title: Breath analysis for noninvasively differentiating Acinetobacter baumannii ventilator-associated pneumonia from its respiratory tract colonization of ventilated patients.

text: A number of multiresistant pathogens including Acinetobacter baumannii (A. baumannii) place a heavy burden on ventilator-associated pneumonia (VAP) patients in intensive care units (ICU). It is critically important to differentiate between bacterial infection and colonization to avoid prescribing unnecessary antibiotics. Quantitative culture of lower respiratory tract (LRT) specimens, however, requires invasive procedures. Nowadays, volatile organic compounds (VOCs) have been studied in vitro and in vivo to identify pathogen-derived biomarkers. Therefore, an exploratory pilot study was conceived for a proof of concept that the appearance and level of A. baumannii-derived metabolites might be correlated with the presence of the pathogen and its ecological niche (i.e. the infection and colonization states) in ICU ventilated patients. Twenty patients with A. baumannii VAP (infection group), 20 ventilated patients with LRT A. baumannii colonization (colonization group) and 20 ventilated patients with neurological disorders, but without pneumonia or A. baumannii colonization (control group) were enrolled in the in vivo pilot study. A clinical isolate of A. baumannii strains was used for the in vitro culture experiment. The adsorptive preconcentration (solid-phase microextraction fiber and Tenax(®) TA) and analysis technique of gas chromatography-mass spectrometry were applied in the studies. Breath profiles could be visually differentiated between A. baumannii cultivation in vitro and culture medium, and among in vivo groups. In the in vitro experiment, nine compounds of interest (2,5-dimethyl-pyrazine, 1-undecene, isopentyl 3-methylbutanoate, decanal, 1,3-naphthalenediol, longifolene, tetradecane, iminodibenzyl and 3-methyl-indene) in the headspace were found to be possible A. baumannii derivations. While there were eight target VOCs (1-undecene, nonanal, decanal, 2,6,10-trimethyl-dodecane, 5-methyl-5-propyl-nonane, longifolene, tetradecane and 2-butyl-1-octanol) exhibiting characteristics of A. baumannii VAP derivations. The selected VOC profile in vivo could be adopted to efficiently differentiate the presence of LRT A. baumannii from its absence, and LRT A. baumannii infection from its colonization (AUC = 0.89 and 0.88, respectively). It is not feasible to simply transfer the metabolic biomarkers from the in vitro condition to in vivo. The direct detection of exhaled A. baumannii-derived VOCs may be adopted for an early alert of the LRT bacterial presence in ventilated ICU patients, and even in different parasitic states of A. baumannii (i.e. infection and colonization). However, further refinement and validation are required before its clinical use.


Anaphylaxis after Idarucizumab Infusion.


title: Treatment Outcomes and Lessons Learned From Transilluminated Powered Phlebectomy for Varicose Veins in 1034 Patients.

text: INTRODUCTION Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique of varicose vein removal, which combines irrigated illumination with tumescent anesthesia for ablation of superficial varicosities and endoscopic-powered venous resection. The objective of this study was to analyze treatment outcomes of this treatment modality. METHODS A retrospective evaluation of prospectively collected data from all patients undergoing TIPP procedure for symptomatic varicose veins during a recent 12-year period was performed. Pertinent patient demographics, disease classification, perioperative complications, quality of life, and treatment outcomes were collected and analyzed. RESULTS A total of 1167 limbs in 1034 patients (mean age, 52.4 years) were treated during the study period. The mean procedure time was 18.4 ± 8.9 minutes (range, 6.0-82.0 minutes). The mean number of incisions for TIPP procedure was 6.3 ± 3.6. All TIPP procedures were technically successful, and no patient required conversion to hook stab phlebectomy. Fifteen (1.5%) patients developed residual or recurrent varicosities, which were treated with sclerotherapy during the follow-up period. Postoperative complications included hematoma at 2 weeks (5.8%), ecchymosis at 2 weeks (32.9%), saphenous neuropathy (0.3%), cellulitis (1.0%), and skin pigmentation (1.9%). There was no postoperative deep vein thrombosis or mortality. CONCLUSIONS Transilluminated powered phlebectomy is an effective method for varicose vein removal and is associated with high clinical success and excellent cosmetic results. Meticulous technical steps are critical in achieving successful outcomes while minimizing complications. Technical considerations and lessons learned from our experiences are discussed in this report.


title: Effects of CO(2) pneumoperitoneum on anastomotic healing in rats receiving preoperative 5-fluorouracil neoadjuvant chemotherapy.

text: BACKGROUND When used separately, antineoplastic agents and carbon dioxide (CO(2)) pneumoperitoneum have been reported to impair anastomotic healing in experimental animals. However, the effects of their combined use have not been previously investigated. The aim of this study was to investigate the possibility that neoadjuvant chemotherapy with 5-fluorouracil followed by CO(2) pneumoperitoneum would affect the healing of anastomoses in the colon. METHODS Sprague-Dawley rats (n = 48) were given 5-fluorouracil (20 mg/kg/day) for 5 days, and were then assigned to one of the three groups. Prior to surgery, the control group received no pneumoperitoneum. The other two groups received pneumoperitoneum at 6 and 12 mmHg, respectively, for 2 hr. The large intestine was transected and anastomosis was performed via median laparotomy. On postoperative days 3 and 7, relaparotomy was performed in half of the rats in each group. From the colon, a segment including the anastomosis was excised. Tissue hydroxyproline levels were measured. For histological evaluation, the Verhofstad scale was modified and used. RESULTS No significant differences in hydroxyproline levels were seen across the groups on postoperative days 3 or 7. However, by postoperative day 7, polymorphonuclear leukocytes and necrosis in the 6-mmHg group had decreased markedly, and granulation had improved. CONCLUSION Overall, these findings suggest that preoperative 5-fluorouracil therapy followed by pneumoperitoneum at 6 or 12 mmHg does not impair anastomotic healing.


title: Families with sleepwalking.

text: BACKGROUND Studies on families with sleepwalking are uncommonly published but can give further information on the phenotype of patients with chronic sleepwalking. SUBJECTS AND METHODS Out of 51 individuals referred for chronic sleepwalking during a 5-year period, we obtained sufficient information on 7 families with direct relatives who reported sleepwalking with or without sleep terrors. Among 70 living direct family members, we obtained questionnaire responses from 50 subjects and identified 34 cases with a history of sleepwalking. Of the 50 subjects, 16 completed only questionnaires, while all the others also completed a clinical evaluation and nocturnal sleep recordings. RESULTS There was a positive history of sleepwalking on either the paternal or maternal side of the family over several generations in our 7 families. Thirty-three clinically evaluated subjects had evidence of sleep-disordered breathing (SDB), with associated craniofacial risk factors for SDB (particularly maxillary and/or mandibular deficiencies). There was a complete overlap with the report of parasomnias and the presence of SDB. In cases with current sleepwalking, treatment of SDB coincided with clear improvement of the parasomnia. CONCLUSION All of our subjects with parasomnias presented with familial traits considered as risk factors for SDB. These anatomical risk factors are present at birth and even subtle SDB can lead to sleep disruption and instability of NREM sleep. The question raised is: are factors leading to chronic sleep disruption the familial traits responsible for familial sleepwalking?


Is ethnicity linked to incidence or outcomes of covid-19?


title: Recurrence patterns of direct and indirect inguinal hernias in a nationwide population in Denmark.

text: BACKGROUND Detailed knowledge on risk of reoperation after direct and indirect inguinal hernia (IIH) repair could be useful in preoperative counseling as well as in the planning of postoperative follow-up. This knowledge is not available in the literature. METHODS Using data from the Danish Hernia Database, we included all male patients operated on for an elective, primary inguinal hernia from 1998 to 2012. Within this prospectively collected cohort, the type of inguinal hernia at primary and recurrent procedures was registered. Furthermore, time from primary procedure to reoperation and number of reoperations was registered. Data were compared using multivariate Cox proportionate hazard analysis and by first-order, semipartial correlation. RESULTS Among the 85,314 male patients who had a primary inguinal hernia repaired electively in the study period (56% IIH; 44% direct inguinal hernia [DIH]), we found an overall reoperation rate of 3.8%. More primary IIHs were operated by Lichtenstein's technique than primary DIH (90.7% vs 85.4%, respectively; P < .001). A total of 93% of the reoperations were for inguinal hernias, and 3.9% were for femoral hernias. DIHs resulted more often in reoperation than IIHs (5.2% vs 2.7%, respectively; P < .001). We found an association between the type of hernia at the primary procedure and the recurrent procedure. Thus, direct primary hernias were correlated with recurrent direct hernias, and indirect primary hernias were correlated with recurrent indirect hernias (P < .001). CONCLUSION DIHs resulted in greater risk of reoperation than IIHs. A clear association was found between the same subtype of primary and recurrent type of inguinal hernia and could be an indication of different pathophysiologic etiologies.


COPD patients in a COVID-19 society: depression and anxiety.


Novel technique for delayed sternal closure: soft tissue approximation with substernal bridge.


Development of an immunomagnetic beads-based test and its application in influenza surveillance.


The burden of disease and the need for a simple staging system in idiopathic pulmonary fibrosis.


title: COVID-19 with silent hypoxemia.

text: Some COVID-19 patients deteriorate rapidly and seemingly without warning. This is also true for relatively young patients who were previously healthy or who had only minor underlying conditions. We describe one such case, in which a man in his sixties developed rapidly progressive respiratory failure with severe hypoxia.


title: Cancer incidence and mortality after gastric bypass surgery.

text: Despite weight loss recommendations to prevent cancer, cancer outcome studies after intentional weight loss are limited. Recently, reduced cancer mortality following bariatric surgery has been reported. This study tested whether reduced cancer mortality following gastric bypass was due to decreased incidence. Cancer incidence and mortality data through 2007 from the Utah Cancer Registry (UCR) were compared between 6,596 Utah patients who had gastric bypass (1984-2002) and 9,442 severely obese persons who had applied for Utah Driver's Licenses (1984-2002). Study outcomes included incidence, case-fatality, and mortality for cancer by site and stage at diagnosis of all gastric bypass patients, compared to nonoperated severely obese controls. Follow-up was over a 24-year period (mean 12.5 years). Total cancer incidence was significantly lower in the surgical group compared to controls (hazard ratio (HR) = 0.76; confidence interval (CI) 95%, 0.65-0.89; P = 0.0006). Lower incidence in surgery patients vs. controls was primarily due to decreased incidence of cancer diagnosed at regional or distant stages. Cancer mortality was 46% lower in the surgery group compared to controls (HR = 0.54; CI 95%, 0.37-0.78; P = 0.001). Although the apparent protective effect of surgery on risk of developing cancer was limited to cancers likely known to be obesity related, the inverse association for mortality was seen for all cancers. Significant reduction in total cancer mortality in gastric bypass patients compared with severely obese controls was associated with decreased incidence, primarily among subjects with advanced cancers. These findings suggest gastric bypass results in lower cancer risk, presumably related to weight loss, supporting recommendations for reducing weight to lower cancer risk.


title: Development of a symptom score for clinical studies to identify children with a documented viral upper respiratory tract infection.

text: The objective of this study was to develop a symptom scoring system for use in clinical studies that differentiates children with cold symptoms who have an identifiable viral etiology for their upper respiratory tract infection (URI) from those in whom no virus is detected. Nasal swabs for PCR testing for identification of respiratory viruses were obtained on children aged 2-11 y at baseline and when parents thought their child was developing a cold. Parental-recorded severity of specific symptoms in children with and without a documented viral URI were compared. Nasal swabs were obtained on 108 children whose parents reported their child was developing a cold. A viral etiology was identified in 62 of 108 (57.4%) samples. Symptom measures that best differentiated children with a viral etiology from those without were significant runny nose and significant cough on days 1-4 of the illness. A URI symptom score was developed based on these symptoms, with a sensitivity of 81.4%, specificity of 61.9%, and accuracy of 73.3%. Parental impression is only a moderately accurate predictor of viral URI in children. Our URI symptom score provided a more accurate method for identifying children with viral URIs for clinical studies.


title: Concomitant Liposuction Reduces Complications of Vertical Medial Thigh Lift in Massive Weight Loss Patients.

text: BACKGROUND Medial thigh lift procedures in the massive weight loss population have been associated with significant complication rates. Liposuction-assisted medial thighplasty has recently been introduced as a technical advancement to improve outcomes. To date, no study is available directly comparing the traditional approach and this new technique. Here, the authors evaluate outcomes and complications of both techniques in a retrospective cohort study. METHODS Outcomes of 59 patients undergoing vertical medial thighplasty at the authors' institution between 2008 and 2014 were assessed retrospectively. Evaluated parameters include age, sex, body mass indices, method of weight loss, comorbidities, and complications (e.g., seroma, infection, wound dehiscence, hematoma, and surgical revision). Appropriate statistical analysis was performed. RESULTS There were 29 patients in the excision-only group and 30 patients in the liposuction-assisted group (all women; average age, 41.5 years). The overall complication rate was significantly reduced in the liposuction-assisted group (13 percent versus 59 percent; p < 0.001). The incidence of individual complications such as seroma formation (zero patients versus 10 patients; p < 0.001) and wound infection (one patient versus eight patients; p = 0.01) was significantly less in the liposuction-assisted group. In addition, we observed a significantly shorter hospital stay (6.0 days versus 7.8 days), reduced number of follow-up visits (2.0 versus 4.4), and reduced time to drain removal (1.8 days versus 4.1 days; p < 0.001) in the liposuction-assisted group. CONCLUSIONS Liposuction-assisted medial thighplasty led to a significant reduction of complications and faster recovery in the massive weight loss patient population. As a consequence, the excision-only vertical thigh lift has been completely abandoned in the authors' clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.


title: Brain edema predicts outcome after nonlacunar ischemic stroke.

text: BACKGROUND AND PURPOSE In malignant infarction, brain edema leads to secondary neurological deterioration and poor outcome. We sought to determine whether swelling is associated with outcome in smaller volume strokes. METHODS Two research cohorts of acute stroke subjects with serial brain MRI were analyzed. The categorical presence of swelling and infarct growth was assessed on diffusion-weighted imaging (DWI) by comparing baseline and follow-up scans. The increase in stroke volume (ΔDWI) was then subdivided into swelling and infarct growth volumes using region-of-interest analysis. The relationship of these imaging markers with outcome was evaluated in univariable and multivariable regression. RESULTS The presence of swelling independently predicted worse outcome after adjustment for age, National Institutes of Health Stroke Scale, admission glucose, and baseline DWI volume (odds ratio, 4.55; 95% confidence interval, 1.21-18.9; P<0.02). Volumetric analysis confirmed that ΔDWI was associated with outcome (odds ratio, 4.29; 95% confidence interval, 2.00-11.5; P<0.001). After partitioning ΔDWI into swelling and infarct growth volumetrically, swelling remained an independent predictor of poor outcome (odds ratio, 1.09; 95% confidence interval, 1.03-1.17; P<0.005). Larger infarct growth was also associated with poor outcome (odds ratio, 7.05; 95% confidence interval, 1.04-143; P<0.045), although small infarct growth was not. The severity of cytotoxic injury measured on apparent diffusion coefficient maps was associated with swelling, whereas the perfusion deficit volume was associated with infarct growth. CONCLUSIONS Swelling and infarct growth each contribute to total stroke lesion growth in the days after stroke. Swelling is an independent predictor of poor outcome, with a brain swelling volume of ≥11 mL identified as the threshold with greatest sensitivity and specificity for predicting poor outcome.


ACP Journal Club. Intermittent pneumatic compression reduced deep venous thrombosis after stroke.


title: RNA viruses in young Nepalese children hospitalized with severe pneumonia.

text: BACKGROUND Pneumonia is among the leading causes of illness and death in children <5 years of age worldwide. There is little information on the viral etiology of severe pneumonia in low-income countries, where the disease burden is particularly high. METHODS We analyzed nasopharyngeal aspirates from 629 children 2 to 35 months of age meeting World Health Organization criteria for severe pneumonia and presenting at Kanti Children's Hospital, Kathmandu, Nepal, from January 2006 through June 2008. We examined one specimen from each child for 7 respiratory viruses using reverse transcription polymerase chain reaction. RESULTS We detected one or more respiratory viruses in 188 (30%; confidence interval: 26.4%-33.7%) of the 627 specimens with a valid polymerase chain reaction result, of which 88 (14%) yielded respiratory syncytial virus (RSV), 28 (4.5%) influenza A, 24 (5.8%) parainfluenza virus (PIV) type 3, 23 (3.7%) PIV type 1, 17 (2.7%) influenza B, 9 (1.4%) human metapneumovirus, and 5 (0.8%) PIV type 2. Episodes of severe pneumonia occurred in an epidemic pattern with 2 main annual peaks, the viral infections contributing importantly to these epidemics. The largest peaks of severe pneumonia coincided with peaks of RSV infection, which occurred during the last part of the monsoon season and in winter. CONCLUSIONS RSV was the dominant respiratory viral pathogen detected in young Nepalese children hospitalized with severe pneumonia.


title: Non-stationarity of EEG during wakefulness and anaesthesia: advantages of EEG permutation entropy monitoring.

text: Monitors evaluating the electroencephalogram (EEG) to determine depth of anaesthesia use spectral analysis approaches for analysis windows up to 61.5 s as well as additional smoothing algorithms. Stationary EEG is required to reliably apply the index algorithms. Because of rapid physiological changes, artefacts, etc., the EEG may not always fulfil this requirement. EEG analysis using permutation entropy (PeEn) may overcome this issue, since PeEn can also be applied to practically nonstationary EEG. One objective was to determine the duration of EEG sequences that can be considered stationary at different anaesthetic levels. The second, more important objective was to test the reliability of PeEn to reflect the anaesthetic levels for short EEG segments. EEG was recorded from 15 volunteers undergoing sevoflurane and propofol anaesthesia at different anaesthetic levels and for each group 10 data sets were included. EEG stationarity was evaluated for EEG sample lengths from 4 to 116 s for each level. PeEn was calculated for these sequences using different parameter settings and analysis windows from 2 to 60 s. During wakefulness EEG can only be considered stationary for sequences up to 12 s. With increasing anaesthetic level the probability and duration of stationary EEG increases. PeEn is able to reliably separate consciousness from unconsciousness for EEG segments as short as 2 s. Especially during wakefulness a conflict between stationary EEG sequence durations and methods used for monitoring may exist. PeEn does not require stationarity and functions for EEG sequences as short as 2 s. These promising results seem to support the application of non-linear parameters, such as PeEn, to depth of anaesthesia monitoring.


Feline pyothorax: the impact of evidence in the real world.


title: Long-term treatment outcome of patients with gastric vascular ectasia treated with argon plasma coagulation.

text: BACKGROUND Gastric vascular ectasia (VE) is an uncommon cause of upper gastrointestinal bleeding. Long-term data on the efficacy of argon plasma coagulation (APC) for the treatment of gastric VE are lacking. METHODS We retrospectively identified consecutive patients, between January 2005 and December 2010, treated with APC for an index diagnosis of gastric VE. Clinical and endoscopic features and APC treatment success were recorded. Treatment success was determined by resolution of symptoms and stabilization of the hemoglobin level at 30% above baseline. RESULTS A total of 62 patients [28 (45.2%) male] with a mean age of 72.6 ± 12.8 years, who had undergone 159 upper endoscopies (mean 2.6, range 1-10), including 140 APC sessions (mean 2.3, range 1-10), were identified. The duration of follow-up was 46.9 ± 26.5 months. Treatment success was achieved in 16 (25.8%) patients. Predictors of success included older age, focal pattern, lack of comorbid liver failure or collagen vascular disease, use of antiplatelet or anticoagulant drugs, and lower baseline hemoglobin level. Of the patients, 26 (41.9%) died during follow-up. CONCLUSION APC is safe and effective for the initial management of gastric VE; however, most patients do not experience long-term resolution of upper gastrointestinal bleeding and anemia.


title: Placement of a non-cross-linked porcine-derived acellular dermal matrix during preperitoneal laparoscopic inguinal hernia repair.

text: This retrospective chart review evaluated outcomes following laparoscopic inguinal herniorrhaphies with non-cross-linked intact porcine-derived acellular dermal matrix (PADM) by one surgeon in a community teaching facility hospital. Mesh was sutured and/or tacked in the preperitoneal space. Postoperative visits were scheduled at 2 weeks, 3 months, and 6 months, and then at 6-month intervals up to 2 years. PADM was placed in 14 male patients (mean age, 41.1 years). Seven patients had bilateral hernias. One patient required intraoperative conversion to open herniorrhaphy based on diagnostic laparoscopy findings. PADM sizes were 6 × 10 to 12 × 16 cm; mean operative time was 102 minutes. All patients were discharged on the day of surgery and resumed full activity. This treatment approach was effective, with no recurrence or complications during a median follow-up period of 18 months (range, 13-25 months).


Anatomy: Beyond the COVID-19 Pandemic.


title: Randomized clinical trial on the postoperative use of an abdominal binder after laparoscopic umbilical and epigastric hernia repair.

text: PURPOSE Application of an abdominal binder is often part of a standard postoperative regimen after ventral hernia repair to reduce pain and seroma formation. However, there is lack of evidence of the clinical effects. The aim of the present study was to investigate the pain- and seroma-reducing effect of an abdominal binder in patients undergoing laparoscopic umbilical or epigastric hernia repair. METHODS Based on power analysis, a minimum of 54 patients undergoing laparoscopic umbilical and epigastric hernia repair were to be included. Patients were randomized to abdominal binders vs. no abdominal binders during the first postoperative week. Standardized surgical technique, anaesthesia, and analgesic regimens were used and study observers were blinded towards the intervention. Postoperative pain (visual analogue score) on day 1 was the primary outcome. In addition, ultrasonographic evaluation of seroma formation and several subjective patient-related parameters were registered. Furthermore, patients in the abdominal binder group were asked to rate benefits or discomforts of wearing the binder. RESULTS Data from 56 patients (abdominal binder, n = 28; no binder, n = 28) were available for analysis. No significant intergroup differences in postoperative pain or any of the other surgical outcomes, including seroma formation, were found. However, the abdominal binder group reported subjective beneficial effect of wearing the binder in 24 of the 28 patients (86%). No adverse effects of the abdominal binder were found. CONCLUSIONS There were no effects of an abdominal binder on pain, movement limitation, fatigue, seroma formation, general well-being, or quality of life. However, most patients claimed a subjective beneficial effect of using their abdominal binder.


title: End-to-end versus end-to-side esophagogastrostomy after esophageal cancer resection: a prospective randomized study.

text: OBJECTIVE To compare single-layered hand-sewn cervical end-to-side (ETS) anastomosis with end-to-end (ETE) anastomosis in a prospective randomized fashion. BACKGROUND The preferred organ used for reconstruction after esophagectomy for cancer is the stomach. Previous studies attempted to define the optimal site of anastomosis and anastomotic techniques. However, anastomotic stricture formation and leakage still remain an important clinical problem. METHODS From May 2005 to September 2007, 128 patients (64 in each group) were randomized between ETE and ETS anastomosis after esophagectomy for cancer with gastric tube reconstruction. Routine contrast swallow studies and endoscopy were performed. Anastomotic stricture within 1 year, requiring dilatation, was the primary endpoint. Secondary endpoints were anastomotic leak rate and mortality. RESULTS Ninety-nine men and 29 women underwent esophagectomy and gastric tube reconstruction. Benign stenosis of the anastomosis, for which dilatation was required, occurred more often in the ETE group (40% vs. ETS 18%, P < 0.01) after 1 year of follow-up. The overall (clinical and radiological) anastomotic leak rate was lower in the ETE group (22% vs. ETS 41%, P = 0.04). Patients with an ETE anastomosis suffered less often from pneumonia; 17% versus ETS 44%, P = 0.002 and had subsequently significantly shorter in-hospital stay (15 days vs. 22 days, P = 0.02). In-hospital mortality did not differ between both groups. CONCLUSION ETS anastomosis is associated with a lower anastomotic stricture rate, compared to ETE anastomosis. However, prevention of stricture formation was at high costs with increased anastomotic leakage and longer in-hospital stay. This study is registered with the Dutch Trial Registry and carries the ID number OND1317772.


title: Mechanical thrombectomy for anterior circulation stroke: 5-year experience in a statewide service with differences in pretreatment time metrics across two hospitals sites.

text: OBJECTIVE To audit our institutional mechanical thrombectomy (MT) outcomes for acute anterior circulation stroke and examine the influence of workflow time metrics on patient outcomes. METHODS A database of 100 MT cases was maintained throughout May 2010-February 2015 as part of a statewide service provided across two tertiary hospitals (H1 and H2). Patient demographics, stroke and procedural details, blinded angiographic outcomes, and 90-day modified Rankin Scale (mRS) scores were recorded. The following time points in stroke treatment were recorded: stroke onset, hospital presentation, CT imaging, arteriotomy, and recanalization. Statistical analysis of outcomes, predictors of outcome, and differences between the hospitals was carried out. RESULTS Thrombolysis in Cerebral Infarction (TICI) 2b/3 reperfusion was 79%. Forty-nine per cent of patients had good clinical outcomes (mRS 0-2). In a subgroup analysis of 76 patients with premorbid mRS 0-1 and first CT performed ≤4.5 h after stroke onset, 60% had good clinical outcomes. Patient and disease characteristics were matched between the two hospitals. H1 had shorter times between hospital presentation and CT (32 vs 55 min, p=0.01), CT and arteriotomy (33 vs 69 min, p=0.00), and stroke onset and recanalization (198 vs 260 min, p=0.00). These time metrics independently predicted good clinical outcome. Median days spent at home in the first 90 days was greater at H1 (61 vs 8, p=0.04) than at H2. A greater proportion of patients treated at H1 were independent (mRS 0-2) at 90 days (54% vs 42%); however, this was not statistically significant (p=0.22). CONCLUSIONS Outcomes similar to randomized controlled trials are attainable in 'real-world' settings. Workflow time metrics were independent predictors of clinical outcome, and differed between the two hospitals owing to site-specific organizational differences.


title: Using bispectral index and cerebral oximetry to guide hemodynamic therapy in high-risk surgical patients.

text: High-risk surgery represents 12.5% of cases but contributes 80% of deaths in the elderly population. Reduction in morbidity and mortality by the use of intervention strategies could result in thousands of lives being saved and savings of up to £400m per annum in the UK. This has resulted in the drive towards goal-directed therapy and intraoperative flow optimization of high-risk surgical patients being advocated by authorities such as the National Institute of Health and Care Excellence and the Association of Anaesthetists of Great Britain and Ireland.Conventional intraoperative monitoring gives little insight into the profound physiological changes occurring as a result of anesthesia and surgery. The build-up of an oxygen debt is associated with a poor outcome and strategies have been developed in the postoperative period to improve outcomes by repayment of this debt. New monitoring technologies such as minimally invasive cardiac output, depth of anesthesia and cerebral oximetry can minimize oxygen debt build-up. This has the potential to reduce complications and lessen the need for postoperative optimization in high-dependency areas.Flow monitoring has thus emerged as essential during intraoperative monitoring in high-risk surgery. However, evidence suggests that current optimization strategies of deliberately increasing flow to meet predefined targets may not reduce mortality.Could the addition of depth of anesthesia and cerebral and tissue oximetry monitoring produce a further improvement in outcomes?Retrospective studies indicate a combination of excessive depth of anesthesia hypotension and low anesthesia requirement results in increased mortality and length of hospital stay.Near infrared technology allows assessment and maintenance of cerebral and tissue oxygenation, a strategy, which has been associated with improved outcomes. The suggestion that the brain is an index organ for tissue oxygenation, especially in the elderly, indicates a role for this technology in the intraoperative period to assess the adequacy of oxygen delivery and reduce the build-up of an oxygen debt.The aim of this article is to make the case for depth of anesthesia and cerebral oximetry alongside flow monitoring as a strategy for reducing oxygen debt during high-risk surgery and further improve outcomes in high-risk surgical patients.


title: Three solutions to a single problem: alternative casting frames for treating infantile idiopathic scoliosis.

text: STUDY DESIGN This is a technique article discussing 3 alternative frames for casting children with infantile scoliosis. OBJECTIVE To provide surgeons with alternatives to expensive specialized casting tables to allow local treatment of these children utilizing readily available materials present at most institutions. SUMMARY OF BACKGROUND Casting for infantile scoliosis has become more popular as reports have shown promising results with this technique without the morbidity and complications associated with more invasive procedures. However, without a specialized casting table, treating these patients has been limited to a few centers throughout the country often causing patients to travel large distances to receive care. METHODS Three different alternatives to commercially available casting frames are presented. Requirements, setup, and techniques are discussed. RESULTS Each surgeon has had success with each of these frames. These provide adequate support and traction while allowing enough access to the trunk to apply a well-molded cast. CONCLUSIONS Cotrel/Metha casting for infantile scoliosis can be accomplished without a specialized table using commonly available equipment.


Elective use of cannula cricothyroidotomy.


title: Household secondary attack rate of COVID-19 and associated determinants in Guangzhou, China: a retrospective cohort study.

text: BACKGROUND As of June 8, 2020, the global reported number of COVID-19 cases had reached more than 7 million with over 400 000 deaths. The household transmissibility of the causative pathogen, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), remains unclear. We aimed to estimate the secondary attack rate of SARS-CoV-2 among household and non-household close contacts in Guangzhou, China, using a statistical transmission model. METHODS In this retrospective cohort study, we used a comprehensive contact tracing dataset from the Guangzhou Center for Disease Control and Prevention to estimate the secondary attack rate of COVID-19 (defined as the probability that an infected individual will transmit the disease to a susceptible individual) among household and non-household contacts, using a statistical transmission model. We considered two alternative definitions of household contacts in the analysis: individuals who were either family members or close relatives, such as parents and parents-in-law, regardless of residential address, and individuals living at the same address regardless of relationship. We assessed the demographic determinants of transmissibility and the infectivity of COVID-19 cases during their incubation period. FINDINGS Between Jan 7, 2020, and Feb 18, 2020, we traced 195 unrelated close contact groups (215 primary cases, 134 secondary or tertiary cases, and 1964 uninfected close contacts). By identifying households from these groups, assuming a mean incubation period of 5 days, a maximum infectious period of 13 days, and no case isolation, the estimated secondary attack rate among household contacts was 12·4% (95% CI 9·8-15·4) when household contacts were defined on the basis of close relatives and 17·1% (13·3-21·8) when household contacts were defined on the basis of residential address. Compared with the oldest age group (≥60 years), the risk of household infection was lower in the youngest age group (<20 years; odds ratio [OR] 0·23 [95% CI 0·11-0·46]) and among adults aged 20-59 years (OR 0·64 [95% CI 0·43-0·97]). Our results suggest greater infectivity during the incubation period than during the symptomatic period, although differences were not statistically significant (OR 0·61 [95% CI 0·27-1·38]). The estimated local reproductive number (R) based on observed contact frequencies of primary cases was 0·5 (95% CI 0·41-0·62) in Guangzhou. The projected local R, had there been no isolation of cases or quarantine of their contacts, was 0·6 (95% CI 0·49-0·74) when household was defined on the basis of close relatives. INTERPRETATION SARS-CoV-2 is more transmissible in households than SARS-CoV and Middle East respiratory syndrome coronavirus. Older individuals (aged ≥60 years) are the most susceptible to household transmission of SARS-CoV-2. In addition to case finding and isolation, timely tracing and quarantine of close contacts should be implemented to prevent onward transmission during the viral incubation period. FUNDING US National Institutes of Health, Science and Technology Plan Project of Guangzhou, Project for Key Medicine Discipline Construction of Guangzhou Municipality, Key Research and Development Program of China.


title: A dry lab for medical engineers?

text: INTRODUCTION We describe a teaching and training method with objective evaluation to improve medical engineering students' knowledge and analysis skills about Minimally Invasive Surgery (MIS) instrumentation and techniques through hands-on experience. Training has been scheduled during a three-month course. METHODS Twenty medical engineering students were trained to perform three times on a pelvic trainer a sequence of standardized drills connected with the selected MIS techniques, in order to improve their dexterity. The time required to perform each dexterity drill was recorded in seconds.Then, the participants were divided into groups and asked to write an essay about an instrument they chose, analyzing and criticizing the instrument itself. RESULTS All the trainees showed steady improvement in skill acquisition on the laparoscopic simulator and discussed their essays, making proposals in order to improve the instrument they tested. CONCLUSION Significant improvement in performance with increasing skillness has been measured; during the course and during their discussion the participants showed deep knowledge of the instrument, ability to analyze and criticize it and ability to make improvement proposals.Dry lab experience for medical engineering students is useful for teaching and improving analysis and management of laparoscopic devices, allowing identification of problems and developing better devices.


What size tube doctor? Bigger may be better--at least for weaning.


Equine disease surveillance: quarterly summary.


title: Genomic analysis reveals age-dependent innate immune responses to severe acute respiratory syndrome coronavirus.

text: The relationship between immunosenescence and the host response to virus infection is poorly understood at the molecular level. Two different patterns of pulmonary host responses to virus were observed when gene expression profiles from severe acute respiratory syndrome coronavirus (SARS-CoV)-infected young mice that show minimal disease were compared to those from SARS-CoV-infected aged mice that develop pneumonitis. In young mice, genes related to cellular development, cell growth, and cell cycle were downregulated during peak viral replication, and these transcripts returned to basal levels as virus was cleared. In contrast, aged mice had a greater number of upregulated immune response and cell-to-cell signaling genes, and the expression of many genes was sustained even after viral clearance, suggesting an exacerbated host response to virus. Interestingly, in SARS-CoV-infected aged mice, a subset of genes, including Tnfa, Il6, Ccl2, Ccl3, Cxcl10, and Ifng, was induced in a biphasic pattern that correlated with peak viral replication and a subsequent influx of lymphocytes and severe histopathologic changes in the lungs. We provide insight into gene expression profiles and molecular signatures underlying immunosenescence in the context of the host response to viral infection.


title: Pure versus hand-assisted retroperitoneoscopic live donor nephrectomy: a retrospective cohort study of 1508 transplants from two centers.

text: BACKGROUND Although minimally invasive procedures have been established as the standard for a donor nephrectomy, there are many different surgical techniques described in the literature. The aim of this study is to compare the outcomes of kidney transplant procedures using the pure retroperitoneoscopic donor nephrectomy (PRDN) and hand-assisted retroperitoneoscopic donor nephrectomy (HARDN) techniques. METHODS A retrospective study involving 1508 transplant procedures was conducted; 874 were PRDN procedures; and 634 were HARDN. We reviewed the outcomes of the PRDN and HARDN groups, which were performed at two different centers over an identical time period. RESULTS Donors in the PRDN group had a longer operation time (P < 0.0001), reduced estimated blood loss (P < 0.0001), less open conversion (P = 0.0002), lower postoperative serum C-reactive protein levels (P < 0.0001), and a shorter postoperative hospital stay (P < 0.0001) than the HARDN group. Recipients in the PRDN group had lower serum creatinine levels at postoperative day 1-6 and the decreased incidence of slow graft function (P = 0.0017) than the HARDN group. The HARDN procedure was an independent risk factor for the incidence of acute rejection (P = 0.0211) and graft loss (P = 0.0193). CONCLUSIONS Our study suggests that the PRDN procedure is less invasive for donors as it results in reduced blood loss, lower postoperative serum CRP levels, and a shorter postoperative stay than the HARDN procedure. Additionally, PRDN provides a better outcome for recipients as it lowers the incidence of acute rejection and improves graft survival compared to HARDN.


title: Monitoring of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference.

text: OBJECTIVE To critically review the potential role of monitoring technologies in the management of pediatric acute respiratory distress syndrome, and specifically regarding monitoring of the general condition, respiratory system mechanics, severity scoring parameters, imaging, hemodynamic status, and specific weaning considerations. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The monitoring subgroup comprised two experts. When published data were lacking a modified Delphi approach, emphasizing strong professional agreement was used. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 21 of which related to monitoring of a child with pediatric acute respiratory distress syndrome. All 21 recommendations had agreement, with 19 (90%) reaching strong agreement. CONCLUSIONS The Consensus Conference developed pediatric-specific recommendations related to monitoring children with pediatric acute respiratory distress syndrome. These include interpreting monitored values such as tidal volume using predicted body weight, monitoring tidal volume at the end of the endotracheal tube in small children, and continuous monitoring of exhaled carbon dioxide in intubated children with pediatric acute respiratory distress syndrome, among others. These recommendations for monitoring in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.


title: Comparison of the intracorporeal triangular and delta-shaped anastomotic techniques in totally laparoscopic distal gastrectomy for gastric cancer: an analysis with propensity score matching.

text: BACKGROUND The delta-shaped anastomotic technique (Delta-SA) has been accepted as a standard reconstruction method in totally laparoscopic distal gastrectomy with Billroth I reconstruction (TLDG B-I). However, some anastomosis-related surgical complications have been reported. We evaluated the safety and feasibility of modified Delta-SA, called intracorporeal triangular anastomotic technique (INTACT), in this study. METHODS From January 2010 to May 2018, we identified patients who underwent TLDG B-I with INTACT (n = 289) and Delta-SA (n = 221). Using one-to-one propensity score matching, surgical outcomes and gastrointestinal function were compared between the two groups. RESULTS After one-to-one propensity score matching, 177 pairs of INTACT and Delta-SA patients were selected. Patient background was closely balanced between the two groups. Operative time (186 [159, 213] min vs. 237 [213, 264] min; P < 0.001), estimated blood loss (0 [0, 10] g vs. 20 [0, 50] g; P < 0.001), and postoperative hospital stay (7 [7, 9] days vs. 10 [9, 13] days; P < 0.001) were significantly lower in the INTACT group than in Delta-SA group. There were no patients with postoperative leakage in the INTACT group and three patients in the Delta group (0.0% vs. 1.7%; P = 0.041). Endoscopic food residue grade ≥ 3 based on the Residue, Gastritis, Bile classification system at 1 year after surgery was observed in 14 patients in the INTACT group and 30 patients in the Delta group (9.6% vs. 17.0%; P = 0.052). CONCLUSION INTACT in TLDG B-I is safe and feasible for gastric cancer. Given its acceptable surgical outcomes, this alternative reconstruction method can be an option with TLDG B-I.


title: Technical characteristics can make the difference in a surgical linear stapler. Or not?

text: BACKGROUND Anastomotic leak (AL) after gastrointestinal surgery is a severe complication associated with relevant short- and long-term sequelae. Most of the anastomosis are currently performed with a surgical stapler that is required to have appropriate characteristics to guarantee good performances. The aim of our study was to evaluate, in the laboratory, pressure resistance and tensile strength of anastomosis performed with different surgical linear staplers, available in the market. MATERIALS AND METHODS We have been studying three linear staplers, with diverse cartridges and staple heights, of three different companies, used for gastrointestinal anastomosis and gastric or intestinal closure. We performed 50 anastomosis for each device, with the pertinent different cartridges, on fresh pig intestine, for a total of 350 anastomosis, then injected saline solution and recorded the pressure that provokes a leak on the staple line. There were no statistically significant differences between the mean pressure necessary to induce an AL in the various instruments (P > 0.05). For studying the tensile strength, we performed a total of 350 anastomosis with the different linear staplers on a special strong paper (Tyvek), then recorded the maximal tensile force that could open the anastomosis. RESULTS There were no statistically significant differences between the different staplers about the strength necessary to open the staple line (P > 0.05). CONCLUSIONS we demonstrated that different linear staplers of three companies available in the market give comparable anastomotic pressure resistance and tensile strength. This might suggest that small dissimilarities between different devices are not involved, at least as major parameters, in AL etiology.


title: Inter-rater reliability of published flow diversion occlusion scales.

text: BACKGROUND With increasing use of flow-diverting stents for the treatment of intracranial aneurysms, standardized methods and a common language to evaluate angiographic outcomes are needed. Multiple grading scales have been developed for this purpose but none has been widely adopted. OBJECTIVE To analyze these scales to determine interobserver reliability. METHODS Four independent assessors scored the intraprocedural angiograms of patients who underwent flow-diverting stent deployment for an intracranial saccular or fusiform aneurysm at our institution between October 2012 and June 2015. Angiographic outcome immediately after flow-diverting stent deployment was scored using three grading scales (Kamran-Byrne (KB), Simple Measurement of Aneurysm Residual after Treatment (SMART), and O'Kelley, Krings, Marotta (OKM)). Statistical analysis was performed using Light's κ for multiple raters (κ), Kendall's coefficient of concordance (W), and intraclass correlation (ICC). RESULTS We included the angiograms of 50 consecutive patients (mean age 58 years, range 30-79) who underwent flow-diverting stent deployment for an intracranial aneurysm (40 saccular, 10 fusiform). Six aneurysms were located in the posterior circulation. The inter-rater reliability was typically poor or fair: SMART aneurysm filling (κ=0.30, W=0.36, ICC=0.12), SMART parent vessel stenosis (κ=0.07, W=0.33, ICC=0.12), KB axis I (κ=0.24, W=0.50, ICC=0.25), KB axis II (κ=0.07, W=0.30, ICC=0.06), OKM aneurysm filling (κ=0.23, W=0.45, ICC=0.13), OKM contrast stasis (κ=0.36,W=0.71, ICC=0.54). CONCLUSIONS Existing flow-diverting stent grading scales have low inter-rater reliability for most categories.


title: Completeness of reporting of randomised controlled trials including people with transient ischaemic attack or stroke: A systematic review.

text: Purpose To assess the adherence of stroke randomised controlled trials to Consolidated Standards Of Reporting Trials reporting guidelines and investigate the factors that are associated with completeness of reporting. Method We took a random sample from the Cochrane Stroke Group's Trial Register of transient ischaemic attack or stroke randomised controlled trials, published in English in 1997-2016 inclusive. Two reviewers assessed the published report of the final primary results of stroke randomised controlled trials with a 10-point truncated Consolidated Standards Of Reporting Trials reporting checklist to investigate adherence over time, univariable associations and independent associations with total Consolidated Standards Of Reporting Trials reporting score in a multiple linear regression model. Findings In this random sample of 177 stroke randomised controlled trials, the mean score on the truncated Consolidated Standards Of Reporting Trials checklist was 5.8 (SD 2.2); reporting improved from 1997-2000 (4.9 SD 2.0) to 2001-2009 (5.8 SD 2.1) and to 2010-2016 (6.8 SD 2.1). A higher Consolidated Standards Of Reporting Trials score was independently associated with publication during epochs following a revision of Consolidated Standards Of Reporting Trials reporting guidelines (p < 0.001), journal endorsement of the Consolidated Standards Of Reporting Trials reporting guideline at the time of randomised controlled trial publication (p < 0.001) and modified journal impact factor using median citation distribution (p = 0.012). Discussion Stroke randomised controlled trial reporting to Consolidated Standards Of Reporting Trials standards has improved over time, but could be better. Conclusion Journal endorsement and enforcement of Consolidated Standards Of Reporting Trials reporting guidelines could further improve the reporting of stroke randomised controlled trials.Systematic review registration: Registered with PROSPERO (CRD42017072193).


title: Spatial-temporal distribution of COVID-19 in China and its prediction: A data-driven modeling analysis.

text: Currently, the outbreak of COVID-19 is rapidly spreading especially in Wuhan city, and threatens 14 million people in central China. In the present study we applied the Moran index, a strong statistical tool, to the spatial panel to show that COVID-19 infection is spatially dependent and mainly spread from Hubei Province in Central China to neighbouring areas. Logistic model was employed according to the trend of available data, which shows the difference between Hubei Province and outside of it. We also calculated the reproduction number R0 for the range of [2.23, 2.51] via SEIR model. The measures to reduce or prevent the virus spread should be implemented, and we expect our data-driven modeling analysis providing some insights to identify and prepare for the future virus control.


title: Local immunization strategy based on the scores of nodes.

text: The problem of finding a better immunization strategy for controlling the spreading of the epidemic with limited resources has attracted much attention because of its great theoretical significance and wide application. In this paper, we propose a successful immunization strategy only depending on local information. Our strategy initializes the scores of nodes with the values of their degree and recalculates the score of a certain immunized node based on its local information, and then replaces the certain immunized node with its nonimmunized higher-score neighbor. To test the effectiveness of the proposed strategy, we conduct the experiments on several synthetic networks and real-world networks. The results show that the proposed strategy outperforms the existing well-known local strategies, even the degree centrality targeted strategy.


title: Primary brachial plexus neoplasia in cats.

text: Conditions affecting the brachial plexus and its branches can cause lameness and/or neurological deficits. There are few reports of schwannomas in cats. In reported cases, the tumours arose from the dermis or subcutis of the limbs, head and neck and thorax, but there are no reports of primary tumours that arose from the brachial plexus itself. The purpose of this study is to present the clinical, radiological, ultrasonographical and pathological findings of primary brachial plexus tumour in three cats.


title: [Epidemiological investigation on a cluster epidemic of COVID-19 in a collective workplace in Tianjin].

text: Objective: To investigate and analysis the epidemiological characteristics of a cluster epidemic of COIVD-19 in a collective workplace in Tianjin, evduate the prevention and control measures based on limited evidence and experience in early period of COVID-19 epidemic. Methods: Descriptive research method was used to describe the distribution and other epidemiological characteristics of the cluster cases of COVID-19. Results: Since the onset of the first index case on January 15, ten confirmed COVID-19 cases had occurred in the workplace, and the epidemic had spread from the workplace to 4 families, infecting 7 family members. The median age of 17 cases was 55 (19-79) years. All the 10 employee cases were males, and in 7 family cases, 3 were males and 4 were females. Of the employee cases, 8 worked in CW workshop and 2 worked in administrative office building. The median exposure-onset interval of all the cases was 4 (0-12) days, and the median exposure-onset interval was 4.5 days in the employee cases and 4 days in the family cases. The median onset-medical care seeking interval was 4 days in the non-isolated cases, 2.5 days in the cases with home isolation after onset, and 0.5 day in the cases with home isolation before onset. Conclusion: The clustering of COVID-19 cases was observed in this workplace in Tianjin, which affected 4 families. In the early stage of the epidemic, accurate and rapid blocking and control measures can completely prevent the large-scale spread of COVID-19.


An Acute Respiratory Infection Runs Into the Most Common Noncommunicable Epidemic-COVID-19 and Cardiovascular Diseases.


Telemedicine in the Time of the Coronavirus.


Participating in telehealth is a complex occupation.


title: COVID-19 and Abdominal Transplant: A Stepwise Approach to Practice During Pandemic Conditions.

text: BACKGROUND The novel severe acute respiratory syndrome Coronavirus (SARS-CoV-2) disease has transformed innumerable aspects of medical practice, particularly in the field of transplantation. MAIN BODY Here we describe a single-center approach to creating a generalizable, comprehensive, and graduated set of recommendations to respond in stepwise fashion to the challenges posed by these conditions, and the underlying principles guiding such decisions. CONCLUSION Creation of a stepwise plan will allow transplant centers to respond in a dynamic fashion to the ongoing challenges posed by the COVID-19 pandemic.


Relevant role of von Willebrand factor in neutrophil recruitment in a mouse sepsis model involving cecal ligation and puncture.


title: Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients.

text: BACKGROUND Findings have shown that single-incision laparoscopic cholecystectomy (SILC) is feasible and reproducible. The authors have pioneered a two-trocar SILC technique at the University of Texas Southwestern. Their results for 100 patients are presented. METHODS From January 2008 to March 2009, 100 patients with symptomatic gallbladder disease underwent SILC through a 1.5- to 2-cm umbilical incision using a two-port (5-mm) technique. For nearly all the patients, a 30 degrees angled scope was used. The gallbladder was retracted, with two or three sutures placed along the gallbladder. These sutures were either fixated internally or placed through the abdominal wall to obtain a critical view of Calot's triangle. The SILC procedure was performed using standard technique with 5-mm reticulating or conventional laparoscopic instruments. The cystic duct and artery were well visualized, clipped, and divided. Cholecystectomy was completed with electrocautery, and the specimen was retrieved through the umbilical incision. RESULTS In this series, 80 women (85%) and 15 men (15%) with an average age of 33.8 years (range, 17-66 years) underwent SILC. Their mean BMI was 29.8 kg/m(2) (range, 17-42.5 kg/m(2)), and 39% of these patients had undergone previous abdominal surgery. The mean operative time was 50.8 min (range, 23-120 min). The mean estimated blood loss was 22.3 ml (range, 5-125 ml), and 5% of the patients had an intraoperative cholangiogram. There were no conversions of the SILC technique. A two-trocar technique was feasible for 87% of the patients. For the remaining patients, either a three-channel port or three individual trocars were required. A SILC technique was used for 5% of the patients to manage acute cholecystitis or gallstone pancreatitis. CONCLUSION The SILC technique with a two-trocar technique is safe, feasible, and reproducible. The operating times are reasonable and can be lessened with experience. Even complex cases can be managed with this technique. Excellent exposure of the critical view was obtained in all cases. The SILC procedure is becoming the standard of care for most of the authors' elective patients with gallbladder disease. Clinical trials are warranted before the SILC technique is adopted universally.


title: Remodeling characteristics and collagen distribution in synthetic mesh materials explanted from human subjects after abdominal wall reconstruction: an analysis of remodeling characteristics by patient risk factors and surgical site classifications.

text: BACKGROUND The purpose of this study was to evaluate the associations between patient characteristics or surgical site classifications and the histologic remodeling scores of synthetic meshes biopsied from their abdominal wall repair sites in the first attempt to generate a multivariable risk prediction model of non-constructive remodeling. METHODS Biopsies of the synthetic meshes were obtained from the abdominal wall repair sites of 51 patients during a subsequent abdominal re-exploration. Biopsies were stained with hematoxylin and eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell infiltration, cell types, extracellular matrix deposition, inflammation, fibrous encapsulation, and neovascularization) and a mean composite score (CR). Biopsies were also stained with Sirius Red and Fast Green, and analyzed to determine the collagen I:III ratio. Based on univariate analyses between subject clinical characteristics or surgical site classification and the histologic remodeling scores, cohort variables were selected for multivariable regression models using a threshold p value of ≤0.200. RESULTS The model selection process for the extracellular matrix score yielded two variables: subject age at time of mesh implantation, and mesh classification (c-statistic = 0.842). For CR score, the model selection process yielded two variables: subject age at time of mesh implantation and mesh classification (r (2) = 0.464). The model selection process for the collagen III area yielded a model with two variables: subject body mass index at time of mesh explantation and pack-year history (r (2) = 0.244). CONCLUSION Host characteristics and surgical site assessments may predict degree of remodeling for synthetic meshes used to reinforce abdominal wall repair sites. These preliminary results constitute the first steps in generating a risk prediction model that predicts the patients and clinical circumstances for which non-constructive remodeling of an abdominal wall repair site with synthetic mesh reinforcement is most likely to occur.


title: Pipeline embolization device for recurrence of previously treated aneurysms.

text: OBJECTIVE The utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms. METHODS The authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group. RESULTS All PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months. CONCLUSIONS The treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.


[Biological characters analysis of COVID-19 patient accompanied with aplastic anemia].


title: Calvarial Model of Bone Augmentation in Rabbit for Assessment of Bone Growth and Neovascularization in Bone Substitution Materials.

text: The basic principle of the rabbit calvarial model is to grow new bone tissue vertically on top of the cortical part of the skull. This model allows assessment of bone substitution materials for oral and craniofacial bone regeneration in terms of bone growth and neovascularization support. Once animals are anesthetized and ventilated (endotracheal intubation), four cylinders made of polyether ether ketone (PEEK) are screwed onto the skull, on both sides of the median and coronal sutures. Five intramedullary holes are drilled within the bone area delimited by each cylinder, allowing influx of bone marrow cells. The material samples are placed into the cylinders which are then closed. Finally, the surgical site is sutured, and animals are awaken. Bone growth may be assessed on live animals by using microtomography. Once animals are euthanized, bone growth and neovascularization may be evaluated by using microtomography, immune-histology and immunofluorescence. As the evaluation of a material requires maximum standardization and calibration, the calvarial model appears ideal. Access is very easy, calibration and standardization are facilitated by the use of defined cylinders and four samples may be assessed simultaneously. Furthermore, live tomography may be used and ultimately a large decrease in animals to be euthanized may be anticipated.


title: Impact of statins and ACE inhibitors on mortality after COPD exacerbations.

text: BACKGROUND The purpose of our study was to examine the association of prior outpatient use of statins and angiotensin converting enzyme (ACE) inhibitors on mortality for subjects >or= 65 years of age hospitalized with acute COPD exacerbations. METHODS We conducted a retrospective national cohort study using Veterans Affairs administrative data including subjects >or=65 years of age hospitalized with a COPD exacerbation. Our primary analysis was a multilevel model with the dependent variable of 90-day mortality and hospital as a random effect, controlling for preexisting comorbid conditions, demographics, and other medications prescribed. RESULTS We identified 11,212 subjects with a mean age of 74.0 years, 98% were male, and 12.4% of subjects died within 90-days of hospital presentation. In this cohort, 20.3% of subjects were using statins, 32.0% were using ACE inhibitors or angiotensin II receptor blockers (ARB). After adjusting for potential confounders, current statin use (odds ratio 0.51, 95% confidence interval 0.40-0.64) and ACE inhibitor/ARB use (0.55, 0.46-0.66) were significantly associated with decreased 90-day mortality. CONCLUSION Use of statins and ACE inhibitors prior to admission is associated with decreased mortality in subjects hospitalized with a COPD exacerbation. Randomized controlled trials are needed to examine whether the use of these medications are protective for those patients with COPD exacerbations.


Blood Glucose Control During Lockdown for COVID-19: CGM Metrics in Italian Adults With Type 1 Diabetes.


title: A prospective randomized trial of tapered-cuff endotracheal tubes with intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill patients.

text: BACKGROUND Endotracheal tube placement is necessary for the control of the airway in patients who are mechanically ventilated. However, prolonged duration of endotracheal tube placement contributes to the development of ventilator-associated pneumonias (VAPs). The aim of this study was to evaluate whether subglottic suctioning using TaperGuard EVAC tubes was effective in decreasing the frequency of VAP. METHODS A total of 276 mechanically ventilated patients for more than 72 hours were randomly assigned to group E (EVAC tube) and group C (conventional tube). All patients received routine care including VAP prevention measures during their intensive care unit stay. In group E, subglottic suctioning was performed every 6 hours. Outcome variables included incidence VAP, intensive care unit length of stay, and mortality. RESULTS Frequency of intraluminal suction, mechanical ventilation-free days, reintubation, the ratio of arterial oxygen partial pressure to fractional inspired oxygen and mortality rate were similar between the 2 groups (P > .05). The mean cuff pressure in group E was significantly less than that in group C (P < .001). Ventilator-associated pneumonia was significantly less in group E compared with group C (P = .015). CONCLUSION The use of intermittent subglottic secretion suctioning was associated with a significant decrease in the incidence of the VAP in critically ill patients. However, larger multicenter trials are required to arrive at a concrete decision on routine usage of TaperGuard tubes in critical care settings.


title: MOSES: A Matlab-based open-source stochastic epidemic simulator.

text: This paper presents an open-source stochastic epidemic simulator. Discrete Time Markov Chain based simulator is implemented in Matlab. The simulator capable of simulating SEQIJR (susceptible, exposed, quarantined, infected, isolated and recovered) model can be reduced to simpler models by setting some of the parameters (transition probabilities) to zero. Similarly, it can be extended to more complicated models by editing the source code. It is designed to be used for testing different control algorithms to contain epidemics. The simulator is also designed to be compatible with a network based epidemic simulator and can be used in the network based scheme for the simulation of a node. Simulations show the capability of reproducing different epidemic model behaviors successfully in a computationally efficient manner.


title: Intravascular optical coherence tomography for the evaluation of arterial bifurcations covered by flow diverters.

text: BACKGROUND AND OBJECTIVE Due to its high spatial resolution, intravascular optical coherence tomography (OCT) has been used as a valid method for in vivo evaluation of several types of coronary stents at straight lumen and bifurcation sites. We sought to evaluate its effectiveness for flow diverting stents deployed in arterial bifurcation sites involving jailing of a side branch. METHODS Four large white swine were stented with flow diverting stents covering the right common carotid artery-ascending pharyngeal artery bifurcation. After 12 weeks of follow-up the animals were evaluated by digital subtraction angiography and intravascular OCT and subsequently sacrificed. Neointimal thickness on the parent arteries and the free segments of the stent were measured. The stented arteries were harvested and underwent scanning electron microscopy (SEM) imaging. Ostia surface values were measured with OCT three-dimensional (3D) reconstructions and SEM images. RESULTS All endovascular procedures and OCT pullback runs were feasible. Stent apposition was satisfactory on the immediate post-stent OCT reconstructions. At 12-week controls, all stents and jailed branches were patent. Mean neointimal thickness was 0.11±0.04 mm on the free segments of the stent. The mean ostia surface at 12 weeks was 319 750±345 533 μm2 with 3D-OCT reconstructions and 351 198±396 355 μm2 with SEM image-derived calculations. Good correlation was found for ostia surface values between the two techniques; the values did not differ significantly in this preliminary study. CONCLUSIONS Intravascular OCT appears to be a promising technique for immediate and follow-up assessment of the orifice of arterial branches covered by flow diverting stents.


Antigen-induced mast cell (MC) activation via cross-linking of IgE-bound high-affinity receptors for IgE (FcεRI) underlies type I allergy and anaphylactic shock. Comprehensive knowledge of FcεRI regulation is thus required. We have identified a functional interaction between FcεRI and CD13 in murine MCs. Antigen-triggered activation of IgE-loaded FcεRI results in cocapping and cointernalization of CD13 and equivalent internalization rates of up to 40%. Cointernalization is not unspecific, because ligand-driven KIT internalization is not accompanied by CD13 internalization. Moreover, antibody-mediated cross-linking of CD13 causes IL-6 production in an FcεRI-dependent manner. These data are indicative of a functional interaction between FcεRI and CD13 on MCs. To determine the role of this interaction, CD13-deficient bone marrow-derived MCs (BMMCs) were analyzed. Intriguingly, antigen stimulation of CD13-deficient BMMCs results in significantly increased degranulation and proinflammatory cytokine production compared to wild-type cells. Furthermore, in a low-dose model of passive systemic anaphylaxis, antigen-dependent decrease in body temperature, reflecting the anaphylactic reaction, is substantially enhanced by the CD13 inhibitor bestatin (-5.9 ± 0.6°C) and by CD13 deficiency (-8.8 ± 0.6°C) in contrast to controls (-1.2 ± 1.97°C). Importantly, bestatin does not aggravate anaphylaxis in CD13-deficient mice. Thus, we have identified CD13 as a novel negative regulator of MC activation in vitro and in vivo-Zotz, J. S., Wölbing, F., Lassnig, C., Kauffmann, M., Schulte, U., Kolb, A., Whitelaw, B., Müller, M., Biedermann, T., Huber, M. CD13/aminopeptidase N is a negative regulator of mast cell activation.


title: A to Z in neurointerventional surgery: A primer for residents.

text: Neurointerventional surgery has evolved rapidly over the last two-and-a-half decades. It is now the treatment of choice for many neurovascular conditions, and its techniques and indications are rapidly expanding. It is the need of the hour that residents in training programs should familiarize themselves with the basic concepts of neurointerventional surgery. There are no set guidelines regarding neuroendovascular training of residents in India. The current article provides an insight into the basic concepts of neurointerventional surgery for residents in training.


Fighting on two fronts: drug-drug interactions in people living with HIV infected with SARS-CoV-2.


title: Neurovirulent Murine Coronavirus JHM.SD Uses Cellular Zinc Metalloproteases for Virus Entry and Cell-Cell Fusion.

text: The coronavirus (CoV) S protein requires cleavage by host cell proteases to mediate virus-cell and cell-cell fusion. Many strains of the murine coronavirus mouse hepatitis virus (MHV) have distinct, S-dependent organ and tissue tropisms despite using a common receptor, suggesting that they employ different cellular proteases for fusion. In support of this hypothesis, we found that inhibition of endosomal acidification only modestly decreased entry, and overexpression of the cell surface protease TMPRSS2 greatly enhanced entry, of the highly neurovirulent MHV strain JHM.SD relative to their effects on the reference strain, A59. However, TMPRSS2 overexpression decreased MHV structural protein expression, release of infectious particles, and syncytium formation, and endogenous serine protease activity did not contribute greatly to infection. We therefore investigated the importance of other classes of cellular proteases and found that inhibition of matrix metalloproteinase (MMP)- and a disintegrin and metalloprotease (ADAM)-family zinc metalloproteases markedly decreased both entry and cell-cell fusion. Suppression of virus by metalloprotease inhibition varied among tested cell lines and MHV S proteins, suggesting a role for metalloprotease use in strain-dependent tropism. We conclude that zinc metalloproteases must be considered potential contributors to coronavirus fusion.IMPORTANCE The family Coronaviridae includes viruses that cause two emerging diseases of humans, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), as well as a number of important animal pathogens. Because coronaviruses depend on host protease-mediated cleavage of their S proteins for entry, a number of protease inhibitors have been proposed as antiviral agents. However, it is unclear which proteases mediate in vivo infection. For example, SARS-CoV infection of cultured cells depends on endosomal acid pH-dependent proteases rather than on the cell surface acid pH-independent serine protease TMPRSS2, but Zhou et al. (Antiviral Res 116:76-84, 2015, doi:10.1016/j.antiviral.2015.01.011) found that a serine protease inhibitor was more protective than a cathepsin inhibitor in SARS-CoV-infected mice. This paper explores the contributions of endosomal acidification and various proteases to coronavirus infection and identifies an unexpected class of proteases, the matrix metalloproteinase and ADAM families, as potential targets for anticoronavirus therapy.


Looking beyond the coronavirus: lessons and principles.


title: Laparoscopic anatomical liver resection after complex blunt liver trauma: a case report.

text: BACKGROUND Various minimally invasive therapies are important adjuncts to management of hepatic injuries. However, there is a certain subset of patients who will benefit from liver resection, but there are no reports in the literature on laparoscopic anatomical liver resection for the management of complications after blunt liver trauma. CASE PRESENTATION A 20-year-old male was admitted to the Emergency Unit of a tertiary referral center following a car accident. The patient was hemodynamically stable, and a radiologic workup demonstrated an isolated grade 3 injury of the left hemiliver. Initially, a nonoperative management was indicated, but during days following the injury, a high-volume biliary fistula complicated the clinical course. Despite percutaneous drainage, the development of devastating consequences of biliary peritonitis was imminent. A pure laparoscopic anatomical liver resection was performed. Left lateral sectionectomy eliminated the source of bile leak, and the surgery was completed with abdominal cavity lavage. Postoperative outcome was uneventful, and the patient was discharged on day 9 after injury and day 4 after surgery returning to his normal activity. CONCLUSIONS In highly selected, hemodynamically stable patients with no other life-threatening concomitant injuries, laparoscopic liver resection in elective setting is feasible and safe for the management of complications after complex blunt trauma of the left liver. Extensive experience with hepatic surgery is needed, and surgeons should understand the increased risk they assume by taking on more complex surgical techniques.


Analyzing the Cost Effectiveness of Policy Responses for COVID-19: The Importance of Capturing Social Consequences.


title: Safe and Sensitive Antiviral Screening Platform Based on Recombinant Human Coronavirus OC43 Expressing the Luciferase Reporter Gene.

text: Human coronaviruses (HCoVs) cause 15 to 30% of mild upper respiratory tract infections. However, no specific antiviral drugs are available to prevent or treat HCoV infections to date. Here, we developed four infectious recombinant HCoVs-OC43 (rHCoVs-OC43) which express the Renilla luciferase (Rluc) reporter gene. Among these four rHCoVs-OC43, rOC43-ns2DelRluc (generated by replacing ns2 with the Rluc gene) showed robust luciferase activity with only a slight impact on its growth characteristics. Additionally, this recombinant virus remained stable for at least 10 passages in BHK-21 cells. rOC43-ns2DelRluc was comparable to its parental wild-type virus (HCoV-OC43-WT) with respect to the quantity of the antiviral activity of chloroquine and ribavirin. We showed that chloroquine strongly inhibited HCoV-OC43 replication in vitro, with a 50% inhibitory concentration (IC50) of 0.33 μM. However, ribavirin showed inhibition of HCoV-OC43 replication only at high concentrations which may not be applicable to humans in clinical treatment, with an IC50 of 10 μM. Furthermore, using a luciferase-based small interfering RNA (siRNA) screening assay, we identified double-stranded-RNA-activated protein kinase (PKR) and DEAD box RNA helicases (DDX3X) that exhibited antiviral activities, which were further verified by the use of HCoV-OC43-WT. Therefore, rOC43-ns2DelRluc represents a promising safe and sensitive platform for high-throughput antiviral screening and quantitative analysis of viral replication.


title: Controversies in neonatal resuscitation.

text: Despite recent advances in perinatal medicine and in the art of neonatal resuscitation, resuscitation strategy and treatment methods in the delivery room should be individualized depending on the unique characteristics of the neonate. The constantly increasing evidence has resulted in significant treatment controversies, which need to be resolved with further clinical and experimental research.


title: Treatment of high- and intermediate-risk pulmonary embolism using the AngioJet percutaneous mechanical thrombectomy system in patients with contraindications for thrombolytic treatment - a pilot study.

text: Introduction Intravenous thrombolysis is the treatment of choice in patients presenting with high- and intermediate-risk pulmonary embolism. The role of percutaneous mechanical pulmonary thrombectomy (PMPT) is not fully established, although selected patients can be managed with this method. Aim This open-label single-centre prospective pilot study was aimed at assessing the feasibility of PMPT for the treatment of severe pulmonary embolism in a Polish hospital. We also evaluated the safety and efficacy of such management. Material and methods We managed 7 patients, aged 52.7 ±16.6 years, presenting with high- and intermediate-risk pulmonary embolism (4 patients with class 5 and one patient with class 4 of the Pulmonary Embolism Severity Index), with occlusion of at least 2 lobar arteries and contraindications for thrombolysis. Percutaneous mechanical pulmonary thrombectomy was performed using the AngioJet system. Results It was possible to introduce the thrombectomy system to the pulmonary arteries in all patients. The procedure was successful in 6 patients (technical success rate: 85.7%). Two (28.6%) patients died during the hospital stay, one patient with unsuccessful thrombectomy and the other due to pneumonia. In all survivors control echocardiography demonstrated normalised function of the right ventricle. Also, dyspnoea disappeared and blood gas parameters normalised. There was no recurrent thromboembolism during 3-14 months of follow-up. Conclusions In the Polish setting, in selected patients, management of high- and intermediate-risk pulmonary embolism with PMPT is technically feasible. Such treatment is relatively safe and effective. It can be an alternative to standard management, especially in patients with contraindications for fibrinolysis or surgical embolectomy.


Systemic coronavirus-associated disease resembling feline infectious peritonitis in ferrets in the UK.


title: Outcomes and outcomes measurements used in intervention studies of pelvic girdle pain and lumbopelvic pain: a systematic review.

text: Background Pelvic girdle pain is a common problem during pregnancy and postpartum with significant personal and societal impact and costs. Studies examining the effectiveness of interventions for pelvic girdle pain measure different outcomes, making it difficult to pool data in meta-analysis in a meaningful and interpretable way to increase the certainty of effect measures. A consensus-based core outcome set for pelvic girdle pain can address this issue. As a first step in developing a core outcome set, it is essential to systematically examine the outcomes measured in existing studies. Objective The objective of this systematic review was to identify, examine and compare what outcomes are measured and reported, and how outcomes are measured, in intervention studies and systematic reviews of interventions for pelvic girdle pain and for lumbopelvic pain (which includes pelvic girdle pain). Methods We searched PubMed, Cochrane Library, PEDro and Embase from inception to the 11th May 2018. Two reviewers independently selected studies by title/abstract and by full text screening. Disagreement was resolved through discussion. Outcomes reported and their outcome measurement instruments were extracted and recorded by two reviewers independently. We assessed the quality of reporting with two independent reviewers. The outcomes were grouped into core domains using the OMERACT filter 2.0 framework. Results A total of 107 studies were included, including 33 studies on pelvic girdle pain and 74 studies on lumbopelvic pain. Forty-six outcomes were reported across all studies, with the highest amount (26/46) in the 'life impact' domain. 'Pain' was the most commonly reported outcome in both pelvic girdle pain and lumbopelvic pain studies. Studies used different instruments to measure the same outcomes, particularly for the outcomes pain, function, disability and quality of life. Conclusions A wide variety of outcomes and outcome measurements are used in studies on pelvic girdle pain and lumbopelvic pain. The findings of this review will be included in a Delphi survey to reach consensus on a pelvic girdle pain - core outcome set. This core outcome set will allow for more effective comparison between future studies on pelvic girdle pain, allowing for more effective translation of findings to clinical practice. Supplementary information Supplementary information accompanies this paper at 10.1186/s12998-019-0279-2.


title: Treatment outcomes of carotid artery stenting with two types of distal protection filter device.

text: PURPOSE Preventing cerebral embolism from debris produced during carotid artery stenting (CAS) is important. This study compared the treatment outcomes of CAS using two types of filter-based embolic protection devices currently in use in Japan. MATERIALS AND METHODS We assessed 121 consecutive cases of CAS performed with FilterWire EZ™ between July 2010 and November 2012 and 37 consecutive cases of CAS performed with the Spider FX™ between November 2012 and June 2013. A Carotid Wallstent™ was used in all cases. The incidence of positive lesions on diffusion-weighted magnetic resonance imaging (DWI) and stroke were compared between the groups. RESULTS Postoperative DWI-positive lesions were observed in 38 (31.4%) and 14 (37.8%) patients in the FilterWire and Spider groups, respectively. In the FilterWire group, complications were transient ischemic attacks in 3 (2.5%) patients, cerebral infarction in 2 (1.7%) patients (1 patient each with minor and major stroke), and cerebral hemorrhage due to hyperperfusion syndrome in 1 (0.8%) patient. In the Spider group, except for cerebral infarction (minor stroke) in 1 (2.7%) patient, no complications were observed. No significant differences were observed in the incidence of complications between the groups. CONCLUSION FilterWire EZ and Spider FX are comparable in terms of treatment outcome.


title: Use of a bioprosthetic mesh in complex hernia repair: early results from a French multicenter pilot study.

text: BACKGROUND Implantation of synthetic meshes for reinforcement of abdominal wall hernias can be complicated by mesh infection, which often requires mesh explantation. The risk of mesh infection is increased in a contaminated environment or in patients who have comorbidities such as diabetes or smoking. The use of biological prostheses has been advocated because of their ability to resist infection. Initial results, however, have shown high hernia recurrence rates and wound occurrences. The objective of the present study is to evaluate early and mid-term outcomes in the largest French series that included 43 consecutive complex abdominal hernias repaired with biological prostheses. MATERIALS AND METHODS Retrospective observational study of a prospective collected data bank. Patient demographics, history of previous repairs, intraoperative findings and degree of contamination, associated procedures, postoperative prosthetic-related complications, and long-term results were retrospectively reviewed. RESULTS There were 25 (58%) incisional, 14 parastomal, and 4 midline hernia repairs. Hernias were considered "clean" (n = 5), "clean-contaminated" (n = 19), "contaminated" (n = 12), or "dirty" (n = 7). Wound-related morbidity occurred in 17 patients; 4 patients needed reoperation for cutaneous necrosis or abscess. Smoking was the only risk factor associated with wound complication (P = .022). No postoperative wound events required removal of the prosthesis. There were 4 hernia recurrences (9%). A previous attempt at repair (P = .018) and no complete fascia closure (P = .033) were associated with hernia recurrence. CONCLUSIONS This study demonstrated that the use of bioprothesis in complex hernia repair allowed successful single-stage reconstruction. Wound-related complications were frequent. Cost-benefit analyses are important to establish the validity of these findings.


title: Simulation of aortopulmonary collateral flow in Fontan patients for use in prediction of interventional outcomes.

text: PURPOSE Patients with complex congenital heart disease may need to be converted to a Fontan circulation with systemic venous return surgically connected to the pulmonary circulation. These patients frequently form aortopulmonary collaterals (APC), that is arterial inflows to the pulmonary artery vascular tree. The aim of this study was to develop a method to calculate the effect of APC on the pulmonary flow distribution based on magnetic resonance imaging (MRI) measurements and computational fluid dynamics simulations in order to enable prediction of interventional outcomes in Fontan patients. METHODS Patient-specific models of 11 patients were constructed in a 3D-design software based on MRI segmentations. APC flow was quantified as the difference between pulmonary venous flow and pulmonary artery flow, measured by MRI. A method was developed to include the modulating effect of the APC flow by calculating the patient-specific relative pulmonary vascular resistance. Simulations, including interventions with a Y-graft replacement and a stent dilatation, were validated against MRI results. RESULTS The bias between simulated and MRI-measured fraction of blood to the left lung was 2·9 ± 5·3%. Including the effects of the APC flow in the simulation (n = 6) reduced simulation error from 9·8 ± 7·0% to 5·2 ± 6·3%. Preliminary findings in two patients show that the effect of surgical and catheter interventions could be predicted using the demonstrated methods. CONCLUSIONS The work demonstrates a novel method to include APC flow in predictive simulations of Fontan hemodynamics. APC flow was found to have a significant contribution to the pulmonary flow distribution in Fontan patients.


title: Assessment of hospital emergency management in the Beijing area.

text: INTRODUCTION In recent years, the number of public health emergencies has increased. Improving hospital emergency management is an important challenge. OBJECTIVE This is a pilot study intended to assess hospital emergency management in the Beijing area, make recommendations to government health authorities and hospital managers, and offer references for similar studies. METHODS This was an observational, cross-sectional survey. Forty-five hospitals in the Beijing area were selected randomly. A self-administered questionnaire was used as a data collection tool. It comprised of three sections: (1) Section A was the introduction; (2) Section B asked for the respondent's personal information; and (3) Section C comprised the major part of the questionnaire and was intended to gather information regarding the hospital's general emergency management situation. RESULTS The survey response rate was 44%, accounting for 29% of total hospitals that the study targeted. No hospital had an established emergency management department or full-time staff for emergency management. A total of 15-45% of the hospitals had established a hospital emergency management committee, performed a vulnerability analysis, or evaluated emergency management regularly. Twenty-five percent of respondents thought that the local government health authority had established an integrated hospital incident command system. A total of 40%-55% of hospitals contracted with outside institutions for supplements, backup of key functional systems and professional support. CONCLUSIONS After the occurrence of the 2003 severe acute respiratory syndrome (SARS) epidemic, Chinese hospital managers took many measures to improve hospital resilience. However, most of these efforts lacked the guidance of theories, concepts, principles, and methods. An integrated, standardized, operational hospital emergency management model has not been established. Although the survey response rate was relatively low, some clues for further study were discovered, and suggestions to the health authority for hospital emergency management improvement were revealed.


Taking a Closer Look at COVID-19, Health Inequities, and Racism.


title: Ergonomic analysis of muscle activity in the forearm and back muscles during laparoscopic surgery: influence of previous experience and performed task.

text: PURPOSE The first aim of this study is to analyze the muscle activity in back and forearm muscles in surgeons during laparoscopic dissection and suturing maneuvers. The second aim is to determine the influence of the surgeons' previous experience in laparoscopic surgery. METHODS A total of 30 laparoscopic surgeons were divided in 3 groups: novice suturing, novice dissecting, and experts suturing. Electromyography data were collected from the trapezius, forearm flexors, and forearm extensors muscles, during the proposed tasks on physical simulator. RESULTS Muscle activity was significantly lower in the expert group. Moreover, muscle activity in the trapezius was significantly higher during the completion of intracorporeal suturing when compared with that during dissection. CONCLUSIONS Results obtained in this study show that the surgeons with a higher degree of laparoscopic experience exhibit a lower level of muscle activity when compared with the novice surgeons. Moreover, in accordance to our results, laparoscopic suturing involves a higher degree of muscle effort than during laparoscopic dissection.


title: Avoiding hyperoxemia during neonatal resuscitation: time to response of different SpO2 monitors.

text: AIM To assess the time to obtain reliable oxygen saturation readings by different pulse oximeters during neonatal resuscitation in the delivery room or NICU. METHODS Prospective study comparing three different pulse oximeters: Masimo Radical-7 compared simultaneously with Ohmeda Biox 3700 or with Nellcor N395, in newborn infants who required resuscitation. Members of the research team placed the sensors for each of the pulse oximeters being compared simultaneously, one sensor on each foot of the same baby. Care provided routinely, without interference by the research team. The time elapsed until a reliable SpO2 was obtained was recorded using a digital chronometer. Statistical comparisons included chi-square and student's T-test. RESULTS Thirty-two infants were enrolled; median gestational age 32 weeks. Seventeen paired measurements were made with the Radical-7 and Biox 3700; mean time to a stable reading was 20.2±7 sec for the Radical-7 and 74.2±12 sec for the Biox 3700 (p=0.02). The Radical-7 and the N- 395 were paired on 15 infants; the times to obtain a stable reading were 20.9±4 sec and 67.3±12 sec, respectively (p=0.03). CONCLUSION The time to a reliable reading obtained simultaneously in neonatal critical situations differs by the type of the pulse oximeter used, being significantly faster with Masimo Signal Extraction Technology. This may permit for better adjustments of inspired oxygen, aiding in the prevention of damage caused by unnecessary exposure to high or low oxygen.


Managing teamwork in the face of pandemic: evidence-based tips.


title: Acceptability of laparoscopy-assisted gastrectomy for patients with previous intra-abdominal surgery.

text: PURPOSE This study assessed the acceptability of laparoscopy-assisted gastrectomy (LAG) for patients with previous intra-abdominal surgery (PIS). METHODS Sixteen patients with PIS had undergone LAG; 9 of laparoscopy-assisted distal gastrectomy, 2 of laparoscopy-assisted total gastrectomy and 5 of laparoscopy-assisted remnant gastrectomy (LARG). Difficulty, safety, and accuracy of LAG were compared between patients with PIS and with no previous intra-abdominal surgery. An independent group of 11 cases with open remnant gastrectomy (ORG) was used for comparing with LARG. RESULTS No significant difference was observed in conversion rate, intraoperative complication, operation time, blood loss, dissected lymph nodes, postoperative complications and hospital stay between PIS, and no PIS. There was no significant difference in operative time, dissected lymph nodes, and postoperative complications between LARG and ORG. Blood loss was lesser and postoperative hospital stay was shorter in LARG than in ORG. CONCLUSION LAG for patients with PIS is acceptable.


Covid-19: Health Education England shares advice for trainees.