title: Poor weaning transition average daily gain in pigs is not correlated with pathological or immunological markers of enteric disease during a porcine reproductive and respiratory syndrome virus outbreak.

text: Previous research suggests that enteric disease and poor gut health interact to decrease pig performance. Our objective was to determine if light birth weight pigs or those from the bottom 10th percentile of transition ADG (tADG) have a higher incidence of pathogen presence or enteric lesions than heavier or faster-growing contemporaries. A total of 1,500 pigs were weighed at birth and divided into 5 birth weight (BRW) categories: <1, 1 to 1.25, 1.26 to 1.5, 1.51 to 1.75, and >1.76 kg. At weaning, 1,054 random pigs were moved to a commercial wean-to-finish barn. Pigs were weighed individually at 0 and 3 wk postweaning. Transition ADG was calculated as the ADG between wk 0 and 3 postweaning. One pig from each of the 10th, 30th, and 70th percentiles of tADG was used to create 1 set of 3 pigs with the same litter size and from the same parity sow. Forty pigs from each of the 3 tADG percentiles were matched for sex, litter size, and sow parity but not BRW to create 20 matched sets of 60 pigs. This allowed for the main effects of BRW and tADG to be studied as a 5 × 3 factorial design. At 3 and 22 wk postweaning, pigs were euthanized for organ system tissue evaluation. Lung, lymph node, and digesta were analyzed for presence of pathogens and for severity of microscopic lesions (0 = not present, 1 = present, with slight erosion, 2 = present, with moderate erosion, and 3 = present and severe erosion). Data were analyzed using PROC GENMOD and GLIMMIX, where pig served as the experimental unit. The fixed effects were BRW and tADG and the random effects were pen and set. There were no BRW × tADG interactions (P = 0.16). There was no correlation (P = 0.12) between tADG and pathogen presence at either 3 or 22 wk postweaning. Incidence and severity of microscopic lesions in the large intestine at 3 wk postweaning decreased linearly with increasing tADG (P = 0.01). Lesion incidence and severity were also affected (P < 0.04) by tADG at 22 wk postweaning, with greater stomach incidence in the 10th percentile. Birth weight affected (P = 0.02) haemolytic Escherichia coli and Salmonella spp. B (includes Salmonella typhimurium) isolation at 3 wk postweaning as well as Brachyspira spp. isolation at 22 wk postweaning (P = 0.05) but in mixed directions. There were no effects (P = 0.21) of BRW or tADG on serum or ileum mucosa immune markers. In summary, it is apparent from this research that neither BRW nor tADG are likely causes of pathogen or lesion incidence.


title: Single-incision laparoscopic adnexectomy in an obese patient with previous laparotomies.

text: INTRODUCTION No case of single-incision laparoscopic surgery in obese patients who had previously undergone multiple midline vertical laparotomies has been described in the literature to date. Hence we report the first case of single-port laparoscopic salpingo-oophorectomy in an obese patient who was affected by a left adnexal mass and who had previously undergone 3 midline vertical laparotomies. CASE DESCRIPTION A postmenopausal 57-year-old woman with a body mass index of 31.2 kg/m(2) and a history of 3 midline vertical cesarean deliveries and a right salpingooophorectomy was diagnosed with a left adnexal mass and underwent a single-incision laparoscopic salpingo-oophorectomy. DISCUSSION The patient was treated successfully. The operative blood loss was minimal. The postoperative hospital stay lasted 18 hours, and postoperative pain was short-lasting. No early or long-term postoperative complications were registered. On histopathologic examination, a diagnosis of ovarian serous cystadenoma was made. Even though this unique case is the first to be reported in the literature, its encouraging results suggest the use of this new surgical technique in similar clinical situations to verify whether the feasibility and safety reported in this article are confirmed.


title: Postoperative recovery with bispectral index versus anesthetic concentration-guided protocols.

text: BACKGROUND Use of the bispectral index (BIS) monitor has been suggested to decrease excessive anesthetic drug administration, leading to improved recovery from general anesthesia. The purpose of this substudy of the B-Unaware and BAG-RECALL trials was to assess whether a BIS-based anesthetic protocol was superior to an end-tidal anesthetic concentration-based protocol in decreasing recovery time and postoperative complications. METHODS Patients at high risk for awareness were randomized to either BIS-guided or end-tidal anesthetic concentration-guided general anesthesia in the original trials. Outcomes included time to postanesthesia care unit discharge readiness, time to achieve a postoperative Aldrete score of 9-10, intensive care unit length of stay, postoperative nausea and vomiting, and severe postoperative pain. Univariate Cox regression and chi-square tests were used for statistical analyses. RESULTS The BIS cohort was not superior in time to postanesthesia care unit discharge readiness (hazard ratio, 1.0; 95% CI, 1.0-1.1; n = 2,949), time to achieve an Aldrete score of 9-10 (hazard ratio, 1.2; 95% CI, 1.0-1.4; n = 706), intensive care unit length of stay (hazard ratio, 1.0; 95% CI, 0.9-1.1; n = 2,074), incidence of postoperative nausea and vomiting (absolute risk reduction, -0.5%; 95% CI, -5.8 to 4.8%; n = 789), or incidence of severe postoperative pain (absolute risk reduction, 4.4%; 95% CI, -2.3 to 11.1%; n = 759). CONCLUSIONS In patients at high risk for awareness, the BIS-guided protocol is not superior to an anesthetic concentration-guided protocol in time needed for postoperative recovery or in the incidences of common postoperative complications.


title: Long-term recurrence of neoplasia and Barrett's epithelium after complete endoscopic resection.

text: BACKGROUND Current endoscopic therapy for neoplastic Barrett's oesophagus (BO) consists of complete resection/ablation of all Barrett's tissue including neoplastic lesions. Recurrence seems to be frequent after thermal therapy, such as radiofrequency ablation. OBJECTIVE To analyse long-term recurrence of neoplasia and BO after successful widespread endoscopic mucosal resection (EMR). DESIGN In a retrospective analysis, all patients undergoing widespread EMR of neoplastic BO between 2002 and 2007 at two referral centres were followed for at least 3 years after completion of endotherapy. Recurrence was diagnosed if neoplasia and/or BO were detected following previous successful complete removal, defined as at least two negative endoscopies and biopsies. RESULTS Ninety patients undergoing widespread EMR were included (mean age 63 years; 82 male), 58% of whom underwent additional thermal ablation for minor residual disease. Complete eradication of neoplasia and Barrett's tissue was achieved in 90% of patients. On further follow-up (mean 64.8 months), recurrence of neoplastic and non-neoplastic BO was found in 6.2% and 39.5%, respectively. Recurring neoplasia (3 adenocarcinomas, 1 low-grade and 1 high-grade dysplasia) were found after a median of 44 months (range 38-85) and could be retreated endoscopically. In a multivariate analysis, Barrett's length was the only factor significantly associated with recurrence (OR 2.73). CONCLUSIONS Even after seemingly complete endoscopic resection, recurrence of BO is frequent and independent of additional thermal therapy. Due to the possibility of neoplasia recurrence even after long disease-free intervals, follow-up should be extended beyond 5 years.


title: Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms : Case Series of 8 Consecutive Patients.

text: BACKGROUND AND PURPOSE Ruptured blister-like aneurysms (BLAs) are challenging lesions to treat, without any consensus on their management. Few studies have evaluated the safety and effectiveness of flow diverter stents (FDS) for this indication, with promising results. The goal was to evaluate the safety and effectiveness of a delayed (≥5 days) flow diversion strategy for the treatment of ruptured intracranial BLAs. MATERIAL AND METHODS A monocentric retrospective analysis of a prospectively collected database of intracranial aneurysms was performed. Eight consecutive patients with 9 ruptured intracranial BLAs from November 2010 to June 2018 were included in the study. The BLA treatment with FDS was delayed from the rupture (minimum rupture to treatment delay = 5 days, mean = 16.9 ± 9.2 days). Procedure-related complications were systematically recorded. Rebleeding occurrences were systematically assessed. Long-term clinical and angiographic follow-ups were recorded. RESULTS No procedure-related death was recorded. Neither early nor late rebleeding was observed and one (12.5%) major procedure-related complication occurred (ischemic stroke). Most of the patients (5/8; 62.5%) had an mRS <2 at discharge. The immediate periprocedural control angiogram showed a complete exclusion of the aneurysm in one patient (12.5%) but at follow-up (mean delay = 19.8 months) all patients had a complete aneurysm occlusion. All patients had a long-term mRS <2. CONCLUSION This case series suggests that a delayed treatment (≥5 days after the hemorrhagic event) of ruptured BLAs with FDS is feasible, and may be safe and effective in terms of rebleeding prevention and long-term angiographic outcome.


title: Fluoxetine for stroke recovery: Meta-analysis of randomized controlled trials.

text: OBJECTIVE To determine whether fluoxetine, at any dose, given within the first year after stroke to patients who did not have to have mood disorders at randomization reduced disability, dependency, neurological deficits and fatigue; improved motor function, mood, and cognition at the end of treatment and follow-up, with the same number or fewer adverse effects. METHODS Searches (from 2012) in July 2018 included databases, trials registers, reference lists, and contact with experts. Co-primary outcomes were dependence and disability. Dichotomous data were synthesized using risk ratios (RR) and continuous data using standardized mean differences (SMD). Quality was appraised using Cochrane risk of bias methods. Sensitivity analyses explored influence of study quality. RESULTS The searches identified 3414 references of which 499 full texts were assessed for eligibility. Six new completed RCTs (n = 3710) were eligible, and were added to the seven trials identified in a 2012 Cochrane review (total: 13 trials, n = 4145). There was no difference in the proportion independent (3 trials, n = 3249, 36.6% fluoxetine vs. 36.7% control; RR 1.00, 95% confidence interval 0.91 to 1.09, p = 0.99, I2 = 78%) nor in disability (7 trials n = 3404, SMD 0.05, -0.02 to 0.12 p = 0.15, I2 = 81%) at end of treatment. Fluoxetine was associated with better neurological scores and less depression. Among the four (n = 3283) high-quality RCTs, the only difference between groups was lower depression scores with fluoxetine. CONCLUSION This class I evidence demonstrates that fluoxetine does not reduce disability and dependency after stroke but improves depression.


title: Pulse Pressure Analysis to Guide Intraoperative Phlebotomy Prior to Cardiac Surgery.

text: Background The aim of this study was to evaluate the response of the LiDCO-rapid™ during intraoperative phlebotomy in anesthetized children prior to surgery for congenital heart disease. Methods After the induction of general anesthesia and endotracheal intubation, baseline vital signs were recorded, along with pulse pressure variability (PPV) and stroke volume variability (SVV) from the LiDCO-rapid™ and cerebral oxygenation (rSO2) using near-infrared spectroscopy (NIRS). Phlebotomy was performed over 5 - 10 min with the volume of blood removed calculated to achieve a hematocrit of 24-28% on cardiopulmonary bypass. The primary outcome was a decline in rSO2 ≥ 5 between the baseline value and the end of phlebotomy. At that time, the correlation of the starting and ending values of SVV and PPV with the NIRS was determined. Results The study cohort included 30 patients (mean age of 21 ± 11 years). Statistically significant changes during the study period were observed in rSO2, but not in the LiDCO-rapid™ parameters. In analysis of continuous NIRS data, the change in NIRS did not correlate with either baseline (r = 0.10, P = 0.644) or final (r = 0.02, P = 0.914) SVV. Likewise, the change in NIRS did not correlate with baseline (r = 0.01, P = 0.953) or final (r = 0.00, P = 0.982) PPV. Conclusion Baseline values as well as changes in the PVV and SVV from the LiDCO-rapid™ did not predict or correlate with changes in cerebral oxygenation measured by NIRS during intraoperative phlebotomy. Our preliminary data suggest that these parameters (PVV and SVV) are not useful in monitoring patient stability or the need for volume replacement during intraoperative phlebotomy prior to cardiac surgery.


title: Conjunctival pigmentation after 23-gauge microincisional vitrectomy surgery.

text: AIM To investigate cases with conjunctival pigmentation originating from sclerotomy sites after 23-gauge microincisional vitrectomy surgery (MIVS). METHODS This is a retrospective study comprised of 185 eyes from 185 consecutive patients who underwent 23-gauge MIVS. The authors investigated the incidence and the clinical factors associated with conjunctival pigmentation, including indication of vitrectomy and surgical procedures. RESULTS Eight eyes (4.3%) from 185 eyes showed conjunctival pigmentation after surgery within 7 days postoperatively. Light microscopic examination of excised tissue showed infiltration of abundant dark brownish colored melanophages with surrounding scattered, finely granular, melanin pigments. C3F8 gas tamponade (OR, 9.4; 95% CI, 1.9-44.5; P=0.005) was significantly associated with conjunctival pigmentation. The mean surface area (21.26±2.21 mm(2)) of three eyes with C3F8 tamponade was significantly larger than that of five eyes (2.51±0.73 mm(2)) without tamponade (P=0.025). Neither leakage nor hypotony was found. CONCLUSIONS Intraocular melanin pigments could prolapse through the sclerotomy site and cause conjunctival pigmentation after 23-gauge MIVS. Thus, preoperative warning is necessary in patients with 23-gauge MIVS.


title: A tyrosine-sulfated CCR5-mimetic peptide promotes conformational transitions in the HIV-1 envelope glycoprotein.

text: The HIV-1 envelope glycoprotein is a trimeric complex of heterodimers composed of a surface glycoprotein, gp120, and a transmembrane component, gp41. The association of this complex with CD4 stabilizes the coreceptor-binding site of gp120 and promotes the exposure of the gp41 helical region 1 (HR1). Here, we show that a 15-amino-acid peptide mimetic of the HIV-1 coreceptor CCR5 fused to a dimeric antibody Fc domain (CCR5mim-Ig) bound two gp120 molecules per envelope glycoprotein complex and by itself promoted HR1 exposure. CCR5mim-Ig also stabilized the association of a CD4-mimetic peptide with the envelope glycoprotein. A fusion of the CD4- and CCR5-mimetic peptides, DM1, bound gp120 and neutralized R5, R5X4, and X4 HIV-1 isolates comparably to CD4, and they did so markedly more efficiently than either peptide alone. Our data indicate that the potency of DM1-Ig derives from its avidity for the HIV-1 envelope glycoprotein trimer and from the bidirectional induction of its receptor-mimetic components. DM1 has significant advantages over other inhibitors that target both coreceptor and CD4-binding sites, and it may serve as a lead for a new class of HIV-1 inhibitor peptides.


title: Mortality, Length of Stay, and Cost Implications of Procedural Bleeding After Percutaneous Interventions Using Large-Bore Catheters.

text: Importance Bleeding complications after percutaneous transcatheter interventions that used large-bore catheters are frequent and associated with high mortality and morbidity. Objective To describe the incidence of bleeding complications among patients undergoing contemporary endovascular interventions involving large-bore catheters and its association with in-hospital mortality, length of stay, and health care cost. Design, Setting, and Participants This retrospective cohort study analyzed all 17 672 patients from the Healthcare Cost and Utilization Project's National Inpatient Sample database who were recorded as having undergone a transcatheter aortic valve replacement (n = 3223), an endovascular aneurysm repair (n = 12 633), or a percutaneous left ventricular assist device implant (n = 1816) between January 1, 2012, and December 31, 2013. Bleeding complication was defined as any transfusion, any hemorrhage or hematoma, or the need for percutaneous or surgical intervention to control the bleeding event. Health care costs were determined by multiplying the total charge for each visit by the cost to charge ratios reported for each hospital code in the database. Data were collected from the database on April 29, 2016. Main Outcomes and Measures Adjusted association between bleeding complications and mortality was determined by multivariable logistic regression. Length of stay and total health care costs were compared using multivariable linear regression between patients who did and patients who did not have bleeding complications. Results Bleeding complications occurred in 3128 patients (17.7%) (1984 men and 1144 women, with a mean [SD] age of 75.6 [11.9] years). Bleeding was associated with higher mortality (adjusted odds ratio, 2.70; 95% CI, 2.27-3.22; P < .001) and longer hospital stay (adjusted multiplicative difference, 2.14; 95% CI, 2.06-2.16; P < .001). Median (interquartile range) total health care costs were $48 663 ($32 620-$71 547) for patients with bleeding complications compared with $29 968 ($21 924-$43 287) for patients without a bleeding complication (adjusted multiplicative difference, 1.55; 95% CI, 1.52-1.59; P < .001). Conclusions and Relevance Periprocedural bleeding was common among patients who underwent transcatheter intervention using large-bore catheters and was associated with a statistically significant increase in mortality, length of stay, and cost.


title: Physical function in patients with resectable cancer of the pancreas and liver-a systematic review.

text: PURPOSE Surgery is the only potentially curative treatment for pancreatic and liver cancer. However, even in high-volume centres, surgical resection is associated with significant morbidity with resultant physical decline. This systematic review explored physical function and its' implications in the management of resectable cancer of the pancreas and liver. METHODS EMBASE, Medline OVID, CINAHL, Cochrane Library and Web of Science were searched up to June 2019 using a predefined search strategy. Screening of titles, abstracts, and full texts, data extraction, and risk of bias assessment was performed independently by two reviewers. A third reviewer resolved disagreements by consensus. RESULTS Sixteen studies with a total of 1224 participants were included. Heterogeneity of the literature prevented a meta-analysis. Physical function across the pancreatic/liver cancer trajectory has been under investigated. The relationship between physical function and pancreatic/liver cancer resection outcome remains unclear, although anaerobic threshold appears the strongest predictor of postoperative outcomes. Conclusions regarding the impact of rehabilitative interventions on physical function were limited due to risk of bias concerns. CONCLUSIONS High-quality evidence regarding the implications of physical function in resectable pancreatic and liver cancers is lacking. Well-designed trials are required to examine physical function across the pancreatic/liver cancer continuum and to measure the impact of rehabilitation on physical function. IMPLICATIONS FOR CANCER SURVIVORS As survival rates for pancreatic and liver cancer slowly improve a greater understanding of the impact of these cancers and their treatments on physical function, and the potential impact of rehabilitative interventions for survivors is required.


title: Emergence of Thailand-like strains of porcine deltacoronavirus in Guangxi Province, China.

text: Porcine deltacoronavirus (PDCoV) has been detected sporadically in China since its first description in 2012. In our study, 62 faecal and intestinal samples from pigs with diarrhoea were collected in Guangxi Province, China, during 2017 and 2018. Twelve samples (19.4%, 12/62) were positive for PDCoV. Five complete genomes of PDCoV were then determined, and sequence alignment revealed that the five strains had discontinuous deletions at 400-401 aa in non-structural protein 2 (NSP2) and 758-760 aa in non-structural protein 3 (NSP3) compared with the respective proteins in the HKU15-44 strain. Notably, the CHN-GX81-2018 strain contained two insertions in the S gene and 3'-UTR. Multiple sequence alignment and phylogenetic analysis showed that four strains shared 98.2%-98.4% nucleotide identity with CHN-AH-2004 and were classified into a new cluster of China lineage strains, whereas the CHN-GX81-2018 strain shared 98.7% nucleotide identity with Vietnam/Binh21/2015 and belonged to the Vietnam/Laos/Thailand lineage. Recombination analyses revealed that four strains were the result of recombination between CHN-HB-2014 and Vietnam/Binh21/2015 strains. This study demonstrated the co-existence of multiple lineages of PDCoV in China, and our findings will aid the reorganization and evolution of the virus.


title: Methodological approaches and magnitude of the clinical unmet need associated with amotivation in mood disorders.

text: BACKGROUND There is growing research interest in studying motivational deficits in different neuropsychiatric disorders because these symptoms appear to be more common than originally reported and negatively impact long-term functional outcomes. However, there is considerable ambiguity in the terminology used to describe motivational deficits in the scientific literature. For the purposes of this manuscript, the term "amotivation" will be utilised in the context of mood disorders, since this is considered a more inclusive/appropriate term for this patient population. Other challenges impacting the study of amotivation in mood disorders, include: appropriate patient population selection; managing or controlling for potential confounding factors; the lack of gold-standard diagnostic criteria and assessment scales; and determination of the most appropriate study duration. METHODS This paper summarises the search for a consensus by a group of experts in the optimal approach to studying amotivation in mood disorders. RESULTS The consensus of this group is that amotivation in mood disorders is a legitimate therapeutic target, given the magnitude of the associated unmet needs, and that proof-of-concept studies should be conducted in order to facilitate subsequent larger investigations. The focus of this manuscript is to consider the study of amotivation, as a residual symptom of major depressive disorder (MDD) or bipolar depression (BD), following adequate treatment with a typical antidepressant or mood stabiliser/antipsychotic, respectively. DISCUSSION There is a paucity of data studying amotivation in mood disorders. This manuscript provides general guidance on the most appropriate study design(s) and methodology to assess potential therapeutic options for the management of residual amotivation in mood disorders.


title: Behavior Change Techniques in Physical Activity eHealth Interventions for People With Cardiovascular Disease: Systematic Review.

text: BACKGROUND Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe, accounting for 4 million deaths per year and costing the European Union economy almost €196 billion annually. There is strong evidence to suggest that exercise-based secondary rehabilitation programs can decrease the mortality risk and improve health among patients with CVD. Theory-informed use of behavior change techniques (BCTs) is important in the design of cardiac rehabilitation programs aimed at changing cardiovascular risk factors. Electronic health (eHealth) is the use of information and communication technologies (ICTs) for health. This emerging area of health care has the ability to enhance self-management of chronic disease by making health care more accessible, affordable, and available to the public. However, evidence-based information on the use of BCTs in eHealth interventions is limited, and particularly so, for individuals living with CVD. OBJECTIVE The aim of this systematic review was to assess the application of BCTs in eHealth interventions designed to increase physical activity (PA) in CVD populations. METHODS A total of 7 electronic databases, including EBSCOhost (MEDLINE, PsycINFO, Academic Search Complete, SPORTDiscus with Full Text, and CINAHL Complete), Scopus, and Web of Science (Core Collection) were searched. Two authors independently reviewed references using the software package Covidence (Veritas Health Innovation). The reviewers met to resolve any discrepancies, with a third independent reviewer acting as an arbitrator when required. Following this, data were extracted from the papers that met the inclusion criteria. Bias assessment of the studies was carried out using the Cochrane Collaboration's tool for assessing the risk of bias within Covidence; this was followed by a narrative synthesis. RESULTS Out of the 987 studies that were identified, 14 were included in the review. An additional 9 studies were added following a hand search of review paper references. The average number of BCTs used across the 23 studies was 7.2 (range 1-19). The top three most frequently used BCTs included information about health consequences (78%, 18/23), goal setting (behavior; 74%, 17/23), and joint third, self-monitoring of behavior and social support (practical) were included in 11 studies (48%, 11/23) each. CONCLUSIONS This systematic review is the first to investigate the use of BCTs in PA eHealth interventions specifically designed for people with CVD. This research will have clear implications for health care policy and research by outlining the BCTs used in eHealth interventions for chronic illnesses, in particular CVD, thereby providing clear foundations for further research and developments in the area.


Modern statistical tools for inference and prediction of infectious diseases using mathematical models.


title: How nurses and other health professionals use learning principles in parent education practice: A scoping review of the literature.

text: Background Health Professionals (HPs) play an important role in supporting parents to care for their children, by facilitating parents' knowledge and skills development through parent education. This is achieved through teaching, whereby planned strategies, based on principles of how people learn, enable learning. Despite Learning Principles being the fundamental tenets of the learning process, how HPs perceive and use Learning Principles in their practice is neglected in the healthcare literature. Objective To identify, describe and map the existing literature on nurses' and HPs' perceptions and use of Learning Principles in parent education practice. Method A scoping review was performed using the Joanna Briggs Institute approach. A comprehensive search of 10 databases and the grey literature was undertaken between March and June 2017 to identify pertinent English-language publications. The search was limited to literature published between 1998 and 2017. Following a screening and inclusion criteria eligibility check, 89 articles were selected for inclusion. Results HPs' perceptions of Learning Principles were diverse, somewhat disorganised, divergent in meaning and implicit. This was until the Dimensions of Learning construct was applied to guide the analyses and mapping. This revealed that HPs, of whom 60.7% were nurses, used Learning Principles in parent education, but only referred to them in the context of Adult Learning. Enablers to HPs using Learning Principles included shared partnerships between parents and HPs, while barriers included parents' health beliefs, psychological issues and organisational assumptions about learning. Evaluation of parents' learning also represented implicit use of Learning Principles by HPs. Conclusion This scoping review is the first to examine HPs' perceptions and use of Learning Principles within parent education practice. The findings reveal a significant gap in this body of knowledge. The paucity of studies containing any explicit descriptions of Learning Principles strongly supports the need for further exploration and codification of Learning Principles, through qualitative methods, whereby a deeper understanding of what is happening in healthcare practice can be established.


title: Comparing written programs and self-reported respiratory protection practices in acute care hospitals.

text: Airborne biological hazards in hospitals require the use of respiratory protection. A well-implemented respiratory protection program can protect health care workers from these exposures. This study examines the relationship between written respiratory programs and reported practices in health care settings. Twenty-eight hospitals in Illinois and Minnesota were recruited to a study of respiratory protection programs and practices in acute care settings. Interviews were conducted with hospital managers, unit managers, and health care workers from departments where respirators are commonly required. Each hospital's written respiratory protection program was scored for the 11 elements required by the Occupational Safety and Health Administration (OSHA), using a standardized tool, for a maximum possible score of 22 (2 pts. per element). Twenty interview questions associated with program practices were also scored by percent correct responses. Written program scores ranged from 2-17 with an average of 9.2. Hospital and unit managers scored on average 82% and 81%, respectively, when compared to the OSHA standard; health care workers scored significantly lower, 71% (p < 0.001). Minnesota written program scores were not significantly higher than Illinois hospitals (p = 0.16), while all Illinois survey respondents scored higher than those in Minnesota (p < 0.001). There was no trend between written programs and interview responses. Written respiratory protection programs in the study sites did not provide the level of detail required OSHA. Interview responses representing hospital practices surrounding respiratory protection indicated that hospitals were aware of and following regulatory guidelines.


title: Effect of overuse-induced tendinopathy on tendon healing in a rat supraspinatus repair model.

text: Supraspinatus tears often result in the setting of chronic tendinopathy. However, the typical repair model utilizes an acute injury. In recognition of that distinction, our laboratory developed an overuse animal model; however it is unclear whether induced overuse is necessary in the repair model. We studied the repair properties of overuse-induced tendons compared to normal tendons. We hypothesized that histological and mechanical properties would not be altered between the overuse-induced and normal tendons 1 and 4 weeks after repair. Thirty-one adult male Sprague-Dawley rats were subjected to either overuse or cage activity for 4 weeks prior to bilateral supraspinatus tendon repair surgery. Rats were sacrificed at 1 and 4 weeks post-surgery and evaluated for histology and mechanics. Results at 1 week showed no clear histologic changes, but increased inflammatory protein expression in overuse tendons. At 4 weeks, percent relaxation was slightly increased in the overuse group. No other alterations in mechanics or histology were observed. Our results suggest that the effects of the surgical injury overshadow the changes evoked by overuse. Because clinically relevant mechanical parameters were not altered in the overuse group, we conclude that when examining tendons 4 weeks after repair in the classic rat supraspinatus model, inducing overuse prior to surgery is likely to be unnecessary.


title: Energy-based devices for hemostasis in thyroid surgery.

text: The evolution of operative techniques in thyroid surgery that has taken place over the past several decades would not have been possible if not for a sui generis revolution in surgery at the turn of the 19th and 20th centuries. The three most important events of the end of the 19th century, i.e., the introduction of anesthesia, the use of artery forceps and ligation of blood vessels, as well as prophylactic management of perioperative infections decidedly affected the improvement of therapeutic results of thyroid surgery. Surgical treatment of thyroid diseases is associated with the possibility of complications developing, of which bleeding is among the most serious ones, starting from the need for an immediate reoperation and ending at a considerable damage to functionally important structures: the laryngeal nerves and parathyroid glands. The consensus reached between the development of science and progress in modern technologies has provided the basis for introducing and popularizing minimally invasive procedures, including operations using the approach through natural body openings. Such an unprecedented development of surgical techniques would not be possible without devices for closing blood vessels. Given the mechanism of hemostasis, current vascular sealing devices can generally be divided into three groups: ultrasonic, bipolar-radiofrequency and hybrid systems combining both energy modalities. While analyzing the innovative, advanced technology of all the energy-based devices, it should be stated that only if they are used in a safe manner, quality of life of patients with various thyroid conditions is improved. The employment of such devices fully confirms their usefulness; nevertheless, all the advantages should never release the surgeon from the obligation to appropriately and safely identify the surrounding structures and let him uncritically use the new device.


Increase in submissions to International Brazilian Journal of Urology during Covid-19 quarentine.


title: Good clinical practice advice for the management of pregnant women with suspected or confirmed COVID-19 in Nigeria.

text: The impact on healthcare services in settings with under-resourced health systems, such as Nigeria, is likely to be substantial in the coming months due to the COVID-19 pandemic, and maternity services still need to be prioritized as an essential core health service. The healthcare system should ensure the provision of safe and quality care to women during pregnancy, labor, and childbirth, and at the same time, maternity care providers including obstetricians and midwives must be protected and prioritized to continue providing care to childbearing women and their babies during the pandemic. This practical guideline was developed for the management of pregnant women with suspected or confirmed COVID-19 in Nigeria and other low-resource countries.


title: A Comparative Examination of the Clinical Outcome and Histological Appearance of Cryopreserved and Fresh Split-Thickness Skin Grafts.

text: The clinical use of frozen, human allogeneic skin grafts is considered a suitable alternative to freshly harvested allogeneic skin grafts when the latter are not available. However, limited functional and histological information exists regarding the effects of cryopreservation on allogeneic skin grafts, especially those across mismatched histocompatibility barriers. Thus, we performed a side-by-side comparative study of fresh vs frozen skin grafts, across both minor and major histocompatibility barriers, in a miniature swine model. Since porcine skin shares many physical and immunological properties with human skin, our findings have relevance to current clinical practices involving allogeneic grafting and may support future, temporary wound therapies involving frozen xenografts, comprised genetically modified porcine skin. Four miniature swine underwent harvest and grafting of split-thickness skin, with and without cryopreservation, in order to observe autologous grafts and grafts across minor and major histocompatibility barriers. A biopsy of the grafts was done at regular intervals for study of architecture, vascularization, and outcomes. All grafts vascularized without technical complications. Differences were noted in the early appearance of some fresh vs frozen grafts, but no significant difference was observed in overall survival times in any of the experimental groups. These results demonstrate that despite early observable differences in the healing process, cryopreservation and thawing does not significantly affect long-term graft survival or time to rejection, thus supporting the clinical and experimental use of fresh and frozen split-thickness skin grafts as comparable and interchangeable.


Outbreak of COVID-19 - an urgent need for good science to silence our fears?


title: Delivery in pregnant women infected with SARS-CoV-2: A fast review.

text: BACKGROUND Few case reports and clinical series exist on pregnant women infected with SARS-CoV-2 who delivered. OBJECTIVE To review the available information on mode of delivery, vertical/peripartum transmission, and neonatal outcome in pregnant women infected with SARS-CoV-2. SEARCH STRATEGY Combination of the following key words: COVID-19, SARS-CoV-2, and pregnancy in Embase and PubMed databases. SELECTION CRITERIA Papers reporting cases of women infected with SARS-CoV-2 who delivered. DATA COLLECTION AND ANALYSIS The following was extracted: author; country; number of women; study design; gestational age at delivery; selected clinical maternal data; mode of delivery; selected neonatal outcomes. MAIN RESULTS In the 13 studies included, vaginal delivery was reported in 6 cases (9.4%; 95% CI, 3.5-19.3). Indication for cesarean delivery was worsening of maternal conditions in 31 cases (48.4%; 95% CI, 35.8-61.3). Two newborns testing positive for SARS-CoV-2 by real-time RT-PCR assay were reported. In three neonates, SARS-CoV-2 IgG and IgM levels were elevated but the RT-PCR test was negative. CONCLUSIONS The rate of vertical or peripartum transmission of SARS-CoV-2 is low, if any, for cesarean delivery; no data are available for vaginal delivery. Low frequency of spontaneous preterm birth and general favorable immediate neonatal outcome are reassuring.


title: A Case of COVID-19 Patient with False-negative for SARS-CoV-2 of Pharyngeal Swab, from a Chinese traveller Returning from Wuhan, Hubei Province, China, January 2020.

text: We report a case of patient in Japan with Coronavirus disease 2019 (COVID-19) with false-negative of reverse transcription polymerase chain reaction for Severe Acute Respiratory Syndrome Coronavirus 2 of pharyngeal swab, from a Chinese traveller returning from Wuhan, Hubei Province, China. If a patient is clinically or epidemiologically suspected of COVID-19, appropriate infection and prevention control measures such as standard, contact, and droplet precaution are needed until the patient is proven to be true-negative.


title: Electrosurgery and Temperature Increase in Tissue With a Passive Metal Implant.

text: Importance: During monopolar electrosurgery in patients, current paths can be influenced by metal implants, which can cause unintentional tissue heating in proximity to implants. Guidelines concerning electrosurgery and active implants such as pacemakers or implantable cardioverter defibrillators have been published, but most describe interference between electrosurgery and the active implant rather than the risk of unintended tissue heating. Tissue heating in proximity to implants during electrosurgery may cause an increased risk of patient injury. Objective: To determine the temperature of tissue close to metal implants during electrosurgery in an in-vitro model. Design, Setting, and Participants: Thirty tissue samples (15 with a metal implant placed in center, 15 controls without implant) were placed in an in vitro measurement chamber. Electrosurgery was applied at 5-60 W with the active electrode at three defined distances from the implant while temperatures at four defined distances from the implant were measured using fiber-optic sensors. Main Outcomes and Measures: Tissue temperature increase at the four tissue sites was determined for all power levels and each of the electrode-to-implant distances. Based on a linear mixed effects model analysis, the primary outcomes were the difference in temperature increase between implant and control tissue, and the estimated temperature increase per watt per minute. Results: Tissues with an implant had higher temperature increases than controls at all power levels after 1 min of applied electrosurgery (mean difference of 0.16°C at 5 W, 0.50°C at 15 W, 1.11°C at 30 W, and 2.22°C at 60 W, all with p < 0.001). Temperature increase close to the implant was estimated to be 0.088°C/W/min (95% CI: 0.078-0.099°C/W/min; p < 0.001). Temperature could increase to above 43°C after 1 min of 60 W. Active electrode position had no significant effect on temperature increases for tissues with implant (p = 0.6). Conclusions and Relevance: The temperature of tissue close to a metal implant increases with passing electrosurgery current. There is a significant risk of high tissue temperature when long activation times or high power levels are used.


title: Aerosol transmission of infectious disease.

text: OBJECTIVE The concept of aerosol transmission is developed to resolve limitations in conventional definitions of airborne and droplet transmission. METHODS The method was literature review. RESULTS An infectious aerosol is a collection of pathogen-laden particles in air. Aerosol particles may deposit onto or be inhaled by a susceptible person. Aerosol transmission is biologically plausible when infectious aerosols are generated by or from an infectious person, the pathogen remains viable in the environment for some period of time, and the target tissues in which the pathogen initiates infection are accessible to the aerosol. Biological plausibility of aerosol transmission is evaluated for Severe Acute Respiratory Syndrome coronavirus and norovirus and discussed for Mycobacterium tuberculosis, influenza, and Ebola virus. CONCLUSIONS Aerosol transmission reflects a modern understanding of aerosol science and allows physically appropriate explanation and intervention selection for infectious diseases.


Public Health and Ethics Intersect at New Levels With Gerontological Nursing in COVID-19 Pandemic.


title: Initial clinical experience with dual-layer detector spectral CT in patients with acute intracerebral haemorrhage: A single-centre pilot study.

text: PURPOSE The purpose of this study was to investigate the clinical feasibility of spectral analyses using dual-layer detector spectral computed tomography (CT) in acute intracerebral haemorrhage (ICH). MATERIAL AND METHODS We retrospectively reviewed patients with acute ICH who underwent CT angiography on a dual-layer detector spectral CT scanner. A spectral data analysis was performed to detect contrast enhancement in or adjacent to acute ICH by using spectral image reconstructions including monoenergetic (MonoE), virtual noncontrast (VNC), and iodine overlay fusion images. We also acquired a spectral plot to assess material differentiation within lesions. RESULTS Among the 30 patients, the most common cause of acute ICH was chronic hypertension (18/30, 60%) followed by trauma (5/30, 16.7%), brain tumour (3/30, 10%), Moyamoya disease (2/30, 6.7%), and haemorrhagic diathesis from anticoagulation therapy (2/30, 6.7%). Of 30 patients, 13 showed suboptimal iodine suppression in the subcalvarial spaces on VNC images compared with true noncontrast images. The CT angiographic spot sign within the acute ICH was detected in four patients (4/30, 13.3%). All three tumours were metastatic and included lung cancer (n = 2) and hepatocellular carcinoma (n = 1) which showed conspicuous delineation of an enhancing tumour portion in the spectral analysis. Spectral analyses allowed the discrimination of acute haemorrhage and iodine with enhanced lesion visualization on the MonoE images obtained at lower keVs (less than 70 keV) and spectral plot. CONCLUSIONS Even though the image quality of VNC is perceived to be inferior, it is feasible to evaluate acute ICH in clinical settings using dual-layer detector spectral CT. The MonoE images taken at lower keVs were useful for depicting contrast enhancing lesion, and spectral plot might be helpful for material differentiation in patients with acute ICH.


title: CMAUP: a database of collective molecular activities of useful plants.

text: The beneficial effects of functionally useful plants (e.g. medicinal and food plants) arise from the multi-target activities of multiple ingredients of these plants. The knowledge of the collective molecular activities of these plants facilitates mechanistic studies and expanded applications. A number of databases provide information about the effects and targets of various plants and ingredients. More comprehensive information is needed for broader classes of plants and for the landscapes of individual plant's multiple targets, collective activities and regulated biological pathways, processes and diseases. We therefore developed a new database, Collective Molecular Activities of Useful Plants (CMAUP), to provide the collective landscapes of multiple targets (ChEMBL target classes) and activity levels (in 2D target-ingredient heatmap), and regulated gene ontologies (GO categories), biological pathways (KEGG categories) and diseases (ICD blocks) for 5645 plants (2567 medicinal, 170 food, 1567 edible, 3 agricultural and 119 garden plants) collected from or traditionally used in 153 countries and regions. These landscapes were derived from 47 645 plant ingredients active against 646 targets in 234 KEGG pathways associated with 2473 gene ontologies and 656 diseases. CMAUP (http://bidd2.nus.edu.sg/CMAUP/) is freely accessible and searchable by keywords, plant usage classes, species families, targets, KEGG pathways, gene ontologies, diseases (ICD code) and geographical locations.


title: Health and Economic Outcomes Associated with Use of an Antimicrobial Envelope as a Standard of Care for Cardiac Implantable Electronic Device Implantation.

text: INTRODUCTION Infection of cardiac implanted electrical devices (CIED) is a problem. In selected patients, use of an "antibacterial envelope" (AIGISRx®) is associated with low CIED infection rates. The value of this device when used as a standard of care is unclear. METHODS AND RESULTS Retrospective analysis of all patients (N = 1,476) who underwent CIED implantation at a single hospital. During the study period, some implanters used the AIGISRx as a standard of care (Yes-AIGISRx Group, N = 365), whereas others did not use it at all (No-AIGISRx Group, N = 1,111). A risk score based on preoperative factors was calculated for each patient. Rates of CIED infection within 6 months were measured, and associated costs were estimated. The Yes-AIGISRx and No-AIGISRx groups had similar preoperative infection risk. In the No-AIGISRx group, 19 infections were observed (1.7%), versus 0 in the Yes-AIGISRx group (P = 0.006). The 6-month mortality rate among patients with infection was significantly greater than among those without infection (15.7% vs. 4.5%, P = 0.021). The average hospital duration for infection care was 13 days. By extrapolating the infection rate and costs observed in the No-AIGISRx group to the Yes-AIGISRx group, we estimated that there would have been 6.2 additional infections costing approximately $340,000. This cost was similar to the actual cost of the devices in the Yes-AIGISRx group, estimated at $320,000. CONCLUSIONS Standard of care use of an antibacterial envelope as a standard of care was associated with a significantly lower rate of CIED infection, and appeared to be economically reasonable. Prospective trials to address these findings may be worthwhile.


title: Cell-surface phosphatidylserine regulates osteoclast precursor fusion.

text: Bone-resorbing multinucleated osteoclasts that play a central role in the maintenance and repair of our bones are formed from bone marrow myeloid progenitor cells by a complex differentiation process that culminates in fusion of mononuclear osteoclast precursors. In this study, we uncoupled the cell fusion step from both pre-fusion stages of osteoclastogenic differentiation and the post-fusion expansion of the nascent fusion connections. We accumulated ready-to-fuse cells in the presence of the fusion inhibitor lysophosphatidylcholine and then removed the inhibitor to study synchronized cell fusion. We found that osteoclast fusion required the dendrocyte-expressed seven transmembrane protein (DC-STAMP)-dependent non-apoptotic exposure of phosphatidylserine at the surface of fusion-committed cells. Fusion also depended on extracellular annexins, phosphatidylserine-binding proteins, which, along with annexin-binding protein S100A4, regulated fusogenic activity of syncytin 1. Thus, in contrast to fusion processes mediated by a single protein, such as epithelial cell fusion in Caenorhabditis elegans, the cell fusion step in osteoclastogenesis is controlled by phosphatidylserine-regulated activity of several proteins.


title: Feasibility of single-incision laparoscopic surgery for appendicitis in abnormal anatomical locations: A single surgeon's initial experience.

text: BACKGROUND Single-incision laparoscopic surgery is considered as a more technically demanding procedure than the standard laparoscopic surgery. Based on an initial and early experience, single-incision laparoscopic appendectomy (LA) was found to be technically advantageous for dealing with appendicitis in unusual anatomical locations. This study aims to highlight the technical advantages of single-incision laparoscopic surgery in dealing with the abnormally located appendixes and furthermore report a case of acute appendicitis occurring in a sub-gastric position, which is probably the first such case to be reported in English literature. MATERIALS AND METHODS A retrospective analysis of the first 10 cases of single-incision LA which were performed by a single surgeon is presented here. RESULTS There were seven females and three males. The mean age of the patients was 30.6 (range 18-52) years, mean BMI was 22.7 (range 17-28) kg/m(2) and the mean operative time was 85.5 (range 45-150) min. The mean postoperative stay was 3.6 (range 1-7) days. The commonest position of the appendix was retro-caecal (50%) followed by pelvic (30%). In three cases the appendix was found to be in abnormal locations namely sub-hepatic, sub-gastric and deep pelvic or para-vesical or para-rectal. All these cases could be managed with this technique without any conversions. CONCLUSION Single-incision laparoscopic surgery appears to be a feasible and safe technique for dealing with appendicitis in rare anatomical locations. Appendectomy may be a suitable procedure for the initial training in single-incision laparoscopic surgery.


title: The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device.

text: OBJECTIVEThromboembolic complications continue to be encountered with Pipeline embolization devices (PEDs) despite routine clopidogrel/aspirin antiplatelet therapy. This study examined the safety and efficacy of prasugrel in the management of clopidogrel-resistant patients treated for cerebral aneurysms.METHODSFour hundred thirty-seven consecutive patients were identified between January 2011 and May 2016. Patients allergic, or having less than 30% platelet inhibition, to a daily 75-mg dose of clopidogrel received 10 mg of prasugrel daily (n = 20) or 90 mg of ticagrelor twice daily (n = 2). The mean (± SD) follow-up duration was 15.8 ± 12.4 months. The primary outcome was the modified Rankin Scale (mRS) score registered before discharge and at each follow-up visit. To control confounding, multivariable mixed-effects logistic regression and propensity score conditioning were used.RESULTSTwenty-six (5.9%) of 437 patients presented with a subarachnoid hemorrhage (SAH). The mean patient age was 56.3 years, and 62 were women (14.2%). One of the 7 patients lost to follow-up received prasugrel. One patient was allergic to clopidogrel and prasugrel simultaneously. All patients receiving prasugrel or ticagrelor (n = 22) had an mRS score ≤ 2 on their latest follow-up visit (mean score 0.67 ± 1.15). In a multivariate analysis, clopidogrel did not affect the mRS score on last follow-up (p = 0.14). Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (OR 0.17, 95% CI 0.01-2.70, p = 0.21), an increased thromboembolic complication rate (OR 0.46, 95% CI 0.12-1.67, p = 0.24), or an increased hemorrhagic event rate (OR 0.39, 95% CI 0.91-1.64, p = 0.20). None of the patients receiving prasugrel or ticagrelor died or suffered a long-term recurrence or a hemorrhagic event; only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. Three patients taking clopidogrel died during the study: 2 from acute SAH and 1 from intraparenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR 2.18, 95% CI 0.11-43.27, p = 0.61). The same associations were present in propensity score-adjusted models.CONCLUSIONSIn a cohort of patients treated with PEDs, prasugrel (10 mg/day) was a safe alternative to clopidogrel-resistant or clopidogrel-allergic patients, or nonresponders.


title: Murine coronavirus ubiquitin-like domain is important for papain-like protease stability and viral pathogenesis.

text: UNLABELLED Ubiquitin-like domains (Ubls) now are recognized as common elements adjacent to viral and cellular proteases; however, their function is unclear. Structural studies of the papain-like protease (PLP) domains of coronaviruses (CoVs) revealed an adjacent Ubl domain in severe acute respiratory syndrome CoV, Middle East respiratory syndrome CoV, and the murine CoV, mouse hepatitis virus (MHV). Here, we tested the effect of altering the Ubl adjacent to PLP2 of MHV on enzyme activity, viral replication, and pathogenesis. Using deletion and substitution approaches, we identified sites within the Ubl domain, residues 785 to 787 of nonstructural protein 3, which negatively affect protease activity, and valine residues 785 and 787, which negatively affect deubiquitinating activity. Using reverse genetics, we engineered Ubl mutant viruses and found that AM2 (V787S) and AM3 (V785S) viruses replicate efficiently at 37°C but generate smaller plaques than wild-type (WT) virus, and AM2 is defective for replication at higher temperatures. To evaluate the effect of the mutation on protease activity, we purified WT and Ubl mutant PLP2 and found that the proteases exhibit similar specific activities at 25°C. However, the thermal stability of the Ubl mutant PLP2 was significantly reduced at 30°C, thereby reducing the total enzymatic activity. To determine if the destabilizing mutation affects viral pathogenesis, we infected C57BL/6 mice with WT or AM2 virus and found that the mutant virus is highly attenuated, yet it replicates sufficiently to elicit protective immunity. These studies revealed that modulating the Ubl domain adjacent to the PLP reduces protease stability and viral pathogenesis, revealing a novel approach to coronavirus attenuation. IMPORTANCE Introducing mutations into a protein or virus can have either direct or indirect effects on function. We asked if changes in the Ubl domain, a conserved domain adjacent to the coronavirus papain-like protease, altered the viral protease activity or affected viral replication or pathogenesis. Our studies using purified wild-type and Ubl mutant proteases revealed that mutations in the viral Ubl domain destabilize and inactivate the adjacent viral protease. Furthermore, we show that a CoV encoding the mutant Ubl domain is unable to replicate at high temperature or cause lethal disease in mice. Our results identify the coronavirus Ubl domain as a novel modulator of viral protease stability and reveal manipulating the Ubl domain as a new approach for attenuating coronavirus replication and pathogenesis.


title: Quality of life in 265 patients with gastroenteropancreatic or bronchial neuroendocrine tumors treated with [177Lu-DOTA0,Tyr3]octreotate.

text: UNLABELLED Quality of life (QOL) is an important outcome in cancer therapy. In this study, we investigated the QOL and symptoms after [(177)Lu-DOTA(0),Tyr(3)]octreotate ((177)Lu-octreotate) therapy in patients with inoperable or metastasized gastroenteropancreatic or bronchial neuroendocrine tumors (NETs). METHODS Two hundred sixty-five Dutch patients completed the QOL questionnaire of the European Organization for the Research and Treatment of Cancer after being treated for NETs. ANOVA was used for statistical analyses, with a P value of 0.05 or less being considered significant. Differences of at least 10 points in global health status (GHS)/QOL scores, symptom scores, and Karnofsky performance scores (KPS) before and after therapy were regarded as indicating an improvement. RESULTS Regardless of the treatment outcome, GHS/QOL, insomnia, appetite loss, and diarrhea improved significantly in the total group. These improvements were also seen in patients with bone metastases or a decrease of 50% or more in chromogranin A. Improvement in the scores by at least 10 points was also analyzed in a subgroup of patients with decreased GHS/QOL or symptoms at the start of therapy: in 36% of these patients, GHS/QOL improved after therapy; in 49%, fatigue; in 70%, nausea plus vomiting; in 53%, pain; in 44%, dyspnea; in 59%, insomnia; in 63%, appetite loss; in 60%, constipation; and in 67%, diarrhea. Additionally, we did not see a statistically significant deterioration in patients who had GHS/QOL 100, KPS 100, or no symptoms at the start. In patients with initial stable disease or remission after treatment, GHS/QOL and KPS decreased significantly when regrowth of the tumors occurred. CONCLUSION GHS/QOL, KPS, and symptoms improved significantly after (177)Lu-octreotate therapy, and there was no significant decrease in QOL in patients who had no symptoms before therapy. In patients who had suboptimal scores for GHS/QOL or symptoms before therapy, a clinically significant improvement was demonstrated. Our results indicate that (177)Lu-octreotate therapy not only reduces tumors and prolongs overall survival but also improves the patients' self-assessed QOL.


title: Mid-term outcomes following endovascular re-intervention for iliac artery in-stent restenosis.

text: OBJECTIVES We sought to evaluate the procedural characteristics and clinical outcomes of endovascular repair for iliac artery (IA) in-stent restenosis (ISR). BACKGROUND An increasing percentage of patients with complex IA occlusive disease are treated with an endovascular approach, but the outcomes of IA-ISR have not been well described. METHODS We analyzed all endovascular procedures for treatment of IA-ISR performed at our institution between July 2006-December 2010. The primary outcome was primary patency, defined as <50% stenosis as assessed by clinical examination and duplex ultrasonography (DUS). RESULTS Forty-one lesions in 24 patients who underwent repeated endovascular intervention for treatment of IA-ISR. Most lesions were unilateral and involved the common IA (66%). The mean length of ISR was 30.1 ± 14.1 mm with type I (focal) and II (diffuse) ISR occurring with the greatest frequency (34% and 39%, respectively). All patients underwent balloon angioplasty; adjunctive stenting zwas performed in 27 (66%) of the lesions. Type II ISR lesions more frequently required stenting (13/16 lesions, P = 0.02 compared with other patterns of ISR). Procedural success was 100% with a mean gain of 0.13 in the ankle-brachial index (P = 0.001). The 6- and 12-month primary patency rates were 96% and 82%, respectively. The 12-month primary-assisted patency rate was 90% with clinically driven target lesion revascularization (TLR) in three patients. CONCLUSIONS Endovascular treatment of IA-ISR using an approach of balloon angioplasty followed by selective stenting is associated with high-patency rates and low rates of TLR at 1 year.


Biotech companies prepare for COVID-19 downturn.


title: The COVID-19 pandemic in Singapore: what does it mean for arthroplasty?

text: Background and purpose - The ongoing Coronavirus Disease-19 (COVID-19) pandemic has taken a toll on healthcare systems around the world. This has led to guidelines advising against elective procedures, which includes elective arthroplasty. Despite arthroplasty being an elective procedure, some arthroplasties are arguably essential, as pain or functional impairment maybe devastating for patients, especially during this difficult period. We describe our experience as the Division of Arthroplasty in the hospital at the epicenter of the COVID-19 pandemic in Singapore.Patients and methods - The number of COVID-19 cases reported both nationwide and at our institution from February 2020 to date were reviewed. We then collated the number of arthroplasties that we were able to cope with on a weekly basis and charted it against the number of new COVID-19 cases admitted to our institution and the prevalence of COVID-19 within the Singapore population.Results - During the COVID-19 pandemic period, a significant decrease in the volume of arthroplasties was seen. 47 arthroplasties were performed during the pandemic period from February to April, with a weekly average of 5 cases. This was a 74% reduction compared with our institutional baseline. The least number of surgeries were performed during early periods of the pandemic. This eventually rose to a maximum of 47% of our baseline numbers. Throughout this period, no cases of COVID-19 infection were reported amongst the orthopedic inpatients at our institution.Interpretation - During the early periods of the pandemic, careful planning was required to evaluate the pandemic situation and gauge our resources and manpower. Our study illustrates the number of arthroplasties that can potentially be done relative to the disease curve. This could serve as a guide to reinstating arthroplasty as the pandemic dies down. However, it is prudent to note that these situations are widely dynamic and frequent re-evaluation is required to secure patient and healthcare personnel safety, while ensuring appropriate care is delivered.


title: A Thickness Calibration Device Is Needed to Determine Staple Height and Avoid Leaks in Laparoscopic Sleeve Gastrectomy.

text: BACKGROUND Leaks after sleeve gastrectomy (SG) may be due to a mismatch between staple height and tissue thickness. The aim of this study was to determine the range of gastric thicknesses in three areas of stapling. METHODS SG was performed using a 40-Fr suction calibration system 4 cm from the pylorus. Measurement of combined gastric walls was accomplished with an applied pressure of 8 g/mm(2) on the fundus, midbody, and antrum. RESULTS We enrolled 26 SG patients (15 women, 11 men; mean age 36.8 years). Body mass index (BMI) averaged 45.3 kg/m(2) overall, 44.7 kg/m(2) for males and 45.7 kg/m(2) for females. Although male patients had a thicker stomach antrum than female patients (3.12 vs. 3.09 mm), the midbody (2.57 vs. 3.09 mm) and proximal areas (1.67 vs. 1.72 mm) were thicker in female patients. However, some maximum fundus thicknesses were up to 2.83 mm in females and 2.28 mm in males. Some antra were as thick as 4.07 mm in females and 5.39 mm in males. Also, men had a longer average staple line (22.95 vs. 19.90 cm). CONCLUSION Because of the range of gastric thicknesses, a single staple height cannot be used to appose the full range of gastric wall thicknesses without potentially causing necrosis or poor apposition. To help avoid leaks, a thickness calibration device is needed to determine correct staple height.


title: The Cor-Knot device may serve as an ideal radiopaque marker of the annular plane for future valve-in-valve implantation.

text: A 55-year-old man underwent aortic root and ascending aortic replacement with a 27-mm Freestyle porcine neoroot with reimplantation of the coronary ostia as well as ascending aortic replacement with a 28-mm straight Dacron graft. A knot-tying device consisting of radiopaque Titan clips (Cor-Knot device, LSI Solutions, Inc, Victor, NY) for anchoring the porcine neoroot was used.


Metabolic constraints on the B cell response to malaria.


title: #CDCGrandRounds and #VitalSigns: A Twitter Analysis.

text: BACKGROUND The CDC hosts monthly panel presentations titled 'Public Health Grand Rounds' and publishes monthly reports known as Vital Signs. Hashtags #CDCGrandRounds and #VitalSigns were used to promote them on Twitter. Objectives: This study quantified the effect of hashtag count, mention count, and URL count and attaching visual cues to #CDCGrandRounds or #VitalSigns tweets on their retweet frequency. METHODS Through Twitter Search Application Programming Interface, original tweets containing the hashtag #CDCGrandRounds (n = 6,966; April 21, 2011-October 25, 2016) and the hashtag #VitalSigns (n = 15,015; March 19, 2013-October 31, 2016) were retrieved respectively. Negative binomial regression models were applied to each corpus to estimate the associations between retweet frequency and three predictors (hashtag count, mention count, and URL link count). Each corpus was sub-set into cycles (#CDCGrandRounds: n = 58, #VitalSigns: n = 42). We manually coded the 30 tweets with the highest number of retweets for each cycle, whether it contained visual cues (images or videos). Univariable negative binomial regression models were applied to compute the prevalence ratio (PR) of retweet frequency for each cycle, between tweets with and without visual cues. FINDINGS URL links increased retweet frequency in both corpora; effects of hashtag count and mention count differed between the two corpora. Of the 58 #CDCGrandRounds cycles, 29 were found to have statistically significantly different retweet frequencies between tweets with and without visual cues. Of these 29 cycles, one had a PR estimate < 1; twenty-four, PR > 1 but < 3; and four, PR > 3. Of the 42 #VitalSigns cycles, 19 were statistically significant. Of these 19 cycles, six were PR > 1 and < 3; and thirteen, PR > 3. Conclusions: The increase of retweet frequency through attaching visual cues varied across cycles for original tweets with #CDCGrandRounds and #VitalSigns. Future research is needed to determine the optimal choice of visual cues to maximize the influence of public health tweets.


title: Evaluation of the effects of cell-dispensing using an inkjet-based bioprinter on cell integrity by RNA-seq analysis.

text: Bioprinting technology is expected to be applied in the fields of regenerative medicine and drug discovery. There are several types of bioprinters, especially inkjet-based bioprinter, which can be used not only as a printer for arranging cells but also as a precision cell-dispensing device with controlled cell numbers similar to a fluorescence activated cell sorter (FACS). Precise cell dispensers are expected to be useful in the fields of drug discovery and single-cell analysis. However, there are enduring concerns about the impacts of cell dispensers on cell integrity, particularly on sensitive cells, such as stem cells. In response to the concerns stated above, we developed a stress-free and media-direct-dispensing inkjet bioprinter. In the present study, in addition to conventional viability assessments, we evaluated the gene expression using RNA-seq to investigate whether the developed bioprinter influenced cell integrity in mouse embryonic stem cells. We evaluated the developed bioprinter based on three dispensing methods: manual operation using a micropipette, FACS and the developed inkjet bioprinter. According to the results, the developed inkjet bioprinter exhibited cell-friendly dispensing performance, which was similar to the manual dispensing operation, based not only on cell viability but also on gene expression levels.


title: Trans-anal minimally invasive surgery for rectal neoplasia: Experience from single tertiary institution in China.

text: AIM To evaluate the feasibility and safety of trans-anal minimally invasive surgery (TAMIS) from single institute in China. METHODS A retrospective review was conducted for patients with rectal neoplasia, who underwent TAMIS using single incision laparoscopic surgery-Port from January 2013 till January 2016 by a group of colorectal surgeons from Gastrointestinal Center Unit III, Peking University Cancer Hospital. Patients' demographic data, surgical related information, post-operational pathology, as well as peri-operative follow-up were all collected. RESULTS Twenty-five patients with rectal neoplasia were identified consequently. Complete full-thickness excision was achieved in all cases without conversion. 22 (88%) cases had rectal malignancies [6 were adenocarcinomas and 16 were neuroendocrine tumors (NET)], while 3 patients had adenomas. Mean surgical duration was 61.3 min, and mean post-operative stay were 2.7 d. Post-operational examination demonstrated 5 cases had positive resection margin: 2 adenocarcinoma cases and 1 NET case with positive lateral margin, and the other 2 NET cases with positive basal margin. The curve of operation time for TAMIS cases suggested a minimum of 10 cases for a laparoscopic surgeon proficient with this technique. CONCLUSION TAMIS was demonstrated to be reproducible and safe, with a relatively short learning process for laparoscopic surgeons in selected cases for rectal neoplasia. Long-term oncological outcome needs to be determined by further investigation.


Covid-19: Trump says added deaths are necessary price for reopening US businesses.


title: Surgical management of postcastration spermatic cord stump infection in horses: A retrospective study of 23 cases.

text: OBJECTIVE To report the surgical management and the short- and long-term follow-up of postcastration spermatic cord infection in horses. STUDY DESIGN Retrospective case series. ANIMALS Twenty-three client-owned horses. METHODS Medical records (2001-2017) of horses that had been surgically treated for spermatic cord stump infection after castration were reviewed. Time from castration to presentation, diagnostic procedures, surgical complications, bacterial culture and ancillary testing, and survival to discharge were collected. Long-term follow-up was obtained by owner survey when possible. Descriptive statistics were used to report results. RESULTS Horses ranged in age from 2 to 14 years (mean age 4.1) and presented 33 days (median; range, 12-3561) after castration. Five of 23 horses required revision surgery because of hemorrhage (2) or persistent infection (3). All horses survived to discharge. Long-term follow up was available for 16 horses at a mean time of 27.4 months postsurgery (range 6-135). Complete resolution of clinical signs and return to previous use was documented in 14 of 16 horses; 1 horse had persistent purulent drainage and a second horse was retired because he did not return to adequate performance. CONCLUSION Postcastration infection of the spermatic cord had a favorable prognosis for short- and long-term survival in this population, although complications included postoperative hemorrhage and persistent infection. CLINICAL SIGNIFICANCE This study describes the treatment of postcastration infection of the spermatic cord which results in a good survival rate.


title: Mitigating absenteeism in hospital workers during a pandemic.

text: OBJECTIVES An influenza pandemic, as with any disaster involving contagion or contamination, has the potential to influence the number of health care employees who will report for duty. Our project assessed the uptake of proposed interventions to mitigate absenteeism in hospital workers during a pandemic. METHODS Focus groups were followed by an Internet-based survey of a convenience sample frame of 17,000 hospital workers across 5 large urban facilities. Employees were asked to select their top barrier to reporting for duty and to score their willingness to work before and after a series of interventions were offered to mitigate it. RESULTS Overall, 2864 responses were analyzed. Safety concerns were the most frequently cited top barrier to reporting for work, followed by issues of dependent care and transportation. Significant increases in employee willingness to work scores were observed from mitigation strategies that included preferential access to antiviral medication or personal protective equipment for the employee as well as their immediate family. CONCLUSIONS The knowledge base on workforce absenteeism during disasters is growing, although in general this issue is underrepresented in emergency planning efforts. Our data suggest that a mitigation strategy that includes options for preferential access to either antiviral therapy, protective equipment, or both for the employee as well as his or her immediate family will have the greatest impact. These findings likely have import for other disasters involving contamination or contagion, and in critical infrastructure sectors beyond health care.


title: Recent advances of therapeutic targets and potential drugs of COVID-19.

text: Since December 2019, numerous cases of coronavirus disease 2019 (COVID-19) caused by the infection of the novel coronavirus (2019-nCoV) have been confirmed in Wuhan, China. The outbreak of 2019-nCoV in China embodied a significant and urgent threat to global health. 2019-nCoV was a new, highly contagious coronavirus discovered following the outbreak of SARS coronavirus (SARS-CoV) and MERS coronavirus (MERS-CoV). The novel coronavirus can cause severe respiratory disease and even death. However, no specific therapeutic drugs have been developed clinically thus far. This article examines the potential of therapeutic drugs by assessing the structure of 2019-nCoV, its mechanism in invading host cells, and the anti-viral mechanism of the human autoimmune system. We also review the latest research regarding the progress of potential therapeutic drugs and provide references for new drug developments of COVID-19.


title: Basic concepts of microarrays and potential applications in clinical microbiology.

text: The introduction of in vitro nucleic acid amplification techniques, led by real-time PCR, into the clinical microbiology laboratory has transformed the laboratory detection of viruses and select bacterial pathogens. However, the progression of the molecular diagnostic revolution currently relies on the ability to efficiently and accurately offer multiplex detection and characterization for a variety of infectious disease pathogens. Microarray analysis has the capability to offer robust multiplex detection but has just started to enter the diagnostic microbiology laboratory. Multiple microarray platforms exist, including printed double-stranded DNA and oligonucleotide arrays, in situ-synthesized arrays, high-density bead arrays, electronic microarrays, and suspension bead arrays. One aim of this paper is to review microarray technology, highlighting technical differences between them and each platform's advantages and disadvantages. Although the use of microarrays to generate gene expression data has become routine, applications pertinent to clinical microbiology continue to rapidly expand. This review highlights uses of microarray technology that impact diagnostic microbiology, including the detection and identification of pathogens, determination of antimicrobial resistance, epidemiological strain typing, and analysis of microbial infections using host genomic expression and polymorphism profiles.


title: Safety and Efficacy of Heparinization During Mechanical Thrombectomy in Acute Ischemic Stroke.

text: Background: The benefits of heparization during mechanical thrombectomy (MT) with newer generation thrombectomy devices, and if it is counterbalanced by the increased risk of intracranial hemorrhage (ICH) remain unknown. Methods: We included eligible patients who underwent MT from the ANGEL registry study (2015-2017) in China. Subjects in the current analysis were dichotomized into two groups according to whether adequate heparinization during MT was performed. In the heparinization group, unfractionated heparin was infused at 50-100 IU/Kg at first and additional 1,000 IU at intervals of an hour during the operation. Safety outcomes (symptomatic intracerebral hemorrhage [sICH], ICH and distal embolization) and efficacy outcomes (artery recanalization and functional outcomes at 3-month follow-up) were compared between groups. Results: We included 619 patients from the entire cohort of 917 patients. The average age of them was 63.9 ± 13.7 years, 269 (43.5%) were treated with heparinization during MT. Heparinization during MT didn't significantly influence recanalization rates, total ICH and long-term mortality (adjusted p > 0.05 for all). But sICH and distal embolization occurred more frequently (9.3 vs. 5.1%, adjusted p = 0.02; 7.1 vs. 3.1%, adjusted p = 0.04, respectively), while functional independence appeared less likely (39.8 vs. 47.4%, adjusted p = 0.01) in heparinization group than that in non-heparinization group. Multivariable logistic regression analyses showed that heparinization during MT was an independent predictor for sICH (Odds ratio 2.36 [1.19-4.67], p = 0.01) in addition to cardio-embolism stroke and posterior circulation stroke (PCS), and an independent predictor for poor outcome (Odds ratio 1.79 [1.23-2.59], p < 0.01) besides age, bridging intravenous thrombolysis, admission NIHSS, drinking and PCS. Conclusion: Heparinization during MT may be associated with increased risk of safety outcomes over sICH and distal embolization, as well as efficacy outcomes over long-term poor outcome. Further randomized controlled trials are needed.


title: Transcervical diverticulectomy for Killian-Jamieson diverticulum.

text: Surgery for Killian-Jamieson diverticulum of the esophagus is scarcely reported in the literature owing to the rarity of this entity. This is a case report of such a diverticulum and a description of the transcervical diverticulectomy that we performed on a 49-year-old lady. The patient was investigated for symptoms of gastroesophageal reflux disease and was diagnosed with a left-sided Killian-Jamieson diverticulum.


title: Clustering of capnogram features to track state transitions during procedural sedation.

text: Procedural sedation has allowed many painful interventions to be conducted outside the operating room. During such procedures, it is important to maintain an appropriate level of sedation to minimize the risk of respiratory depression if patients are over-sedated and added pain or anxiety if under-sedated. However, there is currently no objective way to measure the patient's evolving level of sedation during a procedure. We investigated the use of capnography-derived features as an objective measure of sedation level. Time-based capnograms were recorded from 30 patients during sedation for cardioversion. Through causal k-means clustering of selected features, we sequentially assigned each exhalation to one of three distinct clusters, or states. Transitions between these states correlated to events during sedation (drug administration, procedure start and end, and clinical interventions). Similar clustering of capnogram recordings from 26 healthy, non-sedated subjects did not reveal distinctly separated states.


Editorial.


How Facebook, Twitter and other data troves are revolutionizing social science.


title: Enrollment bias: frequency and impact on patient selection in endovascular stroke trials.

text: BACKGROUND Selection bias may have affected enrollment in first generation endovascular stroke trials. We investigate, evaluate, and quantify such bias for these trials at our institution. METHODS Demographic, clinical, imaging, and angiographic data were prospectively collected on a consecutive cohort of patients with acute ischemic stroke who were enrolled in formal trials of endovascular stroke therapy (EST) or received EST in clinical practice outside of a randomized trial for acute cerebral ischemia at a single tertiary referral center from September 2004 to December 2012. RESULTS Among patients considered appropriate for EST in practice, 47% were eligible for trials, with rates for individual trials ranging from 17% to 70%. Compared with trial ineligible patients treated with EST, trial eligible patients were younger (67 vs. 74 years; p<0.05), more often treated with intravenous tissue plasminogen activator (53% vs. 34%; p<0.01), and had shorter last known well to puncture times (328 vs. 367 min; p<0.05). Focusing on the largest trial with a non-interventional control arm, compared with trial eligible patients treated with EST outside the trial, enrolled patients presented later (274 vs. 163 min; p<0.001), had higher National Institutes of Health Stroke Scale scores (20 vs. 17; p<0.05), and larger strokes (diffusion weighted imaging volumes 49 vs. 18; p<0.001). CONCLUSIONS The majority of patients felt suitable for EST at our institution were excluded from recent trials. Formal entry criteria succeeded in selecting patients with better prognostic features, although many of these patients were treated outside of trials. Acknowledging and mitigating these biases will be crucial to ongoing investigations.


Impact of COVID-19 on Pain Medicine Fellowship Training.


title: Selective inhibition of FLT3 by gilteritinib in relapsed or refractory acute myeloid leukaemia: a multicentre, first-in-human, open-label, phase 1-2 study.

text: BACKGROUND Internal tandem duplication mutations in FLT3 are common in acute myeloid leukaemia and are associated with rapid relapse and short overall survival. The clinical benefit of FLT3 inhibitors in patients with acute myeloid leukaemia has been limited by rapid generation of resistance mutations, particularly in codon Asp835 (D835). We aimed to assess the highly selective oral FLT3 inhibitor gilteritinib in patients with relapsed or refractory acute myeloid leukaemia. METHODS In this phase 1-2 trial, we enrolled patients aged 18 years or older with acute myeloid leukaemia who either were refractory to induction therapy or had relapsed after achieving remission with previous treatment. Patients were enrolled into one of seven dose-escalation or dose-expansion cohorts assigned to receive once-daily doses of oral gilteritinib (20 mg, 40 mg, 80 mg, 120 mg, 200 mg, 300 mg, or 450 mg). Cohort expansion was based on safety and tolerability, FLT3 inhibition in correlative assays, and antileukaemic activity. Although the presence of an FLT3 mutation was not an inclusion criterion, we required ten or more patients with locally confirmed FLT3 mutations (FLT3mut+) to be enrolled in expansion cohorts at each dose level. On the basis of emerging findings, we further expanded the 120 mg and 200 mg dose cohorts to include FLT3mut+ patients only. The primary endpoints were the safety, tolerability, and pharmacokinetics of gilteritinib. Safety and tolerability were assessed in the safety analysis set (all patients who received at least one dose of gilteritinib). Responses were assessed in the full analysis set (all patients who received at least one dose of study drug and who had at least one datapoint post-treatment). Pharmacokinetics were assessed in a subset of the safety analysis set for which sufficient data for concentrations of gilteritinib in plasma were available to enable derivation of one or more pharmacokinetic variables. This study is registered with ClinicalTrials.gov, number NCT02014558, and is ongoing. FINDINGS Between Oct 15, 2013, and Aug 27, 2015, 252 adults with relapsed or refractory acute myeloid leukaemia received oral gilteritinib once daily in one of seven dose-escalation (n=23) or dose-expansion (n=229) cohorts. Gilteritinib was well tolerated; the maximum tolerated dose was established as 300 mg/day when two of three patients enrolled in the 450 mg dose-escalation cohort had two dose-limiting toxicities (grade 3 diarrhoea and grade 3 elevated aspartate aminotransferase). The most common grade 3-4 adverse events irrespective of relation to treatment were febrile neutropenia (97 [39%] of 252), anaemia (61 [24%]), thrombocytopenia (33 [13%]), sepsis (28 [11%]), and pneumonia (27 [11%]). Commonly reported treatment-related adverse events were diarrhoea (92 [37%] of 252]), anaemia (86 [34%]), fatigue (83 [33%]), elevated aspartate aminotransferase (65 [26%]), and increased alanine aminotransferase (47 [19%]). Serious adverse events occurring in 5% or more of patients were febrile neutropenia (98 [39%] of 252; five related to treatment), progressive disease (43 [17%]), sepsis (36 [14%]; two related to treatment), pneumonia (27 [11%]), acute renal failure (25 [10%]; five related to treatment), pyrexia (21 [8%]; three related to treatment), bacteraemia (14 [6%]; one related to treatment), and respiratory failure (14 [6%]). 95 people died in the safety analysis set, of which seven deaths were judged possibly or probably related to treatment (pulmonary embolism [200 mg/day], respiratory failure [120 mg/day], haemoptysis [80 mg/day], intracranial haemorrhage [20 mg/day], ventricular fibrillation [120 mg/day], septic shock [80 mg/day], and neutropenia [120 mg/day]). An exposure-related increase in inhibition of FLT3 phosphorylation was noted with increasing concentrations in plasma of gilteritinib. In-vivo inhibition of FLT3 phosphorylation occurred at all dose levels. At least 90% of FLT3 phosphorylation inhibition was seen by day 8 in most patients receiving a daily dose of 80 mg or higher. 100 (40%) of 249 patients in the full analysis set achieved a response, with 19 (8%) achieving complete remission, ten (4%) complete remission with incomplete platelet recovery, 46 (18%) complete remission with incomplete haematological recovery, and 25 (10%) partial remission INTERPRETATION: Gilteritinib had a favourable safety profile and showed consistent FLT3 inhibition in patients with relapsed or refractory acute myeloid leukaemia. These findings confirm that FLT3 is a high-value target for treatment of relapsed or refractory acute myeloid leukaemia; based on activity data, gilteritinib at 120 mg/day is being tested in phase 3 trials. FUNDING Astellas Pharma, National Cancer Institute (Leukemia Specialized Program of Research Excellence grant), Associazione Italiana Ricerca sul Cancro.


title: Fostering Existential Maturity to Manage Terror in a Pandemic.

text: Background: The COVID-19 pandemic has created an environment in which existence is more fragile and existential fears or terror rises in people. Objective: Managing existential terror calls for being mature about mortality, something with which palliative care providers are familiar and in need of greater understanding. Methods: Using a case to illustrate, we describe existential terror, terror management, and existential maturity and go on to outline how existential maturity is important for not only the dying and the grieving but for also those facing risk of acquiring COVID-19. Results: Next, we describe how essential components in attaining existential maturity come together. (1) Because people experience absent attachment to important people as very similar to dying, attending to those experiences of relationship is essential. (2) That entails an internal working through of important relationships, knowing their incompleteness, until able to "hold them inside," and invest in these and other connections. (3) And what allows that is making a meaningful connection with someone around the experience of absence or death. (4) We also describe the crucial nature of a holding environment in which all of these can wobble into place. Discussion: Finally, we consider how fostering existential maturity would help populations face up to the diverse challenges that the pandemic brings up for people everywhere.


title: Evaluation of Pulmonary Nodules: Clinical Practice Consensus Guidelines for Asia.

text: BACKGROUND American College of Chest Physicians (CHEST) clinical practice guidelines on the evaluation of pulmonary nodules may have low adoption among clinicians in Asian countries. Unique patient characteristics of Asian patients affect the diagnostic evaluation of pulmonary nodules. The objective of these clinical practice guidelines was to adapt those of CHEST to provide consensus-based recommendations relevant to practitioners in Asia. METHODS A modified ADAPTE process was used by a multidisciplinary group of pulmonologists and thoracic surgeons in Asia. An initial panel meeting analyzed all CHEST recommendations to achieve consensus on recommendations and identify areas that required further investigation before consensus could be achieved. Revised recommendations were circulated to panel members for iterative review and redrafting to develop the final guidelines. RESULTS Evaluation of pulmonary nodules in Asia broadly follows those of the CHEST guidelines with important caveats. Practitioners should be aware of the risk of lung cancer caused by high levels of indoor and outdoor air pollution, as well as the high incidence of adenocarcinoma in female nonsmokers. Furthermore, the high prevalence of granulomatous disease and other infectious causes of pulmonary nodules need to be considered. Therefore, diagnostic risk calculators developed in non-Asian patients may not be applicable. Overall, longer surveillance of nodules than those recommended by CHEST should be considered. CONCLUSIONS TB in Asia favors lesser reliance on PET scanning and greater use of nonsurgical biopsy over surgical diagnosis or surveillance. Practitioners in Asia are encouraged to use these adapted consensus guidelines to facilitate consistent evaluation of pulmonary nodules.


title: Permutation entropy in intraoperative ECoG of brain tumour patients in awake tumour surgery- a robust parameter to separate consciousness from unconsciousness.

text: Awake craniotomies represent an essential opportunity in the case of lesions in eloquent areas. Thus, optimal surveillance of the patient during different stages of sedation, as well as the detection of seizure activity during brain surgery, remains difficult, as skin electrodes for electroencephalographic (EEG) analysis are not applicable in most cases. We assessed the applicability of ECoG to monitor different stages of sedation, as well as the influence of different patient characteristics, such as tumour volume, size, entity, and age or gender on permutation entropy (PeEn). We conducted retrospective analysis of the ECoG data of 16 patients, who underwent awake craniotomies because of left-sided brain tumours at our centre between 2014 and 2016. PeEn could be easily calculated and compared using frontal and parietal cortical electrodes. A comparison of PeEn scores showed significantly higher values in awake patients than in patients under anaesthesia (p ≤ 0.004) and significantly higher ones in the state of transition than under general anaesthesia (p = 0.023). PeEn scores in frontal and parietal leads did not differ significantly, making them both applicable for continuous surveillance during brain surgery. None of the following clinical characteristics showed significant correlation with PeEn scores: tumour volume, WHO grade, first or recurrent tumour, gender, and sex. Being 50 years or older led to significantly lower values in parietal leads but not in frontal leads. ECoG and a consecutive analysis of PeEn are feasible and suitable for the continuous surveillance of patients during awake craniotomies. Hence, the analysis is not influenced by patients' clinical characteristics.


title: Psychosocial and Behavioral Impact of COVID-19 in Autism Spectrum Disorder: An Online Parent Survey.

text: The 2019 coronavirus disease (COVID-19) outbreak could result in higher levels of psychological distress, especially among people suffering from pre-existing mental health conditions. Young individuals with autism spectrum disorders (ASD) are particularly at risk due to their vulnerability to unpredictable and complex changes. This study aimed to investigate the impact of the COVID-19 pandemic on ASD individuals, whether any pre-pandemic sociodemographic or clinical characteristics would predict a negative outcome, and to narratively characterize their needs. Parents and guardians of ASD individuals filled out an online survey consisting of 40 questions investigating socio-demographic and clinical characteristics of their children, impact of the COVID-19 outbreak on their wellbeing and needs to deal with the emergency. Data were available on 527 survey participants. The COVID-19 emergency resulted in a challenging period for 93.9% of families, increased difficulties in managing daily activities, especially free time (78.1%) and structured activities (75.7%), and, respectively, 35.5% and 41.5% of children presenting with more intense and more frequent behavior problems. Behavior problems predating the COVID-19 outbreak predicted a higher risk of more intense (odds ratio (OR) = 2.16, 95% confidence interval (CI) 1.42-3.29) and more frequent (OR = 1.67, 95% CI 1.13-2.48) disruptive behavior. Even though ASD children were receiving different types of support, also requiring specialist (19.1%) or emergency (1.5%) interventions in a relatively low proportion of cases, a number of needs emerged, including receiving more healthcare support (47.4%), especially in-home support (29.9%), as well as interventions to tackle a potentially disruptive quarantine (16.8%). The COVID-19 outbreak has undoubtedly resulted in increased difficulties among ASD individuals.


title: M2 occlusions as targets for endovascular therapy: comprehensive analysis of diffusion/perfusion MRI, angiography, and clinical outcomes.

text: BACKGROUND The ideal population of patients for endovascular therapy (ET) in acute ischemic stroke remains undefined. Recent ET trials have moved towards selecting patients with proximal middle cerebral artery (MCA) or internal carotid artery occlusions, which will likely leave a gap in our understanding of the treatment outcomes of M2 occlusions. OBJECTIVE AND METHODS To examine the presentation, treatment, and outcomes of M2 compared with M1 MCA occlusions in patients undergoing ET by assessing comprehensive MRI, angiography, and clinical data. RESULTS We found that M2 occlusions can lead to massive strokes defined by hypoperfused and infarcted volumes as well as death or moderate to severe disability in nearly 50% of patients at discharge. Compared with M1 occlusions, M2 occlusions achieved similar Thrombolysis in Cerebral Infarction (TICI) 2b/3 recanalization rates, with significantly less hemorrhage. M2 occlusions presented with smaller infarct and hypoperfused volumes and had smaller final infarct volumes regardless of recanalization. TICI 2b/3 recanalization of M2 occlusions was associated with smaller infarct volumes compared with TICI 0-2a recanalization, as well as less infarct expansion, in patients who received IV tissue plasminogen activator as well as those that did not. Successful reperfusion of M2 occlusions was associated with improved discharge modified Rankin scale. CONCLUSIONS If suitable as targets of ET, M2 occlusions should be given the same consideration as M1 occlusions.


title: A familial cluster, including a kidney transplant recipient, of Coronavirus Disease 2019 (COVID-19) in Wuhan, China.

text: In December 2019, an outbreak of COVID-19 occurred in Wuhan, China, and spread to the whole of China and to multiple countries worldwide. Unlike SARS and MERS, where secondary transmission mostly occurred in hospital settings, COVID-19 transmission occurs in large numbers within families. Herein we report three cases of a familial cluster with one family member being a kidney transplant recipient. The initial clinical symptoms of COVID-19 in these three patients were the same, but their progression was different. Based on the severity of clinical symptoms, chest computer tomography findings and SARS-Cov-2 RNA test results, we admitted the husband to the respiratory intensive care unit (RICU) and used a treatment consisting of immunosuppressant reduction/cessation and low dose methylprednisolone-based therapy, and his wife to the respiratory isolation ward. In contrast, the son received in-home isolation and home-based care. All three family members made a full recovery.


title: Baculovirus as an expression and/or delivery vehicle for vaccine antigens.

text: The baculovirus/insect cell-expression system has proven to be a valuable tool for rapid expression of abundant recombinant proteins for research purposes and has been increasingly exploited for the production of vaccine candidates for commercial use. Furthermore, baculovirus has been discovered to be capable of efficiently transducing a wide variety of mammalian cells, thus leading to the emergence of baculovirus as a novel vector for in vivo and in vitro gene delivery. By incorporating a mammalian expression cassette into the viral genome and/or genetically modifying the baculovirus envelope for immunogen display, baculovirus has also been exploited recently as a vaccine expression/delivery vehicle. This review will focus primarily on past progress and recent advances with regards to employing baculovirus as an in vitro or in vivo expression/delivery vehicle for vaccine immunogens.


COVID-19 in Spain. Coming back to the "New normality" after two months of confinement.