title: Pharmacological Treatments for Neonatal Abstinence Syndrome: A Systematic Review and Network Meta-analysis.

text: Importance Incidence of neonatal abstinence syndrome is rising rapidly, and optimal pharmacotherapy may meaningfully reduce length of treatment. Objective To compare pharmacological therapies for neonatal abstinence syndrome. Data Sources Systematic review and network meta-analysis of Medline (1946-June 2018), Embase (1974-June 2018), Cochrane CENTRAL (1966-June 2018), Web of Science (1900-June 2018), and ClinicalTrials.gov (June 2018). Study Selection Randomized clinical trials of pharmacological treatments for neonatal abstinence syndrome alone or in combination with adjuvant treatments. Abstract, title, and full-text screening were conducted independently by 2 reviewers (T.D. and C.G.). Data Extraction and Synthesis Data extraction was conducted independently by 2 reviewers (T.D. and C.G.) according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-Network Meta-Analyses guidelines. Quality was assessed with the Cochrane Risk of Bias tool and data were pooled with fixed-effect models as a result of the low number of trials that were included in the analysis. Main Outcomes and Measures The primary outcome was the length of treatment. The length of stay, need for adjuvant therapy, and adverse events were considered as secondary outcomes. Results Eighteen trials (N = 1072) were eligible for inclusion. The treatments that were included in the length of treatment analysis were buprenorphine, clonidine, diluted tincture of opium and clonidine, diluted tincture of opium, morphine, methadone, and phenobarbital. Sublingual buprenorphine was considered the optimal treatment for a reduction in the length of treatment (days: mean difference vs morphine, -12.75 [95% CI, -17.97 to -7.58]; median rank, 1 [3-1]) and length of stay (days: mean difference vs morphine, -11.43 [95% CI, -16.95 to -5.82]; median rank, 1 [3-1]) but not the need for adjuvant treatment (odds ratio vs morphine, 1.23 [95% CI, 0.46-3.44]; median rank, 3 [5-1]). The results were robust to bias but sensitive to imprecision. Conclusions and Relevance The current evidence suggests that buprenorphine is the optimal treatment for neonatal abstinence treatment, but limitations are considerable and wide-scale adoption requires a large multisite trial. Morphine, which is considered standard of care in most hospitals, was the lowest-ranked opioid for length of treatment and length of stay.


title: Association between response rates and survival outcomes in patients with newly diagnosed multiple myeloma. A systematic review and meta-regression analysis.

text: OBJECTIVES We performed a systematic review and meta-regression analysis of randomized control trials to investigate the association between response to initial treatment and survival outcomes in patients with newly diagnosed multiple myeloma (MM). METHODS Response outcomes included complete response (CR) and the combined outcome of CR or very good partial response (VGPR), while survival outcomes were overall survival (OS) and progression-free survival (PFS). We used random-effect meta-regression models and conducted sensitivity analyses based on definition of CR and study quality. RESULTS Seventy-two trials were included in the systematic review, 63 of which contributed data in meta-regression analyses. There was no association between OS and CR in patients without autologous stem cell transplant (ASCT) (regression coefficient: .02, 95% confidence interval [CI] -0.06, 0.10), in patients undergoing ASCT (-.11, 95% CI -0.44, 0.22) and in trials comparing ASCT with non-ASCT patients (.04, 95% CI -0.29, 0.38). Similarly, OS did not correlate with the combined metric of CR or VGPR, and no association was evident between response outcomes and PFS. Sensitivity analyses yielded similar results. CONCLUSIONS This meta-regression analysis suggests that there is no association between conventional response outcomes and survival in patients with newly diagnosed MM.


title: Miniature surgical robots in the era of NOTES and LESS: dream or reality?

text: Laparoscopy is an established method for the treatment of numerous surgical conditions. Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body as entrances to the abdominal cavity. An alternative concept of minimally invasive approach to the abdominal cavity is to insert all the laparoscopic instruments through ports using a single small incision on the abdominal wall. A suggested name for this technique is laparoendoscopic single-site surgery (LESS). Considering the technical difficulties in NOTES and LESS and the progress in informatics and robotics, the use of robots seems ideal. The aim of this study is to investigate if there is at present, a realistic possibility of using miniature robots in NOTES or LESS in daily clinical practice. An up-to-date review on in vivo surgical miniature robots is made. A Web-based research of the English literature up to March 2013 using PubMed, Scopus, and Google Scholar as search engines was performed. The development of in vivo miniature robots for use in NOTES or LESS is a reality with great advancements, potential advantages, and possible application in minimally invasive surgery in the future. However, true totally NOTES or LESS procedures on humans using miniature robots either solely or as assistance, remain a dream at present.


title: Case Report: A COVID-19 Patient Presenting with Mild Rhabdomyolysis.

text: The news was reported from the Wuhan region of China about a novel corona virus in the end of 2019. After spreading around the world, a pandemic was declared by the WHO. Depending on the different involvement of the disease, the most common symptoms are fever, cough, and dyspnea. However, some indeterminate symptoms that make diagnosis difficult, such as myalgia and fatigue, can also be seen alone, without the typical clinical picture. We describe a patient with COVID-19 pneumonia, the only complaint of which is myalgia, and the first diagnosis is mild rhabdomyolysis. The patient had no evidence or history other than viral infection that could explain muscle pain and also increased level of muscle enzymes. When mild rhabdomyolysis lack of myoglobinuria and complications was diagnosed, treatment-related rhabdomyolysis was also avoided as no treatment related to COVID-19 was initiated yet. Apart from the typical symptoms leading to the typical diagnosis of COVID-19 at the first admission, SARS-CoV-2 related with rhabdomyolysis should also be kept in mind.


title: Single-incision laparoscopic cholecystectomy: comparison analysis of feasibility and safety.

text: To maintain operative safety, patient selection criteria for single-incision laparoscopic cholecystectomy (SILC) are more stringent than that for traditional laparoscopic cholecystectomy (TLC). No other method could demonstrate the same feasibility and safety as TLC because the patient selection criteria were too restrictive for SILC to compare with TLC. In this study, we conducted a comparative study between our original SILC and TLC for demonstrating similar feasibility and safety among patients who had the same selection criteria as that for TLC. A statistical comparison between 114 patients of SILC and 201 patients of TLC was conducted during the same time period. The preoperative patient characteristics for SILC and TLC showed no statistical difference. In the operative result analysis, a significant disadvantage of SILC was the prolongation of operative time by only 15 minutes. The original SILC was as feasible and safe as TLC and virtually scarless cholecystectomy could be performed without any selection criteria. This was performed using only 2 trocars from an umbilical incision and 2 incisionless extracorporeal retraction devices.


title: The Association between Perceived Social Hardship and Future Orientation among Hong Kong Young People: The Mediation Role of Belief in a Just World.

text: A positive future orientation (FO) is associated with a range of positive outcomes. It is a crucial resilience factor that assists individuals to navigate developmental difficulties during the transition to young adulthood and during periods of social adversity. Exposure to negative social context threatens young people's FO. The social demonstrations and the outbreak of coronavirus disease in Hong Kong over the past year have caused considerable hardship to the local society. Under such circumstance, young people in Hong Kong may develop a negative FO. Scant research has directly examined the relationship between perceived social hardship and FO as well as the underlying mechanism among Hong Kong young people. In this study, we tested the idea that young people's perceived social hardship would be negatively related to FO via belief in a just world, a well-known foundation for individuals to think, feel, and plan their future. Participants were 554 students recruited from eight universities in Hong Kong. They filled in self-report questionnaires online. Results of structural equation modeling supported our hypothesis. These findings shed light on how to nurture Hong Kong young people to develop a positive mindset during periods of social hardship.


Reply to the Letter to the Editor "Re: A Multicenter, Randomized, Controlled Trial Comparing Reinforced Staplers with Bare Staplers During Distal Pancreatectomy (HiSCO-07 Trial)".


title: Cerebral oximetry assessed by near-infrared spectrometry during preeclampsia: an observational study: impact of magnesium sulfate administration.

text: OBJECTIVES To determine the regional cerebral oxygen saturation of hemoglobin (rcSO2) in severe preeclamptic parturients exhibiting neurologic symptoms compared with healthy pregnant women (control) and to describe the effects of MgSO4 infusion on rcSO2 and cerebral and systemic hemodynamic variables. DESIGN Prospective, observational study. SETTING Obstetric critical care unit in a university-affiliated hospital. PATIENTS Twenty severe preeclamptic parturients presenting with neurologic signs before any administration of MgSO4, and 20 control parturients. INTERVENTION Infusion of MgSO4 in severe preeclamptic patients. MEASUREMENTS AND MAIN RESULTS We measured rcSO2 using near-infrared spectroscopy, blood flow velocities of the middle cerebral artery, and cardiac output at baseline, 5 minutes, 1 hour, and 6 hours after the MgSO4 bolus (4 g), followed by continuous MgSO4 infusion (1 g/h). These measurements were also obtained in 20 control parturients at baseline and 6 hours. Baseline rcSO2 was significantly lower in the severe preeclamptic group: 61% (56-69) vs 66% (63-71) (p = 0.037). At inclusion, blood pressures were significantly higher in the severe preeclamptic group compared with the control group, whereas cardiac output and transcranial Doppler readings were similar. Five minutes after the MgSO4 bolus infusion, a median increase of 8.6% (3.2-18.1) in rcSO2 was observed (p = 0.007), reaching values of the control group that were maintained up to 6 hours. Blood pressures and systolic velocities of the middle cerebral artery significantly decreased (p < 0.01) after the MgSO4 bolus, whereas cardiac output did not change. The percentage increase in rcSO2 was negatively correlated to the mean blood pressure (r = 0.60, p < 0.0001). CONCLUSION Cerebral oxygenation impairment can be detected by near-infrared spectroscopy monitoring in severe preeclamptic parturients. These results suggested the presence of disorders in cerebral microcirculation and/or changes in cerebral oxygenation. MgSO4 infusion in patients with severe preeclampsia restored rcSO2 to control levels with no systemic side effects. Further studies are needed to confirm the usefulness of near-infrared spectroscopy monitoring in patients with preeclampsia and to assess the action of other antihypertensive therapies on rcSO2.


title: Efficacy and Safety of Radiofrequency Ablation for Focal Hepatic Lesions Adjacent to Gallbladder: Reconfiguration of the Ablation Zone through Probe Relocation and Ablation Time Reduction.

text: PURPOSE To evaluate the safety and efficacy of radiofrequency (RF) ablation for treatment of focal hepatic lesions adjacent to the gallbladder with electrode relocation and ablation time reduction. MATERIALS AND METHODS Thirty-nine patients who underwent RF ablation for focal hepatic lesions adjacent to the gallbladder (≤ 10 mm) were evaluated retrospectively from January 2011 to December 2014 (30 men and 9 women; age range, 51-85 y; mean age, 65 y). Of 36 patients with hepatocellular carcinoma, 3 had a second treatment for recurrence (mean tumor size, 15 mm ± 6). Patients were divided into 2 subgroups based on lesion distance from the gallbladder: nonabutting (> 5 mm; n = 19) and abutting (≤ 5 mm; n = 20). Electrodes were inserted parallel to the gallbladder through the center of a tumor in the nonabutting group and through the center of the expected ablation zone between a 5-mm safety zone on the liver side and the gallbladder in the abutting group. Ablation time was decreased in proportion to the transverse diameter of the expected ablation zone. RESULTS Technical success and technical effectiveness rates were 89.7% and 97.4%, respectively, with no significant differences between groups (P = 1.00). Local tumor progression was observed in 3 patients (1 in the nonabutting group and 2 in the abutting group; P = 1.00). There were no major complications. The gallbladder was thickened in 10 patients, with no significant difference between groups (P = .72). Biloma occurred in 1 patient in the nonabutting group. CONCLUSIONS RF ablation with electrode relocation and reduction of ablation time can be a safe and effective treatment for focal hepatic lesions adjacent to the gallbladder.


title: Rapid, Sensitive, Full-Genome Sequencing of Severe Acute Respiratory Syndrome Coronavirus 2.

text: We describe validated protocols for generating high-quality, full-length severe acute respiratory syndrome coronavirus 2 genomes from primary samples. One protocol uses multiplex reverse transcription PCR, followed by MinION or MiSeq sequencing; the other uses singleplex, nested reverse transcription PCR and Sanger sequencing. These protocols enable sensitive virus sequencing in different laboratory environments.


title: Glycoprotein D of bovine herpesvirus 5 (BoHV-5) confers an extended host range to BoHV-1 but does not contribute to invasion of the brain.

text: Bovine herpesvirus 1 (BoHV-1) and BoHV-5 are closely related pathogens of cattle, but only BoHV-5 is considered a neuropathogen. We engineered intertypic gD exchange mutants with BoHV-1 and BoHV-5 backbones in order to address their in vitro and in vivo host ranges, with particular interest in invasion of the brain. The new viruses replicated in cell culture with similar dynamics and to titers comparable to those of their wild-type parents. However, gD of BoHV-5 (gD5) was able to interact with a surprisingly broad range of nectins. In vivo, gD5 provided a virulent phenotype to BoHV-1 in AR129 mice, featuring a high incidence of neurological symptoms and early onset of disease. However, only virus with the BoHV-5 backbone, independent of the gD type, was detected in the brain by immunohistology. Thus, gD of BoHV-5 confers an extended cellular host range to BoHV-1 and may be considered a virulence factor but does not contribute to the invasion of the brain.


title: Bioavailability of tocotrienols: evidence in human studies.

text: As a minor component of vitamin E, tocotrienols were evident in exhibiting biological activities such as neuroprotection, radio-protection, anti-cancer, anti-inflammatory and lipid lowering properties which are not shared by tocopherols. However, available data on the therapeutic window of tocotrienols remains controversial. It is important to understand the absorption and bioavailability mechanisms before conducting in-depth investigations into the therapeutic efficacy of tocotrienols in humans. In this review, we updated current evidence on the bioavailability of tocotrienols from human studies. Available data from five studies suggested that tocotrienols may reach its target destination through an alternative pathway despite its low affinity for α-tocopherol transfer protein. This was evident when studies reported considerable amount of tocotrienols detected in HDL particles and adipose tissues after oral consumption. Besides, plasma concentrations of tocotrienols were shown to be higher when administered with food while self-emulsifying preparation of tocotrienols was shown to enhance the absorption of tocotrienols. Nevertheless, mixed results were observed based on the outcome from 24 clinical studies, focusing on the dosages, study populations and formulations used. This may be due to the variation of compositions and dosages of tocotrienols used, suggesting a need to understand the formulation of tocotrienols in the study design. Essentially, implementation of a control diet such as AHA Step 1 diet may influence the study outcomes, especially in hypercholesterolemic subjects when lipid profile might be modified due to synergistic interaction between tocotrienols and control diet. We also found that the bioavailability of tocotrienols were inconsistent in different target populations, from healthy subjects to smokers and diseased patients. In this review, the effect of dosage, composition and formulation of tocotrienols as well as study populations on the bioavailability of tocotrienols will be discussed.


title: Effects of Slaughter Knife Sharpness on Blood Biochemical and Electroencephalogram Changes in Cattle.

text: The sharpness of the knife used for slaughter is of the utmost importance from an animal welfare perspective. The quantification of knife sharpness is almost impossible in abattoirs. The sharpness of the knife blade used to slaughter an animal, as well as its effects on animals' pain and stress levels, is an important area of investigation that needs to be addressed. The objective of this study was to evaluate the effects of knife sharpness on blood biochemical parameters, plasma catecholamines, and electroencephalographic (EEG) responses. Twenty Brahman crossbred steers were either subjected to slaughter with a sharp knife (n = 10) or a commercial sharp knife (n = 10); knife sharpness was measured with the ANAGO® sharpness tester. There was significant increase in adrenaline (p < 0.0001), glucose (p = 0.0167), creatinine kinase (p = 0.0123) and lactate dehydrogenase (p = 0.0151) at post-slaughter compared to pre-slaughter in commercial sharp knife group than in thesharp knife group. A significant increase was observed in the median frequency (p < 0.0001) and total power (p < 0.0001) of the EEG, the parameters for pain and stress, in the animals slaughtered with the commercial sharp knife than those slaughtered with the sharp knife. Thus, EEG results also supported the hormonal and biochemical results. From the results, it is concluded that animals slaughtered with a sharp knife experienced the least amount of pain and stress compared to those slaughtered with a commercial sharp knife.


title: Comparison of four different suture materials in respect to oral wound healing, microbial colonization, tissue reaction and clinical features-randomized clinical study.

text: OBJECTIVES Sutures are the most frequently used medical device for wound closure. They support tissue during the early phase of healing until it regains enough tensile strength. The aim of this study was to compare four different suture materials in terms of the influence on wound healing, microbial adherence, tissue reaction, and relevant clinical parameters which determine their clinical value. MATERIALS AND METHODS Total number of 32 patients undergoing surgical extraction of four impacted third molars were involved in the study. Clinical parameters were estimated intraoperatively and during the control check-ups. Soft tissue healing around sutures were evaluated on the 3rd and 7th day postoperatively. Microbial colonization was assessed by means of qPCR. Also, histological analysis was done to assess inflammatory reaction. RESULTS Significantly better soft tissue healing was found around monofilament and synthetic sutures compared to multifilament and natural ones respectively. Soft tissue healing was significantly better around all sutures on the 7th day than on the 3rd day postoperatively. CONCLUSIONS Non-resorbable polypropylene suture showed superior clinical characteristics among all sutures. Moreover, the best healing of soft tissue and the least inflammatory reaction was found around this thread. The poorest soft tissue healing was found around non-resorbable silk suture. This suture elicited strongest inflammatory reaction and showed the greatest microbial adherence affinity compared to alternative sutures. CLINICAL RELEVANCE Monofilament synthetic suture should be used in order to obtain the best soft tissue healing, reduce the risk of postoperative infection, and alleviate the suturing after oral surgery procedures.


title: The modified laparoscopic keyhole parastomal hernia repair with in situ re-ostomy has low recurrence rate.

text: PURPOSE This study aimed to present a modified laparoscopic keyhole parastomal hernia repair technique with in situ re-ostomy and show its safety and feasibility at a mid-term follow-up. METHODS The technique begins with adhesiolysis during laparoscopy. An annular incision is made between the skin and stomal mucosa. Then, after all adhesions of the stomal bowel and its mesentery are separated from the hernial sac, the stomal bowel is delivered through the keyhole mesh. The mesh is then stitched to the stomal bowel and placed intraperitoneally. The hernial ring is narrowed, and the mesh is further stitched to the hernial ring and stomal tube. After the mesh is fixed, the redundant stomal bowel is shortened, and a new in situ stoma is matured in the conventional way. RESULTS Altogether, 65 consecutive patients underwent successful hernia repair via a modified laparoscopic keyhole with in situ re-ostomy. Two of the patients had recurrent parastomal hernias. No mortalities occurred during the perioperative period. Morbidities included two cases of seroma and three of ileus, all of which were cured with conservative treatment. In addition, one case of intestinal perforation was rescued by intestinal resection and enteroenterostomy. Median follow-up was 29 months (range 3-60 months). No complications of mesh-related infection or patch erosion were noted during the follow-up. CONCLUSIONS Modified laparoscopic keyhole parastomal hernia repair with in situ re-ostomy is a safe procedure with a low recurrence rate at the mid-term follow-up.


title: Three cases of immature teratoma diagnosed after laparoscopic operation.

text: While mature cystic teratoma of the ovary is the most common ovarian tumor in young women, immature teratoma is a very rare tumor, representing only 1% of all ovarian cancers. In the three cases presented here, young women who were suspected to have mature cystic teratoma, based on CT scan and MRI, were ultimately diagnosed with immature teratoma Ic (b) G1 after laparoscopic operation. They underwent salpingo-oophorectomy of the affected side only and have shown no sign of recurrence during follow-up. We sometimes encounter patients with immature teratoma who have no findings pointing to malignancy on CT or MRI. Generally, if the components of immature nerve cells that represent immature teratoma are very few, it is difficult to diagnose the entity as immature teratoma with imaging evaluations such as CT or MRI. In many hospitals, laparoscopic surgery is selected for patients with ovarian mature teratoma. Therefore, it is essential to attempt as much as possible not to disseminate the fluid content of the tumor into the intra-abdominal space during laparoscopic operation, because in rare cases the tumor turns out not to be benign mature teratoma.


Pandemic (H1N1) 2009 and seasonal influenza A (H3N2) in Children's Hospital, Australia.


title: Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial.

text: OBJECTIVE To investigate the safety and effects of a restrictive red blood cell (RBC) transfusion strategy in pediatric cardiac surgery patients. DESIGN Randomized controlled trial. SETTING Pediatric ICU in an academic tertiary care center, Leiden University Medical Center, Leiden, The Netherlands. PATIENTS One hundred seven patients with non-cyanotic congenital heart defects between 6 weeks and 6 years of age. One hundred three patients underwent corrective surgery on cardiopulmonary bypass. INTERVENTIONS Prior to surgery patients were randomly assigned to one of two groups with specific RBC transfusion thresholds: Hb 10.8 g/dl (6.8 mmol/l) and Hb 8.0 g/dl (5.0 mmol/l). MEASUREMENTS Length of stay in hospital (primary outcome), length of stay in PICU, duration of ventilation (secondary outcome), incidence of adverse events and complications related to randomization (intention to treat analysis). RESULTS In the restrictive transfusion group, mean volume of transfused RBC was 186 (±70) ml per patient and in the liberal transfusion group 258 (±87) ml per patient, (95% CI 40.6-104.6), p < 0.001. Length of hospital stay was shorter in patients with a restrictive RBC transfusion strategy: median 8 (IQR 7-11) vs. 9 (IQR 7-14) days, p = 0.047. All other outcome measures and incidence of adverse effects were equal in both RBC transfusion groups. Cost of blood products for the liberal transfusion group was 438.35 (±203.39) vs. 316.27 (±189.96) euros (95% CI 46.61-197.51) per patient in the restrictive transfusion group, p = 0.002. CONCLUSIONS For patients with a non-cyanotic congenital heart defect undergoing elective cardiac surgery, a restrictive RBC transfusion policy (threshold of Hb 8.0 g/dl) during the entire perioperative period is safe, leads to a shorter hospital stay and is less expensive.


title: Augmented curation of clinical notes from a massive EHR system reveals symptoms of impending COVID-19 diagnosis.

text: Understanding temporal dynamics of COVID-19 patient symptoms could provide fine-grained resolution to guide clinical decision-making. Here, we use deep neural networks over an institution-wide platform for the augmented curation of clinical notes from 77,167 patients subjected to COVID-19 PCR testing. By contrasting Electronic Health Record (EHR)-derived symptoms of COVID-19-positive (COVIDpos; n=2,317) versus COVID-19-negative (COVIDneg; n=74,850) patients for the week preceding the PCR testing date, we identify anosmia/dysgeusia (27.1-fold), fever/chills (2.6-fold), respiratory difficulty (2.2-fold), cough (2.2-fold), myalgia/arthralgia (2-fold), and diarrhea (1.4-fold) as significantly amplified in COVIDpos over COVIDneg patients. The combination of cough and fever/chills has 4.2-fold amplification in COVIDpos patients during the week prior to PCR testing, and along with anosmia/dysgeusia, constitutes the earliest EHR-derived signature of COVID-19. This study introduces an Augmented Intelligence platform for the real-time synthesis of institutional biomedical knowledge. The platform holds tremendous potential for scaling up curation throughput, thus enabling EHR-powered early disease diagnosis.


title: Conventional mesh repair of a giant iatrogenic bilateral diaphragmatic hernia with an enterothorax.

text: PURPOSE Diaphragmatic hernias (DHs) are divided into congenital and acquired hernias, most of which are congenital. Among acquired DHs, up to 80% are left-sided, only a few iatrogenic DHs have been reported, and bilateral hernias are extremely rare. For diagnostic reasons, many DHs are overlooked by ultrasonography or X-ray and are only recognized at a later stage when complications occur. METHODS In 2009, we performed three partial diaphragm replacements in our clinic for repairing DHs using a PERMACOL™ implant. RESULTS As all patients had uneventful postoperative courses and the clinical outcomes were very good, we present one special case of a 65-year-old male with a giant iatrogenic bilateral DH with an enterothorax. CONCLUSION We see a good indication for diaphragm replacements by using a PERMACOL™ implant for fixing especially DHs with huge hernial gaps and in cases with fragile tissue.


title: Phase I study demonstrates safety and tolerability of radiofrequency ablation (RFA) of the anal mucosa.

text: BACKGROUND Anal carcinoma is increasing in high-risk populations. Dysplasia is often distributed throughout the anal mucosa, and focal ablative techniques have high rates of recurrence. METHODS With the goal of eradicating dysplasia from the entire anal mucosa, we conducted a phase I dose-ranging study to determine the safety and tolerability of radiofrequency ablation (RFA). HIV-infected individuals with high-grade anal intraepithelial neoplasia underwent RFA of the anal mucosa. Patient-reported procedural and postprocedural symptoms were recorded, and mucosal healing was visually assessed. RESULTS Four groups of 3 subjects each were treated with incrementally increasing numbers of RF pulses (1-3) applied to a single area of anal mucosa. Two or three doses of 12 J/cm2 were found to have acceptable patient tolerance and healing of the mucosa within 4 weeks of ablation. Using these doses, 2 groups underwent ablation of 180° of contiguous mucosa. Subjects experienced a loss of 1 to 3 days of daily activities of living, 7 to 14 days of postprocedure symptoms, and mucosal healing within 4 weeks. One subject in the first treatment group had the procedure aborted due to severe procedural pain. CONCLUSIONS The study provides evidence of the safety and tolerability of anal RFA of 180° of contiguous mucosa in a single procedure and will allow future RFA efficacy studies in the treatment of anal dysplasia.


title: Successful treatment of cerebral venous sinus thrombosis with the Solitaire FR thrombectomy device.

text: A young woman with factor V Leiden thrombophilia presented with headache due to thrombosis of the right transverse sinus (TS) and superior sagittal sinus. Despite appropriate anticoagulation, she experienced worsening headache, progressive neurologic deficits and spontaneous subarachnoid hemorrhage. Endovascular therapy was therefore undertaken. A 6 mm Solitaire FR device was deployed in the TS and withdrawn in a stepwise fashion, resulting in complete recanalization of the sinus. Her headache improved and her neurologic deficits resolved. Endovascular therapy for cerebral venous sinus thrombosis is currently recommended only for those patients with deterioration despite appropriate anticoagulation. The thrombus burden is usually high in this subset of patients, and recanalization can be challenging with currently available endovascular techniques. This is the first report of cerebral venous sinus thrombectomy with the Solitaire FR device, which may offer another option for those patients requiring endovascular treatment.


title: A System to Assess the Competency for Interpretation of Esophageal Manometry Identifies Variation in Learning Curves.

text: BACKGROUND & AIMS Quality esophageal high-resolution manometry (HRM) studies require competent interpretation of data. However, there is little understanding of learning curves, training requirements, or measures of competency for HRM. We aimed to develop and use a competency assessment system to examine learning curves for interpretation of HRM data. METHODS We conducted a prospective multicenter study of 20 gastroenterology trainees with no experience in HRM, from 8 centers, over an 8-month period (May through December 2015). We designed a web-based HRM training and competency assessment system. After reviewing the training module, participants interpreted 50 HRM studies and received answer keys at the fifth and then at every second interpretation. A cumulative sum procedure produced individual learning curves with preset acceptable failure rates of 10%; we classified competency status as competency not achieved, competency achieved, or competency likely achieved. RESULTS Five (25%) participants achieved competence, 4 (20%) likely achieved competence, and 11 (55%) failed to achieve competence. A minimum case volume to achieve competency was not identified. There was no significant agreement between diagnostic accuracy and accuracy for individual HRM skills. CONCLUSIONS We developed a competency assessment system for HRM interpretation; using this system, we found significant variation in learning curves for HRM diagnosis and individual skills. Our system effectively distinguished trainee competency levels for HRM interpretation and contrary to current recommendations, found that competency for HRM is not case-volume specific.


title: The Impact of Green Space on Violent Crime in Urban Environments: An Evidence Synthesis.

text: Can the presence of green space in urban environments reduce the frequency of violent crime? To ascertain the evidence on this topic, we conducted an in-depth literature review using the PRISMA checklist. The search parameters included US articles written in English and published since 2000. More than 30,000 potential paper titles were identified and ultimately, 45 papers were selected for inclusion. Green spaces typically comprised tree cover, parks and ground cover. Criminal behaviors typically included murder, assault, and theft. The majority of the research reviewed involved quantitative methods (e.g., comparison of green space area to crime data). We extracted multiple mechanisms from the literature that may account for the impact of green space on crime including social interaction and recreation, community perception, biophilic stress reduction, climate modulation, and spaces expressing territorial definition. Recommendations are made for future research, such as meta-analysis of existing data and the development of grounded theory through qualitative data-gathering methods. By providing evidence that access to nature has a mitigating impact on violence in urban settings, city governments and communities are empowered to support these interventions.


title: Against pandemic research exceptionalism.

text: Crises are no excuse for lowering scientific standards.


title: "Slowing the Spread and Minimizing the Impact of COVID-19: Lessons from the Past and Recommendations for the Plastic Surgeon".

text: BACKGROUND COVID-19, a novel coronavirus originating in December 2019 in Wuhan, China, has spread rapidly throughout the globe over 3 months. On March 11, 2020 the World Health Organization declared COVID-19 a global pandemic. COVID-19 represents a nearly unprecedented threat to both the public health and the durability of our healthcare systems and will profoundly affect the field of plastic and reconstructive surgery. The objective of this paper is to provide a natural history of COVID-19 - including virology, epidemiology and transmission patterns - and a guide for plastic surgeons regarding patient and resource management. METHODS The authors reviewed existing literature regarding COVID-19, both primary research and secondary reviews, via PubMed queries, and recommendations from relevant professional organizations (e.g., American College of Surgeons and American Society of Plastic Surgeons). The literature and recommendations were summarized to provide a specific guide for plastic surgeons. RESULTS Internationally, over 5.7 million cases and 357,000 deaths from COVID-19 have been reported at time of writing. No pharmacological treatments have been identified, but epidemiological strategies were identified to prevent viral spread, preserve healthcare resources, and protect patients and surgeons globally. Specific recommendations for plastic and reconstructive surgeons include postponing elective cases and transitioning to telecommunication platforms for patient consultations and education. CONCLUSIONS COVID-19 represents a nearly unprecedented threat to the public health and the durability of healthcare systems in the contemporary era. While plastic and reconstructive surgery may seem relatively remote from the pandemic in direct patient care and exposure, our field can significantly enhance healthcare resource management.


title: Evaluation of Skin Hardness as a Physiological Sign of Human Thermal Status.

text: This is the first ever proposal to use skin hardness as a physiological sign by which to estimate human thermal status and to verify its effectiveness and independence in relation to the two conventional signs: skin temperature and skin conductance. We propose a novel TSV model adding skin hardness to the conventional TSV model for better estimation of human thermal status with higher accuracy and lower error. We survey individual thermal sensation from 30 subjects under four different thermal conditions (normal, warm, hot, and cold); while measuring skin hardness along with the two conventional physiological signs. The novel model for estimation of thermal status from all three signs increases R2 by 17.4% and decreases error by 23.5%, compared to the conventional model using two signs. The novel TSV model has potential for applications to human-machine interaction systems for better estimation of human thermal status.


title: Three-Dimensional Simulation of Collision-Free Paths for Combined Endoscopic Third Ventriculostomy and Pineal Region Tumor Biopsy: Implications for the Design Specifications of Future Flexible Endoscopic Instruments.

text: BACKGROUND Recent innovations to expand the scope of intraventricular neuroendoscopy have focused on transitioning multiple-incision procedures into single-corridor approaches. However, the successful adoption of these combined procedures requires minimizing the unwanted torques applied to surrounding healthy structures. OBJECTIVE To define the geometry of relevant anatomical structures in endoscopic third ventriculostomy (ETV) and pineal region tumor biopsy (ETB). Second, to determine the optimal instrument shaft path required for collision-free single burr hole combined ETV/ETB. METHODS Magnetic resonance and computed tomography data from 15 pediatric patients who underwent both ETV and ETB procedures between 2006 and 2014 was segmented by using the 3DSlicer software package to create virtual 3-D patient models. Anatomical regions of interest were measured including the foramen of Monro, the massa intermedia, the floor of the third ventricle, and the tumor margin. Utilizing the MATLAB software package, virtual dexterous instruments were inserted into the models and optimal dimensions were calculated. RESULTS The diameters of the foramen of Monro, massa intermedia (anterior-posterior, superior-inferior), anterior third ventricle, and tumor margin are 6.85, 4.01, 5.05, 14.2, and 28.5 mm, respectively. The average optimal burr placement was determined to be 22.5 mm anterior to the coronal and 30 mm lateral to the sagittal sutures. Optimal flexible instrument geometries for novel instruments were calculated. CONCLUSION We have established a platform for estimating the shape of novel curved dexterous instruments for collision-free targeting of multiple intraventricular points, which is both patient and tool specific and can be integrated with image guidance. These data will aid in developing novel dexterous instruments.


title: [Advances in the research of cytokine storm mechanism induced by Corona Virus Disease 2019 and the corresponding immunotherapies].

text: Corona Virus Disease 2019 (COVID-19) has seriously affected the treatment of patients and social stability. In the later stage of disease, some COVID-19 patients may develop into acute respiratory distress syndrome or even multiple organ failure. However, one of the most important mechanism underlying the deterioration of disease is cytokine storm. At present, some therapies such as interleukin-6 antibody blocker, stem cell therapy, and transfusion of convalescent plasma have been applied to counteract the cytokine storm and have made some progress. This article reviews the influences of cytokine storm syndrome on the COVID-19 and the corresponding immunotherapies to resist cytokine storm.


title: High variability of teicoplanin concentration in patients with continuous venovenous hemodiafiltration.

text: INTRODUCTION Continuous venovenous hemodiafiltration (CVVHDF) may alter teicoplanin pharmacokinetics and increase the risk of incorrect dosing. The objective of this prospective observational study was to assess the effect of CVVHDF on the pharmacokinetics of teicoplanin as maintenance therapy. METHODS Blood, urine, and dialysate samples were collected to measure teicoplanin levels. CVVHDF clearance (CLCVVHDF ), total clearance (CLTOTAL ), and volume of distribution (Vd) were calculated by simplex-linear modeling. The influence of CVVHDF dose on teicoplanin pharmacokinetics was assessed. FINDINGS Ten samples from eight patients were studied. Creatinine clearance was 3.4 ± 5.1 ml/min/1.73 m2 . Three patients were anuria. The dose for CVVHDF was 32.1 ± 7.0 mL/kg/h. Vd was 1.6 ± 0.7 L/kg. T1/2 was 100.1 ± 42.7 hours. CLTOTAL of teicoplanin was 11.9 ± 5.4 mL/min and CLCVVHDF was 5.8 ± 4.2 mL/min. Contribution of CLCVVHDF to CLTOTAL was 51.2% ± 23.6%. CLCVVHDF of individual teicoplanin varied widely. Large intra-occasion differences were also observed. Dose of CLCVVHDF did not influence overall CLTOTAL , Vd, or half-life. The proportion of CLTOTAL due to CLCVVHDF varied widely. It was high in some cases. DISCUSSION In patients receiving CVVHDF, there is great variability in teicoplanin pharmacokinetics which complicates empiric approach to dosing, suggesting the need for therapeutic drug monitoring.


title: Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study.

text: BACKGROUND Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels. METHODS We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month. FINDINGS We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14-1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12-1·72) irrespective of other patient and service characteristics. INTERPRETATION Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes. FUNDING Chest, Heart and Stroke Scotland.


Accreditation Readiness in US Multidisciplinary Rectal Cancer Care: A Survey of OSTRICH Member Institutions.


title: Imaging Acute Ischemic Stroke: Mapping Present and Future Clinical Practice.

text: Imaging is an increasingly key component of advances in stroke care. Its role in the success of multiple recently reported trials that have now driven new standards of practice highlights its expanding importance in acute stroke management. With significant gains already realized, routine practice only stands to benefit further from additional advances in imaging in the future. The degree to which imaging will impact stroke care, however, is uncertain and complex: multiple aspects of stroke research and its translation into updated practice contribute to it. In this article, a few of these critical issues and questions related to imaging and its potential, both present and future, to drive stroke care forward are addressed.


title: Management of Severe Frostbite in a Grey-Headed Parrot (Poicephalus fuscicollis suahelicus).

text: An approximately 5-year-old female grey-headed parrot (Poicephalus fuscicollis suahelicus) was evaluated after exposure to outdoor temperatures below -20°C (-4°F) for approximately 22 hours. Severe frostbite affecting multiple digits, as well as dehydration and a depressed attitude, were diagnosed. Treatment included oral antibiotics, antifungals, nonsteroidal anti-inflammatories (NSAIDs), pentoxifylline, and topical aloe vera. Surgical amputation of the affected toes was not performed. Mild to moderate pododermatitis over the intertarsal joints developed because of a shift in weight bearing after the loss of most digits. Within 5 months after initial presentation, all frost-damaged toes had self-amputated, and the bird was able to function independently with no limitations in mobility.


title: Seroprevalence of SARS-CoV-2 Among Frontline Healthcare Personnel During the First Month of Caring for COVID-19 Patients - Nashville, Tennessee.

text: Among 249 healthcare personnel who worked in hospital units with COVID-19 patients for one month, 19 (7.6%) tested positive for SARS-CoV-2 antibodies. Only 11 (57.9%) of the 19 personnel with positive serology reported symptoms of a prior illness, suggesting asymptomatic healthcare personnel could be an important source of SARS-CoV-2 transmission.


title: Validation of the Pockit Dengue Virus Reagent Set for Rapid Detection of Dengue Virus in Human Serum on a Field-Deployable PCR System.

text: Dengue virus (DENV) infection, a mosquito-borne disease, is a major public health problem in tropical countries. Point-of-care DENV detection with good sensitivity and specificity enables timely early diagnosis of DENV infection, facilitating effective disease management and control, particularly in regions of low resources. The Pockit dengue virus reagent set (GeneReach Biotech), a reverse transcription insulated isothermal PCR (RT-iiPCR), is available to detect all four serotypes of DENV on the field-deployable Pockit system, which is ready for on-site applications. In this study, analytical and clinical performances of the assay were evaluated. The index assay did not react with 14 non-DENV human viruses, indicating good specificity. Compared to the U.S. CDC DENV-1-4 real-time quantitative RT-PCR (qRT-PCR) assay, testing with serial dilutions of virus-spiked human sera demonstrated that the index assay had detection endpoints that were separately comparable with the 4 serotypes. Excellent reproducibility was observed among repeat tests done by six operators at three sites. In clinical performance, 195 clinical sera collected around Kaohsiung city in 2012 and 21 DENV-4-spiked sera were tested with the RT-iiPCR and qRT-PCR assays in parallel. The 121 (11 DENV-1, 78 DENV-2, 11 DENV-3, and 21 DENV-4) qRT-PCR-positive and 95 qRT-PCR-negative samples were all positive and negative by the RT-iiPCR reagent results, respectively, demonstrating high (100%) interrater agreement (95% confidence interval [CI95%], ∼98.81% to 100%; κ = 1). With analytical and clinical performance equivalent to those of the reference qRT-PCR assay, the index PCR assay on the field-deployable system can serve as a highly sensitive and specific on-site tool for DENV detection.


Chance missed, but still there! Memoirs at the 10(th) anniversary of 2003 SARS outbreak.


title: Potential of Heparin and Nafamostat Combination Therapy for COVID-19.

text: Tang et al. recently reported that (Journal of Thrombosis and Haemostasis), in COVID-19 infections caused by the novel coronavirus (SARS-CoV-2), heparin anticoagulant therapy lowers the mortality rate in patients who present with markedly elevated concentrations of D-dimer 1). In other words, abnormal coagulation may influence the prognosis of COVID-19. This is extremely interesting. The article did not describe to what extent heparin improves the abnormal coagulation and further studies by this group are anticipated. The authors reported in that article 1) and a previous article 2) that the abnormal coagulation seen in non-survivors of COVID-19 clearly differs from the abnormal coagulation typically seen in other severe infectious diseases.


'No one is allowed to go out': your stories from the coronavirus outbreak.


title: Functions of the 5'- and 3'-untranslated regions of tobamovirus RNA.

text: The tobamovirus genome is a 5'-m(7)G-capped RNA that carries a tRNA-like structure at its 3'-terminus. The genomic RNA serves as the template for both translation and negative-strand RNA synthesis. The 5'- and 3'-untranslated regions (UTRs) of the genomic RNA contain elements that enhance translation, and the 3'-UTR also contains the elements necessary for the initiation of negative-strand RNA synthesis. Recent studies using a cell-free viral RNA translation-replication system revealed that a 70-nucleotide region containing a part of the 5'-UTR is bound cotranslationally by tobacco mosaic virus (TMV) replication proteins translated from the genomic RNA and that the binding leads the genomic RNA to RNA replication pathway. This mechanism explains the cis-preferential replication of TMV by the replication proteins. The binding also inhibits further translation to avoid a fatal ribosome-RNA polymerase collision, which might arise if translation and negative-strand synthesis occur simultaneously on a single genomic RNA molecule. Therefore, the 5'- and 3'-UTRs play multiple important roles in the life cycle of tobamovirus.


title: Short-Term Outcomes of Totally Laparoscopic Central Hepatectomy and Right Anterior Sectionectomy for Centrally Located Tumors: A Case-Matched Study with Propensity Score Matching.

text: BACKGROUND Recent advances in technology and accumulation of surgical experience have expanded the indications for laparoscopic liver resection (LLR). However, compared to open liver resection (OLR), the feasibility of laparoscopic anatomical liver resection for centrally located tumor (CLT) has not been clearly established. The aim of our study was to assess the feasibility and safety of laparoscopic anatomical major liver resection for CLT. METHODS From April 2011 to March 2016, 20 cases of anatomical LLR and 86 cases of OLR for CLTs such as central hepatectomy (CH) and right anterior sectionectomy (RAS) were performed at a single institution. We performed one-to-one propensity score matching and analyzed short-term outcomes between the LLR (n = 20) and OLR (n = 20) groups. RESULTS Among 20 cases in the LLR group, two cases underwent open conversion due to common bile duct injury and anatomical distortion, respectively. There were no statistically significant difference between the LLR and OLR groups regarding clamping time of the Pringle maneuver (p = 0.502), blood loss (p = 0.746), surgical margin (p = 0.198), or length of hospital stay (p = 0.110). However, surgical time was significantly longer in the LLR group than in the OLR group (388 vs 268 min; p < 0.001). There were no significant differences between the two groups with regard to morbidity rate or mean comprehensive complication index (p = 0.716 and p = 0.819, respectively). CONCLUSION Total anatomical LLR can be performed safely in selected CLT patients by experienced surgeons. Laparoscopic CH or RAS appears feasible with non-inferior perioperative outcomes compared to OLR.


Terra incognita: clinically suspected myocarditis in a SARS-CoV-2 positive patient.


title: Use of local pro-coagulant haemostatic agents for intra-cavity control of haemorrhage after trauma.

text: INTRODUCTION Uncontrolled haemorrhage as a result of trauma remains a significant surgical challenge, accounting for approximately 25-40% of trauma-related mortality. A wide range of local internal haemostatic agents have been developed to help achieve intra-cavity control of bleeding, with choice of agent influenced by the circumstances and nature of the haemorrhage. Trauma patients are frequently coagulopathic, so products that incorporate pro-coagulant technology and thereby act independently of the clotting cascade may be more effective in these settings. A range of products that utilise thrombin and fibrinogen to promote local haemostasis at intra-cavity bleeding points are available or in development, including fibrin glues (e.g. Tisseel®/Tissucol® and Evicel®/Crosseal®/Quixil®), fibrin sealant patches (e.g. TachoSil®) and products based on a gelatin-thrombin haemostatic matrix (e.g. FloSeal®). MATERIALS AND METHODS This systematic review was performed to assess all peer-reviewed evidence of product efficacy. RESULTS Fibrin sealant patches have shown haemostatic efficacy in a variety of surgical procedures and appear to offer practical advantages over liquid fibrin glues. Existing evidence suggests that patch products enable delivery of pro-coagulants to defined areas with less chance of dilution and/or displacement by blood flow, but they require a pressure buttress for a suitable amount of time to achieve good results after trauma. CONCLUSIONS Our experience, supported by other reports in the literature, suggests the use of such fibrin patches may provide an effective option in helping to control haemorrhage after trauma. However, there is a general paucity of clinical data for intra-cavity haemostatic agent use, with the majority of data being based on animal models and case reports. Further clinical evidence, ideally including comparative studies between different agents, would be beneficial in helping guide surgeon choice to the most appropriate products to use in trauma settings.


title: Methodological systematic review of studies on social inequalities in smoking among young adults: A field coming of age?

text: OBJECTIVE Socioeconomic circumstances are critically important to addressing smoking. In young adulthood (ages 18-25), dynamic transitions in education, employment, family and housing complicate the measurement of socioeconomic circumstances. To better understand approaches to capturing these circumstances, this methodological systematic review examined how socioeconomic characteristics used to identify social inequalities in smoking among young adults are measured. DATA SOURCES We searched PubMed/MEDLINE, Scopus, EMBASE, ERIC and Sociological Abstracts, and used three prior reviews. We updated the search in March 2018. STUDY SELECTION Two reviewers independently screened peer-reviewed records from OECD countries published in English, French, German or Spanish after 1995 whose samples covered at least 1 year between the ages of 18 and 25. We included 89 of 1320 records. DATA EXTRACTION One reviewer extracted study characteristics, indicators used to operationalise socioeconomic circumstances and each indicator's relation to results on smoking (ie, significance and direction). We found 39 indicators of socioeconomic circumstances related to six broad domains. These indicators were used in 425 results. DATA SYNTHESIS We descriptively analysed the extracted data using evidence tables. Educational attainment was most common. Evidence of inequalities varied by indicator used. For example, there was inconsistent evidence regarding the role of parental characteristics and transition stages and insufficient evidence regarding personal income on smoking. CONCLUSION Despite its importance, studies have disproportionally examined inequalities among young adults using traditional indicators. The mismatch between young adults' life transitions and measurement strategies may attenuate evidence of inequalities. We suggest strategies to improve future measurement.


title: A prospective randomized controlled trial of the laryngeal mask airway versus the endotracheal intubation in the thyroid surgery: evaluation of postoperative voice, and laryngopharyngeal symptom.

text: BACKGROUND The present study was performed to determine whether thyroidectomy patients undergoing general anesthesia provided with a laryngeal mask airway (LMA) have a lower risk of voice-related complications and laryngopharyngeal symptoms than those undergoing endotracheal intubation (ETI). MATERIALS AND METHODS In a prospective, double-blinded, randomized clinical trial, we studied 64 patients undergoing elective thyroid lobectomy between July 2013 and February 2014. Acoustic analyses were performed preoperatively and at 48 h and 2 weeks postoperatively. The voice handicap index (VHI), M.D. Anderson dysphagia index (MDADI), and laryngopharyngeal symptom score (LPS) were determined preoperatively and at 24 h, 48 h, 1 week, and 2 weeks post-thyroidectomy. RESULTS In acoustic analysis, jitter, shimmer and noise-to-harmonic ratio showed significantly better results in the LMA group than the ETI group 48 h after surgery, but there was no difference at 2 weeks. The incidence of postoperative lower-pitched voice in the LMA group was also significantly lower than that in the ETI group. In the LMA group, the VHI, MDADI, and LPS were better compared to those in the ETI group at 24 h postoperatively, and improved to the preoperative state within 1 week. However, those in the ETI group remained poorer than the preoperative values 1 week after surgery. CONCLUSIONS Use of the LMA in general anesthesia for thyroid surgery has advantages over the ETI in decreasing patients' subjective and objective voice symptoms, reducing the duration of symptoms, and relieving the laryngopharyngeal symptoms.


title: An Integrative Total Worker Health Framework for Keeping Workers Safe and Healthy During the COVID-19 Pandemic.

text: OBJECTIVE The aim was to recommend an integrated Total Worker Health (TWH) approach which embraces core human factors and ergonomic principles, supporting worker safety, health, and well-being during the COVID-19 pandemic. BACKGROUND COVID-19 has resulted in unprecedented challenges to workplace safety and health for workers and managers in essential businesses, including healthcare workers, grocery stores, delivery services, warehouses, and distribution centers. Essential workers need protection, accurate information, and a supportive work environment with an unwavering focus on effective infection control. METHOD The investigators reviewed emerging workplace recommendations for reducing workers' exposures to the novel coronavirus and the challenges to workers in protecting their health. Using a theoretical framework and guidelines for integrating safety and health management systems into an organization for TWH, the investigators adapted the framework's key characteristics to meet the specific worker safety and health issues for effective infection control, providing supports for increasing psychological demands while ensuring a safe work environment. RESULTS The recommended approach includes six key characteristics: focusing on working conditions for infection control and supportive environments for increased psychological demands; utilizing participatory approaches involving workers in identifying daily challenges and unique solutions; employing comprehensive and collaborative efforts to increase system efficiencies; committing as leaders to supporting workers through action and communications; adhering to ethical and legal standards; and using data to guide actions and evaluate progress. CONCLUSION Applying an integrative TWH approach for worker safety, health, and well-being provides a framework to help managers systematically organize and protect themselves, essential workers, and the public during the COVID-19 pandemic. APPLICATION By using the systems approach provided by the six implementation characteristics, employers of essential workers can organize their own efforts to improve system performance and worker well-being during these unprecedented times.


Cardiovascular and immunological implications of social distancing in the context of COVID-19.


Letter to the Editor about the Article "Excess Mortality Estimation During the COVID-19 Pandemic: Preliminary Data from Portugal https://doi.org/10.20344/amp.13928".


title: Public health education in Saudi Arabia: Needs and challenges.

text: In the last decade, public health (PH) has come to the frontlines in Saudi Arabia. The recent outbreak of a novel corona virus (MERS-CoV) highlighted the importance of PH services and the need for a competent PH workforce. The urgency and panic induced by infectious disease outbreaks explain the heightened interest. Decision makers' interest in public health was observed through a series of decisions, including creating a position for Deputy Minister for Public Health, changing the name of "Directorate of Primary Healthcare Centers" to "Directorate of Public Health" in all health regions and initiating a special scholarship program to prepare health administration professionals in collaboration with US-based universities. A distinguished group of PH leaders in Saudi Arabia was gathered in a structured workshop that was organized by the Al Imam Mohammad Ibn Saud Islamic University, college of medicine to discuss the current status and future needs of PH education in the Kingdom of Saudi Arabia. The workshop highlighted the need for PH education development and outlined the challenges ahead. The main challenges laid out by participants in the workshop were the development of an appropriate PH curriculum, appropriate training spots for practical placement, the development of research priorities for PH to satisfy the needs of PH programs and agencies, attracting the most qualified academic staff, the enrolment of highly motivated students and finally, the establishment of a quality assurance program to ensure the quality of PH education programs. The development of a framework for graduate competencies in PH was perceived to be a top priority. Moreover, setting a PH workforce surveillance system, building partnership between PH academic institutions and PH services providers, implementing national campaigns to explain what PH is about and illuminating the role of PH workers were also of utmost importance.


title: Signalling at tight junctions during epithelial differentiation and microbial pathogenesis.

text: Tight junctions are a component of the epithelial junctional complex, and they form the paracellular diffusion barrier that enables epithelial cells to create cellular sheets that separate compartments with different compositions. The assembly and function of tight junctions are intimately linked to the actomyosin cytoskeleton and, hence, are under the control of signalling mechanisms that regulate cytoskeletal dynamics. Tight junctions not only receive signals that guide their assembly and function, but transmit information to the cell interior to regulate cell proliferation, migration and survival. As a crucial component of the epithelial barrier, they are often targeted by pathogenic viruses and bacteria, aiding infection and the development of disease. In this Commentary, we review recent progress in the understanding of the molecular signalling mechanisms that drive junction assembly and function, and the signalling processes by which tight junctions regulate cell behaviour and survival. We also discuss the way in which junctional components are exploited by pathogenic viruses and bacteria, and how this might affect junctional signalling mechanisms.


title: Loss of DRAK2 signaling enhances allogeneic transplant survival by limiting effector and memory T cell responses.

text: Here, we demonstrate that loss of DRAK2 signaling significantly promotes the acceptance of allogeneic engraftment in two separate transplant models without promoting generalized immunosuppression. Drak2-/- T cells failed to reject allogeneic tumors, and were defective in rejecting Balb/C allogeneic skin grafts on C57BL6/J recipients. A significant fraction of alloreactive Drak2-/- T cells underwent apoptosis following activation, whereas enforced expression of Bcl-xL in Drak2-/- T cells restored allograft rejection. Formation of allogeneic memory was also greatly hampered in T cells lacking the Drak2 gene. Adoptive transfer of memory T cells from Drak2-/- mice failed to promote the rejection of allogeneic tumors, and such cells led to significantly delayed rejection of skin allografts in the Balb/C->C57BL/6J model. Costimulatory blockade by in vivo administration of Cytotoxic T-Lymphocyte Antigen 4 fusion protein (CTLA4-Ig) synergized with the DRAK2 deficiency and led to long-term allogeneic skin graft acceptance. Overall, these results demonstrate that DRAK2 plays an important role in primary and memory T cell responsiveness to allografts. Because previous studies have demonstrated that a loss of DRAK2 does not negatively impact antiviral immunity, the studies here underscore the potential utility of pharmacological blockade of DRAK2 to achieve transplant maintenance without the imposition of generalized immunosuppression.


Development of normal pressure hydrocephalus after the placement of a pipeline embolization device for the treatment of a large aneurysm: case report.


title: Comparison of criteria of International Association of Diabetes and Pregnancy Study Groups (IADPSG) with National Institute for Health and Care Excellence (NICE) for diagnosis of gestational diabetes mellitus.

text: BACKGROUND Different screening procedures and diagnostic criteria are being followed in the same as well as in different countries with no single standard criteria established for diagnosis of GDM. So far, there are no studies in the Indian population comparing IADPSG with NICE criteria. OBJECTIVE To compare International Association of Pregnancy and Study Groups (IADPSG) criteria with the National Institute for Health and Care Excellence (NICE) for diagnosis of gestational diabetes mellitus and its influence on maternal and perinatal outcomes. METHOD This prospective observational study was conducted in the Department of Obstetrics and Gynaecology of a tertiary care institute in South India from March 2017 to October 2018. Six-hundred and eighty women with or without risk factors for GDM were recruited in the study and screened for GDM based on IADPSG and NICE criteria. Women with preexisting diabetes mellitus or with fasting plasma glucose ≥ 126 mg/dl were excluded. RESULTS The overall prevalence of GDM in our study was 27.2% by either IADPSG/NICE criteria. In this study, 25.1% women and 11.6% women were diagnosed as GDM using IADPSG and NICE criteria, respectively. The level of agreement between the two diagnostic criteria was found to be poor in our study and was statistically significant (kappa = 0.429, p < 0.001). Women testing IADPSG-positive NICE-negative had a higher risk of GHTN, abortions, PROM, preterm delivery, caesarean section and congenital anomalies, meconium-stained liquor, and low Apgar scores at 1 min when compared to non GDM group. In addition, except for preterm delivery, women diagnosed as GDM by both IADPSG and NICE criteria had adverse outcomes such as preeclampsia, urinary tract infection, and polyhydramnios. Women diagnosed as GDM in IADPSG-negative NICE-positive had no significant adverse maternal or perinatal outcomes. CONCLUSIONS IADPSG criteria appear to be more robust than NICE criteria for diagnosis of GDM. Women with substantial risk of maternal and perinatal outcomes are better identified by IADPSG criteria who would have been missed if NICE criteria was used.


title: Management of ovarian cancer during the COVID-19 pandemic.

text: COVID-19 infection spread rapidly in Italy during the early months of 2020. Infection can vary in severity from asymptomatic disease to acute respiratory distress syndrome and multiorgan failure. The COVID-19 pandemic represents a severe stress test for the national health system. Very quickly hospitals have had to assist a large and unexpected number of patients owing to the rapid spread of the disease. This has led to a sudden shortage of hospital beds, medical and nursing staff, personal protective equipment (PPE), and ventilators. Entire hospitals have been converted into intensive care units, retired anesthesiologists have been called back to work, and specialists in other branches have been assigned to assist COVID-19 patients. Only urgent and non-postponable medical services are guaranteed.


title: Robotic-assisted laparoscopic intracorporeal urinary diversion.

text: BACKGROUND Recent small case series have now been reported for robotic-assisted laparoscopic radical cystectomy (RALRC). In most of these series, the urinary diversion has been performed in an extracorporeal fashion. There have been few case reports of an intracorporeal diversion and little description of the technique of such a procedure. OBJECTIVE In this paper, we report our initial experience with robotic-assisted laparoscopic intracorporeal urinary diversion, describing stepwise the surgical procedure itself and evaluating perioperative and pathologic outcomes of this novel procedure. DESIGN, SETTING, AND PARTICIPANTS We studied a single-institution case series of patients undergoing robotic-assisted cystectomy and intracorporeal urinary diversion for clinically localized urothelial carcinoma of the bladder (n=10) or for a noncompliant dysfunctional bladder refractory to more conservative management (n=2). Historical comparisons are also made to a consecutive case series of 20 patients undergoing robotic radical cystectomy and extracorporeal urinary diversion. SURGICAL PROCEDURE RALRC and intracorporeal urinary diversion, including ileal conduit (n=9) and orthotopic ileal neobladder (n=3). MEASUREMENTS The stepwise operative procedure is described in detail. Outcome measures evaluated in this series included operative variables, hospital recovery, and complication rate. Comparisons were made to a contemporaneous series of 20 patients who underwent a robotic cystectomy with extracorporeal diversion during this time period (from an experience of >100 robotic cystectomy patients since 2005). RESULTS AND LIMITATIONS Twelve patients (mean age: 60.9 yr) underwent an intracorporeal diversion. Mean operating-room time of all patients was 5.3h, and mean surgical blood loss was 221ml. Mean time to flatus, bowel movement, and hospital discharge was 2.2 d, 3.2 d, and 4.5 d, respectively. Eleven of the 12 patients were discharged on or before postoperative day 5. There were six postoperative complications in five patients (42%), with one complication being Clavien grade 3 or higher. The major limitations of the study are the small sample size and the nonrandomized nature of the compared treatment groups (intracorporeal vs extracorporeal), which limits the ability to directly compare the techniques at a high level of scientific confidence. CONCLUSIONS Our initial experience with robotic-assisted laparoscopic intracorporeal diversion appears to be favorable with acceptable operative and short-term clinical outcomes.


title: Rhinovirus is associated with severe adult community-acquired pneumonia in China.

text: Background Human rhinovirus (HRV) is one of the most common viral etiologies detected in community-acquired pneumonia (CAP) adult cases. However, few is known about the characteristics of HRV-associated CAP. To describe the clinical features of HRV-associated CAP in immunocompetent adults admitted to multiple medical centers in mainland China over a 2-year period. Methods A total of 383 patients admitted to hospitals for CAP were enrolled from 46 medical centers in mainland China between January 2013 and December 2014. Multiplex real-time polymerase chain reaction (RT-PCR) assays for viral detection and DNA-based quantitative loop-mediated isothermal amplification (qLAMP) assays for bacterial detection were implemented to all lower respiratory tract specimens obtained from the patients. Twenty-eight cases (28/383, 7.3%) revealed HRV-positive PCR results. Patients with bronchoalveolar lavage (BAL) HRV-positive PCR results (n=20) were further enrolled and divided into two groups depending on the status of bacterial co-infection (viral group, n=12; viral-Bacterial group, n=8). Demographic, clinical and microbiological data were reviewed and compared in detail. Results Cases with HRV-infection were remarkably correlated with respiratory failure (14/20) and most of them (13/14) received mechanical ventilation. Fever (17/20), productive cough (15/20) and dyspnea (6/20) were common symptoms while flu-like symptoms were rarely observed in the cohort. Streptococcus pneumoniae (3/8), Klebsiella pneumoniae (3/8) and Mycoplasma pneumoniae (2/8) were most frequently identified bacterium in the viral-bacterial group. Compared with the viral group, higher incidence of septic shock (3/8 vs. 1/12, P=0.255), longer ICU length of stay (LOS) (10.0 vs. 6.5 days, P=0.686), longer hospital LOS (18.5 vs. 13.0 days, P=0.208) and higher 28-day mortality (2/8 vs. 2/12, P=1) were observed in the Viral-Bacterial group, although without statistically significant difference. Conclusions HRV is a common etiology in CAP among China adults, especially in severe CAP. Clinicians should be vigilant considering of the poor outcome. Highly qualified multiplex PCR techniques with invasive sampling are needed to increase the detection rate.


title: COVID-19 in a Patient with β-Thalassemia Major and Severe Pulmonary Arterial Hypertension.

text: We here report the successful recovery from coronavirus disease-19 (COVID-19) pneumonia in a patient with β-thalassemia major (β-TM) and severe pulmonary arterial hypertension (PAH), focusing on the patient's comorbidities, therapeutic course and drug interaction.


title: Hand sanitisers amid CoViD-19: A critical review of alcohol-based products on the market and formulation approaches to respond to increasing demand.

text: The world is facing a medical crisis amid the CoViD-19 pandemic and the role of adequate hygiene and hand sanitisers is inevitable in controlling the spread of infection in public places and healthcare institutions. There has been a great surge in demand for hand sanitisation products leading to shortages in their supply. A consequent increase of substandard products in the market has raised safety concerns. This article, therefore, presents a critical review of hand sanitation approaches and products available on the market in light of the scientific evidence available to date. This review also provides a range of hand sanitisation product formulations, and manufacturing instructions to allow for extemporaneous preparations at the community and hospital pharmacies during this urgent crisis. In addition, this emergent situation is expected to continue, hence hand sanitisers will be in demand for an extended time, and the availability and purchase of substandard products on the market create an ongoing safety concern. Therefore, this article shall also provide various commercial organisations, interested in stepping forward the production and marketing of hand sanitisers, with a guide on the development of products of standardised ingredients and formulations.


title: Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.

text: The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for lower gastrointestinal endoscopy. We recommend that endoscopy services across Europe adopt the following seven key performance measures for lower gastrointestinal endoscopy for measurement and evaluation in daily practice at a center and endoscopist level: 1 rate of adequate bowel preparation (minimum standard 90%); 2 cecal intubation rate (minimum standard 90%); 3 adenoma detection rate (minimum standard 25%); 4 appropriate polypectomy technique (minimum standard 80%); 5 complication rate (minimum standard not set); 6 patient experience (minimum standard not set); 7 appropriate post-polypectomy surveillance recommendations (minimum standard not set). Other identified performance measures have been listed as less relevant based on an assessment of their importance, scientific acceptability, feasibility, usability, and comparison to competing measures.


title: 'I have faith in science and in God': Common sense, cognitive polyphasia and attitudes to science in Nigeria.

text: This study, of modern common sense in Nigeria, combines questionnaires and interviews to examine the compatibility and incompatibility of religion and science. Nigeria is a large country with a complex diversity of religious, ethnic and cultural practices that condition the reception and elaboration of science in everyday life. We find evaluative attitudes to science structured as 'progress', 'fear' and 'mythical image'. Scientific knowledge and religiosity have a direct bearing on expectations of progress and feeling of fear and worry about science; mythical image is independent of this. Nigerians trust both scientific and religious authorities in contrast to other social actors. Many of the results are consistent with the hypothesis of cognitive polyphasia of scientific and religious knowing manifesting as a 'hierarchy', when one form is elevated over the other; 'parallelity', when both serve separate functions; and 'empowerment', where one enhances the other.


title: Mucosal injury following short-term tracheal intubation: A novel animal model and composite tracheal injury score.

text: Objectives Postintubation laryngotracheal injury is common. Assessment of histopathological changes currently requires animal models. We set about developing a viable, resource effective animal model to study these effects and to develop a detailed tissue injury score. Methods Six pigs were anesthetized using a standard regimen. We intubated the tracheas using a standard endotracheal tube modified to include optical sensors. Animals were anesthetized for a duration of two to four hours, and their lungs were ventilated using a normoxic gas mixture. Following euthanasia, the tracheas were removed and underwent histological assessment by two independent veterinary pathologists. The histological lesions, including controls, were described and quantified, and two pathologists classified tissues according to a novel injury score. Results Mean duration of tracheal intubation was 191 minutes (SD ± 41.6). In all except one animal, cuff pressures were maintained in the range of 25-45 cmH20. Histopathological findings in all study animals showed more extensive changes than previously described with short-term intubation. Changes were seen in all mucosal layers consistent with acute, suppurative, and ulcerative tracheitis. The range of scores of the developed composite scoring system among the animals was wider than in earlier descriptions. There was a high percentage of agreement between both pathologists. Conclusions We have described a novel tracheal injury score to assess pathological changes following short term intubation in a viable animal model. The scoring system distinguished between the test animals as well as controls and may be appropriate for continuing study of intubation injury. Level of Evidence 3.


title: Laparoscopic frey procedure for chronic pancreatitis.

text: BACKGROUND Chronic pancreatitis can be relentless, resulting in debilitating pain and endocrine and exocrine insufficiency. Medical interventions are used initially but when these fail, surgical therapy is often indicated. Surgical options include resection, drainage, and hybrid procedures. Hybrid procedures, such as the Frey procedure are associated with improved outcomes in select patients. These advantages are even greater when the Frey is performed laparoscopically. METHODS A patient with chronic pancreatitis was referred to our clinic. Preoperative imaging revealed a dilated main pancreatic duct with multiple large pancreatic duct stones. She subsequently underwent a laparoscopic Frey procedure. RESULTS The patient did very well with no pancreatic leak, wound infection, or delayed gastric emptying. She was discharged home on postoperative day 6, symptom free with no narcotic requirement. CONCLUSIONS For patients in whom the laparoscopic Frey procedure is possible, it can be used to treat chronic pancreatitis with the benefits of a minimally invasive approach.


Covid-19: People in most deprived areas of England and Wales twice as likely to die.


Media representations of nurses in the pandemic: Just doing our job?


title: Prognostic classification of histopathologic response to neoadjuvant therapy in esophageal adenocarcinoma.

text: OBJECTIVES To evaluate the histopathologic response to neoadjuvant therapy in esophageal adenocarcinoma according to impact on prognosis and to suggest a classification for clinical routine. BACKGROUND Measures of histopathologic response to neoadjuvant treatment of esophageal cancer such as Mandard tumor regression grading focus on the effect on the primary tumor. Although lymph node infiltration is of significant prognostic importance, this criterion is mostly not included in the response classifications. METHODS A total of 370 patients (89% males, median age: 61 years) with neoadjuvant radiochemotherapy (40 Gy, 5-FU, cisplatin) or chemotherapy (MAGIC or FLOT) for cT3, Nx, M0 esophageal adenocarcinoma were included in the analysis. All patients had undergone transthoracic en bloc esophagectomy, with a median of 27 resected lymph nodes and a R0-resection rate of 92%. Histopathologic regression grading differentiated major or minor response according to less or more than 10% vital cells in the primary tumor. The lymph nodes were classified as ypN0 or ypN+. RESULTS From the patients with R0 resection and M0 category, 3 groups with significantly different 5-year survival rates (5-YSR) could be differentiated: 1. Major response and ypN0 (n=100) with 5-YSR of 64% 2. Either major response and ypN+ (n=34) 5-YSR 42% or minor response and ypN0 (n=84) 5-YSR 44%, together 42% 5-YSR 3. Minor response and ypN+ (n=111) and 5-YSR of 18%. CONCLUSIONS A combined classification of primary tumor regression and lymph node status in 3 grades represents a simple and reproducible prognostic classification of the effect of neoadjuvant treatment in esophageal adenocarcinoma.


title: Strategies for radiology departments in handling the COVID-19 pandemic.

text: The world is facing an unprecedented global pandemic in the form of the coronavirus disease 2019 (COVID-19) which has ravaged all aspects of life, especially health systems. Radiology services, in particular, are under threat of being overwhelmed by the sheer number of patients affected, unless drastic efforts are taken to contain and mitigate the spread of the virus. Proactive measures, therefore, must be taken to ensure the continuation of diagnostic and interventional support to clinicians, while minimizing the risk of nosocomial transmission among staff and other patients. This article aims to highlight several strategies to improve preparedness, readiness and response towards this pandemic, specific to the radiology department.


How does COVID-19 kill? Uncertainty is hampering doctors' ability to choose treatments.


title: In Vitro Lung Model Assessing the Efficacy of Surgical Sealants in Treating Alveolar Air Leaks.

text: PURPOSE The lack of reliable testing methods limits the evidence-based practice of surgical sealants in treating alveolar air leak (AAL). We developed an in vitro lung model to evaluate sealants' efficacy and tested the widely used human thrombin-fibrinogen sponge, TachoSil as an example. MATERIALS AND METHODS The caudal lobe of freshly excised swine lung (n = 10) was intubated and ventilated. A focal superficial parenchymal defect (40 × 25 mm) was created in the inflated lung. AAL was assessed with increasing inspired tidal volume (TVi). After sealant application, AAL was assessed in the same way until burst failure, defined as an AAL exceeding 20 mL. To evaluate the elasticity of the sealant, the length of defect was recorded in the inflated lung. RESULTS Superficial parenchymal defects resulted in AAL increasing with ascending TVi. Multiple linear regression analysis revealed strong correlation between AAL and maximal inspiratory pressure, compliance and resistance. At TVi = 400, 500, and 600 mL, TachoSil achieved sealing in ten, eight, and seven tests, respectively. As TVi increased, superficial defects were still sealed in four, two, and two tests at TVi = 700, 800, and 900 mL, respectively. The burst pressure was 42 ± 5 cmH2O. Adhesive failures were found at the burst pressure in all tests. Concerning elasticity, TachoSil allowed an expansion of the covered lung defect of 7 ± 6 mm. CONCLUSIONS TachoSil demonstrated a strong sealing efficiency and marked elasticity in treating AAL. These results are consistent to that of the previously published animal experiment, suggesting the reliability of the presented in vitro model.


Proving etiologic relationships to disease: the particular problem of human coronaviruses.


title: The Challenges Associated with Generating Reliable Nanogram-Per-Liter Measurements of Hexavalent Chromium in Groundwater.

text: The US EPA and several states are considering regulatory limits for hexavalent chromium (Cr(VI)) below 100 ng/L, increasing the importance of obtaining accurate and reliable data. This paper presents the results of two studies investigating the effectiveness of chemical preservation on ng/L concentrations of Cr(VI) in groundwater. Chemically preserved and unpreserved aliquots of a groundwater sample were spiked with a known amount of Cr(VI), then analyzed in tandem with sets of preserved and unpreserved performance test samples over 28 days. The studies showed that while Cr(VI) appears to be relatively stable over 28 days, it may be sensitive to minor matrix changes after collection. The studies also demonstrated significant challenges to measuring Cr(VI) below 100 ng/L, as the results can be subject to positive bias or contamination that may not be readily apparent. The authors concluded that Cr(VI) measurements using a US EPA published method below 100 ng/L may be categorized as semi-quantitative at best. This article is protected by copyright. All rights reserved.


title: Inadequacy of near-infrared spectroscopy cerebral oximetry monitoring for detecting neurological complication.

text: Near-infrared spectroscopy (NIRS) cerebral oximetry is an established and standard monitoring modality for surgery under extracorporeal circulation with circulatory arrest. It helps to reduce the neurological complication, but in many instances, it becomes not only technically challenging but also is difficult to interpret and take corrective action based on the NIRS values. In this case study, we aimed to present the inadequacy of cerebral oximetry for detecting neurological complication.


title: Three routine free flaps per day in a single operating theatre: principles of a process mapping approach to improving surgical efficiency.

text: BACKGROUND Breast reconstruction is a multi-stage process, involving many individual procedures and many healthcare professionals which take the patient through from diagnosis of breast cancer to the completion of cancer treatment and ultimate breast reconstruction. With an experience of over 3,000 autologous breast reconstructions, we have refined both our surgical technique and overall approach to breast reconstruction to improve the efficiency in free flap based breast reconstruction surgery. METHODS Through a process mapping approach similar to that employed by large-scale industry, we have broken down free flap based breast reconstruction into multiple smaller processes. By looking at various steps as a simple component of the whole, we have improved our theatre efficiency to maximize patient throughput and improve our outcomes for breast reconstruction patients. RESULTS Since beginning free flap breast reconstruction surgery, we have improved overall efficiency by applying a process mapping approach. In our early experience, we undertook a single patient undergoing breast reconstruction with a free flap per theatre list, moving to two patients having breast reconstruction, and now carry out three free flap based reconstructions in a single theatre per day as a routine. Specific times are demonstrated, with no increased complication rate. CONCLUSIONS Through clearly defined processes, operative efficiency in autologous breast reconstruction can achieve three free flaps per day in a single theatre.


The common cold and decongestant therapy.


title: Evaluation of a nasal cannula in noninvasive ventilation using a lung simulator.

text: BACKGROUND Nasal noninvasive ventilation (NIV) is a common form of noninvasive respiratory mode used in newborn infants. A next-generation nasal cannula (Neotech RAM cannula) has recently been used to provide nasal NIV. The impact of the Neotech RAM cannula on the delivery of pressure needs to be studied. METHODS In this ex vivo experimental design, a lung simulator (IngMar ASL 5000, version 3.4) was programmed to model a neonate (∼1-3 kg of body weight) with normal-to-moderately affected lungs. We used a Covidien PB840 ventilator with NIV software activated to compensate for leaks. Nasal NIV was set at peak airway pressures of 15, 20, and 25 cm H2O and PEEP of 5, 6, and 7 cm H2O. Three sizes of the Neotech RAM cannula were used (prong outer diameters of 3.0, 3.5, and 4.0 mm). The nose was designed to keep the leak of the nares by the prongs to 30%. We also created a worst case leak (58% leak) by using the largest simulated nostril diameter with the smallest diameter Neotech RAM cannula prong. The outcome measure was the difference in pressures, referred to as leak effect, measured by the lung simulator relative to the set peak airway pressure and PEEP on the ventilator. RESULTS For the interface with 30% leak, leak effects of peak airway pressure during simulated nasal NIV were similar with all Neotech RAM cannula sizes, with 63-75% of peak airway pressure and 70-90% of PEEP being transmitted across the nasal interface. The worst case scenario produced a 92% leak effect in peak airway pressure and PEEP. CONCLUSIONS When used with ≤ 30% leak, the Neotech RAM cannula interface results in clinically acceptable transmission of pressures. With > 50% leak, a clinically negligible amount of pressure is transmitted to the artificial lungs.


title: Identification of a broad-spectrum antiviral small molecule against severe acute respiratory syndrome coronavirus and Ebola, Hendra, and Nipah viruses by using a novel high-throughput screening assay.

text: UNLABELLED Severe acute respiratory syndrome coronavirus (SARS-CoV) and Ebola, Hendra, and Nipah viruses are members of different viral families and are known causative agents of fatal viral diseases. These viruses depend on cathepsin L for entry into their target cells. The viral glycoproteins need to be primed by protease cleavage, rendering them active for fusion with the host cell membrane. In this study, we developed a novel high-throughput screening assay based on peptides, derived from the glycoproteins of the aforementioned viruses, which contain the cathepsin L cleavage site. We screened a library of 5,000 small molecules and discovered a small molecule that can inhibit the cathepsin L cleavage of all viral peptides with minimal inhibition of cleavage of a host protein-derived peptide (pro-neuropeptide Y). The small molecule inhibited the entry of all pseudotyped viruses in vitro and the cleavage of SARS-CoV spike glycoprotein in an in vitro cleavage assay. In addition, the Hendra and Nipah virus fusion glycoproteins were not cleaved in the presence of the small molecule in a cell-based cleavage assay. Furthermore, we demonstrate that the small molecule is a mixed inhibitor of cathepsin L. Our broad-spectrum antiviral small molecule appears to be an ideal candidate for future optimization and development into a potent antiviral against SARS-CoV and Ebola, Hendra, and Nipah viruses. IMPORTANCE We developed a novel high-throughput screening assay to identify small molecules that can prevent cathepsin L cleavage of viral glycoproteins derived from SARS-CoV and Ebola, Hendra, and Nipah viruses that are required for their entry into the host cell. We identified a novel broad-spectrum small molecule that could block cathepsin L-mediated cleavage and thus inhibit the entry of pseudotypes bearing the glycoprotein derived from SARS-CoV or Ebola, Hendra, or Nipah virus. The small molecule can be further optimized and developed into a potent broad-spectrum antiviral drug.


title: Cholecystomucoclasis: revaluation of safety and validity in aged populations.

text: BACKGROUND We evaluated the safety and validity of cholecystomucoclasis (CM) and compared its intraoperative characteristics with those of standard cholecystectomy (SC). METHODS We enrolled 174 patients who underwent cholecystectomy and retrospectively evaluated the outcomes of patients in the SC and CM groups. RESULTS Significant differences in age (71.1 vs. 61.9 years), American Society of Anesthesiologists physical status (ASA-PS), and serum C-reactive protein levels (CRP) (18.1 vs. 4.7 mg/dL) were observed between the CM and SC groups. Conversely, no significant differences were observed in the operation time (129 vs. 108 min), amount of blood loss (147 vs. 80 mL), intraoperative complications (0% vs. 5.7%), or duration of hospital stay (13.2 vs. 8.9 days) between the 2 groups. A high conversion rate (35.3%), postoperative complications (33%), and frequent drain insertions (94%) were observed in the CM group. CONCLUSIONS CM is a safe and valid surgical procedure and surgeons should not hesitate to transition to CM for patients who are of advanced age, in poor general condition (high ASA classification), or have high levels of serum CRP.


title: Bilateral pediatric pial arteriovenous fistulas accompanying a giant arachnoid cyst with torticollis: A case report.

text: RATIONALE Pial arteriovenous fistula (PAVF) occurs when intracranial arteries communicate directly with veins. PAVFs are very rare congenital vascular lesions that are commonly seen in infants and children. Arachnoid cysts are congenital cavitation often filled with cerebrospinal fluid. We present a very rare associated occurrence of bilateral pediatric PAVF and a giant arachnoid cyst presenting as torticollis in a child. So far, this is the first case. PATIENT CONCERNS A 6-year-old male child was referred to our facility from a local hospital due to severe torticollis. DIAGNOSES An enhanced computed tomography scan revealed 2 slightly high-density masses at the anterior pontine cistern, right circumferential cistern, as well as left posterior occipital region. The same computed tomography scan revealed a giant arachnoid cyst in the left occipital as well as the temporal region with a thin cerebral cortex adjacent to the cyst. INTERVENTIONS Digital subtraction angiography confirmed that the 2 high-flow lesions were PAVFs. The patient was treated with a combination of detachable coils and Onyx Liquid Embolic System (Onyx HD-500) (Covidien/ev3 Neurovascular) via the transarterial endovascular route while the giant arachnoid cyst was managed conservatively. OUTCOMES The torticollis resolved 2 days after the procedure. He is currently well with no neurologic deficit. LESSONS We advocate that in cases of PAVF with accompanying cyst, the cyst should be managed conservatively if it is not associated with intracranial hemorrhage or focal neurologic deficit.


title: Genetic characterisation and analysis of infectious bronchitis virus isolated from Brazilian flocks between 2010 and 2015.

text: 1. Infectious bronchitis virus (IBV) variants in Brazil were isolated during 2010-2015 for epidemiological and molecular analysis to characterise the different variants and perform a bioinformatic analysis to compare with sequences of variants collected over the previous 40 years. 2. Of the 453 samples examined, 61.4% were positive for IBV and 75.9% of these were considered to have the BR-I genotype and were detected in birds of all ages distributed in all five Brazilian regions. 3. The ratio of non-synonymous substitutions per non-synonymous site (dN) to synonymous substitutions per synonymous site (dS), i.e. dN/dS, revealed a predominance of codons with non-synonymous substitutions in the first third of the S1 gene and a dN/dS ratio of 0.67. Additionally, prediction of N-glycosylation sites showed that most of the BR-I variants (from 2003 to early 2014) had an extra site at amino acid position 20, whereas the newest variants lacked this extra site. 4. These results suggest that Brazilian IBV variants probably underwent drastic mutations at various points between 1983 and 2003 and that the selection processes became silent after achieving a sufficiently effective antigenic structure for invasion and replication in their hosts. Brazilian IBV genotype BR-I is currently the predominant genotype circulating in Brazil and South America.