title: Diagnosis and Management of Functional Heartburn.

text: Heartburn is among the most common gastrointestinal symptoms presenting to both generalist physicians and gastroenterologists. Heartburn that does not respond to traditional acid suppression is a diagnostic and therapeutic dilemma. In the era of high utilization of proton pump inhibitors, a substantial proportion of patients presenting to the gastroenterologist with chronic symptoms of heartburn do not have a reflux-mediated disease. Subjects without objective evidence of reflux as a cause of their symptoms have "functional heartburn". The diagnostic role of endoscopy, reflux and motility testing in functional heartburn (FH) patients is discussed. Lifestyle modifications, pharmacological interventions, and alternative therapies for FH are also presented. Recognition of patients with FH allows earlier assignment of these patients to different treatment algorithms, which may allow greater likelihood of success of treatment, diminished resource utilization and improved quality of life. Further data on this large and understudied group of patients is necessary to allow improvement in treatment algorithms and a more evidence-based approach to care of these patients.


title: A critical interpretive synthesis of the roles of midwives in health systems.

text: BACKGROUND Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system. METHODS A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction. RESULTS A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession. CONCLUSIONS Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.


The moment to see the poor.


title: Coagulopathy in COVID-19 and Its Implication for Safe and Efficacious Thromboprophylaxis.

text: The novel coronavirus, SARS-CoV-2, is causing a global pandemic of life-threatening multiorgan disease, called COVID-19. Accumulating evidence indicates that patients with COVID-19 are at significant risk of thromboembolic complications, mainly affecting the venous, but also the arterial vascular system. While the risk of venous thromboembolism (VTE) appears to be higher in patients requiring intensive care unit support compared to those admitted to general wards, recent autopsy findings and data on the timing of VTE diagnosis relative to hospitalization clearly suggest that thromboembolic events also contribute to morbidity and mortality in the ambulatory setting. In addition to a severe hypercoagulable state caused by systemic inflammation and viral endotheliitis, some patients with advanced COVID-19 may develop a coagulopathy, which meets established laboratory criteria for disseminated intravascular coagulation, but is not typically associated with relevant bleeding. Similar to other medical societies, the Society of Thrombosis and Haemostasis Research has issued empirical recommendations on initiation, dosing, and duration of pharmacological VTE prophylaxis in COVID-19 patients.


title: Pathogenic diversity of RNA variants and RNA variation-associated factors in cancer development.

text: Recently, with the development of RNA sequencing technologies such as next-generation sequencing (NGS) for RNA, numerous variations of alternatively processed RNAs made by alternative splicing, RNA editing, alternative maturation of microRNA (miRNA), RNA methylation, and alternative polyadenylation have been uncovered. Furthermore, abnormally processed RNAs can cause a variety of diseases, including obesity, diabetes, Alzheimer's disease, and cancer. Especially in cancer development, aberrant RNAs caused by deregulated RNA modifiers or regulators are related to progression. Accumulating evidence has reported that aberrant RNAs promote carcinogenesis in many cancers, including liver cancer, leukemia, melanoma, lung cancer, breast cancer, and other cancers, in which abnormal RNA processing occurs in normal cells. Therefore, it is necessary to understand the precise roles and mechanisms of disease-related RNA processing in various cancers for the development of therapeutic interventions. In this review, the underlying mechanisms of variations in the RNA life cycle and the biological impacts of RNA variations on carcinogenesis will be discussed, and therapeutic strategies for the treatment of tumor malignancies will be provided. We also discuss emerging roles of RNA regulators in hepatocellular carcinogenesis.


Use of home hemodialysis after peritoneal dialysis technique failure.


title: A Novel Loading Method for Doxycycline Liposomes for Intracellular Drug Delivery: Characterization of In Vitro and In Vivo Release Kinetics and Efficacy in a J774A.1 Cell Line Model of Mycobacterium smegmatis Infection.

text: Doxycycline (doxy) is used in treating intracellular and extracellular infections. Liposomal (LE) antibiotics allow low-frequency dosing and extended efficacy compared with standard (STD) formulations. We developed a novel sulfuric acid-loading method for doxycycline liposomes (LE-doxy). We hypothesized that a single s.c. injection of LE-doxy would be detectable in serum for at least 2 weeks at concentrations equal to or better than STD-doxy and would be bactericidal in an in vitro Mycobacterium smegmatis infection of J774A.1 macrophage cells. Liposomes were encapsulated by sulfuric acid gradient loading, and release kinetics were performed in vitro and in vivo. LE-doxy made using 8.25 mg/ml doxycycline loaded for 24 hours achieved 97.77% capture in 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) and 43.87% in sphingomyelin (sphing). Rats were injected s.c. with 50 mg/kg LE-doxy or 5 mg/kg STD-doxy, and serial blood samples were collected. Pharmacokinetics were analyzed using high-performance liquid chromatography. Liver and injection site skin samples were collected at euthanasia (4 weeks postinjection). Minimal histologic tissue reactions occurred after injection of STD (nonliposomal), DPPC, or sphing-doxy. DPPC-doxy had slightly faster in vitro leakage than sphing liposomes, although both were detectable at 264 hours. The mean residence time for DPPC was the highest (111.78 hours), followed by sphing (56.00 hours) and STD (6.86 hours). DPPC and sphing-doxy were detectable at 0.2 μg/ml in serum at 336 hours postadministration. LE-doxy was not toxic to J774A.1 cells in vitro and produced inhibition of viable Mycobacterium smegmatis at 24 and 48 hours. LE-doxy will require further testing in in vivo infection models.


title: The formation and design of the TRIAGE study--baseline data on 6005 consecutive patients admitted to hospital from the emergency department.

text: BACKGROUND Patient crowding in emergency departments (ED) is a common challenge and associated with worsened outcome for the patients. Previous studies on biomarkers in the ED setting has focused on identification of high risk patients, and and the ability to use biomarkers to identify low-risk patients has only been sparsely examined. The broader aims of the TRIAGE study are to develop methods to identify low-risk patients appropriate for early ED discharge by combining information from a wide range of new inflammatory biomarkers and vital signs, the present baseline article aims to describe the formation of the TRIAGE database and characteristize the included patients. METHODS We included consecutive patients ≥ 17 years admitted to hospital after triage staging in the ED. Blood samples for a biobank were collected and plasma stored in a freezer (-80 °C). Triage was done by a trained nurse using the Danish Emergency Proces Triage (DEPT) which categorizes patients as green (not urgent), yellow (urgent), orange (emergent) or red (rescusitation). Presenting complaints, admission diagnoses, comorbidities, length of stay, and 'events' during admission (any of 20 predefined definitive treatments that necessitates in-hospital care), vital signs and routine laboratory tests taken in the ED were aslo included in the database. RESULTS Between September 5(th) 2013 and December 6(th) 2013, 6005 patients were included in the database and the biobank (94.1 % of all admissions). Of these, 1978 (32.9 %) were categorized as green, 2386 (39.7 %) yellow, 1616 (26.9 %) orange and 25 (0.4 %) red. Median age was 62 years (IQR 46-76), 49.8 % were male and median length of stay was 1 day (IQR 0-4). No events were found in 2658 (44.2 %) and 158 (2.6 %) were admitted to intensive or intermediate-intensive care unit and 219 (3.6 %) died within 30 days. A higher triage acuity level was associated with numerous events, including acute surgery, endovascular intervention, i.v. treatment, cardiac arrest, stroke, admission to intensive care, hospital transfer, and mortality within 30 days (p < 0.001). CONCLUSION The TRIAGE database has been completed and includes data and blood samples from 6005 unselected consecutive hospitalized patients. More than 40 % experienced no events and were therefore potentially unnecessary hospital admissions.


title: Laparoscopic Sleeve Gastrectomy After Endoscopic Sleeve Gastroplasty: Technical Aspects and Short-Term Outcomes.

text: BACKGROUND Endoscopic sleeve gastroplasty (ESG) utilizes full-thickness sutures to plicate the greater curvature of the stomach. As with other weight loss interventions, some patients end up requiring revision to another procedure for insufficient weight loss or weight regain, discomfort, and procedure-related adverse events. OBJECTIVES In this paper, we report our technique and short-term outcomes of revisional sleeve gastrectomy (LSG) after ESG. SETTING Specialized medical center with standardized multidisciplinary protocols for medical, surgical, and endoscopic management of obesity. METHODS A combined laparoscopic-endoscopic technique that identifies plication orientation and the location of anchors and sutures was employed. This prepares the stomach for safe stapling, excluding sutures and anchors from the staple line and the retained sleeve. Hereby, we report this technique with its short-term safety and efficacy outcomes. RESULTS Twenty patients (16 female; mean age 40 ± 6 years) underwent revisional LSG from a total of 1665 (1.2%) who underwent primary ESG. Mean body mass index at the time of primary and revision procedures were 35.0 ± 4.0 and 35.2 ± 3.8 kg/m2, respectively. Nadir % total weight loss (%TWL) after primary ESG was 7.7 ± 3.5%. %TWL at 6 and 12 months after LSG was 21.0 ± 2.7 (n = 11) and 25.6 ± 4.1 (n = 8), respectively. There were no missed follow-up visits. Additionally, there was no mortality, prolonged hospital stay, adverse events, reoperations, or readmissions. CONCLUSIONS Based on this combined laparoscopic-endoscopic technique, laparoscopic sleeve gastrectomy is a safe and feasible revision option for patients who fail ESG.


title: Traumatic peroneal split lesion with retinaculum avulsion: Diagnosis and post-operative multymodality imaging.

text: Tears of peroneus brevis tendon represent a cause of underdiagnosed lateral ankle pain and instability. The typical clinical presentation is retro-malleolar pain, in some cases associated with palpable swelling around the fibular malleolus, pain during activities and difficulty in walking. We present a case of peroneus brevis split lesion with superior peroneal retinaculum avulsion in a young athlete who referred to the emergency ward of our hospital for left ankle pain after an inversion injury. An early diagnosis allowed treating the injury and promptly resuming sport activity, after rehabilitation training. Surgical reconstruction key-points and post-surgical follow-up were also discussed. A late diagnosis would have caused a symptomatology worsening and an increased recovery time.


title: Fetal Transient Skin Edema in Two Pregnant Women With Coronavirus Disease 2019 (COVID-19).

text: BACKGROUND The risk of vertical transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains unknown. Positive reverse-transcription polymerase chain reaction (RT-PCR) test results for SARS-CoV-2 infection in neonates and placental tissue have been reported, and immunoglobulin M antibodies have been detected in neonates born to mothers with infection. CASES The first case is a woman at 22 3/7 weeks of gestation with coronavirus disease 2019 (COVID-19) who was admitted to the intensive care unit. In the second case, the patient remained at home with mild symptoms, starting at 20 weeks of gestation. In both cases, fetal skin edema was observed on ultrasound examination while maternal SARS-COV-2 RT-PCR test results were positive and resolved when maternal SARS-COV-2 RT-PCR test results became negative. The RT-PCR test result for SARS-CoV-2 in amniotic fluid was negative in both cases. The two pregnancies are ongoing and uneventful. CONCLUSION Transient fetal skin edema noted in these two patients with COVID-19 in the second trimester may represent results of fetal infection or altered fetal physiology due to maternal disease or may be unrelated to the maternal illness.


title: Bispectral Index monitoring in cancer patients undergoing palliative sedation: a preliminary report.

text: INTRODUCTION Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) monitoring. PATIENTS AND METHODS We enrolled consecutive patients with refractory symptoms requiring PS. We documented the level of sedation using Ramsay Sedation Scale (RSS) and BIS at 0, 2, 4, 6, 12, and 24 h during the first day of PS and examined their degree of association. Intravenous midazolam or propofol was titrated according to the sedation level. RESULTS Twenty patients on PS were recruited and had BIS continuous monitoring. Delirium was the most frequent reason for PS (n = 15, 75%). The median time of sedation was 24.5 h (interquartile range 6-46). The average time to achieve the desired sedation level was 6 h, and dose titration was required in 80% of the cases. At baseline, 14 (70%) patients were considered to be awake according to RSS (i.e., 1-3) and 19 (95%) were awake according to BIS (i.e., >60%). This proportion decreased to 31 and 56% at 4 h, 27% and 53 at 6 h, and 22 and 33% at 24 h. RS and BIS had moderate correlation (rho = -0.58 to -0.65); however, a small proportion of patients were found to be awake by BIS (i.e., ≥60%) despite clinical observation (i.e., RSS 4-6) indicating otherwise. CONCLUSIONS The BIS is a noninvasive, bedside, real-time continuous monitoring method that may facilitate the objective assessment of level of consciousness and dose titration in patients undergoing PS.


title: Comparison of prasugrel and bivalirudin vs clopidogrel and heparin in patients with ST-segment elevation myocardial infarction: Design and rationale of the Bavarian Reperfusion Alternatives Evaluation (BRAVE) 4 trial.

text: Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI). Effective and safe adjunct antithrombotic therapy is a major determinant for short- and long-term outcomes after primary PCI. Two separate studies have shown significant benefits vs conventional therapy for 2 recently approved drugs. In the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, bivalirudin after pretreatment with clopidogrel resulted in improved net clinical outcome compared with heparin plus glycoprotein IIb/IIIa inhibitors. However, during the first 24 hours after PCI, there was an increase in stent thrombosis rates with bivalirudin. In the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction (TRITON-TIMI) 38 trial, prasugrel was superior to clopidogrel in patients with acute coronary syndrome with and without ST-segment elevation. The synergic actions of prasugrel and bivalirudin may maximize the benefit of antithrombotic therapy for STEMI patients undergoing primary PCI. However, no specifically designed studies have so far compared the combination of prasugrel plus bivalirudin with that of clopidogrel plus unfractionated heparin in these patients. The Bavarian Reperfusion Alternatives Evaluation (BRAVE) 4 study is a randomized, open-label, multicenter trial aimed to test the hypothesis that a strategy based on prasugrel plus bivalirudin is superior to a strategy based on clopidogrel plus unfractionated heparin in terms of net clinical outcome in STEMI patients with planned primary PCI.


title: Early antiviral treatment contributes to alleviate the severity and improve the prognosis of patients with novel coronavirus disease (COVID-19).

text: BACKGROUND At present, the severity of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a focal point. METHODS To assess the factors associated with severity and prognosis of patients infected with SARS-CoV-2, we retrospectively investigated the clinical, imaging, and laboratory characteristics of confirmed 280 cases of novel coronavirus disease (COVID-19) from January 20 to February 20, 2020. RESULTS The median age of patients in the mild group was 37.55 years old, while that in the severe group was 63.04 years old. The proportion of patients over 65 years old in the severe group was significantly higher than that of the mild group (59.04% vs. 10.15%, P < 0.05). 85.54% of severe patients had diabetes or cardiovascular diseases, which was significantly higher than that of the mild group (51.81% vs 7.11%, P = 0.025; 33.73% vs 3.05%, P = 0.042). Patients in the mild group experienced earlier initiation of antiviral treatment (1.19 ± 0.45 vs 2.65 ± 1.06 days in the severe group, P < 0.001). Our study showed that comorbidity, time from illness onset to antiviral, and age >=65 were three major risk factors for COVID-19 progression, while comorbidity and time from illness onset to antiviral were two major risk factors for COVID-19 recovery. CONCLUSIONS The elderly and patients with underlying diseases are more likely to experience a severe progression of COVID-19. It is recommended that timely antiviral treatment should be initiated to slow the disease progression and improve the prognosis.


title: Performance of different mono- and multiplex nucleic acid amplification tests on a multipathogen external quality assessment panel.

text: An external quality assessment (EQA) panel consisting of a total of 48 samples in bronchoalveolar lavage (BAL) fluid or transport medium was prepared in collaboration with Quality Control for Molecular Diagnostics (QCMD) (www.qcmd.org). The panel was used to assess the proficiency of the three laboratories that would be responsible for examining the 6,000 samples to be collected in the GRACE Network of Excellence (www.grace-lrti.org). The main objective was to decide on the best-performing testing approach for the detection of influenza viruses A and B, parainfluenza virus types 1 to 3, respiratory syncytial virus (RSV), human metapneumovirus, coronavirus, rhinovirus, adenovirus, Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila by nucleic acid amplification techniques (NAATs). Two approaches were chosen: (i) laboratories testing samples using their in-house procedures for extraction and amplification and (ii) laboratories using their in-house amplification procedures on centrally extracted samples. Furthermore, three commercially available multiplex NAAT tests-the ResPlex (Qiagen GmbH, Hilden, Germany), RespiFinder plus (PathoFinder, Maastricht, The Netherlands), and RespiFinder Smart 21 (PathoFinder) tests-were evaluated by examination of the same EQA panel by the manufacturer. No large differences among the 3 laboratories were noticed when the performances of the assays developed in-house in combination with the in-house extraction procedures were compared. Also, the extraction procedure (central versus local) had little effect on performance. However, large differences in amplification efficacy were found between the commercially available tests; acceptable results were obtained by using the PathoFinder assays.


title: Suture versus tack fixation of mesh in laparoscopic umbilical hernia repair.

text: BACKGROUND AND OBJECTIVES Mesh fixation in laparoscopic umbilical hernia repair is poorly studied. We compared postoperative outcomes of laparoscopic umbilical hernia repair in suture versus tack mesh fixation. METHODS Patients who underwent laparoscopic umbilical hernia repair were separated by method of mesh fixation: sutures versus primarily tacks. Medical history and follow-up data were collected through medical records. The primary outcome of this study was the recurrence rates of hernias. Postoperative major and minor complications, such as surgical site infection, small-bowel obstruction, and seroma formation, were regarded as secondary outcomes. Additionally, a telephone interview was conducted to assess postoperative pain, recovery time, and overall patient satisfaction. RESULTS Eighty-six patients were identified: 33 in the suture group and 53 in the tacks group. The number of emergent cases was increased in the tacks group (6 vs 0; P = .022). Mean follow-up time was 2.7 years for both groups. Documented postoperative follow-up was obtained in 29 (90%) suture group and 31 (58%) tacks group patients. Hernia recurrence occurred in 3 and 2 patients in the sutures and tacks groups, respectively (P was not significant). No differences were found in secondary outcomes, including subjective outcomes from telephone interviews, between groups. CONCLUSIONS There are no differences in postoperative complication rates in suture versus tack mesh fixation in laparoscopic umbilical hernia repair.


Potentially repurposing adamantanes for COVID-19.


title: The Role of Human Coronavirus Infection in Pediatric Acute Gastroenteritis.

text: Since human coronavirus (HCoV)-like particles were detected in the stool specimens of acute gastroenteritis and necrotizing enterocolitis children with electron microscopy, the relationship between HCoV and the pediatric gastrointestinal illness had been recognized. In recent years, the overall detection rates have been low and have varied by region. HCoVs have not been considered as the major pathogens in pediatric acute gastroenteritis. HCoVs detected in children with acute gastroenteritis have included 229E, OC43, HKU1, NL63, and severe acute respiratory syndrome coronavirus, Middle East Respiratory Syndrome Coronavirus and severe acute respiratory syndrome coronavirus-2 have also been associated with gastrointestinal symptoms in children. Although digestive tract has been recognized as an infection route, it has not been possible to fully investigate the association between HCoVs infection and the gastrointestinal symptoms because of the limited number of pediatric cases. Furthermore, pathological features have not been clear. Till now, our knowledge of severe acute respiratory syndrome coronavirus-2 is limited. However, diarrhea and vomiting have been seen in pediatric cases, particularly in newborns and infants. It has been necessary to pay more attention on gastrointestinal transmission to identify the infected children early and avoid the children without apparent or mild symptoms becoming the sources of infection.


title: Development of a multiplex PCR to detect and discriminate porcine circoviruses in clinical specimens.

text: BACKGROUND A diagnostic method to simultaneously detect and discriminate porcine circovirus type 1 (PCV1), porcine circovirus type 2 (PCV2) and porcine circovirus type 3 (PCV3) in clinical specimens is imperative for the differential diagnosis and monitoring and control of PCVs in the field. METHODS Three primer pairs were designed and used to develop a multiplex PCR assay. And 286 samples from 8 farms in Hubei province were tested by the developed multiplex PCR assay to demonstrate the accuracy. RESULTS Each of target genes of PCV1, PCV2 and PCV3 was amplified using the designed primers, while no other porcine viruses genes were detected. The limit of detection of the assay was 10 copies/μL of PCV1, PCV2 OR PCV3. The results of the tissue samples detection showed that PCV1, PCV2 and PCV3 are co-circulating in central China. The PCV1, PCV2 and PCV3 singular infection rate was 52.4% (150/286), 61.2% (175/286) and 45.1% (129/286), respectively, while the PCV1 and PCV2 co-infection rate was 11.2% (32/286), the PCV1 and PCV3 co-infection rate was 5.9% (17/286), the PCV2 and PCV3 co-infection rate was 23.4% (67/286), and the PCV1, PCV2 and PCV3 co-infection rate was 1.7% (5/286), respectively, which were 100% consistent with the sequencing method and real-time PCR methods. CONCLUSIONS The multiplex PCR assay could be used as a differential diagnostic tool for monitoring and control of PCVs in the field. The results also indicate that the PCVs infection and their co-infection are severe in Hubei province, Central China.


title: Fluorescence angiography with indocyanine green (ICG) to evaluate anastomosis in colorectal surgery: where does it have more value?

text: BACKGROUND Indocyanine green (ICG) fluorescence angiography (FA) was introduced to provide the real-time intraoperative evaluation of the vascular supply of anastomosis. However, further studies are required to evaluate its advantages in colorectal surgery and to know in which procedure this technology has more value. The aim of the present study is to assess the usefulness of the ICG-FA in the colorectal anastomosis evaluation and to evaluate where it is most useful depending on type of resection performed in terms of change of section line based on the ICG-FA and anastomotic leakage (AL) rates. METHODS This is a prospective study. From September 2014 to November 2018, all patients who underwent any colorectal surgical procedure with ICG-FA in our center were enrolled in the study. Based on the type of surgery, patients were grouped in 4 categories: Group A, right hemicolectomy; Group B, segmental resection of the splenic flexure; Group C, left hemicolectomy; and Group D, anterior resection of the rectum. RESULTS One-hundred-ninety-two unselected consecutive patients were enrolled: 67 in group A, 9 in B, 81 in C, and 35 in D. Change of section line based on ICG-FA occurred in 35 cases (18.2%): 4 in group A (6%), 1 in group B (11.1%), 21 in group C (25.9%), and 9 in group D (25.7%). ALs occurred in 5 patients (2.6%): 2 in group A (3%), 1 in C (1.2%), and 2 in D (5.7%). CONCLUSIONS ICG-FA leads to significantly more changes in the resection line in case of left hemicolectomy followed by anterior resection. FA is a promising optical imaging technique to reduce the AL incidence after colorectal procedures. To confirm this data, further studies with wider sample size and with an objective evaluation of the anastomotic perfusion are required.


HIV transmitted from a living organ donor-New York City, 2009.


title: NOVEL INSIGHTS ON THE PULMONARY VASCULAR CONSEQUENCES OF COVID-19.

text: In the last few months, the number of cases of a new coronavirus-related disease (COVID-19) rose exponentially, reaching the status of a pandemic. Interestingly, early imaging studies documented that pulmonary vascular thickening was specifically associated with COVID-19 pneumonia, implying a potential tropism of the virus for the pulmonary vasculature. Moreover, SARS-CoV-2 infection is associated with inflammation, hypoxia, oxidative stress, mitochondrial dysfunction, DNA damage and lung coagulopathy promoting endothelial dysfunction and microthrombosis. These features are strikingly similar to what is seen in pulmonary vascular diseases. Although the consequences of COVID-19 on the pulmonary circulation remain to be explored, several viruses have been previously thought to be involved in the development of pulmonary vascular diseases. Patients with preexisting pulmonary vascular diseases also appear at increased risk of morbidity and mortality. The present article reviews the molecular factors shared by coronaviruses infection and pulmonary vasculature defects, and the clinical relevance of pulmonary vascular alterations in the context of COVID-19.


title: Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience.

text: PURPOSE Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery. METHODS We defined "unexpected intraoperative bleeding" as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels. RESULTS Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3 %) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n = 13) and vein (n = 3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5 days, average, p = 0.20) and postoperative hospital stay (12.7 vs. 11.0 days, average, p = 0.08) were not significantly different. CONCLUSIONS The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.


title: Bilateral adrenal myelolipomas in a woman with chronic anticoagulation, postmenopausal uterine bleeding, primary hyperparathyroidism and hyperthyroidism.

text: Adrenal myelolipomas are rare, usually benign unilateral tumors. Their management has controversially been discussed. The authors here present a 53-year-old African American female Jehovah's witness with postmenopausal uterine bleeding on chronic anticoagulation and episodic right flank pain who was found to have bilateral myelolipomas in addition to primary hyperparathyroidism. In collaboration with gynecology, midline laparotomy was performed to remove uterus and both ovaries in addition to the right adrenal gland for a 62 × 79 mm myelolipoma. An open biopsy of the left adrenal mass measuring 42 × 43 mm revealed myelolipoma and ruled out malignancy. Pathology confirmed bilateral myelolipomas, endometrial polyps, and leiomyomata uteri. After an uneventful recovery, the patient then underwent a right inferior parathyroidectomy for parathyroid adenoma. This case illustrates the challenges in deciding when to surgically intervene for bilateral adrenal myelolipoma and, for the first time, associates various other endocrinopathies, although no known endocrine neoplasia syndrome variant was present.


title: Reconstruction of saccular and dissected intracranial aneurysms using Solitaire™ AB stents.

text: INTRODUCTION We aimed to evaluate the feasibility, safety, efficacy, and predictors for outcome of reconstructive treatment with Solitaire™ AB stent(s) based on 54 cases of saccular aneurysms and 14 of acute symptomatic dissecting aneurysms. METHODS Fifty-eight consecutive patients (M/F = 28/30; median age, 53 years) harbouring 68 aneurysms (ruptured/unruptured = 12/56) underwent treatment with Solitaire™ AB stent(s) implantation between April 2010 and August 2011 in our institution. The data were retrospectively reviewed and analysed. RESULTS The technical success rate of Solitaire™ AB stenting was 100%. The rates of the overall and the treatment-related adverse events were 9% (6/68) and 6% (4/68), respectively, and the recurrent rate was 1% (1/68). All of the adverse events (n = 6) occurred in tiny (n = 1, ≤3 mm) or small (n = 5, >3 to ≤10 mm) aneurysms. The majority (75%, 3/4) of thromboembolic events (thrombus, n = 2; infarction, n = 2) occurred in ruptured lesions, and 2 intraprocedural aneurysm ruptures occurred in the course of coiling when the stent(s) was/were applied within 6 months. Subarachnoid haemorrhages (SAH, p<0.05) and immediate occlusion grades (p<0.05) were predictors for overall adverse events by univariate analysis. Compared with the immediate post-treatment angiographic results, the follow-up angiographic imaging (mean, 13 months; range, 6-25 months) revealed that stent(s) implantation enhanced the rate of class I occlusion from 34% (23/68) to 93% (63/68). SAH was the only predictor for unfavourable outcomes (the modified Rankin Scale score [mRS], 2-6) during the mean 19-month (range, 12-27 months) of clinical follow-ups (p<0.05). CONCLUSIONS Although the complete obliteration of tiny and small aneurysms without complications remains a challenge, stent(s) implantation could lead to further occlusion of incompletely coiled aneurysms. SAH and the occlusion grade were the primary predictors for adverse events. SAH was the only predictor for unfavourable outcomes by univariate analysis.


title: Pharmacomechanical thrombectomy: 2015 update.

text: Pharmacomechanical Thrombectomy (PMT) is recognized as a recent advancement in the treatment of lower extremity deep venous thrombosis (DVT). Evidence for the use of this modality is growing rapidly, primarily based on anecdotal experience and large case series. Currently, the majority of patients with lower extremity DVT are treated with anticoagulation or compressive therapy without adjunctive surgical or interventional procedures. This article reviews the current evidence supporting the use of PMT over catheter directed thrombolysis or simple anticoagulation and the expected benefits that can be realized from each modality. In addition the relevant unique characteristics to each device currently available are described focusing on mechanism of action and potential side effects.


title: Feasibility and safety of retroperitoneoscopic laparoendoscopic single-site nephrectomy: technique and early outcomes.

text: UNLABELLED What's known on the subject? and What does the study add? Laparoendoscopic single-site (LESS) nephrectomy is feasible to remove diseased kidneys. Most of such procedures previously reported were performed through a transperitoneal (trans-abdominal) approach. We report the feasibility, safety, and techniques of performing such operations without disturbing the bowels (a retroperitoneal LESS approach). This approach provides acceptable operative outcomes, and is especially valuable for patients who need to have an intact peritoneal envelope, or those with potentially abnormal or obliterated peritoneal space. OBJECTIVES • To retrospectively review our experience with respect to evaluating the feasibility and safety of retroperitoneoscopic laparoendoscopic single-site surgery (LESS) nephrectomy. • To present the technical details of such a procedure. PATIENTS AND METHODS • In total, eight retroperitoneoscopic LESS nephrectomies (in seven patients) were completed for a variety of indications in a single centre. • The GelPOINT apparatus (Applied Medical, Rancho Santa Margarita, CA, USA) was used as an access platform through a flank incision (3-5 cm). • Except for a bendable grasper and flexible vascular staplers, all instruments used were conventional straight laparoscopic instruments. • Perioperative data were retrospectively obtained for all patients, including demographic data, operative indications, operative records, length of stay, complications, and pathological analysis. RESULTS • All retroperitoneoscopic LESS nephrectomy procedures attempted were completed successfully without complications. No extra working port was required for any case. • Median (range) operating time was 164 (87-198) min and median (range) estimated blood loss was 50 (10-200) cm(3) . Median (range) length of hospital stay was 2 (1-3) days. • The median narcotic used was 34 mg of parental morphine sulphate equivalent. The median (range) visual analogue pain scale score at discharge was 2 (0-3) out of 10. • The present single arm observation study is limited by the small patient number and the absence of a control cohort. CONCLUSIONS • Retroperitoneoscopic LESS nephrectomy using the GelPOINT apparatus as an access platform is feasible and safe. • It provides adequate flexibility and spacing of port placements as well as acceptable operative outcomes. • It is especially valuable for those patients who need to maintain peritoneal integrity or those with an abnormal or obliterated peritoneal space.


title: On the road to single-site laparoscopic adjustable gastric banding: lessons learned from 60 cases.

text: BACKGROUND Single-site laparoscopic surgery is a promising emerging technique with potential to decrease postoperative pain, reduce port-site complications, and improve cosmetic results. Laparoscopic adjustable gastric banding (LapGB) is a procedure that lends itself well to single-site laparoscopic surgery because the surgery is confined to a single region of the body, the need for a larger incision for port implantation and the fact that bariartric patients are more likely to be body image conscious. The procedure is, however, technically challenging and potentially more time consuming and hazardous. To simplify learning, a hybrid technique that used multiple conventional trocars and laparoscopic equipment through a single periumbilical incision while retaining the use of the Nathanson retractor via a separate epigastric incision was developed. The authors' experience and results with this technique are described. METHODS This retrospective review describes the prospectively collected data for the first 60 consecutive cases completed using the minimally invasive technique described. RESULTS The 60 cases in this study comprised 12 men and 48 women with an average age of 39 years (range 20-59 years). Their average body mass index (BMI) was 39.1 kg/m(2) (range 32-52 kg/m(2)). Four patients (6.7%) needed an additional port either for hemostasis or for access difficulties. Concomitant hiatal hernia repair was performed for 13 patients. Five patients (8.3%) had superficial wound infection requiring oral antibiotic therapy and dressings. No other complications were observed. Overall, the average operating time was 55 min (range 30-160 min). For both surgeons, the learning curve was six cases, with a significant difference in the operating times between the first six cases and the remaining cases (p < 0.0001, Mann-Whitney U test). CONCLUSIONS The authors' early experience with the minimally invasive LapGB technique shows that it is feasible and safe. It can be used either as a bridging technique to single-site LapGB or on its own as a minimally invasive technique.


title: Porcine reproductive and respiratory syndrome virus ORF5a protein is essential for virus viability.

text: It has been shown that ORF5a protein in EAV is important but not essential for virus infectivity. In this study, we found that RNA changes in the overlapping region (1-104 nucleotide, nt) between ORF5 and ORF5a introduced by codon-optimized GP5 was lethal for virus viability, suggesting that the nt changes or amino acid (aa) mutations in the GP5 or ORF5a protein did not permit the production of infectious virus. Furthermore, inactivation of ORF5a expression in the context of type 1 (pSHE) and type 2 (pAJXM and pAPRRS) full-length PRRSV cDNA clones was lethal for the production of infectious virus, while viable PRRSV could be recovered by expressing ORF5a protein in trans, suggesting that ORF5a protein was essential for virus viability. Finally, ORF5a protein could be putatively extended to 63 aas by inactivation of the downstream stop codon candidates, thereby demonstrating that the C-terminus of ORF5a may be variable.


title: Disease and healthcare burden of COVID-19 in the United States.

text: As of 24 April 2020, the SARS-CoV-2 epidemic has resulted in over 830,000 confirmed infections in the United States1. The incidence of COVID-19, the disease associated with this new coronavirus, continues to rise. The epidemic threatens to overwhelm healthcare systems, and identifying those regions where the disease burden is likely to be high relative to the rest of the country is critical for enabling prudent and effective distribution of emergency medical care and public health resources. Globally, the risk of severe outcomes associated with COVID-19 has consistently been observed to increase with age2,3. We used age-specific mortality patterns in tandem with demographic data to map projections of the cumulative case burden of COVID-19 and the subsequent burden on healthcare resources. The analysis was performed at the county level across the United States, assuming a scenario in which 20% of the population of each county acquires infection. We identified counties that will probably be consistently, heavily affected relative to the rest of the country across a range of assumptions about transmission patterns, such as the basic reproductive rate, contact patterns and the efficacy of quarantine. We observed a general pattern that per capita disease burden and relative healthcare system demand may be highest away from major population centers. These findings highlight the importance of ensuring equitable and adequate allocation of medical care and public health resources to communities outside of major urban areas.


title: Totally laparoscopic radiofrequency-assisted liver partition with portal vein ligation for hepatocellular carcinoma in cirrhotic liver.

text: RATIONALE Adequate future liver remnant (FLR) volume is often a concern for patients with hepatocellular carcinoma (HCC). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure can rapidly lead to impressive growth of FLR. We describe the technique of an entirely laparoscopic radiofrequency-assisted liver partition with portal vein ligation for staged hepatectomy (RALPP) in a cirrhotic patient with HCC. PATIENT CONCERNS A 33 year-old female cirrhotic patient with HCC in the right liver was indicated for RALPP as the predicted future liver remnant (FLR) was 21%. DIAGNOSES HCC with liver cirrhosis. INTERVENTIONS The first surgery consisted of ligation of the right portal vein and radiofrequency ablation of the liver without parenchymal transection. Three weeks postoperatively, FLR reached 42%, and the patient underwent right hepatectomy. OUTCOMES Operative times for the both surgeries were 60 and 240 minutes respectively, with negligeable blood loss. The patient had an uneventful postoperative course, and the FLR reached 53% 1 week after the second procedure. No recurrence occurred at 10 months. LESSONS Laparoscopic RALPP is feasible in some cirrhotic patients with liver cancer that in line with the indications and this method may be a superior choice for selected cirrhotic patients with HCC, as it decreases potential morbidity associated with open surgery.


title: The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia.

text: BACKGROUND Although minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia. METHODS A total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge. RESULTS There were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux. CONCLUSION All patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.


title: The IASLC Lung Cancer Staging Project: Background Data and Proposed Criteria to Distinguish Separate Primary Lung Cancers from Metastatic Foci in Patients with Two Lung Tumors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer.

text: INTRODUCTION It can be difficult to distinguish between a second primary and a metastasis in patients with lung cancer who have more than one pulmonary site of cancer. METHODS A systematic review of the literature was conducted by a subcommittee of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee to develop recommendations to identify second primary lung cancers. The process entailed review of knowledge relating to the mechanism of metastasis, determination of clonality, and outcomes of patients with resected tumors. RESULTS It is easier to determine that two tumors are different than that they are the same; finding similarities does not establish that they are the same. For example, most second primary lung cancers are of the same histotype. Few criteria are reliable by themselves; these include different histologic cancer types or matching DNA breakpoints by sequencing and a comprehensive histologic assessment of resected specimens. Characteristics that are suggestive but associated with potential misclassification include the presence or absence of biomarkers, imaging characteristics, and the presence or absence of nodal involvement. CONCLUSIONS Clinical and pathologic (i.e., after resection) criteria are presented to identify two foci as separate primary lung cancers versus a metastasis. Few features are definitive; many commonly used characteristics are suggestive but associated with a substantial rate of misclassification. Careful review by a multidisciplinary tumor board, considering all available information, is recommended.


title: Effect of autologous platelet-rich plasma in combination with bovine porous bone mineral and bio-guide membrane on bone regeneration in mandible bicortical bony defects.

text: OBJECTIVE Growth factors contained in platelet-rich plasma (PRP) can induce osteoblast differentiation in certain studies, whereas in others, osteogenesis of PRP on mandible bone defects has not been proved clinically. The aim of the study was to investigate the effect of autologous PRP on the osteogenic potential of combining bovine porous bone mineral (BPBM) and bio-guide membrane (BGM) in promoting mandible bicortical bony defects in rabbits. METHODS One circular mandible bicortical bony defects were created in each of 54 rabbits, which were divided into 3 groups: group 1: 18 of the defects were left unfilled as a negative control; group 2: 18 of the defects were grafted with autologous PRP and BPBM/BGM; group 3: 18 of the defects were grafted with BPBM/BGM without PRP. Animals were killed at 4, 8, and 12 weeks after operation. Harvested tissue and specimens were evaluated histologically and radiographically, and metabolized observation was performed. Histological parameters associated with osteoblast activities, bone trabecula, neovascularization, newly formed mineralized bone, rudimental grafts and connective tissue formation were measured. Densities of the bones at 4, 8, and 12 weeks were studied by radiographic. The bone defect closure ratio was measured at 12 weeks. The bone metabolized parameter alkaline phosphatase was also measured and compared between 4, 8, and 12 weeks. RESULTS The platelet concentration of PRP is 4.19- to 4.43-fold to that of the whole blood. Histological analysis showed new bone formation at all therapeutic sites including BPBM/BGM grafts with or without PRP. A statistically significant difference in new bone formation between group PRP/BPBM/BGM and group BPBM/BGM was observed. Untreated defects of group control showed the less bone regeneration. There was significant difference of bone density between group PRP/BPBM/BGM and control, and group BPBM/BGM and control, at 4, 8, and 12 weeks postoperative. There were more bone defects filling, and the grafts were absorbed at 12 weeks of group PRP/BPBM/BGM compared with group BPBM/BGM. Defects treated with PRP/BPBM/BGM demonstrated significantly increased activity of osteoblasts, enhanced amount of mitochondria and rough endoplasmic reticulum in osteoblasts, and increased concentration of alkaline phosphatase at 4, 8, and 12 weeks compared with those treated with BPBM/BGM and control group. Complete closure ratio of bone defects treated with PRP/BPBM/BGM (50%) was significantly increased compared with that treated with BPBM/BGM (16.6%). CONCLUSIONS The study suggested that PRP combination of BPBM and BGM had significant therapeutic effects on mandible bicortical bony defects of rabbits. The effects are associated with the high concentration of platelet in PRP and the porous configuration of BPBM. Although we cannot reveal the detailed statistical relationship of PRP on promoting BPBM/GBM osteoinductive effects, PRP demonstrated superior results of bone regeneration.


title: Effect of Intracranial Atherosclerotic Disease on Endovascular Treatment for Patients with Acute Vertebrobasilar Occlusion.

text: BACKGROUND AND PURPOSE Although intracranial atherosclerotic disease is often encountered during endovascular treatment for acute vertebrobasilar occlusions, its clinical implication is not well-known. We aimed to evaluate whether intracranial atherosclerotic disease influences the clinical outcomes following endovascular treatment of acute vertebrobasilar occlusive stroke. MATERIALS AND METHODS Fifty-one patients with acute vertebrobasilar occlusive stroke were included. The onset-to-groin puncture time was ≤12 hours, and aspiration- or stent-based thrombectomy was used as the primary treatment method. Following primary endovascular treatment, intracranial atherosclerotic disease (IAD group) was angiographically diagnosed when a fixed focal stenosis was observed at the occlusion site, whereas embolism (embolic group) was diagnosed if no stenosis was observed. Clinical and treatment variables were compared in both groups, and IAD was evaluated as a prognostic factor for clinical outcomes. RESULTS The baseline NIHSS score tended to be lower (14 versus 22, P = .097) in the IAD group (n = 19) than in the embolic group (n = 32). The procedural time was longer in the IAD group (96 versus 61 minutes, P = .002), despite similar rates of TICI 2b-3 (89.5% versus 87.5%, P = 1.000). The NIHSS score at 7 days was higher (21 versus 8, P = .060) and poor outcomes (mRS 4-6 at 3 months) were more frequent in the IAD group (73.7% versus 43.8%, P = .038). IAD (odds ratio, 5.469; 95% CI, 1.09-27.58; P = .040) was independently associated with poor outcomes. CONCLUSIONS An arterial occlusion related to IAD was associated with a longer procedural time and poorer clinical outcome. Further studies are warranted to elucidate the appropriate endovascular strategy.


title: Surgery duration predicts urinary retention after inguinal herniorrhaphy: a single institution review.

text: BACKGROUND Inguinal hernia repair, laparoscopic or open, is one of the most frequently performed operations in general surgery. Postoperative urinary retention (POUR) can occur in 0.2-35 % of patients after inguinal hernia repair. The primary objective of this study was to determine the incidence of POUR after inguinal hernia repair. As a secondary goal, we sought to determine whether perioperative and patient factors predicted urinary retention. METHODS This study is a retrospective review of patients who underwent inguinal hernia repair with synthetic mesh at the Medical College of Wisconsin from January 2007 to June 2012. Procedures were performed by four surgeons. Clinical information and perioperative outcomes were collected up to hospital discharge. Urinary retention was defined as need for urinary catheterization postoperatively. RESULTS A total of 192 patients were included in the study (88 bilateral, 46 %) and (104 unilateral, 54 %). The majority of subjects (76 %) underwent laparoscopic repair. The overall POUR rate was 13 %, with 25 of 192 patients requiring a Foley catheter prior to discharge. POUR was significantly associated with bilateral hernia repairs (p = 0.04), BMI ≥ 35 kg/m(2) (p = 0.05) and longer operative times (p = 0.03). Based on odds ratio (OR) estimates, for every 10-min increase in operative time, an 11 % increase in the odds of urinary retention is expected (OR 1.11, CI 1.004-1.223; p = 0.04). For every 10-min increase in operative time, an 11 % increase in POUR is expected. CONCLUSIONS Bilateral hernia repairs, BMI ≥ 35 kg/m(2), and operative time are significant predictors of POUR. These factors are important to determine potential risk to patients and interventions such as strict fluid administration, use of catheters, and potential premedication.


title: Coronavirus HKU 1 infection with bronchiolitis, pericardial effusion and acute respiratory failure in obese adult female.

text: Seven species of coronavirus cause of acute respiratory illness in humans. Coronavirus HKU 1 (CoV-HKU 1) was first described in 2005 in an adult patient with pneumonia in Hong Kong. Although it is a well-known respiratory tract pathogen, there is not much information about its role in hospitalized adults, especially in southern Europe. Here we describe a case of radiologically demonstrated CoV-HKU 1-related bronchiolitis with acute respiratory failure in an adult female without significant comorbidities except obesity.


title: Finger and forehead photoplethysmography-derived pulse-pressure variation and the benefits of baseline correction.

text: To non-invasively predict fluid responsiveness, respiration-induced pulse amplitude variation (PAV) in the photoplethysmographic (PPG) signal has been proposed as an alternative to pulse pressure variation (PPV) in the arterial blood pressure (ABP) signal. However, it is still unclear how the performance of the PPG-derived PAV is site-dependent during surgery. The aim of this study is to compare finger- and forehead-PPG derived PAV in their ability to approach the value and trend of ABP-derived PPV. Furthermore, this study investigates four potential confounding factors, (1) baseline variation, (2) PPV, (3) ratio of respiration and heart rate, and (4) perfusion index, which might affect the agreement between PPV and PAV. In this work, ABP, finger PPG, and forehead PPG were continuously recorded in 29 patients undergoing major surgery in the operating room. A total of 91.2 h data were used for analysis, from which PAV and PPV were calculated and compared. We analyzed the impact of the four factors using a multiple linear regression (MLR) analysis. The results show that compared with the ABP-derived PPV, finger-derived PAV had an agreement of 3.2 ± 5.1%, whereas forehead-PAV had an agreement of 12.0 ± 9.1%. From the MLR analysis, we found that baseline variation was a factor significantly affecting the agreement between PPV and PAV. After correcting for respiration-induced baseline variation, the agreements for finger- and forehead-derived PAV were improved to reach an agreement of - 1.2 ± 3.8% and 3.3 ± 4.8%, respectively. To conclude, finger-derived PAV showed better agreement with ABP-derived PPV compared to forehead-derived PAV. Baseline variation was a factor that significantly affected the agreement between PPV and PAV. By correcting for the baseline variation, improved agreements were obtained for both the finger and forehead, and the difference between these two agreements was diminished. The tracking abilities for both finger- and forehead-derived PAV still warrant improvement for wide use in clinical practice. Overall, our results show that baseline-corrected finger- and forehead-derived PAV may provide a non-invasive alternative for PPV.


title: A new laparoscopic method of bowel radio-protection before pelvic chemoradiation of locally advanced cervix cancers.

text: BACKGROUND Chemoradiation therapy (CRT) has become the mainstay of locally advanced cervical carcinomas (LACC). However, the price to pay is a significant rate of both early and late colo-rectal toxicities, which may impact on survivors' quality of life. To reduce the incidence of such complications, we suggest a simple technique of pelvic radioprotection. MATERIALS AND METHODS An omental flap is created which is placed to fill the Douglas pouch to both increase the space between rectum and uterine cervix and prevent small bowel to fall in and to be exposed to radiation. In addition, a long sigmoid loop is retracted and fixed in the left paracolic gutter to prevent its irradiation as well. RESULTS From May 2011 to May 2012, 51 successive LACC patients were offered this procedure in addition of a laparoscopic staging. All but 2 with too small an omentum benefitted from omentoplasty, while sigmoidopexy was performed in all but one patient with a long and free sigmoid loop. No immediate adverse effect was observed. The volume of retro-uterine omental flap averaged 7.17 ± 3.79 cm(3). Sequential measurements of the utero-rectal space throughout CRT duration showed a real and durable increase in the distance between these organs, resulting in a drop in the dose of irradiation to recto-sigmoid. With 10 ± 4.5-month median follow-up, we did not observe any rectal or small bowel early or late adverse effects of CRT. CONCLUSIONS Although this series is preliminary, this simple procedure, feasible by laparoscopy (or laparotomy), seems effective to prevent recto-sigmoid as well as small bowel from radio-induced complications due to pelvic CRT.


title: Endovascular Repair of a Short Neck Abdominal Aortic Aneurysm with a Physician-Modified Vascutek Anaconda Stent Graft.

text: An 81-year-old woman was referred for the treatment of a 79-mm-diameter short neck abdominal aortic aneurysm with highly tortuous iliac arteries. She was considered at high risk for open repair and not suitable for standard endovascular repair given the short length of the proximal neck. Delay for a manufactured custom-made fenestrated stent graft was too long given the diameter of the aneurysm. A flexible stent graft was preferred because of severe iliac tortuosity. Endovascular repair was performed using a physician-modified Anaconda stent graft with 1 fenestration for the left renal artery. The technique for device modification and implantation is described. Postoperative course was uneventful and 1-year computed tomography scan showed complete exclusion of the aneurysm sac and patent left renal artery.


Food Safety and COVID-19.


title: Multidetector high-resolution computed tomography of the lungs: protocols and applications.

text: Advances in computed tomography (CT) scanner technology have made isotropic volumetric, multiplanar high-resolution lung imaging possible in a single breath-hold, a significant advance over the incremental high-resolution CT (HRCT) technique in which noncontiguous images sampled the lung, but lacked anatomic continuity. HRCT of the lungs is an established imaging technique for the diagnosis and management of interstitial lung disease, emphysema, and small airway disease, providing a noninvasive detailed evaluation of the lung parenchyma, and providing information about the lungs as a whole and focally. In addition to having a high degree of specificity for diagnosing conditions such as emphysema, sarcoidosis, usual interstitial pneumonitis, Langerhans cell histiocytosis, and small airway disease, there is a growing body of medical evidence to support the use of HRCT findings or diagnosis to predict patient prognosis. In this article, we review the technique, advantages, and clinical applications of the current HRCT technique.


title: Cardiac Magnetic Resonance Imaging in Patients with Acute Ischemic Stroke and Elevated Troponin: A TRoponin ELevation in Acute Ischemic Stroke (TRELAS) Sub-Study.

text: BACKGROUND Elevated high-sensitive cardiac troponin (hs-cTn) can be found in more than 50% of the patients with acute ischemic stroke. The observational TRoponin ELevation in Acute ischemic Stroke (TRELAS) study revealed that about 25% of all stroke patients with elevated troponin had a coronary angiography-detected culprit lesion affording immediate intervention, and about 50% of all patients did not have any obstructive coronary artery disease. Given the risk of procedure-related complications, the identification of stroke patients in urgent need of invasive coronary angiography is desirable. METHODS TRELAS patients were prospectively enrolled into this sub-study. In addition to conventional coronary angiography, a cardiac magnetic resonance imaging (MRI) at 3T was performed during the in-hospital stay after acute ischemic stroke to compare the diagnostic value of both imaging modalities. RESULTS Nine stroke patients (median age 73 years [range 58-87]; four females; median NIH Stroke Severity score on admission 4 [range 0-6] with elevated hs-cTnT [median 74 ng/L, interquartile range 41-247] on admission) completed cardiac MRI and underwent coronary angiography. The absence of MRI-detected wall motion abnormalities and/or late gadolinium enhancement in 5 stroke patients corresponded with the exclusion of culprit lesions or significant coronary artery disease by coronary angiography. Four patients had abnormal MRI findings, whereof 2 showed evidence of myocardial infarction and in whom coronary angiography demonstrated a >70% stenosis of a coronary artery. CONCLUSIONS The TRELAS sub-study indicates that noninvasive cardiac MRI may provide helpful information to identify stroke patients with or without acute coronary syndrome. Our findings might help to select stroke patients in urgent need of coronary angiography.


Treating COVID-19-Off-Label Drug Use, Compassionate Use, and Randomized Clinical Trials During Pandemics.


Sedation level and prevalence of delirium: response to Brummel and Ely.


EMS to stop during coronavirus outbreak.


title: New antibiotic-eluting mesh used for soft tissue reinforcement.

text: The surgical implantation of prostheses for soft tissue repair may be followed by post-operative mesh-related infection, a significant and dramatic complication, that is treated by mesh removal. A new antibiotic-eluting mesh has been manufactured on pre-existing polypropylene prostheses using an airbrush spraying technology. Among the degradable polymers tested as coating agents and drug reservoirs, poly(ε-caprolactone) (PCL), which is deposited after heating, provides a homogeneous, regular and smooth shell around the polypropylene filaments of the mesh without dramatically altering the biomechanical properties of the new modified mesh. An anti-infective drug (e.g. ofloxacin) is incorporated into this polymeric coating giving a limited burst effect followed by sustained drug diffusion for several days. An ofloxacin-eluting mesh has demonstrated excellent antibacterial activity in vitro on Escherichia coli adherence, biofilm formation and inhibitory diameter, even with low drug loads. Although further in vivo investigations are required to draw conclusions on the anti-infective effectiveness of the coated mesh, the airbrush coating of ofloxacin-PCL on existing prostheses is already potentially appealing in an effort to decrease post-operative infection.


title: Branched Thoraco-Abdominal Aortic Aneurysm Repair with Branch Access Through a Transapical Left Ventricular Approach.

text: Branched thoracic aortic aneurysm repair requires arterial access from above the diaphragm in order to insert the visceral branches. This is routinely performed from the subclavian, axillary or carotid arteries and less commonly direct thoracic aorta puncture. The left ventricular apex is an alternative access route which is commonly used for percutaneous aortic valve replacement and rarely used for EVAR, FEVAR and TEVAR access. Here we describe two patients for which the left ventricular apex was the most suitable available access to the visceral branches during a branched thoracic aortic aneurysm repair. This access should be considered as an alternative approach if conventional arterial access is not available.


title: Structural basis and functional analysis of the SARS coronavirus nsp14-nsp10 complex.

text: Nonstructural protein 14 (nsp14) of coronaviruses (CoV) is important for viral replication and transcription. The N-terminal exoribonuclease (ExoN) domain plays a proofreading role for prevention of lethal mutagenesis, and the C-terminal domain functions as a (guanine-N7) methyl transferase (N7-MTase) for mRNA capping. The molecular basis of both these functions is unknown. Here, we describe crystal structures of severe acute respiratory syndrome (SARS)-CoV nsp14 in complex with its activator nonstructural protein10 (nsp10) and functional ligands. One molecule of nsp10 interacts with ExoN of nsp14 to stabilize it and stimulate its activity. Although the catalytic core of nsp14 ExoN is reminiscent of proofreading exonucleases, the presence of two zinc fingers sets it apart from homologs. Mutagenesis studies indicate that both these zinc fingers are essential for the function of nsp14. We show that a DEEDh (the five catalytic amino acids) motif drives nucleotide excision. The N7-MTase domain exhibits a noncanonical MTase fold with a rare β-sheet insertion and a peripheral zinc finger. The cap-precursor guanosine-P3-adenosine-5',5'-triphosphate and S-adenosyl methionine bind in proximity in a highly constricted pocket between two β-sheets to accomplish methyl transfer. Our studies provide the first glimpses, to our knowledge, into the architecture of the nsp14-nsp10 complex involved in RNA viral proofreading.


title: Karyopherin Alpha 6 Is Required for Replication of Porcine Reproductive and Respiratory Syndrome Virus and Zika Virus.

text: Movement of macromolecules between the cytoplasm and the nucleus occurs through the nuclear pore complex (NPC). Karyopherins comprise a family of soluble transport factors facilitating the nucleocytoplasmic translocation of proteins through the NPC. In this study, we found that karyopherin α6 (KPNA6; also known as importin α7) was required for the optimal replication of porcine reproductive and respiratory syndrome virus (PRRSV) and Zika virus (ZIKV), which are positive-sense, single-stranded RNA viruses replicating in the cytoplasm. The KPNA6 protein level in virus-infected cells was much higher than that in mock-infected controls, whereas the KPNA6 transcript remains stable. Viral infection blocked the ubiquitin-proteasomal degradation of KPNA6, which led to an extension of the KPNA6 half-life and the elevation of the KPNA6 level in comparison to mock-infected cells. PRRSV nsp12 protein induced KPNA6 stabilization. KPNA6 silencing was detrimental to the replication of PRRSV, and KPNA6 knockout impaired ZIKV replication. Moreover, KPNA6 knockout blocked the nuclear translocation of PRRSV nsp1β but had a minimal effect on two other PRRSV proteins with nuclear localization. Exogenous restitution of KPNA6 expression in the KPNA6-knockout cells results in restoration of the nuclear translocation of PRRSV nsp1β and the replication of ZIKV. These results indicate that KPNA6 is an important cellular factor for the replication of PRRSV and ZIKV.IMPORTANCE Positive-sense, single-stranded RNA (+ssRNA) viruses replicate in the cytoplasm of infected cells. The roles of transport factors in the nucleocytoplasmic trafficking system for the replication of +ssRNA viruses are not known. In this study, we discovered that PRRSV and ZIKV viruses needed karyopherin α6 (KPNA6), one of the transport factors, to enhance the virus replication. Our data showed that viral infection induced an elevation of the KPNA6 protein level due to an extension of the KPNA6 half-life via viral interference of the ubiquitin-proteasomal degradation of KPNA6. Notably, KPNA6 silencing or knockout dramatically reduced the replication of PRRSV and ZIKV. PRRSV nsp1β depended on KPNA6 to translocate into the nucleus. In addition, exogenous restitution of KPNA6 expression in KPNA6-knockout cells led to the restoration of nsp1β nuclear translocation and ZIKV replication. These results reveal a new aspect in the virus-cell interaction and may facilitate the development of novel antiviral therapeutics.


title: Impact of botulinum toxin A injection on esophageal anastomosis in a rabbit model.

text: PURPOSE The management of esophageal atresia is established, but the rate of postoperative complications remains high. We focused on a new, recently reported method of esophageal elongation using botulinum toxin type A (BTX-A) and evaluated the efficacy of BTX-A injection around esophageal anastomoses with tension in a rabbit model. METHODS Twenty rabbits aged 8-10 weeks and weighing 1.27-1.72 kg underwent resections of the esophagus measuring 1.5 cm long using an anterior cervical approach. Esophagoesophagostomies were performed after intramural administration of Xeomin™ (3 U/body) in the BTX-A group and saline in the control group. Morphological and histological evaluations were examined on postoperative day 14. RESULTS Six rabbits in each group survived. The BTX-A group showed significantly less postoperative anastomotic stricture and less fibrosis than the control group. Changes in wall thickness on both sides of the anastomotic areas were equivalent between the two groups, and no muscle fracturing was observed. CONCLUSION Local administration of BTX-A for esophagoesophagostomy significantly reduced postoperative anastomotic stricture with less fibrosis than that observed in the control group. Reduced anastomotic tension with BTX-A presumably contributed to better anastomotic healing. Determining the optimum dose of BTX-A is necessary for clinical application.


title: Warfarin Use in Hemodialysis Patients With Atrial Fibrillation: A Systematic Review of Stroke and Bleeding Outcomes.

text: Background Given the lack of clear indications for the use of warfarin in the treatment of atrial fibrillation (AF) in patients on hemodialysis and the potential risks that accompany warfarin use in these patients, we systematically reviewed stroke and bleeding outcomes in hemodialysis patients treated with warfarin for AF. Objective To systematically review the stroke and bleeding outcomes associated with warfarin use in the hemodialysis population to treat AF. Design Systematic review. Setting All adult hemodialysis patients. Patients Patients on hemodialysis receiving warfarin for the management of AF. Measurements Any type of stroke and/or bleeding outcomes. Methods MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R) via OVID (1946 to January 11, 2017), and EMBASE via OVID (1974 to January 11, 2017) were searched for relevant literature. Inclusion criteria were randomized controlled trials, observational studies, and case series in English that examined stroke and bleeding outcomes in adult population of patients (over 18 years old) who are on hemodialysis and taking warfarin for AF. Studies with less than 10 subjects, case reports, review articles, and editorials were excluded. Quality of selected articles was assessed using Newcastle-Ottawa Scale (NOS). Results Of the 2340 titles and abstracts screened, 7 met the inclusion criteria. Two studies showed an association between warfarin use and an increased risk of stroke (Hazard Ratio: 1.93-3.36) but no association with an increased risk of bleed (HR: 0.85-1.04), while 4 studies showed no association between warfarin and stroke outcomes (HR: 0.12-1.17) but identified an association between warfarin and increased bleeding outcome (HR: 1.41-3.96). And 1 study reported neither beneficial nor harmful effects associated with warfarin use. Limitations The major limitation to this review is that the 7 included studies were observational cohort studies, and thus the outcome measures were not specified and predetermined in a research protocol. Conclusion Our systematic review demonstrated that for patients with AF who are on hemodialysis, warfarin was not associated with reduced outcomes of stroke but was rather associated with increased bleeding events.


Tackle coronavirus in vulnerable communities.


title: Risk Factors for Anastomotic Leakage of Esophagojejunostomy after Laparoscopy-Assisted Total Gastrectomy for Gastric Cancer.

text: BACKGROUND/AIMS The study aimed to clarify the risk factors for anastomotic leakage after laparoscopy-assisted total gastrectomy (LATG) for gastric cancer. METHODS In this study, we enrolled 131 patients with preoperatively diagnosed early gastric cancer who underwent LATG by a single surgeon between June 2006 and February 2014 at the Department of Surgery, Gastroenterological Center, Yokohama City University. Risk factors for anastomotic leakage (esophagojejunostomy) after LATG were retrospectively evaluated by univariate and multivariate analyses. RESULTS Anastomotic leakage of the esophagojejunostomy was observed in 13 (9.9%) of 131 patients. Univariate analysis of risk factors for anastomotic leakage revealed that the prognostic nutritional index (PNI) is a risk factor for anastomotic leakage (<55, 11 of 63 vs. ≥55, 2 of 55; p = 0.039). Multivariate analysis revealed that PNI is an independent risk factor for anastomotic leakage (OR 0.208; 95% CI 0.044-0.981; p = 0.047). CONCLUSION Gastric cancer patients with a low PNI have a higher risk for anastomotic leakage after LATG. The results of this study must be confirmed by a study with a large cohort of patients receiving LATG reconstructed using the same method by experienced surgeons in multiple institutions.


title: The efficacy of restaging endobronchial ultrasound in patients with non-small cell lung cancer after preoperative therapy.

text: BACKGROUND Patient selection for surgery after neoadjuvant therapy for locally advanced non-small cell lung cancer depends on accurate restaging of mediastinal (N2) lymph nodes. Our objective is to assess the accuracy of endobronchial ultrasound (EBUS) for restaging N2 lymph nodes after neoadjuvant therapy. METHODS This is a retrospective review of patients with non-small cell lung cancer who underwent staging with repeat computed tomography and positron emission tomography and had restaging EBUS for sampling of N2 lymph nodes. Endobronchial ultrasound was performed for suspicious nodes in stations 2R, 2L, 4R, 4L, and 7. Selected patients who were N2-negative underwent thoracotomy with complete thoracic lymphadenectomy. RESULTS There were 32 patients with N2 disease who underwent preoperative chemotherapy or radiotherapy, or both, and subsequently had restaging EBUS. There were 3 patients who had recalcitrant N2 nodal disease detected by EBUS. There were 5 patients with pulmonary function or comorbidities that were prohibitive for surgery. Of the remaining 24 patients with negative EBUS, 3 underwent mediastinoscopy and 2 had recalcitrant N2 disease. The remaining 22 patients underwent thoracotomy. Recalcitrant N2 disease was noted in 1 patient at thoracotomy in the EBUS-assessable nodal stations. Thus EBUS was falsely negative in 3 patients. The sensitivity and negative predictive value of restaging EBUS were 50% and 88%, respectively. CONCLUSIONS Restaging EBUS is relatively accurate at predicting the absence of metastatic disease in N2 mediastinal lymph node in patients who underwent neoadjuvant therapy for non-small cell lung cancer.


title: Estimation of absorbed dose to the kidneys in patients after treatment with 177Lu-octreotate: comparison between methods based on planar scintigraphy.

text: UNLABELLED BACKGROUND Lu-[DOTA0, Tyr3]-octreotate (177Lu-octreotate) is used to treat neuroendocrine tumors with high somatostatin-receptor expression. 177Lu-octreotate is mainly excreted via the kidneys, but to some extent, accumulates in the kidney cortex due to, e.g., tubular reabsorption. Renal toxicity is one of the main limiting factors in 177Lu-octreotate treatment. Further knowledge of the biodistribution and dosimetry of 177Lu-octreotate in individual patients is needed. The aim of this study was to estimate the absorbed dose to the kidneys and compare the results obtained with planar imaging and different dosimetric methods: (1) conjugate-view (CV) method using patient-specific kidney sizes, (2) PA method, based on posterior images only, (3) CV method with reduced number of time points (CVreduced data), and (4) CV method using standard kidney sizes (CVstandard size). METHODS Totally, 33 patients each received 3.4 to 8.2 GBq of 177Lu-octreotate up to five times, with infusion of lysine and arginine to block the renal uptake. Whole-body planar gamma camera images were acquired on days 0, 1, 2, and 7. The 177Lu concentration in the kidneys was determined by the CV method, and the absorbed dose was estimated with patient-specific organ sizes. Comparison to the CV method was made using posterior images only, together with the influence of the number of time points and with standard organ sizes. RESULTS Large interindividual variations were found in the time-activity curve pattern and in the absorbed dose to the kidneys using the CV method: 0.33 to 2.4 Gy/GBq (mean = 0.80 Gy/GBq, SD = 0.30). In the individual patient, the mean deviation of all subsequent kidney doses compared to that of the first administration was 1% (SD = 19%) and 5% (SD = 23%) for the right and left kidneys, respectively. Excluding data for day 7 resulted in large variations in the absorbed dose. CONCLUSION Large interindividual variations in kidney dose were found, demonstrating the need for patient-specific dosimetry and treatment planning.


Distancing? But still I-care: Tele-ophthalmology during COVID-19 era.


title: [Clinical characteristics and risk factors of acute kidney injury in coronavirus disease 2019].

text: OBJECTIVE To investigate the characteristics and the risk factors of coronavirus disease 2019 (COVID-19) associated acute kidney injury (AKI). METHODS A retrospective cohort study was performed to examine the basic data, clinical characteristics and prognosis of patients with COVID-19 in Zhongnan Hospital of Wuhan University and Wuhan Fourth Hospital from January 1st to February 1st in 2020. According to the diagnostic criteria of Kidney Disease: Improving Global Outcomes (KDIGO), patients with AKI were included in AKI group and those without AKI were included in non-AKI group. The differences of each index between the two groups were compared. The prognostic value of AKI for COVID-19 was analyzed by Kaplan-Meier survival curve and Cox regression. RESULTS A total of 394 COVID-19 patients were included, with a total mortality of 5.6%; 37 (9.4%) of them developed AKI. The mortality of patients with COVID-19 associated AKI was 18.9%. There were significant differences in age, gender, smoking history, hypertension history, malignancy history, cardiovascular disease history and cerebrovascular disease history between the two groups. In addition to the difference of serum creatinine (SCr) and blood urea nitrogen (BUN), white blood cell count (WBC), neutrophil count (NEU), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), D-dimer, procalcitonin (PCT) and C-reaction protein (CRP) in AKI group were significantly higher than those in non-AKI group [WBC (×109/L): 5.75 (4.13, 7.83) vs. 4.52 (3.35, 5.90), NEU (×109/L): 4.55 (2.81, 6.11) vs. 3.06 (2.03, 4.50), AST (U/L): 40.0 (24.5, 69.5) vs. 30.0 (23.0, 42.5), LDH (μmol×s-1×L-1): 5.21 (3.68, 7.57) vs. 4.24 (3.05, 5.53), D-dimer (μg/L): 456 (266, 2 172) vs. 290 (152, 610), PCT (μg/L): 0.33 (0.03, 1.52) vs. 0.01 (0.01, 0.11), CRP (mg/L): 53.80 (26.00, 100.90) vs. 23.60 (9.25, 51.10), all P < 0.05], while lymphocyte count (LYM) and platelet count (PLT) were decreased [LYM (×109/L): 0.68 (0.47, 1.05) vs. 0.91 (0.63, 1.25), PLT (×109/L): 142.0 (118.0, 190.0) vs. 171.0 (130.0, 2 190.0), both P < 0.05]. The mortality of AKI group was significantly higher than that of non-AKI group [18.9% (7/37) vs. 4.2% (15/357), P < 0.01]. Kaplan-Meier survival curve showed that the 30-day cumulative survival of AKI group was lower than that of non-AKI group (log-rank: P = 0.003). Cox analysis also showed that AKI increased the odds of patients with COVID-19 mortality by 3.2-fold [hazard ratio (HR) = 3.208, 95% confidence interval (95%CI) was 1.076-9.566, P = 0.037]. CONCLUSIONS The risk of AKI is higher in patients with COVID-19. Early intervention to prevent AKI in patients with COVID-19 is of great significance to improve the prognosis of patients.


title: Single-incision laparoscopic cholecystectomy using glove port in comparison with standard laparoscopic cholecystectomy SILC using glove port.

text: PURPOSE Surgery with minimal scar has become a widely used surgical method during the last decade. Single-incision laparoscopic cholecystectomy (SILC) promises better cosmetic results and probably less pain compared with conventional laparoscopy. METHODS In a period of 5 months, data were collected and analyzed from patients, who underwent SILC using the Glove port. Another group of patients who underwent standard laparoscopic cholecystectomy during the same period has been taken as control group. Demographic data, operative time, successfulness of operation, length of hospital stay, and postoperative findings were collected. RESULTS Twenty-five patients underwent SILC and 30 patients underwent the standard procedure. There were no conversions to open procedure in either group. No major complications occurred. Operative time in SILC cases was significantly more than the standard technique, whereas postoperative pain in the SILC group was considerably less. CONCLUSIONS It seems that in selected patients (with a low risk of adhesions or technical difficulty), SILC can be an acceptable alternative to standard laparoscopic cholecystectomy with acceptable results.


title: Lentivirus-Mediated Overexpression of MicroRNA-210 Improves Long-Term Outcomes after Focal Cerebral Ischemia in Mice.

text: AIMS MicroRNAs play an important role in the pathogenesis of ischemic brain injury and in the repair process during postischemic condition. However, the key miRNAs and their function in these processes remain unclear. METHODS Circulating blood MicroRNAs profiles were examined in the ischemic stroke patients. The predicted network of difference was analyzed by ingenuity pathway analysis. The key MicroRNAs were selected, and the function was further studied in a mouse ischemia model. The predicted downstream target was confirmed. RESULTS We found that 24 MicroRNAs were differently expressed in stroke patients compared to the control (P < 0.05). Bioinformatic analysis showed a MicroRNAs regulated network with the highest score in the stroke cascade, which was consisted of 10 MicroRNAs including key hypoxia-related miR-210 and its predicted downstream target brain derived neurotrophic factor (BDNF). Lentivirus-mediated miR-210 overexpression enhanced the microvessel density and the number of neural progenitor cells in the ischemic mouse brain (P < 0.05) and improved neurobehavioral outcomes in the ischemic mouse (P < 0.05). MiR-210 upregulation increased mBDNF/proBDNF protein expression in the normal and ischemic mouse brain. The dual-luciferase reporter assay identified that BDNF was the direct target of miR-210. CONCLUSION MiR-210 is a crucial ischemic stroke-associated MicroRNAs and a potential target for the stroke therapy.


title: Middle East respiratory syndrome coronavirus (MERS-CoV): A review.

text: As a novel coronavirus first reported by Saudi Arabia in 2012, the Middle East respiratory syndrome coronavirus (MERS-CoV) is responsible for an acute human respiratory syndrome. The virus, of 2C beta-CoV lineage, expresses the dipeptidyl peptidase 4 (DPP4) receptor and is densely endemic in dromedary camels of East Africa and the Arabian Peninsula. MERS-CoV is zoonotic but human-to-human transmission is also possible. Surveillance and phylogenetic researches indicate MERS-CoV to be closely associated with bats' coronaviruses, suggesting bats as reservoirs, although unconfirmed. With no vaccine currently available for MERS-CoV nor approved prophylactics, its global spread to over 25 countries with high fatalities highlights its role as ongoing public health threat. An articulated action plan ought to be taken, preferably from a One Health perspective, for appropriately advanced countermeasures against MERS-CoV.


title: Laparoscopic incisional hernia repair in an ambulatory surgery-extended recovery centre: a review of 259 consecutive cases.

text: PURPOSE The high prevalence of incisional hernias and an average stay of 3-10 days for open procedures have made this pathology both a health problem and an economic issue. A protocol was developed for performing this procedure in an Ambulatory Surgery Center (ASC) with extended recovery. METHODS From January 2000 to December 2011, data about all laparoscopic incisional hernia repairs were gathered prospectively. The patients' clinical features, hernia type, intraoperative and postoperative complications and reasons for hospital admission are studied. RESULTS A total of 259 patients have been operated for incisional hernia (185) or recurrent hernioplasty (74) in our ASC. Laparoscopic repair was successful in 254 patients (98.07 %). Conversion to open surgery was necessary in five patients (1.93 %). A total of 50 patients (19.69 %) in whom surgery was completed laparoscopically were discharged the same day of surgery, 179 (70.47 %) at 24 h and 25 (9.84 %) required a stay of over 24 h. Postoperative pain was severe in 10 % of patients, moderate in 40 %, and mild in 50 %. Complications, mostly minor and self-limiting, were observed in 25 patients (9.84 %) during hospital stay. Five major complications that occured were: bile peritonitis, an acute peritonitis, due to an inadvertent intestinal perforation, and one intestinal obstruction by partial detachment of the mesh, an intra-abdominal hematoma and a colo-cutaneous fistula. There were no deaths in the series. The mean follow-up of patients was 29.35 months (range 12-129 months). The recurrence rate was 7.03 % (n = 18). Four trocar-site hernias were detected. CONCLUSIONS It is essential to create a protocol with selection criteria that take into account the patient, his entourage, the anesthetic-surgical procedure, and a team dedicated to surgical laparoscopic surgery in an ASC with extended recovery to achieve good results in terms of morbidity and patient safety.


Letter to the editor.


title: Monopolar electrosurgery through single-port laparoscopy: a potential hidden hazard for bowel burns.

text: BACKGROUND Surveys indicate that up to 90% of general surgeons and gynecologists use monopolar radiofrequency during laparoscopy and 18% have experienced visceral burns. Monopolar electrosurgery compared with other energy sources is associated with unique characteristics and inherent risks and complications caused by inadvertent direct or capacitive coupling or insulation failure of instruments. These dangers become particularly important with the reemergence of single-port laparoscopy, which requires close proximity and crossing of multiple intraabdominal instruments outside the surgeon's field of view. STUDY OBJECTIVES To determine the effects of monopolar electrosurgery on various tissues/organs during simulated single-port laparoscopic surgery in vitro and in vivo. DESIGN Simulation in a dry laboratory with fresh sheep liver, pig bowel and bowel in an anesthetized dog (Canadian Classification II-3). SETTING University-affiliated teaching hospital and animal facilities. MEASUREMENTS AND MAIN RESULTS We used Valleylab Force 2 and FX electrosurgical generators at clinically used power outputs of 40 to 60 watts, and both high- and low-voltage (coagulation and cut) waveforms and commercially-available single-port devices. The effect on tissue was recorded by pictures and video camera and graded visually and histologically with hematoxylin and eosin stains. During activation of any standard monopolar laparoscopic instrument (scissors, coagulating electrode, etc), capacitive coupled currents resulting in visible tissue burn (blanching) caused by other adjacent cold instrument (graspers, etc) including metallic suction-irrigation cannulas and the laparoscope itself were noted. Histopathologic study confirmed transmural thermal damage extending to the mucosa of small bowel, even in the presence of mild serosa blanching. With prolonged activation of the electrosurgical generator, the capacitive coupled corona discharge burned the insulation and caused rapid insulation breakdown of the electrode instrument resulting in direct coupling (sparking, arcing) to adjacent cold instruments and more severe burning to the contacted tissue/organ. CONCLUSIONS During single-port laparoscopy and use of monopolar radiofrequency, the proximity and crossing of multiple instruments generate capacitive or direct coupled currents, which may cause visceral burns.


title: Palliative care for homeless people: a systematic review of the concerns, care needs and preferences, and the barriers and facilitators for providing palliative care.

text: BACKGROUND Homeless people often suffer from complex and chronic comorbidities, have high rates of morbidity and die at much younger ages than the general population. Due to a complex combination of physical, psychosocial and addiction problems at the end of life, they often have limited access to palliative care. Both the homeless and healthcare providers experience a lot of barriers. Therefore, providing palliative care that fits the needs and concerns of the homeless is a challenge to healthcare providers. This systematic review aims to summarize evidence about the concerns, palliative care needs and preferences of homeless people, as well as barriers and facilitators for delivering high quality palliative care. METHODS PubMed, Embase, PsycINFO, CINAHL and Web of Science were searched up to 10 May 2016. Included were studies about homeless people with a short life expectancy, their palliative care needs and the palliative care provided, that were conducted in Western countries. Data were independently extracted by two researchers using a predefined extraction form. Quality was assessed using a Critical Appraisal instrument. The systematic literature review was based on the PRISMA statement. RESULTS Twenty-seven publications from 23 different studies met the inclusion criteria; 15 studies were qualitative and eight were quantitative. Concerns of the homeless often related to end-of-life care not being a priority, drug dependence hindering adequate care, limited insight into their condition and little support from family and relatives. Barriers and facilitators often concerned the attitude of healthcare professionals towards homeless people. A respectful approach and respect for dignity proved to be important in good quality palliative care. CONCLUSIONS A patient-centred, flexible and low-threshold approach embodying awareness of the concerns of homeless people is needed so that appropriate palliative care can be provided timely. Training, education and experience of professionals can help to accomplish this.


title: Intra-articular Recombinant Human Proteoglycan 4 Mitigates Cartilage Damage After Destabilization of the Medial Meniscus in the Yucatan Minipig.

text: BACKGROUND Lubricin, or proteoglycan 4 (PRG4), is a glycoprotein responsible for joint boundary lubrication. PRG4 has been shown previously to be down-regulated after traumatic joint injury such as a meniscal tear. Preliminary evidence suggests that intra-articular injection of PRG4 after injury will reduce cartilage damage in rat models of surgically induced posttraumatic osteoarthritis. OBJECTIVE To determine the efficacy of intra-articular injection of full-length recombinant human lubricin (rhPRG4) for reducing cartilage damage after medial meniscal destabilization (DMM) in a preclinical large animal model. STUDY DESIGN Controlled laboratory study. METHODS Unilateral DMM was performed in 29 Yucatan minipigs. One week after DMM, animals received 3 weekly intra-articular injections (3 mL per injection): (1) rhPRG4 (1.3 mg/mL; n = 10); (2) rhPRG4+hyaluronan (1.3 mg/mL rhPRG4 and 3 mg/mL hyaluronan [~950 kDA]; n = 10); and (3) phosphate-buffered saline (PBS; n = 9). Hindlimbs were harvested 26 weeks after surgery. Cartilage integrity was evaluated by use of macroscopic (India ink) and microscopic (safranin O-fast green and hematoxylin and eosin) scoring systems. Secondary outcomes evaluated via enzyme-linked immunosorbent assay (ELISA) included PRG4 levels in synovial fluid, carboxy-terminal telepeptide of type II collagen (CTX-II) concentrations in urine and serum, and interleukin 1β (IL-1β) levels in synovial fluid and serum. RESULTS The rhPRG4 group had significantly less macroscopic cartilage damage in the medial tibial plateau compared with the PBS group ( P = .002). No difference was found between the rhPRG4+hyaluronan and PBS groups ( P = .23). However, no differences in microscopic damage scores were observed between the 3 groups ( P = .70). PRG4 production was elevated in the rhPRG4 group synovial fluid compared with the PBS group ( P = .033). The rhPRG4 group presented significantly lower urinary CTX-II levels, but not serum levels, when compared with the PBS ( P = .013) and rhPRG4+hyaluronan ( P = .011) groups. In serum and synovial fluid, both rhPRG4 ( P = .006; P = .017) and rhPRG4+hyaluronan groups ( P = .009; P = .03) presented decreased IL-1β levels. CONCLUSION All groups exhibited significant cartilage degeneration after DMM surgery. However, animals treated with rhPRG4 had the least amount of cartilage damage and less inflammation, providing evidence that intra-articular injections of rhPRG4 may slow the progression of posttraumatic osteoarthritis. CLINICAL RELEVANCE Patients with meniscal trauma are at high risk for posttraumatic osteoarthritis. This study demonstrates that an intra-articular injection regimen of rhPRG4 may attenuate cartilage damage after meniscal injury.


title: Are Social Status and Migration Background Associated with Utilization of Non-medical Antenatal Care? Analyses from Two German Studies.

text: OBJECTIVE Non-medical antenatal care (ANC) refers to a range of non-medical services available to women during pregnancy aiming at supporting women and prepare them for the birth and the postpartum period. In Germany, they include antenatal classes, breastfeeding classes and pregnancy-specific yoga or gymnastics courses. Studies suggest that various types of non-medical ANC carry benefits for both the women and their babies. Little is known about the uptake of non-medical ANC among different socioeconomic population subgroups, but one may expect lower utilization among socio-economically disadvantaged women. We analyzed factors contributing to the utilization of non-medical ANC in general and antenatal classes in particular. METHODS Baseline data of the Bielefeld BaBi birth cohort (2013-2016) and the Berlin perinatal study (2011-2012) were analyzed. Comparing the two cohorts allowed to increase the socio-economic and migration background variance of the study population and to capture the effect of the local context on uptake of services. Multivariate logistic regression analyses were performed to study associations between the uptake of non-medical ANC and socio-economic and migration status. RESULTS In Berlin and Bielefeld, being a first generation migrant and having lower levels of education were associated with lower non-medical ANC uptake. In Berlin, being a 2nd generation woman or having a low income was also associated with lower uptake. CONCLUSIONS FOR PRACTICE Our study suggests that non-medical ANC remains in some part the prerogative of non-migrant, well-educated and economically privileged women. Since differences in non-medical ANC have the potential to create inequalities in terms of birth outcomes and maternal health during pregnancy and post-partum, more efforts are needed to promote the use of non-medical ANC by all population groups.