title: Crohn's disease-associated ATG16L1 polymorphism modulates pro-inflammatory cytokine responses selectively upon activation of NOD2.

text: OBJECTIVE Autophagy has recently been shown to modulate the production of pro-inflammatory cytokine production and to contribute to antigen processing and presentation through the major histocompatibility complex. Genetic variation in the autophagy gene ATG16L1 has been recently implicated in Crohn's disease pathogenesis. The mechanisms underlying this association are not yet known, although experimental models suggest an inhibitory effect of autophagy on interleukin 1β (IL-1β) responses. Here, the effect of ATG16L1 genetic variation on cytokine responses has been assessed in humans. DESIGN AND SETTING Peripheral blood mononuclear cells from healthy individuals and patients with Crohn's disease with different ATG16L1 genotypes were stimulated with ligands for Toll-like receptor 2 (TLR2), TLR4 and nucleotide-binding oligomerisation domain 2 (NOD2), with or without the autophagy inhibitor 3-methyladenine. Induction of cytokine production and related factors were measured at the mRNA and protein level. Furthermore, protein levels of ATG16L1 were assessed by western blot. RESULTS The present study demonstrates that cells isolated from individuals bearing the ATG16L1 Thr300Ala risk variant, which is shown to affect ATG16L1 protein expression upon NOD2 stimulation, display increased production of the pro-inflammatory cytokines IL-1β and IL-6, specifically after stimulation with NOD2 ligands. In contrast, no differences were found when cells were stimulated with TLR2 or TLR4 agonists. These findings were confirmed in two independent cohorts of volunteers and in a group of patients with Crohn's disease. The increased production could be ascribed to increased mRNA expression, while processing of pro-IL-1β by caspase-1 activation was not affected. The effect of the ATG16L1 polymorphism was abrogated when autophagy was blocked. CONCLUSIONS The present study is the first to link the ATG16L1 polymorphism with an excessive production of IL-1β and IL-6 in humans, which may explain the effects of this polymorphism on the inflammatory process in Crohn's disease.


Preparing for the Sickest Patients With 2009 Influenza A(H1N1).


Legal and Policy Interventions to Address Social Isolation.


title: Anesthesia for liver transplantation.

text: Orthotopic liver transplantation is the only definitive treatment for end-stage liver disease. More than 6000 procedures are performed in the United States annually with excellent survival rates. The shortage of donor organs leads to continued interest in techniques to enlarge the potential donor pool. Patients presenting for liver transplant suffer from important cardiovascular, respiratory, renal, neurological, and gastroenterological comorbidity. In the Western world, liver failure is increasingly caused by steatohepatitis, and transplant candidates are thus becoming older and more comorbid. The role of the transplant anesthesiologist is highly important in the preoperative assessment, intraoperative management, and postoperative care of these complex and sick patients. Appropriate investigation and management of comorbidities such as coronary artery disease and portopulmonary hypertension is controversial and differs between programs. The transplant procedure is a major surgery, and although massive transfusion is no longer commonplace, there is potential for significant hemodynamic instability, coagulopathy, and metabolic disturbance. Liver transplant surgery can be divided into the preanhepatic phase, the anhepatic phase, and the reperfusion phase, with important anesthetic considerations at each point. An understanding of the surgical techniques used for vascular exclusion of the liver and the role of venovenous bypass is crucial for the anesthesiologist. Recent trends in perioperative care include the use of antifibrinolytic drugs and point-of-care coagulation tests, intraoperative renal replacement therapy, and "fast-track" extubation and postoperative care. Care of patients with fulminant hepatic failure or those receiving split-liver grafts requires special consideration.


title: Modifications of Surgical Suction Tip Geometry for Flow Optimisation: Influence on Suction-Induced Noise Pollution.

text: Introduction Suction devices for clearing the surgical field are among the most commonly used tools of every surgeon because a better view of the surgical field is essential. Forced suction may produce disturbingly loud noise, which acts as a nonnegligible stressor. Especially, in emergency situations with heavy bleeding, this loud noise has been described as an impeding factor in the medical decision-making process. In addition, there are reports of inner ear damage in patients due to suction noises during operations in the head area. These problems have not been solved yet. The purpose of this study was to analyse flow-dependent suction noise effects of different surgical suction tips. Furthermore, we developed design improvements to these devices. Methods We compared five different geometries of suction tips using an in vitro standardised setup. Two commercially available standard suction tips were compared to three adapted new devices regarding their flow-dependent (10-2000 mL/min) noise emission (dB, weighting filter (A), distance 10 cm) and acoustic quality of resulting noises (Hamilton fast Fourier analysis) during active suction at the liquid-air boundary. Noise maps at different flow rates were created for all five suction devices, and the proportion of extracted air was measured. The geometries of the three custom-made suction tips (new models 1, 2, and 3) were designed considering the insights after determining the key characteristics of the two standard suction models. Results The geometry of a suction device tip has significant impact on its noise emission. For the standard models, the frequency spectrum at higher flow rates significantly changes to high-frequency noise patterns (>3 kHz). A number of small side holes designed to prevent tissue adhesion lead to increased levels of high-frequency noise. Due to modifications of the tip geometry in our new models, we are able to achieve a highly significant reduction of noise level at low flow rates (new model 2 vs. standard models p < 0.001) and also the acoustic quality improved. Additionally, we attain a highly significant reduction of secondary air intake (new model 2 vs. the other models p < 0.001). Conclusion Improving flow-relevant features of the geometry of suction heads is a suitable way to reduce noise emissions. Optimized suction tips are significantly quieter. This may help us to reduce noise-induced hearing damage in patients as well as stress of medical staff during surgery and should lead to quieter operation theatres overall. Furthermore, the turbulence reduction and reduced secondary air intake during the suction process are expected to result in protective effects on the collected blood and thus could improve the quality of autologous blood retransfusions. We are on the way to evaluate potential benefits.


title: A Pre-Hospital Patient Education Program Improves Outcomes of Bariatric Surgery.

text: BACKGROUND We designed an assessment and education program which was delivered to patients prior to first outpatient appointment for bariatric surgery. We hypothesised that this program would streamline care and would lead to improved weight loss following bariatric surgery. METHODS The program incorporates a structured general practitioners (GP) review, a patient information evening and an on-line learning package. It was introduced in September 2012. Patient flow through the program was recorded. Outcomes of the new program were compared with contemporaneously treated patients who did not undertake the pre-hospital program. RESULTS All 636 patients on the waiting list for first appointment at the Alfred Health bariatric surgery clinic were invited to participate. There were 400 patients ultimately removed from the waiting list for first appointment. Of the remaining 236 patients, 229 consented to participate in the new program. The mean BMI was 47.8 ± 9.2. The fail to attend first appointment rate dropped from 12 to 2.1 %. At 12 months post-bariatric surgery, patients who undertook the new program (n = 82) had a mean excess weight loss (EWL) of 41.1 ± 20.3 % where as those treated on the standard pathway (n = 61) had a mean EWL 32 ± 18.0 % (p = 0.012). CONCLUSIONS The introduction of a pre-hospital education program has led to an improvement in attendance rates and early weight loss post-bariatric surgery.


Covid-19 ray of hope as vets lend a hand.


title: Medina® Embolization Device for the Treatment of Intracranial Aneurysms: Safety and Angiographic Effectiveness at 6 Months.

text: BACKGROUND The Medina Embolization Device (MED) is a new concept device that combines the design of a detachable coil and the one of an intrasaccular flow disruption device. OBJECTIVE To evaluate the feasibility, safety, and 6- to 9-mo effectiveness of this new device for the treatment of intracranial wide-necked aneurysms. METHODS Twelve patients (10 females, mean age = 56 yr) with 13 wide-necked intracranial aneurysms (3 ruptured; 10 unruptured) were treated by means of the MED from January 2015 to October 2015. In 15% of the cases, MEDs were used in a standalone fashion; in 85% of the cases, additional regular coils were used. Adjunctive compliant balloon was used in 4 of 13 cases (31%). Procedure-related complications were systematically recorded; discharge and 6- to 9-mo follow-up modified Rankin Scale was assessed. Angiographic follow-up was performed with a mean delay of 5.5 ± 1.7 mo. Occlusion rate was evaluated in postprocedure and at midterm follow-up using the Roy-Raymond scale. RESULTS The deployment of the MED was feasible in all cases. No perforation was recorded. One case of thromboembolic complication was observed in a ruptured anterior communicating artery aneurysm, without any clinical consequence at follow-up. Grade A occlusion rate was 61.5% in postprocedure and 83% at 6-mo follow-up. Two cases (17%) of recanalization were documented angiographically. CONCLUSION The MED is a new generation device combining the design of a detachable coil and an intrasaccular flow disruption device. According to our early experience, this device is safe and provides a satisfactory occlusion rate at angiographic follow-up of 6 mo.


A Message from the Guest Editor.


Critical Organizational Issues for Cardiologists in the COVID-19 Outbreak: A Frontline Experience From Milan, Italy.


title: Diagnostic Yield of Colon Capsule Endoscopy in Detection of Superficial Colorectal Lesions.

text: BACKGROUND The efficacy of second-generation PillCam -COLON2 capsule endoscopy (CCE2) in detecting colorectal superficial lesions remains unclear. OBJECTIVE We sought to determine the diagnostic yield of CCE2 in the detection of colorectal superficial lesions. METHODS We performed CCE2 in 60 consecutive patients between April 2011 and -December 2017. Lesions ≥6 mm in size were detected in 34 patients (25 males, average age: 60.5 years). We performed endoscopic resection and histopathological analysis of all resected lesions within 3 months after CCE2. We considered the optical colonoscopy (OC) findings as the gold standard and evaluated CCE2 sensitivity. RESULTS Sixty-seven lesions (≥6 mm) were detected via OC, with 27 colorectal superficial lesions and 40 protruded lesions. CCE2 sensitivity for ≥6-mm-sized, superficial, and protruded lesions was 84, 78, and 88%, respectively. No significant intergroup differences were observed. CCE2 false-negative colorectal superficial lesions accounted for 31% of right-sided colon lesions and 50% of sessile serrated adenomas/polyps (SSA/Ps). The CCE2 false-negative protruded lesions accounted for 17% of right-sided colon lesions. CONCLUSION CCE2 sensitivities for colorectal superficial and protruded lesions were not significantly different. However, flat-type SSA/Ps in the right colon, especially when the transit time is fast, have a risk of demonstrating CCE2 false-negative results.


title: [Investigation and analysis on characteristics of a cluster of COVID-19 associated with exposure in a department store in Tianjin].

text: Objective: To describe the epidemiological characteristics of a cluster of COVID-19 cases reported in Baodi district of Tianjin as of 18 February, 2020, which might be associated with the exposure in a local department store, and provide suggestions for prevention and control strategy development. Methods: The basic characteristics, time and area distributions, clinical manifestations, epidemiological history and transmission mode of the COVID-19 cases associated with the department store exposure were analyzed. Results: A total of 40 COVID-19 cases were associated with the department store exposure, accounting for 75.47% of the total confirmed cases (53 cases) reported in Baodi district. The cases were mainly at the age of 60 years or older (35.00%) and farmers (40.00%). The main clinical manifestations included fever (95.00%), cough (35.00%), and diarrhea (15.00%). The proportion of confirmed severe cases was 32.50%. The incidence curve showed that the incidence peak occurred on 31 January, 2020. Among the 40 cases, 6(15.00%) were department store employees, 19(47.50%) were customers and 15(37.50%) were close contacts (secondary cases). The first case occurred on 21 January, 2020, this case was a department store employee who had a purchasing history at whole sale markets in other provinces and cities before the onset, and 3 employees were still on duty after symptom onsets. The median of the incubation period of customer cases was 6 days, and the median of the interval between onset and medical treatment of customer cases was 7 days. Conclusion: This was a cluster epidemic of COVID-19, which might be associated with the exposure in the department store. By now, the current prevention and control measures have achieved satisfied effects.


Annals On Call - Understanding the Spread of COVID-19.


COVID-19 Research in Brief: 20 March to 27 March, 2020.


title: Swelling after laparoscopic total extraperitoneal repair of inguinal hernias: review of one surgeon's experience in 1,065 cases.

text: BACKGROUND It is often difficult to assess the clinical significance of scrotal or operative site swelling after a laparoscopic total extraperitoneal (TEP) repair of an inguinal hernia. Specifically, surgeons are often faced with the dilemma of determining whether such a swelling is a recurrent hernia or just a swelling only. MATERIALS AND METHODS A total of 1,065 laparoscopic TEP inguinal hernia repairs were performed on 944 patients by a single surgeon between December 2000 and December 2008, and we reviewed these data. RESULTS The overall incidence of swelling formation was 6.5% (70 of 1,065 cases). Swellings were more frequent in males, and in association with the following diagnoses: indirect inguinal hernias, larger hernia defects, scrotal hernias, omental incarcerations, and the presence of residual distal sacs. Fifty-eight (83%) of 70 patients who had swelling after laparoscopic TEP did not need any intervention for swelling and the swelling resolved spontaneously. CONCLUSIONS Although postoperative swellings are a common complication after laparoscopic TEP repairs of inguinal hernias, swellings are minor complications, are not associated with hernia recurrence, and generally subside spontaneously.


[Cholecystectomy using single-incision laparoscopic surgery (SILS)].


title: Oral diosmectite reduces stool output and diarrhea duration in children with acute watery diarrhea.

text: BACKGROUND & AIMS Diosmectite is a clay used to treat children with acute watery diarrhea. However, its effects on stool output reduction, the key outcome for pediatric antidiarrheal drugs, have not been shown. METHODS Two parallel, double-blind studies of diosmectite efficacy on stool reduction were conducted in children 1 to 36 months old in Peru (n = 300) and Malaysia (n = 302). Inclusion criteria included 3 or more watery stools per day for less than 72 hours and weight/height ratios of 0.8 or greater. Exclusion criteria were the need for intravenous rehydration, gross blood in stools, fever higher than 39 degrees C, or current treatment with antidiarrheal or antibiotic medications. Rotavirus status was determined. Diosmectite dosage was 6 g/day (children 1-12 months old) or 12 g/day (children 13-36 months old), given for at least 3 days, followed by half doses until complete recovery. Patients were assigned randomly to groups given diosmectite or placebo, in addition to oral rehydration solution (World Health Organization). RESULTS Children in each study had comparable average ages and weights. The frequencies of rotavirus infection were 22% in Peru and 12% in Malaysia. Similar amounts of oral rehydration solution were given to children in the diosmectite and placebo groups. Stool output was decreased significantly by diosmectite in both studies, especially among rotavirus-positive children. In pooled data, children had a mean stool output of 94.5 +/- 74.4 g/kg of body weight in the diosmectite group versus 104.1 +/- 94.2 g/kg in the placebo group (P = .002). Diarrhea duration was reduced by diosmectite, which was well tolerated. CONCLUSIONS These results show that diosmectite significantly decreased stool output in children with acute watery diarrhea, especially those who were rotavirus-positive.


COVID-19: new challenges, risks, and the future provision of care in spinal services.


[SARS-CoV-2 infection and its relation with the nutritional status].


title: Companion diagnostics: emerging strategies and issues in pharmaceutical development.

text: This article summarizes the broad messages from pharmaceutical and diagnostic companies on the collaborations required to support companion diagnostics. Since the groundbreaking herceptin HER2 diagnostic model in 1998, it has taken until 2011 for the US FDA to issue a draft guidance document, which was then immediately followed with approvals for two new drugs and their companion diagnostics. This conference summarized the current state of thinking in new projects and innovative technologies in pharmaceutical and diagnostic codevelopment. Attitudes are slowly changing and collaborations are rapidly ensuing, although the alignment between pharmaceutical and diagnostic understanding of value, timelines, outcomes and impact is difficult and remains a contentious area. The value of this conference has been to address these issues.


title: Containing the first outbreak of COVID-19 in a healthcare setting in India: The sree chitra experience.

text: The response to the first health worker case in India and novel strategies adopted in the context of evolving pandemic of COVID-19 is presented here. On the same day of confirmation, institutional COVID cell was established, and contact tracing was started. A total of 184 contacts were identified and quarantined. Hospital services were scaled down, and responsibilities were reassigned. In-house digital platforms were used for daily meetings, contact tracing, line listing, risk stratification, and research. Reverse transcription polymerase chain reaction-based severe acute respiratory syndrome-CoV2 testing facility was established in the institute. All high-risk contacts were given hydroxychloroquine prophylaxis. No secondary cases were found. Hospital preparedness, participatory decision-making through institutional COVID cell, optimal use of in-house digital platforms, and coordination with the state health department and national bodies, including Indian Council of Medical Research, were the supporting factors. Rapidly evolving guidelines, trepidation about the disease, logistic delays, and lack of support systems for people under quarantine were the challenges in the containment exercise.


title: An investigation of the questions posted on medical consultation websites.

text: BACKGROUND Online medical consultation has recently become a more and more popular alternative venue for healthcare. It allows patients and caregivers to discuss their health problems and symptoms with qualified medical health professionals via the Internet. OBJECTIVE This study investigates the questions posted on an asynchronous online medical consultation website, Taiwan eDoctor. Five research themes are explored: (1) length of questions, (2) moment of seeking consultation, (3) strategies of communicating chief complaints, (4) purpose of seeking consultation and (5) identity disclosure. METHODS Data collection was conducted by randomly selecting 50 resolved consultation Q&As for each of 24 medical specialties, resulting in a total of 1200 entries in the primary data set. Data analysis was conducted qualitatively and quantitatively. RESULTS Average length of questions was 161.21 words. Online medical consultation was sought when healthy, healthy but not robust, when suspicious of illness, when diagnosed as ill and during treatment/recovery. In communicating chief complaints, consultation seekers were engaged in contextual, focal or emotional communication styles. Nine distinct purposes to seek online consultation were identified and can be broadly interpreted as intellectual, social and emotional. The finding also suggests that more than two-third of questions were asked for by the patients themselves. CONCLUSION Through content analysis of questions posted on an online medical consultation website, this study characterises communication patterns during the health information seeking process. These findings can help guide the design of more effective patient-centred online medical consultation services.


title: Design and synthesis of MMP inhibitors with appended fluorescent tags for imaging and visualization of matrix metalloproteinase enzymes.

text: We describe the synthesis, MMP-2 and 9 potency, and in vitro evaluation of a series of α-sulfone hydroxmate MMP inhibitors conjugated to a series of dyes with different absorption/emission lamina maxima's that can be used to visualize tumors.


title: The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis.

text: BACKGROUND Synovial fluid white blood cell count is useful for diagnosing periprosthetic infections but the utility of this test in the early postoperative period remains unknown as hemarthrosis and postoperative inflammation may render standard cutoff values inaccurate. QUESTIONS/PURPOSES We evaluated the diagnostic performance of four common laboratory tests, the synovial white blood cell count, differential, C-reactive protein, and erythrocyte sedimentation rate to detect infection in the first 6 weeks after primary TKA. METHODS We reviewed 11,964 primary TKAs and identified 146 that had a knee aspiration within 6 weeks of surgery. Infection was diagnosed in 19 of the 146 knees by positive cultures or gross purulence. We compared demographic information, time from surgery, and the laboratory test values between infected and noninfected knees to determine if any could identify infection early postoperatively. Receiver operating characteristic curves were constructed to determine optimal cutoff values for each of the test parameters. RESULTS Synovial white blood cell count (92,600 versus 4200 cells/μL), percentage of polymorphonuclear cells (89.6% versus 76.9%), and C-reactive protein (171 versus 88 mg/L) were higher in the infected group. The optimal synovial white blood cell cutoff was 27,800 cells/μL (sensitivity, 84%; specificity, 99%; positive predictive value, 94%; negative predictive value, 98%) for diagnosing infection. The optimal cutoff for the differential was 89% polymorphonuclear cells and for C-reactive protein 95 mg/L. CONCLUSIONS With a cutoff of 27,800 cells/μL, synovial white blood cell count predicted infection within 6 weeks after primary TKA with a positive predicted value of 94% and a negative predictive value of 98%. The use of standard cutoff values for this parameter (~ 3000 cells/μL) would have led to unnecessary reoperations. LEVEL OF EVIDENCE Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.


title: Detection of SARS-CoV-2 antibodies using commercial assays and seroconversion patterns in hospitalized patients.

text: OBJECTIVES SARS-CoV-2 antibody assays are needed for serological surveys and as a complement to molecular tests to confirm COVID-19. However, the kinetics of the humoral response against SARS-CoV-2 remains poorly described and relies on the performance of the different serological tests. METHODS In this study, we evaluated the performance of six CE-marked point-of-care tests (POC) and three ELISA assays for the diagnosis of COVID-19 by exploring seroconversions in hospitalized patients who tested positive for SARS-CoV-2 RNA. RESULTS Both the ELISA and POC tests were able to detect SARS-CoV-2 antibodies in at least half of the samples collected seven days or more after the onset of symptoms. After 15 days, the rate of detection rose to over 80% but without reaching 100%, irrespective of the test used. More than 90% of the samples collected after 15 days tested positive using the iSIA and Accu-Tell® POC tests and the ID.Vet IgG ELISA assay. Seroconversion was observed 5 to 12 days after the onset of symptoms. Three assays suffer from a specificity below 90% (EUROIMMUN IgG and IgA, UNscience, Zhuhai Livzon). CONCLUSIONS The second week of COVID-19 seems to be the best period for assessing the sensitivity of commercial serological assays. To achieve an early diagnosis of COVID-19 based on antibody detection, a dual challenge must be met: the immunodiagnostic window period must be shortened and an optimal specificity must be conserved.


Surgical Training With Live Animal Models for Laparoscopic Gastrectomy.


Is BCG vaccination effecting the spread and severity of COVID-19?


title: Screening for cancer in patients with unprovoked venous thromboembolism: protocol for a systematic review and individual patient data meta-analysis.

text: INTRODUCTION Occult cancer is present in 4%-9% of patients with unprovoked venous thromboembolism (VTE). Screening for cancer may be considered in these patients, with the aim to diagnose cancers in an early, potentially curable stage. Information is needed about the risk of occult cancer, overall and in specific subgroups, additional risk factors and on the performance of different screening strategies. METHODS AND ANALYSIS MEDLINE, Embase and CENTRAL databases were searched from November 2007 to January 2016 for prospective studies that had evaluated protocol-mandated screening for cancer in patients with unprovoked VTE and with at least 12 months' follow-up. Two reviewers independently assessed articles for eligibility. Ten eligible studies were identified and individual patient data were obtained from each of them. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool . Generalised linear mixed-effects models was used to calculate estimates in a one-stage meta-analytic approach, overall and in a number of subgroups, including patients undergoing limited screening only, elderly patients, patients with previous VTE, smokers and patients using oestrogens. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review and individual patient data meta-analysis. Findings have been submitted for publication in peer-reviewed journals and presentations at national and international conferences to provide clinicians and other decision-makers with valid and precise risk estimates of occult cancer, overall and in specific clinical subgroups, with risk factors for occult cancer, with estimates of the diagnostic performance of limited screening and with an exploration of the benefit of extensive screening strategies.


title: MHC class I A loci polymorphism and diversity in three Southeast Asian populations of cynomolgus macaque.

text: Cynomolgus macaques (Macaca fascicularis, Mafa) have emerged as important animal models for biomedical research, necessitating a more extensive characterization of their major histocompatibility complex polymorphic regions. The current information on the polymorphism or diversity of the polygenetic Mafa class I A loci is limited in comparison to the more commonly studied rhesus macaque Mafa class I A loci. Therefore, in this paper, to better elucidate the degree and types of polymorphisms and genetic differences of Mafa-A1 among three native Southeast Asian populations (Indonesian, Vietnamese, and Filipino) and to investigate how the allele differences between macaques and humans might have evolved to affect their respective immune responses, we identified 83 Mafa-A loci-derived alleles by DNA sequencing of which 66 are newly described. Most alleles are unique to each population, but seven of the most frequent alleles were identical in sequence to some alleles in other macaque species. We also revealed (1) the large and dynamic genetic and structural differences and similarities in allelic variation by analyzing the population allele frequencies, Hardy-Weinberg's equilibrium, heterozygosity, nucleotide diversity profiles, and phylogeny, (2) the difference in genetic structure of populations by Wright's FST statistic and hierarchical analysis of molecular variance, and (3) the different demographic and selection pressures on the three populations by performing Tajima's D test of neutrality. The large level of diversity and polymorphism at the Mafa-A1 was less evident in the Filipino than in the Vietnam or the Indonesian populations, which may have important implications in animal capture, selection, and breeding for medical research.


title: Complete endoscopic/transgastric retrieval of eroded gastric band: description of a novel technique and review of the literature.

text: Complications of laparoscopic adjustable gastric banding (LAGB) include band slippage, material infection, and band erosion. Band erosion can lead to chronic infection, obstruction, delayed perforation, and ineffectiveness; therefore, removal is indicated. A myriad of approaches exist for band removal and many authors have described novel techniques. A minimally invasive approach, including laparoscopic or endoscopic assistance, is favored given the reduction of postoperative complications compared with laparotomy. We present a novel approach to band retrieval following partial erosion involving a complete endoscopic/transgastric technique. Perioperative management and a review of the literature also are described.


title: Disaster preparedness of families with young children in Hong Kong.

text: AIMS The aims of this study were to explore the perception of disaster among the head of household mainly responsible for family matters of Hong Kong families with young children, and the extent of their preparedness for disasters. BACKGROUND Being prepared for disasters can minimize damage to our health, lives, and property. Families with young children are particularly vulnerable during disasters. METHODS A questionnaire was distributed to a convenience sample of families with young children in March and September in 2008. RESULTS A total of 198 out of 220 questionnaires distributed to heads of households were collected and analyzed for this study. Most of the householders (94.4%) considered the SARS outbreak in Hong Kong in 2003 to have been a disaster. They considered that the disastrous events most likely to occur in Hong Kong were infectious disease outbreaks (96.5%) and major transport accidents (94.4%). In preparing for unexpected events, these families reported having stocked up on ''young children's necessities'' (82.8%, 73.7%) and ''medications'' (82.8%, 60.1%) sufficient for three and seven days respectively. These families also kept a flashlight with adequate batteries (74.7%), extra blankets (69.2%), and a first aid kit (60.6%) at home for safety. They reported ''panic buying'' for necessities during previous typhoon strikes (68.2%) and infectious disease outbreaks (46.0%). Only 9.1% considered themselves adequately prepared for disasters (9.1%). CONCLUSIONS Although the families with young children in this study are prepared for disaster to some extent, their preparedness is still considered grossly inadequate and in need of public attention.


Forced social isolation due to COVID-19 and consequent mental health problems: lessons from hikikomori.


title: Internal dressings for healing perianal abscess cavities.

text: BACKGROUND A perianal abscess is a collection of pus under the skin, around the anus. It usually occurs due to an infection of an anal gland. In the UK, the annual incidence is 40 per 100,000 of the adult population, and the standard treatment is admission to hospital for incision and drainage under general anaesthetic. Following drainage of the pus, an internal dressing (pack) is placed into the cavity to stop bleeding. Common practice is for community nursing teams to change the pack regularly until the cavity heals. Some practitioners in the USA and Australia make a small stab incision under local anaesthetic and place a catheter into the cavity which drains into an external dressing. It is removed when it stops draining. Elsewhere in the USA, simple drainage is performed in an outpatient setting under local anaesthetic. OBJECTIVES To assess the effects of internal dressings in healing wound cavities resulting from drainage of perianal abscesses. SEARCH METHODS In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries to identify ongoing and unpublished studies, and searched reference lists of relevant reports to identify additional studies. We did not restrict studies with respect to language, date of publication, or study setting. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) comparing any type of internal dressing (packing) used in the post-operative management of perianal abscess cavities with alternative treatments or different types of internal dressing. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment, and data extraction. MAIN RESULTS We included two studies, with a total of 64 randomised participants (50 and 14 participants) aged 18 years or over, with a perianal abscess. In both studies, participants were enrolled on the first post-operative day and randomised to continued packing by community district nursing teams or to no packing. Participants in the non-packing group managed their own wounds in the community and used absorbant dressings to cover the area. Fortnightly follow-up was undertaken until the cavity closed and the skin re-epithelialised, which constituted healing. For non-attenders, telephone follow-up was conducted.Both studies were at high risk of bias due to risk of attrition, performance and detection bias.It was not possible to pool the two studies for the outcome of time to healing. It is unclear whether continued post-operative packing of the cavity of perianal abscesses affects time to complete healing. One study reported a mean time to wound healing of 26.8 days (95% confidence interval (CI) 22.7 to 30.7) in the packing group and 19.5 days (95% CI 13.6 to 25.4) in the non-packing group (it was not clear if all participants healed). We re-analysed the data and found no clear difference in the time to healing (7.30 days longer in the packing group, 95% CI -2.24 to 16.84; 14 participants). This was assessed as very low quality evidence (downgraded three levels for very serious imprecision and serious risk of bias). The second study reported a median time to complete wound healing of 24.5 days (range 10 to 150 days) in the packing group and 21 days (range 8 to 90 days) in the non-packed group. There was insufficient information to be able to recreate the analysis and the original analysis was inappropriate (did not account for censoring). This second study also provided very low quality evidence (downgraded four levels for serious risk of bias, serious indirectness and very serious imprecision).There was very low quality evidence (downgraded for risk of bias, indirectness and imprecision) of no difference in wound pain scores at the initial dressing change. Both studies also reported patients' retrospective judgement of wound pain over the preceding two weeks (visual analogue scale, VAS) as lower for the non-packed group (2; both studies) compared with the packed group (0; both studies); (very low quality evidence) but we have been unable to reproduce these analyses as no variance data were published.There was no clear evidence of a difference in the number of post-operative fistulae detected between the packed and non-packed groups (risk ratio (RR) 2.31, 95% CIs 0.56 to 9.45, I(2) = 0%) (very low quality evidence downgraded three levels for very serious imprecision and serious risk of bias).There was no clear evidence of a difference in the number of abscess recurrences between the packed and non-packed groups over the variable follow-up periods (RR 0.72, 95% CI 0.22 to 2.37, I(2) = 0%) (very low quality evidence downgraded three levels for serious risk of bias and very serious imprecision).No study reported participant health-related quality of life/health status, incontinence rates, time to return to work or normal function, resource use in terms of number of dressing changes or visits to a nurse, or change in wound size. AUTHORS' CONCLUSIONS It is unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence or other outcomes. Despite this absence of evidence, the practice of packing abscess cavities is commonplace. Given the lack of high quality evidence, decisions to pack may be based on local practices or patient preferences. Further clinical research is needed to assess the effects and patient experience of packing.


title: COVID-19 in Patient with Sarcoidosis Receiving Long-Term Hydroxychloroquine Treatment, France, 2020.

text: Because of in vitro studies, hydroxychloroquine is under evaluation as a preexposure or postexposure prophylaxis for coronavirus disease (COVID-19) and as a possible COVID-19 curative treatment. We report a case of COVID-19 in a patient with sarcoidosis who was receiving long-term hydroxychloroquine treatment, despite adequate plasma concentrations.


title: Radiofrequency ablation is a valid treatment option for lung metastases: experience in 566 patients with 1037 metastases.

text: BACKGROUND Minimal invasive methods are needed as an alternative to surgery for treatment of lung metastases. PATIENTS AND METHODS The prospective database of two cancer centers including all consecutive patients treated with radiofrequency ablation (RFA) for lung metastasis over 8 years was reviewed. RFA was carried out under general anesthesia, with computed tomography guidance using a 15-gauge multitined expandable electrodes RF needle. RESULTS Five hundred sixty-six patients including 290 men (51%), 62.7 ± 13.2 years old with primary tumor to the colon (34%), rectum (18%), kidney (12%), soft tissue (9%) and miscellaneous (27%) received 642 RFA for 1037 lung metastases. Fifty-three percent of patients had 1 metastasis, 25% had 2, 14% had 3, 5% had 4 and 4% had 5-8. Metastases were unilateral (75%), or bilateral (25%). The median diameter [extremes] of metastases was 15 mm (4-70). Twenty-two percent of patients had extrapulmonary disease amenable to local therapy including 49 liver, 16 bone and 60 miscellaneous metastases. Median follow-up was 35.5 months. Median overall survival (OS) was 62 months. Four-year local efficacy was 89%. Four-year lung disease control rate was 44.1%, with patient retreated safely up to four times. Primary origin, disease-free interval, size and number of metastases were associated with OS in multivariate analysis. Progression at RFA site was associated with poor OS [P = 0.011, hazard ratio (HR): 1.69 (95% confidence interval 1.13-2.54)]. In the 293 colorectal cancer metastases, size >2 cm (HR = 2.10, P = 0.0027) and a number of metastases ≥3 (HR = 1.86, P = 0.011) remained significantly associated with OS. A prognostic score made of three groups based on the four above-mentioned prognostic factors demonstrated 3-year OS rates of respectively 82.2%, 69.5% and 53.6% (log-rank test, P ≤ 0.0001) among the three groups in the overall population, and of 81.3%, 72.8% and 57.9% (log-rank test, P = 0.005) in the colorectal cancer patients. CONCLUSION Radiofrequency is an option for treatment of small size lung metastases, namely the ones below 2-3 cm.


title: Sirt3 Protects Against Ischemic Stroke Injury by Regulating HIF-1α/VEGF Signaling and Blood-Brain Barrier Integrity.

text: Sirtuin 3 (Sirt3) is a member of the Sirtuin family proteins and known to regulate multiple physiological processes such as metabolism and aging. As stroke is an aging-related disease, in this work, we attempt to examine the role and potential mechanism of Sirt3 in regulating ischemic stroke by using a permanent middle cerebral artery occlusion (pMCAO) model in wild type (WT) and Sirt3 knockout (KO) mice, coupled with oxygen glucose deprivation (OGD) experiments in cultured primary astrocytes. Sirt3 deficiency aggravated neuronal cell apoptosis and neurological deficits after brain ischemia. In addition, Sirt3 KO mice showed more severe blood-brain barrier (BBB) disruption and inflammatory responses compared with WT group in the acute phase. Furthermore, specific overexpression of Sirt3 in astrocytes by injecting glial fibrillary acidic protein (GFAP)::Sirt3 virus in ischemic region showed protective effect against stroke-induced damage. Mechanistically, Sirt3 could regulate vascular endothelial growth factor (VEGF) expression by inhibiting hypoxia inducible factor-1α (HIF-1α) signaling after ischemia (OGD). Our results have shown that Sirt3 plays a protective role in ischemic stroke via regulating HIF-1α/VEGF signaling in astrocytes, and reversal of the Sirt3 expression at the acute phase could be a worthy direction for stroke therapy.


title: Global genetic variation at OAS1 provides evidence of archaic admixture in Melanesian populations.

text: Recent analysis of DNA extracted from two Eurasian forms of archaic human shows that more genetic variants are shared with humans currently living in Eurasia than with anatomically modern humans in sub-Saharan Africa. Although these genome-wide average measures of genetic similarity are consistent with the hypothesis of archaic admixture in Eurasia, analyses of individual loci exhibiting the signal of archaic introgression are needed to test alternative hypotheses and investigate the admixture process. Here, we provide a detailed sequence analysis of the innate immune gene OAS1, a locus with a divergent Melanesian haplotype that is very similar to the Denisova sequence from the Altai region of Siberia. We resequenced a 7-kb region encompassing the OAS1 gene in 88 individuals from six Old World populations (San, Biaka, Mandenka, French Basque, Han Chinese, and Papua New Guineans) and discovered previously unknown and ancient genetic variation. The 5' region of this gene has unusual patterns of diversity, including 1) higher levels of nucleotide diversity in Papuans than in sub-Saharan Africans, 2) very deep ancestry with an estimated time to the most recent common ancestor of >3 myr, and 3) a basal branching pattern with Papuan individuals on either side of the rooted network. A global geographic survey of >1,500 individuals showed that the divergent Papuan haplotype is nearly restricted to populations from eastern Indonesia and Melanesia. Polymorphic sites within this haplotype are shared with the draft Denisova genome over a span of ∼90 kb and are associated with an extended block of linkage disequilibrium, supporting the hypothesis that this haplotype introgressed from an archaic source that likely lived in Eurasia.


title: Antineoplastic drug exposure in an ambulatory setting: a pilot study.

text: BACKGROUND Exposure to antineoplastic drugs confers health risks to workers, yet little is known about the exposure after a drug spill, nor has the relationship between exposure and organizational factors such as staffing and work environment been studied. OBJECTIVE The aim of this study was to evaluate drug spills prospectively using biological measures and correlate drug spills with organizational factors. METHODS Prospective questionnaires with 8-hour timed urine samples were collected from nursing and pharmacy personnel who reported drug spill events in 1 academic health center's infusion center. Urine was collected similarly from workers who did not report a spill. Liquid chromatography tandem mass spectrometry techniques identified detectable drug levels. After the prospective sampling period, workers were surveyed on workloads, practice environment, and safety behaviors. RESULTS From 81 eligible individuals, 40 participated in the prospective study and 19 completed retrospective questionnaires. Four spills were reported by 9 personnel, as multiple employees were exposed to drug spills. Four participants who reported a spill showed detectable levels of antineoplastic drugs. Four participants who did not report a spill had detectable levels of docetaxel. Compared with respondents who did not report a spill, collegial relations with physicians were significantly poorer for workers who reported spills. CONCLUSIONS The study protocol successfully captured drug spill reports and biological samples. Workers have detectable levels of antineoplastic drugs through both drug spills and environmental contamination. IMPLICATIONS FOR PRACTICE Multisite research studies and practice-based quality improvement approaches are needed to improve adherence to personal protective equipment use and safe handling procedures.


title: Dengue virus in bats from southeastern Mexico.

text: To identify the relationship between landscape use and dengue virus (DENV) occurrence in bats, we investigated the presence of DENV from anthropogenically changed and unaltered landscapes in two Biosphere Reserves: Calakmul (Campeche) and Montes Azules (Chiapas) in southern Mexico. Spleen samples of 146 bats, belonging to 16 species, were tested for four DENV serotypes with standard reverse transcriptase polymerase chain reaction (RT-PCR) protocols. Six bats (4.1%) tested positive for DENV-2: four bats in Calakmul (two Glossophaga soricina, one Artibeus jamaicensis, and one A. lituratus) and two bats in Montes Azules (both A. lituratus). No effect of anthropogenic disturbance on the occurrence of DENV was detected; however, all three RT-PCR-positive bat species are considered abundant species in the Neotropics and well-adapted to disturbed habitats. To our knowledge, this study is the first study conducted in southeastern Mexico to identify DENV-2 in bats by a widely accepted RT-PCR protocol. The role that bats play on DENV's ecology remains undetermined.


title: Ventricular assist devices as rescue therapy in cardiogenic shock after subarachnoid hemorrhage.

text: We review the journey to myocardial and neurologic recovery of a 42-year-old mother with severe acute cardiogenic shock and multiorgan failure after extensive subarachnoid hemorrhage, who was salvaged successfully using a CentriMag short-term biventricular assist device.


Deep Learning Localization of Pneumonia: 2019 Coronavirus (COVID-19) Outbreak.


title: Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study.

text: BACKGROUND Treatment for claudication that is due to aortoiliac peripheral artery disease (PAD) often relies on stent revascularization (ST). However, supervised exercise (SE) is known to provide comparable short-term (6-month) improvements in functional status and quality of life. Longer-term outcomes are not known. OBJECTIVES The goal of this study was to report the longer-term (18-month) efficacy of SE compared with ST and optimal medical care (OMC). METHODS Of 111 patients with aortoiliac PAD randomly assigned to receive OMC, OMC plus SE, or OMC plus ST, 79 completed the 18-month clinical and treadmill follow-up assessment. SE consisted of 6 months of SE and an additional year of telephone-based exercise counseling. Primary clinical outcomes included objective treadmill-based walking performance and subjective quality of life. RESULTS Peak walking time improved from baseline to 18 months for both SE (5.0 ± 5.4 min) and ST (3.2 ± 4.7 min) significantly more than for OMC (0.2 ± 2.1 min; p < 0.001 and p = 0.04, respectively). The difference between SE and ST was not significant (p = 0.16). Improvement in claudication onset time was greater for SE compared with OMC, but not for ST compared with OMC. Many disease-specific quality-of-life scales demonstrated durable improvements that were greater for ST compared with SE or OMC. CONCLUSIONS Both SE and ST had better 18-month outcomes than OMC. SE and ST provided comparable durable improvement in functional status and in quality of life up to 18 months. The durability of claudication exercise interventions merits its consideration as a primary PAD claudication treatment.


title: Histologic Analysis of Retrieved Clots in Acute Ischemic Stroke: Correlation with Stroke Etiology and Gradient-Echo MRI.

text: BACKGROUND AND PURPOSE It is unclear whether clot composition analysis is helpful to predict a stroke mechanism in acute large vessel occlusion. In addition, the relationship between early vessel signs on imaging studies and clot compositions has been poorly understood. The purpose of this study was to elucidate the relationship between clot composition and stroke etiology following mechanical thrombectomy and to investigate the effect of varied clot compositions on gradient-echo MR imaging of clots. MATERIALS AND METHODS Histopathologic analysis of retrieved clots from 37 patients with acute MCA occlusion was performed. Patients underwent gradient-echo imaging before endovascular therapy. Retrieved clots underwent semiquantitative proportion analysis to quantify red blood cells, fibrin, platelets, and white blood cells by area. Correlations between clot compositions and stroke subtypes and susceptibility vessel signs on gradient-echo imaging were assessed. RESULTS Stroke etiology was classified as cardioembolism in 22 patients (59.4%), large-artery atherosclerosis in 8 (21.6%), and undetermined in 7 (18.9%). The clots from cardioembolism had a significantly higher proportion of red blood cells (37.8% versus 16.9%, P = .031) and a lower proportion of fibrin (32.3% versus 48.5%, P = .044) compared with those from large-artery atherosclerosis. The proportion of red blood cells was significantly higher in clots with a susceptibility vessel sign than in those without it (48.0% versus 1.9%, P < .001), whereas the proportions of fibrin (26.4% versus 57.0%, P < .001) and platelets (22.6% versus 36.9%, P = .011) were significantly higher in clots without a susceptibility vessel sign than those with it. CONCLUSIONS The histologic composition of clots retrieved from cerebral arteries in patients with acute stroke differs between those with cardioembolism and large-artery atherosclerosis. In addition, a susceptibility vessel sign on gradient-echo imaging is strongly associated with a high proportion of red blood cells and a low proportion of fibrin and platelets in retrieved clots.


title: Role of p38 protein kinase in the ligand-independent ubiquitination and down-regulation of the IFNAR1 chain of type I interferon receptor.

text: Phosphorylation-dependent ubiquitination and degradation of the IFNAR1 chain of type I interferon (IFN) receptor is a robust and specific mechanism that limits the magnitude and duration of IFNα/β signaling. Besides the ligand-inducible IFNAR1 degradation, the existence of an "inside-out" signaling that accelerates IFNAR1 turnover in the cells undergoing the endoplasmic reticulum (ER) stress and activated unfolded protein responses has been recently described. The latter pathway does not require either presence of ligands (IFNα/β) or catalytic activity of Janus kinases (JAK). Instead, this pathway relies on activation of the PKR-like ER kinase (PERK) and ensuing specific priming phosphorylation of IFNAR1. Here, we describe studies that identify the stress activated p38 protein kinase as an important regulator of IFNAR1 that acts downstream of PERK. Results of the experiments using pharmacologic p38 kinase inhibitors, RNA interference approach, and cells from p38α knock-out mice suggest that p38 kinase activity is required for priming phosphorylation of IFNAR1 in cells undergoing unfolded protein response. We further demonstrate an important role of p38 kinase in the ligand-independent stimulation of IFNAR1 ubiquitination and degradation and ensuing attenuation of IFNα/β signaling and anti-viral defenses. We discuss the distinct importance of p38 kinase in regulating the overall responses to type I IFN in cells that have been already exposed to IFNα/β versus those cells that are yet to encounter these cytokines.


title: Treatment with potassium bromide mitigates ataxia and reduces tremor in lambs with perennial ryegrass toxicosis.

text: AIMS To assess the use of potassium bromide (KBr) as a therapeutic intervention for perennial ryegrass toxicosis (PRGT) in lambs fed ryegrass seed containing lolitrem B. METHODS Male lambs aged 10-12 months (n = 43) were assigned to received ryegrass seed containing lolitrem B, at a dose of 0.16 mg/kg/day (Groups 2, 3 and 4), or lucerne chaff and molasses (Groups 1 and 5). Lambs in Groups 2 and 3 were observed for clinical signs and gait changes until defined signs of PGRT were observed, when they were transferred, with lambs in Group 1, to the Testing phase of the trial. Lambs in Group 3 were then treated with a single oral dose of 300 mg/kg bromide. Lambs in Groups 4 and 5 received KBr daily from the start of the trial (540 mg/kg bromide over 3 days then 20 mg/kg daily) and were transferred to the Testing phase after 18 days. Clinical examination and gait assessment, and surface electromyography of the triceps muscle, measuring root-mean-square (RMS) voltages, were carried out on Days 0, 1 and 2 of the Testing phase followed by necropsy, histopathology, measurement of concentrations of bromide in serum and CSF and faecal cortisol metabolites (FCM). RESULTS In Group 3 lambs, mean composite gait scores decreased between Testing phase Day 0 and Days 1 and 2 (p < 0.001), but increased in lambs in Group 2 between Day 0 and Day 2 (p = 0.015). Scores for lambs in Group 3 on Day 2 were lower than for lambs in Group 2 (p < 0.001). Mean RMS voltages on Day 2 were higher in lambs in Group 2 than Group 3 (p = 0.045). Mean concentrations of bromide in serum were >800 µg/mL in lambs in Groups 3 and 4 on Day 2. Concentrations of FCM were higher in lambs from Group 2 than in Groups 1 or 5, but were similar in Groups 2, 3 and 4. Histopathological findings in the cerebellum of lambs from Groups 2, 3 and 4 were similar, showing pyknosis of neurons within the granular layer of the cerebellum and Purkinje neuron proximal axonal spheroid formation. CONCLUSIONS AND CLINICAL RELEVANCE A single oral dose of 300 mg/kg bromide in lambs with neurological signs of PRGT resulted in reduced composite gait scores and reduced RMS voltages, indicating a significant improvement in clinical signs of ataxia, movement disorder and muscle tremor associated with the neurotoxic effects of lolitrem B.


Last haircut in Amwaj: COVID-19 in Bahrain.


title: Modified Graded Repair of Cerebrospinal Fluid Leaks in Endoscopic Endonasal Transsphenoidal Surgery.

text: OBJECTIVE Complete sellar floor reconstruction is critical to avoid postoperative cerebrospinal fluid (CSF) leakage during transsphenoidal surgery. Recently, the pedicled nasoseptal flap has undergone many modifications and eventually proved to be valuable and efficient. However, using these nasoseptal flaps in all patients who undergo transsphenoidal surgery, including those who had none or only minor CSF leakage, appears to be overly invasive and time-consuming. METHODS Patients undergoing endoscopic endonasal transsphenoidal tumor surgery within a 5 year-period were reviewed. Since 2009, we classified the intraoperative CSF leakage into grades from 0 to 3. Sellar floor reconstruction was tailored to each leak grade. We did not use any tissue grafts such as abdominal fat and did not include any procedures of CSF diversions such as lumbar drainage. RESULTS Among 200 cases in 188 patients (147 pituitary adenoma and 41 other pathologies), intraoperative CSF leakage was observed in 27.4% of 197 cases : 14.7% Grade 1, 4.6% Grade 2a, 3.0% Grade 2b, and 5.1% Grade 3. Postoperative CSF leakage was observed in none of the cases. Septal bone buttress was used for Grade 1 to 3 leakages instead of any other foreign materials. Pedicled nasoseptal flap was used for Grades 2b and 3 leakages. Unused septal bones and nasoseptal flaps were repositioned. CONCLUSION Modified classification of intraoperative CSF leaks and tailored repair technique in a multilayered fashion using an en-bloc harvested septal bone and vascularized nasoseptal flaps is an effective and reliable method for the prevention of postoperative CSF leaks.


title: Audiometric Outcomes and Middle Ear Disease following Cerebrospinal Fluid Leak Repair.

text: OBJECTIVE To investigate audiometric outcomes and incidence of chronic ear disease following lateral skull base repair (LSBR) of cerebrospinal fluid (CSF) leaks. STUDY DESIGN Retrospective review. SETTING Tertiary skull base center. SUBJECTS AND METHODS Consecutive adults undergoing LSBR of CSF leaks between 2012 and 2018 were reviewed. Audiometric data included mean air conduction pure-tone average (PTA), air-bone gap (ABG), speech recognition threshold (SRT), and word recognition score (WRS). The incidence and management of the following were collected: effusion, retraction, otitis media and externa, perforation, and cholesteatoma. RESULTS Seventy-three patients underwent transmastoid (n = 5), middle cranial fossa (n = 2), or combined approach (n = 67) for repair of spontaneous leaks (sCSFLs, n = 41) and those occurring in the setting of chronic ear disease (ceCSFLs, n = 32). ABG decreased 7.23 dB (P = .01) in sCSFL patients. Perforations (P = .01) were more likely in ceCSFL. No sCSFL patient developed a cholesteatoma, perforation, or infection. Effusions (n = 7) were transient, and retractions (n = 2) were managed conservatively in the sCSFL cohort. Eight ceCSFL patients required tubes, 3 underwent tympanoplasties with (n = 2) and without (n = 1) ossicular chain reconstruction (OCR), and 1 had tympanomastoidectomy with OCR. CONCLUSION Lateral skull base repair of CSF leaks maintained or improved hearing. Patients with preexisting chronic ear disease were more likely to require additional intervention to sustain adequate middle ear aeration compared to the sCSFL cohort. LSBR of sCSFL does not appear to increase risk for developing chronic ear disease.


title: Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage.

text: BACKGROUND Acute stroke from tandem extracranial carotid artery and intracranial large vessel occlusion poses challenges for emergency endovascular treatment. Establishing and maintaining patency of the carotid artery and avoiding intracranial hemorrhage are competing concerns. METHODS Twenty-three consecutive cases of emergency carotid stenting followed by mechanical thrombectomy identified by retrospective review of the endovascular ischemic stroke database maintained prospectively at our institution since January 2011 form the basis for this report. No cases were lost to follow-up. RESULTS Patients were selected with CT angiography or MR angiography and diffusion weighted imaging. Carotid stenting was successful in all cases, and establishment of Thrombolysis in Cerebral Ischemia 2A, 2B or 3 flow was successful in 21/23 (91%). 12/23 (52%) patients achieved a modified Rankin Scale score of 0-2 at 90 days. Symptomatic intracranial hemorrhage (SICH) occurred in 5/23 patients (22%). Of 13 patients receiving an intravenous loading dose of abciximab during the procedure, 4/13 had SICH (31%) compared with 1/10 (10%) of those who did not. Of seven patients who received intravenous tissue plasminogen activator prior to the procedure, none had SICH. 90-day mortality was 9/23 (39%). All patients who had SICH were above the median age. CONCLUSIONS Primary stenting of the extracranial carotid artery combined with intracranial mechanical thrombectomy can be an effective treatment for tandem occlusions, can be performed with a high rate of technical success, and can achieve good clinical outcomes in selected patients. However, the incidence of SICH may be higher than in other patient populations and may be associated with the use of abciximab and advanced patient age.


Diagnostic Value of Chest CT in Coronavirus Disease 2019 (COVID-19).


title: The Interferon-Stimulated Gene Ifi27l2a Restricts West Nile Virus Infection and Pathogenesis in a Cell-Type- and Region-Specific Manner.

text: UNLABELLED The mammalian host responds to viral infections by inducing expression of hundreds of interferon-stimulated genes (ISGs). While the functional significance of many ISGs has yet to be determined, their cell type and temporal nature of expression suggest unique activities against specific pathogens. Using a combination of ectopic expression and gene silencing approaches in cell culture, we previously identified Ifi27l2a as a candidate antiviral ISG within neuronal subsets of the central nervous system (CNS) that restricts infection by West Nile virus (WNV), an encephalitic flavivirus of global concern. To investigate the physiological relevance of Ifi27l2a in the context of viral infection, we generated Ifi27l2a(-/-) mice. Although adult mice lacking Ifi27l2a were more vulnerable to lethal WNV infection, the viral burden was greater only within the CNS, particularly in the brain stem, cerebellum, and spinal cord. Within neurons of the cerebellum and brain stem, in the context of WNV infection, a deficiency of Ifi27l2a was associated with less cell death, which likely contributed to sustained viral replication and higher titers in these regions. Infection studies in a primary cell culture revealed that Ifi27l2a(-/-) cerebellar granule cell neurons and macrophages but not cerebral cortical neurons, embryonic fibroblasts, or dendritic cells sustained higher levels of WNV infection than wild-type cells and that this difference was greater under conditions of beta interferon (IFN-β) pretreatment. Collectively, these findings suggest that Ifi27l2a has an antiviral phenotype in subsets of cells and that at least some ISGs have specific inhibitory functions in restricted tissues. IMPORTANCE The interferon-stimulated Ifi27l2a gene is expressed differentially within the central nervous system upon interferon stimulation or viral infection. Prior studies in cell culture suggested an antiviral role for Ifi27l2a during infection by West Nile virus (WNV). To characterize its antiviral activity in vivo, we generated mice with a targeted gene deletion of Ifi27l2a. Based on extensive virological analyses, we determined that Ifi27l2a protects mice from WNV-induced mortality by contributing to the control of infection of the hindbrain and spinal cord, possibly by regulating cell death of neurons. This antiviral activity was validated in granule cell neurons derived from the cerebellum and in macrophages but was not observed in other cell types. Collectively, these data suggest that Ifi27l2a contributes to innate immune restriction of WNV in a cell-type- and tissue-specific manner.


title: Do statin medications impact renal functional or oncologic outcomes for robot-assisted partial nephrectomy?

text: OBJECTIVE To evaluate if statin medications (3-hydroxyl-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) improve either oncologic or renal functional outcomes for patients undergoing robot-assisted partial nephrectomy (RPN). PATIENTS AND METHODS Patients undergoing RPN between March 2008 and October 2013 were evaluated from a prospectively maintained database for statin usage. The rate of perioperative acute kidney injury (AKI), as defined according to the RIFLE criteria, and the progression of chronic kidney disease (CKD) were compared between users and nonusers. Oncologic outcomes and rate of progression were compared between users and nonusers. RESULTS One hundred four (31%) of 339 patients were on statin therapy preoperatively and continued this medication peri- and postoperatively. Statin patients were older and had higher rates of comorbidities, including coronary artery disease, diabetes, and hypertension (p<0.0001 for all).The rate of AKI in the statin (16%) and nonstatin patients (14%) (p=0.60) and CKD progression based on Kaplan-Meier estimates (p=0.57) were similar between both the groups. Subgroup analysis of the 271 (80%) patients with hilar clamping also had similar rates of AKI, in statin users 10% vs 12% in nonusers (p=0.50). Multivariate analysis of factors affecting CKD progression confirmed these findings. Oncologic progression was not affected by statin therapy (p=0.90). CONCLUSION Statin medications do not appear to influence perioperative renal function following RPN, in either clamped or unclamped procedures. Continuation of these medications may be continued perioperatively, but any effect on renal functional or oncologic outcomes was not elucidated in this study.


title: Single-port laparoscopic adhesiolysis for torsion ileus.

text: Single-incisional laparoscopic surgery (SILS) has emerged as an attempt to further enhance the cosmetic benefits and reduce the morbidity of minimally invasive surgery. We present an approach of SILS adhesiolysis to adhesive strangulated ileus. A 70-year-old female patient, who had undergone laparoscopic low anterior resection 6 years before, underwent SILS adhesiolysis to a midline surgical incision wound adhesion site. The surgery was performed with only a 2.5-cm left-side transrectus incision using the SILS port. Laparoscopy revealed intestinal torsion and congestion with adhesion of the ileum to the previous surgical incision wound. SILS adhesiolysis was successfully carried out. The patient was discharged 4 days after surgery. SILS adhesiolysis is a feasible and efficient procedure in certain cases.


title: Thoracoscopic lobectomy: the gold standard for early-stage lung cancer?

text: Primary lung cancers remain the most lethal of all the malignancies, predicted to account for nearly 160,000 deaths and 220,000 new diagnoses in 2009. The cornerstone of therapy for early-stage lung cancer is surgical resection by lobectomy with concomitant removal of the draining nodal basin. Minimally invasive lobectomy with the use of a thoracoscope has been established as an alternative to standard thoracotomy approaches. Thoracoscopic lobectomy provides advantages over a traditional thoracotomy, including less pain, shorter hospitalization, decreased overall costs, superior chemotherapy compliance, and fewer overall complications. In light of these advantages and with evidence of oncologic equivalence, thoracoscopic lobectomy should be considered the gold standard for the treatment of early-stage lung cancer. This article details the technical strategies for performing thoracoscopic lobectomy and highlights the published evidence demonstrating its advantages over a traditional thoracotomy approach.


title: Deletion of a 197-Amino-Acid Region in the N-Terminal Domain of Spike Protein Attenuates Porcine Epidemic Diarrhea Virus in Piglets.

text: We previously isolated a porcine epidemic diarrhea virus (PEDV) strain, PC177, by blind serial passaging of the intestinal contents of a diarrheic piglet in Vero cell culture. Compared with the highly virulent U.S. PEDV strain PC21A, the tissue culture-adapted PC177 (TC-PC177) contains a 197-amino-acid (aa) deletion in the N-terminal domain of the spike (S) protein. We orally inoculated neonatal, conventional suckling piglets with TC-PC177 or PC21A to compare their pathogenicities. Within 7 days postinoculation, TC-PC177 caused mild diarrhea and lower fecal viral RNA shedding, with no mortality, whereas PC21A caused severe clinical signs and 55% mortality. To investigate whether infection with TC-PC177 can induce cross-protection against challenge with a highly virulent PEDV strain, all the surviving piglets were challenged with PC21A at 3 weeks postinoculation. Compared with 100% protection in piglets initially inoculated with PC21A, 88% and 100% TC-PC177- and mock-inoculated piglets had diarrhea following challenge, respectively, indicating incomplete cross-protection. To investigate whether this 197-aa deletion was the determinant for the attenuation of TC-PC177, we generated a mutant (icPC22A-S1Δ197) bearing the 197-aa deletion from an infectious cDNA clone of the highly virulent PEDV PC22A strain (infectious clone PC22A, icPC22A). In neonatal gnotobiotic pigs, the icPC22A-S1Δ197 virus caused mild to moderate diarrhea, lower titers of viral shedding, and no mortality, whereas the icPC22A virus caused severe diarrhea and 100% mortality. Our data indicate that deletion of this 197-aa fragment in the spike protein can attenuate a highly virulent PEDV, but the virus may lose important epitopes for inducing robust protective immunity.IMPORTANCE The emerging, highly virulent PEDV strains have caused substantial economic losses worldwide. However, the virulence determinants are not established. In this study, we found that a 197-aa deletion in the N-terminal region of the S protein did not alter virus (TC-PC177) tissue tropism but reduced the virulence of the highly virulent PEDV strain PC22A in neonatal piglets. We also demonstrated that the primary infection with TC-PC177 failed to induce complete cross-protection against challenge by the highly virulent PEDV PC21A, suggesting that the 197-aa region may contain important epitopes for inducing protective immunity. Our results provide an insight into the role of this large deletion in virus propagation and pathogenicity. In addition, the reverse genetics platform of the PC22A strain was further optimized for the rescue of recombinant PEDV viruses in vitro This breakthrough allows us to investigate other virulence determinants of PEDV strains and will provide knowledge leading to better control PEDV infections.


Editorial: What will nonoperating room anesthesia look like in the postcoronavirus disease 2019 era?


title: Inflammatory response and oxidative stress during liver resection.

text: BACKGROUND Postoperative complications are still a major concern after liver resection (LR). Systemic inflammation and deregulated reactive oxygen species during major abdominal surgery may impair outcome after hepatectomy. METHODS Patients undergoing LR were included in this study (n = 40). Oxidative stress (OS) was measured peri- and post-operatively as static oxidation-reduction potential markers (sORP) and antioxidant capacity ORP (cORP) by using the RedoxSYS Diagnostic system. Furthermore, Th1- and Th2-specific cytokines were assessed. RESULTS Whereas there was no significant change in systemic sORP during LR and in the early postoperative course, there was a substantial decrease of cORP immediately post-surgery, and on postoperative days 1 and 3 (p<0.001). OS response was tightly regulated, as there was a significant correlation between sORP and cORP (p<0.0001; R2:0.457). An increase of OS (sORP) after LR of more than 3 mV was predictive for severe postoperative complications (53.8% vs. 12.5; p = 0.017). There was a significantly higher IL-2 (p = 0.006) and IL-5 (p = 0.001) increase during hepatectomy in patients who developed a severe morbidity. CONCLUSION Antioxidant capacity remained stable during LR but dropped during the post-surgical period, suggesting a consumption of antioxidants to maintain OS within healthy range. Severe postoperative complications were associated with a pronounced inflammatory response during surgery.


Çağlar A, Er A, Ulusoy E, Akgül F, Çitlenbik H, Yılmaz D, Duman M. Cerebral oxygen saturation monitoring in pediatric cardiopulmonary resuscitation patients in the emergency settings: A small descriptive study. Turk J Pediatr 2017; 59: 642-647. Near infrared spectroscopy (NIRS) is a new technology for monitoring cardiopulmonary resuscitation (CPR). The use of NIRS has advantages in monitoring cerebral oxygenation in cardiac arrest patients. The aim of this study was to describe cerebral regional oxygen saturation (CrSO < sub > 2 < /sub > ) values in a small cohort of pediatric out-of-hospital cardiac arrest patients and to determine if there is an association with CrSO < sub > 2 < /sub > and return of spontaneous circulation (ROSC). All the out-of-hospital cardiac arrest patients admitted to our pediatric emergency department were included in this prospective study. All patients were monitored through NIRS in addition to standard monitoring during CPR. All cerebral rSO < sub > 2 < /sub > measurements were obtained with an INVOS 5100C cerebral/somatic oximeter. Cardiopulmonary resuscitation was performed according to the Pediatric Advanced Life Support 2010 guidelines. The patients were classified as ROSC and non - ROSC. Ten patients were included in this study. The median age of patients was 40.0 (14.0-88.2) months. Three (30%) of the 10 patients achieved sustained ROSC. Abrupt increase in cerebral regional oxygen saturation (CrSO < sub > 2 < /sub > ) was observed in all 3 of these patients. Minimum values of the CrSO < sub > 2 < /sub > were significantly lower and the percentage of median time with CrSO < sub > 2 < /sub > under 30% of CrSO < sub > 2 < /sub > were significantly higher in the non - ROSC group (p=0.02). Our study indicated that the patients in the non - ROSC group have lower minimum CrSO < sub > 2 < /sub > value. Additionally, abrupt increase of CrSO < sub > 2 < /sub > during CPR could be an indicator for ROSC.


title: Genetic variability of the S1 subunit of enteric and respiratory bovine coronavirus isolates.

text: Bovine coronavirus (BCoV) is considered an important pathogen in cattle worldwide. It is a causative agent of enteric and respiratory diseases of cattle. The S1 subunit of the viral S glycoprotein is responsible for virus binding to host-cell receptors, induction of neutralizing antibody and hemagglutinin activity. The entire S1 genomic region (2304 bp) of two enteric bovine coronavirus isolates from Austria, one respiratory and one enteric isolate from Slovakia were analyzed at the genetic level. The comparative analysis of those four isolates revealed 97.1-98.6% similarity at the nucleotide and 95.6-98.6% at the amino acid level. No differences between enteric and respiratory isolates were observed at the genetic level. The isolates were clustered in the phylogenetic tree with European isolates independently of their enteric or respiratory origin.


title: Post Roux-en-Y gastric bypass biliary dilation: natural process or significant entity?

text: BACKGROUND Changes in the biliary system after gastric bypass are not well defined. Dilation may be normal or due to biliary tract pathology. The purpose of this study is to review patients who underwent imaging of their biliary system both before and after Roux-en-Y gastric bypass in an effort to elucidate the effect this operation has on hepatic duct diameter. METHODS Patients with imaging both before and at least 3 months after gastric bypass were analyzed. Hepatic duct was measured at the level of the porta hepatis to determine interval changes. RESULTS Thirty-three patients had postoperative imaging at least 3 months following gastric bypass. Mean hepatic duct diameter was 5.2 ± 2 and 7.1 ± 2.6 mm preoperatively and postoperatively, respectively (p < 0.01). Patients with prior cholecystectomy had hepatic duct diameters of 7.9 ± 1.3 and 9.5 ± 3.5 mm preoperatively and postoperatively, respectively (p = 0.3). Patients who had not previously undergone cholecystectomy had hepatic duct diameters of 4.3 ± 1.1 and 6.4 ± 1.8 mm preoperatively and postoperatively, respectively (p < 0.01). CONCLUSIONS Hepatic duct diameter increases after Roux-en-Y gastric bypass. A better understanding of this phenomenon may limit the need for further work-up in patients with incidentally detected biliary dilation.


title: Laparoscopic completion radical cholecystectomy for T2 gallbladder cancer.

text: BACKGROUND The role of minimally invasive surgery in the surgical management of gallbladder cancer is a matter of controversy. Because of the authors' growing experience with laparoscopic liver and pancreatic surgery, they have begun offering patients laparoscopic completion partial hepatectomies of the gallbladder bed with laparoscopic hepatoduodenal lymphadenectomy. METHODS The video shows the steps needed to perform laparoscopic resection of the residual gallbladder bed, the hepatoduodenal lymph node nodes, and the residual cystic duct stump in a setting with a positive cystic stump margin. The skin and fascia around the previous extraction site are resected, and this site is used for specimen retrieval during the second operation. RESULTS To date, three patients have undergone laparoscopic radical cholecystectomy with hepatoduodenal lymph node dissection for gallbladder cancer. The average number of lymph nodes retrieved was 3 (range, 1-6), and the average estimated blood loss was 117 ml (range, 50-200 ml). The average operative time was 227 min (range, 120-360 min), and the average hospital length of stay was 4 days (range, 3-5 days). No morbidity or mortality was observed during 90 days of follow-up for each patient. CONCLUSION Although controversy exists as to the best surgical approach for gallbladder cancer diagnosed after routine laparoscopic cholecystectomy, the minimally invasive approach seems feasible and safe, even after previous hepatobiliary surgery. If the previous extraction site cannot be ascertained, all port sites can be excised locally. Larger studies are needed to determine whether the minimally invasive approach to postoperatively diagnosed early-stage gallbladder cancer has any drawbacks.


Role of Microcirculatory Disturbances and Diabetic Autonomic Neuropathy in Takotsubo Cardiomyopathy.


title: Molecularly evolved thymidylate synthase inhibits 5-fluorodeoxyuridine toxicity in human hematopoietic cells.

text: Thymidylate synthase (TS) inhibitors, such as 5-fluorouracil (5-FU) and 5-fluorodeoxyuridine (5-FUdR), are amongst the most frequently used chemotherapeutic drugs available, although their efficacy is often limited by myelotoxicity. An emerging strategy for overcoming bone marrow toxicity involves ex vivo genetic transfer of drug resistance to autologous hematopoietic progenitor cells, followed by reimplantation of the transfected cells before chemotherapy. Here we establish that expression of mutant TS genes, selected from millions of engineered variants, renders human hematopoietic cells resistant to 5-FUdR, and identify the most efficacious variant for gene therapeutic rescue of drug-induced myelosuppression.


title: Intravenous olfactory test latency correlates with improvement in post-infectious olfactory dysfunction.

text: CONCLUSION This cohort study showed that onset latency in the intravenous olfactory test (IVO) may help predict when olfaction in patients with post-infectious olfactory dysfunction (PIOD) improves. OBJECTIVES To identify factors that predict the olfactory improvement period in patients with PIOD. METHODOLOGY/PRINCIPAL All consecutive patients presenting with PIOD in 1994-2014 who were followed up for 2 years were identified retrospectively. The ability of demographic/clinical factors (age, sex, body mass index, presence/absence of allergic rhinitis, treatment/non-treatment with herbal medicines, patient dependence on herbal medicine treatment, presence/absence of diabetes mellitus, and smoking status) and olfactory test factors (response/no response and onset latency and duration in the IVO test, and detection and recognition scores on the T&T olfactory test) to predict the olfactory improvement period (defined respectively as the time from PIOD onset or olfactory testing to the first self-report of olfaction improvement) was analyzed by univariate and multivariate regression. RESULTS Of the 187 PIOD patients, the prognostic ability of demographic/clinical factors was analyzed in 65. None predicted the olfactory improvement period. Of the 65 patients, 20 did not respond in the IVO test. In the remaining 45 patients, onset latency (but not the other olfactory test factors) was a significant prognosticator of olfactory improvement period (R2=0.24, p = 0.003).


Is It Time to Liberate Resources for Organ Transplantation Amid the COVID-19 Pandemic?


title: Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients.

text: BACKGROUND Retroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse. OBJECTIVE To evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution. DESIGN, SETTING, AND PARTICIPANTS Records of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS This was a descriptive analysis. RESULTS AND LIMITATIONS The study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5 cm and 1.4 cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343 min, respectively. Mean blood loss was 84 ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation. CONCLUSIONS Postchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.


title: The next step? Use of tissue fusion technology to perform the serial transverse enteroplasty--proof of principle.

text: BACKGROUND Serial transverse enteroplasty (STEP) is an established procedure for intestinal lengthening and tapering. A gastrointestinal linear stapler is used to taper the bowel sequentially. We report preliminary experience with tissue fusion technology to perform STEP in a porcine model. METHODS Four weaned male pigs (mean age, 4 ± 0 weeks; mean weight, 6.8 ± 0.1 kg) first underwent a 60-cm reversed intestinal segment followed by a STEP 4 to 6 weeks later. The LigaSure Impact (Covidien, Valleylab, Tyco Healthcare Group LP, Boulder, CO) was used to perform the procedure. Animals were fed on postoperative day 2 and terminated 1 week later. Morphometric data were collected, and intestinal tissue was obtained for histology. RESULTS Mean bowel caliber of 5.1 ± 0.5 cm was tapered to 1.8 ± 0.3 cm post-STEP with a mean increase in the length of the dilated segment of 82% ± 20%. All animals tolerated enteral feeding, and all survived to termination on day 7. Histologic evaluation revealed the zone of tissue fusion to be 7.1 ± 1.5 mm. Masson trichrome, hematoxylin and eosin, and polarized picrosirius red stains demonstrated that the fusion zone was well healed with overlying granulation tissue. CONCLUSION This is the first report of the successful application of radiofrequency energy to perform the STEP procedure in animals. Although further evaluation is required, tissue fusion devices may eventually provide an alternative to the linear stapler for the STEP procedure.


title: Post-donation COVID-19 identification in blood donors.

text: The coronavirus disease 19 (COVID-19) outbreak, which was characterized as a pandemic on 11 March 2020 by the WHO, started in December 2019 with the emergence of pneumonia cases of unknown cause in Wuhan, Hubei, China [1]. SARS-CoV-2, the causative agent of COVID-19, are enveloped, non-segmented, single stranded positive sense RNA viruses and are classified as a sister clade to the prototype human and bat severe acute respiratory syndrome coronaviruses (SARS-CoVs) of the species Severe acute respiratory syndrome-related coronavirus [2]. So far, no respiratory virus, including SARS-CoV and the Middle East Respiratory Syndrome (MERS)-CoV, has been confirmed as transfusion-transmissible [3,4].


title: Appendectomy using single-incision pediatric endosurgery for acute and perforated appendicitis.

text: BACKGROUND Single-incision pediatric endosurgical (SIPES) appendectomy has been reported in few pediatric surgical centers. We have adopted the technique recently and have offered it to all patients in whom appendectomy was indicated. The purpose of this study was to report our experience with SIPES appendectomy for acute appendicitis, perforated appendicitis, and interval appendectomy, and to compare the results with those from patients who underwent conventional laparoscopic appendectomy 1 year previously. METHODS After IRB approval, data on all SIPES appendectomies performed in our hospital were prospectively collected, including operative time, intra- and postoperative complications, conversion rate, blood loss, and hospital length of stay. Cases were stratified into three categories: acute appendicitis, perforated appendicitis, and interval appendectomy. They were compared to patients operated on in 2007 using conventional laparoscopic (three-trocar) appendectomy. RESULTS During the study period, 75 SIPES appendectomies were undertaken. Mean age was 11 years (range = 2-19 years) and mean weight was 45 kg (range = 12-132 kg). All SIPES appendectomies were completed laparoscopically, and additional trocars were placed in 20% of cases. SIPES interval appendectomies took the longest and had the highest conversion rate (33%). Follow-up data was available in 63 patients (82%) at a median of 3 weeks. There were three wound infections in the SIPES group (4%) and one in the 151 control patients. Compared to historic controls, operative time was shorter with SIPES compared to conventional laparoscopy for acute appendicitis (37 ± 12.3 vs. 44.1 ± 20.3 min, p = 0.01, 95% CI = 32-42 min). CONCLUSION SIPES appendectomy is a very good alternative to the conventional laparoscopic approach, especially for acute appendicitis. It is technically more challenging for perforated appendicitis and interval appendectomy. Yet, with appropriate consideration and skill, scarless appendectomy is achievable.


title: Methusaleh's Zoo: how nature provides us with clues for extending human health span.

text: As impressive as the accomplishments of modern molecular biologists have been in finding genetic alterations that lengthen life in short-lived model organisms, they pale in comparison to the remarkable diversity of lifespans produced by evolution. Some animal species are now firmly documented to live for more than four centuries and even some mammals, like the bowhead whale, appear to survive 200 years or more. Another group of species may not be as absolutely long-lived, but they are remarkably long-lived for their body size and metabolic rate. These species include a number of bats, some of which live for at least 40 years in the wild, as well as the naked mole-rat, which is the same size, but lives nearly 10 times as long as the laboratory mouse. Together these exceptionally long-lived organisms have important roles to play in our future understanding of the causal mechanisms and modulation of ageing. Bats and naked mole-rats in particular have already contributed in the following ways: (1) they have contributed to the abandonment of the rate-of-living theory and weakened enthusiasm for the oxidative stress hypothesis of ageing, (2) they have helped evaluate how the tumour-suppressing role of cellular senescence is affected by the evolution of diverse body sizes as well as diverse longevities, (3) they have shed light on the relationship between specific types of DNA repair and ageing and (4) they have yielded insight into new processes, specifically the maintenance of the proteome and hypotheses concerning how evolution shapes ageing. The continuing acceleration of progress in genome sequencing and development of more and more cross-species investigatory techniques will facilitate even more contributions of these species in the near future.


title: Attitudes of patients and surgeons towards sham surgery trials: a protocol for a scoping review of attributes to inform a discrete choice experiment.

text: INTRODUCTION In order to properly evaluate the efficacy of orthopaedic procedures, rigorous, randomised controlled sham surgery trial designs are necessary. However, randomised controlled trials (RCTs) for surgery involving a placebo are ethically debated and difficult to conduct with many failing to reach their desired sample size and power. A review of the literature on barriers and enablers to recruitment, and patient and surgeon attitudes and preferences towards sham surgery trials, will help to determine the characteristics necessary for successful recruitment. METHODS AND ANALYSIS This review will scope the diverse literature surrounding sham surgery trials with the aim of informing a discrete choice experiment to empirically test patient and surgeon preferences for different sham surgery trial designs. The scoping review will be conducted in accordance with the methodological framework described in Arksey and O'Malley (2005) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. The review will be informed by a systematic search of Medline, Embase, PsycInfo, CINAHL and EconLit databases (from database inception to 21 June 2019), a Google Scholar search, and hand searching of reference lists of relevant studies or reviews. Studies or opinion pieces that involve patient, surgeon or trial characteristics, which influence the decision to participate in a trial, will be included. Study selection will be carried out independently by two authors with discrepancies resolved by consensus among three authors. Data will be charted using a standardised form, and results tabulated and narratively summarised with reference to the research questions of the review. ETHICS AND DISSEMINATION The findings from this review will inform the design of a discrete choice experiment around willingness to participate in surgical trials, the outcomes of which can inform decision and cost-effectiveness models of sham surgery RCTs. The qualitative information from this review will also inform patient-centred outcomes research. The review will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER CRD42019133296.


title: Differences in patient selection and outcomes between SilverHawk atherectomy and laser ablation in the treatment of femoropopliteal in-stent restenosis: a retrospective analysis from a single center.

text: PURPOSE To analyze differences in the application and outcomes of SilverHawk atherectomy (SH) and excimer laser ablation (ELA) in the treatment of femoropopliteal in-stent restenosis (ISR) in an unselected cohort of patients treated at a single center. METHODS Between January 2005 and June 2010, 81 consecutive patients (46 men; mean age 69.1 years, range 43-86) underwent directional atherectomy (41 SH, 40 ELA) for femoropopliteal ISR lesions. Data were reviewed retrospectively on procedural outcomes, major adverse events, and 1-year target lesion revascularization (TLR) obtained from medical records and supplemented with telephone calls. The primary endpoint was symptom-driven TLR at 1 year; secondary endpoints were death and amputation. RESULTS ELA was utilized more frequently than SH in longer lesions (210.4±104 vs. 126.2±79.3 mm, respectively; p=0.001), subacute presentation (55% vs. 14.6%, p=0.001), TASC D lesions (47.5% vs. 12.2%), and in patients with more angiographic thrombus (42.5% vs. 4.9%, p=0.001). Final angiographic success (<30% residual narrowing post final treatment) was similar between ELA and SH (92.5% vs. 100%, respectively, p=0.12). Bailout stenting was significantly higher with ELA vs. SH (50.0% vs. 24.4%, p=0.022). At 1 year, TLR had occurred in 48.7% of the ELA patients vs. 31.7% of the SH cases (p=0.171). Regression analysis confirmed that SH was a predictor of TLR at 1 year (hazard ratio 2.679, 95% CI 1.015 to 7.073, p=0.047). CONCLUSION Both SH and ELA continue to have a high TLR rate in treating ISR of the femoral and popliteal arteries. A higher rate of delayed failure is seen with SH and an earlier, steeper loss of TLR-free survival is seen with ELA.


title: Chronic impedance spectroscopy of an endovascular stent-electrode array.

text: OBJECTIVE Recently, we reported a minimally invasive stent-electrode array capable of recording neural signals from within a blood vessel. We now investigate the use of electrochemical impedance spectroscopy (EIS) measurements to infer changes occurring to the electrode-tissue interface from devices implanted in a cohort of sheep for up to 190 days. APPROACH In a cohort of 15 sheep, endovascular stent-electrode arrays were implanted in the superior sagittal sinus overlying the motor cortex for up to 190 days. EIS was performed routinely to quantify viable electrodes for up to 91 days. An equivalent circuit model (ECM) was developed from the in vivo measurements to characterize the electrode-tissue interface changes occurring to the electrodes chronically implanted within a blood vessel. Post-mortem histological assessment of stent and electrode incorporation into the wall of the cortical vessels was compared to the electrical impedance measurements. MAIN RESULTS EIS could be used to infer electrode viability and was consistent with x-ray analysis performed in vivo, and post-mortem evaluation. Viable electrodes exhibited consistent 1 kHz impedances across the 91 day measurement period, with the peak resistance frequency for the acquired data also stable over time. There was a significant change in 100 Hz phase angles, increasing from -67.8° ± 8.8° at day 0 to -43.8° ± 0.8° at day 91, which was observed to stabilize after eight days. ECM's modeled to the data suggested this change was due to an increase in the capacitance of the electrode-tissue interface. This was supported by histological assessment with >85% of the implanted stent struts covered with neointima and incorporated into the blood vessel within two weeks. CONCLUSION This work demonstrated that EIS could be used to determine the viability of electrode implanted chronically within a blood vessel. Impedance measurements alone were not observed to be a useful predictor of alterations occurring at the electrode tissue interface. However, measurement of 100 Hz phase angles was in good agreement with the capacitive changes predicted by the ECM and consistent with suggestions that this represents protein absorption on the electrode surface. 100 Hz phase angles stabilized after 8 days, consistent with histologically assessed samples. SIGNIFICANCE These findings demonstrate the potential application of this technology for use as a chronic neural recording system and indicate the importance of conducting EIS as a measure to identify viable electrodes and changes occurring at the electrode-tissue interface.


title: How Qualitative Case Study Methodology Informs Occupational Therapy Practice: A Scoping Review.

text: Qualitative case study methodology (QCSM) is a useful research approach that has grown in popularity within the social sciences; however, it has received less attention in the occupational therapy literature. The current scoping review aims to explore how studies utilizing a QCSM help inform occupational therapy knowledge and practice. Electronic searches were conducted in April 2017, and the resultant 388 publications were screened by three reviewers in Covidence. In all, 27 publications met the inclusion criteria and were included in the scoping review. Case studies in the occupational therapy literature have explored phenomena relating to the delivery of intervention, theoretical concepts, clinical reasoning, and education and research methods and were situated in a range of different practice areas and contexts. QCSM is a valuable approach in occupational therapy research that contributes to the body of knowledge and theory that informs occupational therapy practice.