title: Clinical and Molecular Characteristics of Human Rotavirus G8P[8] Outbreak Strain, Japan, 2014.

text: During March-July 2014, rotavirus G8P[8] emerged as the predominant cause of rotavirus gastroenteritis among children in Hokkaido Prefecture, Japan. Clinical characteristics were similar for infections caused by G8 and non-G8 strains. Sequence and phylogenetic analyses suggest the strains were generated by multiple reassortment events between DS-1-like P[8] strains and bovine strains from Asia.


title: Single-incision Laparoscopic surgery for total extraperitoneal repair of inguinal hernias in 23 patients.

text: BACKGROUND Laparoscopic surgery has long been the treatment of choice for recurrent or bilateral hernias, and for unilateral hernias when the patient does not want to undergo open surgery. Each laparoscopic incision or trocar presents risks for hemorrhage, organ injury, incisional hernia, and poor cosmetic outcome. For this reason, single-incision laparoscopic surgery (SILS) is being increasingly used to treat a variety of conditions. The aim of this study was to evaluate the use of SILS for total extraperitoneal (TEP) repair of hernias in the largest series performed to date. PATIENTS AND METHODS During the period from June to September 2009, 23 consecutive patients underwent SILS for TEP repair of inguinal hernias. SILS was performed under general anesthesia, with the use of a single access port device and articulating as well as standard laparoscopic instruments. Demographic and clinical data, intraoperative findings, and postoperative course were recorded. RESULTS In the 23 patients (mean age 48.4 y; 18 males and 5 females), a total of 27 hernias were repaired. Unilateral hernias were present in 19 patients and bilateral hernias in four. Of the unilateral hernias, 11 were on the right and 8 on the left. Indirect hernias occurred in 15 patients, direct hernias in 7 patients, and a direct+indirect hernia was seen in 1 patient. All hernias were repaired successfully with SILS except in 1 patient. In this patient, due to the large size of the hernia and the presence of adhesions, the procedure was converted to a standard laparoscopic TEP repair. Mean operative times for unilateral and bilateral hernias were 48.4 minutes (range: 32-62 min) and 96.7 minutes (range: 85-120 min), respectively. None of the patients experienced intraoperative or postoperative complications. Mean hospital stay was 1.17 days. CONCLUSIONS The use of SILS for TEP repair of hernias provides excellent cosmetic results, and articulating instruments seem to be useful for this procedure.


Covid-19: UK pledges to reintroduce contact tracing to fight virus.


title: Patient-Centred Coordinated Care in Times of Emerging Diseases and Epidemics. Contribution of the IMIA Working Group on Patient Safety.

text: OBJECTIVES In this paper the researchers describe how existing health information technologies (HIT) can be repurposed and new technologies can be innovated to provide patient-centered care to individuals affected by new and emerging diseases. METHODS The researchers conducted a focused review of the published literature describing how HIT can be used to support safe, patient-centred, coordinated care to patients who are affected by Ebola (an emerging disease). RESULTS New and emerging diseases present opportunities for repurposing existing technologies and for stimulating the development of new HIT innovation. Innovative technologies may be developed such as new software used for tracking patients during new or emerging disease outbreaks or by repurposing and extending existing technologies so they can be used to support patients, families and health professionals who may have been exposed to a disease. The paper describes the development of new technologies and the repurposing and extension of existing ones (such as electronic health records) using the most recent outbreak of Ebola as an example.


title: Innate Immune Responses of Bat and Human Cells to Filoviruses: Commonalities and Distinctions.

text: Marburg (MARV) and Ebola (EBOV) viruses are zoonotic pathogens that cause severe hemorrhagic fever in humans. The natural reservoir of MARV is the Egyptian rousette bat (Rousettus aegyptiacus); that of EBOV is unknown but believed to be another bat species. The Egyptian rousette develops subclinical productive infection with MARV but is refractory to EBOV. Interaction of filoviruses with hosts is greatly affected by the viral interferon (IFN)-inhibiting domains (IID). Our study was aimed at characterization of innate immune responses to filoviruses and the role of filovirus IID in bat and human cells. The study demonstrated that EBOV and MARV replicate to similar levels in all tested cell lines, indicating that permissiveness for EBOV at cell and organism levels do not necessarily correlate. Filoviruses, particularly MARV, induced a potent innate immune response in rousette cells, which was generally stronger than that in human cells. Both EBOV VP35 and VP24 IID were found to suppress the innate immune response in rousette cells, but only VP35 IID appeared to promote virus replication. Along with IFN-α and IFN-β, IFN-γ was demonstrated to control filovirus infection in bat cells but not in human cells, suggesting host species specificity of the antiviral effect. The antiviral effects of bat IFNs appeared not to correlate with induction of IFN-stimulated genes 54 and 56, which were detected in human cells ectopically expressing bat IFN-α and IFN-β. As bat IFN-γ induced the type I IFN pathway, its antiviral effect is likely to be partially induced via cross talk.IMPORTANCE Bats serve as reservoirs for multiple emerging viruses, including filoviruses, henipaviruses, lyssaviruses, and zoonotic coronaviruses. Although there is no evidence for symptomatic disease caused by either Marburg or Ebola viruses in bats, spillover of these viruses into human populations causes deadly outbreaks. The reason for the lack of symptomatic disease in bats infected with filoviruses remains unknown. The outcome of a virus-host interaction depends on the ability of the host immune system to suppress viral replication and the ability of a virus to counteract the host defenses. Our study is a comparative analysis of the host innate immune response to either MARV or EBOV infection in bat and human cells and the role of viral interferon-inhibiting domains in the host innate immune responses. The data are useful for understanding the interactions of filoviruses with natural and accidental hosts and for identification of factors that influence filovirus evolution.


Epidemiology. Does viral diversity matter?


title: Diagnostic hypothesis generation and human judgment.

text: Diagnostic hypothesis-generation processes are ubiquitous in human reasoning. For example, clinicians generate disease hypotheses to explain symptoms and help guide treatment, auditors generate hypotheses for identifying sources of accounting errors, and laypeople generate hypotheses to explain patterns of information (i.e., data) in the environment. The authors introduce a general model of human judgment aimed at describing how people generate hypotheses from memory and how these hypotheses serve as the basis of probability judgment and hypothesis testing. In 3 simulation studies, the authors illustrate the properties of the model, as well as its applicability to explaining several common findings in judgment and decision making, including how errors and biases in hypothesis generation can cascade into errors and biases in judgment.


title: Simultaneous laparoscopic anterior resection and left hepatic lobectomy for stage IV rectal cancer.

text: We report the case of a 68-year-old female patient affected by rectal cancer and a synchronous metastatic lesion measuring 8 cm in diameter in the left hepatic lobe. After a laparoscopic ultrasonography exploration of the liver to detect possible occult metastases, a simultaneous colorectal resection and a left hepatic lobectomy including a partial resection of segment IV were performed. Five ports were used for the entire procedure. The resected specimens were extracted through a Pfannenstiel incision. The procedure was completed laparoscopically. Total operative time was 455 minutes with negligible intraoperative blood loss. The postoperative hospital stay was 12 days. At 4-month follow-up, the patient recovered completely. A computed tomography scan performed at this time showed no signs of recurrent disease. This report confirms the feasibility of the laparoscopic approach to simultaneous hepatic and colorectal resections in stage IV rectal cancer. The known advantages of the miniinvasive approach could make such complex procedures more endurable.


title: Totally laparoscopic management of choledochal cyst: Roux-en-Y Jejunojejunostomy and wide hepaticojejunostomy with hilar ductoplasty.

text: BACKGROUND Cyst excision with hepaticojejunostomy is the treatment of choice for choledochal cyst. However, late complications after definitive surgery develop occasionally, including intrahepatic stones and cholangitis, because of bile stasis resulting from anastomotic stricture, intrahepatic bile duct stricture, and remnants of intrahepatic ductal dilatation. In type IV-A choledochal cysts in particular, biliary stricture is frequently observed around the hepatic hilum, and ductoplasty for stricture is necessary. In this article, we present our experiences with totally laparoscopic surgery comprising excision of the extrahepatic bile duct, Roux-en-Y jejunojejunostomy, and wide hepaticojejunostomy combined with hilar ductoplasty for choledochal cyst. METHODS We performed totally laparoscopic surgery on 8 children with choledochal cyst between June 2009 and October 2010. One of them had undergone bile drainage through gallbladder laparoscopically for biliary perforation. Four patients (1 Ic and 3 IV-A cysts) had hepatic duct stricture around the hepatic hilum. Laparoscopic surgery comprising excision of the extrahepatic bile duct and wide Roux-en-Y hepaticojejunostomy with ductoplasty was performed by using four trocars. RESULTS The operation was completed laparoscopically for all patients. The mean operation time was 390 minutes (range, 310-460). The mean postoperative stay was 8.4 days (range, 7-14). After surgery, the dilatation of the intrahepatic bile duct was remarkably reduced in size, and all patients are doing well. CONCLUSION Laparoscopic surgery comprising excision of the extrahepatic bile duct, Roux-en-Y limb formation, and wide hepaticojejunostomy with hilar ductoplasty appears to be feasible for children with choledochal cyst. When there is a stricture near the confluence of the hepatic ducts, laparoscopic ductoplasty appears to be feasible for the surgeon with an advanced laparoscopic skill set.


title: COVID-19: a conundrum to decipher.

text: OBJECTIVE Recent worldwide outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of respiratory coronavirus disease 2019 (COVID-19), is a current, ongoing life-threatening crisis, and international public health emergency. The early diagnosis and management of the disease remains a major challenge. In this review, we aim to summarize the updated epidemiology, causes, clinical manifestation and diagnosis, as well as prevention and control of the novel coronavirus SARS-CoV-2. MATERIALS AND METHODS A broad search of the literature was performed in "PubMed" "Medline" "Web of Science", "Google Scholar" and "World Health Organization-WHO" using the keywords "severe acute respiratory syndrome coronavirus", "2019-nCoV", "COVID-19, "SARS", "SARS-CoV-2" "Epidemiology" "Transmission" "Pathogenesis" "Clinical Characteristics". We reviewed and documented the information obtained from literature on epidemiology, pathogenesis and clinical appearances of SARS-CoV-2 infection. RESULTS The global cases of COVID-19 as of April 2, 2020, have risen to more than 900,000 and morbidity has reached more than 47,000. The incidence rate for COVID-19 has been predicted to be higher than the previous outbreaks of other coronavirus family members, including those of SARS-CoV and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). The main clinical presentation of SARS-CoV-2 infection ranges from asymptomatic stages to severe lower respiratory infection in the form of pneumonia. Most of the patients also presented with fever, cough, sore throat, headache, fatigue, myalgia and breathlessness. Individuals at higher risk for severe illness include elderly people and patients with a weakened immune system or that are suffering from an underlying chronic medical condition like hypertension, diabetes mellitus, cancer, respiratory illness or cardiovascular diseases. CONCLUSIONS SARS-Cov-2 has emerged as a worldwide threat, currently affecting 170 countries and territories across the globe. There is still much to be understood regarding SARS-CoV-2 about its virology, epidemiology and clinical management strategies; this knowledge will be essential to both manage the current pandemic and to conceive comprehensive measures to prevent such outbreaks in the future.


The role of endoscopy in subepithelial lesions of the GI tract.


title: Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs.

text: BACKGROUND Contaminated operative fields pose significant challenges for surgeons performing ventral hernia repair. Although biologic meshes have been utilized increasingly in these fields, recent evidence suggests that synthetic meshes represent a viable option. We analyzed the outcomes of biologic and synthetic mesh utilized in patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields. METHODS We conducted a multicenter, retrospective review of patients undergoing open ventral hernia repair in clean-contaminated/contaminated fields using biologic or synthetic mesh. Patient and hernia details were characterized. Primary outcomes included 90-day surgical site event, surgical site infection, and hernia recurrence. RESULTS A total of 126 patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields (69 biologic and 57 synthetic meshes) were analyzed. Groups were similar in both patient and hernia characteristics. There were 13 (22.8%) surgical site events in the synthetic cohort compared to 29 (42.0%) in the biologic cohort, P = .024. Similarly, surgical site infections were less frequent in the synthetic group, with 7 (12.3%) vs 22 (31.9%), P = .01. With a mean follow-up of 20 months, there were more recurrences in the biologic group: 15 (26.3%) vs 4 (8.9%) in the synthetic group, P = .039. CONCLUSION The choice of mesh for clean-contaminated/contaminated ventral hernia repair remains debatable. We demonstrated that using synthetic sublay mesh resulted in a significantly lower wound morbidity and more durable outcomes versus a similar cohort of biologic repairs. This is likely secondary to improved bacterial clearance and faster integration of macroporous synthetics. Overall, our findings not only support suitability of synthetic mesh in contaminated settings but also challenge the purported advantage of biologics in clean-contaminated/contaminated ventral hernia repairs.


title: Anterior choroidal artery patency and clinical follow-up after coverage with the pipeline embolization device.

text: BACKGROUND AND PURPOSE Endoluminal reconstruction with the Pipeline Embolization Device is an effective treatment option for select intracranial aneurysms. However, concerns for the patency of eloquent branch arteries covered by the Pipeline Embolization Device have been raised. We aimed to examine the patency of the anterior choroidal artery and clinical sequelae after ICA aneurysm treatment. MATERIALS AND METHODS We prospectively analyzed all patients among our first 157 patients with ICA aneurysms treated by the Pipeline Embolization Device who required placement of at least 1 device across the ostium of the anterior choroidal artery. The primary outcome measure was angiographic patency of the anterior choroidal artery at last follow-up. Age, sex, type of aneurysm, neurologic examination data, number of Pipeline Embolization Devices used, relationship of the anterior choroidal artery to the aneurysm, and completeness of aneurysm occlusion on follow-up angiograms were also analyzed. RESULTS Twenty-nine aneurysms requiring placement of at least 1 Pipeline Embolization Device (median = 1, range = 1-3) across the anterior choroidal artery ostium were identified. At angiographic follow-up (mean = 15.1 months; range = 12-39 months), the anterior choroidal artery remained patent, with antegrade flow in 28/29 aneurysms (96.5%), while 24/29 (82.7%) of the target aneurysms were angiographically occluded by 1-year follow-up angiography. Anterior choroidal artery occlusion, with retrograde reconstitution of the vessel, was noted in a single case. A significant correlation between the origin of the anterior choroidal artery from the aneurysm dome and failure of the aneurysms to occlude following treatment was found. CONCLUSIONS After placement of 36 Pipeline Embolization Devices across 29 anterior choroidal arteries (median = 1 device, range = 1-3 devices), 1 of 29 anterior choroidal arteries was found occluded on angiographic follow-up. The vessel occlusion did not result in persistent clinical sequelae. Coverage of the anterior choroidal artery origin with the Pipeline Embolization Device, hence, may be considered reasonably safe when deemed necessary for aneurysm treatment.


title: Hand-assisted laparoscopic retroperitoneal donor nephrectomy: A single-institution experience of over 500 cases-Operative technique and clinical outcomes.

text: OBJECTIVE Although there are several variations of laparoscopic living-donor nephrectomies, there is no consensus as to the best technique. Our objective was to describe our technique and assess the outcomes of our approach to hand-assisted laparoscopic retroperitoneal donor nephrectomies. METHODS From July 2001 to October 2015, 507 consecutive hand-assisted laparoscopic retroperitoneal donor nephrectomies were performed. Their clinical information was retrospectively reviewed including warm ischemia time, skin incision to kidney ready time, estimated blood loss, adverse intraoperative events, and postoperative complications. RESULTS Mean incision time to kidney removal was 135 minutes (55-260), mean warm ischemia time was 125 seconds (30-390), and mean blood loss was 83 mL (20-500). Average length of stay was 3 days (1-6). There were no significant differences between left and right kidney donors based on demographics, length of hospital stay, or warm ischemia time. There were no conversions to open surgery. Complications occurred in 4.9% of patients (25/507), including 4 cases of perioperative bleeding. CONCLUSIONS This is a single-center series describing the safety and efficacy of the hand-assisted laparoscopic retroperitoneal donor nephrectomy for both right and left sides. It does not require intraperitoneal manipulation and allows for safe extraction of either kidney with minimal warm ischemia time.


title: Impact of mass and social media on psychobehavioural responses to COVID-19: A survey of medical university students in Fujian, China during the downward trend of COVID-19.

text: BACKGROUND There was an overwhelmed COVID-related information surfacing through mass and social media in China during the novel coronavirus (COVID-19) epidemic. To date, there is limited evidence on how the infodemic may have the potential to influence psychobehavioural responses to the crisis. OBJECTIVE This study assessed the psychobehavioural responses to the COVID-19 outbreak and examined their associations with mass and social media exposure. METHODS A cross-sectional study among medical university students from the Fujian Medical University, Fuzhou, China, was conducted from 6 to 22 April 2020. RESULTS A total of 2,086 complete responses were received. In multivariable analyses, four constructs of the Health Belief Model (HBM), namely, higher perception of susceptibility (OR = 1.44; 95% CI 1.07-1.94), severity (OR = 1.32; 95% CI 1.10-1.59), self-efficacy (OR = 1.61; 95% CI 1.21-2.15), and perceived control or intention to carry out prevention measures (OR = 1.32; 95% CI 1.09-1.59), were significantly associated with a higher mass media exposure score, whereas only three constructs, namely, higher perception of severity (OR = 1.43; 95% CI 1.19-1.72), self-efficacy (OR = 1.85; 95% CI 1.38-2.48) and perceived control or intention to carry out prevention measures (OR = 1.32; 95% CI 1.08-1.58), were significantly associated with a higher social media exposure score. Lower emotional consequences and barriers to carry out prevention measures were also significantly associated with higher mass and social media exposure. The finding on anxiety levels revealed that 38.1% (95% CI 36.0-40.2) of respondents reported moderate-to-severe anxiety. A lower anxiety level was significantly associated with higher mass and social media exposure in the univariable analyses; however, the associations were not significant in the multivariable analyses. CONCLUSIONS In essence, both mass and social media are useful means of getting health messages across and contribute to the betterment of psychobehavioural responses to COVID-19 to ensure the declining infection trend continues. Findings imply the importance of the credibility of information shared in the mass and social media as well as a viable strategy to counter misinformation during a pandemic. CLINICALTRIAL


title: Transnasal Snare Technique for Retrograde Primary Jejunostomy Placement After Surgical Gastrojejunostomy.

text: PURPOSE To report a transnasal snare technique for retrograde primary jejunostomy placement after surgical gastrojejunostomy. MATERIALS AND METHODS Two patients underwent the transnasal snare technique for retrograde primary jejunostomy placement. Patients included two females, age 58 and 62. In both patients, a gooseneck snare was inserted in a transnasal fashion. After insertion of the snare into the jejunum, the location was confirmed with ultrasound. The snare was then targeted using a Chiba needle through which a 0.018-inch wire was advanced and snared through the nose. The wire was exchanged for a 0.035-inch Amplatz wire over which the tract was serially dilated followed by insertion of the jejunostomy catheter through a peel-away sheath. Technical success, complications, and follow-up were recorded. RESULTS Primary jejunostomy placement was technically successful in both patients. No minor or major complications occurred. Both patients received enteral nutrition the day following placement. Follow-up was at 54 and 38 days for patients 1 and 2, respectively. CONCLUSION The transnasal snare technique provides a novel alternative for primary jejunostomy insertion allowing for targeting of the jejunum with improved procedural success and no complications.


title: Spontaneous pneumothorax associated with Aspergillus bronchopneumonia in a dog.

text: OBJECTIVE To describe a case of pulmonary aspergillosis in a previously healthy dog that manifested as a spontaneous pneumothorax. CASE SUMMARY A 3-year-old neutered male mixed-breed dog was presented with inappetence and respiratory distress. Thoracic radiography revealed a right-sided pneumothorax. Following stabilization, thoracic computed tomography found 1 large and many small pulmonary blebs in the right caudal lung lobe. The dog underwent a right lateral thoracotomy, identifying numerous emphysematous regions in the right middle lung lobe, and a right middle lung lobectomy was performed. Histopathologic examination of the resected lung lobe revealed severe, diffuse bronchopneumonia with necrotizing pleuritis and the presence of fungal organisms strongly suggestive of Aspergillus sp. Surgical removal of the affected lung lobe and continued medical treatment with itraconazole resolved the dog's clinical signs. NEW INFORMATION PROVIDED This report describes the successful surgical and medical management of Aspergillus bronchopneumonia in a dog presenting with spontaneous pneumothorax.


title: Second isolated anastomotic recurrence after curative surgery for colorectal cancer.

text: Introduction The two mechanisms postulated for cancer recurrence at the anastomosis site ('anastomotic recurrence' (AR)) after curative surgery for colorectal cancer are: (i) intraluminal dissemination of viable cancer cells; (ii) metachronous carcinogenesis related with changes in the local milieu provoked by the materials employed to carry out the anastomosis. Case History We describe a 79-year-old female who underwent a left hemicolectomy due to a stenotic lesion shown on colonoscopy: an adenocarcinoma (pT3NO, G2). One year after surgery, control colonoscopy revealed an AR, so a new resection was carried out. Pathology showed it to be a recurrent adenocarcinoma over the staple line (pT3N0, G2). One year after the second surgical procedure, control colonoscopy evinced a new AR, resulting in a new resection. Pathology revealed a new AR. Conclusions This is only the second time that a second isolated AR after curative resection for colorectal cancer has been reported.


title: Occupational respiratory infections.

text: PURPOSE OF REVIEW In the last decade, descriptions of outbreaks of extensively drug-resistant strains of tuberculosis (TB) have increased concern about the nosocomial transmission of TB - a potentially life-threatening occupational respiratory infection. In addition, outbreaks of avian influenza caused by an H5N1 virus, severe acute respiratory syndrome caused by a coronavirus A and the recent pandemic caused by an H1N1 influenza virus have heightened concern about occupational infectious illnesses among workers in healthcare and agriculture. RECENT FINDINGS The last decade has witnessed extensive research into the modes, patterns, determinants and extent of transmission of these illnesses. The most important findings regarding risk, determinants and preventive measures of these occupational infections and recent guidelines are reviewed in this article. SUMMARY Administrative, personal and engineering measures to control respiratory infection are effective and should be implemented in healthcare facilities. The use of N95 personal respirators by healthcare workers who are caring for pulmonary TB and viral respiratory infections patients is strongly recommended. Vaccination against influenza (including H1N1) is effective and strongly recommended for healthcare workers. Ultraviolet germicidal irradiation is underused at present, despite good evidence of safety and efficacy in elimination of airborne respiratory infectious agents including TB.


Endoscopic bariatric therapies.


title: The continued threat of emerging flaviviruses.

text: Flaviviruses are vector-borne RNA viruses that can emerge unexpectedly in human populations and cause a spectrum of potentially severe diseases including hepatitis, vascular shock syndrome, encephalitis, acute flaccid paralysis, congenital abnormalities and fetal death. This epidemiological pattern has occurred numerous times during the last 70 years, including epidemics of dengue virus and West Nile virus, and the most recent explosive epidemic of Zika virus in the Americas. Flaviviruses are now globally distributed and infect up to 400 million people annually. Of significant concern, outbreaks of other less well-characterized flaviviruses have been reported in humans and animals in different regions of the world. The potential for these viruses to sustain epidemic transmission among humans is poorly understood. In this Review, we discuss the basic biology of flaviviruses, their infectious cycles, the diseases they cause and underlying host immune responses to infection. We describe flaviviruses that represent an established ongoing threat to global health and those that have recently emerged in new populations to cause significant disease. We also provide examples of lesser-known flaviviruses that circulate in restricted areas of the world but have the potential to emerge more broadly in human populations. Finally, we discuss how an understanding of the epidemiology, biology, structure and immunity of flaviviruses can inform the rapid development of countermeasures to treat or prevent human infections as they emerge.


An evidence-based approach to cleft palate repair.


title: A systematic review of tumor treating fields therapy for high-grade gliomas.

text: INTRODUCTION Tumor treating fields (TTF) is a unique treatment modality that utilizes alternating electric fields to deliver therapy. Treatment effects have been assessed in patients with newly diagnosed and recurrent glioblastoma in clinical trials and retrospective studies. While the results of these studies led to FDA approval for both populations, a portion of the neuro-oncology and neurosurgery community remains skeptical of TTF. Thus, this review aims to systematically summarize and evaluate prior studies investigating the efficacy and safety of TTF in patients with high-grade gliomas. METHODS A systematic review of the literature was performed according to PRISMA guidelines from database inception through February 2019. To be included, studies must have investigated the efficacy of TTF in adult high-grade glioma patients. RESULTS In total, 852 studies were initially identified, 9 of which met final inclusion criteria. In total, 1191 patients were identified who received TTF. Included studies consisted of two pilot clinical trials, two randomized clinical trials, and five retrospective studies. In randomized clinical trials, TTF improved survival for newly diagnosed glioblastoma patients but not for recurrent glioblastoma patients. Adverse skin reactions were the primary adverse effect associated with TTF. CONCLUSION While TTF has been evaluated for safety and efficacy in a number of studies, concerns remain regarding study design, quality of life, and cost of therapy. Further investigation is needed regarding the therapy, and ongoing trials are already underway to provide more data regarding therapy outcomes and interactions in combination regimens.


title: Small pipes: preliminary experience with 3-mm or smaller pipeline flow-diverting stents for aneurysm repair prior to regulatory approval.

text: Flow diversion has become an established treatment option for challenging intracranial aneurysms. The use of small devices of ≤3-mm diameter remains unapproved by major regulatory bodies. A retrospective review of patients treated with Pipeline Embolization Devices of ≤3-mm diameter at 3 Canadian institutions was conducted. Clinical and radiologic follow-up data were collected and reported. Twelve cases were treated with ≥1 Pipeline Embolization Device of ≤3-mm diameter, including 2 with adjunctive coiling, with a median follow-up of 18 months (range, 4-42 months). One patient experienced a posttreatment minor complication (8%) due to an embolic infarct. No posttreatment hemorrhage or delayed complications such as in-stent stenosis/thrombosis were observed. Radiologic occlusion was seen in 9/12 cases (75%) and near-occlusion in 2/12 cases (17%). Intracranial aneurysm treatment with small-diameter flow-diverting stents provided safe and effective aneurysm closure in this small selected sample. These devices should be further studied and considered for regulatory approval.


title: The role of comics in public health communication during the COVID-19 pandemic.

text: As the COVID-19 pandemic sweeps the globe, evolving containment measures have created an unprecedented need for rapid and effective science communication that is able to engage the public in behavioural change on a mass scale. Public health bodies, governments, and media outlets have turned to comics in this time of need and found a natural and capable medium for responding to the challenge. Comics have been used as a vehicle to present science in graphic narratives, harnessing the power of visuals, text, and storytelling in an engaging format. This perspective paper explores the emerging role and research supporting comics as a public health tool during the COVID-19 pandemic.


title: Implications for Online Management: Two Cases with COVID-19.

text: Satisfactory outcome was observed in one mild case and one severe case of COVID-19 pneumonia after the use of the online/offline multidisciplinary quarantine observation form, online monitoring, and classified diagnosis and treatment, as well as strict compliance with quarantine measures. Conditions of both patients were improved, and cross-infection and disease onset clustering were not observed. The multidisciplinary self-quarantine model provides early judgment, identification, and treatment of disease, improves compliance with early rehabilitation, increases confidence in recovery, and enhances self-management capabilities. This model is applicable to the current novel coronavirus pneumonia epidemic and can actively promote the management of suspected or confirmed mild cases, monitoring of critical cases, and self-management of discharged patients. The application of this new management model is worthy of being promoted in our specialized treatment facilities and in countries with severe epidemics.


title: Rationale and Design of ORCHID: A Randomized Placebo-Controlled Trial of Hydroxychloroquine for Adults Hospitalized with COVID-19.

text: The Outcomes Related to COVID-19 treated with Hydroxychloroquine among In-patients with symptomatic Disease (ORCHID) trial is a multicenter, blinded, randomized trial of hydroxychloroquine versus placebo for the treatment of adults hospitalized with COVID-19. This document provides the rationale and background for the trial and highlights key design features. We discuss five novel challenges to the design and conduct of a large, multi-center, randomized trial during a pandemic, including: 1) widespread, off-label use of the study drug before the availability of safety and efficacy data; 2) the need to adapt traditional procedures for documentation of informed consent during an infectious pandemic; 3) developing a flexible and robust Bayesian analysis incorporating significant uncertainty about the disease, outcomes, and treatment; 4) obtaining indistinguishable drug and placebo without delaying enrollment; and 5) rapidly obtaining administrative and regulatory approvals. Our goals in describing how the ORCHID trial progressed from study conception to enrollment of the first patient in 15 days are to inform the development of other high-quality, multi-center trials targeting COVID-19. We describe lessons learned to improve the efficiency of future clinical trials, particularly in the setting of pandemics. The ORCHID trial will provide high-quality, clinically relevant data on the safety and efficacy of hydroxychloroquine for the treatment of COVID-19 among hospitalized adults. This trial was registered with ClinicalTrials.gov (NCT04332991) prior to enrollment of the first patient on April 2, 2020.


title: The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures.

text: AIMS During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. METHODS This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. RESULTS COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. CONCLUSION Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities.


title: Uniportal lobectomy in Africa: a beginning.

text: Report of the first uniportal wet lab run in South Africa. This included four university centers involving live surgery. Lobectomies as well as other video assisted procedures were performed. The results are the introduction of thorascopic programs in all four centers. The next stage in this program is to extend the outreach to the other centers in the country as well as in the neighboring countries. During 2016 a beginning will be made in Namibia as well as in Botswana.


title: The effect of the COVID-19 lockdown on parents: A call to adopt urgent measures.

text: The COVID-19 health crisis is strongly affecting the mental health of the general population. In particular, the pandemic may be producing psychological distress and collateral concerns for parents in lockdown, due to unstable financial circumstances, school closures, and suspended educational services for children. A call for measures to increase family-based interventions during the emergency is urgently needed to forestall psychopathological trajectories and prevent the exacerbation of vulnerable conditions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Comparison of peribulbar and retrobulbar regional anesthesia with bupivacaine in cats.

text: OBJECTIVE To compare effectiveness and complications associated with peribulbar and retrobulbar anesthesia with bupivacaine in cats. ANIMALS 6 healthy adult cats. PROCEDURES Cats were sedated with dexmedetomidine and received a peribulbar injection of 0.5% bupivacaine (1.5 mL), iopamidol (0.5 mL), and saline (0.9% NaCl) solution (1 mL) or retrobulbar injection of 0.5% bupivacaine (0.75 mL) and iopamidol (0.25 mL) in a crossover study with ≥ 2 weeks between treatments. The contralateral eye was the control. Injectate distribution was evaluated with CT. After atipamezole administration, periocular and corneal sensations, intraocular pressure (IOP), and ocular reflexes and appearance were evaluated for 24 hours. RESULTS All peribulbar and 3 of 6 retrobulbar injections resulted in CT evidence of intraconal injectate. Corneal sensation and periocular skin sensation were absent or significantly reduced relative to that for control eyes for 3 hours after peribulbar injection. Mean ± SD IOP immediately after injection was significantly higher for eyes with peribulbar injections (33 ± 12 mm Hg) than for control eyes or eyes with retrobulbar injections (both 14 ± 4 mm Hg) but 10 minutes later decreased to 18 ± 3 mm Hg. Exophthalmos, chemosis, and ptosis were evident in most injected eyes, and irritation was evident in 3 of 6 peribulbar-injected and 1 of 6 retrobulbar-injected eyes. All conditions resolved within 14 hours. CONCLUSIONS AND CLINICAL RELEVANCE Peribulbar injection resulted in intraconal deposition of bupivicaine in a higher percentage of cats than did retrobulbar injection and induced notable anesthesia relative to that for the control eye; however, IOP increased temporarily.


Coronavirus disease 2019 communication: novel sign language system to aid surgical tracheostomy whilst wearing a respirator.


A race to determine what drives COVID-19 severity.


title: Managing and Coding References for Systematic Reviews and Scoping Reviews in EndNote.

text: This article describes a novel approach for using EndNote to manage and code references in the conduct and reporting of systematic reviews and scoping reviews. The process is simple and easy for reviewers new to both EndNote and systematic reviews. This process allows reviewers to easily conduct and report systematic reviews in line with the internationally recognized PRISMA reporting guidelines and also facilitates the overall task of systematic or scoping review conduct and reporting from the initial search through to structuring the results, discussion, and conclusions in a rigorous, reproducible, and user-friendly manner.


title: Ultrasound for the evaluation of stenosis after flow diversion.

text: BACKGROUND AND PURPOSE Flow diversion is a relatively new strategy used to treat complex cerebral aneurysms. The optimal method for radiographic follow-up of patients treated with flow diverters has not been established. The rate and clinical implications of in-stent stenosis for these devices is unclear. We evaluate the use of transcranial Doppler ultrasound (TCD) for follow-up of in-stent stenosis. MATERIALS AND METHODS We analyzed 28 patients treated with the Pipeline embolization device (PED) over the course of 42 months from January 2009 to June 2012. Standard conventional cerebral angiograms were performed in all patients. TCD studies were available in 23 patients. RESULTS Angiographic and TCD results were compared and found to correlate well. CONCLUSIONS TCD is a potentially useful adjunct for evaluating in-stent stenosis after flow diversion.


title: Making sense of posaconazole therapeutic drug monitoring: a practical approach.

text: PURPOSE OF REVIEW Therapeutic drug monitoring (TDM) may be an important adjunct to optimizing the use of posaconazole. RECENT FINDINGS Limited clinical studies suggest that an exposure-response relationship for posaconazole exists for the treatment of established invasive fungal diseases (IFDs), with emerging but less compelling data supporting its role in prophylaxis. The high prevalence of subtherapeutic levels has not translated to high prophylactic failure rates perhaps because of preferential uptake by effector cells important in the front-line defence against Aspergillus species. Nevertheless, TDM would appear prudent in patients deemed at highest risk for IFD with correction of patient modifiable factors and attention to drug administration important in optimizing drug exposure. TDM performed within a few days after commencing posaconazole may be predictive of steady-state levels, thus minimizing the delay in obtaining results in addition to identifying a subset of patients who may remain persistently subtherapeutic and also resistant to dose-escalation. Trough levels may be supplanted by untimed levels at steady state, thereby expanding the practicalities of TDM. We propose that TDM becomes one of the several measures in an integrated approach to IFD prevention combining screening of high-risk haematology patients for invasive aspergillosis at presentation, together with prospective surveillance for IFD, explicit criteria for switching to an alternative prophylactic agent and adherence to infection control practices. SUMMARY Growing evidence supports the value of TDM for posaconazole to identify patients who may benefit from correction of modifiable factors impacting bioavailability, dosage adjustment or switch to an alternative agent.


title: Obesity education in medical schools, residencies, and fellowships throughout the world: a systematic review.

text: Obesity is pandemic throughout the world, and there is concern that physicians are inadequately trained to treat their patients with obesity despite its prevalence. This review explores obesity education in medical students, resident, and fellow physicians throughout the world from 2005 to 2018. Previous reviews on obesity education were conducted before 2011, focused solely on medical students, and only explored obesity education in the United States. We systematically searched MEDLINE, EMBASE, PsycINFO, and ERIC databases for studies which included the search terms "obesity education" AND either "medical students", "residency", or "fellowship" that met PICOS (Population, Interventions, Comparators, Outcomes, Study Design) criteria for articles published in English for obesity education and evaluation of outcomes. Our initial search yielded 234 articles, and 27 studies met criteria for our review. We described and analyzed these studies for their study design and graded quality, quantity, and consistency for each measured outcome. We applied an evidence grading system that has been previously applied in the literature in which each outcome measure was graded on a scale from A to D. We evaluated obesity education programs for outcomes regarding implicit and explicit bias, changes in attitude towards obesity, weight change, obesity knowledge, counseling confidence, intent to counsel, and counseling quality. There was a significant degree of heterogeneity in the studies included. While obesity knowledge was most frequently studied, counseling confidence was the only outcome with an overall grade A. There is currently a paucity of obesity education programs for medical students, residents, and fellow physicians in training programs throughout the world despite high disease prevalence. However, these programs often improve outcomes when they are administered. Our review suggests that more obesity education should be administered in undergraduate and graduate medical education to ensure optimal treatment of patients with obesity.


title: Evaluation and clinical validation of an alcohol-based transport medium for preservation and inactivation of respiratory viruses.

text: The clinical and public health importance of influenza and other respiratory viruses has accelerated the development of highly sensitive molecular diagnostics, but data are limited regarding preanalytical stages of diagnostic testing. We evaluated CyMol, an alcohol-based transport medium, for its ability to maintain specimen integrity for up to 21 days of storage at various temperatures; for its ability to inactivate virus; and for its compatibility with antigen- or nucleic acid-based diagnostics for respiratory viruses in clinical samples. In mock-infected samples, both universal transport medium (UTM-RT) and CyMol maintained equivalent viral quantities for at least 14 days at room temperature or colder, whereas a dry swab collection maintained viral quantities only if refrigerated or frozen. CyMol inactivated influenza virus within 5 min of sample immersion. UTM-RT- and CyMol-collected nasal swab specimens from 73 symptomatic students attending a campus health clinic were positive for a respiratory virus in 56.2% of subjects by multiplex PCR testing, including influenza A and B viruses, rhinovirus/enteroviruses, coronaviruses, respiratory syncytial virus, parainfluenza viruses, metapneumovirus, and adenovirus. Detection by PCR was equivalent in UTM-RT- and CyMol-collected specimens and in self- and staff-collected swabs. Direct fluorescent antibody (DFA) testing was substantially less sensitive (23.3%) than multiplex PCR, and DFA testing from UTM-RT-collected swabs was more sensitive than that from CyMol-collected swabs. These data indicate that an alcohol-based transport medium such as CyMol preserves respiratory virus integrity, rapidly inactivates viruses, and is compatible with PCR-based respiratory diagnostics.


title: The calm before the storm: clinical observations of Middle East respiratory syndrome (MERS) patients.

text: BACKGROUND Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection emerged in 2012. The majority of cases occurred in the Kingdom of Saudi Arabia and the disease carries a high case fatality rate. METHODS We present three MERS-CoV cases and highlight the salient clinical features and laboratory, and radiographic characteristics. RESULTS Although all nasopharyngeal samples were negative, MERS CoV infection was confirmed by reverse transcription-polymerase chain reaction of the E gene (UpE) and open reading frame (ORF1b) on sputum samples. The Ct value of the ORF1 gene was 24.8-29.11. One patient had been on immune suppressive agent and two patients had diabetes mellitus. The average length of hospital stay was 10.6 days. Two patients received ribavirin and IFN-a2b in addition to supportive management. The clinical course for these patients started with a febrile period lasting five days, a reduction in fever was coinciding with increased respiratory rate and oxygen requirements. All patients were discharged home. None of the 50 contacts tested positive for MERS-CoV. CONCLUSION Resolution of the fever was accompanied by an increase in oxygen requirements and respiratory rate also lasting several days. This was followed by resolution of all symptoms and return to normal.


title: Obesity and bariatrics for the endoscopist: new techniques.

text: Obesity and its associated conditions, including type 2 diabetes and cardiovascular disease, have reached epidemic proportions. Gastrointestinal weight loss surgery (GIWLS) shows the most promise in achieving significant and sustained weight loss and diabetes resolution. However, a large mismatch exists between the magnitude of the obesity epidemic and the number of surgical procedures performed to produce a significant shift in the distribution of obesity on a population level. This mismatch is fueled by high surgical costs, morbidity and mortality associated with surgical interventions, and the fact that the greatest public health burden of obesity comes from those around the center of the population body mass index distribution with mild to moderate obesity, rather than those at the distribution tail with severe obesity that GIWLS targets. New endoscopic methods, capitalizing on advances in our understanding of the physiological mechanisms by which GIWLS works, are developing to provide viable alternatives in the treatment of bariatric surgical complications, and for the primary treatment of obesity. These methods may have the added advantage of reduced invasiveness, reversibility, cost-effectiveness, and applicability to a larger segment of the population with moderate obesity.


Covid-19: Doctors make bid for public inquiry into lack of PPE for frontline workers.


Response of Cardiac Surgery Units to COVID-19: An Internationally-Based Quantitative Survey.


Covid-19: doctors are warned not to go public about PPE shortages.


title: The lack of terminal tubule cells in the submandibular gland of mice deficient in submandibular gland protein C.

text: The submandibular gland (SMG) of newborn mice has no mature acini but has the rudiments of acini called terminal tubules (TT). The TT are composed of TT cells with dark secretory granules and proacinar cells with lighter secretory granules, the latter being considered the immediate precursor of mature acinar cells. TT cells contain a specific secretory protein, submandibular gland protein C (SMGC) and they decrease in number postnatally at a higher rate in males than in females. In the present study, in order to clarify the biological roles of TT cells and their secretory product SMGC, we generated a knockout (KO) mouse strain deficient in SMGC. The KO mice of both sexes grew normally, had normal reproductive capacity and had normal acinar and duct systems in the SMG in adult ages. However, through the neonatal and early postnatal stages, the KO mice were deficient not only in the production of SMGC but also in TT cells. With electron microscopy of the SMG of newborn KO mice, TT cells with characteristic granules were absent and replaced by undifferentiated ductal cells, whereas proacinar cells were normal. These results suggested that the absence of SMGC inhibits the development of TT cells and that the absence of SMGC and TT cells has no notable influence on the postnatal development of the acinar and duct systems in the SMG.


title: Neural reflex pathways in intestinal inflammation: hypotheses to viable therapy.

text: Studies in neuroscience and immunology have clarified much of the anatomical and cellular basis for bidirectional interactions between the nervous and immune systems. As with other organs, intestinal immune responses and the development of immunity seems to be modulated by neural reflexes. Sympathetic immune modulation and reflexes are well described, and in the past decade the parasympathetic efferent vagus nerve has been added to this immune-regulation network. This system, designated 'the inflammatory reflex', comprises an afferent arm that senses inflammation and an efferent arm that inhibits innate immune responses. Intervention in this system as an innovative principle is currently being tested in pioneering trials of vagus nerve stimulation using implantable devices to treat IBD. Patients benefit from this treatment, but some of the working mechanisms remain to be established, for instance, treatment is effective despite the vagus nerve not always directly innervating the inflamed tissue. In this Review, we will focus on the direct neuronal regulatory mechanisms of immunity in the intestine, taking into account current advances regarding the innervation of the spleen and lymphoid organs, with a focus on the potential for treatment in IBD and other gastrointestinal pathologies.


title: A cluster of primary pneumonic plague transmitted in a truck cab in a new enzootic focus in China.

text: We investigated a cluster of five cases of severe pneumonia from one village in Yunnan Province, China. We searched for severe pneumonia in the village and hospitals. We interviewed patients and family members about exposures. We tested acute and convalescent sera for antigen and antibody of severe acute respiratory syndrome, avian influenza, and plague. The only common exposure of the five patients was riding together in the enclosed cab of a truck for 1.5 hours while taking the first patient to the hospital. Seroconversion to plague F1 antigen confirmed plague in three survivors. Unfamiliarity of clinicians with plague and lack of sputum examination, blood culture, or postmortem examination delayed the diagnosis. No plague cases occurred among family and village contacts and health care workers. High infectivity in this cluster was limited to a crowded, poorly ventilated truck.


title: Steady-state and pre-steady-state kinetic evaluation of severe acute respiratory syndrome coronavirus (SARS-CoV) 3CLpro cysteine protease: development of an ion-pair model for catalysis.

text: Severe acute respiratory syndrome (SARS) was a worldwide epidemic caused by a coronavirus that has a cysteine protease (3CLpro) essential to its life cycle. Steady-state and pre-steady-state kinetic methods were used with highly active 3CLpro to characterize the reaction mechanism. We show that 3CLpro has mechanistic features common and disparate to the archetypical proteases papain and chymotrypsin. The kinetic mechanism for 3CLpro-mediated ester hydrolysis, including the individual rate constants, is consistent with a simple double displacement mechanism. The pre-steady-state burst rate was independent of ester substrate concentration indicating a high commitment to catalysis. When homologous peptidic amide and ester substrates were compared, a series of interesting observations emerged. Despite a 2000-fold difference in nonenzymatic reactivity, highly related amide and ester substrates were found to have similar kinetic parameters in both the steady-state and pre-steady-state. Steady-state solvent isotope effect (SIE) studies showed an inverse SIE for the amide but not ester substrates. Evaluation of the SIE in the pre-steady-state revealed normal SIEs for both amide and ester burst rates. Proton inventory (PI) studies on amide peptide hydrolysis were consistent with two proton-transfer reactions in the transition state while the ester data was consistent with a single proton-transfer reaction. Finally, the pH-inactivation profile of 3CLpro with iodoacetamide is indicative of an ion-pair mechanism. Taken together, the data are consistent with a 3CLpro mechanism that utilizes an "electrostatic" trigger to initiate the acylation reaction, a cysteine-histidine catalytic dyad ion pair, an enzyme-facilitated release of P1, and a general base-catalyzed deacylation reaction.


Suicide Safety Planning During a Pandemic: The Implications of COVID-19 on Coping with a Crisis.


Autochthonous dengue fever imported to England from Japan, 2014.


title: Single incision Laparoscopic repair of post CABG sternotomy sub xiphoid hernia.

text: The current decade has witnessed the evolution of Minimal Access Surgery (MAS) from Multi port Laparoscopy to Single Port Laparoscopy. The reduction of ports, subsequent scars and pain makes MAS more patients friendly. Symptomatic Subxiphoid Incisional hernias in patients having post CABG Sternotomy are surgically challenging. This is because of the difficult anatomical position i.e. sternum and the ribs superiorly and the diaphragm posteriorly. Another reason is high intra-abdominal pressure with the shearing forces of the musculature in the upper abdomen. Consequently the conventional open primary anatomical or mesh repairs are difficult to perform and have a high recurrence rate. Laparoscopy promises to be an effective technique to treat this condition. In this case report we describe the use of Laparoscopy in particular: Single Incision for the repair of CABG Sternotomy Subxiphoid Hernia along with relevant literature. This is the first report in English Language Literature.


The COVID-19 Pandemic: Implications for Medical Students and Plastic Surgery Residency Applicants.


title: Inactivating Three Interferon Antagonists Attenuates Pathogenesis of an Enteric Coronavirus.

text: Coronaviruses (CoVs) have repeatedly emerged from wildlife hosts into humans and livestock animals to cause epidemics with significant morbidity and mortality. CoVs infect various organs including respiratory and enteric systems, as exemplified by the newly emerged SARS-CoV-2. The constellation of viral factors that contribute to developing enteric disease remains elusive. Here, we investigated CoV interferon antagonists for their contribution to enteric pathogenesis. Using an infectious clone of an enteric CoV, porcine epidemic diarrhea virus (icPEDV), we generated viruses with inactive versions of interferon antagonist nonstructural proteins 1, 15, and 16 individually, or combined in one virus designated icPEDV-mut4. Interferon-responsive PK1 cells were infected with these viruses and produced higher levels of interferon responses, as compared to wild-type icPEDV infection. icPEDV-mut4 elicited robust interferon responses and was severely impaired for replication in PK1 cells. To evaluate viral pathogenesis, piglets were infected with either icPEDV or icPEDV-mut4. While the icPEDV-infected piglets exhibited clinical disease, the icPEDV-mut4-infected piglets showed no clinical symptoms and exhibited normal intestinal pathology at day 2 post-infection. The icPEDV-mut4 replicated in the intestinal tract, as revealed by detection of viral RNA in fecal swabs, with sequence analysis documenting genetic stability of the input strain. Importantly, icPEDV-mut4 infection elicited IgG and neutralizing antibody responses to PEDV. These results identify nsp1, nsp15, and nsp16 as virulence factors that contribute to the development of PEDV-induced diarrhea in swine. Inactivating these CoV interferon antagonists is a rational approach for generating candidate vaccines to prevent disease and spread of enteric CoVs, including SARS-CoV-2.Author summary Emerging coronaviruses, including SARS-CoV-2 and porcine CoVs, can infect enterocytes, cause diarrhea, and be shed in the feces. New approaches are needed to understand enteric pathogenesis and develop vaccines and therapeutics to prevent the spread of these viruses. Here, we exploit a reverse genetic system for an enteric CoV, porcine epidemic diarrhea virus (PEDV), and outline an approach of genetically inactivating highly conserved viral factors known to limit the host innate immune response to infection. Our study reveals that generating PEDV with inactive versions of three viral interferon antagonists, nonstructural proteins 1, 15 and 16, results in a highly attenuated virus that does not cause diarrhea in animals, and elicits a neutralizing antibody response in virus-infected animals. This strategy may be useful for generating live-attenuated vaccine candidates that prevent disease and fecal spread of enteric CoVs, including SARS-CoV-2.


title: Endoscopic Skull Base Surgery Protocol From the Frontlines: Transnasal Surgery During the COVID-19 Pandemic.

text: OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures. DATA SOURCES We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication. REVIEW METHODS Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed. CONCLUSIONS As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources. IMPLICATIONS FOR PRACTICE The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.


title: Wastewater To Resource: Design of a Sustainable Phosphorus Recovery System.

text: To enable a more sustainable wastewater treatment processes, a transition towards resource recovery methods that have minimal environmental impact while being financially viable is imperative. Phosphorus (P) is a finite resource that is being discharged into the aqueous environment in excessive quantities. As such, understanding the financial and environmental effectiveness of different approaches for removing and recovering P from wastewater streams is important to reduce the overall impact of wastewater treatment. In this study, a process-systems modelling framework for comprehensively evaluating these approaches in terms of both economic and environmental impacts is developed. Applying this framework, treatment pathways are designed, simulated and analysed to determine the most suitable approaches for P removal and recovery. The purpose of this methodology is not only to assist with plant design, but also to identify the principal economic and environmental factors acting as barriers to implementing a given technology, incorporating the impact of waste recovery. The results suggest that the chemical and ion-exchange approaches studied deliver sustainable advantages over biological pathways, both economically and environmentally, with each possessing different strengths. The assessment methodology developed enables a more rational and environmentally sound wastewater plant design approach to be taken.


title: Neuroticism and Individual Differences in Neural Function in Unmedicated Major Depression: Findings from the EMBARC Study.

text: BACKGROUND Personality dysfunction represents one of the only predictors of differential response between active treatments for depression to have replicated. In this study, we examine whether depressed patients with higher neuroticism scores, a marker of personality dysfunction, show differences versus depressed patients with lower scores in the functioning of two brain regions associated with treatment response, the anterior cingulate and anterior insula cortices. METHODS Functional magnetic resonance imaging data during an emotional Stroop task were collected from 135 adults diagnosed with major depressive disorder at four academic medical centers participating in the Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care (EMBARC) study. Secondary analyses were conducted including a sample of 28 healthy individuals. RESULTS In whole-brain analyses, higher neuroticism among depressed adults was associated with increased activity in and connectivity with the right anterior insula cortex to incongruent compared to congruent emotional stimuli (ks>281, ps<0.05 FWE corrected), covarying for concurrent psychiatric distress. We also observed an unanticipated relationship between neuroticism and reduced activity in the precuneus (k=269, p<0.05 FWE corrected). Exploratory analyses including healthy individuals suggested that associations between neuroticism and brain function may be nonlinear over the full range of neuroticism scores. CONCLUSIONS This study provides convergent evidence for the importance of the right anterior insula cortex as a brain-based marker of clinically meaningful individual differences in neuroticism among adults with depression. This is a critical next step in linking personality dysfunction, a replicated clinical predictor of differential antidepressant treatment response, with differences in underlying brain function.


title: Laparoscopic Extirpation of the Medial Iliac Lymph Nodes in Normal Dogs.

text: OBJECTIVE To describe a surgical technique for laparoscopic medial iliac lymph node (MILN) extirpation, and to describe the quality of biopsy specimens obtained. DESIGN Experimental study. ANIMALS Purpose-bred male hound-mix research dogs (n = 8). METHODS Dogs were randomized to groups of left or right-sided laparoscopic surgical approaches. Three transperitoneal portals were established with the dogs in lateral recumbency, and ipsilateral MILN dissection was achieved under CO2 pneumoperitoneum using a vessel-sealing device. RESULTS MILN ipsilateral to the approach were successfully identified and removed laparoscopically in 8 dogs. Observed complications included mild to moderate hemorrhage that was controlled laparoscopically in 4 dogs, and tearing of the MILN capsule during retraction and dissection in 3 dogs. No other major complications occurred and all dogs recovered uneventfully. Areas of either minor peripheral (9/9) or central (4/9) pinch artifact affected a median percentage of 5% of surface area (range, 5-30%) of bisected lymph nodes. CONCLUSIONS Laparoscopic MILN extirpation is feasible in dogs with normal MILN and may serve as a minimally invasive approach for excisional biopsy in the diagnostic staging of canine onocologic patients with normal-sized MILN. This lateral laparoscopic approach allows dissection of the ipsilateral MILN but precludes removal of the contralateral MILN. Minimal handling of the lymph node during dissection and removal is required to reduce the risk of capsular tear, or introduction of possible histologic artifact by tissue crush that may impact diagnosis.


Pancreatic melanoma metastasis diagnosed by endoscopic ultrasound-guided SharkCore biopsy.


title: Toll-like receptor modulators: a patent review (2006-2010).

text: INTRODUCTION The immune response is mediated via two parallel immune components, innate and adaptive, whose effector functions are highly integrated and coordinated for the protection of the human body against invading pathogens and transformed cells. The discovery of pathogen recognition receptors (PRRs), most notably toll-like receptors (TLRs), in innate immunity has evoked increased interest in the therapeutic handling of the innate immune system. TLRs are germ line-encoded receptors that play a potent role in the recognition of a diverse variety of ligands ranging from hydrophilic nucleic acids to lipopolysaccharide (LPS) or peptidoglycan (PGN) structures in pathogens. AREAS COVERED This review discusses recent updates (2006-2010) in completed, ongoing and planned clinical trials of TLR immunomodulator-based therapies for the treatment of infectious diseases, inflammatory disorders and cancer. EXPERT OPINION Since the discovery of human TLRs, modulating immune responses using TLR agonists or antagonists for therapeutic purposes has provoked intense activity in the pharmaceutical industry. The ability of TLRs to initiate and propagate inflammation makes them attractive therapeutic targets. We are now at the stage of evaluating such molecules in human diseases. Additionally, there is also extensive literature available on TLRs in diseased states. These data provide a basis for the identification of novel immunomodulators (agonists and antagonists) for the therapeutic targeting of TLRs.


title: High-density lipoprotein-cholesterol functionality and metabolic syndrome: Protocol for review and meta-analysis.

text: INTRODUCTION The prevalence of metabolic syndrome (MetS) and MetS-related stroke is set to increase dramatically in coming decades. MetS is a complex disease that includes endothelial dysfunction, insulin resistance, diabetes, hypertension, ectopic obesity, and dyslipidaemia and an increased risk of cardiovascular events. One function of high-density lipoprotein (HDL) cholesterol (HDL-C) is the cholesterol-efflux pathway, which is the pathway where cholesterol is removed from macrophages within the arterial walls back into the bloodstream and out to the liver. As one of the key functions of HDL, their hypothesis was that if they could measure HDL-C-efflux capacity, they would have a better handle on the role of HDL in atherosclerosis. However, there are no systematic analyses or well-conducted meta-analyses to evaluate the relationship between HDL-C functionality and MetS. The aim of this study is to examine this association of HDL-C functionality with MetS in different ages and sex. METHODS AND ANALYSIS The update systematic review and meta-analysis will be conducted using published studies that will be identified from electronic databases (i.e., PubMed, EMBASE, Web of Science, and Google Scholar). Studies that examined the association between HDL-C functionality and MetS; focused on cohort, case-control, and cross-sectional studies; were conducted among in adults aged 40 to 70 years; provided sufficient data for calculating odds ratio or relative risk with a 95% confidence interval; were published as original articles written in English or other languages; and have been published until January 2018 will be included. Study selection, data collection, quality assessment, and statistical syntheses will be conducted based on discussions among investigators. ETHICS AND DISSEMINATION Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. TRIAL REGISTRATION NUMBER PROSPERO (CRD42018083465).


Personal Protective Equipment and Covid-19. Reply.


title: COVID-19 and Rheumatology patients on immunomodulatory therapy - can we extrapolate data from previous viral pandemics?

text: The implications of COVID-19 are wide-ranging for specialties, like Rheumatology, where immunomodulatory therapies are prescribed, and there has been much trepidation amongst many healthcare professionals regarding the best course of management during this time. This pandemic has also left many national policy-makers perplexed due to our limited knowledge of the effects of COVID-19 in patients with rheumatic disease. Such limitations have resulted in variable evolving guidance amongst Rheumatologists around the globe.


title: The TaperGuard™ endotracheal tube intracuff pressure increase is less than that of the Hi-Lo™ tube during nitrous oxide exposure: a model trachea study.

text: BACKGROUND Studies have compared sealing effects of the newly developed tapered endotracheal tube cuff with the conventional cylindrical cuff. In this study, we compared the difference between cuffs with regard to the increase in intracuff pressure during nitrous oxide (N(2)O) exposure. METHODS Two types of cuffs were studied using a model trachea connected to a mechanical test lung: high-volume, low-pressure cuff (Mallinckrodt Hi-Lo(TM), Covidien, Dublin, Ireland) and tapered cuff (Mallinckrodt TaperGuardTM, Covidien). The intracuff pressure was set at 20 cm H(2)O, and the increase in pressure was measured during mechanical ventilation using 66% N(2)O. Intracuff pressures were recorded after 5, 10, 15, 30, 45, and 60 minutes of exposure to N(2)O. RESULTS The intracuff pressure recorded during the first 15 minutes of N(2)O exposure in high-volume, low-pressure cuffs was significantly higher than tapered cuffs (2-way repeated-measures analysis of variance, P < 0.0001 for internal diameters [IDs] 7.0 and 7.5 mm, P = 0.0004 for ID 8.0 mm, P = 0.0013 for ID 8.5 mm), and there were also statistically significant differences regarding interaction of time and cuff type (P < 0.0001 for IDs 7.0, 7.5, 8.0, and 8.5 mm). The difference in mean cuff pressures among groups after 10 minutes of N(2)O exposure was -18.5 (SE, 1.4; 99% confidence interval, -22.8 to -14.2; P < 0.0001) for ID 7.5 mm. Tapered endotracheal tube cuffs sealed the trachea with fewer dimples on the carina side of the cuff. Dimples on the cuff surface probably increase the surface for N(2)O diffusion. Therefore, fewer dimples result in a smaller surface area through which N(2)O can diffuse. CONCLUSION During general anesthesia with N(2)O, the intracuff pressure of tapered endotracheal tube cuffs did not increase as rapidly as it did in conventional high-volume, low-pressure cuffs. The pressure in both types of cuffs increased rapidly when exposed to 66% N(2)O, and hence continuous or frequent monitoring is recommended.


title: Posterior meningeal artery DMSO injection resulting in reproducible asystole prior to Onyx therapy of a dural arteriovenous fistula: a previously undescribed variant of the trigeminocardiac reflex or a new phenomenon?

text: We describe a case of reproducible asystole during endovascular treatment of a posterior fossa dural arteriovenous fistula. Catheterisation of the posterior meningeal artery, a branch of the vertebral artery in this patient, followed by dimethyl sulfoxide injection prior to Onyx administration resulted in two episodes of asystole.To the best of our knowledge, this is the first reported case of asystole occurring during endovascular intervention in the posterior meningeal artery. This may represent a previously undescribed variant of the trigemino-cardiac reflex (TGCR) caused by chemical stimulation of small areas of trigeminally innervated posterior fossa dura. Alternatively, this may represent a newly identified phenomenon with chemical stimulation of regions of posterior fossa dura innervated by branches of the vagus nerve leading to increased parasympathetic activity and resultant asystole.In either case, it is important to recognise the potential for such episodes in this vascular territory to allow case planning and management.


title: Time to Endovascular Treatment and Outcome in Acute Ischemic Stroke: MR CLEAN Registry Results.

text: BACKGROUND Randomized, clinical trials in selected acute ischemic stroke patients reported that for every hour delay of endovascular treatment (EVT), chances of functional independence diminish by up to 3.4%. These findings may not be fully generalizable to clinical practice because of strict in- and exclusion criteria in these trials. Therefore, we aim to assess the association of time to EVT with functional outcome in current, everyday clinical practice. METHODS The MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) is an ongoing, prospective, observational study in all centers that perform EVT in The Netherlands. Data were analyzed from patients treated between March 2014 and June 2016. In the primary analysis we assessed the association of time from stroke onset to start of EVT and time from stroke onset to successful reperfusion with functional outcome (measured with the modified Rankin Scale), by means of ordinal logistic regression. RESULTS We analyzed 1488 patients with acute ischemic stroke who underwent EVT. An increased time to start of EVT was associated with worse functional outcome (adjusted common odds ratio, 0.83 per hour; 95% confidence interval, 0.77-0.89) and a 2.2% increase in mortality. Every hour increase from stroke onset to EVT start resulted in a 5.3% decreased probability of functional independence (modified Rankin Scale, 0-2). In the 742 patients with successful reperfusion, every hour increase from stroke onset to reperfusion was associated with a 7.7% decreased probability of functional independence. CONCLUSIONS Time to EVT for acute ischemic stroke in current clinical practice is strongly associated with functional outcome. Our data suggest that this association might be even stronger than previously suggested in reports on more selected patient populations from randomized, controlled trials. These findings emphasize that functional outcome of EVT patients can be greatly improved by shortening onset to treatment times.


title: A comparison between adipose tissue and dental pulp as sources of MSCs for tooth regeneration.

text: In this study, several in vivo and in vitro comparisons were performed to test the possibility of using adipose-derived stem cells (ADSCs), a more convenient cell source than dental pulp stem cells (DPSCs), in tooth regeneration. Using an efficient, non-engineering implantation method, we first demonstrated that both implants of ADSCs and DPSCs were able to grow self-assembled new teeth in adult rabbit extraction sockets with high success rate. The stem cells were necessary because the implants grew no tooth without them. A stepwise comparison showed that the regenerated teeth from these two types of adult stem cells were living with nerves and vascular system and remarkably similar to a normal tooth in many details. Further strictly controlled, side-by-side comparisons between the two types of stem cells also showed that the expression patterns of gene markers and the broad differentiation potentials induced by specific methods in vitro were very similar. Although a few differences were found, they did not affect the tested tooth regeneration in vivo or differentiation in vitro. Furthermore, rabbit ADSCs had a higher growth rate and a better senescence resistance in culture. All these findings suggest that ADSCs, one of the richest adult stem cells in mammals, are very similar and useful as DPSCs for regenerative dentistry.


Potential role of Anti-IL-17 in COVID-19 treatment.


Waiting for Something Positive.


title: International core curriculum for capsule endoscopy training courses.

text: Capsule endoscopy (CE) has become a first-line noninvasive tool for visualisation of the small bowel (SB) and is being increasingly used for investigation of the colon. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines have specified requirements for the clinical applications of CE. However, there are no standardized recommendations yet for CE training courses in Europe. The following suggestions in this curriculum are based on the experience of European CE training courses directors. It is suggested that 12 hours be dedicated for either a small bowel capsule endoscopy (SBCE) or a colon capsule endoscopy (CCE) course with 4 hours for an introductory CCE course delivered in conjunction with SBCE courses. SBCE courses should include state-of-the-art lectures on indications, contraindications, complications, patient management and hardware and software use. Procedural issues require approximately 2 hours. For CCE courses 2.5 hours for theoretical lessons and 3.5 hours for procedural issued are considered appropriate. Hands-on training on reading and interpretation of CE cases using a personal computer (PC) for 1 or 2 delegates is recommended for both SBCE and CCE courses. A total of 6 hours hands-on session- time should be allocated. Cases in a SBCE course should cover SB bleeding, inflammatory bowel diseases (IBD), tumors and variants of normal and cases with various types of polyps covered in CCE courses. Standardization of the description of findings and generation of high-quality reports should be essential parts of the training. Courses should be followed by an assessment of trainees' skills in order to certify readers' competency.


Viral aetiology and clinical characteristics of acute respiratory tract infections in Shenzhen during epidemic of coronavirus disease 2019.


title: Perceptions of public on the COVID-19 outbreak in Singapore: a qualitative content analysis.

text: BACKGROUND Singapore is among the several countries affected by the COVID-19 outbreak. The outbreak has elicited panic and unease among Singapore's public. This study aimed to analyze the comments left on local media news outlets to find common concerns and discuss potential new measures that can be developed to reduce panic and support for Singapore's public during and beyond COVID-19. METHODS A qualitative content analysis on the comments on relevant news articles from the Facebook pages of six online local news publications dated from 23 January 2020 to the 3 April 2020 was carried out. RESULTS Five common themes were derived 1: fear and concern (35.42%), 2 panic buying and hoarding (21.21%), 3 reality and expectations about the situation (20.24%), 4 staying positive amid the 'storm' (10.07%) and 5 worries about the future (5.01%). The analysis revealed that fear and concern were the main reasons behind the public's responses. CONCLUSION Clear communication between the government and the public is one of the best ways to maintain calm among the public and to contribute to greater social cooperation. Timely updates and support measures from the government further help to maintain social peace and cohesion.


title: A Feasibility Study of Urgent Implementation of Cystic Fibrosis Multidisciplinary Telemedicine Clinic in the Face of COVID-19 Pandemic: Single-Center Experience.

text: Introduction: The coronavirus 2019 (COVID-19) pandemic has become a major world health problem. All U.S. states have advised their cystic fibrosis (CF) populations to socially isolate. Major health care payors such as Medicare and most private insurance companies have agreed to reimburse health care providers for telemedicine and telephone visits. Methods: The CF adult team at the University of Virginia (UVA) transitioned from face-to-face clinics to multidisciplinary telemedicine clinics by using WebEx® (Cisco Systems, San Jose, CA), a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant platform. Interventions: Patients were contacted before scheduled visits and triaged into: (1) patients eligible for the multidisciplinary telemedicine clinic, (2) patients to be seen in clinic urgently due to acute needs, and (3) stable patients who can be rescheduled at a later time. Ineligible patients for the telemedicine clinic due to lack of access to technology were followed up via telephone. Results: A total of 63 patients were scheduled to be seen in the UVA clinic over 4 weeks, 10 clinic days. Of these patients, 20 (32%) rescheduled their appointment. In addition, 2 patients (3%) were seen in clinic for acute needs and 38 (60%) were seen by the multidisciplinary team through telemedicine. Conclusions: In the context of the COVID-19 pandemic, implementing a telemedicine clinic process that serves the needs of a multidisciplinary care team is paramount to preserving the CF care model. Through a systematic design and test process, a feasible and sustainable program was created that can be utilized by other multidisciplinary programs to adapt to their context.


title: Vancomycin-resistant enterococcus: risk factors, surveillance, infections, and treatment.

text: BACKGROUND The use of vancomycin has continued to expand because of the increasing number of patients infected or colonized with methicillin-resistant Staphylococcus aureus, causing an increase in the prevalence of vancomycin-resistant Enterococcus (VRE). METHODS Review of the pertinent English language literature. RESULTS Vancomycin-resistant Enterococcus spp. are being identified more often in nosocomial infections of surgical patients. The biology of resistance, modes of transmission, patient risk factors, and current treatment strategies are discussed. CONCLUSIONS The reservoir of resistance in enterococci looms as a major threat for genetic transfer and the emergence of increasing numbers of vancomycin-resistant S. aureus.


title: Short-term outcomes for robotic colorectal surgery by provider volume.

text: BACKGROUND There has been a rapid increase in robotic colorectal surgery. Benefits of this technology are unclear and being investigated. However, differences in outcomes between centers have not been evaluated. Our aim was to evaluate outcomes for robotic colorectal procedures by surgeon and hospital volume. STUDY DESIGN A national inpatient database was reviewed for robotic colorectal resections performed during an 18-month period. Hospitals and surgeons were stratified into high, average, and low case volumes based on a normal distribution scale. High, average, and low volume was defined as ≤ 10, 11 to 20, and >20, respectively, for hospitals, and ≤ 5, 6 to 15, and >15, respectively, for surgeons. Short-term outcomes and hospital cost were evaluated. RESULTS There were 1,428 robotic colorectal cases across 123 hospitals and 411 surgeons evaluated. Only 13% (n = 16) of hospitals and 4.4% (n = 18) of surgeons performed a high volume of robotic colorectal cases. Lower volume was associated with significantly more overall complications (p < 0.001; p < 0.001), longer length of stay (p = 0.005; p < 0.001), and higher cost (p < 0.001; p < 0.001) at the hospital and surgeon level, respectively. High-volume hospitals and surgeons had significantly lower rates of postoperative bleeding (p < 0.001; p < 0.001) and ileus (p = 0.003; p = 0.0014). CONCLUSIONS Lower-volume providers, who are performing the majority of procedures, are generating more complications, longer hospital lengths of stay, and higher costs of care. These results have a negative impact on quality outcomes measures for those facilities. Although surgeons and hospitals continue to selectively explore robotics, this should be limited to high volume and interested surgeons and hospitals to offer high-quality outcomes to patients.


title: Single incision laparoscopic totally extraperitoneal inguinal hernia repair.

text: AIMS Various single incision laparoscopic surgeries (SILS) and natural orifice transluminal endoscopic surgeries (NOTES) have been reported recently. Herein we performed SILS for totally extraperitoneal inguinal hernia repair (TEP) on three cases. CASES Three males of 72, 49, and 73 years old with the diagnoses of bilateral primary inguinal hernia underwent single incision TEP. The operative steps of single incision TEP are very similar to those of a traditional laparoscopic TEP. The difference between them is a 2 cm infraumbilical incision for the placement of three (5 mm) trocars in single incision TEP. We preferred to use a 30° 5 mm laparoscope with some routine laparoscopic instruments during the surgical procedure. All the hernia defects were repaired with VyproII of 15 × 10 cm (Ethicon, NJ, USA). The operations took 32, 26, and 65 min, respectively, with no obvious inconvenience. RESULTS All three patients were discharged on the second postoperative day uneventfully. The postoperative follow-up showed no recurrence in the three patients up to now. CONCLUSION The single incision TEP using an access port device is safe and feasible. Meanwhile SILS may reduce medical costs and complication rates through practice and improvement of SILS instruments.


title: Pelvic Pain and Quality of Life Before and After Laparoscopic Bowel Resection for Rectosigmoid Endometriosis: A Prospective, Observational Study.

text: BACKGROUND Surgery for rectosigmoid endometriosis carries a substantial risk of short- and long-term complications, which has to be counterbalanced against the potential effect of the procedure. Prospective data are scarce in the field of deep infiltrating endometriosis surgery. OBJECTIVE The study aimed to assess pelvic pain and quality of life before and after laparoscopic bowel resection for rectosigmoid endometriosis. DESIGN The study involved prospectively collected data regarding pelvic pain and quality of life before and after surgery. SETTINGS It was conducted at a tertiary endometriosis referral unit at Aarhus University Hospital. PATIENTS A total of 175 women were included. INTERVENTION Patients underwent laparoscopic bowel resection for endometriosis. MAIN OUTCOME MEASURES Questionnaires for pain (Numerical Rating Scale) and quality of life (RAND Short Form-36) were answered before and 1 year after surgery. Data on analgesic and hormone treatment were collected. Preoperative and postoperative pelvic pain and quality-of-life scores were compared, and risk factors for improvement/worsening were identified. RESULTS A total of 97.1% of the women completed the 1-year follow up. A significant decrease (p = 0.0001) was observed on all pelvic pain parameters. Most profound was the decrease in dyschezia. A significant improvement on all quality-of-life scores was observed (p = 0.0001). A surgical complication did not have a negative impact on outcome 1 year after surgery. The postoperative outcome was not related to the type of surgery. LIMITATIONS This is an observational study without a control group. Risk factor data should be interpreted with caution, because the study was relatively underpowered for some of the rare outcomes. CONCLUSIONS A significant and clinically relevant improvement in pelvic pain and quality of life 1 year after laparoscopic bowel resection for endometriosis was found. We strongly recommend surgery for rectosigmoid endometriosis that is unresponsive to conservative treatment. See Video Abstract at http://links.lww.com/DCR/A472.


title: Cecal Resection with Bipolar Sealing Devices in a Rat Model.

text: BACKGROUND Bipolar sealing devices are routinely used to seal blood vessels. The aim of the study is to evaluate the feasibility and safety of colonic sealing with the use of the bipolar energy devices in rats as model for experimental appendectomy. METHODS Seventy-five male Wistar rats underwent a cecal resection with four different bipolar sealing devices or a linear stapler. The harvesting procedure was performed immediately or at postoperative day (POD) 7. The sealing front bursting pressure (BP) was measured in both groups. At POD7, the resection line was clinically examined and the hydroxyproline (HDP) levels were determined. Hematoxylin and Eosin (H&E) staining was used for histopathological evaluation of the sealing front as well. RESULTS There was no mortality and no insufficiency. The BPs between the bipolar sealing devices showed no statistical differences. The early phase of the seal (POD 0) provides a low BP with an 30.8% increase until POD 7. The BPs in the stapler group showed significant better values. The hydroxyproline levels did not differ statistically between the groups. Histopathologically, there were more signs of ischemic necrosis in the stapler group than in the sealing devices groups. CONCLUSION The resection and sealing of the cecum as an experimental appendectomy model with the use of bipolar energy devices proved feasible and safe in rats. The different energy devices in this study produce comparable results. To justify clinical practice in humans, several studies on the underlying mechanisms of early stage wound healing are needed.


title: Ileal pouch anal anastomosis with close rectal dissection using automated vessel sealers for ulcerative colitis: a promising alternative.

text: BACKGROUND Despite decennia of experience, ileal pouch anal anastomosis for ulcerative colitis is still associated with high complication rates. The development of automatic vessel sealers has resulted in the revival of a promising surgical alternative to the conventional procedure: close rectal dissection. By preserving the mesorectal layer it is hypothesized that nerve-related and other postoperative complications can be reduced. METHODS All patients with ulcerative colitis with indication for restorative proctocolectomy at our institution during the pilot study underwent the close rectal pouch procedure with temporary diverting ileostomy. Standardized clinical history, anorectal physiology measurements, and endoscopic and histological examination were carried out before and after surgery. RESULTS The procedure was technically successful in all 10 patients, with a median age of 41 years and a median postoperative follow-up period of 16 months. There were no cases of pelvic sepsis and bladder or sexual dysfunction. The median daytime defecation frequency was 6.0. Endoscopic and histological examination showed no abnormalities. The anorectal physiology supported the good functional results. CONCLUSION The preliminary results of the close rectal pouch procedure are promising, with good functional results and a low complication rate after 1 year.


title: A placebo-controlled crossover study of iloperidone augmentation for residual anger and irritability in major depressive disorder.

text: BACKGROUND Even when patients experience remission with antidepressants, many continue to report anger attacks and excessive irritability despite continued treatment. Iloperidone antagonizes 5-HT-2a, D2, and alpha-1 receptors, which can have anti-aggressive effects. We examined iloperidone's safety and efficacy as an augmentation agent in outpatients with partially remitted major depressive disorder (MDD) with residual symptoms of anger and irritability. METHODS A total of 13 outpatients with partially remitted MDD [currently treated with selective serotonin reuptake inhibitors (SSRIs)] received four weeks of iloperidone or placebo, followed by one week of washout. Patients were then crossed over to the other treatment arm for 4 weeks. Treatment arms were randomized and double blind; and two sites were used for the study. Analyses compared treatment response using the Symptom Questionnaire (SQ) Anger/Hostility Subscale as the primary outcome measure. RESULTS There was no significant differential effect of iloperidone × weeks on the SQ Anger/Hostility Subscore over the course of the study, compared with placebo × weeks, regardless of administration order (p = 0.77). CONCLUSIONS Iloperidone did not significantly outperform placebo on measures of anger or irritability in patients with partially remitted MDD and residual anger/irritability.


title: Treatment of a Full-Thickness Burn Injury With NovoSorb Biodegradable Temporizing Matrix and RECELL Autologous Skin Cell Suspension: A Case Series.

text: Dermal substitutes coupled with split thickness skin graft are the primary method of treating most severe full-thickness burns particularly when there is a lack of healthy donor skin. Although dermal replacements optimize functional and aesthetic outcomes in patients, the risk of infection and the amount of time required to process most dermal substitutes delay treatment potentially compromising graft take and the overall healing process. The purpose of this case series is to describe the treatment course of patients with severe burn injuries using a novel synthetic Biodegradable Temporizing Matrix (NovoSorb BTM) in conjunction with RECELL Autologous Cell Harvesting Device, a new methodology allowing for a timely point-of-care preparation of an autologous skin cell suspension in combination with a 3:1 split-thickness skin graft. To the best of our knowledge, this is the first reported case series to describe the treatment algorithm and clinical outcomes of deep full-thickness burns utilizing BTM in conjunction with RECELL ASCS.


title: Port site hernia after laparoscopic sleeve gastrectomy: a retrospective cohort study of 352 patients.

text: Port site hernia (PSH) following laparoscopic procedures is a rare but serious complication. The aim of this study was to evaluate the rate of PSH after laparoscopic sleeve gastrectomy (LSG), and the efficacy of closure of the port site as a means of preventing PSH. A retrospective analysis was performed on 386 patients who underwent LSG between December 2009 and January 2015. 352 (91.2%) of the patient were followed up for at least 24 months. In the first 206 patients, the fascial layers of the trocar incisions were not closed, while in the next 146 cases, routine closure of the trocar sites was performed. The patients were reviewed in relation to demographics, comorbidities, complications, percentage of excess weight loss, and rates of PSH. The total cohort consisted of 220 female and 132 male patients with a mean age of 36.2 ± 12.3 years. Demographic data, initial BMI, and comorbidities were similar for the patients in both groups. The closure of the fascia was caused by the prolonged duration of the operation with no significant difference. The unclosed fascial defects were associated with a significantly increased incidence of PSH (1.3 vs. 3.9%, p < 0.05). All of the patients who experienced PSH had at least one comorbidity, and no complication was noted in the fascial closure cases. It was found that the rate of PSH after LSG is not as low as previously thought, and that routine closure of fascial defects at port sites may result in a decreased PSH rate.