways and perform tracheostomy are at increased risk for aerosol exposure and require appropriate personal protective equipment, especially during the ongoing COVID-19 pandemic.


title: Exchange of the coronavirus replicase polyprotein cleavage sites alters protease specificity and processing.

text: Coronavirus nonstructural proteins 1 to 3 are processed by one or two papain-like proteases (PLP1 and PLP2) at specific cleavage sites (CS1 to -3). Murine hepatitis virus (MHV) PLP2 and orthologs recognize and cleave at a position following a p4-Leu-X-Gly-Gly-p1 tetrapeptide, but it is unknown whether these residues are sufficient to result in processing by PLP2 at sites normally cleaved by PLP1. We demonstrate that exchange of CS1 and/or CS2 with the CS3 p4-p1 amino acids in engineered MHV mutants switches specificity from PLP1 to PLP2 at CS2, but not at CS1, and results in altered protein processing and virus replication. Thus, the p4-p1 residues are necessary for PLP2 processing but require a specific protein or cleavage site context for optimal PLP recognition and cleavage.


title: Utilization of DC-SIGN for entry of feline coronaviruses into host cells.

text: The entry and dissemination of viruses in several families can be mediated by C-type lectins such as DC-SIGN. We showed that entry of the serotype II feline coronavirus strains feline infectious peritonitis virus (FIPV) WSU 79-1146 and DF2 into nonpermissive mouse 3T3 cells can be rescued by the expression of human DC-SIGN (hDC-SIGN) and that infection of a permissive feline cell line (Crandall-Reese feline kidney) was markedly enhanced by the overexpression of hDC-SIGN. Treatment with mannan considerably reduced infection of feline monocyte-derived cells expressing DC-SIGN, indicating a role for FIPV infection in vivo.


title: Helicobacter pylori TlyA Forms Amyloid-like Aggregates with Potent Cytotoxic Activity.

text: Helicobacter pylori is a potent human gastric pathogen. It is known to be associated with several gastroenteric disorders, including gastritis, peptic ulcer, and gastric cancer. The H. pylori genome encodes a gene product TlyA that has been shown to display potent membrane damaging properties and cytotoxic activity. On the basis of such properties, TlyA is considered as a potential virulence factor of H. pylori. In this study, we show that the H. pylori TlyA protein has a strong propensity to convert into the amyloid-like aggregated assemblies, upon exposure to elevated temperatures. Even at the physiological temperature of 37 °C, TlyA shows a strong amyloidogenic property. TlyA aggregates that are generated upon exposure at temperatures of ≥37 °C show prominent binding to dyes like thioflavin T and Nile Red. Transmission electron microscopy also demonstrates the presence of typical amyloid-like fibrils in the TlyA aggregates generated at 37 °C. Conversion of TlyA into the amyloid-like aggregates is found to be associated with major alterations in the secondary and tertiary structural organization of the protein. Finally, our study shows that the preformed amyloid-like aggregates of TlyA are capable of exhibiting potent cytotoxic activities against human gastric adenocarcinoma cells. Altogether, such a propensity of H. pylori TlyA to convert into the amyloid-like aggregated assemblies with cytotoxic activity suggests potential implications for the virulence functionality of the protein.


title: Characteristics of Misclassified CT Perfusion Ischemic Core in Patients with Acute Ischemic Stroke.

text: BACKGROUND CT perfusion (CTP) is used to estimate the extent of ischemic core and penumbra in patients with acute ischemic stroke. CTP reliability, however, is limited. This study aims to identify regions misclassified as ischemic core on CTP, using infarct on follow-up noncontrast CT. We aim to assess differences in volumetric and perfusion characteristics in these regions compared to areas that ended up as infarct on follow-up. MATERIALS AND METHODS This study included 35 patients with >100 mm brain coverage CTP. CTP processing was performed using Philips software (IntelliSpace 7.0). Final infarct was automatically segmented on follow-up noncontrast CT and used as reference. CTP and follow-up noncontrast CT image data were registered. This allowed classification of ischemic lesion agreement (core on CTP: rMTT≥145%, aCBV<2.0 ml/100g and infarct on follow-up noncontrast CT) and misclassified ischemic core (core on CTP, not identified on follow-up noncontrast CT) regions. False discovery ratio (FDR), defined as misclassified ischemic core volume divided by total CTP ischemic core volume, was calculated. Absolute and relative CTP parameters (CBV, CBF, and MTT) were calculated for both misclassified CTP ischemic core and ischemic lesion agreement regions and compared using paired rank-sum tests. RESULTS Median total CTP ischemic core volume was 49.7ml (IQR:29.9ml-132ml); median misclassified ischemic core volume was 30.4ml (IQR:20.9ml-77.0ml). Median FDR between patients was 62% (IQR:49%-80%). Median relative mean transit time was 243% (IQR:198%-289%) and 342% (IQR:249%-432%) for misclassified and ischemic lesion agreement regions, respectively. Median absolute cerebral blood volume was 1.59 (IQR:1.43-1.79) ml/100g (P<0.01) and 1.38 (IQR:1.15-1.49) ml/100g (P<0.01) for misclassified ischemic core and ischemic lesion agreement, respectively. All CTP parameter values differed significantly. CONCLUSION For all patients a considerable region of the CTP ischemic core is misclassified. CTP parameters significantly differed between ischemic lesion agreement and misclassified CTP ischemic core, suggesting that CTP analysis may benefit from revisions.


title: Chest Computed Tomography Manifestation of Coronavirus Disease 2019 (COVID-19) in Patients With Cardiothoracic Conditions.

text: The coronavirus disease 2019 (COVID-19) pandemic is a serious public health concern, with an exponentially growing number of patients worldwide. Computed tomography (CT) has been suggested as a highly sensitive modality for the diagnosis of pulmonary involvement in the early stages of COVID-19. The typical features of COVID-19 in chest CT include bilateral, peripheral, and multifocal ground-glass opacities with or without superimposed consolidations. Patients with underlying medical conditions are at higher risks of complications and mortality. The diagnosis of COVID-19 on the basis of the imaging features may be more challenging in patients with preexisting cardiothoracic conditions, such as chronic obstructive pulmonary disease, interstitial lung disease, cardiovascular disease, and malignancies with cardiothoracic involvement. The extensive pulmonary involvement in some of these pathologies may obscure the typical manifestation of COVID-19, whereas other preexisting pathologies may resemble the atypical or rare CT manifestations of this viral pneumonia. Thus, understanding the specific CT manifestations in these special subgroups is essential for a prompt diagnosis.


title: Assessment of the Public Health Risks and Impact of a Tornado in Funing, China, 23 June 2016: A Retrospective Analysis.

text: (1) Background: Tornadoes are one of the deadliest disasters but their health impacts in China are poorly investigated. This study aimed to assess the public health risks and impact of an EF-4 tornado outbreak in Funing, China; (2) Methods: A retrospective analysis on the characteristics of tornado-related deaths and injuries was conducted based on the database from the Funing's Center for Disease Control and Prevention (CDC) and Funing People's Hospital. A change-point time-series analysis of weekly incidence for the period January 2010 to September 2016 was used to identify sensitive infectious diseases to the tornado; (3) Results: The 75 to 84 years old group was at the highest risk of both death (RR = 82.16; 95% CIs = 19.66, 343.33) and injury (RR = 31.80; 95% CI = 17.26, 58.61), and females were at 53% higher risk of death than males (RR = 1.53; 95% CIs = 1.02, 2.29). Of the 337 injuries, 274 injuries (81%) were minor. Most deaths occurred indoors (87%) and the head (74%) was the most frequent site of trauma during the tornado. Five diseases showed downward change-points; (4) Conclusions: The experience of the Funing tornado underscores the relative danger of being indoors during a tornado and is successful in avoiding epidemics post-tornado. Current international safety guidelines need modification when generalized to China.


title: Low- versus high-flow oxygen delivery systems in children with lower respiratory infection.

text: BACKGROUND Delivery of supplemental oxygen is the initial vital management of hypoxemic acute lower respiratory infection (HALRI). Oxygen delivery systems include low-flow and high-flow devices. In high-flow devices such as the Venturi mask, a constant mixture of oxygen is delivered. As a result, increased rate of breathing does not affect the concentration of oxygen delivered. In this study, we compared the efficacy of oxygen masks and Venturi masks in the management of hypoxemia in pediatric patients. METHODS A total of 65 children, aged 3-36 months, diagnosed with HALRI, were enrolled. Patients were allocated into groups, via simple alternate randomization, to receive oxygen through an oxygen mask or through a Venturi mask. Respiratory rate, heart rate, retraction, blood gas parameters, oxygen saturation, length of hospitalization, and oxygenation were recorded before and after oxygen treatment. RESULTS After 24 h of treatment, respiratory rate was significantly lower among patients in the Venturi mask group compared with the oxygen mask group. Duration of supplemental oxygen and length of hospitalization were significantly lower in the Venturi mask group compared with the oxygen mask group. CONCLUSION In both groups, there was marked improvement in all measured parameters following introduction of supplemental oxygen. Oxygen was delivered more efficiently, however, by high-flow systems. The Venturi mask may decrease the total duration of oxygen usage time as well as the length of hospitalization among young children with HALRI through rapid symptom resolution.


title: Coexistence of antiphospholipid syndrome and cryoglobulinemia in a patient with rheumatoid arthritis.

text: We present here a case of severe digital necrosis in a patient with long-standing rheumatoid arthritis (RA). The concomitant presence of two autoimmune conditions such as cryoglobulinemia and antiphospholipid syndrome (APS) were diagnosed. To best of our knowledge, this is the first case of the coexistence of RA, cryoglobulinemia, and APS in a single patient. An aggressive treatment was needed including hallux amputation, methylprednisolone pulses followed by rituximab with favorable outcome.


title: Hand Hygiene Among Health Care Workers During COVID-19 Pandemic: Challenges and Recommendations.

text: In-hospital transmission is one of the main routes of the 2019 novel coronavirus (SARS-CoV-2) spreading among health care workers (HCWs) who are the frontline fighters. However, coming into contact with COVID-19-positive patients is unavoidable. Therefore, hand hygiene is of utmost importance for the prevention of COVID-19 among HCWs. This purpose can be achieved by applying alcohol-based hand rubs, washing hands properly with soap and water, and applying other antiseptic agents. Nevertheless, regular hand hygiene could also be challenging, because water, detergents, and disinfectants may predispose HCWs to hand dermatitis. The current article reviews the risk factors for the development of hand dermatitis, with further focus on the most common agents used among HCWs. In addition, the risk of occupational hand dermatitis for each agent is evaluated to increase awareness of this common condition. Finally, some recommendations are discussed to reduce the effect of hand dermatitis on HCWs.


title: Mycoplasma haemolamae and intestinal parasite relationships with erythrocyte variables in clinically healthy alpacas and llamas.

text: BACKGROUND Mycoplasma haemolamae (Mhl) and gastrointestinal nematodes can cause anemia in camelids. Control programs aim to suppress parasitism without promoting anthelminthic resistance, but few evidence-based guidelines define acceptable parasite loads in camelids. HYPOTHESIS/OBJECTIVES In clinically healthy nonanemic camelids, compare erythrocyte variables to Mhl real-time PCR status and to fecal egg count (FEC). Determine the FEC threshold above which erythrocyte variables are consistently below reference interval medians. ANIMALS One hundred fourteen client-owned adult alpacas and llamas. METHODS In a cross-sectional study, whole blood in ethylenediaminetetraacetic acid (EDTA) was assessed for packed cell volume (PCV) by centrifugation, erythrocyte count (RBC), and hemoglobin concentration (HGB) using an ADVIA120 analyzer, and Mhl using real-time PCR. Trichostrongyle eggs per gram (epg) were counted by modified McMaster test on freshly collected feces. Significant differences in erythrocyte variables based on Mhl status and FEC thresholds were assessed by independent t test and one-way ANOVA, respectively. RESULTS Packed cell volume, RBC, and HGB were not significantly different between Mhl-positive and Mhl-negative animals, but were significantly lower in animals with FEC >1000 epg compared to those with <500 epg. All animals with FEC >600 epg had RBC and HGB below the reference interval median. All animals with FEC >750 epg had PCV below the reference interval median. CONCLUSIONS AND CLINICAL IMPORTANCE In healthy nonanemic camelids, positive Mhl PCR is not associated with lower erythrocyte variables and such animals may not warrant treatment. Fecal egg count >600-750 epg has a negative effect on erythrocyte variables, and may be a guide for deworming protocols.


title: An intraoperative technique to reduce superficial surgical site infections in circular stapler-constructed laparoscopic Roux-en-Y gastric bypass.

text: BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been established as one of the most effective treatments for morbid obesity. Surgical site infections are the most common complication after LRYGB surgery. OBJECTIVE To compare the superficial surgical site infections (sSSI) rate before and after the implementation of our intraoperative technique. SETTING Academic medical center. METHODS Our intraoperative technique relies on sterile coverage of the circular stapler, sterile specimen-bag retrieval of the gastrojejunostomy enteric remnant, and port site Penrose drainage. We analyzed our sSSI outcomes before and after implementation of our technique in all LRYGBs performed by a single surgeon from 2009 to 2015. We took into account patient age; sex; baseline body mass index (BMI); smoking status; and co-morbidities such as diabetes, hypertension, and hyperlipidemia. χ(2) and multivariate analysis were performed. RESULTS We performed 486 LRYGBs in 2009-2015. The cohort before implementation of our technique (group 1) included 164 patients (33.7%) and the cohort after implementation (group 2) included 322 patients (66.3%). Both groups were similar in age, sex, smoking status, and rates of diabetes and hyperlipidemia but differed in BMI, operative time, and prevalence of hypertension. Hypertension was not a confounder for sSSI (P = .35). The sSSI rate was 9.15% for group 1 and 3.42% for group 2 (P = .0079). Controlling for BMI and operative time, multivariate analysis revealed a significant reduction in sSSI (odds ratio 2.98 [95% CI 1.33-6.69]) with our technique. CONCLUSIONS We describe a reproducible intraoperative technique that significantly reduces sSSI in LRYGB procedures. Our technique has the potential of hastening postoperative recovery.


title: Arginase 1+ microglia reduce Aβ plaque deposition during IL-1β-dependent neuroinflammation.

text: BACKGROUND Neuroinflammation has long been considered a driver of Alzheimer's disease progression. However, experiments developed to explore the interaction between neuroinflammation and Alzheimer's disease (AD) pathology showed a surprising reduction in amyloid beta (Aβ) plaque deposition. We sought to understand this unexpected outcome by examining microglia phenotypes during chronic neuroinflammation. METHODS Using an adeno-associated virus vector carrying hIL-1β cDNA, inflammation was induced in one hippocampus of 8-month-old amyloid precursor protein (APP)/PS1 mice for 4 weeks, while the other hemisphere received control injections. Bone marrow chimeras and staining analysis were used to identify the origins and types of immune cells present during sustained inflammation. Arginase 1 (Arg1) and inducible nitric oxide synthase (iNOS) immunoreactivity were used as markers of alternatively activated and classically activated cells, respectively, and changes in cellular uptake of Aβ by Arg1+ or iNOS+ microglia was demonstrated by confocal microscopy. To determine if an anti-inflammatory phenotype was present during neuroinflammation, RNA was extracted on flow-sorted microglia and rt-PCR was performed. Interleukin-4 injection was used to induce alternatively activated cells, whereas a minipump and intrahippocampal cannula was used to deliver an interleukin (IL)-4Rα antibody to block the induction of Arg1+ cells in the setting of sustained IL-1β expression. RESULTS We observed a robust upregulation of centrally derived Arg1+ microglia present only in the inflamed hemisphere. Furthermore, in the inflamed hemisphere, greater numbers of Arg1+ microglia contained Aβ when compared to iNOS+ microglia. RNA isolated from flow-sorted microglia from the inflamed hemisphere demonstrated elevation of mRNA species consistent with alternative activation as well as neuroprotective genes such as BDNF and IGF1. To explore if Arg1+ microglia mediated plaque reduction, we induced Arg1+ microglia with IL-4 and observed significant plaque clearance. Moreover, when we reduced Arg1+ microglia induction in the context of neuroinflammation using an anti-IL-4Rα antibody delivered via intrahippocampal cannula, we observed a clear correlation between numbers of Arg1+ microglia and plaque reduction. CONCLUSIONS Together, these findings suggest that Arg1+ microglia are involved in Aβ plaque reduction during sustained, IL-1β-dependent neuroinflammation, opening up possible new avenues for immunomodulatory therapy of AD.


title: Direct evidence of active SARS-CoV-2 replication in the intestine.

text: BACKGROUND Currently, there is no direct evidence to prove the active SARS-CoV-2 replication in the intestinal tract and relevant pathological changes in the colon and rectum. We investigated the presence of virions and pathological changes in surgical rectal tissues of a clinically confirmed COVID-19 patient with rectal adenocarcinoma. METHODS Here, the clinical data were collected during hospitalization and follow-up of this patient. Quantitative RT-PCR was performed on the rectal tissue specimens obtained from surgical resection, succus entericus and intestinal mucosa of ileostomy, and rectal mucosa during follow-up after recovery. Ultrathin sections of surgical samples were observed for SARS-CoV-2 virions using electron microscopy. Histopathological examination was performed using hematoxylin-eosin stain. Immunohistochemical analysis and immunofluorescence were carried out on rectal tissues to evaluate the distribution of SARS-CoV-2 antigen, and immune cell infiltrations. RESULTS The patient had fever and cough on day 3 postoperatively, was diagnosed with COVID-19 on day 7, and was discharged from the hospital on day 41. RNA of SARS-CoV-2 was detected in surgically resected rectal specimens, but not in samples collected on 37 day after discharge. Notably, coincidence with rectal tissues of surgical specimens tested nucleic acid positive for SARS-CoV-2, typical coronavirus virions in rectal tissue were observed under electron microscopy. Moreover, abundant lymphocytes and macrophages (some are SARS-CoV-2 positive) infiltrating the lamina propria were found with no significant mucosal damage. CONCLUSIONS We firstly reported that direct evidence of the active SARS-CoV-2 replication in the patient's rectum during the incubation period, which might explain SARS-CoV-2 fecal-oral transmission.


title: Acute motor and sensory polyganglioradiculoneuritis in a cat: clinical and histopathological findings.

text: Polyneuropathies can have a variety of clinical presentations and tend to be rare in cats. In this report we describe a 6-year-old domestic shorthair cat with an acute and rapidly progressive onset of lower motor neuron and sensory signs affecting the spinal and cranial nerves. Histopathological examination revealed moderate-to-severe multifocal inflammatory infiltrates at the ventral and dorsal nerve roots, and dorsal spinal ganglia at the level of the L4 and cauda equina. The type and severity of inflammation varied between nerve roots, being composed of mainly neutrophils in some and mainly lymphocytes and macrophages in others. Immunohistochemistry showed a combination of neutrophils, macrophages and lymphocytes infiltrating the nerve roots and ganglia. The majority of the lymphocytes were T lymphocytes; only a few B lymphocytes were seen. Neurons within the affected ganglia showed central chromatolysis and necrosis. Wallerian-like degeneration and demyelination were observed in the nerve roots. A sensory and motor polyganglioradiculoneuritis was diagnosed. An autoimmune process similar to the acute motor and sensory neuropathy subtype of Guillain-Barré syndrome in humans or an infection by an unidentified agent were considered most likely.


title: Gastrointestinal stromal tumour presenting as gastroduodenal intussusception.

text: Gastroduodenal intussusception secondary to gastrointestinal stromal tumour is a very rare cause for intestinal obstruction. The diagnosis of this condition can be challenging, as symptoms are often non-specific and intermittent. This article reports a case where the diagnosis was made preoperatively with abdominal imaging and was treated by a combination of endoscopic reduction and laparoscopic resection.


title: Clinical Outcomes of Patients with Delayed Diagnosis of Spinal Dural Arteriovenous Fistulas.

text: BACKGROUND AND PURPOSE Spinal dural arteriovenous fistulas are commonly missed on imaging or misdiagnosed as inflammatory or neoplastic processes. We reviewed a consecutive series of spinal dural arteriovenous fistulas referred to our institution that were missed or misdiagnosed on initial imaging and studied the clinical consequences of missing or misdiagnosing the lesion. MATERIALS AND METHODS We reviewed spinal dural arteriovenous fistulas diagnosed at our institution between January 1, 2000, and November 1, 2014. A lesion was defined as "misdiagnosed" if initial MR imaging or CT myelography demonstrated characteristic imaging features of spinal dural arteriovenous fistula but the patient was clinically or radiologically misdiagnosed. Outcomes included length of delay of diagnosis, increased disability (increase in mRS or Aminoff motor disability of ≥1 point) between initial imaging evaluation and diagnosis date, and posttreatment disability. RESULTS Fifty-three consecutive spinal dural arteriovenous fistulas that were initially misdiagnosed despite having characteristic imaging findings on MR imaging or CT myelography were included in our study. Eight patients (18.9%) underwent spinal angiography before referral, which was interpreted as having negative findings but was either incomplete (6 cases) or retrospectively demonstrated the spinal dural arteriovenous fistulas (2 cases). The median time of delayed diagnosis was 6 months (interquartile range, 2-14 months). Fifty-one patients (96.2%) had increased disability between the initial study, which demonstrated features of a spinal dural arteriovenous fistula, and diagnosis. Thirty-two patients (60.4%) developed a new requirement for a walker or wheelchair. Following treatment, 21 patients (41.2%) had an improvement of 1 point on the mRS or Aminoff motor disability scale. CONCLUSIONS Delayed diagnosis of spinal dural arteriovenous fistula with characteristic imaging features results in high rates of additional disability that are often irreversible despite surgical or endovascular treatment of the fistula.


title: The elusive definition of pandemic influenza.

text: There has been considerable controversy over the past year, particularly in Europe, over whether the World Health Organization (WHO) changed its definition of pandemic influenza in 2009, after novel H1N1 influenza was identified. Some have argued that not only was the definition changed, but that it was done to pave the way for declaring a pandemic. Others claim that the definition was never changed and that this allegation is completely unfounded. Such polarized views have hampered our ability to draw important conclusions. This impasse, combined with concerns over potential conflicts of interest and doubts about the proportionality of the response to the H1N1 influenza outbreak, has undermined the public trust in health officials and our collective capacity to effectively respond to future disease threats. WHO did not change its definition of pandemic influenza for the simple reason that it has never formally defined pandemic influenza. While WHO has put forth many descriptions of pandemic influenza, it has never established a formal definition and the criteria for declaring a pandemic caused by the H1N1 virus derived from "pandemic phase" definitions, not from a definition of "pandemic influenza". The fact that despite ten years of pandemic preparedness activities no formal definition of pandemic influenza has been formulated reveals important underlying assumptions about the nature of this infectious disease. In particular, the limitations of "virus-centric" approaches merit further attention and should inform ongoing efforts to "learn lessons" that will guide the response to future outbreaks of novel infectious diseases.


Peripheral "Swiss Cheese" Appearance in a COVID-19 Patient with Chronic Obstructive Pulmonary Disease.


title: Carrier-resolved technology for homogeneous and multiplexed DNA assays in a 'one-pot reaction'.

text: For clinical diagnosis, a small number of targets (2-10 biomarkers) are often all that is required for disease assessment and accurate early disease diagnosis. In the current paper we have developed novel, carrier-resolved, single-label-based multiplexed assays for the simultaneous detection and quantification of a limited number of DNA targets associated with breast cancer. In contrast to current encoding strategies, every hybridization signal for the corresponding DNA target in our protocol is uniquely immobilized onto one carrier vehicle with a unique and intrinsic physico-chemical signature. Moreover, a simple chemiluminescence setup is employed to read the carrier code instead of expensive and complicated flow-cytometer or imaging-systems commonly used for multiplexed assays. Herein we demonstrate a new protocol using three homogeneous carriers, i.e. thermo-sensitive poly(N-isopropylacrylamide) (PNIP), polystyrene beads, and magnetic beads respectively. This new methodology allowed for the simultaneous determination of three oligonucleotide sequences (60 bases in length) associated with the breast cancer gene (BRCA1) and showed high selectivity and attomolar-femtomolar sensitivity. The mixture of three different capture probe conjugates first hybridizes with three corresponding target sequences, sandwiches with three biotinylated DNAs, and then reacts with peroxidase-streptavidin polymer in a single vessel without any washing, leading to the development of a 'one-pot reaction system'. Only one washing step in our protocol is required prior to detection leading to our whole procedure being simple and efficient. The results show that the hybridization response to sample mixtures containing increasing levels of each target is proportional to the amount of corresponding DNA targets, indicating minimal cross-interferences. The work presented here validates the design and concept of a system for the detection of a limited number of DNA targets and provides the foundation for the development of highly sensitive techniques with increased multi-analyte capabilities.


title: Surgical practice recommendations for minimal access surgeons during COVID 19 pandemic - Indian inter-society directives.

text: These are inter-society guidelines for performance of laparoscopic surgery during COVID-19 pandemic that has affected the way of surgical practice. The safety of healthcare workers and patients is being challenged. It is prudent that our surgical practice should adapt to this rapidly changing health environment. The guidance issued is based on global practices and national governmental directives. The Inter-Society Group urges you to be updated with the developing situation and evolving changes.


Audiology in the Time of the Coronavirus.


title: Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data.

text: BACKGROUND CT perfusion (CTP) and diffusion or perfusion MRI might assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of irreversibly injured ischaemic core and potentially salvageable penumbra volumes were associated with functional outcome and whether they interacted with the treatment effect of endovascular thrombectomy on functional outcome. METHODS In this systematic review and meta-analysis, the HERMES collaboration pooled patient-level data from all randomised controlled trials that compared endovascular thrombectomy (predominantly using stent retrievers) with standard medical therapy in patients with anterior circulation ischaemic stroke, published in PubMed from Jan 1, 2010, to May 31, 2017. The primary endpoint was functional outcome, assessed by the modified Rankin Scale (mRS) at 90 days after stroke. Ischaemic core was estimated, before treatment with either endovascular thrombectomy or standard medical therapy, by CTP as relative cerebral blood flow less than 30% of normal brain blood flow or by MRI as an apparent diffusion coefficient less than 620 μm2/s. Critically hypoperfused tissue was estimated as the volume of tissue with a CTP time to maximum longer than 6 s. Mismatch volume (ie, the estimated penumbral volume) was calculated as critically hypoperfused tissue volume minus ischaemic core volume. The association of ischaemic core and penumbral volumes with 90-day mRS score was analysed with multivariable logistic regression (functional independence, defined as mRS score 0-2) and ordinal logistic regression (functional improvement by at least one mRS category) in all patients and in a subset of those with more than 50% endovascular reperfusion, adjusted for baseline prognostic variables. The meta-analysis was prospectively designed by the HERMES executive committee, but not registered. FINDINGS We identified seven studies with 1764 patients, all of which were included in the meta-analysis. CTP was available and assessable for 591 (34%) patients and diffusion MRI for 309 (18%) patients. Functional independence was worse in patients who had CTP versus those who had diffusion MRI, after adjustment for ischaemic core volume (odds ratio [OR] 0·47 [95% CI 0·30-0·72], p=0·0007), so the imaging modalities were not pooled. Increasing ischaemic core volume was associated with reduced likelihood of functional independence (CTP OR 0·77 [0·69-0·86] per 10 mL, pinteraction=0·29; diffusion MRI OR 0·87 [0·81-0·94] per 10 mL, pinteraction=0·94). Mismatch volume, examined only in the CTP group because of the small numbers of patients who had perfusion MRI, was not associated with either functional independence or functional improvement. In patients with CTP with more than 50% endovascular reperfusion (n=186), age, ischaemic core volume, and imaging-to-reperfusion time were independently associated with functional improvement. Risk of bias between studies was generally low. INTERPRETATION Estimated ischaemic core volume was independently associated with functional independence and functional improvement but did not modify the treatment benefit of endovascular thrombectomy over standard medical therapy for improved functional outcome. Combining ischaemic core volume with age and expected imaging-to-reperfusion time will improve assessment of prognosis and might inform endovascular thrombectomy treatment decisions. FUNDING Medtronic.


title: Impact of HIV-1 Membrane Cholesterol on Cell-Independent Lytic Inactivation and Cellular Infectivity.

text: Peptide triazole thiols (PTTs) have been found previously to bind to HIV-1 Env spike gp120 and cause irreversible virus inactivation by shedding gp120 and lytically releasing luminal capsid protein p24. Since the virions remain visually intact, lysis appears to occur via limited membrane destabilization. To better understand the PTT-triggered membrane transformation involved, we investigated the role of envelope cholesterol on p24 release by measuring the effect of cholesterol depletion using methyl beta-cyclodextrin (MβCD). An unexpected bell-shaped response of PTT-induced lysis to [MβCD] was observed, involving lysis enhancement at low [MβCD] vs loss of function at high [MβCD]. The impact of cholesterol depletion on PTT-induced lysis was reversed by adding exogenous cholesterol and other sterols that support membrane rafts, while sterols that do not support rafts induced only limited reversal. Cholesterol depletion appears to cause a reduced energy barrier to lysis as judged by decreased temperature dependence with MβCD. Enhancement/replenishment responses to [MβCD] also were observed for HIV-1 infectivity, consistent with a similar energy barrier effect in the membrane transformation of virus cell fusion. Overall, the results argue that cholesterol in the HIV-1 envelope is important for balancing virus stability and membrane transformation, and that partial depletion, while increasing infectivity, also makes the virus more fragile. The results also reinforce the argument that the lytic inactivation and infectivity processes are mechanistically related and that membrane transformations occurring during lysis can provide an experimental window to investigate membrane and protein factors important for HIV-1 cell entry.


All hands on deck as cases of COVID-19 surge.


title: Standardized uptake values of (68)Ga-DOTANOC PET: a promising prognostic tool in neuroendocrine tumors.

text: UNLABELLED Despite the fact that several studies have been published regarding the prognostic factors of neuroendocrine tumors (NETs), there are some cases in which available data are not sufficient to predict disease progression and to define a correct therapeutic approach. To our knowledge, the role of maximum standardized uptake value (SUVmax) as a prognostic factor has never been studied in NET patients. Therefore, we prospectively investigated whether (68)Ga-[1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-NaI3-octreotide ((68)Ga-DOTANOC) PET SUVmax could be used as an accurate noninvasive marker for disease prognosis. METHODS Forty-seven patients with NETs were studied with (68)Ga-DOTANOC PET. All patients underwent a baseline visit and laboratory and radiologic examinations. Follow-up was performed in all cases. RESULTS SUVmax was significantly higher in patients with pancreatic NET and in those with well-differentiated NETs. Moreover, SUVmax was significantly higher in patients with an elevated expression of 2A-somatostatin receptor. During the follow-up, the disease was stable or presented a partial response in 25 patients, and in 19 cases the disease progressed. The patients with stable disease or a partial response had an SUVmax significantly higher than did those in the progressive disease group, with the best cutoff ranging from 17.9 to 19.3. At univariate and multivariate analysis, the significant positive prognostic factors were well-differentiated NET, an SUVmax of 19.3 or more, and a combined treatment with long-acting somatostatin analogs and radiolabeled somatostatin analogs. CONCLUSION We demonstrated, for the first time to our knowledge, that (68)Ga-DOTANOC PET SUVmax correlates with the clinical and pathologic features of NETs and is also an accurate prognostic index.


title: Quercetin diacylglycoside analogues showing dual inhibition of DNA gyrase and topoisomerase IV as novel antibacterial agents.

text: A structure-guided molecular design approach was used to optimize quercetin diacylglycoside analogues that inhibit bacterial DNA gyrase and topoisomerase IV and show potent antibacterial activity against a wide spectrum of relevant pathogens responsible for hospital- and community-acquired infections. In this paper, such novel 3,7-diacylquercetin, quercetin 6''-acylgalactoside, and quercetin 2'',6''-diacylgalactoside analogues of lead compound 1 were prepared to assess their target specificities and preferences in bacteria. The significant enzymatic inhibition of both Escherichia coli DNA gyrase and Staphylococcus aureus topoIV suggest that these compounds are dual inhibitors. Most of the investigated compounds exhibited pronounced inhibition with MIC values ranging from 0.13 to 128 μg/mL toward the growth of multidrug-resistant Gram-positive methicillin-resistant S. aureus, methicillin sensitive S. aureus, vancomycin-resistant enterococci (VRE), vancomycin intermediate S. aureus, and Streptococcus pneumoniae bacterial strains. Structure-activity relationship studies revealed that the acyl moiety was absolutely essential for activity against Gram-positive organisms. The most active compound 5i was 512-fold more potent than vancomycin and 16-32-fold more potent than 1 against VRE strains. It also has realistic in situ intestinal absorption in rats and showed very low acute toxicity in mice. So far, this compound can be regarded as a leading antibacterial agent.


Editor's presentation: 'Les liaisones dangerouses. The heart in the time of COVID-19'.


title: Salvation in a Time of Plague.

text: Health workers offer their skills and care to COVID-19 pandemic patients, just as St Roch offered healing to those stricken by bubonic plague during the Renaissance. This article interprets 3 works of art in light of Roch's story of illness and recovery and applies key insights of ethical, artistic, and clinical relevance to the COVID-19 pandemic.


Covid-19: Known risk factors fail to explain the increased risk of death among people from ethnic minorities.


title: Impact of adding breast density to breast cancer risk models: A systematic review.

text: PURPOSE Assessment of a woman's risk of breast cancer is essential when moving towards personalized screening. Breast density is a well-known risk factor and has the potential to improve accuracy of risk prediction models. In this study we reviewed the impact on model performance of adding breast density to clinical breast cancer risk prediction models. METHODS We conducted a systematic review using a pre-specified search strategy for PubMed, EMBASE, Web of Science, and Cochrane Library from January 2007 until November 2019. Studies were screened using the Covidence software. Eligible studies developed or modified existing breast cancer risk prediction models applicable to the general population of women by adding breast density to the model. Improvement in discriminatory accuracy was measured as an increase in the Area Under the Curve or concordance statistics. RESULTS Eleven eligible studies were identified by the search and one by reference check. Four studies modified the Gail model, four modified the Tyrer-Cuzick model, and five studies developed new models. Several methods were used to measure breast density, including visual, semi- and fully automated methods. Eleven studies reported discriminatory accuracy and one study reported calibration. Seven studies found a statistically significantly increased discriminatory accuracy when including density in the model. The increase in AUC ranged 0.03 to 0.14. Four studies did not report on statistical significance, but reported an increased AUC ranging from 0.01 to 0.06. CONCLUSION Including mammographic breast density has the potential to improve breast cancer risk prediction models. However, all models demonstrated limited discrimination accuracy.


title: COVID-19, palliative care and public health.

text: The lack of integration between public health approaches, cancer care and palliative and end-of-life care in the majority of health systems globally became strikingly evident in the context of the coronavirus disease 2019 (COVID-19) pandemic. At the same time, the collapse of the boundaries between these domains imposed by the pandemic created unique opportunities for intersectoral planning and collaboration. While the challenge of integration is not unique to oncology, the organisation of cancer care and its linkages to palliative care and to global health may allow it to be a demonstration model for how the problem of integration can be addressed. Before the pandemic, the large majority of individuals with cancer in need of palliative care in low- and middle-income countries and the poor or marginalised in high-income countries were denied access. This inequity was highlighted by the COVID-19 pandemic, as individuals in impoverished or population-dense settings with weak health systems have been more likely to become infected and to have less access to medical care and to palliative and end-of-life care. Such inequities deserve attention by government, financial institutions and decision makers in health care. However, there has been no framework in most countries for integrated decision-making that takes into account the requirements of public health, clinical medicine and palliative and end-of-life care. Integrated planning across these domains at all levels would allow for more coordinated resource allocation and better preparedness for the inevitability of future systemic threats to population health.


title: Respiratory effort from the photoplethysmogram.

text: The potential for a simple, non-invasive measure of respiratory effort based on the pulse oximeter signal - the photoplethysmogram or 'pleth' - was investigated in a pilot study. Several parameters were developed based on a variety of manifestations of respiratory effort in the signal, including modulation changes in amplitude, baseline, frequency and pulse transit times, as well as distinct baseline signal shifts. Thirteen candidate parameters were investigated using data from healthy volunteers. Each volunteer underwent a series of controlled respiratory effort maneuvers at various set flow resistances and respiratory rates. Six oximeter probes were tested at various body sites. In all, over three thousand pleth-based effort-airway pressure (EP) curves were generated across the various airway constrictions, respiratory efforts, respiratory rates, subjects, probe sites, and the candidate parameters considered. Regression analysis was performed to determine the existence of positive monotonic relationships between the respiratory effort parameters and resulting airway pressures. Six of the candidate parameters investigated exhibited a distinct positive relationship (p<0.001 across all probes tested) with increasing upper airway pressure repeatable across the range of respiratory rates and flow constrictions studied. These were: the three fundamental modulations in amplitude (AM-Effort), baseline (BM-Effort) and respiratory sinus arrhythmia (RSA-Effort); two pulse transit time modulations - one using a pulse oximeter probe and an ECG (P2E-Effort) and the other using two pulse oximeter probes placed at different peripheral body sites (P2-Effort); and baseline shifts in heart rate, (BL-HR-Effort). In conclusion, a clear monotonic relationship was found between several pleth-based parameters and imposed respiratory loadings at the mouth across a range of respiratory rates and flow constrictions. The results suggest that the pleth may provide a measure of changing upper airway dynamics indicative of the effort to breathe.


Renin-angiotensin system inhibition in COVID-19 patients: Friend or foe?


Covid-19: Doctors warn of humanitarian catastrophe at Europe's largest refugee camp.


title: The Validity of Skin Conductance for Assessing Acute Pain in Infants: A Scoping Review.

text: OBJECTIVES Measuring pain in infants is important but challenging, as there is no "gold standard". The measurement of skin conductance (SC) is considered as a measure of stress and a surrogate indicator of pain. To identify the extent of research conducted and to synthesize the validity evidence of SC for assessing acute pain in infants. METHODS Arksey and O'Malley's framework for scoping reviews was followed and nine electronic databases were searched. Data were analyzed thematically and presented descriptively including the following main categories: study information/details, sampling information, characteristics of participants and settings, SC outcome measures and validity evidence. RESULTS Twenty-eight studies with 1061 infants were included, including 23 cross-sectional observation studies and five interventional studies. Most studied infants with mild severity of illness (n=13) or healthy infants (n=12). The validity evidence of SC was tested in relation to referent pain measures (13 variables), stimuli (13 variables), age (2 variables) and other contextual variables (11 variables). SC was not significantly correlated with vital signs, except heart rate in two of the eight studies. SC was significantly correlated with the unidimensional behavioral pain assessment scales and crying time rather than multidimensional measurements. Fourteen of 16 studies (87.5%) showed that SC increased significantly during painful procedures. CONCLUSION Inconsistent findings on validity of SC exist. Future research should aim to identify the diagnostic test accuracy of SC compared to well-accepted referent pain measures in infants, study the validity evidence of SC in critically ill infants and employ rigorous research design and transparent reporting.


title: Transvesical robotic simple prostatectomy: initial clinical experience.

text: BACKGROUND Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands. OBJECTIVE To describe our technique of transvesical robotic simple prostatectomy (RSP). DESIGN, SETTING, AND PARTICIPANTS From May 2011 to April 2013, 25 patients underwent RSP. SURGICAL PROCEDURE We performed RSP using our technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed. RESULTS AND LIMITATIONS Mean patient age was 72.9 yr (range: 54-88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9-35), prostate volume was 149.6 ml (range: 91-260), postvoid residual (PVR) was 208.1 ml (range: 72-800), maximum flow rate (Qmax) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9-56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165-345), estimated blood loss was 143 ml (range: 50-350), and the hospital stay was 4 d (range: 2-8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS (p<0.0001), an 82.2% reduction in mean PVR (p=0.014), and a 77% increase in mean Qmax (p=0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation. CONCLUSIONS Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures. PATIENT SUMMARY We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands.


Pain assessment scales in nonverbal critically ill adult patients: ventilator-related issues.


title: Electrocardiography-guided and retrospective analysis of central venous catheter placement in the dog.

text: OBJECTIVE To compare the success rates of central venous catheter placement (CVCP) in dogs using electrocardiograph (ECG)-guided and external landmark ('blind') techniques. To report success rates determined retrospectively of CVCPs in dogs using external landmarks at a tertiary referral institution. STUDY DESIGN Prospective blinded comparison of techniques. Retrospective analysis of case records. ANIMALS Adult Beagles weighing 11.9 +/- 2.6 kg were used in the experimental group (n = 38). Various breeds of dogs were in the retrospective clinical group (n = 33). METHODS Laboratory dogs were anesthetized and CVCPs were placed using a modified Seldinger technique. Catheter tip position was first based on external landmarks and then the catheter was repositioned using an ECG-guided placement. The ECG-guided technique used the V-lead with the positive electrode attached to the guide wire. Catheter placement was determined by moving the catheter cephalad and caudad to the point of maximum p-wave amplitude and then withdrawing the catheter 1-2 cm from this point. Catheter position with each technique was determined using a lateral thoracic radiograph. Retrospective data were collected from the medical records of dogs that had CVCPs using anatomical landmarks and corresponding thoracic radiographs. RESULTS The number of successful CVCP attempts was the same for both prospective groups (21/38). There was no statistically significant difference in success between the ECG-guided technique and the blind technique. From the retrospective investigation 10/33 of the cases that fit the criteria had correct CVCPs. CONCLUSIONS AND CLINICAL RELEVANCE The odds of correctly placing a central venous catheter by ECG-guidance were the same as the external landmark technique. The ECG-guided technique may be useful in situations where external landmarks are not readily available.


title: Prospective feasibility study of sealing pulmonary vessels with energy in lung surgery.

text: OBJECTIVE Vascular sealing with an energy vessel sealing system during lung resection may allow surgeons to treat small vessels with minimal dissection, possibly decreasing likelihood of injury. Few large prospective trials have examined the proximal sides of vessels not ligated in addition to sealing during surgery. We therefore assessed feasibility of an energy device to seal pulmonary artery and vein branches without further ligation. METHODS This prospective, preoperative registration study at 2 institutions evaluated safety of energy sealing with the LigaSure (Medtronic, Minneapolis, Minn), with no additional reinforcing material such as suture ligation, for pulmonary vessels as large as 7 mm during anatomic lung resection (cohort 1 study). A postoperative hemorrhage occurred in the 128th case, so a cohort 2 study proceeded after we changed inclusion criterion for pulmonary arteries from a maximum of 7 mm to a maximum of 5 mm. RESULTS In cohort 1 (n = 128) and cohort 2 (n = 200), 216 and 250 pulmonary arteries and 189 and 213 pulmonary veins, respectively, were treated with energy sealing. Overall postoperative hemorrhage rate was 0.3% (1/328 patients); however, no serious postoperative complications were associated with energy sealing among the 200 patients in cohort 2. Subsequent inspection of the torn artery stump confirmed that the bleeding in the 128th case was in an area adjacent to the sealing zone. CONCLUSIONS Energy sealing without reinforcement allows secure treatment during lung resection of pulmonary arteries as large as 5 mm in diameter and pulmonary veins as large as 7 mm.


title: Intersecting Pandemics: Impact of SARS-CoV-2 (COVID-19) Protective Behaviors on People Living with HIV, Atlanta, Georgia.

text: BACKGROUND COVID-19 and its social responses threaten the health of people living with HIV. We conducted a rapid-response interview to assess COVID-19 protective behaviors of people living with HIV and the impact of their responses on HIV related healthcare. METHOD Men and women living with HIV (N = 162) ages 20 to 37 participating in a longitudinal study of HIV treatment and care completed routine study measures and an assessment of COVID-19-related experiences. RESULTS At baseline, a majority of participants demonstrated HIV viremia, markers indicative of renal disorders, and biologically confirmed substance use. At follow-up, in the first month of responding to COVID-19, engaging in more social distancing behaviors was related to difficulty accessing food and medications, and increased cancelation of healthcare appointments, both by self and providers. We observed ART adherence had improved during the initial month of COVID-19 response. CONCLUSIONS Factors that may pose added risk for COVID-19 severity were prevalent among people living with HIV and those with greater risk factors did not practice more COVID-19 protective behaviors. Social distancing and other practices intended to mitigate the spread of COVID-19 interfered with HIV care, and impeded access to food and medications, although an immediate adverse impact on medication adherence was not evident. These results suggest social responses to COVID-19 adversely impacted the healthcare of people living with HIV, supporting continued monitoring to determine the long-term effects of co-occurring HIV and COVID-19 pandemics.


title: Robotic assisted gastrectomy compared with open resection: a case-matched study.

text: In recent years, increasingly sophisticated tools have allowed for more complex robotic surgery. Robotic gastrectomy, however, is adopted in only a few selected centers. The goals of this study were to examine the adoption of robotic gastrectomy and to compare outcomes between open and robotic gastric resections. This is a case-matched analysis of patients who underwent robotic and open gastric resection performed at Sanchinarro University Hospital, Madrid from November 2011 to February 2017. Patient data were obtained retrospectively. Clinicopathologic characteristics and perioperative and postoperative outcomes were recorded and analyzed. Two groups of demographically similar patients were analyzed: the robotic group (n = 20) and the open surgery group (n = 19). The patient characteristics of the two groups have been compared. Robotic resection resulted in less blood loss, shorter postoperative hospital stay, and a longer operating time. The two groups had similar complication rates. Pathological data were similar for both procedures. Robotic gastrectomy for locally advanced gastric carcinoma is safe, and long-term outcomes are comparable to those patients who underwent open resection. Robotic gastrectomy resulted in a shorter hospital stay, less blood loss and morbidity comparable with the outcomes of open gastrectomy.


The sprint to solve coronavirus protein structures - and disarm them with drugs.