title: The influence of norepinephrine and phenylephrine on cerebral perfusion and oxygenation during propofol-remifentanil and propofol-remifentanil-dexmedetomidine anaesthesia in piglets.

text: BACKGROUND Vasopressors are frequently used to increase blood pressure in order to ensure sufficient cerebral perfusion and oxygenation (CPO) during hypotensive periods in anaesthetized patients. Efficacy depends both on the vasopressor and anaesthetic protocol used. Propofol-remifentanil total intravenous anaesthesia (TIVA) is common in human anaesthesia, and dexmedetomidine is increasingly used as adjuvant to facilitate better haemodynamic stability and analgesia. Little is known of its interaction with vasopressors and subsequent effects on CPO. This study investigates the CPO response to infusions of norepinephrine and phenylephrine in piglets during propofol-remifentanil and propofol-remifentanil-dexmedetomidine anaesthesia. Sixteen healthy female piglets (25-34 kg) were randomly allocated into a two-arm parallel group design with either normal blood pressure (NBP) or induced low blood pressure (LBP). Anaesthesia was induced with propofol without premedication and maintained with propofol-remifentanil TIVA, and finally supplemented with continuous infusion of dexmedetomidine. Norepinephrine and phenylephrine were infused in consecutive intervention periods before and after addition of dexmedetomidine. Cerebral perfusion measured by laser speckle contrast imaging was related to cerebral oxygenation as measured by an intracerebral Licox probe (partial pressure of oxygen) and transcranial near infrared spectroscopy technology (NIRS) (cerebral oxygen saturation). RESULTS During propofol-remifentanil anaesthesia, increases in blood pressure by norepinephrine and phenylephrine did not change cerebral perfusion significantly, but cerebral partial pressure of oxygen (Licox) increased following vasopressors in both groups and increases following norepinephrine were significant (NBP: P = 0.04, LBP: P = 0.02). In contrast, cerebral oxygen saturation (NIRS) fell significantly in NBP following phenylephrine (P = 0.003), and following both norepinephrine (P = 0.02) and phenylephrine (P = 0.002) in LBP. Blood pressure increase by both norepinephrine and phenylephrine during propofol-remifentanil-dexmedetomidine anaesthesia was not followed by significant changes in cerebral perfusion. Licox measures increased significantly following both vasopressors in both groups, whereas the decreases in NIRS measures were only significant in the NBP group. CONCLUSIONS Cerebral partial pressure of oxygen measured by Licox increased significantly in concert with the vasopressor induced increases in blood pressure in healthy piglets with both normal and low blood pressure. Cerebral oxygenation assessed by intracerebral Licox and transcranial NIRS showed opposing results to vasopressor infusions.


title: The triple variable index combines information generated over time from common monitoring variables to identify patients expressing distinct patterns of intraoperative physiology.

text: BACKGROUND Mean arterial pressure (MAP), bispectral index (BIS), and minimum alveolar concentration (MAC) represent valuable, yet dynamic intraoperative monitoring variables. They provide information related to poor outcomes when considered together, however their collective behavior across time has not been characterized. METHODS We have developed the Triple Variable Index (TVI), a composite variable representing the sum of z-scores from MAP, BIS, and MAC values that occur together during surgery. We generated a TVI expression profile, defined as the sequential TVI values expressed across time, for each surgery where concurrent MAP, BIS, and MAC monitoring occurred in an adult patient (≥18 years) at the University of Pittsburgh Medical Center between January and July 2014 (n = 5296). Patterns of TVI expression were identified using k-means clustering and compared across numerous patient, procedure, and outcome characteristics. TVI and the triple low state were compared as prediction models for 30-day postoperative mortality. RESULTS The median frequency MAP, BIS, and MAC were recorded was one measurement every 3, 5, and 5 min. Three expression patterns were identified: elevated, mixed, and depressed. The elevated pattern displayed the highest average MAP, BIS, and MAC values (86.5 mmHg, 45.3, and 0.98, respectively), while the depressed pattern displayed the lowest values (76.6 mmHg, 38.0, 0.66). Patterns (elevated, mixed, depressed) were distinct across the following characteristics: average patient age (52, 53, 54 years), American Society of Anesthesiologists Physical Status 4 (6.7, 16.1, 27.3%) and 5 (0.1, 0.6, 1.6%) categories, cardiac (2.2, 6.5, 16.1%) and emergent (5.8, 10.5, 12.8%) surgery, cardiopulmonary bypass use (0.3, 2.6, 9.8%), intraoperative medication administration including etomidate (3.0, 7.3, 12.6%), hydromorphone (47.6, 26.3, 25.2%), ketamine (11.2, 4.6, 3.0%), dexmedetomidine (18.4, 16.6, 13.6%), phenylephrine (74.0, 74.8, 83.0), epinephrine (2.0, 6.0, 18.0%), norepinephrine (2.4, 7.5, 21.2%), vasopressin (3.4, 7.6, 21.0%), succinylcholine (74.0, 69.0, 61.9%), intraoperative hypotension (28.8, 33.0, 52.3%) and the triple low state (9.4, 30.3, 80.0%) exposure, and 30-day postoperative mortality (0.8, 2.7, 5.6%). TVI was a better predictor of patients that died or survived in the 30 days following surgery compared to cumulative triple low state exposure (AUC 0.68 versus 0.62, p < 0.05). CONCLUSIONS Surgeries that share similar patterns of TVI expression display distinct patient, procedure, and outcome characteristics.


title: Laparoscopic management for carcinoid metastasis to the spleen.

text: We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy.


title: Current best evidence recommendations on measurement and interpretation of physical function in patients with chronic kidney disease.

text: Chronic kidney disease (CKD) is becoming a serious health problem throughout the world and is one of the most potent known risk factors for cardiovascular disease. Deterioration of physical function is accelerated in patients with CKD to levels that significantly impact on clinically and patient-important outcomes such as morbidity, employment, quality of life and, ultimately, survival. However, meaningful interpretation of the existing physical function-related literature in adult patients with CKD is hindered, possibly due to inconsistent choice of methodology, assessment tools and reporting of data. The current comprehensive review of the literature aims to provide the theoretical rationale and framework for physical function assessment and to identify the prevailing approaches to (i) the characterization (classification and terminology), (ii) interpretation, and (iii) reporting of physical function assessment in people with CKD. Comprehensive assessment of physical function can provide important information about the presence of 'physiological impairment' at a body systems level (exercise tolerance under well controlled, laboratory-based procedures), 'functional limitations' (physical performance during tasks imitating usual daily, personal or occupational tasks) and 'functional disability' (via self-reported physical functioning in the context of a socio-cultural environment). The selection of physical function assessment tools should be guided by the primary purpose of the assessment (e.g. research or routine clinical monitoring), by the overall scientific 'soundness' of the chosen tool (e.g. validity, utility, reproducibility, responsiveness characteristics) and by operational factors (e.g. patient collaboration, cost, personnel expertise). Recommendations for tests, methods and protocols are therefore presented, for the assessment of cardiorespiratory and muscular fitness, physical performance and self-reported physical functioning. These recommendations are based on synthesis of available information as derived from controlled exercise training interventions in adult patients with CKD. Special considerations for physical function assessment and suggestions for future research are also addressed. Such an information synthesis might promote greater standardization of the physical function assessment of patients with CKD in routine clinical care or research settings. This would potentially lead to generation of adequate scientific decision-making criteria to help researchers and healthcare providers in selecting the most appropriate measures according to the physical function areas assessed, and to accurately and meaningfully characterize and compare patients' responses to therapeutic interventions.


title: Isolation and characterization of current human coronavirus strains in primary human epithelial cell cultures reveal differences in target cell tropism.

text: The human airway epithelium (HAE) represents the entry port of many human respiratory viruses, including human coronaviruses (HCoVs). Nowadays, four HCoVs, HCoV-229E, HCoV-OC43, HCoV-HKU1, and HCoV-NL63, are known to be circulating worldwide, causing upper and lower respiratory tract infections in nonhospitalized and hospitalized children. Studies of the fundamental aspects of these HCoV infections at the primary entry port, such as cell tropism, are seriously hampered by the lack of a universal culture system or suitable animal models. To expand the knowledge on fundamental virus-host interactions for all four HCoVs at the site of primary infection, we used pseudostratified HAE cell cultures to isolate and characterize representative clinical HCoV strains directly from nasopharyngeal material. Ten contemporary isolates were obtained, representing HCoV-229E (n = 1), HCoV-NL63 (n = 1), HCoV-HKU1 (n = 4), and HCoV-OC43 (n = 4). For each strain, we analyzed the replication kinetics and progeny virus release on HAE cell cultures derived from different donors. Surprisingly, by visualizing HCoV infection by confocal microscopy, we observed that HCoV-229E employs a target cell tropism for nonciliated cells, whereas HCoV-OC43, HCoV-HKU1, and HCoV-NL63 all infect ciliated cells. Collectively, the data demonstrate that HAE cell cultures, which morphologically and functionally resemble human airways in vivo, represent a robust universal culture system for isolating and comparing all contemporary HCoV strains.


title: Measurement of peritoneal fluid urea nitrogen and creatinine levels is useful to detect iatrogenic urinary tract leakage in colorectal surgery.

text: BACKGROUND Increased peritoneal drainage after colorectal surgery is a common problem. Measurement of peritoneal fluid urea nitrogen (UN) and creatinine (Cr) is a diagnostic tool to detect the urinary tract leakage (UTL). We evaluated its application in colorectal surgery. METHODS We conducted a retrospective chart review study. We enrolled patients with iatrogenic UTL, and measured their UN and Cr levels in peritoneal fluid and compared them with those in blood and urine. Meanwhile, we assigned patients without UTL to a control group and compared clinical parameters of both groups. RESULTS Twenty-three patients with iatrogenic UTL were recruited. The overall incidence was 0.5%. UN level in peritoneal fluid (322 ± 56 mg/dL) was significantly higher than that in blood (18.7 ± 4.0 mg/dL, p < 0.001); Cr level in peritoneal fluid (69.7 ± 14.3 mg/dL) was also significantly higher than that in blood (1.5 ± 0.5 mg/dL, p < 0.001). UN level in peritoneal fluid was significantly higher in the iatrogenic UTL group than in the control group (322 mL/dL vs. 9.3 mL/dL, p < 0.001); Cr level in peritoneal fluid was also significantly higher (69.7 mg/dL vs. 0.98 mg/dL, p < 0.001). CONCLUSION When increased peritoneal drainage is found postoperatively in colorectal surgery, measurement of UN and Cr levels in peritoneal fluid can be a useful diagnostic tool to determine intraperitoneal iatrogenic UTL.


title: Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature

text: The coronavirus disease 2019 (COVID-19) pandemic has emerged as one of the greatest challenges faced by humankind in the recent past. People with diabetes and related comorbidities are at increased risk of its complications and of COVID-19-related death. Older age, multi-morbidity, hyperglycaemia, cardiac injury and severe inflammatory response are predictors of poor outcome. The complex interplay between COVID-19, diabetes and the effects of related therapies is being explored. Most patients experience a mild illness with COVID-19, while people with diabetes are at increased risk of severe disease. Optimising glycaemic control and adopting measures to prevent disease spread are critical aspects. The management of mild disease is supportive, while very many immunomodulatory and antiviral therapies are being investigated for the treatment of severe disease. Several of these agents have specific considerations for use in people with diabetes. Since mass population lockdowns are considered a key step in controlling disease spread, it follows that, in addition to the direct vulnerability to severe COVID-19, people with diabetes can be affected by limited access to healthcare, insulin, other medications and blood glucose monitoring equipment. Measures to prevent disease spread at the individual and community level are the key to mitigating the rapidly escalating pandemic, while agents for chemoprophylaxis and vaccines are being explored. People with diabetes should be recognised as a vulnerable group for complicated disease and are at risk during times of disturbed social systems. Strategies are needed to safeguard the health of patients with diabetes during the pandemic. This review summarises the current knowledge and perceived challenges for prevention and management of COVID-19 in people with diabetes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00125-020-05164-x) contains peer-reviewed but unedited supplementary material including a slideset of the figures for download, which is available to authorised users.


title: Prospective study on serum metal levels in patients with metal-on-metal lumbar disc arthroplasty.

text: PURPOSE Metal-on-metal total disc replacement is a recent alternative treatment for degenerative disc disease. Wear and corrosion of these implants can lead to local and systemic transport of metal debris. This prospective longitudinal study examined the serum chromium and cobalt levels in 24 patients with cobalt-chromium alloy metal-on-metal lumbar disc replacements. METHODS Serum was assayed for chromium (Cr) and cobalt (Co) using high-resolution inductively-coupled plasma-mass spectrometry. Detection limits were 0.015 ng/mL for Cr and 0.04 ng/mL for Co. RESULTS Median serum Co levels at pre-op, 3, 6, 12, 24, and 36-months post-op were 0.10, 1.03, 0.96, 0.98, 0.67, and 0.52 ng/mL, respectively. Median serum Cr levels were 0.06, 0.49, 0.65, 0.43, 0.52, and 0.50 ng/mL, respectively. CONCLUSION In general, these results indicated that serum Co and Cr levels are elevated at all postoperative time points and are of the same order of magnitude as those observed in well-functioning metal-on-metal surface replacements of the hip and in metal-on-metal total hip replacements at similar postoperative time points.


title: Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.

text: BACKGROUND Lobectomy using video-assisted thoracoscopic surgery (VATS) still is a controversial operation despite its many observed benefits. The controversy may be due to difficulties performing the procedure. This study addresses a standardized anterior approach facilitating the operation. METHODS This report describes 156 VATS lobectomies performed with a uniform anterior three-port technique. The surgeon and the assistant stand on the abdominal side of the patient, and the setup is independent of the lobe to be resected. RESULTS From 2005 to 2007, 156 VATS lobectomies and 13 conversions (7.7%) were performed with an anterior three-port technique. No mortality occurred among the VATS lobectomies during a 30-day period. The major comorbidity rate was 78%. The comorbidities included former thoracic surgery (9%) or a history of another cancer (22%), indicating potentially difficult surgery and a nonselected population. The majority (92%) of the patients had lung cancer. The major postoperative problem was air leakage, which usually prolongs the tube time and the in-hospital stay, but a "no-touch fissure" technique significantly reduced the median tube time to 4 days and the postoperative hospital stay to 5 days. CONCLUSIONS This study shows that VATS lobectomies can be performed using a standardized anterior approach with low rates of conversion and morbidity. A "no-touch fissure" technique lowers the postoperative tube time, the in-hospital stay, and the number of patients with prolonged air leakage. A uniform anterior approach facilitates VATS lobectomy and makes this advanced procedure more easily adaptable by many surgeons familiar with an open anterior approach. The findings show that VATS lobectomy can be performed safely for a large proportion of lung cancer patients.


title: Sirt3 Mediates the Inhibitory Effect of Adjudin on Astrocyte Activation and Glial Scar Formation following Ischemic Stroke.

text: In response to stroke-induced injury, astrocytes can be activated and form a scar. Inflammation is an essential component for glial scar formation. Previous study has shown that adjudin, a potential Sirt3 activator, could attenuate lipopolysaccharide (LPS)- and stroke-induced neuroinflammation. To investigate the potential inhibitory effect and mechanism of adjudin on astrocyte activation, we used a transient middle cerebral artery occlusion (tMCAO) model with or without adjudin treatment in wild type (WT) and Sirt3 knockout (KO) mice and performed a wound healing experiment in vitro. Both our in vivo and in vitro results showed that adjudin reduced astrocyte activation by upregulating Sirt3 expression. In addition, adjudin treatment after stroke promoted functional and neurovascular recovery accompanied with the decreased area of glial scar in WT mice, which was blunted by Sirt3 deficiency. Furthermore, adjudin could increase Foxo3a and inhibit Notch1 signaling pathway via Sirt3. Both the suppression of Foxo3a and overexpression of N1ICD could alleviate the inhibitory effect of adjudin in vitro indicating that Sirt3-Foxo3a and Sirt3-Notch1 signaling pathways were involved in the inhibitory effect of adjudin in wound healing experiment.


title: Meeting report: Emerging respiratory viral infections and nonhuman primate case reports.

text: A workshop on Emerging Respiratory Viral Infections and Spontaneous Diseases in nonhuman primates was sponsored by the concurrent Annual Meetings of the American College of Veterinary Pathologists and the American Society for Veterinary Clinical Pathology, held December 1-5, 2012, in Seattle, Washington. The session had platform presentations from Drs Karen Terio, Thijs Kuiken, Guy Boivin, and Robert Palermo that focused on naturally occurring influenza, human respiratory syncytial virus, and metapneumovirus in wild and zoo-housed great apes; the molecular biology and pathology of these viral respiratory diseases in nonhuman primate (NHP) models; and the therapeutic and vaccine approaches to prevention and control of these emerging respiratory viral infections. These formal presentations were followed by presentations of 14 unique case studies of rare or newly observed spontaneous lesions in NHPs (see online files for access to digital whole-slide images corresponding to each case report at http://scanscope.com/ACVP%20Slide%20Seminars/2012/Primate%20Pathology/view.apml). The session was attended by meeting participants that included students, pathology trainees, and experienced pathologists from academia and industry with an interest in respiratory and spontaneous diseases of NHPs.


title: Procedural and indwelling complications with inferior vena cava filters: frequency, etiology, and management.

text: Inferior vena cava (IVC) filters are commonly used in select high-risk patients for the prevention of pulmonary embolism. Potentially serious complications can arise from the use of IVC filters, including thrombosis of the filter itself and filter fragment embolization. This article discusses the utility of IVC filters and reviews the management of two cases of filter-related complications.


title: CT coronary angiography in atrial fibrillation: a comparison of radiation dose and diagnostic confidence with retrospective gating vs prospective gating with systolic acquisition.

text: OBJECTIVE To compare unmodulated, retrospective electrocardiographic (ECG) gating to prospective ECG gating with systolic acquisition for CT coronary angiography (CTCA) in patients with atrial fibrillation (AF), considering the radiation dose and the diagnostic confidence achieved with each technique. METHODS A retrospective service evaluation was conducted before and after prospective gating with systolic acquisition replaced retrospectively gated imaging for patients with AF undergoing CTCA at our institution. 25 consecutive patients were examined in each group. The scan parameters and radiation dose information had been collected in a prospective fashion. The image sets were read by blinded, expert readers who rated their diagnostic confidence using a 5-point Likert scale. RESULTS The radiation dose received by patients was significantly greater in the retrospectively gated group than those being scanned using prospective gating (21 vs 5.9 mSv, p < 0.01). The prospective gating technique was also associated with greater diagnostic confidence (mean, per-patient score 3.09 vs 3.78, p = 0.02). CONCLUSION Prospective gating with systolic acquisition appears to improve diagnostic confidence at a significantly reduced radiation dose compared with retrospective gating in patients with AF. ADVANCES IN KNOWLEDGE The use of prospective gating with systolic triggering significantly reduces the radiation exposure to patients in AF undergoing CTCA. The same protocol also appears to improve diagnostic confidence.


Outpatient Treatment at Home for Medicare Beneficiaries During and After the COVID-19 Pandemic.


title: Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis.

text: BACKGROUND Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis. STUDY DESIGN Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed. RESULTS Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop. CONCLUSIONS Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.


title: COVID-19: is fibrosis the killer?

text: COVID-19 is a respiratory disease A recent report in Lancet examined, retrospectively, 137 patients with COVD-19 Patients that died had elevated IL-6 levels and acute respiratory distress syndrome These data have obvious implications for how to control mortality in COVID-19


title: Adenoid Cystic Carcinoma of Bartholin's Gland: What Is the Best Approach?

text: Background and summary: Among all vulvar cancers, primary adenoid cystic carcinoma (ACC) of Bartholin's gland is a very rare tumor characterized by a slow growth, a high local aggressiveness, and a remarkable recurrence rate. Due to its rarity, treatment remains a challenge for oncologists and gynecological surgeons. Key message: The present paper reports clinical, radiological, and histological features of ACC of Bartholin's gland and reviews the literature data on the treatment options with a particular focus on the potential role of particle radiation therapy.


title: SILS sigmoidectomy versus multiport laparoscopic sigmoidectomy for diverticulitis.

text: BACKGROUND AND OBJECTIVES In this single-institution study, we aimed to compare the safety, feasibility, and outcomes of single-incision laparoscopic sigmoidectomy (SILSS) with multiport laparoscopic sigmoidectomy (MLS) for recurrent diverticulitis. METHODS Between October 2011 and February 2013, 60 sigmoidectomies were performed by the same surgeon. Forty patients had a MLS and 20 patients had a SILSS. Outcomes were compared. RESULTS Patient characteristics were similar. There was no difference in morbidity, mortality or readmission rates. The mean operative time was longer in the SILSS group (P=.0012). In a larger proportion of patients from the SILSS group, 2 linear staplers were needed for transection at the rectum (P=.006). The total cost of disposable items was higher in the SILSS group (P<.0001). No additional ports were placed in the SILSS group. Return to bowel function or return to oral intake was faster in the SILSS group (P=.0446 and P=.0137, respectively). Maximum pain scores on postoperative days 1 and 2 were significantly less for the SILSS group (P=.0014 and P=.047, respectively). Hospital stay was borderline statistically shorter in the SILSS group (P=.0053). SILSS was also associated with better cosmesis (P<.0011). CONCLUSION SILSS is feasible and safe and is associated with earlier recovery of bowel function, a significant reduction in postoperative pain, and better cosmesis.


title: Parental manual ventilation in resource-limited settings: an ethical controversy.

text: Lower respiratory tract infections are a leading cause of paediatric morbidity and mortality worldwide. Children in low-income countries are disproportionately affected. This is in large part due to limitations in healthcare resources and medical technologies. Mechanical ventilation can be a life-saving therapy for many children with acute respiratory failure. The scarcity of functioning ventilators in low-income countries results in countless preventable deaths. Some hospitals have attempted to adapt to this scarcity by using hand-bag ventilation, as either a bridge to a mechanical ventilator, or until clinical improvement occurs rendering mechanical ventilation no longer necessary. In instances of hand-bag ventilation, an endotracheal tube is first placed. Family members are then asked to play the role of a ventilator, manually compressing a bag repeatedly to inflate the child's lungs. This approach is fraught with numerous ethical challenges. A careful examination of the data and a nuanced approach to the ethical considerations are imperative. Ethical arguments in support of and in opposition to allowing parental hand-bag ventilation are explored, including the best interests of the child, the child's right to an open future, beneficence and parental protection, legitimising substandard care, and finally, contextual concerns. An algorithmic, potentially ethically permissible approach to parental participation in manual ventilation is proposed.


title: [Exploration of omics mechanism and drug prediction of coronavirus-induced heart failure based on clinical bioinformatics].

text: Objective: Present study investigated the mechanism of heart failure associated with coronavirus infection and predicted potential effective therapeutic drugs against heart failure associated with coronavirus infection. Methods: Coronavirus and heart failure were searched in the Gene Expression Omnibus (GEO) and omics data were selected to meet experimental requirements. Differentially expressed genes were analyzed using the Limma package in R language to screen for differentially expressed genes. The two sets of differential genes were introduced into the R language cluster Profiler package for gene ontology (GO) and Kyoto gene and genome encyclopedia (KEGG) pathway enrichment analysis. Two sets of intersections were taken. A protein interaction network was constructed for all differentially expressed genes using STRING database and core genes were screened. Finally, the apparently accurate treatment prediction platform (EpiMed) independently developed by the team was used to predict the therapeutic drug. Results: The GSE59185 coronavirus data set was searched and screened in the GEO database, and divided into wt group, ΔE group, Δ3 group, Δ5 group according to different subtypes, and compared with control group. After the difference analysis, 191 up-regulated genes and 18 down-regulated genes were defined. The GEO126062 heart failure data set was retrieved and screened from the GEO database. A total of 495 differentially expressed genes were screened, of which 165 were up-regulated and 330 were down-regulated. Correlation analysis of differentially expressed genes between coronavirus and heart failure was performed. After cross processing, there were 20 GO entries, which were mainly enriched in virus response, virus defense response, type Ⅰ interferon response, γ interferon regulation, innate immune response regulation, negative regulation of virus life cycle, replication regulation of viral genome, etc . There are 5 KEGG pathways, mainly interacting with tumor necrosis factor signaling pathway, IL-17 signaling pathway, cytokine and receptor interaction, Toll-like receptor signaling pathway, human giant cells viral infection related. All differentially expressed genes were introduced into the SREING online analysis website for protein interaction network analysis, and core genes such as signal transducer and activator of transcription 3, IL-10, IL17, TNF, interferon regulatory factor 9, 2'-5'-oligoadenylate synthetase 1, mitogen-activated protein kinase 3, radical s-adenosyl methionine domain containing 2, c-x-c motif chemokine ligand 10, caspase 3 and other genes were screened. The drugs predicted by EpiMed's apparent precision treatment prediction platform for disease-drug association analysis are mainly TNF-α inhibitors, resveratrol, ritonavir, paeony, retinoic acid, forsythia, and houttuynia cordata. Conclusions: The abnormal activation of multiple inflammatory pathways may be the cause of heart failure in patients after coronavirus infection. Resveratrol, ritonavir, retinoic acid, amaranth, forsythia, houttuynia may have therapeutic effects. Future basic and clinical research is warranted to validate present results and hypothesis.


The EU and the social determinants of health in a post-COVID world.


title: Effect of Tri-Staple Technology and Slow Firing on Secure Stapling Using an Endoscopic Linear Stapler.

text: AIM To evaluate the effect of Tri-staple technology and slow firing using the Endo-GIA endoscopic linear stapler. METHODS The cardiac and pyloric portions of porcine stomachs were divided using the endoscopic linear stapler with different reload types. A total of 8 min of waiting time was employed during firing in the slow-firing group and no waiting time was employed in the normal-firing group. The shape of the staples was then evaluated. The length of the staple line and serosal laceration was also determined. RESULTS There was a moderate negative correlation between tissue thickness and secure staple formation. Tri-staple reloads (purple, black) offered more secure staple formation compared with Universal green reload. Although slow firing enhanced secure staple formation, its effect was greater when using green reload, compared with Tri-staple reloads. Significantly shorter staple line length and longer serosal laceration was observed in the thick tissue. Although the cartridge type did not influence lengths of the staple line or serosal laceration, both were better in the slow-firing group. CONCLUSIONS Tri-staple reloads offered more secure staple formation compared with the Universal reload. Although slow firing improved staple line shortening and serosal laceration, its effect on secure stapling was relatively small when using Tri-staple reloads.


title: The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese.

text: BACKGROUND Because of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure. METHODS We performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m(2). The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up. RESULTS Mean patient age was 53 years (range 32-75 yr) with mean BMI of 46 kg/m(2) (range 41-60 kg/m(2)). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively. CONCLUSION The PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.


title: Use of pressure mapping for quantitative analysis of pressure points induced by external coaptation of the distal portion of the pelvic limb of dogs.

text: OBJECTIVE To quantitatively measure the amount of pressure induced at the calcaneus and cranial tibial surface of dogs by use of 2 cast configurations. ANIMALS 13 client- or student-owned dogs. PROCEDURES Pressure sensors were placed over the calcaneus and cranial tibial surface. Dogs then were fitted with a fiberglass cast on a pelvic limb extending from the digits to the stifle joint (tall cast). Pressure induced over the calcaneus and proximal edge of the cast at the level of the cranial tibial surface was simultaneously recorded during ambulation. Subsequently, the cast was shortened to end immediately proximal to the calcaneus (short cast), and data acquisition was repeated. Pressure at the level of the calcaneus and cranial tibial surface for both cast configurations was compared by use of paired t tests. RESULTS The short cast created significantly greater peak pressure at the level of the calcaneus (mean ± SD, 0.2 ± 0.07 MPa), compared with peak pressure created by the tall cast (0.1 ± 0.06 MPa). Mean pressure at the proximal cranial edge of the cast was significantly greater for the short cast (0.2 ± 0.06 MPa) than for the tall cast (0.04 ± 0.03 MPa). CONCLUSIONS AND CLINICAL RELEVANCE A cast extended to the level of the proximal portion of the tibia caused less pressure at the level of the calcaneus and the proximal cranial edge of the cast. Reducing the amount of pressure at these locations may minimize the potential for pressure sores and other soft tissue injuries.


title: Laparoscopic treatment of incisional and primary ventral hernia in morbidly obese patients with a BMI over 35.

text: INTRODUCTION Incisional and ventral hernias are common surgical indications. Their management is associated with significant complications and recurrences in open surgery (15-25%). Since laparoscopy has become a standard in bariatric surgery, there has been a natural trend to treat obese patients with parietal wall defects laparoscopically. The aim of our study was to evaluate the feasibility and the results of the laparoscopic management of parietal wall defects in patients with a BMI >35. MATERIALS AND METHODS A series of 79 patients were included. Data were acquired prospectively and analyzed retrospectively. The surgical procedure was standardized: 3 ports, mesh type (Parietex™ Composite mesh, Covidien, France), fixation with non-absorbable transfascial sutures, and tackers. Complications were evaluated. RESULTS Out of 79 patients (29 men, 50 women), 43 had umbilical and 36 had ventral hernias. Mean age was 52.4 years, and mean BMI was 40.83 kg/m(2). Mean postoperative hospital stay was 2 days. Postoperative pain evaluated by visual analog scale was 2.86. No intraoperative complications or deaths occurred. Seven postoperative complications occurred (8.86%): two parietal wall hematomas treated by radiological embolization, two significant cases of postoperative pain, one postoperative obstruction, one spontaneously resolved respiratory failure, and one early (day 1) parietal wall defect with immediate reoperation. Postoperative seroma rate was 26.58% (21 patients, all of whom were treated conservatively). Postoperative follow-up was 18.10 months (1-84 months), and recurrence rate was 3.8% (3 patients). DISCUSSION This study confirms the feasibility and safety of the laparoscopic approach for ventral hernias in morbidly obese patients. Recurrence rates (3.8%) appeared lower than the ones observed in the literature (15-25%). Postoperative hemorrhage and port-site hernia are specific complications of this approach. Postoperative hospital stay is low (2 days) as compared to open surgery. Laparoscopic management of parietal wall defects should be considered a standard option in morbidly obese patients.


title: Standard "off-the-shelf" multibranched thoracoabdominal endograft in urgent and elective patients with single and staged procedures in a multicenter experience.

text: OBJECTIVE The objective of this study was to assess immediate and midterm outcomes for urgent/emergent and elective patients with thoracoabdominal aortic aneurysms (TAAAs) treated with the first commercially available "off-the-shelf" multibranched endograft for endovascular aneurysm repair, with a single-step or a staged surgical approach. METHODS A multicenter, nonrandomized, retrospective study was conducted of TAAA patients grouped by urgent/emergent and elective treatment with multibranched endograft for endovascular aneurysm repair at 13 Italian centers from November 2012 to August 2016. Urgent/emergent repair was classified as rupture in 16%, impending rupture in 9%, pain in 53%, or a maximum TAAA diameter ≥80 mm in 22%. Study end points were technical success, mortality, spinal cord ischemia, target visceral vessel (TVV) patency, and procedure-related reinterventions at 30 days and at follow-up. RESULTS Seventy-three patients (274 TVVs) were enrolled. Treatment was performed in elective (n = 41 [56%]) or urgent/emergent (n = 32 [44%]) settings, according to a single-step (n = 30 [41%]) or staged (n = 43 [59%]) approach. Technical success was 92%. Mortality within 30 days was 4% (n = 3 urgent/emergent patients) due to myocardial infarction. Spinal cord ischemia was recorded in two patients (3%; elective group). The primary patency of TVVs was 99% (three renal branch occlusions). Procedure-related reinterventions were required in five cases (7%). At least one adverse event from any cause ≤30 days was registered in 42% (n = 31). At a median follow-up of 18 months (range, 1-43 months), eight (11%) deaths (elective vs urgent/emergent, 2% vs 22%; P = .018), three (1%) cases of branch occlusion or stenosis, and five (7%) reinterventions were recorded. A survival of 88% (standard error [SE], 4%), 86% (SE, 4%), and 82% (SE, 5%) was evidenced at 12, 24, and 36 months, respectively. Urgent/emergent repair and female gender were identified as independent risk factors for all-cause mortality (P < .001 and P = .015, respectively), and the staged approach was identified as protective (P = .026). Freedom from reintervention was 86% (SE, 4%) and 83% (SE, 5%) at 12 and 24 months. CONCLUSIONS The first off-the-shelf multibranched endograft seems safe in both urgent/emergent and elective settings. The staged surgical approach appears to positively influence overall survival. This unique device and its operators will usher in a new treatment paradigm for TAAA repair.


title: Reply to "Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy".

text: We have just read with interest the article recently published in your Journal and titled "Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy" by Tang N. et al (1). In this article, it is suggested that those patients with COVID-19 that accomplish the Sepsis-Induced Coagulopathy (SIC) criteria, and receive anticoagulant treatment would present a reduction of mortality rates. It is well known that both shock and disseminated intravascular coagulation (DIC) are the two major causes of organ dysfunction in sepsis (2). Furthermore, DIC is a strong predictor of mortality in patients with sepsis, independently of the severity of sepsis (2).


title: Transitions in state public health law: comparative analysis of state public health law reform following the Turning Point Model State Public Health Act.

text: Given the public health importance of law modernization, we undertook a comparative analysis of policy efforts in 4 states (Alaska, South Carolina, Wisconsin, and Nebraska) that have considered public health law reform based on the Turning Point Model State Public Health Act. Through national legislative tracking and state case studies, we investigated how the Turning Point Act's model legal language has been considered for incorporation into state law and analyzed key facilitating and inhibiting factors for public health law reform. Our findings provide the practice community with a research base to facilitate further law reform and inform future scholarship on the role of law as a determinant of the public's health.


title: Acute basilar artery occlusion: outcome of mechanical thrombectomy with Solitaire stent within 8 hours of stroke onset.

text: BACKGROUND AND PURPOSE Mechanical thrombectomy with a stent retriever applied shortly after symptom onset could increase good functional outcomes and improve survival in patients with acute basilar artery occlusion, but this has not yet been studied. This study evaluated the efficacy and safety of mechanical thrombectomy with a Solitaire stent within 8 hours of stroke onset in patients with acute basilar artery occlusion. MATERIALS AND METHODS We analyzed 25 consecutive patients with acute basilar artery occlusion who were treated with mechanical thrombectomy by use of the Solitaire stent within 8 hours of stroke symptom onset. Successful recanalization was defined as TICI grade 2b or 3. Good outcome was defined as mRS score of 0-2 at 3 months. Clinical and radiologic data in patients with good outcomes were compared with those with poor outcomes. RESULTS Successful recanalization was achieved in 96% (24/25) of patients, and 48% (12/25) of patients had good outcomes. Eighty-eight percent (22/25) of patients survived to 3 months. The median NIHSS score on admission was significantly lower in patients with good outcomes than in those with poor outcomes (9.5 versus 14, P = .005). Procedure-related complications occurred in 2 patients (8%). No symptomatic intracerebral hemorrhages occurred. CONCLUSIONS The current study suggests that mechanical thrombectomy by use of a Solitaire stent within 8 hours of stroke onset increases good outcomes and improves survival in patients with acute basilar artery occlusion.


title: Intrasaccular flow-diversion for treatment of intracranial aneurysms: the Woven EndoBridge.

text: Endovascular approach is now the first option for the treatment of most intracranial aneurysms (IA). However, remaining limitations are the suboptimal stability of aneurysm occlusion and the treatment of complex IA. The use of conventional and flow diverter stents has partially addressed these limitations. Nevertheless, as intraluminal devices, stents require aggressive antiplatelet therapy and are associated with higher thromboembolic (TE) complication rates. Intrasaccular flow disrupters (IFD) are newly developed braided-wire devices designed to achieve flow disruption at the neck without placing material in the parent vessel and without the need of antiplatelet therapy. First clinical series have shown promising anatomical and clinical results. Our purpose is to describe the available IFD and to review the literature about their efficacy, safety, limitations, and developments.


Video-atlas of thoracoscopic formal lung resections emulating traditional open techniques.


title: Maxillofacial prosthodontic rehabilitation of a patient with oral complications during and after multimodality therapy for the management of oral squamous cell carcinoma.

text: Multimodality cancer therapy involving surgical resection, chemotherapy, and radiation therapy is frequently employed in the management of head and neck cancer. Patients who have undergone such therapy face substantial challenges during and after treatment. Prosthodontic rehabilitation is essential during and after tumor ablation to restore function, esthetics, and minimize interruption in daily routine. This clinical report describes the challenges faced by a patient undergoing multimodality therapy for a squamous cell carcinoma of the maxillary sinus and the stages involved in prosthodontic rehabilitation.


title: Totally thoracoscopic basilar segmentectomy.

text: We describe our technique of basilar segmentectomy by using a totally thoracoscopic approach without utility incision. We have performed 65 anatomical segmentectomies by using this approach. Nineteen of these were basilar segmentectomies. On the basis of this experience, we report useful technical details and our results. There was 1 conversion to thoracotomy because of inflammatory and fused fissure (1.5%). In the 18 remaining patients who had a totally endoscopic resection, the mean operative time was 191 minutes (range, 116-315 minutes). The mean operative blood loss was 73 mL (range, 10-150 mL). The postoperative course was uneventful in all but 1 patient who developed pulmonary edema that resolved after 2 days. Chest tubes were removed after a mean time of 2.8 days (range, 2-5 days), no patients had a prolonged air leak, and the mean postoperative stay was 6.1 days (range, 3-14 days).


Race to find COVID-19 treatments accelerates.


title: Single-incision laparoscopy-assisted subtotal gastrectomy for intractable gastric ulcer: a case report.

text: PURPOSE Single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain and accelerated recovery. Although there have been reports of cholecystectomy and appendectomy using SILS, there have been few reports of gastric resection with intracorporeal reconstruction of the digestive tract using SILS. The first single-incision laparoscopic gastrectomy with intracorporeal reconstruction is reported. METHODS Preliminary experience with single-incision laparoscopic gastrectomy with intracorporeal reconstruction for a patient with an intractable gastric ulcer is reported. RESULTS Single-incision laparoscopy-assisted subtotal gastrectomy and Roux-en-Y reconstruction were performed. Operative time for gastrectomy and paraduodenal hernioplasty was 412 minutes, and blood loss was 90 g. No intraoperative or postoperative complications developed. CONCLUSIONS Single-incision laparoscopy-assisted gastrectomy for intractable gastric ulcer is technically feasible. Intracorporeal reconstruction of the digestive tract was performed safely using a linear endoscopic stapler. This surgical approach is a further advance toward scarless surgery of the stomach.


title: Laser-Etched Designs for Molding Hydrogel-Based Engineered Tissues.

text: Rapid prototyping and fabrication of elastomeric molds for sterile culture of engineered tissues allow for the development of tissue geometries that can be tailored to different in vitro applications and customized as implantable scaffolds for regenerative medicine. Commercially available molds offer minimal capabilities for adaptation to unique conditions or applications versus those for which they are specifically designed. Here we describe a replica molding method for the design and fabrication of poly(dimethylsiloxane) (PDMS) molds from laser-etched acrylic negative masters with ∼0.2 mm resolution. Examples of the variety of mold shapes, sizes, and patterns obtained from laser-etched designs are provided. We use the patterned PDMS molds for producing and culturing engineered cardiac tissues with cardiomyocytes derived from human-induced pluripotent stem cells. We demonstrate that tight control over tissue morphology and anisotropy results in modulation of cell alignment and tissue-level conduction properties, including the appearance and elimination of reentrant arrhythmias, or circular electrical activation patterns. Techniques for handling engineered cardiac tissues during implantation in vivo in a rat model of myocardial infarction have been developed and are presented herein to facilitate development and adoption of surgical techniques for use with hydrogel-based engineered tissues. In summary, the method presented herein for engineered tissue mold generation is straightforward and low cost, enabling rapid design iteration and adaptation to a variety of applications in tissue engineering. Furthermore, the burden of equipment and expertise is low, allowing the technique to be accessible to all.


title: Barbed unidirectional V-Loc 180 suture in laparoscopic Roux-en-Y gastric bypass: a study comparing unidirectional barbed monofilament and multifilament absorbable suture.

text: BACKGROUND This study aimed primarily to evaluate the safety of digestive running suture (in gastrojejunal and antecolic jejunojejunal anastomosis closure) using unidirectional absorbable barbed suture (V-Loc 180) in laparoscopic Roux-en-Y gastric bypass (LRYGB) and secondarily to assess the efficacy of V-Loc 180 in reducing operative time. METHODS A prospective cohort study of 315 consecutive patients who underwent LRYGB was performed between October 2009 and October 2012 using an identical procedure technique. For the first 76 patients, a multifilament absorbable suture was used to assess the gastrojejunal anastomosis and the antecolic jejunal suture. For the following 239 patients, a unidirectional barbed monofilament suture was used. Data including operative time, time required for gastric pouch creation, time spent in both anastomoses constructions, conversion rate, and complications were prospectively recorded. RESULTS The postoperative complications did not differ significantly between the two groups. Early complications were observed for 1 patient (1.3%) in the multifilament group and for 14 patients (5.8%) in the barbed procedure group (p > 0.05). Late complications were observed for 1 patient (1.3%) in the multifilament group and for 5 patients (2%) in the barbed procedure group (p > 0.05). A shortened operative time was achieved in the barbed suture group. The mean operative time was 74.3 ± 15.3 min in the Vicryl group versus 62.7 ± 15.5 min in the V-Loc group (p < 0.05). The mean operative time required to fashion the gastrojejunal anastomosis was 21.3 ± 6.3 min in the Vicryl group versus 17.4 ± 5.1 min in the V-Loc group (p < 0.05). The mean operative time required to fashion the jejunojejunal anastomosis was 21.4 ± 4.9 min in the Vicryl group versus 15.2 ± 5.5 min in the V-Loc group (p < 0.05). CONCLUSIONS The authors' experience has demonstrated that the use of interlocked V-Loc suture during LRYGB anastomosis appears to be safe and efficient. The findings show a shortened total operative time in terms of single gastrojejunal or jejunojejunal anastomosis time. No statistically significant differences in early or late postoperative complications were observed between the V-Loc and multifilament absorbable suture patients.


Clinical course and risk factors for mortality of COVID-19 patients with pre-existing cirrhosis: a multicentre cohort study.


title: Change in levels of C-reactive protein (CRP) and serum cortisol in morbidly obese patients after laparoscopic sleeve gastrectomy.

text: BACKGROUND C-Reactive protein (CRP) has been associated with the macro- and microvascular effects of hypertension and diabetes mellitus. Referring to serum cortisol, it has been proposed to contribute to the pathogenesis of metabolic syndrome, and it has been demonstrated that weight loss normalizes cortisol levels and improves insulin resistance. The aims of this study were to analyze CRP and cortisol levels pre- and postoperatively in morbidly obese patients undergoing a laparoscopic sleeve gastrectomy and to correlate them with weight loss and parameters associated with cardiovascular risk. METHODS A prospective study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between October 2007 and May 2011 was performed. RESULTS A total of 40 patients were included in the study. CRP levels decreased significantly 12 months after surgery (median reduction of 8.9 mg/l; p = 0.001). Serum cortisol levels decreased significantly 6 months after surgery (median reduction of 34.9 μg/dl; p = 0.001). CRP values reached the normal range (<5 mg/l) 1 year after surgery. Referring to cortisol, a significant association was observed with the cardiovascular risk predictor (triglyceride/high-density lipoprotein cholesterol ratio) from the 6th month after surgery onward (Pearson correlation coefficient, 0.559; p = 0.008). CONCLUSION CRP levels are increased preoperatively and in the postoperative course up to 1 year after surgery. Serum cortisol levels remain elevated until the 6th month after surgery. From this moment onward, serum cortisol is associated with the cardiovascular risk predictor reflecting the cardiovascular risk decreasement during the weight loss.


title: Early Results of Physician Modified Fenestrated Stent Grafts for the Treatment of Thoraco-abdominal Aortic Aneurysms.

text: OBJECTIVES The aim was to determine whether physician modified stent grafts (PMSGs) are safe and effective for the treatment of high risk patients with thoraco-abdominal aortic aneurysms (TAAAs). DESIGN This was a retrospective single institution study. MATERIAL Consecutive patients with TAAA undergoing endovascular repair using a PMSG between January 2012 and June 2014 were evaluated. METHODS Fenestrations to preserve branch vessels were created in TX2 thoracic (Cook Medical) stent grafts. Pre- intra- and post-operative data were recorded by means of a prospectively maintained database. RESULTS Eleven high risk patients with TAAA (type I, n = 4; type III, n = 3; type IV, n = 3; type V, n = 1) underwent fenestrated endovascular repair using PMSGs. Indications were painful aneurysm (n = 5), >70 mm rapidly enlarging aneurysm (n = 4), saccular aneurysm (n = 1), and visceral patch false aneurysm after open repair of a type IV TAAA (n = 1). In four asymptomatic patients, an additional fenestration was created for temporary selective sac perfusion and occluded 2-4 weeks later. Median duration for stent graft modifications was 2 hours (range 1-3 hours). The median number of fenestrations was three (range 2-4). One patient died during the post-operative period from colonic ischemia, giving a 9% in hospital mortality rate. Four (36%) patients presented with moderate to severe complications. One (9%) patient presented with a paraparesis that resolved completely after spinal fluid drainage. Among surviving patients, four required early endovascular re-intervention for type III endoleak (n = 2), type Ia endoleak (n = 1), or target vessel cannulation failure (n = 1). The median follow up time was 6 months (range 3-20 months). During follow up, no other complications occurred and all target vessels remained patent. One patient presented with a persistent type II endoleak. CONCLUSION PMSGs provided acceptable short-term results and may be a management option for the treatment of TAAA in selected high risk patients. Durability concerns need to be assessed in additional studies with long-term follow up.


title: High Prevalence of Hepatitis C Infection Among Adult Patients at Four Urban Emergency Departments - Birmingham, Oakland, Baltimore, and Boston, 2015-2017.

text: Identifying persons with hepatitis C virus (HCV) infection has become an urgent public health challenge because of increasing HCV-related morbidity and mortality, low rates of awareness among infected persons, and the advent of curative therapies (1). Since 2012, CDC has recommended testing of all persons born during 1945-1965 (baby boomers) for identification of chronic HCV infection (1); urban emergency departments (EDs) are well positioned venues for detecting HCV infection among these persons. The United States has witnessed an unprecedented opioid overdose epidemic since 2013 that derives primarily from commonly injected illicit opioids (e.g., heroin and fentanyl) (2). This injection drug use behavior has led to an increase in HCV infections among persons who inject drugs and heightened concern about increases in human immunodeficiency virus (HIV) and HCV infection within communities disproportionately affected by the opioid crisis (3,4). However, targeted strategies for identifying HCV infection among persons who inject drugs is challenging (5,6). During 2015-2016, EDs at the University of Alabama at Birmingham; Highland Hospital, Oakland, California; Johns Hopkins Hospital, Baltimore, Maryland; and Boston University Medical Center, Massachusetts, adopted opt-out (i.e., patients can implicitly accept or explicitly decline testing), universal hepatitis C screening for all adult patients. ED staff members offered HCV antibody (anti-HCV) screening to patients who were unaware of their status.* During similar observation periods at each site, ED staff members tested 14,252 patients and identified an overall 9.2% prevalence of positive results for anti-HCV among the adult patient population. Among the 1945-1965 birth cohort, prevalence of positive results for anti-HCV (13.9%) was significantly higher among non-Hispanic blacks (blacks) (16.0%) than among non-Hispanic whites (whites) (12.2%) (p<0.001). Among persons born after 1965, overall prevalence of positive results for anti-HCV was 6.7% and was significantly higher among whites (15.3%) than among blacks (3.2%) (p<0.001). These findings highlight age-associated differences in racial/ethnic prevalences and the potential for ED venues and opt-out, universal testing strategies to improve HCV infection awareness and surveillance for hard-to-reach populations. This opt-out, universal testing approach is supported by new recommendations for hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the prevalence of positive results for HCV infection is <0.1% (7).


title: Removal of boron from water by GO/ZIF-67 hybrid material adsorption.

text: With the development of the boron industry, boron pollution is getting more and more serious, and excessive boron will harm human health. In this paper, graphene oxide was used as a template to prepare ZIF-67, and GO/ZIF-67 was successfully prepared. GO/ZIF-67 was used for the first time to remove boron from water. SEM, XRD, and other characterization methods were used to confirm the structure. The adsorption kinetics, adsorption isotherm, adsorption thermodynamics, and adsorption mechanism of boron by GO/ZIF-67 were studied in this paper. The adsorption capacity of GO/ZIF-67 for boron is up to 66.65 mg·g-1 at 25 °C, and adsorption process reaches equilibrium in 400 min. Adsorption kinetics indicates that the adsorption process conforms to the pseudo-first-order kinetic model, and adsorption thermodynamics indicates that the adsorption process is a spontaneous endothermic process controlled by entropy change. The adsorption capacity of boron by GO/ZIF-67 does not decrease significantly after four cycles. The adsorption of boron by GO/ZIF-67 has both chemical and physical adsorption. From Zeta potential and adsorption kinetics, it can be seen that there is physical adsorption during the adsorption process and boron mainly has positive charge on the surface of GO/ZIF-67 and graphene oxide hydroxyl bonding. Based on the adsorption thermodynamics and XPS, it is known that there is chemisorption during the adsorption process, and mainly the combination of boron and cobalt sites.


Fundamental Use of Surgical Energy™ (FUSE): a curriculum on surgical energy-based devices.


title: Fecal shedding of infectious feline leukemia virus and its nucleic acids: a transmission potential.

text: Although it is assumed that fecal shedding of feline leukemia virus (FeLV) constitutes a transmission potential, no study has been performed showing that feces of infected cats can be a source of infection. In this study, we investigated fecal viral shedding of FeLV and its role in viral pathogenesis with the goal to improve infection control. FeLV RNA and DNA levels were determined in rectal swabs of experimentally infected cats by real-time PCR, and the results were correlated with proviral and viral loads in whole blood and plasma, respectively, and plasma p27 levels. All antigenemic cats shed FeLV RNA and DNA in feces. To determine whether the viral RNA detected was infectious, virus isolation from feces was also performed. Infectious virus was isolated from feces of antigenemic cats, and these results perfectly correlated with the isolation of virus from plasma. Naïve cats exposed to these feces seroconverted, showing that infection through feces took place, but remained negative for the presence of FeLV provirus and p27 in blood, an outcome so far not described. Some of the organs collected after euthanasia were provirus positive at low copy numbers. From these results it is concluded that fecal shedding of FeLV plays a role in transmission, but it is probably of secondary importance in viral pathogenesis. Nevertheless, sharing of litter pans by susceptible and viremic cats could increase the environmental infectious pressure and appropriate measures should be taken to avoid unnecessary viral exposure.


title: Case Report of Transmissible Gastroenteritis Coronavirus Infection Associated with Small Intestine and Brain Lesions in Piglets.

text: This case study report describes a transmissible gastroenteritis coronavirus (TGEV) infection presented in a commercial pig herd. The clinical signs of infection appeared in newborn piglets, including medium morbidity and low mortality rates. Rectal swabs were collected from five different affected litters for laboratory examinations. Samples from two dead piglets and two euthanized affected piglets were collected for gross and histopathological examinations. All fecal samples were tested TGEV positive by real-time polymerase chain reaction (RT-PCR). Necropsy revealed nonspecific gross lesions. The histopathological examinations revealed villi fused with denuded tips and severe villus atrophy, leading to extensive epithelial flattening in middle and lower small intestine. The architecture pattern of villi presented columnar and cuboidal poorly differentiated enterocytes with mild subepithelial edema. In some enterocytes, pycnotic nuclei were detected. Microscopic examination of brain tissue revealed diffuse gliosis in the area of pia matter with mild congestion of the meningeal and parenchymal vessels and neuronal degeneration. In conclusion, this case study reported an epidemic TGEV infection in piglets, characterized by low mortality and medium morbidity rates accompanied by typical histopathological lesions in small intestine, as well as by coexisting brain lesions, that are described for the first time.


title: Laparoscopic umbilical hernia repair in the presence of extensive paraumbilical collateral veins: a case report.

text: A patient with an umbilical hernia presenting with collateral veins in the abdominal wall and umbilicus is a case that every hernia surgeon has to deal with occasionally. Several underlying diseases have been described to provoke collateral veins in the abdominal wall. However, the treatment strategy should be uniform. We herein report a case of a successful laparoscopic umbilical hernia repair in a patient with collateral veins in the abdominal wall and umbilicus. A 63-year-old man was referred to the surgical outpatient clinic with a large symptomatic umbilical hernia and collateral veins in the abdominal wall, secondary to an occlusion of both common iliac veins. Because of collateral veins in the umbilicus and the size of the hernial defect, he was offered laparoscopic hernia repair without compromising these veins. Because of the extensive abdominal wall collaterals, duplex sonography vein mapping was performed preoperatively to mark a safe collateral-free area for trocar introduction. The defect was repaired by mesh prosthesis.


title: Long-term results of drug-eluting balloon angioplasty for treatment of refractory recurrent carotid in-stent restenosis.

text: PURPOSE To evaluate the potential role, safety, and efficacy of paclitaxel-eluting balloon angioplasty for treatment of recurrent carotid in-stent restenosis (ISR). METHODS Among 856 consecutive patients who underwent carotid artery stenting from May 2002 to January 2008, 41 patients had a significant ISR (>80% stenosis). Of these, 9 patients (7 women; mean age 78.1±5.6 years) had recurrent ISR despite multiple endovascular treatments (3.4±0.9 interventions) within a short period of time (2-5 months). These patients were treated with drug-eluting balloon (DEB) angioplasty for neointimal hyperplasia. Imaging (ultrasound or computed tomographic angiography) was performed at 1, 3, and 6 months and yearly thereafter. RESULTS Technical success was obtained in 100% of cases, with angiographic stenosis decreasing from 87%±4% to 6%±4% post treatment. Peak systolic velocity decreased significantly from 4.7±1.5 m/s to 0.6.±0.3 m/s after the procedure. Over a mean follow-up of 36.6±2.7 months, ultrasound imaging indicated recurrent ISR in only 3 patients at 18, 25, and 32 months after DEB angioplasty, respectively. The target vessel revascularization rate was 33.3% at 36 months. No neurological or myocardial events were recorded during follow-up. One patient died at 3 months. CONCLUSION DEB may have a potential role improving outcomes of those patients treated for early recurrent carotid ISR.


title: Consultations on driving in people with cognitive impairment in primary care: A scoping review of the evidence.

text: OBJECTIVES To review the empirical evidence on approaches used by Primary Care Physicians (PCPs) in fitness to drive (FtD) consultations with people living with cognitive impairment. DESIGN Scoping review of empirical literature focused on primary studies of any design. SETTING Primary care practice. PARTICIPANTS PCPs or their equivalent and/ or individuals with cognitive impairment across the spectrum of mild cognitive impairment to dementia. MEASUREMENTS Systematic search of Medline, Cinahl, PsychINFO, Academic Search Complete, Psychological and Behavioural Sciences Collection, SocIndex and Social Sciences FT were conducted. Records screened by two reviewers against agreed inclusion criteria. Mixed studies (qualitative and quantitative) were synthesized within overarching themes. RESULTS Eighteen studies met our inclusion criteria. Synthesized data showed PCPs have mixed feelings on the appropriateness of their role in FtD assessments, with many feeling particularly uncomfortable and lacking confidence in the context of possible cognitive impairment. Reasons include lack of familiarity with legal requirements and local resources; fear of damaging the doctor-patient relationship; and impact on the patient's quality of life. Patients voiced their desire to maintain agency in planning their driving cessation. Studies evaluating pragmatic educational programmes suggest these can improve physician confidence in FtD consultations. CONCLUSION The increasing number of older people affected by cognitive impairment, for whom driving may be a concern, has implications for primary care practice. Addressing the reasons for PCPs lack of comfort in dealing with this issue is essential in order for them to better engage in, collaborative discussion with patients on plans and preferences for driving cessation.


title: Antibody Responses to SARS-CoV-2 at 8 Weeks Postinfection in Asymptomatic Patients.

text: We compared levels of severe acute respiratory syndrome coronavirus 2 neutralizing antibodies in recovery plasma from 7 completely asymptomatic coronavirus disease patients with those in symptomatic patients in South Korea. We found that serologic diagnostic testing was positive for 71% (5/7) of completely asymptomatic patients, but neutralizing antibody response occurred in all 7 patients.


title: Impact of pretreatment noncontrast CT Alberta Stroke Program Early CT Score on clinical outcome after intra-arterial stroke therapy.

text: BACKGROUND AND PURPOSE The efficacy of intra-arterial treatment remains uncertain. Because most centers performing IAT use noncontrast CT (NCCT) imaging, it is critical to understand the impact of NCCT findings on treatment outcomes. This study aimed to compare functional independence and safety among patients undergoing intra-arterial treatment stratified by the extent of ischemic change on pretreatment NCCT. METHODS The study cohort was derived from multicenter trials of the Penumbra System. Inclusion criteria were anterior circulation proximal occlusion, evaluable pretreatment NCCT, and known time to reperfusion. Ischemic change was quantified using the Alberta Stroke Program Early CT Score (ASPECTS) and stratified into 3 prespecified groups for comparison: 0 to 4 (most ischemic change) versus 5 to 7 versus 8 to 10 (least ischemic change). RESULTS A total of 249 patients were analyzed: 40 with ASPECTS 0 to 4, 83 with ASPECTS 5 to 7, and 126 with ASPECTS 8 to 10. For ASPECTS 0 to 4, 5 to 7, and 8 to 10, respectively, good outcome (modified Rankin Scale score, 0-2) rates were 5%, 38.6%, and 46% (P<0.0001), and mortality rates were 55%, 28.9%, and 19% (P=0.0001). The only significant pairwise differences were between ASPECTS 0 to 4 and other groups. Symptomatic hemorrhage was more common with lower ASPECTS (P=0.02). Shorter time to reperfusion was significantly associated with better outcomes among patients with ASPECTS 8 to 10 (P=0.01). A similar relationship was seen for ASPECTS 5 to 7 but was not statistically significant. No such relationship was seen for ASPECTS 0 to 4. CONCLUSIONS NCCT seems useful for excluding patients with the greatest burden of ischemic damage from futile intra-arterial treatment, which is unlikely to result in patient functional independence and increases the risk of hemorrhage.


title: Repetitive peripheral magnetic stimulation for activities of daily living and functional ability in people after stroke.

text: BACKGROUND Repetitive peripheral magnetic stimulation (rPMS) is a form of therapy that creates painless stimulation of deep muscle structures to improve motor function in people with physical impairment from brain or nerve disorders. Use of rPMS for people after stroke has been identified as a feasible approach to improve activities of daily living and functional ability. However, no systematic reviews have assessed the findings of available trials. The effect and safety of this intervention for people after stroke currently remain uncertain. OBJECTIVES To assess the effect of rPMS for improving activities of daily living and functional ability in people after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (August 2016), MEDLINE Ovid (November 2016), Embase Ovid (August 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in Ebsco (August 2016), PsycINFO Ovid (August 2016), the Allied and Complementary Medicine Database (AMED) Ovid (August 2016), Occupational Therapy Systematic Evaluation of Evidence (OTseeker) (August 2016), the Physiotherapy Evidence Database (PEDro) (October 2016), and ICHUSHI Web (October 2016). We also searched five ongoing trial registries, screened reference lists, and contacted experts in the field. We placed no restrictions on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) conducted to assess the therapeutic effect of rPMS for people after stroke. Comparisons eligible for inclusion were (1) active rPMS only compared with 'sham' rPMS (a very weak form of stimulation or a sound only); (2) active rPMS only compared with no intervention; (3) active rPMS plus rehabilitation compared with sham rPMS plus rehabilitation; and (4) active rPMS plus rehabilitation compared with rehabilitation only. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion. The same review authors assessed methods and risk of bias and extracted data. We contacted trial authors to ask for unpublished information if necessary. We resolved all disagreements through discussion. MAIN RESULTS We included three trials (two RCTs and one cross-over trial) involving 121 participants. Blinding of participants and physicians was well reported in all trials, and overall risk of bias was low. We found no clear effect of rPMS on activities of daily living at the end of treatment (mean difference (MD) -3.00, 95% confidence interval (CI) -16.35 to 10.35; low-quality evidence) and at the end of follow-up (MD -2.00, 95% CI -14.86 to 10.86; low-quality evidence). Investigators in one study with 63 participants observed no statistical difference in improvement of upper limb function at the end of treatment (MD 2.00, 95% CI -4.91 to 8.91) and at the end of follow-up (MD 4.00, 95% CI -2.92 to 10.92). One trial with 18 participants showed that rPMS treatment was not associated with improved muscle strength at the end of treatment (MD 3.00, 95% CI -2.44 to 8.44). Another study reported a significant decrease in spasticity of the elbow at the end of follow-up (MD -0.48, 95% CI -0.93 to -0.03). No studies provided information on lower limb function and death. Based on the GRADE approach, we judged the certainty of evidence related to the primary outcome as low owing to the small sample size of one study. AUTHORS' CONCLUSIONS Available trials provided inadequate evidence to permit any conclusions about routine use of rPMS for people after stroke. Additional trials with large sample sizes are needed to determine an appropriate rPMS protocol as well as long-term effects. We identified three ongoing trials and will include these trials in the next review update.


Three Reasons to Focus on Patient and Family Engagement During the COVID-19 Pandemic.


title: Evaluation of deep venous thrombosis prophylaxis in low-risk patients undergoing total knee arthroplasty.

text: Our objective of the study was to address the question: "What is the efficacy of a deep venous thrombosis (DVT) and pulmonary embolus prophylaxis protocol after total knee arthroplasty (TKA) in which low-risk patients had only aspirin and mechanical devices for prophylaxis?" A multimodal approach to DVT prophylaxis using aspirin as the primary mode of chemoprophylaxis was successful in preventing DVT-related morbidity and mortality in 312 consecutive TKAs performed in low-risk patients. There were no DVT-related deaths and no deaths in general at 90 days of follow-up coupled with a low rate of readmission for thromboembolic events and no readmissions or reoperations from bleeding in this group. This low-morbidity, low-cost prophylaxis should be considered an appropriate protocol for low-risk patients undergoing TKA. Of all TKAs performed during the time period of the study, 73% qualified for the low-risk group.


title: Predicting effective remifentanil concentration in 95% of patients to prevent emergence cough after laryngomicroscopic surgery.

text: Smooth emergence or cough prevention is a clinically important concern in patients undergoing laryngomicroscopic surgery (LMS). The purpose of this study was to estimate the effective concentration of remifentanil in 95% of patients (EC95) for the prevention of emergence cough after LMS under propofol anesthesia using the biased coin design (BCD) up-down method.A total of 40 adult patients scheduled to undergo elective LMS were enrolled. Anesthesia induction and maintenance were performed with target-controlled infusion of propofol and remifentanil. Effective effect-site concentration (Ce) of remifentanil in 95% of patients for preventing emergence cough was estimated using a BCD method (starting from 1 ng/mL with a step size of 0.4 ng/mL). Hemodynamic and recovery profiles were observed after anesthesia.According to the study protocol, 20 patients were allocated to receive remifentanil Ce of 3.0 ng/mL, and 20 patients were assigned to receive lower concentrations of remifentanil, from 1.0 to 2.6 ng/mL. Based on isotonic regression with a bootstrapping method, EC95 (95% CI) of remifentanil Ce for the prevention of emergence cough from LMS was found to be 2.92 ng/mL (2.72-2.97 ng/mL). Compared with patients receiving lower concentrations of remifentanil, the incidence of hypoventilation before extubation and extubation time were significantly higher in those receiving remifentanil Ce of 3.0 ng/mL. However, hypoventilation incidence after extubation and staying time in the recovery room were comparable between the 2 groups.Using a BCD method, the EC95 of remifentanil Ce for the prevention of emergence cough was estimated to be 2.92 ng/mL (95% CI: 2.72-2.97 ng/mL) after LMS under propofol anesthesia.


title: Wearable activity trackers for monitoring adherence to home confinement during the Covid-19 pandemic: a worldwide picture.

text: BACKGROUND In the context of COVID-19 home confinement, objective, real-time data are needed to assess the population's adherence to home confinement in order to adapt policies and control measures. OBJECTIVE Wearable activity trackers provide continuous monitoring of people's natural activity patterns whatever their location. We asked whether the huge amount of data they provide might reflect adherence to confinement rules. METHODS We analyzed data on number of steps per day from over 740,000 individuals around the world. RESULTS Results: We show physical activity patterns in several representative countries with total, partial or no home confinement. The decrease in steps per day regions with strict total home confinement ranged from -25 to -54%. CONCLUSIONS Aggregate analysis of activity tracker data, with the potential for a daily update, can inform governments on the adherence to home-confinement policies. CLINICALTRIAL


title: [Value of neutrophil-to-lymphocyte ratio in the classification diagnosis of coronavirus disease 2019].

text: OBJECTIVE To investigate the clinical significance of neutrophil-to-lymphocyte ratio (NLR) in classification of patients with coronavirus disease 2019 (COVID-19). METHODS A retrospective analysis was performed on 72 patients with COVID-19 admitted to the critical ward of Cancer Center of Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in Wuhan from February to March in 2020. The patients were divided into two groups: moderate type (non-severe group) and severe/critical type (severe group). The results of white blood cell count (WBC), neutrophil count (NEU), lymphocyte count (LYM), interleukin-6 (IL-6) and D-dimer were collected at the 2nd day after admission from the two groups, and the NLR was calculated. The diagnostic value of WBC, NEU, LYM, IL-6, D-dimer and NLR on COVID-19 classification was evaluated by the receiver operating characteristic (ROC) curve. RESULTS A total of 72 COVID-19 patients were enrolled, among whom 52 were moderate, 17 were severe, and 3 were critical. The most common clinical manifestations of patients were fever (70.8%), cough (36.1%), chest tightness and breathlessness (37.5%), diarrhea (15.3%), fatigue (15.3%), vomiting and nausea (11.1%), occasionally accompanied by acute dyspnea (2.8%), and only one patient had no clinical symptom (1.4%). The levels of WBC, NEU, IL-6, D-dimer and NLR in the severe group were significantly higher than those in the non-severe group [WBC (×109/L): 7.81±3.65 vs. 5.34±1.69, NEU (×109/L): 5.83±3.13 vs. 3.24±1.53, IL-6 (ng/L): 133.63 (71.09, 249.61) vs. 28.05 (6.41, 101.24), D-dimer (mg/L): 0.86 (0.31, 2.56) vs. 0.33 (0.20, 0.71), NLR: 6.14±4.75 vs. 2.66±1.93, all P < 0.05], and the level of LYM was significantly lower than that in the non-severe group (×109/L: 1.09±0.56 vs. 1.49±0.74, P < 0.05). The results of ROC curve analysis showed that the areas under ROC curve (AUC) of WBC, NEU, LYM, IL-6, D-dimer and NLR for COVID-19 classification were 0.790 [95% confidence interval (95%CI) was 0.684-0.897), 0.869 (95%CI was 0.789-0.949), 0.719 (95%CI was 0.592-0.847), 0.790 (95%CI was 0.682-0.898), 0.676 (95%CI was 0.526-0.827), and 0.888 (95%CI was 0.814-0.963) respectively. The AUC of NLR was the highest, which was of high diagnostic value; when the optimum cut-off value of NLR was 3.00, the sensitivity was 100%, and the specificity was 73.1%. CONCLUSIONS NLR can be used as a biomarker to predict classification of COVID-19 patients independently, which can provide a theoretical basis for the classification management of COVID-19 patients.


title: Hepatitis B virus protein X-induced expression of the CXC chemokine IP-10 is mediated through activation of NF-kappaB and increases migration of leukocytes.

text: Interferon-gamma inducible protein 10 (IP-10) involves inflammatory cell recruitment and cellular immune damage during virus infection. Although an increase of the peripheral IP-10 level is known in HBV-infected patients, the molecular basis of HBV infection inducing IP-10 expression has remained elusive. In the present study, we demonstrate that hepatitis B virus protein X (HBx) increases IP-10 expression in a dose-dependent manner. Transfection of the HBx-expressing vector into HepG2 cells results in nuclear translocation of NF-kappaB, which directly binds the promoter of IP-10 at positions from -122 to -113, thus facilitating transcription. The addition of the NF-kappaB inhibitor blocks the effect of HBx on IP-10 induction. In parallel, increase of NF-kappaB subunits p65 and p50 in HepG2 cells also augments IP-10 expression. Furthermore, we show that HBx induces activation of NF-kappaB through the TRAF2/TAK1 signaling pathway, leading to up-regulation of IP-10 expression. As a consequence, up-regulation of IP-10 may mediate the migration of peripheral blood leukocytes in a NF-kappaB-dependent manner. In conclusion, we report a novel molecular mechanism of HBV infection inducing IP-10 expression, which involves viral protein HBx affecting NF-kappaB pathway, leading to transactivation of the IP-10 promoter. Our study provides insight into the migration of leukocytes in response to HBV infection, thus causing immune pathological injury of liver.


title: Killer peptide: a novel paradigm of antimicrobial, antiviral and immunomodulatory auto-delivering drugs.

text: The incidence of life-threatening viral and microbial infections has dramatically increased over recent decades. Despite significant developments in anti-infective chemotherapy, many issues have increasingly narrowed the therapeutic options, making it imperative to discover new effective molecules. Among them, small peptides are arousing great interest. This review will focus in particular on a killer peptide, engineered from an anti-idiotypic recombinant antibody that mimics the activity of a wide-spectrum antimicrobial yeast killer toxin targeting β-glucan cell-wall receptors. The in vitro and in vivo antimicrobial, antiviral and immunomodulatory activities of killer peptide and its ability to spontaneously and reversibly self-assemble and slowly release its active dimeric form over time will be discussed as a novel paradigm of targeted auto-delivering drugs.


title: Prevertebral cervical approach: a pure endoscopic surgical technique for posterior mediastinum parathyroid adenomas.

text: BACKGROUND Parathyroid gland mediastinal ectopia is an unusual but challenging condition in surgical management of hyperparathyroidism. Posterior mediastinum parathyroid ectopia is rare, and glands need to be removed either with a broad open cervical or thoracic approach. In recent years, several minimally invasive approaches to mediastinal parathyroid glands have been described, but for posterior mediastinum adenomas, proposed techniques are transthoracic. METHODS The aim of this paper is to describe, to our best knowledge for the first time, a standardized pure endoscopic cervical technique to approach posterior mediastinal parathyroid adenomas which we have used in three patients. RESULTS The technique was applied in three patients which excellent surgical, postoperative, and cosmetic results. CONCLUSIONS Endoscopic prevertebral approach is a feasible, sure and inexpensive standardized pure endoscopic cervical approach to posterior mediastinal parathyroid adenomas, which may result in a less aggressive surgical option when compared with thoracic approaches.


title: Neuromuscular adaptations to sprint interval training and the effect of mammalian omega-3 fatty acid supplementation.

text: PURPOSE Sprint interval training (SIT) stimulates rapid metabolic adaptations within skeletal muscle but the nature of neuromuscular adaptions is unknown. Omega-3 polyunsaturated fatty acids (N-3 PUFA) are suggested to enhance neuromuscular adaptations to exercise. METHODS We measured the neuromuscular adaptations to SIT (Study-1) and conducted a placebo-controlled randomized double blinded study to determine the effect of N-3 PUFA supplementation on neuromuscular adaptations to SIT (Study-2). In Study-1, seven active men (24.4 ± 2.6 years, VO2 peak 43.8 ± 8.7 ml kg min-1) completed 2-weeks of SIT with pre- and post-training 10 km cycling time trials (TT). In Study-2, 30 active men (24.5 ± 4.2 years, VO2 peak 41.0 ± 5.1 ml kg min-1) were randomly assigned to receive N-3 PUFA (2330 mg day-1) (n = 14) or olive oil (n = 16) during 2-weeks of SIT with pre- and post-training TTs. Four week post-training, a SIT session and TT were also performed. Change in neuromuscular function was assessed from resting twitches, quadriceps maximal voluntary contraction (MVC) force, and potentiated twitch force (Q tw). RESULTS Study-1 showed that SIT did not elicit significant neuromuscular adaptations. Study-2 showed that N-3 PUFA supplementation had no significant effect on neuromuscular adaptations. Training caused lower MVC force [mean ± SD; N-3 PUFA -9 ± 11%, placebo -9 ± 13% (p < 0.05 time)] and Q tw peripheral fatigue [N-3 PUFA -10 ± 19%, placebo -14 ± 13% (p < 0.05 time)]. TT time was lower after training in all groups [Study-1 -10%, Study-2 N-3 PUFA -8%, placebo -12% (p < 0.05 time)]. CONCLUSION Two weeks of SIT improved TT performance in the absence of measurable neuromuscular adaptations. N-3 PUFA supplementation had no significant effect on SIT training adaptations.


title: Adhesion prevention after myomectomy by laparotomy: a prospective multicenter comparative randomized single-blind study with second-look laparoscopy to assess the effectiveness of PREVADH™.

text: OBJECTIVE The objective of this multicenter, randomized study was to investigate the efficacy of the hydrophilic resorbable film PREVADH™ in preventing postoperative adhesions following myomectomy. STUDY DESIGN Women scheduled for laparotomic myomectomy with intramural and/or subserous myomas of >60mm in diameter, and who wished to preserve fertility, were eligible. Patients were randomized immediately prior to abdominal wall closure to receive either hydrophilic resorbable film applied directly to the incisions (P-Group, n=33) or 500mL Ringer's lactate solution instilled into the pelvic cavity (R-Group, n=28). Incidence, severity, and extent of postoperative adhesions to the uterine incisions and adnexal and abdominopelvic adhesions were assessed during second-look laparoscopy 10-20 weeks after the initial surgery. Unedited videotapes of this second-look procedure were reviewed by two blinded independent surgeons. RESULTS Fifty-four patients (P-Group, n=28; R-Group, n=26) underwent second-look laparoscopy. Significantly fewer P-Group patients developed adhesions to uterine incisions than R-Group patients (43% vs. 92%, P=0.001). Adhesions, which were confirmed by independent reviewers, were found in significantly fewer P-Group sites than R-Group sites (29% vs. 76%, P=0.001). No serious adverse events related to the barriers used or adhesion-related complications were reported in either group. CONCLUSION The hydrophilic resorbable anti-adhesion film PREVADH™ significantly reduced adhesion incidence and severity after laparotomic myomectomy. CLINICAL TRIAL REGISTRATION NCT01388907 (www.clinicaltrials.gov).


title: Measurement of cortical microcirculation during intracranial aneurysm surgery by combined laser-Doppler flowmetry and photospectrometry.

text: BACKGROUND Accidental vessel occlusion is one major risk of intracranial aneurysm surgery potentially causing cerebral ischemia. The intraoperative assessment of cerebral ischemia remains a technological challenge. OBJECTIVE As a novel approach, cortical tissue integrity was monitored using simultaneous measurements of regional capillary-venous cerebral blood flow (rvCBF), oxygen saturation (Srvo2), and hemoglobin amount (rvHb) during aneurysm surgery. METHODS Fifteen patients scheduled for aneurysm surgery of the anterior and posterior circulation were included. A fiber optic probe was placed on the cortex associated with the distal branch of the aneurysmatic vessel. Blinded measurements by combined laser-Doppler flowmetry (rvCBF) and photospectrometry (Srvo2, rvHb) were performed before and after surgical clipping or trapping of the aneurysm. Data were correlated with postoperative imaging and neurological outcome. RESULTS Cortical measurements could be successfully performed in all patients. Significant increase (>25% change from baseline) or decrease (<25% change from baseline) of rvCBF, Srvo2, and rvHb was detectable in 33 to 46% of patients after surgical intervention. Severe decrease (>50% change from baseline) of all parameters or solitary of rvCBF was correlated to reduced cerebral perfusion and neurological deficits in 2 patients. CONCLUSION Combined laser-Doppler flowmetry and photospectrometry provides real-time information on cortical microcirculation. Intraoperative alterations of parameters (rvCBF, Srvo2, rvHb) might reflect changes of cerebral tissue integrity during intracranial aneurysm surgery.


Comparison of the diagnostic performance with whole blood and plasma of four rapid antibody tests for SARS-CoV-2.


title: A systematic review of palliative care tools and interventions for people with severe mental illness.

text: BACKGROUND Increasing attention to palliative care for the general population has led to the development of various evidence-based or consensus-based tools and interventions. However, specific tools and interventions are needed for people with severe mental illness (SMI) who have a life-threatening illness. The aim of this systematic review is to summarize the scientific evidence on tools and interventions in palliative care for this group. METHODS Systematic searches were done in the PubMed, Cochrane Library, CINAHL, PsycINFO and Embase databases, supplemented by reference tracking, searches on the internet with free text terms, and consultations with experts to identify relevant literature. Empirical studies with qualitative, quantitative or mixed-methods designs concerning tools and interventions for use in palliative care for people with SMI were included. Methodological quality was assessed using a critical appraisal instrument for heterogeneous study designs. Stepwise study selection and the assessment of methodological quality were done independently by two review authors. RESULTS Four studies were included, reporting on a total of two tools and one multi-component intervention. One study concerned a tool to identify the palliative phase in patients with SMI. This tool appeared to be usable only in people with SMI with a cancer diagnosis. Furthermore, two related studies focused on a tool to involve people with SMI in discussions about medical decisions at the end of life. This tool was assessed as feasible and usable in the target group. One other study concerned the Dutch national Care Standard for palliative care, including a multi-component intervention. The Palliative Care Standard also appeared to be feasible and usable in a mental healthcare setting, but required further tailoring to suit this specific setting. None of the included studies investigated the effects of the tools and interventions on quality of life or quality of care. CONCLUSIONS Studies of palliative care tools and interventions for people with SMI are scarce. The existent tools and intervention need further development and should be tailored to the care needs and settings of these people. Further research is needed on the feasibility, usability and effects of tools and interventions for palliative care for people with SMI.


title: Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial.

text: WHAT WE ALREADY KNOW ABOUT THIS TOPIC Transpulmonary driving pressure (ratio of tidal volume to respiratory system compliance) increases with increased intraabdominal pressure during laparoscopic surgery. High transpulmonary driving pressure during laparoscopic surgery is associated with increased risk of postoperative pulmonary complications.Intraoperative positive end-expiratory pressure prevents atelectasis, but may also cause overdistension. WHAT THIS ARTICLE TELLS US THAT IS NEW This single-center study found that titrating intraoperative positive end-expiratory pressure in relation to observed intraabdominal pressure may counterbalance pneumoperitoneum-related rises in transpulmonary driving pressure during laparoscopic cholecystectomies. BACKGROUND Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. METHODS Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. RESULTS Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. CONCLUSIONS Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.