Objectives Cytokine release syndrome (CRS) is a potentially severe complication of COVID-19 most commonly resulting in respiratory failure. This ten-patient study was designed to determine the efficacy of therapeutic plasma exchange (TPE) in improving oxygenation and in reducing the cytokine load in a critically ill subset of patients. Methods Five single volume plasma exchanges over eight days within a 14-day study period. In mechanically ventilated patients, oxygenation was measured via the PaO2/FiO2 (P/F) ratio and the oxygenation index (OI) daily for 14 days. Supplemental oxygen requirements were tracked daily for non-ventilated patients. Results Non-ventilated patients were liberated from supplemental oxygen after TPE. The response was rapid with an 87% average reduction in oxygenation requirements following and average time to return to room air of 5.25 days. All mechanically ventilated patients demonstrated improvement in oxygenation with a 78% average improvement in the P/F ratio and a 43% improvement in OI. C-reactive protein (CRP) and serum levels of IL-6, IL-8, IL-10, TNFα, IFNγ and GM-CSF, were measured daily with immediate post TPE levels drawn on days 1, 2, 4, 6 and 8. All patients demonstrated significant reductions in CRP, IL-6, IL-10 and TNFα. Conclusions In the majority of patients with Penn class 3 and 4 CRS complicating COVID-19, TPE demonstrated a prompt improvement in oxygenation and reduction in cytokine load without compromising patient safety. As this pilot study was envisioned to be hypothesis generating, expanded trials using TPE alone and in conjunction with novel pharmacologic agents are warranted. Registration ClinicalTrials.gov NCT04374149 .

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FIVE FIGURESF o r the last half century the levator ani muscle has claimed the attention of various writers, who have been, almost wholly, attracted to its study by the surgical importance of the general region whicli it occupies.Owing to the difficulties which are met with in the exposure of this muscle in routine courses in anatomy, a complete understanding can be gained only by special dissections made a t the sacrifice of other structures. Recognizing this fact, many authors have made such special dissections of the perineum, but, as I point out later, abnormal female perinei have been described as normal. Artifacts due to parturition have not been recognized as such.The primary objective of the writer is to present the comparative results of dissections of nulliparous and parous women. Secondarily, information concerning the levator ani of the male and the directions of the perineal openings in both sexes receive consideration. Lastly, there is incorporated a survey of the literature relating to the subject, not only from the standpoint of practical applications, but also including the comparative relationships of the levator ani muscle in the entire vertebrate group.

Disease control with signals of response were demonstrated, which should lead to future validating clinical trials using checkpoint inhibitors in this underserved rare malignancy population.• Although the study of single types of rare cancers is practically challenging, clinical trial designs that aggregate such patients into cohorts treated similarly are feasible, even in the community setting.

TWO FIGURESMany instances are recorded in the literature of the presence in human fetuses and adults of two venae cavae superiores, with or without a transverse inter-jugular anastomosis. The presence, however, of a left vena cava superior persisting without a right (the viscera not being transposed) is comparatively rare. I have studied the original descriptions of all the cases of this nature occurring in the bibliographies by Ancel, P. et Villemin ('08),' Boyd ('93), Halbertsma ('62), McCotter ('16), Niitzel ('14), and Weigert ('81) with the exception of the case of Mausert ('99) which was not available, and find that thirteen such cases have been previously recorded.The subject of the anomaly'here recorded is a middle aged, well developed male. The right internal jugular and subclavian veins unite to form a comparatively long innominate vein (referred to in this description as the right innominate) which extends obliquely downward and to the left, ventral to the roots of the arteries arising from the aortic arch and unites with the short left innominate vein to form the left vena cava superior. The left vena cava superior crosses ventral to the arch of the aorta, to the left pulmonary artery, and ventral to the root of the lung as it approaches the dorsal surface of the heart; here The case of Ancel, P. et Villemin ('08) is usually cited in the literature as being one of simple left vena cava superior, is one of a double vena cava. The case of Cheselden (1713) (the correct reference to which is given in the accompanying bibliography), has been difficult to find on account of the frequence with which an erroneous reference has been given.191