title: Guidelines for the management of diabetes services and patients during the COVID-19 pandemic.

text: The UK National Diabetes Inpatient COVID Response Group was formed at the end of March 2020 to support the provision of diabetes inpatient care during the COVID pandemic. It was formed in response to two emerging needs. First to ensure that basic diabetes services are secured and maintained at a time when there was a call for re-deployment to support the need for general medical expertise across secondary care services. The second was to provide simple safe diabetes guidelines for use by specialists and non-specialists treating inpatients with or suspected of COVID-19 infection. To date the group, comprising UK-based specialists in diabetes, pharmacy and psychology, have produced two sets of guidelines which will be continually revised as new evidence emerges. It is supported by Diabetes UK, the Association of British Clinical Diabetologists and NHS England.


Mountain height might be controlled by tectonic force, rather than erosion.


title: Stimulated innate resistance of lung epithelium protects mice broadly against bacteria and fungi.

text: Pneumonia is a serious problem worldwide. We recently demonstrated that innate defense mechanisms of the lung are highly inducible against pneumococcal pneumonia. To determine the breadth of protection conferred by stimulation of lung mucosal innate immunity, and to identify cells and signaling pathways activated by this treatment, mice were treated with an aerosolized bacterial lysate, then challenged with lethal doses of bacterial and fungal pathogens. Mice were highly protected against a broad array of Gram-positive, Gram-negative, and class A bioterror bacterial pathogens, and the fungal pathogen, Aspergillus fumigatus. Protection was associated with rapid pathogen killing within the lungs, and this effect was recapitulated in vitro using a respiratory epithelial cell line. Gene expression analysis of lung tissue showed marked activation of NF-kappaB, type I and II IFN, and antifungal Card9-Bcl10-Malt1 pathways. Cytokines were the most strongly induced genes, but the inflammatory cytokines TNF and IL-6 were not required for protection. Lung-expressed antimicrobial peptides were also highly up-regulated. Taken together, stimulated innate resistance appears to occur through the activation of multiple host defense signaling pathways in lung epithelial cells, inducing rapid pathogen killing, and conferring broad protection against virulent bacterial and fungal pathogens. Augmentation of innate antimicrobial defenses of the lungs might have therapeutic value for protection of patients with neutropenia or impaired adaptive immunity against opportunistic pneumonia, and for defense of immunocompetent subjects against a bioterror threat or epidemic respiratory infection.


title: Laparoscopic Long Mesh Surgery with Augmented Round Ligaments: A Novel Uterine Preservation Procedure For Apical Pelvic Organ Prolapse.

text: We aim to assess the surgical outcomes of our novel hysteropexy procedure, laparoscopic long mesh surgery (LLMS) with augmented round ligaments. Twenty-five consecutive women with stage II or greater main uterine prolapse defined by the POP quantification staging system were referred for LLMS. Long mesh is a synthetic T-shaped mesh, with the body fixed at the uterine cervix and the two arms fixed along the bilateral round ligaments. The clinical evaluations performed before and 6 months after surgery included pelvic examinations, urodynamic studies, and questionnaires for urinary and sexual symptoms. After a follow-up time of 12 to 24 months, the anatomical reduction rate was 92% (23/25) for the apical compartment. The average operative time was 65.4 ± 28.8 minutes. No major complications were recognized during LLMS. The lower urinary tract symptoms and scores on the questionnaires improved significantly after the surgery, except urgency urinary incontinence and nocturia. Neither voiding nor storage dysfunction was observed after the operations. All of the domains and total Female Sexual Function Index (FSFI) scores of the 15 sexually active women did not differ significantly after LLMS. The results of our study suggest that LLMS is an effective, safe, and time-saving hysteropexy surgery for the treatment of apical prolapse.


Excluding pregnancy from COVID-19 trials: Protection from harm or the harm of protection?


title: Pain in cochlear implant recipients: an uncommon, yet serious, consequence of cochlear implantation.

text: OBJECTIVES/HYPOTHESIS We describe pain around the receiver/stimulator [RS] presenting months to years after implantation. STUDY DESIGN A retrospective chart review. METHODS We performed a retrospective review of all cochlear implant recipients complaining of pain around their RS through the years 2009 through 2013, with a follow-up of at least 6 months. Excluded from the study were patients with an identifiable cause for their pain such as trauma, local infection, or skin breakdown. The therapy regimen and outcomes were reviewed. RESULTS Thirty patients complained of delayed pain over their RS, representing 2.8% of 1,044 implantations performed at the Sheba Medical Center, Tel Hashomer, Israel, as of 2013. The time from implantation to the presentation of pain ranged from 3 months to 12 years. The pain was perceptible even when the external magnet and processor were not used, and was usually most obvious in specific points around the RS. Seventy-seven percent of our patients responded well to conservative therapy. Fifteen (50%) responded to prolonged antibiotic treatment. Five patients (17%) responded to antiinflammatories alone. One patient (3%) responded to deactivation of two electrodes. Six patients (20%) required reimplantation, after which the pain resolved in all. At explantation, no signs of infection, foreign body reaction, or obvious device damage were found. CONCLUSION Delayed pain around the RS that is unrelated to use is a serious consequence of cochlear implantation, and in some cases, those necessitating reimplantation, should be considered a major complication. LEVEL OF EVIDENCE 4.


title: Recommended timing for surveillance ultrasonography to diagnose portal splenic vein thrombosis after laparoscopic splenectomy.

text: BACKGROUND Symptomatic portal or splenic vein thrombosis (PSVT) is a rare but potentially lethal complication of laparoscopic splenectomy (LS). While routine postoperative duplex ultrasound surveillance can be used for early detection, the optimal timing is unknown. The aim of this study is to investigate the incidence and progression of asymptomatic PSVT 1 week and 1 month after LS. METHODS Consecutive patients scheduled for LS for hematologic disease participated in this study. Patients underwent surveillance for PSVT using duplex ultrasonography 1 week and 1 month postoperatively. RESULTS 43 of 48 patients planning to undergo LS in the study period were enrolled, with 3 subsequently excluded, leaving 40 for further analysis. The indications for LS were benign disease in 31 [19 had immune thrombocytopenia purpura (ITP)] and malignant disease in 9. A hand-assisted technique was used in 12 cases. PSVT was diagnosed in 9/40 patients (22.5%). Seven (77.8%) were diagnosed by 1 week with ultrasound, of whom one had mild symptoms (fever and diarrhea). After anticoagulation, subsequent ultrasounds showed resolution or improvement in all seven patients. Thirty-three patients had a normal ultrasound result at 1 week. One of these patients also had a computed tomography (CT) scan that found a PSVT not seen on ultrasound. Twenty-seven patients returned for follow-up after normal 1-week imaging: 26 patients had an ultrasound at 1 month, with no new PSVT found. One additional patient did not return for subsequent ultrasound until 2 months later, when a new distal SVT was found; ultrasound at 6 months showed complete resolution without treatment. CONCLUSION The 1-week incidence of PSVT after LS was 8/40 (20%). The high incidence justifies ultrasonographic screening on postoperative day 7. If asymptomatic PSVT has not developed at this time, it is unlikely to develop by 1 month, and subsequent screening ultrasound at 1 month is not required.


title: Transvaginal repair of stage III-IV cystocele using a lightweight mesh: safety and 36-month outcome.

text: INTRODUCTION AND HYPOTHESIS The aim of this study was to assess the 36-month safety and efficacy of a lightweight polypropylene mesh used for the transvaginal repair of stage III-IV cystocele. METHODS A multicenter prospective cohort study was performed. Preoperative assessment included an interview and evaluation with the Pelvic Organ Prolapse Quantification (POP-Q) system. Inclusion criteria were stage III-IV cystocele and no contraindications for mesh use. A lightweight (28 g/m(2)) four-arm transobturator polypropylene mesh was used for the study. Pre- and postoperative symptoms and quality of life were assessed using the Urinary Symptoms Measurement (MHU), Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The main endpoint was mesh safety. Secondary endpoints were anatomic (Ba point ≤ -1) and functional success. RESULTS In all, 111 patients with a mean age of 67 ± 9 years (range 47-89) were included in the study, and 94 (84.7%) were included in the analysis. Two intraoperative complications occurred (one bladder and one rectal injury, 2.2%). Medium-term analysis of 79 patients (84%) after 36 months showed a satisfaction rate of 98.7% (78/79), a mesh contraction rate of 5.1% (4/78), only one case of vaginal mesh exposure (1.3%), no cases of chronic pelvic pain, and a postoperative dyspareunia rate of 2.8% (1/36). The anatomic success rate of cystocele repair was 75/79 (94.9%) and a highly significant improvement was noted for symptoms and on quality of life questionnaires. Overall, 7/79 patients (8.9%) were reoperated, including 1 for hemorrhage, 1 for vaginal mesh exposure, 3 for stress urinary incontinence, and 2 for cystocele recurrence (2.5%). CONCLUSION Transvaginal cystocele repair using a lightweight transobturator polypropylene mesh was safe and efficient in the medium term. Long-term data and comparative studies are needed.


title: Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index.

text: BACKGROUND The endoscopic, endonasal, extended transsphenoidal approach is a minimal-access technique for managing craniopharyngiomas. Outcome measures such as return to employment and body mass index (BMI) have not been reported and are necessary for comparison with open transcranial approaches. Most prior reports of the endoscopic, endonasal approach have reported unacceptably high cerebrospinal fluid (CSF) leak rates. OBJECTIVE To assess the outcome of endoscopic, endonasal surgery in a consecutive series of craniopharyngiomas with special attention to extent of resection, CSF leak, return to employment, and BMI. METHODS Twenty-six surgeries were performed on 24 patients at Weill Cornell Medical College-New York Presbyterian Hospital. Five patients had recurrent lesions. Gross-total resection (GTR) was attempted in 21 surgeries. Indications for intended subtotal resection were advanced age, medical comorbidities, preservation of pituitary function, and hypothalamic invasion. RESULTS Mean tumor diameter was 2.9 cm. GTR (18 surgeries) or near-total (>95%) resection (2 surgeries) was achieved in 95% when GTR was the goal. Seven patients received postoperative radiation therapy. Mean follow-up was 35 months with no recurrences in GTR cases and stable disease in all patients at last follow-up. Vision improved in 77%. Diabetes insipidus and panhypopituitarism developed in 42% and 38%, respectively. A more than 9% increase in BMI occurred in 39%; 69% returned to their preoperative profession/schooling. The postoperative CSF leak rate was 3.8%. CONCLUSION Minimal-access, endoscopic, endonasal surgery for craniopharyngioma can achieve high rates of GTR with low rates of CSF leak. Return to employment and obesity rates are comparable to microscope-assisted transcranial and transsphenoidal reports.


title: Prognostic Significance of Hyponatremia in Acute Intracerebral Hemorrhage: Pooled Analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial Studies.

text: OBJECTIVES To determine the association of hyponatremia at presentation with clinical and imaging outcomes in patients with acute intracerebral hemorrhage. DESIGN Retrospective pooled analysis of prospectively collected data from 3,243 participants of the pilot and main phases of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials 1 and 2 (international, multicenter, open, blinded endpoint, randomized controlled trials designed to assess the effects of early intensive blood pressure lowering in patients with acute intracerebral hemorrhage). SETTING Clinical hospital sites in 21 countries. PATIENTS Patients with predominantly mild-moderate severity of spontaneous intracerebral hemorrhage within 6 hours of onset and elevated systolic blood pressure (150-220 mm Hg) were included in the study. INTERVENTIONS Patients were assigned to receive intensive (target systolic blood pressure, < 140 mm Hg within 1 hr) or guideline-recommended (target systolic blood pressure, < 180 mm Hg) blood pressure-lowering therapy. MEASUREMENTS AND MAIN RESULTS Presentation hyponatremia was defined as serum sodium less than 135 mEq/L. The primary outcome was death at 90 days. Multivariable logistic regression was used to assess the association of hyponatremia with important clinical events. Of 3,002 patients with available data, 349 (12%) had hyponatremia. Hyponatremia was associated with death (18% vs 11%; multivariable-adjusted odds ratio, 1.81; 95% CI, 1.28-2.57; p < 0.001) and larger baseline intracerebral hemorrhage volume (multivariable adjusted, p = 0.046) but not with baseline perihematomal edema volume nor with growth of intracerebral hemorrhage or perihematomal edema during the initial 24 hours. CONCLUSIONS Hyponatremia at presentation is associated with increased mortality in patients with predominantly deep and modest volume intracerebral hemorrhage through mechanisms that seem independent of growth in intracerebral hemorrhage or perihematomal edema.


Laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunostomy using an absorbable bidirectional monofilament barbed suture: review of the literature and illustrative case video.


Perspectives on Pediatric Appendicitis and Appendectomy During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic.


title: Single-incision video-assisted thoracic resection for extrapulmonary sequestration: a case report.

text: We describe surgical resection of an extralobar pulmonary sequestration via single-incision thoracoscopic surgery (SITS), which we recommend as a suitable surgical option. A 45-year-old Japanese woman was admitted to our hospital for further examination of chest abnormal shadow. A rigid 5-mm 30° video-thoracoscope, an endograsper and an electric cautery were passed within the same single small incision. The tumor was suspended using articulating endograspers and resected after clipping and ligation of the anomalous vessel. The final pathology was determined an extrapulmonary sequestration.


title: Pandemic influenza H1N1 2009 in Thailand.

text: BACKGROUND Developing a quantitative understanding of pandemic influenza dynamics in South-East Asia is important for informing future pandemic planning. Hence, transmission dynamics of influenza A/H1N1 were determined across space and time in Thailand. METHODS Dates of symptom onset were obtained for all daily laboratory-confirmed cases of influenza A/H1N1pdm in Thailand from 3 May 2009 to 26 December 2010 for four different geographic regions (Central, North, North-East, and South). These data were analysed using a probabilistic epidemic reconstruction, and estimates of the effective reproduction number, R(t), were derived by region and over time. RESULTS Estimated R(t) values for the first wave peaked at 1.54 (95% CI: 1.42-1.71) in the Central region and 1.64 (95% CI: 1.38-1.92) in the North, whilst the corresponding values in the North-East and the South were 1.30 (95% CI: 1.17-1.46) and 1.39 (95% CI: 1.32-1.45) respectively. As the R(t) in the Central region fell below one, the value of R(t) in the rest of Thailand increased above one. R(t) was above one for 30 days continuously through the first wave in all regions of Thailand. During the second wave R(t) was only marginally above one in all regions except the South. CONCLUSIONS In Thailand, the value of R(t) varied by region in the two pandemic waves. Higher R(t) estimates were found in Central and Northern regions in the first wave. Knowledge of regional variation in transmission potential is needed for predicting the course of future pandemics and for analysing the potential impact of control measures.


title: A Randomized Controlled Trial of End-Tidal Carbon Dioxide Detection of Preterm Infants in the Delivery Room.

text: OBJECTIVE To compare the ability of qualitative versus quantitative methods of end-tidal carbon dioxide (EtCO2) detection to maintain normocarbia during face mask ventilation (FMV) of preterm infants (<32 weeks) in the delivery room. STUDY DESIGN Preterm infants <32 weeks were randomly assigned to the use of a disposable PediCap EtCO2 detector (Covidien, Dublin, Ireland) (qualitative) or a Microstream side stream capnography device (Covidien) (quantitative) for FMV in the delivery room, via a NeoPuff T-piece resuscitator (Fisher and Paykel, Auckland, New Zealand). The primary outcome was the presence of normocarbia, based on partial pressure of CO2 (PaCO2) readings obtained in the neonatal intensive care unit within an hour of birth. Normocarbia was defined as a PaCO2 measure between 37.5 and 60 mm Hg (5-8 kPa). RESULTS Of the 59 infants included, 59% (35/59) were within the PaCO2 target range within an hour of birth. There was no difference in the primary outcome; 64% (21/33) of infants in the quantitative group were within the PaCO2 range compared with 54% (14/26) in the qualitative group (P = .594); and 93% of participants <28 weeks' gestation were within the PaCO2 normocarbic range (90% [9/10] in quantitative group and 100% [5/5] in the qualitative group [P = 1]). There was no difference in the intubation rate, days of ventilation, or bronchopulmonary dysplasia rates between the 2 groups. CONCLUSIONS Quantitative or qualitative EtCO2 detection methods are both feasible for FMV in the delivery room. Although there was no difference in the incidence of normocarbia, the use of either form of EtCO2 monitoring should be considered during newborn stabilization, especially in infants less than 28 weeks' gestation. TRIAL REGISTRATION ISRCTN: ISRCTN10934870.


title: Safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment after subarachnoid hemorrhage.

text: Balloon angioplasty is often performed for symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. Angioplasty of the anterior cerebral artery (ACA), however, is perceived to be a challenging endeavor and not routinely performed due to technical and safety concerns. Here, we evaluate the safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment. Patients with vasospasm following subarachnoid hemorrhage who underwent balloon angioplasty at our institution between 2011 and 2016 were retrospectively reviewed. All ACA angioplasty segments were analyzed for pre- and post-angioplasty radiographic measurements. The degree of vasospasm was categorized as mild (<25%), moderate (25-50%), or severe (>50%), and relative change in caliber was measured following treatment. Clinical outcomes following treatment were also assessed. Among 17 patients, 82 total vessel segments and 35 ACA segments were treated with balloon angioplasty. Following angioplasty, 94% of segments had increased caliber. Neurological improvement was noted in 75% of awake patients. There were no intra-procedural complications, but two patients developed ACA territory infarction, despite angioplasty treatment. We demonstrate that balloon angioplasty of the ACA for vasospasm treatment is safe and effective. Thus, ACA angioplasty should be considered to treat vasospasm in symptomatic patients recalcitrant to vasodilation infusion therapy.


title: Using vertebrate environmental DNA from seawater in biomonitoring of marine habitats.

text: Conservation management of marine biodiversity depends on biomonitoring of marine habitats, but current approaches are resource-intensive and require different approaches for different organisms. Environmental DNA (eDNA) extracted from water samples is an efficient and versatile approach to detecting aquatic animals. In the ocean, eDNA composition reflects local fauna at fine spatial scales, but little is known about the effectiveness of eDNA-based monitoring of marine communities at larger scales. We investigated the potential of eDNA to characterize and distinguish marine communities at large spatial scales by comparing vertebrate species composition among marine habitats in Qatar, the Arabian Gulf (also known as the Persian Gulf), based on eDNA metabarcoding of seawater samples. We conducted species accumulation analyses to estimate how much of the vertebrate diversity we detected. We obtained eDNA sequences from a diverse assemblage of marine vertebrates, spanning 191 taxa in 73 families. These included rare and endangered species and covered 36% of the bony fish genera previously recorded in the gulf. Sites of similar habitat type were also similar in eDNA composition. The species accumulation analyses showed that the number of sample replicates was insufficient for some sampling sites but suggested that a few hundred eDNA samples could potentially capture >90% of the marine vertebrate diversity in the study area. Our results confirm that seawater samples contain habitat-characteristic molecular signatures and that eDNA monitoring can efficiently cover vertebrate diversity at scales relevant to national and regional conservation and management. Article impact statement: Environmental DNA provides habitat-characteristic molecular signatures and can be used efficiently to map marine biodiversity at large spatial scales. This article is protected by copyright. All rights reserved.


title: Evaluation of the facial artery on computed tomographic angiography using 64-slice multidetector computed tomography: implications for facial reconstruction in plastic surgery.

text: BACKGROUND Preoperative knowledge of a patient's individual variations in facial artery anatomy would benefit plastic surgeons for reconstructive planning. The authors evaluated the feasibility of multislice computed tomographic angiography in vascular mapping of the facial artery. METHODS In total, 187 facial arteries in 94 patients without facial tumor or vascular disease were studied. Anatomical variations of the facial artery were classified into four types: type 1, a short course that terminates proximal to the superior labial artery; type 2, an intermediate course that terminates distal to the superior labial artery near the nasolabial fold; type 3, a classic course that extends to the lateral nasal ala beyond the nasolabial fold with an angular branch; and type 4, duplex with dominant lateral angular branch. Facial artery patterns were compared with dominant patterns of the facial-submental artery bifurcation. The extent of the inferior and superior labial artery was evaluated separately. RESULTS Sixty-four facial artery branches (34 percent) were classified as type 1, 74 (40 percent) as type 2, and 45 (24 percent) as type 3. Type 4 was seen in only four branches (2 percent). The facial artery was dominant in the facial-submental artery bifurcation in 84 percent of type 3 facial arteries. Three-dimensional volume-rendered images allow detailed visualization of the facial artery and its branches and help preoperative mapping. CONCLUSION Facial computed tomographic angiography allows detailed visualization of the facial artery and its branches and is a potential noninvasive imaging tool for preoperative vascular mapping for facial reconstructive operations.


title: Percutaneous vertebroplasty as treatment of malignant vertebral lesions: a systematic review and GRADE evaluation resulting in a Danish national clinical guideline.

text: PURPOSE To summarize the recommendations from the national clinical guideline published by the Danish Health Authority, regarding cemental augmentation as treatment for painful vertebral lesions, in patients with malignant disease. METHODS A multidisciplinary working group formulated recommendations based on the GRADE approach. RESULTS Two of the questions were based on randomized studies and one on professional consensus. The guideline recommends cemental augmentation for painful vertebral lesions in patients with malignant diagnosis, either hematological or non-hematological. Fracture of the posterior wall is not a contradiction to cemental augmentation, but care should always be taken while injecting the cement, to decrease the risk of cemental leaks into the spinal canal. CONCLUSION The recommendations are based on low-to-moderate quality of evidence or professional consensus as well as patient preferences and positive and harmful effects of the intervention. The working group recommends more randomized studies on patients with different malignant diseases and painful vertebral lesions comparing percutaneous vertebroplasty/kyphoplasty and conservative treatment to confirm the conclusion in this guideline. These slides can be retrieved under Electronic Supplementary Material.


title: A Pipeline for Faecal Host DNA Analysis by Absolute Quantification of LINE-1 and Mitochondrial Genomic Elements Using ddPCR.

text: Stool contains DNA shed from cells of the gastrointestinal (GI) tract and has great potential as a bio-specimen for non-invasive, nucleic acid-based detection of GI diseases. Whereas methods for studying faecal microbiome DNA are plentiful, there is a lack of well-characterised procedures for stabilisation, isolation, and quantitative analysis of faecal host DNA. We report an optimised pipeline for faecal host DNA analysis from the point-of-collection to droplet digital PCR (ddPCR) absolute quantification of host-specific gene targets. We evaluated multiple methods for preservation and isolation of host DNA from stool to identify the highest performing methods. To quantify host DNA even if present in partially degraded form, we developed sensitive, human-specific short-amplicon ddPCR assays targeting repetitive nuclear genomic elements (LINE-1) and mitochondrial genes. We validated the ability of these optimised methods to perform absolute quantification of host DNA in 200 stool DNA extracts from samples that were serially collected from three healthy individuals and three hospitalised patients. These specimens allowed assessment of host DNA day-to-day variability in stool specimens with widely varying physical characteristics (i.e., Bristol scores). We further extended this approach to mouse stool analysis, to enable faecal host DNA studies in animal disease models as well.


title: Clinical characteristics of two human-to-human transmitted coronaviruses: Corona Virus Disease 2019 vs. Middle East Respiratory Syndrome Coronavirus.

text: OBJECTIVE Subsequent to a global outbreak of the Middle East Respiratory Syndrome (MERS) in 2012, a novel human coronavirus, known as Corona Virus Disease 2019 (COVID-19) has caused a major disease outbreak. The aim of this study was to perform a systematic review to compare epidemiological, clinical, and laboratory features of COVID-19 and MERS-COV populations. MATERIALS AND METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials database to identify potential studies that have reported COVID-19 or MERS-COV disease. Epidemiology, clinical, and laboratory outcomes, intensive care unit (ICU) admission rates, discharge rates, and fatality rates were evaluated using Graph-Pad Prism software. RESULTS A total of forty-two studies were included in our research, involving in 4,720 patients (COVID-19 = 2,012, MERS-COV = 2,708). The present study revealed that main clinical manifestations of both COVID-19 and MERS-COV populations are fever, cough and generalized weakness or myalgia, and Acute Respiratory Distress Syndrome (ARDS) is the main complication. The COVID-19 population has a lower rate of ICU admissions, discharges, fatalities, and shorter incubation periods than those of MERS-COV population. CONCLUSIONS The main clinical features of both COVID-19 and MERS-COV populations are fever, cough and generalized weakness or myalgia. ARDS is the main complication of both populations. COVID-19 cases have a shorter incubation period and lower rate of ICU admissions, discharges and fatalities compared to MRES-COV population.


title: Molecular characterization of a new species in the genus Alphacoronavirus associated with mink epizootic catarrhal gastroenteritis.

text: A coronavirus (CoV) previously shown to be associated with catarrhal gastroenteritis in mink (Mustela vison) was identified by electron microscopy in mink faeces from two fur farms in Wisconsin and Minnesota in 1998. A pan-coronavirus and a genus-specific RT-PCR assay were used initially to demonstrate that the newly discovered mink CoVs (MCoVs) were members of the genus Alphacoronavirus. Subsequently, using a random RT-PCR approach, full-genomic sequences were generated that further confirmed that, phylogenetically, the MCoVs belonged to the genus Alphacoronavirus, with closest relatedness to the recently identified but only partially sequenced (fragments of the polymerase, and full-length spike, 3c, envelope, nucleoprotein, membrane, 3x and 7b genes) ferret enteric coronavirus (FRECV) and ferret systemic coronavirus (FRSCV). The molecular data presented in this study provide the first genetic evidence for a new coronavirus associated with epizootic catarrhal gastroenteritis outbreaks in mink and demonstrate that MCoVs possess high genomic variability and relatively low overall nucleotide sequence identities (91.7 %) between contemporary strains. Additionally, the new MCoVs appeared to be phylogenetically distant from human (229E and NL63) and other alphacoronaviruses and did not belong to the species Alphacoronavirus 1. It is proposed that, together with the partially sequenced FRECV and FRSCV, they comprise a new species within the genus Alphacoronavirus.


Time to Endovascular Thrombectomy for Acute Stroke-Reply.


title: COVID-19 and Urology: A Comprehensive Review of the Literature.

text: Covid-19 pandemic is the newest and biggest global health threat worldwide. Medical and surgical priorities were changed dramatically at the time of this pandemic. Postponement for all outpatient and elective activities to save facilities and resources for urgent cases and Covid-19 patients was adopted by most of hospitals in the affected countries. Over the coming weeks healthcare workers including urologists will be facing increasingly difficult challenges and consequently they should adopt sufficient protection strategies to guard against infection when dealing with COVID-19 patients. In this review we discussed the impact of Covid-19 on global health, urinary tract and uro-oncologic surgeries . Additionally, we reviewed some of the available recommendations reported on oncological surgeries practice during this pandemic.


DK-Crush Should Become Preferred Strategy for Treating Unprotected LM Bifurcation Lesions: No Pain, No Gain.


Percutaneous dilatational tracheostomy: collaborative team approach for safe airway management.


title: How to train practising gynaecologists in total laparoscopic hysterectomy: protocol for the stepped-wedge IMAGINE trial.

text: INTRODUCTION Hysterectomy is the most common major gynaecological procedure in women and minimally invasive approaches should be used wherever possible; total laparoscopic hysterectomy (TLH) is one such surgical approach which allows removal of the uterus entirely laparoscopically. However, lack of surgical training opportunities is impeding its increased adoption. This study will formally test a surgical outreach training model to equip surgeons with the skills to provide TLH as an alternative to total abdominal hysterectomy (TAH). METHODS AND ANALYSIS Stepped wedge implementation trial of a surgical training programme for practising obstetrician gynaecologist specialists in four hospitals. PRIMARY OUTCOMES Change in the proportion of hysterectomies performed by TAH, measured between preintervention and postintervention; we aim to reduce TAH by at least 30% in 75% of the trainees. SECONDARY OUTCOMES (1) Number of hospitals screened, eligible, agree to training and complete the training; (2) number of surgeons screened for eligibility, eligible, agree to training, who complete training and achieve proficiency; (3) proportion of trainees achieving proficiency in correct theatre setup, vascular exposure, mobilisation and surgery closure; change in proportion proficient over time; (4) adverse events (conversion from TLH to TAH, anaesthetic incident, intraoperative visceral injury, red cell transfusions, hospital stay >7 days, incidental finding of malignancy, unplanned readmission, admission to intensive care, return to theatre, postoperative pulmonary embolism or deep vein thrombosis, development of a fistula, vault haematoma, vaginal vault dehiscence or pelvic infection); (5) hospital length-of-stay; (6) cost-effectiveness and (7) trainee surgeon proficiency with TLH. ETHICS AND DISSEMINATION The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee and has received site-specific approval from all participating hospitals. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03617354; Pre-results.


title: A new endoscopic closure method for gastric mucosal defects: feasibility of endoscopic hand suturing in an ex vivo porcine model (with video).

text: BACKGROUND AND STUDY AIMS More secure endoscopic closure techniques for iatrogenic gastric defects are required for safe endoscopic surgery. We developed a novel endoscopic suturing method, endoscopic hand suturing (EHS), of gastric mucosal defects and determined its feasibility and efficacy ex vivo. MATERIALS AND METHODS We created 24 mucosal defects (each 2 cm in diameter) by endoscopic submucosal dissection. The following three techniques were tested: EHS with a 3 - 0 barbed suture that was grasped with biopsy forceps (n = 6) or a prototype through-the-scope needle holder (n = 6) by endoscopy, looping with endoloops (n = 6) by endoscopy, and clipping with hemoclips (n = 6) by hand. The mucosal edges were attached to each other at three points. The closure strength was compared among the three groups, and the procedural duration was compared between the EHS and looping groups. RESULTS All 12 lesions were completely closed by EHS. The median strength of the closure, measured with a spring scale, was significantly greater in the EHS group (0.74 kg) than in the looping group (0.33 kg, P = 0.0012) or clipping group (0.07 kg, P = 0.0009). The median procedural duration did not significantly differ between the EHS and looping groups (19.7 vs. 19.8 minutes, P = 1.0000). The use of the needle holder significantly reduced the procedural duration compared with the biopsy forceps. CONCLUSION Mucosal defects can be firmly closed with EHS, which may be helpful for establishing a safer and more secure endoscopic surgery.


title: Multimodality Fusion with MRI, CT, and Ultrasound Contrast for Ablation of Renal Cell Carcinoma.

text: Fusion technology with electromagnetic (EM) tracking enables navigation with multimodality feedback that lets the operator use different modalities during different parts of the image-guided procedure. This may be particularly helpful in patients with renal insufficiency undergoing kidney tumor ablation, in whom there is a desire to minimize or avoid nephrotoxic iodinated contrast exposure. EM tracking software merges and fuses different imaging modalities such as MRI, CT, and ultrasound and can also display the position of needles in real time in relation to preprocedure imaging, which may better define tumor targets than available intraoperative imaging. EM tracking was successfully used to ablate a poorly visualized renal tumor, through the combined use of CT, gadolinium-enhanced MR, and contrast-enhanced US imaging to localize the tumor.


title: Robotic approaches to prolapse surgery.

text: PURPOSE OF REVIEW Pelvic reconstructive surgeons in the fields of urology, gynecology and urogynecology have continually adapted new techniques in pelvic organ prolapse (POP) repair in order to improve both anatomic and subjective outcomes. In the last 5 years, robotic surgery has gained a strong foothold in urologic oncology, gynecologic oncology, cardiothoracic surgery and now in female pelvic medicine. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the 'gold standard' technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. This review article aims to discuss the techniques of robotic prolapse repair as well as morbidity, cost and clinical outcomes. RECENT FINDINGS The adaptation of minimally invasive approaches to the treatment of POP initially began with laparoscopy, something only those surgeons with extensive and advanced laparoscopic skills are able to accomplish. Access to robotic technology makes conversion from open or laparoscopic to robotic surgery much more feasible for most pelvic floor surgeons. There are currently no published randomized, controlled trials comparing robotic with open or laparoscopic sacrocolpopexy, however, there are several publications reporting both retrospective and prospective series of women undergoing robotic-assisted sacrocolpopexy. SUMMARY Robotic-assisted pelvic floor surgery has become an important component of the pelvic surgeon's armamentarium in the treatment of symptomatic POP. Those pelvic surgeons without significant expertise in laparoscopy required for sacral dissection and intracorporeal suturing can readily learn the necessary techniques required for robotic surgery.


A Call for Pediatric COVID-19 Clinical Trials.


title: Demographic Predictors of Pain Sensitivity: Results From the OPPERA Study.

text: The demographic factors of sex, age, and race/ethnicity are well recognized as relevant to pain sensitivity and clinical pain expression. Of these, sex differences have been the most frequently studied, and most of the literature describes greater pain sensitivity for women. The other 2 factors have been less frequently evaluated, and current literature is not definitive. Taking advantage of the large Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study cohort, we evaluated the association of sex, age, and self-reported race with 34 measures of pressure, mechanical, and thermal pain sensitivity encompassing threshold and suprathreshold perception. Women were significantly more pain-sensitive than men for 29 of 34 measures. Age effects were small, and only significant for 7 of 34 measures, however, the age range was limited (18-44 years of age). Race/ethnicity differences varied across groups and pain assessment type. Non-Hispanic white individuals were less pain-sensitive than African-American (for 21 of 34 measures), Hispanic (19 of 34), and Asian (6 of 34) individuals. No pain threshold measure showed significant racial differences, whereas several suprathreshold pain measures did. This suggests that racial differences are not related to tissue characteristics or inherent nociceptor sensitivity. Rather, the differences observed for suprathreshold pain ratings or tolerance are more likely related to differences in central nociceptive processing, including modulation imposed by cognitive, psychological, and/or affective factors. PERSPECTIVE The influence of sex, age, and race/ethnicity on various aspects of pain sensitivity, encompassing threshold and suprathreshold measures and multiple stimulus modalities, allows for a more complete evaluation of the relevance of these demographic factors to acute pain perception.


Drugs and the renin-angiotensin system in covid-19.


title: Diagnostic utility of cerebrospinal fluid immunocytochemistry for diagnosis of feline infectious peritonitis manifesting in the central nervous system.

text: Objectives The aim of the study was to evaluate whether an ante-mortem diagnosis of central nervous system (CNS) feline infectious peritonitis (FIP) is possible via immunocytochemical staining (ICC) of feline coronavirus antigen (FCoV) within macrophages of cerebrospinal fluid (CSF). Methods Prospectively, CSF samples of 41 cats were investigated, including cats with histopathologically confirmed FIP and neurological signs (n = 10), cats with confirmed FIP without CNS involvement (n = 11), cats with neurological signs but another confirmed CNS disease (n = 17), and cats without neurological signs and a disease other than FIP (n = 3). ICC staining of CSF macrophages was performed in all cats. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of CSF ICC were calculated. Results Of 10 samples from cats with CNS FIP, eight had detectable CSF macrophages, seven of which were positive for FCoV. Ten of 11 samples from cats with confirmed FIP without neurological signs had macrophages in the CSF, with all 10 being ICC-positive. In cats with other CNS disorders, 11/17 had macrophages, two of which stained positively. In cats with diseases other than FIP and without neurological disorders, 2/3 revealed macrophages, with one cat showing positive ICC staining. Diagnosis of FIP via CSF ICC had a sensitivity of 85.0% and a specificity of 83.3%. PPV and NPV were 85.0% and 83.3%. Conclusions and relevance CSF ICC is a highly sensitive test for ante-mortem diagnosis of FIP manifesting in the CNS. However, CNS ICC specificity is too low to confirm FIP and the method should only be applied in conjunction with other features such as CSF cytology. CNS ICC could be helpful to discover pre-neurological stages of CNS FIP.


title: Hypoxia, color vision deficiencies, and blood oxygen saturation.

text: Chromatic thresholds were measured using the Cambridge Colour Test (CCT), the Colour Assessment and Diagnosis (CAD) test, and the Cone Specific Contrast Test (CSCT) at ground and 3780 m (12,400 ft) for subjects with normal color vision and red-green color vision defects. The CAD revealed a small (~10%) increase in the red-green thresholds for the trichromatic subjects and a similar increase in the blue-yellow thresholds for the dichromats. The other two color vision tests did not reveal any significant change in chromatic thresholds. The CAD results for the trichromats were consistent with a rotation of the discrimination ellipse counterclockwise with little change in the elliptical area. This alteration in the color discrimination ellipse can occur when retinal illumination is lowered.


title: Chromatographic methods development for clinical practice: requirements and limitations.

text: Development of a chromatographic method in bioanalysis is a challenging and complex procedure with many pitfalls and often unexpected reversals that can require several months to accomplish. Even an experienced analytical team must contend many limitations mainly in connection with the strict requirements imposed on current clinical research. These restrictions typically persist throughout the whole development process, from clinical trial assignment, across optimization of extraction of biological materials and chromatographic separation, to validation and data interpretation. This paper describes questions and their possible answers raised during the pre-analytical phase such as use of modern sample preparation techniques in clinical methods, application of internal standards, as well as selection of stationary phases and detection techniques in the analytical phase. Validation problems and interpretation of results are demonstrated with three typical examples of characteristics to be considered, i.e. recovery, matrix effect, and limit of detection vs. lower limit of quantification.


title: Risk factors and consequences of anastomotic leakage after Ivor Lewis oesophagectomy†.

text: OBJECTIVES Oesophageal carcinoma (EC) remains an aggressive disease. Despite extensive changes in therapeutic modalities, surgical resection remains the first choice therapy for curable oesophageal cancer patients. Anastomotic sites are prone to serious complications such as leakage, fistula, bleeding and stricture. Leakage of the anastomosis (AL) remains one of the main causes of postoperative morbidity and mortality. The purpose of this study was to identify predictors associated with postoperative leakage after Ivor Lewis oesophagectomy and its consequences in a single centre. METHODS We performed a retrospective analysis of 412 Ivor Lewis oesophageal resections in a single institute between 2005 and 2014. Univariable and multivariable logistic regression have been used to identify predictors of AL and its impact on postoperative outcome and overall survival. Kaplan-Meier curve was used to analyse overall survival and log-rank analysis to determine odds ratio. RESULTS A total of 412 patients were evaluated. Mean age was 62 ± 11 years (77% male). Overall leak rate was 2.9%. In-hospital or 30-day mortality was 4.4%. Mean intensive care unit (ICU) stay was 1 day and mean hospital stay was 19 days. A history of renal failure, diabetes, higher American Society of Anaesthesiologists score and current cigarette and corticosteroid use were identified as predictors of AL on univariable analysis. Multivariable analysis identified active smoking [P = 0.05, odds ratio (OR) 4.34, 95% confidence interval (CI): 0.98-19.28] and active corticosteroid use (P < 0.001, OR 15.8, 95% CI: 3.25-76.7) as independent significant predictors. A history of diabetes tended to be associated with a higher leakage rate but failed to reach statistical significance. AL was associated with a longer ICU and hospital stay and a significantly higher mortality (42% in the AL group vs 3% in the control group, P < 0.0001). CONCLUSIONS Anastomotic leakage after oesophagectomy is a major cause of postoperative morbidity and mortality. Identifying risk factors preoperatively can contribute to the prevention of postoperative complications.


title: Isolated pharmaco-mechanical thrombectomy (IPMT) for the endovascular treatment of acute axillofemoral graft occlusion.

text: Since the long-term patency of axillofemoral (AXF) grafts is inferior to aorto-bifemoral (ABF) grafts, limb salvage procedures are crucial in this group of patients. Emerging endovascular devices have helped in the successful restoration of flow for acute limb ischemia in both native arteries as well as bypass grafts. One such device, the Trellis thrombectomy system is being used more frequently in this setting. The device has previously been used in veins, native arteries, and rarely in aortofemoral grafts. We present its first successful use for the treatment of occluded AXF bypass graft. The use of this device helped to isolate the treatment zone in the occluded graft, which allowed the use of a lower dose of thrombolytics, less systemic release of thrombolytics, and less distal embolization. Resolution of extensive clot burden was achieved and, with subsequent stenting of the graft at the distal anastomotic site, arterial flow to the leg through the AXF graft was restored and a revision surgery was avoided.


title: Foot-and-mouth disease virus induces autophagosomes during cell entry via a class III phosphatidylinositol 3-kinase-independent pathway.

text: Autophagy is an intracellular pathway that can contribute to innate antiviral immunity by delivering viruses to lysosomes for degradation or can be beneficial for viruses by providing specialized membranes for virus replication. Here, we show that the picornavirus foot-and-mouth disease virus (FMDV) induces the formation of autophagosomes. Induction was dependent on Atg5, involved processing of LC3 to LC3II, and led to a redistribution of LC3 from the cytosol to punctate vesicles indicative of authentic autophagosomes. Furthermore, FMDV yields were reduced in cells lacking Atg5, suggesting that autophagy may facilitate FMDV infection. However, induction of autophagosomes by FMDV appeared to differ from starvation, as the generation of LC3 punctae was not inhibited by wortmannin, implying that FMDV-induced autophagosome formation does not require the class III phosphatidylinositol 3-kinase (PI3-kinase) activity of vps34. Unlike other picornaviruses, for which there is strong evidence that autophagosome formation is linked to expression of viral nonstructural proteins, FMDV induced autophagosomes very early during infection. Furthermore, autophagosomes could be triggered by either UV-inactivated virus or empty FMDV capsids, suggesting that autophagosome formation was activated during cell entry. Unlike other picornaviruses, FMDV-induced autophagosomes did not colocalize with the viral 3A or 3D protein. In contrast, ∼50% of the autophagosomes induced by FMDV colocalized with VP1. LC3 and VP1 also colocalized with the cellular adaptor protein p62, which normally targets ubiquitinated proteins to autophagosomes. These results suggest that FMDV induces autophagosomes during cell entry to facilitate infection, but not to provide membranes for replication.


title: Spacer effects on in vivo properties of DOTA-conjugated dimeric [Tyr3]octreotate peptides synthesized by a "Cu(I)-click" and "sulfo-click" ligation method.

text: We report on the SSTR2-binding properties of a series of four dimeric [Tyr3]octreotate analogues with different spacer lengths (nine, 19, 41, and 57 atoms) between the peptides. Two analogues (9 and 57 atoms) were selected as precursors for the design, synthesis, and biological evaluation of DOTA-conjugated dimeric [Tyr3]octreotate analogues for tumor targeting. These compounds were synthesized by using a two-stage click ligation procedure: a Cu(I) -catalyzed 1,3-dipolar cycloaddition ("copper-click" reaction) and a thio acid/sulfonyl azide amidation ("sulfo-click" reaction). The IC(50) values of these DOTA-conjugated [Tyr3]octreotate analogues were comparable, and internalization studies showed that the nine-atom (111) In-DOTA-labeled [Tyr3]octreotate dimer had rapid and high receptor binding. Biodistribution studies with BALB/c nude mice bearing subcutaneous AR42J tumors showed that the (111) In-labeled [Tyr3]octreotate dimer (nine atoms) had a high tumor uptake at 1 h p.i. (38.8 ± 8.3 % ID g(-1) ), and excellent tumor retention at 4 h p.i. (40.9 ± 2.5 % ID g(-1) ). However, the introduction of the extended hydrophilic 57 atoms spacer led to rapid clearance from the circulation; this limited tumor accumulation of the radiotracer (21.4 ± 4.9 % ID g(-1) at 1 h p.i.). These findings provide important insight on dimerization and spacer effects on the in vivo properties of DOTA-conjugated [Tyr3]octreotate dimers.


title: Partial nephrectomy--contemporary indications, techniques and outcomes.

text: Increased detection of the small renal mass over the last two decades has led to greater utilization of partial nephrectomy techniques. Appreciation of the negative impact of chronic renal impairment has resulted in partial nephrectomy surpassing radical nephrectomy as the preferred treatment for technically feasible lesions. Indeed the management of localized renal tumours has become focused on techniques that maximally preserve nephron quantity and quality, and therefore maximize renal function after surgery. Postoperative renal function is determined primarily by three factors: preoperative renal function, volume of renal mass preserved and surgical renal ischaemia. Minimization of surgical ischaemia is achieved by early unclamping and unclamped (zero ischaemia) techniques. In addition, laparoscopic and robotic approaches to nephron-sparing surgery have significantly reduced the morbidity of the partial nephrectomy procedure compared with the traditional open approach. The contemporary techniques used for partial nephrectomy demonstrate excellent renal functional and oncological outcomes and minimize perioperative complications.


title: Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19.

text: BACKGROUND Progressive respiratory failure is the primary cause of death in the coronavirus disease 2019 (Covid-19) pandemic. Despite widespread interest in the pathophysiology of the disease, relatively little is known about the associated morphologic and molecular changes in the peripheral lung of patients who die from Covid-19. METHODS We examined 7 lungs obtained during autopsy from patients who died from Covid-19 and compared them with 7 lungs obtained during autopsy from patients who died from acute respiratory distress syndrome (ARDS) secondary to influenza A(H1N1) infection and 10 age-matched, uninfected control lungs. The lungs were studied with the use of seven-color immunohistochemical analysis, micro-computed tomographic imaging, scanning electron microscopy, corrosion casting, and direct multiplexed measurement of gene expression. RESULTS In patients who died from Covid-19-associated or influenza-associated respiratory failure, the histologic pattern in the peripheral lung was diffuse alveolar damage with perivascular T-cell infiltration. The lungs from patients with Covid-19 also showed distinctive vascular features, consisting of severe endothelial injury associated with the presence of intracellular virus and disrupted cell membranes. Histologic analysis of pulmonary vessels in patients with Covid-19 showed widespread thrombosis with microangiopathy. Alveolar capillary microthrombi were 9 times as prevalent in patients with Covid-19 as in patients with influenza (P<0.001). In lungs from patients with Covid-19, the amount of new vessel growth - predominantly through a mechanism of intussusceptive angiogenesis - was 2.7 times as high as that in the lungs from patients with influenza (P<0.001). CONCLUSIONS In our small series, vascular angiogenesis distinguished the pulmonary pathobiology of Covid-19 from that of equally severe influenza virus infection. The universality and clinical implications of our observations require further research to define. (Funded by the National Institutes of Health and others.).


title: Outcomes and prognostic factors after pulmonary metastasectomy in patients with colorectal cancer with previously resected hepatic metastases.

text: OBJECTIVES Outcomes and prognostic factors remain obscure in patients with colorectal cancer after pulmonary metastasectomy who had previously received a curative hepatic metastasectomy. METHODS We collected data of 757 patients with pulmonary metastasis from colorectal cancer who underwent curative metastasectomy between 2004 and 2008 from 46 Japanese institutions, from which we extracted data on patients who previously received curative hepatic metastasectomy. Disease-free survival, overall survival, and prognostic factors were analyzed. RESULTS The subjects of this study were 160 patients, of whom 44% had primary rectal tumor, 73% had a single pulmonary metastasis, 11% had a bilateral pulmonary metastasis, and 39% had high (>5 ng/mL) serum carcinoembryonic antigen. Patients' median age was 66 years, and 58% were male. The median follow-up was 64 months. Five-year overall survival and disease-free survival were 65.2% (95% confidence interval, 56.8-72.5) and 33.5% (95% confidence interval, 26.1-41.0), respectively. In multivariable analyses, high prethoracotomy carcinoembryonic antigen level was an independent prognostic factor for overall survival (hazard ratio, 2.01; 95% confidence interval, 1.16-3.47) and disease-free survival (hazard ratio, 2.10; 95% confidence interval, 1.41-3.12). Five-year overall survival and disease-free survival of patients with normal prethoracotomy carcinoembryonic antigen level were 76.4% (95% confidence interval, 66.1-83.9) and 40.7% (95% confidence interval, 30.5-50.5), respectively. CONCLUSIONS After pulmonary metastasectomy, approximately two thirds of patients with colorectal cancer with a history of curative hepatic metastasectomy survived for 5 years-half of them disease-free. Our results indicate that patients with colorectal cancer with pulmonary metastasis and a history of curative hepatic metastasectomy may benefit from sequential pulmonary metastasectomy, especially if prethoracotomy serum carcinoembryonic antigen levels are within normal range.


title: Happy Hypoxemia in COVID-19-A Neural Hypothesis.

text: Many COVID-19 patients are presenting with atypical clinical features. Happy hypoxemia with almost normal breathing, anosmia in the absence of rhinitis or nasal obstruction, and ageusia are some of the reported atypical clinical findings. Based on the clinical manifestations of the disease, we are proposing a new hypothesis that SARS-CoV-2 mediated inflammation of the nucleus tractus solitarius may be the reason for happy hypoxemia in COVID-19 patients.


title: Full-Thickness Skin Grafting for Local Defect Coverage Following Scalp Adjacent Tissue Transfer in the Setting of Cranioplasty.

text: INTRODUCTION Numerous techniques have been described to overcome scalp deficiency and high-tension closure at time of cranioplasty. However, there is an existing controversy, over when and if a free flap is needed during complex skull reconstruction (ie, cranioplasty). As such the authors present here our experience using full-thickness skin grafts (FTSGs) to cover local defects following scalp adjacent tissue transfer in the setting of cranioplasty. METHODS By way of an institutional review board-approved database, the authors identified patients treated over a 3-year period spanning January 2015 to December 2017, who underwent scalp reconstruction using the technique presented here. Patient demographics, clinical characteristics, technical details, outcomes, and long-term follow up were statistically analyzed for the purpose of this study. RESULTS Thirty-three patients, who underwent combined cranioplasty and scalp reconstruction using an FTSG for local donor site coverage, were identified. Twenty-five (75%) patients were considered to have "high complexity" scalp defects prior to reconstruction. Of them, 12 patients (36%) were large-sized and 20 (60%) medium-sized; 21 (64%) grafts were inset over vascularized muscle or pericranium while the remaining grafts were placed over bare calvarial bone. In total, the authors found 94% (31/33) success for all FTSGs in this cohort. Two of the skin grafts failed due to unsuccessful take. Owing to the high rate of success in this series, none of the patient's risk factors were found to correlate with graft failure. In addition, the success rate did not differ whether the graft was placed over bone verses over vascularized muscle/pericranium. CONCLUSION In contrary to previous studies that have reported inconsistent success with full-thickness skin grafting in this setting, the authors present a simple technique with consistent results-as compared to other more complex reconstructive methods-even in the setting of highly complex scalp reconstruction and simultaneous cranioplasty.


Transplantation of mucosa from stomach to esophagus to prevent stricture after circumferential endoscopic submucosal dissection of early squamous cell.


title: [Respiratory and Facial Protection: Current Perspectives in the Context of the COVID-19 Pandemic].

text: The new SARS-CoV-2 pandemic is an example of an international public health emergency, which is associated with considerable social and economic challenges. At the healthcare level there is the risk that nosocomial outbreaks can be local amplifiers. Adequate infection control practices are of critical importance, which include proper use of personal protective equipment. This equipment must be appropriate to the pathogen transmission route that, in the case of SARS-CoV-2, occurs through droplet and contact routes. The infected individual, when talking, coughing or sneezing, spreads droplets containing the virus, directly contaminating other individuals within one to two meters of distance, as well as the surrounding environment. Airborne transmission may occur when aerosol-generating procedures are performed. Concerning respiratory protection, there is currently weak evidence that the use of respirators provides better protection than surgical masks for SARS-CoV-2 or other viruses (with the exception of aerosol-generating procedures, in which case the use of a respirator is recommended). Eye protection should be guaranteed whenever there is a risk of splashes, droplets or aerosols. The use of different, or higher than necessary, level of personal protective equipment, for the transmission route of the agent, is a form of misuse and can affect its supply for situations when it is clearly indicated. The adequate provision of protective equipment, as well as training of healthcare professionals in its correct use, is highly recommended to ensure safety of care.


title: Radiation exposure in transcatheter patent ductus arteriosus closure: time to tune?

text: OBJECTIVES The aims of this study were to describe radiation level at our institution during transcatheter patent ductus arteriosus occlusion and to evaluate the components contributing to radiation exposure. BACKGROUND Transcatheter occlusion relying on X-ray imaging has become the treatment of choice for patients with patent ductus arteriosus. Interventionists now work hard to minimise radiation exposure in order to reduce risk of induced cancers. METHODS We retrospectively reviewed all consecutive children who underwent transcatheter closure of patent ductus arteriosus from January 2012 to January 2016. Clinical data, anatomical characteristics, and catheterisation procedure parameters were reported. Radiation doses were analysed for the following variables: total air kerma, mGy; dose area product, Gy.cm2; dose area product per body weight, Gy.cm2/kg; and total fluoroscopic time. RESULTS A total of 324 patients were included (median age=1.51 [Q1-Q3: 0.62-4.23] years; weight=10.3 [6.7-17.0] kg). In all, 322/324 (99.4%) procedures were successful. The median radiation doses were as follows: total air kerma: 26 (14.5-49.3) mGy; dose area product: 1.01 (0.56-2.24) Gy.cm2; dose area product/kg: 0.106 (0.061-0.185) Gy.cm2/kg; and fluoroscopic time: 2.8 (2-4) min. In multivariate analysis, a weight >10 kg, a ductus arteriosus width <2 mm, complications during the procedure, and a high frame rate (15 frames/second) were risk factors for an increased exposure. CONCLUSION Lower doses of radiation can be achieved with subsequent recommendations: technical improvement, frame rate reduction, avoidance of biplane cineangiograms, use of stored fluoroscopy as much as possible, and limitation of fluoroscopic time. A greater use of echocardiography might even lessen the exposure.


title: Prehospital Acute Stroke Severity Scale to Predict Large Artery Occlusion: Design and Comparison With Other Scales.

text: BACKGROUND AND PURPOSE We designed and validated a simple prehospital stroke scale to identify emergent large vessel occlusion (ELVO) in patients with acute ischemic stroke and compared the scale to other published scales for prediction of ELVO. METHODS A national historical test cohort of 3127 patients with information on intracranial vessel status (angiography) before reperfusion therapy was identified. National Institutes of Health Stroke Scale (NIHSS) items with the highest predictive value of occlusion of a large intracranial artery were identified, and the most optimal combination meeting predefined criteria to ensure usefulness in the prehospital phase was determined. The predictive performance of Prehospital Acute Stroke Severity (PASS) scale was compared with other published scales for ELVO. RESULTS The PASS scale was composed of 3 NIHSS scores: level of consciousness (month/age), gaze palsy/deviation, and arm weakness. In derivation of PASS 2/3 of the test cohort was used and showed accuracy (area under the curve) of 0.76 for detecting large arterial occlusion. Optimal cut point ≥2 abnormal scores showed: sensitivity=0.66 (95% CI, 0.62-0.69), specificity=0.83 (0.81-0.85), and area under the curve=0.74 (0.72-0.76). Validation on 1/3 of the test cohort showed similar performance. Patients with a large artery occlusion on angiography with PASS ≥2 had a median NIHSS score of 17 (interquartile range=6) as opposed to PASS <2 with a median NIHSS score of 6 (interquartile range=5). The PASS scale showed equal performance although more simple when compared with other scales predicting ELVO. CONCLUSIONS The PASS scale is simple and has promising accuracy for prediction of ELVO in the field.


Early combination of Tocilizumab and Corticosteroids: An upgrade in anti-inflammatory therapy for severe COVID.


title: Objective detection of retinal vessel pulsation.

text: PURPOSE Retinal venous pulsation detection is a subjective sign, which varies in elevated intracranial pressure, venous obstruction and glaucoma. To date no method can objectively measure and identify pulsating regions. METHOD Using high resolution video-recordings of the optic disk and retina we measured fluctuating light absorption by haemoglobin during pulsation. Pulsation amplitude was calculated from all regions of the retinal image video-frames in a raster pattern. Segmented retinal images were formed by objectively selecting regions with amplitudes above a range of threshold values. These were compared to two observers manually drawing an outline of the pulsating areas while viewing video-clips in order to generate receiver operator characteristics. RESULTS 216,515 image segments were analysed from 26 eyes in 18 research participants. Using data from each eye, the median area under the receiver operator curve (AU-ROC) was 0.95. With all data analysed together the AU-ROC was 0.89. We defined the ideal threshold amplitude for detection of any pulsating segment being that with maximal sensitivity and specificity. This was 5 units (95% confidence interval 4.3 to 6.0) compared to 12 units before any regions were missed. A multivariate model demonstrated that ideal threshold amplitude increased with increased variation in video-sequence illumination (p = 0.0119), but between the two observers (p = 0.0919) or other variables. CONCLUSION This technique demonstrates accurate identification of retinal vessel pulsating regions with no areas identified manually being missed with the objective technique. The amplitude values are derived objectively and may be a significant advance upon subjective ophthalmodynamometric threshold techniques.


title: Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial.

text: BACKGROUND The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS). These new techniques are considered to be painless procedures, but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy. In this randomized control study, we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy. PATIENTS AND METHODS Forty patients (34 women and 6 men) were randomly assigned to two groups. In group A (n = 20) four-port classic laparoscopic cholecystectomy was performed. Patients in group B (n = 20) underwent SILS cholecystectomy. In all patients, preincisional local infiltration of ropivacaine around the trocar wounds was performed. Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well. Shoulder tip and abdominal pain were registered at 2, 6, 12, 24, 48, and 72 h postoperatively using visual analog scale (VAS). RESULTS Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain, and after the first 6 h for shoulder pain. Total pain after the first 24 h was nonexistent in the SILS group. Also, requests for analgesics were significantly less in the SILS group, while no difference was observed in incidence of nausea and vomiting between the two groups. CONCLUSION SILS cholecystectomy, as well as the invisible scar, has significantly lower abdominal and shoulder pain scores, especially after the first 24 h postoperatively, when this pain is nonexistent. (Registration Clinical Trial number: NTC00872287, www.clinicaltrials.gov ).


title: Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients.

text: BACKGROUND Obesity rates have reached epidemic levels with over 300 million obese individuals worldwide. Laparoscopic sleeve gastrectomy (LSG) as a primarily restrictive bariatric surgical procedure has been shown to be effective in producing marked weight loss. However, LSG-associated gastric leakage and hemorrhages remain the most important challenges postoperatively. Staple line buttress reinforcement has been suggested to reduce these postoperative complications. Our objective was to assess staple line buttress reinforcement via the Duet™ tissue reinforcement stapler system in morbidly obese patients undergoing LSG as part of a comprehensive weight management strategy, focusing on postoperative complications. METHODS Between January 2008 and April 2011, we retrospectively reviewed the medical records of 116 consecutive patients that underwent LSG with staple line buttress reinforcement at an academic teaching hospital with advanced bariatric fellowship. RESULTS The mean age of patients was 44.3 ± 9.5 years, with mean preoperative BMI of 44 ± 7 kg/m2. The mean operative time to perform LSG was 96 ± 25 min. Postoperative weight was significantly lower following LSG at 1-year follow-up compared to baseline (104 ± 25 vs. 125 ± 27 kg, P < 0.05). There were no postoperative gastric leaks observed. Postoperative bleeding from the gastric staple line occurred in one patient (0.9%) and was treated with conservative management. CONCLUSIONS In LSG, staple line buttress reinforcement limits postoperative gastric leakage and bleeding in morbidly obese patients.


title: Discovery of seven novel Mammalian and avian coronaviruses in the genus deltacoronavirus supports bat coronaviruses as the gene source of alphacoronavirus and betacoronavirus and avian coronaviruses as the gene source of gammacoronavirus and deltacoronavirus.

text: Recently, we reported the discovery of three novel coronaviruses, bulbul coronavirus HKU11, thrush coronavirus HKU12, and munia coronavirus HKU13, which were identified as representatives of a novel genus, Deltacoronavirus, in the subfamily Coronavirinae. In this territory-wide molecular epidemiology study involving 3,137 mammals and 3,298 birds, we discovered seven additional novel deltacoronaviruses in pigs and birds, which we named porcine coronavirus HKU15, white-eye coronavirus HKU16, sparrow coronavirus HKU17, magpie robin coronavirus HKU18, night heron coronavirus HKU19, wigeon coronavirus HKU20, and common moorhen coronavirus HKU21. Complete genome sequencing and comparative genome analysis showed that the avian and mammalian deltacoronaviruses have similar genome characteristics and structures. They all have relatively small genomes (25.421 to 26.674 kb), the smallest among all coronaviruses. They all have a single papain-like protease domain in the nsp3 gene; an accessory gene, NS6 open reading frame (ORF), located between the M and N genes; and a variable number of accessory genes (up to four) downstream of the N gene. Moreover, they all have the same putative transcription regulatory sequence of ACACCA. Molecular clock analysis showed that the most recent common ancestor of all coronaviruses was estimated at approximately 8100 BC, and those of Alphacoronavirus, Betacoronavirus, Gammacoronavirus, and Deltacoronavirus were at approximately 2400 BC, 3300 BC, 2800 BC, and 3000 BC, respectively. From our studies, it appears that bats and birds, the warm blooded flying vertebrates, are ideal hosts for the coronavirus gene source, bats for Alphacoronavirus and Betacoronavirus and birds for Gammacoronavirus and Deltacoronavirus, to fuel coronavirus evolution and dissemination.


title: Continuous Development of a Major Incident In-Hospital Victim Tracking and Tracing System, Withstanding the Challenges of Time.

text: OBJECTIVE To describe the development of the Patient Barcode Registration System (PBRS) over time and confirm the usability and feasibility of the system's latest version during a large trauma drill. METHODS The development of a PBRS started around 1993 aiming to provide an effective tool for patient registration, tracking, and tracing during major incidents. The PBRS uses wristbands with barcodes to follow and register patients in the care process. During a large trauma drill, 120 patients and 40 relatives were registered and traced in the system. Errors in registration, tracking, and tracing of persons were registered. RESULTS Of the 120 patients, no patient data were lost and patients could be traced in real time throughout the treatment process by the command team. Strategic decisions could be made based on the information provided by the system. Patient relatives were easily matched and government agencies received regular updates on the number and characteristics of the patients. CONCLUSION The PBRS is a usable, feasible, and sustainable patient tracking and tracing tool to be used during the hospital response to major incidents. Lessons learned during the last 20 years include the need for continuous updates to withstand the challenge of time. (Disaster Med Public Health Preparedness. 2017;11:244-250).


title: A systematic review and meta-analysis of interventions to increase physical activity in children and adolescents with intellectual disabilities.

text: BACKGROUND Increasing physical activity (PA) through intervention can promote physical and mental health benefits in children and adolescents. However, children and adolescents with intellectual disabilities (ID) have consistently been shown to engage in low levels of PA, which are insufficient for long-term health. Despite this, little is known about the effectiveness of interventions to increase PA in children and adolescents with ID. The aims of this study were therefore to systematically review how effective interventions are at increasing PA levels in children and adolescents with ID and to further examine what components have been used in these interventions. METHOD A systematic search of MEDLINE, EMBASE, Education Resources Information Center, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, Cochrane Central Register for Controlled Trials and International Standard Randomised Controlled Trial Number trials registry was conducted (up to July 2016). Articles were included if they met the following eligibility criteria: children and adolescents (<18 years) with ID, measurement of PA at baseline and post-intervention and intervention studies. Effect sizes were calculated as standardised mean difference (d) and meta-analysis calculated between intervention and no treatment control intervention. RESULTS Five studies met the eligibility criteria and were included in the review. Study design, methodological quality and intervention components were varied. Interventions did not support sufficient changes in PA to improve health. The meta-analysis demonstrated that intervention groups were not more effective at increasing PA levels post-intervention (d: 2.20; 95% CI -0.57 to 0.97) compared with control. However, due to a decrease in PA in the control intervention, a moderate significant effect was demonstrated at follow-up (d: 0.49; 95% CI 0.14 to 0.84). CONCLUSIONS There is a lack of studies which aim to increase PA levels in children and adolescents with ID, with current interventions ineffective. Future studies are required before accurate recommendations for appropriate intervention design and components can be made.


title: [A specifikus IgM- és IgG-antitesteket detektáló gyorstesztek értéke a SARS CoV-2 vírusfertőzés kimutatásában (A COVID-19-pandémia orvosszakmai kérdései)].

text: Introduction: At the end of March, 2020, rapid tests detecting the presence of antiviral IgM and IgG antibodies against SARS-CoV-2 virus were introduced in Hungary for the identification of SARS-CoV-2 infection (COVID-19 disease). Aim: We evaluated two rapid tests (Anhui and Clungene) in comparison with those of real-time PCR tests considered as the gold standard in the detection of infection. Method: Between 16, March and 14, April, 2020, we performed rapid IgM and IgG detecting tests without PCR; PCR without rapid tests; and PCR WITH rapid tests in 4140, 3210 and 1654 patients, respectively. (Out of these 1654 patients, Anhui and Clungene tests were used for testing in 625 and 1029 patients, respectively.) Patients were considered as positive in PCR and rapid tests when PCR positivity and IgM or IgG positivity occurred at any time, respectively. (Note: Clungene test is also marketed as 'Lungene'.) Results: The prevalence of PCR positivity in 4864 patients tested with PCR was 6.3%. The sensitivity and specificity of Anhui and Clungene tests were 33.3% and 72.85%, and 35.48% and 85.02%, respectively. At 6% PCR positivity, the positive and negative predictive values of Anhui and Clungene were 7.28%, 94.48%, 13.13%, and 95.38%, respectively. Conclusion: The low positive predictive values indicate that Anhui and Clungene rapid tests detecting the presence of anti-IgM and anti-IgG against SARS-CoV-2 virus infection are not suitable for screening SARS-CoV-2 vírus infection in the general population. These results strongly support that Anhui and Clungene rapid tests detecting IgM and IgG antibodies against SARS-CoV-2 virus should not be used in the differential diagnosis of infection. Orv Hetil. 2020; 161(20): 807-812.


Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV): An Unprecedented Partnership for Unprecedented Times.


title: Humanitarianism in surgery.

text: PURPOSE Humanitarianism is by definition a moral of kindness, benevolence and sympathy extended to all human beings. In our view as surgeons working in underserved countries, humanitarianism means performing the best operation in the best possible circumstances with high income country (HIC) results and training in-country surgeons to do the same. Hernia Repair for the Underserved (HRFU), a not for profit organization, is developing a long term public health initiative for hernia surgery in Western Hemisphere countries. We report the progress of HRFUs methods to render humanitarian care. METHODS In a collaborative effort, Creighton University and the Institute for Latin American Concern developed an outpatient surgery site for hernia surgery in Santiago, Dominican Republic. Based on this experience, we developed a sustainable care model by recruiting American and European Hernia Society expert surgeons, staff members they recommended, building relationships with local and industry partners, and selecting local surgeons to be trained in mesh hernioplasty. HRFU then extended the care model to other Western Hemisphere countries. RESULTS Between 2004 and 2015, the HRFU elective hernia morbidity and mortality rates for 2052 hernia operations were 0.7 and 0%, respectively. This is consistent with outcomes from HICs and confirms the feasibility of a public health initiative based on the principles of the Preferential Option for the Poor. CONCLUSIONS HRFU has recorded HIC morbidity and mortality rates for hernia surgery in low and middle income countries and has initiated a new surgical training model for sustainability of effect.


title: Early Weight Loss as a Predictor of 2-Year Weight Loss and Resolution of Comorbidities After Sleeve Gastrectomy.

text: BACKGROUND The objective of this study was to investigate whether early postoperative weight loss predicts weight loss 1 and 2 years after laparoscopic sleeve gastrectomy (LSG) and to determine its effect on the resolution of comorbidities. METHODS This was a prospective study of patients who underwent LSG at Jordan University Hospital from February 2009 to January 2014. RESULTS One hundred ninety patients (mean age 34.0 ± 10.8 years; mean preoperative body mass index 46.2 ± 7.7 kg/m(2)) were included in the study. Of these, 146 were followed for 1 year and 73 were followed for 2 years. Thirty patients (20.5 %) had hypertension, 23 (15.8 %) had diabetes, 78 (53.4 %) had hyperlipidemia, 30 (20.5 %) had obstructive sleep apnea, and 50 (34.2 %) had more than one comorbidity. The percentage of excess weight loss (%EWL) was 22.7 ± 8.1, 75.1 ± 22.8, and 72.6 ± 17.5 at 1, 12, and 24 months, respectively. Fifty-five patients (37.7 %) had a 1-year %EWL of ≥80 %, and 29 (39.7 %) had a 2-year %EWL of ≥80 %. Linear regression analysis showed a strong correlation between 1-month %EWL and %EWL at 1 year (r (2) = 0.23, p < 0.001) and 2 years (r (2) = 0.28, p < 0.001). Resolution of comorbidities was associated with higher %EWL achieved at 1 year, but early postoperative weight loss did not have a significant effect on comorbidity resolution. CONCLUSIONS Early postoperative weight loss can be used to identify and target poor responders.


title: Does Sex Modify the Effect of Endovascular Treatment for Ischemic Stroke?

text: Background and Purpose- Previous studies have reported less favorable outcome and less effect of endovascular treatment (EVT) after ischemic stroke in women than in men. Our aim was to study the influence of sex on outcome and on the effect of EVT for ischemic stroke in recent randomized trials on EVT. Methods- We used data from 7 randomized controlled trials on EVT within the HERMES collaboration. The primary outcome was 90-day functional outcome (modified Rankin Scale). We compared baseline characteristics and outcomes between men and women. With ordinal logistic regression, we evaluated the association between EVT and 90-day functional outcome for men and women separately, adjusted for potential confounders. We tested for interaction between sex and EVT. Results- We included 1762 patients in the analyses, of whom 833 (47%) were women. Women were older (median, 70 versus 66 years; P<0.001), were smoking less often (30% versus 44%; P<0.001), and had higher collateral grades (grade 3: 46% versus 35%; P<0.001) than men. Functional independence (modified Rankin Scale score, 0-2) at 90 days was reached by 318 women (39%) and 364 men (39%). The effect of EVT on the ordinal modified Rankin Scale was similar in women (adjusted common odds ratio [acOR], 2.13; 95% CI, 1.47-3.07) and men (acOR, 2.16; 95% CI, 1.59-2.96), with a P for interaction of 0.926. Conclusions- Sex does not influence clinical outcome after EVT and does not modify treatment effect of EVT. Therefore, sex should not be a consideration in the selection of patients for EVT.


title: Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force.

text: During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.


title: Covid-19 and its impact on child and adolescent psychiatry - a German and personal perspective.

text: As in other European countries, the current Covid-19 pandemic has not only massively restricted normal life in Germany, it is also having a significant effect on medical treatment, particularly in the areas of child and adolescent psychiatric care, as well as on university teaching. The federal structure of Germany and epidemiological differences between individual federal states has had a crucial impact on the regulations issued and their success. During the last number of weeks, tele-child-psychiatry and psychotherapy have increased, and outpatient services have been used cautiously and sparingly. Medical staff numbers will be augmented by doctors and nurses returning from retirement and also by medical students on a voluntary basis. The federal government has warned that discrepancies in education will increase due to the closure of schools. Questions of child protection are currently of particular importance in the context of such closures and the non-availability of day-care centres.


title: Effect of Aerosol Devices and Administration Techniques on Drug Delivery in a Simulated Spontaneously Breathing Pediatric Tracheostomy Model.

text: BACKGROUND This study was conducted to compare the efficiency of jet nebulizers, vibrating mesh nebulizers, and pressurized metered-dose inhalers (pMDI) during assisted and unassisted administration techniques using a simulated spontaneously breathing pediatric model with a tracheostomy tube (TT). METHODS An in vitro breathing model consisting of an uncuffed TT (4.5-mm inner diameter) was attached to a collecting filter (Respirgard) connected to a dual-chamber test lung and a ventilator (Hamilton Medical) to simulate breathing parameters of a 2-y-old child (breathing frequency, 25 breaths/min; tidal volume, 150 mL; inspiratory time, 0.8 s; peak inspiratory flow, 20 L/min). Albuterol sulfate was administered using a jet nebulizer (MicroMist, 2.5 mg/3 mL), vibrating mesh nebulizer (Aeroneb Solo, 2.5 mg/3 mL), and pMDI (ProAir HFA, 432 μg). Each device was tested 5 times with an unassisted technique (direct administration of aerosols with simulated spontaneous breathing) and with an assisted technique (using a manual resuscitation bag in conjunction with an aerosol device and synchronized with inspiration). Drug collected on the filter was analyzed by spectrophotometry. RESULTS With the unassisted technique, the pMDI had the highest inhaled mass percent (IM%, 47.15 ± 7.82%), followed by the vibrating mesh nebulizer (19.77 ± 2.99%) and the jet nebulizer (5.88 ± 0.77%, P = .002). IM was greater with the vibrating mesh nebulizer (0.49 ± .07 mg) than with the pMDI (0.20 ± 0.03 mg) and the jet nebulizer (0.15 ± 0.01 mg, P = .007). The trend of lower deposition with the assisted versus unassisted technique was not significant for the jet nebulizer (P = .46), vibrating mesh nebulizer (P = .19), and pMDI (P = .64). CONCLUSIONS In this in vitro pediatric breathing model with a TT, the pMDI delivered the highest IM%, whereas the vibrating mesh nebulizer delivered the highest IM. The jet nebulizer was the least efficient device. Delivery efficiency was similar with unassisted and assisted administration techniques.


Surgery: laparoscopic promontofixation is safe and effective for POP.


title: Short-term outcomes of intracorporeal esophagojejunostomy using the transorally inserted anvil versus extracorporeal circular anastomosis during laparoscopic total gastrectomy for gastric cancer: a propensity score matching analysis.

text: BACKGROUND To assess the short-term outcomes of intracorporeal Roux-en-Y esophagojejunostomy using the transorally inserted anvil (OrVil) compared with extracorporeal circular Roux-en-Y anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer. METHODS From January 2011-April 2014, a total of 165 consecutive patients with gastric cancer underwent either intracorporeal Roux-en-Y esophagojejunostomy (n = 25) using the Orvil or extracorporeal circular anastomosis (n = 140) during LTG. After generating propensity scores with six covariates, including gender, age, body mass index (BMI), Eastern Cooperative Oncology Group performance status, tumor location, and tumor size, 25 patients undergoing the OrVil method (intracorporeal group) were one-to-one matched with 25 patients undergoing the extracorporeal method (extracorporeal group). The short-term outcomes were compared between the two groups. RESULTS Both groups were balanced regarding baseline variables. The total operative time was not significantly different between the two groups (216.5 ± 24.9 min versus 224.0 ± 30.5 min, P = 0.344), whereas either the duration of anvil insertion (9.9 ± 2.4 min versus 12.9 ± 2.0 min, P < 0.001) or reconstruction completion (44.4 ± 9.4 min versus 50.1 ± 5.4 min, P = 0.012) in the intracorporeal group was less. The mean length of minilaparotomy in the intracorporeal group was shorter (5.6 ± 0.4 cm versus 7.2 ± 1.7 cm, P < 0.001). No significant differences were observed in intraoperative complication rate, estimated blood loss, length of proximal margin, or postoperative recovery course (including the time to first flatus, liquid resumption, liquid, and soft diet) between the two groups. No patients suffered from anastomosis-related complications. The overall morbidity rates of 28.0% in the intracorporeal group and 32.0% in the extracorporeal group were comparable (P = 0.758). CONCLUSIONS Intracorporeal Roux-en-Y esophagojejunostomy using the transorally inserted anvil system may be a safe procedure during LTG for gastric cancer. However, a longer follow-up in a well-designed randomized controlled trial is necessary to more thoroughly evaluate this technique.


title: Evolution of Laparoscopic Donor Nephrectomy Techniques and Outcomes: A Single-Center Experience with More than 1000 Cases.

text: BACKGROUND Laparoscopic donor nephrectomy (LDN) has evolved and has been established as a surgical standard of care for kidney transplantation. MATERIAL AND METHODS This study retrospectively reviews 1132 patients who underwent 4 different laparoscopic living-donor nephrectomies: hand-assisted laparoscopic nephrectomy (HALDN), pure laparoscopic donor nephrectomy (PLDN), laparoendoscopic single-site plus 1-port donor nephrectomy (LESSOP-DN), and mini laparoscopic donor nephrectomy (MLDN). RESULTS The mean estimated blood loss (EBL) for the HALDN group was meaningfully higher than those of LESSOP-DN and MLDN (57.5±52.2 mL versus 21.0±30.0 mL versus 18.2±28.7 mL) (P<0.001). The EBL for PLDN (53.3±35.3 mL) was also significantly higher than those of LESSOP-DN and MLDN (P<0.001). Length of stay (LOS) for HALDN was longer than that for LESSOP-DN (4.2±1.2 day versus 4.0±1.4 days, P=0.002). There was 1 intraoperative open conversion in the HALDN group and 2 HALDN surgeries that required postoperative exploratory laparotomy. LESSOP-DN had 3 (0.8%) postoperative incisional hernias. For recipients, the results revealed no significant differences between all 4 groups in terms of estimated glomerular filtration rate (eGFR) and the 1-year graft failure rate. CONCLUSIONS The LESSOP-DN group was associated with a shorter incision length than those of HALDN and PLDN and shorter LOS than that of HALDN. Recipient results showed no meaningful difference regarding laparoscopic donor nephrectomy technique.


Management of liver diseases during the pandemic of coronavirus disease-19.


title: Technique of esophagojejunostomy using transoral placement of the pretilted anvil head after laparoscopic gastrectomy for gastric cancer.

text: BACKGROUND During esophagojejunostomy using a circular stapler after laparoscopy-assisted gastrectomy, placement of the anvil head via the transabdominal approach proved difficult. The authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head via the transoral approach. METHODS Between November 2007 and December 2008, esophagojejunostomy was performed using the transoral, pretilted anvil head in 27 patients after laparoscopy-assisted gastrectomy. The anesthesiologist introduced the anvil while observing its passage through the pharynx. During the anastomosis, we kept the jejunum fixed in position with a silicone band Lig-A-Loops, thereby preventing the intestine from slipping off the shaft of the stapler. RESULTS Esophagojejunal anastomosis using the transoral anvil head was achieved successfully in 26 patients; for 1 patient, passage of the anvil head was difficult owing to esophageal stenosis. No other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. No postoperative complications occurred, except for 1 patient who developed anastomotic stenosis, in whom mild relief was achieved using a bougie. CONCLUSION Esophagojejunostomy using the transoral pretilted anvil head is a simple and safe technique.


title: Coronaviruses: severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus in travelers.

text: PURPOSE OF REVIEW Middle East respiratory syndrome coronavirus (MERS-CoV) is currently the focus of global attention. In this review, we describe virological, clinical, epidemiological features and interim travel advice and guidelines regarding MERS-CoV. We compare and contrast these with the severe acute respiratory syndrome coronavirus (SARS-CoV). RECENT FINDINGS MERS-CoV is a novel β CoV that causes a spectrum of clinical illness from asymptomatic to the rapidly fatal disease mainly in those with comorbid conditions. Epidemiological and genomic studies show zoonotic transmission to humans from camels and possibly bats. In contrast to the SARS-CoV pandemic, very limited global spread of fatal MERS-CoV has occurred outside the Arabian Peninsula. Although mainly currently restricted to Middle Eastern countries, MERS-CoV was reported from at least 10 other countries in Europe, Asia and the United States. All primary cases have been linked to travel to the Middle East. Nosocomial transmission of MERS-CoV has occurred because of poor infection control measures. Specific molecular diagnostic tests are available. Currently, there are no specific drugs for prevention or treatment for MERS-CoV and vaccine development is in the early stages. Advice and guidance for travelers to the Middle East are updated regularly by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). SUMMARY Like SARS-CoV, MERS-CoV threatens global health security. All physicians and travelers to the Middle East should be aware of the new threat caused by MERS-CoV and follow CDC and WHO guidelines. Those who develop ill health during their trip or soon after their return should seek medical care.


title: Impact of energy devices during liver parenchymal transection: a multicenter randomized controlled trial.

text: OBJECTIVE To clarify the benefit of energy devices such as ultrasonically activated device and bipolar vessel sealing device in liver surgeries. BACKGROUND Several studies have suggested the benefit of energy devices in liver transection, while a randomized trial has found no association between their use and surgical outcomes. PATIENTS AND METHODS Patients scheduled to undergo open liver resection were eligible for this multicenter non-blinded randomized study. They were randomized to receive an energy device (experimental group) or not (control group) during liver transection. The primary endpoint was the proportion of patients with intraoperative blood loss >1,000 mL. The primary aim was to show non-inferiority of hepatectomy with energy device to that without energy device. RESULTS A total of 212 patients were randomized and 211 (105 and 106 in the respective groups) were analyzed. Intraoperative blood loss >1,000 mL occurred in 15.0% patients with energy device and 20.2% patients without energy device. The experimental minus control group difference was -5.2% (95% confidence interval -13.8 to 3.3%; non-inferiority test, p = 0.0248). Hepatectomy with energy device resulted in a shorter median liver transection time (63 vs. 84 min; p < 0.001) and a lower rate of postoperative bile leakage (4 vs. 16%; p = 0.002). CONCLUSIONS The hypothesis that hepatectomy with energy device is not inferior to that without energy device in terms of blood loss has been demonstrated. The use of energy devices during liver surgery is clinically meaningful as it shortens the liver transection time and reduces the incidence of postoperative bile leakage.


Management of Acute Stroke Patients Amid the Coronavirus Disease 2019 Pandemic: Scientific Statement of the Korean Stroke Society.


Severe acute respiratory syndrome: a vanished evil?


Bee microbiomes go viral.


title: Life, Interrupted.

text: The effects of COVID-19 are still unfolding.


COVID-19 and palliative care.