title: A New Concept in Bariatric Surgery. Single Anastomosis Gastro-Ileal (SAGI): Technical Details and Preliminary Results.

text: BACKGROUND In one anastomosis gastric bypass (OAGB), the measurement of the afferent limb starting at the angle of Treitz may result in insufficient absorptive surface of the intestine of the remaining efferent limb. To address this concern, we recently modified the technique of OAGB by constructing the gastrointestinal anastomosis at a fixed distance from the ileocecal valve (i.e., 300 cm). We adopted the new concept and named it the single anastomosis gastro-ileal bypass (SAGI). METHODS Seven consecutive patients with morbid obesity underwent the SAGI procedure. RESULTS There were no intraoperative complications and there were no deaths. The mean excess weight (EW) loss was 55.1 % at 3 months and 82.1 % at 6 months. CONCLUSIONS The SAGI procedure may constitute a safer alternative to the conventional OAGB.


title: The FRED flow-diverter stent for intracranial aneurysms: clinical study to assess safety and efficacy.

text: BACKGROUND AND PURPOSE Flow-diverter stents are emerging for the endovascular treatment of difficult-to-treat or otherwise untreatable cerebral aneurysms (wide-neck, fusiform, dissecting, blisterlike, or giant). We assessed the clinical safety and efficacy of the Flow-Redirection Endoluminal Device. MATERIALS AND METHODS This was an institutional review board-approved single-center observational clinical study in 29 patients with 34 aneurysms elected to be treated by endovascular intervention. After providing informed consent, patients were included according to the following criteria: aneurysm fundus-to-neck ratio <2 or neck diameter >4 mm, fusiform, dissecting, or giant aneurysms. The primary end point for clinical safety was the absence of death, absence of major or minor stroke, and absence of transient ischemic attack. The primary end point for treatment efficacy was complete angiographic occlusion according to the O'Kelly Marotta grading scale immediately after the procedure and at follow-up after 3 and 6 months (O'Kelly Marotta D: complete occlusion). RESULTS The Flow-Redirection Intraluminal Device deployment was technically successful in all cases. In 26/29 (89%) of patients, the primary end point of safety was reached; in the 3 remaining patients, 1 disabling ischemic stroke and 2 minor strokes with complete recovery at follow-up were observed. Angiographic (DSA and MRA) and clinical follow-up were available after 3 months in 29/29 (100%) and after 6 months in 25/29 (86%) patients (after 6 months, only MRA follow-up was performed according to our study protocol and institutional standard). At 3-month follow-up, complete occlusion was reached in 19/34 aneurysms (O'Kelly Marotta D: 19/34; 56%). At 6-month follow-up, aneurysm occlusion was complete in 22/30 aneurysms (O'Kelly Marotta D: 22/30; 73%). CONCLUSIONS Deployment of the Flow-Redirection Intraluminal Device flow-diverter stent is safe and effective in the treatment of difficult-to-treat or otherwise untreatable intracranial aneurysms.


title: Radiographic Identification of Arthroscopically Relevant Proximal Femoral Structures.

text: BACKGROUND Anatomic landmarks located on the proximal femur have only recently been defined, and there is a lack of radiographic guidelines for their locations presented in the literature. With the confident identification of these landmarks, radiographs could provide more assistance in preoperative evaluations, intraoperative guidance, and postoperative assessments. PURPOSE To quantify the radiographic locations of endoscopic landmarks of the proximal femur. STUDY DESIGN Descriptive laboratory study. METHODS Ten cadaveric specimens were dissected, and radio-opaque hardware was placed for each landmark of interest. Radiographs were obtained and measurements recorded in anteroposterior (AP) and Dunn 45° views. RESULTS In the AP view, the gluteus medius insertion was located a mean 12.9 ± 2.4 mm and 34.7 ± 5.1 mm from the piriformis fossa and vastus tubercle, respectively. The piriformis fossa was a mean 14.8 ± 5.9 mm and 4.9 ± 1.9 mm from the anterior and posterior tips of the greater trochanter, respectively. The anterior and posterior tips of the greater trochanter were a mean 14.8 ± 5.1 mm from each other. In the Dunn 45° view, the piriformis fossa was a mean 13.3 ± 2.0 mm, and the vastus tubercle was a mean 21.5 ± 6.0 mm, from the gluteus medius insertion. Moreover, the vastus tubercle was a mean 33.5 ± 6.4 mm from the anterior tip of the greater trochanter and 31.6 ± 8.5 mm from the posterior tip of the greater trochanter. CONCLUSION In spite of the variation in cadaveric sizes, quantitative descriptions of endoscopic landmarks were reproducible in clinical views. CLINICAL RELEVANCE A detailed understanding of how the described landmarks present radiographically is relevant to preoperative planning, intraoperative evaluations, and postoperative assessments.


title: Embolization is essential in the treatment of leg varicosities due to pelvic venous insufficiency.

text: PURPOSE Pelvic venous insuffiency (PVI) can be responsible for pelvic congestion syndrome (PCS) and also lower limb varicose veins. MATERIAL AND METHODS Charts of all women who had pelvic venography for PVI from September 2013 to August 2014 were reviewed. The procedure was performed under local anesthesia through left femoral approach. In case of reflux without associated obstructive lesions, embolization with coils and polidocanol foam was performed during the same procedure. RESULTS 119 women, with median age 39 years were explored (86 with PCS and 102 with lower limb venous disease). Of these, 78 had an isolated reflux and were embolized and 41 had an obstructive disease (29 iliocaval obstructive lesions (ICOL), 4 nutcracker syndrome (NCS), and 8 with an association of both). Median follow-up was 4 months. Of the 12 NCS, 5 had surgical treatment and 7 had stenting of the left iliac vein without embolization. All patients with ICOL without NCS were treated by stenting in 28 and by a Palma procedure in 1 (failure to recanalize). Primary and secondary patency rates were 97% at 12 months. Embolization led to improvement of PCS in 91% (60% without any pain) and of lower limb varicose veins in 51% by itself. If 82% need an additional treatment of lower limb varicose veins, embolization allowed a switch of strategy from surgery to sclerosis. CONCLUSION PVI can cause lower limb symptoms. In most cases, it is due to reflux and can be treated under local anesthesia by embolization. This technique is safe and efficient. Obstructive lesions must be recognized and treated.


title: Interventions for preventing falls in older people in care facilities and hospitals.

text: BACKGROUND Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012. OBJECTIVES To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017. SELECTION CRITERIA Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals. DATA COLLECTION AND ANALYSIS One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence. MAIN RESULTS Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.


title: Fiducial marker placement via conventional or electromagnetic navigation bronchoscopy (ENB): an interdisciplinary approach to the curative management of lung cancer.

text: BACKGROUND AND AIMS Conventional and electromagnetic navigation bronchoscopy (ENB) is generally used as a diagnostic tool in suspicious pulmonary nodules. The use of this technique for the placement of fiducial markers in patients with inoperable but early-stage lung cancer could present an innovative approach enabling risk-reduced therapy. METHODS We present seven clinical cases where conventional bronchoscopy and ENB were used as part of an experimental interdisciplinary approach to clinical management and therapy planning. In each case, we analyzed the clinical indication, endoscopic procedures and post-interventional outcome. RESULTS In six patients (three females, three males) with peripheral non-small cell lung cancer (NSCLC), stage cT1cN0cM0, surgery and conventional stereotactic radiation therapy was not possible because of end-stage chronic obstructive pulmonary disease. ENB was used for fiducial marker placement prior to cyberknife radiotherapy. No procedure-related complications were observed. Complete remission could be achieved in four cases, partial remission in two cases and no relevant complications induced by radiotherapy were observed. In one male patient, an endoluminal relapse in the right lower lobe was diagnosed following a right upper lobe resection for a NSCLC. The tumor could not be clearly identified by computerized tomography, so that the bronchoscopic placement of a fiducial marker in the tumor was performed in order to allow stereotactic radiochemotherapy, by which complete remission could be achieved. CONCLUSION Fiducial marker placement may be an interesting bronchoscopic technique in the interdisciplinary therapeutic approach to inoperable early-stage lung cancer. In the described cases, therapy planning was successful and no procedure-related complications were observed.


title: Risk mitigation for travelers - managing endemic and emerging threats.

text: International travel continues to increase in numbers and complexity. Despite the availability of pre-travel health advice, travelers remain at risk for exposure to common organisms as well as emerging pathogens. With low rates of travel clinic utilization, it is important for the general practitioner to remain aware of the importance of travel health, risk factors unique to individual patients, and evolving threats. This review highlights important considerations when evaluating ill travelers, incorporating emerging infectious threats.


title: Pediatric Percutaneous Osteoid Osteoma Ablation: Cone-Beam CT with Fluoroscopic Overlay Versus Conventional CT Guidance.

text: PURPOSE To compare technical success, clinical success, complications, radiation dose, and total room utilization time for osteoid osteoma thermal (radiofrequency or microwave) ablation using cone-beam computed tomography (CBCT) with two-axis fluoroscopic navigational overlay versus conventional computed tomography (CT) guidance. MATERIALS AND METHODS A retrospective review was performed to identify all osteoid osteoma ablations performed over a 5.5-year period at a single tertiary care pediatric hospital. Twenty-five ablations (15 radiofrequency and 10 microwave) in 23 patients undergoing fluoroscopic CBCT-guided osteoid osteoma ablation were compared to 35 ablations (35 radiofrequency) in 32 patients undergoing ablation via conventional CT guidance. Dose area product and dose length product were recorded for CBCT and conventional CT, respectively, and converted to effective doses. Technical success, clinical success (cessation of pain and medication use 1 month after ablation), complications, radiation dose, and total room utilization time were compared. RESULTS All procedures were technically successful. Twenty-two of 25 (88.0%) CBCT and 31 of 35 (88.6%) conventional CT-guided ablations achieved immediate clinical success. There were two minor complications in each group and no major complications. Mean effective radiation dose was significantly lower for CBCT compared to CT guidance (0.12 vs. 0.39 mSv, p = 0.02). Mean total room utilization time for CBCT was longer (133.5 vs. 97.5 min, p = 0.0001). CONCLUSIONS Fluoroscopic CBCT guidance for percutaneous osteoid osteoma ablation yields similar technical and clinical success, reduced radiation dose, and increased total room utilization time compared to conventional CT guidance.


title: Meta-analysis of trials on mortality after percutaneous coronary intervention compared with medical therapy in patients with stable coronary heart disease and objective evidence of myocardial ischemia.

text: Outcomes of percutaneous coronary intervention (PCI) versus medical therapy (MT) in the management of stable ischemic heart disease (SIHD) remain controversial, with some but not all studies showing improved results in patients with ischemia. We sought to elucidate whether PCI improves mortality compared to MT in patients with objective evidence of ischemia (assessed using noninvasive imaging or its invasive equivalent). We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PCI to MT in patients with SIHD. To maintain a high degree of specificity for ischemia, studies were only included if ischemia was defined on the basis of noninvasive stress imaging or abnormal fractional flow reserve. The primary outcome was all-cause mortality. We identified 3 RCTs (Effects of Percutaneous Coronary Interventions in Silent Ischemia After Myocardial Infarction II, Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2, and a substudy of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial) enrolling a total of 1,557 patients followed for an average of 3.0 years. When compared with MT in this population of patients with objective ischemia, PCI was associated with lower mortality (hazard ratio 0.52, 95% confidence interval 0.30 to 0.92, p=0.02). There was no evidence of study heterogeneity or bias among included trials. In this meta-analysis of published RCTs, PCI was shown to have a mortality benefit over MT in patients with SIHD and objective assessment of ischemia using noninvasive imaging or its invasive equivalent. In conclusion, this study provides insight into the management of a higher-risk SIHD population that is the focus of the ongoing International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial.


title: Clinical Features and Outcome of 65 Laboratory Confirmed Cases of H1N1 in Muscat, Sultanate of Oman.

text: OBJECTIVES Responding to Pandemic Influenza A (H1N1) virus alert in 2009, Ministry of Health (MoH), Sultanate Of Oman arranged task force to deal with the emergency. MOH published articles in newspapers, prepared guidelines and hospitals were assigned to admit patients of H1N1. All the patients suspected of H1N1 were admitted and isolated as per the guidelines. This report describes clinical features and outcomes of 65 laboratory confirmed cases of H1N1 in Muscat, Sultanate of Oman. METHODS From July to October 2009, 101 cases suspected of suffering from Pandemic Influenza A (H1N1) virus were admitted and isolated in Al Nahdha Hospital in Muscat. All the patients on admission were tested for H1N1, by real time reverse transcriptase polymerase chain reaction (RT-PCR). Immediately on admission, all of them were treated with Oseltamivir and antibiotics. RESULTS Of the 65 confirmed cases of H1N1, 53.84% were males. Age of patients varied from 14 to 60 years, while 53.7% were aged between 31 to 55 years. Results showed that 70.8% had underlying co-morbidity; among which diabetes mellitus and respiratory illness were common. The most common presenting symptoms were fever (95%) and cough (94%). Also, 20% of the patients had leucopenia and 10.8% leucocytosis. Deranged LFT was observed in 26 (42.6%) of cases while 14 (21.5%) had hypokalemia. One patient (0.01%) with underlying severe co-morbidity died. Two patients (3.1%) had ARDS (Acute Respiratory Distress Syndrome); both recovered. Radiological infiltration was documented in 84.6% of cases, with lower zone involvement as the common finding. Hospital stay was between 1 to 12 days, 49.2% of patients were discharged within 3 days. CONCLUSION Mainly adult population was affected during this epidemic. H1N1 infection can lead to severe illness. Incidence of H1N1 was higher in patients with underlying co-morbidity. Timely intervention and administration of Oseltamivir may need to be modified.


title: New suturing technique for robotic-assisted vaginal cuff closure during single-site hysterectomy.

text: To describe a simple and efficient technique for suturing the vaginal cuff in robotic-assisted single-site hysterectomy using barbed suture and a straight needle. Consecutive patients undergoing robotic-assisted single-site hysterectomy from February 2014 to August 2015 at Dong San Hospital, Keimyung University were included. Surgeons used two barbed sutures in a running fashion to close the vaginal cuff. A barbed suture was exclusively used with a straightened needle in upward direction from posterior vaginal cuff to anterior vaginal cuff which played a pivotal role for closure. A total of 100 patients underwent robotic-assisted single-site hysterectomy. The total operation time was 132.5 min and vaginal cuff closure time was 12.0 min. There were no postoperative complications; vaginal cuff dehiscence, vaginal cuff infection, and vaginal bleeding that require surgical intervention or admission. The use of barbed suture with straightened needle to close the vaginal cuff in robotic-assisted single-site hysterectomy is easy to perform and demonstrates safety and efficacy. This technique offers secure, fast, and effective incision closure.


title: Human coronavirus OC43 and other respiratory viruses from acute respiratory infections of Egyptian children.

text: Respiratory infections have a significant impact on health worldwide. Viruses are major causes of acute respiratory infections among children. Limited information regarding its prevalence in Egypt is available. This study investigated prevalence of 10 respiratory viruses; Adenovirus, influenza A, B, respiratory syncytial virus (RSV), Parainfluenza virus (PIV)type 1-4, enterovirus, and human coronavirus OC43 (HCoV-OC43) among children in Alexandria, Egypt presenting with acute lower respiratory tract infections. The study was conducted on children <14 years of age selected from ElShatby Pediatric Hospital, Alexandria University, Egypt. One hundred children presenting during winter season with influenza-like illness were eligible for the study. Oropharyngeal swabs were collected and subjected to viral RNA and DNA extraction followed by polymerase chain reaction. Viral infections were detected in 44% of cases. Adenovirus was the most common, it was found in 19% of the patients. Prevalence of PIV (3 and 4) and enterovirus was 7% each. Prevalence of RSV and HCoV-OC43 was 5% and 3% respectively. Two percentage were Influenza A positive and 1% positive for influenza B. Mixed viral infection was observed in 7%. To the best of our knowledge, this is the first report of the isolation of HCoV-OC43 from respiratory infections in Alexandria, Egypt.


On the front lines of the coronavirus-vaccine battle.


Poster presentations.


title: Inhibition of inflammatory cytokines after early decompression may mediate recovery of neurological function in rats with spinal cord injury.

text: A variety of inflammatory cytokines are involved in spinal cord injury and influence the recovery of neuronal function. In the present study, we established a rat model of acute spinal cord injury by cerclage. The cerclage suture was released 8 or 72 hours later, to simulate decompression surgery. Neurological function was evaluated behaviorally for 3 weeks after surgery, and tumor necrosis factor α immunoreactivity and apoptosis were quantified in the region of injury. Rats that underwent decompression surgery had significantly weaker immunoreactivity of tumor necrosis factor α and significantly fewer apoptotic cells, and showed faster improvement of locomotor function than animals in which decompression surgery was not performed. Decompression at 8 hours resulted in significantly faster recovery than that at 72 hours. These data indicate that early decompression may improve neurological function after spinal cord injury by inhibiting the expression of tumor necrosis factor α.


The course of Covid 19 in Inflammatory Bowel Disease: protective role of TNF antagonists Response to: Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry.


title: Boiling points of the propylene glycol + glycerol system at 1 atmosphere pressure: 188.6-292 °C without and with added water or nicotine.

text: In electronic cigarettes ("electronic nicotine delivery systems", ENDS), mixtures of propylene glycol (PG) and/or glycerol (GL; aka "vegetable glycerin", VG) with nicotine are vaporized to create a nicotine-containing aerosol. For a given composition, the temperature required to boil the liquid at 1 atmosphere must be at least somewhat greater than the boiling point (BP). The use of ENDS is increasing rapidly worldwide, yet the BP characteristics of the PG + GL system have been characterized as the mixtures; here we re-do this, but significantly, also study the effects of added water and nicotine. BP values at 1 atmosphere pressure were measured over the full binary composition range. Fits based on the Gibbs-Konovalov theorem provide BP as a function of composition (by mole-percent, by weight-percent, and by volume-percent). BPs of PG + GL mixtures were then tested in the presence of additives such as water (2.5 and 5 mol% added) and nicotine (3 mol%). Water was found to decrease the BP of PG + GL mixtures significantly at all compositions tested, and nicotine was found to decrease the BP of PG + GL mixtures containing ~75 GL: 25 PG (by moles) or more. The effect of added water (5, 10, and 15 mol% added) on electronic cigarette degradation production (some aldehydes and formaldehyde hemiacetals) was examined and found to have no significant impact on solvent (PG or GL) degradation for the particular device used.


Covid-19: medical students should not work outside their competency, says BMA.


The global health security agenda in an age of biosecurity.


title: Bench study of a new device to display and maintain stable artificial airway cuff pressure.

text: BACKGROUND Artificial airway cuff pressure should be maintained within a narrow range. Excessive cuff pressure presents a risk of tracheal damage and stenosis. Insufficient cuff pressure adds the risk of secretion leak past the cuff, tidal-volume leakage, and accidental extubation. The available cuff-inflation devices do not address these problems. OBJECTIVE In the laboratory I developed and evaluated a new cuff-inflation device that continuously displays the cuff pressure and maintains stable cuff pressure. METHODS The cuff-inflation device evaluation included: test the manometer accuracy; compare the displayed pressure to the pressure delivered to the pilot balloon; determine the device's response to cuff-pressure changes with the addition of 5 mL or 10 mL of air after achieving a 30 cm H(2)O baseline; measure the V(T) leak in an intubated artificial trachea by comparing the device results to benchmark measurements; and determine the stability of baseline cuff pressure during routine cuff checks. RESULTS The mean ± SD bias and precision of device's display, compared to the calibration analyzer, was 1.3 ± 2.6 cm H(2)O. The pressure delivered by the cuff-inflation device's gas-sampling line to the pilot balloon was equal to the pressure displayed by the cuff-inflation device. With the cuff-inflation device the cuff pressure was unchanged, compared to baseline, after adding 5 mL or 10 mL of air. With 2 current cuff methods, cuff pressure increased to means exceeding 160 cm H(2)O and 300 cm H(2)O, respectively. Compared to the benchmark, the difference in exhaled V(T) mean ± SD bias and precision were: cuff-inflation device 1.4 ± 4.8 mL, and syringe-inflation method 2.4 ± 6.2 mL. Representing a single cuff pressure check, disconnecting the endotracheal-tube pilot balloon from the cuff-inflation device's gas-sampling line and then reconnecting it had no effect on baseline cuff pressure at 2 seconds or 60 seconds. CONCLUSIONS The cuff-inflation device demonstrated possible improvements over available cuff-inflation devices and cuff-pressure-control methods.


title: Novel technologies in the treatment of intracranial aneurysms.

text: The treatment of intracranial aneurysms has undergone precipitous expansion since the first detachable coils were used less than two decades ago. With rapidly expanding technology comes the need to keep all involved parties informed. The objective of our review is to provide a comprehensive, succinct overview of novel paradigms and devices used to treat intracranial aneurysms. We have divided these new technologies into: (1) coils, (2) flow diverters, (3) adjunctive balloon devices, and (4) stents.


title: Pedicled facial buccinator (FAB) flap: a new flap for reconstruction of skull base defects.

text: BACKGROUND The expansion of endoscopic endonasal skull base surgery has resulted in an increased demand for reconstructive options. Reconstruction with vascularized tissue has proven indispensable for reliably separating the cranial contents from the paranasal sinuses following extended endoscopic endonasal approaches (EEA). The introduction of the Hadad-Bassagasteguy flap (vascular pedicle nasoseptal flap, HBF) at our institution decreased our postoperative cerebral spinal fluid (CSF) leak rates from more than 20% to less than 5%. The HBF is not always available, as the nasoseptal area or its vascular supply can be compromised by tumor or prior surgery. In an attempt to keep pace with rapidly expanding reconstructive requirements, we present the anatomic and cadaveric foundations for novel modifications of the facial artery musculo (-mucosal) (FAM[M]) and buccinator flaps to allow vascularized reconstruction of the skull base. STUDY DESIGN Feasibility. Cadaveric study. METHODS Using cadaver dissections and measurements, we investigated the feasibility of transposing pedicled buccinator myo/myomucosal flaps into the nasal cavity and skull base. Both muscular and myomuscular flaps were raised, and techniques for transposition into the nasal cavity were investigated. Three fresh and six preserved human specimens were dissected. RESULTS Pedicled facial buccinator flaps with and without mucosa were transposed into the nasal cavity using a variety of maxillary osteotomies. No facial incisions were required. It was demonstrated that the flaps reach the anterior skull base and planum sphenoidale. CONCLUSIONS The transposition of pedicled buccinator muscle flaps with and without mucosa into the nasal cavity could reach the anterior skull base and planum sphenoidale, if the appropriate surgical technique is used. The pedicled Facial Buccinator Flap holds significant potential as a reconstructive alternative for a variety of skull base defects, alone or in combination with existing reconstructive options. 2010.


title: Oral antihistamine-decongestant-analgesic combinations for the common cold.

text: BACKGROUND Although combination formulas containing antihistamines, decongestants and/or analgesics are sold over-the-counter (OTC) in large quantities for the common cold, the evidence of effectiveness is limited. OBJECTIVES To assess the effectiveness of antihistamine-decongestant-analgesic combinations in reducing the duration and alleviating the symptoms of the common cold in adults and children. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, OLDMEDLINE (1953 to 1965), MEDLINE (1966 to November Week 3, 2011) and EMBASE (1990 to December 2011). SELECTION CRITERIA Randomised controlled trials (RCTs) investigating the effectiveness of antihistamine-decongestant-analgesic combinations compared with placebo, other active treatment (excluding antibiotics) or no treatment in children and adults with the common cold. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and summarised data on general recovery, nasal obstruction, rhinorrhoea, sneezing, cough and side effects. We categorised the trials according to the active ingredients. MAIN RESULTS We included 27 trials (5117 participants) of common cold treatments. Fourteen trials studied antihistamine-decongestant combinations; two antihistamine-analgesic; six analgesic-decongestant; and five antihistamine-analgesic-decongestant combinations. In 21 trials the control intervention was placebo and in six trials an active substance. Reporting of methods in most trials was poor and there were large differences in design, participants, interventions and outcomes. Pooling was only possible for a limited number of studies and outcomes.Antihistamine-decongestant: 12 trials. Eight trials report on global effectiveness, six could be pooled; n = 309 on active treatment, n = 312 placebo) the odds ratio (OR) of treatment failure was 0.27 (95% confidence interval (CI) 0.15 to 0.50); the number needed to treat for an additional beneficial outcome (NNTB) was four (95% CI 3 to 5.6). On the final evaluation day 41% of participants in the placebo group had a favourable response compared to 66% on active treatment. Of the two trials that were not included in the pooling, one showed some global effect, the other showed no effect.Antihistamine-analgesic: three trials. Two reported on global effectiveness, data from one study was presented. (n = 290 on active treatment, n = 292 ascorbic acid). The OR of treatment failure was 0.33 (95% CI 0.23 to 0.46) and the NNTB was 6.67 (95% CI 4.76 to 12.5). After six days of treatment 43% were cured in the control group and 70% in the active treatment group. The second study also showed an effect in favour of active treatment.Analgesic-decongestant: six trials. One trial reported on global effectiveness: 73% benefited compared with 52% in the control group (paracetamol) (OR 0.28, 95% CI 0.15 to 0.52).Antihistamine-analgesic-decongestant: Five trials. Four trials reported on global effectiveness, two could be pooled: global effect reported (less than one severity point on a four or five-point scale) with active treatment (52%) and placebo (34%); the OR of treatment failure was 0.47 (95% CI 0.33 to 0.67) and the NNTB was 5.6 (95% CI 3.8 to 10.2). Two other trials found no beneficial effect. Two other studies did not show any effect.Two studies with antihistamine-decongestant (113 children) could not be pooled. There was no significant effect of the active treatment.Adverse effects: the combination of antihistamine-decongestant had more adverse effects than the control intervention but the difference was not significant: 157/810 (19%) versus 60/477 (13%) participants suffered one or more adverse effects (OR 1.58, 95% CI 0.78 to 3.21). Analgesic-decongestant combinations had significantly more adverse effects than control (OR 1.71, 95% CI 1.23 to 2.37); the number needed to treat for an additional harmful outcome (NNTH) was 14. None of the other two combinations caused significantly more adverse effects. Antihistamine-analgesic: 11/90 with combination suffered one or more adverse effects (12%) versus 9/91 (10%) with control (OR 1.27, 95% CI 0.50 to 3.23). Antihistamine-analgesic-decongestant: in one study 5/224 (2%) suffered adverse effects with active treatment versus 9/208 (4%) with placebo. Two other trials reported no differences between treatment groups but numbers were not reported. AUTHORS' CONCLUSIONS Current evidence suggests that antihistamine-analgesic-decongestant combinations have some general benefit in adults and older children. These benefits must be weighed against the risk of adverse effects. There is no evidence of effectiveness in young children.


title: Transumbilical 2-site laparoscopic Roux-en-Y gastric bypass: initial results of 100 cases and comparison with traditional laparoscopic technique.

text: BACKGROUND Single-site or single-incision laparosopic surgery has recently been developed, but it is difficult to use in more complicated gastric bypass surgery. We have introduced a 2-site modified single-incision laparosopic surgery technique for laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS We used the umbilical site incision to place 2 ports (12 and 10 mm) to serve as the video port and working port for the stapler. Another small skin incision was placed at a left lateral abdominal site for the 5-mm working port. Through these working channels, we could use conventional laparoscopic instruments to perform LRYGB. The data from 100 consecutive 2-site LRYGB procedures (February 2009 to September 2009) were compared with the data from 100 traditional LRYGB procedures (September 2008 to January 2009). RESULTS The mean body mass index for the study group was 43 kg/m(2) (range 32-61), and mean age was 34 years (range 18-55). The procedures were successfully performed in all but 18 patients. These 18 patients had required an extra skin incision for a 5-mm port to complete the procedures. The mean operating time was 144 minutes (range 95-160), and blood loss was 56 mL (range 20-150). A total of 3 perioperative major complications (3%) occurred, and 6 patients (6%) had minor complications. The 2-site LRYGB group had a significantly longer operating time and more blood loss than the traditional LRYGB group but less pain and better cosmesis. CONCLUSION Two-site LRYGB generated minimal somatic pain and achieved excellent cosmetic results. We believe it can be applied as routine LRYGB surgery.


Hemato- Oncology Care in COVID-19 Pandemic: Crisis within a Crisis.


title: SPIDER surgical system for urologic procedures with laparoendoscopic single-site surgery: from initial laboratory experience to first clinical application.

text: This case study describes our initial laboratory experience using the SPIDER surgical system (TransEnterix, Morrisville, NC, USA) for laparoendoscopic single-site surgery (LESS) urologic procedures and reports its first clinical application. The SPIDER system was tested in a laboratory setting and used for a clinical case of renal cyst decortication. Three tasks were performed during the dry lab session, and different urologic procedures were conducted in a porcine model. The time to complete the tasks and penalties were registered during the dry lab session. Perioperative outcomes and subjective assessment by the surgeons were registered. The surgeons had a positive experience with the SPIDER system, with a mean overall score of 3.6 (on a scale of 1-5). The surgeons were able to gain proficiency in performing tasks regardless of their level of expertise. The highest scores recorded were for ease of device insertion, instrument insertion and exchange, and triangulation. The lowest scores were for retraction. During the clinical case, the platform provided good triangulation without instrument clashing. However, retraction was challenging because of the lack of strength and precise maneuverability with the tip of the instruments fully deployed. The SPIDER system offers intuitive instrument maneuverability and restored triangulation without external instrument clashing. Further refinements are awaited to define its role in the urologic LESS armamentarium.


title: Thoracoscopic repair of esophageal atresia with a distal fistula - lessons from the first 10 operations.

text: INTRODUCTION Thoracoscopic esophageal atresia (EA) repair was first performed in 1999, but still the technique is treated as one of the most complex pediatric surgical procedures. AIM The study presents a single-center experience and learning curve of thoracoscopic repair of esophageal atresia and tracheo-esophageal (distal) fistula. MATERIAL AND METHODS From 2012 to 2014, 10 consecutive patients with esophageal atresia and tracheo-esophageal fistula were treated thoracoscopically in our center. There were 8 girls and 2 boys. Mean gestational age was 36.5 weeks and mean weight was 2230 g. Four children had associated anomalies. The surgery was performed after stabilization of the patient between the first and fourth day after birth. Five patients required intubation before surgery for respiratory distress. Bronchoscopy was not performed before the operation. RESULTS In 8 patients, the endoscopic approach was successfully used thoracoscopically, while in 2 patients conversion to an open thoracotomy was necessary. In all patients except 1, the anastomosis was patent, with no evidence of leak. One patient demonstrated a leak, which did not resolve spontaneously, necessitating surgical repair. In long-term follow-up, 1 patient required esophageal dilatation of the anastomosis. All patients are on full oral feeding. CONCLUSIONS The endoscopic approach is the method of choice for the treatment of esophageal atresia in our center because of excellent visualization and precise atraumatic preparation even in neonates below a weight of 2000 g.


title: Incidence, mechanisms, and outcomes of esophageal and gastric perforation during laparoscopic foregut surgery: a retrospective review of 1,223 foregut cases.

text: BACKGROUND Intraoperative perforation is a potentially major complication of laparoscopic (lap) foregut surgery. This study analyzed the incidence, mechanism, and outcomes of intraoperative perforations during these procedures in a large institutional experience. METHODS All patients who underwent lap foregut surgery including laparoscopic antireflux surgery (LARS), paraesophageal hernia (PEH) repair, Heller myotomy, and reoperative hiatal hernia (redo HH) repair at the authors' institution from August 2004 to September 2012 were reviewed retrospectively. Perforation events and postoperative outcomes were analyzed, and complications were graded by the modified Clavien system. All data are expressed as means ± standard deviations or as medians. Statistical analysis was performed using Fisher's exact test and the Mann-Whitney U test. RESULTS In this study, the repairs for 1,223 patients were analyzed (381 LARS procedures, 379 PEH repairs, 313 Heller myotomies, 150 redo HH repairs). Overall, 51 patients (4.2 %) had 56 perforations resulting from LARS (n = 4, 1 %), PEH repair (n = 7, 1.8 %), Heller myotomy (n = 18, 5.8 %), and redo HH repair (n = 22, 14.6 %). Redo HH was significantly more likely to result in perforations than LARS or PEH repair (p < 0.001). The locations of the perforations were esophageal in 13 patients (23.6 %), gastric in 40 patients (72.7 %), and indeterminate in 2 patients (3.6 %). The most common mechanisms of perforations were suture placement for LARS (75 %) and traction for PEH repair (43 %) and for Heller myotomy during the myotomy (72 %). The most redo HH perforations resulted from dissection/wrap takedown (73 %) and traction (14 %). Perforations were recognized and repaired intraoperatively in 43 cases (84 %) and postoperatively in eight cases (16 %). Perforations discovered postoperatively were more likely to require reoperation (75 vs 2 %; p < 0.001), to require more gastrointestinal and radiologic interventions (50 vs 2 %; p = 0.004), and to have higher morbidity (88 vs 26 %; p = 0.004) than perforations recognized intraoperatively. CONCLUSIONS In a high-volume center, intraoperative perforations are the most frequent with reoperative HH repair. If perforations are recognized and repaired intraoperatively, they require minimal postoperative intervention. Unrecognized perforations usually require reoperation and result in significantly greater morbidity.


title: COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

text: BACKGROUND AND PURPOSE Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.


title: The Use of Telepsychiatry During COVID-19 and Beyond.

text: The COVID-19 pandemic has disrupted the traditional practice of psychiatric assessment and treatment via face to face interaction. Telepsychiatry, the delivery of psychiatric care remotely through telecommunications technology, is an existing and under-utilised tool that may help to minimise disruption to patient care. Technological advancement is at a stage where it can facilitate widespread use of this practice; however concerns that limited its expansion previously were not unfounded. This article discusses the use of telepsychiatry in the context of the COVID-19 pandemic.


title: Alport-leiomyomatosis syndrome requiring subtotal esophagectomy for refractory gastroesophageal reflux disease after childhood partial esophagogastrectomy: a case report.

text: Alport-leiomyomatosis syndrome is an extremely rare condition occurring at a young age in which Alport syndrome coexists with diffuse leiomyomatosis of the digestive tract (primarily the esophagus). Most patients with diffuse esophageal leiomyomatosis require esophagectomy of variable extents. A 20-year-old man with Alport-leiomyomatosis syndrome was diagnosed with dysphasia and hematuria in childhood. Although he underwent partial esophagogastrectomy at 8 years of age, extremely severe gastroesophageal reflux symptoms were noted postoperatively. He was diagnosed with refractory severe reflux esophagitis associated with diffuse leiomyomatosis and esophagogastric anastomosis, for which he underwent subtotal esophagectomy, gastric tube reconstruction, and esophagogastric anastomosis in the left neck. The postoperative course was generally good, and he had no postoperative reflux symptoms. To achieve long-term control of symptoms, the lesion must be removed completely; nevertheless, unnecessarily extensive esophagectomy should be avoided.


The COPD Foundation Coronavirus Disease 2019 International Medical Experts Survey: Results.


title: Nonenhanced MRI Planning for Endovascular Repair of Abdominal Aortic Aneurysms: Comparison With Contrast-Enhanced CT Angiography.

text: BACKGROUND To assess whether noncontrast-enhanced magnetic resonance imaging (NC-MRI) is an alternative to contrast-enhanced computed tomography angiography (CTA) for aortoiliac measurements before endovascular abdominal aortic aneurysm repair (EVAR). METHODS This study encompasses 30 patients admitted for elective EVAR (27 men and 3 women). Two expert readers (vascular radiologist and vascular surgeon) reviewed CTA images in consensus and chose the proper endograft for each patient. Subsequently, a vascular radiologist and a resident radiologist (observer 1 and 2) reviewed CTA and NC-MRI examinations in a double-blind way and completed standard measurements. The interobserver and intermodality agreement was calculated by intraclass correlation coefficients (ICCs). Furthermore, the correlation between the endograft size chosen by the first pair and the second pair of observers was evaluated. RESULTS Concerning all measurements, no significant difference was found. Both CTA and NC-MRI angiographic measurements showed strong correlation. Interobserver ICCs for CTA and NC-MRI showed ranges of 0.62 to 0.99 (mean: 0.92) and 0.56 to 0.99 (mean: 0.91); intermodality ICCs for observer 1 and 2 showed ranges of 0.64 to 0.99 (mean: 0.92) and 0.56 to 0.99 (mean: 0.92). The CTA and NC-MRI vascular measurements correlated strongly, except for both external iliac artery diameters. The choice of stent size was always the same between the 2 observers; furthermore, graft size was always in agreement with that selected prospectively. CONCLUSION Computed tomography angiography remains the standard of reference for EVAR planning; NC-MRI can be an option for patients with contraindications for CTA, in particular those with renal impairment.


Interview. A challenge to pseudoscience.


title: High-fidelity virtual stenting: modeling of flow diverter deployment for hemodynamic characterization of complex intracranial aneurysms.

text: OBJECT Flow diversion via Pipeline Embolization Device (PED) represents the most recent advancement in endovascular therapy of intracranial aneurysms. This exploratory study aims at a proof of concept for an advanced device-modeling tool in conjunction with computational fluid dynamics (CFD) to evaluate flow modification effects by PED in actual, treated cases. METHODS The authors performed computational modeling of 3 PED-treated complex aneurysm cases. The patient in Case 1 had a fusiform vertebral aneurysm treated with a single PED. In Case 2 the patient had a giant internal carotid artery (ICA) aneurysm treated with 2 PEDs. Case 3 consisted of tandem ICA aneurysms (III-a and III-b) treated by a single PED. The authors' recently developed high-fidelity virtual stenting (HiFiVS) technique was used to recapitulate the clinical deployment process of PEDs in silico for these 3 cases. Pretreatment and posttreatment aneurysmal hemodynamics studies performed using CFD simulation were analyzed. Changes in aneurysmal flow velocity, inflow rate, wall shear stress (WSS), and turnover time were calculated and compared with the clinical outcome. RESULTS In Case 1 (occluded within the first 3 months), the aneurysm had the most drastic flow reduction after PED placement; the aneurysmal average velocity, inflow rate, and average WSS were decreased by 76.3%, 82.5%, and 74.0%, respectively, whereas the turnover time was increased to 572.1% of its pretreatment value. In Case 2 (occluded at 6 months), aneurysmal average velocity, inflow rate, and average WSS were decreased by 39.4%, 38.6%, and 59.1%, respectively, and turnover time increased to 163.0%. In Case 3, Aneurysm III-a (occluded at 6 months) had a decrease by 38.0%, 28.4%, and 50.9% in average velocity, inflow rate, and average WSS, respectively, and turnover time increased to 139.6%, which was quite similar to Aneurysm II. Surprisingly, the adjacent Aneurysm III-b had more substantial flow reduction (a decrease by 77.7%, 53.0%, and 84.4% in average velocity, inflow rate, and average WSS, respectively, and an increase to 213.0% in turnover time) than Aneurysm III-a, which qualitatively agreed with angiographic observation at 3-month follow-up. However, Aneurysm III-b remained patent at both 6 months and 9 months. A closer examination of the vascular anatomy in Case 3 revealed blood draining to the ophthalmic artery off Aneurysm III-b, which may have prevented its complete thrombosis. CONCLUSIONS This proof-of-concept study demonstrates that HiFiVS modeling of flow diverter deployment enables detailed characterization of hemodynamic alteration by PED placement. Posttreatment aneurysmal flow reduction may be correlated with aneurysm occlusion outcome. However, predicting aneurysm treatment outcome by flow diverters also requires consideration of other factors, including vascular anatomy.


title: End-inspiratory pause prolongation in acute respiratory distress syndrome patients: effects on gas exchange and mechanics.

text: BACKGROUND End-inspiratory pause (EIP) prolongation decreases dead space-to-tidal volume ratio (Vd/Vt) and PaCO2. We do not know the physiological benefits of this approach to improve respiratory system mechanics in acute respiratory distress syndrome (ARDS) patients when mild hypercapnia is of no concern. METHODS The investigation was conducted in an intensive care unit of a university hospital, and 13 ARDS patients were included. The study was designed in three phases. First phase, baseline measurements were taken. Second phase, the EIP was prolonged until one of the following was achieved: (1) EIP of 0.7 s; (2) intrinsic positive end-expiratory pressure ≥1 cmH2O; or (3) inspiratory-expiratory ratio 1:1. Third phase, the Vt was decreased (30 mL every 30 min) until PaCO2 equal to baseline was reached. FiO2, PEEP, airflow and respiratory rate were kept constant. RESULTS EIP was prolonged from 0.12 ± 0.04 to 0.7 s in all patients. This decreased the Vd/Vt and PaCO2 (0.70 ± 0.07 to 0.64 ± 0.08, p < 0.001 and 54 ± 9 to 50 ± 8 mmHg, p = 0.001, respectively). In the third phase, the decrease in Vt (from 6.3 ± 0.8 to 5.6 ± 0.8 mL/Kg PBW, p < 0.001) allowed to decrease plateau pressure and driving pressure (24 ± 3 to 22 ± 3 cmH2O, p < 0.001 and 13.4 ± 3.6 to 10.9 ± 3.1 cmH2O, p < 0.001, respectively) and increased respiratory system compliance from 29 ± 9 to 32 ± 11 mL/cmH2O (p = 0.001). PaO2 did not significantly change. CONCLUSIONS Prolonging EIP allowed a significant decrease in Vt without changes in PaCO2 in passively ventilated ARDS patients. This produced a significant decrease in plateau pressure and driving pressure and significantly increased respiratory system compliance, which suggests less overdistension and less dynamic strain.


Asymptomatic SARS-CoV-2 infection: the tip or the iceberg?


title: Prospective randomized trial of ligasure versus harmonic hemostasis technique in thyroidectomy.

text: BACKGROUND Two surgical devices have become popular in thyroid surgery: a bipolar energy sealing system (B) and ultrasonic coagulation (UC). Retrospective and prospective studies have demonstrated that the use of these surgical devices for thyroidectomy compared with conventional thyroidectomy (clamp-and-tie) techniques reduces operative time and cost. We conducted a prospective randomized clinical trial to determine if there is any difference in operative time and cost between B and UC. MATERIALS AND METHODS A single-blinded prospective randomized controlled trial was conducted at a tertiary referral center. A total of 90 patients who required a thyroidectomy for thyroid cancer, thyroid nodules, or hyperthyroidism were randomized to either B or UC during thyroidectomy. The operative time and cost of thyroidectomy were compared between the two groups. RESULTS There was no statistically significant difference in patient age, gender, body mass index, indication for thyroidectomy and thyroid gland weight between the two groups. There was no statistically significant difference in operating room cost or total cost for thyroidectomy between the B and UC groups. There was also no statistically significant difference in the operative time between the B and UC groups (187.6 vs. 184.2 min, P = 0.48) or in postoperative complication rates. The only statistically significant difference in total cost was between surgeons independent of the device used (P < 0.01). CONCLUSIONS In thyroid surgery, total cost and operative time were similar between the two surgical devices used.


title: Nonmotor Symptoms in Amyotrophic Lateral Sclerosis: A Systematic Review.

text: BACKGROUND ALS is a progressive neurodegenerative disease with no curative treatment. Nonmotor symptoms presenting in ALS may cause significant distress, worsen prognosis, and affect survival. OBJECTIVE To systematically review evidence for the prevalence of nonmotor ALS symptoms, and treatment options. METHODS Multiple medical literature databases were searched and studies screened using predefined inclusion criteria. Of 4580 studies, 44 were eligible for inclusion with 25 relating to treatment and 19 to the prevalence of nonmotor symptoms in ALS. RESULTS Nonmotor symptoms involve neuropsychiatric, autonomic, gastrointestinal, and vascular systems, and affect between 5% and 80% of people with ALS. Screening tools for individual nonmotor symptoms are useful in classifying symptom severity and to compare between treatment options. Several methods to relieve nonmotor symptoms have been trialed with varying success rates. CONCLUSIONS Many of the current studies of nonmotor symptoms in ALS have small sample sizes, requiring more evidence to increase precision in prevalence estimates. Further research is needed to assess the efficacy of current treatments and to find new therapies. Symptom relief or treatment of these nonmotor symptoms should therefore be considered during the clinical management of ALS.


title: Human parvovirus B19 NS1 protein modulates inflammatory signaling by activation of STAT3/PIAS3 in human endothelial cells.

text: The pathogenic mechanism by which parvovirus B19 may induce inflammatory cardiomyopathy (iCMP) is complex but is known to involve inflammatory processes, possibly including activation of JAK/STAT signaling. The nonstructural B19 protein NS1 acts as a transactivator triggering signaling cascades that eventually lead to activation of interleukin 6 (IL-6). We examined the impact of NS1 on modulation of STAT signaling in human endothelial cells (HMEC-1). The NS1 sequences were identified from B19 DNA isolated from the myocardia of patients with fatal iCMP. B19 infection as well as NS1 overexpression in HMEC-1 cells produced a significant upregulation in the phosphorylation of both tyrosine(705) and serine(727) STAT3 (P < 0.05). The increased STAT3 phosphorylation was accompanied by dimerization, nuclear translocation, and DNA binding of pSTAT3. In contrast, NS1 expression did not result in increased STAT1 activation. Notably, the expression levels of the negative regulators of STAT activation, SOCS1 and SOCS3, were not altered by NS1. However, the level of PIAS3 was upregulated in NS1-expressing HMEC-1 cells. Analysis of the transcriptional activation of target genes revealed that NS1-induced STAT3 signaling was associated with upregulation of genes involved in immune response (e.g., the IFNAR1 and IL-2 genes) and downregulation of genes associated with viral defense (e.g., the OAS1 and TYK2 genes). Our results demonstrate that B19 NS1 modulates the STAT/PIAS pathway. The NS1-induced upregulation of STAT3/PIAS3 in the absence of STAT1 phosphorylation and the lack of SOCS1/SOCS3 activation may contribute to the mechanisms by which B19 evades the immune response and establishes persistent infection in human endothelial cells. Thus, NS1 may play a critical role in the mechanism of viral pathogenesis in B19-associated iCMP.


title: Intrinsic evolutionary constraints on protease structure, enzyme acylation, and the identity of the catalytic triad.

text: The study of proteolysis lies at the heart of our understanding of biocatalysis, enzyme evolution, and drug development. To understand the degree of natural variation in protease active sites, we systematically evaluated simple active site features from all serine, cysteine and threonine proteases of independent lineage. This convergent evolutionary analysis revealed several interrelated and previously unrecognized relationships. The reactive rotamer of the nucleophile determines which neighboring amide can be used in the local oxyanion hole. Each rotamer-oxyanion hole combination limits the location of the moiety facilitating proton transfer and, combined together, fixes the stereochemistry of catalysis. All proteases that use an acyl-enzyme mechanism naturally divide into two classes according to which face of the peptide substrate is attacked during catalysis. We show that each class is subject to unique structural constraints that have governed the convergent evolution of enzyme structure. Using this framework, we show that the γ-methyl of Thr causes an intrinsic steric clash that precludes its use as the nucleophile in the traditional catalytic triad. This constraint is released upon autoproteolysis and we propose a molecular basis for the increased enzymatic efficiency introduced by the γ-methyl of Thr. Finally, we identify several classes of natural products whose mode of action is sensitive to the division according to the face of attack identified here. This analysis of protease structure and function unifies 50 y of biocatalysis research, providing a framework for the continued study of enzyme evolution and the development of inhibitors with increased selectivity.


title: Characterization of mouse neuro-urological dynamics in a novel decerebrate arterially perfused mouse (DAPM) preparation.

text: AIM To develop the decerebrate arterially perfused mouse (DAPM) preparation, a novel voiding model of the lower urinary tract (LUT) that enables in vitro-like access with in vivo-like neural connectivity. METHODS Adult male mice were decerebrated and arterially perfused with a carbogenated, Ringer's solution to establish the DAPM. To allow distinction between central and peripheral actions of interventions, experiments were conducted in both the DAPM and in a "pithed" DAPM which has no brainstem or spinal cord control. RESULTS Functional micturition cycles were observed in response to bladder filling. During each void, the bladder showed strong contractions and the external urethral sphincter (EUS) showed bursting activity. Both the frequency and amplitude of non-voiding contractions (NVCs) in DAPM and putative micromotions (pMM) in pithed DAPM increased with bladder filling. Vasopressin (>400 pM) caused dyssynergy of the LUT resulting in retention in DAPM as it increased tonic EUS activity and basal bladder pressure in a dose-dependent manner (basal pressure increase also noted in pithed DAPM). Both neuromuscular blockade (vecuronium) and autonomic ganglion blockade (hexamethonium), initially caused incomplete voiding, and both drugs eventually stopped voiding in DAPM. Intravesical acetic acid (0.2%) decreased the micturition interval. Recordings from the pelvic nerve in the pithed DAPM showed bladder distention-induced activity in the non-noxious range which was associated with pMM. CONCLUSIONS This study demonstrates the utility of the DAPM which allows a detailed characterization of LUT function in mice.


title: No Correlation of the Disease Severity of Influenza A Virus Infection with the rs12252 Polymorphism of the Interferon-Induced Transmembrane Protein 3 Gene.

text: The 2009 H1N1 influenza pandemic, which involved a more pathogenic virus than seasonal influenza viruses, rapidly spread around the world and caused many deaths in humans. The members of the interferon-induced transmembrane (IFITM) protein family prevent viral replication and are crucial for defending the host cell against influenza A virus (IAV). Several studies suggest that the CC genotype at the single nucleotide polymorphism (SNP) rs12252 of IFITM3 confers a genetic predisposition to pandemic influenza A in Europeans and Han Chinese, although one study in a British cohort failed to show an association. In order to examine whether an SNP of the IFITM3 gene is correlated with the disease severity of pandemic IAV (H1N1) infection in a Korean population, we investigated the genotype and allele frequencies of this polymorphism in 300 healthy Koreans by automatic direct sequencing and compared the disease severity based on epidemiological studies of the H1N1 virus reported in several countries. The frequencies of the CC genotype and the C allele in the IFITM3 polymorphism were higher in the Korean population than in the European populations, but not in Chinese and Japanese populations. The prevalence of severe cases of the pandemic 2009 IAV infection in Koreans was similar to that in Europeans (p = 0.106). In addition, the prevalence of deaths among all positive cases with pandemic 2009 IAV infection in Koreans was significantly lower than that in Europeans. These results suggest that the IFITM3 genotype may not be a determinant of disease severity of IAV infection.


title: Quantum dots encapsulated with amphiphilic alginate as bioprobe for fast screening anti-dengue virus agents

text: The increasing threats of viral diseases have gained worldwide attention in recent years. Quite a few infectious diseases are still lacking effective prevention or treatment. The pace of developing antiviral agents could be expedited by the availability of quick and efficient drug screening platforms. In this study, quantum dot (QD), an emerging probe for biological imaging and medical diagnostics, was employed to form complexes with virus and used as fluorescent imaging probes for exploring potential antiviral therapeutics. Inorganic CdSe/ZnS QDs synthesized in organic phase were encapsulated by amphiphilic alginate to attain biocompatible water-soluble QDs via phase transfer. Virus employed for this study was dengue virus which is a notorious one in tropical and subtropical regions of the world. To construct a QD–virus imaging modality capable of providing meaningful information, preservation of viral infectivity after tagging virus with QDs is of utmost importance. In order to form colloidal complexes of QD–virus, electrostatic repulsion force generated from both negatively charged virus and QDs was neutralized by various concentrations of cationic polybrene. Results showed that BHK-21 cells infected with dengue viruses incorporated with QDs exhibited bright fluorescence intracellularly within 30 min. To demonstrate the potency of QD–virus complexes as bioprobes for screening antiviral agents, BHK-21 cells were incubated for one hour with allophycocyanin purified from blue-green algae and then infected with QD–virus complexes. Based on the developed cell-based imaging assay, allophycocyanin with concentration of 125 μg/mL led to extremely weak intracellular fluorescence post-infection of QD–virus complexes for 30 min. That is, the efficacy of anti-dengue viral activity of the algae extract was clearly illustrated by the inorganic–organic hybrid platform constructed in current study.


title: Human and Bovine Viruses and Bacteria at Three Great Lakes Beaches: Environmental Variable Associations and Health Risk.

text: Waterborne pathogens were measured at three beaches in Lake Michigan, environmental factors for predicting pathogen concentrations were identified, and the risk of swimmer infection and illness was estimated. Waterborne pathogens were detected in 96% of samples collected at three Lake Michigan beaches in summer, 2010. Samples were quantified for 22 pathogens in four microbial categories (human viruses, bovine viruses, protozoa, and pathogenic bacteria). All beaches had detections of human and bovine viruses and pathogenic bacteria indicating influence of multiple contamination sources at these beaches. Occurrence ranged from 40 to 87% for human viruses, 65-87% for pathogenic bacteria, and 13-35% for bovine viruses. Enterovirus, adenovirus A, Salmonella spp., Campylobacter jejuni, bovine polyomavirus, and bovine rotavirus A were present most frequently. Variables selected in multiple regression models used to explore environmental factors that influence pathogens included wave direction, cloud cover, currents, and water temperature. Quantitative Microbial Risk Assessment was done for C. jejuni, Salmonella spp., and enteroviruses to estimate risk of infection and illness. Median infection risks for one-time swimming events were approximately 2 × 10(-5), 8 × 10(-6), and 3 × 10(-7) [corrected] for C. jejuni, Salmonella spp., and enteroviruses, respectively. Results highlight the importance of investigating multiple pathogens within multiple categories to avoid underestimating the prevalence and risk of waterborne pathogens.


title: Sciatic Nerve Cut and Repair Using Fibrin Glue in Adult Mice.

text: Peripheral nerve injury (PNI) is an excellent model for studying neural responses to injury and elucidating the mechanisms that can facilitate axon regeneration. As such, several animal models have been employed to study regenerative mechanisms after PNI, including Aplysia, zebrafish, rabbits, cats and rodents. This protocol describes how to perform a sciatic nerve injury and repair in mice, one of the most frequently used models to study mechanisms that facilitate recovery after PNI, and that takes advantage of the availability of many genetic models. In this protocol, we describe a method for using fibrin glue to secure the proximal and distal stumps of an injured nerve in close alignment. This method facilitates the alignment of nerve stumps, which aids in regeneration of both sensory and motor axons and allows successful reconnection with peripheral targets.


title: Role of Coatomer Protein I in Virus Replication.

text: Coatomer protein I (COPI) is well known as the protein coat surrounding vesicles involved in returning endoplasmic reticulum (ER)-resident proteins to the ER. COPI coats are also found in vesicles involved in other trafficking processes including endocytosis, autophagy and anterograde transport in the secretory pathway. In view of the diverse functions of COPI proteins, it is expected that they will affect virus replication, and many reports of such COPI involvement have now appeared. The experimental approaches most often employ specific siRNA to deplete COPI subunits or brefeldin A to block COPI activation. Here we briefly describe the results obtained with viruses in which COPI is found to have a role in replication. The results demonstrate that COPI affects viruses quite differently with effects observed in processes such as entry, RNA replication, and intracellular transport of viral proteins.


title: Detection of Pulmonary Embolism in Returning Travelers with Hypoxemic Pneumonia due to COVID-19 in Reunion Island.

text: The aim of this study was to evaluate the occurrence of pulmonary embolism in returning travelers with hypoxemic pneumonia due to COVID-19. All returning travelers to Reunion Island with hypoxemic pneumonia due to COVID-19 underwent computed tomography pulmonary angiography (CTPA) and were included in the cohort. Thirty-five patients were returning travelers with hypoxemic pneumonia due to COVID-19 and had recently returned from one of the countries most affected by the COVID-19 outbreak (mainly from France and Comoros archipelago). Five patients (14.3%) were found to have pulmonary embolism and two (5.9%) were incidentally found to have deep vein thrombosis on CTPA. Patients with pulmonary embolism or deep vein thrombosis had higher D-dimer levels than those without pulmonary embolism or deep vein thrombosis (P = 0.04). Returning travelers with hypoxemic pneumonia due to COVID-19 should be systematically screened for pulmonary embolism.


title: Robotic-Assisted Approach Improves Vessel Preservation in Spleen-Preserving Distal Pancreatectomy.

text: BACKGROUND Vessel-preserving spleen preservation (SP) during distal pancreatectomy (DP) is supposed to be beneficial for patients with benign and borderline tumors. This study evaluated the first experiences with robotic-assisted laparoscopic DP (RA-LDP) and its rate of vessel preservation and SP compared to conventional laparoscopic DP (C-LDP). METHODS Patients scheduled for spleen-preserving DP for benign or borderline tumors by either C-LDP or RA-LDP were retrieved from a prospective database and retrospectively analyzed regarding vessel-preservation and SP, conversion rate, blood loss, operating time, complications, perioperative blood transfusion, postoperative hospital stay (PHS) and mortality. RESULTS Twenty-nine patients underwent C-LDP and 12 patients underwent RA-LDP between September 2009 and May 2015. SP rates were 79% (23 of 29) in the C-LDP and 92% (11 of 12) in the RA-LDP group (p = 0.32). Splenic vessels could be preserved in 17% (5 of 29) of the C-LDP and 50% (6 of 12) of the RA-LDP group (p = 0.052). Operating time, intraoperative blood loss, the number of perioperative red blood cell transfusions, overall morbidity and the rate of postoperative pancreatic fistulas were not different between the groups. PHS was shorter in the RA-LDP group (10.5 vs. 13 days; p = 0.02). CONCLUSION RA-LDP for benign or borderline tumors of the pancreas is a safe procedure and tended to be associated with a better vessel-preservation rate, thereby making it a good alternative to C-LDP.


Commentary: Teleconsultation at a tertiary care set-up during COVID-19 lockdown in India.


Danish bispecifics meet ADCs.


title: Effects of Sleep Fragmentation and Induced Mood on Pain Tolerance and Pain Sensitivity in Young Healthy Adults.

text: Background: Experimental research exploring the sleep/pain-relationship has typically focused on total or partial sleep deprivation, hereby failing to reproduce the mere fragmented sleep pattern typically observed in patients with chronic pain. Further, little research is done on how affect moderates the sleep-pain relationship after sleep fragmentation. The present study sought to clarify the relationship between pain, sleep and positive and negative affect. Methods: In an experimental counterbalanced crossover design, 35 healthy young adults were subjected to several pain measures after one night of fragmented sleep, compared to one control night of normal sleep, both conducted in their own homes, and respectively, positive and negative affect induction using validated film clips and facial feedback procedures. Sleep was monitored using sleep diaries. Results: Increased pain sensitivity after one night of experimentally induced sleep fragmentation was found, compared to after one control night of undisturbed sleep. No main effects of induced affect on pain were found, and sleep x induced affect interaction was not significant. Conclusion: The present study supports the adverse effect of sleep fragmentation on pain sensitivity, however, affect was not found to be a moderator in the sleep-pain relationship. The results underline the need for further research within this field.


title: Transumbilical single-port laparoscopic partial nephrectomy in a pig model.

text: OBJECTIVE To determine the feasibility, instrumentation, and learning curve for single-port laparoscopic partial nephrectomy (SPLPN) in a pig model. MATERIALS AND METHODS Ten transumbilical SPLPN were performed using the R-Port (Advanced Surgical Concepts, Wicklow, Ireland) multi-instrument port, a 5-mm flexible laparoscope (Olympus Surgical, Orangeburg, NY, USA), and custom-engineered articulating needle drivers, graspers, and scissors (Cambridge Endo, Framingham, MA, USA). After general anaesthesia, the pig was placed in the flank position. After umbilical placement of the R-Port, Gerota's fascia was incised and hilar dissection performed with the newly engineered articulating instruments. Either the upper or lower pole of the kidney was scored and excised after placing a bulldog clamp on the renal pedicle. The bolsters were prepared with absorbable haemostat, placed at the site of excision, and secured with polyglactin sutures. RESULTS A fascial incision of > or =2.5 cm should be made to allow adequate room for passing the instruments. Also, use of the 5 mm flexible laparoscope minimizes instrument crowding and allows for optimal visualization. The mean (sd, range) time for hilum dissection was 12.2 (4.3, 7-20) min, while that for total excision was 9.8 (1.7, 8-12) min. Modified suturing techniques were developed to achieve reconstruction in a small working space. Specialized instrumentation is essential for a successful SPLPN with no need for an additional port for triangulation. The mean duration of intracorporeal suturing was 27.7 min (declining from 40 to 15 min). The total ischaemia time decreased from 50 min in the first case to 27 min in the last (mean 37.4 min). The mean estimated blood loss was 81.1 (31.7, 50-150) mL. CONCLUSIONS SPLPN is technically feasible but further refinement of instrumentation and techniques is needed to decrease the ischaemia time and optimize the procedure.


Journal watch.


title: Near-Infrared Spectroscopy: The New Must Have Tool in the Intensive Care Unit?

text: Standard hemodynamic monitoring such as blood pressure and pulse oximetry may only provide a crude estimation of organ perfusion in the critical care setting. Near-infrared spectroscopy (NIRS) is based on the same principle as a pulse oximeter and allows continuous noninvasive monitoring of hemoglobin oxygenation and deoxygenation and thus tissue saturation "StO2" This review aims to provide an overview of NIRS technology principles and discuss its current clinical use in the critical care setting. The study selection was performed using the PubMed database to find studies that investigated the use of NIRS in both the critical care setting and in the intensive care unit. Currently, NIRS in the critical care setting is predominantly being used for infants and neonates. A number of studies in the past decade have shown promising results for the use of NIRS in surgical/trauma intensive care units during shock management as a prognostic tool and in guiding resuscitation. It is evident that over the past 2 decades, NIRS has gone from being a laboratory fascination to an actively employed clinical tool. Even though the benefit of routine use of this technology to achieve better outcomes is still questionable, the fact that NIRS is a low-cost, noninvasive monitoring modality improves the attractiveness of the technology. However, more research may be warranted before recommending its routine use in the critical care setting.


title: A new device for fiducial registration of image-guided navigation system for liver RFA.

text: PURPOSE Radiofrequency ablation for liver tumors (liver RFA) is widely performed under ultrasound guidance. However, discriminating between the tumor and the needle is often difficult because of cavitation caused by RFA-induced coagulation. An unclear ultrasound image can lead to complications and tumor residue. Therefore, image-guided navigation systems based on fiducial registration have been developed. Fiducial points are usually set on a patient's skin. But the use of internal fiducial points can improve the accuracy of navigation. In this study, a new device is introduced to use internal fiducial points using 2D US. METHODS 3D Slicer as the navigation software, Polaris Vicra as the position sensor, and two target tumors in a 3D abdominal phantom as puncture targets were used. Also, a new device that makes it possible to obtain tracking coordinates in the body was invented. First, two-dimensional reslice images from the CT images using 3D Slicer were built. A virtual needle was displayed on the two-dimensional reslice image, reflecting the movement of the actual needle after fiducial registration. A phantom experiment using three sets of fiducial point configurations: one conventional case using only surface points, and two cases in which the center of the target tumor was selected as a fiducial point was performed. For each configuration, one surgeon punctured each target tumor ten times under guidance from the 3D Slicer display. Finally, a statistical analysis examining the puncture error was performed. RESULTS The puncture error for each target tumor decreased significantly when the center of the target tumor was included as one of the fiducial points, compared with when only surface points were used. CONCLUSION This study introduces a new device to use internal fiducial points and suggests that the accuracy of image-guided navigation systems for liver RFA can be improved by using the new device.


title: The Effect of Standardizing Autologous Prime Techniques in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass.

text: Autologous priming (AP) of the extracorporeal circuit has been used as a technique to reduce iatrogenic anemia in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The purpose of this study was to review the results of standardizing AP techniques to reduce variation among clinicians and its effect on clinical outcomes. Standardized goal-directed protocols for AP were established by the cardiac team and applied to all adult cardiac surgical patients where CPB was used. Following Institutional Review Board approval, data were analyzed for two sequential groups of patients: Non-standardized AP (NST-AP) and standardized AP (ST-AP). Exclusion criteria included pre-CPB hemodynamic instability and preoperative hematocrit (Hct) values less than 30%. The primary end point was the transfusion of red blood cells (RBCs), whereas secondary end points included Hct change and other perioperative allogeneic blood product transfusions. Data are presented as mean and SD. Of the 192 patients evaluated, 82 were in the NST-AP group and 110 in the ST-AP group. There were no preoperative demographic differences across groups. Total AP volume was lower in the NST-AP group than in the ST-AP patients (486.8 ± 259.6 mL vs. 1,048.2 ± 218.7 mL, p < .001). Whereas pre-CPB Hct values were identical between the groups, the first on-CPB (25.7% ± 4.5% vs. 27.9% ± 4.2%, p < .001), high CPB (27.7% ± 3.5% vs. 29.1% ± 3.6%, p < .008), and first postoperative (32.5% ± 4.0% vs. 34.3% ± 3.9%, p < .003) were all significantly higher in ST-AP patients. Perioperative transfusion rate was higher in NST-AP patients (63.6%) vs. ST-AP (44.6%), p < .01. There was no difference in intraoperative RBC transfusion, but postoperatively, more patients in the NST-AP group received RBCs than those in the ST-AP group (51.2% vs. 28.2%, p < .01). The application of an ST-AP protocol was effective in reducing hemodilution, which was associated within higher Hcts and lower postoperative transfusion rates.


title: Laparoscopic vs open resection for patients with rectal cancer: comparison of perioperative outcomes and long-term survival.

text: PURPOSE The aim of the study is to assess the safety and oncologic feasibility of laparoscopic-assisted resection for rectal cancer vs open rectal resection as a phase II pilot study for a planned randomized control trial. METHODS A case-matched controlled prospective analysis of 54 patients who underwent laparoscopic-assisted resection for stage I to III (no T4) rectal cancer within 12 cm of the anal verge from 2002 to 2005 was performed. Patients were matched with contemporary patients who underwent open rectal cancer surgery (n = 108) in a 1 to 2 fashion. The perioperative clinical outcomes, postoperative pathology, and oncologic outcomes were compared between the groups. RESULTS The demographic data did not differ significantly between the groups. The laparoscopic group manifested early return of bowel function (P = .003). The complication rate was 22.2% in the laparoscopic group and 32.4% in the open group (P = .178). Local recurrence was similar (2.0% laparoscopic, 4.2% open, P = .417). The 5-year overall and disease-free survival rate also were similar (overall survival, 90.8% laparoscopic, 88.5% open, P = .261; disease-free survival, 80.8% laparoscopic, 75.8% open. P = .390). CONCLUSION The laparoscopic-assisted resection for rectal cancer was acceptable in terms of oncologic outcomes and perioperative clinical outcomes. The present data are the basis for a large-scale randomized trial for comparison of laparoscopic and open rectal cancer surgeries (American College of Surgeons Oncology Group Z6051).


title: Quality of root canal fillings using three gutta-percha obturation techniques.

text: OBJECTIVES The goal of this study was to compare the density of gutta-percha root fillings obturated with the following techniques: cold lateral (CL) compaction, ultrasonic lateral (UL) compaction, and warm vertical (WV) compaction. MATERIALS AND METHODS Thirty-three extracted mandibular first molars, with two separate mesial canals in each, were selected. After instrumentation, the canals were stratified into three groups based on canal length and curvature, and underwent obturation with one of the techniques. No sealer was used in order to avoid masking any voids. The teeth were imaged pre- and post-obturation using micro-computed tomography. The reconstructed three-dimensional images were analyzed volumetrically to determine the amount of gutta-percha present in every 2 mm segment of the canal. P values < 0.05 were considered to indicate statistical significance. RESULTS The overall mean volume fraction of gutta-percha was 68.51 ± 6.75% for CL, 86.56 ± 5.00% for UL, and 88.91 ± 5.16% for WV. Significant differences were found between CL and UL and between CL and WV (p < 0.05), but not between UL and WV (p = 0.526). The gutta-percha density of the roots treated with WV and UL increased towards the coronal aspect, but this trend was not noted in the CL group. CONCLUSIONS WV compaction and UL compaction produced a significantly denser gutta-percha root filling than CL compaction. The density of gutta-percha was observed to increase towards the coronal aspect when the former two techniques were used.


title: Research Progress on Chemical Constituents of Lonicerae japonicae flos.

text: Lonicerae japonicae flos is commonly used in traditional Chinese medicine for thousands of years with confirmed curative effects. Except for medicine, it is also used in healthy food, cosmetics, and soft beverages for its specific activities. Therefore, the chemical constituents, mainly including organic acids, flavonoids, iridoids, triterpenoids, and volatile oils, have been well studied by many scholars in recent years and a comprehensive and systematic review on chemical constituents of Lonicerae japonicae flos is indispensable. This paper aims at reviewing the chemical components of LJF in recent years through searching for the literatures both at home and abroad. Our results show that 212 components have been isolated from Lonicerae japonicae flos, including 27 flavonoids, 40 organic acids, 83 iridoids, 17 triterpenoids, and 45 other compounds, which could lay a foundation for the further application of Lonicerae japonicae flos.


title: Angiographic warning of hemorrhagic transformation after stent retriever thrombectomy procedure.

text: This study reports cerebral angiographic findings observed after stent retriever thrombectomy that is suggestive of a higher risk of hemorrhagic transformation (HT). A woman aged 65-75 presented with a right middle cerebral artery syndrome confirmed by non-contrast CT brain scan. Endovascular revascularization using the Solitaire device was placed across the thromboembolic occlusion and thromboembolectomy was performed. Angiography showed complete recanalization of the left internal carotid artery, anterior and middle cerebral artery branches. Twelve hours following the procedure the patient had a hemorrhagic conversion of the ischemic infarct with significant mass effect causing herniation. Despite surgical intervention (hemicraniectomy) the patient died. The angiographic features following revascularization of the vessels distal to the occlusion showed subtle dilations which were visualized at the branch points of the vessels. This may be a warning sign of increased risk of HT.


The Impact of COVID-19 on Gastrointestinal Endoscopy Training in the United Kingdom.


title: Risk for nephrogenic systemic fibrosis with gadoteridol (ProHance) in patients who are on long-term hemodialysis.

text: BACKGROUND AND OBJECTIVES Recent studies strongly link nephrogenic systemic fibrosis to gadolinium administration for magnetic resonance imaging. In a recent advisory, the Food and Drug Administration stated that all gadolinium-containing chelates are potentially associated with nephrogenic systemic fibrosis; however, most reported cases are linked to gadodiamide (Omniscan) and gadopentetate dimeglumine (Magnevist). Given the severe consequences of nephrogenic systemic fibrosis, it is critical to define the risks associated with each gadolinium-containing chelate. The purpose of this study was to examine nephrogenic systemic fibrosis risk in a hemodialysis population exposed to gadoteridol (ProHance). DESIGN, SETTING, PARTICIPANTS, & OBJECTIVES Appointment logs were used to generate a database of all long-term hemodialysis patients at the Dallas Veterans Affairs hospital since August 2001. These patients were then examined in the Veterans Affair's electronic medical record system for gadolinium exposure during magnetic resonance imaging from 2000 through 2007, a period during which gadoteridol was the sole contrast agent used. RESULTS A total of 141 patients were identified with 198 gadoteridol exposures. No cases of nephrogenic systemic fibrosis were identified. The observed frequency of nephrogenic systemic fibrosis was compared with the expected frequency (2.4%) using one-way chi(2) and binomial analysis, yielding a P < 0.05, indicating that the result was not explained by chance alone. CONCLUSIONS It is concluded that the risk for nephrogenic systemic fibrosis with gadoteridol in patients who are on long-term hemodialysis may be lower than with gadodiamide and gadopentetate dimeglumine.


title: Resuscitation of severely asphyctic newborn pigs with cardiac arrest by using 21% or 100% oxygen.

text: BACKGROUND In spite of evidence suggesting that resuscitation with 100% O(2) is detrimental, international guidelines still recommend its use. Clinical studies comparing 21% and 100% O(2) included many infants with only mild and moderate asphyxia. OBJECTIVES We aimed to investigate the effect of these oxygen fractions on haemodynamic parameters, arterial blood gases, oxygen saturation indices and markers of inflammation and hypoxic damage when resuscitating asystolic newborn pigs following asphyxia. METHODS Newborn swine (n = 32, age 12-36 h, weight 2.0-2.7 kg) were progressively asphyxiated until asystole occurred. Cardiopulmonary resuscitation was initiated with ventilation with either 21% (n = 16) or 100% O(2) (n = 16). Return of spontaneous circulation (ROSC) was defined as a heart rate >or= 100 min(-1). RESULTS Mean time of hypoxia, pH, base excess and pCO(2) at asystole were comparable between the groups. All animals except 2 in the 100% group achieved ROSC. One animal in the 21% group suffered bradycardia at baseline and was excluded. For the remaining 15 animals resuscitated with 21% O(2), median time to ROSC (interquartile range) was 150 s (115-180), whereas animals in the 100% group achieved ROSC after 135 s (113-168); p = 0.80. There were no differences in the temporal changes in mean arterial blood pressure, heart rate, pH, pCO(2), interleukin-1beta or lactate/pyruvate ratios. However, systemic and regional cerebral oxygen saturations were higher in the animals resuscitated with 100% oxygen. CONCLUSION In this animal model of severe perinatal asphyxia, resuscitation with room air seemed to be as safe and effective as the use of 100% oxygen.


title: Fully laparoscopic thermo-ablation of liver malignancies with or without liver resection: tumor location is an independent local recurrence risk factor.

text: BACKGROUND The aim of this study was to analyze risk factors of local recurrence (LR) after exclusive laparoscopic thermo-ablation (TA) with or without associated liver resection. METHODS Between 2012 and 2017, among 385 patients who underwent 820 TA in our department, 65 (17%) patients (HCC = 11, LM = 54) had exclusive laparoscopic TA representing 112 lesions (HCC = 17, LM = 95). TA was associated with other procedures in 57% of cases (liver resection 81%). All TA were done without liver clamping. Median tumor size was 1.8 cm [ranges from 0.3 to 4.5], 18% of the lesions were larger than 3 cm in size and 11% close to major liver vessels. Tumors locations were 77.5% in right liver, 36% in S7&S8, and 46% in S7&S8&S4a. RESULTS Mortality was nil and morbidity rate 15.4% including Dindo-Clavien > II grade 3%. The median follow-up was 24 months [0.77-75]. Per lesion LR rate after TA was 18% (n = 19 patients) with a mean time of 7.6 months. Among patients with LR, 18 (95%) could have been re-treated successfully (new resection = 11, re-TA = 7). Multivariate analyses revealed that tumor location in S7 alone, S7&S8 and/or S7, S8, or S4a were independent risk factors of LR after TA. CONCLUSIONS Exclusive laparoscopic TA is a safe and an effective tool to treat liver malignancies with or without liver resection. Other than classical risk factors, tumor location in upper segments of the liver, are independent risk factors for LR.


Deprescribing in the time of covid-19.


title: Epidemiologic study of influenza infection in Okinawa, Japan, from 2001 to 2007: changing patterns of seasonality and prevalence of amantadine-resistant influenza A virus.

text: To clarify seasonal influenza patterns and the prevalence of amantadine-resistant influenza A viruses in Okinawa, located at the southern extremity of Japan in a subtropical climate, we conducted a laboratory-based study of influenza virus infections from 2001 to 2007. The annual outbreaks tended to show two peaks in Okinawa, in summer and winter, although the main islands of Japan, located in a temperate climate area, showed only winter influenza activity. Epidemic types and subtypes in Okinawa mostly matched those on the main islands of Japan in winter and those in Taiwan in summer. Rates of amantadine resistance dramatically increased, from 7.3% in the November 2002-to-March 2003 season to 90.0% in summer 2005, and a similarly high rate of resistance continued for the rest of the study period. Phylogenetic analysis of the hemagglutinin gene of A/H3N2 isolates collected from 2002 to 2007 revealed a monophyletic lineage that was divided into four period groups. Each group included amantadine-sensitive and -resistant viruses within independent clusters. In the November 2005-to-March 2006 season, all of the amantadine-resistant viruses were clustered in clade N, with dual (position 193 and 225) amino acid mutations in their HA1 subunits. In 2005, clade N amantadine-resistant viruses existed in Okinawa several months before the circulation of this clade on the main islands of Japan. In conclusion, surveillance in Okinawa to monitor influenza virus circulation is important for elucidating the dynamics of virus transmission in a border area between temperate and subtropical areas, as Okinawa is one of the best sentinel points in Japan.


title: Conversion to Gastric Bypass After Either Failed Gastric Band or Failed Sleeve Gastrectomy.

text: BACKGROUND Roux-en-Y gastric bypass (RYGB) is still considered the gold standard in bariatric surgery. Before, adjustable gastric banding (AGB) was regarded as an alternative; nowadays, sleeve gastrectomy (SG) is a more favorable alternative. In case of unsatisfactory results, RYGB is often performed as a secondary procedure. Conversion of an AGB is associated with a high risk of complications; the hypothesis was that this would be less after conversion of an SG. METHODS All patients undergoing conversion to RYGB after AGB or SG between 2005 and 2012 were included for retrospective analysis. Patient characteristics, operative details, postoperative complications, the relief of complaints, weight loss, reasons for failure, and evolution of known comorbidities up to 2 years were analyzed. RESULTS A total of 178 patients were included (79.8 % female): AGB 110 (61.8 %) versus SG 68 (38.2 %). Main reasons for conversion were weight regain/insufficient weight loss (48.4 %) or dysphagia/reflux complaints (39.9 %). Surgical complications were found in 19 patients (AGB 13 vs SG 6; p = 0.530). Infectious complications occurred in 13 patients (AGB 11 vs SG 2; p = 0.135). Total body weight loss was equal between groups after 2 years (AGB 31.6 ± 11.0 % vs SG 31.6 ± 12.0 %; p = 0.998). Similar results were found in a subgroup analysis on patients undergoing conversion for additional weight loss (AGB 31.7 ± 11.7 % vs SG 27.0 ± 13.1 %; p = 0.173). CONCLUSIONS Conversion to RYGB after failed AGB or SG showed comparable short-term results in terms of postoperative complications and weight loss.


title: Letter to the Editor: Robot-Assisted and Minimally Invasive Pediatric Surgery and Urology During the COVID-19 Pandemic: A Short Literature Review.

text: The COVID-19 outbreak has dramatically impacted our activities of pediatric surgeons and urologists over the past 3 months, especially in the field of minimally invasive surgery (MIS) and robotics. Analyzing the available literature, there is very scarce evidence regarding the use of MIS and robotics for treatment of pediatric surgical and urological pathologies during this pandemic. However, we found some useful information that we would like to share with other pediatric surgeons and urologists through this journal. Based upon the available data, we believe that surgery should only be performed in pediatric patients with emergent/urgent and oncological indications until resolution of the COVID-19 outbreak. Robotics and MIS may be safely performed in such selected children by adopting specific technical precautions such as prevention of aerosol dispersion using filters/suction or adapted systems and appropriate use of electrocautery and other sealing devices for reduction of surgical smoke, as reported in our recent experience. Another key point to manage this pandemic emergency is that all hospitals should provide health care professionals with adequate individual protections and perform universal screening in all patients undergoing surgery. Considering that this pandemic is a rapidly evolving situation with new information available daily, these data resulting from the analysis of literature focused on pediatric robotics and MIS may be further revised and updated.