title: Trauma patterns, symptoms, and complications associated with external auditory canal fractures.

text: OBJECTIVES/HYPOTHESIS External auditory canal (EAC) trauma, although rare, can have significant long-term adverse outcomes. This study aims to investigate the frequency, treatment, and complications of external ear canal injury in association with mandibular and temporal bone trauma. STUDY DESIGN Retrospective chart review. METHODS Computed tomography images with mandibular or temporal bone trauma were reviewed for EAC fractures. Patient data were collected from initial presentation and subsequent follow-up clinic visits. RESULTS Thirty-nine percent of temporal bone fractures and 3.3% of mandible trauma involved the EAC. In particular, 10% of condylar or subcondylar trauma included an EAC fracture (P = 0.0006). One patient sustained bilateral EAC fractures despite an isolated, unilateral condylar fracture. The most common presenting sign was blood in the external auditory canal. Two patients underwent exam under anesthesia and removal of debris and stenting as treatment, whereas 42% of the patients were placed on otic drops and 5% received packing or a stent. Follow-up data were only available for 16% of the patients. Hearing loss from otic capsule involvement or ossicular chain disruption were follow-up complaints, and one patient had persistent canal stenosis. CONCLUSIONS External auditory canal trauma is present in a significant proportion of mandibular and temporal bone trauma, including both condylar and noncondylar fractures with a higher incidence of condylar fractures. One case was seen with bilateral EAC fractures despite a unilateral mandibular fracture. Complications of these fractures can include hearing loss and canal stenosis; however, additional outpatient follow-up is needed to further elucidate long-term complications and shape treatment recommendations.


Maternal and neonatal management during COVID-19.


title: Lab-on-a-chip-based PCR-RFLP assay for the confirmed detection of short-length feline DNA in food.

text: Wider availability but lack of legal market trades has given feline meat a high potential for use as an adulterant in common meat and meat products. However, mixing of feline meat or its derivatives in food is a sensitive issue, since it is a taboo in most countries and prohibited in certain religions such as Islam and Judaism. Cat meat also has potential for contamination with of severe acute respiratory syndrome, anthrax and hepatitis, and its consumption might lead to an allergic reaction. We developed a very short-amplicon-length (69 bp) PCR assay, authenticated the amplified PCR products by AluI-restriction digestion followed by its separation and detection on a lab-on-a-chip-based automated electrophoretic system, and proved its superiority over the existing long-amplicon-based assays. Although it has been assumed that longer DNA targets are susceptible to breakdown under compromised states, scientific evidence for this hypothesis has been rarely documented. Strong evidence showed that shorter targets are more stable than the longer ones. We confirmed feline-specificity by cross-challenging the primers against 10 different species of terrestrial, aquatic and plant origins in the presence of a 141-bp site of an 18S rRNA gene as a universal eukaryotic control. RFLP analysis separated 43- and 26-bp fragments of AluI-digest in both the gel-image and electropherograms, confirming the original products. The tested detection limit was 0.01% (w/w) feline meat in binary and ternary admixed as well as meatball matrices. Shorter target, better stability and higher sensitivity mean such an assay would be valid for feline identification even in degraded specimens.


title: Structural analysis of a viral ovarian tumor domain protease from the Crimean-Congo hemorrhagic fever virus in complex with covalently bonded ubiquitin.

text: Crimean-Congo hemorrhagic fever (CCHF) virus is a tick-borne, negative-sense, single-stranded RNA [ssRNA(-)] nairovirus that produces fever, prostration, and severe hemorrhages in humans. With fatality rates for CCHF ranging up to 70% based on several factors, CCHF is considered a dangerous emerging disease. Originally identified in the former Soviet Union and the Congo, CCHF has rapidly spread across large sections of Europe, Asia, and Africa. Recent reports have identified a viral homologue of the ovarian tumor protease superfamily (vOTU) within its L protein. This protease has subsequently been implicated in downregulation of the type I interferon immune response through cleavage of posttranslational modifying proteins ubiquitin (Ub) and the Ub-like interferon-simulated gene 15 (ISG15). Additionally, homologues of vOTU have been suggested to perform similar roles in the positive-sense, single-stranded RNA [ssRNA(+)] arteriviruses. By utilizing X-ray crystallographic techniques, the structure of vOTU covalently bound to ubiquitin propylamine, a suicide substrate of the enzyme, was elucidated to 1.7 Å, revealing unique structural elements that define this new subclass of the OTU superfamily. In addition, kinetic studies were carried out with aminomethylcoumarin (AMC) conjugates of monomeric Ub, ISG15, and NEDD8 (neural precursor cell expressed, developmentally downregulated 8) substrates in order to provide quantitative insights into vOTU's preference for Ub and Ub-like substrates.


title: Oncological safety of ultrasound-guided laparoscopic liver resection for colorectal metastases: a case-control study.

text: Laparoscopic liver surgery has gained widespread acceptance and nowadays it is suggested even for malignant disease. Although the benefits on short-term outcomes have been proven, data on oncological safety are still lacking. The aim of this study is to assess oncologic results after ultrasound-guided laparoscopic liver resection (LLR) or open liver resection (OLR) for colorectal metastases. 37 consecutive patients undergoing LLR between 01/2004 and 03/2014 were matched at a ratio of 1:1 with 37 OLR. Matching criteria were male sex, number and diameter of liver metastases, segment location, synchronous presentation, site and stage of primary tumor, positive lymph nodes of the primary, and concomitant extrahepatic disease. Demographic characteristics were similar among groups. Parenchymal transection time was longer in the LLR group (68 ± 38.2 SD vs 40 ± 33.7 SD, p = 0.01). Mortality was nil in LLR and OLR. Overall morbidity was significantly lower in LLR (13.5 vs 37.8%, p = 0.02), although severe complications were similar among the two groups. Patients undergoing LLR were discharged earlier (5 ± 2.3 SD vs 8 ± 6.6 SD days, p < 0.001). The median margin width was 5 (0-40) mm in LLR vs 8 (0-25) mm in OLR, p = 0.897. R1 resection was recorded in four LLR and three OLR (p = 1). Overall recurrences were similar among groups. Eight patients with hepatic or extrahepatic recurrence among LLR underwent surgery vs four of OLR (p = 0.03). After a median follow-up of 35.7 months in LLR and 47.9 months in OLR, 3-year overall survival was 91.8% LLR and 74.8% OLR (p = 0.14). 3-year disease-free survival was 69.1% LLR and 65.9% OLR (p = 0.53). Multivariate analysis showed that postoperative complications [HR 3.42 (95% CI 1.32-8.89)] and multiple metastases [HR 3.84 (95% CI 1.34-10.83)] were independent predictors of worse survival (p = 0.01). Ultrasound-LLR for colorectal hepatic metastases is safe, ensuring oncologic outcomes comparable to OLR.


title: Comparison of endostapler performance in challenging tissue applications.

text: BACKGROUND Surgical staplers are frequently used in a variety of applications, demanding exacting instrument performance over a huge range of tissue compositions and disease states. The shape of a staple that is formed by a stapling device is one industry-accepted indicator of device performance; typically a B-shaped staple is considered the gold standard for staple formation. This B shape allows blood flow through the tissue, which is one important factor in the healing events that take place clinically after stapling. With the use of an animal model, this ex vivo study investigated staple formation when thick tissue endoscopic staplers were used on challenging and variable tissue. The setting was a corporate institution in the United States. METHODS Two 60-mm linear endoscopic thick tissue reloads, a varied-height stapler (VHS), and a single-height stapler (SHS) were fired on 7 different regions of porcine stomach. Resultant staple formation was assessed per region of the stomach and evaluated for proper B-shaped staple formation and staple malformation. RESULTS The VHS reload had significantly better B-shaped formation (P<.001) for all regions of the stomach and reduced occurrence of malformed staples in 5 of the 7 regions compared with the SHS reload, wherein the remaining 2 regions exhibited comparable malform occurrence. CONCLUSIONS This study compared 2 thick tissue reloads and found that the VHS reload had superior outcomes, with respect to staple formation, compared with the SHS reload.


title: Self-management of patients with advanced cancer: A systematic review of experiences and attitudes.

text: BACKGROUND Patients with advanced cancer are increasingly expected to self-manage. Thus far, this topic has received little systematic attention. AIM To summarise studies describing self-management strategies of patients with advanced cancer and associated experiences and personal characteristics. Also, to summarise attitudes of relatives and healthcare professionals towards patient self-management. DESIGN A systematic review including non-experimental quantitative and qualitative studies. Data were analysed using critical interpretive synthesis. Included studies were appraised on methodological quality and quality of reporting. DATA SOURCES MEDLINE, Embase, Cochrane Central, PsycINFO, CINAHL, Web of Science and Google Scholar (until 11 June 2019). RESULTS Of 1742 identified articles, 31 moderate-quality articles describing 8 quantitative and 23 qualitative studies were included. Patients with advanced cancer used self-management strategies in seven domains: medicine and pharmacology, lifestyle, mental health, social support, knowledge and information, navigation and coordination and medical decision-making (29 articles). Strategies were highly individual, sometimes ambivalent and dependent on social interactions. Older patients and patients with more depressive symptoms and lower levels of physical functioning, education and self-efficacy might have more difficulties with certain self-management strategies (six articles). Healthcare professionals perceived self-management as desirable and achievable if based on sufficient skills and knowledge and solid patient-professional partnerships (three articles). CONCLUSION Self-management of patients with advanced cancer is highly personal and multifaceted. Strategies may be substitutional, additional or even conflicting compared to care provided by healthcare professionals. Self-management support can benefit from an individualised approach embedded in solid partnerships with relatives and healthcare professionals.


title: Risk factors associated with mortality after Roux-en-Y gastric bypass surgery.

text: OBJECTIVE We sought to identify the major risk factors associated with mortality in Roux-en-Y gastric bypass (RYGB) surgery. BACKGROUND Bariatric surgery has become an established treatment for extreme obesity. Bariatric surgery mortality has steadily declined with current rates of less than 0.5%. However, significant variation in the mortality rates has been reported for specific patient cohorts and among bariatric centers. METHODS Clinical outcome data from 185,315 bariatric surgery patients from the Bariatric Outcome Longitudinal Database were reviewed. Of these, 157,559 patients had either documented 30 or more day follow-up data, including mortality. Multiple demographic, socioeconomic, and clinical factors were analyzed by univariate analysis for their association with 30-day mortality after gastric bypass. Variables found to be significant were entered into a multiple logistic regression model to identify factors independently associated with 30-day mortality. On the basis of these results, a RYGB mortality risk score was developed. RESULTS The overall 30-day mortality rate for the entire bariatric surgery cohort was 0.1%. Of the 81,751 RYGB patients, the mortality rate was 0.15%. Factors significantly associated with 30-day gastric bypass mortality included increasing body mass index (BMI) (P<0.0001), increasing age (P<0.005), male gender (P<0.001), pulmonary hypertension (P<0.0001), congestive heart failure (P=0.0008), and liver disease (P=0.038). When the RYGB risk score was applied, a significant trend (P<0.0001) between increasing risk score and mortality rate is found. CONCLUSIONS Increasing BMI, increasing age, male gender, pulmonary hypertension, congestive heart failure, and liver disease are risk factors for 30-day mortality after RYGB. The RYGB risk score can be used to determine patients at greater risk for mortality after RYGB surgery.


Isolated Anosmia as a Presentation of COVID-19: An Experience in a Referral Hospital.


Response to the Letter to the Editor: How to Deal with Suspended Oral Treatment during the COVID-19 Epidemic.


title: Collaterals in endovascular therapy for stroke.

text: PURPOSE OF REVIEW Endovascular therapy is a promising aspect of acute ischemic stroke treatment. The ideal population of patients who benefit from treatment remains undefined, and the status of collateral circulation at presentation may be a key feature in their identification. RECENT FINDINGS Adequate collateral flow has been recently demonstrated to be associated with improved clinical status on presentation, increased likelihood of recanalization with endovascular therapy, and better functional outcome at 3 months. SUMMARY In this review, we define the collateral circulation, review methods of its measurement, and present recent clinical data on its impact in endovascular therapy for acute ischemic stroke. We outline our current understandings and discuss their relevance in future directions with clinical stroke management.


title: Early safety indicators of COVID-19 convalescent plasma in 5,000 patients.

text: BACKGROUND Convalescent plasma is the only antibody based therapy currently available for COVID 19 patients. It has robust historical precedence and sound biological plausibility. Although promising, convalescent plasma has not yet been shown to be safe as a treatment for COVID-19. METHODS Thus, we analyzed key safety metrics after transfusion of ABO compatible human COVID-19 convalescent plasma in 5,000 hospitalized adults with severe or life threatening COVID-19, with 66% in the intensive care unit, as part of the US FDA Expanded Access Program for COVID-19 convalescent plasma. RESULTS The incidence of all serious adverse events (SAEs) in the first four hours after transfusion was <1%, including mortality rate (0.3%). Of the 36 reported SAEs, there were 25 reported incidences of related SAEs, including mortality (n = 4), transfusion-associated circulatory overload (TACO; n = 7), transfusion-related acute lung injury (TRALI; n = 11), and severe allergic transfusion reactions (n = 3). However, only 2 (of 36) SAEs were judged as definitely related to the convalescent plasma transfusion by the treating physician. The seven-day mortality rate was 14.9%. CONCLUSION Given the deadly nature of COVID 19 and the large population of critically-ill patients included in these analyses, the mortality rate does not appear excessive. These early indicators suggest that transfusion of convalescent plasma is safe in hospitalized patients with COVID-19.


title: Bariatric Surgery for Morbid Obesity: Tehran Obesity Treatment Study (TOTS) Rationale and Study Design.

text: BACKGROUND Obesity is a major health concern in the Middle East and worldwide. It is among the leading causes of morbidity, mortality, health care utilization, and costs. With bariatric surgery proving to be a more effective treatment option for overweight and obesity, the need for systematic assessment of different procedures and their outcomes becomes necessary. These procedures have not yet been described in detail in our region. OBJECTIVE We aim to undertake a prospective study evaluating and comparing several surgical bariatric procedures in an Iranian population of morbid obese patients presenting to a specialized bariatric center. METHODS In order to facilitate and accelerate understanding of obesity and its complications, the Tehran Obesity Treatment Study (TOTS) was planned and developed. This study is a longitudinal prospective cohort study in consecutive patients undergoing bariatric surgery. TOTS investigators use standardized definitions, high-fidelity data collection system, and validated instruments to gather data preoperatively, at the time of surgery, postoperatively, and in longer-term follow-up. RESULTS This study has recruited 1050 participants as of September 2015 and is ongoing. CONCLUSIONS This study will ensure creation of high-level evidence to enable clinicians to make meaningful evidence-based decisions for patient evaluation, selection for surgery, and follow-up care.


title: Psychophysiological Effects of Downregulating Negative Emotions: Insights From a Meta-Analysis of Healthy Adults.

text: Assessing psychophysiological responses of emotion regulation is a cost-efficient way to quantify emotion regulation and to complement subjective report that may be biased. Previous studies have revealed inconsistent results complicating a sound interpretation of these findings. In the present study, we summarized the existing literature through a systematic search of articles. Meta-analyses were used to evaluate effect sizes of instructed downregulation strategies on common autonomic (electrodermal, respiratory, cardiovascular, and pupillometric) and electromyographic (corrugator activity, emotion-modulated startle) measures. Moderator analyses were conducted, with moderators including study design, emotion induction, control instruction and trial duration. We identified k = 78 studies each contributing multiple sub-samples and performed 23 meta-analyses for combinations of emotion regulation strategy and psychophysiological measure. Overall, results showed that effects of reappraisal and suppression on autonomic measures were highly inconsistent across studies with rather small mean effect sizes. Electromyography (startle and corrugator activity) showed medium effect sizes that were consistent across studies. Our findings highlight the diversity as well as the low level of standardization and comparability of research in this area. Significant moderation of effects by study design, trial duration, and control condition emphasizes the need for better standardization of methods. In addition, the small mean effect sizes resulting from our analyses on autonomic measures should be interpreted with caution. Findings corroborate the importance of multi-channel approaches.


title: Quercetin derivatives as non-nucleoside inhibitors for dengue polymerase: molecular docking, molecular dynamics simulation, and binding free energy calculation.

text: Dengue is an important public health problem in tropical and subtropical regions of the world. Neither vaccine nor an antiviral medication is available to treat dengue. This insists the need of drug discovery for dengue. In order to find a potent lead molecule, RNA-dependent RNA polymerase which is essential for dengue viral replication is chosen as a drug target. As Quercetin showed antiviral activity against several viruses, quercetin derivatives developed by combinatorial library synthesis and mined from PubChem databases were screened for a potent anti-dengue viral agent. Our study predicted Quercetin 3-(6″-(E)-p-coumaroylsophoroside)-7-rhamnoside as a dengue polymerase inhibitor. The results were validated by molecular dynamics simulation studies which reveal water bridges and hydrogen bonds as major contributors for the stability of the polymerase-lead complex. Interactions formed by this compound with residues Trp795, Arg792 and Glu351 are found to be essential for the stability of the polymerase-lead complex. Our study demonstrates Quercetin 3-(6″-(E)-p-coumaroylsophoroside)-7-rhamnoside as a potent non-nucleoside inhibitor for dengue polymerase.


title: Clinical Pearls in Venovenous Extracorporeal Life Support for Adult Respiratory Failure.

text: Extracorporeal life support (ECLS) has been widely utilized to treat neonatal respiratory failure for two decades. However, its uptake in the case of adult respiratory failure has been slow because of a paucity of quality evidence and a sluggish tempo of ECLS-related technological advances. In recent years, interest in ECLS has been piqued after encouraging results were reported from its use during the 2009 H1N1 influenza pandemic. In a world constantly under threat from another influenza epidemic or deadly novel respiratory infection, e.g., the severe acute respiratory syndrome (SARS) virus, the Middle East respiratory syndrome coronavirus (MERS-CoV), the role of venovenous (VV) ECLS as a treatment modality for acute respiratory distress syndrome (ARDS) cannot be overemphasized. In hopes of standardizing practice, the Extracorporeal Life Support Organization (ELSO) has published books and guidelines on ECLS. However, high-level evidence to guide clinical decisions is still expediently needed in this field. Relying on the available literature and our experience in the recent South Korean MERS-CoV outbreak, we hope to highlight key physiologic and clinical points in VV ECLS for adult respiratory failure in this review.


title: Movie Night! An entertaining online educational method for introducing students to common presentations in neurology.

text: The 2020 coronavirus outbreak has obliged many medical schools to provide exclusively online education. In the current climate, we sought to develop a novel and entertaining online educational method for introducing pre-clerkship students to common clinical presentations in neurology.


title: The best treatment option(s) for adult and elderly patients with chronic primary musculoskeletal pain: a protocol for a systematic review and network meta-analysis.

text: BACKGROUND Chronic primary musculoskeletal pain (CPMP) is one subcategory of the new classification of chronic primary pain for the upcoming ICD-11, defined as chronic pain in the muscles, bones, joints, or tendons that persists or recurs for more than 3 months and is associated with significant emotional distress or functional disability. An array of pharmacological, psychological, physical, complementary, and rehabilitative interventions is available for CPMP, for which previous research has demonstrated varying effect sizes with regard to effectiveness in pain reduction and other main outcomes. This highlights the need for the synthesis of all available evidence. The proposed network meta-analysis will compare all available interventions for CPMP to determine the best treatment option(s) with a focus on efficacy and safety of interventions. METHODS We are interested in comparing interventions of the following types: psychological, pharmacological, physical, complementary, and rehabilitative interventions. We will include all randomized controlled trials that compare one intervention with another, or with a control group, in the treatment of CPMP. Primary efficacy outcomes will be pain intensity, emotional distress, and functional disability. Safety outcomes extracted will include proportion of patients with treatment-emergent adverse events, unwanted events, or drop-out rates due to side effects. Published and unpublished trials will be sought through the search of all relevant databases and trial registries. At least two independent reviewers of the team will select the references and extract data independently. We will assess the risk of bias of each individual study using the Cochrane risk of bias assessment tool. We will conduct a network meta-analysis to synthesize all evidence for each outcome. We will fit our model primarily within a Bayesian framework. DISCUSSION CPMP is a disabling condition for which several interventions exist. To our knowledge, this is the first network meta-analysis to systematically compare all available evidence. This is required by national health institutions to inform their decisions about the best available treatment option(s) with regard to efficacy and safety outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018096114.


title: Flavone synthases from Lonicera japonica and L. macranthoides reveal differential flavone accumulation.

text: Flavones are important secondary metabolites found in many plants. In Lonicera species, flavones contribute both physiological and pharmaceutical properties. However, flavone synthase (FNS), the key enzyme responsible for flavone biosynthesis, has not yet been characterized in Lonicera species. In this study, FNSII genes were identified from Lonicera japonica Thunb. and L. macranthoides Hand.-Mazz. In the presence of NADPH, the recombinant cytochrome P450 proteins encoded by LjFNSII-1.1, LjFNSII-2.1, and LmFNSII-1.1 converted eriodictyol, naringenin, and liquiritigenin to the corresponding flavones directly. The different catalytic properties between LjFNSII-2.1 and LjFNSII-1.1 were caused by a single amino acid substitution at position 242 (glutamic acid to lysine). A methionine at position 206 and a leucine at position 381 contributed considerably to the high catalytic activity of LjFNSII-1.1. In addition, LjFNSII-1.1&2.1 and LmFNSII-1.1 also biosynthesize flavones that were further modified by O-glycosylation in transgenic tobacco. The expression levels of the FNSII genes were consistent with flavone accumulation patterns in flower buds. Our findings suggested that the weak catalytic activity of LmFNSII-1.1 and the relatively low expression of LmFNSII-1.1 in flowers might be responsible for the low levels of flavone accumulation in flower buds of L. macranthoides.


title: Hemodynamic and inflammatory responses following transumbilical and transthoracic lung wedge resection in a live canine model.

text: BACKGROUND Single-port transumbilical surgery is a well-established platform for minimally invasive abdominal surgery. The aim of this study was to compare the hemodynamics and inflammatory response of a novel transumbilical technique with that of a conventional transthoracic technique in thoracic exploration and lung resection in a canine model. METHODS Sixteen dogs were randomly assigned to undergo transumbilical thoracoscopy (n = 8) or standard thoracoscopy (n = 8). Animals in the umbilical group received lung resection via a 3-cm transumbilical incision in combination with a 2.5-cm transdiaphragmatic incision. Animals in the standard thoracoscopy group underwent lung resection via a 3-cm thoracic incision. Hemodynamic parameters (e.g., mean arterial pressure, heart rate, cardiac index, systemic vascular resistance, and global end-diastolic volume index) and inflammatory parameters (e.g., neutrophil count, neutrophil 2',7' -dichlorohydrofluorescein [DCFH] expression, monocyte count, monocyte inducible nitric oxide synthase expression, total lymphocyte count, CD4+ and CD8+ lymphocyte counts, the CD4+/CD8+ratio, plasma Creactive protein level, interleukin-6 level) were evaluated before surgery, during the operation, and on postoperative days 1, 3, 7, and 14. RESULTS Lung resections were successfully performed in all 16 animals. There were 2 surgery-related mortality complications (1 animal in each group). In the transumbilical group, 1 death was caused by early extubation before the animal fully recovered from the anesthesia. In the thoracoscopic group, 1 death was caused by respiratory distress and the complication of sepsis at 5 days after surgery. There was no significant difference between the two techniques with regard to the hemodynamic and immunologic impact of the surgeries. CONCLUSION This study suggests that the hemodynamic and inflammatory changes with endoscopic lung resection performed by the transumbilical approach are comparable to those after using the conventional transthoracic approach. This information is novel and relevant for surgeons interested in developing new surgical techniques in minimally invasive surgery.


Laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy: a feasibility study.


Regulation of medical devices in the United States and European Union.


title: Combined totally endoscopic robotic coronary bypass and mitral valve repair via right-sided ports.

text: We present a case of combined coronary artery bypass grafting and mitral valve (MV) repair using a robotic totally endoscopic right-sided approach. A 61-year-old man presented with fatigue due to significant mitral regurgitation and was found to have a tight stenosis in the mid left anterior descending artery. Using the da Vinci robotic system, the patient underwent a left internal mammary artery graft to the left anterior descending artery using the C-Port Flex A distal anastomotic device followed by a MV repair. Both procedures were performed endoscopically via right chest ports and right femorofemoral bypass successfully. The patient was discharged from the hospital 3 days postoperatively and returned to normal activity within 3 weeks after surgery. This case study shows the feasibility of using an endoscopic robotic approach in selected patients undergoing combined MV coronary artery bypass grafting surgery.


title: Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery disease: 12-month results from the IN.PACT SFA randomized trial.

text: BACKGROUND Drug-coated balloons (DCBs) have shown promise in improving the outcomes for patients with peripheral artery disease. We compared a paclitaxel-coated balloon with percutaneous transluminal angioplasty (PTA) for the treatment of symptomatic superficial femoral and popliteal artery disease. METHODS AND RESULTS The IN.PACT SFA Trial is a prospective, multicenter, single-blinded, randomized trial in which 331 patients with intermittent claudication or ischemic rest pain attributable to superficial femoral and popliteal peripheral artery disease were randomly assigned in a 2:1 ratio to treatment with DCB or PTA. The primary efficacy end point was primary patency, defined as freedom from restenosis or clinically driven target lesion revascularization at 12 months. Baseline characteristics were similar between the 2 groups. Mean lesion length and the percentage of total occlusions for the DCB and PTA arms were 8.94 ± 4.89 and 8.81 ± 5.12 cm (P=0.82) and 25.8% and 19.5% (P=0.22), respectively. DCB resulted in higher primary patency versus PTA (82.2% versus 52.4%; P<0.001). The rate of clinically driven target lesion revascularization was 2.4% in the DCB arm in comparison with 20.6% in the PTA arm (P<0.001). There was a low rate of vessel thrombosis in both arms (1.4% after DCB and 3.7% after PTA [P=0.10]). There were no device- or procedure-related deaths and no major amputations. CONCLUSIONS In this prospective, multicenter, randomized trial, DCB was superior to PTA and had a favorable safety profile for the treatment of patients with symptomatic femoropopliteal peripheral artery disease. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique Identifiers: NCT01175850 and NCT01566461.


title: Perspective: ten thousand hours to patient safety, sooner or later.

text: A call by the Institute of Medicine to advance the cause of patient safety catalyzed the current focus on duty hours limits during resident education. Unrelated benefits to resident education have accrued from those efforts, but, despite rigorous study of the issue, there is little evidence of a positive impact on patient safety resulting from trainee duty hours adjustments. Moreover, the discussion has become worrisomely myopic in its singular preoccupation with the impact of postgraduate medical education duty hours on safe patient care. The author argues that patient safety efforts should focus instead on the three essential elements of capacity, of which a discussion of duty hours and fatigue are an important part, commitment, and competence. Commitment requires altruism and professionalism, which are discouraged by a shift-work orientation. Competence is essential for safe patient care; as duty hours are constricted in the name of reducing fatigue-related medical error, it must be remembered that a certain amount of time is required to both acquire a knowledge base and attain proficiency in needed technical skills. Until a competency-based educational system can be implemented, the profession and patients would be well served by a heightened awareness of the increased number of years required in a constrained work hours environment to achieve proficiency in the independent practice of medicine, especially when procedural competence is required. Such a realization will inevitably result in voluntary lengthening of some residency training programs, particularly in surgical disciplines and those medical specialties with a prominent procedural component.


title: Factors Associated with Burnout among Healthcare Workers during an Outbreak of MERS.

text: OBJECTIVE Although healthcare workers (HCWs) experienced significant stress during the 2015 outbreak of Middle East Respiratory Syndrome (MERS), the factors associated with this stress remain unknown. Thus, the present study assessed burnout among HCWs during the MERS outbreak to identify the influential factors involved in this process. METHODS This study was a retrospective chart review of the psychological tests and questionnaires completed by 171 hospital employees from two general hospitals that treated MERS patients. The tests included the Oldenburg Burnout Inventory, Positive Resources Test, the questionnaires assessed exposure to the MERS outbreak event and perceptions about MERS. RESULTS Of the 171 HCWs, 112 (65.5%) experienced disengagement and 136 (79.5%) suffered from exhaustion. Disengagement was associated with lower levels of purpose and hope, a higher perception of job risk, and exposure to the media. Exhaustion was associated with lower levels of purpose and hope, a higher perception of little control of the infection, a higher perception of job risk, prior experience related to infections, and being female. CONCLUSION Our results revealed the risk and protective factors associated with burnout among HCWs during an outbreak of MERS. These findings should be considered when determining interventional strategies aimed at ameliorating burnout among HCWs.


title: Surface deformation analysis of end-to-end stapled intestinal anastomosis.

text: BACKGROUND Stapling devices for creating anastomosis in internal organs are commonly used during surgery. Despite the obvious advantages of shortened procedure duration and fewer complications to manual suturing, staple-line leakage during intestinal anastomosis likely relates to the interaction between the staples and the tissue and to the tissue mechanical properties. The authors studied the deformation pattern close to the anastomosis to learn more about the mechanism involved in leakage. METHODS End-to-end anastomosis in pig small intestine was done using 21-mm circular staplers. Distension with pressure up to 100 cm H2O was done on the anastomosed segment. Surface markers were tracked using a microscope and a CCD camera. Circumferential and longitudinal strains were computed. RESULTS The staples restricted the deformation both in circumferential and longitudinal directions and induced a heterogeneous strain distribution. Circumferential strains were bigger between the staples (range 0.5-1) than inside the staples (range 0-0.3). The longitudinal strain ranged from 0 to slightly negative between the staples, indicating longitudinal compression. The negative strains turned into positive strains with increasing distance from the anastomosis. Further away from the anastomosis the longitudinal strain was in the range 0.3 to 0.5. CONCLUSION The surface strain field was heterogeneously close to the stapled anastomosis. The longitudinal compression between staples in the longitudinal direction during inflation may have a beneficial effect preventing leakage, a phenomenon that needs further studies. The method may be useful in the design and validation of new staplers.


title: Carotid Webs and Recurrent Ischemic Strokes in the Era of CT Angiography.

text: BACKGROUND AND PURPOSE Carotid webs may cause recurrent ischemic stroke. We describe the prevalence, demographics, clinical presentation, imaging features, histopathology, and stroke risk associated with this under-recognized lesion. MATERIALS AND METHODS A carotid web was defined on CTA as a thin intraluminal filling defect along the posterior wall of the carotid bulb just beyond the carotid bifurcation on oblique sagittal section CTA that was seen as a septum on axial CTA. Using a prospective case series from April 2013 to April 2014, we describe the demographics, spectrum of imaging features on CTA, and histopathology of these carotid webs. From a retrospective analysis of patients at our center from May 2012 to April 2013 who had a baseline head and neck CTA followed by a brain MR imaging within 1-2 days of the CTA, we determine the period prevalence of carotid webs and the prevalence of ipsilateral stroke on imaging. RESULTS In the prospective series, the mean age was 50 years (range, 41-55 years); 5/7 patients were women. Recurrent stroke was seen in 5/7 (71.4%) patients with the carotid web; time to recurrence ranged from 1 to 97 months. Histopathology suggested a high probability of fibromuscular dysplasia. In the retrospective series, carotid webs were seen in 7/576 patients for a hospital-based-period prevalence of 1.2% (95% CI, 0.4%-2.5%). Two of these 7 patients had acute stroke in the vascular territory of the carotid web. CONCLUSIONS A carotid web may contribute to recurrent ischemic stroke in patients with no other determined stroke mechanism. Intimal variant fibromuscular dysplasia is the pathologic diagnosis in most cases. The prevalence of carotid web is low, while the optimal management strategy remains unknown.


Not the Last Word: How Necessary COVID-19 Lockdowns Can Go Too Far.


title: An integrated anaerobic system for on-site treatment of wastewater from food waste disposer.

text: In this study, an integrated system of siphon-driven self-agitated anaerobic reactor (SDSAR) and anaerobic fixed bed reactor (AFBR) was conducted for the treatment of wastewater from food waste disposer (FWD), and the effect of influent total solids (TS) concentration on the process performance was evaluated. When the influent TS concentration increased from 7.04 to 15.5 g/L, the methane gas production rate increased from 0.45 to 0.92 L-CH4/L/day. However, with the influent TS concentration of food waste (FW) further increased to 23.5 g/L, a large amount of scum formed and accumulated in the SDSAR. According to the result of chemical oxygen demand (COD) recovery, the proportion of COD remained in the effluent at different TS concentrations was only around 2%. On the other hand, with an increase in TS concentration, the proportion of COD remained in the reactors increased significantly. Our results demonstrated that effluent from the integrated system can meet the water quality requirements recommended by Japan Sewage Works Association (JSWA) for wastewater from FWD. In addition, to enhance the process stability, the influent TS concentration should be maintained below 15.5 g/L.


title: Emerging viral STIs among HIV-positive men who have sex with men: the era of hepatitis C virus and human papillomavirus.

text: The number of infectious disease outbreaks and the number of unique pathogens responsible have significantly increased since the 1980s. HIV-positive men who have sex with men (MSM) are a vulnerable population with regards to the introduction, spread and clinical consequences of (newly introduced) STIs. After the introduction of combination antiretroviral treatment (cART), the incidence of sexually acquired hepatitis C virus (HCV) infection and human papillomavirus (HPV)-induced anal cancers have significantly increased among HIV-positive MSM. The introduction and expansion of HCV is the result of increased sexual risk behaviour and sexually acquired mucosal trauma within large interconnected networks of HIV-positive MSM in particular. With the availability of cART, postexposure and pre-exposure prophylaxis (PEP and PrEP) and direct-acting antivirals (DAAs) for HCV, less concern for HIV and HCV might require a new approach to develop effective behavioural intervention strategies among MSM. The marked rise in HPV-induced anal cancers can be ascribed to the long-term immunologic defects in an ageing population affected by HIV. More evidence with regards to effective treatment options for anal dysplastic lesions and the usefulness of anal malignancy screening programmes is urgently needed. Most anal cancers in the future generation of HIV-positive MSM could be prevented with the inclusion of boys in addition to girls in current HPV vaccination programmes.


title: Utility of chest CT in diagnosis of COVID-19 pneumonia.

text: PURPOSE We aimed to explore the imaging findings of computed tomography (CT) in diagnosing coronavirus disease 2019 (COVID-19) and its clinical value for further evaluation of suspected cases. METHODS Files of 155 patients visiting the fever clinics at our hospital and affiliated hospitals from January 20th to February 9th, 2020 were searched. Among them, 140 cases (including 82 males and 58 females) were included as suspected COVID-19 cases based on clinical and epidemiological history; the CT image features of 70 cases with suggestive findings on CT, confirmed by positive nucleic acid test were analyzed and evaluated. The sensitivity and specificity of CT in diagnosing COVID-19 were evaluated in patients with epidemiological history. RESULTS Of the 70 patients, 84.3% showed bilateral lung involvement on CT; 27 cases (38.6%) showed ground-glass opacity (GGO), which was mostly distributed in the subpleural area (55.7%), and this sign was mainly observed in early COVID-19 patients. In addition, 41 cases (58.6%) manifested GGO combined with focal consolidation opacity, 2 (2.8%) had flake-like consolidation opacity, with involvements of the periphery of lung field and the central zone (44.3%), and this sign was mostly observed in severe or critical patients. Concomitant signs such as pleural effusion and mediastinal lymph node enlargement were rare. Among patients with epidemiological history, the sensitivity of CT in diagnosing COVID-19 was 89.7% (70/78), and the specificity was 88.7% (55/62). CONCLUSION CT shows high sensitivity and specificity in diagnosing COVID-19. CT is an important examination method in evaluation of suspected cases and assessment of disease severity.


Rift Valley Fever: scientific pathways toward public health prevention and response.


title: Initial Clinical Experience with AView-A Clinical Computational Platform for Intracranial Aneurysm Morphology, Hemodynamics, and Treatment Management.

text: BACKGROUND The management of intracranial aneurysm (IA) is challenging. Clinicians often rely on varied and intuitively disparate ways of evaluating rupture risk that may only partially take into account complex hemodynamic and morphologic factors. We developed a prototype of a clinically oriented, streamlined, computational platform, AView, for rapid assessment of hemodynamics and morphometrics in clinical settings. To show the potential clinical utility of AView, we report our initial multicenter experience highlighting the possible advantages of morphologic and hemodynamic analysis of IAs. METHODS AView software was deployed across 8 medical centers (6 in the United States, 2 in Japan). Eight clinicians were trained and used the AView software between September 2012 and January 2013. RESULTS We present 12 illustrative cases that show the potential clinical utility of AView. For all, morphology and hemodynamics, flow visualization, and rupture resemblance score (a surrogate for rupture risk) were provided. In 3 cases, AView could confirm the clinicians' decision to treat; in 3 cases, it could suggest which aneurysms may be at greater risk among multiple aneurysms; in 5 cases, AView could provide additional information for use during treatment decisions for ambiguous situations. In one stent-assisted coiling case, flow visualization predicted that the intuitive choice for stent placement could have resulted in sacrifice of an anterior cerebral artery due to blockage by coils and led clinicians to reconsider treatment plans. CONCLUSIONS AView has the potential to confirm decisions to treat IAs, suggest which among multiple aneurysms to treat, and guide treatment decisions. Furthermore, the flow visualization it affords can inform aneurysm treatment planning and potentially avoid poor outcomes.


title: Is There a Case for Quarantine? Perspectives from SARS to Ebola.

text: Quarantine has been used for centuries in an effort to prevent the introduction, transmission, and spread of communicable diseases. While backed by legal authority, the public and even the health care worker community's understanding of the term is murky at best and scientific evidence to support the use of quarantine is frequently lacking. The multiple interpretations and references to quarantine, the inconsistent application of public health quarantine laws across jurisdictional boundaries, and reports of ineffectiveness are further complicated by associated infringement of civil liberties and human rights abuses. Given the need to balance public safety with human rights, we must be more precise about the meaning of quarantine and consider the efficacy and negative secondary effects resulting from its implementation. This article explains quarantine terminology and then uses a case study from Taiwan during the 2002-2003 severe acute respiratory syndrome (SARS) outbreak to illustrate the key principles associated with quarantine measures taken during the 2014 Ebola outbreak and the potential hazards that can arise from quarantines. Finally, we provide a quarantine and isolation decision tree to assist policy makers and public health officials in applying medically defensible, outcomes-based data and legal authorities to optimize management of emerging infectious diseases.


title: Transabdominal supra-diaphragmatic self-attached mesh for recurrent type IV diaphragmatic hernia on emergency setting: Case report.

text: INTRODUCTION Adult diaphragmatic hernia is a rare case and usually present with various clinical manifestations. Surgery can be done by thoracic and abdominal approaches. In emergency cases, mostly performed by abdominal approach. The use of mesh to close the defect is currently emerging as a viable option. PRESENTATION OF CASE We report a case of 70-year-old woman with complaints of shortness of breath and abdominal pain. The patient had a history of laparoscopic surgery with the installation of an anti-adhesive mesh for diaphragmatic hernia seven months before admission. Chest X-ray and Computed Tomography (CT) scan found recurrence of diaphragmatic hernia. The patient then received laparotomy showing diaphragmatic hernia with contents in the form of transverse colon, ileum, gastric and omentum. The self-attached mesh was placed on the supra-diaphragm with abdominal approach. The patient was hospitalised four days after surgery. At two weeks and six months follow-up, no complaints were found. CT scan and chest X-ray were within normal limits. DISCUSSION We did a modified technique in managing the recurrence and adhesion of the diaphragmatic hernia using the hernia mesh attached onto the superior side of the diaphragm to minimise the complications and recurrences. CONCLUSIONS Transabdominal supradiaphragmatic self-attached mesh for recurrent diaphragmatic hernia can be considered to be an alternative treatment for recurrent diaphragmatic hernia in an emergency setting because this procedure is relatively easier, safer, causes fewer postoperative complications, and can prevent recurrence.


title: A multi-criteria sustainability assessment framework: development and application in comparing two food waste management options using a UK region as a case study.

text: Preventing food wastage is a key element of sustainable resource management. But as food waste is still generated at high volumes, priority is placed on its proper management as a resource, maximising sustainability benefits. This study, by integrating a multi-criteria decision analysis with a sustainability assessment approach, develops a screening and decision support framework for comparing the sustainability performance of food waste management options. A structured process for selecting criteria based on the consideration of environmental, economic and social aspects related to region-specific food waste system planning, policy and management has been developed. Two food waste management options, namely the use of food waste disposal units, which grind food waste at the household's kitchen sink and discharge it to the sewer, and the anaerobic co-digestion of separately collected food waste with sewage sludge, were selected for comparison due to their potential to create synergies between local authorities, waste and water companies, with local circumstances determining which of the two options to adopt. A simplified process used for assessing and comparing the two food waste management options in the Anglian region in the UK, indicated that there are benefits in using the framework as a screening tool for identifying which option may be the most sustainable. To support decision-making, a detailed analysis that incorporates stakeholders' perspectives is required. An additional use of the framework can be in providing recommendations for optimising food waste management options in a specific region, maximising their sustainability performance.


title: Changes in leg cycling muscle synergies after training augmented by functional electrical stimulation in subacute stroke survivors: a pilot study.

text: BACKGROUND Muscle synergies analysis can provide a deep understanding of motor impairment after stroke and of changes after rehabilitation. In this study, the neuro-mechanical analysis of leg cycling was used to longitudinally investigate the motor recovery process coupled with cycling training augmented by Functional Electrical Stimulation (FES) in subacute stroke survivors. METHODS Subjects with ischemic subacute stroke participated in a 3-week training of FES-cycling with visual biofeedback plus usual care. Participants were evaluated before and after the intervention through clinical scales, gait spatio-temporal parameters derived from an instrumented mat, and a voluntary pedaling test. Biomechanical metrics (work produced by the two legs, mechanical effectiveness and symmetry indexes) and bilateral electromyography from 9 leg muscles were acquired during the voluntary pedaling test. To extract muscles synergies, the Weighted Nonnegative Matrix Factorization algorithm was applied to the normalized EMG envelopes. Synergy complexity was measured by the number of synergies required to explain more than 90% of the total variance of the normalized EMG envelopes and variance accounted for by one synergy. Regardless the inter-subject differences in the number of extracted synergies, 4 synergies were extracted from each patient and the cosine-similarity between patients and healthy weight vectors was computed. RESULTS Nine patients (median age of 75 years and median time post-stroke of 2 weeks) were recruited. Significant improvements in terms of clinical scales, gait parameters and work produced by the affected leg were obtained after training. Synergy complexity well correlated to the level of motor impairment at baseline, but it did not change after training. We found a significant improvement in the similarity of the synergy responsible of the knee flexion during the pulling phase of the pedaling cycle, which was the mostly compromised at baseline. This improvement may indicate the re-learning of a more physiological motor strategy. CONCLUSIONS Our findings support the use of the neuro-mechanical analysis of cycling as a method to assess motor recovery after stroke, mainly in an early phase, when gait evaluation is not yet possible. The improvement in the modular coordination of pedaling correlated with the improvement in motor functions and walking ability achieved at the end of the intervention support the role of FES-cycling in enhancing motor re-learning after stroke but need to be confirmed in a controlled study with a larger sample size. TRIAL REGISTRATION ClinicalTrial.gov, NCT02439515. Registered on May 8, 2015, .


title: Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian context.

text: COVID-19 has created enormous challenges for health systems worldwide, with the rapidly growing number of deaths and critical patients with pneumonia requiring ventilatory support. Alternative methods to control the spread of the disease such as social isolation, extreme quarantine measures, and contact tracing have been used around the world. However, these measures may not be totally effective to fight COVID-19, in step with the necessary national preparations to meet the new patient care demands. A wide range of digital technologies can be used to enhance these public health strategies, and the pandemic has sparked increasing use of telehealth. This field has grown considerably in Brazil in recent years. Still, despite the intense proliferation of recommendations and rules, until the current pandemic the country still lacked a fully consolidated regulatory framework. The emergence of COVID-19 marks a key moment in the expansion of applications and use of telehealth for improving the health system's response to the current crisis. The article discusses telehealth's contribution to the fight against COVID-19 and the recent initiatives triggered in Brazil as opportunities for the consolidation of telemedicine and improvement of the Brazilian Unified National Health System. The authors conclude that telehealth offers capabilities for remote screening, care and treatment, and assists monitoring, surveillance, detection, prevention, and mitigation of the impacts on healthcare indirectly related to COVID-19. The initiatives triggered in this process can reshape the future space of telemedicine in health services in the territory.


title: Our Results of Laparoscopic Partial Nephrectomies Without Pedicle Dissection: Possible Advantages and Disadvantages.

text: OBJECTIVES This study aimed to document the surgical and oncologic results of nephron sparing of non-ischemic laparoscopic partial nephrectomy without the step of hilus controlling and even without dissecting to expose the main renal vascularity and directly focusing on mass removal. MATERIALS & METHODS The records of the patients who underwent our modified laparoscopic partial nephrectomy technique were evaluated retrospectively. The patients' medical records, including tumor complexity calculated via R.E.N.A.L nephrometry scores, operation time, estimated blood loss, blood transfusions, hospital stay, pre- and postoperative serum creatinine levels, complications via the Clavien classification system, pathological status of surgical margin, and follow-up times, were documented. RESULTS The data of 55 patients with 58 renal units were evaluated. Almost all tumors were in the low complex group (91%), with a mean size of 31.74 ± 7.38 mm (range: 12-46 mm). Mean operation time, estimated blood loss, and transfusion rates were 138.62 ± 38.45 minutes (range: 90-240 min), 242.24 ± 107.12 mL (range: 100-500 mL), and 19%, respectively. The hemoglobin level decreased by a mean of 2.05 ± 0.87 g/dL. Whereas the perioperative complications were Clavien grades I, II, and III (74%, 23%, and 3%, respectively), mean hospital stay and follow-up time were 4.05 ± 1.97 and 19.67 ± 13.57 (ranges: 2-10 days and 1-44 months), respectively. CONCLUSION Present un-controlled results pointed that tumor-focusing nephron-sparing non-ischemic partial laparoscopic nephrectomy may be preferable for small-sized, low-complex renal masses.


Case 17-2020: A 68-Year-Old Man with Covid-19 and Acute Kidney Injury.


title: Warm hands, cold heart: progressive whole-body cooling increases warm thermosensitivity of human hands and feet in a dose-dependent fashion.

text: NEW FINDINGS What is the central question of this study? Investigations on inhibitory/facilitatory modulation of vision, touch and pain show that conditioning stimuli outside the receptive field of testing stimuli modulate the central processing of visual, touch and painful stimuli. We asked whether contextual modulation also exists in human temperature integration. What is the main finding and its importance? Progressive decreases in whole-body mean skin temperature (the conditioning stimulus) significantly increased local thermosensitivity to skin warming but not cooling (the testing stimuli) in a dose-dependent fashion. In resembling the central mechanisms underlying endogenous analgesia, our findings point to the existence of an endogenous thermosensory system in humans that could modulate local skin thermal sensitivity to facilitate thermal behaviour. Although inhibitory/facilitatory central modulation of vision and pain has been investigated, contextual modulation of skin temperature integration has not been explored. Hence, we tested whether progressive decreases in whole-body mean skin temperature (Tsk ; a large conditioning stimulus) alter the magnitude estimation of local warming and cooling stimuli applied to hairy and glabrous skin. On four separate occasions, eight men (27 ± 5 years old) underwent a 30 min whole-body cooling protocol (water-perfused suit; temperature, 5°C), during which a quantitative thermosensory test, consisting of reporting the perceived magnitude of warming and cooling stimuli (±8°C from 30°C baseline) applied to the hand (palm/dorsum) and foot (sole/dorsum), was performed before cooling and every 10 min thereafter. The cooling protocol resulted in large progressive reductions in Tsk [10 min, -3.36°C (95% confidence interval -2.62 to -4.10); 20 min, -5.21°C (-4.47 to -5.95); and 30 min, -6.32°C (-5.58 to -7.05); P < 0.001], with minimal changes (∼0.08°C) in rectal temperature. While thermosensitivity to local skin cooling remained unchanged (P = 0.831), sensitivity to skin warming increased significantly at each level of Tsk for all skin regions [10 min, +4.9% (-1.1 to +11.0); 20 min, +6.1% (+0.1-12.2); and 30 min, +7.9% (+1.9-13.9); P = 0.009]. Linear regression indicated a 1.2% °C-1 increase in warm thermosensitivity with whole-body skin cooling. Overall, large decreases in Tsk significantly facilitated warm but not cold sensory processing of local thermal stimuli, in a dose-dependent fashion. In highlighting a novel feature of human temperature integration, these findings point to the existence of an endogenous thermosensory system that could modulate local skin thermal sensitivity in relationship to whole-body thermal states.


title: COVID-19 Lung Injury is Not High Altitude Pulmonary Edema.

text: Not applicable.


Do you know how COVID-19 is changing general practice/family medicine education?


title: Use of a new soft and long coil reduces the number of coils to embolize a small aneurysm.

text: BACKGROUND In embolizing a cerebral aneurysm, achievement of a high-volume embolization ratio (VER: volume of inserted coils / aneurysm volume) is important because it may prevent coil compaction and recanalization. The goal of the study is to examine whether use of softer and longer coils gives an adequate VER with fewer coils, particularly for small aneurysms. METHODS Aneurysm volumes, VERs, and numbers of inserted coils were investigated in 23 cases of small aneurysms embolized using Infini coils, a long soft coil with a primary diameter of 0.010 inches (Infini group). An aneurysm volume- and VER-matched control (non-Infini) group of 59 cases was selected from patients treated at our facility. Data were also compared between subgroups of patients (n = 18 and n = 34 in the Infini and non-Infini groups, respectively) who were not treated with thicker coils with primary diameters of 0.0135-0.015 inches (18-type coils), since these coils affect the number of coils by increasing VER rapidly. RESULTS Average aneurysm volumes and VERs did not differ significantly between the Infini and non-Infini groups. Significantly fewer coils were used per 0.1 ml aneurysm volume in the Infini group (4.08 coils in average) compared with the non-Infini group (5.67) (p < 0.001). In the non-18-type subgroups, the number of coils used remained significantly smaller in the Infini group (4.49) compared with the non-Infini group (6.72), (p < 0.001). CONCLUSION To achieve VER ≥20%, use of Infini coils significantly decreased the number of coils required per unit volume of a small aneurysm.


title: Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients.

text: BACKGROUND Optimal thromboprophylaxis for patients at risk of bleeding remains uncertain. This meta-analysis assessed whether intermittent pneumatic compression (IPC) of the lower limbs was effective in reducing venous thromboembolism and whether combining pharmacological thromboprophylaxis with IPC would enhance its effectiveness. METHODS AND RESULTS Two reviewers searched MEDLINE, EMBASE, and the Cochrane controlled trial register (1966-February 2013) for randomized, controlled trials and assessed the outcomes and quality of the trials independently. Trials comparing IPC with pharmacological thromboprophylaxis, thromboembolic deterrent stockings, no prophylaxis, and a combination of IPC and pharmacological thromboprophylaxis were considered. Trials that used IPC <24 hours or compared different types of IPC were excluded. A total of 16 164 hospitalized patients from 70 trials met the inclusion criteria and were subjected to meta-analysis. IPC was more effective than no IPC prophylaxis in reducing deep vein thrombosis (7.3% versus 16.7%; absolute risk reduction, 9.4%; 95% confidence interval [CI], 7.9-10.9; relative risk, 0.43; 95% CI, 0.36-0.52; P<0.01; I(2)=34%) and pulmonary embolism (1.2% versus 2.8%; absolute risk reduction, 1.6%; 95% CI, 0.9-2.3; relative risk, 0.48; 95% CI, 0.33-0.69; P<0.01; I(2)=0%). IPC was also more effective than thromboembolic deterrent stockings in reducing deep vein thrombosis and appeared to be as effective as pharmacological thromboprophylaxis but with a reduced risk of bleeding (relative risk, 0.41; 95% CI, 0.25-0.65; P<0.01; I(2)=0%). Adding pharmacological thromboprophylaxis to IPC further reduced the risk of deep vein thrombosis (relative risk, 0.54; 95% CI, 0.32-0.91; P=0.02; I(2)=0%) compared with IPC alone. CONCLUSIONS IPC was effective in reducing venous thromboembolism, and combining pharmacological thromboprophylaxis with IPC was more effective than using IPC alone.


Lopinavir-ritonavir in severe COVID-19.


title: Detection of feline coronavirus mutations in paraffin-embedded tissues in cats with feline infectious peritonitis and controls.

text: OBJECTIVES The amino acid substitutions M1058L and S1060A in the spike protein of feline coronavirus (FCoV) have been postulated to be responsible for the development of the pathogenic feline infectious peritonitis virus (FIPV), which causes feline infectious peritonitis (FIP). The aim of the following study was to investigate the presence of mutated virus in tissue samples of cats with and without FIP. METHODS The study population consisted of 64 cats, 34 of which were diagnosed with FIP and 30 control cats. All cases underwent autopsy, histopathology and immunohistochemistry (IHC) for FCoV. Furthermore, a genotype-discriminating quantitative reverse transcriptase PCR (RT-qPCR) was performed on shavings of paraffin-embedded tissues to discriminate between cats with FIP and controls, and the sensitivity and specificity of this discriminating RT-qPCR were calculated using 95% confidence intervals (CIs). RESULTS Specificity of genotype-discriminating RT-qPCR was 100.0% (95% CI 88.4-100.0), and sensitivity was 70.6% (95% CI 52.5-84.9). In cats with FIP, 24/34 tested positive for FIPV. In samples of three control cats and in seven cats with FIP, FCoV was found, but genotyping was not possible owing to low FCoV RNA concentrations. Out of the positive samples, 23 showed the amino acid substitution M1058L in the spike protein and none the substitution S1060A. One sample in a cat with FIP revealed a mixed population of non-mutated FCoV and FIPV (mixed genotype). For one sample genotyping was not possible despite high viral load, and two samples were negative for FCoV. CONCLUSIONS AND RELEVANCE As none of the control animals showed FCoV amino acid substitutions previously demonstrated in cats with FIP, it can be presumed that the substitution M1058L correlates with the presence of FIP. FCoV was detected in low concentration in tissues of control animals, confirming the ability of FCoV to spread systemically. The fact that no negative controls were included in the IHC protocol could potentially lead to an underestimation of the sensitivity of the RT-qPCR.


title: Primary inflammatory myofibroblastic tumor of the stomach in an adult woman: a case report and review of the literature.

text: Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as "pseudostumor ", denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature.


title: Biomechanical evaluation of potential damage to hernia repair materials due to fixation with helical titanium tacks.

text: BACKGROUND This study aimed to determine whether the strength and extensibility of hernia repair materials are negatively influenced by the application of helical titanium tacks. METHODS This study evaluated 14 meshes including bare polypropylene, macroporous polytetrafluoroethylene, absorbable barrier, partially absorbable mesh, and expanded polytetrafluoroethylene materials. Each mesh provided 15 specimens, which were prepared in 7.5 × 7.5-cm squares. Of these, 5 "undamaged" specimens were subjected to ball-burst testing to determine their biomechanical properties before application of helical titanium tacks (ProTack). To 10 "damaged" specimens 7 tacks were applied 1 cm apart in a 3.5-cm-diameter circle using a tacking force of 25 to 28 N. The tacks were removed from five of the specimens before ball-burst testing and left intact in the remaining five specimens. RESULTS The application of tacks had no effect on the tensile strength of Dualmesh, ProLite Ultra, Infinit, Ultrapro, C-QUR Lite (<6 in.), Prolene Soft, or Physiomesh, but the tensile strengths were reduced for Bard Mesh, C-QUR, ProLite, and C-QUR Lite (>6 in.). Most of the meshes did not exhibit significantly different tensile strengths between removal of tacks and tacks left intact. Exceptions included C-QUR, Prolene, Ultrapro, and Bard Soft Mesh, which were weaker with removal of tacks than with tacks left intact during the test. Damage due to the application of helical titanium tacks also caused increased strain at a stress of 16 N/cm for all the meshes except C-QUR Lite (>6 in.) and Physiomesh. CONCLUSIONS Many of the meshes evaluated in this study exhibited damage in the form of reduced tensile strength and increased extensibility after the application of tacks compared with the corresponding "undamaged" meshes. Meshes with smaller interstices and larger filaments were influenced negatively by the application of helical titanium tacks, whereas mesh designs with larger interstices and smaller filaments tended to maintain their baseline mechanical properties.


title: Post operative capnostream monitoring in patients with obstructive sleep apnoea symptoms - Case series.

text: Obstructive sleep apnoea (OSA) patients on opioid analgesic have an increased incidence of postoperative respiratory complications; prevention of these may be possible with appropriate post-operative monitoring. We recruited 4 OSA patients who had general anaesthesia for orthopaedic and septoplasty surgery. They required Patient Controlled Analgesia (PCA) or oral opioids in the post-operative period, hence continuous Saturation of Oxygen (Spo2), End Tidal Carbon dioxide (EtCo2) monitoring on Capnostream monitor with Integrated Pulmonary Index (IPI) was organized in high dependency unit. Overnight data was collected every 30 s which included pulse rate, respiratory rate, EtCo2, Spo2, and IPI. The nursing staff was also asked to document if any intervention was carried out due to altered IPI. For first two patient events occurred during various hours but there were no significant events in early night even though increased opioid use at that time. During the period of desaturation nurse intervention required to increase the O2 flow in the first patient but corrected spontaneously in the second patient. IPI index improved over a period of 2 min in most of the events. The duration of desaturation did not correspond with the IPI in only once, remaining period the clinical symptoms were consistent with fall in O2 saturation. The microstream capnography with IPI may provide complete respiratory status of the patient because of its comprehensive parameters on one screen. Main limitation was duration of monitoring was limited to overnight. Capnostream monitoring with IPI may have a role in patients monitoring with OSA on PCA in the postoperative ward but more trials are necessary.


title: Lessons of the month 1: A case of rhombencephalitis as a rare complication of acute COVID-19 infection.

text: A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient's abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.


Covid-19: diabetes clinicians set up social media account to help alleviate patients' fears.


title: Promoting Motor Cortical Plasticity with Acute Aerobic Exercise: A Role for Cerebellar Circuits.

text: Acute aerobic exercise facilitated long-term potentiation-like plasticity in the human primary motor cortex (M1). Here, we investigated the effect of acute aerobic exercise on cerebellar circuits, and their potential contribution to altered M1 plasticity in healthy individuals (age: 24.8 ± 4.1 years). In Experiment 1, acute aerobic exercise reduced cerebellar inhibition (CBI) (n = 10, p = 0.01), elicited by dual-coil paired-pulse transcranial magnetic stimulation. In Experiment 2, we evaluated the facilitatory effects of aerobic exercise on responses to paired associative stimulation, delivered with a 25 ms (PAS25) or 21 ms (PAS21) interstimulus interval (n = 16 per group). Increased M1 excitability evoked by PAS25, but not PAS21, relies on trans-cerebellar sensory pathways. The magnitude of the aerobic exercise effect on PAS response was not significantly different between PAS protocols (interaction effect: p = 0.30); however, planned comparisons indicated that, relative to a period of rest, acute aerobic exercise enhanced the excitatory response to PAS25 (p = 0.02), but not PAS21 (p = 0.30). Thus, the results of these planned comparisons indirectly provide modest evidence that modulation of cerebellar circuits may contribute to exercise-induced increases in M1 plasticity. The findings have implications for developing aerobic exercise strategies to "prime" M1 plasticity for enhanced motor skill learning in applied settings.


title: Coronavirus anxiety scale: A brief mental health screener for COVID-19 related anxiety.

text: Mental health concerns of people impacted by the coronavirus pandemic have not been adequately addressed. The objective of this study was to develop and evaluate the properties of the Coronavirus Anxiety Scale (CAS), which is a brief mental health screener to identify probable cases of dysfunctional anxiety associated with the COVID-19 crisis. This 5-item scale, which was based on 775 adults with anxiety over the coronavirus, demonstrated solid reliability and validity. Elevated CAS scores were found to be associated with coronavirus diagnosis, impairment, alcohol/drug coping, negative religious coping, extreme hopelessness, suicidal ideation, as well as attitudes toward President Trump and Chinese products. The CAS discriminates well between persons with and without dysfunctional anxiety using an optimized cut score of ≥ 9 (90% sensitivity and 85% specificity). These results support the CAS as an efficient and valid tool for clinical research and practice.


title: Laparoscopic left hepatectomy with prior vascular control.

text: BACKGROUND Laparoscopic major resections remain a challenge for liver surgeons. This video illustrates, step by step, our laparoscopic technique for left hepatectomy. METHODS The control of vascular inflow and outflow as well as the division of the left hepatic duct were carried out extraparenchymally before liver transection. Between 2002 and 2008, 11 left hepatectomies were performed by laparoscopy: 7 for liver tumor and 4 for localized Caroli's disease. RESULTS Mean duration of surgery was 248 +/- 25 min. Mean operative blood loss was 129 +/- 42 ml. Intraoperative blood transfusion or conversion to laparotomy were never required. One postoperative biliary collection occurred and was drained percutaneously. None of the patients died. Mean hospital stay was 7.6 +/- 2.2 days. CONCLUSIONS This technique has proved to be safe and easily reproducible.


title: Mechanisms and methods in ecoimmunology: integrating within-organism and between-organism processes.

text: Ecoimmunology utilizes techniques from traditionally laboratory-based disciplines--for example, immunology, genomics, proteomics, neuroendocrinology, and cell biology--to reveal how the immune systems of wild organisms both shape and respond to ecological and evolutionary pressures. Immunological phenotypes are embedded within a mechanistic pathway leading from genotype through physiology to shape higher-order biological phenomena. As such, "mechanisms" in ecoimmunology can refer to both the within-host processes that shape immunological phenotypes, or it can refer the ways in which different immunological phenotypes alter between-organism processes at ecological and evolutionary scales. The mechanistic questions ecoimmunologists can ask, both within-organisms and between-organisms, however, often have been limited by techniques that do not easily transfer to wild, non-model systems. Thus, a major focus in ecoimmunology has been developing and refining the available toolkit. Recently, this toolkit has been expanding at an unprecedented rate, bringing new challenges to choosing techniques and standardizing protocols across studies. By confronting these challenges, we will be able to enhance ecoimmunological inquiries into the physiological basis of life-history trade-offs; the development of low-cost biomarkers for susceptibility to disease; and the investigation of the ecophysiological underpinnings of disease ecology, behavior, and the coevolution of host-parasite systems. The technical advances in, and crossover technologies from, disciplines associated with ecoimmunology and how these advances can help us understand the mechanistic basis of immunological variability in wild species were the focus of the symposium, Methods and Mechanisms in Ecoimmunology.


title: Dynamic Evaluation of Liver Volume and Function in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy.

text: BACKGROUND Despite a fast and potent growth of the future liver remnant (FLR), patients operated with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are at risk of developing posthepatectomy liver failure. In this study, the relation between liver volume and function in ALPPS was studied using a multimodal assessment. METHODS Nine patients with colorectal liver metastases treated with neoadjuvant chemotherapy and operated with ALPPS were studied with hepatobiliary scintigraphy, computed tomography, indocyanine green clearance test, and serum liver function tests. A comparison between liver volume and function was conducted. RESULTS The preoperative FLR volume of 19.5% underestimated the preoperative FLR function of 25.3% (p = 0.011). The increase in FLR volume exceeded the increase in function at day 6 after stage 1 (FLR volume increase 56.7% versus FLR function increase 28.2%, p = 0.021), meaning that the increase in function was 50% of the increase in volume. After stage 2, functional increase exceeded the volume increase, resulting in similar values 28 days after stage 2. CONCLUSIONS In the inter-stage period of ALPPS, the high volume increase is not paralleled by a corresponding functional increase. This may in part explain the high morbidity and mortality rates associated with ALPPS. Functional assessment of the FLR is advised.


title: Hypoxemia after single-shot anesthesia in common marmosets.

text: BACKGROUND It remains unknown how single-shot anesthesia influences physical parameters, especially respiratory function and blood oxygen level of common marmosets (Callithrix jacchus) which came to be used for laboratory research. METHODS We measured blood oxygen levels, both before and after oxygenation, in 13 common marmosets under two single-shot anesthesia conditions: ketamine/xylazine/atropine and alphaxalone. RESULTS AND CONCLUSIONS We found that SpO2 values decreased to about 80% in the ketamine/xylazine/atropine protocol and fell just below 90% in the alphaxalone protocol. We observed a clear decrease in PaO2 values under the anesthetized condition compared to the awake condition. Our data indicate that single-shot anesthesia may cause hypoxemia in marmosets. Previous studies on other non-human primate have reported no SpO2 decrease and hypoxemia; thus, our experiment suggests that marmosets may have a more fragile respiratory system and require intensive veterinary care during anesthesia.


title: Usefulness of the extracted-overlay function in CT/MR-ultrasonography fusion imaging for radiofrequency ablation of hepatocellular carcinoma.

text: OBJECTIVES We developed a novel technique of the extracted-overlay function in CT/MR-ultrasonography (US) fusion imaging for radiofrequency ablation (RFA), in which only a tumor extracted from CT/MR images with a virtual ablative margin of arbitrary thickness is overlaid on US. The usefulness of this function is investigated in this preliminary report. METHODS The volume data of the extracted tumor with a virtual ablative margin were created on an image-processing workstation, and transported into a US unit equipped with a CT/MR-US fusion imaging system. After the positional registration of US and transported images, the extracted tumor with an ablative margin could be overlaid on US. In RFA, using this function, an electrode was inserted targeting the overlaid tumor with an ablative safety margin of 5 mm on US, and the treatment effect was evaluated by dynamic CT. Treatment results of 23 consecutive hepatocellular carcinomas (HCCs) that underwent RFA using this function were retrospectively analyzed. RESULTS Complete tumor ablation was achieved in 22 (95.7%) and 1 (4.3%) HCCs in 1 and 2 treatment sessions, respectively. CONCLUSIONS Due to the visualization of an extracted tumor with an ablative safety margin on a US image, even during and after ablation, this function is useful for treatment planning and guidance of RFA.


Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation.


title: Relationship between time to target temperature and outcome in patients treated with therapeutic hypothermia after cardiac arrest.

text: INTRODUCTION Our purpose was to study whether the time to target temperature correlates with neurologic outcome in patients after cardiac arrest with restoration of spontaneous circulation treated with therapeutic mild hypothermia in an academic emergency department. METHODS Temperature data between April 1995 and June 2008 were collected from 588 patients and analyzed in a retrospective cohort study by observers blinded to outcome. The time needed to achieve an esophageal temperature of less than 34°C was recorded. Survival and neurological outcomes were determined within six months after cardiac arrest. RESULTS The median time from restoration of spontaneous circulation to reaching a temperature of less than 34°C was 209 minutes (interquartile range [IQR]: 130-302) in patients with favorable neurological outcomes compared to 158 min (IQR: 101-230) (P < 0.01) in patients with unfavorable neurological outcomes. The adjusted odds ratio for a favorable neurological outcome with a longer time to target temperature was 1.86 (95% CI 1.03 to 3.38, P = 0.04). CONCLUSIONS In comatose cardiac arrest patients treated with therapeutic hypothermia after return of spontaneous circulation, a faster decline in body temperature to the 34°C target appears to predict an unfavorable neurologic outcome.


title: A Postpartum Death Due to Coronavirus Disease 2019 (COVID-19) in the United States.

text: BACKGROUND Limited U.S. reports of pregnant women with coronavirus disease 2019 (COVID-19) infection describe a few critical cases and no maternal mortality. CASE A 36-year-old patient at 37 weeks of gestation presented with shortness of breath, fever, cough, and sore throat for 1 week. Within 3 hours of admission, she experienced respiratory distress, required intubation, and underwent cesarean delivery and transfer to the intensive care unit. She subsequently decompensated, with multiorgan failure, sepsis, and cardiopulmonary arrest within 36 hours, despite aggressive supportive care and investigational therapies. CONCLUSION A pregnant patient with COVID-19 infection can experience a rapid onset of critical complications that may prove fatal, despite an indolent presentation. The pathogenesis leading to rapid deterioration is unknown.


title: Interaction of the porcine reproductive and respiratory syndrome virus nucleocapsid protein with the inhibitor of MyoD family-a domain-containing protein.

text: Porcine reproductive and respiratory syndrome (PRRS) virus is an RNA virus that replicates in the cytoplasm, but the viral nucleocapsid (N) protein localizes specifically in the nucleus and nucleolus of virus-infected cells. Nuclear localization of N is non-essential for PRRSV replication in cultured cells but has been shown to modulate the pathogenesis of virus in pigs, suggesting that N plays an accessory role in the nucleus during infection. We identified by yeast two-hybrid screening the inhibitor of MyoD family-a (I-mfa) domain-containing protein (HIC) as a cellular partner for PRRS virus (PRRSV) N protein. This protein is a homolog of human HIC, a recently identified cellular transcription factor. The specific interaction of PRRSV N with HIC was confirmed in cells by mammalian two-hybrid assay and co-immunoprecipitation and in vitro by GST pull-down assay. HIC is a zinc-binding protein and confocal microscopy demonstrated co-localization of N with the HIC-p40 isomer in the nucleus and nucleolus, and in the cytoplasm with HIC-p32, which is the N-terminal truncation of HIC-p40. The porcine homolog of HIC is universally expressed in pig tissues including alveolar macrophages. The interaction of viral capsid with the cellular transcription factor implicates a possible regulation of host cell gene expression by the N protein during PRRSV infection.


Children's Hospital ICU Resource Allocation in an Adult Pandemic.


title: Feasibility of transanal minimally invasive surgery for mid-rectal lesions.

text: BACKGROUND Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery. We assessed the feasibility of TAMIS for lesions located in the mid rectum. METHODS From July 2010 to October 2011, 16 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, pneumorectum was established with a laparoscopic device, followed by transanal excision with conventional laparoscopic instruments, including graspers, monopolar electrocautery, and needle drivers. Clinicopathological findings, surgical procedure results, and perioperative outcomes were determined prospectively. RESULTS Of the 16 patients, 11 had rectal cancers (3 T1 lesions and 8 after preoperative chemoradiotherapy), 4 had neuroendocrine tumors, and 1 had a mucocele. The median length of the lesions from anal verge was 7.5 cm (range 4-10 cm). All procedures were completed laparoscopically without conversion to conventional transanal approach. The median operating time was 86 min (range 33-160 min), and the median estimated blood loss was 15 ml (range 0-150 ml) with no patient requiring intraoperative transfusions. There was no surgical morbidity or mortality, but one patient died during follow-up due to synchronous advanced gastric cancer. The median postoperative hospital stay was 3 days (range 2-6 days). CONCLUSIONS TAMIS seems to be a feasible and safe treatment option for lesions located in the mid rectum.


title: Telemedicine During the COVID-19 Pandemic: Impact on Care for Rare Cancers.

text: PURPOSE Many patients with cancer, often those with rare cancers such as sarcomas, travel long distances to access expert care. The COVID-19 pandemic necessitated widespread changes in delivery of cancer care, including rapid adoption of telemedicine-based care. We aimed to evaluate the impact of telemedicine on patients, clinicians, and care delivery at the Royal Marsden Hospital (RMH) Sarcoma Unit during the pandemic. METHODS Data were extracted from patient records for all planned outpatient appointments at the RMH Sarcoma Unit from March 23 to April 24, 2020. Patients and clinicians completed separate questionnaires to understand their experiences. RESULTS Of 379 planned face-to-face appointments, 283 (75%) were converted to telemedicine. Face-to-face appointments remained for patients who needed urgent start of therapy or performance status assessment. Patients lived on average > 1.5 hours from RMH. Patient satisfaction (n = 108) with telemedicine was high (mean, 9/10), and only 48% (n = 52/108) would not want to hear bad news using telemedicine. Clinicians found telemedicine efficient, with no associated increased workload, compared with face-to-face appointments. Clinicians indicated lack of physical examination did not often affect care provision when using telemedicine. Most clinicians (n = 17; 94%) believed telemedicine use was practice changing; congruently, 80% (n = 86/108) of patients desired some telemedicine as part of their future care, citing reduced cost and travel time. CONCLUSION Telemedicine can revolutionize delivery of cancer care, particularly for patients with rare cancers who often live far away from expert centers. Our study demonstrates important patient and clinician benefits; assessment of longer-term impact on patient outcomes and health care systems is needed.


title: Does central fatigue explain reduced cycling after complete sleep deprivation?

text: PURPOSE Sleep deprivation (SD) is characterized by reduced cognitive capabilities and endurance exercise performance and increased perceived exertion (RPE) during exercise. The combined effects of SD and exercise-induced changes in neuromuscular function and cognition are unknown. This study aimed to determine whether central fatigue is greater with SD, and if so, whether this corresponds to diminished cognitive and physical responses. METHODS Twelve active males performed two 2-d conditions (SD and control (CO)). On day 1, subjects performed baseline cognitive and neuromuscular testing. After one night of SD or normal sleep, subjects repeated day 1 testing and then performed 40-min submaximal cycling and a cycling test to task failure. Neuromuscular and cognitive functions were evaluated during the cycling protocol and at task failure. RESULTS After SD, exercise time to task failure was shorter (1137 ± 253 vs 1236 ± 282 s, P = 0.013) and RPE during 40 min submaximal cycling was greater (P = 0.009) than that in CO. Maximal peripheral voluntary activation decreased by 7% (P = 0.003) and cortical voluntary activation tended to decrease by 5% (P = 0.059) with exercise. No other differences in neuromuscular function or cognitive control were observed between conditions. After SD, mean reaction time was 8% longer (P = 0.011) and cognitive response omission rate before cycling was higher (P < 0.05) than that in CO. Acute submaximal exercise counteracted cognitive performance deterioration in SD. CONCLUSIONS One night of complete SD resulted in decreased time to task failure and cognitive performance and higher RPE compared with the control condition. The lack of difference in neuromuscular function between CO and SD indicates that decreased SD exercise performance was probably not caused by increased muscular or central fatigue.


title: [Evaluation of the effectiveness of ARVI treatment regimen including etiotropic (enisamium iodide) and symptomatic treatment].

text: AIM To assess the effectiveness of the use of the antiviral drug enisamium iodide in the complex treatment of acute respiratory viral infections (ARVI) caused by various pathogens in routine clinical practice. MATERIALS AND METHODS А prospective randomized study included 134 patients who were treated in the epidemic season of influenza and ARVI in 20182019. All patients were examined for the presence of influenza A and B viruses, respiratory syncytial virus, human metapneumovirus, parainfluenza virus, coronaviruses, rhinoviruses, adenoviruses in nasopharyngeal swabs by PCR. Patients of the main group received enisamium iodide along with symptomatic therapy, the control group received only symptomatic therapy. The primary parameter of the effectiveness of therapy was evaluated on the scale of the general severity of the manifestations of ARVI (Total Symptom Score TSS) from the 2nd to the 4th day and by the secondary criteria of effectiveness: assessment of the duration of ARVI, the severity of fever, the proportion of patients with normal body temperature, the duration of the main clinical symptoms of acute respiratory viral infections, the proportion of patients in whom complications requiring antibiotics were noted, the dynamics of interferon status on the 6th day. To conduct a statistical analysis, depending on the efficiency parameter, the ANCOVA method with a fixed group factor and an initial score on the TSS severity scale was used as covariates, a criterion for comparing quantitative indicators in two independent groups. RESULTS According to the results of the analysis of the primary efficacy parameter, the median (interquartile range) of the average score on the scale of the general severity of ARVI manifestations in the main group was 4.33 (3.675.83), in the comparison group 6.00 (4.677.25; p0.001). The duration of systemic and local manifestations of acute respiratory viral infections was statistically significantly less in the main group (p=0.002 and p=0.019, respectively). Prescription of additional therapy was required in 2 (2.9%) patients of the main group (patients taking enisamium iodide), compared with 8 (11.9%) patients in the control group. Serum levels of interferon  and interferon  on the last day of treatment were statistically significantly higher in patients of the main group compared with the control group (p0.001). Treatment (excellent) was evaluated by 42 (62.7%) patients, while in the control group only 17 (25.8%) patients gave similar ratings. Both patients (p0.001) and doctors (p0.002) rated therapy tolerance better in the study group. CONCLUSION The results confirmed the safety and effectiveness of enisamium iodide as a treatment for ARVI and influenza. The antiviral, interferonogenic and anti-inflammatory properties of the drug are involved in the formation of an antiviral response and reduce the risk of complications, which makes it possible to reduce the number of symptomatic agents used.


title: Remote Monitoring of Patients in Quarantine in the Era of SARS-CoV-2 Pandemic.

text: The aim of our study is to propose a remote patient monitoring solution through a smart phone application (Smart Patient) collecting health data to support diagnosis, monitoring and predicting poor outcome in asymptomatic/mild cases of COVID-19, including signs and symptoms, risk factors, comorbidities, medications and vital signs such as body temperature, respiratory rate, heart rate and oxygen saturation. By continuous daily recording of suspected cases and patients, family doctors in the community will be able to follow up cases and intervene promptly when deterioration in vital signs and symptoms takes place referring the patient to the hospital.


title: Silicon carbide as a heat-enhancing agent in microwave ablation: in vitro experiments.

text: PURPOSE Silicon carbide (SiC) is an inert compound material with excellent microwave absorption and heat-conducting properties. The aim of our study was to investigate the heat-enhancing effects of SiC in microwave ablation in an in vitro setting. MATERIALS AND METHODS Different concentrations of SiC powder were mixed with 2% gelatin, producing a 20-ml mixture that was then heated with a clinical microwave ablation system (5 min/45 W). Temperature was measured continuously fiberoptically. Additional heating properties were assessed for the most heatable concentrations at different energy settings (10, 20, and 30 W). As reference, 2% gelatin without SiC was heated. Statistical evaluation by analysis of variance with post hoc Student-Newman-Keuls testing was performed. RESULTS For the different SiC concentrations, maximum temperatures measured were 45.7 ± 1.2°C (0% SiC, control), 50.4 ± 3.6°C (2% SiC), 60.8 ± 1.8°C (10% SiC), 74.9 ± 2.6°C (20% SiC), and 83.4 ± 2.5°C (50% SiC). Differences between all data points were significant (P < 0.05). Maximum temperatures that used 20% SiC were 36.3 ± 2.76°C (10 W), 48.7 ± 4.18°C (20 W), and 50.6 ± 0.68°C (30 W). The use of 50% SiC maximum temperatures resulted in values of 46.2 ± 2.52°C (10 W), 70.1 ± 0.64°C (20 W), and 83.0 ± 4.69°C (30 W). With 20% SiC and 50% SiC mixtures, the 10 W maximum temperatures were significantly lower than at all other power levels, and maximum temperatures with 20 and 30 W were significantly lower when compared with 45 W (P < 0.05). CONCLUSIONS SiC is a nontoxic, highly effective substance for enhancing microwave-induced heating with a microwave ablation system in vitro. These data suggest its usefulness for enhancement of ablative effects in percutaneous tumor therapy. Further investigations need to be performed to evaluate the ex vivo and in vivo ablation effects and the possible methods for administration of SiC particles.


title: Robot-assisted low anterior resection after aluminum potassium sulfate and tannic acid sclerosing therapy for internal hemorrhoids.

text: BACKGROUND Internal hemorrhoids are the most common anal diseases. Aluminum potassium sulfate and tannic acid (ALTA) injection is a new sclerosing therapy for the treatment of internal hemorrhoids. Although ALTA injection has been widely used, there are no previous reports of rectal cancer patients who underwent robot-assisted low anterior resection (Rob-LAR) after ALTA injection to treat internal hemorrhoids. CASE PRESENTATION A 70-year-old man with rectal cancer was presented to our hospital. He had an ALTA injection 2 months before presentation at a clinic due to hematochezia with internal hemorrhoids. The rectal tumor was located 7 cm above the anal verge, and Rob-LAR with the da Vinci Xi system was performed. The patient had sclerosis on the stump of the anal side, which made it difficult to transect the rectum with linear staplers. This required multiple repeats of compression through the SmartClamp feedback. After anastomosis with the double-stapling technique, we constructed a diverting ileostomy. CONCLUSION Although ALTA injection is a promising strategy for internal hemorrhoids, rectal cancer should be excluded before the sclerosing therapy.