title: Correlation of AOL recanalization, TIMI reperfusion and TICI reperfusion with infarct growth and clinical outcome.

text: OBJECTIVE To understand how three commonly used measures of endovascular therapy correlate with clinical outcome and infarct growth. METHODS Prospectively enrolled patients underwent baseline MRI and started endovascular therapy within 12 h of stroke onset. The final angiogram was given a primary arterial occlusive lesion (AOL) recanalization score (0-3), a Thrombolysis in Myocardial Infarction (TIMI) score (0-3) and a Thrombolysis in Cerebral Infarction (TICI) score (0-3). The scores were dichotomized into poor revascularization (AOL 0-2, TIMI 0-1 and TICI 0-2a) versus good revascularization (AOL 3, TIMI 2-3, TICI 2b-3). Patients were classified according to whether or not they had target mismatch (TMM). Good outcome was defined as a 90-day modified Rankin Scale score of 0-2. RESULTS Endovascular treatment was attempted in 100. A good outcome was achieved in 57% of patients with a TICI score of 2b-3 and in 24% of patients with a TICI score of 0-2a (p=0.001). Patients with TIMI scores of 2-3 and an AOL score of 3 had lower rates of good outcome (44% and 47%, respectively), which were not significantly better than those with TIMI scores of 0-1 or AOL scores of 0-2. In patients with TMM, these rates of good outcome improved with all the scoring systems and were significantly better for TIMI and TICI scores. Patients with a TICI score of 2a had rates of good functional outcome and lesion growth which were not different from those with TICI scores of 0-1 but were significantly worse than those with TICI scores of 2b-3. CONCLUSIONS TIMI 2-3 and TICI 2b-3 reperfusion scores demonstrated improved outcome in patients with tissue mismatch with a small infarct core and a larger hypoperfused region but AOL scores did not. Patients with a TICI score of 2a had a poorer outcome and more lesion growth than those with TICI scores of 2b-3.


title: Differences in regional cerebral oximetry during cardiac surgery for patients with or without postoperative cerebral ischaemic lesions evaluated by magnetic resonance imaging.

text: BACKGROUND Near infrared spectroscopy (NIRS) is widely used to monitor regional cerebral tissue oxygenation (rScO2). We compared rScO2 values during cardiac surgery in patients with or without new cerebral ischaemic lesions on diffusion weighted magnetic resonance imaging (DWI). We hypothesised patients with new cerebral lesions would have impaired tissue oxygenation reflected in their rScO2 values. METHODS NIRS and DWI data were collected in 152 elective cardiac surgery patients. Absolute rScO2 values, duration of desaturation below thresholds (baseline, 10%, and 20%), and accumulated cerebral desaturation load were compared between patients with or without new cerebral lesions on DWI. Primary outcome was time below 10% from rScO2 baseline. RESULTS The time below 10% from rScO2 baseline was significantly longer for patients with new cerebral lesions than for patients without [median (inter-quartile range): 11.0 (0.4; 37.5) min vs 1.8 inter-quartile range: (0.05; 20.9) min, P=0.02]. Furthermore, they had a higher accumulated desaturation load below baseline (P=0.02) and 10% below baseline (P=0.02). Finally, their absolute minimum rScO2 value was significantly lower (P=0.01). However, the frequency of patients with desaturation below 10% and 20% was comparable between patients with and without new cerebral lesions. Receiver-operating characteristic curve analysis did not identify a clear-cut critical threshold among the investigated rScO2 variables. CONCLUSIONS Use of NIRS identified significant group differences in rScO2 values between patients with or without new ischaemic lesions. However, a critical threshold could not be identified because of a high variation in NIRS values across both groups. CLINICAL TRIAL REGISTRATION NCT 02185885.


title: De novo gastric adenocarcinoma 1 year after sleeve gastrectomy in a transplant patient.

text: INTRODUCTION It has been reported in the literature that upper gastrointestinal malignancies after bariatric surgery are mostly gastro-esophageal, although it is not clear whether bariatric surgery represents a risk factor for the development of esophageal and/or gastric cancer. We report a case of a de novo gastric adenocarcinoma occurring in a transplant patient 1 year after a laparoscopic sleeve gastrectomy. PRESENTATION OF CASE A 44 year-old woman with a BMI of 38kg/m(2), hypertension, type 1 diabetes mellitus, multiple malignancies and a pancreas transplant underwent laparoscopic sleeve gastrectomy. The patient presented with intense dysphagias during the follow up. Studies were performed and the diagnoses of grade 2/3 adenocarcinoma were made. The patient underwent a robotic assisted total gastrectomy with a roux-en-y intracorporeal esophagojejunostomy. The procedure resulted in multiple metastasic lymph nodes, focal and transmural invasions to multiple organs with a tumor free margin resection. The patient presented with a postoperative pleural effusion, with no further complications. DISCUSSION The diagnosis of gastroesophageal cancer after bariatric surgery is usually late since these patients have common upper gastrointestinal symptoms related to the procedure that could delay the diagnosis. De novo gastric cancer after sleeve gastrectomy has only been reported in one instance, in contrast with other bariatric surgery procedures. CONCLUSIONS No direct relation has been established between sleeve gastrectomy and the development of gastric cancer. Robotic procedures allow for complex multiorgan resections, while preserving the benefits of minimally invasive surgery.


title: The prognostic value of NIRS in preterm infants with (suspected) late-onset sepsis in relation to long term outcome: A pilot study.

text: Late-onset sepsis is frequently seen in preterm infants and is associated with poor neurodevelopmental outcome. White matter damage is proposed as substrate of poor outcome, with contributing factors as regional hypoxia and effects of cytokines on oligodendrocytes. We investigated the relation between cerebral oxygenation during (suspected) late-onset sepsis and neurodevelopmental outcome. Prospective cohort study, including preterm infants (gestational age <32 weeks and/or birthweight <1500 grams) with (suspected) late-onset sepsis underwent NIRS registration during the first 72 hours of suspected late-onset sepsis. At two years corrected age neurodevelopment was scored using the Bayley Scales of Infant Development-II. Thirty-two infants were included. Twenty-seven infants were identified with proven late-onset sepsis and five infants had clinical sepsis without positive blood culture. In this study, late-onset sepsis was predominantly caused by coagulase negative staphylococci (CoNS) (72%). All NIRS values were within normal limits. No association was found between NIRS and impaired neurodevelopmental outcome (n = 4) at corrected age two years: composite cognitive score 105 (80-115), composite motor score 103 (82-118) (median and range). In this pilot study, late-onset sepsis (predominantly caused by CoNS with a relatively mild clinical course), was not associated with aberrant NIRS values, nor with impaired neurodevelopmental outcome. Further research might establish our findings and elucidate effects of other micro-organisms on cerebral perfusion.


title: NIHSS cut point for predicting outcome in supra- vs infratentorial acute ischemic stroke.

text: OBJECTIVE To determine the optimal cut point on the NIH Stroke Scale (NIHSS) for predicting poor 90-day clinical outcome in patients with supratentorial and infratentorial acute ischemic stroke (AIS). METHODS Data are from participants of the alteplase-dose arm of the randomized controlled trial, Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). Associations between baseline characteristics of clinically defined supratentorial and infratentorial AIS patients and poor functional outcome, defined by scores 3-6 on the modified Rankin Scale, were evaluated in logistic regression models, with area under the curve (AUC) receiver operating characteristics defining the optimal NIHSS predictor cut point. RESULTS Patients with infratentorial AIS (n = 289) had lower baseline NIHSS scores than those with supratentorial AIS (n = 2,613) (median 7 vs 9; p < 0.001). NIHSS cut points for poor outcome were 10 (AUC 76, sensitivity 65%, specificity 73%) and 6 (AUC 69, sensitivity 72%, specificity 56%) in supratentorial and infratentorial AIS, respectively. There was no significant difference in functional outcome or symptomatic intracranial hemorrhage between AIS types. CONCLUSIONS In thrombolysis-eligible AIS patients, the NIHSS may underestimate clinical severity for infratentorial compared to supratentorial lesions for a similar prognosis for recovery. Because thrombolysis treatment has low effect on stroke outcome in patients with infratentorial AIS when baseline NIHSS score is more than 6, additional treatment such as endovascular treatment should be considered to improve stroke outcome. CLINICALTRIALSGOV IDENTIFIER NCT01422616.


title: Early corticosteroids in severe influenza A/H1N1 pneumonia and acute respiratory distress syndrome.

text: RATIONALE Despite their controversial role, corticosteroids are often administered to patients with adult respiratory distress syndrome (ARDS) secondary to viral pneumonia. OBJECTIVES To analyze the impact of corticosteroid therapy on outcomes of patients having ARDS associated with influenza A/H1N1 pneumonia. METHODS Patients from the French registry of critically ill patients with influenza A/H1N1v 2009 infection were selected if fulfilling criteria for ARDS, excluding patients having other indication for corticosteroids, or decompensated underlying disease as the primary cause for intensive care unit admission. Survival to hospital discharge was analyzed using Cox regression, accounting for the time to administration of steroids, and after adjustment on the propensity for receiving steroid therapy. MEASUREMENTS AND MAIN RESULTS Of 208 patients with ARDS, 83 (39.9%) received corticosteroids (median initial dose of 270 mg equivalent hydrocortisone per day for a median of 11 d). Steroid therapy was associated with death, both in crude analysis (33.7 vs. 16.8%; hazard ratio, 2.4; 95% CI, 1.3-4.3; P = 0.004) and after propensity score-adjusted analysis (adjusted hazard ratio, 2.82; 95% CI, 1.5-5.4; P = 0.002), controlling for an admission severity Simplified Acute Physiology Score, version 3, greater than 50, initial administration of vasopressors, and immunodepression. Early therapy (≤ 3 d of mechanical ventilation) appeared more strongly associated with mortality than late administration. Patients receiving steroids had more acquired pneumonia and a trend to a longer duration of ventilation. CONCLUSIONS Our study provides no evidence of a beneficial effect of corticosteroids in patients with ARDS secondary to influenza pneumonia, but suggests that very early corticosteroid therapy may be harmful.


title: Preventing COVID-19 Transmission on Labor and Delivery: A Decision Analysis.

text: OBJECTIVE The health care system has been struggling to find the optimal way to protect patients and staff from coronavirus disease 2019 (COVID-19). Our objective was to evaluate the impact of two strategies on transmission of COVID-19 to health care workers (HCW) on labor and delivery (L&D). STUDY DESIGN We developed a decision analytic model comparing universal COVID-19 screening and universal PPE on L&D. Probabilities and costs were derived from the literature. We used individual models to evaluate different scenarios including spontaneous labor, induced labor, and planned cesarean delivery (CD). The primary outcome was the cost to prevent COVID-19 infection in one HCW. A cost-effectiveness threshold was set at $25,000 to prevent a single infection in an HCW. RESULTS In the base case using a COVID-19 prevalence of 0.36% (the rate in the United States at the time), universal screening is the preferred strategy because while universal PPE is more effective at preventing COVID-19 transmission, it is also more costly, costing $4,175,229 and $3,413,251 to prevent one infection in the setting of spontaneous and induced labor, respectively. For planned CD, universal PPE is cost saving. The model is sensitive to variations in the prevalence of COVID-19 and the cost of PPE. Universal PPE becomes cost-effective at a COVID-19 prevalence of 34.3 and 29.5% and at a PPE cost of $512.62 and $463.20 for spontaneous and induced labor, respectively. At a higher cost-effectiveness threshold, the prevalence of COVID-19 can be lower for universal PPE to become cost-effective. CONCLUSION Universal COVID-19 screening is generally the preferred option. However, in locations with high COVID-19 prevalence or where the local societal cost of one HCW being unavailable is the highest such as in rural areas, universal PPE may be cost-effective and preferred. This model may help to provide guidance regarding allocation of resources on L&D during these current and future pandemics. KEY POINTS · Universal screening is the preferred strategy for labor.. · With high prevalence, universal PPE is cost-effective.. · For planned cesarean, universal PPE is cost saving..


title: Intrapulmonary percussive ventilation superimposed on conventional ventilation: bench study of humidity and ventilator behaviour.

text: OBJECTIVE Intrapulmonary percussive ventilation (IPV) is a form of high-frequency ventilation that can be superimposed on spontaneous breathing or conventional ventilation. Drawbacks include difficulties achieving adequate airway humidification and an inability to monitor delivered volumes and pressures, which may vary with patient characteristics. The objectives of this study were to assess various humidification set-ups, to measure intrapulmonary pressures and volumes resulting from IPV superimposed on a conventional driving ventilator (DV) and to test several ventilators regarding their ability to accept added IPV. DESIGN Bench study in a test-lung set-up was used to measure humidification and the effects of adding IPV to a DV under various conditions of compliance, resistance, plateau and positive end-expiratory pressures. Then, five ventilators were tested in combination with IPV. MEASUREMENTS AND RESULTS Adequate humidification required a heated humidifier on the inspiratory line downstream of the IPV device. IPV increased end-inspiratory intrapulmonary pressures up to 10 cmH(2)O, increased delivered volumes up to 237 ml and generated intrinsic PEEP from 1.7 to 4.3 cmH(2)O when no PEEP was set on the DV. Intrinsic PEEP was lower or absent when PEEP was set on the DV. With most tested ventilators, IPV prevented reliable flow monitoring. Autotriggering and missing cycles were common and the PEEP effect varied across DVs. CONCLUSION Achieving adequate humidification with IPV requires a specific set-up. Superimposing IPV on standard ventilation can increase intrapulmonary pressures and tidal volumes importantly and interfere with the triggering sensors of the ventilator. These factors must be taken into account before clinical use.


title: Managing endotracheal tube cuff pressure at altitude: a comparison of four methods.

text: BACKGROUND Ascent to altitude results in the expansion of gases in closed spaces. The management of overinflation of the endotracheal tube (ETT) cuff at altitude is critical to prevent mucosal injury. METHODS We continuously measured ETT cuff pressures during a Critical Care Air Transport Team training flight to 8,000-ft cabin pressure using four methods of cuff pressure management. ETTs were placed in a tracheal model, and mechanical ventilation was performed. In the control ETT, the cuff was inflated to 20 mm Hg to 22 mm Hg and not manipulated. The manual method used a pressure manometer to adjust pressure at cruising altitude and after landing. A PressureEasy device was connected to the pilot balloon of the third tube and set to a pressure of 20 mm Hg to 22 mm Hg. The final method filled the balloon with 10 mL of saline. Both size 8.0-mm and 7.5-mm ETT were studied during three flights. RESULTS In the control tube, pressure exceeded 70 mm Hg at cruising altitude. Manual management corrected for pressure at altitude but resulted in low cuff pressures upon landing (<10 mm Hg). The PressureEasy reduced the pressure change to a maximum of 36 mm Hg, but on landing, cuff pressures were less than 15 mm Hg. Saline inflation ameliorated cuff pressure changes at altitude, but initial pressures were 40 mm Hg. CONCLUSION None of the three methods using air inflation managed to maintain cuff pressures below those associated with tracheal damage at altitude or above pressures associated with secretion aspiration during descent. Saline inflation minimizes altitude-related alteration in cuff pressure but creates excessive pressures at sea level. New techniques need to be developed.


title: Coronavirus infection modulates the unfolded protein response and mediates sustained translational repression.

text: During coronavirus replication, viral proteins induce the formation of endoplasmic reticulum (ER)-derived double-membrane vesicles for RNA synthesis, and viral structural proteins assemble virions at the ER-Golgi intermediate compartment. We hypothesized that the association and intense utilization of the ER during viral replication would induce the cellular unfolded protein response (UPR), a signal transduction cascade that acts to modulate translation, membrane biosynthesis, and the levels of ER chaperones. Here, we report that infection by the murine coronavirus mouse hepatitis virus (MHV) triggers the proximal UPR transducers, as revealed by monitoring the IRE1-mediated splicing of XBP-1 mRNA and the cleavage of ATF6alpha. However, we detected minimal downstream induction of UPR target genes, including ERdj4, ER degradation-enhancing alpha-mannosidase-like protein, and p58(IPK), or expression of UPR reporter constructs. Translation initiation factor eIF2alpha is highly phosphorylated during MHV infection, and translation of cellular mRNAs is attenuated. Furthermore, we found that the critical homeostasis regulator GADD34, which recruits protein phosphatase 1 to dephosphorylate eIF2alpha during the recovery phase of the UPR, is not expressed during MHV infection. These results suggest that MHV modifies the UPR by impeding the induction of UPR-responsive genes, thereby favoring a sustained shutdown of the synthesis of host cell proteins while the translation of viral proteins escalates. The role of this modified response and its potential relevance to viral mechanisms for the evasion of innate defense signaling pathways during coronavirus replication are discussed.


title: The direct first pass aspiration technique in the treatment of acute ischemic stroke resulting from large vessel occlusions.

text: Methods Recanalization was assessed using the modified thrombolysis in cerebral infarction (mTICI) score. Neurological outcomes were assessed using the National Institutes of Health Stroke Scale and modified Rankin Scale. Results Fifteen patients were evaluated. The mTICI score was 2b-3 in 80%, and it was 3 in 60% of patients. No intracranial hemorrhage was seen. At three months, modified Rankin Scale scores ≤ 2 were observed in 60% of patients and the mortality rate was 13.3%. Conclusions The ADAPT appears to be a safe, effective, and fast recanalization strategy for treatment of acute ischemic stroke resulting from large vessel occlusions.


title: Experimental intra-abdominal hypertension influences airway pressure limits for lung protective mechanical ventilation.

text: BACKGROUND Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) may complicate monitoring of pulmonary mechanics owing to their impact on the respiratory system. However, recommendations for mechanical ventilation of patients with IAH/ACS and the interpretation of thoracoabdominal interactions remain unclear. Our study aimed to characterize the influence of elevated intra-abdominal pressure (IAP) and positive end-expiratory pressure (PEEP) on airway plateau pressure (PPLAT) and bladder pressure (PBLAD). METHODS Nine deeply anesthetized swine were mechanically ventilated via tracheostomy: volume-controlled mode at tidal volume (VT) of 10 mL/kg, frequency of 15, inspiratory-expiratory ratio of 1:2, and PEEP of 1 and 10 cm H2O (PEEP1 and PEEP10, respectively). A tracheostomy tube was placed in the peritoneal cavity, and IAP levels of 5, 10, 15, 20, and 25 mm Hg were applied, using a continuous positive airway pressure system. At each IAP level, PBLAD and airway pressure measurements were performed during both PEEP1 and PEEP10. RESULTS PBLAD increased as experimental IAP rose (y = 0.83x + 0.5; R = 0.98; p < 0.001 at PEEP1). Minimal underestimation of IAP by PBLAD was observed (-2.5 ± 0.8 mm Hg at an IAP of 10-25 mm Hg). Applying PEEP10 did not significantly affect the correlation between experimental IAP and PBLAD. Approximately 50% of the PBLAD (in cm H2O) was reflected by changes in PPLAT, regardless of the PEEP level applied. Increasing IAP did not influence hemodynamics at any level of IAP generated. CONCLUSION With minimal underestimation, PBLAD measurements closely correlated with experimentally regulated IAP, independent of the PEEP level applied. For each PEEP level applied, a constant proportion (approximately 50%) of measured PBLAD (in cm H2O) was reflected in PPLAT. A higher safety threshold for PPLAT should be considered in the setting of IAH/ACS as the clinician considers changes in VT. A strategy of reducing VT to cap PPLAT at widely recommended values may not be warranted in the setting of increased IAP.


Editorial - Sofosbuvir/Velpatasvir as a combination with strong potential activity against SARS-CoV2 (COVID-19) infection: how to use direct-acting antivirals as broad-spectrum antiviral agents.


Perioperative management of drug-eluting stents: the Achilles heel of bridging.


Commentary: Preferred practice pattern for primary eye care in the context of COVID-19 in L V Prasad Eye Institute network in India.


title: Robot-assisted single-incision laparoscopic myomectomy: initial report and technique.

text: Single-incision laparoscopic surgery for gynecologic applications has recently been described. Such an ultra-minimally invasive technique is attractive to patients and may have clinical advantages because of the reduced number of abdominal incisions. However, because of its extreme geometrical challenges and instrument crowding, single-incision laparoscopy is such a major deviation from optimum surgical ergonomics that it is unlikely to gain popularity. Robot assistance in single-incision laparoscopy has recently been described for some ablative gynecologic procedures, and it seems to have technical advantages. However, no suture-intensive applications of this technique have yet been reported. We describe our initial experience with robot-assisted single-incision laparoscopic myomectomy and provide essential technical detail to enable successful replication of this technique in the context of an advanced robotic surgical team.


Vaccine initiative marks bold resolution.


title: Human bocavirus as the cause of a life-threatening infection.

text: Human bocavirus is a recently described respiratory pathogen. A case of a life-threatening human bocavirus infection of a previously healthy pediatric patient is described. An initial clinical presentation of acute bronchiolitis developed into an extremely severe course of disease characterized by pneumothorax, pneumomediastinum, and acute respiratory failure with pronounced air-leak syndrome.


title: Preoperative embolization of intracranial meningiomas: efficacy, technical considerations, and complications.

text: BACKGROUND AND PURPOSE Preoperative embolization for intracranial meningiomas offers potential advantages for safer and more effective surgery. However, this treatment strategy has not been examined in a large comparative series. The purpose of this study was to review our experience using preoperative embolization to understand the efficacy, technical considerations and complications of this technique. MATERIALS AND METHODS We performed a retrospective review of patients undergoing intracranial meningioma resection at our institution (March 2001 to December 2012). Comparisons were made between embolized and nonembolized patients, including patient and tumor characteristics, embolization method, operative blood loss, complications, and extent of resection. Logistic regression analyses were used to identify factors predictive of operative blood loss and extent of resection. RESULTS Preoperatively, 224 patients were referred for embolization, of which 177 received embolization. No complications were seen in 97.1%. There were no significant differences in operative duration, extent of resection, or complications. Estimated blood loss was higher in the embolized group (410 versus 315 mL, P=.0074), but history of embolization was not a predictor of blood loss in multivariate analysis. Independent predictors of blood loss included decreasing degree of tumor embolization (P=.037), skull base location (P=.005), and male sex (P=.034). Embolization was not an independent predictor of gross total resection. CONCLUSIONS Preoperative embolization is a safe option for selected meningiomas. In our series, embolization did not alter the operative duration, complications, or degree of resection, but the degree of embolization was an independent predictor of decreased operative blood loss.


title: Extended Intervals after Neoadjuvant Therapy in Locally Advanced Rectal Cancer: The Key to Improved Tumor Response and Potential Organ Preservation.

text: BACKGROUND Many rectal cancer patients experience tumor downstaging and some are found to achieve a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT). Previous data suggest that there is an association between the time interval from nCRT completion to surgery and tumor response rates, including pCR. However, these studies have been primarily from single institutions with small sample sizes. The aim of this study was to examine the relationship between a longer interval after nCRT and pCR in a nationally representative cohort of rectal cancer patients. STUDY DESIGN Clinical stage II to III rectal cancer patients undergoing nCRT with a documented surgical resection were selected from the 2006 to 2011 National Cancer Data Base. Multivariable logistic regression analysis was used to assess the association between the nCRT-surgery interval time (<6 weeks, 6 to 8 weeks, >8 weeks) and the odds of pCR. The relationship between nCRT-surgery interval, surgical morbidity, and tumor downstaging was also examined. RESULTS Overall, 17,255 patients met the inclusion criteria. An nCRT-surgery interval time >8 weeks was associated with higher odds of pCR (odds ratio [OR] 1.12, 95% CI 1.01 to 1.25) and tumor downstaging (OR 1.11, 95% CI 1.02 to 1.25). The longer time delay was also associated with lower odds of 30-day readmission (OR 0.82, 95% CI 0.70 to 0.92). CONCLUSIONS An nCRT-surgery interval time >8 weeks results in increased odds of pCR, with no evidence of associated increased surgical complications compared with an interval of 6 to 8 weeks. These data support implementation of a lengthened interval after nCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation (nonoperative management).


title: A randomized, controlled, prospective study evaluating the effect of patellar eversion on functional outcomes in primary total knee arthroplasty.

text: BACKGROUND Patellar mobilization technique during total knee arthroplasty has been debated, with some suggesting that lateral retraction, rather than eversion, of the patella may be beneficial. We hypothesized that patients with knees surgically exposed using patellar lateral retraction would have comparable outcomes with patients with knees surgically exposed using patellar eversion. METHODS After an a priori power analysis, 120 patients with degenerative arthrosis were prospectively enrolled and were randomized to one of two patellar exposure techniques during the primary total knee arthroplasty: lateral retraction or eversion. The primary outcome measure was one-year, dynamometer-measured quadriceps strength. The secondary outcome measures evaluated during hospital stay included the ability to straight-leg raise, visual analog scale in pain, walking distance, and length of stay. The secondary outcome measures that were evaluated preoperatively and through a one-year follow-up included the Short Form-36 Physical Component Summary and Mental Component Summary scores, range of motion, quadriceps strength, and radiographic rate of patella baja and tilt. RESULTS A mixed-model analysis of variance showed no significant differences between the two groups in the one-year outcome measures. At one year postoperatively, quadriceps strength was not different between groups (p = 0.77), and the range of motion significantly improved (p < 0.01) from preoperative values by a mean value (and standard deviation) of 6° ± 17°, with no significant difference (p = 0.60) between groups. The Short Form-36 Physical Component Summary score and Mental Component Summary score significantly improved (p < 0.01) for both study groups from preoperatively to one year postoperatively with no significantly different effects between groups (time × group, p = 0.85 for the Physical Component Summary score and p = 0.71 for the Mental Component Summary score), and the scores were not different at one year after surgery. There were no significant differences between groups in the change in frequency of the radiographic patella baja (p = 0.99) or the radiographic patellar tilt (p = 0.77) from before surgery to one year after surgery. CONCLUSIONS Lateral retraction of the patella did not lead to superior postoperative results compared with eversion of the patella during total knee arthroplasty as evaluated using our primary outcome measure of one-year, dynamometer-measured quadriceps strength or our secondary outcome measures. LEVEL OF-EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.


title: Determining the Impact of a Cancer Diagnosis on Diabetes Management: A Systematic Literature Review.

text: OBJECTIVES Cancer patients with comorbid diabetes have a 50% increased risk of all-cause mortality compared with cancer patients without diabetes. Less attention to diabetes management (glucose control, medication adherence, and diabetes self-management behaviors) during active cancer treatment is hypothesized as an explanation for worse outcomes among diabetic cancer patients. The objective of this systematic review is to determine and quantify how a cancer diagnosis impacts diabetes management. METHODS Quantitative and qualitative studies evaluating diabetes management among patients were identified by searching 4 databases: MEDLINE, EMBASE, The Cochrane Library, and Web of Science. Two independent reviewers extracted data and summarized results from eligible studies. Study quality was formally assessed. RESULTS Thirty-six studies met all inclusion criteria. We observed heterogeneity across studies in terms of study design, sample size, cancer site, type of diabetes management evaluated, and quality. Numerous articles discussed that overall, glucose control, medication adherence, and diabetes self-management behaviors declined following a cancer diagnosis. However, findings were inconsistent across studies. CONCLUSIONS Although the effects of a cancer diagnosis on diabetes management are mixed, when results across studies were synthesized together, diabetes management appeared to generally decline after a cancer diagnosis. Declines in diabetes management seem to be primarily due to shifts in the priority of care from diabetes management to cancer. A next critical step in this line of work is to identify patient and provider level predictors of better or worse diabetes management to design and test interventions aimed at improving effective diabetes management for cancer patients.


title: Uniportal thoracoscopic lobectomy for intralobar pulmonary sequestration.

text: BACKGROUND Pulmonary sequestration is an uncommon congenital condition for which surgical resection is usually indicated - either via open thoracotomy or conventional multi-port Video-Assisted Thoracoscopic Surgery (VATS). Of the two types of sequestration, intralobar sequestration is technically more challenging to resect. CASE PRESENTATION We report the management of a 34 year old male patient with a long history of respiratory symptoms, and an extensively diseased right lower lobe. A diagnosis of sequestration was confirmed by CT scanning, showing three separate anomalous feeding vessels arising from the abdominal aorta. A right lower lobectomy using a Uniportal VATS approach was performed, and the patient discharged home on the fourth post-operative day. CONCLUSION This is the first report to our knowledge demonstrating the safety and feasibility of the Uniportal approach for the resection of a relatively challenging intralobar sequestration.


title: Identification of irrigation potential areas, using multi-criteria analysis in Khyber District, Pakistan.

text: This study explores the opportunities for irrigated agriculture in Khyber District of Former Federally Administered Tribal Area (FATA). Agriculture continues to be most important economic activity in Pakistan and former FATA is no exception. However, agriculture in the semi-arid Khyber District continues to suffer a decline due to excessive reliance on rainfall, which is drastically insufficient. Khyber District have large expanses of fertile land; however, farmers depend on unpredictable rain-fed agriculture, which has low productivity and food insecurity. There are a number of rivers in the region where great prospects exist for irrigated farming. Geographical information systems (GIS)-based multi-criteria analysis can be used to map areas with irrigation potential. The current study focused on different variables including soil texture, perennial rivers, land cover, topography, and dams. For this study, data was collected from diverse sources which include Google earth images, top sheets, land use land cover, soil texture map of FATA, and SRTM 30 Meter. The collected data was analyzed by using multi-criteria analysis in Arc GIS 10.2.2 by using MIF technique. The results of this research indicate that there is great potential for irrigated farming in the study area. Potential land for this purpose were divided into three categories, i.e., highly suitable which consisted of 678 km2, or 26% of the total area; 1044 km2 representing 40% were moderately suitable to irrigation; while the remaining 698 km2 representing 27% were considered least suitable for irrigation. Likewise, 204 km2 representing 7% were deemed unsuitable for irrigated agriculture mostly consisting of barren rocks. The results also illustrate how GIS as a tool can be used in the exploration of water resources in a scientific approach, thus making decision-making easier and more accurate.


Rebuttal to letter "Is thromboprophylaxis with high-dose enoxaparin really necessary for COVID-19 patients? A new "prudent" randomised clinical trial".


title: Potential benefits of single-port compared to multiport laparoscopic inguinal herniorraphy: a prospective randomized controlled study.

text: BACKGROUND Multiple prospective studies have confirmed safety and efficacy of laparoscopic inguinal herniorraphy with single-port compared to multiport surgery. This prospective randomized controlled trial aimed to assess safety, efficacy and potential benefits of single-port total extraperitoneal inguinal herniorraphy beyond the learning curve. METHODS All referred patients with inguinal/femoral hernias were enrolled from December 2011 to February 2013. Exclusion criteria included workers compensation cases. Identical balloon dissector, light-weight mesh and non-absorbable tacks were used in all cases. For single-port cases Triport™ was used while structural balloon trocar/inflation bulb for multiport cases. Results were analyzed with IBM(®) SPSS(®) version 22 for Windows. RESULTS Participation rate was 100 % with 157 inguinal/femoral hernias in 100 patients: 51 randomized to single-port and 49 to multiport group. There was no conversion to open surgery/need for additional ports. There were no statistical differences between single-port and multiport groups with respect to age, sex, body mass index, American Society of Anesthesiologists scores, preoperative pain, hernia defect sizes and length of hospital stay. Operation times were equivalent for single-port and multiport 60.0 vs 61.0 min, P = 0.23, respectively. Significantly, single-port patients ingested fewer pain killers: 6 tablets vs 14 Dextropropoxyphene tablets, P < 0.001, experienced less pain (visual analog scores) on day 1 and 7 post-op op: 2.5 and 0, P < 0.001 compared to 4.5 and 2.5, P < 0.001, respectively, returned to work/normal physical activities 7 days quicker: 7.0 vs 14.0, P < 0.001 and had higher cosmetic scar scores at 6-week follow-up: 24 vs 21, P < 0.001, compared to multiport patients. There were no mortalities, morbidities or recurrences after follow-up of 6-21 months. CONCLUSIONS Compared to multiport, single-port laparoscopic total extraperitoneal inguinal herniorraphy, when performed by a high-volume and highly dedicated hernia surgeon, resulted in significantly reduced postoperative pain, analgesic requirements, quicker return to work/normal activities, improved cosmesis, and equivalent safety and efficacy.


title: Rhenium and technetium tricarbonyl, {M(CO)3} (+) (M = Tc, Re), binding to mammalian metallothioneins: new insights into chemical and radiopharmaceutical implications.

text: This paper deals with the binding of the four mammalian metallothioneins (MTs) to the organometallic metal fragment {fac-M(CO)3}(+) (M = (99)Tc, Re), which is highly promising for the preparation of second-generation radiopharmaceuticals. The study of the transmetallation reaction between zinc and rhenium in Zn7-MT1 by means of UV-vis and CD spectroscopy demonstrated the incorporation of the {fac-Re(CO)3}(+) fragment to the MTs. This reaction should be performed at 70 °C to accelerate the reaction rate, a result that is consistent with the reported reactivity of the rhenium fragment. ESI-TOF MS demonstrated the formation of mixed-metal species as Zn6,{Re(CO)3}-MT, Zn6,{Re(CO)3}2-MT, and Zn5,{Re(CO)3}3-MT, as well as the different reactivity of the four MT isoforms. Hence, Zn-MT3 showed the highest reactivity, in agreement with its high Cu-thionein character, whereas Zn-MT2 exhibited the lowest reactivity, in line with its high Zn-thionein character. The reactivity of the Zn-loaded forms of MT1 and MT4 is intermediate between those of MT3 and MT2. The study of the binding of the {fac-(99)Tc(CO)3}(+) fragment to MTs showed a significant and very interesting different reactivity in relation to rhenium. The transmetallation reaction is much more effective with technetium than with rhenium and significant amounts of mixed Zn x ,{(99)Tc(CO)3} y -MT species were formed with the four MT isoforms whereas only MT3 rendered similar amounts of rhenium derivatives. The results obtained in this study support the possible use of technetium for labelling mammalian metallothioneins and also for possible radiopharmaceutical applications.


title: Response to COVID-19: Minimizing Risks, Addressing Challenges and Maintaining Operations in a Complex Academic Radiology Department.

text: The coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid response plans to minimize risks of infection in the workforce while ensuring maintenance of essential functions of radiology departments. Plan adoption is, however, challenged by the need to coordinate with institutional efforts, a rapidly expanding number of patients, and the diversity of clinical and administrative functions in the department. Here, we describe the implementation of a response plan in an academic radiology department, challenges encountered, and tactics used to address these challenges.


Estimation of Coronavirus Disease 2019 Burden and Potential for International Dissemination of Infection From Iran.


title: Rickettsia typhi as Cause of Fatal Encephalitic Typhus in Hospitalized Patients, Hamburg, Germany, 1940-1944.

text: We evaluated formalin-fixed paraffin-embedded tissue specimens from 7 patients who died with encephalitic typhus in Hamburg, Germany, during World War II. The archived specimens included only central nervous system tissues >70 years old that had been stored at room temperature. We demonstrated successful detection of Rickettsia typhi DNA by a nested qPCR specific to prsA in 2 patients. These results indicate that R. typhi infections contributed to typhus outbreaks during World War II. Immunohistochemical analyses of brain tissue specimens of R. typhi DNA-positive and -negative specimens showed perivascular B-cell accumulation. Around blood vessels, nodular cell accumulations consisted of CD4-positive and CD8-positive T cells and CD68-positive microglia and macrophages; neutrophils were found rarely. These findings are similar to those of previously reported R. prowazekii tissue specimen testing. Because R. typhi and R. prowazekii infections can be clinically and histopathologically similar, molecular analyses should be performed to distinguish the 2 pathogens.


Partha Kar: What will come after the covid-19 crisis?


title: Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage.

text: BACKGROUND Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. METHOD A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string "colorectal anastomotic ("leak" OR "bleed"), "endoscopy", endoscopic management". Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. RESULTS A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. CONCLUSION Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.


Pandemic: Looking Back and Thinking Ahead.


title: Same day discharge, surgical training and early complications after open and laparoscopic repair of primary paraumbilical hernia.

text: AIMS The aims of this study were to compare same day discharges and early complications after open and laparoscopic primary paraumbilical hernia (PUH) repair, including the procedures performed by surgical trainees (STs). METHODS All patients who had open (suture or mesh) and laparoscopic repair of primary PUH in the Day Surgery Unit (DSU) between January 2007 and June 2009 were identified from the hospital database. The database was questioned regarding the grade of operating surgeon, type of surgical repair, day of admission and discharge from the DSU, and a patient's return to surgical services. Data were stored in Microsoft Excel(®) (TM 2007). Statistical significance was determined using Fisher's exact test. RESULTS PUH was repaired in 337 patients: 252/337 (74.8 %) had open and 85/337 (25.2 %) had laparoscopic repair. Significantly, more patients were discharged home on the day of surgery after an open repair compared to the laparoscopic repair: open repair 187/252 (74.2 %), laparoscopic repair 35/85 (41.17 %), P = 0.0001. Overall early complications such as wound complications and hospital re-visits were similar in both groups: open repair 6.3 % (16/252), laparoscopic repair 11.7 % (10/85), P = 0.1554. STs performed 142/337 (42.1 %) of the PUH repairs with similar same day discharges from the DSU: STs 64.7 % (92/142), consultant surgeons 66.7 % (130/195), P = 0.7285. The difference in hernia recurrence between open repair 7/252 (2.78 %) and laparoscopic group 0/85 was not significant (P = 0.1985). CONCLUSION Patients with PUH repair were more likely to go home on the day of surgery after open than after laparoscopic repair. This was not affected by the grade of the operating surgeon. Early complications were similar following open and laparoscopic repair of primary PUH.


title: Combined pharmacomechanical thrombolysis of complete portomesenteric thrombosis in a liver transplant recipient.

text: Treatment options for portomesenteric venous thrombosis range from anticoagulation to surgery, depending on chronicity, severity of symptoms, extent of thrombosis, and the availability of local expertise. For acute and subacute cases, a variety of endovascular options have been described in limited published series and case reports, including thrombolysis and mechanical thrombectomy. We report what is to our knowledge the first case in which the Trellis pharmacomechanical thrombolysis device was used successfully to treat complete acute thrombosis of the entire superior mesenteric vein and the entire portal vein with extension into all segmental intrahepatic portal branches in a young adult after liver transplantation. This device, coupled with adjunctive techniques using balloon catheters, facilitated complete restoration of flow, resulting in graft salvage and long-term patency.


title: Interplay between SIRT1 and hepatitis B virus X protein in the activation of viral transcription.

text: Hepatitis B virus (HBV) genome is organized into a minichromosome known as covalently closed circular DNA (cccDNA), which serves as the template for all viral transcripts. SIRT1 is an NAD+-dependent protein deacetylase which activates HBV transcription by promoting the activity of cellular transcription factors and coactivators. How SIRT1 and viral transactivator X protein (HBx) might affect each other remains to be clarified. In this study we show synergy and mutual dependence between SIRT1 and HBx in the activation of HBV transcription. All human sirtuins SIRT1 through SIRT7 activated HBV gene expression. The steady-state levels of SIRT1 protein were elevated in HBV-infected liver tissues and HBV-replicating hepatoma cells. SIRT1 interacted with HBx and potentiated HBx transcriptional activity on precore promoter and covalently closed circular DNA (cccDNA) likely through a deacetylase-independent mechanism, leading to more robust production of cccDNA, pregenomic RNA and surface antigen. SIRT1 and HBx proteins were more abundant when both were expressed. SIRT1 promoted the recruitment of HBx as well as cellular transcriptional factors and coactivators such as PGC-1α and FXRα to cccDNA. Depletion of SIRT1 suppressed HBx recruitment. On the other hand, SIRT1 recruitment to cccDNA was compromised when HBx was deficient. Whereas pharmaceutical agonists of SIRT1 such as resveratrol activated HBV transcription, small-molecule inhibitors of SIRT1 including sirtinol and Ex527 exhibited anti-HBV activity. Taken together, our findings revealed not only the interplay between SIRT1 and HBx in the activation of HBV transcription but also new strategies and compounds for developing antivirals against HBV.


Case Image: Endovascular coil treatment of a right coronary artery aneurysm related to atherosclerosis.


title: CODE FAST: a quality improvement initiative to reduce door-to-needle times.

text: BACKGROUND Rapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions. OBJECTIVE To start a quality improvement project called CODE FAST in order to reduce DTN times at our institution. MATERIALS AND METHODS We retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol. RESULTS A total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8 min (p<0.0001) and DTN time with a reduction in the median from 62 to 25 min (p<0.0001). In logistic regression modeling, there was a trend towards more discharges to home in patients treated during the CODE FAST era. CONCLUSIONS We present a quality improvement project that has been overwhelmingly successful in reducing DTN time to <30 min. The template we present may be helpful to other institutions looking to reduce their DTN times and may also reduce costs as we note a trend towards more discharges to home.


title: COVID-19 Molecular Testing in Korea: Practical Essentials and Answers From Experts Based on Experiences of Emergency Use Authorization Assays.

text: Coronavirus disease 2019 (COVID-19) is a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Early detection of COVID-19 and immediate isolation of infected patients from the naive population are important to prevent further pandemic spread of the infection. Real-time reverse transcription (RT)-PCR to detect SARS-CoV-2 RNA is currently the most reliable diagnostic method for confirming COVID-19 worldwide. Guidelines for clinical laboratories on the COVID-19 diagnosis have been recently published by Korean Society for Laboratory Medicine and the Korea Centers for Disease Control and Prevention. However, these formal guidelines do not address common practical laboratory issues related to COVID-19 real-time RT-PCR testing and their solutions. Therefore, this guideline is intended as a practical and technical supplement to the "Guidelines for Laboratory Diagnosis of COVID-19 in Korea".


Peginesatide for anemia in chronic kidney disease.


title: Comparative study on immediate versus delayed meniscus allograft transplantation: 4- to 6-year follow-up.

text: BACKGROUND Meniscus allograft transplantation (MAT) is generally used for patients who sustain symptoms after meniscectomy, which could be called delayed MAT. Meniscus allograft transplantation for patients immediately after meniscectomy has not been reported. HYPOTHESIS Compared with the conventional delayed MAT, immediate MAT might provide better clinical results and reduce joint degeneration. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study was performed with 18 transplanted menisci (6 medial, 12 lateral) from 16 patients. Eight menisci were transplanted immediately after meniscectomy (IM group); 10 menisci, from patients who complained of knee symptoms at a mean time of 35 months (range, 9-92 months) after total meniscectomy, underwent delayed transplantation (DE group). Fourteen patients undergoing meniscectomy during the same period were included as controls (ME group). Degenerative changes in knee joints were evaluated by plain radiographs and magnetic resonance imaging (MRI). Allograft extrusion and relative percentage of extrusion were measured on MRI. Other outcome assessments included preoperative and postoperative International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores; visual analog scale (VAS) for pain; and range of motion and isokinetic muscle strength evaluation. RESULTS The mean length of follow-up was 50.8 months (range, 44-62 months) for the IM group, 72.0 months (range, 44-94 months) for the DE group, and 54.3 months (range, 45-62 months) for the ME group. A statistically significant difference in favor of the IM and ME groups was found on the VAS (0.4 [IM group] vs 1.1 [ME group] vs 2.5 [DE group]) and muscle strength (P < .05). The mean IKDC score in the IM group was significantly higher than that in the DE group (93 [range, 85-99] vs 74 [range, 38-95], respectively; P < .05). The IM group showed significantly less preoperative to postoperative cartilage degeneration changes on radiographs and MRI when compared with the DE and ME groups (Kellgren-Lawrence score changes: 0.25 [IM group] vs 1.0 [DE group] vs 1.7 [ME group]; Yulish score changes: 0.25 [IM group] vs 1.0 [DE group] vs 1.1 [ME group]; P < .05). Extrusion of the allograft was observed in the body of the menisci in all patients. No significant difference was found in terms of the Lysholm score, Tegner score, joint narrowing, or meniscus extrusion (P > .05). CONCLUSION Compared with delayed MAT, immediate MAT led to more satisfactory subjective results, less joint degeneration, and less muscle strength deficits. The short-term results of delayed meniscus transplantation were close to those of meniscectomy.


title: New-onset atrial fibrillation in adult critically ill patients: a scoping review.

text: PURPOSE New-onset atrial fibrillation (NOAF) is common and associated with increased morbidity and mortality. However, its clinical importance and management in critically ill patients are not well described. The aim of this scoping review is to assess the epidemiology and management strategies of NOAF during critical illness. METHOD The review was conducted in accordance with the PRISMA extension for scoping reviews. We searched PubMed, EMBASE and the Cochrane Library for studies assessing the incidence, outcome and management strategies of NOAF in adult critically ill patients. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS A total of 99 studies were included, of which 79 were observational and 20 were interventional. The incidence of NOAF varied from 1.7% to 43.9% with considerable inter-population variation (very low quality of evidence). Commonly identified risk factors for NOAF included higher age, cardiovascular comorbidities and sepsis. The occurrence of NOAF was associated with adverse outcomes, including stroke, prolonged length of stay and mortality (very low quality of evidence). We found limited data on the optimal management strategy with no evidence for firm benefit or harm for any intervention (very low/low quality of evidence). CONCLUSIONS The definition and incidence of NOAF in critically ill patients varied considerably and many risk factors were identified. NOAF seemed to be associated with adverse outcomes, but data were very limited and current management strategies are not evidence-based.


MERS coronavirus has low pandemic potential, so far.


title: Autophagy and role in asthma.

text: PURPOSE OF REVIEW Asthma is a common worldwide respiratory illness with significant morbidity and mortality. The disease is characterized by airway inflammation with involvement of multiple biological pathways. Genetic predisposition and increased susceptibility to severe respiratory viral infections are well known clinical features of asthma. Autophagy is an evolutionarily conserved cellular degradation process with significant impact on immunity and antiviral response. In this review we have described the role of autophagy in immune cell survival, proliferation and function. Autophagy has complex effects on immune response involved in inflammation, specifically Th2 immune response. Common respiratory viruses are associated with increased morbidity and mortality in asthmatic patients. RECENT FINDINGS We describe recent studies showing the effect of autophagy on replication and immune response to common respiratory viruses. The role of autophagy in asthma has recently been investigated. Two studies have been published describing the association of autophagy with asthma. Genetic polymorphism in specific autophagy genes is associated with asthma and influences gene expression in an experimental in-vivo model. SUMMARY These studies provide us with a window into the possible role of autophagy in asthma and offer new clues to pathogenesis. Modulation of autophagy has the potential to develop into a new therapeutic avenue to treat this common respiratory ailment.


title: Saliva as an Alternate Specimen Source for Detection of SARS-CoV-2 in Symptomatic Patients Using Cepheid Xpert Xpress SARS-CoV-2.

text: Among the many facets of the SARS-CoV-2 pandemic is the unprecedented pressure it has placed on different points of the supply chain for hospital systems worldwide such as collection devices for the diagnosis of COVID-19.….


title: Small bowel obstructions following the use of barbed suture: a review of the literature and analysis of the MAUDE database.

text: BACKGROUND Barbed suture has been adopted across all surgical specialties. One of the infrequent complications seen with the use of barbed suture is small bowel obstructions (SBOs). In this study, we perform a review of the literature and the Manufacturer and User Facility Device Experience Database (MAUDE) to characterize SBOs after the use of barbed sutures in a variety of operative procedures. METHODS A review of the literature was performed by searching PubMed and Ovid. We used the search terms: "barbed," "suture," "bowel," and "obstructions." For each case report, we examined the initial surgical procedure, type of barbed suture used, the type of complication, the time to complication, the presentation, and the type of operative interventions required. We did the same with the MAUDE database. RESULTS Our review of the literature revealed 18 different cases of SBO secondary to the use of barbed suture. The four most common procedures, with a total of four cases each, were inguinal hernia procedures, myomectomy, hysterectomy, and pelvic floor reconstructive procedures. The average time of presentation to SBO was found to be 26.3 days post-op (1-196 days). A total of 16 patients (88.9%) presented with abdominal pain. Other common complaints included vomiting (33.3%), abdominal distension (27.8%), oral intolerance (22.2%), and constipation (16.7%). A total of 5 cases were also found to have a possible volvulus on computed tomography (CT), and 2 cases were reported to have strangulation. The MAUDE database had 14 cases reporting on obstruction. CONCLUSIONS Surgeons should have a high index of suspicion for SBO if a patient presents with obstructive symptoms after a surgery that used barbed suture. This will often present as a mesenteric volvulus on CT. These particular SBOs require operative exploration, with laparoscopy being successful in the majority of cases.


title: Pulmonary neuroendocrine (carcinoid) tumors: European Neuroendocrine Tumor Society expert consensus and recommendations for best practice for typical and atypical pulmonary carcinoids.

text: BACKGROUND Pulmonary carcinoids (PCs) are rare tumors. As there is a paucity of randomized studies, this expert consensus document represents an initiative by the European Neuroendocrine Tumor Society to provide guidance on their management. PATIENTS AND METHODS Bibliographical searches were carried out in PubMed for the terms 'pulmonary neuroendocrine tumors', 'bronchial neuroendocrine tumors', 'bronchial carcinoid tumors', 'pulmonary carcinoid', 'pulmonary typical/atypical carcinoid', and 'pulmonary carcinoid and diagnosis/treatment/epidemiology/prognosis'. A systematic review of the relevant literature was carried out, followed by expert review. RESULTS PCs are well-differentiated neuroendocrine tumors and include low- and intermediate-grade malignant tumors, i.e. typical (TC) and atypical carcinoid (AC), respectively. Contrast CT scan is the diagnostic gold standard for PCs, but pathology examination is mandatory for their correct classification. Somatostatin receptor imaging may visualize nearly 80% of the primary tumors and is most sensitive for metastatic disease. Plasma chromogranin A can be increased in PCs. Surgery is the treatment of choice for PCs with the aim of removing the tumor and preserving as much lung tissue as possible. Resection of metastases should be considered whenever possible with curative intent. Somatostatin analogs are the first-line treatment of carcinoid syndrome and may be considered as first-line systemic antiproliferative treatment in unresectable PCs, particularly of low-grade TC and AC. Locoregional or radiotargeted therapies should be considered for metastatic disease. Systemic chemotherapy is used for progressive PCs, although cytotoxic regimens have demonstrated limited effects with etoposide and platinum combination the most commonly used, however, temozolomide has shown most clinical benefit. CONCLUSIONS PCs are complex tumors which require a multidisciplinary approach and long-term follow-up.


title: Surgical treatment of a Morgagni hernia causing intermittent gastric outlet obstruction.

text: A Morgagni hernia is a rare diaphragmatic hernia which develops through a congenital defect in the retrosternal area, usually on the right hand side. Because of its congenital aetiology, Morgagni hernias are rarely considered in the differential diagnosis of gastric outlet obstruction symptoms in adults. We present a patient with an incarcerated Morgagni hernia who presented with gastric outlet obstruction. A 77-year-old woman presented with symptoms and signs of gastric outlet obstruction, dehydration and acute renal impairment. She was treated by fluid resuscitation and nasogastric tube insertion. Radiological imaging showed a Morgagni hernia containing stomach, omentum and colon. This was treated surgically via an abdominal approach and the defect was closed with mesh. The patient recovered well from this procedure and was discharged. We discuss the anatomy, clinical presentation and surgical treatment of this rare diaphragmatic hernia to raise awareness among surgeons and surgical trainees.


Smoking, ACE-2, and COVID-19: Ongoing Controversies.


title: Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review.

text: BACKGROUND Although many case series have been published on the treatment of shoulder periprosthetic joint infection (PJI), few provide direct comparison of outcomes. This systematic review synthesizes the available English literature on shoulder PJI to quantify treatment effectiveness. METHODS The PubMed and Embase databases were searched in April 2014. Keywords included "shoulder replacement infection" and "shoulder arthroplasty infection." Of 663 titles, 55 manuscripts underwent full-text review after application of exclusion criteria. Thirty articles were finally included. RESULTS Propionibacterium acnes was most commonly reported, representing 38.9% of infections, followed by Staphylococcus species. Risk factors for shoulder PJI include previous surgery, increased age, male gender, increased body mass index, and diabetes mellitus. The average white blood cell count in 13 studies was 7472 cells/µL. Ten studies reported a mean erythrocyte sedimentation rate of 27.6 mm/h, whereas 14 studies reported a mean C-reactive protein level of 2.6 mg/dL. P. acnes in intraoperative culture specimens was an independent risk factor for failed treatment for shoulder PJI. When outcomes were pooled, no statistical difference was found in the success rates of 1-stage, 2-stage, or resection arthroplasty revision; each displayed a success rate >90%. However, single-stage revision produced the highest mean Constant score; implant retention resulted in the best range of motion. CONCLUSIONS Our data suggest that single-stage revision can be as effective as 2-stage or resection treatments; however, the retrospective nature of these data precluded our ability to control for confounding variables. Future studies on shoulder PJI should involve direct comparisons of 1-stage vs. 2-stage treatment while comparing cost, morbidity, and functional outcomes.


title: Comparison of Short-term and Long-term Clinical Outcomes Between Laparoscopic and Open Total Gastrectomy for Patients With Gastric Cancer.

text: BACKGROUND AND PURPOSE Validation of laparoscopic total gastrectomy (LTG) for patients with gastric cancer has not been fully investigated. In particular, the technique for esophagojejunostomy remains controversial. We performed 103 cases of LTG for patients with gastric cancer between 2007 and 2013, in which all esophagojejunostomy reconstruction was performed with intracorporeal circular stapling esophagojejunostomy using the OrVil system except for the first 3 cases. The purpose of this study is to retrospectively analyze the clinical usefulness of LTG with intracorporeal circular stapling esophagojejunostomy using the OrVil system and oncological feasibility of LTG as compared with open total gastrectomy (OTG). PATIENTS AND METHOD We retrospectively analyzed clinical course of consecutive 100 operations with LTG in comparison with consecutive 53 operations with OTG for patients with gastric cancer. As an estimation of short-term outcome, operative time, blood loss, postoperative hospital days and postoperative data of blood and drain examination were included. Moreover, relapse-free survival time and overall survival time stratified by each stage were calculated by log-rank test as an estimation of prognostic relevance. RESULTS Blood loss and postoperative hospital stay of LTG were significantly less than that of OTG. Postoperative complications were equivalent between the 2 groups and no patient died within 1 month post-LTG. Only 1 patient had recurrence and died for carcinomatosa peritonitis 50 months after LTG (median follow-up period: 44 mo). CONCLUSIONS Our experience revealed that LTG with intracorporeal circular stapling esophagojejunostomy using the OrVil system could be performed safely and with acceptable oncological outcome for patients with gastric cancer.


title: Thermo-sensitive hydrogel for preventing bowel injury in percutaneous renal radiofrequency ablation.

text: PURPOSE Percutaneous radiofrequency ablation (PRFA) has been used to ablate renal neoplasms with good outcome. However, if bowel lies adjacent to a tumor, ablation increases the risk of thermal bowel injury, and the consequences could be fatal. We describe the technique, effectiveness and safety of using thermo-sensitive hydrogel as insulation to displace the bowel away during PRFA. MATERIALS AND METHODS The study was divided into two main parts: the in vitro and in vivo studies. In in vitro study, to explore the heat insulation of hydrogel, the rabbit kidney was entirely embedded in hydrogel, and then radiofrequency ablation was performed; the temperature on the gel-air and gel-kidney interfaces was measured. In in vivo study, hydrogel of poloxamer 407, 25 % concentration (w/v), was instilled into the perinephric space of 10 rabbits under CT guidance to separate the kidney from adjacent bowel before PRFA performed in the targeted parenchyma in the gel group. For the control group, PRFA was performed in similar portions of 10 rabbits without instillation of hydrogel. Some parameters were recorded such as kidney-to-bowel and electrode-to-bowel distance. Immediately after PRFA, distribution of hydrogel was evaluated and the dimension of radiofrequency ablation zone was measured; bowel thermal injury was compared between the gel and control groups by gross anatomy and histopathological examination. To assess safety, two additional follow-up groups with 10 rabbits in each were set; after PRFA, CT scan was performed every 2 days; gel absorption, thermal damage and some other complications were evaluated during the period. RESULTS AND CONCLUSIONS In in vitro study, temperature was significantly lower at the gel-air than gel-kidney interface (P < .05), and the temperature gradient was positively associated with gel thickness. In in vivo study, hydrogel was instilled successfully in all rabbits in the gel group. The kidney-to-bowel and electrode-to-bowel distances were larger in the gel than control group [(1.1 ± 0.6 cm vs 0.1 ± 0.0 cm, P < .01), (1.8 ± 0.4 cm vs 0.5 ± 0.1 cm, P < .01), respectively]. The gel and control groups did not differ in size of the ablation zones (0.80 ± 0.2 cm vs 0.75 ± 0.3 cm, P > .05). Thermal injury in adjacent bowel was more serious in the control than gel group (P < .01). As for the follow-up, rabbits with gel instillation showed good condition and gel was absorbed gradually within 5 days. Those rabbits with no bowel displacement by gel got significantly lower survival rate and high complication rate (P < .01). CONCLUSION Hydrogel-dissection by means of thermo-sensitive hydrogel instillation is valuable for protecting the bowel adjacent to ablation area against thermal injury during PRFA.


title: [Ethics of clinical trials].

text: L’éthique des essais thérapeutiques. La pandémie de COVID-19 a conduit certains acteurs reconnus de la médecine à renoncer aux méthodes codifiées de la recherche médicale au profit d’affirmations établies dans l’urgence et sans réelle évaluation scientifique. Autant l’on peut comprendre que certains praticiens recourent à ce qui leur est ainsi proposé, autant cette confusion entre action dans l’urgence et recherche scientifique serait lourde de conséquences si elle venait à se généraliser, et cela à de multiples points de vue : image et rôle de la science, qualité et éthique de la recherche médicale et en fin de compte sort des malades soumis à des traitements mal évalués. Ce sont ces questions qui motivent la mise au point qui suit sur les questions d’éthique associées de longue date aux « essais thérapeutiques », cette procédure rationnelle d’acquisition dans les meilleurs délais d’informations fiables sur les avantages et les risques des traitements dont on envisage l’éventuelle utilisation.


title: A diagnostic cohort study on the accuracy of 18-fluorodeoxyglucose (18FDG) positron emission tomography (PET)-CT for evaluation of malignancy in anterior mediastinal lesions: the DECiMaL study.

text: OBJECTIVES The aim of this study is to collate multi-institutional data to determine the value by defining the diagnostic performance of fluorodeoxyglucose positron emission tomography (FDG PET)/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass in order to ascertain the clinical utility of PET/CT to differentiate malignant from benign aetiologies in patients presenting with an anterior mediastinal mass SETTING: DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK surgical sites. PARTICIPANTS Between January 2002 and June 2015, a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. We included all patients undergoing surgery who presented with an anterior mediastinal mass and underwent PET/CT. PET/CT was considered positive for any reported avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria. PRIMARY AND SECONDARY OUTCOME MEASURES Sensitivity, specificity, positive and negative predicted values of [18F]-FDG PET in determining malignant aetiology for an anterior mediastinal mass. RESULTS The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (95% CI 37 to 78). The positive and negative predictive values were 90% (95% CI 83% to 95%) and 42% (95% CI 26% to 61%). CONCLUSIONS The results of our study suggest reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign diseases of the anterior mediastinum.


title: Lessons from the front lines: the prehospital experience of the 2009 novel H1N1 outbreak in Victoria, Australia.

text: The H1N1 (swine influenza) 2009 outbreak in Victoria, Australia, provided a unique opportunity to review the prehospital response to a public health emergency. As part of Ambulance Victoria's response to the outbreak, relevant emergency response plans and pandemic plans were instigated, focused efforts were aimed at encouraging the use of personal protective equipment (PPE), and additional questions were included in the call-taking script for telephone triage of emergency calls to identify potential cases of H1N1 from the point of call. As a result, paramedics were alerted to all potential cases of H1N1 influenza or any patient who met the current case definition before their arrival on the scene and were advised to use appropriate PPE. During the period of May 1 to July 2, Ambulance Victoria telephone triaged 1598 calls relating to H1N1 (1228 in metropolitan areas and 243 in rural areas) and managed 127 calls via a referral service that provides specific telephone triage for potential H1N1 influenza cases based on the national call-taking script. The referral service determines whether a patient requires an emergency ambulance or can be diverted to other resources such as flu clinics. Key lessons learned during the H1N1 outbreak include a focused need for continued education and communication regarding infection control and the appropriate use of PPE. Current guidelines regarding PPE use are adequate for use during an outbreak of infectious disease. Compliance with PPE needs to be addressed through the use of intra-agency communications and regular information updates early in the progress of the outbreak.


title: The effect of xenon-augmented sevoflurane anesthesia on intraoperative hemodynamics and early postoperative neurocognitive function in children undergoing cardiac catheterization: A randomized controlled pilot trial.

text: BACKGROUND In adults, xenon has only minimal hemodynamic side effects when compared with other anesthetics. Moreover, in preclinical experiments, xenon has been demonstrated to possess cardio- and neuroprotective properties. Altogether, the favorable hemodynamic profile combined with its potential for organ-protection could render xenon an attractive option for anesthesia in children with cardiovascular compromise. AIMS The aim of this study was to explore safety and feasibility of sevoflurane-augmented xenon anesthesia in school-aged children and to assess early postoperative neurocognitive effects of xenon-sevoflurane and sevoflurane anesthesia when compared to a control group that did not have anesthesia. METHODS Forty children aged 4-12 years, suffering from congenital heart disease, undergoing diagnostic or interventional cardiac catheterization were randomized to either xenon-augmented sevoflurane anesthesia or sevoflurane alone. Safety was assessed by the incidence of intraprocedural hemodynamic instability and feasibility by anesthetic depth and respiratory profile. In addition, neurocognitive performance was assessed preoperatively, 2 hours after discharge from PACU and at 24 hours after anesthesia using the Amsterdam Neuropsychological Tasks system. A healthy control group of 22 age- and gender-matched children not exposed to anesthesia underwent an identical neurocognitive test battery, at comparable time intervals. RESULTS Overall hemodynamics did not differ between groups. Xenon-sevoflurane anesthesia resulted in decreased intraoperative ephedrine requirements (median [IQR]) (0.00 mg/kg [0.00-0.00] vs 0.00 mg/kg [0.00-0.01], P = 0.047). Only neurocognitive tests in the domain of alertness were significantly impaired 2 hours postoperatively in both anesthesia groups in comparison with the control group (alertness variability: P = 0.02, odds ratio 5.8), but recovered at 24 hours. For working memory, inhibition, cognitive flexibility, and motor coordination tasks, no significant interaction effects of anesthesia were found in the early postoperative period. CONCLUSION In this pilot trial, xenon-augmented sevoflurane anesthesia in school-aged children was feasible, and associated with decreased ephedrine requirements. All children exposed to anesthesia showed impaired neurocognitive performance in the immediate postoperative period when compared to control children; however, without significant differences between both treatment groups.


title: Adaptive human behavior in epidemiological models.

text: The science and management of infectious disease are entering a new stage. Increasingly public policy to manage epidemics focuses on motivating people, through social distancing policies, to alter their behavior to reduce contacts and reduce public disease risk. Person-to-person contacts drive human disease dynamics. People value such contacts and are willing to accept some disease risk to gain contact-related benefits. The cost-benefit trade-offs that shape contact behavior, and hence the course of epidemics, are often only implicitly incorporated in epidemiological models. This approach creates difficulty in parsing out the effects of adaptive behavior. We use an epidemiological-economic model of disease dynamics to explicitly model the trade-offs that drive person-to-person contact decisions. Results indicate that including adaptive human behavior significantly changes the predicted course of epidemics and that this inclusion has implications for parameter estimation and interpretation and for the development of social distancing policies. Acknowledging adaptive behavior requires a shift in thinking about epidemiological processes and parameters.


Conservative treatment for anal fistula: collagen matrix injection.


title: Ventrally dislocated attachment of the ovarian suspensory ligament, a risk factor for tubal occlusion as a postoperative complication of inguinal hernia repair: efficacy of laparoscopic inguinal hernia repair for preventing tubal damage.

text: PURPOSE Although the traditional cutdown inguinal hernia repair in children is well established, tubal occlusion has been reported as a complication in girls. The purpose was to investigate the mechanism of this complication and the efficacy of laparoscopic repair for preventing tubal occlusion. METHODS Between October 2006 and May 2010, we performed laparoscopic hernia repair in 100 girls (54 with a right hernia, including 2 with an inguinal ovarian hernia, 40 with a left hernia, including 3 with an inguinal ovarian hernias, and 6 with bilateral hernias). During laparoscopic repair we examined the anatomical relationship between the ovary, ovarian suspensory ligament, internal inguinal ring, and round ligament on both sides. RESULTS In 17 cases, 5 with an inguinal ovarian hernia and 12 without, the suspensory ligaments were ventrally dislocated and attached around the internal inguinal ring, and the ovary and fallopian tube were positioned near the internal inguinal ring and above the pelvic brim on the side of the original hernia. CONCLUSION This ventrally dislocated attachment may facilitate sliding of the ovaries and tubes into the hernial sac and induce tubal occlusion as a postoperative complication of inguinal hernia repair. The laparoscopic procedure makes it easy to prevent this complication.


title: Association of Padua prediction score with in-hospital prognosis in COVID-19 patients.

text: BACKGROUND Nearly 20% novel coronavirus disease 2019 (COVID-19) patients have abnormal coagulation function. Padua prediction score (PPS) is a validated tools for venous thromboembolism (VTE) risk assessment. However, its clinical value in COVID-19 patients evaluation was unclear. METHODS We prospectively evaluated the VTE risk of COVID-19 patients using PPS. Demographic and clinical data were collected. Association of PPS with 28-days mortality was analyzed by multivariate logistic regression and Kaplan-Meier analysis. RESULTS 274 continuous patients were enrolled, with total mortality of 17.2%. Patients in high PPS group, with significantly abnormal coagulation, have a higher levels of interleukin 6 (25.27 pg/ml vs.2.55 pg/ml, P < 0.001), prophylactic anticoagulation rate (60.7% vs. 6.5%, P<0.001) and mortality (40.5% vs. 5.9%, P<0.001) as compared with that in low PPS group. Critical patients showed higher PPS (6 score vs. 2 score, P<0.001) than that in severe patients. Multivariate logistic regression revealed the independent risk factors of in-hospital mortality included high PPS (OR: 7.35, 95%CI: 3.08 - 16.01), increased interleukin-6 (OR: 11.79, 95%CI: 5.45 - 26.20) and elevated d-dimer (OR: 4.65, 95%CI: 1.15 - 12.15). Kaplan-Meier analysis indicated patients with higher PPS had a significant survival disadvantage. Prophylactic anticoagulation in higher PPS patients show a mild advantage of mortality but without statistical significance (37.1% vs. 45.7%, P=0.42). CONCLUSION Higher PPS associated with in-hospital poor prognosis in COVID-19 patients. Prophylactic anticoagulation showed a mild advantage of mortality in COVID-19 patients with higher PPS, but it remain need further investigation.


title: Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization.

text: BACKGROUND Endovascular treatment of wide-necked aneurysms is challenging. Stent-assisted coiling (SAC) is associated with increased complications and requires dual antiplatelet therapy. OBJECTIVE To compare treatment of unruptured, wide-necked aneurysms with a dual-microcatheter technique (DMT) versus SAC. METHODS Between 2006 and 2011, 100 patients with unruptured wide-necked intracranial aneurysms were treated with DMT and 160 with SAC. Over time there was a significant decrease in the use of SAC and a corresponding increase in DMT. The investigators matched 60 patients treated with DMT blinded to outcome in a 1:2 fashion based on maximal aneurysm dome diameter with 120 patients treated with SAC. Outcomes were determined with conditional (matched) multivariate analysis. RESULTS There were no significant differences in patient or aneurysm characteristics between cohorts, including aneurysm diameter, neck width, or volume. Overall packing density and coil volume achieved was not significantly different between cohorts. There were higher rates of overall complications in those receiving SAC (19.2%) compared with DMT (5.0%; p=0.012), but no significant difference in major complications (8.3% vs 1.7%, respectively; p=0.103). At a mean follow-up of 27.0 ± 18.9 months, rates of retreatment did not differ between DMT (15.1%) and SAC (17.7%). Delayed in-stent stenosis occurred in five patients and in-stent thrombosis in four patients treated with SAC. There was no difference in favorable functional outcome (modified Rankin score 0-2) between those treated with DMT (90.6%) compared with SAC (91.2%). CONCLUSIONS DMT and SAC are effective endovascular approaches for unruptured, wide-necked aneurysms; however, DMT may result in less morbidity. Further long-term studies are necessary to determine the optimal indications for these treatment options.


title: A Case of Ruptured Blood Blister-like Aneurysm Treated with Pipeline Embolization Device: Clinical Significance of Fetal-type Posterior Communicating Artery.

text: Blood-blister like aneurysms (BBAs) are challenging lesions because of their wide fragile neck. Flow-diverting stents (FDSs), such as the Pipeline Embolization Device (PED), have been applied to treat BBAs less amenable to more established techniques of treatment. However, the use of FDSs, including the PED, in acute subarachnoid hemorrhage (SAH) still remains controversial. We report a case of aneurysm regrowth following PED application for a ruptured BBA that overlapped the origin of the dominant posterior communicating artery (PCoA), which was successfully treated after coil trapping of the origin of the fetal-type PCoA. And, we discuss the clinical significance of the fetal-type PCoA communicating with a BBA in terms of PED failure.


title: Retroperitoneal Laparoscopic Radical Nephrectomy for Large (>7 cm) Solid Renal Tumors: Comparison of Perioperative Outcomes with the Transperitoneal Approach.

text: PURPOSE To describe our technique for retroperitoneal laparoscopic radical nephrectomy (LRN) and to present the perioperative outcomes of our retroperitoneal LRN series for large (>7 cm) solid renal tumors and to compare them with those of the transperitoneal approach. MATERIALS AND METHODS A retrospective chart review was performed for patients who had undergone LRN for a solid renal tumor greater than 7 cm in size on computed tomography (CT) scans between June 2008 and January 2016. Perioperative outcomes were compared between transperitoneal and retroperitoneal approaches. RESULTS There were 30 cases in the transperitoneal approach group and 34 cases in the retroperitoneal group. The mean tumor size was 9.0 cm in the transperitoneal approach group and 10.3 cm in the retroperitoneal group (P = .494). In the retroperitoneal approach group, the operation time was shorter, estimated blood loss (EBL) was lower, and time to start diet was shorter (P < .001, P = .037, and P = .002, respectively). The complication rate was comparable between the two approaches. CONCLUSIONS Retroperitoneal LRN for a large (>7 cm) solid renal tumor demonstrated a superior result in terms of operation time, estimated blood loss, and time to start diet than transperitoneal LRN. Other perioperative outcomes and complication rate were comparable between the two approaches. We believe that with sufficient experience, retroperitoneal LRN may be an effective and safe procedure for large (>7 cm) solid renal tumors.


title: Effects of intracanal mineral trioxide aggregate and calcium hydroxide during four weeks on pH changes in simulated root surface resorption defects: an in vitro study using matched pairs of human teeth.

text: INTRODUCTION Diffusion of hydroxyl ions from intracanal calcium hydroxide (CH) through dentin is used to arrest external inflammatory root resorption. However, long-term and short-term CH placement has been associated with an increased risk of root fracture. Intracanal mineral trioxide aggregate (MTA) might provide an alternative to CH as a source of hydroxyl ions. This in vitro study compared the effects of intracanal MTA and CH on hydroxyl ion diffusion through dentin by measuring pH changes over time in simulated root surface resorption defects prepared in matched pairs of teeth; the null hypothesis tested was that there is no difference. METHODS Root surface cavities were prepared 5 mm from the apex in extracted human permanent anterior teeth (21 matched pairs) and 7 additional teeth (controls). Root canals were instrumented to size 50/.04 and filled with either tooth-colored MTA (ProRoot) or CH (UltraCal XS); control teeth were filled with saline. The pH in root surface cavities was measured at 3 hours, 24 hours, 1 week, 2 weeks, 3 weeks, and 4 weeks. RESULTS In controls, pH readings did not differ significantly during the 4 weeks (P > .05, repeated-measures analysis of variance [ANOVA]). For the experimental intragroup effects, significant pH changes occurred over time in the MTA group (P = .005, repeated-measures ANOVA) and the CH group (P < .0001). For the experimental intergroup effects, the overall mean pH was higher in the MTA group (8.66; standard error [SE], 0.07) compared with the CH group (8.46; SE, 0.07) (P = .014, paired t test). At 4 weeks pH was higher in the MTA group (8.30; SE, 0.16) compared with the CH group (7.90; SE, 0.11) (P = .011); at all other time points intergroup differences were insignificant. The null hypothesis was rejected. CONCLUSIONS Intracanal MTA and CH groups differed in their overall effect on pH measured in simulated root surface resorption defects. At 4 weeks intracanal placement of MTA compared with CH resulted in a small but significantly higher pH.


title: The global experience of digital health interventions in COVID-19 management.

text: Digital health interventions are globally playing a significant role to combat coronavirus disease 2019 (COVID-19), which is an infectious disease caused by Severe Acute Respiratory Syndrome coronavirus 2. Here, we present a very brief overview of the multifaceted digital interventions, globally, and in India, for maintaining health and health-care delivery, in the context of the Covid-19 pandemic.


We practised for a pandemic, but didn't brace.


title: Relationship between inflammation and sex hormone profile in female patients receiving different types of renal replacement therapy.

text: BACKGROUND Patients with end-stage renal disease (ESRD) experience female sexual dysfunction (FSD). The purpose of this study was to compare FSD in different types of renal replacement therapy and control patients. METHODS The study was consisted of 47 renal transplantation (RT), 46 hemodialysis (HD), and 28 continuous ambulatory peritoneal dialysis (CAPD) patients and 36 healthy control subjects. All groups were evaluated with the following scales: Female Sexual Function Index (FSFI) questionnaire, Short Form (SF)-36 questionnaires, and Beck Depression Inventory (BDI). Demographic data, laboratory values, and hormone levels were obtained. The patients with FSFI score <26.55 were accepted as experiencing sexual dysfunction. RESULTS Overall, total FSFI scores in RT, HD, CAPD, and control were 22 (range, 2-35), 22.4 (4-34), 18.35 (2-34), and 29.6 (2-35), respectively. The mean total FSFI score was not different in patients receiving different kinds of renal replacement therapy (P > .05) although they were significantly worse then the control group (P < .001). On regression analysis, age was significantly associated with FSD (β = -0.14; P = .001). In addition, the physiologic health domain of SF-36 was significantly better in control groups (P < .001). The difference in terms of mean of BDI score did not reach statistical significance among patient groups (P > .05). Female sexual dysfunction score was negatively correlated with BDI (r = -0.371; P < .001) and positively correlated with the mental-physical components score of SF-36 (r = 0.423 [P < .001] and r = 0.494 [P < .001], respectively) in all patients groups. Regarding the hormones of the patients, there was a significant difference between RT and the HD and CAPD groups in dihydroepiandrosterone sulfate (DHEAS; P < .001), RT and HD in prolactin (P < .001), and RT and CAPD in free testesterone (P < .001). CONCLUSIONS Renal transplantation, hemodialysis, and peritoneal dialysis patients were at more risk of developing sexual dysfunction and lower quality of life scores than healthy subjects. Notably, the mode of renal replacement therapy had no impact on female sexual function.


title: Community eye-health and vision center guidelines during COVID-19 pandemic in India.

text: The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has disrupted our society on an unprecedented scale since its inception in December 2019. As the health-care system is finally re-organizing to mitigate the impact of the pandemic, it was necessary to re-structure primary eye care (PEC) activities as well on the same lines. A consensus meeting was held with leading eye-care experts on 2nd May 2020 to prepare a roadmap for PEC in the days to come. Guidelines are needed for PEC activities like vision testing, refraction, optical dispensing, counseling, etc., Some of the activities at vision centers (VCs) may be postponed or modified in light of the current pandemic situation. PEC workers need to strictly follow social distancing norms (minimum 3 feet) for minimizing risk of exposure and need access to appropriate personal protective equipment (PPE), like gloves, masks and shields while examining beneficiaries. For optometrists, sterilization of instruments and encouraging the people to remain silent during the examination is recommended. Because conjunctivitis may be an early sign which can present at VCs, extra precautions in the form of PPE has to be ensured while examining such patients. This is also an opportunity to start running telemedicine clinics for all emergent cases that cannot be managed at the primary level. The guidelines also need to be updated based on the context of the working environment and changes in government directives from time to time.


title: Systematic Review Looking at the Use of Technology to Measure Free-Living Symptom and Activity Outcomes in Parkinson's Disease in the Home or a Home-like Environment.

text: BACKGROUND The emergence of new technologies measuring outcomes in Parkinson's disease (PD) to complement the existing clinical rating scales has introduced the possibility of measurement occurring in patients' own homes whilst they freely live and carry out normal day-to-day activities. OBJECTIVE This systematic review seeks to provide an overview of what technology is being used to test which outcomes in PD from free-living participant activity in the setting of the home environment. Additionally, this review seeks to form an impression of the nature of validation and clinimetric testing carried out on the technological device(s) being used. METHODS Five databases (Medline, Embase, PsycInfo, Cochrane and Web of Science) were systematically searched for papers dating from 2000. Study eligibility criteria included: adults with a PD diagnosis; the use of technology; the setting of a home or home-like environment; outcomes measuring any motor and non-motor aspect relevant to PD, as well as activities of daily living; unrestricted/unscripted activities undertaken by participants. RESULTS 65 studies were selected for data extraction. There were wide varieties of participant sample sizes (<10 up to hundreds) and study durations (<2 weeks up to a year). The metrics evaluated by technology, largely using inertial measurement units in wearable devices, included gait, tremor, physical activity, bradykinesia, dyskinesia and motor fluctuations, posture, falls, typing, sleep and activities of daily living. CONCLUSIONS Home-based free-living testing in PD is being conducted by multiple groups with diverse approaches, focussing mainly on motor symptoms and sleep.


title: Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy as a definitive surgical procedure for morbid obesity. Mid-term results.

text: BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has been gaining acceptance because it has shown good short- and mid-term results as a single procedure for morbid obesity. The aim of this study was to compare short- and mid-term results between laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG. METHODS Observational retrospective study from a prospective database of patients undergoing LRYGB and LSG between 2004 and 2011, where 249 patients (mean age 44.7 years) were included. Patients were followed at 1, 3, 6, 12, and 18 months, and annually thereafter. Short- and mid-term weight loss, comorbidity improvement or resolution, postoperative complications, re-interventions, and mortality were evaluated. RESULTS One hundred thirty-five LRYGB and 114 LSG were included. Significant statistical differences between LRYGB and LSG were found in operative time (153 vs. 93 min. p < 0.001), minor postoperative complications (21.5 % vs. 4.4 %, p = 0.005), blood transfusions (8.8 % vs. 1.7 %, p = 0.015), and length of hospital stay (4 vs. 3 days, p < 0.001). There were no differences regarding major complications and re-interventions. There was no surgery-related mortality. The percentage of excess weight loss up to 4 years was similar in both groups (66 ± 13.7 vs. 65 ± 14.9 %). Both techniques showed similar results in comorbidities improvement or resolution at 1 year. CONCLUSIONS There is a similar short- and mid-term weight loss and 1-year comorbidity improvement or resolution between LRYGB and LSG, although minor complication rate is higher for LRYGB. Results of LSG as a single procedure need to be confirmed after a long-term follow-up.


title: Measurement and State-Dependent Modulation of Hypoglossal Motor Excitability and Responsivity In-Vivo.

text: Motoneurons are the final output pathway for the brain's influence on behavior. Here we identify properties of hypoglossal motor output to the tongue musculature. Tongue motor control is critical to the pathogenesis of obstructive sleep apnea, a common and serious sleep-related breathing disorder. Studies were performed on mice expressing a light sensitive cation channel exclusively on cholinergic neurons (ChAT-ChR2(H134R)-EYFP). Discrete photostimulations under isoflurane-induced anesthesia from an optical probe positioned above the medullary surface and hypoglossal motor nucleus elicited discrete increases in tongue motor output, with the magnitude of responses dependent on stimulation power (P < 0.001, n = 7) and frequency (P = 0.002, n = 8, with responses to 10 Hz stimulation greater than for 15-25 Hz, P < 0.022). Stimulations during REM sleep elicited significantly reduced responses at powers 3-20 mW compared to non-rapid eye movement (non-REM) sleep and wakefulness (each P < 0.05, n = 7). Response thresholds were also greater in REM sleep (10 mW) compared to non-REM and waking (3 to 5 mW, P < 0.05), and the slopes of the regressions between input photostimulation powers and output motor responses were specifically reduced in REM sleep (P < 0.001). This study identifies that variations in photostimulation input produce tunable changes in hypoglossal motor output in-vivo and identifies REM sleep specific suppression of net motor excitability and responsivity.