title: Comparison of economic and clinical outcomes between patients undergoing laparoscopic bariatric surgery with powered versus manual endoscopic surgical staplers.

text: AIMS To compare economic and clinical outcomes between patients undergoing laparoscopic Roux-en-Y gastric bypass (LRY) or laparoscopic sleeve gastrectomy (LSG) with use of powered vs manual endoscopic surgical staplers. MATERIALS AND METHODS Patients (aged ≥21 years) who underwent LRY or LSG during a hospital admission (January 1, 2012-September 30, 2015) were identified from the Premier Perspective Hospital Database. Use of powered vs manual staplers was identified from hospital administrative billing records. Multivariable analyses were used to compare the following outcomes between the powered and manual stapler groups, adjusting for patient and hospital characteristics and hospital-level clustering: hospital length of stay (LOS), total hospital costs, medical/surgical supply costs, room and board costs, operating room costs, operating room time, discharge status, bleeding/transfusion during the hospital admission, and 30, 60, and 90-day all-cause readmissions. RESULTS The powered and manual stapler groups comprised 9,851 patients (mean age = 44.6 years; 79.3% female) and 21,558 patients (mean age = 45.0 years; 78.0% female), respectively. In the multivariable analyses, adjusted mean hospital LOS was 2.1 days for both the powered and manual stapler groups (p = .981). Adjusted mean total hospital costs ($12,415 vs $13,547, p = .003), adjusted mean supply costs ($4,629 vs $5,217, p = .011), and adjusted mean operating room costs ($4,126 vs $4,413, p = .009) were significantly lower in the powered vs manual stapler group. The adjusted rate of bleeding and/or transfusion during the hospital admission (2.46% vs 3.22%, p = .025) was significantly lower in the powered vs manual stapler group. The adjusted rates of 30, 60, and 90-day all-cause readmissions were similar between the groups (all p > .05). Sub-analysis by manufacturer showed similar results. LIMITATIONS This observational study cannot establish causal linkages. CONCLUSIONS In this analysis of patients who underwent LRY or LSG, the use of powered staplers was associated with better economic outcomes, and a lower rate of bleeding/transfusion vs manual staplers in the real-world setting.


title: Quality improvement during the COVID-19 pandemic.

text: In response to the COVID-19 pandemic, quality improvement teams at Cleveland Clinic initiated a number of measures to guide the care of patients with suspected or confirmed COVID-19 infection and protect care givers. This included increasing the frequency of team meetings from monthly to daily or weekly and creating task forces to create protocols for patient transport, airway management, and management of personal protective equipment and medications in short supply. Enterprise wide, we postponed non-essential surgeries, set up an overflow intensive care unit onsite, created a web-based COVID-19 toolkit for all care givers, and sent daily emails about the most recent developments, decisions, and recommendations from national and international societies.


Domestic abuse in the time of coronavirus.


title: Comparison of cardiac output and hemodynamic responses of intubation among different videolaryngoscopies in normotensive and hypertensive patients.

text: Tracheal intubation with Macintosh laryngoscope (MAC) might result in severe cardiovascular complications. The results of conducted studies investigating the effects of videolaryngoscopies on hemodynamic response of tracheal intubation are conflicting. We know little about the effects of videolaryngoscopies on cardiac output changes during tracheal intubation. We compared cardiac output (COP) and hemodynamic responses in normal blood pressure (n=60) and hypertensive patients (n=60) among 3 intubation devices: the MAC, the UE videolaryngoscopy ® (UE), and the UE video intubation stylet ® (VS). Cardiac index (CI), stroke volume index (SVI), heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded using LidcoRapid (V2)® preinduction, preintubation, and every minute for the first 5 min after intubation. We assessed oropharyngeal and laryngeal structures injury as well. Intubation time was significantly shorter than MAC groups (P<0.001) only in UE group of normotensive and hypertensive patients. In normotensive patients, there were no significant differences in any of COP variables or hemodynamic variables among the three devices. In hypertensive patients, SBP and DBP in the MAC group were significantly higher (P<0.05 or <0.01) than the UE and VS groups at 1, 2 and 3 min after intubation, but there were no significant differences in CI, SVI and HR among the three devices. There was no significant difference in oropharyngeal and laryngeal structures injury among all groups. It was concluded that both the UE and VS attenuate only the hemodynamic response to intubation as compared with the MAC in hypertensive patients, but not in normotensive patients.


title: Ex vivo comparison of the giant and transfixing knot in equine open and closed castration.

text: REASONS FOR PERFORMING STUDY In equine castration, application of a ligature on the spermatic cord to prevent complications such as haemorrhage and evisceration has been reported with controversial results. Characteristics of commonly used knots have not been studied. OBJECTIVES To compare the modified transfixing and giant knots and the emasculator in open and closed equine castration techniques. STUDY DESIGN Ex vivo experiment. METHODS A total of 144 testicles were randomly assigned to 2 groups for open or closed castration. Both groups were divided into 3 subgroups of 18 specimens each: emasculator only, emasculator plus giant knot and emasculator plus transfixing knot and the open castration group also contained 2 further subgroups of 18 testicles each: giant knot only and transfixing knot only. The length of suture material used was measured for each knot and the leaking pressure of the testicular artery measured using dye injection. In the closed castration group, parietal tunic tensile strength was measured with a tensiometer. RESULTS Leaking pressure was higher in open compared with closed castration, with no significant difference among subgroups. In the closed castration group, minimum leaking pressure for the emasculator plus transfixing knot and emasculator only subgroups were close to standard physiological arterial pressures. The giant knot required less suture material than the transfixing knot. Parietal tunic tensile strength was higher when ligatures were applied. CONCLUSIONS The giant and transfixing knot techniques have comparable haemostatic capability and parietal tunic tensile strength, but the giant knot requires less suture material. In open castration, using the emasculator alone may produce adequate haemostasis. In closed castration, using the giant knot in combination with the emasculator increases the bursting pressure and possibly reduces the incidence of haemorrhage. In closed castration, application of a ligature may reduce the risk of evisceration.


title: The need for psychosocial support amid COVID-19 crises in Nigeria.

text: With the closure of all public places, the stay-at-home order and the worsening economic indices occasioned by the fall in the price of crude oil with no foreseeable end, learned helplessness, negative emotions, and other psychosocial problems are bound to thrive. Interventions to improve social capital, coping resources, resilience, and good community and family cohesion are needed to promote psychosocial well-being during and after the COVID-19 pandemic in Nigeria. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Antibody tests for COVID-19: drawing attention to the importance of analytical specificity.


title: Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff.

text: BACKGROUND In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed. OBJECTIVES To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020. SELECTION CRITERIA We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate. MAIN RESULTS Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only. AUTHORS' CONCLUSIONS We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.


Are patients with systemic lupus erythematosus at increased risk for COVID-19?


title: Disease Outbreak Surge Response: How a Singapore Tertiary Hospital converted a multi-storey carpark into a Flu Screening Area to respond to the COVID-19 pandemic.

text: COVID-19, first documented in December 2019, was declared a public health emergency by the World Health Organisation (WHO) on 30th January 20201. The disease, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has affected more than 9 million people and contributed to at least 490,000 deaths globally as of June 2020, with numbers on the rise2.Increased numbers of patients seeking medical attention during disease outbreaks can overwhelm healthcare facilities, hence requiring an equivalent response from healthcare services. Surge capacity is a concept that has not only been defined as the "ability to respond to a sudden increase in patient care demands3" but also to "effectively and rapidly expand capacity4".This narrative review discusses how Singapore's largest tertiary hospital has encapsulated the elements of surge capability and transformed a peacetime multi-storey carpark into a flu screening area in response to the COVID-19 disease outbreak.


Kidney Paired Donation Protocol for Participating Donors 2014.


title: Blood count and C-reactive protein evolution in gastric cancer patients with total gastrectomy surgery.

text: BACKGROUND The complete blood count (CBC) and C-reactive protein (CRP) are useful inflammatory parameters for ruling out acute postoperative inflammatory complications. AIM To determine their changes in gastric cancer patients submitted to total gastrectomy. METHODS This is a prospective study, with 36 patients with gastric cancer who were submitted to elective total gastrectomy. On the first, third and fifth postoperative day (POD), blood count and CRP changes were assessed. Patients with postoperative complications were excluded. RESULTS Twenty-one (58%) were men and 15 (42%) women. The mean age was 65 years. The leukocytes peaked on the 1st POD with a mean of 13,826 u/mm³, and decreased to 8,266 u/mm³ by the 5th POD. The bacilliforms peaked on the 1st POD with a maximum value of 1.48%. CRP reached its maximum level on the 3rd POD with a mean of 144.64 mg/l±44.84. Preoperative hematocrit (HCT) was 35% and 33.67% by the 5th POD. Hemoglobin, showed similar values. CONCLUSIONS Leukocytes increased during the 1st POD but reached normal values by the 5th POD. CRP peaked on the 3rd POD but did not reach normal values by the 5th POD.


title: A review of randomised controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins.

text: OBJECTIVE The last 10 years have seen the introduction into everyday clinical practice of a wide range of novel non-surgical treatments for varicose veins. In July 2013, the UK National Institute for Health and Care Excellence recommended the following treatment hierarchy for varicose veins: endothermal ablation, ultrasound-guided foam sclerotherapy, surgery and compression hosiery. The aim of this paper is to review the randomised controlled trials that have compared endothermal ablation and ultrasound-guided foam sclerotherapy to determine if the level 1 evidence base still supports an "endothermal ablation first" strategy for the treatment of varicose veins. METHODS A PubMed and OVID literature search (until 31 January 2015) was performed and randomised controlled trials comparing endothermal ablation and ultrasound-guided foam sclerotherapy were obtained. RESULTS Although anatomical success appeared higher with endothermal ablation than ultrasound-guided foam sclerotherapy, clinical success and patient-reported outcomes measures were similar. Morbidity and complication rates were very low and not significantly different between endothermal ablation and ultrasound-guided foam sclerotherapy. Ultrasound-guided foam sclerotherapy was consistently less expensive that endothermal ablation. CONCLUSIONS All endovenous modalities appear to be successful and have a role in modern day practice. Although further work is required to optimise ultrasound-guided foam sclerotherapy technique to maximise anatomical success and minimise retreatment, the present level 1 evidence base shows there is no significant difference in clinical important outcomes between ultrasound-guided foam sclerotherapy and endothermal ablation. As ultrasound-guided foam sclerotherapy is less expensive, it is likely to be a more cost-effective option in most patients in most healthcare settings. Strict adherence to the treatment hierarchy recommended by National Institute for Health and Care Excellence seems unjustified.


title: COVID-19, Quarantines, Sheltering-in-Place, and Human Rights: The Developing Crisis.

text: As COVID-19 has spread across the globe, quarantines and sheltering-in-place orders have become important public health tools but, as currently implemented, have eroded human rights, particularly for the marginalized, including essential workers, detainees, women, and children. Quarantines and sheltering-in-place orders must include explicit guarantees of human rights protections. We outline protections for the quarantined that communities and governments should strive to guarantee.


title: Lethal concentration of perfluoroisobutylene induces acute lung injury in mice mediated via cytokine storm, oxidative stress and apoptosis.

text: Perfluoroisobutylene (PFIB) is a highly toxic gas that targets the lungs. Low-level inhalation of the gas can lead to acute lung injury (ALI), pulmonary edema and even death. No specific anti-PFIB drugs are currently available and the pathogenesis of PFIB-induced ALI is not fully understood. Early direct oxidative injury and a secondary hyper-inflammatory response are recognized as the primary mechanisms of PFIB-induced ALI. In the present study, our data demonstrate for the first time that a cytokine storm is associated with PFIB-induced ALI. Levels of 10 pro-inflammatory cytokines and one anti-inflammatory cytokine were significantly increased in lung tissues of PFIB-exposed mice. PFIB inhalation additionally led to significant oxidative stress in lung tissue. Inflammation-associated CD11b+Ly6G+Ly6Cint neutrophils and CD11b+Ly6G-Ly6Chi monocytes were significantly increased in blood in association with PFIB-induced ALI. Bcl-2/Bax-mediated lung cell apoptosis was significantly increased at 1 h, followed by a sustained decrease after 1 h, which was significant at 4-8 h in PFIB-exposed mice. This suppression of apoptosis is possibly associated with the Akt-signaling pathway.


title: The prognosis of infants with neonatal respiratory inhibition syndrome.

text: OBJECTIVE The goal of this study was to investigate the prognosis of infants with neonatal respiratory inhibition syndrome (NRIS). METHODS Infants with a gestational age of at least 36 weeks and a birth weight of at least 2000 g who were born at Nara Prefecture General Medical Center, in Nara, Japan, between March 2013 and June 2016 were screened for NRIS using our established method. NRIS was defined as severe hypoxemia caused by respiratory inhibition immediately after crying (RIAC) or gastroesophageal reflux (RIGER) or as a respiratory pause during feeding (feeding hypoxemia), accompanied clinically by central cyanosis and a decrease in SpO2 to less than 70%. All infants were monitored using pulse oximetry immediately after birth. Diagnosis of RIAC, feeding hypoxemia, and RIGER are based on observation by both parents and medical staff as well as on on-screen computer analysis using specific software. All infants were examined at a one-month check-up. Parents of the infants who experienced one or more episodes of NRIS accompanied by a decrease in SpO2 to less than 70% for more than approximately 60 s received a questionnaire by mail about their child's development. We conducted a logistic regression analysis with developmental problems as the dependent variable. RESULTS NRIS was observed in 362 (28.5%) infants; 216 (17.0%) infants showed RIAC, 254 (20.0%) infants showed feeding hypoxemia, and 54 (4.2%) infants showed RIGER. Although all infants were monitored in the maternity ward nursery, 184 (85.2%) infants with RIAC and 111 (43.7%) infants with feeding hypoxemia were overlooked. All infants with NRIS were found to have successfully recovered at one month after birth. Sixty-two cases were examined in the follow-up study by the mailed questionnaire. The median age of the subjects at time of study was 22 months. Fourteen cases (22.6%) exhibited developmental problems including delayed speech development, stereotyped interests and behaviors, sensory disturbance, hyperactivity, delayed motor development, and short stature. Developmental problems tended to relate to shorter gestational age (odds ratio, 0.622; p = .068; 95% CI, 0.373-1.036), smaller birth weight (odds ratio, 0.998; p = .069; 95% CI, 0.997-1.000), and maximum duration of SpO2 to less than 70% by RIAC (odds ratio, 1.009; p = .086; 95% CI, 0.999-1.020). All cases had experienced severe hypoxemia accompanied by a decrease in SpO2 to less than 60%. Seven cases had experienced prolonged hypoxemia accompanied by a decrease in SpO2 to less than 70% for at least 2 min. Among the subjects, 19 infants were examined closely, and their natural course of NRIS was observed in the neonatal intensive care unit. No cases demonstrated abnormal findings with blood examinations, chest-abdominal X-ray, echocardiogram, laryngoendoscopy, hearing loss screening, or mass screening. Only one case had a small intracranial hemorrhage as evidenced in a magnetic resonance imaging of the head. CONCLUSIONS The infants with severe NRIS tended to have developmental problems. Spreading knowledge about NRIS worldwide is thought to be very important.


title: Human bocavirus: clinical significance and implications.

text: PURPOSE OF REVIEW Human bocavirus (HBoV), a parvovirus, was discovered in 2005 with the use of nonspecific genome amplification techniques. Since its discovery, HBoV has been identified worldwide. This review will focus on the epidemiology and clinical features associated with HBoV infection. RECENT FINDINGS Initial studies demonstrated the presence of HBoV DNA in respiratory specimens of individuals with respiratory tract disease. Data from some studies suggest that HBoV may be the etiological agent responsible for respiratory tract disease, particularly in young children. HBoV, however, is frequently detected in the presence of other common respiratory viruses. HBoV is not confined to the respiratory tract as evidence of the virus has been detected in serum and stool, the significance of which remains unclear. Presence of the virus in respiratory secretions, serum and stool suggests that this virus may cause systemic illness. SUMMARY HBoV is an emerging human parvovirus. The full spectrum of disease associated with HBoV remains to be defined.


title: Laparoscopic ovariectomy in dogs: comparison between laparoendoscopic single-site and three-portal access.

text: This study was conducted to evaluate the feasibility and therapeutic safety of laparoendoscopic single-site ovariectomy (LESS-OVE) and 3-portal laparoscopic ovariectomy (Lap-OVE) in dogs. Ten female mixed breed dogs were included in the study. Dogs were divided into group 1 (LESS-OVE; n = 5) and group 2 (Lap-OVE; n = 5). All procedures were performed by laparoscopic-skilled surgeons, and the anesthetic protocol was the same for all patients. In both groups, the ovarian vascular pedicle and ligaments were transected using a bipolar vessel sealer/divider device. The mean total surgical time was slightly longer in LESS-OVE (36.6 ± 3.5 min) than Lap-OVE (32.0 ± 3.0 min); however, the differences were not significant. Perioperative complications were not reported in any group. Both laparoscopic techniques were shown to be equally feasible and safe for patients. However, surgeons found LESS-OVE to require more skill than Lap-OVE. Therefore, additional studies should be conducted to evaluate this novel approach in clinical veterinary practice, and a proper laparoscopic training program for veterinary surgeons should be developed.


title: Motor cortical and corticospinal function differ during an isometric squat compared with isometric knee extension.

text: NEW FINDINGS What is the central question of this study? In order to discern information about testing modalities when assessing neuroplastic responses to squat resistance training, the present study investigated whether corticospinal and intracortical function was different between a joint-angle-matched isometric squat and isometric knee extension. What is the main finding and its importance? The present data show poor agreement of corticospinal and intracortical function between the isometric squat and isometric knee extension. The data reinforce the notion that task specificity is of the utmost importance for assessing neuroplasticity. ABSTRACT It has been suggested that task-specific changes in neurophysiological function (neuroplasticity) should be assessed using testing modalities that replicate the characteristics of the intervention. The squat is a commonly prescribed resistance exercise that has been shown to elicit changes in CNS function. However, previous studies have assessed squat-induced neuroplasticity using isometric knee extension, potentially confounding the results. The aim of the present study was to assess the agreement between corticospinal and intracortical activity relating to the knee extensors during isometric knee extension compared with an isometric squat task. Eleven males completed a neurophysiological assessment in an isometric squat (IS) and knee-extension (KE) task matched for joint angles (hip, knee and ankle). Single- and paired-pulse transcranial magnetic stimulation was delivered during isometric contractions at a range of intensities to assess short-interval cortical inhibition (SICI) and corticospinal excitability. Group mean values for SICI (70 ± 14 versus 63 ± 12% of unconditioned motor evoked potential during IS and KE, respectively) and corticospinal excitability (mean differences 2-5% of the maximal compound muscle action potential at 25, 50, 75 and 100% maximal voluntary contraction between the IS and KE) were not different between the two tasks (P > 0.05) in the vastus lateralis. However, limits of agreement were wide, with poor-to-moderate average intraclass correlation coefficients (ICCs) (SICI, ICC3,1 = 0.15; corticospinal excitability, average ICC3,1 range = 0.0-0.63), indicating disparate corticospinal and intracortical activity between the IS and KE. These data highlight the importance of task specificity when assessing the modulation of corticospinal excitability and SICI in response to interventions resulting in neuroplastic changes.


Therapeutic decisions in inflammatory bowel disease in the SARS-Cov-2 pandemic.


title: Is postal postoperative follow-up in urogynaecology feasible?

text: Postoperative follow-up after urogynaecological surgery has been little investigated. Traditionally, it is done in hospital but there is wide variation in the assessments and timing. We aimed to determine the viability of postal follow-up in women undergoing urogynaecological surgery. This is a retrospective review of prospectively collected data. All women who underwent prolapse and/or urinary incontinence surgery between January and June 2010 were included. Validated ICIQ questionnaires for prolapse and/or incontinence, as appropriate, were used, before surgery and at 6 months postoperatively. The primary outcome was the response rate to postal follow-up. A total of 70 women had urogynaecology surgery during the study period; 65 (93%) women returned the questionnaires (95% CI 84-97%, p < 0.0001). The postoperative questionnaires scores showed a statistically significant improvement compared with the preoperative scores. This results in only a small proportion of women needing hospital attendance for follow-up (10%). We conclude that postal follow-up is feasible.


title: The prevalence, characteristics and prevention status of skin injury caused by personal protective equipment among medical staff in fighting COVID-19: A multi-center, cross-sectional study.

text: OBJECTIVE To investigate the prevalence, characteristics and preventive status of skin injuries caused by personal protective equipment (PPE) in medical staff. APPROACH A cross-sectional survey was conducted online for understanding skin injuries among medical staff fighting against COVID-19 in February 8-22, 2020. Participants voluntarily answered and submitted the questionnaire with cellphone. The questionnaire items included demographic data, grade of PPE and daily wearing time, skin injuries types, anatomical sites, and preventive measures. Univariable analyses and logistic regression analyses were employed to explore the risk factors associated with skin injuries. RESULTS A total of 4,308 respondents were collected from 161 hospitals and 4,306 respondents were valid. The overall prevalence of skin injuries was 42.8% (95% CI 41.30%-44.30%) with three types of device-related pressure injuries, moist associated skin damage and skin tear. Co-skin injuries and multiple locations injuries were 27.4% and 76.8%, respectively. The logistic regression analysis indicated that sweating (95%CI for OR 87.52-163.11), daily wearing time (95% CI for OR1.61-3.21), male (95% CI for OR 1.11-2.13) and grade 3 PPE (95% CI for OR1.08-2.01) were associated with skin injuries. Only 17.7% respondents took prevention and 45.0% skin injuries were treated. INNOVATION This the first cross-sectional survey to understand skin injuries in medical staff caused by PPE, which is expected to be a benchmark. CONCLUSION The skin injuries among medical staff are serious, with insufficient prevention and treatment. A comprehensive program should be taken in future.


title: X-ray indices of chest drain malposition after insertion for drainage of pneumothorax in mechanically ventilated critically ill patients.

text: Background Chest drain (CD) migration in the pleural cavity may result in inadequate drainage of pneumothorax. The aim of this study was to assess several parameters that might help in diagnosing CD migration on chest X-ray (CXR). Methods Patients with a CD inserted from the safe triangle with a subsequent supine CXR and CT scan performed less than 24 hours apart were assessed for CD foreshortening, angle of inclination of the CD, and CD tortuosity. CD foreshortening was expressed as a ratio between CD length measured in coronal plane only and CD length inside the pleural cavity measured on CT. The angle of inclination of the CD was measured as the angle between the horizontal line and CD at the pleural space entry on CXR. CD tortuosity was calculated as a ratio between the distance from CD pleural space entry to the tip of the CD and the length of CD from the pleural space entry to its tip on CXR. Results Altogether 28 patients were included in the study. The median time between the CXR and CT examinations was 5.4 hours (IQR, 3.8-6.9 hours). CD foreshortening was the best clue of a misplaced CD with AUC of 0.93, 100% sensitivity and 88% specificity for a cut-off value of 82%. The angle of CD inclination was greater in patients with misplaced CD with AUC of 0.83, 75% sensitivity and 92% specificity for a cut-off of 50 degrees. The performance of CD tortuosity was poor. Conclusions Greater foreshortening of the CD and a steep angle of inclination of the CD above the horizontal at chest entry should raise suspicion of CD migration and mandate further investigation by chest ultrasound to rule out residual pneumothorax occult on CXR.


title: Videoscopic basilic vein harvest for creation of transposed brachiobasilic arteriovenous fistulae.

text: INTRODUCTION Due to the extensive dissection required during the standard transposed brachiobasilic arterial venous fistula (BB-AVF) procedure and the potential for postoperative complications, many surgeons are reluctant to construct BB-AVFs. Less invasive vein harvest has been performed for this procedure with good results, but this procedure remains rarely used. METHODS We began to perform videoscopic-assisted BB-AVF creation in selected patients at our institution in 2006. Vein harvesting from the antecubital fossa to the level of the axilla is performed by an experienced surgical technician under the guidance of the dialysis access surgeon. Perioperative data and postoperative outcomes were retrospectively reviewed with institutional review board approval. RESULTS From 2006 to 2010, we performed videoscopic-assisted BB-AVF in 21 patients. Median age was 59 years and median body mass index was 30; women comprised 52% of the cohort. Previous vascular access procedures had been performed on 81% of patients. Of the 21 attempts with the video-assisted approach, only 1 required conversion to a standard open procedure. Of the remaining cases, there were no significant intraoperative or postoperative surgical complications with a median operative time of 159 minutes and maximum length of stay of 1 night. Maturation of the fistula sufficient for cannulation and use occurred in 80% of patients, with the median time to first access in patients who matured being 60 days. At 3 years follow-up, 47% of fistulas that matured were still functional, with 33% lost to death or successful renal transplantation. CONCLUSION Videoscopic-assisted transposition of the basilic vein is a reasonable option for BB-AVF placement. The procedure can be performed in an acceptable expeditious fashion with near elimination of infection, wound breakdown, lymph drainage, nerve injury, and satisfactory maturation (80%) and patency rates. Technicians experienced in lower extremity vein harvest can perform this procedure successfully under the supervision of an experienced access surgeon.


title: SAIL--stereo-array isotope labeling.

text: Optimal stereospecific and regiospecific labeling of proteins with stable isotopes enhances the nuclear magnetic resonance (NMR) method for the determination of the three-dimensional protein structures in solution. Stereo-array isotope labeling (SAIL) offers sharpened lines, spectral simplification without loss of information and the ability to rapidly collect and automatically evaluate the structural restraints required to solve a high-quality solution structure for proteins up to twice as large as before. This review gives an overview of stable isotope labeling methods for NMR spectroscopy with proteins and provides an in-depth treatment of the SAIL technology.


The clinical cutting edge.


Therapeutic approaches for genetic and infectious diseases.


title: Safety and efficiency of gasless laparoscopy: a systematic review protocol.

text: BACKGROUND Gasless laparoscopy, developed in the early 1990s, was a means to minimize the clinical and financial challenges of pneumoperitoneum and general anaesthesia. It has been used in a variety of procedures such as in general surgery and gynecology procedures including diagnostic laparoscopy. There has been increasing evidence of the utility of gasless laparoscopy in resource limited settings where diagnostic imaging is not available. In addition, it may help save costs for hospitals. The aim of this study is to conduct a systematic review of the available evidence surrounding the safety and efficiency of gasless laparoscopy compared to conventional laparoscopy and open techniques and to analyze the benefits that gasless laparoscopy has for low resource setting hospitals. METHODS This protocol is developed by following the Preferred Reporting Items for Systematic review and Meta-Analysis-Protocols (PRISMA-P). The PRISMA statement guidelines and flowchart will be used to conduct the study itself. MEDLINE (Ovid), Embase, Web of Science, Cochrane Central, and Global Index Medicus (WHO) will be searched and the National Institutes of Health Clinical Trials database. The articles that will be found will be pooled into Covidence article manager software where all the records will be screened for eligibility and duplicates removed. A data extraction spreadsheet will be developed based on variables of interest set a priori. Reviewers will then screen all included studies based on the eligibility criteria. The GRADE tool will be used to assess the quality of the studies and the risk of bias in all the studies will be assessed using the Cochrane Risk assessment tool. The RoB II tool will assed the risk of bias in randomized control studies and the ROBINS I will be used for the non-randomized studies. DISCUSSION This study will be a comprehensive review on all published articles found using this search strategy on the safety and efficiency of the use of gasless laparoscopy. The systematic review outcomes will include safety and efficiency of gasless laparoscopy compared to the use of conventional laparoscopy or laparotomy. TRIAL REGISTRATION The study has been registered in PROSPERO under registration number: CRD42017078338.


Creating misinformation: how a headline in The BMJ about covid-19 spread virally.


title: Effect of X-Ray Attenuation of Arterial Obstructions on Intravenous Thrombolysis and Outcome after Ischemic Stroke.

text: OBJECTIVE To assess whether the x-ray attenuation of intra-arterial obstruction measured on non-contrast CT in ischemic stroke can predict response to thrombolysis and subsequent functional outcome. METHODS The Third International Stroke Trial (IST-3) was a multicenter randomized-controlled trial of intravenous thrombolysis (rt-PA) given within six hours of ischemic stroke. Ethical approval and informed consent were obtained. In a subgroup of 109 IST-3 patients (38 men, median age 82 years), a single reader, masked to all clinical and other imaging data, manually measured x-ray attenuation (Hounsfield Units, HU) on non-contrast CT at the location of angiographically-proven intra-arterial obstructions, pre-randomization and at 24-48 hour follow-up. We calculated change in attenuation between scans. We assessed the impact of pre-randomization arterial obstruction attenuation on six-month functional outcome. RESULTS Most arterial obstructions (64/109, 59%) were hyperattenuating (mean 51.0 HU). Compared with control, treatment with rt-PA was associated with a greater, but non-significant, reduction in obstruction attenuation at follow-up (-8.0 HU versus -1.4 HU in patients allocated control, p = 0.117). In multivariable ordinal regression analysis controlled for patient age, stroke severity, location and extent of obstruction, time from stroke onset to baseline scan and rt-PA treatment allocation, the attenuation of pre-randomization arterial obstruction was not independently associated with six-month outcome (odds ratio = 0.99, 95% confidence interval = 0.94-1.03, p = 0.516). CONCLUSIONS In ischemic stroke, the x-ray attenuation of the arterial obstruction may decline more rapidly from baseline to 24-48 hours following treatment with thrombolysis but we found no evidence that baseline arterial obstruction attenuation predicts six-month outcome.


title: Research NoteBacterial Community Assessed by Utilization of Single Carbon Sources in Broiler Ground Meat after Treatment with an Antioxidant, Carnosine, and Cold Plasma.

text: Contaminated poultry meat is a major source of human foodborne illnesses. Many interventions have been developed to reduce and/or eliminate human foodborne pathogens in poultry products; however, treatments with cold plasma or carnosine or a combination of both interventions have not been extensively investigated. In this communication, the bacterial microflora of poultry meat samples after treatments with cold plasma and carnosine were characterized with EcoPlates ™ in the OmniLog ® system. The plates were incubated at 25 o C for seven days in the OmniLog ® chamber, and bacterial growth was monitored by recording formazan production every 30 minutes at OD 590 nm . The kinetics of lag, log and stationary phases of the bacterial growth patterns followed the Gompertz sigmoidal model, but with different inflection times and asymptotes at the log phase and the stationary phase, respectively. Results indicated that treating poultry meat samples with cold plasma technology and carnosine could inhibit growth of the bacteria in the treated meat samples. Of 31 chemicals tested, phenylethylamine, α- D -lactose, D,L -α-glycerol phosphate, 2-hydroxybenzoic acid, γ-hydroxybutyric acid, α-ketobutyric acid or D -malic acid could not be metabolized by bacteria in the meat samples. Future research is required to determine whether these seven chemicals that inhibit growth of bacteria from the meat samples can be used as food preservatives for extending shelf-life of these products. Whether the bacterial flora be as an indicator of effectiveness for meat samples treated with cold plasma, carnosine or both needs further study.


Classic concepts and modern developments in transplant infectious disease: the work of Robert H. Rubin.


title: Delayed Gastric Emptying Following Laparoscopic Repair of Very Large Hiatus Hernias Impairs Quality of Life.

text: BACKGROUND Delayed gastric emptying (DGE) following hiatus hernia surgery may affect a substantial number of patients with adverse clinical consequences. Here, we aim to evaluate the impact of DGE following laparoscopic repair of very large hiatus hernias on patients' quality of life, gastrointestinal symptomatology, and daily function. METHODS Analysis of data collected from a multicenter prospective randomised trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (>50% of stomach in chest). DGE was defined as gastric food retention visualised at endoscopy after 6 h of fasting at 6 months post-surgery. Quality of life (QOL), gastrointestinal symptomatology, and daily function were assessed with the SF-36 questionnaire, Visick scoring and structured surveys administered prior to surgery and at 1, 3, 6 and 12 months after surgery. RESULTS Nineteen of 102 (18.6%) patients had DGE 6 months after surgery. QOL questionnaires were completed in at least 80% of patients across all time points. Compared with controls, the DGE group demonstrated significantly lower SF-36 physical component scores, delayed improvement in health transition, more adverse gastrointestinal symptoms, higher Visick scores and a slower rate of return to normal daily activities. These differences were still present 12 months after surgery. CONCLUSIONS DGE following large hiatus hernia repair is associated with a negative impact on quality of life at follow-up to 12 months after surgery.


title: Telotristat etiprate for carcinoid syndrome: a single-arm, multicenter trial.

text: CONTEXT Carcinoid syndrome (CS) is associated with elevated serotonin, diarrhea, flushing, and increased risk of valvular heart disease. Many patients respond to somatostatin analogs initially, but response diminishes in most patients. Additional options are needed. OBJECTIVE To assess whether telotristat etiprate (TE) can reduce gastrointestinal symptoms in CS and reduce urinary 5-hydroxyindoleacetic acid (u5-HIAA; a biomarker of serotonin). DESIGN A prospective, exploratory, dose-escalating 12-week, open-label, multicenter study of TE with efficacy and safety analyses. SETTING A multicenter study. PATIENTS Eligible patients had metastatic, well-differentiated, neuroendocrine tumors and CS with ≥ four bowel movements (BMs) per day. Somatostatin analog use was allowed. INTERVENTIONS TE, a novel oral inhibitor of peripheral serotonin synthesis. MAIN OUTCOME MEASURES Primary: safety. Secondary: daily BMs, stool form, and u5-HIAA. RESULTS Fifteen patients were enrolled, and 14 completed the treatment period. All patients experienced reductions in BMs per day (mean decrease, 43.5%). A 74.2% mean reduction in u5-HIAA, the main metabolite of serotonin, was observed, with generally greater reductions in patients with greater reductions in BMs per day. Nine patients (75%) reported "adequate relief" of gastrointestinal symptoms at 12 weeks, compared with two (17%) at baseline. Stool form and flushing also improved. Adverse events were mostly gastrointestinal (n = 10; 67%), consistent with underlying illness; three adverse events were serious (abdominal pain, diarrhea, and gastroenteritis) but were judged unrelated. CONCLUSION TE was generally safe and well tolerated. Patients experienced substantial improvement in CS and reductions in u5-HIAA, consistent with the mechanism of action of TE. These results support further evaluation in phase 3 studies.


title: HydroCoils reduce recurrence rates in recently ruptured medium-sized intracranial aneurysms: a subgroup analysis of the HELPS trial.

text: BACKGROUND AND PURPOSE The HydroCoil Endovascular Aneurysm Occlusion and Packing Study (HELPS) was a randomized, controlled trial comparing HydroCoils with bare-platinum coils. The purpose of this study was to perform a subgroup analysis of angiographic and clinical outcomes of medium-sized aneurysms in the HELPS trial. MATERIALS AND METHODS Patients with medium-sized aneurysms (5-9.9 mm) were selected from the HELPS trial. Outcomes compared between the HydroCoil and bare-platinum groups included the following: 1) any recurrence, 2) major recurrence, 3) retreatment, and 4) mRS score of ≤2. Subgroup analysis by rupture status was performed. Multivariate logistic regression analysis adjusting for aneurysm neck size, shape, use of adjunctive device, and rupture status was performed. RESULTS Two hundred eighty-eight patients with medium-sized aneurysms were randomized (144 in each group). At 15-18 months posttreatment, the major recurrence rate was significantly lower in the HydroCoil group than in controls (18.6% versus 30.8%, P = .03, respectively). For patients with recently ruptured aneurysms, the major recurrence rate was significantly lower for the HydroCoil group than for controls (20.3% versus 47.5%, P = .003), while rates were similar between groups for unruptured aneurysms (16.7% versus 14.8%, P = .80). Multivariate analysis of patients with recently ruptured aneurysms demonstrated a lower odds of major recurrence with HydroCoils (OR = 0.27; 95% CI, 0.12-0.58; P = .0007). No difference in retreatment rates or mRS of ≤2 was seen between groups. CONCLUSIONS HydroCoils were associated with statistically significant and clinically relevant lower rates of major recurrence for recently ruptured, medium-sized aneurysms in the HELPS trial. Because this was not a prespecified subgroup analysis, these results should not alter clinical practice but, rather, provide insight into the design of future clinical trials comparing bare platinum with second-generation coils.


title: Investigating the effectiveness of school health services delivered by a health provider: A systematic review of systematic reviews.

text: Schools are the only institution regularly reaching the majority of school-age children and adolescents across the globe. Although at least 102 countries have school health services, there is no rigorous, evidence-based guidance on which school health services are effective and should be implemented in schools. To investigate the effectiveness of school health services for improving the health of school-age children and adolescents, a systematic review of systematic reviews (overview) was conducted. Five databases were searched through June 2018. Systematic reviews of intervention studies that evaluated school-based or school-linked health services delivered by a health provider were included. Review quality was assessed using a modified Ballard and Montgomery four-item checklist. 1654 references were screened and 20 systematic reviews containing 270 primary studies were assessed narratively. Interventions with evidence for effectiveness addressed autism, depression, anxiety, obesity, dental caries, visual acuity, asthma, and sleep. No review evaluated the effectiveness of a multi-component school health services intervention addressing multiple health areas. From the limited amount of information available in existing systematic reviews, the strongest evidence supports implementation of anxiety prevention programs, indicated asthma education, and vision screening with provision of free spectacles. Additional systematic reviews are needed that analyze the effectiveness of comprehensive school health services, and specific services for under-researched health areas relevant for this population.


title: Laparoscopic Resection of Recurrence from Hepatocellular Carcinoma after Liver Transplantation: Case Reports and Review of the Literature.

text: Background. Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) indicates a poor prognosis. Surgery is considered the only curative option for selected patients with HCC recurrence following LT. Traditionally, the preference is given to the open approach. Methods. In this report, we present two cases of laparoscopic resections (LR) for recurrent HCC after LT, performed at Oslo University Hospital, Rikshospitalet. Results. Both procedures were executed without intraoperative and postoperative adverse events. Whereas one of the patients had a recurrence one year after LR, the other patient did not have any sign of disease during 3-year follow-up. Conclusions. We argue that, in selected cases, patients with HCC recurrence following LT may benefit from LR due to its limited tissue trauma and timely start of subsequent treatment if curative resection cannot be obtained. In patients with relatively favorable prognosis, LR facilitates postoperative recovery course and avoids unnecessary laparotomy.


A26 Transmission patterns and evolution of RSV in a community outbreak identified by genomic analysis.


title: Randomized clinical study for assessment of incision characteristics and pain associated with LESS versus laparoscopic cholecystectomy.

text: BACKGROUND Laparoendoscopic single-site surgery (LESS) has emerged as a technique that uses a natural scar, the umbilicus, within which a multiple-entry portal is placed into a 3.0-4.0-cm single incision to perform operations. The objective of this study was to compare incision size, wound complications, and postoperative pain of LESS compared with those of laparoscopic cholecystectomy (LC). METHODS A prospective randomized controlled study was conducted between January and June 2011 at two university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients were randomly assigned to undergo laparoscopic or LESS cholecystectomy. Skin and aponeurosis wound sizes were recorded. A 10-point visual analog scale (VAS) was used to assess pain at postoperative hours 3 and 24. Healing and wound complications were assessed at follow-up. RESULTS A total of 57 patients, 53 women and 4 men with a mean age of 48.7 years, were randomly assigned to undergo LESS (n = 28) or LC (n = 29). The mean length of the umbilical skin incision was 4.0 cm (range = 2.1-5.8) in LESS and 2.7 cm (1.5-5.1) in LC (p < .0001). The mean internal aponeurosis diameter was 3.5 cm (2.0-5.5) in LESS and 2.3 cm (1.2-3.5) in LC (p < .0001). The mean operative time was 60.3 min (32-128) for LESS and 51.3 min (25-120) for LC (p = 0.11). Gallbladder perforation at detachment occurred in 15.69 % of the LESS cases and in 5.88 % of the LC cases (p = 0.028). The mean VAS score for pain at hour 3 was 2.0 points (0-7) for the LESS group and 4.0 (0-10) for the LC group (p = 0.07), and at postoperative hour 24 it was 0.3 points (0-6) for LESS and 2.3 (0-10) for LC (p = 0.03). There were no significant differences in wound complications. Incisional hernias were not found in either group. CONCLUSIONS The LESS single-port (SP) operations demand a bigger incision than LC surgery. However, there were no differences in healing, wound infections, and hernia development. We found a tendency of less postoperative pain associated with LESS/SP than with LC.


title: Collateral flow as causative of good outcomes in endovascular stroke therapy.

text: BACKGROUND Endovascular reperfusion techniques are a promising intervention for acute ischemic stroke (AIS). Prior studies have identified markers of initial injury (arrival NIH stroke scale (NIHSS) or infarct volume) as predictive of outcome after these procedures. We sought to define the role of collateral flow at the time of presentation in determining the extent of initial ischemic injury and its influence on final outcome. METHODS Demographic, clinical, laboratory, and radiographic data were prospectively collected on a consecutive cohort of patients who received endovascular therapy for acute cerebral ischemia at a single tertiary referral center from September 2004 to August 2010. RESULTS Higher collateral grade as assessed by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) grading scheme on angiography at the time of presentation was associated with improved reperfusion rates after endovascular intervention, decreased post-procedural hemorrhage, smaller infarcts on presentation and discharge, as well as improved neurological function on arrival to the hospital, discharge, and 90 days later. Patients matched by vessel occlusion, age, and time of onset demonstrated smaller strokes on presentation and better functional and radiographic outcome if found to have superior collateral flow. In multivariate analysis, lower collateral grade independently predicted higher NIHSS on arrival. CONCLUSIONS Improved collateral flow in patients with AIS undergoing endovascular therapy was associated with improved radiographic and clinical outcomes. Independent of age, vessel occlusion and time, in patients with comparable ischemic burdens, changes in collateral grade alone led to significant differences in initial stroke severity as well as ultimate clinical outcome.


The COVID-19 Pandemic: Critical Care Allocated in Extremis.


title: Early Phase of the COVID-19 Outbreak in Hungary and Post-Lockdown Scenarios.

text: COVID-19 epidemic has been suppressed in Hungary due to timely non-pharmaceutical interventions, prompting a considerable reduction in the number of contacts and transmission of the virus. This strategy was effective in preventing epidemic growth and reducing the incidence of COVID-19 to low levels. In this report, we present the first epidemiological and statistical analysis of the early phase of the COVID-19 outbreak in Hungary. Then, we establish an age-structured compartmental model to explore alternative post-lockdown scenarios. We incorporate various factors, such as age-specific measures, seasonal effects, and spatial heterogeneity to project the possible peak size and disease burden of a COVID-19 epidemic wave after the current measures are relaxed.


title: Heliox for mechanically ventilated newborns with bronchopulmonary dysplasia.

text: OBJECTIVE We assessed the safety and studied the influence of short-term helium-oxygen (heliox) mechanical ventilation (MV) on respiratory function, gas exchange and oxygenation in infants with bronchopulmonary dysplasia (BPD) or at high risk for BPD. DESIGN A pilot, time-series study. SETTING Neonatal intensive care unit. PATIENTS Infants with severe BPD who required MV. INTERVENTIONS MV with helium-oxygen and air-oxygen mixtures. MAIN OUTCOME MEASURES Respiratory parameters, acid-base balance, oxygenation and vital signs were recorded at five time points: initially during MV with air-oxygen, after 15 and 60 min of helium-oxygen MV, and 15 and 60 min after return to air-oxygen MV. RESULTS 15 infants with BPD were enrolled. Helium-oxygen MV was well tolerated and was associated with a statistically significant increase in tidal volume, dynamic compliance and peak expiratory flow rate. An improvement in oxygenation and a decrease in fraction of inspired oxygen was also observed. During helium-oxygen MV there was a significant decrease in the oxygenation index and alveolar-arterial oxygen tension difference. The PaO2/fraction of inspired oxygen (FiO2) ratio increased significantly during helium-oxygen ventilation. A decrease in PaCO2 and an increase in pH were also observed during helium-oxygen administration, however this was not statistically significant. After ventilation with helium-oxygen was discontinued, the infants' respiratory function and oxygenation deteriorated and supplemental oxygen requirements increased accordingly. CONCLUSIONS Helium-oxygen MV is safe and resulted in improvement of respiratory function and oxygenation in infants with severe BPD requiring MV.


title: Laparoscopic Sleeve Gastrectomy Versus Banded Roux-en-Y Gastric Bypass for Diabetes and Obesity: a Prospective Randomised Double-Blind Trial.

text: BACKGROUND There are very few randomised, blinded trials comparing laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB) in achieving remission of type 2 diabetes (T2D), particularly silastic ring (SR)-LRYGB. We compared the effectiveness of (LSG) versus SR-LRYGB among patients with T2D and morbid obesity. METHODS Prospective, randomised, parallel, 2-arm, blinded clinical trial conducted in a single Auckland (New Zealand) centre. Eligible patients aged 20-55 years, T2D of at least 6 months duration and BMI 35-65 kg/m2 were randomised 1:1 to LSG (n = 58) or SR-LRYGB (n = 56) using random number codes disclosed after anaesthesia induction. Primary outcome was T2D remission defined by different HbA1c thresholds at 1 year. Secondary outcomes included weight loss, quality of life, anxiety and depressive symptoms, post-operative complications and mortality. RESULTS Mean ± standard deviation (SD) pre-operative BMI was 42.5 ± 6.2 kg/m2, HbA1c 63 ± 16 mmol/mol (30% insulin-treated, 28% had diabetes duration over 10 years). Proportions achieving HbA1c ≤ 38 mmol/mol, < 42 mmol/mol, < 48 mmol/mol and < 53 mmol/mol without diabetes medication at 1 year in SR-LRYGB vs LSG were 38 vs 43% (p = 0.56), 52 vs 49% (p = 0.85), 75 vs 72% (p = 0.83) and 80 vs 77% (p = 0.82), respectively. Mean ± SD % total weight loss at 1 year was greater after SR-LRYGB than LSG: 32.2 ± 7.7 vs 27.1 ± 7.5%, respectively (p < 0.001). Gastrointestinal complications were more frequent after SR-LRYGB (including 3 ulcers, 1 anastomotic leak, 1 abdominal bleeding). Quality of life and depression symptoms improved significantly in both groups. CONCLUSION Despite significantly greater weight loss after SR-LRYGB, there was similar T2D remission and psychosocial improvement after LSG and SR-LRYGB at 1 year. TRIAL REGISTRATION Prospectively registered at Australia and New Zealand Clinical Trials Register (ACTRN 12611000751976) and retrospectively registered at Clinical Trials (NCT1486680).


title: Elevated Amygdala Activity in Young Adults With Familial Risk for Depression: A Potential Marker of Low Resilience.

text: BACKGROUND Amygdala overactivity has been frequently observed in patients with depression, as well as in nondepressed relatives of patients with depression. A remaining unanswered question is whether elevated amygdala activity in those with familial risk for depression is related to the presence of subthreshold symptoms or to a trait-level vulnerability for illness. METHODS To examine this question, functional magnetic resonance imaging data were collected in nondepressed young adults with (family history [FH+]) (n = 27) or without (FH-) (n = 45) a first-degree relative with a history of depression while they viewed images of "looming" or withdrawing stimuli (faces and cars) that varied in salience by virtue of their apparent proximity to the subject. Activation of the amygdala and 2 other regions known to exhibit responses to looming stimuli, the dorsal intraparietal sulcus (DIPS) and ventral premotor cortex (PMv), were measured, as well as levels of resilience, anxiety, and psychotic and depressive symptoms. RESULTS Compared with the FH- group, the FH+ group exhibited significantly greater responses of the amygdala, but not the dorsal intraparietal sulcus or ventral premotor cortex, to looming face stimuli. Moreover, amygdala responses in the FH+ group were negatively correlated with levels of resilience and unrelated to levels of subthreshold symptoms of psychopathology. CONCLUSIONS These findings indicate that elevated amygdala activity in nondepressed young adults with a familial history of depression is more closely linked to poor resilience than to current symptom state.


title: Cost analysis of intubation-related tracheal injury using a national database.

text: OBJECTIVE To perform risk analysis of tracheal injuries caused by endotracheal intubation (ETI) and to estimate the financial impact of these sequelae. STUDY DESIGN Cost analysis using a national database. SETTINGS The Agency for Healthcare Research and Quality (AHRQ) 2006 National Inpatient Sample. SUBJECTS AND METHODS We identified clinical manifestations and treatments of complications associated with endotracheal tubes and codified them into International Classification of Disease-ninth revision diagnosis and procedure codes, intentionally excluding alternative etiologies of tracheal injury. Using the AHRQ 2006 National Inpatient Sample, we then compared patients with tracheal injury coded during the medical or surgical stay for length of stay (LOS) and mean hospital cost with diagnosis-related group (DRG)-matched controls; we also examined readmissions treating tracheal injury. RESULTS Tracheal injury presents as tracheal stenosis, tracheomalacia, tracheoesophageal fistula, laryngotracheal ulceration, and vocal cord paralysis. A total of 3232 discharge records met criteria for tracheal injury from ETI within the index hospital stay. Average LOS for patients with tracheal injury (6.3 days; 95% confidence interval [CI] 6.0-6.3) exceeded LOS in the uncomplicated sample (5.2 days; CI 5.1-5.3) by 1.1 days. The average hospital cost was $1888 higher with tracheal injury ($10,375 [CI $9762-$10,988] vs $8487 [CI $8266-$8669]). LOS for procedures treating prior tracheal injury averaged 4.7 days and cost an average of $11,025 per discharge. CONCLUSION Tracheal injury from ETI is associated with a significant increase in healthcare costs that accrue both during the index admission and during subsequent hospitalizations required to treat the injury.


title: Rabies encephalitis and extra-neural manifestations in a patient bitten by a domestic cat.

text: Rabies encephalitis is a fatal zoonotic viral disease transmitted to humans either by domestic animals like dogs and cats or by wild animals like bats, skunks and raccoons. We present the case of a 25-year-old woman admitted due to behavioral disorders, generalized paresthesiasand acute respiratory deterioration compatible with a respiratory distress syndrome (ARDS) requiring orotracheal intubation, mechanical ventilation and empirical initiation of antibiotic and antiviral therapy. Chest tomography showed pneumomediastinum and changes suggestive of pulmonary infection. In the presence of neurological symptoms, a central nervous system (CNS) infection was suspected and the cerebrospinal fluid showed no pleocytosis, hiperproteinorrachy without glucose consumption; cranial CT scan was normal. During hospitalization, the family reported that the patient was bitten by a cat 30-day prior to the onset of rabies-like symptoms, and the animal was sacrificed. The patient had an unfavorable clinical evolution, with electroencephalographic activity dissociation evidenced by video telemetry. The zoonotic exposure led to the suspected diagnosis of rabies infection. The patient died and the suspected diagnosis was confirmed by histopathology, with presence of Negri bodies on cerebellum Purkinje cells and a positive immunofluorescence test for rabies virus. Both, initial extra-neural manifestations and late reporting of rabies exposure led to delayed diagnosis.


title: Variability and limitations in home-based exercise program descriptions in oncology: a scoping review.

text: BACKGROUND The literature reflects considerable heterogeneity in what constitutes home-based exercise interventions. The variability for where and what "home-based" exercise can represent challenges interpretation of findings and appropriate advocacy, referral, or development of these models of care. Therefore, the objective of this review was to provide a comprehensive summary of how home-based exercise is defined and reported in the literature and summarize the range of supportive elements utilized in home-based exercise trials. METHODS We followed methodology for scoping reviews. Relevant research databases were searched from inception to March 2019. Two reviewers independently screened articles to determine eligibility and extracted terminology used to describe home-based exercise and intervention details for intervention delivery. RESULTS Of the 9432 records identified, 229 articles met inclusion criteria. Across the literature, exercise interventions were described as home-based if they were completed at-home, outdoors in the neighbourhood, and in community facilities; or in self-selected environments; or if they were unsupervised. Supportive elements for home-based models ranged with respect to the amount of supervision and resources utilized, including the provision of print materials, exercise equipment, telephone support, home visits, and technology. CONCLUSIONS This review provides a comprehensive summary of strategies previously utilized to deliver home-based exercise interventions in oncology, along with the various definitions of the home-based environment for exercise reported by researchers. Specific recommendations to improve the prescription and reporting of home-based exercise interventions are provided in order to facilitate the delivery, evaluation, and translation of findings into clinical practice.


title: Co-expression of hepatitis C virus polytope-HBsAg and p19-silencing suppressor protein in tobacco leaves.

text: CONTEXT Plants transformed by virus-based vectors have emerged as promising tools to rapidly express large amounts and inexpensive antigens in transient condition. OBJECTIVE We studied the possibility of transient-expression of an HBsAg-fused polytopic construct (HCVpc) [containing H-2d and HLA-A2-restricted CD8+CTL-epitopic peptides of C (Core; aa 132-142), E6 (Envelope2; aa 614-622), N (NS3; aa 1406-1415), and E4 (Envelope2; aa 405-414) in tandem of CE6NE4] in tobacco (Nicotiana tabacum) leaves for the development of a plant-based HCV vaccine. MATERIALS AND METHODS A codon-optimized gene encoding the Kozak sequence, hexahistidine (6×His)-tag peptide, and HCVpc in tandem was designed, chemically synthesized, fused to HBsAg gene, and inserted into Potato virus X (PVX-GW) vector under the control of duplicated PVX coat protein promoter (CPP). The resulted recombinant plasmids (after confirmation by restriction and sequencing analyses) were transferred into Agrobacterium tumefaciens strain GV3101 and vacuum infiltrated into tobacco leaves. The effect of gene-silencing suppressor, p19 protein from tomato bushy stunt virus, on the expression yield of HCVpc-HBsAg was also evaluated by co-infiltration of a p19 expression vector. RESULTS Codon-optimized gene increased adaptation index (CAI) value (from 0.61 to 0.92) in tobacco. The expression of the HCVpc-HBsAg was confirmed by western blot and HBsAg-based detection ELISA on total extractable proteins of tobacco leaves. The expression level of the fusion protein was significantly higher in p19 co-agroinfiltrated plants. DISCUSSION AND CONCLUSION The results indicated the possibility of expression of HCVpc-HBsAg constructs with proper protein conformations in tobacco for final application as a plant-derived HCV vaccine.


title: Relative health performance in BRICS over the past 20 years: the winners and losers.

text: OBJECTIVE To determine whether the health performance of Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--has kept in step with their economic development. METHODS Reductions in age- and sex-specific mortality seen in each BRICS country between 1990 and 2011 were measured. These results were compared with those of the best-performing countries in the world and the best-performing countries with similar income levels. We estimated each country's progress in reducing mortality and compared changes in that country's mortality rates against other countries with similar mean incomes to examine changes in avoidable mortality. FINDINGS The relative health performance of the five study countries differed markedly over the study period. Brazil demonstrated fairly even improvement in relative health performance across the different age and sex subgroups that we assessed. India's improvement was more modest and more varied across the subgroups. South Africa and the Russian Federation exhibited large declines in health performance as well as large sex-specific inequalities in health. Although China's levels of avoidable mortality decreased in absolute terms, the level of improvement appeared low in the context of China's economic growth. CONCLUSION When evaluating a country's health performance in terms of avoidable mortality, it is useful to compare that performance against the performance of other countries. Such comparison allows any country-specific improvements to be distinguished from general global improvements.


title: The Early Warning and Response System for communicable diseases in the EU: an overview from 1999 to 2005.

text: Under Decision 2119/98/EC of the European Parliament and of the Council, a network for epidemiological surveillance and control of communicable diseases in the Community was set up in 1998. One pillar of Decision 2119/98/EC is the early warning and response system (EWRS). The main objective of the network is to establish permanent communication between European Union (EU) Member States' public health authorities, which are responsible for determining the measures required to control communicable disease-related events. Since 1998, a web based informatics tool has been developed in order to allow information to be shared between the relevant public health authorities. Between 1998 and December 2005, a total of 583 messages were circulated through the EWRS, notifying 396 events. The information shared through the system helped to coordinate public health measures in the EU. However, only few events prompted specific measures at Community level and most of them were controlled with public health measures applied at national level. Major events (such as the Severe Acute Respiratory Syndrome) and the results of simulation exercises prompted the Commission to upgrade the informatics system on the basis of user needs. Since 1 May 2004 the 10 newest Member States have provided information under the current legislation and since April 2005 the European Centre for Disease Prevention and Control (ECDC) is part of the system. Future developments will include a link between the existing EWRS and the communication platform currently developed by the ECDC.


title: Effectiveness of ventilation of nondependent lung for a brief period in improving arterial oxygenation during one-lung ventilation: A prospective study.

text: BACKGROUND Hypoxemia is common during one-lung ventilation(OLV), predominantly due to transpulmonary shunt. None of the strategies tried showed consistent results. We evaluated the effectiveness of ventilating the operated, non-dependent lung (NDL) with small tidal volumes in improving the oxygenation during OLV. METHODS 30 ASA 1 and 2 patients undergoing elective, open thoracotomy were studied. After standard induction of anesthesia, lung seperation was acheived with left sided DLT. The ventilatory settings for two lung ventilation (TLV) were: FiO 2 of 0.5, tidal volume of 8-10ml/kg and respiratory rate of 10-12/min. After initiating OLV, the dependent lung alone was ventilated with the above settings for 15 minutes and an arterial blood gas (ABG) analysis was done. Then the NDL was ventilated with a separate ventilator, with FiO 2 of 1, tidal volume of 70 ml, I:E ratio of 1:10 and respiratory rate of 6/min for 15 minutes. The NDL ventilation was started early if the patients desaturated to <95%. ABG was done at 5 and 15 mins of NDL ventilation. We compared the PaO 2 values. RESULTS The mean PaO 2 decreased from 232.2 ± 67.2 mm of Hg (TLV-ABG1) to 91.2 ± 31.7 mm of Hg on OLV (OLV-ABG1). The ABG after 5 minutes and 15 minutes after institution of NDL ventilation during OLV showed a PaO2 of 145.7 ± 50.2 mm of Hg and 170.6 ± 50.4 mm of Hg which were significantly higher compared to the one lung ventilation values.


title: Duplication with structural modification through extrachromosomal circular and lariat DNA in the human genome.

text: Duplication plays an important role in creating drastic changes in genome evolution. In addition to well-known tandem duplication, duplication can occur such that a duplicated DNA fragment is inserted at another location in the genome. Here, we report several genomic regions in the human genome that could be best explained by two types of insertion-based duplication mechanisms, where a duplicated DNA fragment was modified structurally and then inserted into the genome. In one process, the DNA fragment is turned into an extrachromosomal circular DNA, cut somewhere in the circle, and reintegrated into another location in the genome. And in the other, the DNA fragment forms a "lariat structure" with a "knot", the strand is swapped at the knot, and is then reintegrated into the genome. Our results suggest that insertion-based duplication may not be a simple process; it may involve a complicated procedures such as structural modification before reintegration. However, the molecular mechanism has yet to be fully understood.


title: Adaptive-size dictionary learning using information theoretic criteria for image reconstruction from undersampled k-space data in low field magnetic resonance imaging.

text: BACKGROUND Magnetic resonance imaging (MRI) is a safe non-invasive and nonionizing medical imaging modality that is used to visualize the structure of human anatomy. Conventional (high-field) MRI scanners are very expensive to purchase, operate and maintain, which limit their use in many developing countries. This study is part of a project that aims at addressing these challenges and is carried out by teams from Mbarara University of Science and Technology (MUST) in Uganda, Leiden University Medical Center (LUMC) in the Netherlands, Delft University of Technology (TU Delft) in the Netherlands and Pennsylvania State University (PSU) in the USA. These are working on developing affordable, portable and low-field MRI scanners to diagnose children in developing countries with hydrocephalus. The challenges faced by the teams are that the low-field MRI scanners currently under development are characterized by low Signal-to-Noise Ratio (SNR), and long scan times. METHODS We propose an algorithm called adaptive-size dictionary learning algorithm (AS-DLMRI) that integrates information-theoretic criteria (ITC) and Dictionary learning approaches. The result of the integration is an adaptive-size dictionary that is optimal for any input signal. AS-DLMRI may help to reduce the scan time and improve the SNR of the generated images, thereby improving the image quality. RESULTS We compared our proposed algorithm AS-DLMRI with adaptive patch-based algorithm known as DLMRI and non-adaptive CSMRI technique known as LDP. DLMRI and LDP have been used as the baseline algorithms in other related studies. The results of AS-DLMRI are consistently slightly better in terms of PSNR, SNR and HFEN than for DLMRI, and are significantly better than for LDP. Moreover, AS-DLMRI is faster than DLMRI. CONCLUSION Using a dictionary size that is appropriate to the input data could reduce the computational complexity, and also the construction quality since only dictionary atoms that are relevant to the task are included in the dictionary and are used during the reconstruction. However, AS-DLMRI did not completely remove noise during the experiments with the noisy phantom. Our next step in our research is to integrate our proposed algorithm with an image denoising function.


Magnitude to thrombocytopenia among the patients with novel Middle East respiratory syndrome.


title: Review of splanchnic oximetry in clinical medicine.

text: Global tissue perfusion and oxygenation are important indicators of physiologic function in humans. The monitoring of splanchnic oximetry through the use of near-infrared spectroscopy (NIRS) is an emerging method used to assess tissue oxygenation status. Splanchnic tissue oxygenation (SrSO2) is thought to be potentially of high value in critically ill patients because gastrointestinal organs can often be the first to suffer ischemic injury. During conditions of hypovolemia, cardiac dysfunction, or decreased oxygen-carrying capacity, blood flow is diverted toward vital organs, such as the brain and the heart at the expense of the splanchnic circulation. While monitoring SrSO2 has great potential benefit, there are limitations to the technology and techniques. SrSO2 has been found to have a relatively high degree of variability that can potentially make it difficult to interpret. In addition, because splanchnic organs only lie near the skin surface in children and infants, and energy from currently available sensors only penetrates a few centimeters deep, it can be difficult to use clinically in a noninvasive manner in adults. Research thus far is showing that splanchnic oximetry holds great promise in the ability to monitor patient oxygenation status and detect disease states in humans, especially in pediatric populations.


title: A Rare Delayed Bladder Migration of a Hem-o-lok Clip 5 Years after Robotic-Assisted Radical Prostatectomy.

text: Bladder migration of a Hem-o-lok® clip, due to robotic-assisted radical prostatectomy (RARP), is uncommon, and would form a foreign body in the bladder and present as lower urinary tract symptoms after the early postoperative period. We hereby report a rare, delayed appearance of a secondary bladder stone due to the migration of a Hem-o-lok® clip that occurred 5 years after RARP.


title: Interventional diabetology: the evolution of diabetes care in the XXI century.

text: It has been observed that bariatric surgery, in addition to its profound weight-reduction effects, leads to a durable resolution of type 2 diabetes. This supports the possibility that a cure for this disease may be obtainable, both by surgery as well as with drugs or devices that mimics the effects of surgery'. Elucidating the mechanisms underlying the beneficial effects of gastrointestinal surgery may also facilitate understanding of the elusive etiology of this condition. Current evidence supports a role for surgical interventions in the treatment algorithm of obese patients with type 2 diabetes, while a number of device-based gastrointestinal interventions are now being investigated as novel and less invasive alternatives. Interventional diabetology could be defined by the use and study of traditional surgical options and novel, gastrointestinal device- based interventions for diabetes. In this manuscript, we discuss how the introduction of interventional diabetology may shape the way we approach diabetes in the 21st century.


title: The host response: Toll-like receptor expression in periprosthetic tissues as a biomarker for deep joint infection.

text: BACKGROUND Toll-like receptors (TLRs) 1 and 6 are consistent molecular indicators of the host inflammatory response against bacterial infection. Our aims were to determine whether TLR elevation could be detected in infected periprosthetic tissues and to assess the utility of these biomarkers as tests for detecting a periprosthetic joint infection. METHODS Fifty-nine patients undergoing revision total joint arthroplasty (twenty-seven hips and thirty-two knees) were prospectively evaluated for periprosthetic joint infection according to currently recommended diagnostic criteria. Nine patients were excluded because of insufficient work-up, leaving fifty available for study. Of these, twenty-one were categorized as infected and twenty-nine as noninfected. Periprosthetic tissues were collected intraoperatively, and total RNA was extracted by standard techniques. Expression of TLR messenger RNAs was assessed by first-strand complementary DNA synthesis from 1 μg of total RNA followed by real-time PCR (polymerase chain reaction). Results were normalized relative to the housekeeping gene GAPDH (glyceraldehyde 3-phosphate dehydrogenase). Expression of TLRs 1, 6, and 10 in the infected and noninfected groups was compared with use of the Student t test. The receiver operating characteristic curve, area under the curve (AUC), sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were calculated to determine the accuracy of each TLR for predicting periprosthetic joint infection at its optimal diagnostic threshold. RESULTS Mean TLR1 mRNA expression was significantly elevated in infected compared with noninfected samples (0.600 compared with 0.005, p = 0.0003); the same was true of TLR6 (0.208 compared with 0.0165, p = 0.0059) but not of TLR10 (0.00019 compared with 0.00014, p = 0.6238). The AUC was 0.995 for TLR1, 0.883 for TLR6, and 0.546 for TLR10. The optimal threshold for diagnosing periprosthetic joint infection was 0.0924 for TLR1 (sensitivity = 95.2%, specificity = 100%, LR+ = 13.80, LR- = 0.91) and 0.0215 for TLR6 (sensitivity = 85.7%, specificity = 82.8%, LR+ = 4.98, LR- = 0.83). CONCLUSIONS In our pilot study, TLR1 expression in periprosthetic tissues most accurately predicted periprosthetic joint infection. This measure of the host response may be particularly helpful in detecting culture-negative infections and avoiding false positives resulting from contamination. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.


Daily Evaluation of COVID-19 Patients Primarily Based on Lung Ultrasound: In Times of Emergency, It's Time to Change Some Paradigms.


title: Arterial Access Port: A Shunt-Less Vascular Access Using a Blind-Ending Artificial Graft Anastomosed to the Brachial Artery.

text: We retrospectively investigated the usability of arterial access ports (AAPs), which are blind-ending short prosthetic grafts anastomosed to the brachial artery (BA) and implanted subcutaneously, via which cannulation and blood-drawing from the BA was performed. Nineteen AAPs in 16 patients were evaluated. The AAP cumulative functional usage rate tended to drop within a year after its implantation because of infection and inappropriate positioning; however, its usability was extended for a maximum of 97 months after re-implantation. The operative modification of minimal superficial repositioning of the BA anastomosed with the graft significantly improved its usage rate by easing the cannulation via the graft and eliminated usage withdrawal caused by infection and dislocation. Occlusion, thrombus, and ligation of the BA never occurred even after surgical repairs for infectious AAP. The use of an AAP as a shunt-less vascular access could be an alternative to BA superficialization with avoidance of direct BA puncture.


A Randomized Trial of Convalescent Plasma for COVID-19-Potentially Hopeful Signals.


title: SARS-CoV-2: Viral Mechanisms and Possible Therapeutic Targets - What to learn from Rheumatologists?

text: It was with great interest that we read the letter from Randy Cron and collaborators (1) linking the cytokine storm syndrome (CSS) seen in macrophage activation syndrome, common in the rheumatological setting, with the CSS postulated to be a background in the novel coronavirus (SARS-CoV-2) infection. Amid the high contagiousness of the virus, science was also infected by an infodemia, compelled to enter a race to find effective therapies studying mechanisms molecular aspects of SARS-CoV-2 concomitant to urgent bedside manage of patients.


title: Excision of the urachal remnant using the abdominal wall-lift laparoscopy: A case report.

text: INTRODUCTION Here, we report the surgical excision of the urachal remnant using the abdominal wall-lift laparoscopy with a camera port in the umbilicus, combined with a small Pfannenstiel incision to optimally treat the bladder apex. PRESENTATION OF CASE A 21-year-old woman presented with periumbilical discharge and pain on urination. Contrast enhanced CT and MRI showed an abscess in the umbilical region that was connected to the bladder via a long tube-like structure. It was diagnosed as an infected urachal sinus. Partial excision of the umbilical fossa followed by dissection of the urachal remnant was easily performed using the abdominal wall-lift laparoscopy from the umbilicus down to the bladder without pneumoperitoneum or additional trocar placement. A Pfannenstiel incision was made above the pubis to get access to the junction between the urachal remnant and the bladder. Under direct vision, we succeeded in accurately dividing the remnant tract, and we adequately closed the bladder opening with absorbable sutures. This method has the advantage of easily closing peritoneal defects after excision of the urachal remnant with direct sutures under a laparoscopic view from the umbilicus. Cosmetic satisfaction was obtained postoperatively. DISCUSSION AND CONCLUSION Urachal sinus excision using the abdominal wall-lift laparoscopy seems to surpass the previously reported methods in term of safety, cosmetics, and adequacy of surgical procedures.


Chest imaging in patients with suspected COVID-19.


title: Perspectives on vaccination in adults.

text: In the Second Conference on Controversies in Vaccination in Adults, leading vaccine experts among manufacturers, physicians, microbiologists, virologists, immunologists and public health specialists came together to discuss recent approaches, developments and strategies in vaccination against worldwide pressing epidemic and endemic infectious diseases (pneumococcal, staphylococcal, influenza, papillomavirus-associated tumors, varicella-zoster, AIDS and tuberculosis), and noninfectious epidemics (atherosclerosis and smoking) outlining arguments surrounding the progress of vaccines.


title: Postoperative Abdominal NIRS Values Predict Low Cardiac Output Syndrome in Neonates.

text: BACKGROUND The development of low cardiac output syndrome (LCOS) after cardiopulmonary bypass (CPB) occurs in up to 25% of neonates and is associated with increased morbidity. Invasive cardiac output monitors such as pulmonary artery catheters have limited availability and are costly. Near-infrared spectroscopy (NIRS) is a noninvasive tool for monitoring regional oxygenation in neonates in the cardiac intensive care unit (CICU). We hypothesize that anterior abdominal NIRS may aid in the early identification of LCOS after cardiac surgery. METHODS Prospective observational study from October 2013 to October 2014 of all neonates with congenital heart disease admitted to the CICU following CPB. Abdominal NIRS values were continuously recorded upon CICU admission and for the subsequent 24-hour period. The primary outcome was the development of LCOS. Low cardiac output syndrome was defined as the presence of metabolic lactic acidosis (pH < 7.3 and lactate > 4) or addition of a new vasoactive agent or a vasoactive inotropic score > 15. Autoregressive time series models were constructed for each patient based on the continuously recorded NIRS values, and patients were stratified by development of LCOS. RESULTS Twenty-seven neonates met inclusion criteria, of whom 11 developed LCOS. Neonates who developed LCOS had lower constant NIRS values (49% vs. 66%, P < .001). Constant NIRS values less than 58% best predicted development of LCOS with a sensitivity of 100% and specificity of 69%. CONCLUSION Lower constant anterior abdominal NIRS values in the early postoperative period may allow early identification of neonates at risk for LCOS.


title: EBV renders B cells susceptible to HIV-1 in humanized mice.

text: HIV and EBV are human pathogens that cause a considerable burden to worldwide health. In combination, these viruses are linked to AIDS-associated lymphomas. We found that EBV, which transforms B cells, renders them susceptible to HIV-1 infection in a CXCR4 and CD4-dependent manner in vitro and that CXCR4-tropic HIV-1 integrates into the genome of these B cells with the same molecular profile as in autologous CD4+ T cells. In addition, we established a humanized mouse model to investigate the in vivo interactions of EBV and HIV-1 upon coinfection. The respective mice that reconstitute human immune system components upon transplantation with CD34+ human hematopoietic progenitor cells could recapitulate aspects of EBV and HIV immunobiology observed in dual-infected patients. Upon coinfection of humanized mice, EBV/HIV dual-infected B cells could be detected, but were susceptible to CD8+ T-cell-mediated immune control.


title: Importance of Neutralizing Monoclonal Antibodies Targeting Multiple Antigenic Sites on the Middle East Respiratory Syndrome Coronavirus Spike Glycoprotein To Avoid Neutralization Escape.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) causes a highly lethal pulmonary infection with ∼35% mortality. The potential for a future pandemic originating from animal reservoirs or health care-associated events is a major public health concern. There are no vaccines or therapeutic agents currently available for MERS-CoV. Using a probe-based single B cell cloning strategy, we have identified and characterized multiple neutralizing monoclonal antibodies (MAbs) specifically binding to the receptor-binding domain (RBD) or S1 (non-RBD) regions from a convalescent MERS-CoV-infected patient and from immunized rhesus macaques. RBD-specific MAbs tended to have greater neutralizing potency than non-RBD S1-specific MAbs. Six RBD-specific and five S1-specific MAbs could be sorted into four RBD and three non-RBD distinct binding patterns, based on competition assays, mapping neutralization escape variants, and structural analysis. We determined cocrystal structures for two MAbs targeting the RBD from different angles and show they can bind the RBD only in the "out" position. We then showed that selected RBD-specific, non-RBD S1-specific, and S2-specific MAbs given prophylactically prevented MERS-CoV replication in lungs and protected mice from lethal challenge. Importantly, combining RBD- and non-RBD MAbs delayed the emergence of escape mutations in a cell-based virus escape assay. These studies identify MAbs targeting different antigenic sites on S that will be useful for defining mechanisms of MERS-CoV neutralization and for developing more effective interventions to prevent or treat MERS-CoV infections.IMPORTANCE MERS-CoV causes a highly lethal respiratory infection for which no vaccines or antiviral therapeutic options are currently available. Based on continuing exposure from established reservoirs in dromedary camels and bats, transmission of MERS-CoV into humans and future outbreaks are expected. Using structurally defined probes for the MERS-CoV spike glycoprotein (S), the target for neutralizing antibodies, single B cells were sorted from a convalescent human and immunized nonhuman primates (NHPs). MAbs produced from paired immunoglobulin gene sequences were mapped to multiple epitopes within and outside the receptor-binding domain (RBD) and protected against lethal MERS infection in a murine model following passive immunization. Importantly, combining MAbs targeting distinct epitopes prevented viral neutralization escape from RBD-directed MAbs. These data suggest that antibody responses to multiple domains on CoV spike protein may improve immunity and will guide future vaccine and therapeutic development efforts.


title: Characterization of the Preclinical Pharmacology of the New 2-Aminomethylphenol, JPC-3210, for Malaria Treatment and Prevention.

text: The new 2-aminomethylphenol, JPC-3210, has potent in vitro antimalarial activity against multidrug-resistant Plasmodium falciparum lines, low cytotoxicity, and high in vivo efficacy against murine malaria. Here we report on the pharmacokinetics of JPC-3210 in mice and monkeys and the results of in vitro screening assays, including the inhibition of cytochrome P450 (CYP450) isozymes. In mice, JPC-3210 was rapidly absorbed and had an extensive tissue distribution, with a brain tissue-to-plasma concentration ratio of about 5.4. JPC-3210 had a lengthy plasma elimination half-life of about 4.5 days in mice and 11.8 days in monkeys. JPC-3210 exhibited linear single-oral-dose pharmacokinetics across the dose range of 5 to 40 mg/kg of body weight with high oral bioavailability (∼86%) in mice. Systemic blood exposure of JPC-3210 was 16.6% higher in P. berghei-infected mice than in healthy mice. In vitro studies with mice and human hepatocytes revealed little metabolism and the high metabolic stability of JPC-3210. The abundance of human metabolites from oxidation and glucuronidation was 2.0% and 2.5%, respectively. CYP450 studies in human liver microsomes showed JPC-3210 to be an inhibitor of CYP2D6 and, to a lesser extent, CYP3A4 isozymes, suggesting the possibility of a metabolic drug-drug interaction with drugs that are metabolized by these isozymes. In vitro studies showed that JPC-3210 is highly protein bound to human plasma (97%). These desirable pharmacological findings of a lengthy blood elimination half-life, high oral bioavailability, and low metabolism as well as high in vivo potency have led the Medicines for Malaria Venture to select JPC-3210 (MMV892646) for further advanced preclinical development.


title: Learning from Adversity: Lessons from the COVID-19 Crisis.

text: One month into the COVID-19 crisis in the US, rheumatologists have begun to feel the effects of our hastily constructed temporary response plans. While we may not be staffing the front lines with our colleagues in emergency medicine and critical care, our patients are uniquely vulnerable to infection and continue to require care.


title: Transumbilical single-port laparoscopic transabdominal preperitoneal repair of inguinal hernia: initial experience of single institute.

text: BACKGROUND Conventional laparoscopic repair of inguinal hernias is generally performed by using 3 ports. In this study, the authors report their initial experiences of transumbilical single-port transabdominal preperitoneal (TAPP) repair of inguinal hernia using a unique "single port." METHODS Since November 2008, transumbilical single-port TAPP was performed in 24 patients with an inguinal hernia. A wound retractor and a surgical glove attached with 5 mm trocar and 2 pipes were inserted through a 1.5 cm-sized transumbilical incision. TAPP procedure was performed similarly compared with conventional laparoscopy. RESULTS Transumbilical single-port TAPP repair of an inguinal hernia was successfully performed in 24 patients (19 male and 5 female; 17 with an indirect hernia and 7 with a recurrent hernia; mean age 54.2 y; mean body mass index 24.2 kg/m). No major or minor intraoperative and postoperative complication was encountered and no conversion to conventional 3-port approach or open surgery was required. Mean operating time was 65.6 minutes and mean hospital stay was 2.1 postoperative days. CONCLUSIONS Transumbilical single-port TAPP repair of an inguinal hernia is technically feasible, provides nearly scarless surgery and can be performed safely and effectively in selected patients with an inguinal hernia.


title: Job burnout is associated with dysfunctions in brain mechanisms of voluntary and involuntary attention.

text: Individuals with job burnout symptoms often report having cognitive difficulties, but related electrophysiological studies are scarce. We assessed the impact of burnout on performing a visual task with varying memory loads, and on involuntary attention switch to distractor sounds using scalp recordings of event-related potentials (ERPs). Task performance was comparable between burnout and control groups. The distractor sounds elicited a P3a response, which was reduced in the burnout group. This suggests burnout-related deficits in processing novel and potentially important events during task performance. In the burnout group, we also observed a decrease in working-memory related P3b responses over posterior scalp and increase over frontal areas. These results suggest that burnout is associated with deficits in cognitive control needed to monitor and update information in working memory. Successful task performance in burnout might require additional recruitment of anterior regions to compensate the decrement in posterior activity.