Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered fxor tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.

Leptin is produced predominantly in adipose tissue but has recently also been found in gastric mucosa. It has been shown that the oral application of leptin induces neuronal activity in the brain stem of rodents. The objective of the present study was to identify this hormone in human saliva and to examine the production and stability of salivary leptin. We have demonstrated production of leptin in salivary glands and oral mucosa by RT-PCR, its storage by immunocytochemistry, and the release of the peptide by RIA . Chromatographic analysis and immunoblotting confirmed the identity of leptin. There is a strong linear correlation (r 2 ‫؍‬ 0.78) between leptin concentrations from simultaneously collected saliva and plasma samples (n ‫؍‬ 61). Stimulation of saliva flow increases total leptin secretion up to 3-fold (P < 0.001). As to the stability of leptin in gastric fluid, we found the peptide was not degraded above pH 3. S INCE THE DISCOVERY of leptin in 1994, research activities have been directed at understanding the regulation and actions of this peptide hormone. Leptin is the product of the obese gene with a single-chain structure and a molecular mass of 16 kDa. It is produced by differentiated adipocytes (1, 2) as well as in the placenta (3, 4). More recently, storage and secretion of leptin has also been demonstrated in the stomach (5-7). The signal function of leptin on the central nervous system has been the major area of research (8 -12). Leptin influences food intake (e.g. by suppressing neuropeptide Y in the hypothalamus [11], and stimulates energy expenditure and thermogenesis (e.g., by interaction with the adrenal cortex [13,14]). However, specific receptors for leptin have been found ubiquitously in the body (e.g., thyroid gland, adrenal glands, lung, placenta, kidney, liver, and endothelial cells [15][16][17]). This suggests a peripheral role for leptin. Interestingly, a specific leptin receptor was recently identified in the gastric mucosa (6) and in other parts of the gastrointestinal tract (18). To date, the sources of leptin as a gastrointestinal receptor ligand have been only partially investigated.It was therefore an objective of the present study to identify and characterize the presence of leptin in saliva. A second aim was to investigate the regulation of leptin in the salivary glands and its stability under gastric conditions. Materials and Methods Sample materialPlasma and saliva were collected simultaneously from healthy adult males (n ϭ 23; age 28 -80 yr; body mass index [BMI] 20 -50 kg/m 2 ) and females (n ϭ 25; age 22-85 yr; BMI 19.5-54 kg/m 2 ) and healthy adolescents (male: n ϭ 13; female: n ϭ 5; age 10 -18 yr; BMI: 15-39.9 kg/m 2 ) recruited in our hospital, who gave informed consent of participation. None of the volunteers took medication or contraceptives and all participants had fasted for at least 2 h. The study was approved by the Ethics Review Board of the University of Erlangen.Plasma was collected with S-Monovettes, saliva was collected with the Salivette device (both Sarst...

Objective The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. Data Sources Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. Review Methods The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. Conclusions Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. Implications for Practice Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Similar to other endoscopic interventions, local infection as a complication of PEG tube placement depends on the experience of the endoscopist. Institutional factors also play a significant role. Additional risk factors include PEG tube size and underlying diseases. These findings indicate that the local infection after PEG tube placement may be influenced by both endoscopy-associated factors and by the underlying disease status of the patient.

Purpose Surgical treatment of benign parotid tumors has developed in the direction of less invasive procedures in recent years and has raised great debate about the best surgical approach. Aim of this article is to analyse anatomical and other factors that are important in selection of the appropriate surgical technique in treatment of benign parotid tumors. Furthermore, to discuss the risk of complications and recurrent disease according to selected operation. Finally, to define patient selection criteria to facilitate decision making in parotid surgery and become a guide for younger surgeons. Methods Literature review and authors' personal opinions based on their surgical experience. Results All possible surgical techniques for benign parotid surgery with advantages and disadvantages are being described. An algorithm with anatomical and other criteria influencing decision making in benign parotid surgery is presented. Conclusion Surgeons nowadays have many options to choose from for benign parotid surgery. ECD is one of the many surgical techniques available in parotid surgery and can achieve excellent results with proper training and if used for proper indications. PSP is mainly indicated in large tumors of the caudal part of the PG (ESGS level II). SP represents a universal solution in parotid surgery and should be the first technique young surgeons learn. TP has only few but important indications in benign parotid surgery. Surgeons need to carefully consider the patient and his/her preoperative imaging as well as her or his own special expertise to select the most appropriate surgical technique.