title: Randomized trial of near-infrared spectroscopy for personalized optimization of cerebral tissue oxygenation during cardiac surgery.

text: Background We assessed whether a near-infrared spectroscopy (NIRS)-based algorithm for the personalized optimization of cerebral oxygenation during cardiopulmonary bypass combined with a restrictive red cell transfusion threshold would reduce perioperative injury to the brain, heart, and kidneys. Methods In a randomized controlled trial, participants in three UK centres were randomized with concealed allocation to a NIRS (INVOS 5100; Medtronic Inc., Minneapolis, MN, USA)-based 'patient-specific' algorithm that included a restrictive red cell transfusion threshold (haematocrit 18%) or to a 'generic' non-NIRS-based algorithm (standard care). The NIRS algorithm aimed to maintain cerebral oxygenation at an absolute value of > 50% or at > 70% of baseline values. The primary outcome for the trial was cognitive function measured up to 3 months postsurgery. Results The analysis population comprised eligible randomized patients who underwent valve or combined valve surgery and coronary artery bypass grafts using cardiopulmonary bypass between December 2009 and January 2014 ( n =98 patient-specific algorithm; n =106 generic algorithm). There was no difference between the groups for the three core cognitive domains (attention, verbal memory, and motor coordination) or for the non-core domains psychomotor speed and visuo-spatial skills. The NIRS group had higher scores for verbal fluency; mean difference 3.73 (95% confidence interval 1.50, 5.96). Red cell transfusions, biomarkers of brain, kidney, and myocardial injury, adverse events, and health-care costs were similar between the groups. Conclusions These results do not support the use of NIRS-based algorithms for the personalized optimization of cerebral oxygenation in adult cardiac surgery. Clinical trial registration http://www.controlled-trials.com , ISRCTN 23557269.


title: Hydromorphone-OROS formulation.

text: IMPORTANCE TO THE FIELD Hydromorphone is a semi-synthetic opioid approved in the USA for the treatment and relief of moderate to severe pain and postoperative pain. However, the compound is short-acting, and there is no extended-release formulation clinically available. A previous hydromorphone extended-release formulation that successfully came to market was subsequently withdrawn on account of safety concerns. Clinical need supports the presence of an extended-release formulation of hydromorphone. AREAS COVERED IN THIS REVIEW Medline articles showing from a search of 'hydromorphone and OROS' were included in the review. In addition, searches were done relating to published data regarding regulatory affairs dealing with this specific topic. Physicians prescribing information for hydromorphone was also reviewed. WHAT THE READER WILL GAIN The reader will gain an increased understanding of the use of an extended-release formulation of hydromorphone using the OROS technology and will appreciate that this technology has safety advantages compared with previous extended-release formulations of hydromorphone. TAKE HOME MESSAGE Hydromorphone-OROS is an effective agent for the long-acting control of pain and a welcome addition to other available opioid formulations.


title: Guidelines on the intraoperative transfusion of red blood cells: a protocol for systematic review.

text: INTRODUCTION A significant proportion of red blood cell (RBC) transfusions are administered intraoperatively; yet there is limited evidence to guide transfusion decisions in this setting. The objective of this systematic review is to explore the availability, quality and content of clinical practice guidelines (CPGs) reporting on the indication for allogenic RBC transfusion during surgery. METHODS Major electronic databases (MEDLINE, EMBASE and CINAHL), guideline clearinghouses and Google Scholar, will be systematically searched from inception to January 2019 for CPGs pertaining to indications for intraoperative allogenic RBC transfusion. Characteristics of eligible guidelines will be reported in a summary table. The AGREE II instrument will be used to appraise the quality of identified guidelines. Recommendations advising on indications for intraoperative RBC transfusion will be manually extracted and presented to allow for comparison of similarities and/or discrepancies in the literature. ETHICS AND DISSEMINATION The results of this systematic review will be disseminated through relevant conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER CRD42018111487.


title: Regional Comparison of Multiphase Computed Tomographic Angiography and Computed Tomographic Perfusion for Prediction of Tissue Fate in Ischemic Stroke.

text: BACKGROUND AND PURPOSE Within different brain regions, we determine the comparative value of multiphase computed tomographic angiography (mCTA) and computed tomographic perfusion (CTP) in predicting follow-up infarction. METHODS Patients with M1-middle cerebral artery occlusions were prospectively included in this multicenter study. Regional analysis was performed for each patient within Alberta Stroke Program Early CT Score regions M2 to M6. Regional pial vessel filling was assessed on mCTA in 3 ways: (1) Washout of contrast within pial vessels; (2) Extent of maximal pial vessel enhancement compared with contralateral hemisphere; (3) Delay in maximal pial vessel enhancement compared with contralateral hemisphere. Cerebral blood flow, cerebral blood volume, and Tmax data were extracted within these Alberta Stroke Program Early CT Score regions. Twenty-four- to 36-hour magnetic resonance imaging/CT was assessed for infarct in each Alberta Stroke Program Early CT Score region (defined as >20% infarction within that region). Mixed effects logistic regression models were used to compare mCTA and CTP parameters when predicting brain infarction. Area under the receiver operating characteristics was used to assess discriminative value of statistical models. RESULTS Seventy-seven patients were included. mCTA parameter washout and CTP parameter Tmax were significantly associated with follow-up infarction in all models (P<0.05). The area under the receiver operating characteristic for mCTA models ranged from 92% to 94% and was not different compared with all CTP models (P>0.05). Mean Tmax and cerebral blood volume values were significantly different between each washout score (P<0.01) and each delay score category (P<0.01). Mean Tmax, cerebral blood flow, and cerebral blood volume values were significantly different between each extent score category (P<0.05). CONCLUSIONS Similar to CTP, multiphase CTA can be used to predict tissue fate regionally in acute ischemic stroke patients.


title: Diagnosing and managing postherpetic neuralgia.

text: Postherpetic neuralgia (PHN) represents a potentially debilitating and often undertreated form of neuropathic pain that disproportionately affects vulnerable populations, including the elderly and the immunocompromised. Varicella zoster infection is almost universally prevalent, making prevention of acute herpes zoster (AHZ) infection and prompt diagnosis and aggressive management of PHN of critical importance. Despite the recent development of a herpes zoster vaccine, prevention of AHZ is not yet widespread or discussed in PHN treatment guidelines. Diagnosis of PHN requires consideration of recognized PHN signs and known risk factors, including advanced age, severe prodromal pain, severe rash, and AHZ location on the trigeminal dermatomes or brachial plexus. PHN pain is typically localized, unilateral and chronic, but may be constant, intermittent, spontaneous and/or evoked. PHN is likely to interfere with sleep and daily activities. First-line therapies for PHN include tricyclic antidepressants, gabapentin and pregabalin, and the lidocaine 5 % patch. Second-line therapies include strong and weak opioids and topical capsaicin cream or 8 % patch. Tricyclic antidepressants, gabapentinoids and strong opioids are effective but are also associated with systemic adverse events that may limit their use in many patients, most notably those with significant medical comorbidities or advanced age. Of the topical therapies, the topical lidocaine 5 % patch has proven more effective than capsaicin cream or 8 % patch and has a more rapid onset of action than the other first-line therapies or capsaicin. Given the low systemic drug exposure, adverse events with topical therapies are generally limited to application-site reactions, which are typically mild and transient with lidocaine 5 % patch, but may involve treatment-limiting discomfort with capsaicin cream or 8 % patch. Based on available clinical data, clinicians should consider administering the herpes zoster vaccine to all patients aged 60 years and older. Clinicians treating patients with PHN may consider a trial of lidocaine 5 % patch monotherapy before resorting to a systemic therapy, or alternatively, may consider administering the lidocaine 5 % patch in combination with a tricyclic antidepressant or a gabapentinoid to provide more rapid analgesic response and lower the dose requirement of systemic therapies.


Health in all policies.


title: Single-incision laparoscopic total extraperitoneal repair for a Grynfeltt hernia: a case report.

text: INTRODUCTION A superior lumbar hernia, which is also known as a Grynfeltt hernia, is a rare abdominal wall defect that can be primary or secondary to trauma or orthopedic surgery. The anatomic location of a lumbar hernia makes diagnosis and repair challenging. We successfully repaired a lumbar hernia using a single-incision laparoscopic total extraperitoneal approach. To the best of our knowledge, this is the first report of the use of this surgical technique in the treatment of a primary Grynfeltt hernia. CASE PRESENTATION A 76-year-old Taiwanese man presented to our hospital with a left lower bulging mass noted for over three months. Abdominal computed tomography revealed a left Grynfeltt hernia. We performed a single-incision laparoscopic total extraperitoneal repair. Our patient was discharged uneventfully on the fourth day after the operation. There was no evidence of recurrence after six months of follow-up. CONCLUSION A laparoscopic total extraperitoneal repair for a lumbar hernia provides an excellent operative view and minimal invasiveness. The single-incision technique also provides better cosmetic outcomes. Our experience suggests that the single-incision laparoscopic total extraperitoneal approach may be a feasible and safe alterative to conventional approaches in lumbar hernia repair.


title: Long-term incisional hernia rate after single-incision laparoscopic cholecystectomy is significantly higher than that after standard three-port laparoscopy: a cohort study.

text: BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) is a feasible technique that provides comparable results to standard laparoscopic cholecystectomy (LC). However, despite the theoretical advantages of minor wound complications and cosmetic results, SILC usually requires a larger incision, which may increase the incidence of incisional hernias. This study evaluated SILC and standard multiport cholecystectomy with respect to perioperative outcomes, hospital stay, cosmetic results, and postoperative complications, including the 5-year incisional hernia rate. METHODS A cohort study was performed with patients who underwent elective laparoscopic surgery for noncomplicated cholelithiasis at our hospital between July 2009 and June 2011. During the study period, there were 45 nonselected patients who underwent SILC, and these patients were compared with a control group of 140 patients who underwent LC using the standard three-trocar technique during the same period. Both patient groups were comparable in age, gender, BMI and ASA classification. RESULTS The mean follow-up was 58.7 ± 10.9 (range 3-80) months. There were no differences between groups in terms of hospital stay, rate and severity of complications, wound infection, and patient cosmetic satisfaction. However, the operating time (57.8 versus 35.2 min) and long-term incisional hernia rate (13.3% versus 4.7%) were significantly higher in the SILC group. CONCLUSION SILC is associated with a statistically significantly higher long-term incisional hernia rate at the umbilical port site than the standard multiport laparoscopic cholecystectomy. Our data show there was no relevant advantage regarding the postoperative course, hospital stay or cosmetic satisfaction. To date, widespread use of SILC cannot be recommended. Registration number: NCT03768661 ( https://www.clinicaltrials.gov ). TRIAL REGISTRATION This study has been registered at www.clinicaltrials.gov . The clinicaltrials.gov ID number is: NCT03768661.


title: Impact and feasibility of an emergency department-based ventilator-associated pneumonia bundle for patients intubated in an academic emergency department.

text: BACKGROUND Ventilator-associated pneumonia (VAP) has been linked to emergency department (ED) intubation and length of stay (LOS). We assessed VAP prevalence in ED intubated patients, feasibility of ED VAP prevention, and effect on VAP rates. METHODS This was a quality improvement initiative using a pre/post design. Phase 1 (PRE1) comprised patients before intensive care unit (ICU) bundle deployment. Phase 2 (PRE2) occurred after ICU but before ED deployment. Phase 3 (POST) included patients received VAP prevention starting at ED intubation. Log-rank test for equality and Cox regression using a Breslow method for ties were performed. Bundle compliance was reported as percentages. Number needed to treat (NNT) was calculated by ventilator day. RESULTS PRE1, PRE2, and POST groups were composed of 195, 192, and 153 patients, respectively, with VAP rates of 22 (11.3%), 11 (5.7%), and 6 (3.9%). Log-rank test showed significant reduction in VAP (χ2 = 9.16, P = .0103). The Cox regression hazard ratio was 1.38 for the Clinical Pulmonary Infection Score (P = .001), and the hazard ratio was 0.26 for the VAP bundle (P = .005). Bundle compliance >50% for head-of-bed elevation, oral care, subglottic suctioning, and titrated sedation improved significantly with introduction of a registered nurse champion. NNT varied from 7 to 11. CONCLUSIONS VAP was common for ED intubated patients. ED-based VAP prevention is feasible. We demonstrate significant reduction in VAP rates, which should be replicated in a multicenter study.


title: Robot-assisted sacrocolpopexy for pelvic organ prolapse: surgical technique and outcomes at a single high-volume institution.

text: BACKGROUND Pelvic organ prolapse (POP) represents a common female pelvic floor disorder that has a serious impact on quality of life. Several types of procedures with different surgical approaches have been described to correct these defects, but the optimal management is still debated. OBJECTIVE To describe our surgical technique of robot-assisted sacrocolpopexy (RASC) for POP and to assess its safety and long-term outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of the medical records of 95 consecutive patients who underwent RASC for POP at our centre from April 2006 to December 2011 was performed. SURGICAL PROCEDURE RASC with use of polypropylene meshes was performed in all cases using a standardised technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes of RASC were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS Median operative time was 101 min. No conversion to open surgery was needed. One vaginal and two bladder injuries occurred and were repaired intraoperatively. Only one Clavien grade 3 postoperative complication was observed (bowel obstruction treated laparoscopically). At a median follow-up of 34 mo, persistent POP was observed in four cases (4.2%). One mesh erosion occurred and required robot-assisted removal of the mesh. Ten (10.5%) patients complained de novo urgency after RASC, which resolved in the first few weeks after surgery. No significant de novo bowel or sexual symptoms were reported. CONCLUSIONS Our technique of RASC for correction of POP is safe and effective, with limited risk of complications and good long-term results in the treatment of all types of POP. The robotic surgical system facilitates precise and accurate placement of the meshes with short operative time, thereby favouring wider diffusion of minimally invasive treatment of POP. PATIENT SUMMARY We studied the treatment of patients with vaginal prolapse by using a robot-assisted surgical technique to fix the vaginal wall with a synthetic mesh. This technique was found to be safe and effective, with limited risk of complications and good long-term results.


title: Long Parallel Stent Grafts for the Treatment of Complex Aortic Aneurysms.

text: PURPOSE To describe our experience with the chimney technique in endovascular aneurysm repair (ch-EVAR) using long parallel grafts (PGs) of 100 mm or more for the treatment of complex aortic aneurysms. MATERIALS AND METHODS From 2009 to 2016, data were prospectively collected for patients who underwent ch-EVAR using long PGs. Data included patient demographics and aortic anatomy, technical success, patency and reintervention rate. RESULTS A total of 29 long PGs were placed in 18 patients (males 16, average age 71 years). Nine (50%) suffered from thoracoabdominal aortic aneurysms, 4 (22%) from juxtarenal aortic aneurysms and 3 (17%) from suprarenal aortic aneurysms and 2 (11%) were treated for abdominal aortic aneurysms that required revascularization of a pelvic kidney. Twenty (70%) of the PGs were 100 mm in length, and 9 (30%) were 150 mm. Long PGs were successfully placed in 16 (89%) patients. Two patients (11%) expired in the perioperative period. Mean period of follow-up was 12 months (range 1-43 months). Sac size decreased in size or remained unchanged in 13 patients (72%). Three patients with sac enlargement underwent successful endovascular treatment the type 1A gutter endoleaks. None required reintervention of the PGs. Three patients expired, none from aneurysm-related deaths. CONCLUSION The use of long PGs is a feasible technique and provides a durable repair of complex aortic aneurysms in midterm follow-up. Despite the length of the PGs, gutter endoleaks are encountered only in a minority of the cases and can be treated minimally invasive techniques.


title: Impact of carbohydrate restriction with and without fatty acid loading on myocardial 18F-FDG uptake during PET: A randomized controlled trial.

text: BACKGROUND Low-carbohydrate (LC) and high-fat, low-carbohydrate (HFLC) dietary preparations may enhance (18)F-FDG-PET-based imaging of small, inflamed structures near the heart by suppressing myocardial FDG signal. We compared myocardial (18)F-FDG uptake in patients randomized to LC, HFLC, and unrestricted (UR) preparations prior to (18)F-FDG-PET. METHODS AND RESULTS We randomized 63 outpatients referred for oncologic (18)F-FDG-PET to LC, HFLC, or UR dietary preparations (1:1:1 allocation) starting the evening before PET. After eating dinner according to instructions, UR and LC patients fasted until FDG injection (mean time 745 minutes for UR, 899 minutes for LC), and HFLC patients drank a fatty drink 60-70 minutes prior to FDG injection. Attenuation-corrected PET imaging was performed 60 minutes after FDG administration. Maximal myocardial standard uptake values (MyoSUV(max)) were systematically measured in axial view and compared between the three groups. Using UR patients as reference, mean MyoSUV(max) was lower in LC patients (3.3 +/- 2.7 vs 6.2 +/- 5.2, P = .03) but not in HFLC patients (5.5 +/- 4.2, P = .63). Ratios of MyoSUV(max) to liver SUV(max), calculated to control for background uptake, were not significantly different amongst the groups (1.9 +/- 2.1 LC, 2.6 +/- 2.3 HFLC, 3.6 +/- 3.5 UR). CONCLUSION In this small randomized controlled trial using UR diet as reference, LC dietary preparation followed by extended fasting resulted in significant myocardial uptake suppression.


title: Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience.

text: The COVID-19 pandemic has rapidly moved telemedicine from discretionary to necessary. Here we describe how the Stanford Neurology Department: 1) rapidly adapted to the COVID-19 pandemic, resulting in over 1000 video visits within four weeks and 2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to: equipment/software, provider engagement, workflow/triage, and training. Upon reflection, the key drivers of our success were provider engagement and a supportive physician champion. The physician champion played a critical role understanding stakeholder needs, including staff and physicians' needs, and creating workflows to coordinate both stakeholder groups. Prior to COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated post-pandemic era.


title: Laboratory practices to mitigate biohazard risks during the COVID-19 outbreak: an IFCC global survey.

text: Objectives A global survey was conducted by the IFCC Task Force on COVID-19 to better understand how general biochemistry laboratories manage the pre-analytical, analytical and post-analytical processes to mitigate biohazard risks during the coronavirus disease 2019 (COVID-19) pandemic. Methods An electronic survey was developed to record the general characteristics of the laboratory, as well as the pre-analytical, analytical, post-analytical and operational practices of biochemistry laboratories that are managing clinical samples of patients with COVID-19. Results A total of 1210 submissions were included in the analysis. The majority of responses came from hospital central/core laboratories that serve hospital patient groups and handle moderate daily sample volumes. There has been a decrease in the use of pneumatic tube transport, increase in hand delivery and increase in number of layers of plastic bags for samples of patients with clinically suspected or confirmed COVID-19. Surgical face masks and gloves are the most commonly used personal protective equipment (PPE). Just >50% of the laboratories did not perform an additional decontamination step on the instrument after analysis of samples from patients with clinically suspected or confirmed COVID-19. A fifth of laboratories disallowed add-on testing on these samples. Less than a quarter of laboratories autoclaved their samples prior to disposal. Conclusions The survey responses showed wide variation in pre-analytical, analytical and post-analytical practices in terms of PPE adoption and biosafety processes. It is likely that many of the suboptimal biosafety practices are related to practical local factors, such as limited PPE availability and lack of automated instrumentation.


title: Robot-Assisted Myomectomy for Large Uterine Myomas: A Single Center Experience.

text: Objective. To determine if robot-assisted myomectomy (RAM) is feasible for women with large uterine myomas. Methods. Retrospective review of one gynecologic surgeon's RAM cases between May 2010 and July 2013. Large uterine myomas, defined as the largest myoma ≥9 cm by preoperative magnetic resonance imaging, was age- and time-matched to controls with the largest myoma <9 cm. Primary surgical outcomes compared were operative time and estimated blood loss (EBL). Results. 207 patients were included: 66 (32%) patients were in the ≥9 cm group, while 141 (68%) patients were in the <9 cm group. There was a statistically significant increase in the operative time (130 min versus 92 min) and EBL (100 mL versus 25 mL) for the ≥9 cm group compared to the <9 cm group. Ten (4.8%) patients had the largest myoma measuring ≥15 cm, and 11 (5.3%) patients had a specimen weight >900 gm, of which no major adverse outcomes were observed. All patients in the study cohort were discharged on the same day after surgery. Conclusion. RAM is a feasible surgical approach for patients with myomas ≥9 cm. Patients with large myomas undergoing RAM are also candidates for same-day discharge after surgery.


title: Early postoperative outcomes and medication cost savings after laparoscopic sleeve gastrectomy in morbidly obese patients with type 2 diabetes.

text: Background. We investigated the effect of laparoscopic sleeve gastrectomy (LSG) on morbidly obese diabetics and examined the short-term impact of LSG on diabetic medication cost. Methods. A prospective database of consecutive bariatric patients was reviewed. Morbidly obese patients with type 2 diabetes who underwent LSG were included in the study. Age, gender, body mass index (BMI), diabetic medication use, glucose, insulin, and HbA1c levels were documented preoperatively, and at 2 weeks, 2 months, 6 months, and 12 months postoperatively. Insulin resistance was estimated using the homeostatic model assessment (HOMA). Use and cost of diabetic medications were followed. Results. Of 178 patients, 22 were diabetics who underwent LSG. Diabetes remission was observed in 62% of patients within 2 months and in 75% of patients within 12 months. HOMA-IR improved after only two weeks following surgery (16.5 versus 6.6, P < 0.001). Average number of diabetic medications decreased from 2.2 to <1, within 2 weeks after surgery; corresponding to a diabetes medication cost savings of 80%, 91%, 99%, and 99.7% after 2 weeks, 2 months, 6 months, and 12 months, respectively. Conclusion. Morbidly obese patients with diabetes who undergo LSG have high rates of diabetes remission early after surgery. This translates to a significant medication cost savings.


title: Randomized clinical trial of ropivacaine wound infusion following laparoscopic colorectal surgery.

text: BACKGROUND Wound infusions with local anaesthesia have been used with varying success following laparotomy for colonic resections. This trial sought to determine the efficacy of ropivacaine wound infusion following laparoscopic colonic surgery. METHODS Forty-eight consecutive patients undergoing elective laparoscopic colorectal resection were randomized to receive either a local anaesthetic wound infusion (ropivacaine 0.5%) or normal saline for a period of 72 h. The primary endpoint was postoperative pain as assessed by analgesic consumption, while secondary endpoints assessed were visual analogue pain scores, respiratory function, gastrointestinal function, length of stay and postoperative complications. RESULTS There was no difference in mean postoperative analgesic consumption between the two groups over 72 h (143 mEq morphine control vs 94 mEq intervention; p = 0.108). Likewise, there was no difference in daily postoperative analgesic consumption or visual analogue pain scores between the two groups. Patients in the ropivacaine group experienced less reduction in their postoperative forced expiratory volume at 1 s on day 1 (mean difference FEV1 0.4 l; p = 0.015). There was no difference between the two groups with respect to return of gut function and postoperative complications. CONCLUSIONS In this study, local anaesthetic wound infusion with ropivacaine following elective laparoscopic colorectal surgery improves early respiratory function, but does not appear to provide an improvement in postoperative analgesia or other clinically relevant postoperative outcomes.


title: Single-step multimodal locoregional treatment for unresectable hepatocellular carcinoma: balloon-occluded percutaneous radiofrequency thermal ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE).

text: PURPOSE This study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year. METHODS AND MATERIALS This pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5-6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). Adverse events and intra- and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed. RESULTS No major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5-5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5-1.3cm). CONCLUSIONS TACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.


title: Canine adenovirus type 1 and Pasteurella pneumotropica co‑infection in a puppy.

text: In 2008, a 2 months-old male German shepherd was presented with fever, depression, and evident organic wasting. The puppy died within 48 hours after the onset of clinical signs. A complete necropsy was performed. Bacteriological examination of samples from the brain, lung, liver, spleen, and bone marrow tested positive for Pasteurella pneumotropica. Histopathology demonstrated inflammatory and vascular lesions in the central nervous system and internal organs. Canine adenovirus type 1 nucleic acid was detected by polymerase chain reaction in the frozen brain but not in the formalin-fixed, paraffin-embedded liver and lung samples. The positive PCR was subsequently confirmed by indirect fluorescent antibody testing of the paraffin-embedded brain and liver sections. Although the liver is the primary site of viral damage, these laboratory findings suggest that Canine adenovirus type 1 infection should be included in the differential diagnosis of neuropathological diseases in dogs and that adenoviral infections could promote septicaemia caused by opportunistic pathogens.


title: Monitoring tissue blood flow and oxygenation: a brief review of emerging techniques.

text: This article describes promising emerging technologies developed for measuring tissue-level oxygenation or perfusion, each with its own inherent limitations. The end user must understand what the instrument measures and how to interpret the readings. Optical monitoring using near-infrared spectrometry, Doppler shift, and videomicroscopy are discussed in terms of their application at the tissue level. Assessment of the metabolic state of the extracellular space with existing technology and proxy indicators of metabolic status are discussed. Also addressed are potential sources of variation for each technique, and the role that the clinician plays in the proper interpretation of the data.


title: Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: 3 consecutive cases.

text: OBJECTIVE We report the feasibility and the technique of single-port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer. METHODS The same single port was used for the transperitoneal step (to discriminate intraperitoneal disease) and the extraperitoneal approach used thereafter (in the absence of peritoneal or ovarian spread) for the lymphadenectomy. Para-aortic lymphadenectomy was performed via the left-sided extraperitoneal approach by a 2- to 3-cm incision, which was made 1 cm above the usual incision to the left of McBurney's point. We used conventional instruments in all cases. RESULTS Three consecutive patients with cervical cancer had undergone a pretherapeutic laparoscopic staging procedure (1 stage IB2 and 2 stage IIB). The histologic types were squamous carcinoma (n = 2) and adenocarcinoma (n = 1). No patients had pelvic or para-aortic uptakes on preoperative positron emission tomography computed tomography imaging. The mean operative time was 223 minutes (range, 210-250 minutes). The mean number of lymph nodes removed was 19 (range, 15-23). The definitive pathological analysis had revealed that one patient had metastatic disease. No failures occurred with the single-port procedure, and no conversion to conventional multiport laparoscopy was reported. CONCLUSIONS This preliminary series reports on the feasibility of the para-aortic lymphadenectomy technique via the extraperitoneal approach with a multichannel single port using conventional instruments. Nevertheless, the safety of this procedure (compared to conventional laparoscopic approach) needs to be explored in a further larger study.


title: Endovascular therapy of extracranial carotid artery pseudoaneurysms: case series and literature review.

text: BACKGROUND Experience with endovascular therapy of extracranial carotid artery pseudoaneurysm (ECAP) has been growing, and various results suggest it as a suitable treatment option. We present a consecutive case series of patients with ECAPs treated with endovascular therapy, and a pertinent literature review. METHODS A prospectively maintained database of neuroendovascular procedures was retrospectively reviewed for cases of ECAP treated between January 2007 and December 2012. The primary outcome of interest was incidence of periprocedural (within 30 days) neurologic and cardiopulmonary complications. PubMed was searched for relevant endovascular studies from 2000 to 2012 for the review. RESULTS In our series, 12 patients with 14 ECAPs received stents, with or without coils. No perioperative neurologic or cardiopulmonary complications occurred. Median duration of clinical follow-up was 6.25 months (range 0-50 months), and median duration of imaging follow-up was 6.25 months (range 0-50 months), with eight patients asymptomatic and three showing improved symptoms (one patient with two lesions was lost to follow-up). Literature review revealed an overall primary outcome of 8.6% and no procedure related deaths. CONCLUSIONS Endovascular treatment of ECAP is safe and effective at improving symptoms. There were no perioperative or permanent neurologic sequelae in the 11 patients with follow-up, and all symptomatology related to ECAP improved or resolved with treatment.


title: Glycyrrhizin inhibits human parainfluenza virus type 2 replication by the inhibition of genome RNA, mRNA and protein syntheses.

text: The effect of glycyrrhizin on the replication of human parainfluenza virus type 2 (hPIV-2) was examined. Cell fusion induced by hPIV-2 was inhibited by glycyrrhizin, and glycyrrhizin reduced the number of viruses released from the cells. Glycyrrhizin did not change cell morphology at 1 day of culture, but caused some damage at 4 days, as determined by the effect on actin microfilaments. However, it affected the cell viability at 1 day: about 20% of the cells were not alive by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay at 1 day of culture. Real-time polymerase chain reaction (PCR) and PCR showed that virus genome synthesis was largely inhibited. mRNA synthesis was also inhibited by glycyrrhizin. Viral protein synthesis was largely inhibited as observed by an indirect immunofluorescence study. Multinucleated giant cell formation was studied using a recombinant green fluorescence protein (GFP)-expressing hPIV-2 without matrix protein (rhPIV-2ΔMGFP). A few single cells with fluorescence were observed, but the formation of giant cells was completely blocked. Taken together, it was shown that viral genome, mRNA and protein syntheses, including F and HN proteins, were inhibited by glycyrrhizin, and consequently multinucleated giant cell formation was not observed and the infectious virus was not detected in the culture medium.


title: Detection of Potential Infectious Enteric Viruses in Fresh Produce by (RT)-qPCR Preceded by Nuclease Treatment.

text: Foodborne illnesses associated with contaminated fresh produce are a common public health problem and there is an upward trend of outbreaks caused by enteric viruses, especially human noroviruses (HNoVs) and hepatitis A virus (HAV). This study aimed to assess the use of DNase and RNase coupled to qPCR and RT-qPCR, respectively, to detect intact particles of human adenoviruses (HAdVs), HNoV GI and GII and HAV in fresh produce. Different concentrations of DNase and RNase were tested to optimize the degradation of free DNA and RNA from inactivated HAdV and murine norovirus (MNV), respectively. Results indicated that 10 µg/ml of RNase was able to degrade more than 4 log10 (99.99%) of free RNA, and 1 U of DNase degraded the range of 0.84-2.5 log10 of free DNA depending on the fresh produce analysed. The treatment with nucleases coupled to (RT)-qPCR was applied to detect potential infectious virus in organic lettuce, green onions and strawberries collected in different seasons. As a result, no intact particles of HNoV GI and GII were detected in the 36 samples analysed, HAdV was found in one sample and HAV was present in 33.3% of the samples, without any reasonable distribution pattern among seasons. In conclusion, RT-qPCR preceded by RNase treatment of eluted samples from fresh produce is a good alternative to detect undamaged RNA viruses and therefore, potential infectious viruses. Moreover, this study provides data about the prevalence of enteric viruses in organic fresh produce from Brazil.


title: A prospective randomised trial of LigaSure Small Jaw® versus conventional neck dissection in head and neck cancer patients.

text: OBJECTIVES We compared the differences between LigaSure Small Jaw®-assisted and conventional neck dissection in patients with head and neck cancer. DESIGN Prospective randomised study. SETTING Tertiary referral hospital. PARTICIPANTS Patients scheduled to undergo neck dissection due to head and neck cancer were eligible for this study. The study group was treated using the LigaSure vessel sealing system (Small Jaw®; Covidien, Colorado, USA) for dissection and hemostasis throughout the whole procedures (ClinicalTrials.gov number: NCT02597582). MAIN OUTCOMES MEASURES Operation duration, perioperative blood loss, postoperative drainage amount and postoperative pain status. RESULTS The study group consisted of 21 patients, while the control group had 20 patients. The operation duration was shorter (97.1 versus 116.3 min, P = 0.022) and the average amount of injected analgesics was lower (8.8 versus 17.7 ampules, P = 0.037) in the study group. CONCLUSIONS The assistance of the LigaSure Small Jaw® during functional neck dissection shortened the operation duration and decreased the amount of injected analgesics needed.


title: One-Year Outcomes Following Directional Atherectomy of Infrapopliteal Artery Lesions: Subgroup Results of the Prospective, Multicenter DEFINITIVE LE Trial.

text: PURPOSE To report a subgroup analysis of the prospective, multicenter, single-arm DEFINITIVE LE trial to assess the effectiveness of directional atherectomy for the treatment of infrapopliteal artery lesions at 1 year. METHODS In the DEFINITIVE LE trial, follow-up assessments occurred up to 1 year postprocedure. Of the 800 patients enrolled, 145 subjects with 189 infrapopliteal lesions met the criteria for this analysis. Seventy (48.3%) and 75 (51.7%) patients were suffering critical limb ischemia (CLI) and intermittent claudication, respectively; 68.3% (99/145) had diabetes. The mean lesion length was 58±44 mm (all lesions); 20.2% were occluded. The primary endpoint for patients with claudication was duplex ultrasound-derived primary patency, while for subjects with CLI it was freedom from major amputation of the target limb at 1 year. Endpoints and adverse events were independently assessed. RESULTS Procedure success (≤30% residual stenosis) was achieved in 84% of treated lesions. The 1-year primary patency rate was 84% (claudicants 89.6% and CLI patients 78%, p=0.11), and the freedom from major amputation rate was 97.1% (claudicants 100% and CLI 93.8%, p=0.03). In both claudication and CLI patients, significant improvements in Rutherford category and objective measures of walking distance and quality of life were seen at 1 year in comparison to baseline. CONCLUSION This study demonstrates that directional atherectomy in infrapopliteal arteries results in promising technical and clinical results at 1 year for claudicant as well as CLI patients.


Raf: a key regulatory kinase for transduction of mitogenic and metabolic signals of the probiotic Saccharomyces boulardii.


title: Bisphenol A induces protection through modulation of the immune response against the helminth parasite Taenia crassiceps.

text: AIMS Industrial growth has increased the exposure to endocrine disruptor compounds (EDCs) in all organisms. Bisphenol A (BPA), an EDC, has been demonstrated to be involved in the susceptibility to parasite infections. However, few studies have analyzed this connection in more depth. The aim of this study was to determine if early BPA exposure in female mice affects the systemic immune response and the susceptibility to T. crassiceps infection. METHODS AND RESULTS BALB/cice were exposed to BPA at postnatal day 3. At 6 weeks of age, they were inoculated with T. crassiceps larvae, and 2 weeks later, were euthanized. The number of parasites was quantified. By flow cytometry, in the spleen, the peripheral and mesenteric lymph nodes, the different innate and adaptive immune cell modulation was analyzed, and RT-PCR cytokine expression was also evaluated. BPA induced a reduction of 40% in parasite load. BPA treatment modulated some lineages of the innate immune response and caused slight changes in cells belonging to the adaptive immune response. Additionally, BPA enhanced the type 2 cytokine profile. CONCLUSION Neonatal BPA treatment in female mice affects not only the percentage of different immune cells but also theirex vivo cytokine gene expression., decreasing T. crassiceps cysticercosis susceptibility.


title: 0.2% chlorhexidine acetate as skin disinfectant prevents skin lesions in extremely preterm infants: a preliminary report.

text: OBJECTIVE The skin disinfectant '0.5% chlorhexidine gluconate in 70% alcohol' (0.5% CHG-70% alc) may cause skin lesions in extremely preterm infants (gestational age <26 weeks). In April 2013, 0.2% chlorhexidine gluconate solution in acetate (0.2% CHG-acetate) was introduced as skin disinfectant for extremely preterm infants in our neonatal intensive care units. We aimed to compare the incidence of skin lesions and central line-associated bloodstream infection (CLABSI) among extremely preterm infants when using 0.5% CHG-70% alc and 0.2% CHG-acetate. DESIGN Retrospective pre-post comparison cohort study. PATIENTS All electronic patient records of extremely preterm infants born between January 2011-March 2013 ('0.5% CHG-70% alc' cohort) and April 2013-October 2015 ('0.2% CHG-acetate' cohort) were reviewed. MAIN OUTCOME MEASURES The incidence of skin lesions and CLABSI. Skin lesions were defined as the presence of erythema, blisters, excoriation, oedema or induration. CLABSI was defined according to the definition of the US Centers for Disease Control and Prevention. RESULTS The incidence of skin lesions was 22% (95% CI 11% to 37%) in the '0.5% CHG-70% alc' cohort (n=41) and 5% (95% CI 1% to 15%; p=0.02) in the '0.2% CHG-acetate' cohort (n=41). The incidence of CLABSI was the same in both groups (28%; 95% CI 14% to 46% in '0.5% CHG-70% alc' vs 27%; 95% CI 14% to 44% in '0.2% CHG-acetate'; p=0.98). CONCLUSIONS Using 0.2% CHG-acetate as skin disinfectant in extremely preterm infants resulted in statistically significant reduction of skin lesions, without increasing the risk of CLABSI as compared with 0.5% CHG-70% alc.


title: T helper type 2 bias and type 17 suppression in primary dengue virus infection in infants and young children.

text: BACKGROUND The immune response to dengue virus (DENV) primary infection in infants and young children is not well characterized. In Northern Argentina, >90% of the population was DENV-naïve before the 2009 outbreak, allowing evaluation of age-dependent primary responses to infection. METHODS We conducted a comparative study of the immune response to DENV in 27 infected infants, young children and their mothers. Lymphocyte T helper (Th) 1, Th2, Th17 and inflammatory responses were assayed in blood during the 2009 DENV-1 epidemic. RESULTS The immune response to DENV-1 was significantly biased to Th2 in infected infants and young children, compared to infants with other febrile illnesses (for IL-4 p < 0.001) and to their infected mothers (for IL-4 p < 0.01). In addition, IL-17 suppression was observed in the memory response to DENV-1 in infected infants (p < 0.01 vs placebo). CONCLUSION Age-related differences in the primary response to DENV, characterized by an immature Th2 polarization and Th17 suppression in infants, should be studied further in order to expand our understanding of the mechanism of dengue pathogenesis.


Are emergency surgical patients "collateral victims" of COVID-19 outbreak?


Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardio


title: Transferrin receptor binds virus capsid with dynamic motion.

text: Canine parvovirus (CPV) is an important pathogen causing severe diseases in dogs, including acute hemorrhagic enteritis, myocarditis, and cerebellar disease. Cross-species transmission of CPV occurs as a result of mutations on the viral capsid surface that alter the species-specific binding to the host receptor, transferrin receptor type-1 (TfR). The interaction between CPV and TfR has been extensively studied, and previous analyses have suggested that the CPV-TfR complex is asymmetric. To enhance the understanding of the underlying molecular mechanisms, we determined the CPV-TfR interaction using cryo-electron microscopy to solve the icosahedral (3.0-Å resolution) and asymmetric (5.0-Å resolution) complex structures. Structural analyses revealed conformational variations of the TfR molecules relative to the binding site, which translated into dynamic molecular interactions between CPV and TfR. The precise footprint of the receptor on the virus capsid was identified, along with the identity of the amino acid residues in the virus-receptor interface. Our "rock-and-roll" model provides an explanation for previous findings and gives insights into species jumping and the variation in host ranges associated with new pandemics in dogs.


title: The Psychosocial Impact of COVID-19 on health care workers.

text: At the end of 2019, a disease was identified, COVID-19, caused by a new type of easy and fast spreading virus, which led to the beginning of a worldwide pandemic. One of the most exposed groups to the virus and its psychosocial consequences is the healthcare workers, due to their implication in caring for affected people. Health workers are exposed to a fast and unpredictable situation that requires more human resources and materials than usual, however, the lack of means on account to this situation entails an increased probability of suffering different consequences, including the burnout syndrome, to which, generally, this professionals are already vulnerable. In addition, quarantine is added as a measure to prevent the spread of the pandemic, which is another handicap for healthcare workers. Quarantine means these professionals are more likely to suffer the foreseeable psychological consequences in general population, specifically, it has been observed that Post-Traumatic Stress Disorder (PTSD) is more prevalent, because of the stress load of the situation experienced.


title: Improved Deep Learning Network Based in combination with Cost-sensitive Learning for Early Detection of Ovarian Cancer in Color Ultrasound Detecting System.

text: With the development of theories and technologies in medical imaging, most of the tumors can be detected in the early stage. However, the nature of ovarian cysts lacks accurate judgement, leading to that many patients with benign nodules still need Fine Needle Aspiration (FNA) biopsies or surgeries, increasing the physical pain and mental pressure of patients as well as unnecessary medical health care costs. Therefore, we present an image diagnosis system for classifying the ovarian cysts in color ultrasound images, which novelly applies the image features fused by both high-level features from deep learning network and low-level features from texture descriptor. Firstly, the ultrasound images are enhanced to improve the quality of training data set and the rotation invariant uniform local binary pattern (ULBP) features are extracted from each of the images as the low-level texture features. Then the high-level deep features extracted by the fine-tuned GoogLeNet neural network and the low-level ULBP features are normalized and cascaded as one fusion feature that can represent both the semantic context and the texture patterns distributed in the image. Finally, the fusion features are input to the Cost-sensitive Random Forest classifier to classify the images into "malignant" and "benign". The high-level features extracted by the deep neural network from the medical ultrasound image can reflect the visual features of the lesion region, while the low-level texture features can describe the edges, direction and distribution of intensities. Experimental results indicate that the combination of the two types of features can describe the differences between the lesion regions and other regions, and the differences between lesions regions of malignant and benign ovarian cysts.


title: Theory-based explanation as intervention.

text: Cogent explanations are an indispensable means of providing new information and an essential component of effective education. Beyond this, we argue that there is tremendous untapped potential in using explanations to motivate behavior change. In this article we focus on health interventions. We review four case studies that used carefully tailored explanations to address gaps and misconceptions in people's intuitive theories, providing participants with a conceptual framework for understanding how and why some recommended behavior is an effective way of achieving a health goal. These case studies targeted a variety of health-promoting behaviors: (1) children washing their hands to prevent viral epidemics; (2) parents vaccinating their children to stem the resurgence of infectious diseases; (3) adults completing the full course of an antibiotic prescription to reduce antibiotic resistance; and (4) children eating a variety of healthy foods to improve unhealthy diets. Simply telling people to engage in these behaviors has been largely ineffective-if anything, concern about these issues is mounting. But in each case, teaching participants coherent explanatory frameworks for understanding health recommendations has shown great promise, with such theory-based explanations outperforming state-of-the-art interventions from national health authorities. We contrast theory-based explanations both with simply listing facts, information, and advice and with providing a full-blown educational curriculum, and argue for providing the minimum amount of information required to understand the causal link between a target behavior and a health outcome. We argue that such theory-based explanations lend people the motivation and confidence to act on their new understanding.


title: Structural Basis of the SARS-CoV-2/SARS-CoV Receptor Binding and Small-Molecule Blockers as Potential Therapeutics.

text: Over the past two decades, deadly coronaviruses have caused major challenges to public health, with the most recent being the severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2, 2019) pandemic. The path for virus invasion into humans and other hosts is mediated by "host-pathogen" interactions, specifically, virus-receptor binding. An in-depth understanding of the virus-receptor binding mechanism is a prerequisite for the discovery of vaccines, antibodies, and/or small-molecule inhibitors that can interrupt this interaction and prevent or cure infection. In this review, we discuss the viral entry mechanism, the known structural aspects of virus-receptor interactions (SARS-CoV-2 S/humanACE2, SARS-CoV S/humanACE2, and MERS-CoV S/humanDPP4), the key protein domains and amino acid residues involved in binding, and the small-molecule inhibitors and other drugs that have (as of June, 2020) exhibited therapeutic potential. Specifically, we review the potential clinical utility of two transmembrane serine protease 2 (TMPRSS2)-targeting protease inhibitors, nafamostat mesylate and camostat mesylate, as well as two novel potent fusion inhibitors and the repurposed Ebola drug, remdesivir, which is specific to RdRp, against human coronaviruses, including SARS-CoV-2. This article has been accepted for publication on June 23, 2020. Changes may still occur before final publication. Expected final online publication date for the Annual Review of Pharmacology and Toxicology, Volume 61 is January 8, 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.


title: Augmented autologous pericranium duraplasty in 100 posterior fossa surgeries--a retrospective case series.

text: BACKGROUND Primary closure of the dura in posterior fossa (p-fossa) surgeries is technically difficult and usually requires the use of a dural substitute. A variety of substitutes are currently available and data suggest that autologous materials are preferred in comparison with nonautologous substitutes. OBJECTIVE To report our experience using locally harvested autologous pericranium as a dural substitute in patients who underwent p-fossa surgeries. METHODS Retrospective analysis of patients who had undergone p-fossa craniotomies between 2005 and 2011. All patients received locally harvested autologous pericranium for duraplasty augmented with a dural sealant. Data were reviewed for complications including: surgical site infection, meningitis, cerebrospinal fluid leak, the radiographic formation of a pseudomeningocele, and any new neurological symptoms related to the incision or repair. RESULTS One hundred patients were identified. Indications for surgery included tumor, vascular lesions, or hemorrhage requiring surgical intervention, symptomatic Chiari I malformation, microvascular decompression for trigeminal neuralgia, and trauma requiring surgical decompression. The complication rate was 1% with 1 patient developing an nonsteroidal anti-inflammatory drug-induced aseptic meningitis and graft dehiscence requiring surgical revision. CONCLUSION Autologous pericranium with dural sealant augmentation is an effective way to repair the durotomy in p-fossa surgeries. To the best of our knowledge, this is currently the largest study using this technique in the adult neurosurgical literature. Our results report a much lower rate of complications in comparison with other duraplasty studies.


title: Construct validity of an inanimate training model for laparoscopic appendectomy.

text: BACKGROUND AND OBJECTIVE The use of training models in laparoscopic surgery allows the surgical team to practice procedures in a safe environment. The aim of this study was to determine the capability of an inanimate laparoscopic appendectomy model to discriminate between different levels of surgical experience (construct validity). METHODS The performance of 3 groups with different levels of expertise in laparoscopic surgery--experts (Group A), intermediates (Group B), and novices (Group C)--was evaluated. The groups were instructed of the task to perform in the model using a video tutorial. Procedures were recorded in a digital format for later analysis using the Global Operative Assessment of Laparoscopic Skills (GOALS) score; procedure time was registered. The data were analyzed using the analysis of variance test. RESULTS Twelve subjects were evaluated, 4 in each group, using the GOALS score and time required to finish the task. Higher scores were observed in the expert group, followed by the intermediate and novice groups, with statistically significant difference. Regarding procedure time, a significant difference was also found between the groups, with the experts having the shorter time. The proposed model is able to discriminate among individuals with different levels of expertise, indicating that the abilities that the model evaluates are relevant in the surgeon's performance. CONCLUSIONS Construct validity for the inanimate full-task laparoscopic appendectomy training model was demonstrated. Therefore, it is a useful tool in the development and evaluation of the resident in training.


title: COVID-19, Australia: Epidemiology Report 10 (Reporting week to 23:59 AEST 5 April 2020).

text: Confirmed cases in Australia notified up to 5 April 2020: Notifications = 5,805; Deaths = 33. Notifications in Australia remain predominantly among people with recent overseas travel, with some locally-acquired cases being detected. Most locally-acquired cases are able to be linked back to a confirmed case, with a small portion unable to be epidemiologically link. The distribution of overseas-acquired cases to locally acquired cases varies by jurisdiction. Early indications are that reduction in international travel, domestic movement, social distancing measures and public health action are slowing the spread of the disease. Internationally, cases continue to increase, with high rates of increase observed in the European region and the United States of America. The epidemiology differs from country to country depending not only on the disease, but also on differences in case detection, testing and implemented public health measures.


Errors in Text, Figure, and End Matter.


title: Laparoscopy-assisted total gastrectomy: a simplified approach.

text: Laparoscopy-assisted total gastrectomy (LATG), esophagojejunostomy is an effective but difficult procedure to perform. We describe a simple modification that substantially facilitates insertion of the anvil into the esophagus and avoids oral injuries and complications. After mobilization of the stomach and esophagus, a semicircumferential esophagotomy is made at the anterior esophageal wall. An OrVil anvil (Orvil, Covidien, Norwalk, CT, USA) is delivered laparoscopically and secured with a POLYSORB (Covidien) suture to the esophagus. The suture is advanced anteriorly so that the center rod penetrates the esophageal wall. The esophagus is transected with the stapler at this point. A circular-stapled esophagojejunostomy is then performed using the hemidouble stapling technique. Laparoscopy-assisted total gastrectomies were performed for 40 patients with gastric cancers (T1N0M0). All procedures were completed laparoscopically without any complications. The time required to place the anvil averaged 5 min compared with 9 min reported by others. There were no major complications or mortality in this series. The major advantage of this technique is that circular stapling is much easier than linear stapling, allowing surgeons without advanced surgical skills in LATG to perform the procedure effectively and safely.


title: Spatio-temporal variation and risk assessment of hydrochemical indices in a large diversion project of the Yellow River, northern China, from 2008 to 2017.

text: Large-scale, inter-basin water diversion projects have been developed to relieve water scarcity crisis and water pollution problems. Environmental status and ecosystem impacts are largely unknown for the Wanjiazhai Yellow River Diversion Project (YRDP-WJZ), a water body critical in northern China. In the current study, twelve hydrochemical indices (including Mn, Cu, Zn, Hg, Pb, NH3-N, COD-Mn, DO, BOD5, COD, TP, and TN) were collected from 2008 to 2017 based on multiple analytical approaches to understand environmental status and ecological risks. Human health risk and threats to aquatic organisms from heavy metals were assessed. Heavy metals have no regular spatial distribution. Biochemical parameters and nutrients pollute seriously in midstream and downstream, respectively. Hydrochemical indices suggested high levels of pollution in the midstream section. Water quality improved downstream of the Fenhe Reservoir, but total nitrogen and total phosphorus in the downstream section increased in recent years. The Canadian Council of Ministers of the Environment Water Quality Index (CWQI) suggested midstream water quality was poor in general, and 80% of annual calculations had a marginal grade. For aquatic organisms, ecological risks of Cu and Zn were high. For local residents, drinking water was generally safe, but continued monitoring is critical due to ongoing threats to water quality in these areas.


title: Surgery with curative intent for stage IV gastric cancer: Is it a reality of illusion?

text: Gastric cancer with metastases outside of the regional lymph nodes is deemed oncologically unresectable. Nevertheless, some metastatic lesions are technically resectable by applying established surgical techniques such as para-aortic lymphadenectomy and hepatectomy. At the time of compilation of the Japanese gastric cancer treatment guidelines version 4, systematic reviews were conducted to see whether it is feasible to make any recommendation to dissect both the primary and metastatic lesions with intent to cure, possibly as part of multimodality treatment. Long-term survivors were found among carefully selected groups of patients both in prospective and retrospective studies. In addition, there is a growing list of publications reporting encouraging outcomes of gastrectomy conducted after exceptionally good response to chemotherapy, usually among patients who underwent R0 resection. This type of surgery is often referred to as conversion surgery. It is sometimes difficult to define a clear borderline between curative surgery scheduled after neoadjuvant chemotherapy and the conversion surgery. This review summarizes what we knew after the literature reviews conducted at the time of compiling the Japanese guidelines and in addition reflects some new findings obtained thereafter through clinical trials and retrospective studies. Metastases were divided into three categories based on the major metastatic pathways: lymphatic, hematogenous, and peritoneal. In each of these categories, there were findings that could provide hope for patients with metastatic disease. These findings implied that the surgical technique that we already use could become more useful upon further developments in antineoplastic agents and drug delivery.


title: Tailored use of transradial access for above-the-knee angioplasty.

text: PURPOSE To report the results and complications of a single-center experience of above-the-knee angioplasty via transradial access (TRA). METHODS In a prospective study, 110 consecutive patients (88 men; mean age 72 years, range 37-90) referred for critical limb ischemia (26, 24%) or claudication were eligible for lower limb angioplasty via TRA (patients with TASC D lesions of the superficial femoral artery and below-the-knee lesions were excluded). RESULTS The majority of patients (84, 76%) were treated via a left TRA. A total of 170 lesions were addressed, of which 38 (22%) were occlusions; 113 stents were positioned in 82 patients. The overall technical success rate was 91%, with a 63% success rate in occlusions and a 98% success rate in stenoses; by location, the success rates were 91% in suprainguinal lesions and 90% in infrainguinal lesions. No hemorrhagic or local complications requiring surgery were observed. At 1-month follow-up, 101 patients had a downward shift of at least one category in the Rutherford classification of symptoms (clinical success rate 92%); 18 (16%) patients had occlusion of their access radial artery, but none had symptoms or discomfort. CONCLUSION The present study demonstrates that TRA is a safe and effective approach for lower extremity arterial revascularization, at least for interventionists with longstanding experience in TRA and in selected anatomical subsets.


title: Long-term analysis of surgical correction of the senile upper lip.

text: OBJECTIVE A quantitative comparison of immediate and long-term results of surgical correction of the senile upper lip using lip advancement and lip lift. METHODS Retrospective review of 30 patients who underwent senile upper lip repair, including lip advancement or lip lift. Digital image analysis was used to standardize each patient's preoperative and postoperative photographs for accurate, objective comparison. RESULTS Lip lift and lip advancement achieve significant improvement in the appearance of the senile upper lip (P < .001). This improvement is sustained during many years (mean, 5 y; P < .001). Using repeated measures analysis of variance, no significant difference was found in the operative group compared with the control group when examining age-related change. CONCLUSION Lip advancement and lip lift can restore the senile upper lip to a more youthful and natural appearance with sustained long-term benefits.


title: Laparoendoscopic single-site surgery for benign urologic disease with a homemade single port device: design and tips for beginners.

text: PURPOSE A single surgeon skilled in conventional laparoscopic surgery used laparoendoscopic single-site surgery (LESS) to treat benign urological diseases. This study reports our surgical results and introduces a simple technique with tips based on our experience. MATERIALS AND METHODS LESS surgery was performed on 116 patients by use of a homemade single-port device composed of an Alexis wound retractor and a powder-free surgical glove. Cases were 44 varicocelectomies (including 8 bilateral cases), 38 renal cyst marsupializations (including 3 bilateral cases), 26 ureterolithotomies (with 1 concomitant ureterolithotomy and contralateral renal cyst marsupialization), 4 prostatic enucleations, and 4 bladder rupture repairs. The mean patient age was 44.43±16.46 years (range, 11 to 76 years), and the male-to-female ratio was 87:29. RESULTS In one ureterolithotomy case, LESS was converted to conventional laparoscopic surgery. The mean operative time was 87.03±45.03 minutes, the estimated blood loss was 61.90 ml (range, 0 to 2,000 ml), and the mean hospital stay was 3.03±2.12 days. Two patients underwent single-port transvesical enucleation of the prostate (STEP) requiring patient-controlled anesthesia. No patients developed major complications, and all patients were satisfied, with 75.86% expressing a high degree of satisfaction. CONCLUSIONS We report successful treatment outcomes for LESS in 116 cases of benign urological disease. Our findings suggest that LESS can replace conventional laparoscopy.


The results of the recent thrombectomy trials may influence stroke care delivery: are you ready?


title: Development of chimpanzee adenoviruses as vaccine vectors: challenges and successes emerging from clinical trials.

text: Replication-defective chimpanzee adenovirus vectors are emerging as a promising new class of genetic vaccine carriers. Chimpanzee adenovirus vectors have now reached the clinical stage and appear to be endowed with all the properties needed for human vaccine development, including high quality and magnitude of the immune response induced against the encoded antigens, good safety and ease of manufacturing on a large-scale basis. Here the authors review the recent findings of this novel class of adenovirus vectors and compare their properties to other clinical stage vaccine vectors derived from poxvirus, alphavirus and human adenovirus.


title: Identifying Core Competencies of Infection Control Nurse Specialists in Hong Kong.

text: PURPOSE To confirm a core competency scale for Hong Kong infection control nurses at the advanced nursing practice level from the core competency items proposed in a previous phase of this study. This would serve as the foundation of competency assurance in Hong Kong hospitals. DESIGN A cross-sectional survey design was used. SETTING All public and private hospitals in Hong Kong. SUBJECTS All infection control nurses in hospitals of Hong Kong. METHODS The 83-item proposed core competency list established in an earlier study was transformed into a questionnaire and sent to 112 infection control nurses in 48 hospitals in Hong Kong. They were asked to rate the importance of each infection prevention and control item using Likert-style response categories. Data were analyzed using the Rasch model. RESULTS The response rate of 81.25% was achieved. Seven items were removed from the proposed core competency list, leaving a scale of 76 items that fit the measurement requirements of the unidimensional Rasch model. CONCLUSIONS Essential core competency items of advanced practice for infection control nurses in Hong Kong were identified based on the measurement criteria of the Rasch model. Several items of the scale that reflect local Hong Kong contextual characteristics are distinguished from the overseas standards. IMPLICATIONS This local-specific competency list could serve as the foundation for education and for certification of infection control nurse specialists in Hong Kong. Rasch measurement is an appropriate analytical tool for identifying core competencies of advanced practice nurses in other specialties and in other locations in a manner that incorporates practitioner judgment and expertise.


title: Early reperfusion rates with IV tPA are determined by CTA clot characteristics.

text: BACKGROUND AND PURPOSE An ability to predict early reperfusion with IV tPA in patients with acute ischemic stroke and intracranial clots can help clinicians decide if additional intra-arterial therapy is needed or not. We explored the association between novel clot characteristics on baseline CTA and early reperfusion with IV tPA in patients with acute ischemic stroke by using classification and regression tree analysis. MATERIALS AND METHODS Data are from patients with acute ischemic stroke and proximal anterior circulation occlusions from the Calgary CTA data base (2003-2012) and the Keimyung Stroke Registry (2005-2009). Patients receiving IV tPA followed by intra-arterial therapy were included. Clot location, length, residual flow within the clot, ratio of contrast Hounsfield units pre- and postclot, and the M1 segment origin to the proximal clot interface distance were assessed on baseline CTA. Early reperfusion (TICI 2a and above) with IV tPA was assessed on the first angiogram. RESULTS Two hundred twenty-eight patients (50.4% men; median age, 69 years; median baseline NIHSS score, 17) fulfilled the inclusion criteria. Median symptom onset to IV tPA time was 120 minutes (interquartile range = 70 minutes); median IV tPA to first angiography time was 70.5 minutes (interquartile range = 62 minutes). Patients with residual flow within the clot were 5 times more likely to reperfuse than those without it. Patients with residual flow and a shorter clot length (≤15 mm) were most likely to reperfuse (70.6%). Patients with clots in the M1 MCA without residual flow reperfused more if clots were distal and had a clot interface ratio in Hounsfield units of <2 (36.8%). Patients with proximal M1 clots without residual flow reperfused 8% of the time. Carotid-T/-L occlusions rarely reperfused (1.7%). Interrater reliability for these clot characteristics was good. CONCLUSIONS Our study shows that clot characteristics on CTA help physicians estimate a range of early reperfusion rates with IV tPA.


title: Bioterrorism: a laboratory who does it?

text: In October 2001, the first disseminated biological warfare attack was perpetrated on American soil. Initially, a few clinical microbiology laboratories were testing specimens from acutely ill patients and also being asked to test nasal swabs from the potentially exposed. Soon after, a significant number of clinical microbiology and public health laboratories received similar requests to test the worried well or evaluate potentially contaminated mail or environmental materials, sometimes from their own break rooms. The role of the clinical and public health microbiology laboratory in response to a select agent event or act of bioterrorism is reviewed.


title: Intubation-related tracheal ischemic lesions: incidence, risk factors, and outcome.

text: PURPOSE To determine incidence, risk factors and outcome of tracheal ischemic lesions related to intubation. METHODS Planned post hoc analysis using patients from a previous randomized controlled study. Fiberoptic tracheoscopy was performed during the 24 h following extubation. In patients with >2 ischemic lesions, ulcer or tracheal rupture, fiberoptic tracheoscopy was repeated 2 weeks after the last extubation. Tracheal ischemic lesions were predefined based on a quantitative score. RESULTS Ninety-six adult patients were included in this study. Eighty (83 %) patients had at least one tracheal ischemic lesion. Thirty-seven (38 %) patients had a tracheal ischemia score > median score (5; IQ 1, 7). The most common tracheal ischemic lesion was ischemia (68 %), followed by hyperemia (54 %), ulcer (10 %), and tracheal rupture (1 %). Univariate analysis identified duration of neuromuscular-blocking agent use, overinflation of tracheal cuff (>30 cmH2O), percentage of P cuff determination >30 cmH2O, duration of assist-control ventilation, and plateau pressure as risk factors for having a tracheal ischemia score >5. Duration of assist-control mechanical ventilation was the only factor independently associated with tracheal ischemia score >5 [OR (95 % CI) 1.10 per hour (1.02-1.20)]. A fiberoptic tracheoscopy was performed 2 weeks after extubation in 22 patients. This examination was normal in all patients, except the one with tracheal rupture who had marked improvement. CONCLUSION Tracheal ischemic lesions are common in intubated, critically ill patients. Duration of assist-control mechanical ventilation through a tracheal tube is the only independent risk factor. These lesions healed in the majority of patients 2 weeks after extubation.


title: Generation of functional hepatocyte-like cells from human deciduous periodontal ligament stem cells.

text: Human deciduous periodontal ligament stem cells have been introduced for as an easily accessible source of stem cells from dental origin. Although recent studies have revealed the ability of these stem cells in multipotential attribute, their efficiency of hepatic lineage differentiation has not been addressed so far. The aim of this study is to investigate hepatic lineage fate competence of periodontal ligament stem cells through direct media induction. Differentiation of periodontal ligament stem cells into hepatocyte-like cells was conducted by the exposure of two phase media induction. First phase was performed in the presence of hepatocyte growth factors to induce a definitive endoderm formation. In the subsequent phase, the cells were treated with oncostatin M and dexamethosone followed by insulin and transferrin to generate hepatocyte-like cells. Hepatic-related characters of the generated hepatocyte-like cells were determined at both mRNA and protein level followed by functional assays. Foremost changes observed in the generation of hepatocyte-like cells were the morphological features in which these cells were transformed from fibroblastic shape to polygonal shape. Temporal expression of hepatic markers ranging from early endodermal up to late markers were detected in the hepatocyte-like cells. Crucial hepatic markers such as glycogen storage, albumin, and urea secretion were also shown. These findings exhibited the ability of periodontal ligament stem cells of dental origin to be directed into hepatic lineage fate. These cells can be regarded as an alternative autologous source in the usage of stem cell-based treatment for liver diseases.


title: Haemorrhagic Transformation after Ischaemic Stroke in Patients Taking Non-vitamin K Antagonist Oral Anticoagulants.

text: BACKGROUND AND PURPOSE To evaluate the frequency and outcome of haemorrhagic transformation (HT) after ischaemic stroke in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). METHODS Patients with stroke on treatment with a NOAC were prospectively enrolled in this multicentre observational study between February 2012 and 2015. Brain imaging at admission and follow-up imaging until day 7 were reviewed for HT. Functional outcome was assessed by the modified Rankin scale (mRS) before the index event, at discharge, and at 3-months. RESULTS 231 patients without recanalisation therapy (no-RT), and 32 patients with RT were eligible for analysis. Any HT was present at admission in 9/231 no-RT patients (3.9%, 95% CI 2.0 to 7.3) and in none of the patients with RT. In patients with follow-up imaging (no-RT, n=129, and RT, n=32), HT was present in 14.0% (no-RT; 95% CI, 8.9 to 21.1), and 40.6% (RT, 95% CI, 25.5 to 57.8), respectively. After adjustment for stroke severity, this difference between the no-RT and RT groups became non-significant. Symptomatic ICH was observed in 1 patient per group. HT was not associated with unfavourable outcome (mRS 3-6) at 3-months in multivariable analysis. Resumption of OAC after stroke was delayed in patients with HT compared to those without (15 d [IQR, 5-26] vs. 1 d [0-4], P<0.001). CONCLUSIONS The frequency and severity of HT after stroke on NOAC appears similar to previous reports for vitamin K antagonists and no anticoagulation. Whether asymptomatic HT should delay resumption of preventive anticoagulation requires further investigation.


title: Impact of transapical aortic cannulation for acute type A aortic dissection.

text: OBJECTIVE Early and mid-term result of transapical aortic (TAA) cannulation technique was evaluated compared with femoral artery (FA) cannulation in Acute Type A Aortic Dissection(AAAD). METHODS From January 2000 to October 2013, 80 consecutive patients with AAAD were underwent the ascending aortic replacement at Nagasaki Kouseikai Hospital. These patients were divided into two groups according to the cannulation site, FA cannulation (n = 34) and TAA cannulation (n = 46). Early and mid-term outcomes were compared between two groups. RESULT Preoperative patient characteristics were almost comparable between groups. The time from skin incision to starting cardiopulmonary bypass (CPB) was significantly shorter in the TAA group (45 ± 16 vs 23 ± 5.1 min; P <0.001). There were no significant differences in post-operative cerebral infarction in two groups (17% versus 11%; P = NS). The operative mortality rate was 8.8% in FA group and 4.3% in TAA group (P = NS). During follow up (mean, 6.8 years), survival at 3 years and 5 years was 77.4% and 71.9% in TAA group and 76.3% and 73.8% in FA group, respectively. CONCLUSION The postoperative morbidity and mortality between the two groups were almost the same. TAA cannulation for acute Type A aortic dissection is faster, easy and safe with acceptable early and mid-term outcome.


title: Bovine Respiratory Disease Treatment Failure: Impact and Potential Causes.

text: Bovine respiratory disease (BRD) is often attributed to complex interactions between the host, pathogen, and the environment. Likewise, many BRD treatment failures result from interactions between the host, pathogen, environment, drug, and drug administrator. Investigating and addressing the underlying causes of BRD treatment failures can improve clinical outcomes and animal welfare of future cases, improve morale of employees, reduce direct costs of dealing with BRD treatment failures, refine antimicrobial prescribing practices, and advance antimicrobial stewardship. This article discusses these interactions and provides guidance to veterinary practitioners on evaluating the success of treatment protocols.


title: Complete genome sequence of a Chinese virulent porcine epidemic diarrhea virus strain.

text: CH/S is a virulent porcine epidemic diarrhea virus (PEDV) strain and is used as the virulent strain to evaluate the protection rates of vaccines against PEDV infection in China. Here, we report the complete genome sequence of strain CH/S, which may aid in understanding the molecular characteristics of this strain.


title: The etiology of community-acquired pneumonia among children under 5 years of age in mainland China, 2001-2015: A systematic review.

text: BACKGROUND The aim of this systematic review was to examine the etiology of community-acquired pneumonia (CAP) among Chinese children younger than 5 y and provide evidence for further cost-effectiveness analyses for vaccine development, diagnostic strategies and empirical treatments. METHODS The literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were obtained by searching PubMed, Embase, Web-of Science, and the Chinese databases Wanfang Data and China National Knowledge Infrastructure. All CAP etiological studies on children under 5 y of age from China published in Chinese and English between the years of 2001 and 2015 were included. A total of 48 studies were included in the final review, comprising 100 151 hospitalized children with CAP episodes. Heterogeneity and the percentage of variation between studies was analyzed based on Q statistic and I2 indices, respectively. Random effect models were used to calculate the weighted average rate in all analyses. RESULTS The most frequently detected bacterial agents were Klebsiella pneumoniae (5.4%), Streptococcus pneumoniae (5.2%), Escherichia coli (5.2%), Staphylococcus aureus (3.9%), Haemophilus influenza (3.6%) and Haemophilus parainfluenzae (3.3%). The most frequently detected viruses were human rhinovirus (20.3%, in just 2 studies), respiratory syncytial virus (RSV, 17.3%), human bocavirus (9.9%), parainfluenza virus (5.8%), human metapneumovirus (3.9%) and influenza (3.5%). Mycoplasma pneumoniae and Chlamydophila pneumoniae were identified in 9.5% and 2.9%, respectively, of children under 5 y of age with CAP. CONCLUSION This article provides the most comprehensive analysis to date of the factors contributing to CAP in children under 5 y of age. S. pneumoniae, H. influenzae and influenza were the most common vaccine-preventable diseases in children. Corresponding, vaccines should be introduced into Chinese immunization programs, and further economic evaluations should be conducted. RSV is common in Chinese children and preventative measures could have a substantial impact on public health. These data also have major implications for diagnostic strategies and empirical treatments.


title: Polyanalgesic Consensus Conference--2012: consensus on diagnosis, detection, and treatment of catheter-tip granulomas (inflammatory masses).

text: INTRODUCTION Continuous intrathecal infusion of drugs to treat chronic pain and spasticity has become a standard part of the algorithm of care. The use of opioids has been associated with noninfectious inflammatory masses at the tip of the intrathecal catheter, which can result in neurologic complications. METHODS The Polyanalgesic Consensus Conference is a meeting of a group of well-published and experienced practitioners; the purpose of the meeting is to update the standard of care for intrathecal therapies to reflect current knowledge gleaned from literature and clinical experience. An exhaustive literature search was performed, and information from this search was provided to panel members. Analysis of the published literature was coupled with the clinical experience of panel participants to form recommendations regarding intrathecal inflammatory masses or granulomas. RESULTS The panel has made recommendations for the prevention, diagnosis, and management of intrathecal granulomas. CONCLUSION The use of chronic infusions of intrathecal opioids is associated with the formation of inflammatory masses at the intrathecal catheter tip in a small minority of treated patients. Nonetheless, the appearance of these space-occupying lesions can lead to devastating neurologic sequelae. The prevention, early detection, and successful treatment of intraspinal granulomas are important considerations when offering intrathecal drug therapy to patients with chronic intractable pain.


title: Interplay between innate immunity and negative-strand RNA viruses: towards a rational model.

text: The discovery of a new class of cytosolic receptors recognizing viral RNA, called the RIG-like receptors (RLRs), has revolutionized our understanding of the interplay between viruses and host cells. A tremendous amount of work has been accumulating to decipher the RNA moieties required for an RLR agonist, the signal transduction pathway leading to activation of the innate immunity orchestrated by type I interferon (IFN), the cellular and viral regulators of this pathway, and the viral inhibitors of the innate immune response. Previous reviews have focused on the RLR signaling pathway and on the negative regulation of the interferon response by viral proteins. The focus of this review is to put this knowledge in the context of the virus replication cycle within a cell. Likewise, there has been an expansion of knowledge about the role of innate immunity in the pathophysiology of viral infection. As a consequence, some discrepancies have arisen between the current models of cell-intrinsic innate immunity and current knowledge of virus biology. This holds particularly true for the nonsegmented negative-strand viruses (Mononegavirales), which paradoxically have been largely used to build presently available models. The aim of this review is to bridge the gap between the virology and innate immunity to favor the rational building of a relevant model(s) describing the interplay between Mononegavirales and the innate immune system.


title: Ictal apnea linked to contralateral spread of temporal lobe seizures: Intracranial EEG recordings in refractory temporal lobe epilepsy.

text: PURPOSE Respiratory mechanisms are implicated in sudden unexpected death in epilepsy (SUDEP). We previously demonstrated a high incidence of ictal hypoxemia in temporal lobe seizures. We now report on the temporal relationship between ictal apnea and seizure onset and spread in patients undergoing video-EEG (electroencephalography) telemetry (VET) with intracranial electrodes. METHODS Ten patients with medically refractory temporal lobe epilepsy (TLE) undergoing VET were studied. Data from synchronously recorded digital pulse oximetry (SaO(2)), end-tidal CO(2) (ETCO(2)), nasal airflow, abdominal excursions, and electrocardiography were obtained. RESULTS Sixty-one seizures were captured. SaO(2) in the ictal/postictal period was available for 52 seizures, apnea onset times for 27 seizures, and ETCO(2) for 16 seizures. Apneas occurred only when seizures spread to the contralateral temporal lobe. The mean delay to apnea onset was significantly shorter after contralateral seizure spread (2.87 s) than after seizure onset (58.4 s); p < 0.001. The mean SaO(2) nadir with partial seizures or partial seizures prior to secondary generalization was 89.4 +/- 8.6% (91.5, 69-100). Following generalized convulsions the mean oxygen saturation nadir was 75.8 +/- 10.6% (78.5, 58-90). ETCO(2) elevations occurred with each ictal desaturation below 85%. CONCLUSIONS There is a close temporal relationship between spread of seizures to the contralateral hemisphere and the onset of seizure-associated apnea. Apnea onsets are more tightly linked to time of contralateral spread than to time of seizure onset. Patients with TLE in whom there is evidence of contralateral seizure spread may be at higher risk for ictal-related respiratory dysfunction than those in whom seizures remain unilateral.


title: Protocol for the SAFEST review: the Shock-Absorbing Flooring Effectiveness SysTematic review including older adults and staff in hospitals and care homes.

text: INTRODUCTION Falls in hospitals and care homes are a major issue of international concern. Inpatient falls are the most commonly reported safety incident in the UK's National Health Service (NHS), costing the NHS £630 million a year. Injurious falls are particularly life-limiting and costly. There is a growing body of evidence on shock-absorbing flooring for fall-related injury prevention; however, no systematic review exists to inform practice. METHODS AND ANALYSIS We will systematically identify, appraise and summarise studies investigating the clinical and cost-effectiveness, and experiences of shock-absorbing flooring in hospitals and care homes. Our search will build on an extensive search conducted by a scoping review (inception to May 2016). We will search electronic databases (AgeLine, CINAHL, MEDLINE, NHS Economic Evaluation Database, Scopus and Web of Science; May 2016-present), trial registries and grey literature. We will conduct backward and forward citation searches of included studies, and liaise with study researchers. We will evaluate the influence of floors on fall-related injuries, falls and staff work-related injuries through randomised and non-randomised studies, consider economic and qualitative evidence, and implementation factors. We will consider risk of bias, assess heterogeneity and explore potential effect modifiers via subgroup analyses and sensitivity analyses. Where appropriate we will combine studies through meta-analysis. We will use the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach to evaluate the quality of evidence and present the results using summary of findings tables, and adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. ETHICS AND DISSEMINATION We will follow the ethical principles of systematic review conduct, by attending to publication ethics, transparency and rigour. Our dissemination plan includes peer-reviewed publication, presentations, press release, stakeholder symposium, patient video and targeted knowledge-to-action reports. This review will inform decision-making around falls management in care settings and identify important directions for future research. PROSPERO REGISTRATION NUMBER CRD42019118834.


title: Translational medicine policy issues in infectious disease.

text: The European Academies Science Advisory Council has published a series of reports on infectious disease policy issues, analyzing priorities for building the science base as part of public health strategy. Among current challenges facing the European Union are the needs to tackle antibiotic resistance, promote vaccine innovation, prepare for the emergence of novel zoonoses, and integrate research approaches to human and animal health. The scientific community must help public policy-makers to address the organization, balance, and sustainability of research funding and infrastructure; encourage the creation of a more supportive regulatory environment for translational medicine; and evaluate new models for public-private partnership to facilitate innovation.


Covid-19: Trump declares intention to "re-open economy" within weeks against experts' advice.


Third-quarter biotech job picture.


title: Re-evaluating the Utility of Stress Ulcer Prophylaxis in the Critically Ill Patient: A Clinical Scenario-Based Meta-Analysis.

text: STUDY OBJECTIVE Because recent studies have challenged the efficacy of stress ulcer prophylaxis (SUP) in the critically ill patient, our objective was to evaluate the efficacy of SUP with proton pump inhibitors (PPIs) or histamine2 -receptor antagonists (H2 RAs) against placebo, control, no therapy, or enteral nutrition alone in critically ill adults. DESIGN Meta-analysis with trial sequential analysis (TSA) of 34 randomized controlled trials. PATIENTS A total of 3220 critically ill adults who received PPIs or H2 RAs versus placebo, control, no therapy, or enteral nutrition. MEASUREMENTS AND MAIN RESULTS A systematic review was performed using a random effects meta-analysis with TSA according to a predefined protocol. Randomized controlled trials comparing PPIs or H2 RAs with either placebo, control, no therapy, or enteral nutrition alone were identified through a comprehensive search of the literature. Two blinded reviewers independently assessed studies for inclusion, risk of bias, and extracted data using Cochrane Collaborative methodology. The predefined primary outcomes were clinically important, overt, and any (clinically important plus overt) gastrointestinal bleeding. Secondary outcomes included pneumonia, Clostridium difficile-associated diarrhea (CDAD), and mortality. Subgroup analyses were conducted for the primary outcome by PPI or H2 RA use, intensive care unit (ICU) subtype, studies published after early goal-directed therapy (EGDT), the presence of risk factors for stress ulceration, and enteral nutrition use. Of the 34 trials included, 33 were judged as high risk of bias and 1 was judged as low risk. Use of SUP significantly reduced clinically important bleeding (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.37-0.76, p<0.001; I2 = 0%), overt bleeding (RR 0.55, 95% CI 0.39-0.76, p=0.0003; I2 = 53%), and any bleeding (RR 0.54, 95% CI 0.41-0.71, p<0.00001; I2 = 58%). TSA confirmed these findings. No significant differences in pneumonia, CDAD, or mortality were noted. Subgroup analyses revealed significant reductions in clinically important bleeding with SUP in neurosurgical patients (RR 0.37, p<0.05) but not in surgery/trauma or medical ICU patients with risk factors. SUP provided no benefit in studies published after EGDT. SUP significantly reduced clinically important bleeding regardless of the use of enteral nutrition (p<0.05). CONCLUSION This meta-analysis demonstrated that SUP use was associated with significant reductions in bleeding but not mortality. SUP should not be abandoned until large randomized trials demonstrate the futility of this intervention.


COVID-19 Curbside Consults at www.CCJM.org.


Pandemic research: UK must coordinate.


title: ESBL-Producing and Macrolide-Resistant Shigella sonnei Infections among Men Who Have Sex with Men, England, 2015.

text: In England in 2015, Shigella sonnei isolates from men who have sex with men produced extended-spectrum β-lactamases and exhibited macrolide resistance. Whole-genome sequencing showed a close relationship among the isolates, which harbored a plasmid that was previously identified in a shigellosis outbreak among this population but has acquired a mobile element.


title: Effect of heliox on end-tidal CO2 measurement in healthy adults.

text: BACKGROUND Therapeutic gases and other modalities delivered by inhalation may affect the accuracy of capnographic measurements in 2 ways. First is the specificity of the measurement of CO2 within the device, and second is the dilution effect of supplemental gases in the ambient air during CO2 sampling by the device. Our goal was to determine if variables such as inhaled gas composition, gas flows delivered via non-rebreather mask, and mouth open or closed affect measurements of end-tidal CO2 pressure (PETCO2) measured with the Capnostream 20 capnograph. METHODS We measured PETCO2 and breathing frequency by capnography in 20 adult normal subjects, with coaching to maintain respiratory frequency between 10 and 20 breaths/min. SpO2 was monitored to detect hypoxemia. A 6 min wash-out period occurred between each 6 min level of testing. RESULTS A mixed models analysis revealed that the mean ± SD PETCO2 for all subjects and flows while breathing heliox (37 ± 5 mm Hg) was not different (P = .50) from the value while breathing room air (36 ± 5 mm Hg). Repeated measurements with given subjects over 6 min periods of breathing spontaneously 0 L/min, with 10 L/min, and with 15 L/min of either air or heliox showed no difference in PETCO2 related to flow: P = .97 for 0 L/min vs 10 L/min, P = .87 for 0 L/min vs. 15 L/min. CONCLUSIONS In normal subjects, PETCO2 measurements with the Capnostream 20 were not affected by heliox or gas flow at 10 or 15 L/min through a non-rebreathing mask.