Corticosteroids Administration Following COVID-19-induced Acute Respiratory Distress Syndrome. Is it harmful or Life-saving?

Until now, April 22, 2020, Covid-19 has been confirmed in 2471136 patients and 203 countries and territories with mortality rate over 169000 patients. Right now, there is no definite cure for it and developing treatments including vaccines and antiviral compounds are under evaluations for efficacy. Covid-19 infection can be mild, severe, or even critical. The symptoms may range from fever (the most common symptom), chills, fatigue and cough to decreased arterial oxygen saturation, changes in respiratory rate and dyspnea. The dyspnea in critically patients is more severe. In severe cases, respiratory failure, acute respiratory distress syndrome (ARDS) and septic shock have been reported. Septic shock is also associated with hypoxia and acidosis. ARDS is the most important cause of death in this group of patients. This feature of the disease may be caused by various factors, including inflammatory mediators and cytokine storm. The computed tomography (CT) imaging findings have shown that the lung with ARDS has a ground-glass appearance, in which white fluid-filled patches are seen inside the lung. The fluid inside these patches has a jelly state. Pathological samples obtained from lung tissue also indicate pulmonary damage, obvious destruction of pneumocytes and formation of a hyaluronan membrane, which more emphasized on ARDS occurrence. Cytokine storm caused by Covid-19 infection is a severe immune response. The occurrence of cytokine storm can lead to severe tissue damages. Pre-inflammatory factors are involved in this process and one of them is interleukin 6 (IL-6) which affects different cells. IL-6 performs various functions such as regulating body temperature, increasing the production of acute phase protein and differentiation of B cells. On the other hand, the production of interleukin 1 (IL-1) as an inflammatory mediator will be increased during cytokine storm, as well. IL-1 can cause fever and stimulating the production of hyaluronan which has been seen in fibrosis. Based on studies on SARS-CoV, rapid spread and proliferation of the virus as a result of delayed interferon-1 production and subsequent rapid accumulation of macrophages and monocytes may also be involved in tissue destructions and a similar mechanism might be seen in Covid-19 infection. When there is no proper immune system response, the virus causes extensive tissue damages, especially to organs where ACE2 is most commonly seen, such as the lungs. Therefore, since the lungs are damaged, efforts should be focused on suppressing the inflammation, managing the symptoms and theoretically any compounds that may help this inflammation subside could play an important role in reducing the incidence of ARDS and consequently the mortality rate. The use of corticosteroids in different phases of ARDS has been inconsistent with conflicting results. Corticosteroids exert their anti-inflammatory effects by regulating the signaling pathways on the membrane and inside the cells, stopping pre-inflammatory gene-related processes (genes responsible for producing pre-inflammatory factors). Furthermore, they are able to increase the production of anti-inflammatory mediators such as interleukin 10 (IL-10). Corticosteroids have been investigated in some clinical protocols for evaluation of their effectiveness in reducing inflammatory responses and cytokine storm. According to the guideline of World Health Organization (WHO), systemic corticosteroids should not be routinely used in viral pneumonia except in clinical trials. However, WHO has recommended that these compounds can be used in exacerbations of asthma and COPD, and septic shock, considering each patient's condition and assessing the benefits and risks. This guideline further states that the use of corticosteroids in similar conditions such as influenza may lead to secondary super infections and increase mortality rate. But in another study on SARS-CoV, the use of corticosteroids was associated with improvement in time to survival in severe patients and decrease in mortality rate. Delayed viral clearance is another concern. In a study on patients with MERS-CoV, the use of corticosteroids did not make a significant difference in mortality rate. However, its association with a delay in viral clearance from the lungs of patients was reported. Side effects are another limiting factors for use of corticosteroids in patients with Covid-19. A similar study in patients with SARS-CoV showed that use of higher doses of corticosteroids in such conditions could cause a corticosteroid-induced diabetes, with 36.3% of patients experiencing such complication. The guideline of Surviving Sepsis Campaign for the management of patients with Covid-19 has recommended the use of corticosteroids under the following conditions: 1) in patients with Covid-19 who are suffering from septic shock, the use of corticosteroids (low-dose) are preferred over not using it. The guideline notes that there is no difference in mortality rate and side effects. However, there is weak recommendation that using corticosteroids in these conditions can reduce the time of resolution of shock and ICU and hospital length of staying; 2) In cytokine storm, if the patient has not yet developed ARDS, corticosteroids are recommended in ways other than routine procedures, and if ARDS occurred, the use of these compounds is recommended over not using them. Lesser need of oxygen, improved radiographic findings and reduced length of staying in ICU and hospital are some of the advantages that this guideline has referred to. However, there is just a week recommendation over the use of these compounds in this guideline. Based on what has been discussed, it could be concluded that the use of corticosteroids in the current situation should be limited, since there are no significant benefits over their effectiveness. On the other hand, there is a risk in prolongation of viral clearance and secondary infections and mortality rate. The use of these compounds should be limited to clinical trials to further evaluate their effectiveness in this new found disease. The clinical conditions of patients should be carefully evaluated throughout the studies and close monitoring should be performed while discontinuing these drugs

Exploring and Evaluating the Effects of Strategic Positioning on Firms Performance with Regard to Physical and Perceptual Positioning

Purpose - The purpose of this paper is to analyze the strategic positioning in door manufacturing industries operating in Iran and to identify the main factors which may have significant influence on the adoption of a physical and perceptual positioning strategy by a firm.Design/ Methodology/ Approach - The paper considers six firm-specific characteristics which can be associated with the adoption of a physical and perceptual positioning strategy which include: technical characteristics, physical characteristics, objective criteria, paying attention to customer’s needs, perceptual characteristics, and subjective criteria.Findings - The results indicate that there is a positive relationship between technical characteristics and physical positioning, a positive relationship between subjective criteria and perceptual positioning, a significant relationship between physical positioning and strategic positioning, and a significant relationship between perceptual positioning and strategic positioning. However, there is not a positive relationship between physical characteristics and physical positioning, there is not a positive relationship between objective criteria and physical positioning, there is not a positive relationship between customer’s needs and perceptual positioning, and there is not a positive relationship between perceptual characteristics and perceptual positioning.Originality/ Value - The paper adds to the international data on physical and perceptual positioning by providing what may well be a first influencing factor on industries operating in Iran situations for production.Key words: Strategic positioning; Physical positioning; Perceptual positioning; Competition; Differentiatio

Diode Laser in Minor Oral Surgery: A Case Series of Laser Removal of Different Benign Exophytic Lesions

Introduction: The role of laser in conservative management of oral disease is well established. Laser procedures are common in the fields of oral surgery, implant dentistry, endodontic, and periodontic therapy.Case: This case series describes the use of diode laser for the excision of oral exophytic lesions. All the patients attended the oral medicine department of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Criteria in patient selection were accessibility to lesions, patient fear from blade surgery, aesthetics, and probability of bleeding. An informed consent was filled by every patient. All of the lesions were completely excised under local anaesthesia by diode laser with 300 μm-fibre tip, 808 nm continuous wavelength and 3-3.5 W power for 3×60 seconds (Dr Smile, Italia). During surgery, the fibre tip was in contact with lesions. No analgesics were prescribed to the patients. The patients were followed for the first, second, and forth week after treatment.Conclusion: The lesions could be excised using the diode laser. This procedure was a quick clinical technique without bleeding

Effect Of The Cardio First Angel™ Device On CPR Indices: A Randomized Controlled Clinical Trial

Background: A number of cardiopulmonary resuscitation (CPR) adjunct devices have been developed to improve the consistency and quality of manual chest compressions. We investigated whether a CPR feedback device would improve CPR quality and consistency, as well as patient survival. Methods: We conducted a randomized controlled study of patients undergoing CPR for cardiac arrest in the mixed medical-surgical intensive care units of four academic teaching hospitals. Patients were randomized to receive either standard manual CPR or CPR using the Cardio First Angel™ CPR feedback device. Recorded variables included guideline adherence, CPR quality, return of spontaneous circulation (ROSC) rates, and CPR-associated morbidity. Results: A total of 229 subjects were randomized; 149 were excluded; and 80 were included. Patient demographics were similar. Adherence to published CPR guidelines and CPR quality was significantly improved in the intervention group (p \u3c 0.0001), as were ROSC rates (72 % vs. 35 %; p = 0.001). A significant decrease was observed in rib fractures (57 % vs. 85 %; p = 0.02), but not sternum fractures (5 % vs. 17 %; p = 0.15). Conclusions: Use of the Cardio First Angel™ CPR feedback device improved adherence to published CPR guidelines and CPR quality, and it was associated with increased rates of ROSC. A decrease in rib but not sternum fractures was observed with device use. Further independent prospective validation is warranted to determine if these results are reproducible in other acute care settings

Detection of Carious Lesions and Restorations Using Particle Swarm Optimization Algorithm

Background/Purpose. In terms of the detection of tooth diagnosis, no intelligent detection has been done up till now. Dentists just look at images and then they can detect the diagnosis position in tooth based on their experiences. Using new technologies, scientists will implement detection and repair of tooth diagnosis intelligently. In this paper, we have introduced one intelligent method for detection using particle swarm optimization (PSO) and our mathematical formulation. This method was applied to 2D special images. Using developing of our method, we can detect tooth diagnosis for all of 2D and 3D images. Materials and Methods. In recent years, it is possible to implement intelligent processing of images by high efficiency optimization algorithms in many applications especially for detection of dental caries and restoration without human intervention. In the present work, we explain PSO algorithm with our detection formula for detection of dental caries and restoration. Also image processing helped us to implement our method. And to do so, pictures taken by digital radiography systems of tooth are used. Results and Conclusion. We implement some mathematics formula for fitness of PSO. Our results show that this method can detect dental caries and restoration in digital radiography pictures with the good convergence. In fact, the error rate of this method was 8%, so that it can be implemented for detection of dental caries and restoration. Using some parameters, it is possible that the error rate can be even reduced below 0.5%

Whole Transcriptome-Based Skin Virome Profiling in Typical Epidermodysplasia Verruciformis Reveals α-, β-, and γ-HPV Infections

HPVs are DNA viruses include approximately 450 types that are classified into 5 genera (α-, β-, γ-, μ-, and ν-HPV). The γ- and β-HPVs are present in low copy numbers in healthy individuals; however, in patients with an inborn error of immunity, certain species of β-HPVs can cause epidermodysplasia verruciformis (EV), manifesting as recalcitrant cutaneous warts and skin cancer. EV presents as either typical or atypical. Manifestations of typical EV are limited to the skin and are caused by abnormal keratinocyte-intrinsic immunity to β-HPVs due to pathogenic sequence variants in TMC6, TMC8, or CIB1. We applied a transcriptome-based computational pipeline, VirPy, to RNA extracted from normal-appearing skin and wart samples of patients with typical EV to explore the viral and human genetic determinants. In 26 patients, 9 distinct biallelic mutations were detected in TMC6, TMC8, and CIB1, 7 of which are previously unreported to our knowledge. Additionally, 20 different HPV species, including 3 α-HPVs, 16 β-HPVs, and 1 γ-HPV, were detected, 8 of which are reported here for the first time to our knowledge in patients with EV (β-HPV-37, -47, -80, -151, and -159; α-HPV-2 and -57; and γ-HPV-128). This study expands the TMC6, TMC8, and CIB1 sequence variant spectrum and implicates new HPV subtypes in the pathogenesis of typical EV

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2—to end preventable child deaths by 2030—we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000–2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations

A Deep Curriculum Learner in an Active Learning Cycle for Polsar Image Classification

The integration of deep learning and active learning has achieved great success in polarimetric synthetic aperture radar (PolSAR) image classification. However, the training samples provided by the active learning approach are inade-quate to promote the performance of deep learning methods. Also, in the initial learning stages, querying a small amount of informative and complex samples, which are plagued by significant speckle noise, not only increases the risk of overfitting, but also makes the further annotations of less importance. To alleviate these problems, by utilization of curriculum learning (CL), we propose a novel classification method for PolSAR images, considering the complexity of informative samples before applying them to the deep learning model. Furthermore, we develop a new lightweight 3D convolutional neural network with high-level feature extraction ability while having a very low computational cost. Experimental results with the two PolSAR benchmark data sets of AIRSAR Flevoland and ESAR Oberpfaffenhofen indicate our proposed method achieved the state-of-the-art classification results with a significantly smaller amount of training data