Introduction COVID 19 in particular affects the lungs causing an ARDS type picture resulting in an atypical form of ARDS whereby there is disproportionately poor oxygenation despite reasonably preserved lung compliance in the early stages 1. Experience from Italy and China suggests that nursing the patient in a prone position is potentially beneficial and can improve outcomes when carried out in the early stages of the disease1,2. This has resulted in its inclusion in several international guidelines and adoption around the world as a valid intervention for COVID 19 patients3Proning is not a new phenomenon and has been used as a treatment option for ARDS for over 20 years. It is not without complications and as well as the displacement of tubes and lines, the exacerbation of existing traumas or dehiscence of surgical wounds there are also reports of pressure necrosis secondary to prone positioning particularly of the face and nose4A cochrane review in 2015 concluded that prone ventilation was directly responsible for an increased risk of pressure sores5There is some suggestion that the pressure damage caused by proning occurs regardless of preventative measures put in place (such as foam supports and measures to relieve pressure)4But it also seems that this pressure damage is often mild and self resolving6. Regular repositioning of the head may also reduce pressure damage accordingly7Given that larger numbers of patients are likely to be proned and that proning is directly linked to pressure damage to the face and nose it would seem logical that this would represent an increase in referrals to ENT to assess this. Anecdotally this is the case in our department where we have received several such calls having never previously encountered this complication in routine practice. Although patients should be proned with the head turned to one side to avoid such pressure damage8 due to the highly unstable nature of COVID 19 patients and in some cases limited cervical spine rotation inevitably some patients will end up in positions where there nose is at risk. We present our approach to the management of these injuries borrowing from theory and practice used to manage patients having undergone rhinological procedures.

• Patients with obstructive sleep apnea (OSA) and lung disease have more prominent nocturnal hypoxemia. • Nocturnal hypoxemia in patients with impaired lung function with co-morbid OSA can enhance the possible mechanisms through which presence of OSA has been associated with adverse outcomes • Hypoxemia-, sympathetic over-activation-, increased oxidative stress-, and systemic inflammation-related to OSA may exaggerate symptoms associated with COVID-19. • It can be suggested that presence of OSA may plays a role in the severity of symptoms associated with COVID-19. • Further investigation in COVID-19 patients with previous diagnosis of OSA is warranted.

As a precursor of graphene, graphene oxide (GO) exhibits excellent mechanical, thermal, and electrical properties, besides appreciable biocompatibility in tissue engineering applications. However, the current GO-3D fabrication technology is still in need of optimization and simplification in order to ensure fine architecture and reasonable mechanical property, which would further promote the performance of GO as bio-scaffolds in cell or microorganism attachment and in material transformation. To address this issue, we proposed a GO ink, with appreciable rheological properties and excellent printing performance via high-speed centrifugation and ferric ion-assisted cross-linking. A woodpile structure with controllable micro-pores was produced by micro-extrusion-based 3D printing technology followed by an optimized freeze-drying process. Cellular adhesion and viability were verified by inoculation and culture of HepaRG cells using the fabricated GO 3D structure, thus suggesting ferric ion-assisted cross-linking and controllable pore distribution to improve the performance of GO construct as a bio-scaffold for in-vitro liver tissue models.

Severe acute respiratory syndrome coronavirus 2 (SARS-COV2) emerged from Wuhan, China at the end of December and spread rapidly around the globe with a higher degree of lethality reported than the endemic coronaviruses. Angiotensin convertase enzyme 2 (ACE2) host cell receptors mediate viral entry by binding to spike S protein of SARS-CoV2. ACE2 binding in viral pathogenesis has opened newer avenues for COVID-19 treatment with ACE2 at the center stage. Recombinant human ACE2 (rhACE2) protein has already shown therapeutic potential for vast array of therapeutic indications. In SARS-CoV2, the competitive binding of viral S protein with circulating ACE2 causing virus neutralization and sparing host ACE2 receptors is being proposed as the potential therapeutic mechanism in COVID-19. Though rhACE2 has moved into clinical trials in SARS-CoV2 patients, there are still some research gaps including lack of sufficient data about the proven efficacy of rhACE2 from in vitro and in vivo studies.

The pharmacological profile of benzodiazepines includes respiratory depression, and theoretically benzodiazepines might contribute to respiratory dysfunction. There are currently no data that indicate that benzodiazepines are problematic in COVID-19, and the risk is expected to be limited. Benzodiazepines are effective and frequently used, and if there is a clear indication in patients with COVID-19 there is insufficient reason to avoid benzodiazepines based on respiratory depression as side effect.

The use of renin-angiotensin system (RAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), is alleged to cause a more severe course of novel coronavirus disease 2019 (COVID-19). We systematically reviewed the available studies to assess the association of RAS inhibitors with mortality as well as disease severity in COVID-19 patients. A systematic literature search was performed to retrieve relevant original studies investigating mortality and severity (critical disease) in COVID-19 patients with and without exposure to ACEIs/ARBs. A total of 13 original studies were included; 11 studies reporting on mortality and 10 studies reporting on disease severity in ACEI/ARB exposed and unexposed groups. Among hypertensive COVID-19 patients, the use of ACEI/ARB was associated with a significant reduction in the risk of mortality exhibiting a pooled relative risk of 0.73 (95% confidence interval: 0.63-0.86). Moreover, there was no significant difference in the risk of developing severe/critical COVID-19 disease between ACEI/ARB and non-ACEI/ARB groups showing relative risk of 0.72 (95% confidence interval: 0.46-1.12). The data indicate that the use of ACEI/ARB was associated with reduced risk of mortality in COVID-19 patients taking these medications to manage their hypertension.

Objective: To review uptake and outcomes of robotic gynaecological surgery in England between 1st April 2006 and 31st March 2018. Design: Retrospective cohort study. Setting: Hospitals of the English National Health Service (NHS). Population or sample: Women aged 18 years and above who had elective gynaecological surgery. Methods: Robotic gynaecological procedures were defined as procedures that used a robotic minimal access approach for hysterectomy, adnexal surgery and urogynaecological surgery (sacrocolpopexy, sacrohysteropexy and colposuspension). Numbers of procedures were reviewed by year and mapped to the 44 NHS regions. Main outcome measures: Length of stay (nights in hospital), laparotomy (conversion during primary procedure or after return to theatre for management of complication), and 30-day emergency readmission rates by year and procedure type. Results: 527217 elective gynaecological procedures were performed in the English NHS (1st April 2006 and 31st March 2018), of which 4384 (0.83%) were performed with robotic assistance (3864 (88%) hysterectomy, 706 (16%) adnexal surgery, 192 (4%) urogynaecological surgery). There was gradual rise in uptake but marked geographical variation. Median (IQR) length of stay (LOS) was 1(1-2) night, laparotomy rate: 0.3% and 30-day emergency readmission rate: 4.7%. LOS was statistically but not clinically different across time. Other outcomes did not differ by year. Conclusions: Robotic gynaecological procedures is increasingly being used in the English NHS, predominantly for hysterectomy, although overall in small proportions (2.6% in the most recent study year). There was wide geographical variation in robotic uptake across England and overall, outcomes were comparable to those reported in other countries.

Evaluate the impact of third trimester ultrasound in identifying ,small for gestational age (SGA) growth restricted (FGR) and appropriately grown fetuses (AGA).Analyse their outcomes ,ascertain the main causes of perinatal death and lastly compare ultrasound intervention to standard antenatal care . Design Prospective observational study Setting Secondary care, government hospital Population Antenatal women Methods Based on estimated fetal weight by scan , patients were categorized into FGR < 3, SGA >3 and <10 and AGA >10 centile. Perinatal outcomes and deaths were analysed by category. Health Ministry data was extracted for standard care outcomes and compared to study group. Main Outcomes Perinatal deaths and causes,composite neonatal morbidity ,severe adverse outcomes Results Number of births in study and standard care was 1817 and 15,427 respectively. Detection rate by ultrasound for FGR/SGA fetuses was 28.5%.This contained 44.8% (13/29) of all perinatal deaths. Neonatal deaths, composite neonatal morbidity, serious adverse perinatal outcomes were significantly more in FGR compared to AGA. Standard care group had twice as many stillbirths RR 2.32(1.3-4.1)and early neonatal deaths (RR2.5 (1.18-5.34) . Majority of perinatal deaths (17/29; 58.6%) in study group were the direct result of failure to recognize antepartum/ intrapartum risk factors, leading to delayed delivery. In addition (3/12 ; 25%), women reported late after decreased fetal movements and ( 3/12 25%)were post dated. Ill-equipped nursery contributed to neonatal mortality in (10/17 ; 58.8%) cases. Conclusion Perinatal outcomes will not improve by ultrasound identification of small fetuses unless concomitantly, obstetric protocols and patient awareness programmes are not improved.

Background: Many guidelines indicated that to continue using anticoagulant drugs to reduce the incidence of symptomatic venous thrombosis (SVT) in total knee arthroplasty (TKA) patients after discharged. Objective: This retrospective analysis included 407 consecutive patients who underwent TKA at the Lanzhou University Second Hospital in China. Cases history from Jan. 2013 to Dec. 2016. Methods: The group A were taken hypodermic injection of low molecular heparin for 5-10 days after surgery at the hospitalization time, then continued oral rivaroxaban after hospital discharge. The group B were only taken hypodermic injection of low molecular heparin for 5-10 days at the hospitalization time. Baseline characteristics of patients, total complications of SVT，any venous thromboembolic disease (VTE), deep venous thrombosis (DVT), pulmonary embolism (PE), lower limbs swelling, bleeding and mortality following hospital discharge were compared between the two groups. Main outcome measures: The main outcome measures were incidence of bleeding and death duration of in-hospital and out-hospital stay in this study. Results: After analysis, the results showed that the incidence of SVT patients had no significant difference between the two groups. Moreover, the incidence of VTE, major/minor bleeding, total–DVT, PE, fatal PE and death all had no significant differences between the two groups. But the patients of no smoking or no drinking were superior than the smoking or drinking in the incidence of symptomatic thrombosis. Conclusion: There is no enough evidence showed that the TKA patients given anticoagulant after hospital discharged had beneficial to decrease the risk of SVT incidence. Furthermore, the smoking and drinking would increase the risk of symptomatic thrombosis for TKA patients.

Abstract Giant right coronary artery aneurysm is a rare coronary artery pathology. We describe a 45-year-old gentleman who presented with unstable angina of recent onset. Diagnostic work up including chest CT angiography and left heart catheterization demonstrated 3-vessel coronary artery disease with giant proximal right coronary artery aneurysm. In the view of the severity of the coronary artery disease and the risk of rupture associated with the giant right coronary artery aneurysm and the clinical presentation, patient was successfully treated by coronary artery bypass surgery. During this procedure, the right coronary artery aneurysm was ligated at both inflow and outflow. Patient recovered well and was discharged home.

Rupture of a congenital left ventricular diverticulum (CLVD), a rare anatomical anomaly, is a catastrophic event, with potential fatal consequences. Repair techniques documented in the literature include primary closure and single patch closure. We describe a case of a 57-year-old woman with symptomatic anterolateral CLVD. Our approach involves a linear incision through the epicardial surface of the diverticulum with exclusion of the cavity, and restoration of normal ventricular geometry via a two patch technique.

A 42-year old man with thrombophilia (prothrombin gene mutation) required the insertion of an inferior vena cava filter because of recurrent gastrointestinal bleeding associated with oral anticoagulation. However, it penetrated through the retro-hepatic vena cava into the liver, being manifested by constant, blunt abdominal pain. Endovascular retrieval was considered of extreme risk, though a surgical approach was performed under cardiopulmonary bypass with deep hypothermic circulatory arrest. The patient has recovered uneventfully with complete symptom relief.

Different grazing practices can have varying impacts on soil properties and soil microbial communities, which are critical for maintaining productivity and functions of grasslands and the overall ecosystem. The Qinghai-Tibetan plateau (QTP) is the largest high-altitude grazing region on earth, and has three different grazing practices, including seasonal grazing (SG), continuous grazing (CG), and exclosure grazing (EG) for 10 years. Vegetation, soil properties from two different depths (0-0.15 and 0.15-0.30 m) and soil microbial communitiesin the surface soil layer (0-0.15 m) were measured in triplicate plots within each grazing practice. The soil conditions in the SG site were the best, the CG site was the worst, while the EG site was intermediate. Dry aboveground biomass, soil organic carbon, total nitrogen, and total phosphorus content under SG were 838 g/m2, 20.73g/kg, 1.74 g/kg, and 0.20 g/kg, respectively, and under CG were 8.80 g/m2, 8.07g/kg, 1.07 g/kg, 0.16 g/kg, respectively. There was no significant difference in the α-diversity of soil bacteria and fungi among the three grazing practices. However, the bacterial communities were significantly different from each other; only the fungal community under EG was significantly different from the other grazing practices. While the relative abundance of Basidiomycota under SG was significantly higher than that under EG, no difference was observed in the relative abundance of Ascomycota, Zygomycota, and unclassified_k_Fungi among the three grazing practices. Compared to SG, CG and EG significantly increased the relative abundance of Actinobacteria, Gemmatimonadetes, Verrucomicrobia, and Nitrospirae, but decreased the relative abundance of Proteobacteria and Bacteroidetes.

Umbilical hernia is occasionally seen with different levels of complexity in animals. However, eviscerated umbilical hernia with extensive adhesion in a bovine calf is not much common. With timely recognition, surgical intervention, and administration of an antibiotic, antihistaminic and anti-inflammatory drugs, the outcome is generally good.

Beyond the protein-only hypothesis: the Lipid-Carrier Initiator prion hypothesisKavitha Reddy, M.D.11Boston, Massachusetts

As COVID-19 continues to challenge the practice of head and neck oncology, clinicians are forced to make new decisions in the setting of the pandemic that impact the safety of their patients, their institutions and themselves.  The difficulty inherent in these decisions is compounded by potentially serious ramifications to the welfare of patients and healthcare staff, amid a scarcity of data on which to base informed choices. This paper explores the risks of COVID-19 incurred while striving to uphold the standard of care in head and neck oncology.  The ethical problems are assessed from the perspective of the cancer patient, healthcare provider, and other patients within the healthcare system.  While no single management algorithm for head and neck cancer can be universally implemented, a detailed examination of these issues is necessary to formulate ethically sound treatment strategies.

IntroductionThe COVID-19 pandemic has resulted in an unprecedented need for critical care intervention. Prolonged intubation and mechanical ventilation has resulted in the need for tracheostomy in some patients. The purpose of this international survey was to assess optimal timing, technique and outcome for this intervention.MethodsAn online survey was generated. Otorhinolaryngologists from both the United Kingdom and Abroad were polled with regards to their experience of tracheostomy in COVID-19 positive ventilated patients.ResultsThe survey was completed by 50 respondents from 16 nations. The number of ventilated patients totalled 3403, on average 9.7% required a tracheostomy. This was on average performed on day 14 following intubation. The majority of patients were successfully weaned (mean 7.4 days following tracheostomy).ConclusionThe results of this brief survey suggest that tracheostomy is of benefit in selected patients. There was insufficient data to suggest improved outcomes with either percutaneous versus an open surgical technique.

Background: An increasing number of COVID-19 patients worldwide will probably need tracheostomy in an emergency or at the recovering stage of COVID-19. We explored the safe and effective management of tracheostomy in COVID-19 patients, to benefit patients and protect healthcare workers at the same time.Methods: We retrospectively analyzed 11 hospitalized COVID-19 patients undergoing tracheostomy. Clinical features of patients, ventilator withdrawal after tracheostomy, surgical complications and nosocomial infection of the healthcare workers associated with the tracheostomy were analyzed.Results: All the tracheostomy of 11 cases (100%) were performed successfully, including percutaneous tracheostomy of 6 cases (54.5%) and conventional open tracheostomy of 5 cases (45.5%). No severe postoperative complications occurred, and no healthcare workers associated with the tracheostomy are confirmed to be infected by SARS-CoV-2. Conclusion: Comprehensive evaluation before tracheostomy, optimized procedures during tracheostomy, and special care after tracheostomy can make the tracheostomy safe and beneficial in COVID-19 patients.

Background: Guidelines for ultrasonic devices use are imperative because infectious aerosols arising from airway procedures were a key etiologic factor in prior coronavirus outbreaks. This manuscript aims to summarize the available recommendations and the most relevant concepts about the use of ultrasonic scalpel during the SARS-CoV-2 pandemic. Methods: Literature review of manuscripts with patients, animal models or in vitro studies where the ultrasonic scalpel was used and the plume produced was analyzed in a quantitative and/ or qualitative way. Discussion: Activated devices with tissue produces a biphasic bioaerosol composed (size 68.3 - 994 nm) of tissue particles, blood, intact and no viable cells, and carcinogenic or irritant hydrocarbons (benzene, ethylbenzene, styrene, toluene, heptene, and methylpropene). Conclusion: It is imperative to use an active smoke evacuator, to avoid ultrasonic scalpel use in COVID-19 positive patients and in upper airway surgery, as well as to follow the protection recommendations of the guidelines for management this type of patients.

In a paper manufacturing system, it can be substantially important to detect machine failure before it occurs and take necessary maintenance actions to prevent a detrimental breakdown of the system. Multiple sensor data collected from a machine provides useful information on the system's health condition. However, it is hard to predict the system condition ahead of time due to the lack of clear ominous signs for future failures, a rare occurrence of failure events, and a wide range of sensor signals which might be correlated with each other. In this paper, we present two versions of feature extraction techniques based on the nearest neighbor combined with machine learning algorithms to detect a failure of the paper manufacturing machinery earlier than its occurrence from the multi-stream system monitoring data. First, for each sensor stream, the time series data is transformed into the binary form by extracting the class label of the nearest neighbor. We feed these transformed features into the decision tree classifier for the failure classification. Second, expanding the idea, the relative distance to the local nearest neighbor has been measured, results in the real-valued feature, and the support vector machine is used as a classifier. Our proposed algorithms are applied to the dataset provided by IISE 2019 data competition, and the results show the better performance than the given baseline.

Context: It has been recently demonstrated that tissue flossing around the ankle joint can be effectively used to improve ankle range of motion, jump and sprint ability. However, there is a lack of studies investigating the acute effects of tissue flossing applied around the thigh. Objective: The study aimed to investigate the acute effects of tissue flossing, and the degree of floss band pressure, around the upper-thigh on Active straight leg raise test, knee extensor and flexor maximum voluntary contraction and associated thigh muscle tensiomyography parameters. Design: Cross-over design in 3 distinct sessions. Setting: University laboratory. Participants: 19 recreationally trained volunteers (age 23.78 ± 4.85). Intervention: Active knee extension and flexion performed for 3 sets of 2 minutes (2 minutes rest between sets with wrapped upper-thigh. Individualized wrapping pressures were applied to create conditions of high (HIGH) and moderate (LOW) vascular occlusion, while a loose band application served as a control condition (CON). Main Outcome Measures: Participants were assessed for Active straight leg raise test (ASLR), tensiomyography displacement (Dm) and contraction time (Tc) for rectus femoris (RF), vastus medialis (VM) and biceps femoris (BF) muscles, maximum voluntary contractions for knee extensors (extMVC) and flexors (flexMVC) for pre (PRE), after (POST) and 30 minutes after (POST30) applying the floss band. There was a statistically significant increase in extMVC and a significant shortening in rectus femoris Tc for the LOW condition, which was associated with small to medium effects in favor of the LOW condition. There were no statistically significant changes observed between CON and HIGH conditions. The ASLR test was unaffected regardless of intervention. Conclusions: The results of this study suggest that tissue flossing around the upper-thigh might have a localized as well as pressure-sensitive response, thereby improving neuromuscular function of the knee extensors.

The coronavirus disease 19 (COVID-19) is a highly transmissible respiratory disease affecting millions of people worldwide. We summarized the current status of COVID-19 outbreaks in Bangladesh. Since the first COVID-19 confirmed case in Bangladesh on 8 March 2020, 7667 cases and 168 deaths were reported until 30 April 2020. Most cases (54%) were detected in the capital city Dhaka. Bangladesh Government declared 41 days shutdown, starting from 26 March 2020 to reduce the transmission of this highly contagious respiratory disease. Likewise, in other COVID-19 affected countries, the increasing trend of COVID-19 positive cases was continuing. People of Bangladesh are highly vulnerable to this disease mainly because of high population density, poor hygienic practice, unnecessary mobility, limited access to the hospitals, and insufficient ICU (intensive care unit) facilities. The government should focus on widespread laboratory testing and rapid response to prevent further spread of SARS-CoV-2 virus.

Zhu-Tokita-Takenouchi-Kim (ZTTK) is a rare disorder caused by heterozygous variants of SON gene, which is an autosomal dominant genetic disease, with only 32 cases and 25 causative variants in SON have been reported to date since the first report in 2015. Herein, we reported 2 additional sporadic cases with clinical features strikingly similar to cases having been reported. Notably, through penetration of left palm print and growth hormone deficiency in our Patient #1 has not been mentioned in reported literature. Whole-exome sequencing revealed 2 novel variants, c.5297 delC (p.S1766Leufs*7) and c.5230 delC (p.Arg1744Valfs*29) in SON resulting in ZTTK syndrome. Our report expands the mutant spectrum of SON gene and refine the genotype-phenotype map of ZTTK syndrome.

Abstract Phenotypic plasticity allows organisms to cope with variable environmental conditions increasing both performance and fitness. We studied within-generation plasticity and transgenerational effects of thermal conditions on temperature tolerance and demographic parameters in Drosophila melanogaster. We employed a fully factorial design, in which both parental (P) and offspring generations (F1) were reared in a constant or a variable thermal environment. Thermal variability during ontogeny increased heat tolerance in P, but with demographic cost as this treatment resulted in substantially lower survival, fecundity and net reproductive rate. The adverse effects of thermal variability (V) on demographic parameters were less drastic in flies from the F1, which exhibited higher net reproductive rates than their parents. These compensatory responses could not totally overcome the challenges of the thermally variable regime, contrasting with the offspring of flies raised in a constant temperature (C) that showed no reduction in fitness with thermal variation. Thus, the parental thermal environment had effect on thermal tolerance and demographic parameters in fruit-fly. These results demonstrate how transgenerational effects of environmental conditions on heat tolerance, as well as their potential costs on other fitness components, can have a major impact on populations’ resilience to warming temperatures and more frequent thermal extremes.