COVID-19 pandemic presents an unprecedented challenge to identify effective drugs for treatment. Despite multiple clinical trials using different agents, there is still a lack of specific treatment for COVID-19. Having the possible role in suppressing inflammation, immune modulation, antiviral and improving respiratory symptoms, this review discusses the potential role of methylxanthine drugs like pentoxifylline and caffeine in the management of COVID-19 patients. COVID-19 pathogenesis for clinical features like severe pneumonia, acute lung injury (ALI) / acute respiratory distress syndrome (ARDS), and multi-organ failures are excessive inflammation, oxidation, and cytokine storm by the exaggerated immune response. Drugs like pentoxifylline have already shown improvement of the symptoms of ARDS and caffeine has been in clinical use for decades to treat apnea of prematurity (AOP) in preterm infants and improve respiratory function. Both pentoxifylline and caffeine are well-known anti-inflammatory and anti-oxidative molecules that have already shown to suppress Tumor Necrosis Factor (TNF-α) as well as other inflammatory cytokines in pulmonary diseases, and this may be beneficial for better clinical outcomes in COVID-19 patients. Pentoxifylline enhances blood flow, improves microcirculation and tissue oxygenation, and caffeine also efficiently improves microcirculation, reduces cardiovascular disease, and an effective analgesic. There are significant shreds of evidence that proved the properties of pentoxifylline and caffeine against virus-related diseases as well. Along with the aforementioned evidences and high safety profiles, both pentoxifylline and caffeine offer a glimpse of considerations for future use as a potential adjuvant to COVID-19 treatment. However, additional clinical studies are required to confirm this speculation.

Counting parameters has become customary in the density functional theory community as a way to infer the transferability of popular approximations to the exchange–correlation functionals. Recent work in data science, however, has demonstrated that the number of parameters of a fitted model is not related to the complexity of the model itself, nor to its eventual overfitting. Using similar arguments, we show here that it is possible to represent every modern exchange–correlation functional approximation using just one single parameter. This procedure proves the futility of the number of parameters as a measure of transferability. To counteract this shortcoming, we introduce and analyze the performance of three statistical criteria for the evaluation of the transferability of exchange–correlation functionals. The three criteria are called Akaike information criterion (AIC), Vapnik–Chervonenkis criterion (VCC), and cross-validation criterion (CVC) and are used in a preliminary assessment to rank 60 exchange–correlation functional approximations using the ASCDB database of chemical data.

It has been reported that the prevalence of cases whose leads were located in the right ventricular lateral wall (RVLW), even though we intended to implant the leads in the right ventricular septum (RVS), is not uncommon. Among the cases whose leads were assumed to be implanted in the RVS, we experienced three cases whose leads were confirmed to be located in the RVLW by postoperative CT. We investigated the intra-operative fluoroscopic index common to these three leads. In the left anterior oblique view (LAO), the transverse movement of the lead-tip seemed to be exceptionally large in all cases. To assess this index, we compared to the consecutive twenty leads confirmed to be located in the RVS. The transverse movement of the lead-tip in the RVLW was clearly greater than that in the RVS (12.8±1.7 mm vs. 4.2±0.9 mm). This difference was large enough to be judged visually. Large transverse movement of the lead-tip in LAO may be a new visual fluoroscopic index that predicts anchoring to the RVLW.

Background: The relative resistance of children to severe course of novel coronavirus infection remains unclear. We hypothesized that there might be a link between this phenomenon and observation from our previous studies, concerning an inhibitory or cytotoxic effect of children exhaled breath condensate (EBC) on endothelial cell cultures. Since we could not find any data on similar effect caused by EBC from adults, the aim of our study was to evaluate and compare the biological activity of EBC from adults and children in an experimental in vitro model. Furthermore, in order to identify a putative agent responsible for these properties of children EBC, we attempted to analyse the composition of selected EBC samples. Methods: The influence of EBC samples on metabolic activity of endothelial cell line C-166 was assessed using colorimetric tetrazolium salt reduction assay (MTT assay). Selected EBC samples were fractionated using size exclusion chromatography and subjected to mass spectrometry analysis. Results: Exhaled breath condensates from healthy children, but not from adults, revealed a cytotoxic effect on in vitro cell cultures. This effect was most significant in condensate fraction, which contained a prominent 4.8 kDa peak in the mass spectra. Conclusion: Breath condensates from healthy children contain the factor, which reveals inhibitory/cytotoxic effect on endothelial cell cultures. Although physiological role of this agent remains unclear, its identification may potentially be useful in ongoing research on SARS-CoV-2/COVID-19.

A document by Cristina Quecchia, written on Authorea.

Background In ~25% of echo studies discrepant diastolic measurements make the assessment of diastolic function indeterminate. We aimed to assess whether left atrial function may contribute to LV filling evaluation in patients with indeterminate diastolic function (IndtDFx). Methods In our retrospective echocardiography database we found 1674 consecutive patients in sinus rhythm, and EF≥45%. Patients were divided according to the parameters mitral E’, mitral E/E’ ratio , left atrial maximal volume index , and pulmonary pressure. Normal diastolic function (NDFx) was defined as less than 2 abnormal parameters, definite diastolic dysfunction (DDFx) as more than 2 abnormal parameters, and IndtDFx as 2 abnormal parameters. We retrospectively and randomly selected 30 patients from each group for left atrial assessment by speckle tracking echocardiography for off line strain and volumes analysis. Results: sixty seven patients were included in strain analysis. The DDFx group (n=21) and IndtDFx (n=19) were significantly different form NDFx (27) in demographics, cardiovascular risk factors., presentation and echocardiographic parameters. Phasic LA maximal and minimal volume indexes were larger in DDFx and indtDFx groups, and overall and passive LA strains were decreased in DDFx and indtDFx groups compared with NDFx group, while active strain remained in the normal range. Phasic LA minimal volume index was found to be associated with HF symptoms. Conclusion LA phasic function suggests that IndtDFx is similar to DDFx , helping in re- classification of patients with IndtDFx as DDFx. LA minimal volume index correlated with symptoms.

Background: End stage renal disease (ESRD) is a well-recognized risk factor for development of sudden cardiac arrest (SCA). There is limited data on baseline characteristics and outcomes after an in-hospital SCA event in ESRD patients. Methods: For the purpose of this study, data were obtained from National Inpatient Sample from January 2007 to December 2017. In-hospital SCA was identified using International Classification of Disease, 9th Revision, Clinical Modification and International Classification of Disease, 10th Revision, Clinical Modification codes of 99.60, 99.63 and 5A12012. ESRD patients were subsequently identified using codes of 585.6 and N18.6. Baseline characteristics and outcomes were compared among ESRD and non-ESRD patients in crude and propensity matched (PS) cohorts. Predictors of mortality in ESRD patients after an in-hospital SCA event were analyzed using a multivariate logistic regression model. Results: A total of 1,412,985 patients sustained in-hospital SCA during our study period. ESRD patients with in-hospital SCA were younger and had a higher burden of key co-morbidities. Mortality was similar in ESRD and non-ESRD patients in PS matched cohort (70.4% vs. 70.7%, p = 0.45) with an overall downward trend over our study years. Advanced age, Black race, diabetes, hypertension and peripheral vascular disease were independently associated with increased mortality in ESRD patients after an in-hospital SCA event. Conclusion: In the context of in-hospital SCA, mortality is similar in ESRD and non-ESRD patients in adjusted analysis. Adequate risk factor modification could further mitigate the risk of in-hospital SCA among ESRD patients.

In this study, we obtain the solutions of some interesting problems by Sumudu transform. We investigate the economic models based on market equilibrium with constant proportional Caputo derivative. We prove the efficiency of the Sumudu transform by some applications.

Despite sinus valsalva aneurysm of a well-known pathology, its presence as a cardiac tumor with the RA compression is rare. A 64-year-old man was accidentally identified with a cardiac tumor during the survey of atrial fibrillation. The initial echocardiography and chest computed tomography (CT) displayed a huge mass at right atrium. Surprisingly, the operative findings diagnosed a sinus valsava aneurysm. This case highlights the diagnostic challenges of a huge sinus valsava aneurysm which mimics an intra-cardiac tumor.

Objectives: Vigilance is safety in cardiac surgery. Performance in cardiac surgery is frequently measured by short-term mortality. Several risk factors like advanced age, female gender, elevated body mass index, decreased left ventricular function, emergent and redo operations have appeared recurrently as poor prognostic variables. Identification of perioperative risk factors is crucial to provide proper care and reduce preventable mortality after cardiac surgery in developing countries with limited infrastructures and resources. Methods: This is a retrospective study conducted in the Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University from 1 January 2014 to 30 May 2018. Statistical analysis of the data of 100 cases of mortality after cardiac surgery was done by collecting the demographics and clinical characteristics of the patients along with their perioperative data. Results: During the study period, about 1627 cases of cardiac surgery were done with an overall mortality rate of 6.15%. But the overall mortality rate is improving as in 2020 the mortality was under 5%. Conclusion: Mortality after cardiac surgery is multifactorial. A large-scale prospective study with comparative groups is required to find out preventable measures of mortality after cardiac surgery which will improve the quality of service provided to the patients in developing countries. Keywords: Cardiac surgery, morbidity, mortality, evaluation, MACE, risk factors.

Key Points:We describe a novel procedure, Endopharyngeal Ultrasound (EPhUS) and EPhUS-guided FNAEPhUS requires an operator and an assistant, can be performed transnasal or transoral, and utilizes a Endoscopic Ultrasonography BronchoscopeEPhUS is a safe and effective method for biopsy of deep space neck masses inaccessible to transcutaneous FNAKey Words: Endoscopic, Ultrasound, Fine needle aspiration, Neck mass, Biopsy, minimally invasiveEthical Considerations: The patient presented below was informed that this procedure has not been reported in the past and agreed to proceed following standard informed consent. The patient consented to having their case published in the literature.

Ultra sound wire guided markers are safe and effective for unpalpable suspicious nodes Particularly useful on the setting of the previously operated neck Placement by an experienced radiologist in the presence of the operating surgeon is advocated

Introduction:In late December 2019, a cluster of pneumonia cases of unknown aetiology were reported in Wuhan, Hubei Province, Central China. The causative agent was subsequently identified as the novel coronavirus (SARS-CoV-2, previously known as 2019-nCoV). The coronavirus disease 2019 (COVID-19) was eventually declared as a global pandemic by the World Health Organisation (WHO), having been detected in over 72 countries worldwide, with Europe and the United States now deemed the viral epicentres [1].Healthcare professionals (HCP) are considered high risk due to a multitude of factors including exposure to higher viral loads [2] and aerosolisation [3,4]. The rising number of deaths amongst healthcare professionals and burden of sick leave secondary to self-isolation, raises significant safety concerns during patient assessment and management. This is particularly of concern when undertaking droplet and aerosol generating procedures (AGP), although the evidence is derived largely from low quality studies [6]. Postulated mechanisms thought to generate aerosol and droplets include laryngeal activity (speech & coughing), high velocity gas flow, and cyclical opening and closure of distal airway. These have been found to generate particles in a range of sizes, increasing the viral load in confined spaces, and possibly increasing transmission risk.Recent literature suggests an increased risk posed to otorhinolaryngologists, as diagnostic, interventional and therapeutic procedures involving the upper aerodigestive tract, paranasal sinuses and middle ear exposes HCPs to both direct and indirect transmission of SARS-CoV-2 [7]. At the point of formulating this article, elective clinical workload has been reduced within the United Kingdom. Two-week-wait clinics have continued due to the prevalence and rising incidence of head and neck cancers [8], albeit at a significantly reduced capacity due to lengthened infection control measures.We describe a novel and cost-effective safety adjunct when undertaking flexible nasendoscopy (FNE) within ward/ outpatient settings.

INTRODUCTION Otolaryngology is one of the branch where endoscopes is being widely used nowadays to perform different surgeries. Ear surgeries are of special interest among the ENT surgeons. It has several advantages compared to the microscopes. METHODS 60 patients underwent endoscopic transcanal myringoplasty by the postgraduate residents under direct supervision of same consultants, using temporalis facia graft. RESULTS The overall success rate in terms of graft uptake was 86.67 % and the AB gap closure 0f <10 DB in 63.3% of cases and 10-20 DB in 33.3%. CONCLUSION Endoscopic myringoplasty was found to be equally effective, less morbid and very cost effective than the microscopic myringoplasty. This was applicable irrespective of the size of the perforation and condition of the middle ear(Dry/Wet) in our centre

Title Value of oesophagoscopy and bronchoscopy in diagnosis of synchronous malignancies in patients with head and neck squamous cell carcinomas: a 10-year single center experience in Chinese population. Objectives Routine screening of patients with head and neck squamous cell carcinomas (HNSCCs) for synchronous malignancies using oesophagoscopy and bronchoscopy had been controversial. The aim of this study is therefore to find out the rate of synchronous malignancies in patients with primary HNSCCs, the risk factors for its occurrence and the effectiveness of oesophagoscopy and bronchoscopy in a single center with Chinese population. Method A retrospective review of medical records was conducted from July 2008 to June 2018 in a tertiary referral center in Hong Kong. All patients with newly diagnosed HNSCCs were screened with oesophagoscopy and bronchoscopy at the time of diagnosis and therefore all patients were included in the study. The incidence of synchronous malignancies along the aerodigestive tract and the yield of oesophagoscopy and bronchoscopy were studied. Result Of the 702 patients included in the study, the overall rate of synchronous malignancies was 8.3% (58/702), with the rate of synchronous esophageal and lung malignancies being 5.8% (41/702) and 0.85% (6/702) respectively. 14 out of the 41 esophageal malignancies were only detectable with esophagoscopy. Only one of the synchronous lung malignancies was detectable by bronchoscopy. Risk factors for synchronous malignancies include male gender, smokers, drinkers and primary hypopharyngeal cancer. Conclusion Oesophagoscopy is essential for detecting synchronous esophageal malignancies in patients with HNSCC especially in male patients, smokers, drinkers and primary hypopharyngeal cancer patients. Bronchoscopy had a low yield for synchronous lung malignancies and can be potentially replaced by imaging techniques.

Objective: As an aerosol generating procedure (AGP), mastoidectomy in the COVID-19 era requires healthcare workers to wear personal protective equipment (PPE); UK guidelines recommend an FFP-3 mask and full-face visor. The aim of this study was to examine the effect of wearing PPE on the view achieved using the operating microscope. Methods: Using the operating microscope, ENT surgeons were asked to view a target so that it filled the entire operating field. The distance between the surgeon’s eye and the microscope was recorded and subsequently measured with the surgeon wearing a range of PPE. In each PPE condition, surgeons scored the visibility of the target; scores were used to calculate the visible area of the surgical field. Results: Eleven surgeons took part, generating 51 eye-microscope and target-view scores. Distance from the eye to the microscope inversely correlated with diameter and area visible (Pearson correlation coefficient -0.983 and -0.894 respectively; p<0.001). Use of PPE increased the eye-microscope distance and reduced the surgical view. The median area visible wearing the FFP-3 mask and full-face visor was 4% (range 4 – 16%). Conclusion: PPE consisting of an FFP-3 mask and full-face visor is incompatible with use of the operating microscope, with less than 10% of the surgical field visible in most cases. Solutions that allow for concurrent use of the operating microscope and drill during mastoid surgery are urgently required so that surgeons are adequately protected from COVID-19 transmission.

In this brief report we describe an extraordinary case of a pediatric patient with a history of medulloblastoma who developed an intracranial mass-like lesion during growth hormone treatment. To our knowledge this is the first case report of a mass-like lesion as a consequence of parenchymal fluid leakage adjacent to an intraventricular catheter due to increased intracranial pressure during growth hormone therapy which has been proven by biopsy.

Summary. Diseases of the paranasal sinuses (DPN) are the most common pathology in otorhinolaryngology. According to the literature, it is known that cystic sinusitis is an infectious and allergic disease, and the formation of cysts is considered as the result of an allergic reaction to infection in sensitized patients. Adverse environmental impact on the immunological system of the human body, reducing natural resistance, increasing the degree of allergization of the population contributes to a high level of General respiratory diseases. In this regard, it is relevant to study the indicators of General and local immunity in patients with chronic cystic sinusitis. We examined 138 patients with chronic cystic sinusitis aged 17 to 64 years. Conducted immunological study of the state of cellular and humoral immunity in accordance with the recommendations Of the Institute of immunology. A comprehensive immunological examination revealed a sharp imbalance of immunological parameters in blood serum, nasal flushes and cystic fluid in patients with chronic cystic sinusitis. In the complex of etiological and pathogenetic treatment in patients suffering from chronic cystic sinusitis, it is necessary to include immunodulators and immunostimulators.Introduction . Diseases of the paranasal sinuses (DPN), sinusitis-are among the most common pathologies in otorhinolaryngology[3,6]. This is facilitated by changes in the environmental situation in the world, the wide prevalence of both allergic and viral respiratory diseases, the irrational use of antibacterial drugs, and a decrease in local and General immune mechanisms. According to the literature, it is known that cystic sinusitis is an infectious and allergic disease. The formation of cysts is considered as a result of an allergic reaction to infection in sensitized patients[10]. To date, the causes of cysts have not been clarified, so it remains relevant to further in-depth study of various factors that may affect the course of the inflammatory process. In a modern city, a person is exposed to a complex of environmental factors that adversely affect their health. The leading one is multi-complex air pollution, which occurs as a result of intensive development of industry and transport [2]. We have identified an adverse effect of environment on the immune system of the human body - the formation of secondary immunosuppression, reduced natural resistance, increase the degree of allergization of the population, resulting in high rates of overall morbidity and, in the first place, the defeat of the respiratory tract that is characterized by high radiation, dust and fumes in the environment.Currently, the influence of three factors - dust, carbon monoxide and sulfur dioxide-on the incidence of acute respiratory infections, bronchitis and pneumonia has been reliably proven. These agents and their various combinations affect the incidence of angina, pharyngitis, rhinitis, and sinusitis [5,8]. The increased content of harmful substances in the inhaled air has not only a General adverse effect on the body, but also leads to a violation of their normal functioning of the nasal cavity, i.e. weakens its protective capabilities, which increases the risk of rhinitis and sinusitis.In connection with the above, it was considered relevant to study the indicators of General and local immunity in patients with chronic cystic sinusitis [2,4,7,9].The aim of the study was the state of immunological reactivity in patients with chronic cystic sinusitis.Materials and methods of research. 138 patients with chronic cystic sinusitis aged 17 to 64 years were examined, including 65 women (47%) and 73 men (53%) who applied to the clinic No. 1 of the Samarkand medical Institute. The number of workers and employees was about the same. For examination, patients with chronic cystic sinusitis were selected with a prescription of this pathology for at least 2 years and there were no concomitant inflammatory diseases. The diagnosis was made on the basis of patient complaints, anamnesis data documented in outpatient records, clinical manifestations of the disease, x-ray, computed tomography examination of the paranasal sinuses (PNS) and the results of maxillary sinus puncture. To determine the regional physiological norm, all the indicators used were determined in 54 clinically healthy donors aged 17 to 50 years of both sexes from the number of volunteers with no history of chronic inflammatory diseases. Immunological indicators of the physiological norm in flushes from the maxillary sinuses were determined in 23 healthy persons from the number of military conscripts. The conducted immunological study included a detailed determination of 3 links of the immune system: all stages of phagocytosis (% of phagocytic cells, phagocytic number and phagocytosis completion index - PCI) and nst-test, rosette formation reactions - active, spontaneous, and with loads of levamizol and theophylline, concentrations of immunoglobulins of classes A, M, G and sec - rotary Ig A, as well as the content of lysozyme and circulating immune complexes (CIC).We studied the state of cellular and humoral immunity according to the recommendations Of the Institute of immunology. Blood for research was taken in the morning on an empty stomach from the ulnar vein. To determine the cellular level of immunity, blood was placed in a heparinized test tube at the rate of 20 units of heparin per 1 ml of blood. The isolation of immunocompetent cells was performed by a conventional method using a ficol-verografin gradient. Mononuclear suspension was studied in a cell concentration of at least 1 million cells per 1 ml.To study the state of local immunity, cystic fluid was used, which was obtained by means of a diagnostic puncture of the maxillary sinus and was aspirated into a sterile syringe. Further calculations took into account the 1:10 dilution.Results and discussion. A comprehensive immunological examination revealed a sharp imbalance of immunological parameters in blood serum in patients with chronic cystic sinusitis. First of all, attention is drawn to the marked decrease in all indicators of serum immunoglobulin content, as well as secretory Ig A (table 1). It should be noted that the physiological norm of the content of immunoglobulins in blood serum is located within a fairly wide range. For example, the amplitude of ”normal” values for Ig A is from 1.7 to 2.55 g / l, and for SIgA-from 1.65 to 2.65. The same significant fluctuation in their indicators is observed in patients with chronic cystic sinusitis. It seems more convenient to use this indicator in the form of the Ig a/ SIgA index in practical health care . In healthy patients, it is equal to 1, i.e. 1: 1, and in patients with chronic cystic sinusitis, it changes significantly and is 3:1.in all the examined patients, this index was the most constant value, i.e. its fluctuations were minimal.Analyzing the phenomenon of a sharp decrease in the content of immunoglobulins of all classes in the examined patients, it can be assumed that this is a manifestation of a fairly common congenital immunodeficiency condition in all classes of immunoglobulins. In the literature, this category of patients is described as a group of frequently and long-term patients. In most cases, the anamnesis data corresponds to this description.When further analyzing the results of immunological examination of individuals with chronic cystic sinusitis, the following Genesis of the phenomenon of deficiency in all classes of immunoglobulins seems more likely, namely: characterizing the indicators of the macrophage system, it should be noted that the percentage of phagocytic cells is usually increased, which is quite consistent with the classical course of the inflammatory process, but the ability of phagocytes to capture and digest the pathogenic object is reduced (table 2).In this case, we are probably dealing with a congenital defect of the a-link of the immune system, which entails, according to the theory of the three-link immune system, a weak immunological signal to the B-link. Thus, the decrease in serum levels of immunoglobulins of all classes in patients with chronic cystic sinusitis appears to be mediated.This assumption is supported by such an increase in the value of the nst test to 56.5+3.4 (with a norm of 22.5-2.3).Defect A-link - bad recognition, capture and digestion of pathogen - creates conditions for the transition of the inflammatory process in chronic, since it entails a high concentration of this agent in the patient’s body, i.e., a high degree of sensitization, as manifested in the examined in the reaction of immunoparalysis.The high percentage of phagocytic cells and the increased values of the nst test are obviously compensatory. Describing the indicators of the T-system in chronic purulent sinusitis (table 3), it should be noted that the number of active test on the formation of the rosette in the resection reaction in these patients is slightly increased compared to the norm, but statistically unreliable.During stress tests, a decrease in test on the formation of the rosette with theophylline was detected, while the indicators of spontaneous tissue-forming test on the formation of the rosette cells with levamisole almost coincide with the lower limit of the norm, i.e. they are statistically unreliable.The most interesting indicator here is already known and actively used by immunologists index-the ratio of T-helper /T-suppressor: normally in healthy people, it is 0.5+0.03 or 1:2, and in patients with chronic purulent sinusitis, its indicator was significantly changed and took the value of 1.16+0.04, which corresponds to the ratio of 1:1 .Analyzing the state of non-specific resistance, we noted a significantly increased concentration of CIC in the blood serum in patients with chronic cystic sinusitis (98.7+8.2 units of opt.pl) compared to the norm (25:3.2 units of opt. pl). A high level of CIC corresponds to the immunological manifestations of chronic inflammation in the body and may reflect the failure of the phagocytosis process.The detected decrease in the lysozyme index in blood serum - 3.28+0.18 mkg/l (at the norm of 3.7±0.09 mkg/l) may be a sign of exhaustion of this system due to the age and severity of the inflammatory process occurring against the background of a defect in the a-link of the immune system. The immunological characteristics of patients with chronic cystic sinusitis are supplemented by a study from the maxillary sinuses, the results of which are presented in table 4.In cystic fluid in chronic cystic sinusitis, there is an almost double increase in the content of serum Ig A, Ig G and a noticeable decrease in serum Ig and secretory lgA compared to the same indicators in healthy volunteers. This ratio of serum immunoglobulins is quite consistent with the reaction of the B-link immunity to chronic inflammatory process, but a significant decrease in the content of SigA, apparently, pathognomonic for this category of patients, because it reflects the initial weakness of the local immune system of the nasal cavity and paranasal sinuses.In flushes, as in blood, with a wide range of values of Ig A and SigA, the ratio of Ig A/Slg a was the least subject to fluctuations and at the same time the most constant. In healthy patients, it was 0.98+0.032, and in patients-1.86-0.04. For convenience, we have expressed this ratio in the form of an ”immunoglobulin” index, which is 1:1 in healthy people and 2:1 in patients.Indicators of non-specific resistance in cystic fluid from the maxillary sinuses in chronic cystic sinusitis are presented in table 5.An increase of almost twice the normal CIC content in flushes from inflamed maxillary sinuses corresponds to immunological manifestations of the inflammatory process.The fact that in the body of patients with chronic cystic sinusitis, the level of CIC is increased both in the blood serum and in sinus flushes, suggests a possible participation of the autoimmune process in the pathogenesis of this disease.The content of lysozyme in flushes from the maxillary sinuses, as well as in the blood serum, is reduced. Obviously, this phenomenon is still systemic. It is possible that the reduced antibacterial capabilities of local immune factors in the maxillary sinus-secretory immunoglobulin and lysozyme are a predisposing factor in the formation of a chronic process in this organ.

Clinical outcomes of salvage endoscopic nasopharyngectomy in recurrent nasopharyngeal carcinoma

Background and Purpose: Asthma is a chronic inflammatory lung disorder with continuously increasing prevalence worldwide. Novel strategies are needed to prevent or improve asthma. The aim of this study was to investigate the effects of sophoricoside from Sophora japonica on allergic asthma. Experimental Approach: Sophoricoside was isolated from the mature seeds of S. japonica. Allergic asthma and passive cutaneous anaphylaxis (PCA) models were generated by ovalbumin (OVA) treatment or antibody-allergen reaction in mice. Allergic and asthmatic symptoms, immune cell infiltration, and the amounts of histamine, lipid metabolites, and pro-inflammatory cytokines were determined, and in vitro CD4+ T cell differentiation was performed. Key Results: The mature seeds of S. japonica contain a large amount of sophoricoside. Sophoricoside reduced allergic and asthmatic symptoms by suppressing airway inflammation and antibody-antigen reaction in mouse models. In particular, sophoricoside suppressed immune cell recruitment into the airway lumens of the lungs and production of pro-inflammatory cytokines in the bronchoalveolar lavage fluid (BALF) of OVA-induced mice. It also decreased the amounts of histamine and lipid metabolites released in OVA-induced mice and antibody-antigen stimulated mast cells. In addition, sophoricoside decreased differentiation of naïve CD4+ T cells into T helper type 1 (Th1), Th2, and Th17 cells. Conclusions and Implications: Sophoricoside from S. japonica inhibited allergic asthma by suppressing mast cell activation and CD4+ T cell differentiation. Thus, it is a promising candidate molecule for the treatment of allergic asthma. Keywords Airway inflammation; Allergic asthma; CD4+ T cell; Mast cell; Ovalbumin; Sophora japonica; Sophoricoside

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

For centuries it has been humankind’s instinct to cover the mouth and nose when coughing or sneezing. Common sense would dictate this instinctively reduces the dispersion of aerosol and droplets and thus the spread of contact and airborne infections.Aerosol generating procedures (AGPs) have become a new byword for procedures that put clinicians at increased risk of contracting COVID-19. Whilst the title suggests the risk is simply in aerosols, the science is much more interesting. Droplets and aerosols are different, with the distinction between them based on size. Whilst experts disagree on the absolute size when an aerosol becomes a droplet, the general acceptance is that anything bigger than 50 microns (0.05mm) is a droplet and those smaller are aerosols.In most contagious respiratory infections, the principal transmission agents are droplets (1). This is due to the relatively high viral load in a droplet, purely due to its large size, and also the fact that large droplets have weight, and so gravity pulls them down onto surfaces that others can touch – so passing it on. This is why washing hands is so effective against droplet spread.Aerosol transmission is thought to be a much less frequent cause of transmission, mainly due to the very small viral load (given the aerosol itself is by definition very small). However, it is clearly more concerning as these very small, and therefore very light particles, can travel large distances on air currents and can be directly inhaled. That said, it is thought to only play a minor role in transmission compared to droplet spread.During the COVID-19 pandemic PHE (Public Health England) updated guidance on what it considers (AGPs) Aerosol Generating Procedures. Included within this list were examinations of the upper aerodigestive tract in ENT. Any procedure enacting air over a fluid mucosal surface therefore poses a risk of viral dispersion within both droplets and aerosol. Healthcare workers were recommended to reduce endoscopy of the nose and throat. Any essential examination had to be performed using high level PPE including an respirator (N95 or FFP3)(2).Anfinrud et al (3) graphically represented a visual reduction in aerosol production by creating light sheet from a 532-nm green LASER. Comparisons were made between a person talking with and without a cover for the mouth, in their instance, a slightly dampened wash cloth. Light flashes were recorded to evaluate the number of droplets ranging between 5-200 microns. They showed that by covering the mouth, virtually no light flashes were seen. This observation supports the well-known concept that covering the mouth does indeed reduce droplet production.On impact with smooth surfaces droplets disperse to smaller sizes and can aerosolise. Similarly impact onto soft surfaces absorbs droplets reducing their projection as well as the tendency to aerosolise (3).As the pandemic plateaus in countries across the world various strategies are to be considered to return to a new normal. This would facilitate the resumption of diagnostic services whilst maintaining the protection to healthcare workers. One suggestion is the use of facemasks to help reduce the risk of inadvertent droplet dispersion (2). Despite the ‘soft surface’ barrier masks create, in the ENT setting, facemasks obscure access to the nasal cavity thus preventing nasoendoscopy.The ‘SNAP’ (Safe Nasoendoscopic Airway Procedure) developed by endoscope-i Ltd (West Midlands, UK) is a single-use, valved endoscopic port, retrofitted to any surgical mask (Figure 1), permitting entry of a 4mm flexible and rigid endoscope to examine the naso and pharyngolarynx. The valve, a 10.9 mm cylindrical tube truncated by two opposing 45 degree inclined membranes 700 microns thick, approaches a point but terminates in a 700 micron thick and 500 micron wide plateau, creating a ‘duck bill’ formation The valves are formed using a FFF (fused filament fabrication) 3D printing technique with a Flashforge Creator Pro 3D printer. The plateau atop the valve serves to provide a reference for introducing a slit using a hardened steel razor blade that is 400 microns thin. The blade is mounted in a jig to ensure angle, penetration depth and position are controlled as it is driven through the membrane. These measures ensure that the valve opening is observably consistent and less than 50 microns. Once the SNAP is fitted to a surgical mask, any cough or sneeze generated during the procedure is caught within the mask. The valve is configured such that pressure from the patient side will serve to collapse the walls of the valve membrane thereby further sealing the slit in the valve. This seal has been in vitro tested with aerosolised fluorescein(figure 2). The 45-degree angle of the valve walls from the non-patient side similarly allows the blunt tip of the nasoendoscope to deform the valve walls with ease. The cylindrical form of the walls encourages the valve membranes to return to their original flat shape following withdrawal of the endoscope.During the COVID-19 pandemic our tertiary head and neck cancer referral centre managed 120 urgent 2ww cases. Using the Tikka et al calculator (4) 40% of referrals were redirected back to the GP. The remaining 60% either went direct for imaging or underwent endoscopy. In total 40 cases were endoscoped, 9 of which using the SNAP. All 9 cases scoped with the SNAP were completed without any adverse effect. No cough or sneeze was elicited during any of the examinations and observations between the two groups were identical. Subsequently one consultant lead FEES examination was performed under controlled conditions. Again, the procedure was completed without any complications. The patient self-remarked on the comfort of the endoscopy as a result of the stability provided by the SNAP device in the alar region the prevented inadvertent movement during the chin tuck and head turn exercises.Our observations demonstrate the SNAP device is a practical and safe tool to aid reduction in droplet dispersion whilst performing nasoendoscopy. We hope to see the inclusion of such a device in recovery guidelines by national bodies in order to facilitate the return of safe nasoendoscopy in the post COVID Pandemic era.

Since December 2019, the rapid spread of SARS CoV-2 across the border, shuffled into a world pandemic situation with an alarming rate of morbidity and mortality. Concerns are mounting as the reports indicate tangled circumstances among the COVID-19 patients due to blood coagulopathy followed by organ dysfunction. COVID-19 induced an alteration in coagulation function increase the risk of pulmonary embolism and deep vein thrombosis associated with poor prognosis as well as high mortality. An elevated level D-dimer and other fibrin degrading protein are documented among the patients with COVID-19; especially in severe cases. Differences in coagulopathy among severe and non-severe cases, required prompt attention to adopt a more effective management strategy.

Background: Little is known about whether coinfection of other respiratory tract viruses contributes to severity of COVID-19 pneumonia. Methods: We retrospectively studied 128 hospitalized patients with COVID-19 pneumonia (64 cases co-infected with influenza A/B vs 64 negative influenza cases via pair-matching on age, sex, and days from onset of symptom). Results: Among 64 co-infected patients, 54 patients (84.4%) had co-infected with influenza A, and 10 (15.6%) with influenza B. The percentages for the severity of pneumonia on admission of the two groups, i.e., with influenza infection and without, were similar (P=0.945). The median duration (days) of viral shedding time from admission was longer for patients with influenza infection (17.0 day) than those without influenza infection (12.0 day) (P<0.001). However, the progression of lung CT in four weeks after onset of symptom were similar in both groups. The multivariable Cox proportional hazards model showed that the HR of pneumonia resolution on CT scans was 0.869 (P=0.612) for patients with influenza (95% CI 0.505, 1.495) compared with patients without influenza, while the HR of resolution in lung involvement was 1.878 (P=0.020) for patients with lopinavir/ritonavir, compared with patients without lopinavir/ritonavir (95% CI 1.103, 3.196). Patients who were treated with lopinavir/ritonavir presented with faster pneumonia resolution in two weeks after symptom onset both in the whole cohort (32.4% vs 13.8%, P=0.036) and in influenza co-infected group (37% vs 1%, P=0.001). Conclusions: Lopinavir/ritonavir eliminated the difference of lung involvement between influenza co-infected and non-infected groups, indicating lopinavir/ritonavir is associated with pneumonia resolution in COVID-19.