title: Single-incision laparoscopic appendectomy versus traditional three-port laparoscopic appendectomy: an analysis of outcomes at a single institution.

text: BACKGROUND Questions have emerged as to whether single-incision laparoscopy has reproducible or superior patient outcomes compared with traditional laparoscopy. A retrospective review comparing single-incision laparoscopic (SILS) appendectomy and traditional multiport laparoscopic (MP) appendectomy was conducted to assess the safety and feasibility of the less invasive laparoscopic technique. METHODS All SILS and MP appendectomies performed by three surgeons at a single institution during 43 months were reviewed. Statistical evaluation included descriptive analysis of demographic data including age and gender, as well as bi- and multi-variate analyses of operative outcomes including operative time, conversions, complications, and hospital length of stay. RESULTS The study reviewed 168 patients who underwent SILS appendectomy and 108 patients who underwent MP appendectomy. No statistically significant difference was found between the mean SILS and MP operative times (43.63 vs. 40.95 min; p = 0.29). Additionally, no statistically significant association was noted between surgical approach and length of hospital stay. Although 0.93 % of MP appendectomies and 2.38 % of SILS appendectomies were converted to open procedure, this difference was not statistically significant (p = 0.65, Fisher's exact test). After exclusion of cases converted to open procedure from the study, the findings showed that 3.66 % of SILS cases were converted to multiport laparoscopy. No increase in the overall complication rate was associated with SILS compared with MP appendectomy. The wound complications documented included one incisional hernia for SILS appendectomy and two wound infections for MP appendectomy. CONCLUSION The findings showed SILS appendectomy to be a safe and feasible alternative to traditional MP appendectomy that can be conducted with operative times, lengths of stay, and complication rates similar to those of the standardized technique. This review is a precursor to prospective studies, which are warranted to demonstrate conclusively the equivalence of operative times, complications, and lengths of hospital stay, as well as to elucidate differences in patient-centered outcomes including postoperative pain, cosmesis, and quality of life.


Can They Do That?: The Limits of Governmental Power over Medical Treatment.


title: Advanced Imaging for Barrett's Esophagus and Early Neoplasia: Surface and Subsurface Imaging for Diagnosis and Management.

text: PURPOSE OF REVIEW Esophageal adenocarcinoma bears one of the fastest rising incidence of any cancers and generally arises in the setting of gastroesophageal reflux and Barrett's esophagus. However, early detection of neoplasia can be challenging since most patients are asymptomatic until they progress to more advanced and less curable stages, and early dysplastic lesions can be small, multifocal, and difficult to detect. Clearly, new imaging tools are needed in light of sampling error associated with random biopsies, the current standard of practice. RECENT FINDINGS Advances in endoscopic imaging including virtual chromoendoscopy, confocal laser endomicroscopy, and subsurface imaging with optical coherence tomography have ushered in a new era for detecting subtle neoplastic lesions. Moreover, in light of esophagus-sparing treatments for neoplastic lesions, such tools are likely to guide ablation and follow-up management. While there is no ideal single imaging modality to facilitate improved detection, staging, ablation, and follow-up of patients with dysplastic Barrett's esophagus, new advances in available technology, the potential for multimodal imaging, and the use of computer-aided diagnosis and biomarkers all hold great promise for improving detection and treatment.


title: Impact of the COVID-19 Pandemic on the Management of Head and Neck Malignancies.

text: The impact of the coronavirus disease 2019 (COVID-19) pandemic on the management of head and neck cancer must be addressed. Immediate measures to reduce transmission rates and protect patients and providers take priority and necessitate some delays in care, particularly for patients with mild symptoms or less aggressive cancers. However, strict guidelines have yet to be developed, and many unintentional delays in care are to be expected based on the magnitude of the looming public health crisis. The medical complexity of head and neck cancer management may lead to prolonged delays that worsen treatment outcomes. Therefore, those caring for patients with head and neck cancer must take action to reduce these negative impacts as the country rallies to overcome the challenges posed by this pandemic.


title: Grief loss and the COVID-19 pandemic.

text: The capacity for grief literacy is something we all need to develop in the midst of this pandemic.


Meat plants-a new front line in the covid-19 pandemic.


Covid-19 and Immunity in Aging Populations - A New Research Agenda.


title: Anesthetic Management for Concomitant Correction of Congenital Cardiac Defects and Long "O" Ring Tracheal Stenosis: A Role for Heliox?: Report of 2 Cases.

text: We present 2 infants with the rare association of long congenital tracheal stenosis, ventricular septal defect, and pulmonary hypertension. We describe a step-by-step assessment of the patients and the necessary procedures for a successful concomitant repair of both cardiac and tracheal malformations. The use of a helium-oxygen mixture (heliox) for the induction of anesthesia and pre-cardiopulmonary bypass is discussed.


title: Anterior approach white line advancement: technique and long-term outcomes in the correction of blepharoptosis.

text: PurposeAnterior approach white line advancement presents a novel surgical option for correction of blepharoptosis. The technique draws on several advantages of other approaches. The aim of this study was to present outcomes using this technique at a minimum follow-up of 18 months.Patients and methodsParticipants having undergone anterior approach white line advancement ptosis correction at a single institution were retrospectively recruited at a minimum of 18 months' follow-up. A total of 18 independent eyelid measurements were recorded at final review. Outcomes included long-term rate of surgical success, upper eyelid margin-reflex distance (MRD1) at both early and late post-operative follow-up, inter-eyelid asymmetry, complications, re-operation rate, patient satisfaction, and quality-of-life improvement using the Glasgow Benefit Inventory (GBI). Pre- and post-operative MRD1, as well as inter-eyelid asymmetry, were compared using a two-tailed t-test.ResultsIn total, 82 eyelids of 47 participants were included with a mean follow-up of 2.3 years (range 1.5-3.7). Surgical success was achieved in 91.5%, with a final mean MRD1 of 3.5 mm (95% confidence 3.2-3.7). An increase of 2.4 mm (2.1-2.8) in eyelid height was observed between baseline and long-term follow-up (P<0.0001). No significant change was observed between early and late post-operative follow-up. Pre-operative asymmetry was reduced from 1.0 mm (0.7-1.3) to 0.4 mm (0.3-0.5; P<0.0001). Patient satisfaction was 95.7% with a mean GBI score of +21.8 (13.2-30.3).ConclusionsAnterior approach white line advancement presents an excellent option for patients undergoing ptosis correction with favourable long-term results. Comparisons are made with other techniques with respect to anatomical, functional, and surgical factors.


title: More extensive white matter hyperintensity is linked with higher risk of remote intracerebral hemorrhage after intravenous thrombolysis.

text: BACKGROUND AND PURPOSE Remote intracerebral hemorrhage (rICH) is infrequent after intravenous thrombolysis (IVT) and its mechanism remains poorly understood. We aimed to assess its frequency and possible relationship with the severity of white matter hyperintensity (WMH) in patients with acute ischemic stroke. METHODS We prospectively analyzed data from consecutive patients with acute ischemic stroke with magnetic resonance imaging and IVT. WMH volume was quantitatively measured. rICH was defined as intracranial hemorrhage that appears in brain regions without visible ischemic changes on 24-h follow-up imaging. Unfavorable outcome was defined as a modified Rankin scale score of 3-6 at 3 months. Logistic regression analysis was used to determine the impact of WMH volume on hemorrhage, including rICH and local parenchymal hemorrhage, as well as clinical outcome. RESULTS Of a total of 503 patients analyzed, 17 (3.4%) patients developed rICH. Logistic regression analysis indicated that patients with rICH had significantly larger whole-brain corrected WMH volume (cWMHv) than those without rICH (22.90 vs. 4.42 mL; odds ratio, 1.562/10 mL; 95% confidence interval, 1.215-2.009; P = 0.001). Not only the corrected peri-ventricular WMH volume (P = 0.001), but also the corrected deep WMH volume (P = 0.013) was associated with the occurrence of rICH. cWMHv was also independently associated with local parenchymal hemorrhage (P = 0.025). rICH was not related to unfavorable outcome (P = 0.323), whereas cWMHv (P = 0.006) was associated with unfavorable outcome. CONCLUSION An increased occurrence rate of rICH after IVT is related to more extensive WMH, which may suggest underlying whole-brain vascular injury in patients with WMH.


Effect of COVID-19 on ocular diseases and ophthalmology residency training program-A developing country's perspective.


title: Fatal influenza A(H1N1) respiratory tract infection in a patient having psoriasis treated with infliximab.

text: BACKGROUND The use of biologic agents represents a remarkable advance for patients with psoriasis and psoriatic arthritis who have experienced an incomplete response to other therapeutic modalities. Decreased mortality and improved quality of life have been reported in patients undergoing treatment with these agents. Increased risk of bacterial, viral, granulomatous, and opportunistic infections also has been associated with the use of these medications. Enhanced patient education, watchful monitoring to promote early detection of infections, discontinuation of the medication when clinical symptoms are identified, and immediate availability of supportive care are advised to balance the benefit of treatment with biologic agents against the potential risk of infection. Herein, we discuss the risk of infection and the monitoring and vaccination guidelines in patients having psoriasis treated with biologic agents. OBSERVATIONS A woman with obesity and psoriasis that had previously been successfully treated with efalizumab (Raptiva) for 3 years was started on a regimen of infliximab (Remicade) to treat a flare. She died 1 week after her first infusion of infliximab and was found to have had influenza A(H1N1). CONCLUSIONS We report the first case to date of a patient with psoriasis who died of influenza A(H1N1) respiratory tract infection while undergoing treatment with infliximab. Further observations are needed to make a causal association.


title: Cortical atrophy and transcallosal diaschisis following isolated subcortical stroke.

text: Following acute ischemic stroke, isolated subcortical lesions induce gray matter atrophy in anatomically connected, yet distant cortical brain regions. We expand on previous studies by analyzing cortical thinning in contralesional, homologous regions indirectly linked to primary stroke lesions via ipsilesional cortical areas. For this purpose, stroke patients were serially studied by magnetic resonance imaging (diffusion tensor imaging and high-resolution anatomical imaging) in the acute (days 3-5) and late chronic stage one year after stroke. We analyzed changes of gray and white matter integrity in 18 stroke patients (median age 68 years) with subcortical stroke. We applied probabilistic fiber tractography to identify brain regions connected to stroke lesions and contralesional homologous areas. Cortical thickness was quantified by semi-automatic measurements, and fractional anisotropy was analyzed. One year after stroke, significant decrease of cortical thickness was detected in areas connected to ischemic lesions (mean -0.15 mm; 95% CI -0.23 to -0.07 mm) as well as homologous contralateral brain regions (mean -0.13 mm; 95% CI -0.07 to -0.19 mm). We detected reduced white matter integrity of inter- and intrahemispheric fiber tracts. There were no significant associations with clinical recovery. Our results indicate that impact of subcortical lesions extends to homologous brain areas via transcallosal diaschisis.


title: Syrian hamsters as a small animal model for SARS-CoV-2 infection and countermeasure development.

text: At the end of 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2; SARS-CoV-2) was detected in Wuhan, China, that spread rapidly around the world, with severe consequences for human health and the global economy. Here, we assessed the replicative ability and pathogenesis of SARS-CoV-2 isolates in Syrian hamsters. SARS-CoV-2 isolates replicated efficiently in the lungs of hamsters, causing severe pathological lung lesions following intranasal infection. In addition, microcomputed tomographic imaging revealed severe lung injury that shared characteristics with SARS-CoV-2-infected human lung, including severe, bilateral, peripherally distributed, multilobular ground glass opacity, and regions of lung consolidation. SARS-CoV-2-infected hamsters mounted neutralizing antibody responses and were protected against subsequent rechallenge with SARS-CoV-2. Moreover, passive transfer of convalescent serum to naïve hamsters efficiently suppressed the replication of the virus in the lungs even when the serum was administrated 2 d postinfection of the serum-treated hamsters. Collectively, these findings demonstrate that this Syrian hamster model will be useful for understanding SARS-CoV-2 pathogenesis and testing vaccines and antiviral drugs.


title: The adaptive immune system in diseases of the central nervous system.

text: Tissues of the CNS, such as the brain, optic nerves, and spinal cord, may be affected by a range of insults including genetic, autoimmune, infectious, or neurodegenerative diseases and cancer. The immune system is involved in the pathogenesis of many of these, either by causing tissue damage or alternatively by responding to disease and contributing to repair. It is clearly vital that cells of the immune system patrol the CNS and protect against infection. However, in contrast to other tissues, damage caused by immune pathology in the CNS can be irreparable. The nervous and immune systems have, therefore, coevolved to permit effective immune surveillance while limiting immune pathology. Here we will consider aspects of adaptive immunity in the CNS and the retina, both in the context of protection from infection as well as cancer and autoimmunity, while focusing on immune responses that compromise health and lead to significant morbidity.


title: Protein phosphatase 1 subunit Ppp1r15a/GADD34 regulates cytokine production in polyinosinic:polycytidylic acid-stimulated dendritic cells.

text: In response to inflammatory stimulation, dendritic cells (DCs) have a remarkable pattern of differentiation that exhibits specific mechanisms to control the immune response. Here we show that in response to polyriboinosinic:polyribocytidylic acid (pI:C), DCs mount a specific integrated stress response during which the transcription factor ATF4 and the growth arrest and DNA damage-inducible protein 34 (GADD34/Ppp1r15a), a phosphatase 1 (PP1) cofactor, are expressed. In agreement with increased GADD34 levels, an extensive dephosphorylation of the translation initiation factor eIF2α was observed during DC activation. Unexpectedly, although DCs display an unusual resistance to protein synthesis inhibition induced in response to cytosolic dsRNA, GADD34 expression did not have a major impact on protein synthesis. GADD34, however, was shown to be required for normal cytokine production both in vitro and in vivo. These observations have important implications in linking further pathogen detection with the integrated stress response pathways.


title: Long-term adherence to a 5 day antibiotic course guideline for treatment of intensive care unit (ICU)-associated Gram-negative infections.

text: OBJECTIVES To determine long-term adherence to a 5 day antibiotic course guideline for treating intensive care unit (ICU)-acquired Gram-negative bacteria (GNB) infections. METHODS Descriptive analysis of patient-level data on all GNB-active antibiotics prescribed from day 3 and all GNB identified in clinical samples in 5350 patients admitted to a 30 bed general ICU between 2002 and 2009. RESULTS Four thousand five hundred and eleven of 5350 (84%) patients were treated with one or more antibiotics active against GNB commenced from day 3. Gentamicin was the most frequently prescribed antibiotic (92.2 days of therapy/1000 patient-days). Only 6% of courses spanned >6 days of therapy and 89% of antibiotic therapy days were with a single antibiotic active against GNB. There was no significant difference between gentamicin and meropenem in the number of first courses in which a resistant GNB was identified in blood cultures [11/1177 (0.9%) versus 5/351 (1.4%); P = 0.43] or respiratory tract specimens [59/951 (6.2%) versus 17/246 (6.9%); P = 0.68] at the time of starting therapy. CONCLUSIONS This study demonstrates long-term adherence to a 5 day course antibiotic guideline for treatment of ICU-associated GNB infections. This guideline is a potential antibiotic-sparing alternative to currently recommended dual empirical courses extending to ≥7 days.


Reply to Kerkhove et al and Oh.


title: Enhancing the fairness of pandemic critical care triage.

text: Historically, the triage of temporarily scarce health resources has served narrow utilitarian ends. The recent H1N1 pandemic experience provided an opportunity for expanding the theoretical foundations/understandings of critical care triage in the context of declared infectious pandemics. This paper briefly explores the ethics-related challenges associated with the development of modern critical care triage protocols and provides descriptions of some 'enhanced fairness' features which were developed through the use of an inclusive deliberative engagement process by a Canadian provincial Department of Health.


title: Quantitative magnetic resonance angiography as a potential predictor for cerebral hyperperfusion syndrome: a preliminary study.

text: OBJECTIVE Cerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk. METHODS In this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors. RESULTS Twenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS. CONCLUSIONS Cerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.


title: Changes in body weight and pulse: outcome events in overweight and obese subjects with cardiovascular disease in the SCOUT trial.

text: BACKGROUND/OBJECTIVES The Sibutramine Cardiovascular OUTcomes (SCOUT) trial showed a significantly increased relative risk of nonfatal cardiovascular events, but not mortality, in overweight and obese subjects receiving long-term sibutramine treatment with diet and exercise. We examined the relationship between early changes (both increases and decreases) in pulse rate, and the impact of these changes on subsequent cardiovascular outcome events in both the placebo and sibutramine groups. SUBJECTS/METHODS 9804 males and females, aged ⩾55 years, with a body mass index of 27-45 kg m(-)(2) were included in this current subanalysis of the SCOUT trial. Subjects were required to have a history of cardiovascular disease and/or type 2 diabetes mellitus with at least one cardiovascular risk factor, to assess cardiovascular outcomes. The primary outcome event (POE) was a composite of nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death. Time-to-event analyses of the POE were performed using Cox regression models. RESULTS During the initial 6-week sibutramine treatment period, the induced pulse rate increase was related to weight change (1.9±7.7 beats per minute (bpm) with weight increase; 1.4±7.3 bpm, 0-5 kg weight loss; 0.6±7.4 bpm, ⩾5 kg weight loss). Throughout the subsequent treatment period, those continuing on sibutramine showed a consistently higher mean pulse rate than the placebo group. There was no difference in POE rates with either an increase or decrease in pulse rate over the lead-in period, or during lead-in baseline to 12 months post randomization. There was also no relationship between pulse rate at lead-in baseline and subsequent cardiovascular events in subjects with or without a cardiac arrhythmia. CONCLUSION Baseline pulse rate and changes in pulse rate may not be an important modifier nor a clinically useful predictor of outcome in an individual elderly cardiovascular obese subject exposed to weight management.


title: Efficacy of endovascular thrombectomy in patients with M2 segment middle cerebral artery occlusions: meta-analysis of data from the HERMES Collaboration.

text: BACKGROUND The Society of Neurointerventional Surgery revised its operational definition of emergent large vessel occlusion (ELVO) recently to include proximal M2 segment middle cerebral artery (MCA) occlusions. We sought to assess the benefit of endovascular thrombectomy (EVT) over best medical care for M2 segment MCA occlusion. METHODS Patient level data from trials in the HERMES Collaboration were included. The HERMES core laboratory identified patients with M2 segment MCA occlusions and further classified them as proximal versus distal, anterior versus posterior division, and dominant versus co-dominant versus non-dominant. Primary outcome was modified Rankin Scale (mRS) score 0-2 at 90 days. Secondary outcomes were modified Thrombolysis in Cerebral Infarction (mTICI) rates at end of procedure, 90-day mRS shift, 90-day mRS 0-1, 24 hours National Institute of Health Stroke Scale (NIHSS) score 0-2, symptomatic intracerebral hemorrhage (ICH), and death. RESULTS 130 patients with M2 MCA (proximal location n=116 vs distal n=14, anterior division n=72 vs posterior n=58, dominant n=73 vs co-dominant n=50 vs non-dominant n=7) were included. Successful reperfusion (mTICI 2b or 3) among those undergoing EVT was seen in 59.2% of patients. Treatment effect favored EVT (adjusted OR 2.39, 95% CI 1.08 to 5.28, p=0.03) for 90-day mRS 0-2 (58.2% EVT vs 39.7% control). Direction of benefit favored EVT for other outcomes. Treatment effect favoring EVT was maximal in patients with proximal M2 segment MCA occlusions (n=116, adjusted OR 2.68, 95% CI 1.13 to 6.37) and in dominant M2 segment MCA occlusions (n=73, adjusted OR 4.08, 95% CI 1.08 to 15.48). No sICH (0%) was observed in patients treated with EVT compared with five (7.9%) in the control arm. CONCLUSION Patients with proximal M2 segment MCA occlusions eligible for EVT trial protocols benefited from EVT.


title: Associations between psychosocial factors and pain intensity, physical functioning, and psychological functioning in patients with chronic pain: a cross-cultural comparison.

text: OBJECTIVE Current models of chronic pain recognize that psychosocial factors influence pain and the effects of pain on daily life. The role of such factors has been widely studied on English-speaking individuals with chronic pain. It is possible that the associations between such factors and adjustment may be influenced by culture. This study sought to evaluate the importance of coping responses, self-efficacy beliefs, and social support to adjust to chronic pain in a sample of Portuguese patients, and discuss the findings with respect to their similarities and differences from findings of studies on English-speaking individuals. MATERIALS AND METHODS Measures of pain intensity and interference, physical and psychological functioning, coping responses, self-efficacy, and satisfaction with social support were administered to a sample of 324 Portuguese patients with chronic musculoskeletal pain. Univariate and multivariate analyses were computed. Findings were interpreted with respect to those from similar studies using English-speaking individuals. RESULTS Coping responses and perceived social support were significantly associated with pain interference and both physical and psychological functioning; self-efficacy beliefs were significantly associated with all criterion variables. All coping responses, except for task persistence, were positively associated with pain interference and negatively associated with physical and psychological functioning, with the strongest associations found for catastrophizing, praying/hoping, guarding, resting, asking for assistance, and relaxation. DISCUSSION The findings provide support for the importance of the psychosocial factors studied in terms of adjustment to chronic pain in Portuguese patients, and also suggest the possibility of some differences in the role of these factors due to culture.


title: Comparison of laparoscopic skills performance between single-site access (SSA) devices and an independent-port SSA approach.

text: BACKGROUND This study compared the performance of validated laparoscopic tasks on four commercially available single-site-access (SSA) devices with the performance of those tasks on an independent-port (IP) SSA setup. METHODS A prospective, randomized comparison of laparoscopic skills performance on four access devices (ADs) (GelPOINT, SILS Port, SSL Access System, TriPort) and one IP-SSA setup was conducted. A laparoscopic trainer box was used to train 18 (2nd- to 4th-year) medical students, four surgical residents, and five attending surgeons to proficiency in multiport laparoscopy using four laparoscopic drills (i.e., peg transfer, bean drop, pattern cutting, extracorporeal suturing). Drills then were performed in random order on each IP-SSA and AD-SSA setup using straight laparoscopic instruments. Repetitions were timed and errors recorded. Data are presented as mean ± standard deviation. Statistical analysis was performed by two-way analysis of variance (ANOVA) with Tukey HSD post hoc tests. RESULTS The attending surgeons had significantly faster total task times than the residents or students (P < 0.001), but the difference between the residents and students was not significant. Pair-wise comparisons showed significantly faster total task times for the IP-SSA setup than for all four AD-SSAs within the student group only (P < 0.05). The total task times for the residents and attending surgeons showed a similar profile, but the differences were not significant. When the data for the three groups were combined, the total task time was less for the IP-SSA setup than for each of the four AD-SSA setups (P < 0.001). Similarly, the IP-SSA setup was significantly faster than three of the four AD-SSA setups for peg transfer, three of the four setups for pattern cutting, and two of the four setups for suturing. No significant differences in error rates between the IP-SSA and AD-SSA setups were detected. CONCLUSIONS Compared with an IP-SSA laparoscopic setup, AD-SSAs are associated with longer task performance times in a trainer box model, independently of the level of training. Task performance was similar across the different SSA devices.


title: Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed.

text: INTRODUCTION Bile duct injury (BDI) remains the dreaded complication of laparoscopic cholecystectomy (LC) over the last two decades. Although the Fundamentals of Laparoscopic Surgery (FLS) certification is now required for new applicants by the American Board of Surgery, the impact of FLS on procedure-specific outcomes is unknown. Moreover, the FLS content centers on fundamental education and not procedure-specific complication reduction such as BDI, magnifying the importance of understanding the educational impact of FLS on specific case types. This study reviewed the impact of FLS certification and other factors on the incidence of bile duct injury in a large insurance claims database. METHODS In total, 53,632 LCs were reviewed from July 2009 to December 2010 from a large private payer claims database. Surgeon National Provider Identifier (NPI), FLS certification status, International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) were available for each event. Each record was analyzed for evidence of any bile duct injury based on associated CPT or ICD-9 data in the claim record. Characteristics of the FLS+ and FLS- surgeon groups were analyzed by a separate reviewer blinded to clinical outcome on a large scale. RESULTS A total of 53,632 LCs were reviewed; 1748 LC were performed by 441 FLS+ surgeons; and 58,870 LCs by 10,851 FLS- surgeons. (Some procedures involved more than one surgeon). Eighty-two BDIs were identified: 8 in the FLS+ and 74 in the FLS- group. The FLS+ group had a higher rate of BDI than the FLS- group (0.47 vs. 0.14 %, p = 0.0013); however, the FLS+ group was also younger (mean age 38.2 FLS+ vs. 50.4 years) and had significantly fewer years in practice (FLS+ = 6.1 vs. FLS- = 20.7, p = 0.0012). No other complications showed differences between the groups. CONCLUSION NPI can be used as a linking intermediary between skills certification and outcomes on claims databases. FLS certification was not associated with a reduction in bile duct injury in this analysis, but FLS+ surgeons were also younger and less experienced overall. Since FLS lacks content specific to BDI, large-scale validated training and assessment programs targeted at BDI prevention are needed to impact the rate of this complication during cholecystectomy.


title: Exosome mimicry by a HAVCR1-NPC1 pathway of endosomal fusion mediates hepatitis A virus infection.

text: Cell-to-cell communication by exosomes controls normal and pathogenic processes1,2. Viruses can spread in exosomes and thereby avoid immune recognition3. While biogenesis, binding and uptake of exosomes are well characterized4,5, delivery of exosome cargo into the cytoplasm is poorly understood3. We report that the phosphatidylserine receptor HAVCR1 (refs. 6,7) and the cholesterol transporter NPC1 (ref. 8) participate in cargo delivery from exosomes of hepatitis A virus (HAV)-infected cells (exo-HAV) by clathrin-mediated endocytosis. Using CRISPR-Cas9 knockout technology, we show that these two lipid receptors, which interact in the late endosome9, are necessary for the membrane fusion and delivery of RNA from exo-HAV into the cytoplasm. The HAVCR1-NPC1 pathway, which Ebola virus exploits to infect cells9, mediates HAV infection by exo-HAV, which indicates that viral infection via this exosome mimicry mechanism does not require an envelope glycoprotein. The capsid-free viral RNA in the exosome lumen, but not the endosomal uncoating of HAV particles contained in the exosomes, is mainly responsible for exo-HAV infectivity as assessed by methylene blue inactivation of non-encapsidated RNA. In contrast to exo-HAV, infectivity of HAV particles is pH-independent and requires HAVCR1 or another as yet unidentified receptor(s) but not NPC1. Our findings show that envelope-glycoprotein-independent fusion mechanisms are shared by exosomes and viruses, and call for a reassessment of the role of envelope glycoproteins in infection.


Efficacy of MSC for steroid-refractory acute GVHD associates with MSC donor age and a defined molecular profile.


title: Acellular dermal matrix in abdominal wall reconstruction.

text: Abdominal wall reconstruction is a complex and challenging surgical undertaking. While permanent prosthetic mesh is considered the gold standard for minimizing hernia recurrence, placement of synthetic mesh is sometimes imprudent due to contamination or risk of infection. Acellular dermal matrices (ADM) offer an exciting biologic alternative. This article provides a historical perspective on the evolution of complex ventral hernia repair leading up to and including the placement of ADM, an explanation of the biology of ADM as it relates to ventral hernia repair, and a description of the current indications, techniques, benefits, and shortcomings of its use in the abdominal wall.


title: 3D imaging and stealth navigation instead of CT guidance for radiofrequency ablation of osteoid osteomas: a series of 52 patients.

text: BACKGROUND Osteoid osteomas are benign bone neoplasms that may cause severe pain and limit function. They are commonly treated by radiofrequency ablation (RFA) through a needle inserted into the nidus of the lesion under CT guidance, which is associated with exposure of young patients to relatively high dose of radiation. The objective of this study was to investigate the amount of radiation, effectiveness and safety of an alternative imaging approach, the 3D image-guided (O-arm) technology and the Stealth navigation. METHODS We retrospectively reviewed 52 electronic medical files of patients (mean age 24.7 years, range 8-59 years) who were treated with thermal ablation of benign osteoid osteomas guided by the navigated O-arm-assisted technique in our institution between 2015 and 2017. Data were extracted on the associated complications, the reduction in pain at 3 months and one year postoperatively, and the amount of radiation administered during the procedure. RESULTS The level of pain on a visual analogue scale decreased from the preoperative average of 7.73 to 0 at the 3-month follow-up. The mean dose-length product was 544.7 mGycm2 compared to the reported radiation exposure of 1971-7946 mGycm2 of CT-guided radio ablations. The one intra-operative complication was a superficial burn in the subcutaneous lesion in a tibia that was treated locally with no major influence on recovery. CONCLUSIONS RFA ablation guided by 3D O-arm stealth navigation is as effective as the traditional CT-guided technique with the advantage of lower radiation exposure. TRIAL REGISTRATION Retrospective study number 0388-17-TLV at Tel Aviv Sourasky Medical Center IRB, approved at 25.10.17.


title: New technologies in ambulatory thyroid surgery.

text: Thyroid operations are increasingly performed in the outpatient setting. In general the essential objectives for thyroidectomy are: sparing the parathyroid glands, avoidance of injury to the laryngeal nerves, an accurate hemostasis and an excellent cosmesis. In the last 10 years major improvements and new technologies have been proposed and applied in thyroid surgery; among these mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, intraoperative neuromonitoring, and PTH assay technology. This paper reviews relevant medical literature published on the influence of these new technologies on quality of thyroid surgery as well as prevention of postoperative morbidity and mortality. Searches were last updated April 2008.


title: Variability in Uremic Control during Continuous Venovenous Hemodiafiltration in Trauma Patients.

text: Introduction. Acute kidney injury (AKI) necessitating continuous renal replacement therapy (CRRT) is a severe complication in trauma patients (TP). We wanted to assess daily duration of CRRT and its impact on uremic control in TP. Material and Methods. We retrospectively reviewed adult TP, with or without rhabdomyolysis, with AKI undergoing CRRT. Data on daily CRRT duration and causes for temporary stops were collected from the first five CRRT days. Uremic control was assessed by daily changes in serum urea (Δurea) and creatinine (Δcreatinine) concentrations. Results. Thirty-six TP were included with a total of 150 CRRT days, 17 (43%) with rhabdomyolysis. The median (interquartile range (IQR)) time per day with CRRT was 19 (15-21) hours. There was a significant correlation between daily CRRT duration and Δurea (r = 0.60, P≤0.001) and Δcreatinine (r = 0.43; P = 0.012). CRRT pauses were caused by filter clotting (54%), therapeutic interventions (25%), catheter related problems (10%), filter timeout (6%), and diagnostic procedures (6%). Rhabdomyolysis did not affect the CRRT data. Conclusions. TP undergoing CRRT had short daily CRRT duration causing reduced uremic control. Clinicians should modify their daily clinical practice to improve technical skills and achieve sufficient dialysis dose.


title: Dual Roles of Group IID Phospholipase A2 in Inflammation and Cancer.

text: Phospholipase A2 enzymes have long been implicated in the promotion of inflammation by mobilizing pro-inflammatory lipid mediators, yet recent evidence suggests that they also contribute to anti-inflammatory or pro-resolving programs. Group IID-secreted phospholipase A2 (sPLA2-IID) is abundantly expressed in dendritic cells in lymphoid tissues and resolves the Th1 immune response by controlling the steady-state levels of anti-inflammatory lipids such as docosahexaenoic acid and its metabolites. Here, we show that psoriasis and contact dermatitis were exacerbated in Pla2g2d-null mice, whereas they were ameliorated in Pla2g2d-overexpressing transgenic mice, relative to littermate wild-type mice. These phenotypes were associated with concomitant alterations in the tissue levels of ω3 polyunsaturated fatty acid (PUFA) metabolites, which had the capacity to reduce the expression of pro-inflammatory and Th1/Th17-type cytokines in dendritic cells or lymph node cells. In the context of cancer, however, Pla2g2d deficiency resulted in marked attenuation of skin carcinogenesis, likely because of the augmented anti-tumor immunity. Altogether, these results underscore a general role of sPLA2-IID as an immunosuppressive sPLA2 that allows the microenvironmental lipid balance toward an anti-inflammatory state, exerting beneficial or detrimental impact depending upon distinct pathophysiological contexts in inflammation and cancer.


Emergency Palliative Care Planning and Support in a COVID-19 Pandemic.


title: CLINICAL AND EPIDEMIOLOGICAL CHARACTERISTICS OF PATIENTS DIAGNOSED WITH COVID-19 IN A TERTIARY CARE CENTER IN MEXICO CITY: A PROSPECTIVE COHORT STUDY.

text: Background Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. Objective The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). Methods We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. Results We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. Conclusions Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.


Purpose The locoregional interventional oncological treatment approach is an accepted modality for liver neoplasms, especially for hepatocellular carcinoma (HCC) and oligonodular liver metastases. Materials and Methods The main aim of ablation therapies like microwave ablation (MWA) is to eradicate all malignant cells in a minimally invasive technique under imaging guidance while preserving the healthy tissue with a sufficient safety margin (at least 5 mm) surrounding the ablated lesion. Results Ablation therapy can be performed via a percutaneous, laparoscopic or intraoperative approach under ultrasound, MRI or CT guidance for adequate localization and monitoring of the ablation process. Conclusion Ablation is the method of choice for oligonodular HCCs ≤ 3 cm. The technical success rate varies from 88 % to 98 % and progression-free survival (PFS) at 3 years from 27 % to 91.7 %. The same criteria apply to the therapy of liver metastases. Key Points · Careful selection of patients proves to be essential for optimum results of MWA. · Interventionists should be familiar with all aspects of complication and rapid assessment of imaging methods in order to evaluate induced damage by thermal ablation. · MWA seems to have some advantages over radiofrequency ablation, like shorter ablation time, less pain, less heat sink effect; however, scientific proof is needed. Citation Format · Vogl TJ, Nour-Eldin A, Hammerstingl RM et al. Microwave Ablation (MWA): Basics, Technique and Results in Primary and Metastatic Liver Neoplasms - Review Article. Fortschr Röntgenstr 2017; 189: 1055 - 1066.


title: Strategies to overcome host immunity to adenovirus vectors in vaccine development.

text: The first clinical evaluations of adenovirus (Ad)-based vectors for gene therapy were initiated in the mid-1990s and led to great anticipation for future utility. However, excitement surrounding gene therapy, particularly Ad-based therapy, was diminished upon the death of Jesse Gelsinger, and recent discouraging results from the HIV vaccine STEP trial have brought efficacy and safety issues to the forefront again. Even so, Ad vectors are still considered among the safest and most effective vaccine vectors. Innate and pre-existing immunity to Ad mediate much of the acute toxicities and reduced therapeutic efficacies observed following vaccination with this vector. Thus, innovative strategies must continue to be developed to reduce Ad-specific antigenicity and immune recognition. This review provides an overview and critique of the most promising strategies, including results from preclinical trials in mice and nonhuman primates, which aim to revive the future of Ad-based vaccines.


title: Cellular Scale Imaging of Transparent Retinal Structures and Processes Using Adaptive Optics Optical Coherence Tomography.

text: High-resolution retinal imaging is revolutionizing how scientists and clinicians study the retina on the cellular scale. Its exquisite sensitivity enables time-lapse optical biopsies that capture minute changes in the structure and physiological processes of cells in the living eye. This information is increasingly used to detect disease onset and monitor disease progression during early stages, raising the possibility of personalized eye care. Powerful high-resolution imaging tools have been in development for more than two decades; one that has garnered considerable interest in recent years is optical coherence tomography enhanced with adaptive optics. State-of-the-art adaptive optics optical coherence tomography (AO-OCT) makes it possible to visualize even highly transparent cells and measure some of their internal processes at all depths within the retina, permitting reconstruction of a 3D view of the living microscopic retina. In this review, we report current AO-OCT performance and its success in visualizing and quantifying these once-invisible cells in human eyes. Expected final online publication date for the Annual Review of Vision Science, Volume 6 is September 15, 2020. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.


Facing Covid-19 in Italy - Ethics, Logistics, and Therapeutics on the Epidemic's Front Line.


title: "Perioperative Presentation of COVID-19 Disease in a Liver Transplant Recipient".

text: In a recent issue of Hepatology, Drs. Qin and Wang report a case of a 37-year old patient with COVID-19 disease after undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC). While these are interesting data on the course of COVID-19 disease in an immunosuppressed patient, we would like to highlight some particularly important issues related to management of liver disease and post-transplant care.


title: Generation of VSV pseudotypes using recombinant ΔG-VSV for studies on virus entry, identification of entry inhibitors, and immune responses to vaccines.

text: Vesicular stomatitis virus (VSV) is a prototypic enveloped animal virus that has been used extensively to study virus entry, replication and assembly due to its broad host range and robust replication properties in a wide variety of mammalian and insect cells. Studies on VSV assembly led to the creation of a recombinant VSV in which the glycoprotein (G) gene was deleted. This recombinant (rVSV-ΔG) has been used to produce VSV pseudotypes containing the envelope glycoproteins of heterologous viruses, including viruses that require high-level biocontainment; however, because the infectivity of rVSV-ΔG pseudotypes is restricted to a single round of replication the analysis can be performed using biosafety level 2 (BSL-2) containment. As such, rVSV-ΔG pseudotypes have facilitated the analysis of virus entry for numerous viral pathogens without the need for specialized containment facilities. The pseudotypes also provide a robust platform to screen libraries for entry inhibitors and to evaluate the neutralizing antibody responses following vaccination. This manuscript describes methods to produce and titer rVSV-ΔG pseudotypes. Procedures to generate rVSV-ΔG stocks and to quantify virus infectivity are also described. These protocols should allow any laboratory knowledgeable in general virological and cell culture techniques to produce successfully replication-restricted rVSV-ΔG pseudotypes for subsequent analysis.


title: From colorectal cancer pattern to the characterization of individuals at risk: Picture for genetic research in Latin America.

text: Colorectal cancer (CRC) is one of the most common cancers in Latin America and the Caribbean, with the highest rates reported for Uruguay, Brazil and Argentina. We provide a global snapshot of the CRC patterns, how screening is performed, and compared/contrasted to the genetic profile of Lynch syndrome (LS) in the region. From the literature, we find that only nine (20%) of the Latin America and the Caribbean countries have developed guidelines for early detection of CRC, and also with a low adherence. We describe a genetic profile of LS, including a total of 2,685 suspected families, where confirmed LS ranged from 8% in Uruguay and Argentina to 60% in Peru. Among confirmed LS, path_MLH1 variants were most commonly identified in Peru (82%), Mexico (80%), Chile (60%), and path_MSH2/EPCAM variants were most frequently identified in Colombia (80%) and Argentina (47%). Path_MSH6 and path_PMS2 variants were less common, but they showed important presence in Brazil (15%) and Chile (10%), respectively. Important differences exist at identifying LS families in Latin American countries, where the spectrum of path_MLH1 and path_MSH2 variants are those most frequently identified. Our findings have an impact on the evaluation of the patients and their relatives at risk for LS, derived from the gene affected. Although the awareness of hereditary cancer and genetic testing has improved in the last decade, it is remains deficient, with 39%-80% of the families not being identified for LS among those who actually met both the clinical criteria for LS and showed MMR deficiency.


title: Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State.

text: Importance Hydroxychloroquine, with or without azithromycin, has been considered as a possible therapeutic agent for patients with coronavirus disease 2019 (COVID-19). However, there are limited data on efficacy and associated adverse events. Objective To describe the association between use of hydroxychloroquine, with or without azithromycin, and clinical outcomes among hospital inpatients diagnosed with COVID-19. Design, Setting, and Participants Retrospective multicenter cohort study of patients from a random sample of all admitted patients with laboratory-confirmed COVID-19 in 25 hospitals, representing 88.2% of patients with COVID-19 in the New York metropolitan region. Eligible patients were admitted for at least 24 hours between March 15 and 28, 2020. Medications, preexisting conditions, clinical measures on admission, outcomes, and adverse events were abstracted from medical records. The date of final follow-up was April 24, 2020. Exposures Receipt of both hydroxychloroquine and azithromycin, hydroxychloroquine alone, azithromycin alone, or neither. Main Outcomes and Measures Primary outcome was in-hospital mortality. Secondary outcomes were cardiac arrest and abnormal electrocardiogram findings (arrhythmia or QT prolongation). Results Among 1438 hospitalized patients with a diagnosis of COVID-19 (858 [59.7%] male, median age, 63 years), those receiving hydroxychloroquine, azithromycin, or both were more likely than those not receiving either drug to have diabetes, respiratory rate >22/min, abnormal chest imaging findings, O2 saturation lower than 90%, and aspartate aminotransferase greater than 40 U/L. Overall in-hospital mortality was 20.3% (95% CI, 18.2%-22.4%). The probability of death for patients receiving hydroxychloroquine + azithromycin was 189/735 (25.7% [95% CI, 22.3%-28.9%]), hydroxychloroquine alone, 54/271 (19.9% [95% CI, 15.2%-24.7%]), azithromycin alone, 21/211 (10.0% [95% CI, 5.9%-14.0%]), and neither drug, 28/221 (12.7% [95% CI, 8.3%-17.1%]). In adjusted Cox proportional hazards models, compared with patients receiving neither drug, there were no significant differences in mortality for patients receiving hydroxychloroquine + azithromycin (HR, 1.35 [95% CI, 0.76-2.40]), hydroxychloroquine alone (HR, 1.08 [95% CI, 0.63-1.85]), or azithromycin alone (HR, 0.56 [95% CI, 0.26-1.21]). In logistic models, compared with patients receiving neither drug cardiac arrest was significantly more likely in patients receiving hydroxychloroquine + azithromycin (adjusted OR, 2.13 [95% CI, 1.12-4.05]), but not hydroxychloroquine alone (adjusted OR, 1.91 [95% CI, 0.96-3.81]) or azithromycin alone (adjusted OR, 0.64 [95% CI, 0.27-1.56]), . In adjusted logistic regression models, there were no significant differences in the relative likelihood of abnormal electrocardiogram findings. Conclusions and Relevance Among patients hospitalized in metropolitan New York with COVID-19, treatment with hydroxychloroquine, azithromycin, or both, compared with neither treatment, was not significantly associated with differences in in-hospital mortality. However, the interpretation of these findings may be limited by the observational design.


Optimizing the Use Of Teleneurology During the COVID-19 Pandemic.


title: Presenting Features and Early Mortality from SARS-CoV-2 Infection in Cancer Patients during the Initial Stage of the COVID-19 Pandemic in Europe.

text: We describe the outcomes in cancer patients during the initial outbreak of the COVID-19 in Europe from the retrospective, multi-center observational OnCovid study. We identified 204 cancer patients from eight centers in the United Kingdom, Italy, and Spain aged > 18 (mean = 69) and diagnosed with COVID-19 between February 26th and April 1st, 2020. A total of 127 (62%) were male, 184 (91%) had a diagnosis of solid malignancy, and 103 (51%) had non-metastatic disease. A total of 161 (79%) had > 1 co-morbidity. A total of 141 (69%) patients had > 1 COVID-19 complication. A total of 36 (19%) were escalated to high-dependency or intensive care. A total of 59 (29%) died, 53 (26%) were discharged, and 92 (45%) were in-hospital survivors. Mortality was higher in patients aged > 65 (36% versus 16%), in those with > 2 co-morbidities (40% versus 18%) and developing > 1 complication from COVID-19 (38% versus 4%, p = 0.004). Multi-variable analyses confirmed age > 65 and > 2 co-morbidities to predict for patient mortality independent of tumor stage, active malignancy, or anticancer therapy. During the early outbreak of SARS-CoV-2 infection in Europe co-morbid burden and advancing age predicted for adverse disease course in cancer patients. The ongoing OnCovid study will allow us to compare risks and outcomes in cancer patients between the initial and later stages of the COVID-19 pandemic.


title: Diagnosis and management of Budd Chiari syndrome: an update.

text: Imaging plays a crucial role in the early detection and assessment of the extent of disease in Budd Chiari syndrome (BCS). Early diagnosis and intervention to mitigate hepatic congestion is vital to restoring hepatic function and alleviating portal hypertension. Interventional radiology serves a key role in the management of these patients. The interventionist should be knowledgeable of the clinical presentation as well as key imaging findings, which often dictate the approach to treatment. This article concisely reviews the etiology, pathophysiology, and clinical presentation of BCS and provides a detailed description of imaging and treatment options, particularly interventional management.


title: Immunoregulatory Potential of Exosomes Derived from Cancer Stem Cells.

text: Head and neck squamous cell carcinomas (HNSCCs) are malignancies that originate in the mucosal lining of the upper aerodigestive tract. Despite advances in therapeutic interventions, survival rates amongst HNSCC patients have remained static for years. Cancer stem cells (CSCs) are tumor initiating cells that are highly resistant to treatment, and are hypothesized to contribute to a significant fraction of tumor recurrences. Consequently, further investigations of how CSCs mediate recurrence may provide insights into novel druggable targets. A key element of recurrence involves the tumor's ability to evade immunosurveillance. Recent published reports suggest that CSCs possess immunosuppressive properties, however, the underlying mechanism have yet to be fully elucidated. To date, most groups have focused on the role of CSC-derived secretory proteins, such as cytokines and growth factors. Here, we review the established immunoregulatory role of exosomes derived from mixed tumor cell populations, and propose further study of CSC-derived exosomes may be warranted. Such studies may yield novel insights into new druggable targets, or lay the foundation for future exosome-based diagnostics.


title: Transcriptomic analysis reveals a mechanism for a prefibrotic phenotype in STAT1 knockout mice during severe acute respiratory syndrome coronavirus infection.

text: Severe acute respiratory syndrome coronavirus (SARS-CoV) infection can cause the development of severe end-stage lung disease characterized by acute respiratory distress syndrome (ARDS) and pulmonary fibrosis. The mechanisms by which pulmonary lesions and fibrosis are generated during SARS-CoV infection are not known. Using high-throughput mRNA profiling, we examined the transcriptional response of wild-type (WT), type I interferon receptor knockout (IFNAR1-/-), and STAT1 knockout (STAT1-/-) mice infected with a recombinant mouse-adapted SARS-CoV (rMA15) to better understand the contribution of specific gene expression changes to disease progression. Despite a deletion of the type I interferon receptor, strong expression of interferon-stimulated genes was observed in the lungs of IFNAR1-/- mice, contributing to clearance of the virus. In contrast, STAT1-/- mice exhibited a defect in the expression of interferon-stimulated genes and were unable to clear the infection, resulting in a lethal outcome. STAT1-/- mice exhibited dysregulation of T-cell and macrophage differentiation, leading to a TH2-biased immune response and the development of alternatively activated macrophages that mediate a profibrotic environment within the lung. We propose that a combination of impaired viral clearance and T-cell/macrophage dysregulation causes the formation of prefibrotic lesions in the lungs of rMA15-infected STAT1-/- mice.


title: Characteristics and diagnostic profile of patients seeking dementia care in a memory clinic in Hong Kong.

text: BACKGROUND Seeking medical advice for dementia involves an understanding of norms, values and attitudes towards care-giving and inter-dependency, which are culturally bounded. We hypothesize that local culture and socioeconomic structure affect our Chinese patients who present with forgetfulness to our memory clinic. METHODS A retrospective case notes review was undertaken on 454 consecutive patients referred to the memory clinic at Princess Margaret Hospital, Hong Kong. RESULTS 385 patients were diagnosed with dementia and 27 had mild cognitive impairment. Reversible dementia was identified in 24 patients and normal cognition in 18. In patients with dementia, 55.8% had Alzheimer's disease, 26.2% had vascular dementia, 6.0% had other irreversible dementia, 5.2% had dementia with Lewy bodies, 4.9% had undetermined dementia and 1.8% had frontotemporal dementia. The median duration from symptom onset to medical consultation was two years; 66.5% had advanced disease with initial Mini-mental State Examination scores < or = 17. On their first visit, 85% of patients were living in the community; after two years this proportion had fallen to 63%. CONCLUSIONS Dementia patients in Hong Kong apparently enjoy a long subclinical period and only seek medical attention at late stages. Local Chinese culture and socioeconomic backgrounds could be the main reasons that underlie these observations.


title: The Pipeline embolization device for treatment of intracranial aneurysms.

text: Flow diversion is a new endovascular technique developed for treatment of intracranial aneurysms. It is based on stent-induced modification of blood flow within and around an aneurysm inflow zone, leading to gradual intra-aneurysmal thrombosis and subsequent atrophy, while preserving flow into the parent vessel and perforating branches. Flow-diversion technique is well-suited for the treatment of large, giant, wide-necked, and fusiform intracranial aneurysms because it does not rely on endosaccular packing with coils but rather on the strategy of placing a stent across the aneurysm "neck" or across the diseased segment of a vessel in case of a fusiform aneurysm. Over time, neointimal endothelium covers the flow diverter such that it becomes incorporated into the parent vessel wall and occludes the aneurysm from the circulation, effectively repairing the diseased parent vessel segment. This report describes in detail the Pipeline embolization device (ev3-Covidien, Irvine, California, USA), its mechanism of action and deployment technique, and reviews the pertinent literature regarding safety, efficacy and potential risks and complications associated with the use of this flow diverter.


title: End-to-end cervical esophagogastric anastomoses are associated with a higher number of strictures compared with end-to-side anastomoses.

text: BACKGROUND Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses. METHODS A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed. RESULTS The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p = 0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p = 0.04). Moreover, a median of 11 (7-17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2-8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p < 0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p = 0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p = 0.03 and p = 0.01, respectively). CONCLUSION The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.


title: Treating acute anxiety in patients with COVID-19.

text: At present, there are no firm guidelines for the treatment of COVID-19-related emotional distress. The current approach is based on our knowledge of how to manage anxiety in medically ill patients, taking into consideration all associated medical comorbidities, drug-drug interactions, and the patient's specific needs and preexisting mental illness. Interventions should be implemented at the bedside to augment the patient's own resiliency in coping with these stressful events. A targeted combination of psychopharmacology (targeting acute anxiety and panic symptoms) and psychotherapy (relaxation techniques, breathing exercises, and encouragement) is recommended.


title: Mesh fixation in open IPOM procedure with tackers or sutures? A randomized clinical trial with preliminary results.

text: PURPOSE In open intra-peritoneal onlay mesh (IPOM) hernia repair, mesh fixation can be done by tacks, sutures or fibrin glue. There are randomized controlled trials (RCTs) on laparoscopic IPOM procedure, but no RCT so far has examined mesh fixation techniques in open IPOM repair. METHODS In a single-center RCT, 48 patients undergoing open IPOM repair of an abdominal wall hernia were included. After randomization, surgery was performed in a standardized fashion. Hernia size, extent of mesh fixation, and duration of surgery were documented. The primary endpoint was postoperative pain intensity. Secondary endpoints were: complications, length of stay, quality of life, return to work, hernia recurrence. Follow-up was 1 year in all 48 patients. RESULTS After using tacks, mean pain intensity was 16.9, which is slightly lower than after suture fixation (19.6, p = 0.20). The duration of surgery was about the same (83 vs. 85 min). When using tack fixation, significantly more fixation points were applied as compared to sutures (19 vs. 12; p = 0.02), although mesh size was similar. The complication rate was similar (tacks: 6/28 vs. sutures: 3/20). Cost of suture fixation was about 26 €, which is markedly lower than the 180 € associated with tacks. However, surgeons clearly preferred mesh fixation with tacks, because it is more comfortable especially in small hernias. CONCLUSIONS The present study failed to show an advantage of tacks over suture fixation and even there are more severe adverse events. Using tacks significantly increases the costs of hernia repair.


title: Feeding duodenostomy decreases the incidence of mechanical obstruction after radical esophageal cancer surgery.

text: BACKGROUND Nutritional support influences the outcome of gastroenterological surgery, and enteral nutrition effectively mitigates postoperative complications in highly invasive surgery such as resection of esophageal cancer. However, feeding via jejunostomy can cause complications including mechanical obstruction, which could be life threatening. From 2009, we began enteral feeding via duodenostomy to reduce the likelihood of complications. In this study, we compared duodenostomy with the conventional jejunostomy feeding, mainly looking at the catheter-related complications. METHODS The database records of 378 patients with esophageal cancer who underwent radical esophagectomy with retrosternal or posterior mediastinal gastric tube reconstruction in our department from January 1998 to December 2012 were examined. Of the 378 patients, 111 underwent feeding via duodenostomy (FD) and 267 underwent feeding via jejunostomy (FJ), and their records were reviewed for the following catheter-related complications: site infection, dislodgement, peritonitis, and mechanical obstruction. RESULTS Mechanical obstruction occurred in 12 patients in the FJ group but none in the FD group (4.5 % vs. 0 %, P = 0.023). Of the 12 cases, 7 (58.3 %) required surgery of which 2 had bowel resection due to strangulated mechanical obstruction. Catheter site infection was seen in 14 cases in the FJ group, of which 2 (14.2 %) had peritonitis following catheter dislocation, while only one case of site infection was seen in the FD group (5.2 % vs. 0.9 %, P = 0.078). CONCLUSIONS Feeding via duodenectomy could be the procedure of choice since neither mechanical obstruction nor relaparotomy was seen during enteral feeding through this technique.


title: [Informations and recommendations of the German Respiratory Society and the Paul-Ehrlich-Society for chemotherapy concerning the outbreak of influenza A(H7N9) virus infections in humans].

text: In March 2013, the first cases of avian influenza virus infections in humans were reported by the authorities of the PR of China to the World Health Organization. This influenza A(H7N9) virus comprises genes of at least four different avian influenza viruses, some segments mimicking human-like influenza-signatures. Until 11 August, 2013 135 humans were infected, 44 (33%) died. The clinical course is characterized by fever, cough, gastrointestinal symptoms, lympho- and thrombopenia as well by the rapid onset of an acute respiratory distress syndrome in nearly 25% of the cases. Although human to human transmission may have occurred only in the context of three clusters, strict hygiene measures should be instituted and any suspect case should be reported to the local health authorities immediately. The detection of influenza A(H7N9) is based on real-time polymerase chain reaction (PCR). Antiviral treatment should be initiated as early as possible for suspect, probable or confirmed cases, even when 48 hours have passed after symptom onset. At present the future development of this epidemic cannot be predicted.


title: Quantification of plasma remdesivir and its metabolite GS-441524 using liquid chromatography coupled to tandem mass spectrometry. Application to a Covid-19 treated patient.

text: Objectives A method based on liquid chromatography coupled to triple quadrupole mass spectrometry detection using 50 µL of plasma was developed and fully validated for quantification of remdesivir and its active metabolites GS-441524. Methods A simple protein precipitation was carried out using 75 µL of methanol containing the internal standard (IS) remdesivir-13C6 and 5 µL ZnSO4 1 M. After separation on Kinetex® 2.6 µm Polar C18 100A LC column (100 × 2.1 mm i.d.), both compounds were detected by a mass spectrometer with electrospray ionization in positive mode. The ion transitions used were m/z 603.3 → m/z 200.0 and m/z 229.0 for remdesivir, m/z 292.2 → m/z 173.1 and m/z 147.1 for GS-441524 and m/z 609.3 → m/z 206.0 for remdesivir-13C6. Results Calibration curves were linear in the 1-5000 μg/L range for remdesivir and 5-2500 for GS-441524, with limit of detection set at 0.5 and 2 μg/L and limit of quantification at 1 and 5 μg/L, respectively. Precisions evaluated at 2.5, 400 and 4000 μg/L for remdesivir and 12.5, 125, 2000 μg/L for GS-441524 were lower than 14.7% and accuracy was in the [89.6-110.2%] range. A slight matrix effect was observed, compensated by IS. Higher stability of remdesivir and metabolite was observed on NaF-plasma. After 200 mg IV single administration, remdesivir concentration decrease rapidly with a half-life less than 1 h while GS-441524 appeared rapidly and decreased slowly until H24 with a half-life around 12 h. Conclusions This method would be useful for therapeutic drug monitoring of these compounds in Covid-19 pandemic.


Why the World Bank ex-chief is on the warpath to end coronavirus transmission.


title: Relationships between geometrical parameters and mechanical properties for a helical braided flow diverter stent.

text: BACKGROUND Although flow diversion is a promising procedure for aneurysm treatment, the safety and efficacy of this strategy have not been sufficiently characterized. Both mechanical properties and flow reduction effects are important factors in the design of an optimal stent. OBJECTIVE We aimed to clarify the contributions of strut size and pitch to the mechanical properties (radial stiffness and longitudinal flexibility) and geometric characteristics (porosity and pore density) related to flow reduction effects. METHODS Crimping and bending behaviors of the stents were simulated with the finite element method. The relationships between the mechanical properties and geometric characteristics were investigated by changing the strut size and pitch. RESULTS Within the porosity range of 79-82%, the radial stiffness of the stent was similarly influenced by either the strut size or pitch. However, the longitudinal flexibility tended to be influenced more by strut size than by pitch. CONCLUSIONS Adjusting the strut size rather than the pitch can change the mechanical properties while minimizing the change in porosity or pore density related to flow reduction effects.


Tackling UK's mortality problem: covid-19 and other causes.


title: Identification and treatment of infected total hip arthroplasty.

text: Periprosthetic joint infection (PJI) in the hip following prosthetic joint placement is a devastating outcome of an otherwise often successful surgical treatment (total-hip arthroplasty). Management of PJI is dependent upon accurate diagnosis and successful treatment, both of which are challenging. Recently, great strides have been made in improving the diagnosis of PJI, which has no 'gold standard' diagnostic tool. Proper diagnosis is essential as untreated or undetected PJI can quickly lead to biofilm formation on the implant surface depending upon the infecting organism. Upon complete biofilm formation, successful treatment requires prosthetic resection with immediate or delayed reimplantation. Even with the most aggressive surgical treatment, PJI eradication currently has a success rate of approximately 80%. Unfortunately, technologies to improve the local delivery of antibiotics are not expected to be available in the near future.


title: The comparison of heavyweight mesh and lightweight mesh in an incisional animal model.

text: PURPOSE An incisional hernia may occur through the incision area following a surgical operation, through the trocar opening and even through drainage exit points. Various synthetic surgical meshes have recently been used for the surgical repair of incisional hernias. In this study, we analysed the burst strength forces of heavyweight mesh and lightweight mesh in an incisional animal model. METHODS Following experimental formation of incisional hernias in 32 Wistar albino rats, they were divided into four groups. Polypropylene suture was used for closure of the abdominal incision in Group 1. In Groups 2, 3 and 4, polyester, polypropylene + polyglactin and polypropylene meshes, respectively, were fixed on the surface of the fascia after closing the defects in the rats. Polypropylene and polyester meshes are classified as heavy mesh. Light mesh is composed of a non-absorbable part (polypropylene) and an absorbable part (polyglactin), which will disappear 80 days after implantation. The rats were sacrificed at the end of the experiment. The pullout force of the fascia and meshes were recorded by use of a digital tension meter. RESULTS The mean pullout forces for Groups 1, 2, 3 and 4 were found to be 123.4 +/- 13.3, 292.33 +/- 17.4, 281.66 +/- 16.3 and 310.60 +/- 26.1 N, respectively. CONCLUSION At the end of the experiment, the polypropylene (25 g/cm(2)) present in the lightweight mesh was found to lose only a small percentage of the burst strength compared to the polypropylene (85 g/cm(2)) present in the heavyweight mesh.


Covid-19: Lopinavir-ritonavir does not benefit hospitalised patients, UK trial finds.


How to get away from work mode during the coronavirus lockdown.


title: Immediate procedural outcomes in 35 consecutive pipeline embolization cases: a single-center, single-user experience.

text: BACKGROUND AND OBJECTIVE Flow diverters are an exciting new class of endovascular devices that treat aneurysms by curative reconstruction of the parent artery. The Pipeline embolization device (PED) is the first FDA-approved intracranial flow diverting device available in the USA. This paper presents periprocedural results with the device in a series of 35 consecutive cases. METHODS All patients who underwent PED treatment of an intracranial aneurysm at our institution following FDA approval of the device in April 2011 were included in the series. Patient demographics, aneurysm characteristics, procedural details and technical and clinical outcomes were analyzed. RESULTS Thirty-four patients (age range 23-78 years, mean 56.4 years) with 41 unruptured aneurysms (37 anterior circulation, four posterior circulation, mean size 11.4 mm, 20/21 large or giant) were treated with the PED in 35 cases (one patient had bilateral aneurysms treated on 2 separate occasions). Thirty-four of 35 cases (97%) were successfully completed. A total of 64 PEDs were implanted, with a mean number of 1.2 PEDs implanted per anterior circulation cases and 6.5 per posterior circulation cases. A single PED was implanted in 73% of cases. Immediate flow disruption occurred in 97% of the cases. The overall rate of major stroke or mortality was 3% (1/35 patients). Minor stroke, cranial nerve palsy, transient neurological deficit and groin complication occurred in one patient each (3% each, 12% total). CONCLUSION Treatment of cerebral aneurysms with the PED carries an acceptable risk profile when a rigorous and uniform technique is used. Although the long-term results will need to be analyzed, the immediate procedural outcomes in the study series using this technique appear quite promising.


title: Simulation study of the effects of interstitial fluid pressure and blood flow velocity on transvascular transport of nanoparticles in tumor microenvironment.

text: BACKGROUND AND OBJECTIVE Although nanoparticle preparations have great potential in the treatment of tumors, nanoparticle preparations have not achieved the desired therapeutic effect. The reason is that the abnormal tumor microenvironment prevents nanoparticles from effective concentrating and reaching tumor area. Therefore, it's very necessary to better understand the effect of the abnormal tumor microenvironment on the transvascular transport of nanoparticles to overcome this critical problem. METHODS In this paper, a tumor abnormal vascular-interstitial model was established, and the transvascular transport process of nanoparticles was simulated in the model by computational fluid dynamics (CFD) modeling. RESULTS The simulation results showed that the transport efficiency of nanoparticles decreased with increasing interstitial fluid pressure (IFP), and nanoparticles could not cross the blood vessel wall when the IFP approached the blood vessel wall pressure. Interestingly, the transport efficiency of nanoparticles first increased with blood flow velocity, and then decreased with blood flow velocity. CONCLUSIONS The results showed that with the continuous malignant development of tumors, the ability of nanoparticles to passively diffuse has almost disappeared. The enhanced permeability and retention (EPR) effect of the nanoparticles disappeared with the disappearance of the pressure gradient inside the tumor. These results provided guidance for future research on the vascular transport pathways and mechanisms of nanoparticles.


title: Pathogenesis of NEC: Impact of an altered intestinal microbiome.

text: Necrotizing enterocolitis (NEC), a disease most commonly seen in preterm infants, often presents without warning and is associated with very high mortality and morbidity. Progress in the prevention and treatment of NEC has been slow. In this article, we will discuss some of the reasons as to why this progress has been slow. We will describe some of the factors that appear to be highly associated and important components in the pathophysiology of NEC. We will discuss the intestinal microbial environment of the fetus as well as the preterm infant and how interaction of dysbiosis with an immature gastrointestinal tract combined with dietary factors play a role in the pathogenesis of NEC. Testable hypotheses are discussed as well as how these may lead to not only a better understanding of the pathophysiology of the disease but also the preventative strategies.


title: The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis.

text: BACKGROUND Concentrations of endogenous sex hormones fluctuate across the menstrual cycle (MC), which could have implications for exercise performance in women. At present, data are conflicting, with no consensus on whether exercise performance is affected by MC phase. OBJECTIVE To determine the effects of the MC on exercise performance and provide evidence-based, practical, performance recommendations to eumenorrheic women. METHODS This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four databases were searched for published experimental studies that investigated the effects of the MC on exercise performance, which included at least one outcome measure taken in two or more defined MC phases. All data were meta-analysed using multilevel models grounded in Bayesian principles. The initial meta-analysis pooled pairwise effect sizes comparing exercise performance during the early follicular phase with all other phases (late follicular, ovulation, early luteal, mid-luteal and late luteal) amalgamated. A more comprehensive analysis was then conducted, comparing exercise performance between all phases with direct and indirect pairwise effect sizes through a network meta-analysis. Results from the network meta-analysis were summarised by calculating the Surface Under the Cumulative Ranking curve (SUCRA). Study quality was assessed using a modified Downs and Black checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group. RESULTS Of the 78 included studies, data from 51 studies were eligible for inclusion in the initial pairwise meta-analysis. The three-level hierarchical model indicated a trivial effect for both endurance- and strength-based outcomes, with reduced exercise performance observed in the early follicular phase of the MC, based on the median pooled effect size (ES0.5 = - 0.06 [95% credible interval (CrI): - 0.16 to 0.04]). Seventy-three studies had enough data to be included in the network meta-analysis. The largest effect was identified between the early follicular and the late follicular phases of the MC (ES0.5 = - 0.14 [95% CrI: - 0.26 to - 0.03]). The lowest SUCRA value, which represents the likelihood that exercise performance is poor, or among the poorest, relative to other MC phases, was obtained for the early follicular phase (30%), with values for all other phases ranging between 53 and 55%. The quality of evidence for this review was classified as "low" (42%). CONCLUSION The results from this systematic review and meta-analysis indicate that exercise performance might be trivially reduced during the early follicular phase of the MC, compared to all other phases. Due to the trivial effect size, the large between-study variation and the number of poor-quality studies included in this review, general guidelines on exercise performance across the MC cannot be formed; rather, it is recommended that a personalised approach should be taken based on each individual's response to exercise performance across the MC.


title: Meta-Analysis of CSF Diversion Procedures and Dural Venous Sinus Stenting in the Setting of Medically Refractory Idiopathic Intracranial Hypertension.

text: BACKGROUND AND PURPOSE In medically refractory idiopathic intracranial hypertension, optic nerve sheath fenestration or CSF shunting is considered the next line of management. Venous sinus stenosis has been increasingly recognized as a treatable cause of elevated intracranial pressure in a subset of patients. In this article, we present the results of the largest meta-analysis of optic nerve sheath fenestration, CSF shunting, and dural venous sinus stenting. This is the only article that compares these procedures, to our knowledge. MATERIALS AND METHODS We performed a PubMed search of all peer-reviewed articles from 1988 to 2014 for patients who underwent a procedure for medically refractory idiopathic intracranial hypertension. RESULTS Optic nerve sheath fenestration analysis included 712 patients. Postprocedure, there was improvement of vision in 59%, headache in 44%, and papilledema in 80%; 14.8% of patients required a repeat procedure with major and minor complication rates of 1.5% and 16.4%, respectively. The CSF diversion procedure analysis included 435 patients. Postprocedure, there was improvement of vision in 54%, headache in 80%, and papilledema in 70%; 43% of patients required at least 1 additional surgery. The major and minor complication rates were 7.6% and 32.9%, respectively. The dural venous sinus stenting analysis included 136 patients. After intervention, there was improvement of vision in 78%, headache in 83%, and papilledema in 97% of patients. The major and minor complication rates were 2.9% and 4.4%, respectively. Fourteen additional procedures were performed with a repeat procedure rate of 10.3%. Three patients had contralateral stent placement, while 8 had ipsilateral stent placement within or adjacent to the original stent. Only 3 patients required conversion to CSF diversion or 2.2% of patients with stents. CONCLUSIONS Patients with medically refractory idiopathic intracranial hypertension have traditionally undergone a CSF diversion procedure as the first intervention. This paradigm may need to be re-examined, given the high technical and clinical success and low complication rates with dural venous sinus stenting.


COVID-19: Yin and Yang and Herd Immunity.


title: Functional analysis of the murine coronavirus genomic RNA packaging signal.

text: Coronaviruses selectively package genomic RNA into assembled virions, despite the great molar excess of subgenomic RNA species that is present in infected cells. The genomic packaging signal (PS) for the coronavirus mouse hepatitis virus (MHV) was originally identified as an element that conferred packaging capability to defective interfering RNAs. The MHV PS is an RNA structure that maps to the region of the replicase gene encoding the nonstructural protein 15 subunit of the viral replicase-transcriptase complex. To begin to understand the role and mechanism of action of the MHV PS in its native genomic locus, we constructed viral mutants in which this cis-acting element was altered, deleted, or transposed. Our results demonstrated that the PS is pivotal in the selection of viral genomic RNA for incorporation into virions. Mutants in which PS RNA secondary structure was disrupted or entirely ablated packaged large quantities of subgenomic RNAs, in addition to genomic RNA. Moreover, the PS retained its function when displaced to an ectopic site in the genome. Surprisingly, the PS was not essential for MHV viability, nor did its elimination have a severe effect on viral growth. However, the PS was found to provide a distinct selective advantage to MHV. Viruses containing the PS readily outcompeted their otherwise isogenic counterparts lacking the PS.


Increased internet search interest for GI symptoms may predict COVID-19 cases in US hotspots.


title: Anesthetic management including extracorporeal membrane oxygenation therapy of liver transplant recipient with life-threatening hypoxemia -a case report-.

text: We present a rare case of successful anesthetic management for a patient who had refractory hypoxia during liver transplantation (LT) with intraoperative veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support. A 49 year-old female patient underwent living donor LT. After reperfusion of the grafted liver, graft congestion and massive oozing developed. Thus it was decided to reoperate with a temporary gauze packing. However, the patient's condition deteriorated with azotemia and severe hypoxemia. VV ECMO with continuous renal replacement therapy was started 24 hours before secondary LT and maintained during secondary LT. VV ECMO was weaned 32 hours after secondary LT. This case indicates that not only after the LT but also before and during LT, VV ECMO can be a treatment option for the patient with end-stage liver disease combined with respiratory failure when there is the possibility of lung recovery.


The need for science in the practice of public health.


title: Single-incision versus conventional three-port laparoscopic appendectomy: A meta-analysis of randomized controlled trials.

text: PURPOSE The aim of this article was to compare the advantages and disadvantages of single-incision laparoscopic appendectomy (SILA) and conventional three-port laparoscopic appendectomy (CTLA). MATERIAL AND METHODS A meta-analysis was performed by analyzing all randomized controlled trials (RCTs) published in English that compared SILA and CTLA for appendicitis in adults and children. These studies compared these two methods from different angles including outcomes of interest, patient characteristics, operative time, pain visual analogue scales scores (VAS scores), length of hospital stay, time to return to full activity, resumption of diet, postoperative complications and cosmetic results The risk ratios (RR) and mean difference (MD) with 95% confidence intervals (CIs) were employed to assess the outcome. RESULTS Seven recent RCTs encompassing 1170 patients (586 SILA and 584 CTLA cases) were included in this meta-analysis. The pooled results demonstrated that conversion rate, drain inserted, reoperation, length of hospital stay, resumption of normal diet and postoperative complications were statistically comparable between the two groups. The postoperative abdominal pain within 24 h was -0.57 in favor of the SILA technique (p = 0.05). Compared with CTLA, SILA showed a better cosmetic satisfaction score (SMD, 0.58; 95% CI, 0.32-0.83; p < 0.0001) and shorter time to recover normal activity (WMD, -0.69; 95% CI, -1.11-0.26; p = 0.001). However, SILA has a longer operative time (WMD, 5.38; 95% CI, 2.94-7.83; p < 0.0001). CONCLUSIONS In selected patients, SILA was confirmed to be as safe and effective as CTLA. Despite the longer operative time, SILA has higher cosmetic satisfaction and shorter recovery time to normal activity. Due to the limitations of the available data, further research is needed.


title: HCoV-229E spike protein fusion activation by trypsin-like serine proteases is mediated by proteolytic processing in the S2' region.

text: Human coronavirus 229E (HCoV-229E) is responsible for common colds. Like other coronaviruses, HCoV-229E exploits cellular proteases to activate fusion mediated by the spike protein. We analysed the proteolytic processing of the HCoV-229E spike protein by trypsin-like serine proteases leading to activation of the fusion process. Unlike in other coronaviruses, HCoV-229E fusion activation appears to be a one-step process. Indeed, cleavage of the S1/S2 interface does not seem to be a prerequisite, and the fusion activation is highly reliant on the S2' region, with arginine residue 683 acting as the recognition site.


Discontinuation of antiviral drugs may be the reason for recovered COVID-19 patients testing positive again.


Cash, currency and COVID-19.


Impact of COVID 19: perspectives from gastroenterology.


title: Situation analysis of onchocerciasis in Cameroon: a protocol for systematic review of epidemiological studies and impact of disease control interventions.

text: BACKGROUND Many control methods have been implemented to tackle onchocerciasis and great successes have been achieved, leading to a paradigm shift from control of morbidity to interruption of transmission and ultimately elimination. The mandate of the African Programme for Onchocerciasis Control (APOC) ended in 2015, and endemic countries are to plan and conduct elimination activities by themselves, with technical assistance by the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN). To this end, an elimination expert committee was set up in Cameroon in 2018. This committee identified the need to update the data on the current situation of onchocerciasis. The present study aims to systematically review and report all available epidemiological data, including prevalence, intensity and transmission of onchocerciasis to provide pertinent information that will be useful to design optimal strategies to achieve onchocerciasis elimination in Cameroon. METHODS PubMed/MEDLINE, EMBASE and Web of Science will be searched from inception onwards. Grey literature will be identified through Google Scholar searches, dissertation databases and other relevant documents such as government reports. Eligible studies will be mostly observational, including cohort and cross-sectional surveys. No limitations will be imposed on publication status and study period. The primary outcomes will be (1) the prevalence and intensity of Onchocerca volvulus infection in humans, (2) transmission intensity and (3) impact of interventions on prevalence, intensity and transmission of onchocerciasis. Secondary outcomes will be environmental and socio-demographic factors supporting the primary outcomes. Two reviewers will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion. Methodological quality including bias will be appraised using appropriate approaches. A narrative synthesis will describe quality and content of the epidemiological evidence. Prevalence and intensity of infection estimates will be stratified according to gender, age, geographical location and year of publication. DISCUSSION This study will provide the health authorities as well as the scientific community with up-to-date information about the epidemiological situation of onchocerciasis in Cameroon. Understanding the spatiotemporal dynamics of the infection will help to define alternative and complementary strategies to accelerate onchocerciasis elimination in the country. Results of this review will also be used to update existing epidemiological models for onchocerciasis in order to fine-tune predictions of elimination timeframes in the country. SYSTEMATIC REVIEW REGISTRATION This protocol is under registration review in PROSPERO.


title: Comparison between circular- and linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass--a cohort from the Scandinavian Obesity Registry.

text: BACKGROUND Although laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common bariatric procedure worldwide, no consensus on the optimal technique for the gastrojejunostomy (GJ) has been reached. Circular stapling (CS) immediately results in a GJ of standardized width, whereas linear stapling (LS) requires a technically challenging closure of the stapler defect. The aim was to study differences in outcomes between CS and LS. SETTING Nationwide Swedish cohort. METHODS The Scandinavian Obesity Registry (SOReg) included prospective data from 34,284 primary LRYGB patients operated on in 2007-2013. We studied operative time, length of hospital stay, postoperative complications, and percent excess body mass index loss (%EBMIL) after 1 year. Outcomes were assessed through multivariate analysis adjusting for gender, age, preoperative body mass index (BMI), and diabetes. RESULTS Preoperatively the groups were similar (40.9 yr, BMI 42.4 kg/m(2), 76% female). For CS and LS, operative time and hospital stay were 114 and 73 minutes (P<.001) and 4.6 and 2.0 days (P<.001), respectively. Using LS as a reference, adjusted odds ratio (OR) for CS patients to have anastomotic leakage was 2.8 (95% CI 1.5-5.0), postoperative hemorrhage 1.9 (95% CI 1.2-2.9), wound complication 9.7 (95% CI 6.8-13.9), and marginal ulcer 3.1 (95% CI 1.8-5.3). The %EBMIL at 1 year was 80% for both techniques and 31% of total weight was lost. Follow-up rate at 6 weeks and 1 year was 96% and 73%, respectively. CONCLUSION CS was found to be associated with disadvantages regarding operative time, hospital stay, and postoperative complications compared with LS.


Lung ultrasonography in a woman with COVID-19: This examination could be remote.


title: A Coronavirus Associated with Runting Stunting Syndrome in Broiler Chickens.

text: Runting stunting syndrome (RSS) is a disease condition that affects broilers and causes impaired growth and poor feed conversion because of enteritis characterized by pale and distended small intestines with watery contents. The etiology of the disease is multifactorial, and a large variety of viral agents have been implicated. Here we describe the detection and isolation of an infectious bronchitis virus (IBV) -like coronavirus from the intestines of a flock of 60,000 14-day-old brown/red broiler chicks. The birds showed typical clinical signs of RSS including stunting and uneven growth. At necropsy, the small intestines were pale and distended with watery contents. Histopathology of the intestines revealed increased cellularity of the lamina propria, blunting of villi, and cystic changes in the crypts. Negative stain electron microscopy of the intestinal contents revealed coronavirus particles. Transmission electron microscopy of the intestine confirmed coronavirus in the cytoplasm of enterocytes. Using immunohistochemistry (IHC), IBV antigen was detected in the intestinal epithelial cells as well as in the proventriculus and pancreas. There were no lesions in the respiratory system, and no IBV antigen was detected in trachea, lung, air sac, conjunctiva, and cecal tonsils. A coronavirus was isolated from the intestine of chicken embryos but not from the allantoic sac inoculated with the intestinal contents of the broiler chicks. Sequencing of the S1 gene showed nucleic acid sequence identities of 93.8% to the corresponding region of IBV California 99 and of 85.7% to IBV Arkansas. Nucleic acid sequence identities to other IBV genotypes were lower. The histopathologic lesions in the intestines were reproduced after experimental infection of specific-pathogen-free chickens inoculated in the conjunctiva and nares. Five days after infection, six of nine investigated birds showed enteritis associated with IBV antigen as detected by IHC. In contrast to the field infection, birds in the experimental group showed clear respiratory signs and lesions in the upper respiratory tract. The results suggest a broader tissue tropism of this isolate, which might be related to the mutations in the S1 gene.


title: Measuring Error Identification and Recovery Skills in Surgical Residents.

text: BACKGROUND Although error identification and recovery skills are essential for the safe practice of surgery, they have not traditionally been taught or evaluated in residency training. This study validates a method for assessing error identification and recovery skills in surgical residents using a thoracoscopic lobectomy simulator. METHODS We developed a 5-station, simulator-based examination containing the most commonly encountered cognitive and technical errors occurring during division of the superior pulmonary vein for left upper lobectomy. Successful completion of each station requires identification and correction of these errors. Examinations were video recorded and scored in a blinded fashion using an examination-specific rating instrument evaluating task performance as well as error identification and recovery skills. Evidence of validity was collected in the categories of content, response process, internal structure, and relationship to other variables. RESULTS Fifteen general surgical residents (9 interns and 6 third-year residents) completed the examination. Interrater reliability was high, with an intraclass correlation coefficient of 0.78 between 4 trained raters. Station scores ranged from 64% to 84% correct. All stations adequately discriminated between high- and low-performing residents, with discrimination ranging from 0.35 to 0.65. The overall examination score was significantly higher for intermediate residents than for interns (mean, 74 versus 64 of 90 possible; p = 0.03). CONCLUSIONS The described simulator-based examination with embedded errors and its accompanying assessment tool can be used to measure error identification and recovery skills in surgical residents. This examination provides a valid method for comparing teaching strategies designed to improve error recognition and recovery to enhance patient safety.