title: Cannulation of the mouse submandibular salivary gland via the Wharton's duct.

text: Severe salivary gland hypofunction is frequently found in patients with Sjögren's syndrome and those who receiving therapeutic irradiation in their head and neck regions for cancer treatment. Both groups of patients experience symptoms such as xerostomia (dry mouth), dysphagia (impaired chewing and swallowing), severe dental caries, altered taste, oro-pharyngeal infections (candidiasis), mucositis, pain and discomfort. One innovative approach of regenerative medicine for the treatment of salivary gland hypo-function is speculated in RS Redman, E Mezey et al. 2009: stem cells can be directly deposited by cannulation into the gland as a potent method in reviving the functions of the impaired organ. Presumably, the migrated foreign stem cells will differentiate into glandular cells to function as part of the host salivary gland. Also, this cannulation technique is an expedient and effective delivery method for clinical gene transfer application. Here we illustrate the steps involved in performing the cannulation procedure on the mouse submandibular salivary gland via the Wharton's duct (Fig 1). C3H mice (Charles River, Montreal, QC, Canada) are used for this experiment, which have been kept under clean conventional conditions at the McGill University animal resource center. All experiments have been approved by the University Animal Care Committee and were in accordance with the guidelines of the Canadian Council on Animal Care. For this experiment, a trypan blue solution is infused into the gland through the opening of the Wharton's duct using a insulin syringe with a 29-gauge needle encased inside a polyethylene tube. Subsequently, the mouse is dissected to show that the infusions migrated into the gland successfully.


title: Easy, reproducible extraperitoneal pelvic access for robot - assisted radical prostatectomy.

text: Robot - assisted radical prostatectomy is commonly performed transperitoneally (tRARP), although the extraperitoneal (eRARP) approach is a safe and effective alternative that may be preferred in certain situations. We developed a novel method of direct access into the space of Retzius with a visual obturator port (VisiportTM) for laparoscopic or robotic prostatectomy. We present an instructional video of extraperitoneal pelvic access for eRARP with both internal and external camera views. The patient is first placed in lithotomy and 15° Trendelenburg position. The camera is inserted infraumbilically and angled caudally. The pre-peritoneal space is accessed through the anterior rectus fascia using a VisiportTM (Covidien, $ 60 www.esutures.com), and the working space is developed with a kidney - shaped balloon OMSPDBS2TM (Covidien, $ 49 www.esutures.com). After the space is insufflated, subsequent trocars are angled in extraperitoneally under direct vision. The average time from incision to final port placement after a learning curve of about 50 cases is 8 minutes (IQR 7-10). We have performed over 1.000 cases using this technique and eRARP has become our procedure of choice. Our last 500 + cases were performed robotically. Approximately 10% of the time peritoneotomies were noted, but rarely did these require conversion to tRARP. There have been no bowel or other abdominal organ injuries, major vascular or other complications in any of these cases.


Repair of abdominal wall hernias with restoration of abdominal wall function.


title: Evaluating the predictive capabilities of haematoma expansion scores in patients with acute intracerebral haemorrhage: protocol for a scoping review.

text: INTRODUCTION Patients presenting with acute intracerebral haemorrhage are at a high risk of exhibiting haematoma expansion, a phenomenon that can significantly worsen long-term functioning. Numerous clinical and radiological factors are associated with expansion. In a bid to better select patients at increased risk of expanding, these factors have been collated together into clinical scores. Several clinical scores have been developed, but comparisons of diagnostic potential between these scores are limited and the frequency of use in clinical trial enrolment is unknown. OBJECTIVE To perform a scoping review of haematoma expansion scores and explore numerous factors such as the methodology of development and diagnostic capabilities. METHODS AND ANALYSIS MEDLINE, PubMed, EMBASE, CENTRAL and ClinicalTrials.gov will be searched with assistance from an experienced information specialist. Eligible studies will involve adults presenting with spontaneous intracerebral haemorrhage who received baseline assessments, follow-up imaging and risk stratification through a haematoma expansion score. Reviewers will independently extract data from the included studies and will collect data on patient demographics and medical history, details on score development, diagnostic capabilities and usage proportions. Analysis of extracted data will focus on comparing the predictive capability of each score and similarities/differences in score development. The exact analysis technique will be dictated on the type of data extracted. ETHICS AND DISSEMINATION Formal ethics is not required as primary data will not be collected. The findings of this study will be disseminated through conference presentations and peer-reviewed publications.


How mental health services are adapting to provide care in the pandemic.


Use of eye drops obtained from homologous blood source in the time of COVID-19: is there cause for ophthalmological concern?


title: Pediatric Tracheostomy Decannulation: 11-Year Experience.

text: OBJECTIVE To determine the successful decannulation rate with a published pediatric tracheostomy decannulation protocol. STUDY DESIGN Case series with chart review. SETTING A single tertiary care institution. SUBJECTS AND METHODS A chart review was performed for patients aged ≤5 years who underwent tracheostomy. Extracted data included demographic data, indication for tracheostomy, age at tracheostomy and decannulation, comorbidities, and surgical complications. Records were searched for documentation of early decannulation failure (within 1 month of decannulation) or late failure (within 1 year). RESULTS Forty patients with a tracheostomy aged ≤5 years underwent attempted decannulation during the 11-year study period. Seventeen patients were excluded from the study for documentation of nonprotocol decannulation. The final study population of 23 patients underwent a total of 27 decannulations, 26 of which were performed by protocol. Of the 26 protocol decannulations, 22 were successful, for a failure rate of 15%. CONCLUSION Twenty-six protocol decannulations were attempted among 23 patients, 4 of which were unsuccessful for an overall failure rate of 15%. This result is consistent with rates reported in other published decannulation protocols. We believe that our protocol minimizes resource utilization in its use of pulse oximetry over polysomnography, while maximizing patient safety and success through the use of capping trials for very young and very small pediatric patients.


title: Clinical experience with the pREset stent retriever for the treatment of acute ischemic stroke--a review of 271 consecutive cases.

text: INTRODUCTION The purpose of this study was to evaluate the safety and efficacy of the pREset stent retriever in a real-world clinical setting. METHODS Patients treated with pREset were selected from a prospectively maintained single-center database. A TICI score ≥2b after ≤3 passes was regarded as successful recanalization. All device-related complications and their clinical significance were reported. Parenchymal hematomas (PH) were classified according to ECASS, adding focal and diffuse subarachnoid hemorrhage (SAH) as categories. A 90-day mRS of 0-2 was defined as favorable outcome. In addition, we separately analyzed patients treated with >3 pREset passes and patients receiving other rescue maneuvers. RESULTS We included 271 patients. Successful recanalization was achieved in 76.4 %. Device-related complications occurred in 9.2 % of which 2.2 % were clinically significant. PH I, PH II, focal SAH, and diffuse SAH was observed in 5.2, 4.8, 12.2, and 2.2 %, respectively. A total of 39.5 % of patients had favorable clinical outcome. Considering treatments with >3 pREset passes or other rescue procedures, an additional 8.5 and 9.3 % of target vessels were recanalized. The chance of favorable clinical outcome decreased significantly with any kind of rescue therapy. In addition, the rate of PH I was significantly higher in patients treated with >3 pREset passes, whereas all other types of hemorrhage showed no difference. CONCLUSION In terms of safety and effectiveness, pREset performed comparably to other stent retriever devices. To avoid futile recanalization and potential additional harm, escalation of therapy beyond three thrombectomy passes should only be performed after careful individual consideration of each case.


title: Theoretical and in vitro studies of a C-terminal peptide from PGKC of Leishmania mexicana mexicana.

text: Trypanosomatids cause deadly diseases in humans. Of the various biochemical pathways in trypanosomatids, glycolysis, has received special attention because of being sequestered in peroxisome like organelles critical for the survival of the parasites. This study focuses on phosphoglycerate kinase (PGK) from Leishmania spp. which, exists in two isoforms, the cytoplasmic PGKB and glycosomal PGKC differing in their biochemical properties. Computational analysis predicted the likelihood of a transmembrane helix only in the glycosomal isoform PGKC, of approximate length 20 residues in the 62-residue extension, ending at, arginine residues R471 and R472. From experimental studies using circular dichroism and NMR with deuterated sodium dodecyl sulfate, we find that the transmembrane helix spans residues 448±2 to 476 in Leishmania mexicana PGKC. The significance of this observation is discussed in the context of glycosomal transport and substrate tunneling.


title: Prevalence of sleep breathing complaints reported by treatment-seeking chronic insomnia disorder patients on presentation to a sleep medical center: a preliminary report.

text: PURPOSE Few studies have examined the co-morbidity between insomnia and sleep-disordered breathing in the clinical setting. This study evaluated treatment-seeking insomnia patients and their self-report of sleep breathing complaints. METHODS A retrospective chart review was conducted on 1,035 consecutive treatment-seeking, chronic insomnia patients who reported insomnia as their primary problem upon seeking care at a private, community-based sleep medical center. Measurements included the insomnia severity index, standard subjective sleep measures as well as rankings, attributions, and self-reports about sleep breathing disorders, problems, and symptoms. RESULTS A total of 1,035 adult, treatment-seeking insomnia patients indicated insomnia interfered with daytime functioning, and their average insomnia severity was in the range of a clinically relevant problem: total sleep time (5.50 h, SD = 1.60), sleep efficiency (71.05 %, SD = 18.26), wake time after sleep onset (120.70 min, SD = 92.56), and an insomnia severity index (18.81, SD = 5.09). Of these 1,035 insomnia patients, 42 % also ranked a sleep breathing disorder among their list of reasons for seeking treatment, another 13 % revealed a concern about a sleep breathing problem, and another 26 % reported awareness of sleep breathing symptoms. Only 19 % of this clinical insomnia sample reported no awareness or concerns about sleep breathing disorders, problems, or symptoms. A greater proportion of men than women reported significantly more sleep breathing disorders, problems, or symptoms. CONCLUSIONS Sleep breathing complaints were extremely common among a large sample of treatment-seeking, self-identified, adult chronic insomnia patients. Prospective prevalence research is needed to corroborate or revise these findings, and polysomnography should be considered in appropriate cohorts to determine the clinical relevance of treatment-seeking chronic insomnia patients' sleep breathing complaints.


Factors Affecting the Preventability of Stroke-Reply.


Covid-19 exposes weaknesses in European response to outbreaks.


title: Nephrogenic systemic fibrosis: pathogenesis, diagnosis, and therapy.

text: Nephrogenic systemic fibrosis (NSF) is a newly recognized disorder occurring exclusively in patients with renal failure. Exposure to gadolinium-based magnetic resonance (MR) contrast media has been associated with subsequent development of NSF. Nephrogenic systemic fibrosis is characterized by skin induration preferentially affecting the extremities. In addition, involvement of internal organs occurs, which leads ultimately to death. Skin biopsy is important for confirmation of the diagnosis. The main therapeutic goal is restoration of renal function. To reduce the risk of NSF, renal function must be determined before exposure to gadolinium-containing MR contrast agents. Gadolinium-based MR contrast media should be avoided in the presence of advanced renal failure with estimated glomerular filtration rate below 30 ml/min/1.73 m2, unless the diagnostic information is essential and not available with noncontrast magnetic resonance imaging techniques. The recommended dose of contrast agent should not be exceeded. In addition, a sufficient period of time for elimination of the contrast agent from the body should be allowed before readministration of the contrast agent.


title: Inhibition of Middle East respiratory syndrome coronavirus infection by anti-CD26 monoclonal antibody.

text: We identified the domains of CD26 involved in the binding of Middle East respiratory syndrome coronavirus (MERS-CoV) using distinct clones of anti-CD26 monoclonal antibodies (MAbs). One clone, named 2F9, almost completely inhibited viral entry. The humanized anti-CD26 MAb YS110 also significantly inhibited infection. These findings indicate that both 2F9 and YS110 are potential therapeutic agents for MERS-CoV infection. YS110, in particular, is a good candidate for immediate testing as a therapeutic modality for MERS.


title: Treatment of poor-grade subarachnoid hemorrhage trial.

text: BACKGROUND AND PURPOSE Management of poor-grade subarachnoid hemorrhage is based on limited evidence from small single-center retrospective observational studies. The purpose of this study was to undertake a single-center randomized controlled feasibility trial comparing a strategy of early endovascular aneurysm treatment with treatment after neurologic recovery in this group of patients. MATERIALS AND METHODS Patients with poor-grade SAH were randomized within 24 hours of admission to early treatment or treatment after neurologic recovery. If a patient was randomized to early treatment, the aneurysm was treated endovascularly within 24 hours of randomization. Recruitment rate, safety profile, and functional outcome at the time of discharge and at 6 months were assessed. RESULTS Fourteen of 51 patients screened were eligible for the trial. Of these 14, 8 patients were randomized (57%). All patients in the early coiling arm received treatment within 24 hours of randomization. There was no treatment-related complication. Overall, good outcome occurred in 25% of patients; the mortality rate was 75%. Patients in the early treatment arm (n = 5) had a good outcome rate of 20%, while those in treatment after neurologic recovery arm (n = 3) had a good outcome rate of 33.3%. CONCLUSIONS This was a feasibility study that demonstrated that recruitment and randomization for comparing management strategies in poor-grade SAH are feasible. The recruitment rate among eligible patients was encouraging (57%), though a number of patients had to be excluded due to ineligibility. A multicenter study is necessary to recruit the numbers required to compare the clinical outcomes of these management strategies.


title: Multimodality Monitoring in the Neurocritical Care Unit.

text: PURPOSE OF REVIEW This article focuses on the multiple neuromonitoring devices that can be used to collect bedside data in the neurocritical care unit and the methodology to integrate them into a multimodality monitoring system. The article describes how to apply the collected data to appreciate the physiologic changes and develop therapeutic approaches to prevent secondary injury. RECENT FINDINGS The neurologic examination has served as the primary monitor for secondary brain injury in patients admitted to the neurocritical care unit. However, the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care concluded that frequent bedside examinations are not sufficient to detect and prevent secondary brain injury and that integration of multimodality monitoring with advanced informatics tools will most likely enhance our assessments compared to the clinical examinations alone. This article reviews the invasive and noninvasive technologies used to monitor focal and global neurophysiologic cerebral alterations. SUMMARY Multimodal monitoring is still in the early stages of development. Research is still needed to establish more advanced monitors with the bioinformatics to identify useful trends from data gathered to predict clinical outcome or prevent secondary brain injury.


title: What is the best tool for transanal endoscopic microsurgery (TEM)? A case-matched study in 74 patients comparing a standard platform and a disposable material.

text: PURPOSE Transanal endoscopic microsurgery (TEM) is the gold standard for local excision of rectal lesions, but no study exists concerning the best material. The objective was to compare TEM using a disposable material vs a standard platform through a case-matched study. METHODS Patients who underwent TEM for rectal neoplasms were identified from prospective databases in two tertiary referral centers and matched according to four criteria (sex, tumor location, size, distance from the anal verge): TEM using a disposable material (GelPoint Applied®; group A) and TEM using a standard TEO® platform (Karl Storz, Tuttlingen, Germany; group B). RESULTS A total of 74 patients were included and divided into group A (n = 33) and group B (n = 41). Full-thickness resection was less frequent in group A (85%) than B (100%; p = 0.01). Adenocarcinoma was less frequent in group A than B: 27 vs 42% (p = 0.03). No difference was noted regarding median operative time (53 vs 53 min; p = 0.6) and a peritoneal perforation rate (6 vs 20%; p = 0.17). Median length of stay was shorter in group A than B (4 vs 5 days; p < 0.008). No significant difference was noted for major morbidity (12 vs 10%; p = 0.66), R1 resection (21 vs 10%; p = 0.2), and recurrence rates (8 vs 7%; p = 0.62). No difference was noted for rectal stenosis (3 vs 12%; p = 0.22) and transit disorder rates (12 vs 17%; p = 0.74). CONCLUSIONS Our study suggested that TEM can be performed using either a TEO® platform or a disposable material, with similar surgical results. The TEO® platform seems to be superior to obtain full-thickness and R0 resection.


title: Intensive laparoscopic training course for surgical residents: program description, initial results, and requirements.

text: INTRODUCTION The Department of Surgery at the University of Arizona has created an intensive laparoscopic training course for surgical residents featuring a combined simulation laboratory and live swine model. We herein report the essential components to design and implement a rigorous training course for developing laparoscopic skills in surgical residents. MATERIALS AND METHODS At our institution, we developed a week-long pilot intensive laparoscopic training course. Six surgical residents (ranging from interns to chief residents) participate in the structured, multimodality course, without any clinical responsibilities. It consists of didactic instruction, laboratory training, practice in the simulation laboratory, and performance (under the direction of attending laparoscopic surgeons) of surgical procedures on pigs. The pigs are anesthetized and attended by veterinarians and technicians, and then euthanized at the end of each day. Three teams of two different training-level residents are paired. Daily briefing, debriefing, and analysis are performed at the close of each session. A written paper survey is completed at the end of the course. RESULTS This report describes the results of first 36 surgical residents trained in six courses. Preliminary data reveal that all 36 now feel more comfortable handling laparoscopic instruments and positioning trocars; they now perform laparoscopic surgery with greater confidence and favor having the course as part of their educational curriculum. CONCLUSION A multimodality intensive laparoscopic training course should become a standard requirement for surgical residents, enabling them to acquire basic and advanced laparoscopic skills on a routine basis.


COVID-19 and orthopaedic and trauma surgery.


title: Amyand hernia repaired with Bio-A: a case report and review.

text: A 53-year-old man with an Amyand hernia with indirect and direct components was repaired with a Bio-A (Gore, Newark, Delaware) plug and a patch made of Bio-A tissue reinforcement material. The repair of an Amyand hernia addresses the pathology of the appendix as well as the hernia. We report a case in which a plug and patch repair was undertaken using Bio-A implants in a clean-contaminated field with no signs of infection or recurrence in the follow-up period, and we review the literature regarding the diagnosis and repair of an Amyand hernia.


title: Post-SARS knowledge sharing and professional commitment in the nursing profession.

text: AIM The aim of the present study was to examine the 2003 severe acute respiratory syndrome (SARS) crisis in relation to the degree of knowledge sharing and professional commitment, as perceived by the current nursing staff in Taiwan. BACKGROUND The mortality rate for medical personnel during the SARS outbreak in Taiwan, which began in April 2003, was the highest among Asian countries. The SARS crisis severely challenged not only the medical skills of nurses, but also their professional commitment. DESIGN Survey. METHODS This study was conducted between August-December 2005, in Taiwan. Data were collected by structured questionnaire. The questionnaire was distributed by post to 8056 nurses nationwide; 2833 nurses completed and returned the questionnaire for a valid response rate of 39%. RESULTS The results showed that knowledge sharing correlated positively with professional commitment but negatively with the impact of SARS. Professional commitment negatively correlated with SARS impact (r = -0.074, p < 0.001); however, as knowledge sharing was a controlled variable, the partial correlation between SARS impact and professional commitment was -0.039 with a p-value of 0.045, indicating virtual insignificance. That is, knowledge sharing was an antecedent variable for both SARS impact and professional commitment. CONCLUSION This cross-sectional study provides preliminary evidence that knowledge sharing is significantly correlated with impact of SARS and professional commitment of nursing personnel. RELEVANCE TO CLINICAL PRACTICE Hospitals and healthcare services can enhance retention of medical personnel by encouraging knowledge sharing, which enhances professional commitment and alleviates the impact of newly introduced contagious diseases.


title: Can Robotic-Assisted Surgery Overcome the Risk of Mortality in Cardiac Reoperation?

text: OBJECTIVE A robotic-assisted approach potentially has many advantages for cardiac reoperation, which include sternum-sparing and three-dimensional visualization leading to precise adhesiolysis and excellent exposure in a limited field. METHODS We retrospectively reviewed our patients undergoing robotic cardiac reoperation (redo group) from July 2013 to April 2017 at our institution and compared with our patients undergoing standard robotic surgery (nonredo group). In the reoperative cases, a thoracoscope was inserted through a 5-mm port placed away from the previous scar. Another 5-mm port was inserted under direct vision to make space for one or two robotic arms, and further precise dissection was performed robotically. RESULTS A total of 486 patients underwent robotic-assisted cardiac surgery. There were 36 patients who had one or more previous cardiac surgeries (42 surgeries). Although the mean operative and cardiopulmonary bypass time were longer in the redo group (median = 351 minutes vs. 289 minutes and 219 minutes vs. 178 minutes, P < 0.05, respectively), cardiac arrest time was similar between two groups. The redo group had a higher incidence of postoperative prolonged ventilation (16.7% vs. 6.9%, P = 0.046) and pneumonia (11.1% vs. 0.2%, P < 0.001). The 30-day mortality was 2.8% (1/36) in the redo group and similar to that in the nonredo group (1.3%, P = 0.419). CONCLUSIONS Robotic cardiac reoperation is feasible with acceptable clinical outcomes including a low mortality rate similar to standard robotic surgery in our hands. Robotic assistance may have the potential to minimize morbidity and mortality.


title: Cytoplasmic tails of hantavirus glycoproteins interact with the nucleocapsid protein.

text: Here we characterize the interaction between the glycoproteins (Gn and Gc) and the ribonucleoprotein (RNP) of Puumala virus (PUUV; genus Hantavirus, family Bunyaviridae). The interaction was initially established with native proteins by co-immunoprecipitating PUUV nucleocapsid (N) protein with the glycoprotein complex. Mapping of the interaction sites revealed that the N protein has multiple binding sites in the cytoplasmic tail (CT) of Gn and is also able to bind to the predicted CT of Gc. The importance of Gn- and Gc-CTs to the recognition of RNP was further verified in pull-down assays using soluble peptides with binding capacity to both recombinant N protein and the RNPs of PUUV and Tula virus. Additionally, the N protein of PUUV was demonstrated to interact with peptides of Gn and Gc from a variety of hantavirus species, suggesting a conserved RNP-recognition mechanism within the genus. Based on these and our previous results, we suggest that the complete hetero-oligomeric (Gn-Gc)(4) spike complex of hantaviruses mediates the packaging of RNP into virions.


title: Recruitment manoeuvres for adults with acute lung injury receiving mechanical ventilation.

text: BACKGROUND Recruitment manoeuvres are often used to treat patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) but the effect of this treatment on clinical outcomes has not been well established. OBJECTIVES The objective of this review was to examine recruitment manoeuvres compared to standard care as therapy for adults with acute lung injury in order to quantify the effects on patient outcomes (mortality, length of ventilation, and other relevant outcomes). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 2); MEDLINE (January 1966 to May 2008); EMBASE (January 1980 to May 2008); LILACS (1982 to May 2008); CINAHL (1982 to May 2008); and Current Controlled Trials (www.controlled-trials.com). SELECTION CRITERIA We included randomized controlled trials of adults who were mechanically ventilated comparing recruitment manoeuvres to standard care for those patients diagnosed with ALI or ARDS. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS Seven trials met the inclusion criteria for this review (the total number of included participants was 1170). All trials included a recruitment manoeuvre as part of the treatment strategy for patients on mechanical ventilation for ARDS or ALI. However, two of the trials included a package of ventilation that was different from the control ventilation in aspects other than the recruitment manoeuvre. The intervention group showed no significant difference on 28-day mortality (RR 0.73, 95% CI 0.46 to 1.17, P = 0.2). Similarly there was no statistical difference for risk of barotrauma (RR 0.50, 95% CI 0.07 to 3.52, P = 0.5) or blood pressure (MD 0.9 mm Hg, 95% CI -4.28 to 6.08, P = 0.73). Recruitment manoeuvres significantly increased oxygenation above baseline levels for a short period of time in four of the five studies that measured oxygenation. There were insufficient data on length of ventilation or hospital stay to pool results. AUTHORS' CONCLUSIONS There is not evidence to make conclusions on whether recruitment manoeuvres reduce mortality or length of ventilation in patients with ALI or ARDS.


title: Bleeding Events Before Coronary Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

text: BACKGROUND Upstream administration of antithrombotic drugs to patients with non-ST-segment elevation acute coronary syndromes before coronary angiography is a common practice despite an incomplete understanding of the risks and benefits. OBJECTIVES The authors analyzed the incidence of bleeding and ischemic events occurring before angiography and assessed their association with antithrombotic drugs and mortality risk. METHODS All patients from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial with planned angiography after enrollment were included. Bleeding events were classified according to the ACUITY scale as major or nonmajor bleeding. Kaplan-Meier and Cox proportional hazards analyses were performed. RESULTS Of 13,726 patients, 275 (2.0%) bled before angiography, including 52 (0.4%) with major bleeding. Forty-four (0.3%) experienced myocardial infarction. The median time from randomization to coronary angiography was 4.5 h (interquartile ratio [IQR]: 1.7 to 19.7 h) for patients who did not bleed while waiting for angiography and 27.9 h (IQR: 21.9 to 65.6 h) for patients who bled while waiting for angiography (p < 0.001). Bleeding events accrued linearly over time, reaching 10.4% at 96 h post-randomization. Independent predictors of bleeding before angiography included age (adjusted hazard ratio [HR]: 1.03 per year of age; 95% confidence interval [CI]: 1.01 to 1.04; p < 0.001), renal insufficiency (adjusted HR: 1.48; 95% CI: 1.07 to 2.04; p = 0.02), and use of multiple antithrombotic drugs (adjusted HR: 1.33; 95% CI: 1.14 to 1.56; p < 0.001). Bleeding before coronary angiography was associated with longer hospitalization (4.8 days [IQR: 3.0 to 8.9 days] vs. 3.0 days [IQR: 1.9 to 5.9 days]; p < 0.001). Patients who bled before angiography were more likely to die within 1 year than patients who did not bleed (8.5% vs. 4.1%; p < 0.001; adjusted HR: 1.89 (95% CI: 1.23 to 2.90; p = 0.004). CONCLUSIONS Upstream antithrombotic treatment of patients with non-ST-segment elevation acute coronary syndromes awaiting coronary angiography is associated with excess bleeding with mortality implications. Bleeding avoidance strategies before angiogram, including early angiography, may negate the need to prolong upstream antithrombotic treatment and improve the overall risk-benefit balance for these patients. (Acute Catheterization and Urgent Intervention Triage Strategy [ACUITY]; NCT00093158).


title: Meeting Abstracts - AMCP 2020.

text: The abstracts presented in this program were originally slated to be presented at the AMCP 2020 meeting in Houston, Texas, April 21-24. The meeting was canceled because of the COVID-19 crisis. In lieu of the scheduled poster presentations, many poster presenters have shared additional information about their research at https://plan.core-apps.com/amcp2020. Professional abstracts that have been reviewed are published in the Journal of Managed Care & Specialty Pharmacy's Meeting Abstracts supplement.


title: Neutralizing the MERS coronavirus threat.

text: Human neutralizing monoclonal antibodies are candidates for prophylactic and therapeutic interventions against Middle East respiratory syndrome coronavirus (MERS-CoV) infection.


title: Membrane-on-a-chip: microstructured silicon/silicon-dioxide chips for high-throughput screening of membrane transport and viral membrane fusion.

text: Screening of transport processes across biological membranes is hindered by the challenge to establish fragile supported lipid bilayers and the difficulty to determine at which side of the membrane reactants reside. Here, we present a method for the generation of suspended lipid bilayers with physiological relevant lipid compositions on microstructured Si/SiO2 chips that allow for high-throughput screening of both membrane transport and viral membrane fusion. Simultaneous observation of hundreds of single-membrane channels yields statistical information revealing population heterogeneities of the pore assembly and conductance of the bacterial toxin α-hemolysin (αHL). The influence of lipid composition and ionic strength on αHL pore formation was investigated at the single-channel level, resolving features of the pore-assembly pathway. Pore formation is inhibited by a specific antibody, demonstrating the applicability of the platform for drug screening of bacterial toxins and cell-penetrating agents. Furthermore, fusion of H3N2 influenza viruses with suspended lipid bilayers can be observed directly using a specialized chip architecture. The presented micropore arrays are compatible with fluorescence readout from below using an air objective, thus allowing high-throughput screening of membrane transport in multiwell formats in analogy to plate readers.


title: Computational hemodynamics analysis of intracranial aneurysms treated with flow diverters: correlation with clinical outcomes.

text: BACKGROUND AND PURPOSE Recent studies have shown promising results regarding intracranial aneurysms treated with flow diverters. However, these have had adverse effects, including delayed aneurysm occlusion, posttreatment symptoms, and rupture. The hemodynamic profiles of aneurysms treated with flow diverters were analyzed to determine the ones associated with successful and failed treatments. MATERIALS AND METHODS Patient-specific computational fluid dynamics were used to simulate hemodynamic profiles, including the presence of jet flow, energy loss, volume flow, and wall shear stress in 4 successful occlusions of aneurysms and 4 failed cases after flow-diverter deployment. In these 4 failed cases, hemodynamic profiles were examined again after a hypothetic second intervention. This involved replacing the failed flow diverter with a hypothetic optimally deployed flow diverter or simulated placement of a second flow diverter within the first (double hypothetic optimally deployed). RESULTS Where successful occlusions were achieved, a marked obliteration of jet flow was observed. Flow entering the aneurysm sac was diverted via the center of the flow diverter and joined smoothly with the continuation of flow leaving the aneurysm sac into the parent arteries. These observations were supplemented by a reduction in the other hemodynamic profiles. Aneurysm neck geometry might influence the efficacy of the flow diverter. CONCLUSIONS Hemodynamic indices, as calculated by using computational fluid dynamics techniques, have close correlation with flow-diverter treatment outcome. Computational fluid dynamics could be potentially useful as a planning tool for neurointerventionists by simulating an optimized flow-diverter deployment strategy before the procedure and evaluating posttreatment outcome.


title: Effect of Intrinsic Patterns of Functional Brain Connectivity in Moderating Antidepressant Treatment Response in Major Depression.

text: OBJECTIVE Major depressive disorder is associated with aberrant resting-state functional connectivity across multiple brain networks supporting emotion processing, executive function, and reward processing. The purpose of this study was to determine whether patterns of resting-state connectivity between brain regions predict differential outcome to antidepressant medication (sertraline) compared with placebo. METHODS Participants in the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study underwent structural and resting-state functional MRI at baseline. Participants were then randomly assigned to receive either sertraline or placebo treatment for 8 weeks (N=279). A region of interest-based approach was utilized to compute functional connectivity between brain regions. Linear mixed-model intent-to-treat analyses were used to identify brain regions that moderated (i.e., differentially predicted) outcomes between the sertraline and placebo arms. RESULTS Prediction of response to sertraline involved several within- and between-network connectivity patterns. In general, higher connectivity within the default mode network predicted better outcomes specifically for sertraline, as did greater between-network connectivity of the default mode and executive control networks. In contrast, both placebo and sertraline outcomes were predicted (in opposite directions) by between-network hippocampal connectivity. CONCLUSIONS This study identified specific functional network-based moderators of treatment outcome involving brain networks known to be affected by major depression. Specifically, functional connectivity patterns of brain regions between and within networks appear to play an important role in identifying a favorable response for a drug treatment for major depressive disorder.


Coronavirus 2019 Video Conferencing: Preserving Resident Education with Online Meeting Platforms.


Impact of cancelling foundation year rotations due to the covid-19 outbreak in the UK.


title: Recent Developments at DG Competition: 2016/2017.

text: The Directorate General for Competition at the European Commission enforces competition law in the areas of antitrust, merger control, and state aids. This year's article provides first a general presentation of the role of the Chief Competition Economist's team and surveys the main achievements of the Directorate General for Competition over 2016/2017. The article then reviews the economic work undertaken in one merger case between Dow/DuPont, which raised specific issues related to innovation, as well as in an antitrust case on parity clauses related to Amazon e-books.


title: Preemptive thoracic drainage to eradicate postoperative pulmonary complications after living donor liver transplantation.

text: BACKGROUND Thoracic fluid retention after living donor liver transplantation (LDLT) has various negative consequences, including atelectasis, pneumonia, and respiratory distress or failure. STUDY DESIGN We analyzed the clinical impact of preemptive thoracic drainage in 177 patients undergoing adult-to-adult LDLT for chronic liver diseases at a single center. Recipients were divided into 2 time periods. The earlier cohort (n = 120) was analyzed for risk factors for postoperative atelectasis retrospectively; the later cohort (n = 57), with a risk factor for postoperative atelectasis, underwent preemptive thoracic drainage prospectively. The incidence of postoperative pulmonary complications was compared between these 2 cohorts. RESULTS Independent risk factors for atelectasis in earlier cohort were body mass index ≥27 kg/m(2) (p < 0.001), performance status ≥3 (p = 0.003) and model for end-stage liver disease score ≥23 (p = 0.005). The rates of atelectasis (21.1% vs 42.5%, p = 0.005) and pneumonia (1.8% vs 10.0%, p = 0.049) were significantly lower in later than in earlier cohort. Moreover, the mean durations of ICU stay (3.6 ± 0.2 days vs 5.7 ± 0.6 days, p = 0.038) and postoperative oxygen support (5.1 ± 0.8 days vs 7.1 ± 0.5 days, p = 0.037) were significantly shorter in the later than in the earlier cohort. There were no significant differences in the incidence of adverse events associated with thoracic drainages between these 2 cohorts. CONCLUSIONS Preemptive thoracic drainage for transplant recipients at high risk of postoperative atelectasis could decrease morbidities after LDLT.


Genomic Technologies Speed Pathogen Detection.


title: Novel mandibular advancement bite block with supplemental oxygen to both nasal and oral cavity improves oxygenation during esophagogastroduodenoscopy: a bench comparison.

text: Drug-induced respiratory depression is a major cause of serious adverse events. Adequate oxygenation is very important during sedated esophagogastroduodenoscopy (EGD). Nasal breathing often shifts to oral breathing during open mouth EGD. A mandibular advancement bite block was developed for EGD using computer-assisted design and three-dimensional printing techniques. The mandible is advanced when using this bite block to facilitate airway opening. The device is composed of an oxygen inlet with one opening directed towards the nostril and another opening directed towards the oral cavity. The aim of this bench study was to compare the inspired oxygen concentration (FiO2) provided by the different nasal cannulas, masks, and bite blocks commonly used in sedated EGD. A manikin head was connected to one side of a two-compartment lung model by a 7.0 mm endotracheal tube with its opening in the nasopharyngeal position. The other compartment was driven by a ventilator to mimic "patient" inspiratory effort. Using this spontaneously breathing lung model, we evaluated five nasal cannulas, two face masks, and four new oral bite blocks at different oxygen flow rates and different mouth opening sizes. The respiratory rate was set at 12/min with a tidal volume of 500 mL and 8/min with a tidal volume of 300 mL. Several Pneuflo resistors of different sizes were used in the mouth of the manikin head to generate different degrees of mouth opening. FiO2 was evaluated continuously via the endotracheal tube. All parameters were evaluated using a Datex anesthesia monitoring system. The mandibular advancement bite block provided the highest FiO2 under the same supplemental oxygen flow. The FiO2 was higher for devices with oxygen flow provided via an oral bite block than that provided via the nasal route. Under the same supplemental oxygen flow, the tidal volume and respiratory rate also played an important role in the FiO2. A low respiratory rate with a smaller tidal volume has a relative high FiO2. The ratio of nasal to oral breathing played an important role in the FiO2 under hypoventilation but less role under normal ventilation. Bite blocks deliver a higher FiO2 during EGD. The ratio of nasal to oral breathing, supplemental oxygen flow, tidal volume, and respiratory rate influenced the FiO2 in most of the supplemental oxygen devices tested, which are often used for conscious sedation in patients undergoing EGD and colonoscopy.


title: Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12.

text: A significant number of surgical patients are at risk of intra- or post-operative complications or both, which are associated with increased lengths of stay, costs, and mortality. Reducing these risks is important for the individual patient but also for health-care planners and managers. Insufficient tissue perfusion and cellular oxygenation due to hypovolemia, heart dysfunction or both is one of the leading causes of perioperative complications. Adequate perioperative management guided by effective and timely hemodynamic monitoring can help reduce the risk of complications and thus potentially improve outcomes. In this review, we describe the various available hemodynamic monitoring systems and how they can best be used to guide cardiovascular and fluid management in the perioperative period in high-risk surgical patients.


title: The magnitude of antibiotic resistance to Helicobacter pylori in Africa and identified mutations which confer resistance to antibiotics: systematic review and meta-analysis.

text: BACKGROUND Worldwide Helicobacter pylori (H.pylori) treatment is of great challenge due to increased antibiotic resistance. The burden of H. pylori antibiotic resistance in Africa is high with unclear information regarding the real magnitude. This systematic review and meta-analysis was conducted to investigate the magnitude of H.pylori antibiotic resistance in Africa to gain insight of the extent of the problem among H.pylori naïve treatment patients. METHOD The search was performed in the academic databases, Embase, PubMed, Web of Science and Africa Wide Information. ProQuest Dissertation and Theses, Scopus, Ethos, Africa Index Medicus (WHO), BioMed Central Proceedings, BASE, British Library, Open grey, Library of Congress and the New York Academy of Grey Literature Report were additionally searched for grey literature. Published articles from Africa on H.pylori antibiotic resistance between 1986 and June 2017 were systematically reviewed to estimate the H. pylori extent of resistance to macrolides, quinolones, amoxicillin, tetracycline and metronidazole. RESULTS In 26 articles a total of 2085 isolates were tested for metronidazole, 1530 for amoxicillin, 1277 for tetracycline, 1752 for clarithromycin and 823 for quinolones.The overall pooled proportion of H.pylori resistance to quinolones, clarithromycin, tetracycline, metronidazole and amoxicillin were: (17.4%, 95%CI 12.8 - 21.9), (29.2%, 95%CI:26.7-31.8), (48.7%, 95%CI: 44.5-52.9), (75.8%, 95% CI: 74.1-.77.4) and (72.6%, 95% CI: 68.6-76.6), respectively. The commonest mutation detected were A2143G (49/97) for clarithromycin, RdxA (41/56) for metronidazole and D87I (16/40) for quinolones. CONCLUSION Prevalence of metronidazole, clarithromycin, and amoxicillin resistance is high in developing world including Africa. This could impair the first line triple therapy of the H.pylori infection. There is a need of conducting surveillance of H.pylori susceptibility pattern in Africa for dual and triple resistance which can be used for the empirical treatment.


title: Development of a bronchospasm device model.

text: There is no strong evidence to support ventilatory management for critical limitation of expiratory flow, such as bronchospasm during anesthesia or an acute exacerbation of severe asthma and chronic obstructive pulmonary disease (COPD). Animal models cannot be used to develop reproducible experimental models for conducting mechanical ventilation strategy research relating to these etiologies due to the resulting respiratory and hemodynamic instabilities. Therefore, we developed a device model by modifying a positive end-expiratory pressure (PEEP) valve that can simulate the characteristics of airway bronchoconstriction (i.e., limited peak expiratory flow and a prolonged expiratory phase). These characteristics were found to improve upon narrowing the expiratory port. We believe that this device model will facilitate future mechanical ventilation experiments.


title: Investigating unexplained fatigue in general practice with a particular focus on CFS/ME.

text: Unexplained fatigue is not infrequent in the community. It presents a number of challenges to the primary care physician and particularly if the clinical examination and routine investigations are normal. However, while fatigue is a feature of many common illnesses, it is the main problem in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). This is a poorly understood condition that is accompanied by several additional symptoms which suggest a subtle multisystem dysfunction. Not infrequently it is complicated by sleep disturbance and alterations in attention, memory and mood.Specialised services for the diagnosis and management of CFS/ME are markedly deficient in the UK and indeed in virtually all countries around the world. However, unexplained fatigue and CFS/ME may be confidently diagnosed on the basis of specific clinical criteria combined with the normality of routine blood tests. The latter include those that assess inflammation, autoimmunity, endocrine dysfunction and gluten sensitivity. Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations.There is presently an on-going debate as to the precise criteria that best confirms CFS/ME to the exclusion of other medical and psychiatric/psychological causes of chronic fatigue. There is also some disagreement as to best means of investigating and managing this very challenging condition. Uncertainty here can contribute to patient stress which in some individuals can perpetuate and aggravate symptoms. A simple clinical scoring system and a short list of routine investigations should help discriminate CFS/ME from other causes of continued fatigue.


Sleeve gastrectomy. A point of technique.


title: Assessment of Conduit-Assisted Primary Nerve Repair Strength With Varying Suture Size, Number, and Location.

text: BACKGROUND Outcomes following digital nerve repair are suboptimal despite much research and various methods of repair. Increased tensile strength of the repair and decreased suture material at the repair site may be 2 methods of improving biologic and biomechanical outcomes, and conduit-assisted repair can aid in achieving both of these goals. METHODS Ninety-nine fresh-frozen digital nerves were equally divided into 11 different groups. Each group uses a different combination of number of sutures at the coaptation site and number of sutures at each end of the nerve-conduit junction, as well as 2 calibers of nylon suture. Nerves were transected, repaired with these various suture configurations using an AxoGuard conduit, and loaded to failure. RESULTS The 2-way analysis of variance (ANOVA) showed that repairs performed with 8-0 suture have significantly higher maximum failure load compared with 9-0 suture repairs ( P < .01). Increasing the number of sutures in the repair significantly increased the maximum failure load in all groups regardless of suture caliber used ( P < .01). Repairs with 9-0 suture at the coaptation site did not jeopardize repair strength when compared with 8-0 suture. CONCLUSIONS Conduit-assisted primary digital nerve repairs with 8-0 suture increases the maximum load to failure compared with repairs with 9-0 suture, as does increasing the overall number of sutures. Using 9-0 suture at the coaptation site with 8-0 suture at the nerve-conduit junction does not jeopardize tensile strength when compared with similar repairs using all 8-0 suture and may decrease inflammation at the repair site while still achieving sufficient tensile strength.


title: The Experience of the Derivo® Embolisation Device in Intracranial Aneurysms.

text: AIM Flow diverters were popular tools for treating intracranial aneurysms in the last decade. The Derivo® embolisation device (DED) is a new-generation flow diverter designed to treat cerebrovascular aneurysms. The safety and efficacy of flow diverters and their long-term clinical outcome must be investigated. In the present study, the clinical outcomes of using the DED on 182 aneurysms are presented Material and Methods: In total, 146 patients with 182 aneurysms were treated with DED. The mean age of the participants was 51.5 years; among them, 46 (31.5%) presented with acute subarachnoid haemorrhage. The mean aneurysm size was 8.3 mm, and 12 aneurysms were involved the vertebrobasilar system. Ophthalmic aneurysms account for most internal carotid artery (ICA) aneurysms. RESULTS The Glasgow Coma Scale (GCS) score of 12 patients was 15. DED was associated with a mortality rate of 2.7% and permanent morbidity rate of 3.4%, and a complete aneurysm occlusion rate was achieved in 78.7% of cases after 7.02 months Conclusion: The DED device is a new-generation flow diverter with excellent opening behaviour and navigational benefits. Our results indicated a safe aneurysm occlusion with optimum morbidity and mortality values despite the fact that almost one-third of the patients presented with subarachnoid haemorrhage.


title: Identification of Bartonella henselae in 2 cats with pyogranulomatous myocarditis and diaphragmatic myositis.

text: Most cats infected with Bartonella henselae remain outwardly healthy carriers for years; however, self-limiting fever, transient anemia, neurologic dysfunction, lymphadenopathy, reproductive disorders, aortic valvular endocarditis, and neutrophilic myocarditis have been described in experimentally or naturally infected cats. Two cats in a North Carolina shelter died with pyogranulomatous myocarditis and diaphragmatic myositis. Bacteria were visualized in the lesions by Warthin-Starry silver impregnation and by B. henselae immunohistochemistry. B. henselae DNA was amplified and sequenced from the heart of 1 cat and from multiple tissue samples, including heart and diaphragm, from the second cat. This study supports a potential association between B. henselae and what has been historically described as "transmissible myocarditis and diaphragmitis" of undetermined cause in cats.


title: Software-Related Recalls of Health Information Technology and Other Medical Devices: Implications for FDA Regulation of Digital Health.

text: Policy Points: Medical software has become an increasingly critical component of health care, yet the regulation of these devices is inconsistent and controversial. No studies of medical devices and software assess the impact on patient safety of the FDA's current regulatory safeguards and new legislative changes to those standards. Our analysis quantifies the impact of software problems in regulated medical devices and indicates that current regulations are necessary but not sufficient for ensuring patient safety by identifying and eliminating dangerous defects in software currently on the market. New legislative changes will further deregulate health IT, reducing safeguards that facilitate the reporting and timely recall of flawed medical software that could harm patients. CONTEXT Medical software has become an increasingly critical component of health care, yet the regulatory landscape for digital health is inconsistent and controversial. To understand which policies might best protect patients, we examined the impact of the US Food and Drug Administration's (FDA's) regulatory safeguards on software-related technologies in recent years and the implications for newly passed legislative changes in regulatory policy. METHODS Using FDA databases, we identified all medical devices that were recalled from 2011 through 2015 primarily because of software defects. We counted all software-related recalls for each FDA risk category and evaluated each high-risk and moderate-risk recall of electronic medical records to determine the manufacturer, device classification, submission type, number of units, and product details. FINDINGS A total of 627 software devices (1.4 million units) were subject to recalls, with 12 of these devices (190,596 units) subject to the highest-risk recalls. Eleven of the devices recalled as high risk had entered the market through the FDA review process that does not require evidence of safety or effectiveness, and one device was completely exempt from regulatory review. The largest high-risk recall categories were anesthesiology and general hospital, with one each in cardiovascular and neurology. Five electronic medical record systems (9,347 units) were recalled for software defects classified as posing a moderate risk to patient safety. CONCLUSIONS Software problems in medical devices are not rare and have the potential to negatively influence medical care. Premarket regulation has not captured all the software issues that could harm patients, evidenced by the potentially large number of patients exposed to software products later subject to high-risk and moderate-risk recalls. Provisions of the 21st Century Cures Act that became law in late 2016 will reduce safeguards further. Absent stronger regulations and implementation to create robust risk assessment and adverse event reporting, physicians and their patients are likely to be at risk from medical errors caused by software-related problems in medical devices.


title: EANM 2012 guidelines for radionuclide imaging of phaeochromocytoma and paraganglioma.

text: PURPOSE Radionuclide imaging of phaeochromocytomas (PCCs) and paragangliomas (PGLs) involves various functional imaging techniques and approaches for accurate diagnosis, staging and tumour characterization. The purpose of the present guidelines is to assist nuclear medicine practitioners in performing, interpreting and reporting the results of the currently available SPECT and PET imaging approaches. These guidelines are intended to present information specifically adapted to European practice. METHODS Guidelines from related fields, issued by the European Association of Nuclear Medicine and the Society of Nuclear Medicine, were taken into consideration and are partially integrated within this text. The same was applied to the relevant literature, and the final result was discussed with leading experts involved in the management of patients with PCC/PGL. The information provided should be viewed in the context of local conditions, laws and regulations. CONCLUSION Although several radionuclide imaging modalities are considered herein, considerable focus is given to PET imaging which offers high sensitivity targeted molecular imaging approaches.


title: A randomized controlled experimental study comparing chitosan coated polypropylene mesh and Proceed™ mesh for abdominal wall defect closure.

text: BACKGROUND Abdominal wall defects and hernias are commonly repaired with synthetic or biological materials. Adhesions and recurrences are a common problem. A study was conducted to compare Chitosan coated polypropylene mesh and a polypropylene-polydioxanone composite with oxidized cellulose coating mesh (Proceed™) in repair of abdominal wall defect in a Rabbit hernia model. METHODS A randomized controlled experimental study was done on twelve New Zealand white rabbits. A ventral abdominal defect was created in each of the rabbits. The rabbits were divided into two groups. In one group the defect was repaired with Chitosan coated polypropylene mesh and Proceed mesh™ in the other. The rabbits were operated in two phases. They were followed up at four weeks and twelve weeks respectively after which the rabbits were sacrificed. They were evaluated by open exploration and histopathological examination. Their efficacy in reducing adhesion and ability of remodeling and tissue integration were studied. RESULTS There was no statistical significance in the area of adhesion, the force required to remove the adhesions, tissue integration and remodeling between Chitosan and Proceed™ group. Histological analysis revealed that the inflammatory response, fibrosis, material degradation and remodeling were similar in both the groups. There were no hernias, wound infection or dehiscence in any of the studied animals. CONCLUSION Chitosan coated polypropylene mesh was found to have similar efficacy to Proceed™ mesh. Chitosan coated polypropylene mesh, can act as an anti adhesive barrier when used in the repair of incisional hernias and abdominal wall defects.


title: Effects of ischemic preconditioning on short-duration cycling performance.

text: It has been demonstrated that ischemic preconditioning (IPC) improves endurance performance. However, the potential benefits during anaerobic events and the mechanism(s) underlying these benefits remain unclear. Fifteen recreational cyclists were assessed to evaluate the effects of IPC of the upper thighs on anaerobic performance, skeletal muscle activation, and metabolic responses during a 60-s sprint performance. After an incremental test and a familiarization visit, subjects were randomly submitted in visits 3 and 4 to a performance protocol preceded by intermittent bilateral cuff inflation (4 × (5 min of blood flow restriction + 5 min reperfusion)) at either 220 mm Hg (IPC) or 20 mm Hg (control). To increase data reliability, each intervention was replicated, which was also in a random manner. In addition to the mean power output, the pulmonary oxygen uptake, blood lactate kinetics, and quadriceps electromyograms (EMGs) were analyzed during performance and throughout 45 min of passive recovery. After IPC, performance was improved by 2.1% compared with control (95% confidence intervals of 0.8% to 3.3%, P = 0.001), followed by increases in (i) the accumulated oxygen deficit, (ii) the amplitude of blood lactate kinetics, (iii) the total amount of oxygen consumed during recovery, and (iv) the overall EMG amplitude (P < 0.05). In addition, the ratio between EMG and power output was higher during the final third of performance after IPC (P < 0.05). These results suggest an increased skeletal muscle activation and a higher anaerobic contribution as the ultimate responses of IPC on short-term exercise performance.


title: Updates on the Pharmacology of Chloroquine against Coronavirus Disease 2019 (COVID-19): A Perspective on its Use in the General and Geriatric Population.

text: BACKGROUND Chloroquine has been used to treat malaria for more than 70 years. Its safety profile and costeffectiveness are well-documented. Scientists have found that chloroquine has in vitro activity against novel coronavirus (SARS-CoV-2). Currently, chloroquine has been adopted in the Protocol for Managing Coronavirus Disease 2019 (COVID19) (Version 7) issued by China National Health Commission for clinically managing COVID-19. OBJECT This review will focus on the antiviral mechanism, effectiveness and safety, dosage and DDIs of chloroquine, for the purpose to provide evidence-based support for rational use of chloroquine in the treatment of COVID-19. Method：Use the search terms 'chloroquine' linked with 'effectiveness', 'safety', 'mechanism', 'drug-drug interaction (DDIs)' or other terms respectively to search relevant literature through PubMed. RESULT After searching, we found literature about antivirus mechanism, dosage, DDIs of chloroquine. However, studies of effectiveness and safety on chloroquine treatment of COVID-19 for the general and geriatric patients are not enough. CONCLUSION According to literature reports, chloroquine has been proved to have anti-SARS-CoV-2 effect in vitro and the potential mechanism of chloroquine in vivo. Pharmacokinetic characteristics and DDIs study are helpful to guide rational drug use in general and geriatric patients. Although there have been reports of successful clinical application of chloroquine in treatment COVID-19，more clinical test data are still needed to prove its effectiveness and safety.


title: A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery.

text: BACKGROUND Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery. METHODS The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach. RESULTS A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group. CONCLUSIONS Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.


title: Effect of 1.5% Topical Diclofenac on Clinical Neuropathic Pain.

text: BACKGROUND Neuropathic pain is a condition resulting from injury to the peripheral and/or central nervous system. Despite extensive research over the last several decades, neuropathic pain remains difficult to manage. METHODS The authors conducted a randomized, placebo-controlled, double-blinded, and crossover clinical trial to examine the effect of 1.5% topical diclofenac (TD) on neuropathic pain. The authors hypothesized that 1.5% TD would reduce the visual pain score and improve both quantitative sensory testing and functional status in subjects with neuropathic pain. The authors recruited subjects with postherpetic neuralgia and complex regional pain syndrome. The primary outcome was subject's visual pain score. RESULTS Twenty-eight subjects completed the study (12 male and 16 female) with the mean age of 48.8 yr. After 2 weeks of topical application, subjects in 1.5% TD group showed lower overall visual pain score compared with placebo group (4.9 [1.9] vs. 5.6 [2.1], difference: 0.8; 95% CI, 0.1 to 1.3; P = 0.04) as well as decreased burning pain (2.9 [2.6] vs. 4.3 [2.8], difference, 1.4; 95% CI, 0.2 to 2.6; P = 0.01). There were no statistical differences in constant pain, shooting pain, or hypersensitivity over the painful area between the groups. This self-reported improvement of pain was corroborated by the decreased pain summation detected by quantitative sensory testing. There were no statistically significant changes in functional status in these subjects. There were no complications in both groups. CONCLUSION The findings indicate that 1.5% TD may serve as an effective treatment option for patients with neuropathic pain from postherpetic neuralgia and complex regional pain syndrome.


title: An Endovascular Strategy for Occlusion or Stenosis with Severe Calcification in the Non-Stenting Zone, creatinG Lumens And SlitS with Crosser in Unique Technique (GLASS CUT): A Case Report.

text: In treating non-stenting zones (NSZs), such as the common femoral artery (CFA) and popliteal artery (PA), the best method to treat severely calcified NSZ lesions remains controversial. Here we describe a new method for the treatment of severely calcified PA and CFA lesions using the Crosser® system (CS). After the first wire passed the lesion, the CS was passed through the other wire to create new cracks and lumens (NCAL) in both cases. After creating NCAL around the lumen of the first wire, a large scoring balloon was inflated to crush the severe calcification like a "GLASS CUT" with a glass knife.


title: Investigation of febrile passengers detected by infrared thermal scanning at an international airport.

text: OBJECTIVE To determine the best approach for the evaluation of fever, detected by infrared thermal scanning, at an international airport. METHODS Arriving passengers with fever were divided into three groups: community evaluation by a GP, with or without cost compensation, or evaluation at the airport by a health practitioner. Uptake of offered evaluations was measured, diagnoses were recorded, and region-specific rates of fever measured. Observations were made on practical aspects of thermal screening. RESULTS Over a six-month period, 181,759 passengers were screened for fever at the Cairns international airport, Queensland, Australia. Fever was identified in 118 (0.06%) of the arriving passengers and 76 were enrolled in the study. Only 19 of these passengers (25%) voluntarily underwent further evaluation. No differences were observed in the three approaches. CONCLUSIONS Public health surveillance of febrile passengers arriving at an international airport should not rely on voluntary passenger participation for the detection of imported contagious diseases.


title: Strand-Specific Dual RNA Sequencing of Bronchial Epithelial Cells Infected with Influenza A/H3N2 Viruses Reveals Splicing of Gene Segment 6 and Novel Host-Virus Interactions.

text: Host-influenza virus interplay at the transcript level has been extensively characterized in epithelial cells. Yet, there are no studies that simultaneously characterize human host and influenza A virus (IAV) genomes. We infected human bronchial epithelial BEAS-2B cells with two seasonal IAV/H3N2 strains, Brisbane/10/07 and Perth/16/09 (reference strains for past vaccine seasons) and the well-characterized laboratory strain Udorn/307/72. Strand-specific RNA sequencing (RNA-seq) of the infected BEAS-2B cells allowed for simultaneous analysis of host and viral transcriptomes, in addition to pathogen genomes, to reveal changes in mRNA expression and alternative splicing (AS). In general, patterns of global and immune gene expression induced by the three IAVs were mostly shared. However, AS of host transcripts and small nuclear RNAs differed between the seasonal and laboratory strains. Analysis of viral transcriptomes showed deletions of the polymerase components (defective interfering-like RNAs) within the genome. Surprisingly, we found that the neuraminidase gene undergoes AS and that the splicing event differs between seasonal and laboratory strains. Our findings reveal novel elements of the host-virus interaction and highlight the importance of RNA-seq in identifying molecular changes at the genome level that may contribute to shaping RNA-based innate immunity.IMPORTANCE The use of massively parallel RNA sequencing (RNA-seq) has revealed insights into human and pathogen genomes and their evolution. Dual RNA-seq allows simultaneous dissection of host and pathogen genomes and strand-specific RNA-seq provides information about the polarity of the RNA. This is important in the case of negative-strand RNA viruses like influenza virus, which generate positive (complementary and mRNA) and negative-strand RNAs (genome) that differ in their potential to trigger innate immunity. Here, we characterize interactions between human bronchial epithelial cells and three influenza A/H3N2 strains using strand-specific dual RNA-seq. We focused on this subtype because of its epidemiological importance in causing significant morbidity and mortality during influenza epidemics. We report novel elements that differ between seasonal and laboratory strains highlighting the complexity of the host-virus interplay at the RNA level.


title: Predicting Patient-ventilator Asynchronies with Hidden Markov Models.

text: In mechanical ventilation, it is paramount to ensure the patient's ventilatory demand is met while minimizing asynchronies. We aimed to develop a model to predict the likelihood of asynchronies occurring. We analyzed 10,409,357 breaths from 51 critically ill patients who underwent mechanical ventilation >24 h. Patients were continuously monitored and common asynchronies were identified and regularly indexed. Based on discrete time-series data representing the total count of asynchronies, we defined four states or levels of risk of asynchronies, z1 (very-low-risk) - z4 (very-high-risk). A Poisson hidden Markov model was used to predict the probability of each level of risk occurring in the next period. Long periods with very few asynchronous events, and consequently very-low-risk, were more likely than periods with many events (state z4). States were persistent; large shifts of states were uncommon and most switches were to neighbouring states. Thus, patients entering states with a high number of asynchronies were very likely to continue in that state, which may have serious implications. This novel approach to dealing with patient-ventilator asynchrony is a first step in developing smart alarms to alert professionals to patients entering high-risk states so they can consider actions to improve patient-ventilator interaction.


title: Infiltrative cutaneous hemangiolipoma in a goat.

text: An approximately 4-year-old castrated male, Saanen cross goat presented to the Colorado State University Veterinary Teaching Hospital for evaluation and removal of a 22 cm × 22 cm, dark red, thickened, and crusted cutaneous lesion along the left ventrolateral thorax. An initial incisional biopsy performed approximately 8 weeks earlier was suspicious for cutaneous hemangiosarcoma. Surgical excision was deemed to be the most appropriate treatment option for this goat. A complete physical exam, complete blood count, and chemistry profile were performed and results were within normal limits. Thoracic radiographs and abdominal ultrasound were performed to rule out metastatic disease and comorbid conditions; no metastatic lesions or other abnormalities were observed. En bloc surgical excision of the affected skin was performed and the entire tissue was submitted for histopathology. A final diagnosis of cutaneous hemangiolipoma was reached upon extensive sectioning and histologic examination of the larger tissue specimen. The goat recovered well from surgery and has had no further complications up to 9 months postoperatively. To our knowledge, this is the first case report of a hemangiolipoma in a goat and surgical excision for such lesions appears to be a viable treatment method.


title: Transumbilical, single-port, totally extraperitoneal, laparoscopic inguinal hernia repair using a homemade port and a conventional instrument: an initial experience.

text: OBJECTIVE To assess the feasibility, safety, and short-term outcome of a transumbilical, single-port, totally extraperitoneal (TEP) laparoscopic inguinal hernia repair, using a homemade port and a conventional instrument. PATIENTS AND METHODS Thirty consecutive patients with inguinal hernias (including 20% with bilateral inguinal hernias) underwent a transumbilical, single-port, TEP laparoscopic hernia (LH) repair using a homemade port composed of a segment of corrugated anesthesia tube and a pair of surgical gloves. All operation procedures were done using conventional laparoscopic instruments with manually angled shafts in the same manner as standard multiple-port surgeries, but using the reverse hand technique. RESULTS All the procedures were completed uneventfully and did not require additional ports. Operation times averaged 98.3 ± 26.7 minutes for the unilateral LH and 121.4 ± 13.5 minutes for the bilateral LH. There were no perioperative complications except for 2 patients (7%) who developed wound seromas, which resolved after conservative treatment. No hernia recurred during the 6-month follow-up. CONCLUSION A transumbilical, single-port, TEP laparoscopic hernioplasty using a homemade port and a conventional instrument permitted nearly scarless surgery for the treatment of inguinal hernias. Further studies are necessary before this approach can be recommended as a standard procedure.


title: Catheter ablation of atrial flutter in patients with left ventricular assist device improves symptoms of right heart failure.

text: Persistent atrial flutter (AFL) in left ventricular assist device (LVAD) recipients can result in loss of AV synchrony, impaired ventricular filling and right heart failure (RHF). The authors report the largest series of HeartMate II (HMII) patients who developed AFL with decompensated RHF, which successfully resolved with AFL ablation. Eight patients with HMII LVAD (mean age, 57±12 years) had medically refractory AFL, with 7 developing de novo AFL after LVAD implant (onset range, 2 days-22 months post-implant). Three patients developed recurrent syncope, 2 had inappropriate implantable cardioverter-defibrillator shocks, and 6 had new or escalating need for inotropes. All had features of decompensated RHF. Seven patients underwent electrophysiology testing where mapping confirmed typical counterclockwise AFL (mean AFL cycle length, 252±49 ms) and radiofrequency ablation of cavotricuspid isthmus restored sinus rhythm in all patients. Complete resolution of symptoms and signs of RHF with improved quality of life were noted in all. No procedural complications were noted. During a mean follow-up of 9±5 months, all patients remained free of atrial flutter. Catheter ablation of AFL in LVAD patients is safe and highly effective, resulting in immediate and significant improvement in symptoms of RHF, and should be considered first-line therapy for AFL in these patients.


title: Mechanical Recanalization Using Solitaire AB Device for Severe Thromboembolic Events in Endovascular Treatment of Intracranial Aneurysms.

text: INTRODUCTION Severe thromboembolism with complete occlusion of the proximal arteries during or after coil embolization can cause serious neurologic deficits. The study aimed to assess the effectiveness and safety of Solitaire AB device as a rescue therapy for severe thromboembolic complications in the endovascular treatment of intracranial aneurysms. MATERIALS AND METHODS Between February 2013 and April 2016, 1047 intracranial aneurysms treated with endovascular procedures were retrospectively reviewed in our center. Severe thromboembolisms occurred in ten patients and were treated by Solitaire AB device including clot retriever and permanent stent deployment. RESULTS The location of arterial occlusion was distal to the aneurysm rather than the coil/parent artery interface or in-stent area. Four patients had distal thromboembolic events before coil embolization, and six patients had it after coiling. The complete arterial recanalization (TICI 3) was achieved in all patients, and no cerebral hemorrhage was related to the procedure after the rescue therapy. Among these patients with the aforementioned neurovascular procedures, the mean Glasgow Outcome Scale (GOS) score was 4.5 (ranging 3-5) and eight cases had good outcome with a score of GOS 4-5 at discharge, while eight patients presented mRS ≤2 at 3-month follow-up. CONCLUSIONS These results demonstrate that mechanical recanalization using Solitaire AB device seems to be effective and safe as a rescue therapy for severe thromboembolic events during cerebral aneurysm embolization.


title: Viral infection in community-acquired pneumonia: a systematic review and meta-analysis.

text: The advent of PCR has improved the identification of viruses in patients with community-acquired pneumonia (CAP). Several studies have used PCR to establish the importance of viruses in the aetiology of CAP.We performed a systematic review and meta-analysis of the studies that reported the proportion of viral infection detected via PCR in patients with CAP. We excluded studies with paediatric populations. The primary outcome was the proportion of patients with viral infection. The secondary outcome was short-term mortality.Our review included 31 studies. Most obtained PCR via nasopharyngeal or oropharyngeal swab. The pooled proportion of patients with viral infection was 24.5% (95% CI 21.5-27.5%). In studies that obtained lower respiratory samples in >50% of patients, the proportion was 44.2% (95% CI 35.1-53.3%). The odds of death were higher in patients with dual bacterial and viral infection (OR 2.1, 95% CI 1.32-3.31).Viral infection is present in a high proportion of patients with CAP. The true proportion of viral infection is probably underestimated because of negative test results from nasopharyngeal or oropharyngeal swab PCR. There is increased mortality in patients with dual bacterial and viral infection.


title: Primary stenting for acute ischemic stroke using the Enterprise vascular reconstruction device: early results.

text: OBJECTIVE Primary stenting for acute ischemic stroke (AIS) using the Wingspan stent delivery system has been reported. Major technical limitations in that study were difficulties in delivering the device and a few cases in which the Enterprise vascular reconstruction device (stent) was used as a bailout procedure. The Enterprise, which has relatively less radial force and more flexibility than other intracranial stents, is an ideal device for revascularization as it is easily delivered through tortuous intracranial vessels. We tested the safety and effectiveness of this stent as the primary revascularization device for AIS in an FDA-approved investigational device exemption prospective cohort study. METHODS Twenty patients presenting with AIS due to confirmed intracranial large vessel occlusion within 8 h of onset of stroke symptoms were treated with the Enterprise as the primary revascularization device. The primary outcome was recanalization to Thrombolysis In Myocardial Infarction (TIMI) flow of ≥2. Perioperative safety was measured by major complication incidence within 30 days of stent revascularization. A secondary measure of outcome was 30-day modified Rankin Scale (mRS) score. RESULTS Recanalization to TIMI 2 (n=6) or 3 (n=12) flow was achieved in 18 patients (90% revascularization rate). Three major complications were noted (15%) including one myocardial infarction, one symptomatic intracranial hemorrhage and one ischemic stroke in a distribution other than the qualifying vessel. Good outcome (mRS ≤2) was obtained in 10 patients (50%). CONCLUSIONS In this prospective study the Enterprise stent was found to be a safe and effective revascularization tool in the setting of AIS.


Mind the Gap: The Hospital Breakroom.


title: Image-Guided Thermal Ablative Therapies in the Treatment of Sarcoma.

text: OPINION STATEMENT Percutaneous thermal ablation, including microwave ablation (MWA), radiofrequency ablation (RFA), and cryoablation, is a well-established focal treatment option for primary and metastatic malignancies. While published literature specific to ablation of sarcomas is relatively lacking compared with non-sarcomatous malignancies, what is available is promising. In situations where a focal treatment option is desired, strong consideration should be given to percutaneous thermal ablation, in addition to surgery and radiation therapy. A significant advantage of percutaneous thermal ablation over surgery and radiation includes the repeatability of ablation, as there is no absolute limit on the number of times an ablation can be performed. Compared with surgery, ablation offers the potential of decreased recovery time, a less invasive procedure, and is often performed in patients deemed not medically fit for surgery.


title: Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial.

text: OBJECT Cerebrospinal fluid leakage is an immanent risk of cranial surgery with dural opening. Recognizing the risk factors for this complication and improving the technique of dural closure may reduce the associated morbidity and its surgical burden. The aim of this paper was to investigate whether the addition of TachoSil on top of the dural suture reduces postoperative CSF leakage compared with dural suturing alone and to assess the frequency and risk factors for dural leakage and potentially related complications after elective craniotomy. METHODS The authors conducted a prospective, randomized, double-blinded single-center trial in patients undergoing elective craniotomy with dural opening. They compared their standard dural closure by running suture alone (with the use of a dural patch if needed) to the same closure with the addition of TachoSil on top of the suture. The primary end point was the incidence of CSF leakage, defined as CSF collection or any open CSF fistula within 30 days. Secondary end points were the incidence of infection, surgical revision, and length of stay in the intensive care unit (ICU) or intermediate care (IMC) unit. The site of craniotomy, a history of diabetes mellitus, a diagnosis of meningioma, the intraoperative need of a suturable dural substitute, and blood parameters were assessed as potential risk factors for CSF leakage. RESULTS The authors enrolled 241 patients, of whom 229 were included in the analysis. Cerebrospinal fluid leakage, mostly self-limiting subgaleal collections, occurred in 13.5% of patients. Invasive treatment was performed in 8 patients (3.5%) (subgaleal puncture in 6, lumbar drainage in 1, and surgical revision in 1 patient). Diabetes mellitus, a higher preoperative level of C-reactive protein (CRP), and the intraoperative need for a dural patch were positively associated with the occurrence of the primary end point (p = 0.014, 0.01, and 0.049, respectively). Cerebrospinal fluid leakage (9.7% vs 17.2%, OR 0.53 [95% CI 0.23-1.15], p = 0.108) and infection (OR 0.18 [95% CI 0.01-1.18], p = 0.077) occurred less frequently in the study group than in the control group. TachoSil significantly reduced the probability of staying in the IMC unit for 1 day or longer (OR 0.53 [95% CI 0.27-0.99], p = 0.048). Postoperative epidural hematoma and empyema occurred in the control group but not in the study group. CONCLUSIONS Dural leakage after elective craniotomy/durotomy occurs more frequently in association with diabetes mellitus, elevated preoperative CRP levels, and the intraoperative need of a dural patch. This randomized controlled trial showed no statistically significant reduction of postoperative CSF leakage and surgical site infections upon addition of TachoSil on the dural suture, but there was a significant reduction in the length of stay in the IMC unit. Dural augmentation with TachoSil was safe and not related to adverse events. Clinical trial registration no. NCT00999999 ( http://www.ClinicalTrials.gov ).


title: Expression of pluripotency and multipotency factors in human ocular surface tissues.

text: AIM Mechanisms that control ocular surface stem cells (SCs) are unclear. Recent studies have shown that several adult SCs express pluripotency markers. Our objective was to analyze the expression of key molecules of pluripotency in human ocular surface tissues as well as in cultivated limbal epithelium. METHODS Four samples of human corneal, limbal and on amniotic membrane cultivated limbal epithelium (HLEC-AM), as well as bulbar and fornical conjunctiva were analyzed. Human embryonic stem (ES) cells and human umbilical vein endothelial cells served as controls. Expression of corneal epithelial differentiation markers (K3, K12, Cx43), putative limbal SC markers (ABCG2, p63, K15), and molecules associated with pluripotency/multipotency (NANOG, OCT4, SOX2, KLF4, KIT, NESTIN, PAX6, NOTCH1) was examined using real-time polymerase chain reaction (PCR) and immunohistochemical staining. RESULTS Limbal epithelium showed a significantly (p < 0.05) higher expression of K15, ABCG2, OCT4, SOX2, NESTIN and NOTCH1, but a lower expression of K3 than corneal epithelium. Besides a higher expression of ABCG2 in fornix, the expression of pluripotency markers was similar in both conjunctival regions, although lower than in limbal epithelium. Expression of pluripotency factors in ES cells was significantly higher than in ocular surface SCs, whereas the expression in limbal epithelium was the closest to ES cells. HLEC-AM in comparison to limbal epithelium showed a lower expression of differentiation markers, a similar expression of ABCG2 but a significantly lower expression of pluripotency factors. CONCLUSION Human ocular surface epithelial cells and especially limbal epithelial cell express genes are important for pluripotency and may have preserved some common mechanisms with pluripotent SCs.


Negative-Pressure Aerosol Cover for COVID-19 Tracheostomy.


title: Difficult Management of a Double-Lumen Endotracheal Tube and Difficult Ventilation during Robotic Thymectomy with Carbon Dioxide Insufflation.

text: Robotic surgery with carbon dioxide (CO2) insufflation to the thorax is frequently performed to gain a better operative field of view, although its intraoperative complications have not yet been discussed in detail. We treated two patients with difficult ventilation caused by distal migration of a double-lumen endotracheal tube (DLT) during robotic thymectomy. In the first case, migration of the DLT during one-lung ventilation (OLV) occurred after CO2 insufflation to the bilateral thoraxes was started. Oxygenation rapidly deteriorated because dependent lung expansion was restricted by CO2 insufflation. In the second case, migration of the DLT during OLV occurred while CO2 insufflation to a unilateral thorax and mediastinum was performed. In both cases, once migration of the DLT during OLV occurred with CO2 insufflation, readjusting the DLT became very difficult because our manipulation of bronchofiberscopy was prevented by the robot arms located above the patient's head and because deformation of the trachea/bronchus induced by CO2 insufflation caused a poor image of the bronchofiberscopic view. Thus, during robotic-assisted thoracoscopic surgery with CO2 insufflation, since there is a potential risk of difficult ventilation with a DLT and since readjustment of the DLT is very difficult, discontinuing CO2 insufflation and switching to double-lung ventilation are needed in such a situation.


title: Effect of bismuth breast shielding on radiation dose and image quality in coronary CT angiography.

text: BACKGROUND Coronary computed tomographic angiography (CCTA) is associated with high radiation dose to the female breasts. Bismuth breast shielding offers the potential to significantly reduce dose to the breasts and nearby organs, but the magnitude of this reduction and its impact on image quality and radiation dose have not been evaluated. METHODS Radiation doses from CCTA to critical organs were determined using metal-oxide-semiconductor field-effect transistors positioned in a customized anthropomorphic whole-body dosimetry verification phantom. Image noise and signal were measured in regions of interest (ROIs) including the coronary arteries. RESULTS With bismuth shielding, breast radiation dose was reduced 46%-57% depending on breast size and scanning technique, with more moderate dose reduction to the heart, lungs, and esophagus. However, shielding significantly decreased image signal (by 14.6 HU) and contrast (by 28.4 HU), modestly but significantly increased image noise in ROIs in locations of coronary arteries, and decreased contrast-to-noise ratio by 20.9%. CONCLUSIONS While bismuth breast shielding can significantly decrease radiation dose to critical organs, it is associated with an increase in image noise, decrease in contrast-to-noise, and changes tissue attenuation characteristics in the location of the coronary arteries.


title: Overview of Coronavirus Disease 2019 (COVID-19): Treatment Updates and Advances.

text: In late December 2019, several cases of pneumonia with unknown cause were reported in Wuhan, China, and this new type of pneumonia spread rapidly to across provinces during the subsequent weeks. The pathogen was identified quickly and was named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The infectious disease caused by this virus is referred to as coronavirus disease 2019 (COVID-19). Within months, it has caused a global pandemic and posed a major threat to public health worldwide. As of May 23, 2020, 5,252,452 patients have been confirmed to have the disease, and 339,026 deaths have been reported. Multiple therapeutic trials are ongoing, and some promising results have been released. A vaccine would provide the most effective approach to fight the virus by preventing infection, but none are currently available. To control the COVID-19 outbreak, large-scale measures have been applied to reduce human-to-human transmission of SARS-CoV-2. Susceptible populations, including older adults, children, and health care providers, warrant particular attention to avoid transmission and infection. This review introduces current understanding of SARS-CoV-2 infection and treatment strategies, emphasizing the relevant challenges associated with prevention, diagnosis, and management.


Successful treatment of a 20-year nonhealing venous leg ulcer in a patient with systemic lupus erythematosus.


title: Efficacy of cilostazol-based dual antiplatelet treatment in patients undergoing carotid artery stenting.

text: BACKGROUND It is essential that patients undergoing carotid artery stenting (CAS) receive optimal antiplatelet inhibition. Although a reduction in platelet reactivity and improved clinical outcomes occur when using adjunctive cilostazol with dual antiplatelet therapy, this can lead to an increased risk of hemorrhagic complications. Therefore, our current study examined patients undergoing CAS and evaluated the impact of cilostazol-based dual antiplatelet treatment on the outcomes. METHODS Between 2010 and 2015, 137 consecutive patients underwent CAS. From 2010 to 2011 (period 1), 28 patients underwent CAS in conjunction with aspirin and clopidogrel dual antiplatelet treatment (DAPT). From 2010 to 2013 (period 2), 44 patients underwent a preoperative assessment of their platelet function, with the clopidogrel-resistant patients receiving adjunctive cilostazol in addition to the aspirin and clopidogrel. From 2013 to 2015 (period 3), 65 patients underwent CAS in conjunction with cilostazol and clopidogrel treatment. In all patients, the incidence of new ipsilateral ischemic lesions observed by diffusion-weighted imaging on the day after CAS, and ischemic or hemorrhagic events occurring within 30 days were assessed. RESULTS Clopidogrel resistance was identified in 43% of the patients in period 1, in 16% in period 2, and in 5% in period 3 (P < 0.001). The on-treatment platelet reactivity results indicated that the PRU value during cilostazol-based DAPT was significantly lower than that observed for the standard DAPT (P < 0.05). New ipsilateral ischemic lesions decreased by 9% and 8% in periods 2 and 3, respectively, versus a 25% decrease in period 1 (P = 0.047). However, there were no significant differences noted for any of the hemorrhagic or thromboembolic events. CONCLUSIONS Compared to the standard aspirin and clopidogrel dual antiplatelet therapy, cilostazol-based dual antiplatelet treatment reduces the rate of clopidogrel resistance and suppresses new ischemic lesions without hemorrhagic complications.


title: No development of ciprofloxacin resistance in the Haemophilus species associated with pneumonia over a 10-year study.

text: BACKGROUND The widespread overuse of antibiotics promotes the development of antibiotic resistance in bacteria, which can cause severe illness and constitutes a major public health concern. Haemophilus species are a common cause of community- and nosocomial-acquired pneumonia. The antibiotic resistance of these Gram-negative bacteria can be prevented through the reduction of unnecessary antibiotic prescriptions, the correct use of antibiotics, and good hygiene and infection control. This article examines, retrospectively, antibiotic resistance in patients with community- and nosocomial-acquired pneumonia caused by Haemophilus species. METHODS The demographic, clinical, and laboratory data of all patients with community- and nosocomial-acquired pneumonia caused by Haemophilus species were collected from the hospital charts at the HELIOS Clinic, Witten/Herdecke University, Wuppertal, Germany, within a study period from 2004 to 2014. Antimicrobial susceptibility testing was performed for the different antibiotics that have been consistently used in the treatment of patients with pneumonia caused by Haemophilus species. RESULTS During the study period of January 1, 2004, to August 12, 2014, 82 patients were identified with community- and nosocomial-acquired pneumonia affected by Haemophilus species. These patients had a mean age of 63.8 ± 15.5 (60 [73.2%, 95% CI 63.6%-82.8%] males and 22 [26.8%, 95% CI 17.2%-36.4%] females). Haemophilus species had a high resistance rate to erythromycin (38.3%), ampicillin (24.4%), piperacillin (20.8%), cefuroxime (8.5%), ampicillin-sulbactam (7.3%), piperacillin-sulbactam (4.3%), piperacillin-tazobactam (2.5%), cefotaxime (2.5%), and levofloxacin (1.6%). In contrast, they were not resistant to ciprofloxacin in patients with pneumonia (P = 0.016). CONCLUSION Haemophilus species were resistant to many of the typically used antibiotics. Resistance toward ciprofloxacin was not detected in patients with pneumonia caused by Haemophilus species.


title: Why is There Low Morbidity and Mortality of COVID-19 in Africa?

text: Three months since the detection of the first COVID-19 case in Africa, almost all countries of the continent continued to report lower morbidity and mortality than the global trend, including Europe and North America. We reviewed the merits of various hypotheses advanced to explain this phenomenon, including low seeding rate, effective mitigation measures, population that is more youthful, favorable weather, and possible prior exposure to a cross-reactive virus. Having a youthful population and favorable weather appears compelling, particularly their combined effect; however, progression of the pandemic in the region and globally may dispel these in the coming months.


Letter to the editor: Multimodal treatment of co-existent callosal cavernous malformation and anterior communicating artery aneurysm associated with an infraoptic anterior cerebral artery.