Plant roots and their fungal associates have a dominant role in terrestrial carbon and nutrient cycling. Yet, how different root orders that vary in their production, quality, and function impact ecosystem processes remains uncertain. Across five orders of fine roots taken from forty woody plant species, we found consistently decreasing carbon and nitrogen release during four years of decomposition in the field the finer and more short-lived the roots (i.e., with decreasing root order from 5th to 1st order roots). Differences among root orders were remarkably well predicted by root carbon chemistry and diameter, with mycorrhizal type effects only in the coarsest roots (4th and 5th order roots). Our data shed an entirely new light on how different root orders and associated mycorrhizae contribute to biogeochemical cycling, refining the understanding and predictions of drivers and pathways of soil carbon and nitrogen dynamics.

IntroductionAtrial tachycardias (ATs) after open-heart surgery are challenging reentrant arrhythmias, associated with increased mortality and morbidity, and difficult to control with medications(1-3). Underlying arrhythmogenic mechanism is usually considered to be a reentry that involves incisional line, cannulation-related scar and surgical ablation lesions with a resultant sophisticated atrial substrate (4-6).Conventional 3D activation mapping is a cornerstone for the diagnosis and the ablation of reentrant ATs(7). However, most studies adopted the combination of activation mapping and entrainment mapping for AT; therefore, the efficacy of activation mapping alone remains unknown and is limited by misannotation of the fractionated potential and arbitrary window of interest, among other factors(8, 9). Ripple mapping (RM) allows the visualization of activation conduction on a 3-dimensinal voltage map thereby addressing the limitations of local activation time (LAT) mapping(10). Several studies have demonstrated that the utility of ripple mapping can improve diagnostic accuracy and ablation outcome compared with LAT mapping approach(11, 12). Radiofrequency ablation of atrial tachycardia post cardiac surgery has not been investigated, and is the subject of this study on ripple mapping for interpreting reentrant circuits and critical isthmus.

BACKGROUND AND PURPOSE Type II Diabetes mellitus (T2DM) is a worrying chronic metabolic disorder accompanied by multiple serious complications, makes threaten public health. In the present study, we evaluated the therapeutic effects against T2DM of the cycloastragenol (CAG), a key metabolite of astragaloside IV (AST) isolated from traditional Chinese plant Astragalus membranaceus and revealed its molecular mechanism. EXPERIMENTAL APPROACH The plasma glucose-decreasing effects of AST and CAG were monitored in KunMing mice by performing an OGTT test. Furthermore, the effect of CAG on the metabolism of Zuker diabetic fat (ZDF) rats was demonstrated after treatment for 5 weeks, as well as on diabetes-relevant clinical symptoms and glucose absorbance. The underlying molecular mechanism of the therapeutic effects of CAG was explored in both wild-type and sodium/glucose co-transporter 2 (SGLT2)-overexpressed HEK293 cells. KEY RESULTS CAG showed stronger effects in lowering plasma glucose and enhancing glucose tolerance than AST in KM mice and ZDF rats. In the ZDF rats, the potential antidiabetic properties of CAG were associated with amelioration in hyperglycemia, dyslipidemia, myocardial and kidney fibrosis. Interestingly, glucose reuptake was inhibited in the kidneys of mice treated with CAG, while urine glucose and sodium levels were elevated. The underlying mechanism might be that CAG reduced the expression of SGLT2 in the kidney and inhibited glucose transport as well. CONCLUSIONS AND IMPLICATIONS CAG can ameliorate the T2DM-related metabolic syndromes of ZDF rats by acting on the SGLT2, which provides a certain references for the application of CAG in T2DM therapy.

Bt toxins kill insects by binding to various receptors at insect midgut and creating pores on the midgut membranes. However, the application of Bt toxins in agriculture is threatened by evolved resistance of insects. Our understanding of molecular basis in insects involved in Bt toxin binding is incomplete, especially in diamondback moth (DBM, Plutella xylostella), a major agricultural pest. Identifying Bt toxin receptors has remained challenging due to lacking sufficiently sensitive methods. Here, we report a novel technique, on-membrane capture, that identified numbers of previously unknown proteins, in addition to known receptors like cadherin and APN2, from the DBM midgut as binding partners of three Bt toxins Cry1Ac, Cry1Ab, and Cry1Bd. Among them, glucosinolate sulfatases GSS1 and GSS2 are receptors specifically interacted with Cry1Bd. Reduction in GSSs expression increased tolerance of DBM to Bt toxins. Expressing DBM GSSs in silkworms dramatically decreased the tolerance of the transgenic silkworms to Cry1Bd. Therefore, the on-membrane capture provides a new solution to identify Bt toxin receptors in insects.

Gaurav S Desai*Department of Obstetrics and GynecologyBandra Bhabha Municipal General HospitalMumbai, IndiaCorresponding AuthorGaurav S Desai MS FCPSDepartment of Obstetrics and GynecologyBandra Bhabha Municipal General HospitalMumbai, India+91-8169936775Running title: COVID 19 in pregnancyAuthor contributions: GSD was responsible for this manuscript

CD36, also known as scavenger receptor B2, is a multifunctional receptor widely expressed in various organs. CD36 plays a crucial role in the uptake of long-chain fatty acids, the main metabolic substrate in myocardial tissue. The maturation and transportation of CD36 was regulated by the post-translational modifications including phosphorylation, ubiquitination, glycosylation, and palmitoylation. CD36 is decreased in pathological cardiac hypertrophy caused by ischemia-reperfusion and pressure overload, while increased in diabetic cardiomyopathy. Deficiency of CD36 alleviate diabetic cardiomyopathy, while overexpression of CD36 eliminates the damage of ischemia-reperfusion, suggesting that CD36 is closely associated with the progression of cardiovascular diseases. and it is expected to be a new therapeutic target. This review summarizes the regulation and post-translational modifications of CD36, and evaluates its role in main cardiovascular diseases and its potential as a therapeutic target.

In December 2019, the new acute respiratory syndrome coronavirus 2 (SARS-Cov-2) emerged in Wuhan, China, with an infection of pandemic proportions. Data from Wuhan showed that mortality from coronavirus disease 2019 (COVID-19) is strongly associated with cardiovascular diseases. Similar to SARS-Cov-1, which was responsible for the SARS epidemic from 2002 to 2004, SARS-Cov-2 also utilizes the host protein angiotensin II-converting enzyme (ACE2) as a coreceptor to gain intracellular entry. Hence, upregulation of ACE2 has been proposed as a potential factor in infectivity and a higher risk of harmful outcomes of COVID-19. In this context, data obtained from experimental models of hyperthyroidism have demonstrated increased cardiac ACE2, which can theoretically facilitate SARS-Cov-2 entry. However, there is currently no consistent scientific research on how COVID-19 specifically affects hyperthyroid patients, and more clinical and experimental evidence is urgently required to clarify this point. In this review, we highlight important known and unknown features of COVID-19 related to ACE2 and hyperthyroidism.

The ethanol concentration in batch cultivation with the yeast S. cerevisiae was predicted on-line using a gas sensor array. Head space samples were pumped past the gas sensors array every five minutes for 10 seconds and the voltage changes of the sensors were measured. For the calibration procedure no off-line sampling was used. Instead, a theoretical model of the process has been applied to simulate the ethanol production at any given time. However, the kinetic parameters of the simulation model are unknown at the beginning of the calibration. It will be demonstrated that these kinetic parameters of the theoretical process model can be acquired from the response of the gas sensor array alone. The calculated parameters result in a simulation model that is at least as accurate as a model whose parameters are acquired by least squares fitting to off-line measurements. The root mean square error of calibration as well as the percentage error for validation sets was below 0.2 g/L and 7 %, respectively. The obtained results indicate that, the model-based calibrated gas sensor array can be a cheap alternative to other tools that are used for monitoring yeast cultivations such as spectroscopy based methods.

Cel9B, an endocellulase produced by Thermobifida fusca YX, contains a number of structural domains, including carbohydrate binding modules 2 and 4 (CBM2 and CBM4), a fibronectin-like (Fn3) domain, an Eset domain (an Ig-like domain that may play a role in enzyme folding), a catalytic domain, and a fibronectin-like (Fn3) domain. To elucidate the roles of these domains with respect to Cel9B function, a series of truncation mutants were designed and examined for their binding properties and activities on different substrates. Different binding properties of CBM2 and 4 with a variety of substrates distinguish important roles for these domains and provide insight as to how distinct domains interact with each other during substrate degradation. The results of this study implicate the collective roles of the non-catalytic domains with respect to Cel9B function, and in turn, this information can be incorporated into protein engineering strategies for improved biomass conversion.

Atrioventricular septal defects (AVSD) are a complicated subtype of congenital heart defects for which the genetic basis is poorly understood. Many evidences have demonstrated that transcription factor SOX7 which can interact with GATA4 plays a pivotal role in the cardiovascular development. The critical role of GATA4 in the morphogenesis of atrioventricular septum implies SOX7 a potential involvement of AVSD. However, whether SOX7 variants are involved in the pathogenesis of AVSD needs to be explored. Through target sequencing, we identified three rare variants c.40C>G, c.542G>A, and c.743C>T of SOX7 in 100 sporadic non-syndromic AVSD Chinese Han patients. All mutant sites were highly conserved in mammals. The mRNA and protein levels of SOX7 variants were altered compared with those of the wildtype. Moreover, SOX7 overexpression promoted the expression of GATA4 in human umbil-ical vein endothelial cells. Chromatin immunoprecipitation assay uncovered that SOX7 could directly bind to the region of GATA4 promoter. Luciferase assays demonstrated that SOX7 activated GATA4 promoter and the variants impaired the transcriptional activity of SOX7. Furthermore, the variants of SOX7 altered the regulation to the activity of GATA4 on its target genes. Our studies provide evidence that deleterious variants in SOX7 are potential contributors to human AVSD and provide novel insights into the etiology of AVSD.

Recent research in island biogeography has highlighted the important role of late Quaternary sea-level fluctuations in shaping biogeographical patterns in insular systems, but largely focused on volcanic oceanic systems. Through this study we aim to extend this work by investigating the role of late Quaternary sea-level fluctuations in shaping species richness patterns in continental shelf island systems. Focusing on the Aegean archipelago, we first reconstructed the area’s geography using published data, under three sea-level stands: 1) current; 2) median over the last nine Glacial-Interglacial cycles; 3) Late Glacial Maximum (LGM). We compiled taxon-island occupancy for angiosperms (70 islands) and centipedes (56 islands). We investigated the impact of present-day and past geographical settings on chorological groups by analysing Island Species-Area Relationships (ISARs) and using Generalized Linear Mixed Models selection based on multiple metrics of goodness-of-fit. Our results confirm that the Aegean’s geography has changed dramatically since the LGM, while the median sea-level scenario only modestly differs from the present configuration. Paleogeographical changes largely shaped Aegean plant diversity patterns, and to a lesser degree centipede species richness patterns. The LGM geographic configuration affected both native and endemic species diversity through establishing connections between land-bridge islands and the mainland. Particularly on land-bridge islands we detected supersaturation of native species and stronger underrepresentation of endemics on those same islands. Unlike oceanic islands, where the longer lasting median configuration has ample effect on the current species diversity, the shorter lasting LGM configurations promoted increased connectivity with the mainland counteracting processes promoting endemism. Our study shows that in terms of processes affecting species richness patterns, continental archipelagos differ fundamentally from oceanic systems, highlighting the importance of distinguishing between them while studying biota from the perspective of historical biogeography.

Objective: Surgical/anesthetic management of patients undergoing surgical tracheostomy for Covid-19 pneumonia aiming at minimizing the risk of health care workers (HCWs) infection. Design, Setting and Paticipants: Twenty-three Caucasian patients, mean age 67 years, with long-term orotracheal intubation for severe acute respiratory syndrome Covid-19 pneumonia were submitted to surgical tracheostomy, between February 3rd and March 22nd 2020, according to our specific procedure. Main outcomes and Measures: Air exposure time (AET) and frequency of infection in HCWs. Results: No complication, in terms of bleeding or tracheostomy cannula displacement, was observed. No HCWs involved in the procedures contracted Covid-19. Conclusions: The tracheostomy technique we describe minimizes the risk of surgeon’s exposure to patient’s aerosol drops/expired air and the possibility of HCWs infection during the procedure carried out in patients with Covid-19 pneumonia. The details and advantages of our approach with respect to “standard” tracheotomy and percutaneous procedures are discussed.

Objective The main aim of the study was to assess the influence of maternal age on the incidence of significant pregnancy and childbirth complications in women with low-risk pregnancies. Design A retrospective cohort study. Setting Data collected from hospital delivery admission electronic medical records and discharge summaries of patients hospitalized in St Sophia’s Hospital in 2010-2016. Population or Sample 25063 women with low-risk singleton pregnancies. We excluded all patients with known main comorbidities influencing perinatal outcome. Methods The univariate and multivariate statistical analysis was performed to estimate the impact of age on the primary endpoint. Main Outcome Measures The primary endpoint was defined as a compiled adverse pregnancy outcome, which included several components. Results Maternal age is a significant risk factor for adverse pregnancy outcomes. Each subsequent year of life increases the incidence of pregnancy and childbirth complications (OR 1,014; 95%CI 1,008–1,021). Conclusions Maternal age is an independent risk factor for some of the complications of pregnancy and childbirth. Keywords maternal age, perinatal outcome, advanced maternal age, risk factor

Based on soil sampling, lab experiment and support resistance monitoring, the disturbance of soil physical quality indices between different underground mining stages of No 52303 working face was studied in semi-arid region of western China. Soil sampling was conducted in same locations before and after mining in 2014. This study proved that soil water content, soil cohesion and soil porosity were greatly decreased, while bulk density and dry density were increased by coal mining. In comparison, coal mining had slight effect on organic matter, internal fraction angle, and D1 and D2 percent. Underground pressure monitoring showed that P1 during stage 2 was significantly greater than that during stage 1, indicating the large difference of pressure characteristics in tail areas of working face between two stages. Both soil water content and soil cohesion were decreased during two stages in two sites. Soil cohesion was strongly correlated to soil water content, and D1 and D2 percent in 2013 and 2014. Coal mining subsidence increased the cumulative probability to reach the same value of soil water content and soil cohesion. The cover depth produced different elastic and plastic zone widths between sites by theoretical model calculation, consistent with the support resistances in tail areas of working face. Higher pressure might cause a more serious destructive rock-soil body and a larger groundwater level decrease. The dryer and more serious erosive soil column induced by coal mining is a non negligible matter for the semi-arid region.

Situs viscerum inversus always poses clinical and diagnostic challenge. We report the case of an unexpected and late discover of dextrocardia requiring aortic valve replacement.

Background: Aortic root abscess surgery has significant mortality but can be performed safely by trainees supervised by senior surgeons. Methods: Between 2007 and 2017, 54 consecutive patients (mean 64 years old) with active aortic endocarditis complicated with periannular abscess underwent aortic root replacement with homograft. Twenty-eight cases (52%) in which postgraduate year 5-8 residents or junior attending surgeons performed under senior attending supervision were compared to 26 cases the senior attending performed. Mean follow-up was 2.2 years. Results: Forty-three patients (80%) had previous aortic valve replacement and 26 (48%) were in New York Heart Association class III or IV status. Forty-two patients (78%) had concomitant procedure including 20 (37%) aorto-mitral curtain reconstruction and 6 (11%) hemi aortic arch replacement under circulatory arrest. Median cross clamp time was 218 minutes. There was no operative mortality. One patient (2%) had re-exploration for bleeding and 3 (6%) had stroke. Median hospital stay was 10 days. Preoperative characteristics and short and mid-term results were all comparable between mentee cases vs senior attending cases. Survival at 6 years were 67.3% (95% CI 38.0 – 85.0%) in mentee cases and 75.6% (95% CI 47.1 – 90.1%) in senior attending cases (adjusted hazard ratio 1.48, 95% CI 0.33- 6.73, P=0.61). During follow up, 2 patients (3.7%) required reoperation on the aorta valve for structural valve deterioration and 1 (1.8%) had recurrent endocarditis. Conclusions: Homograft aortic root replacement can be performed safely by trainees with an experienced surgeon showing favorable outcomes, midterm survival, and freedom from recurrent endocarditis.

Background &objectives:The present study was to carry out 90 days repeated oral toxicity of Urai mathirai in wistar albino rats. Methods:The chronic toxicity study was carried out as per (OECD) test guideline 408 and Central Council for Research in Ayurvedic Sciences (CCRAS) respectively. In this study, theUrai mathirai drug solution was administered at dose of (10, 50 and 100mg/kg b.wt) for every 24 hours orally upto 90 days for all the three groups. At the end of each study, hematological and biochemical analysis were evaluated. Histopathological examination of vital organs of the rats were taken for gross findings, compared to controls. Distilled water aided as a control in all the tests. Results: There was no significant difference (p > 0.05) observed in the relative organs weight, body weight, hematological, biochemical parameters, and gross abnormalities when compared to the control. No mortality was recorded with respect drug effect. Interpretation&conclusions: The results may lead that the oral administration of the Urai mathiraiat doses of 10, 50 and100 mg/kg.b.wtdoes not showedany toxicity effect in wistar rats during the experimental period. Keywords: Urai mathirai; chronic toxicity; herbal formulation; histopathology.

Terrestrial squamate reptiles from the Galápagos archipelago have limited gene flow among islands, providing an opportunity to test paleogeographic models. Previous work suggests that Pleistocene glaciations had a strong influence on the evolution of Galápagos’ land-locked vertebrates, such as lizards and snakes, by allowing dispersal and contact among populations from different islands or islets through land connections. One prediction of this model is that extant populations, despite being isolated at present, are genetically similar due to recent (Pleistocene) gene flow. Here we test this prediction with a simple comparative phylogeographic analysis of two sympatric lizards from Floreana island and surrounding islets. Based on two mitochondrial genes, we show that Floreana lava lizards (Microlophus grayii) and leaf-toed geckos (Phyllodactylus baurii) from Floreana Island are very similar genetically to conspecifics from Champion, an islet in the Floreana group that was connected to Floreana during Pleistocene glacial maxima. Moreover, they are significantly less similar to conspecifics from Gardner, an islet in the Floreana group that was not in contact with Floreana during Pleistocene glacial maxima. Thus, our results support the idea of Pleistocene glaciation-driven contact among populations from different islands in the Floreana cluster with no identifiable subsequent dispersal. These results also show that Floreana and Champion populations are part of the same evolutionary significant unit for both species, which might be at risk due to an upcoming invasive mammal eradication program in Floreana. Therefore, Champion represents a reasonable source for potential reintroductions of both lava lizards and leaf-toed geckos into Floreana.

Soil salinity is a major abiotic stress that limits plant growth and productivity. Understanding the mechanisms of plant salinity tolerance can facilitate engineering for quality improvement. Apocynum venetum L. exhibits tolerance to salinity. Due to the lack of a genomic database, RNA-seq based transcriptomics and isobaric tag for relative and absolute quantitation (iTRAQ) based proteomic profiles of Apocyni Veneti Folium (AVF) exposed to four levels of salt treatments were performed. A total of 143, 162 and 167 differentially expressed proteins (DEPs) were found between salt-treated AVF compared with control, respectively. They were mainly involved in carbohydrate and energy metabolism, biosynthesis of metabolites and signal transduction. Furthermore, results showed that carbon and nitrogen metabolisms were altered under salt stress; low and moderate levels of salt stress enhanced photosynthetic functions and ramped up carbohydrate metabolism. However, severe salt stress depressed biosynthesis of secondary metabolites, consistent with the metabolomics results. In conclusion, the protein profiles combined with transcriptomics and metabolomics indicate that halophyte uses a multipronged approach to overcome salt stress, and provides some novel information for revealing the mechanisms of adaption and quality formation of this herbal medicine.

AbstractThe human microbiome, especially the microbiomes of the gastrointestinal and respiratory tracts, are potentially important in determining susceptibility to COVID-19 and the immunopathology that leads to severe disease. Data is beginning to be gathered on the risk factors for severe disease in the coronavirus disease of 2019 (COVID-19). This data will be discussed in connection with some highlights of what is being learned about the human microbiome and its relationship with viral illnesses and inflammation-related chronic diseases. In particular, possible roles for diet, lifestyle, and microbiota manipulation as means of reducing rates of severe viral disease will be explored. Some potential pharmaceutical approaches to treating severe COVID-19 disease, involving the microbiome, mast cells and hypersensitivity responses, are also discussed. It is proposed that chronic low-grade infections and/or dysbiosis may underlie the age-related diseases that are risk factors for severe disease from SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). It is also suggested that the connection between these chronic diseases and COVID-19 may have implications for understanding some of the reasons for the severity of COVID-19 in a proportion of patients. Whether or not the hypothesis of a causal role for dysbiosis or prior infection is correct, some of the suggested treatment approaches might still be worth investigating.Keywords: microbiome, COVID-19, Westernized diet, exercise, stress, mast cells, cytokine storm, IL-6, plant-based diet, inflammation, dysbiosisIntroductionResearchers are rapidly gaining knowledge about COVID-19 to help address the current global pandemic, with a focus on treatment and prevention of the spread of the disease[1–3]. This article has two primary aims. The first aim is to examine the characteristics of the disease and the individuals who are most susceptible to severe disease to see if they can help reveal how humans can become less susceptible. A second aim is to explore whether these considerations might suggest treatment approaches that have potential to help at least some of those who are already suffering from severe disease. It is hoped that this review will be able to suggest areas of research that could be helpful in dealing with both the current pandemic and with other similar diseases or future epidemics.The emphasis here will be on the human microbiome and the diet, lifestyle and medical intervention factors that often affect it. This emphasis arises from the increasing research showing the profound impact of the human microbiome on immune function and many aspects of diverse disease processes[4,5]. The human genetic makeup is certainly important; however, the microbiotas inhabiting different parts of the human body are increasingly being shown to be crucial factors. It has been estimated that there are as many bacterial cells in the human body as human cells[6], and numerous microbial metabolites from the microbiome reach the blood stream and are increasingly being investigated[7]. This has led to the human microbiome being called the second genome[8]. One advantage of focusing on this second genome is that studies are showing that it can be altered much more easily than the human genome, apparently with beneficial effects, such as in the treatment of antibiotic-associated diarrhea due to Clostridiodes dificile infection using fecal microbiota transplants[9].The rapid changes in diet, lifestyle, environmental exposures and medical interventions in the last 75 years has led to changes in the human microbiome that may not be optimally compatible with our evolved immune responses to pathogens. This perspective is closely related to the hygiene hypothesis[10] and its newer forms, such as the altered microflora hypothesis[11] and an extension of these earlier hypotheses that focuses on the potentially pathogenic microbes within the post-hunter-gatherer era microbiota (PHM)[12]. Throughout this review, attention will be paid to factors that might lead to the establishment of these potentially pathogenic microbes, which include environmental microbes that are less coevolved with their human hosts and thus could have greater immune suppressing/dysregulating potential.

Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Recent telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource, with limited success. Clinical-effectiveness studies of these practice standards have thus far not included care settings in which resident-physicians are the primary caregivers. Furthermore, studies of the role of nurses in appropriate telemetry use are lacking. In this report, we describe two interventions implemented on general internal medicine units of a large academic hospital over three years. The first intervention, or nurse-discontinuation protocol, allowed nurses to trigger the discontinuation of telemetry once the appropriate duration had passed according to practice standards. The second intervention, or physician-discontinuation protocol, instituted a Best Practice Advisory that notified the resident-physician via the electronic medical record when the appropriate telemetry duration for each patient had elapsed and suggested termination of telemetry. Results showed that the nurse-discontinuation protocol reduced mean patient time on telemetry and the physician-discontinuation protocol reduced mean telemetry orders per patient. These findings validate a prior study and expand on our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers.

Background: We aimed to clarify the surgical management of ectopic cervical thymus (ECT) in children. Methods: Case report and systematic review of the literature. Results: We report a case of ECT in a 10-year old girl initially misdiagnosed as branchial cyst. A systematic review of the literature (1997-2018) identified 143 paediatric patients (150 ECT) diagnosed as follows: 10 incidentally at autopsy, 107 after complete surgical excision, 33 after needle/ incisional biopsy/ imaging only. There were no reports of malignancy. Conclusions: ECT is a benign and relatively rare condition in children. ECT can be the only active thymus and careful consideration should be taken prior to its excision in young children. We recommend that ECT should be considered in the differential diagnosis of lateral neck masses in children. In cases where the exact aetiology is unclear investigation with an MRI scan of neck and thorax to avoid inappropriate surgical intervention.

KEYPOINTSCOVID-19 patients often require prolonged mechanical ventilation, and tracheostomy is a common choice.Shared guidelines for intensive care unit patient tracheostomies for COVID-19 patients do not exist.Our survey indicates the timing and technique of COVID-19 tracheostomies vary considerably among hospitals in Lombardy, Italy.Otolaryngologists are seldom involved with decision-making regarding tracheostomies for intensive care unit COVID-19 patients.Evidence-based interventions are essential for providing the best care to invasively ventilated COVID-19 patients.KEYWORDSSARS-Cov-2; COVID-19; coronavirus; tracheostomy; percutaneous tracheotomy; surgical tracheostomy; intubation; ventilation.INTRODUCTIONAfter identifying the first Italian COVID-19 infected patient on 20 February 2020, a rapidly escalating infection cluster was discovered. On 21 February, a response coordinated by a governmental task force progressively led to a countrywide lockdown beginning on 9 March. Italy became the first Western country to address COVID-19, which on 20 March, the World Health Organization declared a pandemic.Although pneumology, infectious disease, and intensive care units (ICUs), as well as emergency departments, have carried the heaviest healthcare burden during this outbreak,1 other departments must also address the increased infectious risk while meeting patient needs. Given the number of COVID-19 patients requiring long-term invasive ventilation, a surge in tracheostomies have ensued. Otolaryngologists have quickly become involved in patient management, despite previously having been ’second-line’ specialists during infectious outbreaks.2 This unprecedented need for tracheostomies reopened decades-old debates about ICU patient tracheostomy timing, techniques and operators: supporters of late versus early tracheostomies, percutaneous tracheostomies (PTs) versus open surgical tracheostomies (STs) and otolaryngologists versus anaesthesiologists.This unprecedented situation similarly affected all hospitals in the region, overburdening ICUs and inpatient units. Our study aimed to illustrate the COVID-19 healthcare situation and investigate ICU tracheostomy management decisions.MATERIALS AND METHODSWe prepared a 13-item questionnaire asking the following: the number of COVID-19 patients treated, ICU dedicated beds, tracheostomies performed and their timing, preferred tracheostomy techniques with reasons for choosing PT or ST. The questionnaire was sent to each otolaryngology department in the Lombardy region, during the first week of April 2020. Department directors, instructed to collect data by collaborating directly with their respective ICUs, responded by phone the following week.

Recently (2019), a novel coronavirus (SARS-CoV-2) first reported in Wuhan, China has been declared a pandemic by the World Health Organization and is rapidly spreading throughout the globe which is associated with high morbidity and mortality, especially in the elderly and those with existing chronic conditions. SARS-CoV-2 infects cells through interaction of its surface glycoprotein with the human angiotensin converting enzyme 2 (ACE-2). This study conducted a analysis of mutation frequency in the surface glycoprotein of 796 sequenced SARS-CoV-2 isolates from different geographical locations in the GISAID and GenBank databases. Multiple sequence alignment analysis of the surface glycoprotein identified 64 different mutations at the protein level spanning multiple geographic locations globally. A cluster of mutations was identified in the receptor binding domain (RBD) of the surface glycoprotein. Significantly, the analysis showed that 68.5% of the isolates contain a D614 residue compared to 31.5% which contain a G614 suggesting virus is spreading in two forms. Furthermore, our investigation found that one isolate from Belgium had acquired 5 cumulative mutations in the surface glycoprotein indicating possible antigenic drift. The findings of this study are of critical importance for the design of vaccines and novel drugs against this severe acute respiratory syndrome coronavirus.