Despite rapid progress in the field, scalable high-yield production of AAV is still one of the critical bottlenecks the manufacturing sector is facing. The insect cell-baculovirus expression vector system (IC-BEVS) has emerged as a mainstream platform for a scalable production of recombinant proteins with clinically approved products for human use. In this review, we provide a detailed overview on advancements in IC-BEVS for rAAV production. Since the first report of baculovirus induced production of rAAV in insect cells in 2002, this platform has undergone significant evolutions. The original three baculovirus system was improved to enhance expression stability and further streamlined to reduce the number of baculoviruses to two and eventually one. The one baculovirus system consisting of an inducible packaging insect cell line was further improved to enhance the AAV vector quality and potency. In parallel, implementation of advanced manufacturing approaches and control of critical processing parameters have demonstrated promising results with process validation in large scale bioreactor runs. Moreover, optimization of molecular design of vectors to enable higher cell-specific yield of functional AAV particles in combination with bioprocess intensification strategies may further contribute to addressing current and future manufacturing challenges.

Prolonged normothermic cardiac arrest is associated with a high incidence of neurological morbidity and mortality1. Whole body temperature-controlled perfusion has been applied to limit reperfusion injury and minimize ischemia2. We describe the full recovery of a patient after the application of rapid hypothermia following an intraoperative aortic rupture with ten minutes of absent cerebral blood flow.

Background. Unroofed coronary sinus syndrome (UCSS) is rare and often associated with Left superior vena cava (LSVC). We report our experience in 159 patients with UCSS during a 20-year period in terms of clinical features, diagnosis, associated anomalies, surgical procedures and late outcomes. Methods. Between May 1998 and May 2019, 159 patients with UCSS were treated surgically and followed up. UCSS was confirmed by preoperative echocardiography or CT scan in 97 patients and by the surgeons during surgery in 62. LSVC directly drained into the left atrium (LA) was found in 100 cases. In these patients, 8 cases of LSVC were ligated, 59 cases were reconstructed the intracardiac tunnel to drain LSVC to right atrium (RA), and the extracardiac procedure was constructed to lead the LSVC draining to RA in 2. The associated cardiac lesions were corrected concomitantly. Results There were 5 hospital deaths. We followed up 143 early survivors, and there was no death. Except for one case of avulsion of the patch in which LSVC was drained by internal tunnel, there were no serious complications in other follow-up patients. Conclusion. UCSS is often misdiagnosed in the preoperative evaluation of congenital heart diseases. Preoperative transthoracic echocardiography (TTE) is still the most important method in the diagnosis of UCSS. When associated with LSVC, UCSS should be considered as a possible additional finding．We performed different surgical approaches to deal with the different types of UCSS with LSVC with a good result.

To summarize and analyze the clinical features of Apical hypertrophic cardiomyopathy (ApHCM) which was misdiagnosed before the gross deformity of the papillary muscles and moved down to the apex of the heart due to the presence of Giant Negative T-wave (GNT). The clinical data of 215 patients who were previously diagnosed with ApHCM due to the presence of GNT in our hospital from 2006 to 2018 were retrospectively analyzed. Results: After careful observation and combined with LVO examination, 11 cases were found to have clinical features of large papillary muscle deformity and the position was moved down to the apex (ADPM). 9 cases of them were: anterior wall myocardial ischemia, patients with 6–14mm T wave inversion in leads V4-V6; 2 cases of inferior wall ischemia, middle-aged male patients with recurrent chest tightness, shortness of breath1 More than hours, especially after fatigue. ECG tips: sinus rhythm, normal ECG axis, 6-10mm T wave inversion, no abnormal angiography, echocardiography shows left ventricular wall structure, exercise, and left ventricular ejection fraction (LVEF) Within normal range. Echocardiography showed that the papillary muscles were thick and moved down, and the GNT corresponded to leads II, III, and AVF. This report shows that the huge negative T wave is not a specific manifestation of myocardial ischemia. The diagnosis is ApHCM is a misdiagnosis. Abnormal papillary muscle location and papillary muscle morphology can also lead to the occurrence of GNT.

The assessment of left ventricular (LV) function in the setting of mitral stenosis (MS) has been critically examined for decades. Accurate assessment of aberrations in diastolic function is important as these subjects often present with signs and symptoms of heart failure and pulmonary congestion that cannot be solely explained by the severity of mechanical obstruction. Echocardiographic evaluation of diastolic dysfunction includes an evaluation of reduced LV compliance, diminished restoring forces and enhanced stiffness, which are challenging in the setting of MS owing to altered hemodynamic loading. Conventional echocardiographic and Doppler measures offer limited information. Novel assessments employing speckle tracking echocardiography are relatively less studied. A more comprehensive assessment including clinical evaluation, identification of concomitant disorders and comorbidities is particularly warranted in older subjects with degenerative MS to suspect diastolic dysfunction and arrive at optimal medical therapy or intervention. This review provides an overview of etiological, pathophysiological, echocardiographic and invasive assessment of diastolic dysfunction in the setting of MS, with specific focus on strengths and limitations of available echocardiographic and Doppler techniques.

The whole world is suffering with a new health crises due to the spread of a novel human virus known as the severe acute respiratory syndrome corona virus 2 (SARS-COV-2) or the Corona virus disease 2019 (COVID-19). This new virus which originated in December 2019 from Wuhan, China has now spread all across the globe posing a major threat to the human life. There is substantial evidence that the virus outbreak is fueled by the zoonotic transmission since this new virus belongs to the same family of viruses as SARS-COV and MERS-COV. Although, the exact route of transmission of this virus to humans is still unknown, however, based on the various reported evidences bats, pangolins, snakes or minks were found to be the probable reservoir as well as intermediate host of the SARS-COV-2. Along with the human life damage, the animal welfare has also been seriously endangered. With numerous reports on the transmission of COVID-19 from humans to animals, the cases of the abandonment household pets from their owners are increasing. Many experimental studies as well as evidences from zoos of different countries demonstrated the possibility of transmission of COVID-19 virus from the infected human companions to their pets or household animals. Therefore, precautionary measures are required to protect the pets and other animals from the virus transmission. The present article highlighted the different ways to promote awareness and corroborate practices for helping people as well as animals to stay secure and healthy.

Background: We hypothesized that signal averaged ECG during tachycardia would facilitate P wave recognition and assist in SVT diagnosis. P waves adjacent to the QRS during tachycardia would lengthen the filtered QRS and be recognized by subtracting QRS duration during sinus rhythm from that of tachycardia. Aims: to assess the feasibility of SaECG during SVT; to correlate the difference between the filtered QRS duration in SVT and sinus rhythm (ΔfQRSd) with the endocardial VA time; Methods & Results: Patients referred for an EP study and ablation of any SVT were included. A SAECG was acquired during SVT and compared with another during SR. 40 patients were included, 20 had AVNRT and 20 AVRT. For AVNRT, the P wave was detected as a pseudo-late potential in 16 patients. In 4 patients, P wave was invisible and presumed within the confines of the QRS. The mean ΔfQRSd was 2017 ms and the VA time was 1415 ms. For AVRT a distinct P wave separated from the QRS was detected in all patients. The ΔfQRSd was 10742ms and the VA time was 9631 ms. ΔfQRSd was longer during AVRT than AVNRT (p<0.0001). Over all, the ΔfQRSd correlated with the longest VA time (R=0.796). Motion artifact and sensing of T waves during tachycardia were 2 confounders. Conclusion: SaECG provides a rapid adjunct to the 12 lead ECG and is capable of identifying P waves and facilitating diagnosis of SVT mechanism.

Covid-19 is a respiratory illness caused by coronavirus SARS-1CoV-2. High levels of cytokines, particularly interleukin 6 (IL-6) are found in Covid-19 patients. IL-6 induce sympathetic hyperactivation that trig premature ventricular contraction (PVC). Ten point five percentage of Covid-19 patients of our Hospital developed right outflow tract (RVOT) PVC associated to high value of IL-6. After administration of Tocilizumab (IL-6 antagonist) once the infection was resolved, the PVC disappeared. Are the increased values of IL-6 an aspect of myocardial RVOT initial inflammation and fibrosis, or the effect of the high pulmonary pressure and RV pressure overload that determine myocardial stretch and subsequent PVC? The question of whether the elevation of this inflammatory biomarker is the cause or consequence of ventricular arrhythmia manifestation.

Trachea plays a vital role in the human body for transporting oxygen to the lungs. Tracheal stenosis is one of the destructive conditions that majorly affects the trachea and may lead to the death. Over the several years, research has been directed for the development of biomaterials which can initiate the replacement and regeneration of the trachea and the field is known as tracheal tissue engineering. This review summarizes the efforts in the field of tracheal tissue engineering and its regeneration in terms of the sources of cells, different types of materials used and several types of fabrication techniques such as electrospinning, three-dimensional (3D) bioprinting and decellularisation. We have also discussed possible animal models which could be used for in vivo implantation of the developed substitutes to check its efficacy and biocompatibility. Bioreactors are mandatory equipments for 3D culturing of certain cells inside the developed scaffold and for optimal conditioning of the scaffolds. Therefore, various bioreactor models have also been discussed in detail for scaffold development towards tracheal tissue engineering.

Currently, stable Chinese hamster ovary cell lines producing therapeutic, recombinant proteins are established either by antibiotic and/or metabolic selection. Here we report a novel technology, PTSelect™ that utilizes an siRNA cloned upstream of the gene of interest (GOI) that is processed to produce functional PTSelect™-siRNAs, which enable cell selection. Cells with stably integrated GOI are selected and separated from cells without GOI by transfecting CD4/siRNA mRNA regulated by PTSelect™-siRNAs and exploiting the variable expression of CD4 on the cell surface. This study describes the PTSelect™ principle and compares the productivity, doubling time and stability of clones developed by PTSelect™ with conventionally developed clones. PTSelect™ rapidly established a pool population with comparable stability and productivity to pools generated by traditional methods and can further be used to easily monitor productivity changes due to clonal drift, identifying individual cells with reduced productivity.

A term newborn with a right-sided CDH and severe pulmonary hypertension with systemic hypotension required veno-arterial ECMO. Despite appropriate cannulas size, high drainage pressure exceeding 60 mmHg was needed to maintain an ECMO flow at 120 ml/kg/min. Pericardial tamponade and misplacement of the venous cannula within the azygos vein were detected. Open thorax surgery was performed, and the cannula was repositioned. Postoperative X-rays showed an anomalous tip position of the cannula, suggesting the kinking inside the right atrium (Fig. 1). Reintervention was needed to restore the cannula. Cannula problems complicate about 12.8% of all neonatal respiratory ECMO. Both cannula malposition and kinking can affect the proper functioning of the ECMO support, and they should be carefully ruled out anytime suboptimal venous drainage and insufficient ECMO flow are experienced. Nevertheless, their diagnosis can be challenging, and both X-ray and echocardiography are essential tools. In particular, incidental azygos vein cannulation represents a possible rare ECMO complication in right-sided CDH and should always be kept in mind in this specific population. The decision to reposition or replace the cannula is mandatory, although not risk-free, in case of inadequate venous drainage or case of possible cardiac or vessel perforation.

We report herein successful treatment of a case of acute type A aortic dissection complicated by cardiac tamponade and mesenteric malperfusion. The patient was a 60-year-old man, with back and abdominal pain and in shock, who was transported to our hospital 2 hours after symptom onset. Computed tomography revealed DeBakey type I dissection with massive hemopericardium and obstruction of both the celiac artery and superior mesenteric artery. After emergency pericardiotomy and removal of the hematoma, superior mesenteric artery-external iliac artery bypass was constructed with a vein graft, and this restored mesenteric perfusion. Open distal hemiarch replacement was then performed. The postoperative course was uneventful. Superior mesenteric artery revascularization achieved immediately after release of the cardiac tamponade prevented further mesenteric ischemia and paved the way for the aortic repair.

Primary cardiac leiomyosarcoma is not common but is lethal. Prompt surgery is mandatory for identifying the etiology while a comprehensive examination of pathology is crucial especially in the condition of two tumors with different etiologies. A 52-year-old man with medical history of systemic hypertension presented with chest discomfort and dyspnea. Echocardiography revealed the dilated right ventricle with a mass at right ventricular outlet tract (RVOT) (Figure 1A). It caused critical obstruction and resulted in severely pulmonary hypertension (estimated pulmonary systolic pressure up to 108mmHg). Cardiac magnetic resonance imaging confirmed a heterogeneous mass at RVOT with a high-intensity in T2 weighted image but failed to differentiate whether it is myxoma, metastasis or primary cardiac malignancy (Figure 1B). Given the exacerbating dyspnea, he received a prompt surgery which identified two tumors. One in the size of 9*4 cm originated from the RV dome extending to RVOT and pulmonary artery. The other smaller one (5*3 cm) mainly located within the RV (Figure 1C). The surgeon excised the smaller one for the frozen section while the immediate pathology reported that it was a benign lesion. Both tumors were removed. Surprisingly, post the operation the final pathology revealed that despite one tumor of benign degenerative tissues, the other of rare cardiac leiomyosarcoma at T1 stage. Immunohistochemical staining showed positive for smooth muscle actin and h-Caldesmon which is specific for leiomyosarcoma (Figure 1D). The patient subsequently received chemotherapies of Doxorubicin 75mg/m2 for 4 cycles.

Patient selection and cannulation arguably represent the key steps for the successful implementation of Extracorporeal Membrane Oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real-time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients’ critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite. Therefore, with the objective of avoiding delay with initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation. In the current pandemic, this strategy may have additional benefits for the care of patients with refractory acute respiratory distress syndrome (ARDS) due to COVID-19 decreasing risk of healthcare worker or other patients exposure to the novel SARS-CoV-2 virus occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation.

Eccrine Angiomatous Hamartoma (EAH) is a rare malformation with the proliferation of eccrine glands and other dermal structures. It typically presents as a solitary lesion on extremities. We report a case of Verrucous EAH on the heel of a 27-years old man which is an uncommon presentation of this tumor

Objectives: This study aimed to investigate whether auditory steady-state response (ASSR) can be a prognostic indicator of hearing outcome in patients with sudden sensorineural hearing loss (SSNHL). Design: Prospective clinical study. Setting: Tertiary-care hospital center. Participants: Fifty-three patients with unilateral SSNHL of ≤ 90 dB HL were included. Patients with a worse ASSR threshold of ≥ 15 dB HL compared to pure-tone threshold were included in the worse ASSR (WASSR) group. Patients without a worse ASSR thresholds were included in the similar or better ASSR (SBASSR) group. Main outcome measures: Pure-tone audiometry (PTA) was gathered before and after steroid treatment. The hearing recovery was defined as a < 25 dB HL of final hearing level or a > 15 dB HL of hearing gain. Hearing outcome of SSNHL according to the ASSR grouping was evaluated. Results: Twenty-one patients were included in the WASSR group, whereas the remaining of 32 patients were included in the SBASSR group. Although WASSR and SBASSR groups had similar initial pure-tone thresholds, WASSR group had significantly worse last pure-tone thresholds compared to SBASSR group (p = 0.021). The ASSR grouping was significantly associated with the hearing recovery in univariate and multivariate logistic regression model (all p-values < 0.05) Conclusions: This study suggests that ASSR measurements can be used to predict the hearing prognosis of SSNHL.

Safety and efficacy of tracheostomy in COVID-19 patients: a preliminary retrospective study of 14 casesKeypointsThe outbreak of COVID-19 in Wuhan, China, since December, 2019, has become a pandemic.This highly infectious disease increases the risk of converting to acute progressive respiratory failure, which needs the treatment with invasive mechanical ventilation, including tracheostomy.Up to now, there is no data describing tracheostomy cases in COVID-19 pandemic.we retrospectively analyzed 14 cases of critically ill COVID-19 patients with tracheostomy, concentrating on surgical indication, complication, procedure and precaution.Bedside open tracheostomy in COVID-19 patients is a relatively safe procedure for skilled surgeons under appropriate precautions, and the critically ill patients may benefit from it.Introduction The outbreak of Corona Virus Disease 2019 (COVID-19) has become a pandemic. It has been reported that in an early study, about 20% COVID-19 hospitalized patients developed into acute respiratory distress syndrome (ARDS) and required invasive mechanical ventilation.1 For some patients on prolonged intubation, tracheostomy may be considered as an important option for optimal respiratory care. Although recent several articles described the principles and procedures of tracheostomy on COVID-19 patients,2,3 there is no data describing tracheostomy cases in COVID-19 pandemic. In this study, we retrospectively analyzed 14 cases of COVID-19 patients with tracheostomy in [removed for blind peer review], the only designated hospital which still has a dozen intubated patients in [removed for blind peer review], concentrating on surgical indication, complication, procedure and precaution.

Objectives: To investigate how surgeons interpret the ATA 2015 and BTA 2014 guidelines for low risk well differentiated thyroid cancers (LRDTCs) and how they impact patient experiences across the UK. Design: Three nationally disseminated anonymised questionnaires. Setting: A nationwide snapshot of LRDTC management. Participants: Thyroid surgeons and their respective thyroid cancer multidisciplinary teams (MDTs) and thyroid cancer patients. Main outcome measures: The outcomes of interest were how surgeons/MDTs are managing LRDTCs and patient perspectives on ‘shared-decision-making’ and their ideal surgical management for LRDTCs. Results: 74 surgeons responded. 88% utilised BTA guidelines to assess recurrence risk. Tumour size, histology, stage T3b and central nodal involvement were important for >85%, but age (>45 years) only for 50%. In T1 (2cm), Thy5 solitary nodule, 58% supported hemi-thyroidectomy (HT), with 33% for total thyroidectomy (TT). In T2 (3cm) PTC, 54% opted for TT, with 24% favouring HT. Over 90% recommended TT for any incidentally excised microscopically positive lymph nodes. In T1a(m) multifocal micro-PTC, 63% suggested HT, but with contralateral benign nodules, 66% supported TT. 40% of patients felt ‘pros and cons’ of different managements were not fully explained. 47% felt they didn’t have significant input in their management, with 53% feeling final management was clinician’s choice. 60% preferred TT, with 80% wanting to ensure there was no cancer left and avoid recurrence. 20% preferred HT, with 46% wishing to avoid lifelong thyroxine. Conclusions: There is variation in risk assessment and management of LRDTCs nationally, with contrasting views of optimum treatment between patients and clinicians. These variations in practice are affecting patient experiences nationally.

Land use surveys show 30.5% of Brazil´s territory is dedicated to production of food, fibers, biofuels and raw materials; however, soil erosion is the main agent of land degradation and productivity decreasing. This paper reports the impacts of the adoption of conservation agriculture (CA) principles in controlling soil loss by water erosion, where Zero Tillage (ZT) and integrated Crop-Livestock-Forest (iCLF) management systems are the central policies. Annual soil loss potential, estimated for a scenery lacking CA practices, intensive conventional tillage and monoculture, is of 3.0 billion tons, with 29.5% of losses in croplands and 61.4% in rangelands. The economic impact of soil erosion based only on nutrient losses is estimated in 15.7 billion US dollars. Efforts to control water erosion, intensify agricultural production and mitigate the emission of greenhouse gases are the goal of a recent national governmental program for detailed soil survey and interpretation for land use - PronaSolos. Practices and technologies based on CA, such as ZT and iCLF, already adopted in 44.4 million hectares, with an economic impact of 2.3 billion US dollars, will be recommended to reach 60 million ha by the year 2025. Other benefits are maintenance of rural roads, reduction of soil and water pollution, increase of water quality and storage capacity of reservoirs. The success of the program and current achievements with CA in Brazil result from determination of farmers and many actors involved in controlling soil erosion; as well as plans and policies to implement practices and technologies based on CA principles.

El Niño is a major driver of fluctuations in tropical precipitation and fruiting production, with cascading effects on frugivores. As places get wetter, mutualistic networks tend to become more modular and less nested. In order to test the impact of severe floods and droughts caused by the El Niño cycle of 2015-2016 on nestedness and modularity of mutualistic networks, we determined the links between frugivorous bats and the plants in their diets by DNA barcoding bat faeces and used null models for our network comparisons. Despite the contrasting effects of droughts and floods in the dry forest and rainforest, respectively, we observed similar changes in network structure for both forests. We found higher values of modularity, but lower of nestedness for most networks comparisons. Over all we found higher nestedness in the dry forest than the rainforest and minimal difference between wet and dry season in the dry forest. A lower nestedness might reduce the number of species supported by the habitat as well as increase species competition. Although the increase in modularity might reduce the number of coexisting species in the environment, higher network compartmentalization leads to greater stability, slower spread of disturbance and smaller chances of having trophic cascades. Therefore, changes in network structure promoted by El Niño are likely to have dual effects on networks with some effects leading to greater stability while others to increasing competition.

The complex interaction of climate change and human activities has led to significant changes in hydrological patterns, thus affecting the catchment hydrological processes around the world. This has resulted in increased water resource problems and conflicts between social development and environmental sustainability. Moreover, the groundwater resource is less concerned than others due to the challenges posed by groundwater and aquifer monitoring. Recession analysis is typically used to explore the groundwater-streamflow relationship with easily accessible streamflow data. The environmental impacts can be considered as a variable into the recession analysis to assess the changes in dynamic groundwater storage and storage-discharge relationships. Seventeen gauge stations in Southern Taiwan were selected as a case study to elucidate the spatial and temporal results under a comprehensive impact. In addition, the quantified environmental impacts and changes in vegetation coverage were compared to assess whether these changes were consistent and their effect on the catchment drainage processes. The results showed that the regional differences in low-flow recession characteristics and the dynamic storage indicated the local differences in the aquifer properties. Decreasing dynamic storage and increasing storage-discharge sensitivities in most catchments indicated a consistent change with quantified environmental impacts. This demonstrated that the environmental change led to more groundwater loss and a lower streamflow with a reduced flow variation. This study attempted to explore the storage-discharge dynamics caused by the overall environmental impact, and the quantified impact can help us to realize whether the groundwater storage and the susceptibility to baseflow increase or decrease in the catchment drainage behaviors. This provides a simple way to explain comprehensive effect on storage-discharge processes under the environmental co-evolution.

Drought, a natural hazard, greatly damages environment, agriculture, hydrology and thus, economy and our society at large. The national-scale variation and propagation characteristics of different types of droughts are critical for developing strategies and policies, while information is limited in China. This research investigated the evolution and propagation characteristics of three types of droughts using standardized indices; Standardized Precipitation Index (SPI), Standardized Soil Moisture Index (SSI) and Standardized Runoff Index (SRI) representing meteorological, agricultural and hydrological droughts based on precipitation (PPT), soil water storage (SWS) and baseflow-groundwater runoff (BGR), respectively at multi-timescales in different sub-regions of mainland China over 1948-2010. The most appropriate probability density distributions of PPT, SWS and BGR were selected for the calculation of drought indices and wavelet analysis was used to reveal their periodical characteristics. Modified Mann-Kendall trend test was used to compare the trend among drought indices. Pearson correlation coefficients were calculated to identify the lags of SPI with SSI and SRI. In general, SPI showed an agreement with the historical severe or extreme drought events at different sub-regions. The main periods of SSI were closer to SPI than SRI, indicating stronger connections of agricultural drought with meteorological drought. A weaker connection between meteorological and agricultural/hydrological droughts at shorter timescales was observed in northwestern arid and semi-arid regions. The propagation from meteorological to agricultural or hydrological droughts were well denoted by the lagged time (months) from SPI to SSI or SRI at a timescale ranged from 0 (mostly located in south China) to 5 months (mostly located in northeastern China) for certain timescale. The study provides crucial information and guidance to the policy makers in developing drought management strategies at regional to national scale and their critical time of action.

Chiari malformations are a group of heterogeneous disorders; Chiari I malformation is characterized by a form of structural defect in the cerebellum and the cranial base. The case report highlights the possibility of underlying neurological disease in cases where acute Type 2 respiratory failure is unexplainable.

In Tanzania, Tuberculosis is among the most common and important diagnoses in a patient presenting with constitutional symptoms and lung opacities on plain radiography. We report a 32-year-old male who was misdiagnosed as extrapulmonary tuberculosis based on symptoms and imaging. Further workup revealed a rare but aggressive metastatic angiosarcoma.