title: Digital crowdsourcing: unleashing its power in rheumatology.

text: The COVID-19 pandemic forces the whole rheumatic and musculoskeletal diseases community to reassemble established treatment and research standards. Digital crowdsourcing is a key tool in this pandemic to create and distil desperately needed clinical evidence and exchange of knowledge for patients and physicians alike. This viewpoint explains the concept of digital crowdsourcing and discusses examples and opportunities in rheumatology. First experiences of digital crowdsourcing in rheumatology show transparent, accessible, accelerated research results empowering patients and rheumatologists.


title: Cholesterol: A new game player accelerating endothelial injuries caused by SARS-CoV-2?

text: The pandemic of coronavirus disease 2019 (COVID-19) has become a global threat to public health. Functional impairments in multiple organs have been reported in COVID-19 including lungs, heart, kidney, liver, brain and vascular system. Patients with metabolic-associated preconditions such as hypertension, obesity and diabetes are susceptible to experience severe symptoms. The recent emerging evidence of coagulation disorders in COVID-19 suggests that vasculopathy appears to be an independent risk factor promoting disease severity and mortality of affected patients. We have recently found that the decreased levels of low-density lipoprotein cholesterols (LDL-c) correlate with disease severity in COVID-19 patients, indicating pathological interactions between dyslipidemia and vasculopothy in COVID-19 patients. However, this clinical manifestation has been unintentionally underestimated by physicians and scientific communities. As metabolic-associated morbidities are generally accompanied with endothelial cell (EC) dysfunctions, these pre-existing conditions may make ECs more vulnerable to SARS-CoV-2 attack. In this mini-review, we summarize the metabolic and vascular manifestations of COVID-19 with an emphasis on the association between changes in LDL-c levels and the development of severe symptoms as well as the pathophysiologic mechanisms underlying the synergistic effect of LDL-c and SARS-CoV-2 on EC injuries and vasculopathy.


Prevalence of SARS-CoV-2 Among Patients Admitted for Childbirth in Southern Connecticut.


title: Laparoscopic sacrohysteropexy: the Pilsner modification.

text: INTRODUCTION AND HYPOTHESIS Laparoscopic sacrocolpopexy is the preferred contemporary procedure for the surgical management of a significant apical pelvic organ prolapse. In the presence of a uterus it is possible for the patient to have subtotal hysterectomy and cervicopexy, total hysterectomy with colpopexy or uterine conservation and hysteropexy. However, hysteropexy seems to be associated with a higher risk of anterior compartment failure compared with cervicopexy or colpopexy. It is not uncommon for an asymmetrically large anterior compartment defect to co-exist with a symptomatic apical pelvic organ prolapse. In a cervicopexy or colpopexy, this asymmetry can be balanced by creating a de novo vaginal apex from the superior part of the anterior vaginal wall. However in a hysteropexy the attachment of the base of the anterior mesh to the vagina and cervical isthmus limits the ability to do this. METHODS In this video we present a solution where the shape of the posterior mesh is modified to include two horizontal arms that are passed through openings in the broad ligament and attached to the cervical isthmus anteriorly. RESULTS This frees the anterior Y-shaped mesh to be fixed to the anterior vaginal wall only and hence provides the required tension to create the de novo apex. CONCLUSION Prior to wide adoption, this technique should be further investigated in the context of robustly designed comparative studies.


title: Human milk oligosaccharide effects on intestinal function and inflammation after preterm birth in pigs.

text: Human milk oligosaccharides (HMOs) may mediate prebiotic and anti-inflammatory effects in newborns. This is particularly important for preterm infants who are highly susceptible to intestinal dysfunction and necrotizing enterocolitis (NEC). We hypothesized that HMO supplementation of infant formula (IF) improves intestinal function, bacterial colonization and NEC resistance immediately after preterm birth, as tested in a preterm pig model. Mixtures of HMOs were investigated in intestinal epithelial cells and in preterm pigs (n=112) fed IF supplemented without (CON) or with a mixture of four HMOs (4-HMO) or >25 HMOs (25-HMO, 5-10 g/L given for 5 or 11 days). The 25-HMO blend decreased cell proliferation and both HMO blends decreased lipopolysaccharide-induced interleukin-8 secretion in IPEC-J2 cells, relative to control (P<.05). All HMOs were found in urine and feces of HMO-treated pigs, and short-chain fatty acids in the colon were higher in HMO vs. CON pigs (P<.05). After 5 days, NEC lesions were similar between HMO and CON pigs and 25-HMO increased colon weights (P<.01). After 11 days, the 4-HMO diet did not affect NEC (56 vs. 79%, P=.2) but increased dehydration and diarrhea (P<.05) and expression of immune-related genes (IL10, IL12, TGFβ, TLR4; P<.05). Bacterial adherence and diversity was unchanged after HMO supplementation. CONCLUSION Complex HMO-blends affect intestinal epithelial cells in vitro and gut gene expression and fermentation in preterm pigs. However, the HMOs had limited effects on NEC and diarrhea when supplemented to IF. Longer-term exposure to HMOs may be required to improve the immature intestinal function in formula-fed preterm neonates.


title: Detection of human herpesvirus-7 DNA in bronchoalveolar lavage.

text: OBJECTIVES Human herpesvirus-7 (HHV-7) is a highly seroprevalent virus that, following primary infection, establishes latency or persistence in some tissues, including lung. The aim of this study was to investigate the prevalence of HHV-7 in the lower respiratory tract of hospitalized adult patients. METHODS The prevalence of HHV-7 DNA was determined by quantitative real-time PCR in 212 bronchoalveolar lavage (BAL) samples obtained from 153 patients. The molecular epidemiology and clinical role of HHV-7 were evaluated. RESULTS HHV-7 DNA was positive in 44 of 212 specimens (20.7%), obtained from 40 of 153 patients (26.1%), in particular 22/68 (32.35%) and 18/86 (20.9%) in transplant and non-transplant patients, respectively (1 patient evaluated both before and after transplantation). No significant difference according to transplant condition or discharge diagnosis was found. Viral load was >100,000 genome equivalents/ml BAL in 6/22 (27.3%) transplant recipients and 4/18 (22.2%) non-transplant patients (p = n.s.). CONCLUSIONS The evaluation of HHV-7 DNA in BAL may be useful to investigate its potential role in lower respiratory tract infection, alone or in association with other viral and/or non-viral pathogens and to distinguish latency from reactivation.


title: Peptide vaccination is superior to genetic vaccination using a recombineered bacteriophage λ subunit vaccine.

text: Genetic immunization holds promise as a vaccination method, but has so far proven ineffective in large primate and human trials. Herein, we examined the relative merits of genetic immunization and peptide immunization using bacteriophage λ. Bacteriophage λ has proven effective in immune challenge models using both immunization methods, but there has never been a direct comparison of efficacy and of the quality of immune response. In the current study, this vector was produced using a combination of cis and trans phage display. When antibody titers were measured from immunized animals together with IL-2, IL-4 and IFNγ production from splenocytes in vitro, we found that proteins displayed on λ were superior at eliciting an immune response in comparison to genetic immunization with λ. We also found that the antibodies produced in response to immunization with λ displayed proteins bound more epitopes than those produced in response to genetic immunization. Finally, the general immune response to λ inoculation, whether peptide or genetic, was dominated by a Th1 response, as determined by IFNγ and IL-4 concentration, or by a higher concentration of IgG2a antibodies.


title: Viral-derived complement inhibitors: current status and potential role in immunomodulation.

text: The complement system is one of the body's major innate immune defense mechanisms in vertebrates. Its function is to detect foreign bodies and promote their elimination through opsonisation or lysis. Complement proteins play an important role in the immunopathogenesis of several disorders. However, excessive complement activation does not confer more protection but instead leads to several autoimmune and inflammatory diseases. With inappropriate activation of the complement system, activated complement proteins and glycoproteins may damage both healthy and diseased tissues. Development of complement inhibitors represents an effective approach in controlling dysregulated complement activity and reducing disease severity, yet few studies have investigated the nature and role of novel complement inhibitory proteins of viral origin. Viral complement inhibitors have important implications in understanding the importance of complement inhibition and their role as a promising novel therapeutic approach in diseases caused by dysregulated complement function. In this review, we discuss the role and importance of complement inhibitors derived from several viruses in the scope of human inflammatory and autoimmune diseases.


title: A feasibility and dosimetric evaluation of endoscopic radiofrequency ablation for human colonic and rectal epithelium in a treat and resect trial.

text: BACKGROUND Endoscopic radiofrequency ablation (RFA) has been used effectively for ablation of foregut disorders and also may have a role in treating colonic pathology. This study aimed to assess the feasibility of delivering RFA to locations within the colon and to determine a range of safe treatment parameters. METHODS Patients undergoing left hemicolectomy or proctocolectomy were evaluated. Focal RFA using a colonoscope-mounted device was delivered to normal segments of the colon and rectum within the planned surgical resection specimen. Endoscopic accessibility and feasibility of delivering heat energy to the colon and rectum were assessed as well as the maximum incurred histologic depth of ablation in relation to the number of applications (2 or 4) and the energy density (12, 15, or 20 J/cm2). RESULTS A total of 51 ablation zones in 16 patients had available histopathology. None of the sites receiving two applications demonstrated serosal layer alteration compared with 15% of the sites receiving four applications (p=0.11). Muscularis propria alterations were seen in 25% of the two-application sites and 63% of the four-application sites (p<0.05). Increasing energy density from 12 to 20 J/cm2 did not correlate with a deeper ablation effect. CONCLUSIONS Endoscopic RFA is capable of delivering therapy to the distal colon. Injury is limited to the muscularis propria or less depth when no more than two ablations are applied regardless of the energy density used. Based on these feasibility and dosimetry results, the authors will continue investigation using these and smaller energy doses to initiate trials ultimately with patients who have suitable mucosal and submucosal disorders of the lower gastrointestinal tract including chronic, nonulcerated hemorrhagic radiation proctitis and angiodyplasia.


title: Smoking cessation and the risk of hospitalization for pneumonia.

text: BACKGROUND Smoking increases the risk of hospitalization for pneumonia, yet it is unknown if smoking cessation changes this risk. We sought to determine if smoking cessation and the duration of abstinence from tobacco reduce the risk of pneumonia hospitalization. METHODS We performed secondary analysis of data collected from male United States Veterans participating in a randomized trial. We used Cox proportional-hazard models to estimate risk of hospitalization for pneumonia within one year of enrollment. We adjusted for confounders, including: demographics, comorbidity, alcohol use, prior pneumonia, inhaled corticosteroid use, and intensity of tobacco exposure. Among a restricted cohort excluding never smokers, we assessed for effect modification by a diagnosis of chronic obstructive pulmonary disease (COPD). RESULTS Of the 25,235 participants, we identified 6720 current, 13,625 former, and 4890 never smokers. Compared to current smokers, never smokers had a decreased (adjusted HR 0.48, 95% CI 0.31-0.74), while former smokers had no difference in (adjusted HR 0.83, 95% CI 0.63-1.09) risk of hospitalization for pneumonia. Among participants without COPD, former smokers had a lower risk of hospitalization (adjusted HR 0.65, 95% CI 0.45-0.95). However, this lower risk was isolated to those who quit tobacco more than 10 years previously (adjusted HR 0.62, 95% CI 0.41-0.93). Among those with COPD, there was no difference in risk with smoking cessation or duration of remaining tobacco-free. CONCLUSIONS Tobacco cessation is likely important in reducing hospital admissions for pneumonia, but its benefit depends on duration of smoking cessation and is likely attenuated in the presence of COPD.


The Importance of Long-term Care Populations in Models of COVID-19.


Anticipated Challenges for Medical Students Choosing a Career in Radiology During the COVID-19 Pandemic.


Viewing spikes.


title: Pneumonia in immunocompromised patients.

text: The diagnosis and identification of causative microorganisms of pneumonia are often difficult in immunocompromised patients. Immunosuppression can divided into three categories; neutropenia (or neutrophil dysfunction); humoral immunodeficiency and cellular immunodeficiency. Presumptive pathogen identifications of pneumonia could be made systematically based on the type of impaired immune function. Since there are a number of diseases that must be differentiated, the collection of respiratory tract specimens and appropriate serum antigen tests should be done whenever possible to identify the causative microorganisms. Empirical antibiotic therapy should be started as soon as possible. If initial treatment proves ineffective, invasive diagnostic procedures, including surgical lung biopsy, should be considered.


Response to: 'COVID-19 pandemic: an opportunity to assess the utility of telemedicine in patients with rheumatic diseases' by Lopez-Medina et al.


title: Clinical Outcomes of Subintimal vs. Intraluminal Revascularization Approaches for Long Femoropopliteal Occlusions in a Korean Multicenter Retrospective Registry Cohort.

text: BACKGROUND There are limited data comparing the outcomes of subintimal vs. intraluminal approach in the treatment of long femoropopliteal artery occlusions. The objective of this study was to investigate the efficacy and safety of the subintimal approach for long femoropopliteal artery occlusions.Methods and Results:From a multicenter retrospective registry cohort, we included a total of 461 patients with 487 femoropopliteal artery occlusions classified as Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II C/D for this analysis. We compared the immediate and mid-term outcomes of subintimal vs. intraluminal approaches. There were 228 patients with 243 limbs in the subintimal group, and 233 patients with 244 limbs in the intraluminal group. Baseline clinical and lesion characteristics were comparable between the 2 groups. The technical success rate was significantly higher in the subintimal group than in the intraluminal group (95.1% vs. 89.8%, P=0.041). The clinical primary patency (67.5% vs. 73.4% at 12 months, 54.0% vs. 61.3% at 24 months; P=0.086) and target lesion revascularization (TLR)-free survival (89.5% vs. 86.3% at 12 months, 77.6% vs. 76.0% at 24 months; P=0.710) did not differ significantly between the subintimal and the intraluminal groups. CONCLUSIONS In long femoropopliteal occlusions, the subintimal approach achieved a higher technical success rate and similar mid-term primary patency and TLR-free survival compared with intraluminal approach.


title: Knowledge of stroke symptoms and treatment among community residents in Western Urban China.

text: BACKGROUND Prehospital delay is still now the main barrier in receiving acute stroke therapy. Increase public awareness of stroke warning signs may help to activate emergency medical services and reduce prehospital delay. Our objectives were to survey the recognition of stroke warning signs among residents of Yuzhong District in Chongqing, China, and determine the proportion of these residents who would make an emergency call (120, in China) if suddenly faced with unexpected stroke warning signs and analyze the relationship between recognition of stroke warning signs and the response of calling for emergency assistance. METHODS In 2011, a population-based face-to-face interview survey using a multistage sampling method was conducted in Yuzhong District, Chongqing. We assessed residents' recognition of stroke warning signs and the proportion of those who would call the emergency number, 120, if suddenly encountering unexpected stroke warning signs. The association between the knowledge of stroke warning signs and activation of 120 was examined. RESULTS A total of 1101 participants completed the questionnaire. Only 15.6% of respondents knew all 5 stroke warning signs; 17.6% reported that they would call 120 for all 5 stroke warning signs. Recognition of stroke warning signs was associated with the response of calling 120 (odds ratios, 1.92-3.34). Even among those who knew all 5 warning signs of stroke, only 35.5% (95% confidence interval, 28.3-42.6) would call 120 for all 5 signs. CONCLUSIONS Residents of the examined district in Chongqing exhibited low recognition of stroke warning signs and low awareness of appropriate emergency responses to stroke-related symptoms.


title: Cautionary findings for motor evoked potential monitoring in intracranial aneurysm surgery after a single administration of rocuronium to facilitate tracheal intubation.

text: Administration of rocuronium to facilitate intubation has traditionally been regarded as acceptable for intraoperative motor evoked potential (MEP) monitoring because of sufficiently rapid spontaneous neuromuscular blockade recovery. We hypothesized that residual neuromuscular blockade, in an amount that could hinder optimal neuromonitoring in patients undergoing intracranial aneurysm clipping, was still present at dural opening. We sought to identify how often this was occurring and to identify factors which may contribute to prolonged blockade. Records of 97 patients were retrospectively analyzed. Rocuronium was administered to facilitate intubation with no additional neuromuscular blockade given. Prolonged spontaneous recovery time to a train-of-four (TOF) ratio of 0.75 after rocuronium administration was defined as 120 min, which was approximately when dural opening and the setting of baseline MEPs were occurring. Logistic regression analysis was used to identify factors related to prolonged spontaneous recovery time. Prolonged spontaneous recovery time to a TOF ratio of 0.75 was observed in 44.3% of patients. Multivariable analysis showed that only the dosage of rocuronium based on ideal body weight had a positive correlation with prolonged spontaneous recovery time (P = 0.01). There was no significant association between dosage of rocuronium based on total body weight, age, sex, or body temperature and prolonged recovery time. This study demonstrates that the duration of relaxation for MEP monitoring purposes is well-beyond the routinely recognized clinical duration of rocuronium. Residual neuromuscular blockade could result in lower amplitude MEP signals and/or lead to higher required MEP stimulus intensities which can both compromise monitoring sensitivity.


title: Human metapneumovirus in lung transplant recipients: characteristics and outcomes.

text: Human metapneumovirus (hMPV) causes serious respiratory tract infections in lung transplant recipients (LTRs). We evaluated the characteristics and adverse drug reactions (ADR) of oral ribavirin therapy for hMPV infections in LTRs. LTRs with respiratory symptoms or suspected infection of unknown origin were routinely sampled with nasopharyngeal swabs (NPS) for virological and bacteriological analysis as part of a diagnostic workup. Medical records of hMPV polymerase chain reaction (PCR)-positive LTRs at the University Hospital of Zurich were reviewed retrospectively. Between January 2012 and June 2014, 12 (80%) of 15 consecutive patients with documented hMPV infection received oral ribavirin therapy (800 mg/d, after 48 h: 400 mg/d). Mean duration of therapy was 28.6 days (range: 11-54). Mean duration of viral shedding was 16.3 days (range: 5-48). In general, oral ribavirin was well tolerated in LTRs. The most common ADR was moderate anaemia. All patients recovered from infection without immediate serious sequelae within 3 months of infection.


title: Modifications and Further Development of the Original Nuss Procedure: Blessing or Curse?

text: The procedure introduced by Donald Nuss in 1997 for the treatment of pectus excavatum at the American Pediatric Surgical Association meeting has now been adopted by pediatric, thoracic, and plastic surgeons around the world. Rather than resection of the costal cartilages and sternal fracture, which had been standard practice for decades, he advocated using a metal bar to push the sternum into position. Reasoning that the chest wall of children is very flexible, he felt that resection was unnecessary. Since that time, medical centers from around the world have reported their experience with the procedure. There is now robust evidence of its safety and efficacy. As the Nuss procedure has become a standard treatment, indications for operation have expanded, and numerous modifications have been introduced. Some of these were intended to improve upon the original procedure, and others to adapt it to new circumstances, such as use in adults whose chest is not as flexible. This report reviews those modifications.


Beyond acute care: Why collaborative self-management should be an essential part of rehabilitation pathways for COVID-19 patients.


title: The safety and efficacy of on-site paramedic and allied health treatment interventions targeting the reduction of emergency department visits by long-term care patients: systematic review protocol.

text: BACKGROUND Older adults are more likely to access the emergency department, which suffers from overcrowding and congestion, for conditions that could potentially be treated in other settings. Older adults living in long-term care centers have access to healthcare resources in their residence, and several programs have been created with the intent of treating medical conditions on-site. The aim of this study is to identify and systematically review programs and interventions at long-term care centers that aim to treat patients on-site, avoiding unscheduled transportation to the emergency department. METHODS We will follow the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We will perform a comprehensive search of Embase, MEDLINE, CINAHL, ClinicalTrials.gov , PROSPERO, and the Cochrane Central Registry of Controlled Trials using a broad search strategy. Two independent reviewers will assess titles and abstracts against inclusion criteria, and we will further evaluate relevant full-text articles for inclusion. We will assess the risk of bias using the Newcastle-Ottawa scale for included non-randomized studies and the Cochrane Risk of Bias tool for randomized trials. We will present a narrative synthesis of results and complete a meta-analysis only if enough homogeneity is found. We will create funnel plots to evaluate possible reporting bias and use The Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology to assess the confidence in cumulative evidence. DISCUSSION As pressure on the healthcare system continues to rise, many areas are looking for alternative models of care. Several programs have been put in place in long-term care centers that seek to avoid transportation to the emergency department by providing enhanced care on-site. These programs are quite variable, and, to date, there is no standardized program or model of care. SYSTEMATIC REVIEW REGISTRATION PROSPERO ( CRD42018091636 ).


title: Real time monitoring of biofilm formation on coated medical devices for the reduction and interception of bacterial infections.

text: Real time monitoring of bacterial attachment to medical devices provides opportunities to detect early biofilm formation and instigate appropriate interventions before infection develops. This study utilises long period grating (LPG) optical fibre sensors, incorporated into the lumen of endotracheal tubes (ETTs), to monitor in real time, Pseudomonas aeruginosa surface colonisation and biofilm formation. The wavelength shift of LPG attenuation bands was monitored for 24 h and compared with biofilm biomass, quantified using confocal fluorescence microscopy imaging. Biofilm formation was compared on uncoated ETTs and optical fibres, and on a biofilm resistant acrylate polymer, after challenge in an artificial sputum or minimal growth medium (RPMI-1640). The LPG sensor was able to detect a biofilm biomass as low as 81 μg cm-2, by comparison with the confocal image quantification. An empirical exponential function was found to link the optical attenuation wavelength shift with the inverse of the biofilm biomass, allowing quantification of biofouling from the spectral response. Quantification from the sensor allows infection interception and early device removal, to reduce, for example, the risk of ventilator associated pneumonia.


title: Population-based surveys of antibodies against SARS-CoV-2 in Southern Brazil.

text: Population-based data on COVID-19 are urgently needed. We report on three rounds of probability sample household surveys in the state of Rio Grande do Sul (Brazil), carried out in nine large municipalities using the Wondfo lateral flow point-of-care test for immunoglobulin M and G antibodies against SARS-CoV-2 (https://en.wondfo.com.cn/product/wondfo-sars-cov-2-antibody-test-lateral-flow-method-2/). Before survey use, the assay underwent four validation studies with pooled estimates of sensitivity (84.8%; 95% confidence interval (CI) = 81.4-87.8%) and specificity (99.0%; 95% CI = 97.8-99.7%). We calculated that the seroprevalence was 0.048% (2/4,151; 95% CI = 0.006-0.174) on 11-13 April (round 1), 0.135% (6/4,460; 95% CI = 0.049-0.293%) on 25-27 April (round 2) and 0.222% (10/4,500; 95% CI = 0.107-0.408) on 9-11 May (round 3), with a significant upward trend over the course of the surveys. Of 37 family members of positive individuals, 17 (35%) were also positive. The epidemic is at an early stage in the state, and there is high compliance with social distancing, unlike in other parts of Brazil. Periodic survey rounds will continue to monitor trends until at least the end of September, and our population-based data will inform decisions on preventive policies and health system preparedness at the state level.


title: ECG artifact cancellation in surface EMG signals by fractional order calculus application.

text: BACKGROUND AND OBJECTIVE New aspects for automatic electrocardiography artifact removal from surface electromyography signals by application of fractional order calculus in combination with linear and nonlinear moving window filters are explored. Surface electromyography recordings of skeletal trunk muscles are commonly contaminated with spike shaped artifacts. This artifact originates from electrical heart activity, recorded by electrocardiography, commonly present in the surface electromyography signals recorded in heart proximity. For appropriate assessment of neuromuscular changes by means of surface electromyography, application of a proper filtering technique of electrocardiography artifact is crucial. METHODS A novel method for automatic artifact cancellation in surface electromyography signals by applying fractional order calculus and nonlinear median filter is introduced. The proposed method is compared with the linear moving average filter, with and without prior application of fractional order calculus. 3D graphs for assessment of window lengths of the filters, crest factors, root mean square differences, and fractional calculus orders (called WFC and WRC graphs) have been introduced. For an appropriate quantitative filtering evaluation, the synthetic electrocardiography signal and analogous semi-synthetic dataset have been generated. The examples of noise removal in 10 able-bodied subjects and in one patient with muscle dystrophy are presented for qualitative analysis. RESULTS The crest factors, correlation coefficients, and root mean square differences of the recorded and semi-synthetic electromyography datasets showed that the most successful method was the median filter in combination with fractional order calculus of the order 0.9. Statistically more significant (p < 0.001) ECG peak reduction was obtained by the median filter application compared to the moving average filter in the cases of low level amplitude of muscle contraction compared to ECG spikes. CONCLUSIONS The presented results suggest that the novel method combining a median filter and fractional order calculus can be used for automatic filtering of electrocardiography artifacts in the surface electromyography signal envelopes recorded in trunk muscles.


Response by Gheblawi et al to Letter Regarding Article, "Angiotensin-Converting Enzyme 2: SARS-CoV-2 Receptor and Regulator of the Renin-Angiotensin System: Celebrating the 20th Anniversary of the Discovery of ACE2".


title: Complications of mesh repair in hiatal surgery: about 3 cases and review of the literature.

text: Primary repair of large hiatal hernia is associated with high recurrence rate. The use of prosthetic mesh to reinforce the cure seems to lead to less recurrence. Unfortunately, this procedure is still controversial in regard of the possible complications that may occur. We report here 3 cases of complications related to mesh placement in hiatal hernia surgery: an esophageal perforation, an intragastric migration, and a fundic erosion. When a patient complains of epigastric pain or dysphagia with no peritoneal signs, in the postoperative course of mesh placement, an upper endoscopy should be achieved to rule out those complications. The patient must be informed about the mesh placement and he must notify the endoscopist in case of an upper gastrointestinal endoscopy.


title: A point-of-care diagnostic system to influenza viruses using chip-based ultra-fast PCR.

text: In order to diagnose the infectious disease from clinical samples, the various protocols such as culturing microorganism, rapid diagnostic test using chromatographic method, ELISA, conventional PCR are developed. Since a novel strain of avian influenza can be cross-infected human as well as birds and livestock due to genetic reassortment, some strains of influenza such as H7N9 and H5N1 have emerged as a severe virus which can be threaten the health of poultry as well as human. Therefore, we explored the development of simultaneously and rapid diagnostic tool for seasonal influenza (A/H1N1, A/H3N2, B) and highly pathogenic avian influenza (A/H5N1, A/H7N9). We analyzed the unique nucleotide sequences of influenza types including three seasonal influenza, A/H7N9, and A/H5N1, and distinguished each type of influenza and diagnosed through One Step RT-PCR. In the results, Chip-based PCR technique can be diagnosed rapidly and directly from naked eye with EvaGreen the influenza also respiratory specimens within 23 min 15 s, including reverse transcription. The Chip-based PCR is a point-of-care system, and it is expected to reduce diagnosis time and to develop a diagnostic kit. Furthermore the Chip based PCR technique can be used for high risk pathogen in bioterror and/or biological warfare in the field.


title: Middle East respiratory syndrome: SARS redux?

text: Middle East respiratory syndrome (MERS) is caused by the Middle East respiratory syndrome coronavirus (MERS-CoV). Although predominantly affecting countries across the Arabian Peninsula, the infection has been exported by travelers to countries around the world, including the United States. The virus has caused several healthcare-related outbreaks, so prompt recognition and patient isolation are critical to containing the spread of infection. Healthcare providers are urged to stay current on the evolving outbreak, and to screen at-risk travelers for possible MERS.


title: New device for temporary hemorrhage control in penetrating injuries to the ventricles.

text: Background The best way to control hemorrhage from cardiac injuries is through digital occlusion followed by suture. However, this is difficult to accomplish in the emergency department (ED) setting. Generally, temporary control is obtained in advance of definitive treatment in the operating room. Despite safety and efficacy concerns, balloon Foley catheter insertion through the injury is still an option following ED thoracotomies. We developed a new device for temporary hemorrhage control in cardiac injuries and compared it to the Foley. Methods 6 adult swine (n=6) underwent full-thickness (1.5 cm) injury along the longitudinal axis of the right ventricle (RV). After 5 s of bleeding, hemorrhage control was attempted with either the device or the Foley, and blood loss quantified. Subsequently, the wound was sutured and mean arterial pressure was restored to baseline with lactated Ringer's infusion. Subsequently, another injury 2 cm apart in the same ventricle was managed with apparatus not employed in the first injury. The same followed in the LV totaling 4 injuries per animal, 2 in each ventricle. Intraoperative echocardiogram, laboratory test and final wound sizes assessed. Results The device resulted in less bleeding than the Foley; RV 58.7±11.3 vs 147.7±30.9 mL, LV 81.7±11.9 vs 187.5±40.3 mL (p<0.05). Percent change in tricuspid regurgitation was less with the device than FO, 66.6% vs 400%. Mitral regurgitation increased 16% with Foley, but remained unchanged with the device. Changes in stroke volume and LV ejection fraction were less with the device than with Foley; SV 2.09% vs 12.48%, left ventricular ejection fraction 0.46% vs 5.45%. Foley insertion enlarged the wounds. Platelet count, complete blood count, prothrombin time, activated prothrombin time and fibrinogen decreased, whereas troponin and lactate increased compared with baseline, underscoring the magnitude of shock. Conclusions Cardiac hemorrhage was effectively controlled with the new device. The low-profile collapsible blocking membrane interfered less with cardiac function than did the balloon of the Foley, an important asset in the context of shock.


title: T-cell deplete versus T-cell replete haploidentical hematopoietic stem cell transplantation for sickle cell disease: where are we?

text: Introduction: Severe sickle cell disease is associated with progressive end-organ damage and early mortality in adults. While allogeneic hematopoietic cell transplant from a matched related donor is curative, the vast majority of patients do not have a compatible sibling. Accordingly, platforms using haploidentical donors have been developed, which provide near universal availability. Areas covered: This review focuses on the two commonly used approaches for haploidentical hematopoietic transplants, namely T-cell deplete and T-cell replete, each of which is associated with unique benefits and drawbacks. The purpose of this paper is to facilitate individualized decision making for patients and providers by reviewing the pros- and cons of these differing approaches. Expert opinion: Individuals with sickle cell disease eligible for a hematopoietic cell transplant can be considered based on recent results. Comparable outcomes are seen with T-cell deplete and T-cell replete approaches. The choice depends largely on institutional preference.


title: Laparoendoscopic single-site surgery for partial nephrectomy without ischemia using a microwave tissue coagulator.

text: BACKGROUND Herein, we report our initial experience with laparoendoscopic single-site surgery for partial nephrectomy (LESSPN) using a microwave tissue coagulator (MTC). METHODS Two patients with small and exophytic renal tumors underwent LESSPN. A multichannel port was inserted into the peritoneal or retroperitoneal space through a 3-cm skin incision. After tumor exposure, the surgeon introduced a laparoscopic MTC instrument through a 5-mm port and the tumor margin was coagulated circumferentially. After coagulation, the tumor was resected without renal pedicle clamping. RESULTS These procedures were successfully performed without any conversions to standard laparoscopy or need for placement of additional trocars. The operative times were 183 and 160 minutes, respectively. The estimated blood loss was <150 mL in both cases. The final length of the LESS wound was 3 cm. Using the transumbilical approach, the operative scar receded into the umbilicus and was hardly visible. CONCLUSIONS This novel surgical technique is feasible and enables the bloodless resection of a renal tumor without renal pedicle clamping. Further clinical experience and longer follow-up are needed to define the benefits of this new technique.


COVID-19 in an elderly patient treated with secukinumab.


title: The Risk of Children Hospitalized With Severe COVID-19 in Wuhan.

text: BACKGROUND Novel coronavirus disease (COVID-19) is spreading globally. Little is known about the risk factors for the clinical outcomes of COVID-19 in children. METHODS A retrospective case-control study was taken in children with severe acute respiratory syndrome coronary virus-2 infection in Wuhan Children's Hospital. Risk factors associated with the development of COVID-19 and progression were collected and analyzed. RESULTS Eight out of 260 children diagnosed with severe COVID-19 pneumonia were included in the study. Thirty-five children with COVID-19 infection matched for age, sex and date of admission, and who classified as non-severe type, were randomly selected from the hospital admissions. For cases with severe pneumonia caused by COVID-19, the most common symptoms were dyspnea (87.5%), fever (62.5%) and cough (62.5%). In laboratory, white blood cells count was significantly higher in severe children than non-severe children. Levels of inflammation bio-makers such as hsCRP, IL-6, IL-10 and D-dimer elevated in severe children compared with non-severe children on admission. The level of total bilirubin and uric acid clearly elevated in severe children compared with non-severe children on admission. All of severe children displayed the lesions on chest CT, more lung segments were involved in severe children than in non-severe children, which was only risk factor associated with severe COVID-19 pneumonia in multivariable analysis. CONCLUSIONS More than 3 lung segments involved were associated with greater risk of development of severe COVID-19 in children. Moreover, the possible risk of the elevation of IL-6, high total bilirubin and D-dimer with univariable analysis could identify patients to be severe earlier.


title: [Model for a threshold of daily rate reduction of COVID-19 cases to avoid hospital collapse in Chile].

text: Using a mathematical model, we explore the problem of availability versus overdemand of critical hospital processes (e.g., critical beds) in the face of a steady epidemic expansion such as is occurring from the COVID-19 pandemic. In connection with the statistics of new cases per day, and the assumption of maximum quota, the dynamics associated with the variables number of hospitalized persons (critical occupants) and mortality in the system are explored. A parametric threshold condition is obtained, which involves a parameter associated with the minimum daily effort for not collapsing the system. To exemplify, we include some simulations for the case of Chile, based on a parameter of effort to be sustained with the purpose of lowering the daily infection rate.


title: The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study.

text: BACKGROUND CONTEXT Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery. PURPOSE The study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques. STUDY DESIGN/SETTING The study is set in a fresh tissue dissection laboratory. SAMPLE SIZE The sample includes eight fresh human cadavers. OUTCOME MEASURES A watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines. METHODS Fresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7-T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n=3) or 4-0 Nurolon (n=3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage. RESULTS Spinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (±2.9) mm Hg in the 6-0 Prolene group and at 43.3 (±14.4) mm Hg in the 4-0 Nurolon group (p>.05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0±4.5 mm Hg vs. 4-0 Nurolon: 32.5±2.7 mm Hg; p<.01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0±0.0 mm Hg vs. 4-0 Nurolon: 70.0±33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p=.01) and the 4-0 Nurolon group (p<.01) when compared with mean pressures without the hydrogel sealant. CONCLUSIONS We described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model.


title: Transanal Total Mesorectal Excision With Single-Incision Laparoscopy for Rectal Cancer.

text: BACKGROUND AND OBJECTIVES There has been great enthusiasm for the technique of transanal total mesorectal excision. Coupled with this procedure, we performed single-incision laparoscopic surgery for left colon mobilization. This is a description of our initial experience with the combined approach. METHODS Patients with distal or mid rectal cancer were included. The operation was performed by 2 teams: one team performed the single-incision mobilization of the left colon via the right lower quadrant ileostomy site, and the other team performed the total mesorectal excision with a transanal platform. RESULTS During the study period, 10 patients (5 men) with cancer of the rectum underwent the surgery. The mean age was 62.2 ± 11.1 years, and the mean body mass index was 23.4 ± 3.2 kg/m(2). The tumor's mean distance from the anal verge was 5.1 ± 2.5 cm. The median operating time was 247.5 minutes (range, 188-462 minutes). The mean estimated blood loss was 124 ± 126 mL (range, 10-188 mL). Conversion to multiport laparoscopy was needed in one case (10%). Postoperative pain, as reflected by the pain score, was minimal. The mean number of lymph nodes harvested was 15.6 ± 3.8. All specimens had clear distal and circumferential radial margins. The overall complication rate was 10%. CONCLUSION Our experience showed transanal total mesorectal excision with single-incision laparoscopy to be a feasible option for rectal cancer. Patients reported minimal postoperative pain. Further studies on the long-term outcome are warranted.


title: Compression anastomosis revisited: prospective audit of short- and medium-term outcomes in 62 rectal anastomoses.

text: BACKGROUND The ColonRing™ represents a further advancement in compression anastomosis by using superelastic materials. In contrast to other compression devices, its field of application is identical to circular staplers. Yet, limited data are available and there are no reports on the use of this compression device for anastomoses in the lower rectum and in diverted cases. METHODS Between November 2008 and March 2010 a nonrandomized prospective study of patients undergoing colorectal resection was done. RESULTS Sixty-two patients (30 female) with a median age of 67 years (range = 23-87) underwent surgery for benign (35) and malignant (27) indications;the surgery was performed laparoscopically in 53 (85.5%) cases. There were no leaks or other major complications related to the compression anastomosis. One patient died from sepsis caused by a leak of a colonic J-pouch. Three of 12 (25%) patients after (ultra-)low anterior resection experienced pain caused by the presence of the ring. Of 53 undiverted patients, rings were passed spontaneously in 52 (98.1%). No spontaneous passage occurred in patients with a stoma. Their rings were removed transanally prior to stoma closure. After a median of 6 months, endoscopic follow-up was performed in 60 patients (96.8%). Two anastomotic stenoses were detected (3.3%). CONCLUSION Construction of rectal anastomosis using this novel compression device is feasible and safe and appears to cause only few anastomotic strictures in the medium term. Discomfort or pain from the presence of the ring at anastomosis following (ultra-)low anterior resection can be observed in a relevant number of patients.


title: Coronavirus Disease-2019: Implication for the care and management of patients with systemic lupus erythematosus.

text: Systemic lupus erythematosus is a chronic remitting-relapsing autoimmune disease that affects multiple organ systems. In this article we discuss aspects in the management of lupus patients that are particularly relevant during the current SARS-CoV-2 pandemic. We speculate that lupus patients might be more susceptible for a more severe COVID-19 disease course and emphasize the importance of maintaining remission in lupus patients. We discuss the critical role hydroxychloroquine plays in the management of lupus patients and suggest considering the psychosocial implications of the current pandemic on lupus care.


Severe course of COVID-19 in a middle-aged man without risk factors.


title: Ultrasonographic, endoscopic and histological appearances of the caecum in cats presenting with chronic clinical signs of caecocolic disease.

text: Objectives This study aimed to describe the ultrasonographic, endoscopic and histological characteristics of the caecum and ileocaecocolic junction in cats suffering from chronic clinical signs compatible with caecocolic disease. Methods Cats presenting with clinical signs suggestive of a caecocolic disease were prospectively recruited. All cats underwent an ultrasonographic examination of the caecum, ileum, colon, ileocolic lymph nodes and local mesenteric fat, in addition to comprehensive abdominal ultrasonography. This was followed by a colonoscopy with a macroscopic assessment of the caecocolic mucosa; caecocolic tissue samples were systematically collected for histologic analysis. Results Eighteen cats were included. Eleven of 18 cats had ultrasonographic abnormalities adjacent to the ileocaecocolic junction (lymphadenopathy, local steatitis) and 13/18 cats had abnormalities directly related to the junction (wall thickening, loss of wall layering). Seventeen of 18 cats had at least one ultrasonographic abnormality. Endoscopically, hyperaemia, oedema, discoloration and/or erosions were found in all cats. Each cat was classified as having mild or moderate-to-severe lesions according to endoscopic results; no classification could be established statistically for ultrasonographic results. The accentuation of the dimpled pattern tended to be inversely related to the severity of endoscopic lesion scoring. Histologically, a large proportion of cats showed typhlitis (13/16), one had lymphoma and two were normal. All cats with typhlitis also had colitis. There was only slight agreement between endoscopic and histological caecal results regarding the severity of lesions. Loss of caecal wall layering on ultrasound was found in 7/18 cats and, surprisingly, did not appear as a reliable predictor of the severity of inflammation or of malignancy; neither did local steatitis nor lymph node size. Conclusions and relevance Ultrasonography and endoscopy should not be used as the sole methods to investigate the ileocaecocolic region in cats with clinical signs suggestive of caecocolic disease. The presence of chronic clinical signs should routinely prompt histological biopsy.


title: Comparison of short-term outcomes between transvaginal hybrid NOTES cholecystectomy and laparoscopic cholecystectomy.

text: INTRODUCTION A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC). METHODS Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18 years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.). RESULTS Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68 min; p < 0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8 mg morphine equivalents; p = 0.02). Visual Analog Scale pain scores (scale 0-10) were less in the TVC group at 30 min (1 vs. 5; p = 0.02) and 60 min (2 vs. 5; p = 0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p = 0.01). SF-36 scores were similar at 1 and 3 months postoperatively. CONCLUSIONS This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.


title: Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome.

text: INTRODUCTION Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique. PRESENTATION OF CASE A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal. DISCUSSION There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients. CONCLUSION J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.


title: Bare metal stents for treatment of extracranial internal carotid artery aneurysms: long-term results.

text: PURPOSE To examine the long-term outcomes of bare metal stent placement for exclusion of extracranial internal carotid artery (ICA) aneurysms. METHODS From 2006 to 2011, 7 consecutive symptomatic patients (4 men; mean age 52 years) with surgically inaccessible extracranial ICA aneurysms were treated with a bare stent at a single center. Patients received clopidogrel for 3 months after the procedure and aspirin for life. Clinical follow-up with duplex ultrasound and/or computed tomographic angiography was performed at 3, 6, and 12 months and yearly thereafter. RESULTS All procedures were technically successful; no neurological complications occurred. After 6 months, there was complete thrombosis of the aneurysm in all except one case. In this asymptomatic patient, the residual active flow was successfully obliterated by additional coil embolization. Over a mean follow-up of 57 ± 22 months, all patients were alive and free of local or central neurological symptoms. All stents were patent, and thrombosis of the aneurysms was complete. CONCLUSION In this small series, treatment of extracranial ICA aneurysms with a bare stent seems technically feasible and safe. All treated extracranial ICA aneurysms were excluded by primary intervention or secondary coil embolization.


title: WITHDRAWN: Prevalence and correlates of depression among elderly people living in rural communities in Southwestern Nigeria.

text: This article has been withdrawn at the request of the author. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.


COVID-19 From a Psychiatry Perspective: Meeting the Challenges.


title: Greater omentum folding in the open surgical placement of peritoneal dialysis catheters: a randomized controlled study and systemic review.

text: BACKGROUND Mechanical catheter dysfunction caused by omentum entrapment remains a major complication of peritoneal dialysis (PD) therapy. The purpose of this study was to determine the outcomes of omentum folding at the time of primary open catheter insertion. METHODS From March 2008 to December 2012, a total of 67 PD subjects were enrolled in the study and randomly assigned to receive either regular open insertion (ROI group, n = 33) or open insertion with omentum folding (OIOF group, n = 34). The primary outcome was defined as PD catheter tip migration with dysfunction. A systematic review was performed to analyze the outcomes of omentum management in PD catheter implantation, based on published data from 1990 to 2013. RESULTS There was no statistical difference in baseline patient characteristics between the ROI and OIOF groups. Nine (27.3%) patients in the ROI group presented with catheter malposition in the late stage (>60 days) of the study, significantly more than in the OIOF group (two; 5.9%) (P = 0.049). Significant differences in catheter survival rate between the two groups were observed in the late stage (P = 0.030) and over the entire study period (P = 0.028). A higher incidence of irreversible catheter dysfunction was shown in the ROI group (15.2%), whereas none occurred in the OIOF group (P = 0.031). No statistical difference was determined in other catheter-related complications or patient survival rate. There were no statistical differences in peritoneal transport characteristics or dialysis adequacy between the two groups upon evaluation at 3, 6 and 12 months. Systemic review of current publications suggested that PD catheter placement with omentum management could lead to less irreversible catheter dysfunction and improved outcome of catheter survival. CONCLUSIONS Our data suggest that omentum folding at the initial time of open catheter placement can significantly reduce the risk of catheter tip migration with dysfunction and improve the outcome of the PD technique.


COVID-19 and telehealth: a window of opportunity and its challenges.


title: Targeting the translation machinery in cancer.

text: Dysregulation of mRNA translation is a frequent feature of neoplasia. Many oncogenes and tumour suppressors affect the translation machinery, making aberrant translation a widespread characteristic of tumour cells, independent of the genetic make-up of the cancer. Therefore, therapeutic agents that target components of the protein synthesis apparatus hold promise as novel anticancer drugs that can overcome intra-tumour heterogeneity. In this Review, we discuss the role of translation in cancer, with a particular focus on the eIF4F (eukaryotic translation initiation factor 4F) complex, and provide an overview of recent efforts aiming to 'translate' these results to the clinic.


title: Successful treatment of gestational trophoblastic neoplasia in the uterine cornus with laparoscopic cornuostomy and postoperative methotrexate injection.

text: OBJECTIVE Management of cornual gestational trophoblastic neoplasia (GTN) has never been reported. Here, we describe the first case of cornual GTN. CASE REPORT A 32-year-old woman was diagnosed with left cornual GTN after evacuation of a complete mole. Laparoscopic cornuostomy was performed with intramural vasopression injection and barbed sutures. Histopathology revealed hydropic chorionic villi. Complete hydatidiform mole was diagnosed, and treated with adjuvant methotrexate, to address the poor decline of β-human chorionic gonadotropin levels during follow-up. The β- human chorionic gonadotropin levels declined to < 1 mIU/mL 9 months after cornuostomy. She successfully conceived 16 months after cornuostomy, and underwent cesarean section at 37 gestational weeks due to concomitant severe preeclampsia. CONCLUSION Cornual GTN can be successfully managed with laparoscopic cornuostomy and adjuvant methotrexate.


title: Single-port access (SPA) laparoscopic surgery in gynecology: a surgeon's experience with an initial 200 cases.

text: OBJECTIVE To report our initial two hundred single-port access (SPA) gynecologic surgeries and present the perioperative outcomes. STUDY DESIGN This is a prospective single-center study (Canadian Task Force classification II-2). Two hundred selected patients with gynecological disease were recruited for the study from May 2008 through December 2009 at Samsung Medical Center. RESULTS Two hundred patients underwent SPA gynecological surgery (105 a total hysterectomy; 11 a subtotal hysterectomy; 43 an oophorectomy; 31 an ovarian cystectomy; 5 a salpingectomy; 2 a myomectomy; 3 adhesiolysis only). The median age and body mass index were 45.5 and 22.9 kg/m(2), respectively. SPA surgery was successfully completed in 187 patients, without the need for ancillary ports (93.5%). Two cases required a conventional multiport, and nine cases needed one additional port. Two patients were converted to a laparotomy. One intra- and five post-operative complications occurred. The complication rate was 3.2% (6/187). The median operative time was 120 min (54-250) for a total hysterectomy, 180 (150-345) for a subtotal hysterectomy, 60 (27-245) for an oophorectomy, 105 (50-185) for a cystectomy, and 60 (30-115) for a salpingectomy. CONCLUSION Single-port surgery was safe and feasible for gynecological indications. Further study of single-port surgery is required to determine whether it has significant benefits compared to conventional techniques.


title: Reduction of postoperative pain after lumbar microdiscectomy with DuraSeal Xact Adhesion Barrier and Sealant System.

text: BACKGROUND CONTEXT An excessive amount of scar tissue after lumbar microdiscectomy may increase postoperative pain. Several fibrosis inhibitors have been used in the past in an endeavor for better functional outcome. PURPOSE The goal of this study was to evaluate DuraSeal Xact Adhesion Barrier and Sealant System (DSX), a polyethylene glycol-based synthetic fibrosis inhibitor, for its ability to reduce postoperative pain after lumbar microdiscectomy. STUDY DESIGN This is a prospective randomized controlled study. PATIENT SAMPLE Twenty patients between 19 and 71 years of age about to undergo elective lumbar single-level discectomy were randomized into two groups of 10. OUTCOME MEASURES Assessments included the visual analog scale (VAS) pain score, the short form (SF)-36 questionnaire, and the Oswestry low back pain scale, preoperatively and at discharge, and 30, 90, and 180 days after surgery. METHODS One group was treated with DSX, and the control group received the local standard of care. DSX was applied as a thin layer on the nerve root and surrounding area after microdiscectomy. RESULTS The VAS pain scale was lower at all time points in the DSX treatment group than in the control group. The reductions at 30, 90, and 180 days for DSX and control groups, respectively, were 43.9% versus 35.6%, 64.3% versus 44.8%, and 75.4% versus 59.6%. The SF-36 scores in the DSX treatment group showed more improvement than in the control group as soon as 30 days for physical functioning, general health, vitality, social functioning, mental health, and emotional patterns, and by 90 days for bodily pain and general health. The Oswestry pain score was lower at all time points in the DSX treatment group than in the control group. The reductions at 30, 90, and 180 days for DSX and control groups, respectively, were 41.5% versus 34.3%, 68.2% versus 42.4%, and 73.3% versus 55.4%. Wound healing was normal in the DSX treatment group, there were no complications related to DSX use, and no patient in either group required reoperation. CONCLUSIONS Although this study is too small to have conclusions of efficacy and will need confirmation by larger trials, treatment of a microdiscectomy site with DSX for fibrosis prevention shows promising results in terms of safety, reduction of postoperative pain and functional results when compared to control with the additional advantage of being suitable for use in the presence of a dural tear.


Pernicious anaemia: switch to oral B12 supplementation to reduce risk of covid-19 transmission.


title: Prevalence of pre-stroke depression and its association with post-stroke depression: a systematic review and meta-analysis.

text: BACKGROUND Depression is a common post-stroke complication. Pre-stroke depression may be an important contributor, however the epidemiology of pre-stroke depression is poorly understood. Using systematic review and meta-analysis, we described the prevalence of pre-stroke depression and its association with post-stroke depression. METHODS We searched multiple cross-disciplinary databases from inception to July 2017 and extracted data on the prevalence of pre-stroke depression and its association with post-stroke depression. We assessed the risk of bias (RoB) using validated tools. We described summary estimates of prevalence and summary odds ratio (OR) for association with post-stroke depression, using random-effects models. We performed subgroup analysis describing the effect of depression assessment method. We used a funnel plot to describe potential publication bias. The strength of evidence presented in this review was summarised via 'GRADE'. RESULTS Of 11 884 studies identified, 29 were included (total participants n = 164 993). Pre-stroke depression pooled prevalence was 11.6% [95% confidence interval (CI) 9.2-14.7]; range: 0.4-24% (I2 95.8). Prevalence of pre-stroke depression varied by assessment method (p = 0.02) with clinical interview suggesting greater pre-stroke depression prevalence (~17%) than case-note review (9%) or self-report (11%). Pre-stroke depression was associated with increased odds of post-stroke depression; summary OR 3.0 (95% CI 2.3-4.0). All studies were judged to be at RoB: 59% of included studies had an uncertain RoB in stroke assessment; 83% had high or uncertain RoB for pre-stroke depression assessment. Funnel plot indicated no risk of publication bias. The strength of evidence based on GRADE was 'very low'. CONCLUSIONS One in six stroke patients have had pre-stroke depression. Reported rates may be routinely underestimated due to limitations around assessment. Pre-stroke depression significantly increases odds of post-stroke depression.Protocol identifierPROSPERO identifier: CRD42017065544.


title: Dermatopathic lymphadenitis associated with human papilloma virus infection and verruca vulgaris.

text: Here we present a pediatric case of human papilloma virus associated with dermatopathic lymphadenitis (DL). A 5-year-old boy presented to the pediatric oncology clinic with swelling of the neck and warts on his lower jaw. His blood chemistry and complete blood count were normal, as was chest x-ray. HIV, EBV, CMV, and parvovirus serologies were negative. The patient was investigated for malignancy and lymphoma but no association was found. Histopathologic examination of the lymph node and the lesion revealed DL and verruca vulgaris, respectively. DL represents a benign form of reactive lymph node hyperplasia and described in patients with HIV and EBV infections. It is a rare entity described in patients with human papilloma virus infection. To our knowledge, this is the first report of DL in a patient with human papilloma virus infection.


title: The Syrian conflict and infectious diseases.

text: The conflict in Syria is a big humanitarian emergency. More than 200,000 Syrians have been killed, with more than half of the population either having been displaced or having immigrated. Healthcare has been interrupted due to the destruction of facilities, a lack of medical staff, and a critical shortage of life-saving medications. It produced suitable conditions leading to the re-emergence of tuberculosis, cutaneous leishmaniasis, polio, and measles. Lebanon and Jordan reported increased rates of tuberculosis among Syrian refugees. Cutaneous leishmaniasis outbreaks were noted not only in Syria but also in Turkey, Jordan, and Lebanon. After a polio-free 15 years, Syria reported a polio outbreak. Ongoing measles outbreaks in the region was accelerated by the conflict. Iraq declared a cholera outbreak among the Syrian refugees. The healthcare facilities of the countries hosting immigrants, mainly Turkey, Lebanon, Jordan, Iraq, and Egypt, are overburdened. The majority of the immigrants live in crowded and unsanitary conditions. Infectious diseases are big challenges for Syria and for the countries hosting immigrants. More structured support from international organizations is needed for the prevention, control, diagnosis, and treatment of infectious diseases.


title: One does not fit all: new adjuvants are needed and vaccine formulation is critical.

text: In recent years, adjuvant research has moved from empirical trial and error to a more rational approach engaging the multidisciplinary fields of immunology, biochemistry, pharmacy and physical chemistry. At the Modern Vaccines/Adjuvants Formulation meeting held in Cannes, France in October 2010, scientists from this broad field met to discuss recent progress in adjuvant research and development. The focus of the meeting was on formulation and as a result clinically and pharmaceutically relevant aspects of how to design and optimize vaccines and adjuvants were also addressed.


title: Meta-analysis of randomized trials comparing the effectiveness of different strategies for the treatment of drug-eluting stent restenosis.

text: The investigators performed a network meta-analysis of randomized trials comparing the effectiveness of currently available strategies for the treatment of drug-eluting stent (DES) restenosis. Despite the widespread use of DES in patients who undergo percutaneous coronary intervention, the optimal treatment for DES restenosis remains poorly defined. A systematic search of electronic resources was performed. The primary end point was diameter stenosis at follow-up angiography. Seven trials were included, enrolling a total of 1,586 patients with 1,728 restenotic lesions. The following treatment options were found: balloon angioplasty (BA) in 343 patients (19.3%), iopromide-based paclitaxel-eluting balloons (PEB) in 343 (21.6%), sirolimus-eluting stents in 441 (27.8%), paclitaxel-eluting stents in 462 (29.1%), and everolimus-eluting stents in 34 (2.2%). Compared with BA, PEB (-17.74%, 95% credible interval [CI] -25.17% to -11.31%), everolimus-eluting stents (-14.93%, 95% CI -33.47% to 1.16%), paclitaxel-eluting stents (-15.3%, 95% CI -22.96% to -8.35%), and sirolimus-eluting stents (-11.08%, 95% CI -17.89% to -3.4%) had similar reductions in diameter stenosis at follow-up angiography. PEB (85%) and everolimus-eluting stents (68%) had the greatest probabilities for being the best treatment option. Furthermore, PEB were the best treatment in terms of late luminal loss (85%) and binary restenosis (85%). BA had the lowest efficacy with respect to all study end points. In conclusion, in patients with DES restenosis, repeat DES implantation and iopromide-based PEB are valid alternatives. However, PEB had greater angiographic efficacy and therefore should be considered the new benchmark comparator in the treatment of DES restenosis. The use of BA should be discouraged in patients with DES restenosis.


title: Rapid detection of ermB gene in Clostridium difficile by loop-mediated isothermal amplification.

text: Macrolide-lincosamide-streptogramin B resistance in Clostridium difficile is mostly due to the ermB resistance determinant. Here, we describe a sensitive and rapid molecular method to detect ermB in C. difficile to contribute to the wider epidemiological study. Five sets of loop-mediated isothermal amplification (LAMP) primers were designed and optimized for rapid detection of ermB. The specificity and sensitivity of the primers for ermB were detected, and the ermB LAMP assay was compared to conventional PCR with 80 clinical isolates of C. difficile. Real-time monitoring of turbidity and chromogenic reaction were used to determine negative and positive results. A total of 26 pathogenic bacterial strains of different species were found to be negative for ermB, which indicated the high specificity of the primers. ermB was detected in 78.8 % (63/80) of the clinical isolates by both LAMP and conventional PCR. The detection limit of LAMP was 36.1 pg DNA μl- 1 and its sensitivity was 10-fold greater than that of conventional PCR. This study is the first report regarding the development and application of the LAMP assay for detection of the ermB gene in C. difficile strains. The developed LAMP method is sensitive, specific and provides a user-friendly visual approach for the rapid detection of ermB-bearing C. difficile.


title: Fluorescence-enhanced europium-diethylenetriaminepentaacetic (DTPA)-monoamide complexes for the assessment of renal function.

text: Real-time, noninvasive assessment of glomerular filtration rate (GFR) is essential not only for monitoring critically ill patients at the bedside, but also for staging and monitoring patients with chronic kidney disease. In our pursuit to develop exogenous luminescent probes for dynamic optical monitoring of GFR, we have prepared and evaluated Eu(3+) complexes of several diethylenetriamine pentaacetate (DTPA)-monoamide ligands bearing molecular "antennae" to enhance metal fluorescence via intramolecular ligand-metal fluorescence resonance energy transfer process. The results show that Eu-DTPA-monoamide complex 18b, which contains a quinoxanlinyl antenna, exhibits large (ca. 2700-fold) Eu(3+) fluorescence enhancement. Indeed, complex 18b exhibits the highest fluorescent enhancement observed thus far in the DTPA-type metal complexes. The renal clearance property was assessed using the corresponding radioactive (111)In complex 18a, and the data suggest that this complex clears via a complex mechanism that includes glomerular filtration.


title: Haemodynamic changes with the use of neuromuscular electrical stimulation compared to intermittent pneumatic compression.

text: INTRODUCTION Enhancement of peripheral circulation has been shown to be of benefit in many vascular disorders, and the clinical effectiveness of intermittent pneumatic compression is well established in peripheral vascular disease. This study compares the haemodynamic efficacy of a novel neuromuscular electrical stimulation device with intermittent pneumatic compression in healthy subjects. METHODS Ten healthy volunteers (mean age 27.1 ± 3.8 years, body mass index 24.8 ± 3.6 kg/m(2)) were randomised into two groups, in an interventional crossover trial. Devices used were the SCD Express™ Compression System, (Covidien, Ireland) and the geko™, (Firstkind Ltd, UK). Devices were applied bilaterally, and haemodynamic measurements taken from the left leg. Changes to haemodynamic parameters (superficial femory artery and femoral vein) and laser Doppler measurements from the hand and foot were compared. RESULTS Intermittent pneumatic compression caused 51% (p = 0.002), 5% (ns) and 3% (ns) median increases in venous peak velocity, time-averaged maximum velocity and volume flow, respectively; neuromuscular electrical stimulator stimulation caused a 103%, 101% and 101% median increases in the same parameters (all p = 0.002). The benefit was lost upon deactivation. Intermittent pneumatic compression did not improve arterial haemodynamics. Neuromuscular electrical stimulator caused 11%, 84% and 75% increase in arterial parameters (p < 0.01). Laser Doppler readings taken from the leg were increased by neuromuscular electrical stimulator (p < 0.001), dropping after deactivation. For intermittent pneumatic compression, the readings decreased during use but increased after cessation. Hand flux signal dropped during activation of both devices, rising after cessation. DISCUSSION The neuromuscular electrical stimulator device used in this study enhances venous flow and peak velocity in the legs of healthy subjects and is equal or superior to intermittent pneumatic compression. This warrants further clinical and economic evaluation for deep venous thrombosis prophylaxis and exploration of the haemodynamic effect in venous pathology. It also enhances arterial time-averaged maximum velocity and flow rate, which may prove to be of clinical use in the management of peripheral arterial disease. The effect on the microcirculation as evidenced by laser Doppler fluximetry may reflect a clinically beneficial target in microvascular disease, such as in the diabetic foot.


title: A novel technique for tumor localization and targeted lymphatic mapping in early-stage lung cancer.

text: OBJECTIVE To investigate safety and feasibility of navigational bronchoscopy (NB)-guided near-infrared (NIR) localization of small, ill-defined lung lesions and sentinel lymph nodes (SLN) for accurate staging in patients with non-small cell lung cancer (NSCLC). METHODS Patients with known or suspected stage I NSCLC were enrolled in a prospective pilot trial for lesion localization and SLN mapping via NB-guided NIR marking. Successful localization, SLN detection rates, histopathologic status of SLN versus overall nodes, and concordance to initial clinical stage were measured. Ex vivo confirmation of NIR+ SLNs and adverse events were recorded. RESULTS Twelve patients underwent NB-guided marking with indocyanine green of lung lesions ranging in size from 0.4 to 2.2 cm and located 0.1 to 3 cm from the pleural surface. An NIR+ "tattoo" was identified in all cases. Ten patients were diagnosed with NSCLC and 9 SLNs were identified in 8 of the 10 patients, resulting in an 80% SLN detection rate. SLN pathologic status was 100% sensitive and specific for overall nodal status with no false-negative results. Despite previous nodal sampling, one patient was found to have metastatic disease in the SLN alone, a 12.5% rate of disease upstaging with NIR SLN mapping. SLN were detectable for up to 3 hours, allowing time for obtaining a tissue diagnosis and surgical resection. There were no adverse events associated with NB-labeling or indocyanine green dye itself. CONCLUSIONS NB-guided NIR lesion localization and SLN identification was safe and feasible. This minimally invasive image-guided technique may permit the accurate localization and nodal staging of early stage lung cancers.


title: Noninvasive ventilation for patients with acute lung injury or acute respiratory distress syndrome.

text: Few studies have been performed on noninvasive ventilation (NIV) to treat hypoxic acute respiratory failure in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The outcomes of these patients, for whom endotracheal intubation is not mandatory, depend on the degree of hypoxia, the presence of comorbidities and complications, and their illness severity. The use of NIV as an alternative to invasive ventilation in severely hypoxemic patients with ARDS (ie, P(aO(2))/F(IO(2)) < 200) is not generally advisable and should be limited to hemodynamically stable patients who can be closely monitored in an intensive care unit by highly skilled staff. Early NIV application may be extremely helpful in immunocompromised patients with pulmonary infiltrates, in whom intubation dramatically increases the risk of infection, pneumonia, and death. The use of NIV in patients with severe acute respiratory syndrome and other airborne diseases has generated debate, despite encouraging clinical results, mainly because of safety issues. Overall, the high rate of NIV failure suggests a cautious approach to NIV use in patients with ALI/ARDS, including early initiation, intensive monitoring, and prompt intubation if signs of NIV failure emerge.


title: Evaluation of airway management associated hands-off time during cardiopulmonary resuscitation: a randomised manikin follow-up study.

text: INTRODUCTION Airway management is an important component of cardiopulmonary resuscitation (CPR). Recent guidelines recommend keeping any interruptions of chest compressions as short as possible and not lasting more than 10 seconds. Endotracheal intubation seems to be the ideal method for establishing a secure airway by experienced providers, but emergency medical technicians (EMT) often lack training and practice. For the EMTs supraglottic devices might serve as alternatives. METHODS 40 EMTs were trained in a 1-hour standardised audio-visual lesson to handle six different airway devices including endotracheal intubation, Combitube, EasyTube, I-Gel, Laryngeal Mask Airway and Laryngeal tube. EMTs performances were evaluated immediately after a brief practical demonstration, as well as after 1 and 3 months without any practice in between, in a randomised order. Hands-off time was pair-wise compared between airway devices using a repeated-measures mixed-effects model. RESULTS Overall mean hands-off time was significantly (p<0.01) lower for Laryngeal tube (6.1s; confidence interval 5.2-6.9s), Combitube (7.9s; 95% CI 6.9-9.0s), EasyTube (8.8s; CI 7.3-10.3s), LMA (10.2s; CI 8.6-11.7s), and I-Gel (11.9s; CI 10.2-13.7s) compared to endotracheal intubation (39.4s; CI 34.0-44.9s). Hands-off time was within the recommended limit of 10s for Combitube, EasyTube and Laryngeal tube after 1 month and for all supraglottic devices after 3 months without any training, but far beyond recommended limits in all three evaluations for endotracheal intubation. CONCLUSION Using supraglottic airway devices, EMTs achieved a hands-off time within the recommended time limit of 10s, even after three months without any training or practice. Supraglottic airway devices are recommended tools for EMTs with lack of experience in advanced airway management.


title: Emerging infectious disease risk: shared drivers with environmental change.

text: Outbreaks of emerging infectious diseases (EIDs) seemingly appear without warning, severely exacerbating public and animal health burdens and spreading across borders. Since 1940, the rate of infectious disease emergence events has risen. Given the considerable economic and other societal costs associated with EIDs, understanding the specific drivers of these diseases and developing concrete measures to prevent and mitigate their spread is urgently needed in both health security and sustainable development discussions. Human modification of the environment serves as an underlying driver in EID risk: environmental change thus warrants consideration in surveillance and outbreak investigations to identify the origin of the disease and contribute to the development of effective actions to prevent, prepare for or reduce the risk of future events. Coordinated approaches to address the underlying and, in some cases, overlapping causes of both disease emergence and global environmental change may yield benefits for sustainable and healthy solutions to meet or reshape the demands of a growing global population and contribute to global health security.


title: Initial Experience with p64: A Novel Mechanically Detachable Flow Diverter for the Treatment of Intracranial Saccular Sidewall Aneurysms.

text: BACKGROUND AND PURPOSE Flow diverters are important tools for the treatment of intracranial aneurysms. We report a retrospective evaluation of the safety and efficacy of p64, a fully resheathable, detachable flow diverter, in the endovascular treatment of intracranial sidewall aneurysms. MATERIALS AND METHODS Results of 121 patients with 130 aneurysms (median neck size, 3 mm; median fundus size, 4 mm), treated from April 2012 through October 2014, were analyzed. Aneurysms were unruptured or beyond the acute SAH phase. Thirteen aneurysms were located in the posterior circulation. Twenty-three aneurysms had previous saccular treatment but no previous parent vessel stent placement. In 19 aneurysms, a combination of coiling and flow diversion was performed. RESULTS Successful p64 deployment was achieved in 127/130 aneurysms. The average number of p64s used was 1.1 per aneurysm. The rates of transient and permanent morbidity and mortality were 5%, 1.7%, and 0.8%, respectively. Three-month DSA follow-up in 123/130 aneurysms showed complete occlusion in 58.5%. Nine-month DSA follow-up in 93/106 (87.7%) eligible aneurysms showed complete occlusion in 79.6%. Late follow-up (median, 496 days) has already been performed in 35 aneurysms, showing complete occlusion in 30 (85.7%). CONCLUSIONS p64 offers an efficacious treatment option for intracranial sidewall aneurysms with a high aneurysm occlusion and an acceptable complication rate. The possibility of repositioning or removing the device was an advantage. The higher attenuation may lead to fewer devices per case and early aneurysm occlusion. Long-term follow-up data are pending.


title: The use of prosthetic mesh for abdominal wall repairs: A semi-systematic-literature review.

text: Following abdominal wall surgery, incisions are commonly sutured, stapled, or glued together by primary intention. Developments within the field of tissue engineering have led to the use of prosthetic meshes, with over 20 million meshes implanted each year worldwide. The function of the mesh is to hold together abdominal wall incisions and repair abdominal hernias. This has been demonstrated to be highly effective in some individuals; however, some patients have experienced postoperative complications, including dehiscence with further abdominal herniation (viscera protruding through the abdominal wall). Little is currently known about why these complications occur in a subset of patients who have had prosthetic mesh implants in abdominal wall repairs; therefore, this literature review examined existing studies identified via six electronic databases. A total of 463 studies were identified, of which 13 were included in this review. The results identified that the prosthetic mesh is highly successful in a large proportion of patients who have had a had a hernia repair in a range of locations; however, the prosthetic mesh has long-term complications, with rejection being observed in a subset of patients. The reason why the prosthetic is being rejected is still largely unknown, and therefore, further investigation needs to be carried out.


title: Communicable diseases in the South-East Asia Region of the World Health Organization: towards a more effective response.

text: This article looks at the current burden of communicable diseases in the South-East Asia Region of the World Health Organization and analyses whether the current levels and trends in funding are adequate to meet the needs of control, prevention and treatment. Our analysis considers the Millennium Development Goals (MDGs) for health and indicators of economic progress in each country, as well as the impact of the global financial crisis on progress towards MDGs for communicable diseases in the region. The analysis indicates that the current focus of funding may need to be expanded to include less-discussed but high-burden diseases often related to inadequacies in the health sector and the particular development paths that countries pursue. Scarce funding during times of global economic recession could be used more effectively if informed by a careful analysis of the complex set of factors, including behavioural, environmental and health systems factors, that determine the burden of communicable diseases. Significant gaps in funding as well as varying regional needs warrant a more diverse set of national and international aid measures. Although regional and global collaboration is critical, the effectiveness of future policies to deal with the burden of communicable diseases in the region will only be assured if these policies are based on evidence and developed by policy-makers familiar with each country's needs and priorities.


title: Dose-response and transmission: the nexus between reservoir hosts, environment and recipient hosts.

text: Dose is the nexus between exposure and all upstream processes that determine pathogen pressure, and is thereby an important element underlying disease dynamics. Understanding the relationship between dose and disease is particularly important in the context of spillover, where nonlinearities in the dose-response could determine the likelihood of transmission. There is a need to explore dose-response models for directly transmitted and zoonotic pathogens, and how these interactions integrate within-host factors to consider, for example, heterogeneity in host susceptibility and dose-dependent antagonism. Here, we review the dose-response literature and discuss the unique role dose-response models have to play in understanding and predicting spillover events. We present a re-analysis of dose-response experiments for two important zoonotic pathogens (Middle East respiratory syndrome coronavirus and Nipah virus), to exemplify potential difficulties in differentiating between appropriate models with small exposure experiment datasets. We also discuss the data requirements needed for robust selection between dose-response models. We then suggest how these processes could be modelled to gain more realistic predictions of zoonotic transmission outcomes and highlight the exciting opportunities that could arise with increased collaboration between the virology and epidemiology disciplines. This article is part of the theme issue 'Dynamic and integrative approaches to understanding pathogen spillover'.


Response to: 'Antimalarial use and arrhythmias in COVID-19 and rheumatic patients: a matter of dose and inflammation?' by Erre et al.


title: Thoracic cancer surgery during the COVID-19 pandemic: A consensus statement from the Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery.

text: OBJECTIVES Healthcare resources have been mobilized to combat the COVID-19 pandemic of 2020. The Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery reports a consensus statement on the provision of thoracic cancer surgery during this pandemic. METHODS A Thoracic Experts Panel was convened by the Society. A consensus on the provision, safety, and setting of thoracic cancer surgery during the pandemic was obtained through a Delphi process. RESULTS Responses were received from 26 panel members (96% response rate) from 10 regions across Asia. The Society recommended that elective thoracic cancer surgery services may need to be reduced or postponed if medical resources were needed for COVID-19 patients, especially intensive care unit beds and ventilators. However, thoracic cancer surgery should proceed as normal for all solid tumors, without restrictions based on disease stage, availability of non-surgical treatment options, or patient condition (unless there is a high likelihood of postoperative intensive care unit stay). Aerosol-forming procedures should be avoided intra- and perioperatively. The surgical approach does not make a difference in terms of safety. Services for thoracic cancer patients should be offered only in hospitals that maintain isolation wards for patients with confirmed or suspected COVID-19. CONCLUSIONS Services for patients with thoracic cancer should be maintained during the COVID-19 pandemic. The position of the Society is that thoracic surgeons have a responsibility to perform good surgical management of thoracic cancer during the pandemic, to advocate for patients' rights to receive it, and to safeguard patients and staff from infection.


title: Incursions of Candida auris into Australia, 2018.

text: Candida auris is an emerging global healthcare-associated pathogen. During July-December 2018, four patients with C. auris were identified in Victoria, Australia, all with previous overseas hospitalization. Phylogenetic analysis revealed putative transmission between 2 patients and suspected overseas acquisition in the others. Vigilant screening of at-risk patients is required.


title: Evaluation of a multi-epitope subunit vaccine against avian leukosis virus subgroup J in chickens.

text: The intricate sequence and antigenic variability of avian leukosis virus subgroup J (ALV-J) have led to unprecedented difficulties in the development of vaccines. Much experimental evidence demonstrates that ALV-J mutants have caused immune evasion and pose a challenge for traditional efforts to develop effective vaccines. To investigate the potential of a multi-epitope vaccination strategy to prevent chickens against ALV-J infections, a recombinant chimeric multi-epitope protein X (rCMEPX) containing both immunodominant B and T epitope concentrated domains selected from the major structural protein of ALV-J using bioinformatics approach was expressed in Escherichia coli Rosetta (DE3). Its immunogenicity and protective efficacy was studied in chickens. The results showed that rCMEPX could elicit neutralizing antibodies and cellular responses, and antibodies induced by rCMEPX could specifically recognize host cell naturally expressed ALV-J proteins, which indicated that the rCMEPX is a good immunogen. Challenge experiments showed 80% chickens that received rCMEPX were well protected against ALV-J challenge. This is the first report of a chimeric multi-epitope protein as a potential immunogen against ALV-J.


title: Fighting Liver Fibrosis with Naturally Occurring Antioxidants.

text: Liver fibrosis is a wound-healing response characterized by the accumulation of extracellular matrix following various liver injuries, which results in the deformation of the normal liver architecture and the development of liver cirrhosis and even hepatocellular carcinoma. Numerous in vitro and in vivo studies indicated that oxidative stress mediates the initiation and progression of liver fibrosis. Overaccumulation of reactive oxygen species disrupts macromolecules, induces necrosis and apoptosis of hepatocytes, stimulates the production of pro-fibrogenic mediators, and directly activates hepatic stellate cells, thereby resulting in liver damage and initiating liver fibrosis. Ameliorating oxidative stress is a potential therapeutic strategy for the treatment of liver fibrosis. Natural antioxidants have attracted increasing attention in treating liver fibrosis due to their safety and efficacy. In this review, the pathogenesis of liver fibrosis and the role of oxidative stress in liver fibrosis were discussed. Naturally occurring antioxidants that can treat and prevent liver fibrosis were summarized. Advances in clinical trials were also presented. The main purpose of this review is to provide a comprehensive and up-to-date knowledge from the biological importance of oxidative stress in liver fibrosis to representative antioxidants for treating liver fibrosis. Naturally occurring antioxidants show a potential for further investigations as lead compounds in fighting liver fibrosis.


title: Synthesis and biological evaluation of tylophorine-derived dibenzoquinolines as orally active agents: exploration of the role of tylophorine e ring on biological activity.

text: A series of novel tylophorine-derived dibenzoquinolines has been synthesized and their biological activity evaluated. Three assays were conducted: inhibition of cancer cell proliferation, inhibition of TGEV replication for anticoronavirus activity, and suppression of nitric oxide production in RAW264.7 cells (a measure of anti-inflammation). The most potent compound from these assays, dibenzoquinoline 33b, showed improved solubility compared to tylophorine 9a, in vivo efficacies in a lung A549 xenografted tumor mouse model and a murine paw edema model, good bioavailability, and no significant neurotoxicity (as tested by a rota-rod test for motor coordination). This is the first study to explore in detail the role of the tylophorine E ring on biological activity and very strongly suggests that tylophorine-derived dibenzoquinolines merit further development into orally active agents.


title: Clinical evaluation of the role of ceftaroline in the management of community acquired bacterial pneumonia.

text: Ceftaroline fosamil (ceftaroline) was recently approved for the treatment of community- acquired pneumonia (CAP) and complicated skin infections. This newly developed cephalosporin possesses a broad spectrum of activity against gram-positive and gram-negative bacteria. Most importantly, ceftaroline demonstrates potent in vitro antimicrobial activity against multi-drug resistant Streptococcus pneumoniae and methicillin-resistant strains of Staphylococcus aureus. In two Phase III, double-blinded, randomized, prospective trials (FOCUS 1 and FOCUS 2), ceftaroline was shown to be non-inferior to ceftriaxone for the treatment of CAP in hospitalized patients. Ceftaroline exhibits low resistance rates and a safety profile similar to that of other cephalosporins. In this review, we will evaluate the pharmacological characteristics, safety, antimicrobial properties, and efficacy of ceftaroline and its applications in the treatment of CAP.


title: Slow versus fast rewarming after hypothermic circulatory arrest: effects on neuroinflammation and cerebral oedema.

text: OBJECTIVES Among the factors that could determine neurological outcome after hypothermic circulatory arrest (HCA) rewarming is rarely considered. The optimal rewarming rate is still unknown. The goal of this study was to investigate the effects of 2 different protocols for rewarming after HCA on neurological outcome in an experimental animal model. METHODS Forty-four Sprague Dawley rats were cooled to 19 ± 1°C body core temperature by cardiopulmonary bypass (CPB). HCA was maintained for 60 min. Animals were randomized to receive slow (90 min) or fast (45 min) assisted rewarming with CPB to a target temperature of 35°C. After a total of 90 min of reperfusion in both groups, brain samples were collected and analysed immunohistochemically and with immunofluorescence. In 10 rats, magnetic resonance imaging was performed after 2 and after 24 h to investigate cerebral perfusion and cerebral oedema. RESULTS Interleukin 6, chemokine (C-C motif) ligand 5, intercellular adhesion molecule 1 and tumour necrosis factor α in the hippocampus are significantly less expressed in the slow rewarming group, and microglia cells are significantly less activated in the slow rewarming group. Magnetic resonance imaging analysis demonstrated better cerebral perfusion and less water content in brains that underwent slow rewarming at 2 and 24 h. CONCLUSIONS Slow rewarming after HCA might be superior to fast rewarming in neurological outcome. The present experimental study demonstrated reduction in the inflammatory response, reduction of inflammatory cell activation in the brain, enhancement of cerebral blood flow and reduction of cerebral oedema when slow rewarming was applied.


title: Middle cerebral artery aneurysm endovascular and surgical therapies: comprehensive literature review and local experience.

text: The middle cerebral artery is a common location for cerebral aneurysms and is associated with a lower risk of rupture than aneurysms located in the anterior or posterior communicating arteries. No evidence supports the superiority of clipping over coiling to treat middle cerebral artery aneurysm (MCAA) or vice versa. The feasibility of treating the MCAA with endovascular therapy as the first choice of treatment in cohorts of nonselected aneurysms exceeds 90%. A randomized clinical trial comparing the 2 approaches in nonselected cases with long-term follow-up will shed light on which patients may benefit from one approach over another.