We report the case of a man affected by atopic dermatitis on dupilumab. During the treatment, the patient showed a worsening of head and neck dermatitis. Blue light irradiation is a safe and efficacy tool for head and neck dermatitis persisting or developed during therapy with dupilumab.

Various causes of Recurrent Acute pancreatitis have been identified in the past. This report presents a novel case of “recurrent” acute pancreatitis in the setting of superior mesenteric artery syndrome (SMAS). Thus, highlighting SMAS as a rare yet possible cause of recurrent pancreatitis facilitating early diagnosis and prompt treatment.

Drug reaction with eosinophilia and systemic symptoms is a quite unusual condition related to drug reaction. A case report of sulfasalazine-induced liver failure is described. The patient was submitted to liver transplantation. Liver transplantation is an option when DRESS is associated with acute liver failure, but the prognosis remains poor.

The new corona virus has become a global health concern.Voice has the potential to provide an easily obtained, non-invasive way to monitor physiological changes throughout the body. For health care providers with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS and MERS, as well as sepsis and ARDS, the application of acoustical voice analysis should serve as a foundation for optimized supportive care to ensure the best possible chance for survival.

Enterolithiasis or formation of gastrointestinal concretions is an uncommon medical condition that develops in the setting of intestinal stasis due to various pathologies. Its prevalence ranges upto 10% and can present in different clinical picture to challenge a clinician.

Introduction:The 2019 novel coronavirus disease (COVID-19) was initially identified in December 2019 in Wuhan, China. Following its spread across the globe within a matter of months, the World Health Organization classified COVID-19 as a pandemic.1 Its rapid transmission and high hospitalization rate have forced health professionals to drastically alter their practices in order to slow its proliferation. The rapid influx of COVID-19 related admissions in hospitals around the United States has led to a widespread shortage of crucial healthcare resources, particularly personal protective equipment (PPE), ventilators, and free ICU beds. Surgical procedures further deplete such resources in a time of acutely high need. Additionally, evidence has shown that healthcare workers may be particularly susceptible to infection from the causative pathogen, SARS-CoV-2, with roughly 20% of exposed professionals becoming infected in Italy.2Following these developments, the Centers for Disease Control and Prevention (CDC) recommended that all inpatient facilities postpone or cancel any elective surgeries.3 In the ensuing weeks, the American College of Surgeons and the American Academy of Otolaryngology-Head and Neck Surgery followed suit with this recommendation.4,5Furthermore, many hospitals and practices have opted to cancel in-person outpatient clinic visits, where patients oftentimes receive critical longitudinal care. Like other surgeons, otolaryngologists, and specifically head and neck surgical oncologists, have been deeply affected by these drastic measures. It is evident, however, that physicians must find ways to continue to monitor such patients’ conditions or treat them in some aspect. The popularity and prevalence of telemedicine has grown rapidly during this pandemic as many physicians have sought ways to maintain a continuum of care with their patients.6 Such initiatives have previously been shown to decrease costs, decrease visit time, and lead to high patient satisfaction in surgical fields.7,8Within otolaryngology specifically, certain telehealth assessments have been shown to allow for quicker examinations without compromising the communication of crucial information from the patient to the physician, or vice versa.9 However, the rapid implementation of telehealth has been a relatively new phenomenon during the COVID-19 pandemic, meaning that physicians oftentimes have to learn how to optimize their virtual visits to maximize their efficiency and effectiveness. In otolaryngology, telemedicine has not been routinely used to evaluate patients, despite estimates that 62% of otolaryngology patients would be amenable to virtual appointments.10Thus, it may be difficult for physicians to anticipate barriers to their care during a telehealth visit. Based on the authors’ experience, there exists a steep learning curve following the onset of such visits due to a variety of factors on both the patient’s and physician’s side.To our knowledge, there are no set guidelines or best practices for patients or head and neck cancer physicians conducting virtual visits. Drawing upon our experience, we aim to compile a set of guidelines for physicians and patients alike to navigate telehealth visits during the era of COVID-19. We also created a handout that can be distributed to patients prior to the visit, such that patients can familiarize themselves with general expectations and key examination steps that they may be asked to perform during the visit.

Multidisciplinary conferences (MDC) are an important component of head and neck oncologic care including diagnosis, treatment, and survivorship. Virtual MDC allows for improved collaboration between providers at distant sites and proper allocation of healthcare resources in a time of crisis. When approached systematically, a virtual MDC is feasible to design and implement in a large academic medical center with multiple satellite hospitals.

INTRODUCTIONWe are quite familiar with the COVID-19 epidemic and its unprecedented implications. It has clearly changed our lives, healthcare, clinical practice, urgency of the health problems, financial implications and mental health. The issues of mental health are applicable both to the patients and healthcare providers. Obviously, we need to pay special attention to the patients suffering from COVID-19 especially those who are symptomatic or having major health crisis such as pulmonary issues and multiorgan failure.As of the 8th of April, globally there have been approximately 1.52 million confirmed cases of COVID-19 of whom 90,000 are dead. In the United States, the confirmed COVID-19 cases are reported to be 435,564 while the reported deaths are 14,829. New York State has faced the major brunt of this pandemic with confirmed cases of 147,037 and death number of 6,220.In spite of this major health crisis patients are always concerned about their own problems in relation to other health issues especially with fear of proven or suspicious cancers. Clearly, some of the cancers are life-threatening and will require urgent attention while other tumors may be monitored or treated at a later date when the COVID-19 issues are relatively settled. In a referral center or a tertiary care cancer center it is fairly common to receive consultations regarding thyroid problems or thyroid tumors.Even though, there are no set guidelines in the management of patients asking for thyroid surgery it would be appropriate to manage these patients based on the risk group analysis and the overall risks of progression to life-threatening issues. We need to explain every patient that thyroid tumors grow slowly and there is no need for active and emergent intervention. It is quite appropriate to wait for 4-6 months.If the patient is extremely anxious a follow up ultrasound may be performed in 3-4 months to document the stability of thyroid tumor. We have divided thyroid cancer patients for almost 50 years into low, intermediate and high-risk groups based on their prognostic features1. We popularly described this as good, bad and ugly tumors. The prognostic factors were described as age, grade of the tumor, size of the tumor, extrathyroidal extension, distant metastases, etc. Other prognostic factors such as multiple lymph node metastases and the molecular analysis should go into the equation of management of these patients. Needless to say, patients are extremely concerned for the fear of any cancer whether it is thyroid or pancreatic cancer. It is our responsibility to explain to the patients the concern about these cancers on their overall prognosis and the best timeline definition for active intervention. The new American Thyroid Association guidelines published in 2015 have done a fantastic job in line with the biology of these tumors and appropriate management 2. As a matter of fact, the ATA endorsed observation as a definitive approach in proven microcarcinomas. This clearly reflects the management of these tumors in relation to their biology and avoiding over treatment. Let the punishment fit the crime or let the treatment not be worse than the disease is quite appropriately applied to thyroid cancer. However, it would be important to define certain indications and road map of active management of some these thyroid cancers. If we use the analogy of management of thyroid cancer during pregnancy and delaying the treatment by 9-10 months, it would be the same philosophy of managing these patients during the COVID-19 pandemic. Clearly, some patients will require urgent or active intervention in a timely fashion. The following summary will describe some of the decision-making issues.Anaplastic Thyroid Cancer – patients with rapidly growing thyroid tumors with proven anaplastic thyroid cancer will obviously require emergent management. The decision regarding surgical intervention should be made based on the extent of the disease and cross-sectional imaging. Appropriate BRAF based therapies and external radiation therapy should be implemented. If the tumor appears to be unresectable there is no reason to bring these patients to the operating room. The definitive diagnosis could easily made with ultrasound guided core biopsy, and appropriate immunohistochemistry. The issue of airway management is always a difficult problem in anaplastic thyroid cancer and more so during COVID-19 pandemic. Obviously, testing the patient for Covid-19 is important since patient may require either active airway intervention or hospitalization with concern of exposing healthcare workers. As mentioned in the first anaplastic thyroid cancer guidelines, elective tracheostomy is best avoided however may be necessary if the patient is having acute airway distress 3. A due consideration should be given to controlled cricothyrotomy.Medullary Thyroid Cancer – Appropriate evaluation of extent of the disease with calcitonin, CEA, ultrasound and cross-sectional imaging is very important before consideration of timely surgical intervention. If the disease appears to be limited and calcitonin levels are not high (under 400) patients can be monitored for a few months without surgical intervention hoping for COVID-19 peak to settle. Generally, medullary carcinoma is a chronic disease and observation with close monitoring would be quite appropriate until the social circumstances get better. Obviously, this will require extensive discussion with the patient and the family which can be easily done even by phone conversations or Facebook. A discussion directly by responsible attending surgeon would give a lot of confidence to the patient and the family. They need to understand that waiting for the best time for surgery is unlikely to hurt them or lead to major progress of the disease. The prognosis essentially would remain the same.Locally Aggressive Thyroid Cancer – These are the patients who will require detailed evaluation of the extent of the disease, its involvement in relation to the central compartment vital organs such as recurrent laryngeal nerve, trachea, esophagus, and major vascular structures. Appropriate cross-sectional imaging will be of great help. If patient does require fiberoptic evaluation it would be best done with the hospital guidelines and appropriate protection to the healthcare staff. Obviously, COVID-19 testing would be important prior to any active intervention. The decisions about surgery in light of COVID-19 pandemic would be quite critical as to how long we can delay the surgical procedure without compromising the total surgical resection and encroachment on vital central compartment structures. The decisions may be slightly different if the preoperative FNA has resulted in poorly differentiated thyroid cancer. It would be quite appropriate to discuss some of these cases with our colleagues in multidisciplinary team since we are able to hold virtual tumor boards. Avoiding surgical compromise is important in these patients however waiting for a reasonable time would not be inappropriate.Patients with Large Primary Tumors and Bulky Nodal Disease – The history of the presence of tumor and the duration of the nodal metastasis would be quite helpful to project the best timing of surgery in these patients. Again, appropriate cross-sectional imaging and approximation of the tumor to the vital structures is critical in making the best decision regarding appropriate timing of surgery in these patients.Low and Intermediate Risk Thyroid Carcinomas – These patients can wait for surgery for a period of time (3-6 months) until we have a better handle on COVID-19, and they are not a risk to the healthcare workers. If the patients need extended period of observation, a repeat imaging with ultrasound in 3-4 months will encourage the patients to delay the surgery further.Microcarcinomas – As reported by a large series of patients from Kobe, Japan; Sloan Kettering, these patients with microcarcinomas can definitely be observed 4,5. Most of these patients can be encouraged not only to delay the surgery but to remain under active surveillance or deferred intervention. Again, appropriate ultrasound will define the exact location of the disease and need of active intervention.Recurrent Thyroid Carcinoma – The majority of the recurrences especially in the central compartment nodes or lateral neck nodes are essentially the persistent diseases. They could be observed for an extended period of time with repeat imaging studies in 4-6 months. The only time one would consider active surgical intervention, if the tumor is plastered against the trachea for the fear of future encroachment into the trachea. Alternate treatment choices such as alcohol injection, radio frequency ablation may be considered for localized nodal recurrences.Indeterminate Thyroid Nodules – most of these patients will be in the group of Bethesda III and IV categories. These patients can be easily monitored and if the tumors are small even if they’re BRAF or TERT positive, could be monitored for a period of time before active surgical intervention. The positivity of the molecular markers and the quantification of the risk of malignancy is not a determinate for emergent surgical intervention.Large Goiters – the majority of the large goiters have generally been there for a long period of time and surgery could be easily avoided even with tracheal deviation and mild compression unless there is a rapid progression, major compression symptoms or impending acute airway issues.Benign Thyroid Conditions – benign thyroid nodules, Hashimoto’s thyroiditis, or Graves’ disease could be managed appropriately as before and probably may not be in-person consultation. The majority of these patients can be easily consulted on telephone, Skype or Facetime which will give patients a sense of confidence and make them feel that the treating physician is actively involved in their care and follow up. The guidelines recommended by ATA for fine needle aspirations of incidental thyroid nodules should be applied vigorously. It would be best to avoid FNA on smaller and non-suspicious thyroid nodules.Moral Dilemma – I am sure there will be many discussion points in above recommendations. These are not written in any of the textbooks or guidelines. These are clinical observations during the early period of COVID-19 pandemic. Hopefully, God willing, the pandemic will be over soon, and we will go back to our regular clinical practices. However, until then, it is our responsibility to manage our patients best, give them a full sense of confidence and avoiding major progression of their tumors and life-threatening issues. We also have a responsibility to the healthcare workers who take the major brunt of exposing themselves to the COVID-19 which may become lethal in a few individuals. This definitely raises a major new dilemma to the healthcare workers. Every profession has certain risks and concerns. For example, a frontline army personnel, a firefighter, or a policeman where both the individuals and their families are aware about the life-threatening risks. However, until the COVID-19 pandemic occurred nobody realized the life-threatening risks to the healthcare workers. This clearly creates a major social and ethical dilemma amongst healthcare workers and their families. Even though the non-essential staff can work from home, the essential staff such as frontline healthcare workers have to be exposed themselves to proven and unproven COVID-19 patients. This may lead to major ethical issues and mental depression amongst healthcare workers. What would be the answer to the 10-year-old child when he tells his father, “Dad, please don’t go to work. I’m afraid you may catch COVID-19 and you are the only one I have.”We don’t have the answers to these questions, however, I would like to salute the frontline healthcare workers who have been actively involved in offering the best medical care to the patients suffering from COVID-19 and offering them and the society a Glimpse of Hope. These are the true Noble Laureates.References:Shaha, AR. Implications of prognostic factors and risk groups in the management of differentiated thyroid cancer. Laryngoscope. 2004, 114; 393-402.Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association – Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer; the American Thyroid Association Guidelines Task Force on Thyroid nodules and differentiated thyroid cancer. Thyroid. 2016, 26; 1-133.Smallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Berman KD et al, American Thyroid Association Guidelines for Management of patients with anaplastic thyroid cancer. Thyroid. 2012, 22; 1104-39.Miyauchi, A. Clinical trials of active surveillance of papillary microcarcinoma of the thyroid. World J Surg. 2016, 40; 516-22.Tuttle, RM, Fagin JA, Minkowitz G, Wong RJ, Roman B, Patel S et al, Natural history and tumor volume kinetics of papillary thyroid cancers during active surveillance. JAMA Otolaryngol Head Neck Surg. 2017, 143; 1015-1020.

Growth models are a fundamental aspect of metabolic theory but remain controversial. It is a century since the first theoretical model of growth was put forward by Pütter. His insights were deep, but his model ended up being attributed to von Bertalanffy and his ideas largely forgotten. Here I review Pütter’s ideas and trace their influence on existing theoretical models for growth and other aspects of metabolism, including those of von Bertalanffy, the Dynamic Energy Budget (DEB) theory, the Gill-Oxygen Limitation Theory and the Ontogenetic Growth Model (OGM). I then synthesise, compare and critique the ideas of the two most comprehensive theories, DEB and the OGM, in relation to Pütter’s original ideas, and discuss how these theories have been used to explain ‘macrometabolic’ patterns including the scaling of respiration, the temperature size rule (first modelled by Pütter), and the connection to life history. Although theoretical work on growth and metabolism has generally proceeded in an un-coordinated and disconnected fashion, significant progress has been made and it has been built upon the original and fundamental insights of Pütter. What we need now is a coordinated empirical research program to test the existing ideas and motivate new theoretical directions.

After surgical removal of bone tumors, elimination of the remains of cancer cells along with tissue healing and functionality is a therapeutic goal. Regarding the destructive effect of chemo-/radiotherapy on healthy cells, the development of multimodal scaffolds with simultaneous anticancer and osteo-regenerative potency is of particular importance as regenerative medicine for bone tissue engineering. Our previous study demonstrated that hollow pollen grain (HPG) of Pistacia vera L. offers a unique bone-forming activity and encapsulating capacity that it can be considered as an excellent scaffolding building block in bottom-up bone engineering. In the present study, for the first time, the anticancer potential of Pistacia vera L. HPG was investigated in-vitro using human osteosarcoma cell line MG63. Optical imaging of the HPG-cell interface indicated large focal adhesion due to the HPG unique surface features such as functionality and ornamentation. MTT assay results showed an anti-proliferative effect of HPG on the MG63 cells. Moreover, from the gene expression and DAPI staining analyses, HPG of Pistacia vera L. was found to be an apoptosis-inducing building block against MG63 bone cancer cells. So therefore, such a multifunctional building block with the ability of discriminatory killing human osteosarcoma cell line is proposed to be used after surgery to not only hinder cancer recurrence after surgery but also to stimulate bone healing.

Cardiac computed tomography (CT) is increasingly used to plan transcatheter structural heart interventions, however, intra-operative guidance relies on trans-esophageal echocardiography (TEE) and fluoroscopy. This study sought to develop the methods of stepwise CT multi-planar reconstruction manipulation to mimic TEE thus bridging the gap between preoperative planning and intra-operative guidance tools. This CT manipulation successfully reproduces similar configurations as TEE views in mid-esophageal left ventricle (LV) views, transgastric LV 2-chamber views for mitral apparatus, and other miscellaneous views. Stepwise cardiac CT manipulation to mimic TEE is the final piece of the puzzle in the mental co-registration of these three crucial imaging modalities. With it, we are enabled to foresee the TEE images and fluoroscopy projections in a preoperative rehearsal thus improving the intra-operative accuracy of interventions.

A document by Shreetal Nair. Click on the document to view its contents.

Ortner's syndrome is a really rare complication that manifest by hoarseness of voice. It is usually due to left recurrent laryngeal nerve compression. Cardiac causes of Ortner's syndrome are rarely encountered and it is usually due to left atrial enlargement as a complication of valvular lesions affecting mitral valve but other rare causes include ascending aortic aneurysm or pulmonary artery aneurysm. Hereby, we present the 3rd case in the literature to report Ortner's syndrome due to pulmonary artery aneurysm in a 38-year old female patient with previous history of bilharziasis.

Antimicrobial photodynamic therapy (APDT) is a promising alternative to traditional antibiotics for bacterial infections, which inactivates a broad spectrum of bacteria. However, it has some disadvantages including poor water solubility and easy aggregation of hydrophobic photosensitizers (PS), and poor tissue penetration and cytotoxicity when using UV as light source, leading to photodynamic therapy efficacy. Herein, we develop a novel water-soluble natural PS (sorbicillinoids) obtained by microbial fermentation using filamentous fungus Trichoderma reesei (T. reesei). Sorbicillinoids could effectively generate singlet oxygen (1O2) under UV light irradiation, and ultimately display photoinactivation activity on Gram-positive bacteria, but not Gram-negative ones. Staphylococcus aureus (S. aureus) treated with sorbicillinoids and UV light displayed high levels of intracellular reactive oxygen species (ROS), notable DNA photocleavage, and compromised membrane permeability without overt cell membrane disruption. Moreover, the dark toxicity, phototoxicity or hemolysis activity of sorbicillinoids is negligible, showing its excellent biocompatibility.

Scavenging can have important consequences for food web dynamics, for example, it may support additional consumer species and affect predation on live prey. Still, few food web models include scavenging. We develop a dynamic model that includes predators, scavengers, live prey, and a carrion pool to show ramifications of scavenging for predation in simple food webs. We explicitly model carrion biomass and scavenging behavior and investigate the effect of scavenging for predation under different assumptions. Our modeling suggests that the presence of scavengers can both increase and decrease predator kill rates and overall predation in model food webs and the impact varies (in magnitude and direction) with context. In particular, we explore the impact of the amount of dynamics allowed in the predator, scavenger, and prey populations as well as the direction and magnitude of interference competition between predators and scavengers. We provide a road map to the different outcomes and link these theoretical outcomes to evidence from different empirical studies.

Pressure ulcers are commonly associated with microbial infections on the wounds which need an effective wound dressing. However, the silver dressings have shown promising result but they have toxicity and argyria. Hence, this study aimed to develop and characterize chitosan-polyethylene glycol (PEG) nanocomposite hydrogel loaded with phomopsidione as an antimicrobial dressing. The hydrogel being synthesized was analyzed with transmission and scanning electron microscopes. Drug release and mechanical properties were studied having confirmed the functional groups with Fourier transform infrared (FTIR) spectroscopy. Finally, antimicrobial activities were evaluated against the clinical wound pathogens. The developed hydrogel was soft, flexible and elastic, having nanospheres of chitosan-PEG but no sign of aggregation under the electron microscopes. Releasing of phomopsidione from the nanocomposite hydrogel was slow and gradual following the first order of kinetic. On average, 34 μg/mL phomopsidione released per hour and 67.9% active ingredients delivered into the surrounding medium over the study period. Although, the bioactivity activity of the hydrogel was narrow-spectrum, it showed significant results against all Gram-negative bacteria and Candida utilis with 99.99% reduction of microbial growth. The findings reveal that the phomopsidione loaded hydrogel has a great promise to act as an antimicrobial dressing for chronic wounds.

Introduction Proteins are among the basic most abundant bio macromolecules, which involve in various biological functions, as building blocks in biological structure, enzymes and hormones (Chen et al. 2015; Nelson et al. 2008). Protein denaturation and unfolding can lead to a number of chaos in the protein science, food and biopharmaceutical industry. Protein aggregation which results from the non-native folded proteins under the influence of various environmental and intrinsic factors like thermal, shear, ionic strength and molecular crowding. The aggregation of proteins leads to the formation of insoluble β-sheet rich fibrils (Pandey et al. 2012; Solá et al. 2006), which are associated with different amyloidogenic diseases like Parkinson’s disease, Huntington’s disease (neurodegenerative diseases) and also diabetes mellitus (systemic diseases) (Chiti and Dobson 2017; Lansbury and Lashuel 2006; Ross and Poirier 2004).Generally, a protein in a solution is stabilized by different interactions among the amino acid residues, which include the van der Waals, hydrogen bond, hydrophobic interaction, electrostatic interaction and disulphide bridges. These interactions favour the native compact conformation (Anand et al. 2011; Sprague-Piercy et al. 2020). The aggregation of proteins initiates by forming disordered structure in the presence of adverse factors like high temperature, extreme pH, and mechanical stress. The external energy from these factors breaks intramolecular interactions. Thus, native conformation and its original compact conformation slowly deteriorate, leading to a more flexible and open structures, which expose the hydrophobic patches and other free disulphide bonds. This finally renders the intermolecular interactions through these exposed regions leading to the formation of protein aggregates (Bratko et al. 2007; Vetri et al. 2007; Wälchli et al. 2020).Among the various proteins, Bovine serum albumin (BSA) also called as “Fraction V” is the most significant serum protein physiologically, which has a multi diversified function, be it as a carrier molecule and stabilizer. It comprises of three domains with each having two subdomains and is intricately stabilized by 17 intermolecular disulphide bonds excluding one free thiol residue Cys34 (Murayama and Tomida 2004). BSA has a molecular weight around ̵̴ 66 kDa and is majorly constituted of helical secondary structure (Pandey et al. 2013). These features make BSA a model protein for various biophysical and biochemical studies (Chen et al. 2015). Apart from physiological importance, BSA is one of the main components of the whey protein, which is majorly used as gelling agent, emulsifier or foaming agent and therefore the quality of these agents wholly depends on the processing conditions. For instance, the extrusion process in the process biotechnology involves both thermal and mechanical treatments of the protein formulations (Quevedo et al. 2020). Therefore, the knowledge of how this protein behaves under a certain external force or stimuli is essential to decide the processing parameters and finally the desired product (Rondeau et al. 2010).In this direction, effects of various thermal and mechanical stimuli on the properties of proteins have been investigated. Various heat stability studies had been done by researchers in different temperature conditions and found that BSA almost retains its native conformation till 40-50°C range and at around 52-60°C. It shows irreversible unfolding after going through some amount of denaturation. As the temperature increases, approximately above 60°C prominent unfolding and denaturation was obtained resulting in aggregation (Bekard et al. 2012; Murayama and Tomida 2004; Yamasaki et al. 1990). Melting temperature of BSA is reported to be about 63°C (Pal et al. 2020). In another study by Arakawa et al. , BSA was exposed to thermal stressed at 50, 60 and 70°C and the aggregation was checked through native gel electrophoresis and circular dichroism (CD). It was found that no aggregates were formed at 50°C as there were only monomer and dimer bands and in the other cases the monomer band was reduced and few new aggregate bands were observed (Arakawa and Kita 2000).Mechanical impact like shearing or extreme pressure also denatures the conformation of proteins and its formulations (Belitz and Grosch 2013; Quevedo et al. 2020). Proteins have been found to denature under such mechanical force through physically rupturing of the intramolecular interactions. It has been proposed that under a fluid shear a protein undergoes denaturation through two critical steps; firstly, the unfolding protein molecules and secondly the collision between them leading to the aggregation. This ultimately forms larger particles (Anema and McKenna 1996). Various studies have explored the effect of shear on the aggregation of proteins. Stirring, shaking, mechanical agitation and ultrasonication were found to affect the fibril formation (Collins et al. 2004; Grigolato and Arosio 2019; Liu and Lindquist 1999; Maruyama et al. 2001; Serio et al. 2000). However, in most of the practical applications like fluid flow, bioprocessing, formulations, mixing and transportations, thermal and mechanical stresses are simultaneously experienced (Bogahawaththa and Vasiljevic 2020). Thus, it is important to explore thermomechanical behaviour of a protein to grain better insights of the aggregation process.In this regard, thermodynamic aspects of the thermomechanical treatment of BSA and its related impact on the aggregation behaviour have been explored in the present study. The insights associated with the dissipation energy generated during the shearing process and its implications towards the unfolding and aggregation have been investigated. To understand the thermal stability, a hysteresis temperature loop scans of BSA in solution at physiological pH (7.4) were conducted in the three temperature ranges i.e. 25-50-25°C, 25-65-25°C and 25-75-25°C at the ramping rate of 1°C/min. Next, shear induced aggregation of the BSA solution at a constant shear rate of 300 s-1 was conducted at the three temperature conditions (55, 60 and 65 °C) using a MCR 72 Rheometer. To investigate the aggregation behaviour Thioflavin T (Th-T) fluorescence assay was performed to monitor the aggregation kinetics, hydrodynamic diameter was measured using dynamic light scattering (DLS). Far-UV CD was conducted in the range of 190-260 nm to analyze the structural conformational changes. Morphological analysis was performed using atomic force microscopy (AFM).

Early detection of Hepatitis B virus (HBV) in pregnant females starts by a request of the gynecologists, which is based on their knowledge and awareness of the guidelines on conducting these tests. This is an observational cross-sectional study that investigated the gynecologists’ knowledge, attitude and practice regarding HBV during pregnancy across Jordan. A random sample of 150 gynecologists were approached, from 3 major cities in Jordan, and asked to fill a questionnaire that assessed their knowledge, attitude and practice. Statistical analysis was conducted using SPSS. One hundred and seven gynecologists have participated in the study. Most of the respondents were females, residents, and less than thirty years old. Although 97.2% of the practitioners agreed on the importance of the pregnant females on HBV, only 43% were aware of the obligatory protocol in Jordan regarding HBV screening, and only 55% would screen the pregnant females to HBV in-practice. Significant association was found between screening rates to HBV and both, level of specialty and experience of practitioners. Approximately 60% of practitioners were aware of HBV perinatal transmission risk. Only 19.6% always referred the infected pregnant females to other specialists regardless of the viral load. While 47.7% of practitioners agreed on recommending antiviral therapy for third trimester pregnant females, only 12.1% would always/often prescribe them. A noteworthy lack of Hepatitis B knowledge and screening practice among gynecologists in Jordan have been observed. A national program designed to increase the awareness of HBV testing in Jordan for both patients and gynecologists is called for.

EditorialShortly after I finished delivering a keynote lecture on minor salivary gland cancers on February 23, 2020 at the Candiolo Cancer Institute in Turin, Italy, the conference chairs Drs. Giovanni Succo and Piero Nicolai announced that the conference was urgently adjourned and the rest of the program canceled. This unexpected announcement was in compliance with the Italian government’s orders to immediately end all public gatherings. Two days earlier as I set out to travel to Italy, where no cases of coronavirus infection had yet been reported, news reports were focused mostly on South Korea and Iran as hotspots of COVID-19. Out of an abundance of caution, I double-checked again before leaving for the airport and confirmed that Italy had no reported cases. Upon my arrival in Turin I was greeted by the usual warm welcome and well-known hospitality of our Italian colleagues. At the welcome reception they discussed the earlier morning report of the first five confirmed cases of COVID-19 in Lombardy region and its capital Milan. The next day, as the unplanned adjournment was announced on the first day of the 3-day conference, there were more than 120 reported cases ushering what would be the first significant outbreak in Europe. The conference chair read the Italian government emergency prohibition of public gatherings, canceling the Milan fashion week, the Venice carnival, and closing all schools and universities. But when he announced that the football (aka Soccer) game was canceled I knew that the situation was grave. As most of us know it almost takes an act of God to cancel a football game in Italy! Without delay I scrambled to get a flight back home only 24 hours after I arrived in Turin. On my way to the airport I saw on my news app that France had stopped a train of passengers from Italy and diverted it back. I was concerned about my connection in Frankfurt and ultimately getting back to USA. As I passed every step of screening and temperature checks I finally landed in Houston with a huge sigh of relief. Following instructions that were urgently sent that day, I immediately contacted our employee health at MD Anderson where I was carefully screened and cleared to go back to work.

UpdatesA general consensus exists on coronavirus diffusion by droplet transmission, especially the aerosolisation during hospital procedures like intubation or bronchoscopy might represent a big concern, exposing other patients and health-care staff to an increased risk of infection In this context, the general otolaryngology procedures may determine an aerosolisation with nosocomial amplification of the infection.In particular flexible and/or rigid nasolaryngoscopy may include some maneuvers such as puffing out your cheeks, talking, swallowing some coloured water or poking out your tongue. Further, the introduction of the endoscope may cause sneezing and cough.These risks can increase when in-office surgical procedures are applied to cure urgent and emergent pathologies such as epistaxis, removal of foreign bodies in upper aero-digestive tract, cricothyroidotomy as well as elective procedures such as biopsies, inferior turbinoplasty etc.Based on the available evidence, it appears that SARS-CoV-2 can be transmitted by asymptomatic carriers, which contributes to its basic reproduction number and pandemic potential1.Zou et al2 showed higher viral loads after symptom onset, with higher viral loads detected in the nose than in the throat. Further in the asymptomatic patients, the viral load was similar to symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients.The common work-load of a ENT are symptoms related to upper airways inflammations or infections. Sore throat with or without fever, sneezing, hoarseness may be prodromic symptoms of a COVID-19 infection in the incubation period3. Moreover, the coughing patients with a negative chest X-ray is one of the most consultation required.Direct contact of droplet spray produced by coughing, sneezing or talking involves relatively large droplets containing organisms and requires close contact usually within 1 m 4. Indirect contact may take place after the droplets are removed from the air by surface deposition5.Han et al6 studied the dynamic features of bio-aerosolisation by sneezing. The velocity of the airflow exhaled by sneeze is much larger than that of breath and cough. Moreover, the total number of droplets generated during sneeze is also larger than that of other respiratory activities. According to the study on flow dynamics and characterization of cough, the maximum velocity of exhaled airflow can be found at t = 57–110 ms for different persons which is most likely to occur at 100 ms. Usually, sneeze lasts 0.3–0.7 s, so t = 100 ms is in the duration of the sneeze. As the velocity of the airflow exhaled by sneeze is really high, it can be assumed that the droplets that are exhaled at t =0–100 ms will not re-enter the measurement zone before t=100 ms. The high-speed airflow and corresponding turbulence produced by sneeze may also lead to a large number of droplets, i.e. the number of the droplets generated by sneeze is about 18 times larger than that of cough. Further, the size of sneezing droplets is 341.5–398.1 µm for unimodal distribution and 73.6–85.8 µm for bimodal distribution. After the droplets are exhaled into the indoor environment, the evaporation effects will strongly influence the size and mass of the droplets. The final equilibrium diameter of expiratory droplets after evaporation is highly dependent upon the temperature and relative humidity of the environment. In the indoor environment, the relative humidity and temperature are much lower than those in the respiratory tract. So the volatile content of these droplets will keep evaporating and result in the shrinkage of the droplets.Definitively, these findings demonstrate that the routine activities of an otolaryngologist are constantly at high risk of contagion in COVID-19 epidemic areas.Taking a look at the current Italian situation, the experience of the region Veneto demonstrated that the application of COVID-19 screening also in asymptomatic people can reduce the contagion spreading. Thus, it seems clear that extend the screening to all health-workers included otolaryngologists could be a valid strategy to reduce the onset of a worst case scenario, the hospital outbreak.In conclusion, the professional exposure to SARS-CoV-2 is really high for the otolaryngologist and nurse staff, even in in-office settings. Personal protective equipments are strongly recommended as well as for health-workers in close contact with infected patients.REFERENCESZhu W, Xie K, Lu H, Xu L, Zhou S, Fang S. Initial clinical features of suspected Coronavirus Disease 2019 in two emergency departments outside of Hubei, China. J Med Virol. 2020 Mar 13. doi: 10.1002/jmv.25763. [Epub ahead of print]Zou L, Ruan F, Huang M et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med. 2020 Feb 19. doi: 10.1056/NEJMc2001737. [Epub ahead of print]Lauer SA, Grantz KH, Bi Q et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 Mar 10. doi: 10.7326/M20-0504. [Epub ahead of print]Leder K, Newman D. Respiratory infections during air travel. Intern Med J. 2005 Jan;35(1):50-5.Chao CYH, Wan MP, Sze To GN. Transport and removal of expiratory droplets in hospital ward environment. Aerosol Sci Technol 2008;42, 377 – 394.Han ZY, Weng WG, Huang QY. Characterizations of particle size distribution of the droplets exhaled by sneeze. J R Soc Interface. 2013 Sep 11;10(88):20130560.

Background: The SARS-CoV-2 (COVID-19) pandemic has caused rapid changes in head and neck cancer (HNC) care. ‘Real-time’ methods to monitor practice patterns can optimize provider safety and patient care.Methods: Head and neck surgeons from 14 institutions in the United States regularly contributed their practice patterns to a shared spreadsheet. Data from March 27th, 2020 to April 5th, 2020 was analyzed.Results: All institutions had significantly restricted HNC clinic evaluations. 2 institutions stopped free flap surgery with the remaining scheduling surgery by committee review. Factors contributing to reduced clinical volume included lack of personal protective equipment (PPE) (35%) and lack of rapid COVID-19 testing (86%).Conclusions: The COVID-19 pandemic has caused a reduction in HNC care. Rapid COVID-19 testing and correlation with infectious potential remain paramount to resuming the care of head and neck cancer patients. Cloud-based platforms to share practice patterns will be essential as the pandemic evolves.

The COVID-19 pandemic has upended head and neck cancer care delivery in ways unforeseen and unprecedented. The impact of these changes parallels other fields in oncology, but is disproportionate due to protective measures and limitations on potentially aerosolizing procedures and related interventions specific to the upper aerodigestive tract. The moral and professional dimensions of providing ethically appropriate and consistent care for our patients in the COVID-19 crisis are considered herein for head and neck oncology providers.

The year 2020 began quietly, except for the news of a novel virus outbreak, felt to be a local problem in Wuhan, China. In the United States, economy was booming and the world had great expectations of a wonderful 2020., What followed has stunned the world with a ‘never seen before’, calamity, the Covid-19 Pandemic, , with over one and a quarter million individuals infected, and over 70000 lives lost so far.. The havoc created by this global tragedy has impacted upon many lives in many ways. We need to quickly think and to plan, as to how our professional and personal lives will be conducted in the days, weeks, months and years ahead.At the moment there is total chaos, in every part of the world, particularly in New York city. The day to day life is disrupted, regular patient care of diseases and cancers is in disarray, with the focus of medical care shifted to the management of patients with Covid-19. Surgery is limited to emergencies, and cancer cases that can be, are postponed without a negative impact on their outcome. The Great majority of hospital beds are occupied by Covid-19 patients, and sudden make shift hospitals are created to accommodate the surge. Temporary morgues in refrigerated trucks are to be seen at every local hospital in New York city to “house’ the over 4700 patients who have died in the last two weeks. What comes next, and when this will end is unknown; our future, and the future of the world is frightening in its uncertainty.With a fragile future, how do we conduct our day to day activities, and plan to retain our robust education and training programs, to educate and train the next generation of Head and Neck Surgeons? The major onslaught of the first wave of cases and mortality from those exposed to the disease may slow down in the weeks to come, as observed in China, but life is unlikely to return to normal in the foreseeable future. “Business as usual” will not work, since we do not know the impact of the aftermath of this Pandemic, the risk of a rebound second cycle of splurge in the number of cases worldwide in the fall and winter, and the potential risk of annual outbreaks from Covid-19., We have great expectations from our scientists, that we will find a therapeutic solution for the treatment of Covid-19, and great hopes that a vaccine would be developed in the future to prevent infection. , We have to develop strategies, to modify, devise and reshape our current methods of education and training to sustain a robust training program and continue to support our current work force geared to educate and train succeeding generations of students and trainees. (1) The drastic changes that have affected our work and life during the past two months, has taught us, that remote communications, education, teaching, learning and training is possible, and has to be incorporated in our current systems.Communications: Human communication for ever has been practiced on a one to one basis with the production of sounds/ verbal speech and the ability to hear and interpret spoken words. Science and technology permitted the transmission of spoken words to be heard at a distance with the introduction of the megaphone. Advancing technology, gave us the Radio to hear people from remote distances, and television gave us the capability to see and hear people ‘live’ from remote distances. The internet and development of social media made human communications, a ‘norm’ in the current generation. We can now communicate with not one but multiple individuals thru multiple platforms and applications. The development of these technologies in remote communication can easily be applied to remote learning.Academic Activities: The usual academic activities occupying good part of our working week involves, Lectures, Grand Rounds Tumor Boards, Case conferences, Journal clubs and other similar activities. All of these activities had required, physical presence and an assembly of individuals, but, we have come to realize that nearly all of these activities can be conducted remotely thru the internet. Live video lectures, and Grand Rounds can be easily and effectively delivered thru webex or zoom conferencing where hundreds of people are able to see / hear the speaker live with the ability to interact with two way conversations. Case conferences and tumor boards can be conducted quite effectively on these platforms with screen sharing. The need to be ‘physically present’ is not essential for conducting most academic activities. Even after the passing of the current pandemic, such activities may continue to be conducted on such platforms. This would be convenient and effective, and can offer such activities to an even larger audience. We can imagine a future where every Institution and Academic Center will have an open “on line book”,where every learning activity is available to world..Remote Learning: With easy access to internet in every part of the world, remote learning has become a way of life in many domains of education and learning. This is vividly demonstrated by a plethora of on line courses available from many Universities around the world. In the specialty of Otolaryngology / General Surgery / and Head and Neck Surgery, even operative surgery is possible to be learnt, by watching expertly demonstrated surgical procedures performed by leading surgeons and surgical educators, on the web sites of the American College of Surgeons (ACS), American Academy of Otolaryngology Head and Neck Surgery,(AAOHNS), the International Federation of Head and Neck Oncologic Societies (IFHNOS) and other similar organizations., Remote learning in all domains of surgical education is feasible and available.Validation and Certification: Testing and examinations have traditionally required the candidates to report to a designated location, where the examination in paper form is handed to the candidates to be completed in the designated time frame, while a proctor is supervising the candidates. That is no longer necessary. Multiple choice written examinations can be taken securely on line, with defined time limits.. Many Universities and Colleges offer these examinations coordinated and conducted by commercial examination companies such asExam Soft. Offering such examinations on line is less labor intensive, more cost effective, more practical and may attract a larger number of students from remote locations to participate.Traditionally oral examinations are conducted “in person”, where the candidate and the examiner /s, meet in private and conduct face to face conversation with questions and answers. The purpose of this exercise is to assess the candidates immediate assessment,judgment and knowledge However, with modern technology and two way private video platforms , such an encounter can be effectively conducted remotely. .Global On Line Fellowship(GOLF): The IFHNOS has taken a lead on developing the first remote learning , on line fellowship program in head and neck surgery and oncology, which has been in existence for the past six years. (2) The Global On Line Fellowship (GOLF) program was introduced in 2014. It is a two year curriculum, with seven written multiple choice on line examinations, a one month of observership and an oral examination. (www.ifhnos.net/global ). Nearly 400 candidates have registered from 48 countries during the past six years, and 244 have graduated. The goal of this program is to improve the knowledge base and judgment of surgeons in their own home environment, without displacing them, within their resources, in their institution or place of practice, and on their own patients. This program has been very successful and is received enthusiastically in all parts of the world. In the past the oral examinations were conducted on site in various locations in Australasia, Central Asia, Europe and Latin America. Beginning this year, IFHNOS plans to conduct the oral examinations on line, either using Webex , Zoom, or a similar technological platform.Telemedicine: Medical consultations, conversations and office visits in the private office or in clinics is the mainstay of practice inhead and neck surgery, where follow up visits form a large percentage of our office or clinic volume. With the risk of loco regional failure of up to 40% and the risk of developing multiple primaries approaching 35%, post treatment follow up or surveillance have been emphasized thru decades. This takes a significant amount of investment of time , effort and personnel on the part of the clinician, and an expense, in travel and investment of time away from work and home on the part of the patient. In the past when surgery was the only treatment of mucosal cancers of the head and neck the follow up schedule recommended was very laborious. The common practice was once a month the first year, every other month the second year, every three months the third year, every four months the fourth year, and every six months thereafter. After discovery of a second primary or a recurrence patients were put back on the same schedule. In head and neck surgery the stringent follow up schedule was designed on the basis that nearly 80% of the patients who were to recur, would have recurred in the first 24 months, with a median time to recurrence of 9 months. However, with the combination of surgery and radiotherapy, the loco regional recurrence rates declined significantly, and the median time to recurrence was also prolonged. Thus the need to see the patients every month in the first year, or every two months in the second year, became less compelling. Many have argued against such intensive physician /patient personal interactions, and suggested less stringent follow up schedules. Multiple trials of close follow up vs less stringent follow up for similar staged patients have been proposed, but rarely accepted or came to fruition. (3). The absolute benefit of detecting an asymptomatic recurrence or a new primary during routine follow up examination is questioned, compared to the patient who reports for examination when the earliest symptoms develop suggesting a recurrence. Although, there are no randomized trials to compare this, the probability of a major difference in outcome is unlikely. In addition, only a very small number of patients are found to have recurrence or a new primary which is totally asymptomatic during a routine follow up examination. Some institutions and practices have transitioned the follow up care of low risk patients to “survivorship clinics” run by Physician Assistants / Advanced practice providers (APP) or nurse practitioners. This second level of care for low risk patients will reduce the follow up volume for the clinician, but will still not do away with the inconvenience of travel, and investment of time and cost of the service, on the part of the patient.It is in this arena, that telemedicine will play an important role. Many patients who are at low risk of recurrence can be followed by telemedicine on a video call. If during that call, the care giver finds the need for a close physical examination, the patient may be asked to see his / her primary care physician, closer to home, and a clinical picture, intra oral photograph or a picture of larynx / pharynx done with a fiberoptic laryngoscope can be sent to the head and neck surgeon. Imaging studies can be read and reviewed on line and avoid the need for “physical presence” of patient and surgeon. This practice will require a culture change amongst head and neck surgeons, and their trainees. We will have to train our Residents / Fellows in developing a work ethic of practicing telemedicine.Physician compensation for remote consulatation: . The current methodology of payment is “procedure” based. (CPT). To adequately compensate the specialist for his time, talent, expertise and opinion, a new methodology or codes will need to be developed from current procedural terminology (CPT) to current expertise terminology (CET). An entirely new payment schedule will be required dependent on the extent of consulattion; mail review, telephone, video consultation, tumor board , involving multiple physicians will all require redefinition. For many institutions, including our own this already exists for the International patient, and has been high lighted by the current Covid outbreak..Fellowship Training: The events experienced in the past few weeks has put a significant strain on the practice of medicine in general, and head and neck surgery in particular. They have forced us to think and develop strategies for transition of our current practices in patient care, education and training to innovative solutions, and prioritize the levels of patient care. Only within the past several days numerous guide lines have appeared in all media and means of communications to strategize the optimal use of operating room space and staff. Conduct of safe surgery avoiding exposure to aerosolized viral transmission, and prioritizing patients at high risk of an adverse outcome if surgery is not performed have been put into practice. Routine and elective cancer surgery is being postponed. If the pandemic continues for several months, the current fellows in training will not have the volume of the required surgical cases to gain the experience necessary for completing the fellowship. One solution to address this problem is to extend their fellowship by 3-6 months. However, this may prove to be impractical due to a variety of reasons. These include, commitments made to incoming fellows who will start their training on July 1st , additional salary support, housing, and the fellows themselves may have made personal or professional commitments for their respective post fellowship careers. We will need to develop ongoing tele education, much as is being done with the IFHNOS GOLF program , with similarly defined goals and expectations to be met before certiifcation Another potential solution is to implement regular operative techniques group discussions with faculty members with video demonstration of surgical techniques highlighting the finer details of operative procedures and the “dos” and “donts” in the operative procedure.Experiencing the huge impact of the Covid Pandemic on the society and economy of the globe, and the severe strain it has put on the health care systems has been a humbling experience. It has brought the realization, that all medical and surgical training programs, have a component of disaster management.Surgical manpower: We need a complete reassesment of man power needs, how many surgeons were lost during this Pan endemic? How many more Senior surgeons have elected to take early retirement/ were some lost to Covid? What are the manpower needs for increasing remote evaluation? What new technology is needed ?Current platforms like Zoom , cannot handle the chaos . what are the Privacy issues of remote consultation ?We have many challenges to face, but with challenge comes opportunity.The challenge created by the Covid-19 Pandemic has brought reality to life and humility in our minds, and has given us the appreciation of the “luxuries and comforts” in which we practiced, taught and trained head and neck surgery. I have shared my thoughts for dealing with these difficult times , and any such future calamity that may come, to keep our education and training programs sustainable by embracing technology and alternative means to teach and train our younger generation.Acknowledgment: The author appreciates the input from Dr. Murray Brennan, Director of the International Center of Memorial Sloan Kettering Cancer Center, in the preparation of this manuscript.Full author list: Jatin P. Shah, MD, PhD(Hon), DSc(Hon), FACS,  FRCS(Hon), FDSRCS(Hon), FRCSDS(Hon), FRCSI(Hon), FRACS(Hon) Prof. of Surgery, E W Strong Chair in Head and Neck Oncology Memorial Sloan Kettering Cancer Center, New York, NY. 10065. e mail: shahj@mskcc.orgReferences:Shah JP. Training of a Head and Neck Surgeon. In Head and Neck Surgery by DeSouza C. pp 1514-1526. Jaypee publishers, , India 2009.Shah J,, O’Neil P., and Brennan M. Global On line fellowship. JACS. 2020. (In press)Shah J and Harrison L. Personal communication. (1996)

Background: During the SARS-CoV-2 pandemic, tracheostomy may be required for COVID-19 patients requiring long term ventilation in addition to other conditions such as airway compromise from head and neck cancer. As an aerosol generating procedure, tracheostomy increases healthcare worker exposure to COVID-19 infection. Performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care.Methods: A multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. Modifications to support clinical-decision making in the context of COVID-19 were derived by consensus and available evidence.  Results: Modified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of COVID-19 are presented. Discussion: During the various phases of the  COVID-19 pandemic,  clinicians must carefully consider the indications, procedural precautions, and post-operative care for tracheostomies. We present guidelines to mitigate risk to healthcare workers while preserving the quality of care.