Background: A structured multidisciplinary team is very important during every phase of the amputation process and a good communicative team guarantees a greater tranquility for the patient, thanks to more homogenous information, that is already discussed between the clinicians. Aim: The aim of this study was to define the efficacy and outcome value of an innovative procedure tool (TRIA-MF protocol) in the treatment of lower limb amputees before and after prosthesis use with the purpose to quantify the quality of the procedure and its economic impact on the clinical patients’ recovery. Setting: A rehabilitation institute for the treatment of neurological and orthopaedic gait disorders. Methods: 12 patients (4 women and 8 males) subjected to lower limb amputation and admitted according to the principles of inclusion criteria of the TRIA-MF protocol at the Rehabilitation Department of the Clinical Institute Città di Brescia were recruited in this study. All patients were included in an integrated and task-specific management protocol of the amputee, which allowed to follow the rehabilitation process from amputation to the final restoration, for a period of 6 months for each patient. Patients were evaluated 5 times during the study, collecting their degree of pain (VAS), their independence profile (Barthel Index) and the cirtometry of their amputation stump. Data on the duration of their admission to the rehabilitation unit, the inter-time between the amputation and acquisition of the temporary prosthesis, and between temporary prosthesis acquisition and the final prosthesis acquisition were also reported. Results: Patients of our sample, at the end of their hospitalization, highlight a significant modification of the temporal data at 1 month and 6 months from their hospital discharge. A statistical significant increase of the Barthel Index value was observed in all patients recruited in this study proceeding from time T0 to time T4; in the same way, a statistical significant decrease of the VAS scale was observed in all patients recruited proceeding from time T0 to time T4; the cirtometry of the amputation stump (expressed in cm) showed a statistical significant decrease in all patients recruited proceeding from time T0 to time T4. We haven’t observed a statistical significant correlation between the duration of the rehabilitative hospitalization and our clinical data; no statistical significant correlation was observed between the amputation stump cirtometry time-related modification and our intertime data. Conclusions: The protocol was found to be a clear and relevant tool with the definition of the operational profile for each single professional figure involved; it could also be considered as an optimal tool for coding the management and evaluation of the effectiveness of amputee treatment, with a related high reproducibility, sensitivity and specificity profile. In line with the literature, the TRIA-MF protocol has allowed us not to exceed a period of hospitalization in rehabilitation units of more than 23 days, thus showing that it is an excellent tool for optimizing the management costs of the amputee over time.

We read with interest the case report entitled “Dieulafoy’s Lesion related massive Intraoperative Gastrointestinal Bleeding during Single Anastomosis Gastric Bypass necessitating total Gastrectomy: A Case Report” published in Archives of Surgery and Clinical Research b Ashraf Imam et al. [1]. We appreciate the authors for managing such a complicated case and for sharing their experience but, we have some conflict about the management, and we wanted to add some comments regarding the importance of EGD before bariatric surgery. In the published case, no preoperative EGD was done and the authors mentioned that Dieulafoy’s Lesion is very unlikely to be diagnosed in the routine endoscopy. We agree with that statement but, it is not a good reason to eliminate this diagnostic modality before surgery. Though controversial, there is growing evidence which supports the importance of routine EGD prior to obesity surgery [2]. This may alter the surgical or medical plan for the obese patient, Furthermore, we have a different opinion about this patient’s management and, we wanted to share this with the authors. In the reported patient, after control of the bleeding during gastrojejunal anastomosis, the OAGB(One Anastomosis Gastric Bypass) concluded successfully but, the patient was re-intubated because of severe bloody emesis at the recovery room and then an arterial bleeding point in the posterior wall of the lesser curvature close to the esophagogastric junction was found. This does not illustrate the reason for the huge gastric remnant seen at the laparoscopy because it was at least 200 cm far from the pouch and backwards flow of blood is very unlikely. Our opinion is, due to 90% diagnostic rate and about 75-100% success in hemostasis, on-table EGD should have a more highlighted role in treatment of the reported case [3]. Even if the pouch was dilated, it was not rational to perform a total gastrectomy in such an unstable patient and a laparoscopic pouch resection followed by Roux- en-y esophagojejunostomy could be a better choice in our point of view. Moreover, Feeding gastrostomy could be a better option rather than feeding jejunostomy, if needed. In summary the essential role of endoscoy for screening the patients before bariatric surgery and, for the management of complications (though controversial), should always be kept in mind by bariatric surgeons.

A 35-year-old man presented with swelling in the lower abdomen for 2 months. He was found to have left undescended testis. An ultrasound scan showed a solid floating pelvic mass. His chest x-ray and tumour markers for testicular cancer were normal. Exploratory laparotomy revealed the left intra-abdominal testicular tumour. Intra-abdominal left orchiectomy was performed. The patient made an uneventful recovery. Histology showed immature seminoma. A mass in the lower abdomen with a cryptorchidic testis strongly points towards the diagnosis of malignancy in abdominal testis. To prevent this complication all undescended testis gets orchiopexy before 2nd year or orchiectomy in post-adolescent life. But some cases remain unnoticed, which leads to this kind of presentation. So, we decided to present this rare and interesting case of intra-abdominal testicular tumour.

Purpose: To compare the outcomes of Abdelhamid technique in treatment of inguinal hernia to conventional TAPP with mesh stapling, Prolene hernia system (PHS) and Lichtenstein repair. Background: the mesh is applied and fixed externally aiding in decreasing port size and cost. There is controversy concerning the necessity of securing the mesh during laparoscopic TAPP repair. Patients: The study was carried out at the faculty of medicine – Beni Suef University, Egypt from September 2008 to April 2018. 672 patients with unilateral inguinal hernia participated in the study. 432 were treated using Abdelhamid Technique, 382 of which were unilateral primary inguinal hernia and 50 were unilateral recurrent. 50 patients were treated using Prolene Hernia System (PHS). 50 patients with recurrent hernias were treated using Lichtenstein repair and 140 patients went TAPP with mesh stapling. Results: Abdelhamid technique showed more cost effectiveness than stapling (1800$ vs 3000$) , pronounced less recurrence rate in comparison with Liechtenstein and PHS (2% vs 4%), same LOS compared to other techniques and mean operative time of 76 minutes which is longer than stapling (60 mins), Liechtenstein (65 mins) and PHS (55 mins). Conclusion: Abdelhamid technique was a more lengthy operation costing more than open surgery but less than mesh stapling. The recurrence rate is considerably reduced with shorter recovery period. The technique is done with smaller port size that leads to cost reduction

Pyogenic liver abscess (PLA) is a life-threatening infection that may develop as a result of an underlying hepatobiliary disease. A possible complication of PLA is metastatic spread, resulting in distant seeding of infection in other organs, and occasionally in the epidural space. Spinal epidural abscess (SEA) is a rare infection with severe potential complications. We describe a 71-year-old patient who presented with ascending cholangitis that was complicated by micro PLA, with a subsequent Escherichia coli bacteremia and metastatic SEA. An emergent surgical intervention with laminotomy and drainage of the epidural collection was performed. The patient was treated with a prolonged antibiotic regimen, with uneventful recovery and no neurologic sequelae. To our knowledge, this is the first reported case of a SEA following E. coli PLA.

Background: Laparoscopic cholecystectomy (LC), is one of the most commonly performed surgical procedures worldwide, it is accepted as the gold standard in the treatment of symptomatic gallstones for its minimal invasiveness, less pain and early recovery. Purpose: To predict the difficulty of laparoscopic cholecystectomy in patients according to the recently published scoring system and select the difficult cases to be done by a senior surgeon. Patients: This is a prospective cohort study. This study took place Oct 6th University Hospital and Kasr El Aini Hospital, Cairo university; the study involved 120 patients admitted with calcular cholecystitis, arranged for laparoscopic cholecystectomy. Methods: Laparoscopic cholecystectomy after applying the scoring system. Results: In our study we found that age, sex and ultrasonographic data were significant predictive factors for assessment preoperatively difficult cases that will be operated upon. We found 14 patients above 50 years who scored to be difficult and very difficult were at outcome difficult, only three patients converted to open surgery over fifty. Conclusion: We can report that obese patient who were over fifty with history of previous upper abdominal surgery and ultrasonographic picture showed thick walled GB and pericholecystic collection had high risk of conversion. At this study scoring system was used for prediction of difficult laparoscopic cholecystectomy sensitivity was 93.75% and specificity was 52.94% of the scoring system at score 5 for prediction of easy or difficult laparoscopic cholecystectomy.

A knee arthroscopy in spinal anaesthesia was performed on a 67 years old male patient. During the procedure the patient was hemodynamically stable, until he suddenly turned pale and started complaining of severe pain in lower abdomen with signs of guarding. The procedure was finished as urgently as possible and after releasing the tourniquet we noticed significant difference in volume of the leg, with redness distal to tourniquet. Urgent lab results were essentially unremarkable and the patient was sent for the urgent radiological diagnostics. CD of the left leg described fluid in the soft tissues of the thigh, scrotum, and abdomen; and the unenhanced CT of the abdomen showed free fluid along the entire femoral shaft of the left thigh, extending towards pelvis and abdomen to perihepatic and perisplenic space, and retroperitoneum, with gas bubbles tracking along anterior aspect of the left thigh into the left retroperitoneum. He was admitted to the ICU, and within few hours all symptoms have resolved and his further recovery was without complications.

Laparoscopic approach in emergency theatre is an irreplaceable tool to manage patients with acute surgical pathology. We retrospectively reviewed surgical access records from the Emergency Department for acute right iliac fossa pathology. We considered 51 patients (16 male, 35 female, mean age 23.8 years) access for acute right iliac fossa pathology over the last year. 44 patients underwent laparoscopic approach (86%); 8 patients were treated with an open approach. Outcomes evaluation was based on data comparison from open appendicectomy over 4 year time period. Variables considered for data analyses were: role of laparoscopic surgery for gangrenous/perforated appendicitis, Conversion rate, Laparoscopy appendicectomy for elderly patients. Our study demonstrated that a laparoscopic approach at acute right iliac fossa pathology is feasible, safe and can offer a low incidence of infectious complications, less post-operative pain, rapid recovery, and represent a valid diagnostic tool in doubtful cases, at the expense of longer operating time than OA. We suggest that LA should be the initial choice for all patients with acute right iliac fossa pathology.

Purpose: Some physiological events in women’s life such as pregnancy and lactation can be associated to a condition known as Transient Osteoporosis of the Hip (TOH); if not promptly diagnosed it can lead to significant consequences such as femoral neck fracture. In this paper we describe a case of bilateral TOH, focusing on the importance of early treatment and how it influenced the outcome. Methods: A 40 years old post-delivery woman came to our attention for hip pain and a left femoral neck fracture was diagnosed. Magnetic resonance (MRI) showed bilateral edema of the femoral head. She underwent total hip replacement on the left side; toe-touch weight bearing and pharmacological therapy were prescribed for the right hip. Results: MRI at nine months showed complete regression of the femoral head and neck edema; the patient was clinically asymptomatic. Conclusion: If not promptly diagnosed and treated, TOH can potentially evolve in fracture. Many therapeutic strategies have been suggested since now; we believe that avoiding weight bearing on the involved hip as early as possible is the key to recovery.

Purpose: This work is aimed at demonstrating that scraping cytology and scanning electron microscopy can successfully assist in the diagnosis of nontuberculous mycobacteria infection. For this purpose, we report the use of both these techniques in the diagnosis of cornel ulcer in a previously healthy young man. Methods: Cytological samples were achieved by scraping technique on the mucosa, both sub palpebral and temporal area of the eye tarsal conjunctiva. The obtained sample was affixed to a sanded rectangular slide, stained with the Pappenheim method, washed in bidistilled water, treated in Giemsa solution, washed again and subsequently dried on a hot plate and observed with a microscope at various magnifications. Results: After a therapy based on a 500 mg clarithromycin tablet administered every 12 hours for 30 days as systemic therapy, a complete recovery of the patient from left eye inflammation was observed and SEM cytology showed that NTM colonies had disappeared. Conclusion: Conjunctival cytology scraping and SEM technologies can be therefore exploited as new tools in diagnosis and fast identification of these newly discovered mycobacteria. In fact, they have a new way for studying ocular pathology, because of the simple execution and remarkable accuracy in the diagnosis. In fact, this technique allows to gather valuable information about all pathogens expression and the cellular action involved in pathology. As a further plus, this technique provides clinicians with the opportunity to repeat the SEM cytology for monitoring patients during therapy, hence leading to evaluate the efficacy of the pharmaceutical regimen in real time.

Sexual activity during healthy pregnancy is safe. There are little data on how coital activity affects outcome of the high-risk pregnancies. Hereby we report a case demonstrating that orgasmic coitus triggered placental abruption resulting in preterm stillbirth. A 38-year-old 8-para, 12-gravida woman lived unmarriedly with a constant partner in low socioeconomic conditions. Her previous pregnancies included 7 deliveries without complication, two early miscarriages and two pregnancy terminations. Her present pregnancy was complicated with gestational hypertension successfully treated with nifedipine. She had coitus 2 to 4 times a month, mostly without orgasm. The last coitus which happened in side-by-side position was accompanied by orgasm which continued in uterine hypertonicity and massive vaginal bleeding at 29 weeks gestation. Two hours subsequently, on admission to hospital, placental abruption and fetal demise were diagnosed. At the emergency cesarean section, a dead female infant weighing 1,510 g was born. Fetal pathology was not discovered. Placental histopathology showed retroplacental hematoma, intervillous and decidual hemorrhages, focal distal villous hypoplasia and avascular villuses. Patient’s recovery rapidly occurred after intensive care. Placental abruption complicates 0.4% - 1.0% of deliveries. It is known that most cases of abruption cannot be predicted and prevented. Our report suggests that orgasmic coitus may be a trigger for placental abruption in those women who have gestational hypertension and multiple risks for placental abruption. We infer from the above case that sexual intercourse is advised to avoid during pregnancy of such women in order to prevent placental abruption.

Introduction: Arachnoid cyst (AC) is a congenital, benign, extra-axial lesion often found incidentally on intracranial imaging and makes up almost 1% of all intracranial masses. It arises from the splitting of arachnoid membranes with components similar to the cerebrospinal fluid. It’s reported that AC can be complicated by chronic subdural haematoma in athletes with repeated head injuries. Case report: we describe a case of a soccer player with an AC that underwent surgery for a chronic subdural haematoma with full recovery. Material and method: From a PubMed research, we found 14 relevant studies reporting a total of 15 patients who met the inclusion criteria: playing soccer, subdural hematoma and arachnoid cyst. Results: Patients underwent different surgical treatment. In the case of hygroma with no midline shift, a conservative treatment was performed. In all cases the reported follow up was a full recovery. Discussion: Soccer is not usually considered a contact sport related to a high risk of head trauma or shaking head. From our review we can postulate that a soccer player with AC has an augmented risk to have a subdural haemorrhage, more rarely intracerebral haemorrhage. Conclusion: ACs are common meningeal abnormalities. They may bleed after minor head trauma, although it is rare. Asymptomatic patients with known AC should be monitored by a neurosurgeon and decision to engage this patient in soccer sport participation is still controversial.

A 27-year-old man presented to our hospital for abdominal pain and a cheesy discharge from the umbilicus which lasted for a few days. He was afebrile. The physical examination revealed periumbilical tenderness and discharge from the umbilicus. There were no signs of general infection. Otherwise, he had neither specific symptoms nor a palpable abdominal mass. Pelvic computerized tomographic (CT) scanning) confirmed the presence of a cyst in the midline of the abdominal wall, with communication with the bladder and peripheral calcification. The mass was infiltrated to the perivesical fat (Figure 1). The patient was prepared for surgery. During laparotomy, a urachal cyst with the cuff of the bladder dome were removed (Figure 2). Recovery was unremarkable. The resected specimen was a partial cystectomy specimen with perivesical fat and the median umbilical ligament

The infectivity and pathogenesis: SARS-CoV-2, the causative agent of Covid-19, involves Angiotensin-converting enzyme 2 (ACE2) receptors on type II alveolar type 2 (AT2) cells in lungs. Apart from, the upper and lower respiratory tracts, the disease affects the gastrointestinal system prominently, as evidenced by the significant GI symptoms, early in the course of the disease. In addition, the virus infects ACE2-bearing cells in other organs including the heart and blood vessels, brain, and kidneys. Clinical features and morbidity: The clinical spectrum of COVID-19 varies from asymptomatic or pauci-symptomatic presentation to moderate to severe states characterized by respiratory failure necessitating mechanical ventilation and ICU support and those manifesting critical clinical condition with complications like sepsis, septic shock, and multiple organ dysfunction failure. The CT chest is an important tool for early identification of COVID-19 pneumonia as well as for prognostic purposes. The recovery and residual damage: The recovery and other outcomes vary depending on age and other aspects including sex, comorbidities, and genetic factors. The outlook for older adults, who account for a disproportionate share of critical disease, is unfavorable, and most of those who survive are unlikely to return to their previous level of functioning. The disease affects their long-term health and quality of life as well as brings in propensity for truncated post-disease survival. COVID-19 aftermath and follow up: The patients discharged from hospital following severe COVID-19, continue to suffer with lingering impact of the disease as well as that of the emergency treatments that saved their life. The post-infection reduced exercise tolerance and other subtle factors, like post viral fatigue syndrome, post-traumatic stress disorder, impaired concentration, delirium, and disturbed sleep-wake cycle often underly the functional impairment. In fact, there is need of step-down care and later a multidisciplinary support involving regular clinical assessment, respiratory review, physiotherapy, nutritional advice, and psychiatric support. Conclusion: The life after COVID-19: After recovery from the disease, the virus SARS-CoV-2, may persist for uncertain period. In addition, the chance of reinfection cannot be ruled out. The vitamin D supplementation may be helpful. In general, the quality of life (QOL) in ICU survivors improves but remains lower than general population levels, but most of the patients adapt well to their level of self-sufficiency and QOL. Also, the debility due to co-morbidities may further compromise the activity of daily living and QOL issues. The Age and severity of illness appear to be the major predictors of post-discharge physical functioning.

The outbreaks and resurgence: The disease which reportedly began in the Chinese city Wuhan in November-December 2019, soon spread to various parts of the world, and was named and declared a pandemic disease by WHO. While the European countries were recovering from the epidemic, the disease took hold in the USA, the South American countries, Arabian countries, and South Asian countries, predominantly affecting Brazil, Peru, Iran, and India. Presently, many European countries are witnessing a resurgence and recurrent outbreaks of COVID-19. Spread and evolving new insights: Whereas there is workplace-related infection rise as people are returning to their offices, in other places the outbreaks are related to the people crowding and meeting care-freely and trying to resort back to their earlier way of life. The reopening of the educational facilities across the continents may make matters worse. Impact on health and healthcare: Most cases of COVID-19 infections go unnoticed and are followed by self-recovery. But what may appear good from the clinical perspective, appears to complicate epidemiological efforts to contain the outbreak. With the evolving information about the disease, there seem to be certain possible outcomes such as control and containment, or the persistence of the disease as global endemic accompanied with outbreaks and resurgent episodes. Gnetic factors linked to disease severity: With the COVID-19 pandemic, not all infected patients develop a severe respiratory illness. Further, there is a large variation in disease severity, which may be due to the genetic factors underlying the variable response to the virus. It is becoming clear that apart from the advanced age and pre-existing conditions, certain genetic constituent factors render some patients more vulnerable to the more severe forms of the diseases. Integration of virus into human genome: A significant part of the human genome is derived from viruses especially the RNA viruses. In fact, about 8 percent of the human genome is made up of endogenous retroviruses (ERVs), which are viral gene sequences that have become a permanent part of the human lineage after they infected our ancient ancestors. With this background, a novel concept emerging that if COVID-19 persists for several generations, its genetic material is projected to be integrated or assimilated into human genome. The involved mechanisms are conceptualized through the transposons or transposable elements of the SARS-CoV-2.

Managing municipal solid waste correctly is critical to the success of a society. Many regions and countries in the world are behind others in the context of solid waste management. In order to compare three such regions within this context, a meta-analysis was conducted in order to develop a decision matrix. Within this decision matrix, the United States, Europe, and Asia were compared to determine which region is managing municipal solid waste the best. This research design allowed for compiling information from many sources to increase the accuracy of data used in the justifications for the decision matrix. Purposive sampling was used to select and evaluate sources that discuss solid waste management to discern which region’s processes are most favorable in many parameters. The decision matrix consists of nine parameters: main management techniques; finances; landfill taxes; jobs created; waste generation; waste composition; waste storage, collection, and transportation; energy recovery; and environmental health. Each was scored on a scale from zero to ten, ten being the best score and zero being the worst. The final score from the decision matrix suggested that Europe had the most favorable municipal solid waste management (MSWM) system, and the United States had a notably close yet lower score. Asia had the lowest score that was hardly comparable to the other two regions.

Industrial control systems (ICS) are critical, as in these systems, cyber threats have the potential to affect, disorganize, change their mode of operation, act as an information extraction vehicle, and ultimately turn against itself. Creating risks to the system itself, infrastructure, downtime, leakage of sensitive data, and even loss of human life. Industrial control systems (ICS) are vital to the operation of all the modern automated infrastructure in the western world, such as power plant and power stations. Industrial control systems (ICS) differ from the traditional information systems and infrastructures of organizations and companies, a standard cyber security strategy cannot be implemented but part of it adapting to the real facts and needs of each country, legislation and infrastructure. These systems require continuous operation, reliability and rapid recovery when attacked electronically with automated control, isolation and attack management processes. Incorrect settings and lack of strategic planning can lead to unprotected operation of critical installations, as they do not meet the cyber security requirements. Industrial control systems (ICS) require special protection in their networks, as they should be considered vulnerable in all their areas, they need protection from cyber attacks against ICS, SCADA servers, workstations, PLC automations, etc. Security policies to be implemented should provide protection against cyber threats, and systems recovery without affecting the operation and reliability of operating processes. Security policies such as security assessment, smart reporting, vulnerability and threat simulation, integrity control analysis, apply security policy to shared systems, intrusion detection and prevention, and finally firewall with integrated antivirus and sandbox services should be considered essential entities.

Purpose: In an aspect of qualitative treatment, this research gathered lung cancer patients’ actual experiences to understand deeply, such as their expectation for treatment results, their difficulties during treatment, and their various requests to their family and medical teams. Methods: From May to June 2013, semi-structured interviews were conducted with 9 lung cancer patients. Data were collected through a tape-recorded in-depth interview. The analysis of the data was made through the qualitative method. Results: 124 themes regarding the experience were found. From these 35 concepts, 24 subcategories were emerged. The core category was enduring hardship of the treatment with the hope for full recovery. Six categories included ‘Wishing to be cured but concern about recurrence’, ‘Receiving radiation treatment with pleasure and difficult at the same time’. ‘Being sorry for their family’s full support and trying to stand alone‘, ‘Having confidence in their medical team’, ‘regretting for their old days’, and ‘Wanting to live a long life without illness and pain’. Conclusion: The results of this study would help oncology nurses to understand the lung cancer patients receiving concurrent chemo-radiotherapy (CCRT) and to develop a quality of life improvement program for physical, psychosocial, and spiritual aspects of nursing.

Zinc induced pediatric preventing respiratory 2019-nCoV is required that supplementation with zinc gluconate 20 mg in Zn deficient children resulted in a nearly twofold reduction of acute lower respiratory infections as well as the time to recovery. Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Preventing 2019-nCoV pneumonia is required that zinc supplementation alone (10 to 20 mg) for more than 3 months significantly reduces in the rate of pneumonia. zinc pediatric intake may be required to be effective range 10～20 mg/d for 2019-CoV prevention, 10～30 mg/d for reduction of COVID-19 bronchitis, and 20～30 mg/d for recovery from COVID-19 pneumonia, in which Zn2+ could bind with viral surface proteins by Zn2+ions-centered tetrahedrally coordination pattern. On the other hand, for aults, the zinc-homeostatic immune concentration may provide a protective role against the COVID-19 pandemic, likely by improving the host’s resistance against viral infection. 50 mg of zinc per day might provide an additional shield against the COVID-19 pandemic, possibly by increasing the host resistance to viral infection to minimize the burden of the disease. In order to prevent that an outbreak of respiratory sickness caused by a novel coronavirus (COVID-19) has become a serious public threat and disrupted many lives,assessing the efficacy of FDA-approved Zn-ejector drugs such as disulfiram combined with interferon to treat COVID-19 infected patients has been proposed. The key strategies for preventing lung damages include avoiding direct lung infection, altering host-virus interactions, promoting immune responses, diluting virus concentrations in lung tissues by promoting viral migration to the rest of the body, maintaining waste removal balance, protecting heart function and renal function, avoiding other infections, reducing allergic reactions and anti-inflammatory. The interactions had been found on the binding specificity by Zn2+ ions-centered tetrahedral geometric coordination of the inhibitors against 3C and 3C-like proteases. In addition, transient zinc chelation TPEN and EPDTC have been noted as preventing virus replication. Zinc-induced ROS production in COVID-19 respiratory ailment and pneumonia occurs both in children and adults. In children. ROS production in zinc (Ⅱ)-immune pediatric patient with COVID-19 bronchitis and pneumonia cannot be elucidated yet. In adults, zinc induced ROS generation in pulmonary COVID-19 infected cells is that alterations of ROS-producing and scavenging pathways that are caused by respiratory viral infections are implicated in inflammation, lung epithelial disruption, and tissue damage, and, in some cases, even pulmonary fibrosis. The involvement of oxidative stress in cell deaths caused during RNA virus infection and ROS production is correlated with host cell death.

Treatment options in multiple myeloma (MM) based on novel agents are often limited by dose-related neurotoxicity. Bortezomib, a highly active reversible proteasome inhibitor, frequently causes peripheral neuropathy (PN). Bortezomib-induced PN (BIPN) is characterized by a length-dependent, sensory, axonal polyneuropathy (PNP) with predominant small fiber-affection. Following dose reduction or drug discontinuation, BIPN resolves within 3-4 months in the majority of patients. The pathophysiological mechanisms of BIPN are unclear. Rare cases of a severe demyelinating or mixed BIPN with prominent motor involvement have been attributed to autoimmune or inflammatory reactions. A case report, including nerve pathology, is presented of a 59-year-old man with stage III IgG-κ MM who was treated with bortezomib on the occurrence of progressive disease. After the fourth cycle, he developed a painful distal symmetric sensory PNP followed by gait instability and muscle weakness increasing over 3 months despite early cessation of bortezomib.Neurological examination revealed a distal flaccid tetraparesis mainly of the lower limbs with sensory loss and severe ataxia, electrophysiological features of a mixed axonal-demyelinating PNP, and pathomorphological evidence of neuritis. Steroid treatment was initiated, and partial recovery of the neurological symptoms within 6 months was observed. While a neurotoxic effect may explain the initial distal sensory disturbances, the worsening of neurological dysfunction after bortezomib withdrawal and the clinical pattern with steroid-responsive muscle weakness predominantly of the legs are consistent with an immune-mediated mechanism. This is in line with the sural nerve biopsy findings. Toxic BIPN followed by an immune-mediated BIPN in the same patient has not been reported before.