SARS-CoV-2 infection in brown-headed spider monkeys (Ateles fusciceps) at a wildlife rescue center on the coast of Ecuador-South America

Human populations can be affected in unpredictable ways by the emergence and spread of zoonotic diseases. The COVID-19 (coronavirus disease of 2019) pandemic was a reminder of how devastating these events can be if left unchecked. However, once they have spread globally, the impact of these diseases when entering non-exposed wildlife populations is unknown. The current study reports the infection of brown-headed spider monkeys (Ateles fusciceps) at a wildlife rescue center in Ecuador. Four monkeys were hospitalized, and all tested positive for SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) by RT-qPCR (Quantitative Reverse Transcription PCR). Fecal samples (n = 12) from monkeys at the rescue center also tested positive; three zookeepers responsible for feeding and deworming the monkeys also tested positive, suggesting human-animal transmission. Whole genome sequencing identified most samples' omicron clade 22B BA.5 lineage. These findings highlight the threat posed by an emerging zoonotic disease in wildlife species and the importance of preventing spillover and spillback events during epidemic or pandemic events.IMPORTANCEAlthough COVID-19 (coronavirus disease of 2019) has been primarily contained in humans through widespread vaccination, the impact and incidence of SARS-CoV-2 (Severe acute respiratory syndrome coronavirus) and its transmission and epidemiology in wildlife may need to be addressed. In some natural environments, the proximity of animals to humans is difficult to control, creating perfect scenarios where susceptible wildlife can acquire the virus from humans. In these places, it is essential to understand how transmission can occur and to develop protocols to prevent infection. This study reports the infection of brown-headed spider monkeys with SARS-CoV-2, a red-listed monkey species, at a wildlife recovery center in Ecuador. This study reports the infection of brown-headed spider monkeys with SARS-CoV-2, indicating the potential for transmission between humans and wildlife primates and the importance of preventing such events in the future.

Domestic dogs in indigenous Amazonian communities: Key players in Leptospira cycling and transmission?

BACKGROUND

Leptospirosis is the world's most common zoonotic disease. Mitigation and control rely on pathogen identification and understanding the roles of potential reservoirs in cycling and transmission. Underreporting and misdiagnosis obscure the magnitude of the problem and confound efforts to understand key epidemiological components. Difficulties in culturing hamper the use of serological diagnostics and delay the development of DNA detection methods. As a result, especially in complex ecosystems, we know very little about the importance of different mammalian host species in cycling and transmission to humans.

METHODOLOGY/PRINCIPAL FINDINGS

We sampled dogs from five indigenous Kichwa communities living in the Yasuní National Park in the Ecuadorian Amazon basin. Blood and urine samples from domestic dogs were collected to assess the exposure of these animals to Leptospira and to identify the circulating species. Microscopic Agglutination Tests with a panel of 22 different serovars showed anti-leptospira antibodies in 36 sampled dogs (75%), and 7 serogroups were detected. Two DNA-based detection assays revealed pathogenic Leptospira DNA in 18 of 19 dog urine samples (94.7%). Amplicon sequencing and phylogenetic analysis of 16S rRNA and SecY genes from 15 urine samples revealed genetic diversity within two of three different Leptospira species: noguchii (n = 7), santarosai (n = 7), and interrogans (n = 1).

CONCLUSIONS/SIGNIFICANCE

The high prevalence of antibodies and Leptospira DNA provides strong evidence for high rates of past and current infections. Such high prevalence has not been previously reported for dogs. These dogs live in the peridomestic environment in close contact with humans, yet they are free-ranging animals that interact with wildlife. This complex web of interactions may explain the diverse types of pathogenic Leptospira observed in this study. Our results suggest that domestic dogs are likely to play an important role in the cycling and transmission of Leptospira. Future studies in areas with complex ecoepidemiology will enable better parsing of the significance of genotypic, environmental, and host characteristics.

Study of two approaches for the process water management from hydrothermal carbonization of swine manure: Anaerobic treatment and nutrient recovery

Hydrothermal carbonization (HTC) is a promising alternative to transform biomass waste into a solid carbonaceous material (hydrochar) and a process water with potential for material and energy recovery. In this study, two alternatives for process water treatment by conventional and acid-assisted HTC of swine manure are discussed. Process water from conventional HTC at 180 °C showed high biodegradability (55% COD removal) and methane production (∼290 mL STP CH4 g-1 CODadded) and the treatment in an upflow anaerobic sludge blanket reactor allowed obtaining a high methane production yield (1.3 L CH4 L-1 d-1) and COD removal (∼70%). The analysis of the microbiota showed a high concentration of Synergistota and Firmicutes phyla, with high degradation of organic nitrogen-containing organic compounds. Acid-assisted HTC proved to be a viable option for nutrient recovery (migration of 83% of the P to the process water), which allowed obtaining a solid salt by chemical precipitation with Mg(OH)2 (NPK of 4/4/0.4) and MgCl2 (NPK 8/17/0.5), with a negligible content of heavy metals. The characteristics of the precipitated solid complied with the requirements of European Regulation (2019)/1009 for fertilizers and amendments in agricultural soils, being a suitable alternative for the recycling of nutrients from wastes.

Swine manure management by hydrothermal carbonization: Comparative study of batch and continuous operation

Hydrothermal carbonization (HTC) is considered a promising technology for biomass waste management without pre-drying. This study explores the potential for swine manure management by comparing batch and continuous processes, emphasizing the benefits of the continuous mode, particularly for its potential full-scale application. The continuous process at low temperature (180 °C) resulted in a hydrochar with a lower degree of carbonization compared to the batch process, but similar characteristics were found in both hydrochars at higher operating temperatures (230-250 °C), such as C content (∼ 52 wt%), fixed carbon (∼ 24 wt%) and higher calorific value (21 MJ kg-1). Thermogravimetric and combustion analyses showed that hydrochars exhibited characteristics suitable as solid biofuels for industrial use. The process water showed a high content of organic matter as soluble chemical oxygen demand (7-22 g L-1) and total organic carbon (4-10 g L-1), although a high amount of refractory species such as N- and O-containing long aromatic compounds were detected in the process water from the batch process, while the process water from the continuous process presented more easily biodegradable compounds such as acids and alcohols, among others. The longer time required to reach operating temperature in the case of the batch system (longer heating time to reach operating temperature) resulted in lower H/C and O/C ratios compared to hydrochar from the continuous process. This indicates that the dehydration and decarboxylation reactions of the feedstock play a more important role in the batch process. This study shows the efficiency of the continuous process to obtain carbonaceous materials suitable for use as biofuel, providing a solution for swine manure management.

Light and shadow of watch-and-wait strategy in rectal cancer: oncological result, clinical outcomes, and cost-effectiveness analysis

BACKGROUND

The watch-and-wait (WW) strategy is a potential option for patients with rectal cancer who obtain a complete clinic response after neoadjuvant therapy. The aim of this study is to analyze the long-term oncological outcomes and perform a cost-effectiveness analysis in patients undergoing this strategy for rectal cancer.

MATERIAL AND METHODS

The data of patients treated with the WW strategy were prospectively collected from January 2015 to January 2020. A control group was created, matched 1:1 from a pool of 480 patients undergoing total mesorectal excision. An independent company carried out the financial analysis. Clinical and oncological outcomes were analyzed in both groups. Outcome parameters included surgical and follow-up costs, quality-adjusted life years (QALYs), and the incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER).

RESULTS

Forty patients were included in the WW group, with 40 patients in the surgical group. During a median follow-up period of 36 months, metastasis-free survival (MFS) and overall survival (OS) were similar in the two groups. In the WW group, nine (22%) local regrowths were detected in the first 2 years. The permanent stoma rate was slightly higher after salvage surgery in the WW group compared to the surgical group (48.5% vs 20%, p < 0.01). The cost-effectiveness analysis was slightly better for the WW group, especially for low rectal cancer compared to medium-high rectal cancer (ICER =  - 108,642.1 vs ICER =  - 42,423).

CONCLUSIONS

The WW strategy in locally advanced rectal cancer offers similar oncological outcomes with respect to the surgical group and excellent results in quality of life and cost outcomes, especially for low rectal cancer. Nonetheless, the complex surgical field during salvage surgery can lead to a high permanent stoma rate; therefore, the careful selection of patients is mandatory.

Can 3D imaging modeling recognize functional tissue and predict liver failure? A retrospective study based on 3D modelling of the major hepatectomies after hepatic modulation

BACKGROUND

Thanks to the introduction of radiomics, 3d reconstruction can be able to analyse tissues and recognise true hypertrophy from non-functioning tissue in patients treated with major hepatectomies with hepatic modulation.The aim of this study is to evaluate the performance of 3D Imaging Modelling in predict liver failure.

METHODS

Patients submitted to major hepatectomies after hepatic modulation at Sanchinarro University Hospital from May 2015 to October 2019 were analysed. Three-dimensional reconstruction was realised before and after surgical treatment. The volumetry of Future Liver Remnant was calculated, distinguishing in Functional Future Liver Remnant (FRFx) i.e. true hypertrophy tissue and Anatomic Future Liver Remnant (FRL) i.e. hypertrophy plus no functional tissue (oedema/congestion) These volumes were analysed in patients with and without post hepatic liver failure.

RESULTS

Twenty-four procedures were realised (11 ALPPS and 13 PVE followed by major hepatectomy). Post hepatic liver failure grade B and C occurred in 6 patients. The ROC curve showed a better AUC for FRFxV (74%) with respect to FRLV (54%) in prediction PHLF > B. The increase of anatomical FRL (iFRL) was superior in the ALPPS group (120%) with respect to the PVE group (73%) (p = 0,041), while the increase of functional FRFX (iFRFx) was 35% in the ALLPS group and 46% in the PVE group (p > 0,05), showing no difference in the two groups.

CONCLUSION

The 3D reconstruction model can allow optimal surgical planning, and through the use of specific algorithms, can contribute to differential functioning liver parenchyma of the FLR.

Pronation Reveals a Heterogeneous Response of Global and Regional Respiratory Mechanics in Patients With Acute Hypoxemic Respiratory Failure

OBJECTIVES

Experimental models suggest that prone position and positive end-expiratory pressure (PEEP) homogenize ventral-dorsal ventilation distribution and regional respiratory compliance. However, this response still needs confirmation on humans. Therefore, this study aimed to assess the changes in global and regional respiratory mechanics in supine and prone positions over a range of PEEP levels in acute respiratory distress syndrome (ARDS) patients.

DESIGN

A prospective cohort study.

PATIENTS

Twenty-two intubated patients with ARDS caused by COVID-19 pneumonia.

INTERVENTIONS

Electrical impedance tomography and esophageal manometry were applied during PEEP titrations from 20 cm H2O to 6 cm H2O in supine and prone positions.

MEASUREMENTS

Global respiratory system compliance (Crs), chest wall compliance, regional lung compliance, ventilation distribution in supine and prone positions.

MAIN RESULTS

Compared with supine position, the maximum level of Crs changed after prone position in 59% of ARDS patients (n = 13), of which the Crs decreased in 32% (n = 7) and increased in 27% (n = 6). To reach maximum Crs after pronation, PEEP was changed in 45% of the patients by at least 4 cm H2O. After pronation, the ventilation and compliance of the dorsal region did not consistently change in the entire sample of patients, increasing specifically in a subgroup of patients who showed a positive change in Crs when transitioning from supine to prone position. These combined changes in ventilation and compliance suggest dorsal recruitment postpronation. In addition, the subgroup with increased Crs postpronation demonstrated the most pronounced difference between dorsal and ventral ventilation distribution from supine to prone position (p = 0.01), indicating heterogeneous ventilation distribution in prone position.

CONCLUSIONS

Prone position modifies global respiratory compliance in most patients with ARDS. Only a subgroup of patients with a positive change in Crs postpronation presented a consistent improvement in dorsal ventilation and compliance. These data suggest that the response to pronation on global and regional mechanics can vary among ARDS patients, with some patients presenting more dorsal lung recruitment than others.

Domestic dogs in indigenous Amazonian communities: key players in Leptospira cycling and transmission?

Background

Leptospirosis is the world's most common zoonotic disease. Mitigation and control rely on pathogen identification and understanding the roles of potential reservoirs in cycling and transmission. Underreporting and misdiagnosis obscure the magnitude of the problem and confound efforts to understand key epidemiological components. Difficulties in culturing hamper the use of serological diagnostics and delay the development of DNA detection methods. As a result, especially in complex ecosystems, we know very little about the importance of different mammalian host species in cycling and transmission to humans.

Methodology/Principal Findings

We sampled five indigenous Kichwa communities living in the Yasuní National Park in the Ecuadorian Amazon basin. Blood and urine samples from domestic dogs were collected to assess the exposure of these animals to Leptospira, and to identify the circulating species. Microscopic Agglutination Tests with a panel of 22 different serovars showed anti-leptospira antibodies in 36 sampled dogs (75%), and 10 serotypes were detected. Two DNA-based detection assays revealed pathogenic Leptospira DNA in 18 of 19 dog urine samples (94.7%). Amplicon sequencing and phylogenetic analysis of 16s rDNA and SecY genes from 15 urine samples revealed genetic diversity within two of three different Leptospira species: noguchii (n=7), santarosai (n=7), and interrogans (n=1).

Conclusions/Significance

The high prevalence of antibodies and Leptospira DNA provides strong evidence for high rates of past and current infections. Such high prevalence has not been previously reported for dogs. These dogs live in the peridomestic environment in close contact with humans, yet they are free-ranging animals that interact with wildlife. This complex web of interactions may explain the diverse types of pathogenic Leptospira observed in this study. Our results suggest that domestic dogs are likely to play an important role in the cycling and transmission of Leptospira. Future studies in areas with complex ecoepidemiology will enable better parsing of the significance of genotypic, environmental, and host characteristics.

Co-hydrothermal carbonization of swine manure and lignocellulosic waste: A new strategy for the integral valorization of biomass wastes

Co-hydrothermal carbonization (co-HTC) is a promising strategy to improve hydrothermal carbonization (HTC) of low-quality wastes. HTC of swine manure (SM), with high N (2.9 wt%), S (0.7 wt%) and ash (22.6 wt%) contents, as well as low C (35.6 wt%) and higher heating value (HHV; 14.3 MJ kg-1), resulted in a hydrochar with unsuitable characteristics as a solid fuel. Co-HTC of SM and garden and park waste (GPW) improved hydrochar properties (C content (43 - 48 wt%) and HHV (18 - 20 MJ kg-1), and decreased N (∼2 wt%), S (<0.3 wt%) and ash (<15 wt%) content. A high GPW ratio (>50 wt%) during co-HTC resulted in a hydrochar similar to that obtained from GPW. The co-HTC increased nutrient migration to the process water, which allowed the precipitation of salt with high P (7.8 wt%) and negligible heavy metal content. Anaerobic digestion of co-HTC process water allowed high organic matter removal (up to 65%), and methane production (315 - 325 mL CH4 g-1CODadded). Gross energy recovery by HTC and anaerobic digestion was 5 - 6-fold higher than anaerobic treatment of feedstocks. Therefore, co-HTC of SM and GPW with a ratio > 50% GPW proved to be a suitable approach to valorize and manage SM and obtain value-added products (hydrochar, mineral fertilizer and methane).

Pancreatic head resection with segmental duodenectomy for the treatment of benign and malign pancreatic diseases. Case series experience of a single center

INTRODUCTION AND IMPORTANCE

Duodenum-preserving pancreatic resections (DPPHR) is a reasonable surgical option for benign or low-grade malignant tumours of the pancreatic head. Several techniques have been proposed, with or without common biliary duct preservation.

CASE PRESENTATION

We report for the first time two cases of pancreas divisum treated with this technique and we illustrate two other cases of pancreatic disease in which this procedure was realized from January 2015 to January 2020 in the HM Sanchinarro University Hospital.

CLINICAL DISCUSSION

Pancreatic head resection with pancreatic parenchyma sparing, and duodenal preservation has been commonly accepted in the treatment of benign pancreatic head disease.

CONCLUSION

This technique offers a wide application in the treatment of pancreatic and duodenal benign disease, including pancreatic malformation such as pancreas divisum and duodenal tumour that require segmental resection, in order to assure complete pancreatic head resection and to avoid duodenal and biliary duct ischemia.

Closed hyperthermic intraperitoneal chemotherapy with CO2 recirculation system compared with the open Coliseum technique in peritoneal malignity treatment

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis can be performed in two ways: first, the standard open abdominal technique (Open HIPEC); or second, the closed technique. In recent years, a new technique has been introduced to perform closed HIPEC; the Peritoneal Recirculation System (PRS-1.0 Combat) with CO₂ recirculation technology (PRS Closed HIPEC). The objective of this study is to present our experience with the PRS Closed HIPEC by comparing the intraoperative, postoperative and oncological results with the standard Open HIPEC technique (the Coliseum technique).

METHODS

Data on patients undergoing CRS and HIPEC at the Sanchinarro University Hospital, Madrid from October 2012 to June 2021 were collected in a prospective database. The inclusion criteria were patients with primary or recurrent peritoneal metastases in gastrointestinal malignancies or ovarian cancer. The presence of an unresectable peritoneal carcinomatosis, the coexistence of another oncological disease, unresectable and distant metastases were the exclusion criteria.

RESULTS

From October 2014 to June 2021, 84 patients underwent CRS and HIPEC at the Sanchinarro University Hospital, Madrid with curative intent. Since the introduction of the PRS Closed HIPEC technique in 2016, 65 patients have been treated. Before the introduction of PRS Closed HIPEC, 19 cases were performed using the Coliseum technique (the Open HIPEC group). The intraoperative results were similar in the two groups. Complete cytoreduction was achieved in all cases in the Open HIPEC group and in 98% in the PRS Closed HIPEC group. The rate of major complications was similar between the groups. Median Overall Survival (OS) resulted better in the Closed HIPEC group (67 months) with respecto to the Open group (43 months) (p < 0,001). Median Disease-Free Survival (DFS) was 15 months in the Open HIPEC group and 40 months in the PRS Closed HIPEC group (p < 0.001).

CONCLUSION

The Peritoneal Recirculation System with CO₂ recirculation technology (PRS Closed HIPEC) is a reproducible and safe technique and may represent a valid alternative for the administration of HIPEC.

Thoracic Aortic Aneurysm Presenting as a Subacute Cough

The suprasternal aortic notch cardiac point of care ultrasound (POCUS) window is a useful view for evaluating thoracic aortic pathologies. However, it is not routinely included in the standard cardiac POCUS exam despite its ability to capture emergent pathologies such as aortic dissection and thoracic aortic aneurysm (TAA). Ruptured aortic aneurysms can present with sudden, severe chest or back pain, as well as hemodynamic instability, resulting in a high mortality. We present an atypical case of a patient with hemoptysis who was found to have a contained aortic rupture. In this case, POCUS, specifically the suprasternal aortic notch view, was used to expedite definitive care.

Critical review of technologies for the on-site treatment of hospital wastewater: From conventional to combined advanced processes

This review aims to assess different technologies for the on-site treatment of hospital wastewater (HWW) to remove pharmaceutical compounds (PhCs) as sustances of emerging concern at a bench, pilot, and full scales from 2014 to 2020. Moreover, a rough characterisation of hospital effluents is presented. The main detected PhCs are antibiotics and psychiatric drugs, with concentrations up to 1.1 mg/L. On the one hand, regarding the presented technologies, membrane bioreactors (MBRs) are a good alternative for treating HWW with PhCs removal values higher than 80% in removing analgesics, anti-inflammatories, cardiovascular drugs, and some antibiotics. Moreover, this system has been scaled up to the pilot plant scale. However, some target compounds are still present in the treated effluent, such as psychiatric and contrast media drugs and recalcitrant antibiotics (erythromycin and sulfamethoxazole). On the other hand, ozonation effectively removes antibiotics found in the HWW (>93%), and some studies are carried out at the pilot plant scale. Even though, some families, such as the X-ray contrast media, are recalcitrant to ozone. Other advanced oxidation processes (AOPs), such as Fenton-like or UV treatments, seem very effective for removing pharmaceuticals, Antibiotic Resistance Bacteria (ARBs) and Antibiotic Resistance Genes (ARGs). However, they are not implanted at pilot plant or full scale as they usually consider extra reactants such as ozone, iron, or UV-light, making the scale-up of the processes a challenging task to treat high-loading wastewater. Thus, several examples of biological wastewater treatment methods combined with AOPs have been proposed as the better strategy to treat HWW with high removal of PhCs (generally over 98%) and ARGs/ARBs (below the detection limit) and lower spending on reactants. However, it still requires further development and optimisation of the integrated processes.

Aortic and vascular involvement in Loeys-Dietz Syndrome. Results from the REPAG registry (Spanish network of genetic aortic diseases)

Background

LDS is a rare disease due to genetic variants in the TGFB pathway. Limited information is available regarding the overall aortic and vascular outcome of these patients

Purpose

To evaluate aortic and vascular complications of patients with mutations in the TGFB pathway.

Methods

Retrospective longitudinal study including patients with (likely) pathogenic (LP/P) variants in the TGFbeta pathway from 10 tertiary centers. Clinical and imaging data were reviewed and data on aortic and vascular outcome included.

Results

A total of 163 patients were included (47.9% women, 38.6% index cases), mean age at first evaluation 32.3±20.4 years, 27.0% with age &lt;16 years. 70 TGFBR1, 43 TGFBR2, 29 SMAD3, 9 TGFB2 and 12 TGFB3 (Table1)

During a mean follow-up of 4.7±3.7 years, 54 (33.1%) patients had at least 1 aortic surgery (max 6). Mean age at first aortic surgery was 37.2±16.8 years (Range 1.2–72.9). First surgery was elective in 42 (77.8%), and included aortic root or ascending aorta in 40 (95.2%) and isolated descending aorta in 2 (4.8%). Emergent surgery included aortic root or ascending aorta in 11 (92.7%). Ascending aorta-root diameter previous to elective surgery was 48.9±4.9mm (range 41–65). 7 patients died during follow-up (2 intracranial bleeding, 1 SD, 2 aortic ruptures, 1post aortic surgery, 1 non-CV). Furthermore, 19 acute aortic syndromes (AAS) were reported (17 dissections, 2 haematomas) in 18 patients, 10 type A (52.6%). Mean age at first AAS was 42.3±11.1 years (min 19.7 years to 62.9 years)

Median survival free of intervention, dissection or death was 57.1 years, being worst for men than women (44.7 yrs vs 69.1 years, p&lt;0.001) (Figure 1), these gender-difference only remained significant in the TGFBR1 and SMAD3 groups (p=0.005 and p=0.008) Regarding aortic branch and intracranial aneurysms, a total of 383 imaging studies of aortic branches and 223 cranial imaging studies were performed during the clinical follow-up. 21 cranial aneurysms and 73 aortic branch aneurisms were reported. 14 (11.5%) patients suffered 19 aneurysms-related events (3 dissections, 3 ruptures, 13 interventions).

Conclusions

In patients with Loeys-Dietz Syndrome, there's a high prevalence of aortic surgeries and acute aortic events, with high numbers of peripheral and intracranial aneurysms. A worst prognosis in men than in women is observed in TGFBR1 and SMAD3 variants. Thus, specialized clinical and imaging follow-up is crucial in the management of these patients

Funding Acknowledgement

Type of funding sources: None.

Giant fibrovascular polyps of the esophagus. Trans oral versus surgical approach. Case report and systematic literature review

INTRODUCTION

Giant fibrovascular esophageal polyp is a rare benign intraluminal tumour. The aim of this study is to perform a review of the most recent literature in order to describe and analyse the current range of possible diagnostics and treatment strategies.

CASE REPORT

We present two cases of giant fibrovascular esophageal polyp treated with a combined minimally invasive transluminal approach at Sanchinarro University Hospital. Further, we perform a literature review.

CONCLUSION

We present two cases of grant fibrovascular polyp submitted to minimally invasive transluminal approach. Furthermore, 54 original articles reporting 59 cases have been analysed. In the surgical group, an esophagotomy and polyp resection were performed in 31 (91 %) patients and a total esophagectomy in two patients (5,8 %). Severe morbidity occurred in two patients (5,8 %.) The median hospital stay was 9.25 days. A total of two (5,8 %) cases of recurrence have been registered. In the minimally invasive transluminal approach group, 27 patients had a polyp resection performed completely by endoscopy/transoral. There were no complications but there was one case of recurrence.

CONCLUSION

The transluminal approach is safe and should be considered also in the treatment of large esophageal polyps.

Deep brain stimulation of the anterior thalamus attenuates PTZ kindling with concomitant reduction of adenosine kinase expression in rats

BACKGROUND

Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is an emerging therapy to provide seizure control in patients with refractory epilepsy, although its therapeutic mechanisms remain elusive.

OBJECTIVE

We tested the hypothesis that ANT-DBS might interfere with the kindling process using three experimental groups: PTZ, DBS-ON and DBS-OFF.

METHODS

79 male rats were used in two experiments and exposed to chemical kindling with pentylenetetrazole (PTZ, 30 mg/kg i.p.), delivered three times a week for a total of 18 kindling days (KD). These animals were divided into two sets of three groups: PTZ (n = 26), DBS-ON (n = 28) and DBS-OFF (n = 25). ANT-DBS (130 Hz, 90 μs, and 200 μA) was paired with PTZ injections, while DBS-OFF group, although implanted remained unstimulated. After KD 18, the first set of PTZ-treated animals and an additional group of 11 naïve rats were euthanized for brain extraction to study adenosine kinase (ADK) expression. To observe possible long-lasting effects of ANT stimulation, the second set of animals underwent a 1-week treatment and stimulation-free period after KD 18 before a final PTZ challenge.

RESULTS

ANT-DBS markedly attenuated kindling progression in the DBS-ON group, which developed seizure scores of 2.4 on KD 13, whereas equivalent seizure scores were reached in the DBS-OFF and PTZ groups as early as KD5 and KD6, respectively. The incidence of animals with generalized seizures following 3 consecutive PTZ injections was 94%, 74% and 21% in PTZ, DBS-OFF and DBS-ON groups, respectively. Seizure scores triggered by a PTZ challenge one week after cessation of stimulation revealed lasting suppression of seizure scores in the DBS-ON group (2.7 ± 0.2) compared to scores of 4.5 ± 0.1 for the PTZ group and 4.3 ± 0.1 for the DBS-OFF group (P = 0.0001). While ANT-DBS protected hippocampal cells, the expression of ADK was decreased in the DBS-ON group compared to both PTZ (P < 0.01) and naïve animals (P < 0.01).

CONCLUSIONS

Our study demonstrates that ANT-DBS interferes with the kindling process and reduced seizure activity was maintained after a stimulation free period of one week. Our findings suggest that ANT-DBS might have additional therapeutic benefits to attenuate seizure progression in epilepsy.

Long-term outcomes of a phase II trial of neoadjuvant immunotherapy for advanced, resectable cutaneous squamous cell carcinoma of the head and neck (CSCC-HN)

9519

Background: In a pilot phase II trial, we investigated the use of neoadjuvant immunotherapy to induce a pathologic response in patients with stage III/IV (M0) cutaneous squamous cell carcinoma of the head and neck (CSCC-HN). Here, we report the long-term outcomes according to pathologic response. Methods: Patients with newly diagnosed or recurrent stage III/IV (M0) (AJCC 8th Ed) CSCC-HN were treated with 2 doses of cemiplimab 350 mg intravenously every 3 weeks prior to surgery. The primary endpoint was overall response rate (ORR) per RECIST v1.1. Secondary endpoints included safety, pathologic response, disease-free and overall survival. Results: Of 20 patients enrolled, 7 (35%) had recurrent disease and 12 (60%) were stage IV on presentation. Neoadjuvant immunotherapy was generally well-tolerated and there were no surgical delays. Adverse events (AEs) were observed in 7 (35%) patients; 1 (5%) grade 3 diarrhea, 6 (30%) ≤ grade 2 AEs. ORR by RECIST was 30%. However, 85% (17/20) achieved a pathologic response (≤50% viable tumor), with pathologic complete response (pCR) in 11 (55%), major pathologic response (MPR, ≤10% viable tumor) in 4 (20%) and pathologic partial response (pPR, >10% and ≤50% viable tumor) in 2 (10%). Patients with a pCR did not receive planned radiotherapy after surgery. Patients who did not have a pathologic response (> 50% viable tumor) either progressed and died (1, 5%) or developed recurrence (2, 10%) despite surgery and adjuvant radiation or chemoradiation. At a median follow up of 34.5 months (range: 7.7-42.7), none of the patients who achieved a pathologic response have recurred. Conclusions: Consistent with other cancer types, pathologic response to neoadjuvant immunotherapy is durable in patients with advanced, resectable CSCC-HN. Adjuvant radiation therapy may be spared in patients who achieve a pCR and warrants further investigation. Clinical trial information: NCT03565783.

Energy recovery from garden and park waste by hydrothermal carbonisation and anaerobic digestion

Hydrothermal carbonisation (HTC) can transform wet lignocellulosic biomass, which is not considered an effective biofuel for energy production at the industrial level, into a carbonaceous product called hydrochar (HC) that is suitable for combustion and a process water (PW). PW is an interesting by-product that can be valorised for biogas production via anaerobic digestion (AD). This study presents a new approach for the valorisation of garden and park wastes (GPW) by integrating HTC to generate HC for energy production, while PW is subjected to AD for biogas production. The hydrothermal treatment was performed at 180, 210, and 230 °C, yielding HC with improved physicochemical properties, such as an elevated higher heating value (21-25 MJ kg^-1); low ash (<5 wt.%), nitrogen (1.3 wt.%), and sulphur (0.2 wt.%) contents; better fuel ratio (0.4-0.6); and a broad comprehensive combustibility index (8.0×10^-7 to 9.6×10^-7 min^-2 °C^-3). AD of the generated PW was conducted under mesophilic conditions (35 °C), resulting in a methane production in the range of 253-326 mL g^-1 COD_added and COD removal of up to 65%. The combination of HTC and AD allowed the recovery of 91% and 94% of the energy content feedstock, as calculated from the combustion of HC and methane, respectively.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control

OBJECTIVE

To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS).

DESIGN

A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016).

SETTING

ICU at a University Hospital in Spain.

PATIENTS

All consecutive patients admitted to the ICU with CASS.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths.

RESULTS

During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control.

CONCLUSIONS

The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

Access to health services for non-Covid-19 causes during the pandemic. A literature review

Background

Negative effects of the Covid-19 pandemic on access to care for other diseases are currently at debate.

Aim

To review existing literature on care access for non-Covid-19 conditions since the pandemic onset.

Methods

Scoping review using various databases (Medline, VHL, Web of Science, 2020/21). Terms used: ‘access', ‘health services', ‘Covid-19'. Out of 4,060 identified articles, 37 were selected after reviewing and assessing titles, abstracts and full text. Aday and Andersen's framework guided the analysis.

Results

Of selected articles, 21 analyse impact on health services use; 8 on performance; 8 on access barriers. Most analyse specific services during early pandemic stages through register review, showing an initial decline in use with inconsistent results on recovery. Some indicate increased complexity of treated patients and treatment delays. Studies surveying professionals analyse the impact on services performance or clinical practice, reporting a decrease in consultations/interventions for diverse pathologies and response implementation (e.g. telemedicine), but not how they affected access. Few studies focus on social inequalities in use, showing a greater reduction in low-income or ethnic minority users. Studies on unmet needs, access or barriers based on user surveys or qualitative methods are scarce, focused on a pathology or clinical area. Particularly in Spain, studies analyse impact on use of emergency, primary care and cancer diagnosis, and on emergency and cardiology services functioning. Studies based on user surveys are lacking: only a qualitative study analysed access difficulties for chronic patients in confinement. Methodological weaknesses are identified.

Conclusions

Although currently emerging, studies analysing the pandemic impact on equal access to care for non-Covid-19 conditions are scarce, limited in focus and methodology, especially in Spain. Comprehensive medium/long-term impact assessments, including analysis of causes, are needed.

Key messages

Research is lacking on the impact of the COVID-19 pandemic on healthcare access, particularly for vulnerable groups. Further evidence is needed to improve health systems resilience in the future.

The Bergen Declaration 2018: Did it drive the Migration Health Agenda forward in Norway?

 

The growing body of migrant health research at all levels focuses around disease burden, risk factors/behaviours and on distal factors but research on policy issues remains limited. Internationally published declarations and recommendations to take the migrant health agenda forward address policy issues. However declarations at country are few and not systematically followed up.

The Bergen Declaration was endorsed at Norway's' First National Conference on Migration Health (2018) by the multi-disciplinary participants. The declaration reflects the ‘upstream' and ‘downstream' areas addressed and discussed at the conference and includes concrete recommendations for key areas. It was widely disseminated, including high-level policy makers. Prior to the second Migration Health Conference (2020), the progress of the recommendations were reviewed. Since 2018, Migrant Integration Policy Index (MIPEX) in Norway from 2015 was updated in 2019 and a Country Assessment as part of the WP7 of Joint Action on Health Equity Europe (JAHEE) was conducted providing the basis to review the recommendations of the Bergen Declaration. In addition, the 2020 Committee conducted a desk review and search to follow up the recommendations. The review revealed that among identified ‘upstream' areas most progress had been made with data collection and research and the least in policy and governance. Among the ‘downstream' areas some progress was observed regarding practise and access to health services. Education and Training had received some attention. The Bergen Declaration reflects the consensus regarding migrant health and recommendations to address these issues in Norway. Monitoring the progress made through data that included policy review revealed progress and gaps. Progress in research, education and practise was evident whereas policy change was not. Policy makers have not paid heed to the Bergen Declaration.

Key messages

The Bergen Declaration was a useful tool for initiating and monitoring progress in research, education and practice. Declarations do not support advancement of policies and other means are required to push the policies forward.

Vector-borne zoonotic blood parasites in wildlife from Ecuador: A report and systematic review

Background and Aim:

Ecuador is a hugely diverse country, but information on infectious diseases in local wild animals is scarce. The aim of this study was to screen the presence of blood parasites in free-ranging wild animals admitted to the Wildlife Hospital at Universidad San Francisco de Quito, from April 2012 to January 2019.

Materials and Methods:

We identified blood parasites by microscopic observation of blood smears from free-ranging wildlife species that attended the Wildlife Hospital of Universidad San Francisco de Quito (Ecuador) from April 2012 to January 2019.

Results:

The microscopic evaluations of animals as potential reservoirs for vector-borne zoonotic blood parasites revealed the presence of Anaplasma spp., Babesia spp., Ehrlichia spp., Hepatozoon spp., microfilaria, Mycoplasma spp., and Trypanosoma spp. in previously unreported wildlife species. In addition, we performed a systematic review to understand the current knowledge gaps in the context of these findings.

Conclusion:

Our data contribute to the knowledge of blood parasites in wildlife from Ecuador. Furthermore, the potential transmission of these parasites to humans and domestic animals, current anthropogenic environmental changes in the region, and the lack of information on this suggest the importance of our results and warrant further investigations on infectious diseases in animals and humans and their relationship with environmental health as key domains of the One Health concept.

A Systematic Analysis of Metal and Metalloid Concentrations in Eight Zebrafish Recirculating Water Systems

Metals and metalloids are integral to biological processes and play key roles in physiology and metabolism. Nonetheless, overexposure to some metals or lack of others can lead to serious health consequences. In this study, eight zebrafish facilities collaborated to generate a multielement analysis of their centralized recirculating water systems. We report a first set of average concentrations for 46 elements detected in zebrafish facilities. Our results help to establish an initial baseline for trouble-shooting purposes, and in general for safe ranges of metal concentrations in recirculating water systems, supporting reproducible scientific research outcomes with zebrafish.

Role of 18F-PET-CT to predict pathological response after neoadjuvant treatment of rectal cancer

OBJECTIVES

Neoadjuvant chemoradiation (nCRT) is universally considered to be a valid treatment to achieve downstaging, to improve local disease control and to obtain better resectability in locally advanced rectal cancer (LARC). The aim of this study is to correlate the change in the tumour 18F-FDG PET-CT standardized uptake value (SUV) before and after nCRT, in order to obtain an early prediction of the pathologic response (pR) achieved in patients with LARC.

DATA DESCRIPTION

We performed a retrospective analysis of patients with LARC diagnosis who underwent curative resection. All patients underwent a baseline 18F-FDG PET-CT scan within the week prior to the initiation of the treatment (PET-CT SUV1) and a second scan (PET-CT SUV2) within 6 weeks of the completion of nCRT. We evaluated the prognostic value of 18F-FDG PET-CT in terms of disease-free survival (DFS) and overall survival (OS) in patients with LARC.A total of 133 patients with LARC were included in the study. Patients were divided in two groups according to the TRG (tumour regression grade): 107 (80%) as the responders group (TRG0-TRG1) and 26 (25%) as the no-responders group (TRG2-TRG3). We obtained a significant difference in Δ%SUV between the two different groups; responders versus no-responders (p < 0.012). The results of this analysis show that 18F-FDG PET-CT may be an indicator to evaluate the pR to nCRT in patients with LARC. The decrease in 18F-FDG PET-CT uptake in the primary tumour may offer important information in order for an early identification of those patients more likely to obtain a pCR to nCRT and to predict those who are unlikely to significantly regress.

Effect of group treatment on physical inactivity among Syrian refugees. Randomized controlled trial

Background

Refugees in Norway show low levels of physical activity, and have relatively high prevalence of pain disorders and post-traumatic symptoms. Physical inactivity can be both a cause of and a consequence of physical and mental symptoms. In CHART study (Changing Health and health care needs Along the Syrian Refugees' Trajectories to Norway), two group interventions, one based on physiotherapy and body awareness (PAAI) and the other on Teaching Recovery Techniques (TRT), were developed to treat patients with pain disorders and/or post-traumatic symptoms.

Objective

As a secondary outcome of study, we assessed the effect of these group interventions on physical inactivity.

Methods

We conducted a randomized controlled trial testing two group interventions. Syrian adults ≥16 years with pain and/or post-traumatic symptoms were randomized to either intervention group or control group. Effect of the intervention was measured after 8 (PAAI) and 6 (TRT) weeks, as relative risk (RR) with 95% confidence intervals for being inactive for intervention versus control groups, using log-binomial regression with adjustment for baseline inactivity and type of intervention (PAAI or TRT).

Results

177 Syrian refugees were recruited between July 2018-September 2019. 88 were randomized to the intervention group and 89 to the control group. Mean age was 35 years (SD 11) and 38% were women. Inactivity at recruitment was reported by 126 (71%) participants. The follow-up questionnaire was completed at 6/8 weeks by 116 (66%) participants. At that point, 39% in the intervention group were inactive as compared to 56% in the control group. RR for inactivity for the intervention group adjusted for inactivity at baseline was 0.68 (0.47-0.99) and remained 0.68 (0.48-0.99) when further adjusting for type of intervention (PAAI vs TRT).

Conclusions

PAAI and TRT group interventions reduced inactivity among refugees by 32%. Effect on physical inactivity was similar between PAAI and TRT interventions.

Key messages

Public health care should be aware of physical inactivity, especially in relation to pain disorders and post-traumatic symptoms among refugees. Group treatment interventions succeeded to encourage refugees to increase their physical activity.

Access to healthcare and self-rated health among refugees in transit and after arrival in Norway

Background

Lack of basic infrastructure and poor provision of health services in conflict settings and during flight can have a negative impact on health. The overall health status of refugees seems to improve after arrival at a safe destination. This may be related to a safer environment and better access to health care services, but prior studies on this topic are limited. This study aims to assess self-perceived access to healthcare and its relationship with self-rated health (SRH) among refugees in transit and when settled in a host country.

Methods

We used data from the CHART study (Changing Health and health care needs Along the Syrian Refugees' Trajectories to Norway), which includes a cohort of 353 Syrian refugees who were contacted in 2017-2018 in Lebanon while waiting for relocation, and one year after their arrival to Norway. Information on self-perceived access to healthcare and its association with SRH was analyzed separately at each time-point. Data analysis was performed with STATA using logistic regression adjusting for age, gender, ethnicity and years of education and presented as adjusted odds ratios (AOR) with 95% CI.

Results

Fifteen percent reported good access to healthcare and 62% reported good SRH in Lebanon vs. 91% and 77% respectively, in Norway. Measures in Lebanon showed no association between access to healthcare and good SRH (AOR: 1.2 (0.6-2.2)), and men reported worse access to healthcare than women (AOR: 0.5 (0.3-1.0). In Norway, access to healthcare was strongly associated with good SRH (AOR: 4.7 (2.1-10.7) and was negatively associated with belonging to one specific minority group (AOR: 0.1 (0.0-0.3)).

Conclusions

Both SRH and perceived access to care improved from being in transit to being settled in Norway, the latter substantially more. There was a significant association between access to healthcare and good SRH after the refugees' arrival to a safe host country but not in transit.

Key messages

Refugee’s self-reported health and access to healthcare seem to improve shortly after arrival to a host country. To ensure that the UN’S Sustainable Development Goals concerning health equity are reached, refugees’ access to healthcare in transit and its impact on overall health needs to be addressed.

Non-communicable diseases and use of medication among Syrian refugees: a prospective cohort study

Background

Conflict-driven disruption in continuity of care for non-communicable diseases (NCDs) is likely to have adverse public health impact. Yet, data on the prevalence and treatment coverage of NCDs among refugees is scarce. In this study we aim to assess the changes in prevalence of NCDs and use of relevant medication among Syrian refugees from a near-conflict phase in Lebanon to a resettlement phase in Norway.

Methods

This is a prospective cohort study. Survey data were collected during 2017-2018 among adult Syrian refugees in Lebanon selected for quota resettlement and at follow-up approximately one year after resettlement in Norway. Our primary outcomes were changes in NCDs as defined by the WHO and use of relevant medication. We calculated prevalence proportions with confidence intervals and assessed changes in prevalence over time using generalized estimating equations.

Results

Altogether 353 Syrians participated. The median age was 34 years and 51 percent were women. The overall prevalence of NCDs was 12 (9-16) percent at baseline and 9 (6-12) percent at follow-up. The odds ratio for reporting any NCD at follow-up compared to baseline was 0.68 (0.46, 1.00). Among those reporting NCDs, the prevalence of using either antithrombotic or cholesterol lowering medication, antihypertensives, antidiabetics, or drugs for asthma or chronic obstructive pulmonary disease was 55 (39-70) percent at baseline and 63 (44-80) percent at follow-up. The odds ratio for using relevant medication at follow-up compared to baseline was 1.01 (0.63, 2.05).

Conclusions

In our study around one tenth of the refugees reported at least one NCD. Nearly half of those reporting NCDs in a conflict-near setting did not seem to receive relevant medication, while the same was true for more than one third of respondents after resettlement. We call for innovative public health approaches and interventions to protect continuity of care for NCDs in settings of conflict-driven exodus.

Key messages

A high share of Syrian refugees reporting NCDs do not seem to receive relevant medication. The management of NCDs among refugees needs attention in order to avoid negative health effects.

Changes in health among Syrian refugees along their migration trajectories from Lebanon to Norway: a prospective cohort study

OBJECTIVES

Conflict-driven displacement is an indisputable social determinant of health. Yet, data on changes in health along the migration trajectories of refugees are scarce. This study aims to assess the longitudinal changes in somatic and mental health and use of medication among Syrian refugees relocating from a conflict-near transit setting in the Middle East to a resettlement setting in Europe. Further, we examine different health status trajectories and factors that predict health in the early postmigration period.

STUDY DESIGN

This is a prospective cohort study.

METHODS

Survey data were collected during 2017-2018 among adult Syrian refugees in Lebanon selected for quota resettlement and at follow-up approximately one year after resettlement in Norway. Our primary outcomes were non-communicable disease (NCD), chronic impairment, chronic pain, anxiety/depression, post-traumatic stress symptoms, and daily use of drugs. We estimated longitudinal changes in prevalence proportions using generalized estimating equations and evaluated effect modification of health outcomes.

RESULTS

Altogether, 353 Syrians participated. NCDs declined (12%-9%), while the prevalence of chronic impairment, chronic pain, and use of drugs remained nearly unchanged (29%-28%, 30%-28%, and 20%-18%) between baseline and follow-up. Conversely, mental health outcomes improved (anxiety/depression 33%-11%, post-traumatic stress disorder 5%-2%). Effect modifiers for improvement over time included younger age, short length of stay, and non-legal status in the transit country before resettlement in Europe.

CONCLUSIONS

We find that mental health outcomes improve from a conflict-near transit setting in Lebanon to an early resettlement setting in Norway, while somatic health outcomes remain stable. Temporal changes in health among moving populations warrant attention, and long-term changes need further scrutiny.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control

OBJECTIVE

To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS).

DESIGN

A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016).

SETTING

ICU at a University Hospital in Spain.

PATIENTS

All consecutive patients admitted to the ICU with CASS.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths.

RESULTS

During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control.

CONCLUSIONS

The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

Head and neck surgical oncology in the time of a pandemic: Subsite-specific triage guidelines during the COVID-19 pandemic

BACKGROUND

COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of health care personnel.

METHODS

The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging head and neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular.

RECOMMENDATIONS

Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred.

CONCLUSION

These guidelines are intended to help clinicians caring for patients with HNC appropriately allocate resources during a health care crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.

Robotic-assisted right colectomy versus laparoscopic approach: case-matched study and cost-effectiveness analysis

AIM

The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis.

METHODS

This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective.

RESULTS

Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p < 0.001). No significant difference was observed in terms of total costs between the robotic and laparoscopic groups (9455.14 vs 8227.50 respectively, p = 0.21). At a willingness-to-pay threshold of 20,000 and 30,000, there was a 78.78-95.04% probability that the robotic group was cost effective relative to laparoscopic group.

CONCLUSION

Robot-assisted right colectomy is a safe and feasible technique and is a cost-effective procedure.

Cation and anion effect on the biodegradability and toxicity of imidazolium- and choline-based ionic liquids

This work studies the effect of the cation and anion on the biodegradability and inhibition of imidazolium- and choline-based ionic liquids (ILs) using activated sludge. Six commercial ILs, formed by combination of 1-Butyl-3-methylimidazolium (Bmim⁺) and N,N,N-trimethylethanolammonium (Choline⁺) cations and chloride (Cl^-), acetate (Ac^-) and bis(trifluoromethanesulfonyl)imide (NTf₂^-) anions were evaluated, all representative counter-ions with markedly different toxicity and biodegradability. Inherent and fast biodegradability tests were used to evaluate both the microorganism inhibition and the IL biodegradability. In addition, the ecotoxicological response (EC₅₀) of the ILs was studied using activated sludge and Vibrio fischeri (Microtox® test). Bmim⁺ and NTf₂^- can be considered as non-biodegradable, whereas aerobic microorganisms easily degraded Choline⁺ and Ac^-. The biodegradation pattern of each cation/anion is nearly unaffected by counter-ion nature. Moreover, concentrations of CholineNTf₂ higher than 50 mg/L caused a partial inhibition on microbial activity, in good concordance with its low EC₅₀ (54 mg/L) measured by respiration inhibition test, which alerts on the negative environmental impact of NTf₂-containing ILs on the performance of sewage treatment plants.

Venous Resection for Locally Advanced Pancreatic Cancer: Time Trend and Outcome Analysis of 65 Consecutive Resections at a High-Volume Center

INTRODUCTION

Locally advanced pancreatic cancer (LAPC) is a highly malignant carcinoma with an extremely poor prognosis. Vascular venous invasion is a frequent finding in patients with pancreatic cancer. The aim of this study was to investigate the morbidity, mortality, and survival of patients with advanced pancreatic cancer.

METHODS

We retrospectively reviewed our experience of 65 consecutive pancreatic surgeries with venous resection for pancreatic cancer in three hospitals: Ramon y Cajal (Madrid, Spain) from 2002 to 2004, Monteprincipe University Hospital (Madrid, Spain) from 2005 to 2006 and Sanchinarro University Hospital (Madrid, Spain) from 2007 to December 2017. Prognostic factors were analyzed by the log-rank test and a multivariate proportional hazard regression analysis.

RESULTS

Major venous reconstruction was performed by primary lateral venorrhaphy in 11 patients (17%), primary end-to-end anastomosis in 46 (70.7%) and reconstruction with a Gore-Tex® patch (W.L. Gore & Associates, Inc., Flagstaff, AZ) in 8 (12.3%). In 58% of the patients, the pathological examination showed infiltration of the vascular specimen. About 85% of the procedures performed were R0. The perioperative morbidity rate with Dindo-Clavien classification = III was 21.5%. Tumor size and nodal status were the only prognostic variables, which significantly decreased survival by a multivariate analysis.

CONCLUSIONS

Major vascular resection to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. Nevertheless, it is justified only in carefully selected cases.

Self Rated Health among Syrian refugees in Lebanon and Norway – a cross sectional study

Background

Refugees are often exposed to various stressors before, during and after migration that can cause adverse health effects. Prior research indicates that the health status of refugees is a significant factor in determining their success in resettlement. This study aims to assess self-rated health (SRH) and factors associated with SRH among Syrian refugees in Lebanon and Norway.

Methods

The study uses a cross-sectional design with data from a self-administered survey among 827 adult Syrian asylum seekers of whom 506 were recruited in Lebanon, and 321 in Norway. Inclusion criteria were subjects who self-identified as Syrian nationals above the age of 16. The survey was conducted in 2017 and 2018 in collaboration with International Organization of Migration in Lebanon and through mandatory educational activities in Norway. Data analysis was performed for the main outcome self-rated health (SRH), a validated health status indicator, which was dichotomized into “good” and “poor” SRH. Odds Ratios for poor SRH were estimated adjusting for age, gender and country of residence.

Results

A total of 827 of 972 (85%) who were invited answered the questionnaire. The mean age was 33 years and 74% were men. Factors associated with good SRH were being Kurdish (AOR: 0.48 (0.23 to 0.97)) compared to Arabic ethnicity, being married (AOR 0.54 (0.29 to 0.99)) compared to being single, migrating alone (AOR 0.59 (0.37 to 0.96)) compared to co-migration and having low health literacy level (AOR: 0.64 (0.42 to 0.93)). In contrast, poor SRH was significantly increased with long time in transit country/ies (AOR 1.49 (1.07 to 2.06)) and with older age (age 30-34 AOR 3.2, age 35-39 AOR 2.2, age 40 + AOR 2.6) compared to age group 16-24.

Conclusions

Older refugees and those who stay long time in transit are at great risk of reporting poor SRH. Some of the factors associated with better health, like Kurdish ethnicity, low health literacy or migrating alone, deserve further research.

Key messages

Age and long stay in transit is associated with poor SRH among Syrian refugees. Demographic background and migrant related factors should be taken into account when planning refugee resettlement and healthcare provision.

Chronic pain and migration-related factors among Syrian refugees: a cross-sectional study

Background

Refugees display high rates of chronic pain. However, the relationship between refugee-related exposures introduced along their migration trajectories and the development of chronic pain remains unclear. The aim of this study was to assess the impact of stressors induced at various migration stages on chronic pain in Syrian refugees.

Methods

This is a cross-sectional survey among adult Syrian refugees in Lebanon and in Norway. We conducted logistic regression to study the associations between chronic pain and migration-related factors experienced prior to or during flight (trauma exposure, migrating alone and detainment) and after arrival in a new country (legal status, social relationships, living conditions and access to health care).

Results

Altogether 827 Syrians participated (response rate 85%). The mean age was 33 years and 41% were women. The overall prevalence of chronic pain was 30%. The mean WHO Quality of Life (WHOQOL) domain scores for both social relationships (13.4) and environment (10.2) were significantly lower among those reporting chronic pain, with low scores indicating less satisfaction. Regression analyses revealed an association between chronic pain and exposure to trauma (adjusted odds ratio (AOR) 2.5 (1.8; 3.4)), but no clear association between chronic pain and migrating alone or history of detention. Poor social relationships (AOR 1.9 (1.2; 3.1)), poor support from friends (AOR 1.5 (1.0; 2.1)) and poor living place (AOR 1.4 (1.0; 2.0)) were associated with reporting chronic pain, although associations reduced when adjusting for traumatic experiences. The associations between chronic pain and poor economy (AOR 1.6 (1.1; 2.5)) and poor access to health care (AOR 1.5 (1.0; 2.1)) persisted after trauma exposure adjustment.

Conclusions

We found a strong relationship between trauma exposure and chronic pain. Further, perceived poor economy and poor access to health care were associated with chronic pain regardless of trauma history.

Key messages

Trauma exposure, perceived poor economy and poor access to health care are associated with chronic pain among Syrian refugees. Public health care interventions should consider the combined impact of risk factors throughout the migration trajectory.

Robotic-assisted gastrectomy compared with open resection: a comparative study of clinical outcomes and cost-effectiveness analysis

In the last decade, there have clearly been important changes in the surgical approach of gastric cancer treatment due to an increased interest in the minimally invasive surgical approach (MIS). The higher cost of robotic surgery procedures remains an important issue of debate. The objective of the study is to compare the main operative and clinical outcomes and to assess the incremental cost-effectiveness ratios (ICERs) of the two techniques. This is a prospective cost-effectiveness and clinical study when comparing the robotic gastrectomy (RG) technique with open gastrectomy (OG) in gastric cancer. Outcome parameters included surgical and post-operative costs, quality-adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). The incremental utility was 0.038 QALYs and the estimated ICER for patients was dominated by robotic approach. The probability that the robotic approach was cost effective was 94.04% and 94.20%, respectively, at a WTP threshold of 20,000€ and 30,000€ per QALY gained. RG for gastric cancer represents a cost-effective procedure compared with the standard OG.

The learning curve of contrast-enhanced 'microbubble' voiding urosonography-validation study

INTRODUCTION

Vesicoureteral reflux (VUR) is a common pediatric urologic condition associated with urinary tract infection and pyelonephritis. It can be diagnosed via fluoroscopic voiding cystourethrogram (VCUG) and, more recently, contrast-enhanced voiding ultrasonography (ceVUS), which does not expose the patient to ionizing radiation. Voiding urosonography contrast agents used for the diagnosis of VUR have been widely available in Europe but were approved by the Food and Drug Administration for use in the United States only in 2016.

OBJECTIVE

The objective was to optimize a protocol and compare the diagnostic performance of ceVUS to fluoroscopic VCUG in an academic medical center naïve to previous use of contrast-enhanced voiding urosonography.

STUDY DESIGN

Thirty-nine patients referred for clinically indicated evaluation of VUR were enrolled between September 2016 and March 2017. Patients underwent contrast-enhanced ultrasonography with prediluted Lumason and under the same catheterization underwent fluoroscopic VCUG. Comparative grading was performed by pediatric radiologists on-site at the time of examination.

RESULTS

Reflux was observed in 16 of 39 patients (20 of 64 renal units) ranging from grades 1 through 5. VCUG and ceVUS were concordant for detecting reflux in 10 of 39 patients (14 of 84 renal units) and excluding reflux in 23 of 39 patients (64 of 84 renal units) (Fig. 1). Using contrast enhanced voiding urosonography, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that was not found on fluoroscopy. Using fluoroscopy, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that had not been found on ceVUS. Two of 20 renal units were upgraded from low-grade on ceVUS to high-grade on fluoroscopy. This corresponds to a Cohen's kappa of 0.72 (confidence interval [CI] 0.54-0.91) or 'moderate.'

DISCUSSION

During our investigation, we noted that there was a technical learning curve related to poor contrast mixing and the need to titrate the concentration of Lumason. However, over the course of the study, we were able to correct the technical aspects. Ultimately, our results showed good correlation between VCUG and Lumason ceVUS and only slightly less correlation than published studies by experienced centers. Future studies with voiding should allow for improved urethral visualization.

CONCLUSION

While there is a considerable learning curve to the implementation of ceVUS for the diagnosis of pediatric VUR, these technical aspects can be corrected. Even a center previously naïve to contrast-enhanced ultrasound technology can, over a short period of time, demonstrate good correlation between VCUG and ceVUS in the diagnosis of VUR. Translation of ceVUS into clinical practice is an alternative to VCUG for diagnosis of reflux, is feasible, and can eliminate the radiation exposure associated with a VCUG.

Diagnosis and treatment of pancreas divisum: A literature review

BACKGROUND

Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis. Recurrent acute pancreatitis, chronic pancreatitis or chronic abdominal pain are the main clinical syndromes at presentation and occur in only 5% of the patients with pancreas divisum. This review aimed to discuss diagnosis and treatment strategies in patients with symptomatic pancreas divisum.

DATA SOURCES

We report a literature review from 1990 up to January 2018 to explore the various diagnostic modalities and surgical techniques and results reported in the surgical treatment of pancreas divisum.

RESULTS

There are limited reports available on this topic in the literature. We analyzed and described the main indications in the treatment of pancreas divisum, focusing on surgical treatment and a discussion of the different approaches. Furthermore, we report the results from our experience in two cases of pancreas divisum treated by pancreatic head resection with segmental duodenectomy (the Nakao procedure).

CONCLUSIONS

Pancreas divisum is a common pancreatic malformation in which only a few patients develop a symptomatic disease. Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications. Many techniques, of greater or lesser complexity, have been proposed.

Comparison of the defined daily dose and days of treatment methods for evaluating the consumption of antibiotics and antifungals in the intensive care unit

OBJECTIVE

To compare the measurement of antimicrobial consumption by defined daily dose (DDD) versus by days of therapy (DOT).

DESIGN

Retrospective analysis of clinical and administrative data from patients admitted to a polyvalent ICU.

SETTING

ICU at a University Hospital in Spain.

PATIENTS

All patients admitted to the ICU.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

For the DDD method, the World Health Organization (WHO)-assigned DDD was determined for the all the prescribed antimicrobials. For the DOT method, one DOT represented the administration of a single agent on a given day regardless of the number of doses administered. To express aggregate use, total DDDs and total DOTs were normalized to 100 patient-days.

RESULTS

During the study period, 2393 adult patients were admitted to the ICU. Total median antimicrobial drugs measured by DDDs was 535.3 (IQR 319.8-845.5) vs. 344.0 (IQR 117.2-544.5) when measured by DOTs, p<0.001. When antimicrobial consumption was normalized to 100 patient-days, median antimicrobial consumption was also higher when measured by DDDs [2.98/100 patient-days (IQR 1.76-5.25) vs. 1.89/100 patient-days (IQR 0.64-3.0) when measured by DOTs, p<0.001].

CONCLUSIONS

For most antibacterial and antifungal drugs used in critically ill patients, estimates of aggregate antibiotic use by DDDs per 100 patient-days and DOTs per 100 patient-days are discordant because the administered dose is dissimilar from the WHO-assigned DDD. DOT methods should be recommended to avoid the overestimation that occurs with DDDs in adult critically ill patients.