In the last years, powder-based Laser Metal Deposition (LMD) has been attracting attention as a disruptive Additive Manufacturing (AM) technique for both the fabrication and restoration of Inconel 718 components, enabling to overcome current limitations faced by conventional manufacturing processes in terms of manufacturing costs, tool wear, and lead time. Nevertheless, the uncertainty related to the final mechanical performance of the as-built LMD parts limits a wider adoption of such technology at industrial level. This research work focuses on the mechanical characterization of as-built Inconel 718 specimens through split Hopkinson tensile bar tests performed at different strain rate conditions. The influence of laser power on the final mechanical behavior of the as-built tensile samples is discussed and compared with the mechanical response of as-cast ones. The as-built specimens exhibit a high internal density  and a more ductile behavior compared to the as-cast ones for every evaluated strain rate condition. The strain hardening capacity of the as-built samples increases with the laser power involved in the LMD process, reaching an average Yield Strength of 703 MPa for specimens realized at 400 W and tested at 800/s. Inconel 718 is a Ni-based Superalloy specifically designed to endure severe operating conditions that demand significant mechanical resistance to critical dynamic loads applied under harsh working environments ,3. NeverTM technology. A consistent reduction in the microstructure anisotropy and an improved metal bonding between successive layers as well as an enhanced homogenization of the final mechanical properties have been obtained after HIP, removing any evidence of poor interlayer bonding. Further, Sui et al. [Because of the thermal gradients and the rapid cooling rates involved in part manufacturing, as-built Inconel 718 LMD parts generally exhibit an anisotropic microstructure and undesired segregations that have a relevant influence on the final mechanical response of the realized components. Heat treatments performed after LMD part manufacturing have demonstrated to be an effective means to improve both mechanical performance and homogenize the final microstructure of the as-built part . Blackwei et al.  have impi et al.  have anaDespite heat treatments have proved to benefit from the final properties of as-built Inconel 718 components, their implementation is not always feasible. For LMD applications involving part refurbishment or surface repairing, the high temperatures, usually required for the homogenization of the microstructure and the dissolution of segregations, can deteriorate the wrought material and degrade the overall mechanical performance of the repaired part . For thi- split Hopkinson tensile bar. The experimental results demonstrate a strong influence of LMD process parameters on the as-deposited material performance, observing a good experimental repeatability and a relevant mechanical response of the as-built material compared to the as-cast one. For this reason, in this work, the authors focus on the influence of LMD process parameters on the final mechanical behavior of as-built Inconel 718 components tested at room temperature and at different strain rates  by means of aThe present research work presents the first scientific achievements related to the SUPSI-funded project named DED-In718, aiming to analyze the feasibility and develop the performance of LMD technology for the refurbishment and reuse of damaged Inconel 718 structural components for Aerospace applications.The metal powder involved in the experimental campaign was an Inconel 718 gas atomized powder  connected to the deposition head.The LMD system was a three-axis Laserdyne 430 laser cutting machine  retrofitted and adopted in order to perform powder-based material depositions see a. The sycharacterization of the influence of the main process parameters  on the final quality of simple depositions and identification of suitable process recipes for tensile sample manufacturing , axis speed (mm/min), and single track overlapping (%) was investigated following the LMD process design procedure discussed in . Firstlyavg) and maximum average ST height (havg) was analyzed by means of 61 profiles crossing the track length  was characterized by means of 122 profiles traced both along  and transverse  the laser path  and three as-built cylinders for each evaluated combination of LMD process parameters were trimmed through wire-EDM as depicted in P mainly affects ST width and clad stability, reaching a maximum ST width of 2.2 mm for 700 W and 300 mm/min see . When hiFrom the analysis of the ST cross-sections, no internal pores or cracks are observed see , provingThe influence of ST overlapping on SL deposition has been analyzed by taking into account the four combinations of process parameters listed in The realized cylindrical specimens show a good dimensional accuracy and no evident distortions. The structural characterization reveals an average internal density of 99.92% and 99.90% for as-built samples realized at 300 W and 400 W, respectively see . Due to The experimental outputs highlight an improved repeatability and a more ductile behavior of the as-built LMD material compared to the as-cast specimens, exhibiting higher elongations at break and reaching an elongation of 51.6% and 45.9%  at 20 °C and 800/s of strain rate see . Moreove2  exhibit the lower UTS and a longer elongation at break in conjunction with both a lower presence and a lower size  of segregations due to the lower cooling rates involved in part manufacturing. On the contrary, increasing the energy input  both the presence and the size  of segregation increases, resulting in an improved final mechanical behavior of the realized specimens. In order to validate such assumptions, a further analysis on the resulting final microstructure and chemical element distribution is running with the perspective to better explain the final mechanical properties of the as-built samples and their comparison with the as-cast ones. Despite such considerations, the good repeatability of the experimental results coming out from split Hopkinson tensile bar testing demonstrates the robustness of the combinations of LMD process parameters involved for LMD sample manufacturing.The reason for the higher mechanical strength and the lower elongation at break detected for the as-built specimens realized at 400 W can be explained by an increased presence of inclusions compared to the samples built at 300 W, which appear as bright areas in The Dynamic Increase Factors (DIFs) for both the YS (DIF fy) and the UTS (DIF fu) are reported in The ratio between the UTS to the YS (fu/fy) as well as the uniform and failure strains are reported in Inconel 718 exhibits a wide processability window with respect to the range of evaluated LMD process parameters, allowing the formation of proper metal beads with deep melt pool penetration depths to be involved in the refurbishment of worn Inconel 718 components;the as-built specimens exhibit good mechanical properties with a more ductile behavior compared to as-cast ones;y and DIFfu compared to the as-cast ones for strain rates ranging between 200 and 800/s;the as-built specimens show a weak sensitivity to strain rate for both combinations of process parameters employed in the experimental campaign, detecting a smaller increment in both DIFfincreasing laser power up to 400 W, the measured UTS increases for all the evaluated testing conditions, detecting a mechanical behavior similar to the as-cast one;the increase in UTS and decrease in elongation at break detected for the as-built specimens at 400 W can be explained by a higher presence of inclusions compared to the as-built specimens at 300 W. Nevertheless, further analyses are required to properly characterize the mechanical behavior of the as-built samples and a microstructural characterization is currently running in order to identify and quantify the metallic inclusions detected by optical imaging;experimental observations point out that the achievement of suitable mechanical properties is possible without the implementation of post-heat treatments;the achieved research outputs demonstrate the feasibility to involve LMD for both the refurbishment of Inconel 718 worn parts and the production of Inconel 718 high-aspect-ratio features with acceptable as-built final mechanical properties which are comparable to the as-cast specimens.In this research work, the influence of the LMD process parameters on the final mechanical properties of as-built Inconel 718 specimens is analyzed and discussed, providing a proper process window for defect-free Inconel 718 depositions for the repairing of damaged metal surfaces. The main research outputs are:


Meningitis is a life-threatening inflammation of the membranes covering the brain and spinal cord . It is uHaemophilus influenzae Type b, Streptococcus pneumoniae, and Neisseria meningitidis  for meningitis in the Pacific Islands are in decline . This maA recent paper published in this journal called attention to the role of otorhinolaryngology and ophthalmology services in the aftermath of the measles epidemic in the Pacific Islands . The aimStreptococcus pneumoniae (55%) was the most common bacterial pathogen for meningitis among children in the 0-5 age group, followed by Neisseria meningitidis (15%) and Haemophilus influenzae type b (10%) [Streptococcus pneumoniae. There was an outbreak of enterovirus at the time of the Fijian study, and this viral pathogen was reported as the most common cause of meningitis during the data collection time frame.There is very little in the research literature on the epidemiology of meningitis in the Pacific Islands. A recent hospital-based study from Fiji found that  b (10%) . The stuStreptococcus pneumoniae (n = 180) and Haemophilus influenzae (n = 153) as the leading causal microbial agents. This pattern, and their serotypes described in the study, may have altered since the introduction of the current immunization schedules.Another hospital-based study from Papua New Guinea investigated causal pathogens for suspected cases of meningitis among 1884 children between 1996 and 2005 . IdentifNeisseria meningitidis would be beneficial for evidence-based decision-making regarding the introduction of immunization against this pathogen into routine immunization schedules in the Pacific Islands.A recent review of meningococcal disease in the Asia-Pacific region is available, however, the Pacific Islands were not represented in this study . InformaA review of the literature found five papers addressing the leading neurological sequelae of meningitis among survivors in the Pacific Islands. There were four papers describing hearing impairment, with two of the papers published in the early 1990s , and theThe fifth paper addressed physical disability and associated mobility challenges among meningitis survivors in Papua New Guinea . The autVisual impairment is another well-known neurological sequelae of bacterial meningitis. The present review did not find any papers describing visual disability among meningitis survivors in the Pacific Islands.Neisseria meningitidis) and meningitis-related disabilities (Streptococcus pneumoniae). At this time, all Pacific Islands include the Haemophilus influenzae vaccine in their immunization schedules, eight out of fourteen countries include the Streptococcus pneumoniae vaccine, and only the Marshall Islands offer the Neisseria meningitidis vaccine.The table above indicates that there is an opportunity to strengthen routine childhood immunizations against the leading causal bacterial pathogens of meningitis in the Pacific Islands. Ideally, immunization should be available in all Pacific Island countries against the main bacterial pathogens of meningitis fatalities (The barriers preventing optimal immunization coverage rates should also be addressed. The table indicates that the most recent coverage rate data was lowest for Samoa, and this is most likely related to the urgent recall of vaccines and necessary suspension of the National Immunization Program. The second lowest coverage rate is for Papua New Guinea, the largest archipelago of the Pacific Island countries, and therefore the nation with the greatest challenge of accessing all rural and remote areas for optimal immunization program delivery. This is an opportunity for cross-sector collaboration under the Sustainable Development Goals, where improved transport and infrastructure will also benefit health outcomes.As advocated for the case of measles in the Pacific Islands, health promotion activities regarding meningitis in this region should highlight that routine childhood immunizations not only save lives, but also prevent the risk of life-long disabilities. The neurological sequelae of meningitis are well-known from the global literature. The Sustainable Development Goal Agenda offers an excellent platform to establish or strengthen clinical and rehabilitation services for meningitis survivors living with physical, hearing, and/or visual impairments. Among young children in particular, routine ear/hearing and eye/vision assessment is recommended because mild or moderate degrees of impairment may often be overlooked. Where specialized health professions are scarce or non-existent, the World Health Organization promotes Community-Based Rehabilitationists for the care of children and adults with disabilities.Although there is little in the research literature regarding meningitis and associated sequelae in the Pacific Islands, this should not deter efforts to strengthen current childhood immunization schedules, improve coverage rates, and include the leading causal meningitis pathogens of death and disability in the programme. Routine ear/hearing and eye/vision assessments for all meningitis survivors is also vital to ensure early identification of any sensory impairment, and facilitate early intervention options as required. Improved rehabilitation services for people with physical disabilities is also essential. As clinical and rehabilitation services are strengthened in urban settings, a regular outreach programme to rural/remote settings is strongly advocated.


The Research Topic on “Biomechanics in Translation: From Vascular Biology to Cardiovascular Drug Discovery” collects novel studies of the cross-disciplinary research in biomechanics and vascular biology. This collection covers a wide range of research work from basic biology, computational modeling, material characterization, imaging to clinical studies. It provides a comprehensive overview of the advances in biomechanical technologies and their applications in diagnosis and treatment of cardiovascular diseases (CVD).Paritala et al. developed a methodology to experimentally and numerically characterize the stress-relaxation and cyclic mechanical behavior of carotid plaque tissues. The time-dependent mechanical response of the carotid plaque tissue was investigated by applying cyclic loading under physiological temperature and hydration medium. There was a decrease in the peak force as a function of cycle number indicating mechanical distension due to repeated loading. The tissue accumulated residual deformation as a function of cycle number, which was attributed to fatigue softening. This work represents a step toward an improved understanding of the material behavior of the human atherosclerotic plaques, which may assist in plaque vulnerability assessment.CVD is a major health burden and the leading cause of mortality and morbidity worldwide. The main underlying cause of CVD is atherosclerosis, where abnormal deposits of fat, cholesterol, and other substances build up in the inner lining of the arteries to form plaque. Plaques often rupture without warning, causing acute vascular events, such as myocardial infarction and stroke, which are life-threatening events that occur when a blood vessel supplying the heart or brain is suddenly blocked, causing damage to the tissue and its function. A better understanding of plaque morphology, mechanical behavior, and hemodynamics is essential for the identification of vulnerable plaques pre-rupture. This Research Topic collected three studies covering these three important aspects. To better understand the mechanical response of plaque tissue under cyclic loading conditions, Wang et al. combined in vivo MR imaging, histological analysis, and computational simulation to investigate the hemodynamics in a patient with a tandem carotid stenosis. In this study, a patient with a tandem carotid stenosis at both internal carotid artery and common carotid artery was recruited. Multi-sequence pre-surgery MR imaging and post-surgery carotid plaque tissue samples were collected for analysis. The 3D patient-specific geometrical model was reconstructed from the in vivo MR imaging. Computational fluid dynamics (CFD) simulation was conducted to investigate how the tandem stenosis developed and affected each other. The results of this study suggest that when planning carotid endarterectomy, CFD simulation on the presumptive models could help clinicians to estimate the blood flow behavior after surgery. Particular attention should be paid to the case of tandem stenosis, as the local hemodynamic environment is more complex and treatment of one stenosis may lead to a variation in the hemodynamic loading on the second plaque, which may result in either a higher risk of plaque rupture or restenosis.To better understand the impact of hemodynamics on plaque stability, He C. et al. developed a machine learning algorithm to segment plaque components from in vivo optical coherence tomography (OCT) imaging. Intravascular OCT has been used to characterize coronary plaque morphology in recent years. There is an urgent need to develop a validated algorithm for plaque characterization which can help facilitate the standardization of OCT image interpretation of plaque morphology. In He C. et al.'s study, a total of 31 patients underwent carotid endarterectomy and the ex vivo carotid plaques were imaged with OCT. Optical parameter, texture features and relative position of pixels were extracted and then used to quantify the tissue characterization of plaque components. The results show the developed algorithm was capable of characterizing plaque components with an excellent accuracy using the combined feature set.In terms of plaque morphology, Li et al. summarizes a wealth of research in this field and explores the roles of macrophages in the development process of vascular calcification. It was pointed out that further exploration of the potential molecular mechanism of how macrophages regulate the progression and regression of vascular calcification is expected to reveal a new entry point for the prevention and treatment of vascular calcification, with far-reaching implications.Vascular calcification is an abnormal cell-mediated process in which bone-specific hydroxyapatite crystals are actively deposited on the blood vessel wall and is a significant pathological basis for the increased incidence and mortality of adverse cardiovascular events. Macrophages play an important regulatory role in the occurrence, development, and regression of vascular calcification. Wei et al. performed both structural and hemodynamic analyses to evaluate the performance of different stent structures. Structural analyses were firstly performed to obtain the deformed luminal boundaries of a curved artery. Hemodynamic analyses were then conducted to quantify the critical hemodynamic parameters. The effects of stent structure by changing the structure and connection way of the stent struts were investigated. This study provides a better understanding of the deployment of different stents inside curved stenotic arteries to facilitate the clinical choice of suitable commercial stents. In another study, Zhu et al. used biomechanics to evaluate the pulmonary flow conditions. Recent developments in the expanded-polytetrafluoroethylene (ePTFE) pulmonary prosthetic valves provide promising progress in the management procedures of various congenital heart diseases. In Zhu et al.'s study, the hemodynamic characteristics of bileaflet and trileaflet ePTFE valve designs were experimentally evaluated under pulmonary flow conditions. The results indicate that the current bileaflet prosthetic valve design is capable of providing a better overall hemodynamic performance than the trileaflet design. In a clinical study, He D. et al. developed a new approach of 3D-printed extravascular stenting of the left renal vein for the treatment of nutcracker syndrome (NCS). 28 patients were admitted for laparoscopic 3D-printed extravascular stenting treatment. After treatment, the NCS symptoms in all patients resolved or improved during the follow-up period. Compared to endovascular stenting or polytetrafluoroethylene artificial vessel procedures, 3D-printed polyetheretherketone extravascular stenting has more advantages in terms of stent design and rigidity and approach rationality while successfully preventing stent migration and thrombosis. The method may serve as an accurate and effective treatment for NCS patients.This collection also includes applications of biomechanics in design or evaluation of medical devices such as stents and valves. Coronary artery stenting is commonly used for the treatment of coronary stenosis, and different stent structures have various impacts on the stress distribution within the plaque and artery as well as the local hemodynamic environment. To better understand the mechanical interaction between blood flow, stent, and artery, This exciting collection of papers represent the recent developments in biomechanics and vascular biology with state-of-the-art contributions and critical reviews on the new advances in this growing field, with an emphasis on the interface between engineering and clinical medicine. We are delighted to be a part of this effort and witness the rapid expansion of the biomechanics in clinical applications, providing more opportunities for future discussions and exchanges of ideas and experiences in translating biomechanics into a wider range of applications.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Because of the complex structure of cancer and tumor behavior, the assessment methods have been updated and metabolic imaging has gained weight. The most popular of these techniques is hybrid positron emission tomography/computed tomography (PET/CT) systems. Prostate cancer is the second most common cancer in the world, is the fifth common type in cancer-related male deaths. Estimation of prognosis and treatment planning of the patients are based on the TNM classification. Bone metastasis is a prognostic factor of morbidity and mortality in prostate cancer. Sodium fluoride (NaF) PET/CT is a promising imaging modality in evaluation of skeletal system. This article will review the involvement of


Recent advances in high-throughput sequencing techniques have significantly accelerated the development of personalized diagnostic tools and cancer treatments. However, a comparative analysis of experimental animals that share similar genetic, physiological, and behavioral traits with humans remains the basis for understanding the pathological mechanisms associated with human diseases, including cancer. The generation and characterization of suitable animal models mimicking tumor growth and progression thus represents an important “component” of tumor biology research. The presented Special Issue contains ten review articles, which, based on data obtained from various animal models, summarize a number of aspects of the tumor formation process that include gastrointestinal neoplasia, breast cancer, hematological malignancies, melanoma, and brain tumors. This Special Issue nicely illustrates how the study of suitable living models uncovers not only the fundamental molecular and cellular bases of neoplastic growth, but might also indicate approaches to efficient cancer treatments. The use of animal models to study the process of cell transformation and tumor formation has become a routine experimental approach. Initially, various types of neoplasms were induced in the experimental animal by exogenous substances or radiation. These techniques were extended by genetic models. Such models were first obtained by selecting “random” phenotypes, and later also by targeted genome modifications. Additionally, xenotransplantation techniques for implanting tumor cells or tumor tissue fragments directly into animals’ bodies have been developed. Another technical improvement that accelerated and streamlined the preparation of animal models was based on the introduction of the method of conditional genetic modifications , which enabled tissue-specific and time-defined genetic changes. A breakthrough was brought by the introduction of programmable nuclease technology and the clustered regularly interspaced short palindromic repeats (CRISPR)/CAS9 system. The tumor process is associated with a number of genetic changes in the particular cell type, and these inventions have led to well-defined and sophisticated tumor models that resemble the complex pathological situations observed in human tumor tissue. This Special Issue has been dedicated to animal models used for cancer research and contains ten review articles. Not surprisingly, most of them are dedicated to rodents  as the main experimental model used in tumor biology.Danio rerio). The use of fish in biomedical research has its obvious advantages. These are, in particular, the relatively low costs of their breeding (related to a high reproductive capacity), extracorporeal development of embryos, and the possibility of performing genetic manipulations. The above advantages are somewhat complicated by the fact that during evolution, the zebrafish genome has undergone duplication, and its genes thus have more paralogs. The resulting redundancy or, conversely, species-specific variability of the original function of the studied gene might complicate the analysis and interpretation of the obtained results. On the other hand, the natural transparency of zebrafish embryos and the existence of a mutant strain called casper, whose individuals are transparent even in adulthood, making it possible to monitor the growth and distribution of tumor cells directly in a living organism. Another complication is the relatively small amount of commercially available antibodies that recognize fish antigens. However, this disadvantage can be very well compensated for by the use of transgenic “reporter” strains, a large number of which are currently available. The above-mentioned features, together with the fact that the development of the hematopoietic system has cellular bases and regulatory mechanisms very similar to those described in mammals, make zebrafish a unique model for the study of hematooncological diseases. This is well illustrated by examples of myeloproliferative neoplasms (MPN) [Non-mammalian models are dominated by zebrafish (ms (MPN)  and acutms (MPN) . A comprms (MPN) .Carcinoma of the colon and rectum ) represents one of the most frequently diagnosed neoplasia in developed countries. Therefore, it is also not surprising that the two articles included in the Special Issue are dedicated to mouse models of intestinal cancer. The majority of CRCs progress through the conventional adenoma–carcinoma pathway. In recent years, there have been considerable efforts to unify the classification of colorectal tumors. These efforts have led to the establishment of the system of four consensus molecular subtypes (CMSs) defined by multiple characteristics that include gene expression profiles, microsatellite instability, genomic DNA methylation status, and differences in the status of the immune response and various signaling pathways. In their review, M. Stastna and colleagues have presented a broad spectrum of mouse intestinal cancer models that display pathological changes in Wnt, Hippo, p53, epidermal growth factor (EGF), and transforming growth factor β (TGFβ) signaling. They have also described microsatellite instability models and models of chemically induced tumorigenesis. Importantly, the authors reflect the categorization of human CRC into the CMS groups and indicate a possible assignment of the described mouse model to the CMS group . The mamCdx2) gene in esophageal and gastrointestinal cancer and leukemias, as shown by the analysis of mice and zebrafish models. Cdx2 is an important factor in defining the positional identity of cells. Pathological situations associated with tissue damage and its subsequent regeneration may cause changes to the cell identity called metaplasia, or an abnormal localization of otherwise morphologically and cytologically normal tissue. Importantly, metaplasias represent a significant factor in the development of cancer. An aberrant expression of the Cdx2 gene induces a shift in cellular identity towards more posterior types and, in animal models, it results in an intestinal type of metaplasia of the esophageal epithelium  and stomach. In contrast, a loss of the Cdx2 gene in the colon induces neoplasias producing gastric markers. Finally, leukemia is one of the neoplasms for which Cdx2 (over)production is typical [The issue of intestinal neoplasias is related to the article of K. Chawengsaksophak, which is fully dedicated to the role of the caudal type homeobox 2  of MPN, which are represented by polycythemia vera, essential thrombocytosis and primary myelofibrosis. The authors introduce mouse and fish models with these disorders. They also provide examples of how the technology of induced pluripotent stem cells (iPSCs) has initiated a new era in human disease modeling. For example, iPS cells prepared from MPN allow for the reconstruction of the clonal hierarchy and investigation of the effects of oncogenic mutations at their endogenous settings . The artThe article by V. Horak and colleagues focuses on animal models used in the study of melanoma. Melanoma is a very aggressive and deadly type of cancer, the incidence of which is increasing worldwide, especially in the Caucasian population. The introductory part comprehensively describes our current knowledge about the genetic changes and molecular mechanisms related to the origin and progression of the disease. A detailed description of animal models follows, which includes not only mouse models, but also dog and horse models, as well as three non-mammalian animal models . The most extensive part of the review is dedicated to the Melanoma-Bearing Libechov Minipig. The origin of this genetic model dates back to the late 1960s, and the knowledge about this model is thus very deep and extensive. The (mini)pig as a model for melanoma research has a number of advantages. The structure and distribution of melanocytes in the pig skin is more similar (unlike mouse skin) to the situation in the human skin. Moreover, the relatively long lifespan (12–18 years) allows the long-term monitoring of the experimental animals. Large animals also allow blood or tissue samples to be taken repeatedly during their life (and disease progression) of the experimental individuals .Research over the last few decades has clearly shown that dysfunction of the evolutionarily conserved Wnt, Notch, and TGFβ signaling pathways may have critical consequences for cellular fate, often leading to cell transformation and tumorigenesis. The article by N. Baloghova and colleagues offers a new perspective on the regulation of these signaling pathways by the ubiquitin–proteasome (UPS) system. The authors summarized (in an “exhaustive” manner) the results obtained in the mouse models . It shouThe last two review articles offer a somewhat different view of the use of animal models in tumor biology. R.A. Moorhead evaluates the possibility of whether the consumption of soy products or soy-derived isoflavones might prevent (or reduce) the risk of breast cancer. The author summarizes that while epidemiological studies conducted in Asian countries show that high levels of soy and soy product consumption are associated with a reduced risk of breast cancer, experiments using mouse or rat breast tumor models  have not been confirmatory . ObviousI thank all the authors and reviewers of the published articles and I wish the readers inspiring reading.


Bubble hair abnormality describes hair damage characterized by the formation of air cavities within the cortex of the hair, due to the high temperature of water inside the shaft, that induces keratin hydrolysis and local air expansion. It is linked to excessive cosmetic treatments, in particular, prolonged exposure of damp hair to the high temperatures (> 125 C°) of blow dryers or electric curlers, and is typically encountered in women. We describe the trichoscopic features of 3 cases of bubble hair abnormality highlighting the utility of trichoscopy.A 51-year-old Caucasian woman complained of a 6-month history of hair breakage that started with frequent at-home hair dyeing. Physical examination revealed a circumscribed area of short and broken hairs localized to her vertex. In-vivo trichoscopy revealed numerous hair shafts containing irregularly spaced bubbles and broken hairs. We made a diagnosis of bubble hair abnormality and advised her to discontinue all dye and heat-related practices.A 42-year-old Caucasian woman complained of increased hair shedding. Trichoscopy showed signs of telogen effluvium, and upon careful observation of the anterior region of the fringe, some bubble hairs were discovered . The patA 35-year-old Caucasian woman complained of diffuse hair loss and the presence of damaged strands of hair that resulted after hot-combing the hair while it was still wet. A tuft of short broken hairs, paler than the surrounding hair, was evident in the affected area. Trichoscopy showed the presence of broken and bubble hair in the site of the thermal trauma.Cosmetic hair treatments, such as hair straighteners and relaxers, cleave disulfide bonds and can cause hair damage to the superficial cuticles. The loss of lipids on the hair surface during chemical hair treatments may lead to loss of cohesiveness between cuticle cells, and the reduction in the hair shaft cysteine levels correlates to a greater susceptibility to hair weathering and hair fragility. For a correct diagnosis in cases of hair fragility, direct examination of hair shafts with trichoscopy is recommended.In the literature, previous reports have underlined the utility of trichoscopy for bubble hair abnormality and describe white oval spaces with Swiss-cheese structure and dysmorphia of the distal hair shaft ,2.In 2 of our patients, there was a history of blow drying wet hair, while 1 patient had only bleached it with an at-home procedure. When wet, the hair fiber can expand up to 30% in diameter and it retains water within its structure, resulting in the formation of expanding and destructive bubbles within the fiber. As reported in Case 1, chemical treatments and previous hair damage may also precipitate the onset of bubble hair abnormality and lower the threshold for bubble formation [All our patients improved after discontinuation of hot blow drying or avoiding the application of chemicals, confirming the acquired nature of the disease.In conclusion, bubble hair abnormality is an acquired hair shaft disorder that can present as a circumscribed area of broken hairs that do not grow, especially when there is a history of frequent cosmetic or thermal hair practices.


We studied the impact of age and the serum anti-Müllerian hormone (AMH)/follicle-stimulating hormone (FSH) levels on the number of cumulus–oocyte complexes (COCs) retrieved from female reciprocal and Robertsonian translocation carriers after controlled ovarian hyperstimulation (COH). The number of COCs retrieved after COH was retrospectively analyzed in female translocation carriers and 46,XX partners of male translocation carriers from 100 couples. The median number of COCs varied from nine to 16 and did not differ among subgroups of women categorized by age, presence and type of a translocation. The number of COCs correlated negatively with the woman’s age in both the reciprocal and the Robertsonian translocation carriers, while in 46,XX women no correlation was detected. The number of COCs did not differ between the reciprocal and the Robertsonian translocation carriers aged either <35 or ≥35 years. In translocation carriers, the number of COCs correlated with the serum AMH level only in the younger-age subgroups; the correlation was strong positive in reciprocal and moderate positive in Robertsonian translocation carriers. The 46,XX women aged both <35 and ≥35 years showed similar moderate positive correlations. Across all subgroups, the number of COCs correlated moderately negatively with the serum FSH level only in Robertsonian translocation carriers aged <35 years. Our results suggest that chromosomal translocations per se do not increase the risk of poor oocyte retrieval outcome after COH. In translocation carriers, oocyte retrieval outcome depends to a large extent on their age. The serum AMH level strongly predicts oocyte retrieval outcomes only in young reciprocal translocation carriers, while the serum FSH level has a moderate predictive value in young Robertsonian translocation carriers. A frequent occurrence in the modern world, reproductive disorders are regarded as one of the primary public health challenges. Considering the significant contribution of genetic factors to these disorders , in partA common genetic cause of reproductive disorders in a couple is a balanced chromosomal rearrangement in one of the partners. The most widespread and clinically significant chromosomal rearrangements are translocations: reciprocal, an exchange of material between non-homologous chromosomes, and Robertsonian, a centric fusion of two acrocentric autosomes . CharactThe aim of the present study was to analyze the number of cumulus–oocyte complexes (COCs) retrieved from female reciprocal and Robertsonian translocation carriers after COH and to verify the possible correlation with the woman’s age and the serum level of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH).The study retrospectively included 137 IVF cycles in 100 couples who were referred to the D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology  or the AVA-Peter Clinic  for IVF/PGT-SR for balanced translocations in the period from March 2009 to May 2019. The number of COCs retrieved after COH in female translocation carriers was compared to that in karyotypically normal partners of male translocation carriers. All of the couples referred for IVF/PGT-SR already had a cytogenetic diagnosis. In all of the cases, the initial indications for karyotyping were infertility or pregnancy loss. Prior to the start of an IVF/PGT-SR cycle, cytogenetic diagnoses in all of the translocation carriers were verified by conventional karyotyping followed by fluorescence in situ hybridization (FISH) if required. All conventional karyotyping and FISH procedures including PHA-stimulation of peripheral blood lymphocytes, preparation of metaphase chromosomes, QFH/AcD staining and hybridization were performed according to standard protocols with modifications repeatedly used in our previous studies ,7,8,9,10Before inclusion in the first IVF/PGT-SR protocol, all of the female patients were tested for serum levels of day 2–3 AMH and FSH . The COHhttps://www.r-project.org). The inter-group comparison of the patients’ age was performed using the Kruskal–Wallis test. The median numbers of COCs were compared with Mood’s median test. The comparison of the number of COCs between the female reciprocal and Robertsonian translocation carriers <35 years of age and between their counterparts ≥35 years of age was carried out using the Mann–Whitney U test. The correlations between the number of COCs and the patients’ age and between the number of COCs and the serum AMH/FSH levels were measured using Spearman’s rank correlation coefficient. The α-level was set at 0.05.The statistical analysis was performed using The R Project for Statistical Computing  or among the subgroups of their counterparts aged ≥35 years .The female patients from the studied couples were subcategorized into six subgroups by age (<35 and ≥35 years of age) and presence of a chromosomal rearrangement . The subgroups of patients within the groups aged <35 and ≥35 years were checked for age-matching. No statistically significant difference was detected either among the subgroups of reciprocal and Robertsonian female translocation carriers and 46,XX patients aged <35 years . Thus, the younger- and the older-age subgroups of both the female translocation carriers and the karyotypically normal partners of male translocation carriers produced an equal median number of COCs that is categorized as optimal. We have therefore concluded that the presence of a balanced translocation per se has no impact on the COH outcome and that the IVF/PGT-SR cycle with own gametes is a procedure of choice for female balanced translocation carriers.We compared the median numbers of COCs retrieved after COH in IVF/PGT-SR cycles in the above-described six subgroups of women . For eacIn the literature, the question of ovarian response to COH in female carriers of balanced translocations remains controversial, which is most likely explained by different approaches used by the authors. In the study by Chen et al., who applied up to 450 IU of gonadotropin for stimulation and used serum level of E2 on the day of hCG administration as an indicator of ovarian response, the proportion of very poor responders was significantly higher in the female carriers compared with the partners of male carriers . D’Ippolp = 0.0062) and Robertsonian . In the karyotypically normal women, the correlation was not statistically significant . Thus, it is in female carriers of balanced translocations that age is a significant predictor of the number of oocytes retrieved after COH. It is likely that age-dependent deterioration of the biological control of the physiological and biochemical processes involved in oocyte maturation is enhanced by the presence of chromosomal rearrangement in female translocation carriers. During oogenesis, the germline cells undergo several quality control checkpoints to initiate apoptosis of abnormal cells including those with genetic defects. As translocation carriers have an increased probability to produce chromosomally unbalanced cells, they are at higher risk of drastically depleted overall oocyte production with age than karyotypically normal women.Using correlation analysis, we checked the strength and the direction of the relationship between the number of COCs and the woman’s age in three groups: female reciprocal translocation carriers, female Robertsonian translocation carriers and karyotypically normal partners of male translocation carriers . In all p = 0.5452) or ≥35 years  and presence of a chromosomal rearrangement . The subgroups of female Robertsonian translocation carriers aged <35 years and karyotypically normal partners (aged <35 years) of male translocation carriers showed correlations of similar strength . No significant correlation was detected in either reciprocal  or Robertsonian  translocation carriers aged ≥35 years. However, to further confirm this finding, a larger group of patients needs to be tested. The subgroup of karyotypically normal women aged ≥35 years, however, showed a rather strong positive correlation . Why this correlation is present only in young Robertsonian but not reciprocal translocation carriers is an open and very intriguing question. Further studies will probably shed light on the biological mechanisms underlying this association. In the rest of the analyzed subgroups, the serum FSH level had no impact on the number of COCs retrieved after COH , a balanced translocation, either Robertsonian or reciprocal, may still drastically increase the risk of a poor COH outcome. The response to COH in translocation carriers may not differ from that in 46,XX women. However, due to abnormal chromosome conjugation and increased probability of unbalanced gametes, some of which are removed through apoptosis, the depletion of the ovarian pool in translocation carriers progresses faster than in karyotypically normal women. This makes the age especially critical for oocyte retrieval outcome in balanced translocation carriers.The serum AMH level may be regarded as the strong predictor of a good response to COH only in young (<35 years of age) female reciprocal translocation carriers. The predictive value of the serum AMH level on oocyte retrieval is moderate in young female Robertsonian translocation carriers and karyotypically normal partners of male translocation carriers. In older female translocation carriers, the serum AMH level does not correlate with the number of retrieved oocytes and cannot be regarded as a significant predictor of the COH outcome. It is also necessary to consider that an increased serum FSH level has a negative predictive value of the number of oocytes only in the younger age group of Robertsonian translocation carriers.The limitations of this study should be mentioned. The first one concerns heterogeneity of the group of reciprocal translocation carriers. Most reciprocal translocations are unique, thus potentially providing a variety of genetic defects caused by translocation breakpoints, which, in turn, may result in very individual effects on ovarian response to COH . The secTo summarize, either a reciprocal or a Robertsonian chromosomal translocation per se does not increase the risk of a poor COH outcome in an IVF/PGT-SR cycle. The success of the procedure, however, is to a large extent determined by the woman’s age being <35 years, the serum AMH level in younger female reciprocal translocation carriers and the serum FSH level in younger female Robertsonian translocation carriers.


Superior medullary velum cerebral cavernous malformations pose a challenge in terms of appropriate microsurgical approach. Safe access to this deep location as well as preservation of surrounding anatomical structures, in particular the superior cerebellar peduncle just lateral to the superior medullary velum and the dentate nuclei, is paramount to achieve a good functional outcome.Cadaveric dissections provide useful knowledge of the normal anatomy while tractography allows a better understanding of the individual anatomy in the presence of a lesion. The medial-tonsillar telovelar approach provides a feasible corridor for accessing superior velum cerebral cavernous malformations without compromising the fibres contained in the superior cerebellar peduncle. The major cerebellar efferents—cerebello-rubral, cerebello-thalamic and cerebello-vestibular tracts—and afferents, anterior spinocerebellar, tectocerebellar and trigeminocerebellar tracts, within the superior cerebellar peduncle are preserved, and the dentate nuclei are not affected.A retraction-free exposure through this natural posterior fossa corridor allows the patient with the anatomical and functional subtract to make a good functional recovery by minimizing the risk of a superior cerebellar syndrome, ataxia, tremor and dysmetria; decomposition of movement in the ipsilateral extremities, nystagmus and hypotonia; or akinetic mutism, reduced or absent speech with onset within the first post-operative week. Cerebral cavernous malformations of the superior medullary velum represent a challenge in terms of safest surgical approach. A very good understanding of the anatomical structures surrounding the superior medullary velum and the efferent pathways of the cerebellum at risk of being damaged is mandatory to approach the superior medullary velum region. Moreover, access to this deep region requires knowledge on how to enhance the advantages offered by opening microsurgically the uvulotonsillar compartment of the cerebello-medullary fissure and consequently the tela choroidea and the inferior medullary velum to gain access to the cavernous of the superior medullary velum.cerebellomedullary fissure separates the cerebellum from the medulla, extending upwards between these regions. This fissure is at the dorsolateral aspect of the inferior half of the roof of the fourth ventricle and has to be surgically enlarged in order to perform the telovelar approach. Its anterior wall is formed by the posterior surface of the medulla, the inferior medullary velum and the tela choroidea; its posterior wall is formed by the uvula and nodule of the vermis medially and the tonsils and biventral lobules laterally [The aterally .  originates at the vertebral artery and course within the cerebellomedullary fissure, forming its telovelotonsillar segment between the tonsil posteriorly and the tela choroidea and inferior medullary velum anteriorly  is the largest cerebellar efferent bundle, which is a group of fibres that emerge from the hilus of the dentate nucleus. These fibres pass rostrally into the upper fourth ventricle. The superior cerebellar peduncles emerge from the upper and medial part of the white substance of the hemispheres. They project in parallel and are placed under cover of the superior and inferior colliculi. They connect the dentate nucleus to the red nucleus—where they decussate, forming the dentatorubrothalamic tract, part of Guillain-Mollaret triangle . The superior cerebellar peduncles are joined by the superior medullary velum, can be followed up to the inferior colliculi and disappear in the red nucleus  is a thin lamina of white matter extending between the cerebellar peduncles and participates in the formation of the roof of the fourth ventricle. The dorsal surface of the lower half is covered by the lingula of the cerebellum, caudal to the exit of the fourth cranial nerve, and separating the lingula from the superior medullary velum creates a working corridor  [The fissure) . The supfissure)   . Venous fissure) .uvulotonsillar telovelar approach is developed in between the structures of the paleocerebellum, mainly responsible for the muscle tonus. The medial tonsillar surface is displaced laterally away uvula, exposes the inferior half of the ventricular roof (tela choroidea and inferior medullary velum) and the opening the tela choroidea upward to the telovelar junction provides access to the floor of the fourth ventricle, from the aqueduct to the obex and to the medial portion of the lateral recesses [The recesses   [b value = 2000 s/mm2; 18 B0 volumes; 1.25 mm isotropic voxels; TE = 89.5 ms and TR = 5520 ms. Data were corrected for motion, eddy-current distortions and susceptibility distortions, according to the HCP minimal pre-processing pipelines [https://www.mr-startrack.com/) with a fractional anisotropy (FA) threshold of 0.2, step size of 0.5 mm and angle threshold of 30°.Diffusion MRI data were obtained for one healthy young adult  from the Human Connectome Project  (me.org/) . The datipelines . Diffusihttp://trackvis.org/) based on sphere regions of interest (ROI). The first ROI was placed in the cerebellum at the level of the dentate nucleus and the second in the brain stem at the level of the red nucleus. Only tractography streamlines terminating in both ROIs survived the filtering process, thereby effectively isolating the pathway of interest. To visualize the control tractography data on the patient’s brain, linear and non-linear image registration were performed using the Advanced Normalization Tools [The superior cerebellar peduncles were manually dissected in TrackVis . The dura was opened under the microscope in a Y-shaped fashion. The arachnoid of the cistern magna was incised longitudinally and suspended to the dura with titanium Ligaclips (Ethicon®). With microneurosurgical technique, the uvulotonsillar compartment was carefully dissected and enlarged throughout its whole extension exposing the PICA, the tela choroidea and the inferior medullary velum. Fixed retraction to cerebellar structures was never applied through the whole procedure. The tela choroidea was opened starting from the foramen of Magendie and extending upward to the telovelar junction. Additionally, the inferior medullary velum was incised, and direct access was obtained to the upper portion of the fourth ventricle. Once the aqueduct of Sylvius was visualized inside the fourth ventricle for orientation, yellowish discoloration of the superior medullary velum was noted. Incision of the superior medullary velum 2 mm off midline on the right side allowed visualization of the cerebral cavernous malformation and its surrounding haemorrhagic constituents. The lesion was gently dissected and removed. No attempt was made to address the surrounding haemosiderin deposits in order to preserve the fibres of the superior cerebellar peduncle, in particular the dentatorubrothalamic fibres. Moreover, the superior medullary velum does not represent an epileptogenic zone, which would warrant removal of surrounding brain tissue with haemosiderin deposits (Fig. The patient was placed in pins in the park-bench position. A prone The post-operative MRI documented complete resection of the cerebral cavernous malformation Fig. .Fig. 6PoSuperior cerebellar peduncle syndrome was first described in monkeys by Ferrier and Turner in 1894 . Other gGirard et al published in 1950  the firsGreat attention has been given to the SCP in the last decade as a major player in the cerebellar mutism. This condition is characterized by reduced or entirely absent speech with onset generally within the first post-operative week, and multiple case reports in both children , 5, 20 aThese symptoms related SCP injury render crucial the preservation of this structure during the surgical approaches to SMV lesions. Both this function-preserving approach and the fact that the SCP is not known to be epileptogenic supported the decision of not removing the haemosiderin deposits around the lesion. This is supported by the most recent literature that advocates a careful risk-benefit approach to the haemosiderin deposits in eloquent cerebral cavernous malformations . The claTonsils have been extensively explored, and different names have been given to similar approaches via similar spaces and fissures [Even though telovelar, transvermian and supracerebellar infratentorial are the most common approaches to posterior fossa pathology, different groups described new surgical approaches to lesions within mesencephalum and fourth ventricle , 9, 26 efissures . These cfissures  and supefissures .For the first time, we describe a medial-tonsillar approach to a SMV lesion. This approach is safer for preservation of both SCP and dentate nucleus when compared with lateral-tonsillar approach. The inferior cerebellar peduncle is an anatomic reference to dentate nucleus presentation as it runs anterior to it . This alTonsils are key anatomical structures in defining the surgical corridors in posterior fossa pathology located in the four ventricles, brain stem and surrounding structures. The telovelar approach allows a retraction-free and anatomical tract-sparing approach to the SMV region. The retraction or resection of normal anatomical and pathological-free SCP should be avoided in order to minimize the risk of post-operative cerebellar mutism, ataxia, tremor, dysmetria, decomposition of movement in the ipsilateral extremities, nystagmus, hypotonia or palatal tremor, all possible complications of SCP injury.The


One of the greatest challenges facing mental health research is the development and testing of bone-fide causal theories of psychopathology that inform the development of more effective treatments. Unfortunately, apart from the major progress offered by cognitive-behavior therapy over 40 years ago, there have been few advances in models and treatments that have improved outcomes. Developments are hindered by the prevailing clinical research strategy that has attempted to innovate by combining therapeutic techniques taken from a wide range of existing sources, but in the absence of an understanding of causal mechanisms. This raises crucial questions: how can the researcher or practitioner know which of the plethora of techniques to choose, should they be combined or used in the absence of a theoretical rationale and are they compatible?2019) based on the cognitive science of emotion. The present Research Topic aims to capture the breadth of current ideas and studies in MCT and bring together active researchers at the forefront of the field. The objectives are to demonstrate the universal influence of MCT, present data probing theoretical mechanisms and to offer a grounding from which ideas can spring that will support future investigations.It is evident that progress could be made by developing a more rigorous, scientifically grounded theory of causal mechanisms, and devising treatment techniques ground-up from this theoretical platform. This approach was used by Wells and Matthews , see al in the dThere are 30 articles in this issue covering advanced theory, evaluation of mechanisms, clinical evaluations of treatment efficacy, feasibility of novel applications of treatment and studies of assessment tools. The articles consist of clinical, non-clinical, cognitive and neuroscience studies, research in adults and children, and studies of personality, stress, psychosis, alcohol abuse, anxiety, trauma, obsessions and depression. The articles are grouped into two clusters. First, work on theory and mechanisms is presented and this is followed by studies of the clinical effects of MCT.MCT is based on some basic principles central to the S-REF model: (1) most disorders are caused by a common or transdiagnostic set of processes made up of difficult to control extended negative thinking, (2) psychological distress is prone to self-correct but is thwarted in doing so by maladaptive self-regulatory strategies, (3) metacognitions are key to adaptive and maladaptive self-regulatory processes.Wells elaborates on the original S-REF model and makes important and more detailed distinctions between cognitive and metacognitive structures and processes, drawing out the necessary components and hypothesized circuits in formulating adaptive and maladaptive self-regulation. The paper describes a metacognitive control system involved in psychological disorders and elucidates different types of metacognitive information that influence the way cognition is experienced. Repetitive and extended negative processing that maintains psychological distress is a process normally prone to decay but this is thwarted by maladaption in the metacognitive system leading to persistence of negative processing. The model leads to predictions of the existence of several important mechanisms and types of metacognitive information including “cybernetic code” generated by the metacognitive system that impact on neural networks and contribute to emotional recovery or sustained processing and psychological disorder. The model is broadened to consider how metacognitive information and its flow between systems helps to create embodiment, self-awareness and meta-representational states that provide resources for self-regulation. The paper concludes by exploring how the model has shaped the development and focus of MCT and explores the implications for future treatment development and advances in theory and research.Nordahl et al. show that negative and positive beliefs about worry are both cross sectional and prospective predictors of trait-anxiety, suggesting that dysfunction in metacognition might be the underlying mechanism that is captured by emotion-vulnerability measures. The direction of causality in metacognition-emotion relationships is addressed by Capobianco et al. using cross-lagged structural equation modeling. They found that metacognitive beliefs predicted subsequent anxiety and anxiety predicted subsequent metacognition over different time-courses suggesting mutual causal links that might (if measured over a longer time-frame) constitute a dysfunctional metacognition-emotion cycle. One important way to examine emotional vulnerability is to assess multiple traits that contribute not only to dysfunction but also those that may confer the opposite; psychological resilience. Matthews et al. examined the effects of meta-worry, worry and resilience traits on the performance of a complex task under two types of stressor, differing in self-reference. Meta-worry was associated with subjective stress and EEG responses to the more self-referent stressor (negative feedback). Moderator effects on associations between state worry, performance and EEG measures suggested that high trait meta-worry blocks adaptation to stress through compensatory effort.Concepts of neuroticism and trait-anxiety are widely used to measure psychological vulnerability. Nevertheless, they can be limiting because they do not identify the underlying mechanisms of disorder; instead, they focus on the likelihood of experiencing symptoms. Myers et al. These authors examined the psychometric properties of variants of the MCQ, demonstrating a similar latent structure, reliability, and validity estimates in child versions to those obtained in the original scale. Furthermore, theoretically expected relationships between metacognitions and emotion disorder symptoms are evident, resembling those found in adults.The Metacognitions Questionnaire (MCQ) is the most commonly used measure of adult metacognitive beliefs linked to disorder in the metacognitive theory. The MCQ has also been adjusted for use in children and adolescents as reviewed in this special issue by Reinholdt-Dunne et al. demonstrated elevated dysfunctional metacognitions and lower self-report attentional control in a clinical compared with a community sample of 7–14 year-olds. In the community but not the clinical sample, MCQ-total interacted with attentional control in explaining symptoms of anxiety. The result is consistent with the idea that detrimental effects of metacognitive beliefs might be remediated by high-levels of perceived attention control.Utilizing the child version of the MCQ, Fergus et al. specifically examined the effect of metacognitive beliefs on mental contamination  in women who had experienced sexual trauma. Following exposure to an evoking stimulus, metacognitions concerning uncontrollability and danger, low cognitive confidence, and need to control thoughts positively correlated with the severity of mental contamination. The strength of relationship between specific metacognitive beliefs and symptoms of psychological disorder is likely to be subject to a range of other metacognitive influences as specified in the MCT model. Bardeen and Fergus examined this issue in the context of PTSD symptoms. They found that amongst adults exposed to trauma, deficits in executive control strengthened the positive association between positive metacognitive beliefs  and PTSD symptom scores. The positive relationship between negative metacognitive beliefs and symptoms was not moderated by executive control.Faija et al. report on the Cognitive Attentional Syndrome Scale-1 (CAS-1) adapted for research in cardiac rehabilitation patients reporting anxiety and depression. A three-factor solution was supported by confirmatory factor analysis composed of coping strategies, negative, and positive metacognitive beliefs. Each subscale independently contributed to anxiety while coping strategies independently contributed to depression symptoms.Two articles in this special issue specifically examine the Cognitive Attentional Syndrome (CAS) defined as a combination of repetitive negative thinking, unhelpful coping strategies and underlying dysfunctional metacognitions. In one of these studies, Kowalski et al. Their study explored the neural correlates of the CAS using fMRI during induced negative thinking. Low- and high-CAS groups differed in functional connectivity during induced negative and abstract thinking and also in resting state fMRI. The results suggest disrupted self-referential processing in individuals who score high on self-report CAS dimensions.One way to objectively validate the effects of the CAS as proposed in the S-REF model is by testing for specific neural correlates of this syndrome, a task undertaken by Knowles and Wells demonstrated that a single session of the ATT increased resting alpha and beta oscillations in front-parietal brain regions when compared with a control condition. The signature and location of effects is consistent with the ATT affecting executive control processes for which it was designed. Continuing with the evaluation of objective ATT effects. Barth et al. tested effects on attentional performance across attention bias, inhibition, working memory and disengagement tasks. The results showed specific effects on attention bias suggesting that ATT might promote greater attention flexibility in healthy subjects. In a related paper, Heitland et al. tested whether pre-treatment attentional control was related to these effects of ATT. Individuals who scored high in self-report attentional control at pre-intervention showed the largest improvements in attention task performance. The data imply that pre-existing metacognitions concerning attention control might moderate the effectiveness of the ATT.Three articles report on laboratory-based effects of an individual MCT treatment technique; the Attention Training (ATT). ATT was developed to attenuate the CAS, by reducing self-focused processing and strengthening knowledge concerning flexible control of thinking. Normann and Morina present a systematic review and meta-analysis of randomized trials of MCT for anxiety and depression disorders. The data appear to show that MCT is highly effective in reducing primary symptoms of anxiety or depression, secondary symptoms and hypothesized causal variables. The magnitude of effects reported seem larger than those of comparison treatments classified as cognitive-behavioral therapies. Direct comparisons of MCT with CBT in disorders such as generalized anxiety . Treatment was associated with large improvements in PTSD symptoms and high recovery rates. The results show MCT is feasible and acceptable in traumatized youth as young as 8 years of age and justify larger scale studies.Parker et al. explored the feasibility and acceptability of MCT in Individuals at high risk of developing psychosis. The majority of patients were able to complete treatment and gains on psychosis symptoms and secondary measures were observed. Retention at 6-month follow-up was lower and this is an area future studies should consider in the planning phase. The result is consistent with an earlier study on medication resistant patients with schizophrenia, suggesting that treatment with MCT is feasible and might be associated with significant benefit  showed significant improvement in meta-worry and perceived stress compared to those that did not. The outcome indicates that ATT may reduce negative appraisal processes at both metacognitive and cognitive levels within the context of academic stress symptoms.Exploration of the novel application of MCT not only addresses diagnoseable problems but is applied to modifying stress-related processes in the study by Callesen et al. report an uncontrolled evaluation of MCT when applied to a group of patients with a range of different diagnoses. Large pre to post treatment improvements in symptoms were observed during treatment sessions, and treatment gains appeared to be stable over follow-up.Most often, treatment is delivered in a one-to-one interaction between patient and therapist, but the nature of MCT, focusing on universal mechanisms, means it should be well-suited to application in groups and trans-diagnostically. These topics are addressed in three papers presented in the special issue. Papageorgiou et al. examined group treatment of obsessive-compulsive disorder and compared group delivered MCT with group delivered CBT. The study provides additional interest because MCT was introduced within a particular service as an attempt to improve patient outcomes beyond CBT that was traditionally offered. Whilst there was no randomization, the study is based on a benchmarking of effects of each treatment in large samples as a pragmatic evaluation of service change. CBT was associated with large improvements in OCD and related symptomatology and the effects compared favorably with those reported in the literature, but MCT was associated with better outcomes.The study by Haseth et al. contribute to the group treatment literature in their feasibility study of group MCT applied to patients suffering from generalized anxiety disorder. Out of 23 consecutively referred patients 19% declined group MCT in favor of individual MCT. The group intervention was associated with a 65% recovery rate at post treatment and 78% at 3 month follow-up.Several published studies have tested the effects of MCT in the treatment of GAD, and MCT is recognized in NHS NICE guidelines as a treatment option. Most often the treatment is delivered on a one-to-one-basis. Hjemdal et al. present 1-year follow-up data on their randomized trial of MCT for major depression. The results suggest a high level of maintenance of positive treatment effects following MCT, with 67% (intention to treat) and 75% of those who completed treatment classified as recovered. This is encouraging in a condition that normally has high rates of relapse. An important issue in depression treatment centers on the management of recurrent or persistent depression cases. It has been suggested that such cases require special considerations and a different treatment approach. Winter, Gottschalk et al. compared the response to MCT of patients with major depression or persistent depression. All of the persistent depression group had failed to benefit from antidepressant treatment and most of them had also received previous psychotherapy. Both sets of patients showed large and similar levels of improvement in symptoms and rates of remission during MCT and at follow-up.Depression is the second largest cause of global disability and a major contributor to risk through self-harm and suicide. MCT is proving that it might be a highly effective treatment for depression as shown in recent studies. Winter, Alam et al. capitalized on the opportunity to directly read neuronal local field signals from implanted brain electrodes in a patient with OCD during a series of MCT treatment techniques. OCD symptoms decreased after treatment and increases in alpha, beta and gamma bands and reduced theta were detected. In a different study, Johnson and Hoffart analyzed mechanism data from their earlier trial where they reported that transdiagnostic MCT was more effective than disorder-specific CBT for anxiety disorders. They found that both MCT and CBT shared some mechanisms of change; worry and attention, but additionally central to MCT was change in metacognitive beliefs about uncontrollability. Interestingly, the set of change mechanisms (in both treatments) that seemed important would be better captured by the S-REF model than by a CBT model.Two studies in the special issue examine the question of mechanisms of change in MCT. Another study by Jacobsen et al. present evidence of metacognition predicting response to treatment. They delivered a brief return-to-work rehabilitation package. Whilst it was not an MCT based intervention the authors did assess metacognitive beliefs at pre-treatment and their change during treatment. Pre-treatment metacognitions were not related to return to work, but reduction in metacognitive beliefs about the need to control thoughts gave 20% greater odds of returning to work over 1 year.Schweiger et al., in a wider context of innovation in psychotherapy. They raise important discussion questions that invite a retrospective evaluation of the barriers that have existed (and still exist in many areas) in psychotherapy evolution. They show how the process of development used in MCT offers a model that might be adopted more widely in improving psychotherapy research and treatment outcomes in the future.Innovation in psychotherapy through the systematic use of theory-driven empiricism has been the guiding principle behind MCT development, and is a process amply demonstrated in the array of papers in this issue. The process of MCT development has eschewed the integrative and eclectic technique-driven approach in favor of developing strong theory, grounded in cognitive psychology that can inform the discovery of mechanisms of disorder and the design of specific treatment techniques. This theme is discussed in the opinion paper by AW acted as chief guest editor and conceived the Research Topic. All authors contributed to reviewing manuscripts for the special issue, acted in an editorial capacity and contributed to drafts of the editorial.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Over the last decades, due to high rates of immigration, many high-income countries have witnessed demographic shifts towards more cultural diversity in the population. Socio-economic deprivation and traumatic experiences pre-migration contribute to a high risk for mental health problems among immigrant background youth. Moreover, when adapting to the multi-cultural contexts of the resettlement countries they face several acculturation demands, which may also affect their mental health in adaptive or hazardous ways. One of these acculturation tasks involves developing the cultural competence necessary to thrive and participate socially within the heritage and the majority cultural domains. From a public mental health perspective, it is important to have thorough knowledge about acculturation-related risk and protective factors. However, this responsibility has been challenged by a lack of acculturation measures that are theoretically linked to mental health, and target the cultural competencies of immigrant background youth. Therefore, the current study aimed at examining if a construct of peer-related culture competence, operationalized in the Youth Culture Competence Scale (YCCS), captured the same competence-phenomenon across different language, age, and immigrant groups in two immigrant-receiving countries. The scale includes two dimensions: one of heritage, and one of majority peer-related culture competence.Self-report questionnaire data were collected from 895 unaccompanied refugees and 591 immigrant background high school students in Norway, and from 321 immigrant university students in the United States. To examine if the measure assessed the same phenomenon of peer-related culture competence across these three multi-ethnic samples with an age range from 13 to 28, we examined its measurement equivalence. Additionally, we examined if the association between peer-related culture competence and depressive symptoms was similar in these groups.Confirmatory factor analyses supported the proposed two factor structure of the YCCS across the three samples. The structural equation model assessing the effects of heritage and majority culture competence on depressive symptoms confirmed that each culture competence dimension had a unique association with depressive symptoms across the samples.We conclude that the YCCS is a robust acculturation measure that may be included in public health studies of mental health among multi-ethnic refugee and immigrant samples of varied ages. Acculturation is a commonly used term in scholarly discussions concerning the adaptation of immigrant and ethnic minority populations. Even if the meaning assigned to the concept differs, most researchers today agree that acculturation is a two-dimensional process that should be addressed both in relation to the heritage and the majority cultures  peers?” and “How easy is it for you to know how to behave when visiting friends and families from your culture?”, respectively. Response alternatives varied from 1 - Depressive symptoms were measured by the 20-item Center for Epidemiologic Studies Depression Scale for adolescents . CES-D asks for the frequency of symptoms over the last week and includes dimensions of depressed affect (7 items), lack of positive affect (4 items), somatic activity (7 items), and interpersonal problems (2 items). Response categories range from 0 (rarely/never) to 3 . A previous confirmatory factor analysis supported the use of the four dimensions across gender and various cultural groups among unaccompanied refugees as well as ethnic minority and majority youth in Norway  peers”?), in addition to the factor means for the first-order MCC and HCC behavioral latent factors across groups. This partial scalar invariance model did not have a significantly worse fit than the full metric invariance model (ΔCFI = .008).Subsequently, we tested the invariance of the measurement model across the three groups. First, the reported fit indices of a configural model in which all parameters were allowed to vary across groups, suggested an adequate fit of the two higher-order latent factor model of culture competence , and showed that higher levels of MCC and HCC predicted lower levels of depressive symptoms . Thus, the effects of MCC and HCC on depressive symptoms were also invariant across groups.We therefore examined whether the size of the effects of the MCC or the HCC on depressive symptoms were This study examined if a construct of peer-related culture competence, operationalized in the Youth Culture Competence Scale (YCCS), captured the same competence-phenomenon across in three different immigrant-background groups of different ethnicities, languages and ages, in two immigrant-receiving countries. The YCCS includes two dimensions: one of heritage, and one of majority peer-related culture competence. We approached the goal by first examining and comparing the factor structure of the scale among the three groups. Next we investigated the association between MCC and HCC respectively, and depressive symptoms, in the three different samples of refugee and immigrant background youth of varying ages and ethnicities in Norway and the United States.Overall, the factor structure of the YCCS was supported across the three different groups of immigrant-background youth, implying that the same concepts were measured in all three samples.The measurement model involving one language and one behavioral first order latent factor for each culture competence dimension, and two higher order latent culture competence factors had acceptable fit across the three samples. Importantly, the multi-group assessment of the factor structure showed an adequate fit for a metric model, implying that the same latent factors were measured in each of the three groups. In the partial scalar model that we preferred because it was more parsimonious than the metric model, there was variation in the intercept of the means of the latent behavioral factors of MCC and HCC. This finding implies differences among the groups in the level of culture competence, which was expected. The acquisition and maintenance of culture competence is affected by a series of individual and environmental variables such as length of stay in the receiving country, attitudes towards maintaining heritage culture, frequency of interaction with, and the supportive quality of, social networks of either culture .The presence of culturally competent role models and productive feedback from significant others can also influence the development of culture competence . FurtherThe YCCS was primarily developed to be used with junior and senior high school students. The present validation study included participants beyond high school up to 28 years of age, and our findings support the utility of this scale in samples of young adults. Thus, based on the established partial scalar invariance of the scale in the present study, we conclude that the analyses support the generalizability of the YCCS as a measure of cultural resources to older age groups, in different migrant groups, across different acculturation contexts , 58. FutThe final multi-group examination of a structural model involving the effects from MCC and HCC on depression symptoms supported previous findings, as both culture competence dimensions had unique effects on depressive symptoms , 59. ThiTheoretical formulations and empirical findings have pointed out that competence of importance to the self, and the capacity to exercise control over things one values is critical to depression , 62. FacSeveral limitations of the present study should be noted. First, there is an imbalance in the number of items in the verbal and non-verbal dimensions of the YCCS . Including language competence items within a broader range will likely increase individual and group differences in MCC and HCC, which will contribute to improving the psychometric qualities of the measure. However, short scales are of value in psychological and health research, and the current version of the YCCS generally demonstrate good psychometric properties, and can be recommended for use with relevant populations.Second, the information obtained was based on self-reported questionnaire information only. A mixed-methods approach to assessing cultural competence, involving additional information from tests and observations based on standardized criteria, as well as reports from friends, family, or teachers, could have added more broad and objective information. However, it should be noted that the individual’s own perceived competence within a valued domain is of most importance to his or her mental health .The inclusion of, and comparison with a traditional acculturation measures would have added strength to our study. Unfortunately, this was not part of our research design. Comparison of variations in the associations with mental health between various acculturation measures, could be of value to better understand the complexities of the link between acculturation and health among immigrant background youth.Finally, although the present study supports the use of the YCCS in acculturation contexts outside Norway and in older age-groups, more languages and variation in acculturation contexts are still needed to make final conclusions about the invariance and validity of this new acculturation measure.The results supported the importance of culture competence in relation to mental health. Furthermore, the YCCS captured a similar phenomenon of cultural competence within the peer context in three samples of refugee- and immigrant- background adolescents and young adults with different ethnic heritage backgrounds in Norway and the United States. The study also corroborates the applicability of the YCCS as a measure to assess competence relevant to youth mental health throughout the high school years and into young adulthood among university students. This implies that the YCCS is a robust acculturation measure that may be included in public health studies of mental health among multi-ethnic refugee and immigrant samples of varied ages.


Giant cell tumour of tendon sheath is a benign soft tissue lesion most commonly found in the flexor aspect of hand and wrist. However, it is uncommon in foot and ankle and rare in bilateral achilles tendon. We report a case of 17-year-old female who presented with progressive enlargement of bilateral achilles tendon for six months. MRI findings showed that most of the tumour had intermediate to low signal intensity. Histopathology confirmed the diagnosis of giant cell tumour of tendon sheath. To help the patient regain the strength of the achilles tendon and walking abilities, a large area of tendon tumour was excised, followed by reconstruction with transfer of the peroneus brevis (PB) and posterior tibial (PT) tendon autograft. At two years follow-up, functional result was satisfactory. Among the foot and ankle region, GCTTS of achilles tendon (AT) is less commonly reported and its bilateralism is rare. This case report highlights the rare occurrence of GCTTS and discussed a novel approach to reconstruct a large defect of the AT. We performed surgery on bilateral AT and the tumour affecting almost the entire length of tendon was widely resected. Both the peroneus brevis (PB) and posterior tibial (PT) tendon were harvested and transferred for reconstruction of AT. This surgical procedure was unique and provided reconstruction of large area defect with satisfactory functional result.Giant cell tumour of the tendon sheath (GCTTS) is seen commonly in the hand but their occurrence in the foot, ankle, knee or hip is less commonA 17-year-old female presented with a slow growing painless swelling on the posterior aspect of ankle for last six months. The swelling had progressively increased in the last two months with difficulty in walking. On examination, nontender, symmetrical, firm masses noted bilaterally above the calcaneus along the course of AT . A neuroOperative procedure: (1) Incision: with the patient in prone position, a posteromedial skin incision of approximately 10cm was made till the insertion of AT. The exposed AT revealed large yellowish white nodular mass involving the entire distal part of both AT . (2) ExcThe excised specimen sent for histopathological examination showed scattered groups of mononuclear cells with occasional osteoclastic multinucleated giant cells, foamy cells, accumulation of histiocytes and hemosiderin laden macrophages without mitotic figures . Postope1. Complete surgical excision of affected tissue remains the mainstay of treatment. The gross pathological features include a well circumscribed lobulated or multi-nodular encapsulated mass with varying degrees of hyalinisation. On microscopy, the cellular infiltrate is constituted by macrophage-like mononuclear cells, epithelioid histiocyte-like cells, osteoclast-like giant cells. Because recurrence is thought to be due to incomplete excision of the tumour or satellite lesions, a balance must be maintained between salvaging tissue and adequate excision of tumour margins2. The defect in the achilles tendon can be filled either by cadaveric allograft or autograft3. Autograft is preferred in developing countries due to the limitation of allograft availability and pre-operative preparation. Among autogenous tendon transfer, methods such as PB transfer and flexor hallucis longus transfer are commonly used4.GCTTS of the foot and ankle can occur in any age. The lesions are common in the forefoot, especially in the great toe. Because bilateral GCTTS of AT is rare, it may be misdiagnosed as other foot and ankle tumours. Approximately one third of all benign lesions are ganglions5. At final follow-up, the functional improvement was satisfactory in term of AOFAS score with ROM and able to walk tiptoe with good cosmetic appearance.For regaining better strength of the AT and functional abilities, we decided to undertake reconstruction using both PB and PT autograft transfer. Advantages include improved length of the tendon and strength of the muscle in comparison to that of other transfer candidates, especially in treatment of the excision and reconstruction of large tumours of the ATB/L GCTTS of AT is extremely rare. Other differential diagnosis should be excluded in the presence of bilateral enlargement of Achilles tendon. Reconstruction of large defects following wide excision of AT is often challenging in presence of limited graft sources. Combined transfer of both PB and PT tendon is a unique method to bridge the large defects with satisfactory result.


The COVID-19 global pandemic has resulted in a plethora of guidance and opinion from surgical societies. A controversial area concerns the safety of surgically created smoke and the perceived potential higher risk in laparoscopic surgery.The limited published evidence was analysed in combination with expert opinion. A review was undertaken of the novel coronavirus with regards to its hazards within surgical smoke and the procedures that could mitigate the potential risks to healthcare staff.Using existing knowledge of surgical smoke, a theoretical risk of virus transmission exists. Best practice should consider the operating room set-up, patient movement and operating theatre equipment when producing a COVID-19 operating protocol. The choice of energy device can affect the smoke produced, and surgeons should manage the pneumoperitoneum meticulously during laparoscopic surgery. Devices to remove surgical smoke, including extractors, filters and non-filter devices, are discussed in detail.There is not enough evidence to quantify the risks of COVID-19 transmission in surgical smoke. However, steps can be undertaken to manage the potential hazards. The advantages of minimally invasive surgery may not need to be sacrificed in the current crisis. The COVID-19 pandemic is unprecedented and raises concerns regarding transmission of the virus within surgical smoke. This review summarizes the current evidence and provides advice for its management.Bad for your health? The 2020 pandemic of the novel coronavirus, COVID-19, has raised concerns about the risk of virus transmission to staff in the operating room. This relates not just to intubation and extubation of the airway during anaesthesia, but also to the release of potential infectious particles in laparoscopic smoke or plume.2 for aerosolized particles should be strongly considered’.The risks of laparoscopic smoke, or plume, have been recognized for a long time, but the advent of COVID-19 has brought its importance into sharp reliefonly in selected individual cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission in that particular situation’. This expeditious advice is a pragmatic response to the widespread anxiety surrounding possible virus transmission in the operating room.A rapid, joint publication from Italian and Chinese surgeonsThis article reviews the best available evidence to understand the risk of transmission of COVID-19 in laparoscopic smoke, and what steps, based on physical properties of the virus, may be best placed to reduce this and justify continuing laparoscopic surgery under strict safety guidelines.There is currently no evidence that COVID-19 is transmissible through surgical smoke. Previous studies have, however, demonstrated the presence of different viruses in surgical smoke, including: corynebacterium, human papillomavirus (HPV), poliovirus, human immunodeficiency virus (HIV) and hepatitis BThe possibility of disease transmission through surgical smoke does exist in humans, but documented cases are rarein vitro laser vaporization of cultured HIV cellset al.18.In addition to HPV transmission, Baggish and co-workers reported that HIV proviral DNA was captured in the inner lumen of smoke evacuation tubing after Sarbecovirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), which is a member of the betacoronavirus family (subgenus Sarbecovirus). Like its close relatives, Middle East respiratory syndrome coronavirus (MERS-CoV) and SARS-CoV, it is believed to have its origins in bats. Sequence analysis from cases around the world strongly indicate that the pandemic resulted from a single recent emergence of the virus from an animal reservoir.It is essential to understand the physical properties of the virus in order to predict the risk of transmission and the effectiveness of preventative measures. The correct term for the virus causing COVID-19 is 22. In each case, the interaction is thought to occur with the S protein, which appears pivotal for cellular tropism.SARS-CoV2 is a positive-sense single-stranded RNA virus, containing a linear genome of approximately 30 kb. Like other members of the coronavirus family, the virion is typically around 120 nm in diameter, although this can vary from 50 to 200 nmThe extended S protein is a trimeric protein, each monomer being approximately 1100 amino acids in length. The structure of the protein (based on Protein Data Bank (PDB) 6CRV) is depicted in Excellent theatre discipline and the use of checklists is highly recommended to minimize the risk of surgery and anaesthesia, regardless of surgical approach. Expert recommendations from China suggest using a designated operating theatre for COVID-19-positive patientsIn deciding which operating theatre to use, the theatre ventilation system should be considered. Negative pressure ventilation can limit the contamination of surgical smoke into neighbouring areas through doors and vents. During the SARS outbreak in Hong Kong in 2004, Chow and colleagues26. They produce a continuous flow of highly filtered ultraclean air and can display 99·97 per cent efficiency in removing airborne particles of 0·3 μm and largerUnidirectional air flow (laminar flow) systems remain controversial in their ability to decrease surgical-site infections and so are not recommended by the WHOThere is a limited amount of evidence related to the choice of tissue-cutting energy device used. Monopolar electrocautery using Teflon®  blades and a feedback mechanism to automatically reduce the voltage produces less surgical smokeThe operating room ventilation system is not the only method of smoke extraction; protection from surgical smoke can also be achieved by local extraction at the site of surgery or by the use of personal filtration masks. There are several benefits to using smoke extractors; they keep the surgical field clear, prevent corrosion of equipment due to released chemical, and reduce odour. However, for the purpose of this review, the main benefit is that they capture the smoke close to the source of emission, therefore minimizing exposure of healthcare professionals to potential contaminants and maintaining a safer environment. For this reason, the surgical colleges in the UK currently recommend their use3/s), the ability to vary both the flow rate and noise level , ergonomic features, portability, cost-effectiveness and ease of maintenanceThe particulate removal capability of smoke evacuator devices is, by design, limited to the efficiency and size of their filters. Other factors to consider include: the minimum flow rate  delivers aerosol chemotherapy under pressure during laparoscopy for the treatment of peritoneal carcinomatosis. By its very nature, the procedure has necessitated a high level of investigation into ways of mitigating the risk of gas leakage during surgery. Both experimental and human models have shown that, with the development of standard operating procedures (SOPs) for laparoscopy, the risk of contamination of the operating theatre environment with potentially harmful chemotherapy agents is negligibleOpen Hasson umbilical port insertion may result in a larger defect in the fascia than is required for the port, allowing pressurized carbon dioxide to escape around the trocar. PIPAC surgeons frequently use either off-midline open cutdown or alternative first entry techniques , which result in a fascia defect that is more snug around the port, reducing the risk of gas leakage at this site.PIPAC SOPs recommend the use of balloon ports. Balloon-secured trocars reduce the chance of inadvertent displacement of the trocar during instrument changes, thus reducing the risk of loss of pneumoperitoneum to the operating theatre environment. Trocars also contain a valve preventing gas leakage when an instrument is passed through into the peritoneum; surgeons should be aware of the inherent risks if the valve should become damaged. In addition, the authors believe that, when the balloon is inflated inside the peritoneum and traction is applied against the posterior rectus sheath, a more secure seal is achieved around the body of the trocar, therefore reducing the risk of gas leakage.Ten-millimetre ports should be closed under direct vision once the pneumoperitoneum has been safely evacuated using techniques described elsewhere in this article. The authors recommend against the use of devices such as EndoClose™ , which require maintenance of the pneumoperitoneum to facilitate closure, as this will increase the risk of gas leakage.Pneumoperitoneum should be maintained throughout the procedure at the lowest possible pressure. At the end of the procedure, the pneumoperitoneum should be removed in a controlled fashion by first switching off the insufflation, and then aspirating the pneumoperitoneum using a suction device (preferably passed through a filter mechanism)The Ultravision™ system  removes smoke and particulate matter produced during electrosurgical procedures, as an aid to maintaining a clear visual field. Active throughout surgery, the system prevents the build-up of smoke by electrostatically precipitating particulate matter generated within the peritoneal cavity during the use of electrosurgical tools. It has been shown to negate the periprocedural venting of insufflation gas to facilitate clearance of smoke45. Ultravision™ has also been used to enhance safety in PIPACThe principle on which the Ultravision™ system operates is derived from electrostatic precipitators that are widely used to remove fine particulate matter from exhaust gases produced during, for example, the commercial manufacture of cement and paper. The system comprises a generator and a single-use electrode that together create negative ions in the abdominal cavity. These ions impart a transient negative charge to the particles of surgical smoke as they are created. The electrostatically charged particles are attracted to the patient tissue owing to the presence of the standard patient return electrode used during surgery. The charge is neutralized as each particle precipitates on to the surface of the peritoneal wall, where it remains unchanged physically and chemicallyThere is not enough evidence available to allow a balanced risk estimation for the infectious nature of surgical smoke. It is unclear whether laparoscopic smoke represents a greater risk than that created during open surgery. Given the novel status of the COVID-19 pathogen, and the evidence of other viruses being present in surgical smoke, maximizing intraoperative precautions at this time would seem prudent. There has never been a time when knowledge and guidelines are changing on an almost daily basis as a result of the unprecedented worldwide communication and information sharing. Minimal access surgery offers advantages to patients in terms of hospital stay. With strict locally agreed theatre protocols aligned to evidence-based protective measures, it may be possible to continue to offer minimal access surgery to those who might benefit most.J.T. holds stock in Alesi Surgical and has received educational grants from Medtronic and Ethicon. The authors declare no other conflict of interest.