title: Recommendations on basic requirements for intensive care units: structural and organizational aspects.

text: OBJECTIVE To provide guidance and recommendations for the planning or renovation of intensive care units (ICUs) with respect to the specific characteristics relevant to organizational and structural aspects of intensive care medicine. METHODOLOGY The Working Group on Quality Improvement (WGQI) of the European Society of Intensive Care Medicine (ESICM) identified the basic requirements for ICUs by a comprehensive literature search and an iterative process with several rounds of consensus finding with the participation of 47 intensive care physicians from 23 countries. The starting point of this process was an ESICM recommendation published in 1997 with the need for an updated version. RESULTS The document consists of operational guidelines and design recommendations for ICUs. In the first part it covers the definition and objectives of an ICU, functional criteria, activity criteria, and the management of equipment. The second part deals with recommendations with respect to the planning process, floorplan and connections, accommodation, fire safety, central services, and the necessary communication systems. CONCLUSION This document provides a detailed framework for the planning or renovation of ICUs based on a multinational consensus within the ESICM.


title: Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive-a Laboratory and Clinical Perspective.

text: Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care.


title: Decrease in cuff pressure during the measurement procedure: an experimental study.

text: BACKGROUND To prevent endotracheal tube (ETT)-related complications during mechanical ventilation, ETT cuff pressure should be kept within proper range. In clinical settings, cuff pressure often decreases from target values. METHODS We performed an experimental study to investigate the effects of measuring devices and endotracheal tubes on change in cuff pressure. We continuously measured cuff pressure by inserting a three-way stopcock in the middle of an ETT pilot balloon system. After adjusting the cuff pressure to 24 cmH2O, we disconnected and reconnected each cuff inflator to the inflation valve of the ETT and measured the changes in the cuff pressure. We measured the change in cuff pressure with different ETT sizes, cuff shapes, brands of cuff inflator, and with and without added extension tubes. RESULTS The cuff pressure decreased, on average, by 6.6 cmH2O (standard deviation 1.9), when connecting the cuff inflator to the pilot balloon. The measured cuff pressure was less than 20 cmH2O in 67% of the tests. The cuff pressure decreased more when an extension tube was used. The brand of cuff inflator made no difference to the pressure loss. The cuff pressure decreased more with ETTs of smaller size and with ETTs with pyriform cuffs. CONCLUSIONS Procedures to connect cuff inflators to inflation valves resulted in the loss of cuff pressure by 6.6 cmH2O on average.


title: Mental health and primary dysmenorrhea: a systematic review.

text: Several factors including demographic, reproductive, lifestyle, psychological and social factors can affect incidence and severity of primary dysmenorrhea. This study aimed to systematically review the psychological risk factors associated with primary dysmenorrhea. Embase, ISI web of knowledge, ProQuest, Science Direct, Scopus and PubMed central were searched using keywords related to risk factors and primary dysmenorrhea. Observational studies, published in English after 2000, focusing solely on psychological factors affecting primary dysmenorrhea were included. The search process retrieved 11,928 potential related articles. Thirty three articles met inclusion criteria and were assessed for final synthesis. The STROBE checklist was used to quality assessment of studies. Results of study showed that few studies had investigated relationship between dysmenorrhea and most psychological disorders. Most studies have investigated the relationship between dysmenorrhea and depression, anxiety, stress, alcohol abuse and somatic disorders. So, further studies are needed to investigate relation between most psychological disorders with primary dysmenorrhea. Significant relationship between some mental health components such as depression, anxiety and stress with primary dysmenorrhea shows the importance of psychological assessment before the choice of therapeutic methods. Also, the feasibility of designing and evaluating the effectiveness of the use of psychotherapy interventions for the treatment of primary dysmenorrhea as alternative therapies can be considered.


Mild or Moderate Covid-19.


title: Single-access retroperitoneoscopic adrenalectomy (SARA) versus conventional retroperitoneoscopic adrenalectomy (CORA): a case-control study.

text: BACKGROUND Stimulated by the concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES), minimizing the access even further has become a new trend in minimally invasive surgery. We compare our recently described new method of endoscopic single-access adrenalectomy with the conventional retroperitoneoscopic approach in a matched-pairs study. METHODS Fifty single-access retroperitoneoscopic adrenalectomies (SARA) were performed in 47 selected patients suffering from Conn's adenomas (n = 20), pheochromocytomas (n = 15), Cushing's adenomas (n = 6), and other diseases (n = 6). For SARA, a single 2-cm skin incision beneath the 12th rib was used. Following creation of the retroperitoneal space with the rigid endoscope, dissection was carried out single-handed. Another 47 patients served as control group; they were treated by the traditional retroperitoneoscopic three-port approach (CORA). Patients were matched with respect to gender, body mass index, diagnoses, tumor size, and tumor site. RESULTS Mortality was zero and no major complications occurred in both groups. SARA was completed in 41 cases (86%). The overall complication rate was 8.5% in SARA and 6.4% in CORA. Operative time was longer for SARA (56 +/- 28 min) than for CORA (40 +/- 12 min) (P < 0.05). Postoperatively, pain medication was administered in 47% of SARA patients and in 75% of CORA patients (P = 0.01). Mean hospital stay was 2.4 +/- 0.7 days (SARA) and 3.1 +/- 1.2 days (CORA) (P < 0.01). CONCLUSIONS Because feasibility and safety of SARA could be demonstrated in a large group of selected patients, this surgical technique may represent a new milestone in minimally invasive endocrine surgery.


Piecemeal mucosectomy, submucosal dissection or transanal microsurgery for large colorectal neoplasm.


title: Far from Standardized: Using Surgical Videos to Identify Variation in Technique for Laparoscopic Sleeve Gastrectomy.

text: BACKGROUND Video assessment is an emerging tool for understanding variation in surgical technique. METHODS Representative videos of laparoscopic sleeve gastrectomy (LSG) were voluntarily submitted by 20 surgeons who participated in a statewide quality improvement collaborative. The amount of time required to complete the salient steps of the operation was measured and variations in the tasks performed during each step were captured. RESULTS Twenty-two videos of LSG were submitted and 11 videos included concurrent hiatal hernia repair. Data obtained from video analysis identified variation in time to complete each step of the procedure: prestapling dissection of stomach (5-25 minutes), gastric stapling (8-20 minutes), and management of the staple line (1-25 minutes). Time required to perform a hiatal hernia repair also varied (1-26 minutes), as did the type of repair: 55% were performed with a posterior cruropexy, 27% were performed with an anterior cruropexy, and 18% were performed with both. Ten different permutations of staple heights and buttressing material were used during division of the stomach with a gastric stapler. Management of the staple line included use of buttressing (64%), fibrin sealant (36%), oversewing (9%), surgical clips (18%), imbrication of the staple line (36%), and omentoplasty (55%). CONCLUSIONS LSG technique is not uniform. Video analysis identified variation in (1) time to complete each step of the procedure, (2) hiatal hernia repair technique, (3) stapling technique, and (4) post-transection staple line management. Future efforts linking video analysis with clinical outcomes can provide objective evidence to support best practices.


title: The neurogenic bladder and incontinent urinary diversion.

text: Management of the neurogenic bladder with an incontinent stoma is necessary in situations in which intermittent catheterization via the urethra or a continent stoma is not feasible. Cutaneous ureterostomy, vesicostomy, ileal conduit, and ileovesicostomy have all been used for this purpose. Vesicostomy is most commonly used as a temporizing measure in the pediatric neurogenic population. Both ileal conduit, with or without cystectomy, and ileovesicostomy have contemporary roles in the management of the neurogenic bladder.


title: Efficacy of auditory evoked potential follow-up in viral meningitis of infants.

text: PURPOSE To examine the rate of occurrence of hearing impairments among the infants who had recovered from viral meningitis under 1 year of age through auditory evoked potential (AEP) test and to investigate the efficacy of the follow-up AEP test in viral meningitis infants. METHODS Two hundred twenty infants (440 ears) were examined through AEP test once, and 47 (94 ears) of them went back for a second examination and were diagnosed with viral meningitis. The first AEP tests were compared with the second results in 47 infants. I latency, V latency, I-III interpeak latency (IPL), and III-V IPL were checked. RESULTS In the first AEP test conducted on 440 ears, the average values of I and V latency and I-III IPL were delayed as compared with normal values. The second AEP results were conducted on 47 infants 92.36 days after the first exam. I latency and V latency of second exam were improved significantly (p < 0.05), but I-III and III-V IPL showed no significant changes. Two hearing impaired patients (4 ears) were confirmed through chart reviews. CONCLUSION The AEP test is a helpful study for early detection of hearing problem. However, in this study, AEP test was too sensitive in acute period, and later, the incidence rate of hearing impairment was relatively low. Therefore, age of onset, severity of neurologic symptom, and clinical examination must be considered before the AEP test.


title: A Piglet Model of Neonatal Hypoxic-Ischemic Encephalopathy.

text: Birth asphyxia, which causes hypoxic-ischemic encephalopathy (HIE), accounts for 0.66 million deaths worldwide each year, about a quarter of the world's 2.9 million neonatal deaths. Animal models of HIE have contributed to the understanding of the pathophysiology in HIE, and have highlighted the dynamic process that occur in brain injury due to perinatal asphyxia. Thus, animal studies have suggested a time-window for post-insult treatment strategies. Hypothermia has been tested as a treatment for HIE in pdiglet models and subsequently proven effective in clinical trials. Variations of the model have been applied in the study of adjunctive neuroprotective methods and piglet studies of xenon and melatonin have led to clinical phase I and II trials(1,2). The piglet HIE model is further used for neonatal resuscitation- and hemodynamic studies as well as in investigations of cerebral hypoxia on a cellular level. However, it is a technically challenging model and variations in the protocol may result in either too mild or too severe brain injury. In this article, we demonstrate the technical procedures necessary for establishing a stable piglet model of neonatal HIE. First, the newborn piglet (< 24 hr old, median weight 1500 g) is anesthetized, intubated, and monitored in a setup comparable to that found in a neonatal intensive care unit. Global hypoxia-ischemia is induced by lowering the inspiratory oxygen fraction to achieve global hypoxia, ischemia through hypotension and a flat trace amplitude integrated EEG (aEEG) indicative of cerebral hypoxia. Survival is promoted by adjusting oxygenation according to the aEEG response and blood pressure. Brain injury is quantified by histopathology and magnetic resonance imaging after 72 hr.


title: Effects of totally extraperitoneal and lichtenstein hernia repair on men's sexual function and quality of life.

text: BACKGROUND In the literature, there have been scant studies that compare the effects of totally extraperitoneal (TEP) and Lichtenstein hernia (LH) repairs on men's sexual function and quality of life. Our aim in this study was to study the sexual function of men after TEP and LH repair according to SF 36 (Health Survey Scoring Demonstration) and IIEF (The International Index of Erectile Function). METHODS A total of 176 men with unilateral inguinal hernia were randomized into two groups. Group T (n = 88) received TEP hernia repair, and Group L (n:88) received LH repair. Patients' demographics and perioperative findings were recorded. For all patients, the preoperative as well as postoperative 7th, 30th and 90th day SF 36 and IIEF were recorded. RESULTS A total of 176 operations consisting of 88 TEP and 88 LH repairs were evaluated. There were no differences in demographics, hernia type, and complications except for body mass index (BMI). The operative time was higher in Group T (29.6 ± 5.8 vs. 43.5 ± 5.7 min; p = 0.001). The averages of the SF 36-Vitality and Social Function for Postoperative (PO) 30th day scores were higher in Group T. The averages of the SF 36-Bodily Pain, General Health, Physical Role, Emotional Role for PO 7-30th days SF36- Mental Health for PO 7th day and SF 36 Physical Function for PO 30-90th days scores were statistically higher in Group T. The averages of the IIEF- Erectile Function for PO 30th day, IIEF- Orgasmic Function, Sexual Desire, Intercourse Satisfaction, and Intercourse Satisfaction for PO 7th and 30th days scores were higher in Group T. CONCLUSIONS TEP and LH repairs have similar results for recurrence, complications, and hospital stay; otherwise, TEP repair yields better results than the LH repair in the postoperative course at the 7th and 30th day evaluation, concerning sexual function and quality of life, but this benefit is no longer apparent at the 90th day. Although the short-term differences were statistically significant, they were moderate and might have a limited impact from the clinical point of view.


title: Atopic eczema and major cardiovascular outcomes: A systematic review and meta-analysis of population-based studies.

text: BACKGROUND Atopic eczema is a common inflammatory skin disease. Various inflammatory conditions have been linked to cardiovascular disease, a major cause of global mortality and morbidity. OBJECTIVE We sought to systematically review and meta-analyze population-based studies assessing associations between atopic eczema and specific cardiovascular outcomes. METHODS MEDLINE, Embase, and Global Health were searched from inception to December 2017. We obtained pooled estimates using random-effects meta-analyses. We used a multivariate Bayesian meta-regression model to estimate the slope of effect of increasing atopic eczema severity on cardiovascular outcomes. RESULTS Nineteen relevant studies were included. The effects of atopic eczema reported in cross-sectional studies were heterogeneous, with no evidence for pooled associations with angina, myocardial infarction, heart failure, or stroke. In cohort studies atopic eczema was associated with increased risk of myocardial infarction (n = 4; relative risk [RR], 1.12; 95% CI, 1.00-1.25), stroke (n = 4; RR, 1.10; 95% CI, 1.03-1.17), ischemic stroke n = 4; RR, 1.17; 95% CI, 1.14-1.20), angina (n = 2; RR, 1.18; 95% CI, 1.13-1.24), and heart failure (n = 2; RR, 1.26; 95% CI, 1.05-1.51). Prediction intervals were wide for myocardial infarction and stroke. The risk of cardiovascular outcomes appeared to increase with increasing severity (mean RR increase between severity categories, 1.15; 95% credibility interval, 1.09-1.21; uncertainty interval, 1.04-1.28). CONCLUSION Significant associations with cardiovascular outcomes were more common in cohort studies but with considerable between-study heterogeneity. Increasing atopic eczema severity was associated with increased risk of cardiovascular outcomes. Improved awareness among stakeholders regarding this small but significant association is warranted.


title: Heritable thrombophilia-hypofibrinolysis and osteonecrosis of the femoral head.

text: We hypothesized that inherited thrombophilia and hypofibrinolysis were risk factors for osteonecrosis of the femoral head. We compared measures of thrombophilia and hypofibrinolysis in referred new adult patients with idiopathic osteonecrosis (n = 71) or secondary osteonecrosis (n = 62) with the same measures in sex- and race-matched healthy control subjects. Heritable thrombophilic Factor VIII and hypofibrinolytic Lp(a) were more frequently high in the 71 patients with idiopathic osteonecrosis than in control subjects. High Factor VIII, Factor V Leiden heterozygosity, and resistance to activated protein C, all heritable thrombophilias, were more frequently present in the 62 patients with secondary osteonecrosis than in control subjects. Our data suggest inherited thrombophilia and hypofibrinolysis are risk factors for both idiopathic and secondary osteonecrosis of the head of the femur.


title: Pulmonary Toxicity and Inflammatory Response of E-Cigarette Vape Cartridges Containing Medium-Chain Triglycerides Oil and Vitamin E Acetate: Implications in the Pathogenesis of EVALI.

text: Recently, there has been an outbreak associated with the use of e-cigarette or vaping products, associated lung injury (EVALI). The primary components of vaping products, vitamin E acetate (VEA) and medium-chain triglycerides (MCT), may be responsible for acute lung toxicity. Currently, little information is available on the physiological and biological effects of exposure to these products. We hypothesized that these e-cig vape cartridges and their constituents (VEA and MCT) induce pulmonary toxicity, mediated by oxidative damage and inflammatory responses, leading to acute lung injury. We studied the potential mechanisms of e-cig vape cartridge aerosol induced inflammatory response by evaluating the generation of reactive oxygen species by MCT, VEA, and cartridges and their effects on the inflammatory state of pulmonary epithelium and immune cells both in vitro and in vivo. Cells exposed to these aerosols generated reactive oxygen species, caused cytotoxicity, induced epithelial barrier dysfunction, and elicited an inflammatory response. Using a murine model, the parameters of acute toxicity to aerosol inhalation were assessed. Infiltration of neutrophils and lymphocytes was accompanied by significant increases in IL-6, eotaxin, and G-CSF in the bronchoalveolar lavage fluid (BALF). In mouse plasma, eicosanoid inflammatory mediators, leukotrienes, were significantly increased. Plasma from e-cig users also showed increased levels of hydroxyeicosatetraenoic acid (HETEs) and various eicosanoids. Exposure to e-cig vape cartridge aerosols showed the most significant effects and toxicity compared to MCT and VEA. In addition, we determined SARS-CoV-2 related proteins and found no impact associated with aerosol exposures from these tested cartridges. Overall, this study demonstrates acute exposure to specific e-cig vape cartridges induces in vitro cytotoxicity, barrier dysfunction, and inflammation and in vivo mouse exposure induces acute inflammation with elevated proinflammatory markers in the pathogenesis of EVALI.


Covid-19: collateral damage of lockdown in India.


title: Pre-implementation guidelines for infectious disease point-of-care testing in medical institutions.

text: Infectious disease point-of-care test (ID-POCT) devices are becoming widely available, and in this respect, international quality standards and guidelines are available for consultation once ID-POCT has been implemented into medical institutions. However, specific guidelines for consultation during the initial pre-implementation decision-making process are currently lacking. Further, there exist pre-implementation issues specific to ID-POCT. Here we present pre-implementation guidelines for consultation when considering the implementation of ID-POCT in medical institutions.


title: Pupillary dilation reflex and pupillary pain index evaluation during general anaesthesia: a pilot study.

text: Background Pupillary response by pupillary dilatation reflex (PDR) is a robust reflex, even measurable during general anaesthesia. However, the ability of infrared pupillometry to detect PDR differences obtained by intraoperative opioid administration in anaesthesized patients remains largely unknown. We analyzed the performance of automated infrared pupillometry in detecting differences in pupillary dilatation reflex response by a inbuilt standardized nociceptive stimulation program in patients under general anesthesia with a standardized propofol/fentanyl scheme. Methods In this single center, interventional cohort study 38 patients (24-74 years) were enrolled. Patients were anesthetized with propofol until loss of consciousness. Two dynamic pupil measurements were performed in each patient (before opioid administration and after opioid steady state). Automated infrared pupillometry was used to determine PDR during nociceptive stimulations (10-60 mA) applied by a inbuilt pupillary pain index protocol (PPI) to the skin area innervated by the median nerve. Increasing stimulations by protocol are device specific and automatically performed until pupil dilation of > 13%. Pupil characteristics, blood pressure, heart rate values were collected. Results After opioid administration, patients needed a higher stimulation intensity (45.26 mA vs 30.79 mA, p = 0.00001). PPI score showed a reduction after analgesic treatment (5.21 vs 7.68, p = 0.000001), resulting in a 32.16% score reduction. Conclusions PDR via automated increased tetanic stimulation may reflect opioid effect under general anaesthesia. Further research is required to detect possible confounding factors such as medication interaction and optimization of individualized opioid dosage.


title: Viral infection after renal transplantation: surveillance and management.

text: Viral infections remain a significant cause of morbidity and mortality following renal transplantation. Although cytomegalovirus is the most common opportunistic pathogen seen in transplant recipients, numerous other viruses have also affected outcomes. In some cases, preventive measures such as pretransplant screening, prophylactic antiviral therapy, or post transplant viral monitoring may limit the impact of these infections. Recent advances in laboratory monitoring and antiviral therapy have improved outcomes. This review will summarize the major viral infections seen following transplant and discuss strategies for prevention and management of these potential pathogens.


Virtual Reality as a Bridge in Palliative Care during COVID-19.


title: Lessons learned and new directions regarding Discharge Direct from Adult Intensive Care Units Sent Home (DISH): A narrative review.

text: Purpose To perform a narrative review of the literature regarding the discharge of patients directly to home (DDH) from the intensive care unit, and to identify patient characteristics and clinical outcomes associated with this practice. Methods We searched MEDLINE and EMBASE from 1946 to present. We also manually searched the references of relevant articles. A two-step review process with three independent reviewers was used to identify relevant articles based on predetermined inclusion/exclusion criteria. Results Four studies were included in the final review. Two studies were retrospective and two studies were prospective that shared data from the same patient cohort. All were single center studies. Two of the four studies outlined clinical outcomes associated with DDH. Conclusions This study highlights the relative dearth in the literature regarding the increasingly common practice of DDH, underscores the importance of further studies in this area, and identifies future important foci of research.


title: Characterization of radiation-induced cavernous malformations and comparison with a nonradiation cavernous malformation cohort.

text: OBJECT The objective of this study was to characterize the clinical features of radiation-induced cavernous malformations (RICMs). METHODS The authors retrospectively reviewed the clinical and radiological characteristics of patients with RICMs. The features of these RICMs were then compared with features of nonradiation cavernous malformations (CMs) in 270 patients. RESULTS Thirty-two patients with RICMs were identified (56.2% men), with a median age of 31.1 years at RICM diagnosis. The median latency from radiation treatment to RICM diagnosis was 12.0 years (interquartile range 5.0-19.6 years). RICMs were always within the previous radiation port. RICMs were symptomatic at diagnosis in 46.9%, and were associated with symptomatic intracranial hemorrhage at any time in 43.8%. Older age at the time of radiation treatment and higher radiation dose were associated with shorter latency. RICMs tended to be diagnosed at a younger age than nonradiation CMs (median 31.1 vs 42.4 years, respectively; p = 0.054) but were significantly less likely to be symptomatic at the time of diagnosis (46.9% vs 65.8%, respectively; p = 0.036). RICMs were more likely to be multiple CMs than nonradiation CMs (p = 0.0002). Prospectively, the risk of symptomatic hemorrhage was 4.2% for RICMs and 2.3% for nonradiation CMs per person-year (p = 0.556). In the absence of symptoms at presentation, the risk of hemorrhage for RICMs was higher than for nonradiation CMs (4.2% vs 0.35%, respectively; p = 0.118). CONCLUSIONS In this patient population, RICMs occurred within the radiation port approximately 12 years after radiation treatment. Compared with nonradiation CMs, RICMs were more likely to occur as multiple CMs, to present at a younger age, and were at least as likely to cause symptomatic hemorrhage.


title: Pipeline Embolization Device Flow Diversion for a Dissecting Ruptured Posterior Cerebral Artery Aneurysm in a Pediatric Patient.

text: BACKGROUND Intracranial aneurysms (IAs) are rare in the pediatric population and are usually considered difficult to treat with traditional microsurgery owing to their complex morphology. Endovascular techniques have become the standard option for treating IAs in adults. More recently, flow diverters, such as the Pipeline embolization device (PED), are being widely adopted for unruptured IAs, with proven safety and efficacy in adults; however, their use in the pediatric population is not well defined. Here we report a pediatric patient with a ruptured posterior cerebral artery (PCA) aneurysm successfully treated with a PED, and provide a review of the literature on the current status of PED use in this subset of patients. CASE DESCRIPTION A previously healthy 4-year old boy presented to the emergency department with a subarachnoid hemorrhage. Magnetic resonance angiography (MRA) suggested a ruptured dissecting aneurysm in the right PCA. After discussing treatment options with the child's parents, off-label use of the PED device was chosen. A single PED device was successfully deployed within 24 hours of onset. At a 6-month follow-up, the patient was fully recovered, with a modified Rankin Scale score of 0, and MRA showed complete occlusion of the aneurysm and patency of the parent vessel. CONCLUSIONS Even though the PED has not received Food and Drug Administration approval to treat IAs in children, the literature reports favorable outcomes with this application. Thus, the PED may be a feasible option for treating challenging cases occurring more frequently in the pediatric population. Further studies in pediatric populations are needed to determine whether this technology is a viable and durable option for treating aneurysms in children.


title: Evaluation of a CO2 partial rebreathing functional residual capacity measurement method for use during mechanical ventilation.

text: OBJECTIVE There is a need for an automated bedside functional residual capacity (FRC) measurement method that does not require a step change in inspired oxygen fraction. Such a method can be used for patients who require a high inspired oxygen fraction to maintain arterial oxygenation and for patients ventilated using a circle breathing system commonly found in operating rooms, which is not capable of step changes in oxygen. We developed a CO(2) rebreathing method for FRC measurement that is based on the change in partial pressure of end-tidal carbon dioxide and volume of CO(2) eliminated at the end of a partial rebreathing period. This study was designed to assess the accuracy and precision of the proposed FRC measurement system compared to body plethysmography and nitrogen washout FRC. METHODS Accuracy and precision of measurements were assessed by comparing the CO(2) rebreathing FRC values to the gold standard, body plethysmography FRC, in twenty spontaneously breathing volunteers. The CO(2) rebreathing FRC measurements were then compared to nitrogen washout FRC in twenty intensive care patients whose lungs were mechanically ventilated. For each subject, an average value of CO(2) rebreathing FRC was compared to the average gold standard method. Measurements were accepted for statistical analysis if they had been recorded from periods of stable tidal ventilation, defined as a coefficient of variation of tidal volume of <0.13. RESULTS Compared to body plethysmography, the accuracy (average error) for the CO(2) rebreathing method during stable ventilation (n = 8) was 0.03 L and precision (1 standard deviation of the error) was 0.29 L (0.8 ± 7.6% of body plethysmography). During stable mechanical ventilation (n = 9), the accuracy was -0.02 L and precision was 0.26 L (-1.1 ± 12.6% of nitrogen washout). CONCLUSIONS The CO(2) rebreathing method for FRC measurement provides acceptable accuracy and precision during stable ventilation compared to the gold standards of body plethysmography and nitrogen washout. The results based on periods of stable ventilation best approximate the performance of the system in the likely areas of application during controlled mechanical ventilation. Further study of the CO(2) rebreathing method is needed to evaluate accuracy in a larger group of controlled mechanical ventilation patients, including patients with respiratory insufficiency and significant lung injury.


title: Ligasure versus Ultracision in thyroid surgery: a prospective randomized study.

text: PURPOSE New hemostatic technologies (NT) are often employed in thyroid surgery in the effort to reduce operating time and complications. The aim of this study is to compare three different hemostatic techniques. METHODS This is a prospective randomized study. There were 150 patients, aged 56 +/- 14 years, randomized for total thyroidectomy with conventional technique (CT), Ligasure vessel sealing system (LI) or Harmonic Scalpel (HS) at the university surgical department. One hundred thirty-five patients had benign diseases; 15 had malignancies. RESULTS Mean postoperative hospital stay was 2.6 days. Mean operation time was 113 +/- 31 min; in HS patients, it was significantly shorter (p < 0.001). Morbidity was 43.3%; mortality was nil. Morbidity was significantly different between CT and NT groups (p = 0.0002); HS and LI groups had a higher morbidity (p = 0.0001 and p = 0.02, respectively). Mean postoperative calcemia was 1.12 +/- 0.1 mmol/l with a significant difference between groups; NT patients had a significantly lower calcemia (p < 0.05). There was no difference in recurrent laryngeal nerve palsies and in intraoperative blood losses (p = ns). CONCLUSIONS According to our experience, the only real advantage of new hemostatic technologies was a shorter operation time with HS.


title: Older Adults and Covid-19: The Most Vulnerable, the Hardest Hit.

text: Older adults in the United States have been the age group hardest hit by the Covid pandemic. They have suffered a disproportionate number of deaths; Covid patients eighty years or older on ventilators had fatality rates higher than 90 percent. How could we have better protected older adults? Both the popular press and government entities blamed nursing homes, labeling them "snake pits" and imposing harsh fines and arduous new regulations. We argue that this approach is unlikely to improve protections for older adults. Rather than focusing exclusively on acute and critical resources, including ventilators, a plan that respected the best interests of older adults would have also supported nursing homes, a critical part of the health care system. Better access to protective equipment for staff members, early testing of staff members and patients, and enhanced means of communication with families were what was needed. These preventive measures would have offered greater benefit to the oldest members of our population than the exclusive focus on acute care.


title: Asthma in pregnancy: a hit for two.

text: Asthma commonly occurs in pregnant females, and recent data have outlined the risks of adverse perinatal outcomes among this population. There is an increased risk of low birth weight and small for gestational age, particularly among females with moderate-to-severe asthma and exacerbations during pregnancy. There is also an increased risk of preterm birth, especially with oral steroid use, a small but statistically significant increased risk of congenital malformations, particularly of cleft lip with or without cleft palate, and an increased risk of neonatal hospitalisation and death. Active management may reduce these risks, possibly through reductions in exacerbations. Additional reassuring data have been presented for asthma medication use, which support the benefits outweighing the risks of indicated asthma medication use in pregnancy. Viral infections are an important trigger of asthma exacerbations in pregnancy, and recent data provides possible immunological changes that may explain this. Poor medication adherence despite worsening asthma symptoms in pregnancy is a problem which continues to be demonstrated in the literature. Improving asthma control in pregnancy has the potential to improve not only the mother's health but also that of her child.


title: Pain after laparoscopic appendectomy: a comparison of transumbilical single-port and conventional laparoscopic surgery.

text: PURPOSE Conventional laparoscopic appendectomy is performed using three ports, and single-port appendectomy is an attractive alternative in order to improve cosmesis. The aim of this study was to compare pain after transumbilical single-port laparoscopic appendectomy (SA) with pain after conventional three-port laparoscopic appendectomy (TA). METHODS From April to September 2011, 50 consecutive patients underwent laparoscopic appendectomy for simple appendicitis without gangrene or perforation. Patients who had undergone appendectomy with a drainage procedure were excluded. The type of surgery was chosen based on patient preference after written informed consent was obtained. The primary endpoint was postoperative pain evaluated by the visual analogue scale score and postoperative analgesic use. Operative time, recovery of bowel function, and length of hospital stay were secondary outcome measures. RESULTS SA using a SILS port (Covidien) was performed in 17 patients. The other 33 patients underwent TA. Pain scores in the 24 hours after surgery were higher in patients who underwent SA (P = 0.009). The change in postoperative pain score over time was significantly different between the two groups (P = 0.021). SA patients received more total doses of analgesics (nonsteroidal anti-inflammatory drugs) in the 24 hours following surgery, but the difference was not statistically significant. The median operative time was longer for SA (P < 0.001). CONCLUSION Laparoscopic surgeons should be concerned about longer operation times and higher immediate postoperative pain scores in patients who undergo SA.


IOM report advises shift in focus for next phase of US AIDS relief program.


title: The association of resistance training with mortality: A systematic review and meta-analysis.

text: BACKGROUND The benefits of aerobic exercise are well-studied; there is no consensus on the association between resistance training and major adverse cardiovascular outcomes. This systematic review and meta-analysis aimed to address this issue. DESIGN AND METHODS We searched for randomized trials and cohort studies that evaluated the association between resistance training and mortality and cardiovascular events. Two investigators screened the identified abstracts and full-texts independently and in duplicate. Cochrane tools were used to assess the risk of bias. We calculated hazard ratios and 95% confidence intervals using random effect models. RESULTS From the 1430 studies identified, 11 (one randomized trial and 10 cohort studies) met the inclusion criteria, totaling 370,256 participants with mean follow-up of 8.85 years. The meta-analysis showed that, compared with no exercise, resistance training was associated with 21% (hazard ratio (95% confidence interval (CI)), 0.79 (0.69-0.91)) and 40% (hazard ratio (95% CI), 0.60 (0.49-0.72)) lower all-cause mortality alone and when combined with aerobic exercise, respectively. Furthermore, resistance training had a borderline association with lower cardiovascular mortality (hazard ratio (95% CI), 0.83 (0.67-1.03)). In addition, resistance training showed no significant association with cancer mortality. Risk of bias was low to intermediate in the included studies. One cohort study looked at the effect of resistance training on coronary heart disease events in men and found a 23% risk reduction (risk ratio, 0.77, CI: 0.61-0.98). CONCLUSION Resistance training is associated with lower mortality and appears to have an additive effect when combined with aerobic exercise. There are insufficient data to determine the potential beneficial effect of resistance training on non-fatal events or the effect of substituting aerobic exercise with resistance training.


title: Inhibition of angiotensin II-induced contraction of human airway smooth muscle cells by angiotensin-(1-7) via downregulation of the RhoA/ROCK2 signaling pathway.

text: Sustained renin-angiotensin system (RAS) activation in asthmatic patients plays a crucial role in airway hyperresponsiveness and airflow limitation. Angiotensin II (Ang II), as a key peptide of RAS, contributes to the contraction of human airway smooth muscle by activating the RhoA/Rho-associated coiled-coil containing protein kinase 2 (ROCK2) signaling pathway. Angiotensin-(1-7) [Ang-(1-7)], is a component of the angiotensin I converting enzyme 2 (ACE2)-Ang-(1-7)-Mas axis which counteracts the detrimental effects of the ACE- Ang II-angiotensin type 1 receptor (AT1R) axis in vivo; however, whether Ang-(1-7) can inhibit the effect of Ang II in the contraction of human airway smooth muscle cells (HASMCs) is unknown. In our study, collagen gel lattices and immunofluorescence were used to evaluate the contraction of HASMCs induced by Ang II. Real-time PCR and western blot analysis were performed to confirm the regulatory mechanism and the participating signaling pathway. Ang II caused the contraction of HASMCs; this effect was reversed by Ang‑(1‑7). In addition, irbesartan and A779, which are inhibitors of AT1R and Mas, respectively, attenuated the effect of Ang II and Ang-(1-7). Furthermore, Y-27632, an inhibitor of ROCK2, attenuated the Ang II-induced contraction of HASMCs by blocking the RhoA/ROCK2 signaling pathway which is involved in this contraction, and thus may be a major regulator involved in the basal maintenance of contractility in HASMCs. These data demonstrate that Ang II induces the contraction of HASMCs and that this effect can be reversed by Ang-(1-7), partially through the downregulation of of the RhoA/ROCK2 signaling pathway.


Intrasaccular Flow Diversion for Wide-Neck Bifurcation Aneurysms: Should the Bar Be Set Higher?


From the literature.


title: Mainstreaming nutrition in maternal, newborn and child health: barriers to seeking services from existing maternal, newborn, child health programmes.

text: In the light of mainstreaming nutrition programs into health services, this review article approaches the issue of barriers to existing maternal child health programs from both theoretical and applied perspectives. It begins with a discussion of salient literature on models of health service utilization. The mid-section of the paper presents the results of a review of research studies that illuminate the barriers to care. Categorical themes emerged from the review of studies in the form of barriers based on geographic factors, temporal factors, a myriad of socio-cultural factors, financial factors and quality of care. The discussion focuses on the need to overcome existing restrictions to health services in order to facilitate initiatives to mainstream nutrition and achieve Millennium Development Goal #1.


title: Detection of viruses in human adenoid tissues by use of multiplex PCR.

text: By PCR, we detected a high frequency of viruses in adenoids obtained from children without acute respiratory symptoms. Our results suggest that persistent/latent viral infection in the respiratory tract confounds interpretation of the association of pathogen detection by PCR with acute respiratory infection in these sources.


title: Synergy of IL-27 and TNF-α in regulating CXCL10 expression in lung fibroblasts.

text: IL-27 is involved in inflammatory reactions. CXCL10 is an important chemokine contributing to airway inflammatory disease. In this study, we investigated whether IL-27 modulated the synthesis of CXCL10 in primary human lung fibroblasts (HLFs). HLFs were activated by IL-27 alone, or in combination with other cytokines. CXCL10 synthesis was measured by real-time PCR and ELISA. An examination of transcriptional regulation was performed via the transient transfection of promoter constructs, whereas mRNA stability was assessed by actinomycin D chase and real-time PCR. The underlying signaling pathways were studied by Western blotting and intracellular staining, using flow cytometry. Our results demonstrated that IL-27 induced and synergized with TNF-α to up-regulate CXCL10 mRNA and protein concentrations in a steroid-insensitive manner. This synergistic CXCL10 production was dependent on the transcriptional regulation of CXCL10 gene promoter activity and the enhanced stability of CXCL10 mRNA because of IL-27 and TNF-α, and this synergism was regulated by the activation of p38 mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-OH kinase (PI3K)-Akt dominantly, and in small part via NF-κB. Interestingly, IL-27 promoted the basal and enhanced TNF-α-induced phosphorylation of p38 MAPK and Akt, but not IκBα. Moreover, enhanced CXCL10 mRNA stability occurred via a p38 MAPK-dependent pathway. Finally, clinical analysis showed that IL-27 was detected in the bronchoalveolar lavage of patients with asthma, chronic obstructive pulmonary disease (COPD), and pulmonary tuberculosis (PTB), and increased IL-27 concentrations were correlated with increased CXCL10 concentrations in patients with COPD and PTB. Our findings suggest that IL-27 has the potential to amplify airway inflammation via the induction of CXCL10 from HLFs, in combination with TNF-α.


title: Research with older people in a world with COVID-19: identification of current and future priorities, challenges and opportunities.

text: Older people are disproportionately affected by the COVID-19 pandemic, which has had a profound impact on research as well as clinical service delivery. This commentary identifies key challenges and opportunities in continuing to conduct research with and for older people, both during and after the current pandemic. It shares opinions from responders to an international survey, a range of academic authors and opinions from specialist societies. Priorities in COVID-19 research include its specific presentation in older people, consequences for physical, cognitive and psychological health, treatments and vaccines, rehabilitation, supporting care homes more effectively, the impact of social distancing, lockdown policies and system reconfiguration to provide best health and social care for older people. COVID-19 research needs to be inclusive, particularly involving older people living with frailty, cognitive impairment or multimorbidity, and those living in care homes. Non-COVID-19 related research for older people remains of critical importance and must not be neglected in the rush to study the pandemic. Profound changes are required in the way that we design and deliver research for older people in a world where movement and face-to-face contact are restricted, but we also highlight new opportunities such as the ability to collaborate more widely and to design and deliver research efficiently at scale and speed.


title: A New Flow-Diverter (the FloWise): In-Vivo Evaluation in an Elastase-Induced Rabbit Aneurysm Model.

text: OBJECTIVE We aimed to evaluate the efficacy and safety of a newly developed, partially retrievable flow-diverter (the FloWise) in an elastase-induced rabbit aneurysm model. MATERIALS AND METHODS We developed a partially retrievable flow diverter composed of 48 strands of Nitinol and platinum wire. The FloWise is compatible with any microcatheter of 0.027-inch inner diameter, and is retrievable up to 70% deployment. The efficacy and safety of the FloWise were evaluated in the elastase-induced rabbit aneurysm model. The rate of technical success (full coverage of aneurysm neck) and assessment of aneurysm occlusion and stent patency was conducted by angiograms and histologic examinations at the 1-month, 3-month, and 6-month follow-up. The patency of small arterial branches (intercostal or lumbar arteries) covered by the FloWise were also assessed in the 5 subjects. RESULTS We attempted FloWise insertion in a total of 32 aneurysm models. FloWise placement was successful in 31 subjects (96.9%). Two stents (6.2%) were occluded at the 3-month follow-up, but there was no evidence of in-stent stenosis in other subjects. All stented aneurysms showed progressive occlusion: grade I (complete aneurysm occlusion) in 44.4% and grade II (aneurysm occlusion > 90%) in 55.6% at 1 month; grade I in 90% and II in 10% at 3 months; and grade I in 90% and II in 10% at 6 months. All small arterial branches covered by the FloWise remained patent. CONCLUSION A newly developed, partially retrievable flow-diverter seems to be a safe and effective tool of aneurysm occlusion, as evaluated in the rabbit aneurysm model.


Digital Smartphone Tracking for COVID-19: Public Health and Civil Liberties in Tension.


title: Genetic variation and metabolic pathway intricacy govern the active compound content and quality of the Chinese medicinal plant Lonicera japonica thunb.

text: BACKGROUND Traditional Chinese medicine uses various herbs for the treatment of various diseases for thousands of years and it is now time to assess the characteristics and effectiveness of these medicinal plants based on modern genetic and molecular tools. The herb Flos Lonicerae Japonicae (FLJ or Lonicera japonica Thunb.) is used as an anti-inflammatory agent but the chemical quality of FLJ and its medicinal efficacy has not been consistent. Here, we analyzed the transcriptomes and metabolic pathways to evaluate the active medicinal compounds in FLJ and hope that this approach can be used for a variety of medicinal herbs in the future. RESULTS We assess transcriptomic differences between FLJ and L. japonica Thunb. var. chinensis (Watts) (rFLJ), which may explain the variable medicinal effects. We acquired transcriptomic data (over 100 million reads) from the two herbs, using RNA-seq method and the Illumina GAII platform. The transcriptomic profiles contain over 6,000 expressed sequence tags (ESTs) for each of the three flower development stages from FLJ, as well as comparable amount of ESTs from the rFLJ flower bud. To elucidate enzymatic divergence on biosynthetic pathways between the two varieties, we correlated genes and their expression profiles to known metabolic activities involving the relevant active compounds, including phenolic acids, flavonoids, terpenoids, and fatty acids. We also analyzed the diversification of genes that process the active compounds to distinguish orthologs and paralogs together with the pathways concerning biosynthesis of phenolic acid and its connections with other related pathways. CONCLUSIONS Our study provides both an initial description of gene expression profiles in flowers of FLJ and its counterfeit rFLJ and the enzyme pool that can be used to evaluate FLJ quality. Detailed molecular-level analyses allow us to decipher the relationship between metabolic pathways involved in processing active medicinal compounds and gene expressions of their processing enzymes. Our evolutionary analysis revealed specific functional divergence of orthologs and paralogs, which lead to variation in gene functions that govern the profile of active compounds.


title: Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke.

text: PURPOSE Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication. METHODS Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID. RESULTS Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups. CONCLUSION The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy.


title: Porcine incisional hernia model: Evaluation of biologically derived intact extracellular matrix repairs.

text: We compared fascial wounds repaired with non-cross-linked intact porcine-derived acellular dermal matrix versus primary closure in a large-animal hernia model. Incisional hernias were created in Yucatan pigs and repaired after 3 weeks via open technique with suture-only primary closure or intraperitoneally placed porcine-derived acellular dermal matrix. Progressive changes in mechanical and biological properties of porcine-derived acellular dermal matrix and repair sites were assessed. Porcine-derived acellular dermal matrix-repaired hernias of additional animals were evaluated 2 and 4 weeks post incision to assess porcine-derived acellular dermal matrix regenerative potential and biomechanical changes. Hernias repaired with primary closure showed substantially more scarring and bone hyperplasia along the incision line. Mechanical remodeling of porcine-derived acellular dermal matrix was noted over time. Porcine-derived acellular dermal matrix elastic modulus and ultimate tensile stress were similar to fascia at 6 weeks. The biology of porcine-derived acellular dermal matrix-reinforced animals was more similar to native abdominal wall versus that with primary closure. In this study, porcine-derived acellular dermal matrix-reinforced repairs provided more complete wound healing response compared with primary closure.


title: Safety considerations for synthetic sling surgery.

text: Implantation of a synthetic midurethral sling (SMUS) is the most commonly performed anti-incontinence operation in women worldwide. The effectiveness of the SMUS is comparable to that of the historical gold standards--autologous fascial slings and the Burch colposuspension. Much controversy, however, has evolved regarding the safety of this type of sling. Overall, the quality of the studies with respect to assessing risks of SMUS-associated complications is currently poor. The most common risks in patients with SMUS include urethral obstruction requiring surgery (2.3% of patients with SMUS), vaginal, bladder and/or urethral erosion requiring surgery (1.8%) and refractory chronic pain (4.1%); these data likely represent the minimum risks. In addition, the failure rate of SMUS implantation surgery is probably at least 5% in patients with stress urinary incontinence (SUI). Furthermore, at least one-third of patients undergoing sling excision surgery develop recurrent SUI. Considering the additional risks of refractory overactive bladder, fistulas and bowel perforations, among others, the overall risk of a negative outcome after SMUS implantation surgery is ≥15%.


Coronavirus pandemic: how is neurosurgical-oncology practice affected?


title: Transgenic CCL2 expression in the central nervous system results in a dysregulated immune response and enhanced lethality after coronavirus infection.

text: Chemokine (C-C motif) ligand 2 (CCL2), a chemoattractant for macrophages, T cells, and cells expressing CCR2, is upregulated during acute and chronic inflammation. CCL2 has been implicated in both proinflammatory and anti-inflammatory responses and has been suggested as a target for therapy in some inflammatory disorders. To examine the role of CCL2 during virus infection, we infected mice transgenically expressing CCL2 in the central nervous system (CCL2 Tg) with an attenuated neurotropic coronavirus (rJ2.2 strain of mouse hepatitis virus). Infection of wild-type mice with rJ2.2 results in mild acute encephalitis, followed by a nonlethal, chronic demyelinating disease. Proinflammatory innate and adaptive immune responses mediate virus clearance. In marked contrast, CCL2 Tg mice infected with rJ2.2 ineffectively cleared virus and rapidly succumbed to the infection. CCL2 Tg mice mounted a dysregulated immune response, characterized by augmented accumulation of regulatory Foxp3(+)CD4(+) T cells and of nitric-oxide- and YM-1-expressing macrophages and microglia, suggestive of mixed M1/M2 macrophage activation. Further, macrophages from infected CCL2 Tg brains relative to non-Tg controls were less activated/mature, expressing lower levels of major histocompatibility complex class II (MHC-II), CD86, and CD40. Collectively, these results show that persistent CCL2 overexpression establishes and sustains an immunological milieu that is both inflammatory and immunosuppressive and predisposes mice to a defective immune response to a minimally lethal virus.


title: Characteristics of lung cancer after a previous malignancy.

text: BACKGROUND In the era of improving overall survival rates of malignant diseases, the impact of a previous malignancy (PM) on treatment and outcome of lung cancer (LC) remains unclear. METHODS We reviewed all LC patients from our institution that were treated from 2004 to 2006 for the occurrence of LC with PM excluding patients with multiple primary LC. RESULTS A total of 444 and 2698 LC patients with and without a history of a PM were identified (prevalence of 14.1%). PM were most often located in breast (15.5%), prostate (14.9%), bladder (9.0%) and kidney (8.8%). Compared to never smokers, patients with nicotine consumption had more often a cancer history of prostate, gastrointestinal, and the head-neck region. The median interval until diagnosis of LC was 72.2 months (range 0-537 months) with most LC diagnosed 5 years after PM diagnosis. With a similar distribution of histology, stage and localization compared to controls, NSCLC patients with PM and stage IV disease showed a favorable overall survival (p < 0.0001). In contrast, SCLC patients had similar survival curves (n.s.). CONCLUSIONS A considerable subgroup of LC patients has a history of PM that may indicate a favorable prognostic factor. However, these patients should be treated similar to other LC patients.


title: Use of a prosthetic mesh to prevent parastomal hernia during laparoscopic abdominoperineal resection: a randomized controlled trial.

text: PURPOSE Prevention of parastomal hernia represents an important aim when a permanent stoma is necessary. The objective of this work is to assess whether implantation of a prophylactic prosthetic mesh during laparoscopic abdominoperineal resection contributed to reduce the incidence of parastomal hernia. METHODS Rectal cancer patients undergoing elective laparoscopic abdominoperineal resection with permanent colostomy were randomized to placement of a large-pore lightweight mesh in the intraperitoneal/onlay position by the laparoscopic approach (study group) or to the control group (no mesh). Parastomal hernia was defined radiologically by a CT scan performed after 12 months of surgery. The usefulness of subcutaneous fat thickness measured by CT to discriminate patients at risk of parastomal hernia was assessed by ROC curve analysis. RESULTS Thirty-six patients were randomized, 19 to the mesh group and 17 to the control group. Parastomal hernia was detected in 50 % of patients in the mesh group and in 93.8 % of patients in the control group (P = 0.008). The AUC for thickness of the subcutaneous abdominal was 0.819 (P = 0.004) and the optimal threshold 23 mm. Subcutaneous fat thickness ≥23 mm was a significant predictor of parastomal hernia (odds ratio 15.7, P = 0.010), whereas insertion of a mesh was a protective factor (odds ratio 0.06, P = 0.031). CONCLUSIONS Use of prophylactic large-pore lightweight mesh in the intraperitoneal/onlay position by a purely laparoscopic approach reduced the incidence of parastomal hernia formation. Subcutaneous fat thickness ≥23 mm measured by CT was an independent predictor of parastomal hernia.


title: Variation in the IL1B, TNF and IL6 genes and individual susceptibility to prosthetic joint infection.

text: BACKGROUND Prosthetic joint infection (PJI) is an important failure mechanism of total joint arthroplasty (TJA). Here we examine whether the particular genetic variants can lead to increased susceptibility to PJI development. RESULTS We conducted a genetic-association study to determine whether PJI could be associated with functional cytokine gene polymorphisms (CGP) influencing on innate immunity response. A case-control design was utilized and previously published criteria for PJI were included to distinguish between cases and control subjects with/without TJA. Six single nucleotide polymorphisms (SNPs) located in the genes for interleukin-1beta (SNP: IL1B-511, +3962), tumour necrosis factor alpha (TNF-308, -238) and interleukin-6 (IL6-174, nt565) were genotyped in 303 Caucasian (Czech) patients with TJA (89 with PJI / 214 without PJI), and 168 unrelated healthy Czech individuals without TJA. The results showed that carriers of the less common IL1B-511*T allele were overrepresented in the group of TJA patients with PJI (69%) in comparison with those that did not develop PJI (51%, p = 0.006, p(corr) = 0.037) and with healthy controls (55%, p = 0.04, p(corr) = N.S.). There was no significant difference in the distribution of the remaining five investigated CGPs and their haplotypes between groups. CONCLUSION A functional variant of the gene encoding for IL-1beta was preliminarily nominated as a genetic factor contributing to the susceptibility to PJI. Our results should be independently replicated; studies on the functional relevance of IL1B gene variants in PJI are also needed.


title: Isodeoxyelephantopin, a sesquiterpene lactone from Elephantopus scaber Linn., inhibits pro-inflammatory mediators' production through both NF-κB and AP-1 pathways in LPS-activated macrophages.

text: Isodeoxyelephantopin (IDET) has been identified as an anti-tumor natural constituent whose anti-tumor activity and mechanism have been widely investigated. Since the occurrence and development of cancer usually accompany with inflammation, and tumor signaling shares many components with inflammation signaling, the agents with anti-tumor activity are likely to possess anti-inflammation potential. Thus, the current study aims to demonstrate the anti-inflammatory activity along with the underlying mechanism of IDET in lipopolysaccharide (LPS)-primed macrophages. By using Griess method and ELISA, we found that in both bone marrow derived macrophages and alveolar macrophage cell line, IDET, at relatively low concentrations (0.75, 1.5 and 3 μM), could inhibit LPS-induced expression of various pro-inflammatory mediators including nitric oxide (NO) generated by inducible nitric oxide synthase (iNOS), interleukin (IL)-6, monocyte chemotactic protein-1 (MCP-1) and IL-1β. Meanwhile, in activated MH-S cells, the inhibitory action of IDET on mRNA expression levels of these cytokines was also detected using qPCR. Mechanistically, the effects of IDET on two key inflammatory signalings, nuclear factor-κB (NF-κB) and activator protein-1 (AP-1) pathways, were determined in LPS-activated MH-S cells by reporter gene along with western blot assays. On the one hand, IDET suppressed NF-κB signaling via down-regulating phosphorylation and degradation of inhibitor of NF-κB (IκB)-α and the subsequent p65 translocation. On the other hand, IDET dampened AP-1 signaling through attenuating phosphorylation of both c-jun N-terminal kinase 1/2 (JNK1/2) and extracellular signal regulated kinase 1/2 (ERK1/2). Our study indicates that IDET might be a promising constituent from the anti-inflammatory herb Elephantopus scaber Linn. in mitigating inflammatory conditions, especially respiratory inflammation.


title: Developing a guidance resource for managing delirium in patients with Covid-19.

text: As the Covid-19 pandemic escalates worldwide it is apparent that many patients with more severe illness will also experience delirium. These patients pose a particular challenge in the application of optimal care due to issues with infectious risk, respiratory compromise and potential interactions between medications that can be used to manage delirium with antiviral and other treatments used for Covid-19. We describe a guidance resource adapted from existing guidelines for delirium management that has been tailored to the specific challenge of managing delirium in patients with Covid-19 infection. Issues around the assessment and treatment of these patients are examined and distilled into a simple (one-paged guidance resource that can assist clinicians in managing suspected delirium.


The SEIRS model for infectious disease dynamics.


title: Predictive capability of left atrial size measured by CT, TEE, and TTE for recurrence of atrial fibrillation following radiofrequency catheter ablation.

text: BACKGROUND Recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA) has been well established and is in part related to left atrial (LA) size. The purpose of this study was to assess the predictive capability of LA diameter (LAD) and LA volume (LAV) by echocardiography and computed tomography (CT) to determine success in patients undergoing RFCA of AF. METHODS Eighty-eight patients with paroxysmal or persistent AF who had undergone RFCA and had a prior transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), and CT were enrolled in the study. TTE LADs and LV ejection fraction as well as TEE LADs and LAVs in three views were recorded. CT LAVs were also recorded. Clinical parameters prior to ablation as well as at 1-year follow-up were assessed. RESULTS A total of 40 (45%) patients with paroxysmal AF and 48 (55%) patients with persistent AF were analyzed. Paroxysmal AF patients had a RFCA success rate of 88% at 1 year with persistent AF patients having a 52% success rate (P < 0.001). A CT-derived LAV >or= 117 cc was associated with an odds ratio (OR) for recurrence of 4.8 (95% confidence interval [CI]=[1.4-16.4], P = 0.01) while a LAV >or=130 cc was associated with an OR for recurrence of 22.0 (95% CI =[2.5-191.0], P = 0.005) after adjustment for persistent AF. CONCLUSIONS LA dimensions and AF type are highly predictive of AF recurrence following RFCA. LAV by CT has significant predictive benefit over standard LADs in severely enlarged atria even after adjustment for AF type.


title: SEDATIVE, CARDIORESPIRATORY, AND THERMOREGULATORY EFFECTS OF ALFAXALONE ON BUDGERIGARS (MELOPSITTACUS UNDULATUS).

text: Alfaxalone is a neurosteroid anesthetic agent that has been extensively used in both human and veterinary medicine for more than 50 yr. Previous studies involving avian species demonstrated various dose ranges and multiple routes of administration. The aim of this study was to evaluate the short-term sedative, cardiorespiratory, and thermoregulatory effects of an intramuscular injection of alfaxalone on budgerigars (Melopsittacus undulatus). A crossover study was performed with a sample size of 10 male budgerigars, previously determined to be healthy based on physical examination. Alfaxalone was administered intramuscularly at two doses: 15 and 20 mg/kg. The lower dose resulted in mild to moderate sedation for 29 ± 5 min, whereas the higher dose resulted in moderate to profound sedation for 29 ± 7 min. A statistically significant decrease in heart rate was observed 2 min after administration of alfaxalone at 15 mg/kg; however, this finding was noted to be transient. A statistically significant decrease in respiratory rate was observed at 6 and 10 min after injection in both groups. Cloacal temperature measurement with a digital thermometer and eye temperature calculated from thermographic images demonstrated a decrease in body temperature over time but was not found to be statistically significant. Intramuscular use of alfaxalone proved to provide short-term sedation in budgerigars, with statistically significant but clinically mild cardiorespiratory effects. Due to a significant decrease in body temperature, active warming is recommended when using alfaxalone in budgerigars.


COVID-19 and changing social norms.


title: The learning curve of laparoendoscopic single-Site (LESS) fundoplication: definable, short, and safe.

text: BACKGROUND AND OBJECTIVES This study of laparoendoscopic single-site (LESS) fundoplication for gastroesophageal reflux disease was undertaken to determine the "learning curve" for implementing LESS fundoplication. METHODS One hundred patients, 38% men, with a median age of 61 years and median body mass index of 26 kg/m(2) , underwent LESS fundoplications. The operative times, placement of additional trocars, conversions to "open" operations, and complications were compared among patient quartiles to establish a learning curve. Median data are reported. RESULTS The median operative times and complications did not differ among 25-patient cohorts. Additional trocars were placed in 27% of patients, 67% of whom were in the first 25-patient cohort. Patients undergoing LESS fundoplication had a dramatic relief in the frequency and severity of all symptoms of reflux across all cohorts equally (P < .05), particularly for heartburn and regurgitation, without causing dysphagia. CONCLUSION LESS fundoplication ameliorates symptoms of gastroesophageal reflux disease without apparent scarring. Notably, few operations required additional trocars after the first 25-patient cohort. Patient selection became more inclusive (eg, more "redo" fundoplications) with increasing experience, whereas operative times and complications remained relatively unchanged. The learning curve of LESS fundoplication is definable, short, and safe. We believe that patients will seek LESS fundoplication because of the efficacy and superior cosmetic outcomes; surgeons will need to meet this demand.


title: The retrograde transvenous push-through method: a novel treatment of peripheral arteriovenous malformations with dominant venous outflow.

text: PURPOSE To evaluate the efficacy and safety of a novel retrograde transvenous embolization technique of peripheral arteriovenous malformations (AVMs) using Onyx. MATERIALS AND METHODS We conducted a retrospective analysis of all patients who underwent transvenous retrograde Onyx embolization of peripheral AVMs with dominant venous outflow over a 29-month period. The embolization is aimed at retrograde filling of the nidus after building a solid plug in the dominant venous outflow (push-through). Classification, clinical signs, technical aspects, clinical and technical success rates, and complications were recorded. Short-term outcome was assessed. RESULTS 11 Symptomatic patients (8 female; mean age 31.4 years) were treated at our Vascular Anomalies Center with this method between January 2012 and May 2014. The AVMs were located on the upper extremity (n = 3), pelvis (n = 2), buttock (n = 2), and lower extremity (n = 4). Retrograde embolization was successfully carried out after preparatory transarterial-flow reduction in eight cases (73 %) and venous-flow reduction with Amplatzer Vascular Plugs in four cases (36 %). Complete devascularization (n = 10; 91 %) or 95 % devascularization (n = 1; 9 %) led to complete resolution (n = 8; 73 %) or improvement of clinical symptoms (n = 3; 27 %). One minor complication occurred (pain and swelling). During a mean follow-up time of 8 months, one clinically asymptomatic recurrence of AVM was detected. CONCLUSION Initial results suggest that retrograde transvenous Onyx embolization of peripheral AVMs with dominant venous outflow is a safe and effective novel technique with a low complication rate.


title: Is low pathogenic avian influenza virus virulent for wild waterbirds?

text: Although low pathogenic avian influenza virus (LPAIV) is traditionally considered to have adapted to its wild waterbird host to become avirulent, recent studies have suggested that LPAIV infection might after all have clinical effects. Therefore, I reviewed the literature on LPAIV infections in wild waterbirds. The virulence of LPAIV was assessed in 17 studies on experimental infections and nine studies on natural infections. Reported evidence for virulence were reductions in return rate, feeding rate, body weight, long-range movement and reproductive success, as well as pathological changes in infected organs. However, major caveats in studies of experimental infections were unnatural route of LPAIV inoculation, animal husbandry not simulating natural stressors and low sensitivity of clinical assessment. Major caveats in studies of natural infections were incomplete measurement of LPAIV infection burden, quasi-experimental design and potential misclassification of birds. After taking these caveats into account, the only remaining evidence for virulence was that presence and intensity of LPAIV infection were negatively correlated with body weight. Based on this correlation, together with the demonstrated LPAIV tropism for the intestinal tract, I hypothesize that LPAIV reduces digestive tract function, and suggest how future studies could be directed to test this hypothesis.


title: A primary inferior lumbar hernia misdiagnosed as a lipoma.

text: Lumbar hernias can be superior (Grynfelt) and inferior (Petit). Inferior lumbar hernias are extremely rare and, therefore, are associated with diagnostic difficulty. We present a case of a primary spontaneous inferior lumbar hernia in a 79-year-old woman that was initially diagnosed as a large lipoma on ultrasound. The first operation was abandoned and an open mesh repair was conducted. Lumbar hernias can be primary acquired (55%), secondary acquired (25%) or congenital (20%). Cross-sectional imaging by CT or MRI appears to be the gold standard in diagnosis as ultrasound may lead to misdiagnosis. Strangulation, incarceration and obstruction are recognised complications, requiring prompt surgical intervention. There are currently no guidelines for surgical managements, although laparoscopic surgery may give the best results. In view of the scarcity of published cases, we aim to add to the literature to raise the index of suspicion and to promote prompt surgical management of lumbar hernias.


title: First whole genome characterization of porcine astrovirus detected in swine faeces in Italy.

text: Porcine astroviruses (PoAstV) are found in the gastrointestinal tract of healthy and diseased pigs worldwide. However, their role in causing enteric disease in pigs and other animals has not been elucidated. In the present report, we describe for the first time in Italy, the identification and genetic characterization, through whole genome sequencing, of a PoAstV2 in pigs in Northeast Italy in 2015. This instance is the first detection of PoAstV2 in pigs in Italy. The phylogenetic analysis of the complete ORF2 segment highlights the high similarity of this virus to those circulating that same year in Japan. There are very few full astrovirus genomes available, and the present data represent an important contribution towards a better understanding of the characteristics and evolution of these viruses.


First CRISPR test for the coronavirus approved in the United States.


title: A Traumatic Direct Inguinal Hernia from Pelvic Ring Disruption.

text: Introduction Pelvic fractures usually involve a high-energy traumatic mechanism and account for approximately 3% of all blunt traumatic skeletal injuries. Additional musculoskeletal injuries are found in over 80% of unstable pelvic fractures. Traumatic abdominal wall hernias (TAWHs) are a rare entity, and traumatic inguinal hernias (TIHs) associated with open-book pelvic fractures have not been described previously. Case Presentation We present the case of a 45-year-old male motorcyclist involved in a collision resulting in a traumatic direct inguinal hernia due to abdominal wall disruption from an open-book pelvic fracture. He underwent a combined operation with an open reduction and internal fixation (ORIF) of his pelvic fracture and an abdominal wall reconstruction with a modified Stoppa technique utilizing mesh for his hernia. Discussion This is a unique presentation of a TIH due to an open-book pelvic fracture after blunt abdominal trauma. The formation of TAWH is typically from a combination of local tangential shearing forces and a sudden rise in intraabdominal pressures damaging the muscle, fascia, and peritoneum while the skin remains intact. In patients without hollow viscous injuries and gross contamination, these hernias can be repaired safely with mesh in the acute setting simultaneously with pelvic reduction.


title: Yoga, mindfulness-based stress reduction and stress-related physiological measures: A meta-analysis.

text: BACKGROUND AND OBJECTIVES Practices that include yoga asanas and mindfulness-based stress reduction for the management of stress are increasingly popular; however, the neurobiological effects of these practices on stress reactivity are not well understood. Many studies investigating the effects of such practices fail to include an active control group. Given the frequency with which people are selecting such interventions as a form of self-management, it is important to determine their effectiveness. Thus, this review investigates the effects of practices that include yoga asanas, with and without mindfulness-based stress reduction, compared to an active control, on physiological markers of stress. MATERIALS AND METHODS A systematic review and meta-analysis of randomised controlled trials published in English compared practices that included yoga asanas, with and without mindfulness-based stress reduction, to an active control, on stress-related physiological measures. The review focused on studies that measured physiological parameters such as blood pressure, heart rate, cortisol and peripheral cytokine expression. MEDLINE, AMED, CINAHL, PsycINFO, SocINDEX, PubMed, and Scopus were searched in May 2016 and updated in December 2016. Randomised controlled trials were included if they assessed at least one of the following outcomes: heart rate, blood pressure, heart rate variability, mean arterial pressure, C-reactive protein, interleukins or cortisol. Risk of bias assessments included sequence generation, allocation concealment, blinding of assessors, incomplete outcome data, selective outcome reporting and other sources of bias. Meta-analysis was undertaken using Comprehensive Meta-Analysis Software Version 3. Sensitivity analyses were performed using 'one-study-removed' analysis. Subgroup analysis was conducted for different yoga and control group types, including mindfulness-based stress reduction versus non-mindfulness-based stress reduction based interventions, different populations, length of intervention, and method of data analysis. A random-effects model was used in all analyses. RESULTS Forty two studies were included in the meta-analysis. Interventions that included yoga asanas were associated with reduced evening cortisol, waking cortisol, ambulatory systolic blood pressure, resting heart rate, high frequency heart rate variability, fasting blood glucose, cholesterol and low density lipoprotein, compared to active control. However, the reported interventions were heterogeneous. CONCLUSIONS Practices that include yoga asanas appear to be associated with improved regulation of the sympathetic nervous system and hypothalamic-pituitary-adrenal system in various populations.


title: Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review.

text: BACKGROUND When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use. METHODS Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix. RESULTS Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies. CONCLUSIONS Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.


title: Randomized comparison of McGrath MAC videolaryngoscope, Pentax Airway Scope, and Macintosh direct laryngoscope for nasotracheal intubation in patients with manual in-line stabilization.

text: BACKGROUND The objective of this study was to determine the clinical usefulness of videolaryngoscopes (VLs) by comparing the time to intubation (TTI) and the ease of intubation of McGrath MAC VL (MVL), Pentax Airway Scope VL (PVL), and Macintosh direct laryngoscope (DL) during nasotracheal intubation using manual in-line stabilization to simulate difficult airways. METHODS One hundred and twenty patients were randomly assigned to the MVL group (n = 40), the PVL group (n = 40), and the DL group (n = 40). Nasotracheal intubation was performed using MVL, PVL, or DL, according to group assignments. The primary outcome was TTI and secondary outcomes were glottic view, ease of intubation, and bleeding. RESULTS The TTI was significantly shorter in the MVL group than in the DL group (45 sec vs 57 sec; difference in means: - 12; 95% confidence interval [CI], - 21 to - 3; P = 0.01). The percentage of glottic opening and Cormack Lehane grade were significantly superior in the MVL and the PVL groups compared with the DL group (both P < 0.001). The intubation difficulty scale and numeric rating scale regarding ease of intubation were also significantly lower in the MVL and PVL groups than in the DL group (all P < 0.007). The incidence of bleeding was significantly lower in the MVL group than in the DL group (3 vs 15, relative risk 0.2; 95% CI, 0.06 to 0.64; P = 0.001). CONCLUSION This study showed that both MVL and PVL provided better visualization of the glottis and easier intubation, with less additional manipulation than DL during nasotracheal intubation in simulated difficult airways. Additionally, use of the MVL significantly shortened the TTI compared with the DL. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02647606); registered 6 January, 2016.


title: What robot for tomorrow and what improvement can we expect?

text: PURPOSE OF REVIEW The purpose of this review is to summarize the status of robotic surgery currently, contextualizing the advances and improvements we can expect in the immediate future. Robotics continues to demonstrate increased utility and expansion in medicine, particularly surgery. When coupled with the imminent expiry of Intuitive patents in the next few years, it is timely to consider what we can expect to see from new platforms; what new features might we anticipate and what technology will be available to enhance and improve patient care. RECENT FINDINGS There really are no limits with the anticipated developments in the field of medical robotics. Multiple large companies and academic institutions continue to invest in design and production with the release of a number of platforms already having occurred, whereas others are to come in the near future. The main anticipated advances will be haptic feedback, decreased cost, improved theatre assimilation with open consoles permitting free communication and lower theatre footprint. The robot patient interface is to be enhanced with single port platforms in production with a better interface including haptic feedback. The addition of NOTES and smarter flexible robotics is the next key area of interest, whereas the introduction of technology with image guidance and networking where large data sets or connectivity permit increased clinical acumen to enhance decision making. SUMMARY We are at the cusp of a tipping point as the intellectual property for the first major robotic system in surgery comes to an end. It is likely to be a period of great opportunity with enhanced surgery and patient outcomes through significant innovation, multiple platforms nearing dissemination, with various technological advances. We anticipate this will yield a great period of innovation and diversity. Will we see a truly automated robot soon; the Smart Tissue Autonomous Robots are the limit.


title: Assessment of Per-Endoscopic Placement of Fiducial Gold Markers for Small Peripheral Lung Nodules < 20 mm Before Stereotactic Radiation Therapy.

text: BACKGROUND Stereotactic radiotherapy is used to treat peripheral lung cancer in inoperable patients. Placement of fiducial gold markers (FMs) is crucial for tracking small lesions that are not visible on chest radiographs. Our objective was to assess endoscopic FM placement in small peripheral lung nodules (PLNs) that are not trackable using automated tracking software. METHODS All patients benefiting from virtual bronchoscopy and radial endobronchial ultrasonography (R-EBUS)-guided placement of FMs for PLNs < 20 mm were included. After confirmation by biopsy sampling, a gold-seed FM was inserted into the nodule using a bronchial brush, without the use of fluoroscopy. The performance and complications of the procedure were recorded. RESULTS From May 2010 to June 2015, FMs were placed in the PLNs of 54 consecutive patients, 34 of whom presented with a nodule < 20 mm. Seventy-six percent of the procedures were performed using local anesthesia on an outpatient basis. The median long- and short-axis diameters of nodules were 15 mm (9-20 mm) and 11 mm (6-20 mm), respectively, with 31 of 34 nodules exhibiting a short axis of < 15 mm. In 23 cases (79%), histologic samples were obtained during the procedure that allowed FM placement. Migration occurred in six cases, including two in the hours following the procedure. FMs were in place and visible on CT imaging performed 3 months after radiation therapy in 80% of cases. No complications were reported. CONCLUSIONS Diagnosis of peripheral nodules < 20 mm and FM placement using R-EBUS are efficient and safe in a single procedure.


title: Endovascular therapy for ischemic stroke.

text: The utility of intravenous tissue plasminogen activator (IV t-PA) in improving the clinical outcomes after acute ischemic stroke has been well demonstrated in past clinical trials. Though multiple initial small series of endovascular stroke therapy had shown good outcomes as compared to IV t-PA, a similar beneficial effect had not been translated in multiple randomized clinical trials of endovascular stroke therapy. Over the same time, there have been parallel advances in imaging technology and better understanding and utility of the imaging in therapy of acute stroke. In this review, we will discuss the evolution of endovascular stroke therapy followed by a discussion of the key factors that have to be considered during endovascular stroke therapy and directions for future endovascular stroke trials.


title: Law and Politics, an Emerging Epidemic: A Call for Evidence-Based Public Health Law.

text: As Jacobson v. Massachusetts recognized in 1905, the basis of public health law, and its ability to limit constitutional rights, is the use of scientific data and empirical evidence. Far too often, this important fact is lost. Fear, misinformation, and politics frequently take center stage and drive the implementation of public health law. In the recent Ebola scare, political leaders passed unnecessary and unconstitutional quarantine measures that defied scientific understanding of the disease and caused many to have their rights needlessly constrained. Looking at HIV criminalization and exemptions to childhood vaccine requirements, it becomes clear that the blame cannot be placed on the hysteria that accompanies emergencies. Indeed, these examples merely illustrate an unfortunate array of examples where empirical evidence is ignored in the hopes of quelling paranoia. These policy approaches are not only constitutionally questionable, they generate their own risk to public health. The ability of the law to jeopardize public health approaches to infectious disease control can, and should, be limited through a renewed emphasis on science as the foundation of public health, coordination through all levels and branches of government, and through a serious commitment by the judiciary to provide oversight. Infectious disease creates public anxiety, but this cannot justify unwarranted dogmatic approaches as a response. If we as a society hope to ensure efficient, constitutional control over the spread of disease, it is imperative that science take its rightful place at the forefront of governmental decision-making and judicial review. Otherwise, the law becomes its own public health threat.


title: Brain AVMs: an endovascular, surgical, and radiosurgical update.

text: Brain arteriovenous malformations (bAVMs) are complex vascular lesions. Despite multiple studies, several classifications, and a great interest of the scientific community, case selection in AVM patients remains challenging. During the last few years, tremendous advancements widened therapeutic options and improved outcomes spreading indications for patients harboring lesions deemed inoperable in the past. Anatomical and biological case specific features, and natural history with a focus on presenting symptoms should be evaluated case by case and always kept in mind while planning a therapeutic management for a bAVMs. A multidisciplinary approach is strongly recommended when dealing with bAVMs and should involve physicians expertise in this kind of challenging lesions. The goal of this paper is to provide a focused review of the most recent acquisitions and therapeutic strategies regarding surgical, endovascular, and radiosurgical treatment.


title: Mouse hepatitis virus stem-loop 2 adopts a uYNMG(U)a-like tetraloop structure that is highly functionally tolerant of base substitutions.

text: Stem-loop 2 (SL2) of the 5'-untranslated region of the mouse hepatitis virus (MHV) contains a highly conserved pentaloop (C47-U48-U49-G50-U51) stacked on a 5-bp stem. Solution nuclear magnetic resonance experiments are consistent with a 5'-uYNMG(U)a or uCUYG(U)a tetraloop conformation characterized by an anti-C47-syn-G50 base-pairing interaction, with U51 flipped out into solution and G50 stacked on A52. Previous studies showed that U48C and U48A substitutions in MHV SL2 were lethal, while a U48G substitution was viable. Here, we characterize viruses harboring all remaining single-nucleotide substitutions in the pentaloop of MHV SL2 and also investigate the degree to which the sequence context of key pentaloop point mutations influences the MHV replication phenotype. U49 or U51 substitution mutants all are viable; C47 substitution mutants also are viable but produce slightly smaller plaques than wild-type virus. In contrast, G50A and G50C viruses are severely crippled and form much smaller plaques. Virus could not be recovered from G50U-containing mutants; rather, only true wild-type revertants or a virus, G50U/C47A, containing a second site mutation were recovered. These functional data suggest that the Watson-Crick edges of C47 and G50 (or A47 and U50 in the G50U/C47A mutant) are in close enough proximity to a hydrogen bond with U51 flipped out of the hairpin. Remarkably, increasing the helical stem stability rescues the previously lethal mutants U48C and G50U. These studies suggest that SL2 functions as an important, but rather plastic, structural element in stimulating subgenomic RNA synthesis in coronaviruses.


title: How emergency physicians choose chest tube size for traumatic pneumothorax or hemothorax: a comparison between 28Fr and smaller tube.

text: Most traumatic pneumothoraxes and hemothoraxes can be managed non-operatively by means of chest tube thoracostomy. This study aimed to investigate how emergency physicians choose chest tube size and whether chest tube size affects patient outcome. We reviewed medical charts of patients who underwent chest tube insertion for chest trauma within 24 hours of admission in this retrospective, single-institution study. Patient characteristics, inserted tube size, risk of additional tube, and complications were evaluated. Eighty-six chest tubes were placed in 64 patients. Sixty-seven tubes were placed initially, and 19 additionally, which was significantly smaller than the initial tube. Initial tube size was 28 Fr in 38 and <28 Fr in 28 patients. Indications were pneumothorax (n=24), hemothorax (n=7), and hemopneumothorax (n=36). Initial tube size was not related to sex, BMI, BSA, indication, ISS, RTS, chest AIS, or respiratory status. An additional tube was placed in the same thoracic cavity for residual pneumothorax (n=13), hemothorax (n=1), hemopneumothorax (n=1), and inappropriate extrapleural placement (n=3). Risk of additional tube placement was not significantly different depending on tube size. No additional tube was placed for tube occlusion or surgical intervention for residual clotted hemothorax. Emergency physicians did not choose tube size depending on patient sex, body size, or situation. Even with a <28 Fr tube placed in chest trauma patients, the risk of residual hemo/pneumothorax and tube occlusion did not increase, and drainage was effective.


UpdatesMental support for health care professionals essential during the COVID-19 pandemic.


Acute kidney injury and chronic kidney disease as interconnected syndromes.


title: Acute Kidney Injury in Patients With Chronic Kidney Disease Undergoing Internal Carotid Artery Stent Implantation.

text: OBJECTIVES This study sought to investigate acute kidney injury (AKI) following carotid artery stenting (CAS). BACKGROUND Few data exist on AKI following CAS. METHODS This study evaluated 126 chronic kidney disease (CKD) patients who underwent CAS. The risk for contrast-induced AKI was defined by the Mehran score. Hemodynamic depression (i.e., periprocedural systolic blood pressure <90 mm Hg or heart rate <60 beats/min), AKI (i.e., an increase of ≥0.3 mg/dl in the serum creatinine concentration at 48 h), and 30-day major adverse events (including death, stroke, and acute myocardial infarction) were assessed. RESULTS AKI occurred in 26 patients (21%). Although baseline kidney function and contrast volume were similar in the AKI group and the non-AKI group, the risk score was higher (10 ± 3 vs. 8 ± 3; p = 0.032), and hemodynamic depression (mostly due to hypotension) (65.5% vs. 35%; p = 0.005) was more common in the AKI group. The threshold of hemodynamic depression duration for AKI development was 2.5 min (sensitivity 54%, specificity 82%). Independent predictors of AKI were hemodynamic depression (odds ratio [OR]: 4.01; 95% confidence interval [CI]: 1.07 to 15.03; p = 0.009), risk score (OR: 1.29; 95% CI: 1.03 to 1.60; p = 0.024), and male sex (OR: 6.07; 95% CI: 1.18 to 31.08; p = 0.021). Independent predictors of 30-day major adverse events that occurred more often in the AKI group (19.5% vs. 7%; p = 0.058) were AKI (HR: 4.83; 95% CI: 1.10 to 21.24; p = 0.037) and hemodynamic depression (HR: 5.58; 95% CI: 1.10 to 28.31; p = 0.038). CONCLUSIONS AKI in CKD patients undergoing CAS is mostly due to hemodynamic depression and is associated with a higher 30-day major adverse events rate.


title: On the problem of biological form.

text: Embryonic development, which inspired the first theories of biological form, was eventually excluded from the conceptual framework of the Modern Synthesis as irrelevant. A major question during the last decades has centred on understanding whether new advances in developmental biology are compatible with the standard view or whether they compel a new theory. Here, I argue that the answer to this question depends on which concept of morphogenesis is held. Morphogenesis can be conceived as (1) a chemically driven or (2) a mechanically driven process. According to the first option, genetic regulatory networks drive morphogenesis. According to the second, morphogenesis results from an invariant tendency of embryonic tissues to restore changes in mechanical stress. While chemically driven morphogenesis allows an extension of the standard view, mechanically driven morphogenesis would deeply transform it. Which of these hypotheses has wider explanatory power is unknown. At present, the problem of biological form remains unsolved.


title: International Health Regulations (2005) facilitate communication for in-flight contacts of a Middle East respiratory syndrome case, Hong Kong Special Administrative Region, 2014.

text: The International Health Regulations (IHR) (2005) require World Health Organization Member States to notify events fulfilling two of four criteria: (1) serious public health impact; (2) unusual or unexpected event; (3) significant risk of international spread; or (4) significant risk of international travel or trade restrictions. (1) In-flight transmission of infections like severe acute respiratory syndrome is well documented. (2) With the enormous amount of air travel today, the risk of increasing in-flight transmission and subsequent international spread of infections are increasing. Prompt notification and information sharing under the IHR mechanism is critical for effective contact tracing and prompt control measures. We report on a case of in-flight exposure to an infection with significant public health risks that was successfully resolved using IHR (2005) guidelines.