title: Evaluation of a nursing and midwifery exchange between rural and metropolitan hospitals: A mixed methods study.

text: INTRODUCTION This paper reports on the findings of the Nursing and Midwifery Exchange Program, initiated to promote rural and remote nursing and midwifery, and to facilitate clinical skills development and clinical collaboration between health services in Queensland, Australia. The project was undertaken over an 18-month period in one state of Australia, offering structured, temporary exchange of personnel between metropolitan and rural health services. BACKGROUND Globally, there is an increasing awareness of nursing shortages, and with it, the need to ensure that nurses and midwives are prepared for specialist roles and practice. This is particularly important in rural and remote areas, where there are pre-existing barriers to access to services, and difficulties in attracting suitably qualified, permanent staff. METHODS A mixed methods approach to the evaluation was undertaken with two cohorts. One cohort was the nurses and midwives who participated in the exchange (n = 24) and the other cohort were managers of the participating health services (n = 10). The nurses and midwives who participated in the exchange were asked to complete a questionnaire that included questions related to embeddedness and job satisfaction. The managers participated in a Delphi series of interviews. RESULTS Those who participated in exchange reporting a higher score on the reported degree of understanding of rural client, which was accompanied with a moderate-to-large effect size estimate (d = 0.61). Nurses/midwives in the exchange group reported higher scores on their perceptions of aspects of their home community that would be lost if they had to leave, which was accompanied with a large effect size (d = 0.83). Overall, NMEP was reported by the participants to be a positive way to improve professional development opportunities for nurses and midwives. The findings also show the program supported practical collaboration and raised the profile of nursing and midwifery in rural areas. CONCLUSION Exchange programs support clinical and professional development, raising the awareness of different contexts of practice and related skills requirements, and thereby supporting a greater understanding of different nursing roles. In the light of increasingly complex care required by patients with chronic conditions being managed in community-based services, programs such as NMEP provide the opportunity to build collaborative networks between referring and referral centres as well as contribute to the ongoing skills development.


Radiofrequency ablation: treatment of primary lung cancer.


title: A tailored approach to overcoming challenges of a bovine aortic arch during left internal carotid artery stenting.

text: PURPOSE To investigate the efficacy and safety of a tailored approach to fit access and engagement techniques to the individual arch anatomy in patients with bovine-type aortic arch (BTAA) to overcome the perceived increased risk of technical failure and cerebral embolization during left internal carotid artery (LICA) stenting. METHODS Thirty-five high surgical risk patients (23 men; mean age 68.6 years, range 62-90) with BTAA and LICA stenosis underwent carotid artery stenting (CAS). Left common carotid artery (LCCA) engagement was achieved by means of different techniques according to the configuration of the BTAA, arch type (I, II, or III), and angle between the innominate artery and the LCCA. The clinical, anatomical, and procedural data were retrieved from a prospectively maintained database and analyzed retrospectively to identify technical modifications required during the procedure compared with planning. RESULTS The technical success rate was 100%. Transfemoral access was used in 21 (60%) cases. In this group, the soft engagement technique with hockey stick (HS) guiding catheter and buddy wire in the external carotid artery (ECA) was used in 13 (62%) cases, a simple telescopic technique with 6-F armed introducer or 7-F 40° guiding catheter in 5 (24%) cases, and a sequential technique with a MOMA proximal protection system in the remaining 3 (14%) cases. Among the 14 (40%) right brachial access cases, the telescopic technique with 6-F armed introducer was used in 13 cases. The remaining case was the only one in which the planned technique was changed (from the telescopic to sequential technique with ECA wire exchange). There were no intraprocedural or 30-day neurological events. CONCLUSION An appropriate tailored interventional strategy, planned by means of preprocedural recognition of bovine arch anatomy, is associated with satisfactory safety and good success.


title: Surgical hardware-related iatrogenic venous compression syndrome.

text: Deep vein thrombosis related to immobilization is a common and extensively studied disorder, particularly in hospitalized patients. However, the phenomenon of iatrogenic venous compression (IAVC) and related deep venous thrombosis (DVT) is under-recognized and under-reported. In the absence of relieving the compressive pathology, the recanalization rates are expected to be very low - thereby putting patients at a significant risk for the development of post-thrombotic syndrome (PTS). In this report, we describe two cases of DVT related to IAVC, and review similar cases that have been previously reported in the literature. With advancements in catheter-based technology, patients with IAVC (with or without DVT) may now be offered advanced endovascular treatment options such as catheter-directed pharmacomechanical thrombolysis (PMT) and percutaneous venoplasty and/or stenting. Hence, timely recognition and treatment is essential in the prevention of disabling PTS or life-threatening pulmonary embolism.


title: Safety and Efficacy of Polymeric Clips for Appendiceal Stump Closure.

text: BACKGROUND AND OBJECTIVES Laparoscopic appendectomy remains one of the most common emergency general surgical procedures in the United States. In an era of increasing focus on costs in medical care, we sought to evaluate the use of polymeric clips to secure the appendiceal base during laparoscopic appendectomy. METHODS We performed a prospective cohort study of patients undergoing laparoscopic appendectomy from April 2013 through September 2014 at a single academic teaching institution. Polymeric clips were used to secure the appendiceal stump. Tissue dissection techniques and control of the mesoappendix were the operating surgeon's choice. Clinical outcomes are reported. RESULTS A total of 25 patients (56% women; mean age, 41 y; body mass index of 29 kg/m(2)) were enrolled in our study and underwent laparoscopic appendectomy with polymeric clips. One patient was unable to have polymeric clips placed due to inflammation of the appendiceal base. There were no major perioperative complications. One patient developed a suture abscess in the umbilical incision, and another had prolonged ileus with computed tomography demonstrating persistent pelvic fluid that did not require intervention. Median length of stay was 1 d and mean length of follow-up was 81 d. The use of polymeric clips contributed ∼ $32 to the overall operative cost. CONCLUSIONS Polymeric clips are a safe alternative for securing the appendiceal base in laparoscopic appendectomy. They offer significant cost savings without any evidence of increased complications.


Improving the efficacy of the plastic tents and boxes used for airway management of corona virus disease-19 patients: seal and negative suction.


COVID-19 and the Editorial Process: Reflections from The Journal of Pediatrics.


title: Evaluation of liver parenchyma and perfusion using dynamic contrast-enhanced computed tomography and contrast-enhanced ultrasonography in captive green iguanas (Iguana iguana) under general anesthesia.

text: BACKGROUND Contrast-enhanced diagnostic imaging techniques are considered useful in veterinary and human medicine to evaluate liver perfusion and focal hepatic lesions. Although hepatic diseases are a common occurrence in reptile medicine, there is no reference to the use of contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT) to evaluate the liver in lizards. Therefore, the aim of this study was to evaluate the pattern of change in echogenicity and attenuation of the liver in green iguanas (Iguana iguana) after administration of specific contrast media. RESULTS An increase in liver echogenicity and density was evident during CEUS and CECT, respectively. In CEUS, the mean ± SD (median; range) peak enhancement was 19.9% ± 7.5 (18.3; 11.7-34.6). Time to peak enhancement was 134.0 ± 125.1 (68.4; 59.6-364.5) seconds. During CECT, first visualization of the contrast medium was at 3.6 ± 0.5 (4; 3-4) seconds in the aorta, 10.7 ± 2.2 (10.5; 7-14) seconds in the hepatic arteries, and 15 ± 4.5 (14.5; 10-24) seconds in the liver parenchyma. Time to peak was 14.1 ± 3.4 (13; 11-21) and 31 ± 9.6 (29; 23-45) seconds in the aorta and the liver parenchyma, respectively. CONCLUSION CEUS and dynamic CECT are practical means to determine liver hemodynamics in green iguanas. Distribution of contrast medium in iguana differed from mammals. Specific reference ranges of hepatic perfusion for diagnostic evaluation of the liver in iguanas are necessary since the use of mammalian references may lead the clinician to formulate incorrect diagnostic suspicions.


title: RNA helicases in infection and disease.

text: RNA helicases unwind their RNA substrates in an ATP-dependent reaction, and are central to all cellular processes involving RNA. They have important roles in viral life cycles, where RNA helicases are either virus-encoded or recruited from the host. Vertebrate RNA helicases sense viral infections, and trigger the innate antiviral immune response. RNA helicases have been implicated in protozoic, bacterial and fungal infections. They are also linked to neurological disorders, cancer, and aging processes. Genome-wide studies continue to identify helicase genes that change their expression patterns after infection or disease outbreak, but the mechanism of RNA helicase action has been defined for only a few diseases. RNA helicases are prognostic and diagnostic markers and suitable drug targets, predominantly for antiviral and anti-cancer therapies. This review summarizes the current knowledge on RNA helicases in infection and disease, and their growing potential as drug targets.


title: Lentiviral Gene Therapy Combined with Low-Dose Busulfan in Infants with SCID-X1.

text: BACKGROUND Allogeneic hematopoietic stem-cell transplantation for X-linked severe combined immunodeficiency (SCID-X1) often fails to reconstitute immunity associated with T cells, B cells, and natural killer (NK) cells when matched sibling donors are unavailable unless high-dose chemotherapy is given. In previous studies, autologous gene therapy with γ-retroviral vectors failed to reconstitute B-cell and NK-cell immunity and was complicated by vector-related leukemia. METHODS We performed a dual-center, phase 1-2 safety and efficacy study of a lentiviral vector to transfer IL2RG complementary DNA to bone marrow stem cells after low-exposure, targeted busulfan conditioning in eight infants with newly diagnosed SCID-X1. RESULTS Eight infants with SCID-X1 were followed for a median of 16.4 months. Bone marrow harvest, busulfan conditioning, and cell infusion had no unexpected side effects. In seven infants, the numbers of CD3+, CD4+, and naive CD4+ T cells and NK cells normalized by 3 to 4 months after infusion and were accompanied by vector marking in T cells, B cells, NK cells, myeloid cells, and bone marrow progenitors. The eighth infant had an insufficient T-cell count initially, but T cells developed in this infant after a boost of gene-corrected cells without busulfan conditioning. Previous infections cleared in all infants, and all continued to grow normally. IgM levels normalized in seven of the eight infants, of whom four discontinued intravenous immune globulin supplementation; three of these four infants had a response to vaccines. Vector insertion-site analysis was performed in seven infants and showed polyclonal patterns without clonal dominance in all seven. CONCLUSIONS Lentiviral vector gene therapy combined with low-exposure, targeted busulfan conditioning in infants with newly diagnosed SCID-X1 had low-grade acute toxic effects and resulted in multilineage engraftment of transduced cells, reconstitution of functional T cells and B cells, and normalization of NK-cell counts during a median follow-up of 16 months. (Funded by the American Lebanese Syrian Associated Charities and others; LVXSCID-ND ClinicalTrials.gov number, NCT01512888.).


title: Mathematical models for assessing the role of airflow on the risk of airborne infection in hospital wards.

text: Understanding the risk of airborne transmission can provide important information for designing safe healthcare environments with an appropriate level of environmental control for mitigating risks. The most common approach for assessing risk is to use the Wells-Riley equation to relate infectious cases to human and environmental parameters. While it is a simple model that can yield valuable information, the model used as in its original presentation has a number of limitations. This paper reviews recent developments addressing some of the limitations including coupling with epidemic models to evaluate the wider impact of control measures on disease progression, linking with zonal ventilation or computational fluid dynamics simulations to deal with imperfect mixing in real environments and recent work on dose-response modelling to simulate the interaction between pathogens and the host. A stochastic version of the Wells-Riley model is presented that allows consideration of the effects of small populations relevant in healthcare settings and it is demonstrated how this can be linked to a simple zonal ventilation model to simulate the influence of proximity to an infector. The results show how neglecting the stochastic effects present in a real situation could underestimate the risk by 15 per cent or more and that the number and rate of new infections between connected spaces is strongly dependent on the airflow. Results also indicate the potential danger of using fully mixed models for future risk assessments, with quanta values derived from such cases less than half the actual source value.


title: Clinical relevance of multiple respiratory virus detection in adult patients with acute respiratory illness.

text: Because increasing numbers of nasopharyngeal swab specimens from adult patients with acute respiratory illness (ARI) are being tested by respiratory virus (RV) multiplex reverse transcriptase PCR (RVM-RT-PCR), multiple RV detection (MRVD) is being encountered more frequently. However, the clinical relevance of MRVD in adult patients has rarely been evaluated. The clinical characteristics of hospitalized adult patients with ARI and MRVD by RVM-RT-PCR tests were compared to those of patients with single RV detection (SRVD) during a single year at a tertiary care center. MRVD was observed in 26 of the 190 adult patients (13.7%). The patients with MRVD had a higher incidence of chronic lung disease than the patients with SRVD (34.6% versus 15.9%, crude odds ratio [OR]=2.81, 95% confidence interval [CI]=1.13 to 6.98, P=0.03). Although the former were more likely than the latter to receive mechanical ventilation (19.2% versus 6.7%, crude OR=3.31, 95% CI=1.05 to 10.47, P=0.049), the length of hospital stay (median, 7 versus 6.5 days; P=0.66), and the in-hospital mortality rate (7.7% versus 4.3%, crude OR=1.87, 95% CI=0.37 to 9.53, P=0.35) were not different between the two groups. In multivariate analysis, chronic lung disease was associated with MRVD (adjusted OR=3.08, 95% CI=1.12 to 8.46, P=0.03). In summary, it was not uncommon to encounter adult patients with ARI and MRVD by RVM-RT-PCR tests of nasopharyngeal swab specimens. MRVD was associated with chronic lung disease rather than the severity of the ARI.


title: The cytokine storm of COVID-19: a spotlight on prevention and protection.

text: INTRODUCTION The cytokine release syndrome (CRS) of COVID-19 is associated with the development of critical illness requiring multi-organ support. Further research is required to halt progression of multi-organ injury induced by hyper-inflammation. AREAS COVERED PubMed/MEDLINETM databases were accessed between May 9th-June 9th, 2020, to review the latest perspectives on the treatment and pathogenesis of CRS. EXPERT OPINION Over-activity of chemotaxis triggers a macrophage activation syndrome (MAS) resulting in the release of pro-inflammatory cytokines. IL-6 and TNF- α are at the forefront of hyper-inflammation. The inflammatory cascade induces endothelial activation and capillary leak, leading to circulatory collapse and shock. As endothelial dysfunction persists, there is activation of the clotting cascade and microvascular obstruction. Continued endothelial activation results in multi-organ failure, regardless of pulmonary tissue damage. We propose that targeting the endothelium may interrupt this cycle. Immuno-modulating therapies have been suggested, however, further data is necessary to confirm that they do not jeopardize adaptive immunity. Inhibition of IL-6 and the Janus Kinase, signal transducer and activator of transcription proteins pathway (JAK/STAT), are favorable targets. Remote ischemic conditioning (RIC) reduces the inflammation of sepsis in animal models and should be considered as a low risk intervention, in combination with cardiovascular protection.


title: Analysis of Gastric Physiology After Laparoscopic Sleeve Gastrectomy (LSG) With or Without Antral Preservation in Relation to Metabolic Response: a Randomised Study.

text: INTRODUCTION Laparoscopic sleeve gastrectomy is one of the most common techniques in bariatric surgery, but there is no consensus on the optimal distance from the pylorus to start the gastric transection. The aim of this study is to determine the differences in gastric emptying, gastric distension and metabolic response between two starting distances. MATERIAL AND METHODS This is a prospective randomised study of 60 patients (30 patients with the section at 3 cm and 30 patients at 8 cm from the pylorus). We calculate at 6 and 12 months from surgery gastric emptying by scintigraphy (T1/2 min), gastric volume by CT scan (cc) and metabolic response by blood sample analysis (glucose, HbA1c, insulin, HOMA-IR, GLP-1, GIP and C-peptide). RESULTS Gastric emptying increases the speed significantly in both groups but is greater in the 3-cm group (p < 0.05). Dividing groups into type 2 diabetic patients and non-diabetic patients, the speed in non-diabetic patients is significantly higher for the 3-cm group. Residual volume increases significantly in both groups, and there are no differences between them. One year after surgery, there are significant improvements in the hyperinsulinaemia in the patients of the 3-cm group with respect to the 8-cm group, but only in diabetic patients. No differences between groups are found regarding changes in GLP-1 or GIP. CONCLUSIONS Gastric emptying is faster in patients with antrum resection. The distance does not influence the gastric emptying of diabetic patients. Other mechanisms may explain metabolic response besides GLP-1 and its association with improvements in diabetes via gastric emptying.


title: Detection and molecular characterization of enteric viruses in breeder turkeys.

text: The present study was undertaken to detect and characterize enteric viruses (rotavirus, astrovirus, reovirus, and coronavirus) in breeder poults. Five turkey breeder flocks were selected. Faecal samples were collected from all flocks at 1 week of age and then every other week until the poults reached 9 weeks of age. The faecal samples were pooled in groups of five. Of the 193 pools ("samples") tested by reverse transcription-polymerase chain reaction, 47.2%, 30.6%, and 10.4% samples were positive for astrovirus, rotavirus, and reovirus, respectively. No coronavirus was detected in any of the samples. Overall, 118 (61.1%) samples were positive for one or more enteric viruses. Of the 118 samples, 70 (59.3%) were positive for a single virus and 48 (40.7%) for a combination of viruses. Phylogenetic analysis based on the polymerase gene showed that astroviruses clustered into two groups with sequence homology ranging from 85.6 to 100% at the nucleotide level. Based on NSP4 gene sequences, rotaviruses clustered in a group and had 96.3 to 99.9% sequence homology at the nucleotide level. The reoviruses, based on their S4 gene sequences, clustered in a single group with sequence homology of 96.9 to 100%. Differing amino acid sequences of all three viruses may affect the antigenicity and/or pathogenicity of these viruses and may merit further study. The presence of two or three different viruses in combination may affect the dynamics of turkey health and disease.


title: Ventilator Settings to Avoid Nuisance Alarms During Mouthpiece Ventilation.

text: BACKGROUND A recent study found that activation of disconnection and low-pressure alarms is common during mouthpiece ventilation and may represent a major limitation to its use. The aim of this bench study was: (1) to investigate the technical aspects that can influence the setting of the ventilator during mouthpiece ventilation and (2) to provide a practical setting strategy to avoid the alarm activation. METHODS Eight life-support ventilators able to deliver volume controlled ventilation were tested in a bench study using a single-limb non-vented circuit configuration connected to a standard mouthpiece. Disconnection and apnea alarm were turned off or set at the least sensitive setting. The backup frequency was set at the lowest available level. Different tidal volumes (VT) (from 500 to 1,200 mL) were tested with the rectangular and descending flow shape. For each VT, we reported the maximum set inspiratory time (TI) that allowed preventing activation of the low-pressure alarm. The presence of auto-triggering was also surveyed. RESULTS We found that a correct combination of VT and TI avoided the activation of disconnection and low-pressure alarms in all but 3 ventilators. One ventilator did not allow mouthpiece ventilation independently from the settings used. The inability to turn off the apnea alarm in two other ventilators led to the alarm going off in any tested conditions after 120 s without triggered breaths. Auto-triggering was seldom found and easily worked out, except for in one ventilator. CONCLUSIONS An appropriate alarm setting and combination of VT and TI would allow the majority of the tested ventilators to be used for mouthpiece ventilation without alarm activation.


title: Perioperative outcomes and survival in elderly patients undergoing laparoscopic distal pancreatectomy.

text: BACKGROUND The outcomes following laparoscopic distal pancreatectomy (LDP) in elderly patients have not been widely reported to date. This study aimed to analyze perioperative and oncologic outcomes in patients aged ≥70 years (elderly group) and compare with those <70 years (non-elderly group). METHODS From April 1997 to September 2015, 402 consecutive patients with lesions in the body and tail of the pancreas underwent LDP at Rikshospitalet, Oslo University Hospital. RESULTS Of these, 118 (29.4%) were elderly, whereas 284 (70.6%) were non-elderly. Despite higher rate of comorbidities and American Society of Anesthesiologists score (P = 0.001 and 0.001, respectively), elderly patients had lower postoperative morbidity, pancreatic fistula (PF) and readmission rates, compared with non-elderly (P = 0.032, 0.001 and 0.025, respectively). Spleen-preserving LDP (SPLDP) resulted in similar postoperative outcomes in the two groups. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) were comparable to non-elderly in terms of median and 3-year survival (20.2 vs. 19 months (P = 0.94, log-rank) and 26.7% vs. 34.3%, respectively). CONCLUSIONS Both LDP and SPLDP are safe in patients aged ≥70 years, providing outcomes similar to those in younger group. Elderly patients with PDAC can benefit from LDP, since age itself is not associated with decreased survival after surgery.


title: Retrospective analysis of cases of intraoperative awareness in a large multi-hospital health system reported in the early postoperative period.

text: BACKGROUND Awareness with recall under general anesthesia remains a rare but important issue that warrants further study. METHODS We present a series of seven cases of awareness that were identified from provider-reported adverse event data from the electronic anesthesia records of 647,000 general anesthetics. RESULTS The low number of identified cases suggests an under-reporting bias. Themes that emerge from this small series can serve as important reminders to anesthesia providers to ensure delivery of an adequate anesthetic for each patient. Commonalities between a majority of our identified anesthetic awareness cases include: obesity, use of total intravenous anesthesia, use of neuromuscular blockade, and either a lack of processed electroencephalogram (EEG) monitoring or documented high depth of consciousness index values. An interesting phenomenon was observed in one case, where adequately-dosed anesthesia was delivered without technical issue, processed EEG monitoring was employed, and the index value suggested an adequate depth of consciousness throughout the case. CONCLUSIONS Provider-reported adverse event data in the immediate post-operative period are likely insensitive for detecting cases of intraoperative awareness. Though causation cannot firmly be established from our data, themes identified in this series of cases of awareness with recall under general anesthesia provide important reminders for anesthesia providers to maintain vigilance in monitoring depth and dose of anesthesia, particularly with total intravenous anesthesia.


title: Gene expression profile of the fibrotic response in the peritoneal cavity.

text: The cellular response to materials implanted in the peritoneal cavity has been utilised to produce tissue for grafting to hollow smooth muscle organs (blood vessels, bladder, uterus and vas deferens). To gain insight into the regulatory mechanisms involved in encapsulation of a foreign object, and subsequent differentiation of encapsulating cells, the present study used microarray technology and real-time RT-PCR to identify the temporal changes in gene expression associated with tissue development. Immunohistochemical analysis showed that 3-7 days post-implantation of foreign objects (cubes of boiled egg white) into rats, they were encapsulated by tissue comprised primarily of haemopoietic (CD45(+)) cells, mainly macrophages (CD68(+), CCR1(+)). By day 14, tissue capsule cells no longer expressed CD68, but were positive for myofibroblast markers alpha-smooth muscle (SM) actin and SM22. In accordance with these results, gene expression data showed that early capsule (days 3-7) development was dominated by the expression of monocyte/macrophage-specific genes (CD14, CSF-1, CSF-1R, MCP-1) and pro-inflammatory mediators such as transforming growth factor (TGF-beta). As tissue capsule development progressed (days 14-21), myofibroblast-associated and pro-fibrotic genes (associated with TGF-beta and Wnt/beta-catenin signalling pathways, including Wnt 4, TGFbetaRII, connective tissue growth factor (CTGF), SMADs-1, -2, -4 and collagen-1 subunits) were significantly up-regulated. The up-regulation of genes associated with Cardiovascular and Skeletal and Muscular System Development at later time-points suggests the capacity of cells within the tissue capsule for further differentiation to smooth muscle, and possibly other cell types. The identification of key regulatory pathways and molecules associated with the fibrotic response to implanted materials has important applications not only for optimising tissue engineering strategies, but also to control deleterious fibrotic responses.


People with Intellectual Disabilities and the COVID-19 Pandemic.


title: Heparin-bonded covered stents versus bare-metal stents for complex femoropopliteal artery lesions: the randomized VIASTAR trial (Viabahn endoprosthesis with PROPATEN bioactive surface [VIA] versus bare nitinol stent in the treatment of long lesions in superficial femoral artery occlusive disease).

text: OBJECTIVES The hypothesis that endovascular treatment with covered stents has equal risks but higher efficacy than bare-metal stents (BMS) in long femoropopliteal artery disease was tested. BACKGROUND Although endovascular treatment of short superficial femoral artery lesions revealed excellent results, efficacy in long lesions remains unsatisfactory. METHODS In a prospective, randomized, single-blind, multicenter study, 141 patients with symptomatic peripheral arterial disease were assigned to treatment with heparin-bonded, covered stents (Viabahn 72 patients) or BMS (69 patients). Clinical outcomes and patency rates were assessed at 1, 6, and 12 months. RESULTS Mean ± SD lesion length was 19.0 ± 6.3 cm in the Viabahn group and 17.3 ± 6.6 cm in the BMS group. Major complications within 30 days were observed in 1.4%. The 12-month primary patency rates in the Viabahn and BMS groups were: intention-to-treat (ITT) 70.9% (95% confidence interval [CI]: 0.58 to 0.80) and 55.1% (95% CI: 0.41 to 0.67) (log-rank test p = 0.11); treatment per-protocol (TPP) 78.1% (95% CI: 0.65 to 0.86) and 53.5% (95% CI: 0.39 to 0.65) (hazard ratio: 2.23 [95% CI: 1.14 to 4.34) (log-rank test p = 0.009). In lesions ≥20 cm, (TransAtlantic Inter-Society Consensus class D), the 12-month patency rate was significantly longer in VIA patients in the ITT analysis (VIA 71.3% vs. BMS 36.8%; p = 0.01) and the TPP analysis (VIA 73.3% vs. BMS 33.3%; p = 0.004). Freedom from target lesion revascularization was 84.6% for Viabahn (95% CI: 0.72 to 0.91) versus 77.0% for BMS (95% CI: 0.63 to 0.85; p = 0.37). The ankle-brachial index in the Viabahn group significantly increased to 0.94 ± 0.23 compared with the BMS group (0.85 ± 0.23; p < 0.05) at 12 months. CONCLUSIONS This randomized trial in symptomatic patients with peripheral arterial disease who underwent endovascular treatment for long femoropopliteal lesions demonstrated significant clinical and patency benefits for heparin-bonded covered stents compared with BMS in lesions ≥20 cm and for all lesions in the TPP analysis. In the ITT analysis for all lesions, which was flawed by major protocol deviations in 8.5% of the patients, the difference was not significant. (GORE VIABAHN® endoprosthesis with bioactive propaten surface versus bare nitinol stent in the treatment of TASC B, C and D lesions in superficial femoral artery occlusive disease; ISRCTN48164244).


Covid-19: environmental health officers and retired doctors step up to fill contact tracing void.


title: Modified classification of surgical meshes for hernia repair based on the analyses of 1,000 explanted meshes.

text: BACKGROUND It is an undisputable fact that meshes have become standard for repair of abdominal wall hernias. Whereas in the late eighties there were only a couple of different devices available, today we have to choose among some hundreds, with lots of minor and major variations in polymer and structure. As most of the minor variations may not lead to significant change in clinical outcome and may be regarded as less relevant, we should focus on major differences. Eventually, this is used to structure the world of mesh by forming groups of textile devices with distinct biological response. Many experimental and some clinical studies have underlined the outstanding importance of porosity, which fortunately, in contrast to other biomechanical quanlities, is widely unaffected by the anisotropy of meshes. METHODS In accordance with the major manufacturers of meshes, a classification of meshes was derived from a huge pool of textile data based briefly on the following: (1) large pores, (2) small pores, (3) additional features, (4) no pores, (5) 3D structure and (6) biological origin. At 1,000 explanted meshes the value of this classification was evaluated by group-specific assessment of inflammatory and connective tissue reaction. RESULTS Application of this classification to common products has proved feasable, and each of the six different classes includes devices that in clinical trials failed to show relevant differences in patients' outcome when comparing products within the same group. Furthermore, histological analysis confirmed significant differences in tissue reactions between but not within the different classes. CONCLUSIONS Classifying implants according to a similar response enables grouping patients into comparable cohorts despite implantation of different devices. Furthermore, it enables the examination of the impact of mesh classes for the various indications even from heterogenous data of registries. Finally and not the least, any grouping supports the surgeon to select the best device to meet the individual need and to tailor patients therapy.


title: One-year single-center experience with the Aperio thrombectomy device in large vessel occlusion in the anterior circulation: safety, efficacy, and clinical outcome.

text: BACKGROUND AND PURPOSE The Aperio thrombectomy device (Aperio) is a stent retriever designed to achieve rapid and substantial flow restoration in acute ischemic stroke due to large-vessel occlusions (LVOs). We evaluated the safety and efficacy of the Aperio device and compared it with published data of established stent retrievers. METHODS We retrospectively analyzed institutional data of consecutive stroke procedures in patients with LVO in the anterior circulation that were treated between January 2017 and December 2017 with the Aperio. Reperfusion rate regarding to the extended thrombolysis in cerebral infarction scale (eTICI), procedural times, early clinical outcome, and complications were documented. RESULTS Eighty-two patients were treated by using the Aperio in LVO in the anterior circulation. Median age was 77 (± 12) years (w = 59.8%). Median Baseline National Institutes of Health Stroke Scale (NIHSS) score was 14. Fifty-three (64.6%) patients received intravenous thrombolysis. Successful recanalization (eTICI≥2b) was achieved in 85.3%. Mean time from groin puncture to final recanalization was 52.3 ± 34.8 min. Embolization to new territories occurred in one case. Symptomatic intracranial hemorrhage within 24 h was observed in six patients (7.3%). Twenty-eight (41.2%) out of 68 patients available for assessment of functional outcome at 3 months achieved favorable outcome (mRS 0-2). CONCLUSION The Aperio stent retriever mechanical thrombectomy device demonstrated high rates of successful reperfusion and a good safety profile in patients with acute ischemic stroke due to LVO in the anterior circulation.


title: Does State-Level Nurse Practitioner Scope-of-Practice Policy Affect Access to Care?

text: There is heated debate surrounding policy reform granting full state-level nurse practitioner (NP) scope of practice (SOP) in all U.S. states. NP SOP policy is argued to impact access to care; however, a synthesis of empirical studies assessing this relationship has yet to be performed. Our study fills this critical gap by systematically reviewing studies that examine this relationship. We apply Aday and Andersen's Access Framework to operationalize access to care. We also use this framework to map components of access to care that may relate to NP SOP through concepts identified in this review. Our findings suggest that full state-level NP SOP policy is associated with increases in various components of access to care, but additional work is needed to evaluate causality and underlying mechanisms behind this policy's effect on access. This work is necessary to align research, practice, and policy efforts surrounding NP SOP with healthcare accessibility.


title: Patient selection guidelines in MR-guided focused ultrasound surgery of uterine fibroids: a pictorial guide to relevant findings in screening pelvic MRI.

text: Uterine leiomyomas (fibroids), the most common benign tumor in women of childbearing age, can cause symptoms including dysmenorrhea, menorrhagia, urinary symptoms, pain and infertility. Hysterectomy is a common approach to treating uterine fibroids, and less invasive surgical approaches such as myomectomy and uterine artery embolization also have been shown to alleviate symptoms. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is the only totally non-invasive surgical approved method for treating uterine fibroids. In clinical trials, MRgFUS resulted in significant relief of uterine fibroid symptoms. The safe and effective use of MRgFUS is affected by fibroid type and location, position relative to adjacent anatomical structures and the presence of co-existent pelvic disease. Additionally, successful outcomes with MRgFUS have been correlated with the volume of fibroids ablated during the procedure. Thus, selection of patients in whom sufficient fibroid volumes can be treated safely using the MRgFUS system is critical for successful outcomes. The MR images in this pictorial essay provide examples of uterine fibroids for which MRgFUS should be considered and is designed to facilitate the selection of patients for whom MRgFUS is most likely to provide sustained symptom relief.


title: Emergent pneumonectomy for lung gangrene: does the outcome warrant the procedure?

text: BACKGROUND Sloughing and gangrene of a complete lung are only very infrequently encountered complications of necrotizing pneumonia and fulminant pulmonary abscess formation. Thus far the role of emergent pneumonectomy is not established. METHODS The outcome of patients who underwent anatomic lung resection for lung gangrene at 3 centers for thoracic surgery during the last 13 years was retrospectively analyzed. Only cases of necrotizing pneumonia were included whereas malignant lesions were excluded. RESULTS Overall 44 patients were indentified (average age 56.3 years). Pulmonary sepsis (27 of 44), pleural empyema (29 of 44), persistent air leakage (14 of 44), and respiratory failure with mechanical ventilation (14 of 44) were present preoperatively. The mean Charlson comorbidity index was 2.77. Procedures were segmentectomy (7), lobectomy (26), and pneumonectomy (11). In-hospital mortality was 7 of 44; 2 following pneumonectomy and 5 after lobectomy. In comparing the pneumonectomy group with the lobectomy group we found no significant differences in age (p=0.59), Charlson comorbidity index (p=0.18), and postoperative mortality (p=1). Charlson comorbidity index 3 or greater (odds ratio [OR], 8.41; 95% confidence interval [CI], 0.88 to 421.71; p=0.04), preoperative pleural empyema (OR, 3.56; 95% CI, 0.37 to 179.62; p=0.39) and preoperative persistent air leak (OR, 7.34; 95% CI, 1.00 to 89.98; p=0.02) were associated with higher risk for fatal outcome. Furthermore, patients with sepsis (p=0.03) and patients sustaining acute renal failure (p=0.04) had significantly higher mortality. CONCLUSIONS Pulmonary sepsis and its complications as well as preexisting comorbidity are the major reasons for fatal outcome, whereas the extent of surgical resection shows no significant influence. Emergent pneumonectomy as ultimate ratio is not only justified but also life saving. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.


title: COVID-19 and Acute Pulmonary Embolism in Postpartum Patient.

text: We report a 36-year-old woman in Iran who sought care for left shoulder pain and cough 5 days after a scheduled cesarean section. Acute pulmonary embolism and coronavirus disease were diagnosed. Physicians should be aware of the potential for these concurrent conditions in postpartum women.


title: Otologic and Audiologic Considerations for COVID-19.

text: The COVID-19 pandemic has created a number of considerations for otolaryngology; anosmia and ageusia in particular have gained significant attention. Here we present considerations in regard to treatment with quinine-derived drugs and the influence of masks on communication.


title: Survival after radiofrequency ablation in 122 patients with inoperable colorectal lung metastases.

text: PURPOSE To analyze the factors associated with favorable survival in patients with inoperable colorectal lung metastases treated with percutaneous image-guided radiofrequency ablation. METHODS Between 2002 and 2011, a total of 398 metastases were ablated in 122 patients (87 male, median age 68 years, range 29-90 years) at 256 procedures. Percutaneous CT-guided cool-tip radiofrequency ablation was performed under sedation/general anesthesia. Maximum tumor size, number of tumors ablated, number of procedures, concurrent/prior liver ablation, previous liver or lung resection, systemic chemotherapy, disease-free interval from primary resection to lung metastasis, and survival from first ablation were recorded prospectively. Kaplan-Meier analysis was performed, and factors were compared by log rank test. RESULTS The initial number of metastases ablated was 2.3 (range 1-8); the total number was 3.3 (range 1-15). The maximum tumor diameter was 1.7 (range 0.5-4) cm, and the number of procedures was 2 (range 1-10). The major complication rate was 3.9 %. Overall median and 3-year survival rate were 41 months and 57 %. Survival was better in patients with smaller tumors-a median of 51 months, with 3-year survival of 64 % for tumors 2 cm or smaller versus 31 months and 44 % for tumors 2.1-4 cm (p = 0.08). The number of metastases ablated and whether the tumors were unilateral or bilateral did not affect survival. The presence of treated liver metastases, systemic chemotherapy, or prior lung resection did not affect survival. CONCLUSION Three-year survival of 57 % in patients with inoperable colorectal lung metastases is better than would be expected with chemotherapy alone. Patients with inoperable but small-volume colorectal lung metastases should be referred for ablation.


title: Unwanted detachment of the Solitaire device during mechanical thrombectomy in acute ischemic stroke.

text: BACKGROUND The use of retrievable stents for endovascular clot retrieval has dramatically improved successful revascularization and clinical outcome in selected patients with acute stroke. OBJECTIVE To describe the rate and clinical consequences of unwanted spontaneous detachment of these devices during mechanical thrombectomy. METHODS We studied 262 consecutive patients treated with the retrievable stent, Solitaire, for acute ischemic stroke between November 2008 and April 2015. Clinical, procedural, and outcome variables were compared between patients with and without unexpected detachment of this device. Detachment was classified as proximal to the stent proximal marker (type A) or distal to the marker (type B). Poor functional outcome was defined as modified Rankin scale score >2 at 90 days. RESULTS Unwanted detachment occurred in 6/262 (2.3%) cases, four of type A and two of type B. Stent recovery was possible in three patients, all of 'type A', but in none of 'type B'. The number of prior passes was higher in patients with undesired detachment (3 (2-5) vs 2 (1-3), p=0.007). Detachment was associated with higher rate of symptomatic intracranial hemorrhage (SICH) (33.3% vs 4.3%, p=0.001), poorer outcome (100% vs 54.8%, p=0.028), and higher mortality rate at 90 days (50% vs 17%, p=0.038). CONCLUSIONS Unwanted detachment of a Solitaire is an uncommon complication during mechanical thrombectomy in patients with acute ischemic stroke and is associated with the clot retrieval attempts, SICH, poor outcome, and higher mortality.


title: ARTS (Aspiration-Retriever Technique for Stroke): Initial clinical experience.

text: BACKGROUND A new generation of highly navigable large-bore aspiration catheters and retriever devices for intracranial mechanical thrombectomy has markedly improved recanalization rates, time and clinical outcomes. We report collected clinical data utilizing a new technique based on combined large lumen aspiration catheter and partially resheathed stent retriever (ARTS: Aspiration (catheter)-(stent) Retriever Technique for Stroke). This technique is applied, especially in presence of bulky/rubbery emboli, when resistance is felt while retracting the stent retriever; at that point the entire assembly is locked and removed in-toto under continuous aspiration with additional flow arrest. METHODS A retrospective data analysis was performed to identify patients with large cerebral artery acute ischemic stroke treated with ARTS. The study was conducted between August 2013 and February 2015 at a single high volume stroke center. Procedural and clinical data were captured for analysis. RESULTS Forty-two patients (median age 66 years) met inclusion criteria for this study. The ARTS was successful in achieving Thrombolysis in Cerebral Infarction (TICI) ≥2b revascularization in 97.6% of cases (TICI 2b = 18 patients, TICI 3 = 23 patients). Patients' median National Institutes of Health Stroke Scale score at admission was 18 (6-40). A 3-month follow-up modified Rankin Scale value of 0-2 was achieved in 65.7% of the successfully treated patients (average 2.4). Two patients (4.8%) developed symptomatic intraparenchymal hemorrhages. Six procedure unrelated deaths were observed. CONCLUSIONS We found that ARTS is a fast, safe and effective method for endovascular recanalization of large vessel occlusions presenting within the context of acute ischemic stroke.


title: Transumbilical versus lateral transabdominal removal of benign adnexal masses in laparoscopic surgery-A randomized trial.

text: OBJECTIVE In laparoscopic adnexal surgery the conventional method of removing a mass from the abdominal cavity in Finland is through a 10-mm-wide lateral abdominal port. The larger the lateral trocar, the greater the risk of pain, complications and delayed recovery. Here, we assumed that adnexal mass removal through a 10-mm umbilical port together with 5-mm side trocars would decrease the postoperative need of analgesics when compared with removal through a 10-mm lateral abdominal port. STUDY DESIGN Women scheduled for laparoscopic surgery of a benign adnexal mass were invited to participate. The participants were randomized into two groups: removal via the transumbilical (TU) (n=21) or lateral transabdominal (TA) (n=21) route. General anesthesia and use of local anesthetics were standardized. The amount of postoperative opioid (oxycodone) and visual analog scale (VAS) scores for pain were the primary outcome measures. Secondary outcome measures were nausea/vomiting (VAS evaluation), time to discharge, peri- and postoperative complications, surgeons' opinions of the alternative methods and patients' satisfaction, evaluated via a questionnaire sent six months postoperatively. RESULTS There were no significant differences in the use of opioids or median pain-VAS scores between the groups during the first 24h postoperatively. However, in the TU group the amount of women with very low pain-VAS scores (0-1) during the whole 12-h follow-up time was significantly greater than in the TA group (4 vs. 0 women p=0.04). The amounts of nausea and vomiting, and median times to discharge were similar in both groups. There were no major complications. CONCLUSIONS Both transumbilical and transabdominal routes of abdominal mass removal during laparoscopy were feasible and safe. However, the transumbilical route resulted in more women with very low pain-VAS scores.


Sick chinchillas languish at farms that supply researchers.


title: A multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study.

text: We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases. A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%). The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up. We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.


title: 3D-printable headlight face shield adapter. Personal protective equipment in the COVID-19 era.

text: The coronavirus SARS-CoV-2 (COVID19) pandemic has pushed health workers to find creative solutions to a global shortage of personal protection equipment (PPE). 3D-printing technology is having an essential role during the pandemic providing solutions for this problem, for instance, modifying full-face snorkel masks or creating low-cost face shields to use as PPE (Ishack and Lipner, 2020 [1]). Otolaryngologists are at increased occupational risk to COVID19 infection due to the exposure to respiratory droplets and aerosols, especially during the routine nose and mouth examinations where coughing and sneezing happen regularly (Rna et al., 2017 [2]; Tysome and Bhutta, 2020 [3]). The use of a headlight is essential during these examinations. However, to our knowledge, none of the commercially available or 3D-printable face shields are compatible with a headlight. Hence, using a face shield and a headlight at the same time can be very uncomfortable and sometimes impossible. To solve this problem, we have designed a 3D-printable adapter for medical headlights, which can hold a transparent sheet to create a face shield as an effective barrier protection that can be used comfortably with the headlight. The adapter can be printed in different materials with the most commonly used nowadays being the cost-efficient PLA (Polylactic Acid) used for this prototype. The resulting piece weighs only 7 g and has an estimated cost of $0.15 USD. The transparent sheets, typically made from polyester and used for laser printing, can be purchased in any office material store with a standard price of 0.4 USD per unit. After use, the transparent sheet can be easily removed. We trialed the adapter in 7 different headlights. All of these headlights accommodated the printed blocks extremely well. The headlights were used in many different settings, including the ENT clinic, the operating room, the emergency room, the ENT ward and the COVID19 intensive care unit (ICU) for a two weeks period. All doctors using the headlight felt they were fully protected from respiratory droplets, blood, sputum and other fluids. The face shield with the headlight has been found very useful for treating epistaxis, changing tracheostomy cannulas and during routine nasal and oral examinations. The headlight face shield adapter was designed to solve a specific problem among the ENT community; however other specialist can find it useful as well. Nonetheless, manufacturers should take care of specifics problems like this and provide commercially available products to protect the ENT workforce in this new era.


title: A new dual current-mode controller improves power regulation in electrosurgical generators.

text: A new dual current-mode controller produces a fast, accurate constant-power high-frequency ac output, with maximum current and voltage limits for an electrosurgical generator. The regulation of ac output power is achieved with near-deadbeat control, without measurement or feedback of the output voltage or current. Compared to existing technology, the prototype generator reduces unintended tissue damage by significantly improving regulation of output power, while reducing complexity and parts count.


title: LDL cholesterol: should guidelines include targets?

text: Elevated low-density lipoprotein cholesterol (LDL-C) is associated with adverse cardiovascular outcomes. The strategy of target-based LDL-C lowering to reduce the risk of coronary heart disease and secondary event rates is now well established. However, the strategy for treating to a target LDL-C, and whether there is a lower threshold level for LDL-C continues to be debated. We present, and critically analyze the evidence for a target-based LDL-C lowering strategy, and the safety and efficacy of intensive plasma LDL-C-lowering with traditional, and novel LDL-lowering therapies below current guideline targets.


COVID Towers: low- and medium-intensity care for patients not in the ICU.


title: Fibrodysplastic implications for transvenous embolization of a high-flow pelvic arteriovenous malformation in Osler-Weber-Rendu syndrome.

text: Osler-Weber-Rendu syndrome is a rare genetic disorder that commonly features high-flow arteriovenous malformations (AVM) within the pulmonary, intracranial, and visceral circulation. We present a patient with a unique case of Osler-Weber-Rendu syndrome featuring a high-flow pelvic AVM in addition to fibromuscular dysplasia affecting multiple vascular beds. This required a unique modification of our embolic therapeutic approach for adequate treatment of the AVM.


How do we define cure of diabetes?


title: Comparison of open, laparoscopic, and robotic approaches for total abdominal colectomy.

text: BACKGROUND The utilization of minimally invasive surgery is increasing in colorectal surgery. We sought to compare the outcomes of patients who underwent elective open, laparoscopic, and robotic total abdominal colectomy. METHODS The NIS database was used to examine the clinical data of patients who underwent an elective total colectomy procedure during 2009-2012. Multivariate regression analysis was performed to compare the three surgical approaches. RESULTS We sampled a total of 26,721 patients who underwent elective total colectomy. Of these, 16,780 (62.8 %) had an open operation, while 9934 (37.2 %) had a minimally invasive approach (9614 laparoscopic surgery, and 326 robotic surgery). The most common indication for an operation was ulcerative colitis (31 %). Patients who underwent open surgery had significantly higher mortality and morbidity compared to laparoscopic (AOR 2.48, 1.30, P < 0.01) and robotic approaches (AOR 1.04, 1.30, P < 0.01 and P = 0.04, respectively). There was no significant difference in mortality and morbidity between the laparoscopic and robotic approaches (AOR 0.96, 1.03, P = 0.10, P = 0.78). However, conversion rate of laparoscopic surgery to open was significantly higher than that of robotic approach (13.3 vs. 1.5 %, P < 0.01). Patients who underwent laparoscopic surgery had significantly lower total hospital charges compared to patients who underwent open surgery (mean difference = $21,489, P < 0.01). Also, total hospital charges for a robotic approach were significantly higher than for a laparoscopic approach (mean difference = $15,595, P < 0.01). CONCLUSION Minimally invasive approaches to total colectomy are safe, with the advantage of lower mortality and morbidity compared to an open approach. Although there was no significant difference in the morbidity between minimally invasive approaches, robotic surgery had a significantly lower conversion rate compared to laparoscopic approach. Total hospital charges are significantly higher in robotic surgery compared to laparoscopic approach.


title: Management of viral infections in solid organ transplant recipients.

text: Management of viral infections after transplantation involves antiviral drug therapy (if available) and reduction in immunosuppression, which allows for development of pathogen-specific immunity to the offending virus. Prevention of viral infections is of the utmost importance, and this may be accomplished through vaccination, antiviral strategies and infection control measures. This article discusses the current management of selected viral pathogens that cause clinical illness in solid organ transplant recipients. The benefits and toxicities of antiviral therapies are discussed in the context of prevention and treatment of various viral diseases. The emerging issue of antiviral resistance is emphasized for cytomegalovirus, recurrent hepatitis B and influenza, while the importance of immunominimization is discussed in the management of BK nephropathy and virus-associated malignancies.


title: Increased Intraoperative Vasopressor Use as Part of an Enhanced Recovery After Surgery Pathway for Pancreatectomy Does Not Increase Risk of Pancreatic Fistula.

text: Purpose: Enhanced recovery after surgery (ERAS) pathways are increasingly implemented. Goal directed fluid therapy (GDFT) is a core component of ERAS pathways that limit excessive volume administration and is associated with increased use of intraoperative vasopressors. Vasopressor effects on anastomotic healing and pancreatic fistula are inconclusive. We hypothesized that intraoperative vasopressor use in an ERAS GDFT algorithm would not increase risk of pancreatic fistulas. Methods: We reviewed all adult patients undergoing pancreatectomy at an academic institution from January 2013 to February 2016, before and after implementation of an ERAS pathway in July 2014. Retrospective chart review was performed. Log-binomial regression, weighted by stabilized inverse probability-of-treatment weights, estimated effect of ERAS and intraoperative vasopressors on fistula risk. Results: One hundred thirty two patients met inclusion criteria: 74 (56.1%) in the ERAS cohort. No significant differences in overall leak risk (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.38-2.09) were observed between the ERAS and pre-ERAS cohorts. Similarly, vasopressor infusions, independent of ERAS pathway, did not significantly increase the risk of anastomotic leaks (RR 1.19, 95% CI 0.52-2.72). Conclusions: Increased use of vasopressor infusions as part of an ERAS pathway for pancreatic surgery is not associated with an increase in the risk of clinically significant pancreatic fistulas.


Are women publishing less during the pandemic? Here's what the data say.


Ensuring animal welfare during Covid-19 pandemic.


title: Influence of different interfaces on synchrony during pressure support ventilation in a pediatric setting: a bench study.

text: BACKGROUND In adults and children, patient-ventilator synchrony is strongly dependent on both the ventilator settings and interface used in applying positive pressure to the airway. The aim of this bench study was to determine whether different interfaces and ventilator settings may influence patient-ventilator interaction in pediatric models of normal and mixed obstructive and restrictive respiratory conditions. METHODS A test lung, connected to a pediatric mannequin using different interfaces (endotracheal tube [ETT], face mask, and helmet), was ventilated in pressure support ventilation mode testing 2 ventilator settings (pressurization time [Timepress]50%/cycling-off flow threshold [Trexp]25%, Timepress80%/Trexp60%), randomly applied. The test lung was set to simulate one pediatric patient with a healthy respiratory system and another with a mixed obstructive and restricted respiratory condition, at different breathing frequencies (f) (30, 40, and 50 breaths/min). We measured inspiratory trigger delay, pressurization time, expiratory trigger delay, and time of synchrony. RESULTS At each breathing frequency, the helmet showed the longest inspiratory trigger delay compared with the ETT and face mask. At f30, the ETT had a reduced Tpress. The helmet had the shortest Tpress in the simulated child with a mixed obstructive and restricted respiratory condition, at f40 during Timepress50%/Trexp25% and at f50 during Timepress80%/Trexp60%. In the simulated child with a normal respiratory condition, the ETT presented the shortest Tpress value at f50 during Timepress80%/Trexp60%. Concerning the expiratory trigger delay, the helmet showed the best interaction at f30, but the worst at f40 and at f50. The helmet showed the shortest time of synchrony during all ventilator settings. CONCLUSIONS The choice of the interface can influence patient-ventilator synchrony in a pediatric model breathing at increased f, thus making it more difficult to set the ventilator, particularly during noninvasive ventilation. The helmet demonstrated the worst interaction, suggesting that the face mask should be considered as the first choice for delivering noninvasive ventilation in a pediatric model.


title: A better fit: industry collaboration with nurse-clinicians in the development and redesign of a pneumatic compression device.

text: BACKGROUND Intermittent pneumatic compression (IPC) devices offer a safe and effective means of thromboprophylaxis but are often uncomfortable, leading to poor compliance. METHODS Two multicenter, prospective trials compared traditional IPC sleeves with newly designed IPC sleeves. The primary outcome measure was overall patient acceptance. Secondary measures involved nurses' impressions, patients' experiences, and device safety. RESULTS In Trial 1 (n = 110), 87% of patients preferred the new knee-length sleeve compared with the traditional knee-length sleeve. Thigh-length sleeve enrollment was discontinued early (n = 38), because nurses reported that the new sleeve did not remain in place. Following redesign of the thigh-length sleeve, Trial 2 (n = 110) was executed and 82% of patients preferred this sleeve compared with the traditional thigh-length sleeve. Patients' experiences and clinicians' impressions were better with the new sleeves. No device-related adverse events were reported. CONCLUSIONS Collaboration with nurses yielded a more comfortable IPC sleeve with properties that should improve compliance and optimize patient outcomes.


title: Incidental left main bronchus obstruction during left-sided double-lumen tube intubation of a patient with an unrecognized tracheal bronchus: A case report.

text: INTRODUCTION Tracheal bronchus is a right-sided anomalous bronchus arising from the trachea above the main carina and occurs in 0.1% to 2% of the general population. CASE PRESENTATION We present a case of left main bronchus obstruction during a left-sided double-lumen tube intubation in a patient with an unrecognized tracheal bronchus. After the intubation, to confirm the position of the tube, we observed what we believed was the carina with a fiberoptic bronchoscope, but it was a site between the tracheal bronchus and the right main bronchus. Thus, a right-sided intubation was performed, and the left main bronchus was obstructed with a bronchial cuff. As a result of the inappropriate ventilation, peak inspiratory pressure was elevated and arterial oxygen saturation decreased. CONCLUSION Anesthesiologists should keep in mind the possibility of anatomical variation in the large airways, and bronchoscopy should be accompanied by cautious auscultation and confirmation of the division of the bronchus.


title: [New insights into the seriousness of acute myocardial injury during COVID-19].

text: Retrospective data from Chinese cohorts published in the last few days have placed a strong emphasis on the possibility that acute myocardial injury represents a critical component in the development of serious complications in patients hospitalized with COVID-19. These analyses showed that 19-27% of hospitalized patients with moderate/severe COVID-19 developed acute myocardial injury, defined as an increase in troponin levels. Fifty-sixty percent of these patients died. The highest mortality rate was detected among patients with both progressively incremental troponin levels and a history of cardiovascular disease. Some pathophysiological reasons have been hypothesized regarding the frequently observed increase in troponin levels in patients hospitalized with COVID-19, but, at the moment, these data could already suggest some clinical management implications, also with the aim of prospectively collecting research data: a troponin dosage should be considered, as a prognostic indicator, in all patients with moderate/severe COVID-19 at hospital admission, periodically during hospitalization, and in the case of clinical deterioration. In those patients with increased troponin levels, serial determinations should be carried out to define the enzymatic trajectory and therefore also the degree of clinical attention that must necessarily be closer in those who turn out to have persistently high or increasing troponin levels. In order to reduce the overdiagnosis risk of acute myocardial injury in critically ill patients, detection of increased troponin levels should always be contextualized into a multi-parametric evaluation.


title: Combined robotic-assisted laparoscopic prostatectomy and laparoscopic hemicolectomy.

text: A 60-year-old man with prostatic adenocarcinoma and a synchronous tubulovillous adenomatous polyp of the colon underwent a successful robotic radical prostatectomy combined with a laparoscopic right hemicolectomy. We describe the initial report of this combined, minimally invasive procedure involving separate organ systems and surgical disciplines, and describe our technique.


title: One versus two-step Roux-en-Y gastric bypass after gastric banding—data analysis of the German Bariatric Surgery Registry.

text: BACKGROUND Bariatric surgery outcomes have been examined in Germany since January 1, 2005. All data were registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. METHODS The data were collected from an online data bank. Data collection began in 2005 for gastric banding (GB) and Roux-en-Y gastric bypass (RYGB) results. In addition to primary bariatric operations, data regarding the complications of revision procedures and redo operations were analyzed. Participation in the quality assurance study was required for all certified centers in Germany. RESULTS RYGBs are a popular redo operation after failed gastric banding. In the German Bariatric Surgery Registry (GBSR), we analyzed data from 263 RYGB operations that used a one-step approach after GB and 116 operations that used a two-step approach. The leakage rates for primary RYGB decreased to 1.8%. The incidence of leakage after a one-step RYGB after GB was lower (1.9%) than after the two-step procedure (2.6%). CONCLUSION RYGBs are popular procedures after failed GB in Germany. The multivariable analysis for overall intraoperative complications revealed a significant difference between the two-step and the one-step procedure. In an unadjusted and multivariate assessment, the one-step procedure had statistically lower general postoperative complications than the two-step approach. Therefore, we suggest performing band removal and RYGB as a one-step procedure. Further analysis is necessary to evaluate the risk factors for the one-step procedure. Follow-up investigations must be performed to determine whether RYGB is an effective and safe option after GB.


Admissions to Veterans Affairs Hospitals for Emergency Conditions During the COVID-19 Pandemic.


title: Porcine reproductive and respiratory syndrome virus induces autophagy to promote virus replication.

text: An increasing number of studies demonstrate that autophagy, an intrinsic mechanism that can degrade cytoplasmic components, is involved in the infection processes of a variety of pathogens. It can be hijacked by various viruses to facilitate their replication. In this study, we found that PRRSV infection significantly increases the number of double- or single-membrane vesicles in the cytoplasm of host cells in ultrastructural analysis. Our results showed the LC3-I was converted into LC3-II after virus infection, suggesting the autophagy machinery was activated. We further used pharmacological agents and shRNAs to confirm that autophagy promoted the replication of PRRSV in host cells. Confocal microscopy analysis showed that PRRSV inhibited the fusion between autophagosomes and lysosomes, suggesting that PRRSV induced incomplete autophagy. This suppression caused the accumulation of autophagosomes which may serve as replication site to enhance PRRSV replication. It has been shown that NSP2 and NSP3 of arterivirus are two components of virus replication complex. We also found in our studies that NSP2 colocalized with LC3 in MARC-145 cells by performing confocal microscopy analysis and continuous density gradient centrifugation. Our studies presented here indicated that autophagy was activated during PRRSV infection and enhanced PRRSV replication in host cells by preventing autophagosome and lysosome fusion.


title: [Acute management of ischemic stroke in 2017].

text: Acute management of ischemic stroke is a burning topic in 2017 since stroke represents the leading cause of acquired handicap in adults. Over the last past years, major improvement took place, especially with the demonstration of the efficacy of mechanical thrombectomy, thus needing to better organize care pathways, and optimize access to neurologists and interventional neuroradiology platforms. Intensive care stroke units remain the pivotal place of patients' management. A multidisciplinary coordination is required, with continuous teaching of all the actors involved in stroke management, so as to increase the number of patients who could benefit from available active treatments.


title: Hypertension and its severity or mortality in Coronavirus Disease 2019 (COVID-19): a pooled analysis.

text: INTRODUCTION As the coronavirus disease 2019 (COVID-19) outbreak, identification of clinical predictors of severe or fatal disease are necessary to enable risk stratification and optimize allocation of limited resources. Hypertension has been widely reported to be associated with increase disease severity, however, other studies have reported different findings. OBJECTIVES To evaluate the association of hypertension and severe and fatal COVID-19. PATIENTS AND METHODS Scopus, Medline, and Web of Science was performed to identify studies reporting the rate of hypertension in COVID-19 patients with severe or non-severe disease or among survivors and non-survivors. The obtained data was pooled into a meta-analysis to calculate odds ratio (OR) with 95% confidence intervals (95%CI). RESULTS Hypertension was associated with a nearly 2.5-fold significantly increased risk of severe COVID-19 disease (OR: 2.49 [95%CI: 1.98-3.12] I2=24%), as well as with a similarly significant higher risk of mortality (OR: 2.42 [95%CI: 1.51-3.90] I2=0%). In meta-regression, a significant correlation was observed with an increase in mean age of patients with severe COVID-19 associated with increased log odds of hypertension and severity (p=0.03). CONCLUSIONS The results of this pooled analysis of the current scientific literature would suggest that hypertension may be associated with an up to 2.5-fold higher risk of severe and fatal COVID-19, especially among older individuals.


title: Transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney morcellation: a proof of concept study.

text: UNLABELLED Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Until now, the transvaginal approach has been the only method of removing larger specimens from the abdominal cavity using natural orifice transluminal endoscopic surgery. There has been no means of extracting larger specimens in men and the means are restricted even in women, particularly in young women. The present study shows that the difficulty of large specimen retrieval can be overcome, irrespective of the diameter of the chosen port, through natural orifices using morcellation. OBJECTIVE To show, in a porcine model, the feasibility of a complete transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney extraction after morcellation through the same port. MATERIALS AND METHODS Transvesical nephrectomy and morcellation were performed in six pigs at Minho University, Braga, Portugal after institutional review board approval. The transvesical port and the cystotomy were created under the guidance of a ureteroscope, while the remaining steps were done under the guidance of an operating telescope. Dissection of the renal vessels and kidney was performed using dissection grasping forceps and a vessel sealing system (LigaSure(™) ; Covidien, Mansfield, MA, USA) and morcellation was done using a Piranha(™) morcellator (Richard Wolf, Knittlingen, Germany). RESULTS There were no complications related to the creation of transvesical access. The image provided by the telescope was superior to that of the ureteroscope, especially underwater. Morcellation was quick and effective, with the support of a fixing needle through the abdominal wall, designed to fix the kidney, after laceration of a bowel loop occurred in the first experiment. It was found that technical improvements are needed to ensure safety of NOTES morcellation. CONCLUSIONS Kidney morcellation after nephrectomy, using a natural orifice exclusively, is feasible. Despite technical limitations, this proof of concept study can be regarded as a potential step towards the application of NOTES in urology.


title: Interferon antagonist function of Japanese encephalitis virus NS4A and its interaction with DEAD-box RNA helicase DDX42.

text: The interferon (IFN) antagonists of Japanese encephalitis virus (JEV) proteins contribute to the JE pathogenesis. Most flavivirus non-structural (NS) proteins correlate with virus-induced inflammation and immune escape. NS4A proteins of West Nile virus and dengue type 2 virus have been demonstrated to inhibit IFN signaling. In this study, JEV NS4A without the C-terminal 2K domain has been demonstrated to partially block activation of an IFN-stimulated response element (ISRE)-based cis-reporter by IFN-alpha/beta. In addition, JEV NS4A significantly inhibited the phosphorylation levels of STAT1 and STAT2, but not TYK2 in the IFN-treated cells. Moreover, the N-terminus of a RNA helicase DDX42 protein identified using a phage display human brain cDNA library have been demonstrated to specifically bind to JEV NS4A in vitro using a co-immunoprecipitation assay. The interaction between JEV NS4A and RNA helicase DDX42 showed partial co-localization in human medulloblastoma TE-671 cells by confocal microscopy. Importantly, the expression of N-terminal DDX42 is able to overcome JEV-induced antagonism of IFN responses. Therefore, these results show that JEV NS4A without the C-terminal 2K domain is associated with modulation of the IFN response and the interaction of JEV NS4A with RNA helicase DDX42 could be important for JE pathogenesis.


title: Transanal Minimally Invasive Surgery: State of the Art.

text: The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.


title: Oral health interventions for people living with mental disorders: protocol for a realist systematic review.

text: Background The increasing number of people who experience mental disorders is a global problem. People with mental disorders have high rates of co-morbidity and significantly poorer oral health outcomes than the general public. However, their oral health remains largely a hidden and neglected issue. A complex range of factors impact the oral health of this group. These include anxiety and dental phobia, dietary habits, including the heavy consumption of sugary drinks, substance misuse of tobacco, alcohol, and/or psychostimulants, the adverse orofacial side effects of anti-psychotic and anti-depression medications, and financial, geographic, and social barriers to accessing oral health care. Methods The aim of this realist systematic review is to (a) identify and synthesise evidence that explores oral health interventions for people living with mental disorders; (b) explore the context and mechanisms that have contributed to the success of interventions or the barriers and challenges; (c) produce program theories on causal, contextual and mechanistic factors to facilitate outcomes and (d) produce recommendations and guidelines to guide future oral health interventions for people with mental disorders at both the policy and practice level. Using a five-step process, that incorporates primary data collection from key stakeholders, a beginning theoretical framework will be developed to describe contextual and mechanistic factors and how they might impact on the success or failure of oral health interventions for people with mental disorders. Key database searches will be conducted, with data extraction focused on the factors that might have impacted on intervention implementation and outcomes. Quality appraisal of studies will occur, and the theoretical framework will be populated with extracted data. Stakeholder input will support the development and refinement of a theory on oral health interventions for people with mental disorders. Discussion This will be the first review to take a realist approach to explore the broad scope of causal factors that impact on the success or failure of oral health interventions for people with mental disorders. The approach includes extensive stakeholder engagement and will advance realist systematic review methodology. Review outcomes will be important in guiding policy and practice to ensure oral health interventions better meet the needs of people with mental disorders.Systematic review registration This review protocol is registered with PROSPERO (Number) 155969.


title: Navigating the Root of the Mesentery: A Guided Approach to an Artery-First Pancreatoduodenectomy.

text: In the standard technique of pancreatoduodenectomy (PD), the superior mesenteric artery (SMA) is approached following Kocher maneuver of the duodenum. Alternative approaches include SMA first with no touch approaches. The aim of this article is to report the preoperative planning for and operative techniques of a combined artery first with no touch technique (CTPD) for the performance of PD. The CTPD technique is described with a detailed discussion of the operative anatomy, and of the importance of preoperative mapping using computed tomography to aid dissection of the mesenteric root and identification of the SMA. The use of careful preoperative mapping of arterial anatomy on cross-sectional imaging helps to facilitate identification of the SMA and simplifies the operative approach to PD. By incorporating detailed preoperative planning and a careful anatomical dissection, the CTPD technique provides an earlier assessment of the superior mesenteric vessels and determination of resectability.


title: Heart Transplant Recipient Patient with COVID-19 Treated with Tocilizumab.

text: A heart transplant 62-year-old patient referred for Coronavirus-19 disease (COVID-19) pneumonia. At admission he was febrile, tachypnoeic, and mild hypoxic with dry cough; during hospitalization a diffuse morbilliform skin rash appeared. He was treated with tocilizumab with symptoms improvement, without a complete pulmonary function recovery. Skin rash, highly suggestive for COVID-19 cutaneous involvement, persisted for ten days despite tocilizumab administration.


title: Predictive factors for complete renal tumor ablation using RFA.

text: BACKGROUND Radiofrequency ablation (RFA) can be used to treat renal masses in patients where surgery is preferably avoided. As tumor size and location can affect ablation results, procedural planning needs to identify these factors to limit treatment to a single session and increase ablation success. PURPOSE To identify factors that may affect the primary efficacy of complete renal tumor ablation with radiofrequency after a single session. MATERIAL AND METHODS Percutaneous RFA (using an impedance based system) was performed using computed tomography (CT) guidance. Fifty-two renal tumors (in 44 patients) were retrospectively studied (median follow-up, 7 months). Data collection included patient demographics, tumor data (modified Renal Nephrometry Score, histopathological diagnosis), RFA treatment data (electrode placement), and follow-up results (tumor relapse). Data were analyzed through generalized estimating equations. RESULTS Primary efficacy rate was 83%. Predictors for complete ablation were optimal electrode placement (P = 0.002, OR = 16.67) and increasing distance to the collecting system (P = 0.02, OR = 1.18). Tumor size was not a predictor for complete ablation (median size, 24 mm; P = 0.069, OR = 0.47), but all tumors ≤2 cm were completely ablated. All papillary tumors and oncocytomas were completely ablated in a single session; the most common incompletely ablated tumor type was clear cell carcinoma (6 of 9). CONCLUSION Optimal electrode placement and a long distance from the collecting system are associated with an increased primary efficacy of renal tumor RFA. These variables need to be considered to increase primary ablation success. Further studies are needed to evaluate the effect of RFA on histopathologically different renal tumors.


title: Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis.

text: INTRODUCTION There are numerous reports in the literature documenting high recurrence rates after laparoscopic paraesophageal hernia repair. The purpose of this study was to determine the learning curve for this procedure using the Cumulative Summation (CUSUM) technique. METHODS Forty-six consecutive patients with paraesophageal hernia were evaluated prospectively after laparoscopic paraesophageal hernia repair. Upper GI series was performed 3 months postoperatively to look for recurrence. Patients were stratified based on the surgeon's early (first 20 cases) and late experience (>20 cases). The CUSUM method was then used to further analyze the learning curve. RESULTS Nine patients (21%) had anatomic recurrence. There was a trend toward a higher recurrence rate during the first 20 cases, although this did not achieve statistical significance (33% vs. 13%, p = 0.10). However, using a CUSUM analysis to plot the learning curve, we found that the recurrence rate diminishes after 18 cases and reaches an acceptable rate after 26 cases. CONCLUSIONS Surgeon experience is an important predictor of recurrence after laparoscopic paraesophageal hernia repair. CUSUM analysis revealed there is a significant learning curve to become proficient at this procedure, with approximately 20 cases required before a consistent decrease in hernia recurrence rate is observed.


title: Analyzing Electroencephalography (EEG) Waves Provides a Reliable Tool to Assess the Depth of Sevoflurane Anesthesia in Pediatric Patients.

text: BACKGROUND Studies have reported that BIS is unreliable in children because its algorithm provides misleading information about the actual depth of anesthesia. Raw EEG analysis provides direct neurophysiologic measurement of cerebral activity. The relationship between age and EEG has rarely been reported, thus the aim of the present study was to compare raw electroencephalography (EEG) among different age groups of surgical patients under general anesthesia with 1.0 MAC sevoflurane. MATERIAL AND METHODS We enrolled 135 patients aged 0-80 years old (ASA physical status I or II) undergoing surgery, who were divided into 6 groups: 1-12 months old (group 1), 1-3 years old (group 2), 3-6 years old (group 3), 6-18 years old (group 4), 18-65 years old (group 5), and 65-80 years old (group 6). Different raw EEG waves (alpha, delta, and theta) were compared for all subjects. RESULTS The BIS values in groups 1 to 6 were 52.2±12.7, 55.0±8.0, 44.5±7.3, 43.8±7.3, 44.2±6.2, and 49.1±6.2 respectively. Compared with groups 1 and 2 (52.2±12.7, 55.0±8.0), BIS values of groups 3, 4, and 5 (44.5±7.3, 43.8±7.3, 44.2±6.2, respectively) were lower (P<0.05). Theta frequency was observed in the 6 groups. The EEG frequencies in groups 1 to 6 were 6.0 (5.5-6.0), 6.0 (5.5-6.0), 6.0 (5.5-6.0), 6.0 (6.0-7.0), 6.3 (6.0-7.0), and 6.0 (5.1-6.0), respectively. Compared with group 6, EEG frequencies in groups 4 and 5 were higher (P<0.05). BIS value was significantly correlated with EEG frequency (R²=0.063, P<0.01). CONCLUSIONS Analyzing raw EEG waves provides more accurate judgement of depth of anesthesia, especially in pediatric cases in which monitors often provide misleading values.


title: Strategies for success: a multi-institutional study on robot-assisted partial nephrectomy for complex renal lesions.

text: OBJECTIVE To describe our technique, illustrated with images and videos, of robot-assisted partial nephrectomy (RAPN) for challenging renal tumours. PATIENTS AND METHODS A study of 249 patients who underwent RAPN in multiple institutions was performed. Patients were identified using prospective RAPN databases. Complex renal lesion were defined as those with a RENAL nephrometry score ≥10. Data were analysed and differences among groups examined. RESULTS A total of 31 (12.4%) RAPNs were performed for complex renal tumours. The median (interquartile range [IQR]) patient age was 57 (50.5-70.5) years and 21 patients (67.7%) were men. The median (IQR) American Society of Anesthesiologists score was 2 (2-3). The median (IQR) operating time was 200 (50-265) min, warm ischaemia time was 23 (18.5-29) min, and estimated blood loss was 200 (50-265) mL. There were no intra-operative complications. Two patients (6.4%) had postoperative complications. One patient (3.2%) had a positive surgical margin. The median (IQR) length of stay was 3.5 (3-5) days and the median (IQR) follow-up was 12.5 (7-24) months. There were no recurrences. RAPN resulted in statistically significant changes in renal function 3 months after RAPN compared with preoperative renal function (P < 0.001). CONCLUSION Our results showed that RAPN was a safe approach for selected patients with complex renal tumours and may facilitate tumour resection and renorrhaphy for challenging cases, offering a minimally invasive surgical option for patients who may otherwise require open surgery.


title: The impact of PCR in the management of prosthetic joint infections.

text: An accurate diagnosis of prosthetic joint infection (PJI) remains a challenging clinical problem and is essential for the success of treatment regardless of the treatment option chosen by patients and surgeons. In recent years, PCR for the diagnosis of PJI has received much attention. Here, we review the impact of common PCR-based techniques on identifying causative organisms, antibiotic management and economics of PJI.


Curved Needles: Beyond Diagnostic Procedures.


title: Acute Ischemic Stroke due to Common Carotid Ostial Disease with Tandem Intracranial Occlusions Treated with Thrombectomy and Staged Retrograde Stenting.

text: Background Acute ischemic stroke due to tandem occlusive lesions of the anterior circulation involves an intracranial large vessel occlusion as well as a concurrent occlusion or high-grade stenosis of the proximal carotid system. The vast majority of proximal lesions in tandem occlusive cases involve the extracranial internal carotid artery, although the lesion can theoretically exist anywhere along the carotid artery pathway, including the common carotid ostium. Summary To the best of our knowledge, only 1 report describes common carotid artery ostial lesions in the setting of acute ischemic stroke due to tandem occlusions, in which the authors describe an anterograde treatment paradigm. We present the first 2 cases of acute ischemic stroke secondary to common carotid ostial disease with tandem intracranial occlusion, treated with intracranial thrombectomy followed by subsequent staged balloon-mounted stenting of the common carotid ostium. We review the pathophysiology of tandem occlusions, the controversy surrounding treatment techniques, and various approaches used in the treatment of ostial occlusive lesions. Key Message In certain situations where acute carotid stenting is not safe or technically possible, immediate intracranial thrombectomy with a subsequent staged balloon-mounted stenting of the ostial lesion may be a reasonable and safe option.


title: Nucleic acid chaperone activity associated with the arginine-rich domain of human hepatitis B virus core protein.

text: UNLABELLED Hepatitis B virus (HBV) DNA replication occurs within the HBV icosahedral core particles. HBV core protein (HBc) contains an arginine-rich domain (ARD) at its carboxyl terminus. This ARD domain of HBc 149-183 is known to be important for viral replication but not known to have a structure. Recently, nucleocapsid proteins of several viruses have been shown to contain nucleic acid chaperone activity, which can facilitate structural rearrangement of viral genome. Major features of nucleic acid chaperones include highly basic amino acid residues and flexible protein structure. To test the nucleic acid chaperone hypothesis for HBc ARD, we first used the disassembled full-length HBc from Escherichia coli to analyze the nucleic acid annealing and strand displacement activities. To exclude the potential contamination of chaperones from E. coli, we designed synthetic HBc ARD peptides with different lengths and serine phosphorylations. We demonstrated that HBc ARD peptide can behave like a bona fide nucleic acid chaperone and that the chaperone activity depends on basic residues of the ARD domain. The loss of chaperone activity by arginine-to-alanine substitutions in the ARD can be rescued by restoring basic residues in the ARD. Furthermore, the chaperone activity is subject to regulation by phosphorylation and dephosphorylation at the HBc ARD. Interestingly, the HBc ARD can enhance in vitro cleavage activity of RNA substrate by a hammerhead ribozyme. We discuss here the potential significance of the HBc ARD chaperone activity in the context of viral DNA replication, in particular, at the steps of primer translocations and circularization of linear replicative intermediates. IMPORTANCE Hepatitis B virus is a major human pathogen. At present, no effective treatment can completely eradicate the virus from patients with chronic hepatitis B. We report here a novel chaperone activity associated with the viral core protein. Our discovery could lead to a new drug design for more effective treatment against hepatitis B virus in the future.


title: Optimal cut-off criteria for duplex ultrasound compared with computed tomography angiography for the diagnosis of restenosis in stented carotid arteries in the international carotid stenting study.

text: Introduction Previous studies that reported duplex-ultrasound cut-off criteria, based on blood velocity parameters, for the degree of stenosis in a stented carotid artery were either retrospective, or the reference test was carried out only when a patient was suspected of having restenosis at duplex ultrasound, which is likely to have resulted in verification bias. We performed a prospective study of diagnostic accuracy to find new blood velocity cut-offs in duplex ultrasound for in-stent restenosis. Patients and methods Stented patients within the international carotid stenting study were eligible. Patients had a carotid computed tomography angiography in addition to routine duplex ultrasound performed at a yearly follow-up. Duplex-ultrasound bloodflow velocity parameters were compared to the degree of stenosis on computed tomography angiography. The results were analysed using receiver-operating-characteristic curves. Results We included 103 patients in this study. On computed tomography angiography, 30 (29.1%) patients had a 30%-49% in-stent restenosis, 21 (20.4%) patients had 50%-69% in-stent restenosis and 5 (4.9%) patients a ≥70% in-stent restenosis. The cut-off value ≥50% stenosis was a peak systolic velocity of 125 cm/s (sensitivity: 63% (95% CI: 41-79), specificity: 83% (95% CI: 72-90)). Discussion This study provides a level 2b evidence for new cut-off values for in-stent restenosis. Unfortunately, we could not say anything about severe stenosis because of the low number of severe stenosis after one year. Conclusions The 125 cm/s cut-off value on duplex ultrasound is lower than found in previous studies and equal to unstented arteries. Duplex-ultrasound measurements made in stented carotid arteries should not be corrected for the presence of a stent when determining the degree of stenosis.


title: Central Venous Pressure Drop After Hypovolemic Phlebotomy is a Strong Independent Predictor of Intraoperative Blood Loss During Liver Resection.

text: BACKGROUND Intraoperative hypovolemic phlebotomy (HP) has been suggested to reduce central venous pressure (CVP) before hepatectomy. This study aimed to analyze the impact of CVP drop after HP on intraoperative blood loss and postoperative renal function. METHODS A retrospective review of a prospective database including 100 consecutive patients (43 males and 57 females; mean age, 65 years; range 23-89 years) undergoing liver resection with HP was performed. The primary outcome variable was estimated blood loss (EBL), and the secondary outcome was postoperative serum creatinin (Scr). A multivariate linear regression analysis was performed to identify predictors of intraoperative blood loss. RESULTS The median CVP before blood salvage was 8 mmHg (range 4-30 mmHg). The median volume of hypovolemic phlebotomy was 400 ml (range 200-1000 ml). After HP, CVP decreased to a median of 3 mmHg (range -2 to 16 mmHg), resulting in a median CVP drop of 5.5 mmHg (range 2-14 mmHg). The median EBL during liver resection was 165 ml (range 0-800 ml). The median preoperative serum creatinin (Scr) was 0.82 g/dl (range 0.5-1.74 g/dl), and the postoperative Scr on day 1 was 0.74 g/dl (range 0.44-1.68 g/dl). The CVP drop was associated with EBL (P < 0.001). There was no significant impact of CVP drop on postoperative Scr. CONCLUSION A CVP drop after HP is a strong independent predictor of EBL during liver resection. The authors advocate the routine use of HP to reduce perioperative blood loss and transfusion rates in liver surgery. As a predictive tool, CVP drop might help surgeons decide whether a laparoscopic approach is safe.


title: Next-Generation Service Delivery: A Scoping Review of Patient Outcomes Associated with Alternative Models of Genetic Counseling and Genetic Testing for Hereditary Cancer.

text: The combination of increased referral for genetic testing and the current shortage of genetic counselors has necessitated the development and implementation of alternative models of genetic counseling and testing for hereditary cancer assessment. The purpose of this scoping review is to provide an overview of the patient outcomes that are associated with alternative models of genetic testing and genetic counseling for hereditary cancer, including germline-only and tumor testing models. Seven databases were searched, selecting studies that were: (1) full-text articles published ≥2007 or conference abstracts published ≥2015, and (2) assessing patient outcomes of an alternative model of genetic counseling or testing. A total of 79 publications were included for review and synthesis. Data-charting was completed using a data-charting form that was developed by the study team for this review. Seven alternative models were identified, including four models that involved a genetic counselor: telephone, telegenic, group, and embedded genetic counseling models; and three models that did not: mainstreaming, direct, and tumor-first genetic testing models. Overall, these models may be an acceptable alternative to traditional models on knowledge, patient satisfaction, psychosocial measures, and the uptake of genetic testing; however, particular populations may be better served by traditional in-person genetic counseling. As precision medicine initiatives continue to advance, institutions should consider the implementation of new models of genetic service delivery, utilizing a model that will best serve the needs of their unique patient populations.


title: Pure laparoscopic donor right hepatectomy in a living donor with type 3a biliary variation: A case report.

text: RATIONALE With refinements in the operative technique, laparoscopic surgery has become the standard practice for liver resection. In the field of living donor liver transplantation, a few centers adopted laparoscopic surgery as an alternative to conventional open donor hepatectomy, and the application of pure laparoscopic donor right hepatectomy has been limited to the donors with simple, favorable biliary anatomy. PATIENT CONCERNS The candidate donor was a 19-year-old woman with type 3a bile duct variation. INTERVENTIONS After confirming precise cutting points under the guidance of a radiopaque marker rubber band, the bile ducts were divided and the remnant stumps were closed with suture and clipping using Hem-o-lok, respectively. OUTCOMES The postoperative course was uneventful and she was satisfactory 6 months after surgery. LESSONS A laparoscopic donor hepatectomy for the living donor with biliary variation was feasible. Biliary variations are commonly encountered during living donor surgery, and we think that such variations in laparoscopic donor hepatectomy need to be overcome to expand the selection criteria.


title: Identification of a Novel Small Molecule Inhibitor Against SARS Coronavirus Helicase.

text: A new chemical inhibitor against severe acute respiratory syndrome (SARS) coronavirus helicase, 7-ethyl-8-mercapto-3-methyl-3,7-dihydro-1H-purine-2,6-dione, was identified. We investigated the inhibitory effect of the compound by conducting colorimetry-based ATP hydrolysis assay and fluorescence resonance energy transfer-based double-stranded DNA unwinding assay. The compound suppressed both ATP hydrolysis and double-stranded DNA unwinding activities of helicase with IC50 values of 8.66 ± 0.26 μM and 41.6 ± 2.3 μM, respectively. Moreover, we observed that the compound did not show cytotoxicity up to 80 µMconcentration. Our results suggest that the compound might serve as a SARS coronavirus inhibitor.


COVID-19 and mental health among older people in Sweden.