Covid has blatantly uncovered the disconnect between the healthcare professionals who have the responsibility for the health of the nation but little of the authority, and politicians and business people who have the authority and political power over healthcare, but none of the responsibility for the health of the nation. The time has come to review this dichotomy and to reinvent medical education in order to empower and train healthcare professionals, particularly mid-career ones, to become adept in the business of medicine; including budgeting, management, leadership, hiring and firing, brand building and other important aspects of running complex healthcare entities. It is no longer acceptable for physicians to accept backseat for non-physician managers and concede their rules and regulations without question. The time is now for health professionals to train themselves and take charge of the profession.

Aluminum-based metal matrix composite material found to be the best alternative to make auto components with its unique mechanical properties and lightweight. This present work, an attempt has made to use finite element based software to find out stress analysis of steel spring and composite leaf spring. EN 45 steel spring used in automobile vehicles has selected as principle application. For analysis purposes, metal matrix composite based leaf spring prepared and compared with steel leaf spring. The main objective of this research work to find the possibilities to replace the steel spring by metal matrix composite based leaf spring. Finite element based software ANSYS 18.0 was used for analysis purposes. The Result showed that metal matrix composite leaf spring has 38% less stress as compared to the steel spring. Compared to steel spring, the composite leaf spring has 50% less weight.

Objective: To determine the impact of the introduction and establishment of a daily medical liaison service provided to patients aged 65 years and older attending a regional vascular surgery centre. Methods and Analysis: Descriptive before-and-after study concerning 375 patients (pre-intervention n=171, post-intervention n=204). Retrospective case-note analysis during two three-month periods (January-March, 2017 and 2018). Intervention comprised daily senior-led medical liaison review. Primary outcome measure was length of stay (LOS). Results were analysed using SPSS Statistics 23. Descriptive analyses were performed in addition to correlation and regression analyses to identify key predictors of postoperative outcome. Results: There was a trend reduction in LOS from 10.75 to 7.95 days (p=0.635, 95% CI 0 – 1 day) with a significant reduction in mean LOS for patients admitted for longer than seven days (7.84 days, p=0.025, 95% CI for mean difference, 1.5 to 14 days). This group also benefited reduced 30-day readmission rates (12/60 to 8/72, p=0.156, 95% CI -3% to 21%). Trend reduction in the number of postoperative complications was seen (1.09 to 0.86 per person, p=0.181, 95% CI -0.11 to 0.56), which reached statistical significance in emergency vascular admissions (1.81 to 0.97 per person, p=0.01, mean difference = 0.84, 95% CI 0.21 – 1.46). Conclusion: This study has demonstrated reduced LOS and complications associated with daily medical liaison in selected older patients admitted under vascular surgery. The greatest benefit appears to be in patients admitted for more than seven days or in emergency admissions. These data are amongst the first to reproduce randomised control trial findings in a non-trial setting. They indicate which patient groups may benefit most from collaborative models of care where resources are finite.

Aims: To determine associations between severity of hypertension and risk of starting dialysis in the presence or absence of diabetes mellitus (DM). Methods: A nationwide database with claims data on 258,874 people with and without DM aged 19-72 y in Japan was used to elucidate the impact of severity of hypertension on starting dialysis. Initiation of dialysis was determined from claims using ICD-10 codes and medical procedures. Using multivariate Cox modeling, we investigated severity of hypertension as a predictor of the initiation of dialysis with and without DM. Results: Hypertension was significantly associated with the initiation of dialysis regardless of DM. The incidence of starting dialysis in those with SBP ≤119 mmHg and DM (DM+) was almost the same as in those with SBP ≥150 mmHg and absence of DM (DM-). In comparison with SBP ≤119 mmHg, SBP ≥150 mmHg significantly increased the risk of the initiation of dialysis about 2.5 times regardless of DM+ or DM-. Compared with DM- and SBP ≤119mmHg, the HR for DM+ and SBP ≥150 mmHg was 6.88 (95% CI 3.66-12.9). Conclusions: Although the risks of hypertension differed only slightly regardless of the presence or absence of DM, risks for the initiation of dialysis with DM+ and SBP ≤119 mmHg were equivalent to DM- and SBP ≥150 mmHg, indicating more strict blood pressure interventions in DM+ are needed to avoid dialysis. Future studies are needed to clarify the cut-off SBP level to avoid initiation of dialysis considering the risks of strict control of blood pressure.

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been declared a global pandemic and urgent treatment and prevention strategies are needed. Nitazoxanide, an anthelmintic drug has been shown to exhibit in vitro activity against SARS-CoV-2. The present study used physiologically-based pharmacokinetic (PBPK) modelling to inform optimal doses of nitazoxanide capable of maintaining plasma and lung tizoxanide exposures above the reported nitazoxanide SARS-CoV-2 EC90. Methods: A whole-body PBPK model was validated against available pharmacokinetic data for healthy individuals receiving single and multiple doses between 500–4000 mg with and without food. The validated model was used to predict doses expected to maintain tizoxanide plasma and lung concentrations above the nitazoxanide EC90 in >90% of the simulated population. PopDes was used to estimate an optimal sparse sampling strategy for future clinical trials. Results: The PBPK model was successfully validated against the reported human pharmacokinetics. The model predicted optimal doses of 1200 mg QID, 1600 mg TID, 2900 mg BID in the fasted state and 700 mg QID, 900 mg TID and 1400 mg BID when given with food. For BID regimens an optimal sparse sampling strategy of 0.25, 1, 3 and 12h post dose was estimated. Conclusion: The PBPK model predicted tizoxanide concentrations within doses of nitazoxanide already given to humans previously. The reported dosing strategies provide a rational basis for design of clinical trials with nitazoxanide for the treatment or prevention of SARS-CoV-2 infection.

Objectives This study aims to determine the association between parosmia and clinically relevant recovery in olfactory function in patients with smell loss receiving olfactory training. Design and setting This was a retrospective cohort study of patients that received olfactory training. Adult patients with the major complaint of quantitative smell loss were recruited and treated at several ENT clinics in German between 2008 and 2018. Participants A total of 243 participants were included. Main outcome measures Changes in olfactory function after olfactory training. Age, gender, baseline olfactory function, etiology and duration of smell loss, duration of training, and presence of parosmia and phantosmia were assessed for their impact on clinically relevant changes in overall and subdimension olfactory function using binary logistic regression analysis. Results Relevant improvements in discrimination function were more likely in those that had lower baseline olfactory function, postinfectious reasons compared to posttraumatic or idiopathic causes and those that had parosmia at initial visit. Relevant improvements in odour identification were more likely in those that had a lower baseline olfactory function, female gender, and in those who had parosmia at the first visit. Clinically significant improvements in odour threshold were more likely in postinfectious causes compared to posttraumatic reasons and those who were older in age. Conclusions This study demonstrated that the presence of parosmia is associated with clinically relevant recovery in olfactory function in patients with smell loss receiving olfactory training.

Our understanding of IgE-mediated drug allergy relies on the hapten concept, which is well established in inducing reactions of the immune system to small molecules like drugs. The role of hapten-carrier adducts in re-challenge reactions leading to mast cell degranulation and anaphylaxis is unclear. Based on clinical observations, the speed of adduct formation, skin and in-vitro tests to inert drug molecules, a different explanation of IgE-mediated reactions to drugs is proposed: These are a) A natural role of reduced mast cell (MC) reactivity in developing IgE-mediated reactions to drugs. This MC-unresponsiveness is antigen-specific and covers the serum drug concentrations, but allows reactivity to locally higher concentrations. b) Some non-covalent drug-protein complexes rely on rather affine bindings and have a similar appearance as covalent hapten-carrier adducts. Such drug-protein complexes represent so-called “fake antigens”, as they are unable to induce immunity, but may react with and crosslink preformed drug-specific IgE. As they are formed very rapidly and in high concentrations, they may cause fulminant MC degranulation and anaphylaxis. c) The generation of covalent hapten-protein adducts requires hours, either because the formation of covalent bonds requires time or because first a metabolic step for forming a reactive metabolite is required. This slow process of stable adduct formation has the advantage that it may give time to desensitize mast cells, even in already sensitized individuals. The consequences of this new interpretation of IgE mediated reactions to drugs are potentially wide-reaching for IgE-mediated drug allergy but also allergy in general.

To the Editor:COVID-19 is a disease caused by severe acute respiratory syndrome coronavirus 2 of the genus Betacoronavirus (SARS-CoV-2). It was first described in Wuhan (China) on December 2019 and has spread to become a pandemic. Its clinical presentation is mainly characterized by cough, fever and dyspnea, although many other symptoms have been described within its presentation pattern. In some cases, it causes an acute respiratory distress that has lead to the death of thousands of people around the world. Furthermore, different type of skin lesions have been described during the infection period of illness due to SARS-CoV-2.1 The first report of cutaneous manifestations described different forms of skin lesions such as erythematous rash, urticaria and chicken-pox-like vesicles.2 In this exceptional situation of global health emergency, physicians are undertaking research work in order to achieve notions on the etiopathogenesis of these skin lesions. Acro-ischaemic lesions have also been notified and attributed to disseminated intravascular coagulation and to the expression of secondary microthrombosis due to endotelial damage.3-5However, to date, there is no clear understanding on whether the skin lesions are secondary to the viral infection nor why there are different presentations of skin lesions for the same viral infection.We present 4 patients with COVID-19, confirmed by positive polymerase chain reaction, who were referred to our service due to the appearance of skin lesions. Two of them developed skin lesions during hospitalization whilst presenting respiratory symptoms and the other two developed skin lesions many days after hospital discharge. Demographic data, description and histology of skin lesions, blood parameters, clinical symptoms and drugs administered are shown in table I. The algorithm of the spanish pharmacovigilance system (ASPS), which evaluates the possible implication of a drug reaction as a cause of the skin lesions6 was also applied. The ASPS analizes: i) the interval between drug administration and the aparition of skin lesions, ii) the degree of knowledge of the relationship between the drug and the effect described in literature, iii) the evaluation of drug withdrawal, iv) the rechallenge effect, and v) alternative causes. Each item receives and individual subscore, and a total sum ≥ 6 indicates a probable causality.6As mentioned above, skin lesions appear to be a sign within patients suffering from COVID-19. To date, no hypothesis has been proposed to explain if the lesions (including the different types) are attributable to the virus, to drug adverse reactions or to any other clinical condition. In our series, small enough to draw conclusions, we have found no differences between the multiple types of skin lesions and analytical or clinical features. Even in lesions with apparent vascular involvement, which have been associated with alterations in coagulation,3-5 the values detected do not differ from those with other types of skin lesions. Regarding drug involvement, since all the patients were exposed to multiple drugs at the same time, the ASPS was not able to differentiate the possibility of drug implication nor the immune mechanisms involved. Thus, further assays with selective (in vitro or in vivo ) tests for each drug seem necessary in order to completely rule out drug involvement. In addition, since many patients worldwide are being infected with SARS-Cov-2, and many of them present similar medical history and receive the same treatments, it seems necessary to investigate the existence of an individual predisposition that facilitates the developement of skin lesions. In this new scenario that we are facing in these last months, providing light on these still unresolved questions, can contribute to prevent or to manage the symptoms in an early way.

In the midst of a global public health crisis, medical providers find themselves on the frontline of unprecedented circumstances caring for patients as they fight the coronavirus disease 2019 (COVID-19) pandemic. Pediatricians are faced with the reality that COVID-19 positions marginalized groups of children and youths at an increased vulnerability to health care inequities. These at-risk groups include children and youth who are ethnic and racial minorities, immigrants, LGBTQ, homeless, in foster care, as well as those who have medically complex health conditions and/or mental health and substance use disorders (1, 2, 3). Now more than ever, health disparities have the potential to result in fatal health outcomes and healthcare professionals have the power to advocate for and protect their young patients. Given the urgent and pressing impacts of the current pandemic, Tsai and Kesselheim offer a timely and critical dialogue in this issue of Pediatric Blood & Cancer, focused on the effects of provider implicit bias that contribute to health disparities.Tsai and Kesselheim underscore the well documented literature on implicit bias in pediatric medical oncology and note the limited research in pediatric hematology-oncology, despite the complexities that exists in prognosis and treatment plans for this clinical population. Additionally, the case examples are thoughtful, transparent self-reflections from the authors personal clinical experiences with implicit bias in the field of pediatric hematology-oncology. The authors then outline a plan of action towards mitigating implicit bias in healthcare. They first emphasize the importance of acknowledging implicit bias, which is ubiquitous in human nature and exists under many circumstances. Subsequently, upon acknowledgment of existing implicit bias, providers should cultivate self-awareness via medical education in order to have the autonomy and ability to identify and detect implicit bias that negatively affect patient care. Moreover, the authors deduce that diversifying the medical team, both demographically and interprofessionally, can optimize detection of implicit bias. The authors go on to conclude that more research is needed in the specialty field of hematology-oncology to identify how implicit bias specifically affects provider’s ability to communicate complex diagnoses, prognoses, and treatment options.Derived from social psychology research, implicit bias refers to unconscious, unintentional, and automatic positively or negatively skewed classifications people make based on their own experiences and demographic background which then influences behavior and perceptions. The Institute of Medicine published a pivotal report illuminating how implicit bias can negatively influence patient care and may lead to health disparities (4). Examples of implicit bias affecting health outcomes include biases toward race, weight, sexual orientation, socioeconomic status, age, marital status and history of drug use (5, 6). There are two paths that may explain how implicit bias amongst medical providers may contribute to health disparities (5, See Figure 1). Path A suggests provider judgements and decisions regarding patient care can result in health disparities. Path B proposes that implicit bias amongst providers can lead to ineffective communication which affects the providers ability to cultivate a trusting relationship and environment. Patient’s distrust with their providers affects their willingness and ability to adhere to treatment recommendations which subsequently leads to health disparities. Moreover, this model also explains the conduit for interaction effects between path A and B. That is, compromised judgment leading to poor medical decisions may strengthen the probability of poor communication and distrust in the provider-patient relationship or the inverse. Also imperative to the discourse of health disparities and bias, not discussed by Tsai and Kesselheim, is the notion of “privilege” that, unlike minorities, many non-minorities may experience in their rise to becoming a medical professional as well as their medical decision making (7). Such privilege can inadvertently bias providers to behave in ways that illuminate implicit bias. Therefore, the ability to acknowledge privilege is essential to increasing one’s proclivity to recognize their implicit biases. The authors provide vignettes that pointedly describe the importance of self-awareness. Practicing self-awareness promotes the ability to detect implicit biases that may affect patient care and result in unintentional health disparities. Moreover, central to the author’s argument, it is fundamentally important to identify and implement practical steps to address provider implicit bias.The use of research to inform best clinical practice by implementing skills training is key in addressing health disparities related to provider implicit bias. A potential barrier to successful training and education on provider implicit bias is limited support from institutional leadership (8). Committed leadership on curricula related to implicit bias at an institutional level is likely to reflect long-term systemic change (9, 10). Furthermore, providing a nonjudgmental and safe environment for providers to address difficult content is also key in fostering self-awareness that is more likely to result in long-term change (10). Considering the role of power dynamics in practice and training is also fundamental for cultivating a safe environment for self-disclosure and self-awareness and bringing about systemic long-standing modifications. Tsai and Kesselheim highlight the importance of building demographically diverse and interdisciplinary medical teams. Purposeful team development can also reveal and mitigate any systemic workforce and recruitment biases (11). Having various perspectives while discussing a treatment plan can combat implicit bias. For example, if a complex case is presented at morning rounds with a team that is homogeneous in background and trainings there is potential for groupthink that is anchored in one or two individuals’ implicit biases. Specific to complex cases in pediatric hematology-oncology this can be critical especially during a pandemic that is particularly impacting vulnerable populations, who are often less likely to be represented among medical decision makers. A diverse team can provide insight for culturally competent care as well as provide important perspectives that could optimize diagnostic and treatment outcomes.As a clinician, it is not an easy task to be open to becoming vulnerable to exploring self-awareness as it relates to implicit bias. It is also our ethical duty to do no harm. Acknowledging implicit bias as a catalyst to health disparities while implementing effective skills training to address implicit bias is crucial to protecting our most vulnerable pediatric patients.ReferencesSilliman Cohen RI, Adlin Bosk E. Vulnerable youth and the COVID-19 pandemic. Pediatrics . 2020; doi: 10.1542/peds.2020-1306Cholera R, Falusi OO, Linton JM. Sheltering in place in a xenophobic climate: 12 COVID-19 and children in immigrant families. Pediatrics. 2020; doi: 10.1542/peds.2020-1094Wong CA, Ming D, Maslow G, Gifford EJ. Mitigating the impacts of the COVID-19 pandemic response on at-risk children. Pediatrics . 2020; doi: 10.1542/peds.2020-0973Smedley BD, Stith SY, Nelson AR, Smedley BD, Stith SY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Institute of Medicine. National Academies Press; Washington, D.C: 2002. doi.org/10.17226/12875Zestcott C, Blair I, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Processes & Intergroup Relations . 2016;19(4):528-542. doi:10.1177/1368430216642029DelFattore J. Death by Stereotype? Cancer Treatment in Unmarried Patients. New England Journal of Medicine . 2019;381(10):982-985. doi:10.1056/nejmms1902657Hall J, Carlson K. Marginalization. Advances in Nursing Science . 2016;39(3):200-215. doi:10.1097/ans.0000000000000123Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Academic Emergency Medicine. 2017;24(8):895-904. doi:10.1111/acem.13214Pereda B, Montoya M. Addressing Implicit Bias to Improve Cross-cultural Care. Clin Obstet Gynecol . 2018;61(1):2-9. doi:10.1097/grf.0000000000000341Sherman M, Ricco J, Nelson S, Nezhad S, Prasad S. Implicit Bias Training in Residency Program: Aiming for Enduring Effects. Fam Med. 2019;51(8):677-681. doi:10.22454/fammed.2019.947255Hall W, Chapman M, Lee K et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health. 2015;105(12):2588-2588. doi:10.2105/ajph.2015.302903a

Background: Hypertension and sarcopenia are commonly seen in older adults. The renin-angiotensin system and the therapeutic use of angiotensin converting enzyme (ACE) inhibitors have been on the agenda of sarcopenia in different perspectives. Our aim was to explore the frequency of sarcopenia in patients with hypertension and to investigate the association between the use of ACE inhibitors and sarcopenia. Methods: A total of 233 community dwelling adults were recruited. Anterior thigh muscle thickness was measured by ultrasound. Handgrip strength, gait speed and chair stand test were evaluated. Presarcopenia was diagnosed in the presence of low sonographic thigh adjustment ratio (STAR) values and sarcopenia was diagnosed if low STAR values were coupled with low functional tests. Results: 109 subjects (46.8%) had no comorbid disease; 93 (75.0%) had one, 21 (16.9%) had two, eight (6.5%) had three and two (1.6%) had four comorbid diseases. Both presarcopenia (48.3% vs. 21.1%) and sarcopenia (33.3% vs. 7.0%) were more commonly seen in hypertensive when compared to normotensive older adults. Subgroup analysis of older adults with hypertension revealed that sarcopenia was less prevalent (p=0.020) in patients using ACE inhibitors (9.1%) than those using angiotensin receptor blockers (ARBs) (40.5%) and other antihypertensive drugs (42.9%). After binary logistic regression analyses; only the presence of hypertension seemed to independently predict the development of sarcopenia in older adults [OR=7.9 (95% CI: 2.6-24.5, p<0.001)]. Conclusions: Sarcopenia is highly prevalent in hypertensive older adults. Among many antihypertensive medications, ACE inhibitors seem to have favorable effects on both disorders.

Global climate change and extensive socio-economic development together decrease ground cover in the semi-arid sandy grasslands of Horqin district in northern China and thereby increase the direct exposure of surface soil to erosion by strong winds—a process that ultimately converts the grassland into a sandy desert. Three ways to restore such degraded lands through afforestation were evaluated in terms of total carbon stored in the restored ecosystems compared to that in the control. Total carbon comprised that stored in the biomass of trees, herbs, and standing litter and in soil (up to a depth of 100 cm). The three restoration treatments were (1) enclosing the grassland within a shelter belt of Populus × beijingensis, (2) afforesting small but well-distributed patches within the grassland using Pinus sylvestris var. mongolica, and (3) similar afforestation using Ulmus pumila. Total ecosystem carbon storage increased significantly in all the three treatments over more than 20 years; at the end of that period, total ecosystem carbon was maximum (104.29 t/ha) in the grassland enclosed by the forest belt, followed, in that order, by afforestation with P. sylvestris (102.96 t/ha), that with U. pumila (92.24 t/ha), and the control (24.48 t/ha). The structure of the plant community created by these treatments is different from that found in natural stands of forest and in grasslands without trees or shrubs, and all the three treatments are suitable for restoring the moderately desertified sandy grasslands in south-eastern Horqin, northern China, depending on the availability of water and soil nutrients.

COVID-19, a newly discovered virus disease, can be affected by probiotics. So, we tried to review the possible effects and associations of probiotics on viral infections focusing on SARS-CoV-2. We searched on PubMed, EMBASE, Google Scholar, Science Direct, Scopus and Web of Science up to May 2020 to identify interventional & observational studies documenting the effects of probiotics strains on interleukins, virus titres, and antibody production with a focus on confirmed diagnosis of SARS-CoV-2 infection. From a total of 93 records, 21 studies were obtained and classified into three domains based on the efficacy of probiotics on 1)the level of interleukins (n=7), 2)virus titres reduction (n=2), and 3)antibody production (n=12). The suppuration of proinflammatory interleukins and type I interferon (IFN) production seemed to be the main anti-viral strategy of probiotics. Based on evidence, some probiotic strains may be useful in SARS-CoV-2 infection; randomized trials are needed to confirm these findings.

In this case report we described the results in a patient whose left anterior descending coronary artery (LAD) was totally occluded. We revascularized the patient with diffuse atherosclerosis in LAD only by performing endarterectomy without CABG. We think that this method may be an alternative technique to conventional revascularization in LAD diffuse atherosclerosis

During coronavirus disease 2019 (COVID-19) pandemic, coinfections with other viral infections are not uncommon, but concomitant atypical bacteria are rare. Herein, we describe a young female COVID-19 patient who developed acute cold agglutinin disease secondary to Mycoplasma pneumoniae. Using an azithromycin-containing COVID-19 therapeutic regimen, both pneumonia and anemia resolved uneventfully.

Portal Hypertension is not a classical presentation of Caroli's Syndrome. However, some young children can present with overt signs and symptoms indicative of advanced disease state despite the improvement in imaging technology which has decreased its diagnostic age. High index of clinical suspicion can help in timely diagnosis and management

A 63 year old patient with chronic lymphocytosis and neutropenia is described. A bone marrow biopsy showed a markedly hypercellular specimen with an interstitial and intrasinusoidal lymphoid infiltrate. Immunohistochemistry and immunophenotyping identified these as LGLs. With paucity of erythropoiesis diagnosis of LGL leukemia with pure red cell aplasia is reached.

Roe deer (Capreolus spp.) are a little odd. They are one of only a few placental mammals — and the only genus among even-toed ungulates — capable of putting embryonic development “on ice”, also known as embryonic diapause (Fig. 1). It would seem such an unusual trait is likely the product of natural selection, but a big question is, how does selection for important traits, such as diapause, interact with the historical demography of a species? In a ‘From the Cover’ article in this issue of Molecular Ecology, de Jong et al. (2020) demonstrate that selection is acting on genes associated with reproductive biology in roe deer, despite heightened genetic drift due to reduced effective population size through the Pleistocene.

The objective of this study is to increase awareness of a rare and atypical presentation of a large glomus tympanicum coexisting with a cholesteatoma in a patient who presented with infectious otorrhea and sensorineural hearing loss.

The present study reports nonlinear optical properties such as first and second hyper polarizabilities (β and γ) of Y-shaped polymer (P1) and substituted polymers. The basic Y-shaped polymer (R=R1=H) named as P1. Upon substitution of one OCH3 group in ortho position of Oxygen becomes polymer P2 (R1=H, R=OCH3) and two OCH3 group as P3 (R1=R=OCH3). We have also reported structural parameters, vibrational and electronic absorption spectra of polymer and substituted using quantum chemical methods. The geometrical parameters such as dipole moment, bond length and angles are reported at B3LYP/6-311++g** level of theory. In addition, the vibrational, electronic absorption spectra and NLO properties are also reported at the same level of theory. There is significant change in dipole moment and energy observed whereas symmetry, bond length and angles are resembling in Y-shaped and substituted polymer. The vibrational spectra of Y-shaped polymer (P1) having the intense peak is C-H stretching mode observed at 1258 cm-1. These Theoretical vibrational modes are well matching with available experimental determinations. The method dependent and the along the X, Y and Z-direction hyperpolarizabilites also reported. This study confirms the polymer P1 and P2 showing first and second hyperpolarizability response whereas P3 do not show. The electronic absorption spectra for polymer and substituted polymers are also reported at the same level of theory using (TDDFT) approach. The wavelength of electronic transition, oscillator strength and HOMO-LUMO gap also reported.

Recently, because of regional climate changes and human activities, the risk and intensity of droughts in the upper and middle Huaihe River Basin, China, have increased. These changes in rainfall may have, in turn, had an influence on the pathways of nitrate transport in this predominantly agricultural watershed. In this study, the characteristics of nitrate transport over consecutive dry years in this watershed were examined using records of streamflow and nitrate concentration data that spanned a period of 12 years (2007-2018) that included 3 consecutive dry years (2011–2013). The baseflow was separated from the streamflow using a digital filter method and the nitrate loads were estimated using a regression method. The annual discharge and nitrate load in streamflow and baseflow averaged 23.5 billion m3 and 41.9 kiloton (kt), and 7.4 billion m3 and 14.7 kt, respectively. Baseflow contributed more to the total discharge and total nitrate load in the consecutive dry years (41.0% of the total discharge and 56.2% of the total nitrate load) than in wet, normal, and single dry years. Averaged over the whole study period, the monthly baseflow nitrate index (BFNI) was higher than 50% in the dry season and lower than 30% in the flood season. Over the study period, the annual baseflow enrichment ratio (BER) ranged from 0.94 to 1.46 and averaged 1.13, and was highest (1.46) in the consecutive dry years. The results suggest that nitrate was mainly transported to surface water via baseflow during dry conditions and that this process was particularly important during the consecutive dry years. Therefore, to protect surface water, measures should be urgently implemented to control nitrate transport in groundwater during consecutive dry years.

The manuscript "A Comparison of Quantum and Traditional Fourier Transform Computations" discusses a very important and often overlooked aspect of quantum computing, namely a fair and detailed comparison of a quantum algorithm, its classical simulation, and its classical counterpart taking into account the complexity of I/O. Such an article is valuable and worth publishing. The current manuscript, however, still contains some inaccuracies that should be fixed and I will make suggestion on how the presentation can be improved.Let me first summarize the main result in my own words: a quantum Fourier transform (QFT) can calculate the Fourier transform of a vector with time complexity \(O\left(\log^2N\right)\), compared to the complexity \(O\left(N\log N\right)\) of a classical FFT. However, if one needs to read out the full vector instead, the complexity becomes \(O\left(N \text{ polylog}(N) \right)\) again, without an advantage over the classical algorithm. It is actually worse than the author discusses, if one also takes into account the complexity of loading the initial state. Loading an initial classical data vector has complexity \(O\left(N\right)\), and this has to be repeated at every repetition, giving a complexity of \(O\left(N^2\ \text{polylog}\ N\right)\), worse than classical. As the author correctly mentions, the QFT is thus a useful algorithm if the input data is prepared algorithmically, and limited sampling of the result vector is sufficient, as is the case for Shor's algorithm.This is a valuable observation that deserves a paper in CiSE, since these important considerations are not all known to people outside the quantum computing community, and are sometimes  ignored even by quantum computing specialists. I thus want to encourage the author to improve the presentation to make it more accessible to a broader audience and fix a couple of technical flaws.Before discussing presentation issues, I want to address one technical flaw and a few points where more clarity is needed: This statement towards the end is too simplistic and needs to be clarified: "...  if we want to measure each coefficient, we must redo our operations for each coefficient (since our wave function will collapse for every measurement)." The manuscript does not explain how to read out a specific coefficient. If one samples the wave function, one measures the result and gets a certain value \((s_1, \cdots,\ s_N)\) with a probability depending on the wave function. More complex amplitude-estimation algorithms are needed to read out specific coefficients, which then takes time \(O(N/\epsilon)\). This needs to be better explained.  This also raises another issue of normalization and precision. The quantum wave function has to be normalized to have an \(L_2\) norm of \(1\). We thus need to measure to a precision of epsilon divided by the \(L_2\) norm of the classical data, and if that increases with \(N\) the scaling is even worse. For example, if all entries are of order unity, the \(L_2\) norm is \(\sqrt{N}\). The one technical flaw in the paper is in preparing the input state to the QFT, and the complexity of the classical simulation of the quantum algorithm.  There, the numbers are wrong. The classical complexity can easily be estimated by realizing that any sparse quantum gate (such as a 1-qubit or 1-qubit gate) can be simulated in time \(O(N)=O(2^n)\), where \(N=2^n\). Thus, the overhead is just \(O(N)\), not \(O(N^2)\), and the simulation complexity is just \(O(N)\) times the complexity of the quantum algorithm. This will be more apparent if, as I propose below, the author shows the quantum algorithm also through a sequence of quantum gates. However, note that in the simulation we then have the full vector, and thus do not incur the overhead of quantum state tomography. We need to simulate the algorithm only once and not \(O(N/\epsilon)\) times. This means the simulation remains at \(O(N\ \log^2{N})\) even if we read out all entries, which is not bad compared to the classical \(O(N\ \log{N})\) of the FFT. The reason why the author seems to end with a different complexity is that his Matlab simulation does not simulate the quantum algorithm but the computation of the effect of the QFT applied to just one basis state. That is a suboptimal implementation. I thus propose to replace the Matlab code by a discussion of how a quantum gate (Hadamard or controlled phase rotation) can be implemented, and that will then nicely give the scaling discussed above.As mentioned in my summary at the beginning, the value of the paper can be increased if the author could also discuss the complexity of quantum state preparation from classical input data, e.g., following Shende-Bullock-Markov \citep{markov2006}, which has a complexity of \(O\left(N\ \log\ \frac{1}{\epsilon}\right)\). That means, that if the data is read from a classical vector (and not computed as, e.g., in Shor's algorithm), then the complexity of state preparation of  \(O\left(N\ \log\ \frac{1}{\epsilon}\right)\) completely dominates the QFT itself, and if one furthermore wants to read out the full vector instead of sampling it, the complexity becomes \(O\left(N^2\log^2\left(\frac{1}{\epsilon}\right)\right)\).In the conclusion the author writes that "QEC research is still in very early development and it is currently difficult to determine how the required resources for these corrections could scale with qubit usage." That is incorrect, as the overhead is pretty well known by now for certain QEC codes, such as the surface code. The asymptotic scaling of the overhead has long been known, and also detailed resource costs have been worked out for various algorithms. I suggest to focus the QEC section on the need for fault tolerance, and the large overhead associated with it. This is definitely not something that can be done on NISQ devices at an interesting scale. I would also use another reference for QEC than the Gil Kalai paper.Now, to suggestions for improved presentation:In the abstract, I suggest to present fewer technical details. "radix-2 DIT case of the Cooley-Tukey Algorithm" can just be called Fast Fourier transform,  the QUBIT4MATLAB package does not need to be mentioned in the abstract, and neither does the "Master Theorem" have to be mentioned.In the abstract and in the rest of the paper, it is also better to talk about quantum speedup and not quantum supremacy. The paper is about asymptotic scaling (the author uses the big-O notation throughout), and not about supremacy, which is a specific size problem that is solved better on quantum hardware rather than classical hardware. A supremacy claim needs all constants to be worked out, and assumptions for the specific classical and quantum hardware. Replacing quantum supremacy by quantum speedup can fix this. The observations are still valuable and correct.The first section is called "The shortcomings of classical computing and the early developments of quantum computing". That title sounds strange to me. What are the shortcomings? The author may rather want to stress the additional capabilities of quantum computers. Given that most readers will not be physicists and have no experience with quantum mechanics, it would be valuable to expand this first section. Discuss equation (3) before equation (1), and then introduce equation (1), to show that this means that the state of a qubit is actually a two-dimensional complex vector, After that only go to the many-quit state. After equation 4 it may be good to talk about amplitudes first, and then probabilities. Saying that the state is determined by "the qubit simply has a probability...", ignores the all important phases that are the crucial difference between quantum computing and probabilistic classical computing. "Quantum gates, unlike classical gates, do not delete information and are fully reversible." Needs further explanation. This comes from the reversibility of the microscopic laws of physics. Here it may be worthwhile to mention that, as quantum gates are time evolution of a quantum system, they are unitary operators on the Hilbert space that was introduced above. The discussion in the next sentence about them not using energy is misleading as well. In fact, the control and operation of the quantum gate always needs energy. It is only the free evolution of a quantum system that conserves energy. The part on " subatomic systems such as a superposition of quantum states. " would also need more explanation. Does the author here want to describe specific implementations of qubits? If so, more detail is needed. If not, I propose to drop this part."The definition and use of the classical discrete Fourier transform": here is an abrupt jump from Shor's algorithm to the DFT. Since Shor's algorithm again gets mentioned later on as a case where the QFT is better than a classical DFT, it make sense to discuss more details of Shor's algorithm, and that in essence it solvers the factor problem by using a QFT to find the period of a function. In light of the above complexity discussion this is important: we don't deal with classical data that one has to load but with a state that is computed (the function f(x) = a^x mod N ), and one is not interested in the full vector but just in finding the period. This can be done just by measuring the result of the QFT, which in this particular case will return a random multiple of the base frequency, and with a few repeated measurements one can then extract the period).The Fourier transform should be well known to the reader, and it is thus not obvious to me that equation 6 is needed. I would instead introduce \omega in equation 5. For the discussion of the implementation I suggest to mention that the rest of the paper limits itself to the case of powers of 2, i.e. N=2^n, for which the radix-2 version applies. Since the implementation is well known for most computational scientists, it could be moved from to supplementary material, as can be the derivation of the O(N log N) complexity, which is also well known.In the discussion of the QFT, unfortunately the quantum algorithm is not presented. What is presented is the mathematical unitary operation. It would be very valuable for the reader to see an actual implementation of the quantum algorithm, i.e. the sequence of O(n^2) Hadamard gates and controlled rotations – either as a circuit drawing, or more useful as quantum code, either using a quantum programming language that allows loops (such as Q#), or as some quantum pseudo code with loops. Then the reader will see the sequence of O(n^2) operations and how it creates the unitary operation of the QFT."The implementation of the QFT in MATLAB...". This section can be improved as well., As discussed above, the Matlab code does not implement the quantum algorithm but rather implements the application of the unitary operation to one of the basis states. It would be more useful for the reader to instead get implementations of the Hadamard and controlled phase gates, which could then be combined with the above quantum algorithm (maybe all in Matlab even?) for a full simulation of the algorithm – and in time O(N n^2), not O(N^2 n^2)."Evaluating the complexity of the QFT Implementation" – I discussed the issues with the complexity estimates already above. If one replaces it by an estimate of the complexity of simulating the H and controlled phase gate each in O(N) operations then it both becomes simpler and the complexity becomes just O(N) times that of the quantum version"Evaluating the complexity of the theoretical form of the QFT Implementation”. I assume that by "theoretical" the author means the actual quantum operation? The comparison section needs to be fixed, since that's where there is the mentioned flaw based on the suboptimal Matlab code, and that will also change table 1. I suggest that table 1 could have three cases: A) ignoring state preparation and one only wants to sample the output a constant number of times; B) ignoring state preparation but one wants to read the full vector; C) including state preparation from classical data and one only wants to sample the output a constant number of times; D) including state preparation from classical data and one wants to read the full vectorThe reader will then see that only case A has a speedup, and that in the other cases even the simulation of the quantum algorithm is faster than the quantum algorithm on a quantum computer.The conclusions should then be updated, taking these slightly modified comparisons into account. The case of Shor's algorithm, which falls into category A) above, is indeed interesting but deserves a deeper explanation so that the reader understands that Shor's algorithm can compute the input with complexity \(O\left(N^3\right)\) (up to log factors), and why only a few samples of the output are needed. That way, the exponential speedup over the FFT remains, and the super polynomial speedup over the name sieve. However, if classical data has to be loaded or should be returned then there is no speedup. I call this the I/O problem of quantum algorithms, which indeed—as the author writes—means that in these cases quantum computing is no better than classical computing.This is an important observation that the paper beautifully works out. Fixing the flaw in the simulation section and improving the presentation will make this a very nice paper.

Oreste Gallo, MD; Luca Giovanni Locatello, MDDepartment of Otorhinolaryngology, Careggi University Hospital, Florence - Largo Brambilla, 3 - 50134 Florence, Italy* Corresponding author: Prof. Oreste Gallo, MD, Department of Otorhinolaryngology, Careggi University Hospital, Florence - Largo Brambilla, 3 - 50134 Firenze, Italy. +39 0557947989, oreste.gallo at unifi.itKeywords: COVID-19, laser-assisted surgery, surgical plume, prevention, surgical safetyAuthors’ contributions: Gallo: Conceptualization, supervision and writing - review and editing; Locatello: Conceptualization, resources, supervision, and writing - review and editing.Conflict of Interest: all authors declare they have nothing to disclose.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Many of the safety issues related to the novel COVID-19 in our routine surgical practice were thoroughly presented in this Journal. [1] However, the authors did not discuss an important field of head and neck surgery: laser-assisted procedures. Historically, human-papillomavirus (HPV) in the setting of respiratory recurrent papillomatosis is the prototype of the biological hazards of the laser-generated surgical plume.[2] In the past, it was shown that surgical vaporization was capable to contaminate the staff’s personal protective equipment (PPE) with viable and infectious HPV virions. [2] Despite the growing evidence documenting a key role of high-risk HPV infections in the pathogenesis and development of head and neck cancer, the risk assessment of potential viral infection after exposure to laser plume is still controversial. [3] The biohazard might not be limited to HPV airborne transmission, but also other bacteria and viruses, including (possibly) SARS-CoV-2. For instance, Kwak et al. documented Hepatitis B (HBV) DNA in surgical smoke from 10 out of 11 HBV+ patients undergoing robotic laparoscopic surgery thus suggesting a potential risk of airborne HBV infection.[4] Heat-generating procedures by electrosurgical equipment or lasers can induce thermal disruption of viable human cells and they are able to aerosolize hazardous particles. The thermal effect of lasers on biological tissues is a complex process resulting from the conversion of light to heat whose effects depend upon several factors: the physical denaturation and/or destruction is a function of laser settings (wavelength, power, time and mode of emission, beam profile, and spot size) and the target of the procedure (thermal parameters, optical coefficient, etc.).[5,6] During ablative surgery, the tissue is heated by the absorbed laser energy and it evaporates or sublimates, while, at higher power, the tissue is typically converted to plasma. This means that during laser-tissue interaction aerosolized blood and interstitial and intracellular fluids, along with their possible burden of viral pathogens and hazardous chemicals are forcefully ejected in the operating room.[6] Nonetheless, controversies exist in the literature regarding efficient viral infection of healthcare staff after exposure to surgical smoke. [3,5,6]Surgical use of different types of lasers (CO2, Nd:YAG, KTP…) is common not only in the head and neck but also in gynecology, dermatology, and respiratory medicine among other fields. Even though there is a lack of conclusive data on plume-borne contamination, there is an urgent need to raise awareness of its risks during the COVID-19 pandemic. In the next years, our daily practice of transoral laser-assisted surgery, an incontournable strategy to treat several benign and malignant lesions of the upper aerodigestive tract with excellent oncological and functional results, is going to be deeply modified. High viral loads, especially in the nose and the pharynx, can be detected after symptom onset but general consensus exists on SARS-CoV-2 diffusion by droplet transmission even from asymptomatic individuals, therefore it is conceivable that every laser procedure is to be considered as high-risk.[7]While waiting for more robust specific evidence, we would like to recall some precautionary measures, inspired by the most recent literature,[8] that ought to be implemented for all laser-assisted procedures:Always discuss alternative therapeutic strategies in a multidisciplinary team and postpone laser therapy if it is not urgent;Perform RT-PCR test for detection of SARS-CoV-2 RNA before every procedure;During routine preoperative exams, non-enhanced chest computed tomography is reported to have a higher sensitivity for COVID-19 detection than RT-PCR;For small and easily accessible lesions, resection by cold instruments should be preferred;Laser surgery should be performed in an operating room with a highly efficient negative-pressure system;Sterilize laser handpieces after use and frequently change surgical gloves, especially after direct contact with the instrument;8. All the staff should wear highly protective PPE, including goggles and gloves and highly protective masks (i.e., N95) with gas adsorption filters;9. Disposable double plume evacuation systems with filters that remove particulates up to 0.1 microns (the so-called ULPA, ultra-low particulate air filters) should be available;10. Reduce the presence in the theater of all the unnecessary personnel and perform adequate training for all staff members to enhance awareness about the hazards of the surgical smoke in the COVID-19 outbreak.In this evolving context, head and neck laser-assisted surgery must be in all cases considered a high-risk aerosol-generating procedure and the highest attention must be paid to surgical safety until evidence-based protocols are available.

The COVID-19 pandemic has had a significant impact on many aspects of head and neck cancer care.  The uncertainty and stress resulting from these changes has led many patients and caregivers to turn to head and neck cancer advocacy groups for guidance and support.  Here we outline some of the issues being faced by head and neck cancer patients during the current crisis and provide examples of programs being developed by advocacy groups to address them.  We also highlight the increased utilization of these organizations that has been observed as well as some of the challenges being faced by these not-for-profit groups as they work to serve the head and neck community. 

Unprecedented times call for extraordinary measures. While surgeons across the globe try to comprehend the evolving façade of the COVID 19 pandemic and improvise surgical practice to the best of their ability, the psychological impact of the stress on their own mental health and wellbeing has been underestimated. This paper aims to review the indirect and overt factors that may affect the mental health of a surgeon in the present circumstances. Furthermore, it will aim to highlight key coping mechanisms at individual and institutional level, so as to mitigate the negative psychological impact on surgeons.