title: An automatically contamination-avoiding technique for intracorporeal esophagojejunostomy using a transorally inserted anvil during laparoscopic total gastrectomy for gastric cancer.

text: BACKGROUND Intracorporeal Roux-en-Y esophagojejunostomy during laparoscopic total gastrectomy for gastric cancer remains a challenging manipulation due to the uncontrolled direction of the jejunal side or unintended embedded tissues, although several methods have been introduced. In this study, we simplified the procedure based on a surgical string fixing technique using a transorally inserted anvil (OrVil™; Covidien Ltd., Mansfield, MA, USA). METHODS From March 2012 to September 2013, 14 consecutive patients underwent simplified intracorporeal Roux-en-Y esophagojejunostomy using OrVil™ during laparoscopic total gastrectomy for gastric cancer at our hospital. Clinicopathologic characteristics and surgical outcomes of these patients were retrospectively analyzed. RESULTS All of the procedures were successful completed with no complication or conversion to open surgery. The mean overall operative time was 193.8 ± 41.8 min, whereas the mean reconstruction time was 32.6 ± 4.6 min. The mean estimated blood loss was 105.7 ± 65.4 ml. The mean diameter of anastomosis measured by upper gastrointestinal contrast X-ray test at 1 month after operation was 2.3 cm. During a median follow-up period of 12 months, neither local recurrence nor anastomosis-related morbidity was observed. CONCLUSIONS Our preliminary results suggested that this automatically contamination-avoiding technique based on a surgical-string-fixing strategy using OrVil™ during laparoscopic total gastrectomy for gastric cancer might be feasible and safe and provide a simple solution for intracorporeal Roux-en-Y esophagojejunostomy.


title: Current status of management of malignant disease: what are the options for premalignant lesions of the esophagus and stomach?

text: INTRODUCTION Premalignant lesions of the foregut (esophagus and stomach) are common entities usually incidentally identified on either endoscopic or radiographic imaging studies. SYMPTOMS These lesions are often asymptomatic or associated with vague gastrointestinal symptoms. TREATMENT Current management of benign and premalignant lesions of the foregut includes primarily ablative and resective endoscopic techniques as well as thoracoscopic, laparoscopic, and open surgical techniques of enucleation and segmental resections. The appropriate procedure, however, is based on the depth of penetration, lesion location, and suspicion for underlying malignant potential.


title: Single-incision laparoscopic surgery used to perform transanal endoscopic microsurgery (SILSTEM) for T1 rectal cancer under spinal anesthesia: report of a case.

text: Transanal endoscopic surgery has slowly gained widespread acceptance among colorectal surgeons, despite the need for specific training and the high costs of specialized instrumentation. At the other extreme, some laparoscopic surgeons recommend single port access surgery using a single-incision laparoscopic surgery port. Single-incision laparoscopic surgery was applied to perform transanal endoscopic microsurgery in a patient with T1 rectal cancer under spinal anesthesia. The patient was a 74-year-old man who presented with a 2-cm elevated lesion in the right anterior portion of the rectum. Ordinary laparoscopic instruments were used to perform submucosal resection. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. The patient recovered uneventfully and was discharged 4 days after the operation. There was no fecal incontinence or soiling during the postoperative follow-up. Colonoscopy at 4 months after the operation showed no recurrence of either adenocarcinoma or adenoma.


Ensuring Access to Medications in the US During the COVID-19 Pandemic.


title: Comparison of CTA- and DSA-Based Collateral Flow Assessment in Patients with Anterior Circulation Stroke.

text: BACKGROUND AND PURPOSE Collateral flow is associated with clinical outcome after acute ischemic stroke and may serve as a parameter for patient selection for intra-arterial therapy. In clinical trials, DSA and CTA are 2 imaging modalities commonly used to assess collateral flow. We aimed to determine the agreement between collateral flow assessment on CTA and DSA and their respective associations with clinical outcome. MATERIALS AND METHODS Patients randomized in MR CLEAN with middle cerebral artery occlusion and both baseline CTA images and complete DSA runs were included. Collateral flow on CTA and DSA was graded 0 (absent) to 3 (good). Quadratic weighted κ statistics determined agreement between both methods. The association of both modalities with mRS at 90 days was assessed. Also, association between the dichotomized collateral score and mRS 0-2 (functional independence) was ascertained. RESULTS Of 45 patients with evaluable imaging data, collateral flow was graded on CTA as 0, 1, 2, 3 for 3, 10, 20, and 12 patients, respectively, and on DSA for 12, 17, 10, and 6 patients, respectively. The κ-value was 0.24 (95% CI, 0.16-0.32). The overall proportion of agreement was 24% (95% CI, 0.12-0.38). The adjusted odds ratio for favorable outcome on mRS was 2.27 and 1.29 for CTA and DSA, respectively. The relationship between the dichotomized collateral score and mRS 0-2 was significant for CTA (P = .01), but not for DSA (P = .77). CONCLUSIONS Commonly applied collateral flow assessment on CTA and DSA showed large differences, indicating that these techniques are not interchangeable. CTA was significantly associated with mRS at 90 days, whereas DSA was not.


title: Comparison of initial experiences of robot-assisted radical cystectomy with those of laparoscopic for bladder cancer.

text: OBJECTIVE The aim of the present study was to evaluate perioperative outcomes in initial experiences of robot-assisted laparoscopic radical cystectomy (RARC) in comparison with those of laparoscopic radical cystectomy (LRC) for muscle-invasive or high-risk non-muscle-invasive bladder cancer. METHODS We performed RARC on six patients with muscle-invasive or high-risk non-muscle-invasive bladder cancer starting in October 2011. During the same period, another five patients underwent LRC. Perioperative outcomes in initial experiences of RARC were elucidated by comparing them with those of LRC. RESULTS Robot-assisted procedures were completed in all cases without conversion to open surgery. The median time of pneumoperitoneum was 252 minutes, and the median blood loss was 340 mL. No severe complications were observed. Perioperative outcomes did not significantly differ between RARC and LRC. Although two cases of troubles in uretero-conduit anastomosis sites were observed after LRC, no patients experienced postoperative complication related to urinary diversion after RARC. CONCLUSIONS Our data indicate that RARC is an acceptable option even in the initial period, and it may become one of the most favorable procedures for treatment of muscle-invasive bladder cancer in the near future, although more tests and longer follow-ups are required to confirm its effectiveness and safety.


title: Anxiety and depression and its correlates in patients with coronavirus disease 2019 in Wuhan.

text: OBJECTIVES Coronavirus disease 2019 (COVID-19) first broke-out in Wuhan China in December 2019, and spread throughout the entire country within a short time. This cross-sectional study investigated the prevalence of depression and anxiety and associated risk factors were analysed in patients with COVID-19. METHODS This single-center cross-sectional study focussed on measuring depression and anxiety using self-report scales. Linear regression was used to determine independent predictors for depression and anxiety. RESULTS A total of 78 patients who were confirmed to have COVID-19 were enrolled in the study. Prevalence of depression and anxiety symptoms were diagnosed in 35.9% and 38.5% of the patients, respectively. Multivariate linear regression analysis found female gender was an independent predictor for higher depression severity index. Having family members who were diagnosed with COVID-19 and family members who died from COVID-19 were independently associated with higher depression severity index and anxiety score. CONCLUSIONS Patients with COVID-19 especially those who had family members diagnosed with COVID-19 or died from COVID-19 were more susceptible to depression and anxiety than were other patients. Effective strategies should be pursued to improve the mental health of this patient population. Key points Patients with COVID-19 showed a significantly high prevalence of depression and anxiety. Female patients were associated with higher risk of depression. Patients with family members diagnosed as COVID-19 or died from this disease were associated with higher risk of depression and anxiety.


title: Swallowing changes related to chronic temporomandibular disorders.

text: OBJECTIVES To investigate whether chronic temporomandibular disorder (TMD) patients showed any changes in swallowing compared to a control group. Moreover, it was examined whether swallowing variables and a valid clinic measure of orofacial myofunctional status were associated. MATERIAL AND METHODS Twenty-three patients with chronic TMD, diagnosed with disc displacement with reduction (DDR) and pain, according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), and 27 healthy volunteers (control group) were compared. Surface electromyography (EMG) of the temporalis, masseter, sternocleidomastoid, and suprahyoid muscles was performed during swallowing tasks of thin liquid (10 and 15 mL) and spontaneous saliva. Data were normalized. RESULTS Compared to the control group, TMD patients showed a prolonged duration of swallowing for liquid and saliva and required a longer time to reach the activity peak and half the integral. While the overall mean value of the relative peaks was similar for the groups, the suprahyoid peak was significantly lower in the TMD group during swallowing of liquid. Moreover, TMD patients recruited the jaw elevator muscles proportionally more than controls. The orofacial myofunctional status was moderately correlated with EMG parameters. CONCLUSION Patients with chronic TMD showed temporal prolongation and changes in the relative activity of the muscles during the swallowing tasks. CLINICAL RELEVANCE The present results contribute additional evidence regarding the reorganization of muscle activity in patients with chronic TMD.


title: Novel Gold Nanorod-Based HR1 Peptide Inhibitor for Middle East Respiratory Syndrome Coronavirus.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) causes a severe acute respiratory syndrome-like illness with high pathogenicity and mortality due to the lack of effective therapeutics. Currently, only few antiviral agents are available for the treatment of MERS, but their effects have been greatly impaired by low antiviral activity, poor metabolic stability, and serious adverse effects. Therefore, the development of effective treatment for MERS is urgently needed. In this study, a series of heptad repeat 1 (HR1) peptide inhibitors have been developed to inhibit HR1/HR2-mediated membrane fusion between MERS-CoV and host cells, which is the major pathway of MERS-CoV-induced host infections. Particularly, peptide pregnancy-induced hypertension (PIH) exhibits potent inhibitory activity with IC50 of 1.171 μM, and its inhibitory effects can be further increased to 10-fold by forming a gold nanorod complex (PIH-AuNRs). In addition, PIH-AuNRs display enhanced metabolic stability and biocompatibility in vitro and in vivo and, therefore, effectively prevent MERS-CoV-associated membrane fusion. In summary, PIH-AuNRs represent a novel class of antiviral agents and have a great potential in treating MERS in the clinic.


COVID-19: don't forget deaf people.


title: Intravital microscopy of osteolytic progression and therapy response of cancer lesions in the bone.

text: Intravital multiphoton microscopy (iMPM) in mice provides access to cellular and molecular mechanisms of metastatic progression of cancers and the underlying interactions with the tumor stroma. Whereas iMPM of malignant disease has been performed for soft tissues, noninvasive iMPM of solid tumor in the bone is lacking. We combined miniaturized tissue-engineered bone constructs in nude mice with a skin window to noninvasively and repetitively monitor prostate cancer lesions by three-dimensional iMPM. In vivo ossicles developed large central cavities containing mature bone marrow surrounded by a thin cortex and enabled tumor implantation and longitudinal iMPM over weeks. Tumors grew inside the bone cavity and along the cortical bone interface and induced niches of osteoclast activation (focal osteolysis). Interventional bisphosphonate therapy reduced osteoclast kinetics and osteolysis without perturbing tumor growth, indicating dissociation of the tumor-stroma axis. The ossicle window, with its high cavity-to-cortex ratio and long-term functionality, thus allows for the mechanistic dissection of reciprocal epithelial tumor-bone interactions and therapy response.


title: Laparoscopic and Robotic Urology Surgery during Global Pandemic COVID19.

text: Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.


title: Role of Non-Profit Organization During COVID-19 for Diabetes Care: Healthcare Inequities and Role of Virtual Specialty Clinic.

text: Today, in the US, we have a health care system designed to treat symptoms, not people - and to do so as cheaply as possible with the dual goals of minimizing costs and preventing hospital visits. We are failing on all fronts. We spend more money on healthcare per capita than our Organization for Economic Co-operation and Development (OECD) peers, and our outcomes are mediocre at best. Medicine is not personal, health care professionals often have their hands tied by payers, and geography has too much influence on the quality of care available. This has to end, especially since we have the technology to create a truly patient-focused, whole-person approach - one that treats physical and mental health equally and meets people where they are in every sense. Telemedicine can level the playing field and enable higher-quality, decentralized care that - when needed - brings specialty care to the masses. Other technologies have an important role, too. For patients with insulin-dependent diabetes (type 1 diabetes), widespread uptake of continuous glucose monitors (CGM) the game-changer we need right now that can facilitate telemedicine to remote places and remove healthcare disparities. Health professionals and patients will both win - and ultimately payers will, too.


Sentinel lymph node biopsy for tumors of the hand and wrist.


title: Endovascular Interventions in Acute Ischemic Stroke: Recent Evidence, Current Challenges, and Future Prospects.

text: After many years of clinical research, endovascular thrombectomy has been conclusively proven to be an effective treatment in acute ischemic stroke. The evidence is compelling; however, it is generated in high volume stroke centers with stroke expertise. Challenges remain ahead on translating and implementing this evidence in routine clinical care across the world. The current evidence has opened up avenues for further research and innovation in this field. In this review, we will discuss the evolution of evidence on endovascular thrombectomy followed by a discussion of challenges and future prospects in this exciting field of stroke care.


title: Plating up appropriate portion sizes for children: a systematic review of parental food and beverage portioning practices.

text: Consumption of larger portion sizes is associated with higher energy intake and weight status in children. As parents play a pivotal role in child feeding, we synthesized literature on 'parental portioning practices' using a mixed methods systematic design to inform future strategies addressing portion sizes served to children. Electronic databases PubMed, EMBASE, SCOPUS, PsycINFO and CINAHL Plus were searched. Two reviewers independently screened 385 abstracts and assessed 71 full-text articles against eligibility criteria: studies assessing portioning of foods or beverages by parent(s) with ≥1 child aged 2-12 years. Narrative synthesis of 14 quantitative studies found that portion sizes parents serve vary substantially and are influenced by amounts parents serve themselves, perceived child hunger and parent and child body size. Thematic synthesis of 14 qualitative studies found that parents serve the portion sizes they learn to be appropriate for their child to be fed. Portioning is influenced by parents' desires for a healthy child with a balanced diet. Future guidance on appropriate portion sizes for children would ideally present recommended portion sizes for first serving, incremental with age. Future research is however needed to assess the adoption and efficacy of providing such guidance to families.


title: Impact of gastrojejunostomy diameter on long-term weight loss following laparoscopic gastric bypass: a follow-up study.

text: BACKGROUND Stenosis of the gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass is a common occurrence. We have previously presented data demonstrating that the use of a 25-mm circular stapler results in a decreased incidence of stenosis compared to the results of a 21-mm circular stapler (6.2 vs. 15.9%, P=0.03). One potential drawback of the larger-diameter stapler is the possibility for impaired long-term weight loss due to decreased restriction. We sought to determine the impact of circular stapler diameter on excess weight loss up to 5 years after surgery. METHODS Our initial technique for creating the gastrojejunostomy after laparoscopic gastric bypass involved the transgastric passage of a 21-mm circular stapler anvil (group 1). After a large initial experience, we switched to a 25-mm circular stapler (group 2). Follow-up data were entered prospectively into a computer database. Weight loss was recorded as percent of excess weight lost. Only patients with follow-up beyond 3 years postoperatively were eligible for inclusion. RESULTS Group 1 consisted of 145 consecutive patients and group 2 consisted of 116 consecutive patients. There was no significant difference in weight loss between the groups at 3 (66.1 vs. 65.2%, P=0.76, n=134), 4 (66.4 vs. 58.6%, P=0.1, n=66), and 5 years after gastric bypass (62.7 vs. 57.5%, P=0.24, n=75). CONCLUSIONS The use of a 25-mm circular stapler in laparoscopic gastric bypass operations instead of a 21-mm stapler does not result in significantly different long-term weight loss. The 25-mm stapler is preferred with our technique.


Surgical intervention in patients with proximal femoral fractures confirmed positive for COVID-19-a report of 2 cases.


title: Clinical utility of the Covidien Closure Fast™ Endovenous Radiofrequency Ablation Catheter.

text: The Closure Fast™ Endovenous Radiofrequency Ablation Catheter is the latest version of a minimally invasive system for the treatment of patients with superficial venous disease. The Closure Fast™ catheter heats the vein wall to 120°C, causing denaturation of the collagen of the vein wall and contraction of the vessel such that no blood can flow through it. Nearly one million systems have been sold since the product was launched. Many, if not all, patients can be treated under local anesthesia with the Closure Fast™ catheter. Duplex ultrasound reports occlusion rates for the treated vein of 94%-98% at 1 year and 85%-93% at 3 years. The system produces average postoperative pain scores of less than 2 out of 10 on a visual analog score. In the first postoperative week, 76% of patients do not require analgesia. Some 45% of patients return to normal activity on the first postoperative day. Serious complications appear to be rare following the Closure Fast™ procedure. Transient paresthesia occurs in 0.2% of cases, thrombophlebitis in 1%-10%, and thromboembolic events in up to 1.4%, mainly heat-induced thrombosis. Closure Fast™ adds significant costs to treating superficial venous disease but studies have shown it to be cost-effective when used in an office setting.


title: Entry of Human Coronavirus NL63 into the Cell.

text: The first steps of human coronavirus NL63 (HCoV-NL63) infection were previously described. The virus binds to target cells by use of heparan sulfate proteoglycans and interacts with the ACE2 protein. Subsequent events, including virus internalization and trafficking, remain to be elucidated. In this study, we mapped the process of HCoV-NL63 entry into the LLC-Mk2 cell line and ex vivo three-dimensional (3D) tracheobronchial tissue. Using a variety of techniques, we have shown that HCoV-NL63 virions require endocytosis for successful entry into the LLC-MK2 cells, and interaction between the virus and the ACE2 molecule triggers recruitment of clathrin. Subsequent vesicle scission by dynamin results in virus internalization, and the newly formed vesicle passes the actin cortex, which requires active cytoskeleton rearrangement. Finally, acidification of the endosomal microenvironment is required for successful fusion and release of the viral genome into the cytoplasm. For 3D tracheobronchial tissue cultures, we also observed that the virus enters the cell by clathrin-mediated endocytosis, but we obtained results suggesting that this pathway may be bypassed.IMPORTANCE Available data on coronavirus entry frequently originate from studies employing immortalized cell lines or undifferentiated cells. Here, using the most advanced 3D tissue culture system mimicking the epithelium of conductive airways, we systematically mapped HCoV-NL63 entry into susceptible cells. The data obtained allow for a better understanding of the infection process and may support development of novel treatment strategies.


Swift antibodies to counter emerging viruses.


title: Residual heat of laparoscopic energy devices: how long must the surgeon wait to touch additional tissue?

text: BACKGROUND Energy devices are essential laparoscopic tools. Residual heat is defined as the increased instrument temperature after energy activation is completed. This study aimed to determine the length of time a surgeon needs to wait before touching other tissue using four common laparoscopic energy sources. METHODS Thermal imaging quantified instrument and tissue temperature ex vivo using monopolar coagulation, argon beam coagulation, ultrasonic dissection, and bipolar tissue fusion devices. To simulate realistic operative usage, each instrument was activated for 5 s four consecutive times with 5 s pauses between fires. Thermal conductivity to bovine liver tissue was measured 2.5, 5, 10, and 20 s after final activation. RESULTS The maximum increase in instrument tip temperature was 172 ± 63°C for the ultrasonic dissection, 81 ± 18°C for the monopolar coagulation, 46 ± 19°C for the bipolar tissue fusion, and 1 ± 1°C for the argon beam coagulation (P < 0.05 for all comparisons). Touching the instrument tip to tissue at four intervals after the final activation (2.5, 5, 10, and 20 s) found that ultrasonic energy raised the tissue temperature higher (maximum change, 58°C) than the other three energy devices at all four time points (P < 0.05). CONCLUSIONS Ultrasonic energy instruments have greater residual heat than monopolar electrosurgery, bipolar tissue fusion, and argon beam. The ultrasonic energy instrument tips heated tissue more than 20°C from baseline even 20 s after activation; whereas all the other energy sources raised the tissue temperature less than 20°C by 5 s. These practical findings may alter a surgeon's usage of these common energy devices.


title: Why COVID-19 Silent Hypoxemia is Baffling to Physicians.

text: Patients with COVID-19 are described as exhibiting oxygen levels incompatible with life without dyspnea. The pairing-dubbed happy hypoxia, but more precisely termed silent hypoxemia-is especially bewildering to physicians and is considered as defying basic biology. This combination has attracted extensive coverage in media but has not been discussed in medical journals. It is possible that coronavirus has an idiosyncratic action on receptors involved in chemosensitivity to oxygen, but well-established pathophysiological mechanisms can account for most, if not all, cases of silent hypoxemia. These mechanisms include how dyspnea and the respiratory centers respond to low levels of oxygen, how prevailing carbon dioxide tensions (PaCO2) blunt the brain's response to hypoxia, effects of disease and age on control of breathing, inaccuracy of pulse oximetry at low oxygen saturations, and temperature-induced shifts in the oxygen dissociation curve. Without knowledge of these mechanisms, physicians caring for hypoxemic patients free of dyspnea are operating in the dark-placing vulnerable COVID-19 patients at considerable risk. In conclusion, features about COVID-19 that physicians find baffling become less strange when viewed in the light of long-established principles of respiratory physiology; an understanding of these mechanisms will enhance patient care if the much-anticipated second wave emerges. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).


title: Using electronic medical records to enable large-scale studies in psychiatry: treatment resistant depression as a model.

text: BACKGROUND Electronic medical records (EMR) provide a unique opportunity for efficient, large-scale clinical investigation in psychiatry. However, such studies will require development of tools to define treatment outcome. METHOD Natural language processing (NLP) was applied to classify notes from 127 504 patients with a billing diagnosis of major depressive disorder, drawn from out-patient psychiatry practices affiliated with multiple, large New England hospitals. Classifications were compared with results using billing data (ICD-9 codes) alone and to a clinical gold standard based on chart review by a panel of senior clinicians. These cross-sectional classifications were then used to define longitudinal treatment outcomes, which were compared with a clinician-rated gold standard. RESULTS Models incorporating NLP were superior to those relying on billing data alone for classifying current mood state (area under receiver operating characteristic curve of 0.85-0.88 v. 0.54-0.55). When these cross-sectional visits were integrated to define longitudinal outcomes and incorporate treatment data, 15% of the cohort remitted with a single antidepressant treatment, while 13% were identified as failing to remit despite at least two antidepressant trials. Non-remitting patients were more likely to be non-Caucasian (p<0.001). CONCLUSIONS The application of bioinformatics tools such as NLP should enable accurate and efficient determination of longitudinal outcomes, enabling existing EMR data to be applied to clinical research, including biomarker investigations. Continued development will be required to better address moderators of outcome such as adherence and co-morbidity.


title: Multivariate time series analysis on the dynamic relationship between Class B notifiable diseases and gross domestic product (GDP) in China.

text: The surveillance of infectious diseases is of great importance for disease control and prevention, and more attention should be paid to the Class B notifiable diseases in China. Meanwhile, according to the International Monetary Fund (IMF), the annual growth of Chinese gross domestic product (GDP) would decelerate below 7% after many years of soaring. Under such circumstances, this study aimed to answer what will happen to the incidence rates of infectious diseases in China if Chinese GDP growth remained below 7% in the next five years. Firstly, time plots and cross-correlation matrices were presented to illustrate the characteristics of data. Then, the multivariate time series (MTS) models were proposed to explore the dynamic relationship between incidence rates and GDP. Three kinds of MTS models, i.e., vector auto-regressive (VAR) model for original series, VAR model for differenced series and error-correction model (ECM), were considered in this study. The rank of error-correction term was taken as an indicator for model selection. Finally, our results suggested that four kinds of infectious diseases (epidemic hemorrhagic fever, pertussis, scarlet fever and syphilis) might need attention in China because their incidence rates have increased since the year 2010.


title: Clinicopathologic features of a systemic coronavirus-associated disease resembling feline infectious peritonitis in the domestic ferret (Mustela putorius).

text: From 2002 to 2007, 23 ferrets from Europe and the United States were diagnosed with systemic pyogranulomatous inflammation resembling feline infectious peritonitis (FIP). The average age at the time of diagnosis was 11 months. The disease was progressive in all cases, and average duration of clinical illness was 67 days. Common clinical findings were anorexia, weight loss, diarrhea, and large, palpable intra-abdominal masses; less frequent findings included hind limb paresis, central nervous system signs, vomiting, and dyspnea. Frequent hematologic findings were mild anemia, thrombocytopenia, and hypergammaglobulinemia. Grossly, whitish nodules were found in numerous tissues, most frequently the mesenteric adipose tissue and lymph nodes, visceral peritoneum, liver, kidneys, spleen, and lungs. One ferret had a serous abdominal effusion. Microscopically, pyogranulomatous inflammation involved especially the visceral peritoneum, mesenteric adipose tissue, liver, lungs, kidneys, lymph nodes, spleen, pancreas, adrenal glands, and/or blood vessels. Immunohistochemically, all cases were positive for coronavirus antigen using monoclonal antibody FIPV3-70. Electron microscopic examination of inflammatory lesions identified particles with coronavirus morphology in the cytoplasm of macrophages. Partial sequencing of the coronavirus spike gene obtained from frozen tissue indicates that the virus is related to ferret enteric coronavirus.


title: Accelerating drug development through repurposed FDA approved drugs for COVID-19: speed is important, not haste.

text: A life-threatening, emerging respiratory disease called Coronavirus Disease 2019 (COVID-19) 26 originated in the city of Wuhan in China's Hubei province in December, 2019 and has been classified as 27 an international pandemic by the World Health Organization.….


title: Factors influencing suicide risk assessment clinical practice: protocol for a scoping review.

text: INTRODUCTION Every year, suicide accounts for nearly 800 000 deaths worldwide. Appropriate risk assessment and intervention are imperative since evidence demonstrates that a large proportion of those who die by suicide visit health professionals prior to their death. Much previous research has focused on identifying patient-level risk factors that can improve the risk assessment process through scales and algorithms. However, the best practice guidelines emphasise the importance of clinical interviews and prioritise the clinician's final judgement. The purpose of this review is to (1) understand the clinician and organisational level barriers and facilitators that influence a clinician's assessment of suicide risk, (2) identify the types of biases that exist within this process and (3) list any evidence-based training protocols and educational initiatives to aid (or support) clinicians with this process. METHODS AND ANALYSIS This scoping review protocol uses the Arksey and O'Malley framework, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines for scoping reviews. Literature will be identified using a multidatabase search strategy developed in consultation with a medical librarian. The proposed screening process consists of a title and abstract scan, followed by a full-text review by two reviewers to determine the eligibility of articles. Studies outlining any factors that affect a clinician's suicide risk assessment process, ranging from individual experience and behaviours to organisational level influences, will be included. A tabular synthesis of the general study details will be provided, as well as a narrative synthesis of the extracted data, organised into themes using the Situated Clinical Decision-Making framework. ETHICS AND DISSEMINATION Ethical approval is not required for this review. Results will be translated into educational materials and presentations for dissemination to appropriate knowledge users. Knowledge outputs will also include academic presentations at relevant conferences, and a published, peer-reviewed journal article.


title: Capecitabine versus S-1 as adjuvant chemotherapy for patients with stage III colorectal cancer (JCOG0910): an open-label, non-inferiority, randomised, phase 3, multicentre trial.

text: BACKGROUND Adjuvant chemotherapy with oral fluoropyrimidine alone after D3/D2 lymph node dissection improves disease-free survival and overall survival in patients with stage III colon cancer. Adjuvant S-1 has been shown to be non-inferior to uracil and tegafur plus leucovorin in terms of disease-free survival. This study aims to confirm the non-inferiority of S-1 compared with capecitabine as adjuvant treatment in patients with stage III colorectal cancer. METHODS This study was an open-label, non-inferiority, randomised, phase 3, multicentre trial done in 56 Japanese centres to assess the non-inferiority of S-1 to capecitabine as adjuvant chemotherapy. Eligible patients were aged 20-80 years with stage III colorectal adenocarcinoma, as defined by the presence of an inferior margin of the primary tumour above the peritoneal reflection; R0 resection; and colectomy with D3 or D2 lymph node dissection. Patients were randomly assigned (1:1) to receive eight courses of capecitabine (1250 mg/m2 orally twice daily, days 1-14, every 21 days) or four courses of S-1 (40 mg/m2 orally twice daily, days 1-28, every 42 days). Randomisation was done via phone call, fax, or web-based systems to the Japan Clinical Oncology Group Data Center and used a minimisation method with a random component adjusted by institution, tumour location (colon vs rectosigmoid and upper rectum), number of positive lymph node metastases (≤3 vs ≥4), and surgical technique (conventional vs non-touch isolation). The primary endpoint was disease-free survival with a non-inferiority margin for the hazard ratio (HR) set at 1·24, analysed by intention to treat. This trial was registered with UMIN Clinical Trial Registry, number UMIN000003272. FINDINGS Between March 1, 2010, and Aug 23, 2013, 1564 patients were randomly assigned to capecitabine (n=782) or S-1 (n=782), all of whom were included in the efficacy analysis; 777 patients in the capecitabine group and 768 in the S-1 group were included in the safety analysis. At the prespecified second interim analysis after final accrual, 258 (48%) of 535 required events were reported, and the Data and Safety Monitoring Committee recommended early publication because S-1 could not show non-inferiority compared with capecitabine for disease-free survival. With a median follow-up of 23·7 months (IQR 14·1-35·2), 3-year disease-free survival was 82·0% (95% CI 78·5-85·0) for the capecitabine group and 77·9% (74·1-81·1) for the S-1 group (HR 1·23, 99·05% CI 0·89-1·70; one-sided pnon-inferiority=0·46). The most frequent grade 3 or higher adverse events in the capecitabine group were hand-foot skin reactions (123 [16%] of 777 patients), and in the S-1 group were diarrhoea (64 [8%] of 768 patients) and neutropenia (61 [8%]). There was one (<1%) treatment-related death in each group. INTERPRETATION Adjuvant capecitabine remains one of the standard treatments for stage III colorectal cancer in Japan; S-1 is not recommended. FUNDING National Cancer Center and Ministry of Health, Labour and Welfare of Japan.


title: Current and future applications of natural language processing in the field of digestive diseases.

text: Natural language processing (NLP) is a technology that uses computer-based linguistics and artificial intelligence to identify and extract information from free-text data sources such as progress notes, procedure and pathology reports, and laboratory and radiologic test results. With the creation of large databases and the trajectory of health care reform, NLP holds the promise of enhancing the availability, quality, and utility of clinical information with the goal of improving documentation, quality, and efficiency of health care in the United States. To date, NLP has shown promise in automatically determining appropriate colonoscopy intervals and identifying cases of inflammatory bowel disease from electronic health records. The objectives of this review are to provide background on NLP and its associated terminology, to describe how NLP has been used thus far in the field of digestive diseases, and to identify its potential future uses.


Early adaptation of urology residency educational programs during COVID-19 clinical and gathering restrictions.


title: A comparison among three different apheretic techniques for treatment of hyperbilirubinemia.

text: Liver failure is associated to high mortality due to the accumulation of protein-bound metabolites, such as bilirubin, not removed by conventional hemodialysis. Different methods can efficiently remove them, such as the molecular adsorbent recirculating system (MARS), plasma exchange (PEX), and bilirubin or plasma adsorption perfusion (PAP). No direct comparison exists between MARS, PEX and PAP, and current guidelines do not specify which method (and when) to use. We have retrospectively evaluated MARS, PEX and PAP in their effectiveness in lowering plasma bilirubin concentration, and their effects on liver and kidney function. A total of 98 patients have been recruited, which comprised 68 patients treated with PAP (177 sessions), 16 patients with PEX (41 sessions) and 11 patients with MARS (21 sessions). Bilirubin, creatinine, liver enzymes were analyzed before and after the first treatment with each technique. The three methods did not differ for bilirubin lowering efficiency, with MARS showing only slightly less effective reductions. Finally, the three techniques did not differ in the amount of change of cholinesterase, but a lower reduction in AST was found using PAP. Our retrospective observation is one of the largest case series of hepatic failure treated with bilirubin absorption. The choice of the technique cannot be based on the desired reduction in bilirubin concentration. Based on costs and duration of treatment, we suggest that PAP could be considered as a first-line approach. In case of kidney involvement, MARS remains a valuable option.


title: Prevalence of viral infections in Norwegian cats with and without feline lower urinary tract disease.

text: The prevalence of various viral infections was examined in primary accession cases of feline lower urinary tract disease (FLUTD) and healthy control cats in Norway. Urine samples from 102 cats with clinical signs of FLUTD and 73 healthy control cats were tested for the presence of feline calicivirus (FCV), feline coronavirus (FCoV) and feline herpesvirus-1 (FHV-1) by polymerase chain reaction. All urinary samples were negative for FCV and FCoV. One (1%) of the FLUTD cats was found to be positive for FHV-1. The results did not indicate an association between the viral infections examined and signs of FLUTD in the study sample.


The Next Wave of Health Care Strain Related to COVID-19: Heart Failure Patients Coming Back in Force: We Must Not Fail Them.


title: Therapeutic targeting of autophagy in disease: biology and pharmacology.

text: Autophagy, a process of self-digestion of the cytoplasm and organelles through which cellular components are recycled for reuse or energy production, is an evolutionarily conserved response to metabolic stress found in eukaryotes from yeast to mammals. It is noteworthy that autophagy is also associated with various pathophysiologic conditions in which this cellular process plays either a cytoprotective or cytopathic role in response to a variety of stresses such as metabolic, inflammatory, neurodegenerative, and therapeutic stress. It is now generally believed that modulating the activity of autophagy through targeting specific regulatory molecules in the autophagy machinery may impact disease processes, thus autophagy may represent a new pharmacologic target for drug development and therapeutic intervention of various human disorders. Induction or inhibition of autophagy using small molecule compounds has shown promise in the treatment of diseases such as cancer. Depending on context, induction or suppression of autophagy may exert therapeutic effects via promoting either cell survival or death, two major events targeted by therapies for various disorders. A better understanding of the biology of autophagy and the pharmacology of autophagy modulators has the potential for facilitating the development of autophagy-based therapeutic interventions for several human diseases.


title: Hybrid pancreatoduodenectomy in laparoscopic and robotic surgery: a single-center experience in China.

text: BACKGROUND Minimally invasive surgery is beneficial for pancreatic surgery, and the indication has been expanded to pancreatoduodenectomy (PD). The aim of this study was to share our experiences with hybrid PD in laparoscopic and robotic surgery. METHODS Sixty-four patients underwent hybrid PD in which specimen resection and gastrojejunostomy were performed through the laparoscopic route and pancreatojejunostomy and hepaticojejunostomy were performed via a robotic approach by the same surgeon at a single institution between July 2016 and June 2019. The primary endpoint was complications; secondary endpoints were operative time (OT), the length of hospital stay, and blood loss. The data for the patients were retrospectively obtained from electrical medical records. RESULTS All patients underwent surgery with the hybrid procedure. The mean OTs and estimated blood loss (EBL) were 309.7 ± 77.6 min (range 17-620 min), 160 ± 31.7 mL (range 50-800 mL). The mean number of lymph nodes retrieved was 7.3 ± 6.7 (range 0-37), and that among 45 malignant cases was 8.42 ± 6.7 (range 1-37). The average length of postoperative stay in the hospital was 11.14 ± 7.03 days (range 6-47 days). Clinically relevant postoperative pancreatic fistulas (POPFs) occurred in 39 (60.9%) cases, and most were biochemical leak POPF (29 cases, 45.3%); only 10 (15.6%) cases were grade B/C (8 cases were Grade B and 2 cases were Grade C treated with digital subtraction angiography). Bile leakage occurred in 2 (3.1%) patients. One (1.5%) patient had a gastric fistula, and 3 (4.7%) developed postoperative delayed gastric emptying categorized as International Study Group of Pancreatic Surgery (ISGPS) Grade A. Three (4.7%) patients were readmitted for postoperative bleeding, and 2 (3.1%) died within 30 days. CONCLUSION Hybrid PD with laparoscopic and robot surgery is safe and feasible. OT can be reduced by switching from the laparoscopic approach to the robotic procedure at the appropriate timepoint.


title: Moving Health Education and Behavior Upstream: Lessons From COVID-19 for Addressing Structural Drivers of Health Inequities.

text: In this Perspective, we build on social justice and emancipatory traditions within the field of health education, and the field's long-standing commitment to building knowledge and shared power to promote health equity, to examine lessons and opportunities for health education emerging from the COVID-19 pandemic. Examining patterns that emerged as the pandemic unfolded in Metropolitan Detroit, with disproportionate impacts on African American and low-income communities, we consider conditions that contributed to excess exposure, mortality, and reduced access to critical health protective resources. Using a life course framework, we consider enduring impacts of the pandemic for health equity. Finally, we suggest several strategic actions in three focal areas-environment, occupation, and housing-that can be taken by health educators working in partnership with community members, researchers, and decision makers, using, for example, a community-based participatory research approach, to reduce adverse impacts of COVID-19 and promote long-term equity in health.


title: Robotic single-site staging operation for early-stage endometrial cancer: initial experience at a single institution.

text: Objective The aims of this study were to introduce surgical guidelines, and to evaluate the feasibility and safety of a robotic single-site staging (RSSS) operation for early-stage endometrial cancer. Methods Patients with a preoperative diagnosis of endometrial cancer (International Federation of Gynecology and Obstetrics stages IA to IB) from endometrial curettage and preoperative imaging studies were selected at Dongsan Medical Center from March 2014 to November 2015. All surgical procedures, including hysterectomy, salpingo-oophorectomy, bilateral pelvic node dissection, and cytology aspiration, were performed by robotic single-site instruments (da Vinci Si® surgical system; Intuitive Surgical, Sunnyvale, CA, USA). Results A total of 15 women with early-stage endometrial cancer underwent the RSSS operation. The median patient age and body mass index were 53 years (range, 37-70 years) and 25.4 kg/m2 (range, 18.3-46.4 kg/m2). The median docking time, console time, and total operative time were 8 minutes (range, 4-15 minutes), 75 minutes (range, 55-115 minutes), and 155 minutes (range, 125-190 minutes), respectively. The median retrieval of both pelvic lymph nodes was 9 (range, 6-15). There were no conversions to laparoscopy or laparotomy. Conclusion The RSSS operation is feasible and safe in patients with early-stage endometrial cancer. In this study, operative times were reasonable, and the surgical procedure was well-tolerated by the patients. Further evaluation of patients with early-stage endometrial cancer should be performed in large-scale comparative studies using the laparoendoscopic, single-site staging operation to confirm the safety and benefits of the RSSS operation for early-stage endometrial cancer.


title: Capsule endoscopy in young patients with iron deficiency anaemia and negative bidirectional gastrointestinal endoscopy.

text: Background Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology. Materials and methods This was a retrospective, multicentre study (2010-2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age <19 or >50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression. Results Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn's disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3-11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92-0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn. Conclusion In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.


title: A prospective randomized comparison of single-port laparoscopic procedure with open and standard 3-port laparoscopic procedures in the treatment of acute appendicitis.

text: BACKGROUND This prospective randomized study aimed to evaluate the surgical outcomes of single-incision laparoscopic appendectomy (SILA) comparing with open appendectomy (OA) and standard 3-port laparoscopic appendectomy (SLA) in the treatment of acute appendicitis (AA). METHODS Adult patients older than 18 years presenting with AA were randomized into 3 groups to undergo OA, SLA, and SILA from September 2010 to May 2011. The groups were compared with regard of patient's characteristics, perioperative findings/complications, operative time, pain severity, analgesic requirement, time to oral tolerance and flatus, length of hospital stay, and cosmetic results. RESULTS A total of 75 consecutive patients enrolled in the study. Each group included 25 patients. The groups showed no significant differences in patient's characteristics. The mean operative time was significantly longer in SILA than OA with a mean difference of 7 minutes (P < 0.05). Postoperative pain after OA were significantly higher than SLA and SILA (P < 0.05). The average time to oral tolerance and flatus was significantly higher in OA than the laparoscopic groups with a mean difference of 1 and 2.5 hours (P = 0.04 and 0.023, respectively). The length of hospital stay in SLA and SILA was significantly lower than OA with a mean difference of 0.8 days (P < 0.05). There was no difference in overall complications between the groups. There was no difference between SLA and SILA in terms of surgical outcomes. CONCLUSIONS Either SLA or SILA offer patients faster recovery period with acceptable complications than OA. Hence, laparoscopic approach might be considered as first option in the treatment of AA. However, all 3 techniques provide equivalent clinical outcomes despite the significant findings. Therefore, technique selection is based on surgeon's decision, experience, and availability of laparoscopic instruments.


title: Molecular Characterization of the Viroporin Function of Foot-and-Mouth Disease Virus Nonstructural Protein 2B.

text: Nonstructural protein 2B of foot-and-mouth disease (FMD) virus (FMDV) is comprised of a small, hydrophobic, 154-amino-acid protein. Structure-function analyses demonstrated that FMDV 2B is an ion channel-forming protein. Infrared spectroscopy measurements using partially overlapping peptides that spanned regions between amino acids 28 and 147 demonstrated the adoption of helical conformations in two putative transmembrane regions between residues 60 and 78 and between residues 119 and 147 and a third transmembrane region between residues 79 and 106, adopting a mainly extended structure. Using synthetic peptides, ion channel activity measurements in planar lipid bilayers and imaging of single giant unilamellar vesicles (GUVs) revealed the existence of two sequences endowed with membrane-porating activity: one spanning FMDV 2B residues 55 to 82 and the other spanning the C-terminal region of 2B from residues 99 to 147. Mapping the latter sequence identified residues 119 to 147 as being responsible for the activity. Experiments to assess the degree of insertion of the synthetic peptides in bilayers and the inclination angle adopted by each peptide regarding the membrane plane normal confirm that residues 55 to 82 and 119 to 147 of 2B actively insert as transmembrane helices. Using reverse genetics, a panel of 13 FMD recombinant mutant viruses was designed, which harbored nonconservative as well as alanine substitutions in critical amino acid residues in the area between amino acid residues 28 and 147. Alterations to any of these structures interfered with pore channel activity and the capacity of the protein to permeabilize the endoplasmic reticulum (ER) to calcium and were lethal for virus replication. Thus, FMDV 2B emerges as the first member of the viroporin family containing two distinct pore domains.IMPORTANCE FMDV nonstructural protein 2B is able to insert itself into cellular membranes to form a pore. This pore allows the passage of ions and small molecules through the membrane. In this study, we were able to show that both current and small molecules are able to pass though the pore made by 2B. We also discovered for the first time a virus with a pore-forming protein that contains two independent functional pores. By making mutations in our infectious clone of FMDV, we determined that mutations in either pore resulted in nonviable virus. This suggests that both pore-forming functions are independently required during FMDV infection.


title: An Approach to Teaching Psychiatry to Medical Students in the Time of Covid-19.

text: In this time of Covid-19, life in healthcare has changed immeasurably. It has rapidly been injected with an 'all hands-on deck' approach, to facilitate the necessary adaptations required to reduce the spread of the virus and deliver frontline clinical care. Inevitably aspects of these changes have disrupted the delivery of medical education, notably clinical placements have been cancelled and social distancing guidelines prohibit face-to-face teaching. The training of future doctors is an essential part of this effort. Indeed, the emergence of a global health threat has underlined its continued importance. For medical educators and students alike, we have been presented with a challenge. Concurrently this presents us with an impetus and opportunity for innovation. For some time now, a transformation in medical education has been called for, with an increasing recognition of the need to prepare students for the changing landscape of healthcare systems. This has included a focus on the use of technology enhanced, and self-directed learning. As a team of educators and clinicians in psychiatry, working in the School of Medicine and Medical Sciences (SMMS) in University College Dublin (UCD), we will share how we have responded. We outline the adaptations made to our 'Psychiatry' module, and consider the influence this may have on its future delivery. These changes were informed by direct student input.


title: Synchrotron Radiation X-Ray Phase-Contrast Tomography Visualizes Microvasculature Changes in Mice Brains after Ischemic Injury.

text: Imaging brain microvasculature is important in plasticity studies of cerebrovascular diseases. Applying contrast agents, traditional μCT and μMRI methods gain imaging contrast for vasculature. The aim of this study is to develop a synchrotron radiation X-ray inline phase-contrast tomography (SRXPCT) method for imaging the intact mouse brain (micro)vasculature in high resolution (~3.7 μm) without contrast agent. A specific preparation protocol was proposed to enhance the phase contrast of brain vasculature by using density difference over gas-tissue interface. The CT imaging system was developed and optimized to obtain 3D brain vasculature of adult male C57BL/6 mice. The SRXPCT method was further applied to investigate the microvasculature changes in mouse brains (n = 14) after 14-day reperfusion from transient middle cerebral artery occlusion (tMCAO). 3D reconstructions of brain microvasculature demonstrated that the branching radius ratio (post- to preinjury) of small vessels (radius < 7.4 μm) in the injury group was significantly smaller than that in the sham group (p < 0.05). This result revealed the active angiogenesis in the recovery brain after stroke. As a high-resolution and contrast-agent-free method, the SRXPCT method demonstrates higher potential in investigations of functional plasticity in cerebrovascular diseases.


title: Effects of national containment measures on decelerating the increase in daily new cases of COVID-19 in 54 countries and four epicenters of pandemic.

text: BACKGROUND COVID-19 presents a worldwide epidemic, and various countries have responded differently in terms of containment measures to reduce disease transmission, including stay-at-home orders, curfews and lockdowns. Comparative studies are yet to be conducted to investigate the impact of these containment measures, which would be needed to facilitate public health policy-making across countries. OBJECTIVE To describe and evaluate the effects of national containment measures and policies (stay-at-home orders, curfews and lockdowns) on decelerating the increase in daily new cases (DNC) of COVID-19 in 54 countries and four epicenters of pandemic in different jurisdictions around the world. METHODS We reviewed the effective dates of national containment measures (stay-at-home order, curfew, or lockdown) of 54 countries and four epicenters of coronavirus pandemic (Wuhan, New York, Lombardy, and Madrid), and searched cumulative numbers of COVID-19 confirmed cases and DNC from health authorities. Data were drawn from an open, crowdsourced, daily updated COVID-19 dataset from covid.ourworldindata.org hosted by Our World in Data. We examined the trends in the % increase in DNC from 7 days before to 30 days after the effective dates of measures by continents, World Bank income classification, types of containment measure, effective dates of containment measures, sizes of confirmed cases at effective date of containment measures. RESULTS We included 122,366 patients with confirmed COVID-19 infection from 54 countries, and 24,071 patients from four epicenters on the effective dates of containment measures where stay-at-home orders, curfews, or lockdowns took place between 23rd January and 11st April 2020. Stay-at-home, curfew, and lockdown were commonly commenced for countries with around 30%, 20%, and 10% increase in DNC, respectively. All three measures were found to lower the % increase in DNC to <5% within one month. 40.7% of countries had an average % increase in DNC of ≥50% over seven days prior to the commencement of containment measures, where the % increase in DNC was curbed to 10% and 5% in at most 18 days and 26 days after the implementation of containment measures, respectively. CONCLUSIONS Different national containment measures were associated with a decrease in the DNC confirmed with COVID-19 infection. Stay-at-home orders, curfews and lockdowns curbed the % increase in DNC to <5% within a month. Resurgence in cases within one month was observed in some South American countries.


Quo vadis after COVID-19: a new path for global emergency preparedness?


title: Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia.

text: OBJECTIVES Tracheal intubation of ICU patients is frequently associated with severe hypoxemia. Although noninvasive ventilation reduces desaturation during intubation of severely hypoxemic patients, it does not allow for per-procedure oxygenation and has not been evaluated in mild-to-moderate hypoxemic patients for whom high-flow nasal cannula oxygen may be an alternative. We sought to compare pre- and per-procedure oxygenation with either a nonrebreathing bag reservoir facemask or a high-flow nasal cannula oxygen during tracheal intubation of ICU patients. DESIGN Prospective quasi-experimental before-after study (ClinicalTrials.gov: NCT01699880). SETTING University hospital medico-surgical ICU. PATIENTS All adult patients requiring tracheal intubation in the ICU were eligible. INTERVENTIONS In the control (before) period, preoxygenation was performed with a nonrebreathing bag reservoir facemask and in the change of practice (after) period, with high-flow nasal cannula oxygen. MEASUREMENTS AND MAIN RESULTS Primary outcome was median lowest SpO2 during intubation, and secondary outcomes were SpO2 after preoxygenation and number of patients with saturation less than 80%. One hundred one patients were included. Median lowest SpO2 during intubation were 94% (83-98.5) with the nonrebreathing bag reservoir facemask versus 100% (95-100) with high-flow nasal cannula oxygen (p < 0.0001). SpO2 values at the end of preoxygenation were higher with high-flow nasal cannula oxygen than with nonrebreathing bag reservoir facemask and were correlated with the lowest SpO2 reached during the intubation procedure (r = 0.38, p < 0.0001). Patients in the nonrebreathing bag reservoir facemask group experienced more episodes of severe hypoxemia (2% vs 14%, p = 0.03). In the multivariate analysis, preoxygenation with high-flow nasal cannula oxygen was an independent protective factor of the occurrence of severe hypoxemia (odds ratio, 0.146; 95% CI, 0.01-0.90; p = 0.037). CONCLUSIONS High-flow nasal cannula oxygen significantly improved preoxygenation and reduced prevalence of severe hypoxemia compared with nonrebreathing bag reservoir facemask. Its use could improve patient safety during intubation.


Clostridium difficile in ground meat, France.


title: Postmortem swabs in the Sars-CoV-2 Pandemic: Report on 12 complete clinical autopsy cases.

text: Context Clinical autopsies have historically provided a fundamental contribution in the definition of the clinico-pathological basis of infectious diseases. Even though we are witnessing the decline of the clinical autopsy, its importance remains unchanged as it is the most exhaustive way to investigate diseases. The identification of the virus in postmortem tissues is a fundamental step in the definition of its clinical features. Objective To investigate the presence of Sars-CoV-2 in the postmortem with swabs. Design We performed postmortem swabs in 12 autopsy cases of patients with a clinical diagnosis of Sars-CoV-2 related pneumonia. Our protocol, consisted of a rhino-pharingeal and a tracheal swab in order to search for the virus in the upper airways and of two swabs on the parenchyma of each lung. We also performed a fifth swab on the parenchyma of both lungs in order to search for other viruses that could evolve in a clinical picture of interstitial pneumonia Results Overall we found that 9 out of 12 cases had at least one postmortem swab to be positive for Sars-CoV-2. Moreover we evaluated the time lapse between the antemortem and the postmortem swabs, the time between death and the postmortem swabs, and the time lapse between the postmortem swabs and the acceptance to the microbiology laboratory. Interestingly we did not find a relation neither between the results of the swabs and the time lapsed from their collection, or with the time lapsed before their acceptance in the microbiology laboratory. Conclusions A thorough knowledge of the eventual persistence of pathogens in deaths related to infectious diseases is fundamental for the safety of the operators during the autopsy practice, especially when referring to emergent pathogens like Sars-Cov-2. Our study highlights the importance in performing multiple swabs in the postmortem, since Sars-CoV-2 swab positivity can be limited to only a single swab.


Clinical Decision Support Tools and the COVID-19 Pandemic.


title: Living under the shadow of a pandemic: The psychological challenges underlying social distancing and awareness raising.

text: The efforts of containing the novel virus (COVID-19) have now begun to show signs of psychological impact on societies across the globe. Social distancing and awareness campaigns can be double-edged sword, if handled inadequately. Herein, authors have shed light on the favorable and unfavorable aspects of living under lockdown. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Peptide Receptor Radionuclide Therapy (PRRT) during the COVID-19 pandemic: are there any concerns?


The role of T helper 25 cells in the immune response to Mycobacterium leprae.


title: Correlates and prognostic impact of new-onset heart failure after ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: insights from the INFUSE-AMI trial.

text: BACKGROUND The determinants and significance of early (30-day) heart failure symptoms after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) remain unclear. We investigated the clinical and imaging correlates of early post-discharge heart failure in patients with STEMI, and evaluated its impact on clinical outcomes. METHODS Patients from the INFUSE-AMI trial were categorized according to New York Heart Association (NYHA) functional classification at their 30-day visit (NYHA class ≥2 versus 1). Independent correlates of NYHA class ≥2 were determined by multivariable logistic regression. A landmark analysis beyond 30 days was performed to assess the impact of 30-day NYHA class ≥2 on 1-year risk of death or hospitalization for heart failure. RESULTS Among 402 patients enrolled in the INFUSE-AMI trial with data on NYHA class at 30 days, 76 (18.9%) had NYHA class ≥2. Independent correlates of 30-day NYHA class ≥2 were age, Killip class ≥2 at presentation, heart rate at presentation, intraprocedural no-reflow, and 30-day infarct size (% total ventricular mass). After adjustment for infarct size, patients with NYHA class ≥2 remained at higher risk of death or hospitalization for heart failure at 1-year follow-up compared to those in NYHA class 1 (11.8% vs. 2.8%, adjusted hazard ratio 3.78, 95% confidence interval 1.16-12.22, P=0.03). CONCLUSIONS Clinical, procedural, and imaging variables predict the development of clinical heart failure after primary percutaneous coronary intervention in patients with STEMI. Early post-discharge heart failure symptoms identify a high-risk patient cohort for subsequent heart failure hospitalization and death, independent of infarct size. TRIAL REGISTRATION ClinicalTrials.gov ; NCT00976521.


title: From Four-Way Linking to a One Health Platform in Egypt: institutionalisation of a multidisciplinary and multisectoral One Health system.

text: The convergence of humans, animals and our shared environment results in a dynamic in which the health of each group is inextricably linked. Taking into account the fact that the majority of emerging pathogens (e.g. highly pathogenic avian influenza [HPAI], severe acute respiratory syndrome coronavirus, Nipah virus, Middle East respiratory syndrome coronavirus) are zoonotic diseases, Egypt has established a national One Health coordination mechanism. The primary purpose of this mechanism is to provide a comprehensive, strategic approach to concurrent and future health challenges that are facing public and animal heath, including environmental impacts. In this way, the public health, animal health and environment sectors can improve disease mitigation measures, develop stronger and more stable public and animal health services, promote effective national communication strategies and improve One Health collaboration among all relevant sectors. In Egypt, the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) currently assist in hosting the country's Four-Way Linking Task Force with the participation of the convening Ministries (Ministry of Health and Population, Ministry of Environment, and Ministry of Agriculture and Land Reclamation [MOALR] - through the General Organisation for Veterinary Services and the MOALR's laboratories). In the context of the Emerging Pandemic Threats 2 Program, funded by the United States Agency for International Development (USAID), FAO plans to assist Egypt in establishing a robust, multidisciplinary and multisectoral One Health system. This system is based on the solid foundation of the Four-Way Linking Platform, which combines information from four functional streams - epidemiology, laboratories, and animal and human health. Egypt's platform will involve all sectors concerned with HPAI control and combine all stakeholders in an integrated, holistic approach to improve the detection of, response to and control of any threats at the human- animal-environment interface in Egypt.


Coronavirus: global solutions to prevent a pandemic.


title: Prehospital Triage of Acute Stroke Patients During the COVID-19 Pandemic.

text: The coronavirus disease 2019 (COVID-19) pandemic has broad implications on stroke patient triage. Emergency medical services providers have to ensure timely transfer of patients while minimizing the risk of infectious exposure for themselves, their co-workers, and other patients. This statement paper provides a conceptual framework for acute stroke patient triage and transfer during the COVID-19 pandemic and similar healthcare emergencies in the future.


title: Effects of altered photoperiod due to COVID-19 lockdown on pregnant women and their fetuses.

text: Maternal circadian rhythms provide highly important input into the entrainment and programming of fetal and newborn circadian rhythms. The light-dark cycle is an important regulator of the internal biological clock. Even though pregnant women spend a greater part of the day at home during the latter stages of pregnancy, natural light exposure is crucial for the fetus. The current recommended COVID-19 lockdown might dramatically alter normal environmental lighting conditions of pregnant women, resulting in exposure to extremely low levels of natural daylight and high-intensity artificial light sources during both day and night. This article summarizes the potential effects on pregnant woman and their fetuses due to prolonged exposure to altered photoperiod and as consequence altered circadian system, known as chronodisruption, that may result from the COVID-19 lockdown.


title: Effect of ingredients from Chinese herbs on enterovirus D68 production.

text: Human enterovirus 68 (EVD68) is a primary causative agent for respiratory illness worldwide. Until now, there has been no available medication for treating EVD68-related diseases. Rheum emodin, artemisinin, astragaloside, pseudolaric acid B, oridonin, and erianin are natural extracts from Chinese herbs that have traditionally been used for the treatment and prevention of epidemic diseases. Our results showed that pseudolaric acid B protected cells from EVD68-induced cytopathic effects and decreased viral production. However, the same effects were not observed with rheum emodin, astragaloside, or artemisinin. Pseudolaric acid B inhibited EVD68 production by manipulating the host cell cycle in G2/M phase. Further, either oridonin or erianin related G2/M arrest also inhibited viral production. Due to inducing G2/M phase arrest, pseudolaric acid B, oridonin, and erianin might be good candidates for inhibiting EVD68 production, and Chinese herbs with natural compounds inducing G2/M arrest should be considered for the treatment of EVD68-related diseases.


title: Consideration in the management of renal cell carcinoma during the COVID-19 Pandemic.

text: INTRODUCTION Recently the COVID-19 pandemic became the main global priority; main efforts and health infrastructures have been prioritized in favor of COVID-19 battle and the treatment of benign diseases has been postponed. Renal cell cancer (RCC) patients configure a heterogenous populations: some of them present indolent cases which can safely have postponed their treatments, others present aggressive tumors, deserving immediate care. These scenarios must be properly identified before a tailored therapeutic choice. Objectives We propose a risk- based approach for patients with RCC, to be used during this unprecedented viral infection time. MATERIALS AND METHODS After a literature review focused in COVID-19 and current RCC treatments, we suggest therapeutic strategies of RCC in two sections: surgical approach and systemic therapy, in all stages of this malignance. RESULTS Patients with cT1a tumors (and complex cysts, Bosniak III/IV), must be put under active surveillance and delayed intervention. cT1b-T2a/b cases must be managed by partial or radical nephrectomy, some selected T1b-T2a ((≤7cm) cases can have the surgery postponed by 60-90 days). Locally advanced tumors (≥cT3 and or N+) must be promptly resected. As possible, minimally invasive surgery and early hospital discharge are encouraged. Upfront cytoreduction, is not recommendable for low risk oligometastatic patients, which must start systemic treatment or even could be put under surveillance and delayed therapy. Intermediate and poor risk metastatic patients must start target therapy and/or immunotherapy (few good responders intermediate cases can have postponed cytoreduction). The recommendation about hereditary RCC syndromes are lacking, thus we recommend its usual care. Local or loco regional recurrence must have individualized approaches. For all cases, we suggest the application of a specific informed consent and a shared therapeutic choice. CONCLUSION In the pandemic COVID -19 times, a tailored risk-based approach must be used for a safe management of RCC, aiming to not compromise the oncological outcomes of the patients.


title: Larger, but not better, motor adaptation ability inherent in medicated Parkinson's disease patients revealed by a smart-device-based study.

text: Generating appropriate motor commands is an essential brain function. To achieve proper motor control in diverse situations, predicting future states of the environment and body and modifying the prediction are indispensable. The internal model is a promising hypothesis about brain function for generating and modifying the prediction. Although several findings support the involvement of the cerebellum in the internal model, recent results support the influence of other related brain regions on the internal model. A representative example is the motor adaptation ability in Parkinson's disease (PD) patients. Although this ability provides some hints about how dopamine deficits and other PD symptoms affect the internal model, previous findings are inconsistent; some reported a deficit in the motor adaptation ability in PD patients, but others reported that the motor adaptation ability of PD patients is comparable to that of healthy controls. A possible factor causing this inconsistency is the difference in task settings, resulting in different cognitive strategies in each study. Here, we demonstrate a larger, but not better, motor adaptation ability in PD patients than in healthy controls while reducing the involvement of cognitive strategies and concentrating on implicit motor adaptation abilities. This study utilizes a smart-device-based experiment that enables motor adaptation experiments anytime and anywhere with less cognitive strategy involvement. The PD patients showed a significant response to insensible environmental changes, but the response was not necessarily suitable for adapting to the changes. Our findings support compensatory cerebellar functions in PD patients from the perspective of motor adaptation.


title: Is there an association between flow diverter fish mouthing and delayed-type hypersensitivity to metals?-a case-control study.

text: PURPOSE Flow diverters are increasingly used in the treatment of complex and giant intracranial aneurysms. However, they are associated with complications like late aneurysmal rupture. Additionally, flow diverters show focal structural decrease in luminal diameter without any intimal hyperplasia. This resembles a "fish mouth" when viewed en face. In this pilot study, we tested the hypothesis of a possible association between flow diverter fish-mouthing and delayed-type hypersensitivity to its metal constituents. METHODS We retrospectively reviewed patient records from our center between May 2010 and November 2015. A total of nine patients had flow diverter fish mouthing. A control group of 25 patients was selected. All study participants underwent prospective patch test to detect hypersensitivity to flow diverter metal constituents. Analysis was performed using logistic regression analysis and Wilcoxon sign rank sum test. Univariate and multivariate analyses were performed to test variables to predict flow diverter fish mouthing. RESULTS The association between flow diverter fish mouthing and positive patch test was not statistically significant. In multivariate analysis, history of allergy and maximum aneurysm size category was associated with flow diverter fish mouthing. This was further confirmed on Wilcoxon sign rank sum test. CONCLUSION The study showed statistically significant association between flow diverter fish mouthing and history of contact allergy and a small aneurysmal size. Further large-scale studies are needed to detect a statistically significant association between flow diverter fish mouthing and patch test. We recommend early and more frequent follow-up imaging in patients with contact allergy to detect flow diverter fish mouthing and its subsequent evolution.


title: Multicenter review of robotic versus laparoscopic ventral hernia repair: is there a role for robotics?

text: BACKGROUND The utilization of robotic platforms for general surgery procedures such as hernia repair is growing rapidly in the United States. A limited amount of data are available evaluating operative outcomes in comparison to standard laparoscopic surgery. We completed a retrospective review comparing robotic and laparoscopic ventral hernia repair to provide safety and outcomes data to help design a future prospective trial design. METHODS A retrospective review of 215 patients undergoing ventral hernia repair (142 robotic and 73 laparoscopic) was completed at two large academic centers. Primary outcome measure evaluated was recurrence. Secondary outcomes included incidence of primary fascial closure, and surgical site occurrences. RESULTS Propensity for treatment match comparison demonstrated that robotic repair was associated with a decreased incidence of recurrence (2.1 versus 4.2%, p < 0.001) and surgical site occurrence (4.2 versus 18.8%, p < 0.001). This may be because robotic repair was associated with increased incidence of primary fascial closure (77.1 versus 66.7%, p < 0.01). Analysis of baseline patient populations showed that robotic repairs were completed on patients with lower body mass index (28.1 ± 3.6 versus 34.2 ± 6.4, p < 0.001) and fewer comorbidities. CONCLUSIONS Our retrospective data show that robotic repair was associated with decreased recurrence and surgical site occurrence. However, the differences noted in the patient populations limit the interpretability of these results. As adoption of robotic ventral hernia repair increases, prospective trials need to be designed in order to investigate the efficacy, safety, and cost effectiveness of this evolving technique.


title: Effect of catheter-based renal denervation on left ventricular function, mass and (un)twist with two-dimensional speckle tracking echocardiography.

text: BACKGROUND Speckle tracking echocardiography (STE) is an echocardiography modality that is able to measure left ventricular (LV) characteristics, including rotation, strain and strain rate. Strain measures myocardial fibre contraction and relaxation. This study aims to assess the effect of renal sympathetic denervation (RDN) on functional myocardial parameters, including STE, and to identify potential differences between responders and non-responders. METHODS The study population consisted of 31 consecutive patients undergoing RDN in the context of treatment for resistant hypertension. Patients were included between December 2012 and June 2014. Transthoracic echocardiography and speckle tracking analysis was performed at baseline and at 6 months follow-up. RESULTS The study population consisted of 31 patients with treatment-resistant hypertension treated with RDN (mean age 64 ± 10 years, 15 men). The total study population could be divided into responders (n = 19) and non-responders (n = 12) following RDN. RDN reduced office blood pressure by 18.9 ± 26.8/8.5 ± 13.5 mmHg (p < 0.001). A significant decrease was seen in LV posterior wall thickness (LVPWd) (0.47 ± 1.0 mm; p = 0.020), without a significant change in the LV mass index (LVMI). In the total cohort, only peak late diastolic filling velocity (A-wave velocity) decreased significantly by 5.3 ± 13.2 cm/s (p = 0.044) and peak untwisting velocity decreased significantly by 14.5 ± 28.9°/s (p = 0.025). CONCLUSION RDN reduced blood pressure and significantly improved functional myocardial parameters such as A-wave velocity and peak untwisting velocity in patients with treatment-resistant hypertension, suggesting a potential beneficial effect of RDN on myocardial mechanics.


Is glucose-6-phosphate dehydrogenase enzyme deficiency a factor in Coronavirus-19 (COVID-19) infections and deaths?


title: Technique for Fenestrated Stent-Graft Implantation as a Proximal Extension to a Previous Fenestrated Endovascular Repair for Abdominal Aortic Aneurysm.

text: PURPOSE To describe planning and a technique for fenestrated endovascular repair of a large Crawford type IV thoracoabdominal aortic aneurysm after previous 2-fenestration endovascular aneurysm repair (FEVAR). TECHNIQUE The first FEVAR procedure performed at another center implanted a standard Zenith device with 2 fenestrations and 1 scallop for a juxtarenal abdominal aortic aneurysm. The diameter of the Crawford type IV thoracoabdominal aortic aneurysm had progressed from 68 to 75 mm within a year after the FEVAR. Since the celiac trunk was already occluded, a 3-fenestration 22-×172-mm stent-graft was chosen to extend the existing stent-graft further proximally. A tapered 38/22-×179-mm Zenith custom-made device was designed for the thoracic component. The technique addresses several issues that arise during a FEVAR-in-FEVAR case, such as the orientation of the new stent-graft and its fenestrations, the absence of space between the 2 devices for maneuvers, and the difficulty in catheterizing target vessels with existing bridging stents, for which a bailout "snare-ride" maneuver is described. CONCLUSION FEVAR after previous FEVAR is a feasible and efficient treatment option. The modified "snare-ride" technique can be used to catheterize target vessels in the absence of an Indy snare.


title: COVID-19: Symptoms, course of illness and use of clinical scoring systems for the first 42 patients admitted to a Norwegian local hospital.

text: BACKGROUND The COVID-19 outbreak is presenting the health system with new challenges, and there is a great need for knowledge about symptoms, clinical findings and course of illness in patients admitted to Norwegian hospitals with COVID-19. MATERIAL AND METHOD In this observational qualitative study, all patients admitted to a Norwegian local hospital (Bærum Hospital) with proven COVID-19 infection were included consecutively from the start of the outbreak. We present here patient characteristics, symptoms, clinical findings, experience of using clinical scoring systems and course of illness based on data in medical records. RESULTS In the period 9-31 March 2020, 42 patients, of whom 28 (67 %) were men, were admitted to hospital with COVID-19 infection. The median age was 72.5 years (range 30-95). Fever (79 %), reduced general condition (79 %), dyspnoea (69 %) and cough (67 %) were the most common symptoms. A total of nine patients (21 %) had a critical course of illness with treatment in the Intensive Care Department and/or death during their stay in hospital. Patients with a critical course had a higher average score on National Early Warning Score 2 (NEWS2) on admission (7.6 vs 3.3). Only one of the most severely ill patients scored ≥ 2 on the quick Sepsis-related Organ Failure Assessment (qSOFA) on admission. INTERPRETATION Most patients admitted to our hospital with COVID-19 had a fever and respiratory tract symptoms. A high percentage of patients had a critical course of illness. A NEWS2 score of ≥ 5 on admission may be a useful aid in identifying patients at risk of a critical course of illness, while CRB-65 and qSOFA score ≥ 2 proved to be of little usefulness for this purpose in our material.


American Society of Clinical Oncology 2013 top five list in oncology.


Editorial: the new normal for refractive surgery.


title: Insight into the evolution of nidovirus endoribonuclease based on the finding that nsp15 from porcine Deltacoronavirus functions as a dimer.

text: Nidovirus endoribonucleases (NendoUs) include nonstructural protein 15 (nsp15) from coronaviruses and nsp11 from arteriviruses, both of which have been reported to participate in the viral replication process and in the evasion of the host immune system. Results from a previous study of coronaviruses SARS-CoV, HCoV-229E, and MHV nsp15 indicate that it mainly forms a functional hexamer, whereas nsp11 from the arterivirus PRRSV is a dimer. Here, we found that porcine Deltacoronavirus (PDCoV) nsp15 primarily exists as dimers and monomers in vitro Biological experiments reveal that a PDCoV nsp15 mutant lacking the first 27 amino acids of the N-terminal domain (Asn-1-Asn-27) forms more monomers and displays decreased enzymatic activity, indicating that this region is important for its dimerization. Moreover, multiple sequence alignments and three-dimensional structural analysis indicated that the C-terminal region (His-251-Val-261) of PDCoV nsp15 is 10 amino acids shorter and forms a shorter loop than that formed by the equivalent sequence (Gln-259-Phe-279) of SARS-CoV nsp15. This result may explain why PDCoV nsp15 failed to form hexamers. We speculate that NendoUs may have originated from XendoU endoribonucleases (XendoUs) forming monomers in eukaryotic cells, that NendoU from arterivirus gained the ability to form dimers, and that the coronavirus variants then evolved the capacity to assemble into hexamers. We further propose that PDCoV nsp15 may be an intermediate in this evolutionary process. Our findings provide a theoretical basis for improving our understanding of NendoU evolution and offer useful clues for designing drugs and vaccines against nidoviruses.


Forced Choices: Ethical Challenges in Cardiology During the COVID-19 Pandemic.


title: Single-port splenectomy: Current update and controversies.

text: Multiport laparoscopic splenectomy (LS) is considered the "gold standard" for the management of surgical diseases in normal or slightly enlarged spleens. The concept of minimal-invasive surgical techniques has progressed since the early 1990s from standard multiport laparoscopy to natural orifice transluminal endoscopic surgery (NOTES) and, more recently, to single-port access (SPA). In this paper, we describe our technique for SPA splenectomy and provide a critical review of the current literature on SPA for splenic diseases.Preliminary results published to date indicate that the spleen can be safely removed using single-incision surgery and all the authors have unanimously endorsed the feasibility of this approach. However, available evidence is still scarce. It is based only on case reports and one small series, with a total of 17 patents and, therefore, firm conclusions cannot yet be drawn and more experience and comparative trials are needed to determine the exact role of this interesting new approach.


title: Point prevalence of surgical checklist use in Europe: relationship with hospital mortality.

text: BACKGROUND The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. METHODS We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist exposure was associated with lower crude hospital mortality (OR 0.84, CI 0.75-0.94; P=0.002). This effect remained after adjustment for baseline risk factors in a multivariate model (adjusted OR 0.81, CI 0.70-0.94; P<0.005) and strengthened after adjusting for variations within countries and hospitals in a three-level generalized mixed model (adjusted OR 0.71, CI 0.58-0.85; P<0.001). CONCLUSIONS The use of surgical checklists varies across European nations. Reported use of a checklist was associated with lower mortality. This observation may represent a protective effect of the surgical checklist itself, or alternatively, may be an indirect indicator of the quality of perioperative care. CLINICAL TRIAL REGISTRATION The European Surgical Outcomes Study is registered with ClinicalTrials.gov, number NCT01203605.


title: Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery.

text: BACKGROUND Propionibacterium acnes infection is a significant problem after shoulder surgery. Residual P. acnes is found on the skin up to 29% of the time immediately after surgical skin preparation and in 70% of dermal biopsy specimens. These residual bacteria may be a source for infection. Identifying more ideal skin preparation may help reduce the risk of infection. The purpose of this study was to evaluate the effect that topical benzoyl peroxide (BPO), with chlorhexidine skin preparation, would have on the presence of P. acnes cultured at the time of shoulder surgery. We hypothesized that adding topical BPO to our skin preparation would reduce the number of positive P. acnes cultures identified during surgery. METHODS Fifty patients undergoing first-time shoulder surgery were treated with topical 5% BPO cream 48 hours before surgery. After skin preparation, 13 samples per subject were obtained. Cultures were held for 14 days. RESULTS Fifty patients underwent arthroscopic shoulder surgery; 650 culture specimens were obtained. The skin was positive at the initiation of surgery in 6% of cases. Tissue samples were positive in 6%. The skin was positive in 10% at the end of surgery. None of these rates of positive culture were different from the 4% rate observed with a control swab. CONCLUSION Application of BPO is an effective way to reduce P. acnes on skin at the beginning and, importantly, at the end of a surgical procedure. This may result in a lower risk for postoperative infection.


title: Trans-vaginal specimen extraction following totally laparoscopic subtotal gastrectomy in early gastric cancer.

text: BACKGROUND Although natural orifice extraction is now widely performed, there have been no reports of this procedure following subtotal gastrectomy for gastric cancer. This report describes trans-vaginal specimen extraction in four patients with early gastric cancer. METHODS The clinical data of four patients with early gastric cancer were reviewed. Totally laparoscopic subtotal gastrectomy and D1 + β lymph node dissection was performed using five trocars and a conventional procedure. Posterior colpotomy was performed by an experienced gynecologist, who retrieved the specimens in a retrieval bag via the trans-vaginal route. The colpotomy site was repaired immediately following specimen removal. Reconstruction was performed using the intracorporeal Billroth II method and an endo-GIA 60. RESULTS Totally laparoscopic subtotal gastrectomy and trans-vaginal specimen extraction was successfully accomplished in all patients without intraoperative complications. CONCLUSIONS The present technique may be a safe and feasible operative procedure for some limited groups of elderly female patients with early gastric cancer.


title: More with LESS: a novel report of nerve sparing radical hysterectomy performed using LESS.

text: Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery are now being used in gynecologic oncologic procedures. We used our expertise with LESS to perform nerve-sparing laparoscopic radical hysterectomy. A 45-year-old woman with stage IA2 cervical cancer was referred to us. The biopsy specimen showed grade II invasive keratinizing squamous cell carcinoma. We duplicated the steps of our laparoscopic nerve-sparing radical hysterectomy procedure to perform a nerve-sparing radical hysterectomy via LESS using conventional ports and instruments. Oncologic clearance was comparable to that in conventional laparoscopic radical hysterectomy. Bladder function recovered completely after removal of the Foley catheter. Nerve-sparing laparoscopic radical hysterectomy using fewer ports is technically feasible. The oncologic clearance and functional results are comparable to those in the multiport variant.


Genomic analysis of SARS-CoV-2 strains among Indians returning from Italy, Iran & China, & Italian tourists in India.


title: Clinical Significance of Closure of Mesenteric Defects in Laparoscopic Colectomy: A Single-Institutional Cohort Study.

text: BACKGROUND The effect of closure of mesenteric defects to prevent complications, such as internal hernia, during laparoscopic colectomy remains controversial and is a subject of debate. PURPOSE This retrospective single-institution study aimed to clarify the clinical significance of mesenteric defect closure during a laparoscopic colectomy. METHODS We evaluated 58 patients who underwent laparoscopic right-side colectomy or transverse colectomy. The statistical relevance of complications, surgical maneuvers, and clinical factors was examined. RESULTS The mesenteric defects were closed in 30 patients and not closed in 28 patients. Two patients with ileus and 1 with a deep incisional surgical site infection required a second surgery. The reoperation rate was significantly higher in the nonclosure group than in the closure group (11% vs. 0%, respectively; P=0.033). CONSIDERATION Serious complications requiring reoperation occurred only in the nonclosure group. The procedure for closing the defect did not extend the operation time or increase the bleeding.


title: Psychological states of COVID-19 quarantine.

text: The psychological effects of mass quarantine following the COVID-19 lockdown are likely to be significant. Emotional and behavioural responses to quarantine are related to a psychological state of anxiety. These and other emotions are normal and may even be adaptive. The exceptional circumstances of a national lockdown provide an opportunity to develop mental health literacy in the form of psychological first aid, to enable wider awareness of how individuals can contribute to listening and supporting others psychologically. This has potential implications for skilling clinicians and the public about responding to mental distress. As frontline health-care workers, general practitioners may themselves need to be recipients of psychological first aid and support as they deal with adverse consequences of the quarantine period.


Vaccine-Associated Posterior Uveitis.


title: Development of (99m)Tc-N4-NIM for molecular imaging of tumor hypoxia.

text: The nitro group of 2-nitroimidazole (NIM) enters the tumor cells and is bioreductively activated and fixed in the hypoxia cells. 1,4,8,11-tetraazacyclotetradecane (N4) has shown to be a stable chelator for (99m)Tc. The present study was aimed to develop (99m)Tc-cyclam-2-nitroimidazole ((99m)Tc-N4-NIM) for tumor hypoxia imaging. N4-NIM precursor was synthesized by reacting N4-oxalate and 1,3-dibromopropane-NIM, yielded 14% (total synthesis). Cell uptake of (99m)Tc-N4-NIM and (99m)Tc-N4 was obtained in 13762 rat mammary tumor cells and mesothelioma cells in 6-well plates. Tissue distribution of (99m)Tc-N4-NIM was evaluated in breast-tumor-bearing rats at 0.5-4 hrs. Tumor oxygen tension was measured using an oxygen probe. Planar imaging was performed in the tumor-bearing rat and rabbit models. Radiochemical purity of (99m)Tc-N4-NIM was >96% by HPLC. Cell uptake of (99m)Tc-N4-NIM was higher than (99m)Tc-N4 in both cell lines. Biodistribution of (99m)Tc-N4-NIM showed increased tumor-to-blood and tumor-to-muscle count density ratios as a function of time. Oxygen tension in tumor tissue was 6-10 mmHg compared to 40-50 mmHg in normal muscle tissue. Planar imaging studies confirmed that the tumors could be visualized clearly with (99m)Tc-N4-NIM in animal models. Efficient synthesis of N4-NIM was achieved. (99m)Tc-N4-NIM is a novel hypoxic probe and may be useful in evaluating cancer therapy.