Chinese herbal medicine and COVID-19: quality evaluation of clinical guidelines and expert consensus and analysis of key recommendations

Objective:To systematically review the clinical practice guidelines(CPGs)for the treatment of patients with coronavirus disease 2019(COVID-19)using Chinese herbal medicine(CHM),assess the methodological quality as well as clinical credibility and implementability of specific recommendations,and summarize key recommendations.Methods:As of April 2022,we conducted a comprehensive search on major electronic databases,guideline websites,academic society websites,and government websites to assess the methodological quality and clinical applicability of the included CPGs using the Appraisal of Guidelines for Research and Evaluation(AGREE)II tool and Evaluation-Recommendations EXcellence(AGREE-REX)instructions,respectively.Results:The search yielded 61 CPGs,which were mostly published in 2020;moreover,98.4%of the CPGs were published in China.Only five CPGs achieved a high-quality AGREE II rating;further,six CPGs could be directly recommended,with most of the CPGs still showing much room for improvement.CPGs had a low overall score in the AGREE-REX evaluation,with the domains of clinical applicability,values and preferences,and implementability being standardized in 21.80%±12.56%,16.00%±11.81%,and 31.33%±14.55%of the CPGs,respectively.Five high-quality CPGs mentioned 56 Chinese herbal formulas.Half of the recommendations had moderate or strong evidence level in the GRADE evaluation.The most frequently recommended herbal medicines were Lianhua Qingwen granule/capsule and Jinhua Qinggan granule;however,the strength of recommendation for each prescription varied across CPGs and populations.Conclusions:The overall quality of current CPGs for COVID-19 for CHM still needs to be improved;moreover,the strength of the evidence remains to be standardized across CPGs.

The Impact of Black Sea Sand Treatment Effectively Reducing Different Type of Pain

Purpose: Low back pain (LBP), Gonarthrosis, knee, and Carpal Tunnel Syndrome have been regarded as affecting more than three-quarters’ of individuals in their lifetime. The aim of this study was conducted to determine and compare the effects of topical patients with sand compared with control related to Gonarthrosis, LBP, knee, and Carpal Tunnel Syndrome pain. Methods: This is a prospective case and control designed study based on 101 pain case with Sand and 101 control subjects. The interventional groups in addition either topical sand or without sand 2 months after the intervention were assessed. We assessed tolerability of an established pain perception scale by the Numeric Rating Scale (NRS). Categorical variables were compared using the chi-square (χ2) test. The paired t-test was used to compare the two groups before and after the intervention. One-way analysis of variance (ANOVA) was employed for comparison of several group means. Results: The study was based on 202 patients, 41 males (20.3%) and 161 females (79.7%). There were statistically significant differences between subjects with and without Sand in term of Gonarthrosis, Rheumatoid Arthritis LBP, knee, and Carpal Tunnel Syndrome pain (p = 0.033). Majority of patients were over age 55 years old (55%) and females 78 (77.2%). The mean score of total pain experience before and after the intervention was 7.41 ± 1.1 for black sand, and 4.24 ± 2.38 for without sand as control group. The mean scores of these 5 groups were highly significant before and after the intervention (p There was statistically highly significant in regarding subjects with Sand as compared with those before Sand after treatment mean score specifically with gonarthrosis before pain 7.23 ± 1.86 vs after treatment 4.54 ± 2.18 p < 0.001;rheumatoid arthritis before 8.28 ± 1.48 vs after treatment 4.80 ± 3.71 p < 0.001;Low Back Pain before 8.42 ± 1.83 vs after treatment 4.37 ± 1.52 p < 0.001;knee pain before 8.93 ± 0.89 vs after treatment 4.24 ± 0.24 p < 0.001;Carpal Tunnel Syndrome before 7.664 ± 1.04 vs after treatment 4.26 ± 1.03 p Conclusion: The current study has revealed that the topical treatments with sand could have a significant effect on the perception of pain compared to those in the control group with respect of gonarthrosis, rheumatoid arthritis, LBP, knee, and Carpal Tunnel Syndrome pain .

Translation, Adaptation and Validation of a Chinese Medicine Questionnaire to Brazilian Portuguese

The Constitution in Chinese Medicine Questionnaire [CCMQ] organizes 9 body constitutions according to Traditional Chinese Medicine [TCM]. The translation was realized by a Medical Doctor [MD] specialized in TCM and the back translation by an english-speaking MD. Comprehensibility assessment was performed (N = 40, main scores ranged from 4.20 to 4.95). On the test-retest reliability Cronbach’s alpha was 0.920 in the first application and 0.943 in the second, the intraclass correlation scores ranged between good and excellent (0.6 - >0.80). The results show that the adaptation of the CCMQ is valid and ready to be used.

ARGA-Unet:Advanced U-net segmentation model using residual grouped convolution and attention mechanism for brain tumor MRI image segmentation

Background Magnetic resonance imaging(MRI)has played an important role in the rapid growth of medical imaging diagnostic technology,especially in the diagnosis and treatment of brain tumors owing to its non invasive characteristics and superior soft tissue contrast.However,brain tumors are characterized by high non uniformity and non-obvious boundaries in MRI images because of their invasive and highly heterogeneous nature.In addition,the labeling of tumor areas is time-consuming and laborious.Methods To address these issues,this study uses a residual grouped convolution module,convolutional block attention module,and bilinear interpolation upsampling method to improve the classical segmentation network U-net.The influence of network normalization,loss function,and network depth on segmentation performance is further considered.Results In the experiments,the Dice score of the proposed segmentation model reached 97.581%,which is 12.438%higher than that of traditional U-net,demonstrating the effective segmentation of MRI brain tumor images.Conclusions In conclusion,we use the improved U-net network to achieve a good segmentation effect of brain tumor MRI images.

Cholangiocarcinoma:A compact review of the literature

Cholangiocarcinoma(CC) is a devastating cancer aris-ing from biliary epithelia.Unfortunately,the incidence of this disease is increasing in Western countries.These tumors progress insidiously,and liver failure,biliary sepsis,malnutrition and cancer cachexia are general modes of death associated with this disease.To date,no established therapy for advanced dis-ease has been established or validated.However,our knowledge in tumor biology is increasing dramatically and new drugs are under investigation for treatment of this notorious tumor.In clinical practice,there are better diagnostic tools in use to facilitate an earlier diagnosis of CC,at least in those patients with known risk factors.CC is resectable for cure in only a small percentage of patients.Preoperative staging for vas-cular and biliary extension of CC is very important in this tumor.Laparoscopy and recently endosonography seem to protect against unnecessary laparotomies in these patients.During the last 15 years,aggressive surgical approaches,including combined liver resec-tions and vascular reconstructive surgical expertise,have improved survival in patients with CC.Surgery is contraindicated in CC cases having primary sclerosing cholangitis(PSC).Although CC was previously consid-ered a contraindication to liver transplantation,new cautious protocols,including neo-adjuvant chemora-diation therapies and staging procedures before the transplantation,have made it possible to achieve long-term survival after liver transplantation in this disease.New ablative therapies with photodynamic therapy,intraductal high-intensity ultrasonography and chemo-therapy-impregnated plastic biliary endoprosthesis are important steps in the palliative management of extra-hepatic CCs.Radiofrequency and chemo-embolization methods are also applicable for intra-hepatic CCs as palliative modes of treatment.We need more prospec-tive randomized controlled trials to evaluate the role of the new emerging therapies for CC patients.

Understanding the medial ulnar collateral ligament of the elbow: Review of native ligament anatomy and function

The medial ulnar collateral ligament complex of the elbow, which is comprised of the anterior bundle [AB, more formally referred to as the medial ulnar collateral ligament(MUCL)], posterior(PB), and transverse ligament, is commonly injured in overhead throwing athletes. Attenuation or rupture of the ligament results in valgus instability with variable clinical presentations. The AB or MUCL is the strongest component of the ligamentous complex and the primary restraint to valgus stress. It is also composed of two separate bands(anterior and posterior) that provide reciprocal function with the anterior band tight in extension, and the posterior band tight in flexion. In individuals who fail co-mprehensive non-operative treatment, surgical repair or reconstruction of the MUCL is commonly required to restore elbow function and stability. A comprehensive understanding of the anatomy and biomechanical properties of the MUCL is imperative to optimize reconstructive efforts, and to enhance clinical and radiographic outcomes. Our understanding of the native anatomy and biomechanics of the MUCL has evolved over time. The precise locations of the origin and insertion footprint centers guide surgeons in proper graft placement with relation to bony anatomic landmarks. In recent studies, the ulnar insertion of the MUCL is described as larger than previously thought, with the center of the footprint at varying distances relative to the ulnar ridge, joint line, or sublime tubercle. The purpose of this review is to consolidate and summarize the existing literature regarding the native anatomy, biomechanical, and clinical significance of the entire medial ulnar collateral ligament complex, including the MUCL(AB), PB, and transverse ligament.

Osteopontin is an important mediator of alcoholic liver disease via hepatic stellate cell activation

AIM: To investigate over-expression of Osteopontin(OPN) pathway expression and mechanisms of action in human alcoholic liver disease(ALD), in vivo and in vitro acute alcohol models. METHODS: OPN pathway was evaluated in livers from patients with progressive stages of human ALD and serum from drinkers with and without liver cirrhosis. In vitro stellate LX2 cells exposed to acute alcohol and in vivo in acute alcoholic steatosis mouse models were also investigated for OPN pathway expression and function. WT and OPN-/- mice were administered an acute dose of alcohol and extent of liver injury was examined by histopathology and liver biochemistry after 16-24 h. The causative role of OPN was studied in OPN knockout animals and in vitro in stellate LX2 cells, utilizing siRNA, aptamer and neutralizing antibodies to block OPN and OPN pathway. OPN pathway expression and downstream functional consequences were measured for signaling by Western blotting, plasmin activation by spectrophotometric assays and cell migration by confocal imaging and quantitation. RESULTS: OPN expression positively correlated with disease severity in patients with progressive stages of ALD. In vivo, associated with alcoholic steatosis, a single dose of acute alcohol significantly increased hepatic OPN mRNA and protein, and a cleaved OPN form in a dose dependent manner. OPN mRNA and secreted OPN also increased in parallel with activation of LX2 stellate cells within 4 h of a single dose of alcohol. Expression of OPN receptors, αvβ3-integrin and CD44, increased in human ALD, and in vivo and in vitro with alcohol administration. This was accompanied by downstream phosphorylation of Akt and Erk, increased mRNA expression of several fibrogenesis, fibrinolysis and extracellular matrix pathway genes, plasmin activation and hepatic stellate cell(HSC) migration. Inhibition of OPN and OPN-receptor mediated signaling partially inhibited alcohol-induced HSC activation, plasmin activity and cell migration. CONCLUSION: OPN is a key mediator of the alcoholinduced effects on hepatic stellate cell functions and liver fibrogenesis.

The impacts of infectious complications on outcomes in acute pancreatitis: a retrospective study

Background: The occurrence of infectious complications characterizes the more severe forms of acute pancreatitis(AP) and is associated with high mortality. We investigated the effects of infection at different sites in patients with AP, including those with necrotizing pancreatitis(NP).Methods: We conducted a retrospective analysis of 285 patients who met the inclusion criteria for AP and were admitted to Tianjin Nankai Hospital between January 2016 and September 2019. According to the source of the culture positivity during hospitalization, patients were divided into four groups: sterile group(n=148), pancreatic infection group(n=65), extrapancreatic infection group(n=22) and combined infection group(n=50). The source of infection, microbiology, biochemical parameters and prognostic indicators were analyzed.Results: In terms of baseline characteristics, the four groups were similar in age, sex, aetiology, previous pancreatitis and diabetes. Compared with the severity of the disease in the other groups, the APACHE II scores(9.91±4.65, 9.46±5.05, respectively) and organ failure rate(40.9% and 50%, respectively)were higher in the extrapancreatic infection group and the combined infection group(P<0.05). The frequency of surgical intervention and hospitalization time in patients with NP complicated with extrapancreatic infection was greatly increased(P<0.05). Regarding the primary outcome, patients in the combined infection group had longer hospital stays(68.28±51.80 vs. 55.58±36.24, P<0.05) and higher mortality(24.0% vs. 9.2%, P<0.05) than patients in the pancreatic infection group. In addition, patients in the extrapancreatic infection group also showed high intensive care utilization(59.1%) and mortality rates(18.2%). Among the 137 AP patients with infection complications, 89 patients exhibited multidrug-resistant(MDR) microorganisms, and the mortality rate of patients with MDR bacterial infection was higher than that of patients with non-MDR bacterial infection(24.7% vs. 3.6%, P=0.001).Conclusions: Clinicians should be aware that extrapancreatic infection(EPI) significantly aggravates the main outcome in pancreatic infection patients. Infection with MDR bacteria is also associated with AP mortality.

Liver transplantation and the management of progressive familial intrahepatic cholestasis in children

Progressive familial intrahepatic cholestasis(PFIC) is a constellation of inherited disorders that result in the impairment of bile flow through the liver that predominantly affects children. The accumulation of bile results in progressive liver damage, and if left untreated leads to end stage liver disease and death. Patients often present with worsening jaundice and pruritis within the first few years of life. Many of these patients will progress to end stage liver disease and require liver transplantation. The role and timing of liver transplantation still remains debated especially in the management of PFIC1. In those patients who are appropriately selected, liver transplantation offers an excellent survival benefit. Appropriate timing and selection of patients for liver transplantation will be discussed, and the short and long term management of patients post liver transplantation will also be described.

Serological profiling of Crohn’s disease and ulcerative colitis patients reveals anti-microbial antibody signatures

BACKGROUND The healthcare burden of inflammatory bowel disease(IBD)is rising globally and there are limited non-invasive biomarkers for accurate and early diagnosis.AIM To understand the important role that intestinal microbiota play in IBD pathogenesis and identify anti-microbial antibody signatures that benefit clinical management of IBD patients.METHODS We performed serological profiling of 100 Crohn’s disease(CD)patients,100 ulcerative colitis(UC)patients and 100 healthy controls against 1173 bacterial and 397 viral proteins from 50 bacteria and 33 viruses on protein microarrays.The study subjects were randomly divided into discovery(n=150)and validation(n=150)sets.Statistical analysis was performed using R packages.RESULTS Anti-bacterial antibody responses showed greater differential prevalence among the three subject groups than anti-viral antibody responses.We identified novel antibodies against the antigens of Bacteroidetes vulgatus(BVU_0562)and Streptococcus pneumoniae(SP_1992)showing higher prevalence in CD patients relative to healthy controls.We also identified antibodies against the antigen of Streptococcus pyogenes(SPy_2009)showing higher prevalence in healthy controls relative to UC patients.Using these novel antibodies,we built biomarker panels with area under the curve(AUC)of 0.81,0.87,and 0.82 distinguishing CD vs control,UC vs control,and CD vs UC,respectively.Subgroup analysis revealed that penetrating CD behavior,colonic CD location,CD patients with a history of surgery,and extensive UC exhibited highest antibody prevalence among all patients.We demonstrated that autoantibodies and anti-microbial antibodies in CD patients had minimal correlation.CONCLUSION We have identified antibody signatures for CD and UC using a comprehensive analysis of antimicrobial antibody response in IBD.These antibodies and the source microorganisms of their target antigens improve our understanding of the role of specific microorganisms in IBD pathogenesis and,after future validation,should aid early and accurate diagnosis of IBD.

Resection of bilateral occipital lobe lesions during a single operation as a treatment for bilateral occipital lobe epilepsy

BACKGROUND Neurosurgical treatment of severe bilateral occipital lobe epilepsy usually involves two operations several mos apart.AIM To evaluate surgical resection of bilateral occipital lobe lesions during a single operation as a treatment for bilateral occipital lobe epilepsy.METHODS This retrospective case series included patients with drug-refractory bilateral occipital lobe epilepsy treated surgically between March 2006 and November 2015.RESULTS Preoperative evaluation included scalp video-electroencephalography(EEG),magnetic resonance imaging,and PET-CT.During surgery(bilateral occipital craniotomy),epileptic foci and important functional areas were identified by EEG(intracranial cortical electrodes)and cortical functional mapping,respectively.Patients were followed up for at least 5 years to evaluate treatment outcome(Engel grade)and visual function.The 20 patients(12 males)were aged 4-30 years(median age,12 years).Time since onset was 3-20 years(median,8 years),and episode frequency was 4-270/mo(median,15/mo).Common manifestations were elementary visual hallucinations(65.0%),flashing lights(30.0%),blurred vision(20.0%)and visual field defects(20.0%).Most patients were free of disabling seizures(Engel grade I)postoperatively(18/20,90.0%)and at 1 year(18/20,90.0%),3 years(17/20,85.0%)and≥5 years(17/20,85.0%).No patients were classified Engel grade IV(no worthwhile improvement).After surgery,there was no change in visual function in 13/20(65.0%),development of a new visual field defect in 3/20(15.0%),and worsening of a preexisting defect in 4/20(20.0%).CONCLUSION Resection of bilateral occipital lobe lesions during a single operation may be applicable in bilateral occipital lobe epilepsy.

Case Report of Duodenal Gastrointestinal Stromal Tumor Masquerading a Pancreatic Head Tumor

Gastrointestinal stromal tumor (GIST) represents the most common kind of mesenchymal tumor that arises from the alimentary tract. Tumors arising from the first and the second part of the duodenum (DI and DII, respectively) can be wrongly diagnosed as pancreatic mass. We report a case of a 58-year-old male patient with the history of vomiting just after eating, loss of appetite, lethargic and weight loss for 25 days. CT scan of abdomen and pelvis showed a soft tissue mass with slight heterogeneous enhancement at the region of the uncinate process of the head of pancreas and (MPR) on CT enhanced showed the closely attached mass to the head of the pancreas. On operative exploration, the mass was found to be originated from duodenum. Then, surgical resection of the duodenal tumor was performed by wedge resection successfully. Postoperative laboratory diagnosis was “low risk” duodenal gastrointestinal stromal tumor.

Outcomes and Cost Effectiveness of a Respiratory Coordinated Care Program in Patients with Severe or Very Severe COPD

Multidisciplinary community coordinated care programs are widely adopted to optimise care of chronic disease patients, but there is a need for further evaluation in the setting of COPD. This observational study evaluated 147 patients with severe or very severe COPD who were enrolled in a multidisciplinary community respiratory coordinated care program (RCCP) from 2007 to 2012. Comparison was made of hospitalisation rates and length of stay for 12 months prior to joining the program, and the first 12 months after joining the program. This data was used to inform a cost analysis. Enrolment into RCCP halved the annual hospital admission rate from 1.18 to 0.57 admissions per year (relative risk reduction 51.4%, p < 0.001), and annual total length of stay was reduced from 8.06 to 3.59 days per patient per year (p < 0.001). Hospital admissions were reduced from 5.05 days to 2.00 days (p < 0.001). Accounting for the program’s costs, these changes resulted in a $US 906.94 ($AUD 972.80) cost saving per patient per year. A RCCP program can reduce patient hospitalisation and overall costs in the COPD setting.

Adenovirus-mediated transfer of suicide gene for treatment of metastatic pancreatic cancer in an animal model

Background: Unresectable pancreatic cancer haspoor prognosis and no effective treatment. Somatic genetherapy is currently being investigated as a possibletreatment for malignancies. One of the most promisingstrategies is the introduction of herpes simplex virus type-1 thymidine kinase (HSV-tk) in the cells, followed bytreatment with the antiviral drug ganciclovir (GCV).

Meta-analysis of the efficacy and safety of rhbnp in the treatment of acute myocardial infarction with heart failure

Objective:Systematic review of the efficacy and safety of neoactivin re-acute myocardial infarction with heart failure.Methods:The computer retrieved CNKI,Wan Fang,Weipu Chinese Science and Technology Periodicals Database(VIP),China Biomedical Literature Database(CBM),Medline,Cochrane Library,and Clinical Trail.Gov collected clinical randomized controlled trials(RCTs)of neoactivin in the treatment of acute myocardial infarction with heart failure from the establishment of the database to December 2019.Data were extracted according to the Jadad scale,disease inclusion and exclusion criteria,and RevMan 5.3 software was used for Meta analysis.Results:A total of 23 RCTs were included,with a total of 2024 patients,including 1012 patients in the control group(conventional treatment with western medicine)and 1012 patients in the test group(on the basis of the control group+neoactivin treatment).Meta analysis results show that:in the total effective rate,the test group was better than the control group,and the difference was statistically significant(OR=4.30,95%CI[3.26,5.67],P<0.00001);In terms of left ventricular ejection fraction,the test group was better than the control group,and the difference was statistically significant(OR=1.58,95%CI[1.27,1.90],P<0.00001).In terms of the left ventricular end-diastolic diameter,the test group was better than the control group,with a statistical difference Significance(OR=-0.91,95%CI[-1.50,-0.33],P=0.002);In terms of stroke volume,the test group was better than the control group,and the difference was statistically significant(OR=1.24,95%CI[0.55,1.94],P=0.0005);In terms of brain natriuretic peptide precursors,the experimental group was better than the control group,the difference was statistically significant(OR=-4.37,95%CI[-6.21,-3.25],P<0.00001);In terms of heart rate,the test group was better than the control group,and the difference was statistically significant(OR=-13.70,95%CI[-14.95,-12.46],P<0.00001);In terms of systolic blood pressure,the test group was better than the control Group,the difference was statistically significant(OR=-12.38,95%CI[-17.98,-6.79],P<0.00001);In diastolic blood pressure,the test group was better than the control group Group,the difference was statistically significant(OR=-7.42,95%CI[-8.53,-6.30],P<0.00001);In terms of adverse reactions,the difference was not statistically significant(OR=0.95,95%CI[0.29,3.16],P=0.94).Conclusions:In patients with acute myocardial infarction and heart failure,the timely application of neoactivin treatment can improve clinical efficacy,improve cardiac function,inhibit ventricular remodeling,improve blood pressure and heart rate,which has good clinical efficacy and safety.

The Current Treatment and Prevention of Post Herpetic Neuralgia

Post herpetic neuralgia (PHN) is a chronic neuropathic pain syndrome in the area of the herpes zoster (HZ) rash, persisting after the cutaneous lesions have subsided. Despite numerous treatment advances, many patients remain refractory to the current therapies and continue to have pain, physical, economical and psychological distress. In this review, we will focus on the current treatment and prevention of PHN.

Current systems and recent developments of subthreshold laser systems in glaucoma:a narrative review

Background and Objective:Subthreshold laser technologies and their applications in ophthalmology have greatly expanded in the past few decades.Initially used for retinal diseases such as central serous chorioretinopathy and diabetic macular edema,subthreshold lasers have recently shown efficacy in the treatment of various types of glaucoma.Our primary objectives are to review the clinical applications of subthreshold laser in the context of glaucoma treatment and discuss the mechanisms of different subthreshold laser techniques,including subthreshold selective laser trabeculoplasty(SSLT),micropulse laser trabeculoplasty(MLT),pattern-scanning laser trabeculoplasty(PSLT),titanium laser trabeculoplasty(TLT),and micropulse transscleral cyclophotocoagulation(MP-TSCPC).Methods:This was a narrative review compiled from literature of PubMed and Google Scholar.The review was performed from March 2021 to October 2021 and included publications in English.We also included information from web pages to cover details of relevant laser systems.We discuss the history of subthreshold laser,recent advancements in subthreshold techniques,and commercially available systems that provide subthreshold capabilities for glaucoma.We highlight basic science and clinical studies that deepen the understanding of treatment mechanisms and treatment effectiveness in the clinical setting respectively.We review commonly used parameters for each technique and provide comparisons to conventional treatments.Key Content and Findings:We found five distinct types of subthreshold laser used in the management of glaucoma.Numerous subthreshold laser systems are commercially available and can provide this treatment.Therefore,understanding the differences between subthreshold techniques and laser systems will be critical in utilizing subthreshold laser in the clinical setting.Conclusions:Traditional laser trabeculoplasty(LT)and cyclophotocoagulation(CPC)have shown effectiveness in the treatment of various types of glaucoma but are associated with visible damage to the underlying tissue and adverse effects.Subthreshold laser systems aim to provide the therapeutic effect found in traditional lasers,while minimizing unwanted treatment related effects.Further clinical studies are needed to evaluate the role of subthreshold lasers in the management of glaucoma.

Updated outcomes using clockwise technique for laparoscopic distal pancreatectomy:Optimal treatment of benign and malignant disease of the left pancreas

Background:Laparoscopic distal pancreatectomy(LDP)has become the preferred approach for surgical management of left sided pancreas pathology.Our institution previously published its experience with distal pancreatectomies using a clockwise technique with good outcomes.We now reexamine our outcomes across a longer time interval.Methods:From August 2008 to November 2020,364 patients underwent LDP by hepatobiliary surgeons(HA and JS).All procedures were performed using the same clockwise approach,which includes the stepwise slow compression technique.Retrospective descriptive analysis of patient demographic,clinical,operative,and pathologic data was conducted.Results:Of the 364 patients who underwent LDP using this technique,clinically significant postoperative pancreatic fistula(POPF)was noted in 26(7.1%)patients,while major morbidity and mortality were reported in 9.9%and 0.3%,respectively.Hand-assisted method was required for 18(4.9%)patients and unplanned conversion in 20(5.5%)patients.In a subset analysis of patients with pancreatic adenocarcinoma(n¼90),POPF was noted in 13(14.4%),with minor complications occurring in 34.4%and major morbidity in 14.4%.Conclusion:LDP with a clockwise approach for dissection,combined with the stepwise slow compression technique results in excellent outcomes,with even lower POPF rates than originally reported.Subset analysis of patients with pancreatic adenocarcinoma shows acceptable perioperative outcomes with this technique.

Interrogating the interplay of angiogenesis and immunity in metastatic colorectal cancer

Colon cancer is the third most common malignancy and the fifth most frequent cause of death from neoplastic disease worldwide.At the time of diagnosis,more than 20%of patients already have metastatic disease.In the last 20 years,the natural course of the disease has changed due to major changes in the management of metastatic disease such as the advent of novel surgical and local therapy approaches as well as the introduction of novel chemotherapy drugs and targeted agents such as anti-epidermal growth factor receptor,anti-BRAF and antiangiogenics.Angiogenesis is a complex biological process of new vessel formation from existing ones and is an integral component of tumor progression supporting cancer cells to grow,proliferate and metastasize.Many molecules are involved in this proangiogenic process,such as vascular endothelial growth factor and its receptors on endothelial cells.A well-standardized methodology that is applied to assess angiogenesis in the tumor microenvironment is microvascular density by using immunohistochemistry with antibodies against endothelial CD31,CD34 and CD105 antigens.Even smaller molecules,such as the micro-RNAs,which are small non-coding RNAs,are being studied for their usefulness as surrogate biomarkers of angiogenesis and prognosis.In this review,we will discuss recent advances regarding the investigation of angiogenesis,the crosstalk between elements of the immune microenvironment and angiogenesis and how a disorganized tumor vessel network affects the trafficking of CD8+T cells in the tumor bed.Furthermore,we will present recent data from clinical trials that combine antiangiogenic therapies with immune checkpoint inhibitors in colorectal cancer.

Critical care practices in the world:Results of the global intensive care unit need assessment survey 2020

BACKGROUND There is variability in intensive care unit(ICU)resources and staffing worldwide.This may reflect variation in practice and outcomes across all health systems.AIM To improve research and quality improvement measures administrative leaders can create long-term strategies by understanding the nature of ICU practices on a global scale.METHODS The Global ICU Needs Assessment Research Group was formed on the basis of diversified skill sets.We aimed to survey sites regarding ICU type,availability of staffing,and adherence to critical care protocols.An international survey‘Global ICU Needs Assessment’was created using Google Forms,and this was distributed from February 17^(th),2020 till September 23^(rd),2020.The survey was shared with ICU providers in 34 countries.Various approaches to motivating healthcare providers were implemented in securing submissions,including use of emails,phone calls,social media applications,and WhatsApp^(TM).By completing this survey,providers gave their consent for research purposes.This study was deemed eligible for category-2 Institutional Review Board exempt status.RESULTS There were a total 121 adult/adult-pediatrics ICU responses from 34 countries in 76 cities.A majority of the ICUs were mixed medical-surgical[92(76%)].108(89%)were adult-only ICUs.Total 36 respondents(29.8%)were 31-40 years of age,with 79(65%)male and 41(35%)female participants.89 were consultants(74%).A total of 71(59%)respondents reported having a 24-h inhouse intensivist.A total of 87(72%)ICUs were reported to have either a 2:1 or≥2:1 patient/nurse ratio.About 44%of the ICUs were open and 76%were mixed type(medical-surgical).Protocols followed regularly by the ICUs included sepsis care(82%),ventilator-associated pneumonia(79%);nutrition(76%),deep vein thrombosis prophylaxis(84%),stress ulcer prophylaxis(84%),and glycemic control(89%).CONCLUSION Based on the findings of this international,multi-dimensional,needs-assessment survey,there is a need for increased recruitment and staffing in critical care facilities,along with improved patientto-nurse ratios.Future research is warranted in this field with focus on implementing appropriate health standards,protocols and resources for optimal efficiency in critical care worldwide.