title: Stifle Disarticulation as a Pelvic Limb Amputation Technique in a Cockatiel ( Nymphicus hollandicus ) and a Northern Cardinal ( Cardinalis cardinalis ).

text: This clinical report describes the use of stifle disarticulation in 2 avian patients as an alternative to transfemoral limb amputation. A northern cardinal ( Cardinalis cardinalis ) was presented for soft tissue swelling and a traumatic fracture of the third digit of the left limb, with secondary bacterial infection and necrosis. A 25-year-old cockatiel ( Nymphicus hollandicus ) was diagnosed with distal extremity necrosis after a nonunion of a closed tibiotarsal fracture. In both cases amputation was recommended due to the poor prognosis for healing and because both birds were poor surgical candidates for traditional methods of amputation due to patient size or age. Therefore, stifle disarticulation surgery for amputation of the pelvic limb was performed successfully in both cases and recovery was unremarkable. The outcomes of these 2 cases suggest that stifle disarticulation may be used as an alternative to transfemoral amputation in birds where prolonged surgery, anesthesia, or patient size precludes traditional amputation techniques.


title: Low-value injury care in the adult orthopaedic trauma population: a protocol for a rapid review.

text: INTRODUCTION Orthopaedic injuries affect almost 90% of trauma patients. A previous scoping review and expert consultation survey identified 15 potential low-value intra-hospital practices in the adult orthopaedic trauma population. Limiting the frequency of such practices could reduce adverse events, improve clinical outcomes and free up resources. The aim of this study is to synthesise the evidence on intra-hospital practices for orthopaedic injuries, previously identified as potentially of low value. METHODS AND ANALYSIS We will search Medline, Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials and Epistemonikos to identify systematic reviews, randomised controlled trials (RCTs), quasi-RCTs, cohort studies and case-control studies that evaluate selected practices according to a priori PICOS statements (Population-Intervention-Comparator-Outcome-Study design) . We will evaluate the methodological quality for systematic reviews using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2). Risk of bias in original studies will be evaluated with the Cochrane revised tool for RCTs (RoB2) and with the risk of bias in non-randomised studies of interventions (ROBINS-I) tool. If for a given practice, more than two original studies on our primary outcome are identified, we will conduct meta-analysis using a random effects model and assess heterogeneity using the I2 index. We will assess credibility of evidence (I-IV) based on statistical significance, sample size, heterogeneity and bias as per published criteria. ETHICS AND DISSEMINATION Ethics approval is not required as original data will not be collected. Knowledge users from three level I trauma centres are involved in the design and conduct of the study in accordance with an integrated knowledge translation approach. Findings related to the rapid review will be available in May 2020. They will be presented to key stakeholders to inform discussions and raise awareness on low-value injury care. In addition, results will be disseminated in a peer-reviewed journal, at national and international scientific meetings and to healthcare associations.


title: Strain-Level Diversity Impacts Cheese Rind Microbiome Assembly and Function.

text: Diversification can generate genomic and phenotypic strain-level diversity within microbial species. This microdiversity is widely recognized in populations, but the community-level consequences of microbial strain-level diversity are poorly characterized. Using the cheese rind model system, we tested whether strain diversity across microbiomes from distinct geographic regions impacts assembly dynamics and functional outputs. We first isolated the same three bacterial species (Staphylococcus equorum, Brevibacterium auranticum, and Brachybacterium alimentarium) from nine cheeses produced in different regions of the United States and Europe to construct nine synthetic microbial communities consisting of distinct strains of the same three bacterial species. Comparative genomics identified distinct phylogenetic clusters and significant variation in genome content across the nine synthetic communities. When we assembled each synthetic community with initially identical compositions, community structure diverged over time, resulting in communities with different dominant taxa. The taxonomically identical communities showed differing responses to abiotic (high salt) and biotic (the fungus Penicillium) perturbations, with some communities showing no response and others substantially shifting in composition. Functional differences were also observed across the nine communities, with significant variation in pigment production (light yellow to orange) and in composition of volatile organic compound profiles emitted from the rinds (nutty to sulfury).IMPORTANCE Our work demonstrated that the specific microbial strains used to construct a microbiome could impact the species composition, perturbation responses, and functional outputs of that system. These findings suggest that 16S rRNA gene taxonomic profiles alone may have limited potential to predict the dynamics of microbial communities because they usually do not capture strain-level diversity. Observations from our synthetic communities also suggest that strain-level diversity has the potential to drive variability in the aesthetics and quality of surface-ripened cheeses.


title: New microwave ablation system for unresectable liver tumors that forms large, spherical ablation zones.

text: BACKGROUND AND AIM The aim of this study was to assess the efficacy of a new microwave ablation (MWA) system, the Emprint Ablation System, for the ablation of unresectable large liver tumors (≥ 30 mm). METHODS Twenty-one hepatic tumors (mean diameter, 34.7 mm) from 21 patients who underwent percutaneous MWA were included in this cross-sectional study. A volume analyzer based on computed tomography imaging was used for all patients within the month before and month after the procedure to evaluate the shape and volume of ablation zones. In addition, computed tomography imaging was performed again 3 months after the procedure to evaluate the presence of residual tumors and local recurrence. RESULTS Mean ablation time was 11.3 min, and mean overall procedure time was 33.4 min. An ablated adrenal gland-induced Takotsubo (stress) cardiomyopathy occurred immediately after MWA as a major complication in one patient. Roundness index A, B, and C presented a mean value of 0.94, 0.94, and 1.01, respectively (all values near 1 is a perfect sphere), indicating that a spherical ablation zone was achieved. The mean ablation volume was larger than the volume of tumors (24.5 vs 41.7 cm3 ). Residual tumors were confirmed in only 4.8% of tumors after a single ablation session. There was no local recurrence. CONCLUSIONS In our experience, the new MWA system provides an effective treatment option for unresectable large liver tumors. However, to ablate the liver tumors safely, it is necessary to consider the surrounding organs, such as the adrenal glands.


title: The Sequelae of Metallosis Resulting in Skin Pigmentation and Tattooing: A Case Presentation and Literature Review.

text: With advancing technologies in orthopedics and increasing demands of the population for orthopedic interventions, younger patients are now receiving joint replacements. One of the potential risks of joint replacement is metallosis, or the local and systemic release of metal ions. Metallosis is caused by the release of metallic debris, secondary to hardware failure. The phenomenon is most commonly associated with failed metal-on-metal hip prostheses and is characterized locally by heavy staining of surrounding soft tissue, metallic synovitis, joint effusion, and gradual loosening of the prosthesis. Additionally, metallic debris can also lead to periarticular superficial skin manifestations. The release of metal ions has further been known to lead to systemic upsets including neurologic deficit (declining vision, hearing, or cognition; headaches), cardiac failure, and hypothyroidism. As the number of patients seeking major orthopedic interventions grows, the incidence of metallosis-related skin tattooing will also increase. The structural components of a failed joint replacement can be revised (improving patients' pain and functioning). However, any skin tattooing secondary to metallosis presents the treating dermatologist with clinical challenge, due to lack of research regarding treatment of this condition. Our aim is to review the published literature on metallosis, including the pathophysiology. After assessing publications on the treatment of traumatic and cosmetic tattooing, we hope to stimulate further research regarding treatment. This article should also serve to remind orthopedic surgeons that with increasing patient concern regarding cosmesis, a multispecialty approach including referral to a dermatologist is valuable.


title: Laparoscopic liver resection: when to use the laparoscopic stapler device.

text: Minimally invasive hepatic resection was first described by Gagner et al. in the early 1990s and since then has become increasingly adopted by hepatobiliary and liver transplant surgeons. Several techniques exist to transect the hepatic parenchyma laparoscopically and include transection with stapler and/or energy devices, such as ultrasonic shears, radiofrequency ablation and bipolar devices. We believe that coagulative techniques allow for superior anatomic resections and ultimately permit for the performance of more complex hepatic resections. In the stapling technique, Glisson's capsule is usually incised with an energy device until the parenchyma is thinned out and multiple firings of the staplers are then used to transect the remaining parenchyma and larger bridging segmental vessels and ducts. Besides the economic constraints of using multiple stapler firings, the remaining staples have the disadvantage of hindering and even preventing additional hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during minimally invasive major hepatic resections. Techniques to safely perform major hepatic resection with the above techniques will be described with an emphasis on when and how laparoscopic vascular staplers should be used.


title: Chemotherapy-sparing treatment of haemophagocytic lymphohistiocytosis with intravenous immunoglobulins and corticosteroids.

text: Haemophagocytic lymphohistiocytosis (HLH) can be a rapidly fatal disease. Current treatment in adults is extrapolated from the HLH-2004 protocol that specifies a regimen of etoposide, dexamethasone and cyclosporine. However, HLH presents as a spectrum of disease severity. A therapeutic challenge arises for milder cases where the harms of potent chemotherapy such as etoposide may outweigh its benefit. We present a case of an adult with HLH who developed significant pancytopenia but was otherwise not critically ill and who responded to treatment with a chemotherapy-sparing approach consisting of intravenous immunoglobulins and corticosteroids alone. The case illustrates that tailored therapy may allow effective treatment of the disorder while minimising therapy-related toxicities.


title: Coronavirus and Quarantine: Catalysts of Domestic Violence.

text: The pandemic of COVID-19 has resulted in quarantines imposed all around the world; these and other restrictions could produce an increase in domestic violence.


title: Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions.

text: BACKGROUND A systematic review found that 3% of working adults who had received influenza vaccine and 5% of those who were unvaccinated had laboratory-proven influenza per season; in healthcare workers (HCWs) these percentages were 5% and 8% respectively. Healthcare workers may transmit influenza to patients. OBJECTIVES To identify all randomised controlled trials (RCTs) and non-RCTs assessing the effects of vaccinating healthcare workers on the incidence of laboratory-proven influenza, pneumonia, death from pneumonia and admission to hospital for respiratory illness in those aged 60 years or older resident in long-term care institutions (LTCIs). SEARCH METHODS We searched CENTRAL (2015, Issue 9), MEDLINE (1966 to October week 3, 2015), EMBASE (1974 to October 2015) and Web of Science (2006 to October 2015), but Biological Abstracts only from 1969 to March 2013 and Science Citation Index-Expanded from 1974 to March 2013 due to lack of institutional access in 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) and non-RCTs of influenza vaccination of healthcare workers caring for individuals aged 60 years or older in LTCIs and the incidence of laboratory-proven influenza and its complications (lower respiratory tract infection, or hospitalisation or death due to lower respiratory tract infection) in individuals aged 60 years or older in LTCIs. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Effects on dichotomous outcomes were measured as risk differences (RDs) with 95% confidence intervals (CIs). We assessed the quality of evidence with GRADE. MAIN RESULTS We identified four cluster-RCTs and one cohort study (n = 12,742) of influenza vaccination for HCWs caring for individuals ≥ 60 years in LTCIs. Four cluster RCTs (5896 residents) provided outcome data that addressed the objectives of our review. The studies were comparable in their study populations, intervention and outcome measures. The studies did not report adverse events. The principal sources of bias in the studies related to attrition, lack of blinding, contamination in the control groups and low rates of vaccination coverage in the intervention arms, leading us to downgrade the quality of evidence for all outcomes due to serious risk of bias.Offering influenza vaccination to HCWs based in long term care homes may have little or no effect on the number of residents who develop laboratory-proven influenza compared with those living in care homes where no vaccination is offered (RD 0 (95% CI -0.03 to 0.03), two studies with samples taken from 752 participants; low quality evidence). HCW vaccination probably leads to a reduction in lower respiratory tract infection in residents from 6% to 4% (RD -0.02 (95% CI -0.04 to 0.01), one study of 3400 people; moderate quality evidence). HCW vaccination programmes may have little or no effect on the number of residents admitted to hospital for respiratory illness (RD 0 (95% CI -0.02 to 0.02, one study of 1059 people; low quality evidence). We decided not to combine data on deaths from lower respiratory tract infection (two studies of 4459 people) or all cause deaths (four studies of 8468 people). The direction and size of difference in risk varied between the studies. We are uncertain as to the effect of vaccination on these outcomes due to the very low quality of evidence. Adjusted analyses, which took into account the cluster design, did not differ substantively from the pooled analysis with unadjusted data. AUTHORS' CONCLUSIONS Our review findings have not identified conclusive evidence of benefit of HCW vaccination programmes on specific outcomes of laboratory-proven influenza, its complications (lower respiratory tract infection, hospitalisation or death due to lower respiratory tract illness), or all cause mortality in people over the age of 60 who live in care institutions. This review did not find information on co-interventions with healthcare worker vaccination: hand-washing, face masks, early detection of laboratory-proven influenza, quarantine, avoiding admissions, antivirals and asking healthcare workers with influenza or influenza-like illness (ILI) not to work. This review does not provide reasonable evidence to support the vaccination of healthcare workers to prevent influenza in those aged 60 years or older resident in LTCIs. High quality RCTs are required to avoid the risks of bias in methodology and conduct identified by this review and to test further these interventions in combination.


title: The role of biologics in pelvic floor surgery.

text: The advent of laparoscopic surgery and with it Laparoscopic Ventral Mesh Rectopexy (LVMR) has revolutionised the management of internal/external rectal and vaginal vault prolapse. These procedures have traditionally been performed with synthetic meshes. Biologics have gained a prominent role over the last decade in LVMR as well as perineal procedures for rectocoele and cystocoele repair. We examine the existing literature on the use of biologics in pelvic floor surgery comparing this with literature on synthetic mesh for the key outcomes of infection rates, bowel/sexual function and recurrence.


title: Viral infection is associated with an increased proinflammatory response in chronic obstructive pulmonary disease.

text: The development of new diagnostic methods based on molecular biology has led to evidence of the important role of respiratory viruses in chronic obstructive pulmonary disease (COPD) exacerbations. Cytokines and chemokines are recognized as key actors in the pathogenesis of COPD. The objective of this study was to evaluate the association between viral infection and host cytokine responses in 57 COPD patients hospitalized with an acute exacerbation. Seventeen cytokines were profiled using a Luminex-Biorad multiplex assay in plasma samples collected in the first 24 h following hospital admission. Stepwise linear regression analysis was performed, taking into account the influence of seven potential confounding factors in the results. Twenty-four out of 57 showed radiological signs of community-acquired pneumonia (CAP) at hospital admission, 25 patients required admission to the intensive care unit (ICU), 20 had a bacterial infection, and 20 showed a detectable respiratory virus in pharyngeal swabs. Regression analysis showed that viral infection correlated with higher levels of interleukin-6 (IL-6) (log value of the coefficient of regression B, p=0.47, 0.044), and monocyte chemoattractant protein-1 (MCP-1) (p=0.43, 0.019), and increased admission to the ICU. Viral infection also correlated with higher levels of interferon-γ (IFN-γ) (p=0.70, 0.026), which, in turn, was inversely associated with the severity of illness. Finally, viral infection was independently associated with higher levels of tumor necrosis factor-α (TNF-α) (p=0.40, 0.002). Thus our study demonstrates that in patients with COPD exacerbations, viral infection is directly associated with higher systemic levels of cytokines central to the development of the antiviral response, which are also known to contribute to inflammation-mediated tissue damage. These results reveal a potential specific role of viral infection in the pathogenesis of COPD exacerbations.


title: Cavernous Malformation Hemorrhagic Presentation at Diagnosis Associated with Low 25-Hydroxy-Vitamin D Level.

text: BACKGROUND Cavernous malformations (CM) are angiographically occult vascular malformations that may be incidental or present with intracerebral or spinal hemorrhage, seizures, or nonhemorrhagic focal neurologic deficit (FND). Recently in vitro data have suggested vitamin D may play a role in stabilizing CCM2 endothelial cells. Little is known about the effect of vitamin D in human CM disease. METHODS Beginning in 2015, consecutive patients at our institution with radiologically confirmed CM were recruited to participate in a prospective clinical registry as well as 25-hydroxy-vitamin D study. A structured interview, survey, and examination were performed at baseline. Medical records and magnetic resonance imaging studies were reviewed and data collected included comorbid conditions, medication use, and location of CM. Standard definition of clinical hemorrhage, FND, and seizures was used. Univariate and multivariate logistic regression models were used, and OR, 95% CIs, and likelihood-ratio p values were calculated to determine the influence of the 25-hydroxy-vitamin D level on clinical presentation with hemorrhage. RESULTS Of 213 patients enrolled in the clinical registry between January 2015 and October 2018, 70 participated in the vitamin D study (median age: 38.3 years; 51.4% female). Of the 70 participants, 30 (42.9%) presented with hemorrhage. 25-Hydroxy-vitamin D levels were performed within 1 year of symptoms in 64.1% of patients. Patients presenting with hemorrhage had a lower 25-hydroxy-vitamin D level compared to those presenting with seizure without hemorrhage, FND, or as an incidental finding (median 25.5 ng/mL; range 11-59 hemorrhage vs. median 31.0; range 14-60, no hemorrhage; p = 0.04). After adjusting for age, month of blood draw, and body mass index, 25-hydroxy-vitamin D remained a significant predictor of hemorrhagic presentation. Brainstem location also predicted hemorrhage at presentation. CONCLUSION Low 25-hydroxy-vitamin D level was more common in patients with CM presenting with hemorrhage. This study supports the potential role of modifiable factor in the initial clinical presentation of CM. Further study is needed to determine the role of vitamin D on prospective hemorrhage risk and whether supplementation may be beneficial.


title: Hydrogel versus Bare Platinum Coils in Patients with Large or Recurrent Aneurysms Prone to Recurrence after Endovascular Treatment: A Randomized Controlled Trial.

text: BACKGROUND AND PURPOSE Some patients are at high risk of aneurysm recurrence after endovascular treatment: patients with large aneurysms (Patients Prone to Recurrence After Endovascular Treatment PRET-1) or with aneurysms that have previously recurred after coiling (PRET-2). We aimed to establish whether the use of hydrogel coils improved efficacy outcomes compared with bare platinum coils. MATERIALS AND METHODS PRET was an investigator-led, pragmatic, multicenter, parallel, randomized (1:1) trial. Randomized allocation was performed separately for patients in PRET-1 and PRET-2, by using a Web-based platform ensuring concealed allocation. The primary outcome was a composite of a residual/recurrent aneurysm, adjudicated by a blinded core laboratory, or retreatment, intracranial bleeding, or mass effect during the 18-month follow-up. Secondary outcomes included adverse events, mortality, and morbidity (mRS > 2). The hypothesis was that hydrogel would decrease the primary outcome from 50% to 30% at 18 months, necessitating 125 patients per group (500 for PRET-1 and PRET-2). RESULTS The trial was stopped once 250 patients in PRET-1 and 197 in PRET-2 had been recruited because of slow accrual. A poor primary outcome occurred in 44.4% (95% CI, 35.5%-53.2%) of those in PRET-1 allocated to platinum compared with 52.5% (95% CI, 43.4%-61.6%) of patients allocated to hydrogel (OR, 1.387; 95% CI, 0.838-2.295; P = .20) and in 49.0% (95% CI, 38.8%-59.1%) in PRET-2 allocated to platinum compared with 42.1% (95% CI, 32.0%-52.2%) allocated to hydrogel (OR, 0.959; 95% CI, 0.428-1.342; P = .34). Adverse events and morbidity were similar. There were 3.6% deaths (1.4% platinum, 5.9% hydrogel; P = .011). CONCLUSIONS Coiling of large and recurrent aneurysms is safe but often poorly effective according to angiographic results. Hydrogel coiling was not shown to be better than platinum.


[COVID-19 in Spanish and immigrant patients in a sanitary district of Madrid].


title: Burnout and Depression: Two Entities or One?

text: OBJECTIVES The purpose of this study was to examine the overlap in burnout and depression. METHOD The sample comprised 1,386 schoolteachers (mean [M]age = 43; Myears taught = 15; 77% women) from 18 different U.S. states. We assessed burnout, using the Shirom-Melamed Burnout Measure, and depression, using the depression module of the Patient Health Questionnaire. RESULTS Treated dimensionally, burnout and depressive symptoms were strongly correlated (.77; disattenuated correlation, .84). Burnout and depressive symptoms were similarly correlated with each of 3 stress-related factors, stressful life events, job adversity, and workplace support. In categorical analyses, 86% of the teachers identified as burned out met criteria for a provisional diagnosis of depression. Exploratory analyses revealed a link between burnout and anxiety. CONCLUSIONS This study provides evidence that past research has underestimated burnout-depression overlap. The state of burnout is likely to be a form of depression. Given the magnitude of burnout-depression overlap, treatments for depression may help workers identified as "burned out."


title: The six-minute walk test as a measure of postoperative recovery after colorectal resection: further examination of its measurement properties.

text: INTRODUCTION Patients, clinicians and researchers seek an easy, reproducible and valid measure of postoperative recovery. The six-minute walk test (6MWT) is a low-cost measure of physical function, which is a relevant dimension of recovery. The aim of the present study was to contribute further evidence for the validity of the 6MWT as a measure of postoperative recovery after colorectal surgery. METHODS This study involved a sample of 174 patients enrolled in three previous randomized controlled trials. Construct validity was assessed by testing the hypotheses that the distance walked in 6 min (6MWD) at 4 weeks after surgery is greater (1) in younger versus older patients, (2) in patients with higher preoperative physical status versus lower, (3) after laparoscopic versus open surgery, (4) in patients without postoperative complications versus with postoperative complications; and that 6MWD (5) correlates cross-sectionally with self-reported physical activity as measured with a questionnaire (CHAMPS). Statistical analysis was performed using linear regression and Spearman's correlation. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to guide the formulation of hypotheses and reporting of results. RESULTS One hundred and fifty-one patients who completed the 6MWT at 4 weeks after surgery were included in the analysis. All hypotheses tested for construct validity were supported by the data. Older age, poorer physical status, open surgery and occurrence of postoperative complications were associated with clinically relevant reduction in 6MWD (>19 m). There was a moderate positive correlation between 6MWD and patient-reported physical activity (r = 0.46). CONCLUSIONS This study contributes further evidence for the construct validity of the 6MWT as a measure of postoperative recovery after colorectal surgery. Results from this study support the use of the 6MWT as an outcome measure in studies evaluating interventions aimed to improve postoperative recovery.


title: Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation: A Patient-Level Meta-Analysis.

text: BACKGROUND The risk-benefit ratio of left atrial appendage closure (LAAC) versus systemic therapy (warfarin) for prevention of stroke, systemic embolism, and cardiovascular death in nonvalvular atrial fibrillation (NVAF) requires continued evaluation. OBJECTIVES This study sought to assess composite data regarding left atrial appendage closure (LAAC) in 2 randomized trials compared to warfarin for prevention of stroke, systemic embolism, and cardiovascular death in patients with nonvalvular AF. METHODS Our meta-analysis included 2,406 patients with 5,931 patient-years (PY) of follow-up from the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device In Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy) trials, and their respective registries (Continued Access to PROTECT AF registry and Continued Access to PREVAIL registry). RESULTS With mean follow-up of 2.69 years, patients receiving LAAC with the Watchman device had significantly fewer hemorrhagic strokes (0.15 vs. 0.96 events/100 patient-years [PY]; hazard ratio [HR]: 0.22; p = 0.004), cardiovascular/unexplained death (1.1 vs. 2.3 events/100 PY; HR: 0.48; p = 0.006), and nonprocedural bleeding (6.0% vs. 11.3%; HR: 0.51; p = 0.006) compared with warfarin. All-cause stroke or systemic embolism was similar between both strategies (1.75 vs. 1.87 events/100 PY; HR: 1.02; 95% CI: 0.62 to 1.7; p = 0.94). There were more ischemic strokes in the device group (1.6 vs. 0.9 and 0.2 vs. 1.0 events/100 PY; HR: 1.95 and 0.22, respectively; p = 0.05 and 0.004, respectively). Both trials and registries identified similar event rates and consistent device effect in multiple subsets. CONCLUSIONS In patients with NVAF at increased risk for stroke or bleeding who are candidates for chronic anticoagulation, LAAC resulted in improved rates of hemorrhagic stroke, cardiovascular/unexplained death, and nonprocedural bleeding compared to warfarin.


title: The effect of alvimopan on recovery after laparoscopic segmental colectomy.

text: BACKGROUND Alvimopan, a peripherally acting μ-opioid receptor antagonist, was recently approved for the reduction of postoperative ileus after open colectomy. No data are available regarding the use of alvimopan following laparoscopic segmental colectomy. OBJECTIVE This study was designed to evaluate the effectiveness of alvimopan in patients undergoing laparoscopic segmental colectomy. DESIGN A retrospective review of segmental laparoscopic colectomy was conducted in a population of patients using an accelerated postcolectomy care pathway. Patients that received alvimopan were identified from an institutional review board-approved database and matched with nonalvimopan patients for age, sex, procedure, and diagnosis. Patients with a diverting ileostomy or with contraindications for alvimopam were excluded. RESULTS One hundred patients undergoing laparoscopic colectomy received alvimopan perioperatively and were matched with a similar group of nonalvimopan patients. Although patients on alvimopan were significantly less likely to develop postoperative ileus (4% vs 12%; P = .04), there was no difference in length of hospital stay (3.63 days in the alvimopan group vs 3.78 in the nonalvimopan group; P = .84) or 30-day readmission rate (4.0% vs 4.2%; P = .95). CONCLUSIONS As the cost of providing health care continues to increase, reductions in perioperative complications and hospital stay are important to hospital efficiency and patient care. Alvimopan effectively reduces the incidence of postoperative ileus in patients undergoing open colectomy; however, hospital stay and readmission rates were not altered in this laparoscopic group. Further study is required before alvimopan can be routinely used in patients undergoing laparoscopic colectomy.


COVID-19 in patients with sickle cell disease - a case series from a UK Tertiary Hospital.


title: Osteoid osteoma of the scaphoid bone associated with flexor carpi radialis calcific tendinitis and treated with CT-guided RF ablation.

text: Osteoid osteomas of the wrist are relatively rare and the diagnosis is challenging due to atypical clinical features. We describe a case of an osteoid osteoma of the scaphoid bone associated with calcific tendinitis of the adjacent flexor carpi radialis tendon and periarticular soft tissue calcifications in a 21-year-old man presenting with radial-sided wrist pain. The lesion was successfully treated with CT-guided RF ablation. To our knowledge, this is the first description of an osteoid osteoma of the wrist associated with calcific tendinitis and periarthritis. In addition, we discuss the technical details and difficulties of CT-guided RF ablation of scaphoid osteoid osteomas.


title: Open Lung Approach for the Acute Respiratory Distress Syndrome: A Pilot, Randomized Controlled Trial.

text: OBJECTIVE The open lung approach is a mechanical ventilation strategy involving lung recruitment and a decremental positive end-expiratory pressure trial. We compared the Acute Respiratory Distress Syndrome network protocol using low levels of positive end-expiratory pressure with open lung approach resulting in moderate to high levels of positive end-expiratory pressure for the management of established moderate/severe acute respiratory distress syndrome. DESIGN A prospective, multicenter, pilot, randomized controlled trial. SETTING A network of 20 multidisciplinary ICUs. PATIENTS Patients meeting the American-European Consensus Conference definition for acute respiratory distress syndrome were considered for the study. INTERVENTIONS At 12-36 hours after acute respiratory distress syndrome onset, patients were assessed under standardized ventilator settings (FIO2≥0.5, positive end-expiratory pressure ≥10 cm H2O). If Pao2/FIO2 ratio remained less than or equal to 200 mm Hg, patients were randomized to open lung approach or Acute Respiratory Distress Syndrome network protocol. All patients were ventilated with a tidal volume of 4 to 8 ml/kg predicted body weight. MEASUREMENTS AND MAIN RESULTS From 1,874 screened patients with acute respiratory distress syndrome, 200 were randomized: 99 to open lung approach and 101 to Acute Respiratory Distress Syndrome network protocol. Main outcome measures were 60-day and ICU mortalities, and ventilator-free days. Mortality at day-60 (29% open lung approach vs. 33% Acute Respiratory Distress Syndrome Network protocol, p = 0.18, log rank test), ICU mortality (25% open lung approach vs. 30% Acute Respiratory Distress Syndrome network protocol, p = 0.53 Fisher's exact test), and ventilator-free days (8 [0-20] open lung approach vs. 7 [0-20] d Acute Respiratory Distress Syndrome network protocol, p = 0.53 Wilcoxon rank test) were not significantly different. Airway driving pressure (plateau pressure - positive end-expiratory pressure) and PaO2/FIO2 improved significantly at 24, 48 and 72 hours in patients in open lung approach compared with patients in Acute Respiratory Distress Syndrome network protocol. Barotrauma rate was similar in both groups. CONCLUSIONS In patients with established acute respiratory distress syndrome, open lung approach improved oxygenation and driving pressure, without detrimental effects on mortality, ventilator-free days, or barotrauma. This pilot study supports the need for a large, multicenter trial using recruitment maneuvers and a decremental positive end-expiratory pressure trial in persistent acute respiratory distress syndrome.


title: Impact of a mandatory infection control education program on nosocomial acquisition of methicillin-resistant Staphylococcus aureus.

text: OBJECTIVE To assess the impact of an institution-wide infection control education program on the rate of transmission of methicillin-resistant Staphylococcus aureus (MRSA). DESIGN Before-and-after study. SETTING A 472-bed, urban, university-affiliated hospital.Intervention. During the period March-May 2004, all hospital staff completed a mandatory infection control education program, including the receipt of hospital-specific MRSA data and case-based practice with additional precautions. OUTCOME MEASURE The rate of nosocomial MRSA acquisition was calculated as the number of cases of nosocomial MRSA acquisition per 100 days that a person with MRSA colonization or infection detected at admission is present in the hospital ("admission MRSA" exposure-days) for 3 time periods: June 2002-February 2003 (before the Toronto outbreak of severe acute respiratory syndrome [SARS]), June 2003-February 2004 (after the outbreak of SARS), and June 2004-February 2005 (after education). A case of nosocomial acquisition of MRSA colonization or infection represented a patient first identified as colonized or infected more than 72 hours after admission or at admission after a previous hospitalization. RESULTS The rate of nosocomial acquisition of MRSA colonization or infection was 8.8 cases per 100 admission MRSA exposure-days for the period before SARS, 3.8 cases per 100 admission MRSA exposure-days for the period after SARS (P<.001 for before SARS vs after SARS), and 1.9 cases per 100 admission MRSA exposure-days for the period after education (P=.02 for after education vs before education). The volume of alcohol-based handrub purchased was apparently stable, with 4,010 L during fiscal year 2003-2004 (April 2003-March 2004) compared with 3,780 L during fiscal year 2004-2005. The observed rate of compliance with hand washing did not change significantly (40.9% during education vs 44.2% after education; P=.23). The total number of patients screened for MRSA colonization was not different in the 3 periods. CONCLUSIONS The rate of nosocomial acquisition of MRSA colonization or infection decreased after SARS and was further reduced in association with a hospital-wide education program.


title: Laparoscopic transhiatal esophagectomy and gastric pull-up in long-gap esophageal atresia: description of the technique in our first 10 cases.

text: The definition accepted for the largely controversial and multiple criteria condition known as long-gap esophageal atresia (LGEA) is "inability to achieve primary end-to-end anastomosis," particularly in the presence of a tracheo-esophageal fistula. In this article we report our technique of laparoscopic transhiatal esophagectomy and gastric pull-up (TEGPUL) in LGEA, based on the open approach of Spitz. Differences between TEGPUL and the original technique are the absence of a pyloromyotomy, the peel-away technique, the gastric pull-up through the distal esophagus, and its extracorporeal section. We performed the technique in 10 patients: 6 girls and 4 boys. Six had esophageal atresia type III (60%), three had esophageal atresia type I (30%) and one had esophageal atresia type II (10%). Mean time in surgery was 4.43 hours (range, 3.3-7 hours). Average stay in the pediatric intensive care unit was 5.9 days (range, 3-25 days). Average time under mechanical ventilation was 4.6 days (range, 2-8 days). Average total hospital stay was 19.4 days (range, 11-40 days). Oral feeding began at 15.6 days (range, 5-30 days). We believe these steps and the early realization of the technique will reduce the morbidity and mortality among these patients and decrease the number of contraindications to gastric pull-up. Nevertheless, a valid conclusion will require more studies with a larger number of patients and longer follow-up.


title: Adequacy of US Hospital Security Preparedness for Mass Casualty Incidents: Critical Lessons From the Israeli Experience.

text: CONTEXT Due to Israel's threat environment, Israeli hospitals have developed effective and innovative security preparations for responding to all-hazards incidents. Although Israeli hospital preparedness has been the subject of international praise and attention, there has been a dearth of research focused specifically on applying Israeli hospital security measures to the US hospital setting to augment emergency planning. OBJECTIVE This study examined practical and cost-effective lessons from the Israeli experience for improving US hospital security preparedness for a wide range of mass casualty incidents, both natural and man-made. DESIGN Sixty semi-structured interviews were conducted with officials throughout Israel's and America's health, defense, and emergency response communities. Hospital preparedness was examined and disaster drills were evaluated in both countries, with San Francisco hospitals analyzed as a case study. Qualitative analysis was conducted and recommendations were made on the basis of an all-hazards approach to emergency preparedness. RESULTS US hospitals examined in this study had not undertaken crucial preparations for managing the security consequences of a large-scale disaster. Recommendations from Israel included installing permanent emergency signage, improving security perimeter protocols and training, increasing defense against primary and secondary attacks, enhancing coordination with law enforcement, the National Guard, and other outside security agencies, and conducting more frequent and realistic lockdown exercises. CONCLUSIONS A number of US hospitals have overlooked the important role of security in emergency preparedness. This study analyzed practical and cost-effective security recommendations from Israel to remedy this dangerous deficiency in some US hospitals' disaster planning.


Covid-19 and Kawasaki Disease: An Etiology or Coincidental Infection?


title: Flange Gastroenterostomy Results in Reduction in Delayed Gastric Emptying after Standard Pancreaticoduodenectomy: A Prospective Cohort Study.

text: BACKGROUND Delayed gastric emptying (DGE) is a common serious problem after pancreaticoduodenectomy (PD). Flange gastrojejunostomy (FL-GE) is a previously described technique that creates an internal flange in a hand-sewn gastroenterostomy. Results of FL-GE on incidence and severity of DGE after PD are presented. STUDY DESIGN Data were extracted from a prospective database of PD. Standard PD with antrectomy were performed with flange gastroenterostomy (FL-GE) or other techniques (NonFL-GE) at a single institution. The International Study Group of Pancreatic Surgery (ISGPS) definition of DGE was used, and DGE severity was graded based on the ISGPS grading system and the Modified Accordion Grading System (MAGS). RESULTS There were 215 standard PDs performed. Sixty-eight (32%) were FL-GE and 147 (68%) were NonFL-GE. Delayed gastric emptying rates in FL-GE and NonFL-GE were 9% and 23%, respectively (p = 0.012). Differences in severity of DGE were even more prominent: 29% of DGEs in the NonFL-GE group were ISGPS grade C vs 0% in FL-GE. Also, 35% of DGEs in the NonFL-GE group were MAGS 3 vs 0% in FL-GE. Because of some differences in sex and inflammatory complications between groups, a propensity score analysis was performed, creating 57 matched patients in the FL-GE and NonFL-GE groups. The incidence of DGE remained significantly different in the groups (5% in FL-GE vs 18% in NonFL-GE; p = 0.039). CONCLUSIONS In this cohort study, the flange technique was associated with a marked reduction in the incidence of DGE after PD.


title: Androgen Action via the Androgen Receptor in Neurons Within the Brain Positively Regulates Muscle Mass in Male Mice.

text: Although it is well established that exogenous androgens have anabolic effects on skeletal muscle mass in humans and mice, data from muscle-specific androgen receptor (AR) knockout (ARKO) mice indicate that myocytic expression of the AR is dispensable for hind-limb muscle mass accrual in males. To identify possible indirect actions of androgens via the AR in neurons to regulate muscle, we generated neuron-ARKO mice in which the dominant DNA binding-dependent actions of the AR are deleted in neurons of the cortex, forebrain, hypothalamus, and olfactory bulb. Serum testosterone and luteinizing hormone levels were elevated twofold in neuron-ARKO males compared with wild-type littermates due to disruption of negative feedback to the hypothalamic-pituitary-gonadal axis. Despite this increase in serum testosterone levels, which was expected to increase muscle mass, the mass of the mixed-fiber gastrocnemius (Gast) and the fast-twitch fiber extensor digitorum longus hind-limb muscles was decreased by 10% in neuron-ARKOs at 12 weeks of age, whereas muscle strength and fatigue of the Gast were unaffected. The mass of the soleus muscle, however, which consists of a high proportion of slow-twitch fibers, was unaffected in neuron-ARKOs, demonstrating a stimulatory action of androgens via the AR in neurons to increase the mass of fast-twitch hind-limb muscles. Furthermore, neuron-ARKOs displayed reductions in voluntary and involuntary physical activity by up to 60%. These data provide evidence for a role of androgens via the AR in neurons to positively regulate fast-twitch hind-limb muscle mass and physical activity in male mice.


title: Laparoscopic organ-sparing resection of von Hippel-Lindau disease-associated pancreatic neuroendocrine tumors.

text: BACKGROUND Pancreatic neuroendocrine tumors (PNETs) are a characteristic feature of the tumor syndromes multiple endocrine neoplasia type 1 (MEN-1) and von Hippel-Lindau disease (VHL). With VHL, about 10% of the patients exhibit PNETs by age 40 years. Metastatic potential is high if the tumors have grown to >3 cm in diameter. Optimal surgical treatment is still a challenge. METHODS We report three cases, all women, ages 22, 30, and 39 years, respectively, who had known VHL, confirmed by classic organ manifestations and germline mutations of the VHL gene. All were diagnosed, in an asymptomatic stage, with solid tumors of the pancreatic tail or tail/corpus area measuring 2.9-5.6 cm diameter. All accepted the offer of laparoscopic organ-sparing removal of the tumors. RESULTS In all three cases, the tumor was entirely removed. In two cases, resection of the spleen was also necessary as dissection of the tumor from the major splenic vessels was impossible. Operating time was 215-365 min, and blood loss was 200-700 ml. Histolopathology revealed benign PNETs in two cases, but the third patient had regional lymph node metastases. There were no complications, and the hospital stay was 4-7 days. CONCLUSIONS Organ-sparing laparoscopic surgery is an important option for treating VHL-associated PNETs of the pancreatic tail.


title: The value of interleukin-6 in predicting disease relapse for Takayasu arteritis during 2-year follow-up.

text: OBJECTIVE To evaluate the value of interleukin-6 (IL-6) in predicting long-term disease prognosis for Takayasu arteritis (TA). METHODS Sixty-seven TA patients, who had IL-6 levels detected at the first visit and had a regular follow-up of at least 2 years, were enrolled. Data recorded up to March 31, 2019, including clinical presentations, laboratory indices, treatments, and radiological images were collected and used for analysis. The value of IL-6 in predicting disease relapse and imaging progression was analyzed. RESULTS IL-6 levels were positively related with disease activity index, including Kerr scores, C-reactive protein (CRP) levels. Patients were divided into three groups according to baseline serum IL-6 levels: low group (< 5.4 pg/mL, n = 29), medium group (5.4-11.5 pg/mL, n = 20), and high group (> 11.5 ng/mL, n = 18). Patients in the medium and high group had higher disease activity than those in the low group (p < 0.01). Baseline IL-6 levels were correlated with luminal stenosis (p < 0.05), although no significant correlations with long-term imaging progression were observed. Patients with more than 2 episodes of disease relapses were most commonly seen in the medium group (p < 0.05). Multivariate Cox proportional hazard regression analysis indicated that medium and high IL-6 levels were positive predictors for disease relapse (HR 4.3, 95%CI 1.3-18.7 p = 0.07 for medium group; HR 2.1, 95% CI 0.7-48.9, p = 0.19 for high group) with disease status and treatment adjusted. CONCLUSIONS IL-6 may be a valuable predictor of TA disease relapse during long-term follow-up. Treatments targeted at IL-6 pathways might reduce disease relapse and have better prognostic effects for TA.Key Points• Positive relationships between IL-6 levels and disease activity index, including Kerr scores, C-reactive protein (CRP) levels, etc. were indicated.• Medium and high baseline IL-6 levels were valuable for predicting disease relapse during the 2-year follow-up.• Baseline IL-6 levels were positively correlated with luminal stenosis on imaging.


title: The 2009 H1N1 Influenza Pandemic: the role of threat, coping, and media trust on vaccination intentions in Canada.

text: Swine flu (H1N1) reached pandemic proportions in 2009, yet ambivalence was met concerning intentions to be vaccinated. The present investigation determined predictors of perceived H1N1 contraction risk and vaccination intentions among Canadian adults (N = 1,027) responding to an online questionnaire. The relatively low rate of vaccination intent (30.12%, and 34.99% being unsure of their intent) was related to a sense of invulnerability regarding illness contraction and symptom severity. Most individuals were skeptical that H1N1 would be widespread, believing that less than 10% of the population would contract H1N1. Yet, they also indicated that their attitudes would change once a single person they knew contracted the illness. Also, worry regarding H1N1 was related to self-contraction risk and odds of individuals seeking vaccination. Moreover, vaccination intent was related to the perception that the threat was not particularly great, mistrust of the media to provide accurate information regarding H1N1, and whether individuals endorsed problem-focused versus avoidant coping strategies. Given the role media plays in public perceptions related to a health crisis, trust in this outlet and credibility regarding the threat are necessary for adherence to recommended measures to minimize health risk.


title: Exposure to low-dose ionizing radiation from medical imaging procedures.

text: BACKGROUND The growing use of imaging procedures in the United States has raised concerns about exposure to low-dose ionizing radiation in the general population. METHODS We identified 952,420 nonelderly adults (between 18 and 64 years of age) in five health care markets across the United States between January 1, 2005, and December 31, 2007. Utilization data were used to estimate cumulative effective doses of radiation from imaging procedures and to calculate population-based rates of exposure, with annual effective doses defined as low (< or = 3 mSv), moderate (> 3 to 20 mSv), high (> 20 to 50 mSv), or very high (> 50 mSv). RESULTS During the study period, 655,613 enrollees (68.8%) underwent at least one imaging procedure associated with radiation exposure. The mean (+/-SD) cumulative effective dose from imaging procedures was 2.4+/-6.0 mSv per enrollee per year; however, a wide distribution was noted, with a median effective dose of 0.1 mSv per enrollee per year (interquartile range, 0.0 to 1.7). Overall, moderate effective doses of radiation were incurred in 193.8 enrollees per 1000 per year, whereas high and very high doses were incurred in 18.6 and 1.9 enrollees per 1000 per year, respectively. In general, cumulative effective doses of radiation from imaging procedures increased with advancing age and were higher in women than in men. Computed tomographic and nuclear imaging accounted for 75.4% of the cumulative effective dose, with 81.8% of the total administered in outpatient settings. CONCLUSIONS Imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation.


title: Do depressive patients with family history of dementia constitute a separate group? A case report study.

text: INTRODUCTION Recently it has been suggested that patients with both depression and a family history of dementia are seven times as likely to develop Alzheimer's disease as are controls. METHOD Fifty patients aged 21 - 60 years suffering from DSM-IV Major Depression entered the study; three of them (6%) had a positive family history of dementia. Diagnosis was by SCAN v 2.0. The family history method was used to record family history. All depressed patients were investigated with the Dexamethasone Suppression Test (DST), brain SPECT, electro-oculogram (EOG), flash-electroretinogram (f-ERG) and Pattern-Reversal Visual Evoked Potentials (PR-VEPs). Student's t-test was used to analyse the results. All patients with positive family history had atypical features. RESULTS Two of them suffered from borderline personality disorder, in comparison to eight in the remainder of the sample and five in the rest of the atypicals. The age of onset of depression was lower. DST, SPECT, EOG and PR-VEPs findings were similar between groups. The only significant finding concerned the latency of the bs wave of the scotopic ERG (P < 0.01), but even in this, patients with positive history did not differ from the rest of the atypical patients. CONCLUSION The present study provided limited data connecting atypical features of depression, personality traits, psychological stressors, hypercortisolaemia and family history of dementia. Further research with larger samples is essential. ( Int J Psych Clin Pract 2000; 4: 215 - 222).


title: Design and mechanical properties of a novel cerebral flow diverter stent.

text: Brain arterial aneurysms are localised dilatation in the wall of cerebral arteries that are common among adult population and associated with high incidence of morbidity and mortality. Using flow diverter stent alone to treat cerebral aneurysm is recognized as a safe and effective method. However, flow diverter stents currently available have limitations due to their braided structures. In this paper a novel flow diverter stent is proposed. It is made out of nitinol tubes that provide adequate radial stiffness and tailored surface coverage to overcome problems of currently available braided stents while retaining low porosity and excellent longitudinal flexibility. Finite element analysis using Abaqus has been conducted to investigate radial stiffness, longitudinal flexibility, and maximum strain during packaging of a series of novel stent designs with varied geometric parameters. Results show that porosity below 70% can be achieved and provides radial stiffness and longitudinal flexibility comparable to those of the Neuroform stent that is commonly used for stent assisted coiling. The novel flow diverter has showed great potential for direct treatment of cerebral aneurysms.


title: Comparison of the performance of laboratory tests in the diagnosis of feline infectious peritonitis.

text: We compared the performance of clinicopathologic and molecular tests used in the antemortem diagnosis of feline infectious peritonitis (FIP). From 16 FIP and 14 non-FIP cats, we evaluated retrospectively the sensitivity, specificity, and likelihood ratios (LRs) of serum protein electrophoresis, α1-acid glycoprotein (AGP) on peripheral blood, screening reverse-transcription nested PCR (RT-nPCR) on the 3'-untranslated region (3'-UTR), and spike (S) gene sequencing on peripheral blood, body cavity effusions, and tissue, as well as body cavity cytology and delta total nucleated cell count (ΔTNC). Any of these tests on blood, and especially the molecular tests, may support or confirm a clinical diagnosis of FIP. A negative result does not exclude the disease except for AGP. Cytology, 3'-UTR PCR, and ΔTNC may confirm a clinical diagnosis on effusions; cytology or 3'-UTR PCR may exclude FIP. Conversely, S gene sequencing is not recommended based on the LRs. On tissues, S gene sequencing is preferable when histology is highly consistent with FIP, and 3'-UTR PCR when FIP is unlikely. Combining one test with high LR+ with one with low LR- (e.g., molecular tests and AGP on blood, ΔTNC and cytology in effusions) may improve the diagnostic power of the most used laboratory tests.


title: Four arms robotic-assisted pulmonary resection-left lower lobectomy: how to do it.

text: Numerous published articles have shown the safety and efficacy of robotic lung resection, including lobectomy. The robotic approach offers similar survival rate to the open and video-assisted thoracoscopic surgery methods. Potential advantages provided by robotic technology, such as three-dimensional (3D) high-quality camera, wristed tools and ergonomic ease that seems to overcome certain video-assisted thoracic surgery (VATS) limits have been widely described. Several techniques have been developed by different surgeons to perform a robotic lobectomy. In this study, we present our technique for performing a four-arm robotic lobectomy for the treatment of early stage lung cancer. This is shown in clear, sequential steps. We also provide an instrument preference card, some operative tips and a high-quality video.


title: Information Overload and Infodemic in the COVID-19 Pandemic.

text: The world has experienced pandemics worse than the coronavirus disease (COVID-19) which resulted in great loss of life and economy. However, the global effect of this pandemic has been devastating. Billions of people are in lockdown and isolation on six continents around the world. Most have easy access to information due to internet connectivity and electronic media, which has helped share information about the pandemic. However, information overload during the current COVID-19 pandemic has posed a set of challenges not encountered before. There is an "infodemic" in which false news, conspiracy theories, magical cures and racist news are being shared at an alarming rate, with the potential to increase anxiety and stress and even lead to loss of life. This review highlights some of these challenges and suggests general measures to avoid information overload and infodemic in the connected world of 21st century.


Left ventricular dysfunction in COVID-19: a diagnostic issue.


title: Endovascular recanalization of occluded superior mesenteric artery using retrograde access through the inferior mesenteric artery.

text: Symptomatic occlusion of the superior mesenteric artery can be treated by open repair, hybrid procedure, or endovascular revascularization. In most cases, endovascular procedures are done by the antegrade approach. We report a case of a 67-year-old woman who presented with acute-on-chronic mesenteric ischemia successfully treated by retrograde endovascular recanalization of an occluded common hepatomesenteric trunk through the inferior mesenteric artery and arc of Riolan.


title: Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?

text: Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. "Treatment success" was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1-11) per patient, of covered SEMS was three (range, 1-8), and of pigtail drains was three (range, 1-4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n = 1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity-mortality than covered SEMS.


title: Antibody responses in primary HIV-1 infection.

text: PURPOSE OF REVIEW HIV-1 establishes persistent infections characterized by high levels of viral replication. This finding is remarkable given the presence of apparently vigorous HIV-specific cellular and humoral immune responses. We review the dynamics of antibody responses and viral escape from these responses during primary HIV-1 infection. RECENT FINDINGS Many B cell dysfunctions appear early in HIV-1 infection, and compromise humoral responses to HIV-1 and other pathogens. The rate of viral escape from autologous neutralization varies greatly between individuals with primary HIV-1 infection, and is on average higher than the rate of escape in chronically infected individuals. Mutations, changes in glycosylation and insertions and deletions in the viral envelope may all contribute to viral escape. There may be differences in neutralization sensitivity and evolution of neutralization escape between different HIV-1 subtypes. Although several broadly neutralizing monoclonal antibodies have been identified, the factors that contribute to the development of broad heterologous responses remain unclear. SUMMARY The rapid escape of HIV-1 in response to neutralizing antibodies and the plethora of B cell dysfunctions that occur during HIV infection pose significant obstacles to the design of an effective HIV-1 vaccine. The study of large cohorts of individuals enrolled during primary HIV-1 infection using high-throughput immunoassays, sequencing of the virus and the host, and new statistical tools may help to elucidate the pathways of viral escape, to elicit broadly neutralizing antibody responses, and to suggest means of minimizing the impact of HIV-1 on humoral immunity.


title: Diabetes is associated with persistent pain after hip and knee replacement.

text: BACKGROUND AND PURPOSE In some patients, for unknown reasons pain persists after joint replacement, especially in the knee. We determined the prevalence of persistent pain following primary hip or knee replacement and its association with disorders of glucose metabolism, metabolic syndrome (MetS), and obesity. PATIENTS AND METHODS The incidence of pain in the operated joint was surveyed 1-2 years after primary hip replacement (74 patients (4 bilateral)) or primary knee replacement (119 patients (19 bilateral)) in 193 osteoarthritis patients who had participated in a prospective study on perioperative hyperglycemia. Of the 155 patients who completed the survey, 21 had undergone further joint replacement surgery during the follow-up and were excluded, leaving 134 patients for analysis. Persistent pain was defined as daily pain in the operated joint that had lasted over 3 months. Factors associated with persistent pain were evaluated using binary logistic regression with adjustment for age, sex, and operated joint. RESULTS 49 of the 134 patients (37%) had a painful joint and 18 of them (14%) had persistent pain. A greater proportion of knee patients than hip patients had a painful joint (46% vs. 24%; p = 0.01) and persistent pain (20% vs. 4%; p = 0.007). Previously diagnosed diabetes was strongly associated with persistent pain (5/19 vs. 13/115 in those without; adjusted OR = 8, 95% CI: 2-38) whereas MetS and obesity were not. However, severely obese patients (BMI ≥ 35) had a painful joint (but not persistent pain) more often than patients with BMI < 30 (14/21 vs. 18/71; adjusted OR = 5, 95% CI: 2-15). INTERPRETATION Previously diagnosed diabetes is a risk factor for persistent pain in the operated joint 1-2 years after primary hip or knee replacement.


Planning for a COVID-19 Vaccination Program.


title: Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline.

text: OBJECTIVE The aim was to formulate practice guidelines on the management of hyperglycemia in hospitalized patients in the non-critical care setting. PARTICIPANTS The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, six additional experts, and a methodologist. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society members, American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine reviewed and commented on preliminary drafts of this guideline. CONCLUSIONS Hyperglycemia is a common, serious, and costly health care problem in hospitalized patients. Observational and randomized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients. Implementing a standardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes. We provide recommendations for practical, achievable, and safe glycemic targets and describe protocols, procedures, and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care settings.


title: Hispidin and Lepidine E: two Natural Compounds and Folic acid as Potential Inhibitors of 2019-novel coronavirus Main Protease (2019-nCoVMpro), molecular docking and SAR study.

text: 2019-nCoVis a novel coronavirus was isolated and identified in 2019 in Wuhan, China. On 17 February and according to the world health organization, a number of 71 429 confirmed cases worldwide, among them 2162 new cases recorded in the last 24 hours. One month later the confirmed cases jumped to 179111, with 11525new cases in the last 24 hours, with 7426total deaths. There is no drug or vaccine for humanand animal coronavirus.The inhibition of 3CL hydrolase enzyme provides a promising therapeutic principle for developing treatments against CoViD-19.The 3CLpro (Mpro) known for involving in counteracting the host innate immune response.Thiswork presents the inhibitory effect of some natural compounds against 3CL hydrolase enzyme, and explain the main interactions in inhibitor-enzyme complex. Molecular docking study carried out using Autodock Vina. By screening several molecules, we identified three candidate agents that inhibit the main protease of coronavirus. Hispidin, lepidine E,and folic acid bound tightly in the enzyme, strong hydrogen bonds have been formed (1.69-1.80Å) with the active site residues.This study provides a possible therapeutic strategy for CoViD-19.


title: Synthesis and biological evaluation of novel 1,2,3-triazolonucleotides.

text: A general procedure for the preparation of 1,2,3-triazole analogs of nucleosides from diethyl 2-azidoethoxymethyl- and 2-azidoethoxyethylphosphonates was elaborated. The application of microwave irradiation shortened the reaction time to 10 min in comparison to ca. 48 h when 1,3-dipolar cycloadditions were performed under standard conditions. All compounds were evaluated in vitro for inhibitory activity against a broad variety of DNA and RNA viruses. None of the compounds were antivirally active at subtoxic concentrations. Compound 17k exhibited moderate inhibitory effects on the proliferation of human T-lymphocyte cells (IC50=64 µM for CEM).


title: IFITM-2 and IFITM-3 but not IFITM-1 restrict Rift Valley fever virus.

text: We show that interferon-induced transmembrane protein 1 (IFITM-1), IFITM-2, and IFITM-3 exhibit a broad spectrum of antiviral activity against several members of the Bunyaviridae family, including Rift Valley fever virus (RVFV), La Crosse virus, Andes virus, and Hantaan virus, all of which can cause severe disease in humans and animals. We found that RVFV was restricted by IFITM-2 and -3 but not by IFITM-1, whereas the remaining viruses were equally restricted by all IFITMs. Indeed, at low doses of alpha interferon (IFN-α), IFITM-2 and -3 mediated more than half of the antiviral activity of IFN-α against RVFV. IFITM-2 and -3 restricted RVFV infection mostly by preventing virus membrane fusion with endosomes, while they had no effect on virion attachment to cells, endocytosis, or viral replication kinetics. We found that large fractions of IFITM-2 and IFITM-3 occupy vesicular compartments that are distinct from the vesicles coated by IFITM-1. In addition, although overexpression of all IFITMs expanded vesicular and acidified compartments within cells, there were marked phenotypic differences among the vesicular compartments occupied by IFITMs. Collectively, our data provide new insights into the possible mechanisms by which the IFITM family members restrict distinct viruses.


Endoscopic removal of a proximally migrated pancreatic stent using a gooseneck snare.


title: Dynamics of Interorganizational Public Health Emergency Management Networks: Following the 2015 MERS Response in South Korea.

text: We investigated public health emergency management networks during the recent outbreak of Middle East respiratory syndrome coronavirus that affected more than 17 000 people in South Korea. We administered a survey to 169 organizations in order to map the pattern of communication and response networks during the Middle East respiratory syndrome outbreak. We also conducted 11 semistructured interviews with national, regional, and local government officials to comprehend inhibiting and facilitating factors in risk communication and response to the system. National ministries or agencies play central roles in coordinating and supporting the overall response, and local and regional governments or agencies interact with other governments and agencies. Governmental agencies coordinating and/or supporting the outbreak response had difficulties in communicating with other agencies because of the ambiguity of the nature of the infectious disease, slow information disclosure, differences in the organizational priorities, different information standards, and the limitations of the information system. To better respond to a virus outbreak, government agencies need to improve hierarchical communication among different levels of governments, horizontal communication and cooperation between same types or different types of agencies, and information systems.


title: Mechanical Thrombectomy for Isolated M2 Occlusions: A Post Hoc Analysis of the STAR, SWIFT, and SWIFT PRIME Studies.

text: BACKGROUND AND PURPOSE Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies. MATERIALS AND METHODS We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3. RESULTS We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0-2 at follow-up (60% versus 56%, P = .64). CONCLUSIONS Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.


Passing the Baton.


title: Personal healthcare worker (HCW) and work-site characteristics that affect HCWs' use of respiratory-infection control measures in ambulatory healthcare settings.

text: OBJECTIVES To identify healthcare worker (HCW) and work-site characteristics associated with HCWs' reported use of recommended respiratory-infection control practices in primary and emergency care settings. DESIGN A cross-sectional study using a self-administered questionnaire for HCWs during the summer and fall of 2005. SETTING Primary and emergency care clinics at 5 medical centers in King County, Seattle, Washington. RESULTS Nurse professionals who reported receiving training (odds ratio [OR], 2.5 [confidence interval {CI}, 1.1-5.9]; P=.029), instructional feedback from supervisors (OR, 3.0 [CI, 1.5-5.9]; P=.002), and management support for implementing safe work practices had a higher odds of also reporting adherence to recommended respiratory precautions, compared with nurses who did not. Training was the only important determinant for adherence to respiratory precaution measures among medical practitioners (OR, 5.5 [CI, 1.2-25.8]; P=.031). The reported rate of adherence to hand hygiene practices was higher among nurse professionals who were male (OR, 2.2 [CI, 1.0-4.9]; P=.045), had infants, small children, or older adults living at home (OR, 2.2 [CI, 1.2-3.9]; P=.007), reported cleanliness and orderliness of the establishment where they worked (OR, 2.0 [CI, 1.1-3.5]; P=.019), had received respiratory-infection control training (OR, 3.2 [CI, 1.8-6.0]; P<.001), and reported fears about catching a dangerous respiratory infection at work (OR, 2.3 [CI, 1.2-4.5]; P=.011). CONCLUSION A number of HCW and work-site characteristics associated with HCWs' use of recommended respiratory-infection control measures have been identified. These potentially influential characteristics should be considered as targets or guides for further investigation, which should include the evaluation of intervention strategies.


title: [Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances.]

text: On February 21st, 2020 the first case of severe acute respiratory syndrome due to the coronavirus 2 (SARS-CoV-2) causing the CoViD-19 disease, was identified in Italy. In the following days, despite the restrictive public health measures aimed to avoid the infection's spread, the number of cases increased. As of March 8th, 2020, Italy is the 2nd most affected country in the world. As of March 6th, 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published operational recommendations and ethical considerations to support the clinicians involved in the care of critically-ill CoViD-19 patients, in regard a probable scenario where an imbalance between supply and demand of ICU beds, is put in place by a steadily rising number of these patients.


title: Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position: A Prospective Interventional Study with a Randomized Comparison of Two Anesthetics.

text: BACKGROUND Beach chair positioning during general anesthesia is associated with cerebral oxygen desaturation. Changes in cerebral oxygenation resulting from the interaction of inspired oxygen fraction (FIO2), end-tidal carbon dioxide (PETCO2), and anesthetic choice have not been fully evaluated in anesthetized patients in the beach chair position. METHODS This is a prospective interventional within-group study of patients undergoing shoulder surgery in the beach chair position that incorporated a randomized comparison between two anesthetics. Fifty-six patients were randomized to receive desflurane or total intravenous anesthesia with propofol. Following induction of anesthesia and positioning, FIO2 and minute ventilation were sequentially adjusted for all patients. Regional cerebral oxygenation (rSO2) was the primary outcome and was recorded at each of five set points. RESULTS While maintaining FIO2 at 0.3 and PETCO2 at 30 mmHg, there was a decrease in rSO2 from 68% (SD, 12) to 61% (SD, 12) (P < 0.001) following beach chair positioning. The combined interventions of increasing FIO2 to 1.0 and increasing PETCO2 to 45 mmHg resulted in a 14% point improvement in rSO2 to 75% (SD, 12) (P <0.001) for patients anesthetized in the beach chair position. There was no significant interaction effect of the anesthetic at the study intervention points. CONCLUSIONS Increasing FIO2 and PETCO2 resulted in a significant increase in rSO2 that overcomes desaturation in patients anesthetized in the beach chair position and that appears independent of anesthetic choice.


title: Limitations of ceftriaxone compared with cefazolin against MSSA: an integrated pharmacodynamic analysis.

text: Objectives Despite the convenience of once-daily dosing, the use of ceftriaxone for Staphylococcus aureus infections has significant limitations, including scarce clinical evidence and increasingly questionable pharmacodynamic activity. Our goal was to conduct an integrated pharmacokinetic-pharmacodynamic analysis of the appropriateness of ceftriaxone compared with cefazolin for treating serious MSSA infections. Methods Ceftriaxone and cefazolin activity against five clinical MSSA isolates was characterized in an in vitro pharmacodynamic model. Monte Carlo simulations were then used to evaluate various dosing regimens of ceftriaxone and cefazolin based on relevant patient pharmacokinetic data, significant pharmacodynamic targets derived from the in vitro studies (55%ƒT>MIC for bacteriostasis, 75%ƒT>MIC for 1 log10 bacterial kill, 100%ƒT>MIC for ≥3 log10 bacterial kill) and MIC distributions for MSSA from national surveillance data. Results Ceftriaxone at 1 g once daily had poor activity against MSSA with net bacterial growth predicted in 76% of simulated subjects. The standard 2 g of ceftriaxone once daily had predicted bacterial growth or bacteriostasis in 54% of cases with bactericidal effects in only 17%. Cefazolin at 2 g once daily was notably similar to ceftriaxone in expected target attainments. Cefazolin at 2 g twice daily demonstrated maximal pharmacodynamic activity with bactericidal effects in 97% of simulated subjects. Conclusions Given the limited activity of ceftriaxone against S. aureus, particularly for serious infections when bacterial kill is desired, the convenience of once-daily dosing should be weighed against the risks of using an overly broad, suboptimal therapy. Cefazolin warrants further consideration, particularly as optimal pharmacodynamics against MSSA may be achieved with twice-daily dosing in most patients.


Assessment of unintended volume loss of six closed system transfer devices.


title: Human Rhinovirus Diversity and Evolution: How Strange the Change from Major to Minor.

text: Rhinoviruses are the most common causes of the common cold. Their many distinct lineages fall into "major" and "minor" groups that use different cell surface receptors to enter host cells. Minor-group rhinoviruses are more immunogenic in laboratory studies, although their patterns of transmission and their cold symptoms are broadly similar to those of the major group. Here we present evolutionary evidence that minor-group viruses are also more immunogenic in humans. A key finding is that rates of amino acid substitutions at exposed sites in the capsid proteins VP2, VP3, and VP1 tend to be elevated in minor-group relative to major-group viruses, while rates at buried sites show no consistent differences. A reanalysis of historical virus watch data also indicates a higher immunogenicity of minor-group viruses, consistent with our findings about evolutionary rates at amino acid positions most directly exposed to immune surveillance. The increased immunogenicity and speed of evolution in minor-group lineages may contribute to the very large numbers of rhinovirus serotypes that coexist while differing in virulence.IMPORTANCE Most colds are caused by rhinoviruses (RVs). Those caused by a subset known as the minor-group members of rhinovirus species A (RV-A) are correlated with the inception and aggravation of asthma in at-risk populations. Genetically, minor-group viruses are similar to major-group RV-A, from which they were derived, although they tend to elicit stronger immune responses. Differences in their rates and patterns of molecular evolution should be highly relevant to their epidemiology. All RV-A strains show high rates of amino acid substitutions in the capsid proteins at exposed sites not previously identified as being immunogenic, and this increase is significantly greater in minor-group viruses. These findings will inform future studies of the recently discovered RV-C, which also appears to exacerbate asthma in adults and children. In addition, these findings draw attention to the difficult problem of explaining the long-term coexistence of many serotypes of major- and minor-group RVs.


title: Totally extraperitoneal inguinal hernia repair in patients on antithrombotic therapy: a retrospective analysis.

text: This report addresses whether it is safe to perform totally extraperitoneal (TEP) inguinal hernia repair for patients taking antithrombotic agents. Between January 2011 and June 2012, 77 patients (70 men, 7 women) underwent TEP repair at Osaka Police Hospital, 22 (28.6 %) of whom had been treated with antithrombotic drugs preoperatively. Warfarin was stopped at least 3 days preoperatively and antiplatelet drugs were stopped at least 7 days preoperatively. Standard bridging intravenous heparin therapy was used according to the operative risk of each patient. The mean operative time, intraoperative bleeding, postoperative complications, and length of hospital stay did not differ significantly between these patients and a control group, although the patients on antithrombotic therapy were significantly older with higher surgical risk. No major complications or recurrence developed in either group. Our TEP repair method and bridging heparin therapy seem to be safe and feasible for minimizing postoperative complications.


title: Site and Rate of Occlusive Disease in Cervicocerebral Arteries: A CT Angiography Study of 2209 Patients with Acute Ischemic Stroke.

text: BACKGROUND AND PURPOSE CTA can rapidly and accurately detect and localize occlusive disease in patients with ischemic stroke. We have used CTA to assess arterial stenosis and occlusion in an ischemic stroke population arriving at a tertiary stroke center within 24 hours of symptom onset in order to obtain a comprehensive picture of occlusive disease pattern, and to determine the proportion of eligible candidates for endovascular treatment. MATERIALS AND METHODS Data from consecutive patients with acute ischemic stroke admitted to a single center between 2003 and 2012, collected in the Acute Stroke Registry and Analysis of Lausanne data base, were retrospectively analyzed. Patients with a diagnostic CTA within 24 hours of symptom onset were selected. Relevant extra- and intracranial pathology, defined as stenosis of ≥50% and occlusions, were registered and classified into 21 prespecified segments. RESULTS Of the 2209 included patients (42.1% women; median age, 72 years), 1075 (48.7%) had pathology in and 308 (13.9%) had pathology outside the ischemic territory. In the 50,807 arterial segments available for revision, 1851 (3.6%) abnormal segments were in the ischemic (symptomatic) territory and another 408 (0.8%) were outside it (asymptomatic). In the 1211 patients with ischemic stroke imaged within 6 hours of symptom onset, 40.7% had symptomatic large, proximal occlusions potentially amenable to endovascular therapy. CONCLUSIONS CTA in patients with acute ischemic stroke shows large individual variations of occlusion sites and degrees. Approximately half of such patients have no visible occlusive disease, and 40% imaged within 6 hours show large, proximal segment occlusions amenable to endovascular therapy. These findings show the importance of early noninvasive imaging of extra- and intracranial arteries for identifying occlusive disease, planning recanalization strategies, and designing interventional trials.


title: Impact of surgical approach on postoperative delirium in elderly patients undergoing gastrectomy: laparoscopic versus open approaches.

text: BACKGROUND Postoperative delirium is a frequent complication in elderly patients undergoing major abdominal surgery and is associated with a poor outcome. We compared postoperative delirium in elderly patients following laparoscopic gastrectomy (LG) versus open gastrectomy (OG). METHODS In total, 130 patients aged ≥ 65 years with gastric cancer undergoing LG and OG were enrolled prospectively. Postoperative delirium and cognitive status were assessed daily using the Confusion Assessment Method (CAM) and Mini-Mental Status Examination (MMSE), respectively, for 3 days postoperatively. For CAM-positive patients, delirium severity was then assessed using the Delirium Index (DI). RESULTS In total, 123 subjects (LG, n = 60; OG, n = 63) were included in the analysis. In both groups, the overall incidences of postoperative delirium were similar: 31.6% (19/60) in the LG group and 41.2% (26/63) in the OG group. When considering only those with delirium, the severity, expressed as the highest DI score, was similar between the groups. A decline in cognitive function (reduction in MMSE ≥ 2 points from baseline) during 3 days postoperatively was observed in 23 patients in the LG group (38.3%) and 27 patients in the OG group (42.9%) (P = 0.744). In both groups, postoperative cognitive decline was significantly associated with postoperative delirium (P < 0.001). CONCLUSIONS We found that, compared with traditional open gastrectomy, laparoscopic gastrectomy did not reduce either postoperative delirium or cognitive decline in elderly patients with gastric cancer.


Impact of the global COVID-19 outbreak on the management of other communicable diseases.


title: Middle rectal artery: myth or reality? Retrospective study with CT angiography and digital subtraction angiography.

text: This work aimed to study the prevalence and radiologic anatomy of the middle rectal artery (MRA) using computed tomographic angiography (CTA) and digital subtraction angiography (DSA). The retrospective study (October 2010-February 2012) focused in 167 male patients with prostate enlargement (mean age 64.7 years, range 47-81 years) who underwent selective pelvic arterial embolization for the relief of lower urinary tract symptoms. All patients underwent CTA previously to DSA to evaluate the vascular anatomy of the pelvis and to plan the treatment. MRAs were identified and classified according to their origin, trajectory, termination and relationship with surrounding arteries. We found MRAs in 60 (35.9 %) patients (23.9 % of pelvic sides, n = 80) and of those, 20 (12 %) had bilateral MRAs; 24 MRAs (30 %) were independent of neighbouring arteries and 56 MRAs (70 %) had common origins with prostatic arteries (prostato-rectal trunk). The most frequent MRA origin was the internal pudendal artery (60 %, n = 48), followed by the inferior gluteal artery (21.3 %, n = 17) and common gluteal-pudendal trunk (16.2 %, n = 13). In 2 patients the MRA originated from the obturator artery (2.5 %). Anastomoses to the superior rectal and inferior mesenteric arteries were found in 87.5 % of cases (n = 70). We concluded that MRAs are anatomical variants present in less than half of male patients; have variable origins and frequently share common origins with prostatic arteries. Their correct identification is likely to contribute to improve interventional radiology procedures and prostatic or rectal surgeries.


title: A case-based learning approach to online biochemistry labs during COVID-19.

text: With biochemistry forced to transition to remote-teaching online, the cooperative active learning and problem-solving normally in labs have been limited. With little ability to perform experiments with laboratory equipment, determining how to mimic the qualities integral to these labs in an online environment is necessary. We propose one possible solution to provide online labs: short case-based learning activities.


title: SARS-CoV-2 vaccines: 'Warp Speed' needs mind melds not warped minds.

text: In this review, we address issues that relate to the rapid "Warp Speed" development of vaccines to counter the COVID-19 pandemic. We review the antibody response that is triggered by SARS-CoV-2 infection of humans, and how it may inform vaccine research. The isolation and properties of neutralizing monoclonal antibodies from COVID-19 patients provide additional information on what vaccines should try to elicit. The nature and longevity of the antibody response to coronaviruses are relevant to the potency and duration of vaccine-induced immunity. We summarize the immunogenicity of leading vaccine candidates tested to date in animals and humans, and discuss the outcome and interpretation of virus-challenge experiments in animals. By far the most immunogenic vaccine candidates for antibody responses are recombinant proteins, which are not included in the initial wave of "Warp Speed" immunogens. A substantial concern for SARS-CoV-2 vaccines is adverse events, which we review by considering what was seen in studies of SARS-CoV-1 and MERS-CoV vaccines. We conclude by outlining the possible outcomes of the "Warp Speed" vaccine program, which range from the hoped-for rapid success to a catastrophic adverse influence on vaccine uptake generally.


title: Endoscopic Versus Microscopic Transsphenoidal Approach for Pituitary Adenomas: Comparison of Outcomes During the Transition of Methods of a Single Surgeon.

text: OBJECTIVE The transition from microscopic to fully endoscopic transsphenoidal surgery requires a surgeon to assess how the change in technique will affect the extent of tumor resection (EOR), outcomes, and complications. We compared a single surgeon's experience transitioning from one technique to the other and examined the operative outcomes and EOR between microscopic versus endoscopic transsphenoidal surgery. METHODS Retrospective data analysis of adult patients who were treated surgically for a pituitary adenoma between August 2005 and May 2015 by a single neurosurgeon, who was originally trained and practiced in the microscopic transsphenoidal approach. Patient demographics, perioperative conditions, tumor characteristics, operative times, volumetric EOR, postoperative outcome, and the endoscopic learning curve were evaluated. RESULTS One hundred and nine patients underwent microscopic transsphenoidal surgery and 275 patients underwent a fully endoscopic approach. The patient characteristics were similar in the 2 groups. Operative room time was significantly shorter in the endoscopic group than in the microscopic group (180.2 vs. 215.6 minutes; P < 0.001). The endoscopic and microscopic groups had similar volumetric EOR (85.1% vs. 82.8%; P = 0.371) as well as residual tumor volume (1.06 cm3 vs. 1.15 cm3; P = 0.765). The mean length of hospital stay was 2.4 days in the endoscopic group and 3.2 days in the microscopic group (P = 0.03). CONCLUSIONS During the transition from the microscopic to the endoscopic approach, similar surgical outcomes and EOR were achieved in the 2 cohorts. In our experience, the endoscopic approach offers the advantage of shorter operative times and lengths of hospital stays after the surgeon has developed more experience with the technique.


The Covid-19 pandemic: Provoking thought and encouraging change.


title: Robotic single-site versus multiport laparoscopic cholecystectomy: a case-matched analysis of short- and long-term costs.

text: BACKGROUND Multiport laparoscopy is the gold-standard approach for cholecystectomy, and single-port laparoscopy has been developed to further reduce its invasiveness. A specific robotic single-port platform (da Vinci single-site, Intuitive Surgical Inc., Sunnyvale, CA, USA) has been released in 2011, which could technically facilitate single-site cholecystectomy. Current data show its feasibility; however, detailed short- and long-term analyses of costs and comparisons relative to multiport laparoscopy are not available to date. METHODS Patients who underwent robotic single-site cholecystectomy for benign, clinically noninflammatory disease between 2011 and 2015 were matched for disease, age, gender, BMI, ASA classification, diagnosis, and elapsed year of surgery to a cohort of multiport cholecystectomies. Demographic, perioperative, and long-term data were collected retrospectively and analyzed. Perioperative and long-term costs including re-operations due to the primary procedure until February 2017 were compared across both cohorts. RESULTS 99 patients who underwent robotic single-site cholecystectomy were matched to 99 patients with multiport cholecystectomy. A higher rate of outpatient procedures in the robotic cohort (31.3 vs. 17.2%, p = 0.0305) was found, and demographic parameters and perioperative clinical outcomes were similar. Perioperative costs were significantly higher for the robotic single-site patients (6158.0 vs. 4288.0 USD, p < 0.0001). With similar follow-up times of 59.0 and 58.9 months, respectively (p = 0.9552), significantly more patients of the robotic Single-Site cohort underwent follow-up surgery (7.1 vs. 0.0%, p = 0.0140), and follow-up costs were significantly higher for the robotic cohort (694.7 vs. 0.0 USD, p = 0.0145). CONCLUSION With similar early postoperative clinical results and a higher rate of re-operations, perioperative and long-term costs are significantly higher with robotic Single-Site cholecystectomy compared with multiport cholecystectomy. Considering the unclear clinical value of robotic single-site cholecystectomy and the significant short- and long-term costs, a call for further research and a debate as to who should bear the costs beyond the ones of the gold-standard treatment appear reasonable.


title: Mandatory Change From Surgical Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce Surgical Site Infections in Class I Surgical Cases: A Single-Center Experience With More Than 15 000 Patients.

text: BACKGROUND Surgical site infections (SSIs) are noteworthy and costly complications. New recommendations from a national organization have urged the elimination of traditional surgeon's caps (surgical skull caps) and mandated the use of bouffant caps to prevent SSIs. OBJECTIVE To report SSI rates for >15 000 class I (clean) surgical procedures 13 mo before and 13 mo after surgical skull caps were banned at a single site with 25 operating rooms. METHODS SSI data were acquired from hospital infection control monthly summary reports from January 2014 to March 2016. Based on a change in hospital policy mandating obligatory use of bouffant caps since February 2015, data were categorized into nonbouffant and bouffant groups. Monthly and cumulative infection rates for 13 mo before (7513 patients) and 13 mo after (8446 patients) the policy implementation were collected and analyzed for the groups, respectively. RESULTS An overall increase of 0.07% (0.77%-0.84%) in the cumulative rate of SSI in all class I operating room cases and of 0.03% (0.79%-0.82%) in the cumulative rate of SSI in all spinal procedures was noted. However, neither increase reached statistical significance (P > .05). The cumulative rate of SSI in neurosurgery craniotomy/craniectomy cases decreased from 0.95% to 0.75%; this was also not statistically significant (P = 1.00). CONCLUSION National efforts at improving healthcare performance are laudable but need to be evidence based. Guidelines, especially when applied in a mandatory fashion, should be assessed for effectiveness. In this large, single-center series of patients undergoing class I surgical procedures, elimination of the traditional surgeon's cap did not reduce infection rates.


title: Small animal models of filovirus disease: recent advances and future directions.

text: INTRODUCTION Small animal models have played a critical role in understanding the pathogenesis and transmission of disease caused by filoviruses. Notably, small animals have served to identify and validate many different approaches to countering infection with these highly pathogenic viruses. Nonetheless, predictive efficacy between each model does not appear to be equivalent as higher order animals seem to be more prognostic and therefore successful in the evaluation of medical countermeasures (MCM). Areas covered: This review comprehensively details the available small animal models of filovirus infection and discusses the benefits and shortcomings of each model with respect to the development of MCM. An up-to-date evaluation of mouse, hamster, guinea pig, and ferret models is provided. Expert opinion: The recent development of the domestic ferret model for ebolavirus offers a small animal model that faithfully reproduces most features of human disease without the need for viral adaptation or an immunocompromised host. That being said, choosing a small animal model to evaluate a particular MCM must consider potential confounders associated with each model. These confounding issues include incomplete host immune systems or mutations in the challenge virus that enables the disease.


[COVID-19 trials: surfing between expectations and illusions, looking forward to evidence].


Endoscopic full-thickness resection for GI stromal tumors.