Posterior fossa arteriovenous malformations (AVMs) can be a challenging disease, especially those large in size. AVMs can be treated with a combination of endovascular treatment and microsurgery. Here, the authors present the case of a 16-year-old female patient with progressive dizziness and episodic syncope. The workup of the patient showed a hemispheric cerebellar AVM, Spetzler-Martin grade IV. She underwent combined treatment (endovascular and microsurgery) with no complications and cure of the malformation.https://youtu.be/rNw_Kyd76MgThe video can be found here:  This is a case of a 16-year-old female patient who presented progressive dizziness and episodic syncopes.0:28 Radiological Findings. Further MRI investigation showed a diffuse left paramedian Spetzler-Martin grade IV cerebellar AVM, associated to a large vein of drainage. There were several intranidal fistulas. The venous drainage was toward the great vein of Galen and the tentorial sinuses.The digital angiography demonstrated the main arterial feeders from the enlarged left PICA, which presented some aneurysms along its distal part. The right vermian branch arises from the left PICA.1:06 Endovascular Treatment. She was submitted to three preoperative sections of embolization with the embolic liquid PHIL, with near-total occlusion of the AVM, remaining only a partial portion on the tentorial surface. This is the final endovascular treatment cast.PHIL is a novel liquid embolic agent composed of a nonadhesive copolymer dissolved in DMSO with an iodine component. The potential advantages of PHIL are faster plug formation, more consistent visibility, fewer artifacts in postinterventional imaging, lower volumes required of liquid agent embolic. Considering these peculiarities in our present case, the extensive nidus represents a good indication for PHIL use, as an embolic agent.1:59 Positioning and Opening Technique. The patient was operated in a semisitting position, and a wide far-lateral approach was performed.2:06 Corticectomy and Dissection of the AVM. After dural opening, microsurgical corticectomy was started laterally to the AVM, and then surrounding the nidus. Now we see the left and right PICA with the differences between them caused by the embolic agent. were cut. Because of this embolic material, PHIL, the dissection of the AVM became easier, and the soft consistency of the cast facilitate the dissection.The inferior part of the AVM included the left cerebellar tonsil, and the previously tonsillomedullary and telovelotonsillar segments of PICAThe dissection continues in the superior part of the AVM, at the tentorial surface of the cerebellum, once there are located the drainage veins. and the fourth ventricle cavity exposed. Choroidal branches, feeders, and the left vermian branch be coming from the right PICA were found and cut, and the AVM was finally removed.The anterior aspect of the AVM was then dissectedThis is the final surgical cavity and the measure of the AVM.4:06 Postoperative Images and Final Considerations. Postoperative MRI showed no residual nidus and preserved medullary parenchyma. The digital angiography confirmed the complete resection. The patient was discharged with no deficits.Primary surgeon: Chaddad-Neto. Assistant surgeon: de Campos Filho. Editing and drafting the video and abstract: Silva da Costa, Loof de Amorim, Wainberg, Paz-Archila, Lessa, Bustamante Vargas, Campos. Critically revising the work: Silva da Costa, Bocca, Chaddad-Neto. Reviewed submitted version of the work: Silva da Costa, Bocca, Chaddad-Neto. Approved the final version of the work on behalf of all authors: Silva da Costa. Supervision: Silva da Costa, Chaddad-Neto.


Oocyte quality was negatively correlated with CCDFI . Receiver operator characteristics curves (ROC) suggested that a cut-off value of 24% CCDFI was able to discriminate the capacity of the gametes to result in syngamy with a sensitivity and specificity of 75.6% and 65%, respectively. This cut-off supports the application of CCDFI as potential index for the evaluation of the reproductive potential of oocytes prior to fertilization.The determination of oocyte quality is crucial for achieving effective syngamy post-sperm injection and embryonic development. Cumulus cells (CCs) have been proposed as biomarkers of oocyte quality because of their close bio-dynamic relationship with the oocyte. To determine the quality of the oocyte, CCs were sampled during oocyte preparation for ICSI to determine a CC DNA fragmentation index (CCDFI) of each individual oocyte using a variant of the chromatin dispersion test. One hundred and thirty oocytes were selected and studied from two Spanish fertility clinics, 90 of which were fertilized and developed to embryos. Significant differences were found between the CCDFI of unfertilized and fertilized oocytes ( The use of morphological criteria for determining oocyte quality is regarded as controversial given its low predictive value with respect to embryo survival and pregnancy outcome , 2. It iCumulus cells (CCs) are a unique sub-lineage of granulosa cells that surround the oocyte of an antral follicle and that play an essential role in metabolic and nutritional support of the oocyte, the control of oocyte meiosis, ovulation, oocyte developmental competence, and fertilization. An increasing body of evidence highlight the importance of cumulus gene expression for the positive health of the oocyte , 5. HencThe dependent relationship of the oocyte and the cumulus cell is reinforced because of the existence of cellular communication via gap junctions between both type of cells . The oocWithin this scenario, it seems logical that a fully functional state of the CCs would be directly related with the competence of the oocyte. In fact, apoptosis and DNA fragmentation at the CCs and oocyte competence, using techniques such TUNEL, have indicated a direct relationship , 16. TheThe CCs used in study were obtained during the normal preparation of the oocyte for the ICSI procedure and were obtained from two Spanish fertility clinics . Informed consent for the use of the patient’s CCs was obtained from all couples. This study was approved by the Autonomus University of Madrid Instituional Review Board (CEI-106- 2075). All 25 couples included in the study were diagnosed as presenting with idiopathic infertility for which no specific female or male factor was identified. All couples presented to the respective clinic after 1 year of failed pregnancy following natural conception. The study cohort included couples attending the clinic for their first reproductive cycle. The women included in this study had a mean (± SD) age of 33.5 ± 1.3 years, were not obese, tobacco smokers, or regular consumers of alcohol. In addition, these women signed a declaration indicating that they had no clinical history of diabetes, high blood pressure, recent bacterial infections, genetic determined alterations, evidence of hydrosalpinx, or polycystic ovaries.In preparation for ICSI, all couples received homogenous follicular stimulation using 150–200 IU of r-FSH  and 75 IU of hMG . This treatment was followed by the administration of synthetic gonadotropin . Ovulation was induced with 250 µg recombinant human chorionic gonadotropin . ICSI fertilization was performed using normozoospermic semen samples from the partner. After aspiration retrieval of the cumulus oophorus complex (COC), the CCs were stripped from the oocyte by gentle pipetting in a solution of hyaluronic acid 1X . g for 10 min and reconstituted with fresh RPMI media  in preparation for fragmentation analysis. To ascertain that the cryopreservation and thawing procedures had adverse influence on CC DNA damage, a preliminary analysis comparing the DNA fragmentation of freshly collected and frozen-thawed CCs was conducted and no significant differences were observed . It is important to note that once the cells are thawed, they need to be processed quickly (within 1 h) for DNA quality visualization; otherwise, the cells and the DNA molecule may deteriorate. While we cryopreserved the CCs in this study for logistical purposes, from a clinical perspective, the assay is most likely to be used on freshly collected CCs from individual patients.Given that the clinics who participated in the study were in different regions of Spain and in order to stock-pile the CCs for more efficient processing and evaluation at the Autonomous University of Madrid, the CCs were cryopreserved. Cryoprotection involved using a freezing solution and a standard straw freezing protocol . The CCs were stored in liquid nitrogen for approximately 1 week before being evaluated. For analysis, the CCs were thawed by rapid immersion of the straw containing the cells in a waterbath set at 37 °C for 3 min. The cells were then pelleted at 400DNA fragmentation was assessed using a variant of the chromatin dispersion test . ThawedTwo primary types of CCs were identified as previously described by Barcena et al. . Cells pDFI was analyzed with respect to oocyte and embryo quality. In analysis 1, the relationship between CCDFI and oocyte quality was categorized based on (1) oocytes that were recovered that were either immature or atretic , (2) oocytes that failed to fertilize after ICSI , and (3) oocytes that were successfully fertilized following ICSI . Data for studies of oocyte quality were supplied from both fertility clinics with 130 oocytes examined in total from 25 women. In analysis 2, in vitro embryo quality with respect to CCDFI was categorized based on whether or not the embryos were rejected following ICSI because of poor quality or developmental arrest after 1 day incubation (REJ) or whether they were suitable for either transfer or cryopreservation as assessed on day 3 or 5 of incubation (EMB). In analysis 3, the relationship between CCDFI and grade quality of the resulting fertilized embryo   was examThree ROC curves were also constructed. The first involved data from analysis 1 in which the ability of CC DFI to predict oocytes that failed to achieve syngamy (no syngamy = NIO + UFO) were compared to those that were fertilized (FEO). For the 2nd ROC curve, data from analysis 2 was used to determine the capacity of CCDFI to predict oocytes that were ultimately rejected by the embryologist (REJ) compared to those that were suitable for transfer and/or cryopreservation (EMB). The 3rd ROC curve examined how useful CCDFI was at predicting those oocytes following ICSI that developed to the stage where they were suitable for transfer or cryopreservation (EMB) compared those oocytes that failed to reach this status (REJ) and those that failed to achieve syngamy (NIO + UFO).U and Kruskal–Wallis tests were used to compare independent groups. Receiver operator characteristic (ROC) curves were conducted to test the predictive value of CCDFI with respect to oocyte and embryo quality. When determining predictive power, an area under the curve (AUC) of 0.7–0.8 was considered acceptable, whereas a value of 0.8–0.9 was considered excellent [p < 0.05.Statistical analysis was performed using the SPSS 25 statistics package . As data were not normally distributed, the Mann–Whitney xcellent . In all p < 0.001). Two independent sample comparisons between respective CCDFI categories based on an analysis with a Mann–Whitney U test were significantly different over the groups . Oocyte quality was negatively correlated with CCDFI .A total of 130 COC were retrieved from 25 patients and the results of the CCDFI of the different pre-stablished groups are shown in Fig. 2U =  − 4.27; p < 0.001).With respect to embryo development, a total of 90 oocytes resulted in embryos that were incubated further, and the results of whether these embryos arrested and were then rejected by the embryologist or were suitable quality for transfer or cryopreservation are shown in Fig. 2p = 0.33) revealed that CCDFI was not significantly different over these 3 groups.The relationship between the grade of embryos produced after 3 to 5 days of incubation and CCDFI was also examined, and the results reported in Fig. 2N = 34) with oocytes that were successfully fertilized (FEO) (N = 90). For this analysis, the area under the curve was 0.769 . A threshold value of 24% CCDFI was able to discriminate the capacity of the gametes to result in syngamy with a 75.6% sensitivity and specificity of 65%  against those that were chosen for transfer or cryopreservation . The area under the curve was 0.775 . The cut-off value for CCDFI was established at 20.3% with a sensitivity of 71.2% and a specificity of 61%  with those oocytes that did not reach this development following the ICSI procedure (N = 71). The area under the curve for this analysis was 0.808  and the cut-off value for CCDFI was established at 21% with a sensitivity of 74.6% and a specificity of 64% . In this way, this 21% DFI could be established as the maximum limit to identify a good quality oocyte. This would increase the efficiency of the implantation and, therefore, the rate of reproductive outcome in ART. Although CCDFI in this study was not helpful in predicting the morphological grade of embryos, we must bear in mind that some studies have shown that embryos with good morphology can still show chromosomal abnormalities .Finally, we want to highlight that while the assessment of pooled CCs may indeed provide information about the general capacity of the female to produce oocytes of a certain quality , the in


Human faces are a core part of our identity and expression, and thus, understanding facial geometry is key to capturing this information. Automated systems that seek to make use of this information must have a way of modeling facial features in a way that makes them accessible. Hierarchical, multi-level architectures have the capability of capturing the different resolutions of representation involved. In this work, we propose using a hierarchical transformer architecture as a means of capturing a robust representation of facial geometry. We further demonstrate the versatility of our approach by using this transformer as a backbone to support three facial representation problems: face anti-spoofing, facial expression representation, and deepfake detection. The combination of effective fine-grained details alongside global attention representations makes this architecture an excellent candidate for these facial representation problems. We conduct numerous experiments first showcasing the ability of our approach to address common issues in facial modeling  and capture facial symmetry, then demonstrating its effectiveness on three supplemental tasks. Facial representation has always been a core part of computer vision. One of its applications, face detection, was one of the most successful image analysis tasks in the early years of computer vision . Since tUnexpected changes to the environment often have an adverse effect on computer vision tasks. Implementations that have vastly different background conditions from training data often generalize poorly . These cAs a result of these challenges, many authors have worked to overcome these difficulties in various facial tasks ,14,15,16The identity component of facial representation corresponds to face recognition and re-identification tasks. These tasks are extensively integrated into biometric security systems . These sIn addition to recognizing the person’s identity, facial representations are important for understanding the state of a person. People communicate in many more ways than just the words that are spoken. The expressions we present while interacting shape the context and meaning of the words we speak. To understand communication better, computer systems must learn to capture human emotions through expression. In addition, facial expression recognition (FER) can be used for certain medical diagnosis purposes ,31. The Human perception can be attacked with facial manipulation techniques. This incorporates many techniques through procedures such as face swapping and expression manipulation. We will refer to this category of attacks as deepfakes. Deepfakes present a substantial threat to various facets of our lives. False criminal or civil accusations can be made with fabricated video as proof. Conversely, the utility of video evidence deteriorates if false videos cannot be detected. Similarly, elections can be swayed by conjured footage of politicians engaged in incriminating activity. Detection of these attacks can be done through the examination of regions of abnormal distortion as well as inconsistencies in the face. When facial manipulation algorithms replace or modify facial identities or expressions, there are regions that span the gap between the modified content and the original content. Deepfake algorithms are trained to make these regions as realistic as possible, but such images are still artificial, generated content with the potential for an unnatural distribution of pixels. Examining the image with sufficient resolution makes it possible to detect the artifacts left by deepfake manipulations.We propose a deep-learning facial representation architecture that uses a multi-level transformer model to capture fine-grained and global facial characteristics. To capture the physical characteristics of the target in each sample, our proposed method uses a Swin transformer  which acWe propose a hierarchical transformer model to learn multi-scale details of face geometry. We structure this model to capture both fine-grained details and global relationships.We validate the geometry learning capability of our facial representation approach with various tests. This demonstrates its resilience to rotation, occlusion, pose, and background variation.We apply and validate the model on three facial representation use cases. The three tasks, face anti-spoofing, facial expression recognition, and deepfake detection, highlight the robustness and versatility of facial geometry representation.Our contributions are summarized as follows:Various early works involving facial representation used Haar-like features for face detection. The Haar sequence, proposed by Alfred Haar , forms tAs convolutional neural network (CNN) models permeated computer vision, various CNN solutions for facial representation emerged ,43,44,45In addition to their success in NLP, transformers have shown promising results for image processing. The capability to model image relationships with attention allows the model to focus on key regions and relationships in the image. It also better facilitates the modeling of relationships between more distant image regions. The visual transformer (ViT)  achievedetection ,49,50. Setection ,51,52 haStructure learning problems in images require learning information from granular-level data. Transformer models provide fine-grained representation learning with attention mechanisms. The quadratic cost of attention parameters inspires many solutions to address the large size and unique challenges of images ,55,56,57One of the simplest and most common adaptations has been the ViT model . This moMuch of the recent literature on FAS has focused on building models that achieve domain generalization, attack type generalization, or both. Jia et al.  use an aThe challenge of facial expression recognition (FER) comes from two directions. First, models must ensure expression recognition is not tied to the identity of the individual with the expression. Second, models must learn to navigate intra-expression variance and inter-expression similarities. Zhang et al.  separateZhao et al.  look at Facial geometry consists of both smaller local details and larger shape and positioning. To model these well, we implement a multi-level transformer architecture that captures fine-grained details at lower layers and regional relationships at higher layers. These layers are connected hierarchically to combine these features into a complete representation. The structure of the hierarchy is determined by two factors: model depth and window size. The model depth is composed of multiple transformer blocks divided by patch merging layers as shown in Q, K, and V refer to the query, key, and value vectors derived from each input by matrix multiplication. Each W variable represents a different set of weights learned during training.As described by Vaswani et al. , MSA canx term represents one element of the patch pixel value vector, M is the window size. These windows are connected through a process in which window borders are shifted in subsequent layers. This places previously separated nearby patches into the same window, allowing for representation across patches, as shown in Algorithm 1 Face geometry representation using hierarchical shifted windows architectureInput: P = {nth x.MSA, SW-MSA = multiheaded self-attention and shifted window MSA.MLP = multi-layer perceptronLN = layer normalizationOutput: Face Representation Classification 1:fordo                      ▹ For each patch 2:p)     3:     4:     5:end for 6:X←P 7:for block pair in transformer blocks do 8:X← MSA(LN(X)) + X     9:X← MLP(LN(X)) + X    10:X← SW-MSA(LN(X)) + X   11:X← MLP(LN(X)) + X   If at block pair 1, 2, 11:12:for do    13:        14:end for    15:end forFor each of the facial geometry tasks, the initial embeddings are created by dividing the input image into y et al. , this veFor the face anti-spoofing problem, we hypothesize that spoof-related features can be found in both the fine-grained details and the global representations. The fine-grain details include unnatural texture, reflection, or lighting. Global cues involve unnatural bowing or skew. We use our hierarchical architecture as a backbone for binary classification. The detailed representation layers give us the capability to detect based on fine cues, whereas the coarser layers enable the discovery of global spoofing cues. For training and inference, live and spoof images are sampled from their corresponding videos and classified through the model.Similarly, deepfake detection also makes use of these diverse layers. Deepfake cues can be found both in fine-grained textures as demonstrated by Zhao et al.  or in laFacial expression recognition is somewhat different as most of the clues come from certain key regions  . Howevern can be found by the equationx, y, w, and C represent the input, target, weight, and number of classes, respectively. For binary problems, this simplifies toFor the FAS, FER, and deepfake experiments, we fine-tuned the Swin transformer using binary and multi-class cross-entropy loss with one additional fully connected layer. Cross-entropy is an entropy-based measurement of the difference between two inputs. Specifically, it refers to the amount of information required to encode one input using the other. The cross-entropy loss for a given class We selected the AdamW  optimizeWe test the symmetry and robustness capabilities of our facial representations with multiple experiments. The effect of pose and occlusion variance is tested by comparing the embeddings using one quantitative and one qualitative experiment. We also perform one separate experiment measuring the effect of background variation. Then, we examine the capability of our facial geometry modeling on three use cases, FAS, FER, and deepfake detection. Finally, we further explore and test the limits of the symmetry modeling capability through two occlusion-based experiments.Experiments were performed on a Tesla V100-SXM2 GPU with the assistance of up to 16 Intel(R) Xeon(R) Gold 6152 CPU @ 2.10 GHz processors. For embedding experiments, and pretraining for additional experiments, we used a model pretrained on facial recognition from the FaceX-Zoo suite . This loPose and occlusion variance experiments were performed using selected images sampled from the SiW dataset  because For the use case of the facial representation capabilities of our approach, we tested our approach on three additional face-related tasks: face anti-spoofing, deepfake detection, and facial expression recognition. For the face anti-spoofing task, we used the SiW dataset . SiW conFor testing on the video datasets, four frames were selected at random from each video. Each sequence in the CK+ dataset progresses from a neutral expression to the most expressive. The final three frames of each sequence were selected for the corresponding emotion category, and the first frame was used as the neutral category. The dataset was divided into train and test sets with a roughly 70/30 split. The frames were cropped to each subject’s face using the facial detection and cropping code in the FaceX-Zoo  suite. DTo evaluate the pose and occlusion variance quantitatively, we compare the cosine similarity of four embeddings. The first embedding is one generated from an ordinary frontal image of a person. The second embedding comes from an askance image of the same person’s face. The third is from the original face with the occlusion mask placed over one eye. For comparison, we select the fourth image from a different person. The similarity among these embeddings is presented in For a qualitative measure of pose and occlusion variance, The experiments have shown that a hierarchical transformer architecture learns a robust facial geometry representation. As shown in The additional use cases further highlight the versatility of the approach. Anti-spoofing, expression recognition, and deepfake detection examine more specialized and localized regions. The demonstrated capability on these tasks in addition to the global identity representation shows the hierarchical transformer’s ability to pivot to more specialized facial representation applications without much alteration.The third SiW protocol for the FAS task showed comparatively poor results. This protocol involves testing on unseen attack types (print vs. video). This domain generalization problem is a common and difficult problem that often requires specialized model augmentation to address it. Investigating how the hierarchical transformer can be augmented to deal with this domain generalization problem is a topic of further study.The facial geometry modeling of this method is generated from a single image or video frame. This speeds up computation and makes the model usable with a larger variety of inputs. However, it loses the ability to capture time-related facial features such as motion. Various facial representation tasks involve motion that could be useful for classification, such as the movement of the mouth or eyes in expression recognition. To extend the functionality of this method to capture these details, our approach could be expanded to include temporal features in its decision-making. It may be worth exploring the merits of either a direct temporal expansion of the model or some augmented approach such as optical flow.In this paper, we proposed a hierarchical architecture for capturing facial geometry features. This model’s ability to model both fine-grained details and global relationships makes it versatile in addressing a wide range of facial representation tasks. We demonstrated its symmetry and robust modeling capability through a series of experiments. First, we compared embeddings of various circumstances . The consistency of the embeddings generated demonstrated the robustness of our approach to disturbances. Next, we tested symmetry modeling with a sliding window experiment. The sharp contrast between occluding less than half the face and more than half illustrated the facial symmetry modeling capabilities. Finally, we further demonstrated the flexibility of the approach by applying it to various facial representation tasks. These tasks, anti-spoofing, facial expression recognition, and deepfake detection, showcase the different ways this facial geometry modeling can be applied to problems. The results on anti-spoofing and deepfake detection showed its ability on fine-grained details whereas facial expression recognition demonstrated its ability on broader facial representation.


Apex and mesopredators such as elasmobranchs are important for maintaining ocean health and are the focus of conservation efforts to mitigate exposure to fishing and other anthropogenic hazards. Quantifying fishing mortality components such as at-vessel mortality (AVM) is necessary for effective bycatch management. We assembled a database for 61 elasmobranch species and conducted a global meta-synthesis to estimate pelagic longline AVM rates. Evolutionary history was a significant predictor of AVM, accounting for up to 13% of variance in Bayesian phylogenetic meta-regression models for Lamniformes and Carcharhiniformes clades. Phylogenetically related species may have a high degree of shared traits that explain AVM. Model-estimated posterior mean AVM rates ranged from 5% (95% HDI 0.1%–16%) for pelagic stingrays and 76% (95% HDI 49%–90%) for salmon sharks. Measures that reduce catch, and hence AVM levels, such as input controls, bycatch quotas and gear technology to increase selectivity are appropriate for species with higher AVM rates. In addition to reducing catchability, handling-and-release practices and interventions such as retention bans in shark sanctuaries and bans on shark finning and trade hold promise for species with lower AVM rates. Robust, and where applicable, phylogenetically-adjusted elasmobranch AVM rates are essential for evidence-informed bycatch policy. Overexploitation is the primary cause of declines of marine species. It can cause protracted or irreparable harm and permanent loss of populations, with changes and loss in marine biodiversity and ecosystem services5. Bycatch in pelagic longline fisheries is a global threat to the conservation of some elasmobranchs6. Pelagic sharks experienced a 71% decline in abundance over the past 50 years7. Depending on a fishery’s management framework and markets, catch composition and practices of individual vessels, sharks and rays may be discarded or retained as either incidental or target catch9. Retention may entail the entire fish or only shark fins or ray gill rakers.Elasmobranchs (sharks and rays) belong to one of the most diverse marine taxonomic groups and include apex and mesopredators essential for maintaining ecosystem structure, functions and stability12. There has also been increasing attention to the socioeconomic costs to fisheries from shark interactions such as from the depredation of catch and bait13 and risks to food, nutrition and livelihood security of coastal fishing communities from declining elasmobranch abundance15.There has been increasing concern in recent decades over the sustainability of elasmobranch mortality in pelagic fisheries given elasmobranchs’ vulnerability to exploitation, ecosystem-level cascading effects from declines in elasmobranch abundance, and fisheries-induced evolution and reduced population fitness that results from selective removals based on heritable traits17. For non-retained catch, a key component of total fishing morality is at-vessel mortality (AVM), also referred to as haulback or capture mortality, which is the proportion of the catch that is dead upon retrieval of the fishing gear before being handled by crew. Because small changes in mortality can result in large changes in mature biomass and therefore population growth, uncertainty in AVM rates is a major impediment to effective management and sustainable fisheries, in particular for elasmobranchs18. Robust estimates of species-specific AVM rates enable performance assessments of conservation and management measures, such as retention bans—including within Shark Sanctuaries, bans on international trade, bycatch quotas, shark finning bans, gear design requirements and handling-and-release practices. Identifying informative predictors of AVM risk, including phylogeny, physiological attributes, fishing methods and gear designs, facilitates estimation of AVM rates for data-limited species and identification of effective methods to mitigate AVM.Accurate estimates of all sources of mortality are needed for robust assessments of the ecological effects of fishing, including through quantitative stock assessments, population viability models and multispecies ecosystem models21. Independent and unbiased synthesis of all accumulated scientific information is a fundamental transparency principle for developing evidence-informed conservation management decisions23. Meta-analytic based synthesis approaches typically produce the strongest evidence with generalizable results that are optimal for global and regional decision-making25.There is limited information available on AVM rates for most elasmobranchs, and quantitative meta-analytic synthesis studies of AVM rates in longline fisheries have been conducted for few elasmobranch species30 through: (1) the inclusion of a much larger number of studies and species; (2) applying Bayesian multilevel or hierarchical meta-regression models to account for informative covariates; and (3) phylogenetically adjusting the AVM rate estimates for the evolutionary history for two major shark clades with either relatively high (Carcharhiniformes) or low (Lamniformes) extant species diversity31. The study objectives were to:Derive robust species-specific estimates and measures of uncertainty of AVM rates for elasmobranchs captured in pelagic longline fisheries;Determine if phylogeny, operational longline fishing methods and gear designs, ventilation mode, morphology and ocean region are informative predictors of AVM rates; andIdentify gaps in information on priority potentially informative predictors and in taxonomic groups and regions for which additional primary studies are required for robust meta-syntheses of AVM rates.This study fills this priority research gap on elasmobranch AVM rates. We assembled an extensive database and conducted a global meta-synthesis to aggregate, test and summarize species-specific AVM rates for elasmobranchs captured in pelagic longline fisheries. The study significantly extends previous meta-analysesThe AVM rates derived for 61 elasmobranch species, estimated using robust statistical procedures for synthesizing evidence from multiple studies, supports evidence-informed conservation and fisheries management for sharks and rays.The random forest derived variable importance plot identified several potentially informative predictors of elasmobranch AVM for the entire sample of 1,438 effect sizes summarized in Fig. Rhat < 1.0132, reflected convergence of the Bayesian GAMMs with binomial-Normal likelihood. The best-fit GAMMs identified by the LOOcv and Bayesian stacking metrics fitted the clade-specific AVM datasets well as shown for example by the graphical posterior predictive check tests summarized in Fig. Convergence diagnostics such as multiple chain rank plots, and the effective posterior sample size (ESS) metrics coupled with the rank-based diagnostic statistic The pooled mean AVM estimates for the Carcharhiniform species Fig. A and LamThe mean phylogenetic signal or constraint estimated for Carcharhiniform species was estimated to be 0.06 (95% HDI 0.01–0.23) and 0.13 (95% HDI 0.01–0.42) for Lamniform species. These are significant but moderate phylogenetic signals, implying that evolutionary history played an important but relatively minor role in explaining the AVM rate differences among the 26 Carcharhiniform species and the 13 Lamniform species.Carcharhiniform species had a > 0.95 probability of lower AVM rates in the Pacific Ocean than the Atlantic Ocean. Carcharhiniform species in the Atlantic were 2.9 times 95% HDI 1.6–4.8) more likely to be dead at haulback than in the Pacific. The ocean-specific effect was significant for sharks caught on either circle or J-shaped hooks . The overall AVM rate from a binomial-Normal GAMM was mean of 0.047 (95% HDI 0.001–0.157) (Table The pelagic stingray 7) Table . Ocean b7) Table A and hoo7) Table C were si7) Table B and num7) Table D were noMobula birostris, cookie cutter shark Isistius brasiliensis and velvet dogfish Zameus squamulosus, overall AVM rates from binomial-Normal GAMMs were a mean of 0.332 (95% HDI 0.015–0.707), 0.295 (95% HDI 0.055–0.564), and 0.226 (95% HDI 0.071–0.368), respectively  for the night shark Carcharhinus signatus. For rays, mean AVM rates ranged from a low for the pelagic stingray (“Glaucostegus cemiculus.AVM rates were estimated for 54 shark species (n = 1322 records), and for 7 ray species (n = 116 records) Table . Of thestingray “” sectionRhizoprionodon terraenovae, with separate forest plots from records using only squid bait shown in Panel A and records using only fish, a mix of fish and squid, or unknown bait type in Panel B. Weighted relative risk estimates are ordered by effect size, and an estimated overall Pooled Effect log relative risk ratio is shown at the bottom of the forest plot and by the dashed vertical line. The overall AVM rate with only squid bait of 0.878 (95% HDI 0.75–0.99) was significantly higher than a mix of bait types of 0.427 (95% HDI 0.26–0.61).Figure 34. Not accounting for phylogeny potentially risks estimating biased species-specific AVM rates, reduces the robustness of stock assessments, perhaps drawing incorrect conclusions and adopting misinformed policy. This finding is consistent with conclusions of previous studies that not accounting for phylogenetic non-independence of taxa in ecological meta-analyses produces biased results35.This is the first study to comprehensively assess the relationship between phylogeny and AVM risk for elasmobranch species exposed to pelagic longline fisheries. The finding of a moderate but significant relationship highlights the importance of accounting for phylogenetic dependence in elasmobranch multispecies meta-analytic syntheses on AVM rateMore accurate estimates of shark species-specific AVM rates are obtained when meta-analytic syntheses are designed to account for phylogeny—the degree of shared evolutionary histories between species. Accounting for phylogeny in meta-analytic syntheses produces more robust species-specific AVM estimates for Lamniform and Carcharhiniform clades. The significant phylogenetic signal does not mean that species within these two clades have similar AVM rates; conversely, there is a broad range in species-specific AVM within these clades Figs. . Instead36. They may have a high degree of shared non-heritable as well as heritable traits—if traits were conserved during evolution leading to descendent lineages, which occurs when traits are under strong selection (phylogenetic niche conservatism)38. For example, while there is some co-occurrence, most extant Lamniformes and Carcharhiniformes are ecologically differentiated by diet, morphology and in some cases habitat type39. Some shared physiological, morphological and behavioral traits may be informative predictors of AVM risk. For example, the lamnid sharks and common thresher shark (Alopias vulpinus) are the only elasmobranchs with regional red aerobic myotomal muscle endothermy41. They can occupy deeper and cooler habitats on an ephemeral basis. Not being dependent on ambient temperature for thermoregulation may contribute to their AVM rate being less affected by the duration hooked and ocean temperature relative to ectothermic elasmobranchs42. Endothermic sharks, which may have had a single origin in the Cretaceous, also tend to have larger body sizes than ectothermic sharks, which previous studies have found to be an informative predictor of AVM risk—larger fishes have larger energy stores relative to smaller individuals, making them more resilient to stressors, including a fight response to capture46. However, not all traits may be conserved during evolution. Trait divergence can occur during adaptive radiation, when species quickly diverge to avoid competition and fill different ecological niches37. Fisheries are also altering populations’ evolution through selective removals based on heritable traits12, possibly including through selective AVM within populations based on traits such as for fitness47.The phylogenetic signal estimated by the Bayesian multilevel meta-regression models accounted for the dependence among elasmobranch species due to shared evolutionary histories. Closely related taxa share a phylogenetic history and would be expected to be ecologically similar48. While conserved traits, such as thermal tolerance and niche tracking, will be expressed consistently by individuals of a population, flexible, labile traits such as stress response, shyness/boldness and timing of reproduction may have high variability in their expression both by an individual and between individuals of a population49. The strength of any phylogenetic signal may be decreased by this complex mixture of conserved and labile traits that affect AVM rates49.Furthermore, it is likely that vulnerability to AVM is a function of both evolutionarily conserved and labile traitsAlopias pelagicus), with a relatively high mean AVM rate of 58%, which is categorized as Endangered by IUCN50, with a relatively low phylogenetically adjusted rmax  of 0.1551 and low mean rmax of 0.0652. Based on phylogenetically adjusted estimates of rmax, Lamniformes have a high extinction risk and have moderate to high AVM rates. Carcarhiniformes had highest AVM rates but a lower extinction risk relative to Lamniformes51.Some sharks with high AVM rates have relatively high extinction risks due to pelagic longline fisheries. This includes the pelagic thresher shark  and environmental factors  may be more important predictors of AVM than manageable, operational fishing parameters. Similarly, there may be fisheries where a species tends to be retrieved alive but are subsequently discarded dead. For elasmobranch species with low AVM rates, in fisheries where these species have low retention, comparing at-vessel and release conditions would help determine if improved handling and release practices could increase the proportion of released catch that are alive, as well as reduce the post-release mortality rate. Furthermore, in fisheries where elasmobranch species with low AVM rates are retained, output controls that limit or ban their retention or trade have the potential to substantially reduce fishing mortality.For elasmobranchs with relatively high AVM rates, methods that avoid and reduce their catch risk hold promise to reduce total fishing mortality. For these species, retention bans, shark finning restrictions and other output controls may be inappropriate approaches, unless they indirectly lead to the use of methods that reduce catch rates. Instead, measures that avoid and minimize shark and ray catch in pelagic longline fisheries are needed, either by: (1) reducing effort; or reducing one or more capture susceptibility attributes of: (2) spatial and temporal overlap through static and dynamic area-based management tools; (3) vertical overlap by managing fishing depth and the time of day of fishing; and (4) selectivity such as by adjusting leader material, hook and bait type and restricting the use of light attractors Section . For spe54. Supplemental Information Section 56. We found little support for such predictors affecting estimated AVM rates for our two clades of 39 shark species. Species-specific interactions with all operational predictors could not be explored for most of these 39 species because the publications compiled to assemble our dataset provided insufficient coverage of all predictors included in the models. However, the sample forest plot presented for the Atlantic sharpnose shark , may also cause fishers to discontinue using fishing methods and gear designs used to target sharks, such as shark lines, wire leaders, and using pieces of incidental catch for bait. If both a bycatch quota and consequences of reaching the threshold are sufficient, then quotas may incentivize fishers to adjust fishing gear and methods to increase selectivity66. Furthermore, relative to species with low AVM rates, for shark species with high AVM rates, finning bans will be less effective at reducing fishing mortality.Bans on shark finning, where fins are retained and the remaining carcass is discarded, might reduce retention of sharks with little or no market value other than for the fins, and might discontinue fishing methods and gear designs used to target sharks. If shark carcasses have low market value, then shark finning bans will be a disincentive for targeting sharks, as fishers will want to use space in the fish hold for more valuable catch. However, for shark species that are retained for their meat and various other products, finning bans are unlikely to affect fishing mortality rates67. While most pelagic longline elasmobranch catch is from incidental capture by fisheries targeting tuna and tuna-like species (Scombroidei) and billfishes (Xiphioidei)11, these fisheries may also use gear designs to target sharks on shallower branchlines. This shark targeting would be discontinued if shark retention or trade were banned68 and subject to robust surveillance and enforcement. Several elasmobranch species are listed on Appendix II of the Convention on International Trade in Endangered Species of Wild Fauna and Flora, which establishes close control of their international trade, but none are currently listed on Appendix I, which would ban their international trade69. Retention bans, such as through measures adopted by regional fisheries management organizations (RFMOs) and under national Shark Sanctuaries, have been documented to decrease shark fishing mortality rates in some fisheries68 but may be ineffective under certain management frameworks70.Banning elasmobranch retention and international trade might cause pelagic longline fisheries to change targeting practices, discontinue retention and prevent sharks from becoming targets72. While discard bans may incentivize fishers to implement more selective fishing gear designs and methods to reduce catch rates of unwanted species and sizes of catch subject to the policy, this may be counterproductive, in particular for species with low AVM and post-release mortality rates53.Reducing discards is prescribed in international guidelines and required by a growing number of fisheries management frameworks77. This leaves substantial opportunities to improve regional conservation and management measures for elasmobranch longline bycatch.The five tuna RFMOs tap a very small subset of elasmobranch bycatch mitigation methods. They all ban shark finning and have retention bans in place for certain elasmobranch species. One has catch limits for two shark stocks, some restrict the use of wire leaders and shark lines, and some have voluntary guidelines on handling and release practices78. We found a paucity of elasmobranch haulback condition records from the Indian Ocean and Mediterranean Sea, and no records from the Black Sea. Addressing these regional gaps is an additional priority.Completely resolving elasmobranch phylogeny may enable more robust accounting of phylogenetic dependence in multispecies meta-syntheses of AVM rates. Several species had insufficient sample sizes for robust meta-regression models. Additional haulback condition records are needed for these species, in particular for threatened, rare and phylogenetically distinct species which may play relatively large roles in shaping evolutionary processes and ecosystem resilience56. Unfortunately, most of these variables are rarely or never measured.Richer datasets would enable the inclusion of additional potentially informative predictors of AVM. Numerous predictors could not be explored here due to limitations of the assembled database. This includes, for example, duration spent hooked (fight time), dissolved oxygen, sea surface temperature, depth of the thermocline/mixed layer, salinity, body size and sex of the catch, hook number of the catch (which hook between two floats and hence relative fishing depth), whether the catch was on a shark line, anatomical hooking position, hook size, hook degree of offset, and time-of-day of the gear soak18. Compiling records from a broader range of pelagic longline fisheries employing diverse fishing methods and gear designs, including from artisanal, small-scale longline fisheries, would enable a more robust assessment of the significance of these variables.Furthermore, many of the potentially informative predictors that were extracted from the compiled publications had low variability, including soak duration, hooks between floats and branchline length, the latter being particularly important for obligate ram-ventilating elasmobranchs53, ventilation mode and body form (morphology) were not informative predictors of haulback condition for pelagic elasmobranchs in our study. Body form categories based on gill slit morphology and ventilation mode used here may be correlated with phylogeny80, so when models are phylogenetically adjusted, these variables become redundant.Phylogeny was a moderate but significant predictor of pelagic longline AVM rate. This was the first comprehensive study to assess the influence of elasmobranch phylogeny on AVM. Contrary to some hypothesesThe most promising approach to reduce total fishing mortality of species with high AVM rates is to employ methods that reduce catch risk. To reduce total fishing mortality of species with low AVM rates, in addition to reducing catchability, handling-and-release practices and policy interventions that, under certain enabling environments, reduce retention, including retention bans in blue water shark sanctuaries, and shark finning and trade bans, are appropriate. The elasmobranch AVM rates, estimated here through Bayesian meta-regression analysis, a robust statistical procedure for synthesizing evidence from multiple studies, support evidence-informed elasmobranch conservation and fisheries bycatch management. When combined with robust estimates of natural and other anthropogenic hazards, including other components of fishing mortality, these AVM rates can improve the reliability of models of elasmobranch population dynamics and support developing strategies to mitigate risks.81, Collaboration for Environmental Evidence83 and Preferred Reporting Items for Systematic reviews and Meta-Analyses84. An unstructured literature search was implemented by reviewing reference lists of the compiled publications from the systematic search. Supplemental Information Section A two-tiered literature search was employed to compile relevant peer-reviewed published and grey literature and assemble a dataset suitable for meta-analytic evaluation. A link to the assembled dataset, which includes references for retained publications, is provided in the Data Availability section. The methods for the systematic literature review were adapted from the Reporting Standards for Systematic Evidence Synthesesca. 70%). We excluded from meta-regression modelling the remaining 18 species with limited data records, including zero dead for 1 or more of the records but, nonetheless, derived AVM rates for further qualitative consideration in our meta-synthesis. The AVM rate for each of those 18 species  was estimated using a Bayesian binomial likelihood estimator that accounts for zero recorded mortalities85. The mean posterior rate and a 95% highest posterior density interval (HDI) was summarized by sampling from a binomial likelihood with a Bayes-Laplace prior85 using the binom package for R86—rather than just using the raw study-specific summaries.Our dataset comprised 1438 study-specific summary or aggregate AVM rates for 61 elasmobranch species from 33 genera, 22 families and 9 orders. Two shark clades or taxonomic orders  accounted for 39 of those species (ca 64%) and phylogenetic Bayesian meta-regression models were fitted to those data. Separate Bayesian meta-regression models without phylogenetic adjustment were fitted to the AVM data for 4 other species —far too few species to explicitly account for any phylogenetic resolution. Overall, we used some form of Bayesian meta-regression model to summarize the AVM rates for 43 of the 61 elasmobranch species  phylogeny remains unresolved94, so we derived the phylogenetic correlation matrix for all the 61 elasmobranch (shark and ray) species in our study by using the phylogenetic tree construction proposed by Stein et al.95 for 1192 Chondrichthyan species. Credible sets of the species-level phylogenetic history are available for subsetting and downloading at http://vertlife.org/phylosubsets. We recovered 100 random Chondrichthyan phylogenetic trees in NEXUS file format96 from a posterior of distribution of 10,000 phylogenetic trees using the “[fully resolved 1 fossil (set of 10 k trees)]” source—Upham et al.97 provide details on how these phylogenetic tree posterior distributions have been constructed using a Bayesian 2-level “backbone-and-patch” approach. We then randomly selected one tree from that 100-tree selection, which was used as the phylogenetic hypothesis or template for our meta-synthesis. Similar results were found using other randomly selected trees. With that phylogenetic tree we were then able to derive variance and correlation matrices using the ape package for R98 and tree visualisations using the ggtree package for R99—see Fig. The multilevel or hierarchical meta-regression modelling approach100. We fitted this model to each of the two clades: the Carcharhiniformes  and the Lamniformes . These data comprised 706 study-specific effect sizes for the Carcharhiniformes and 466 effect sizes for the Lamniformes, covering both the Atlantic and Pacific Oceans for both clades—records from the Mediterranean and Indian Ocean were excluded from this meta-analysis due to small sample sizes. We fitted these meta-analytic models to the study-specific proportion for each species recorded dead at haulback in pelagic longline gear. The multilevel structure for each model comprised the individual study identification, multiple records nested within some studies and the research group cluster for the various studies . We included the potentially informative covariates or predictors in the meta-regression structured models to evaluate whether AVM rate was a function of those predictors. We had previously screened a range of potential predictors to determine a minimal set of informative predictors using machine learning approaches discussed above.We modelled the effect of potentially informative predictors on elasmobranch species-specific AVM rates using a Bayesian multilevel or hierarchical regression modelling approach, which included a species-level phylogenetic structure as a group-level or random effect to adjust for any phylogenetic dependence101 using the Stan computation back-end102 via the brms interface for R103. This is also known as a binomial-Normal hierarchical meta-analytic model104 but was fit within a Bayesian inference framework105 using weakly informative priors106. It is a binomial-Normal GAMM regression model because: (1) the model likelihood is binomial to account for the proportion response data, (2) the group-level or random effects including the phylogenetic structure are sampled from a multivariate Gaussian distribution104, and (3) any nonlinear covariate functional form was accounted for using a thin plate regression spline basis commonly applied to fit generalized additive mixed models or GAMMs107. The fitted binomial-Normal model to the study-specific estimates for each species were then used to derive the overall or pooled mean AVM rate based on the posterior for each estimate comprising 10,000 samples or draws that were also used to derive the uncertainty estimates.We fitted these random-effects meta-regression models with binomial likelihood appropriate for proportion data108. The HDIs were summarized from the posterior samples for each species meta-analytic model fit using the tidybayes package for R109. A probability statement about the existence of a particular predictor-specific effect can also be determined with those 10,000 draws using the probability of direction metric proposed recently using the BayestestR package for R110.We used HDI as our measure of uncertainty, which is the shortest credible interval111 and implemented using the emmeans package for R112. We then summarized the marginal effect posterior densities to assess any apparent difference for instance between the estimated marginal AVM rates for the Atlantic and Pacific estimates. The posterior ratio summary was included in the summary plot for this effect.The estimated effect summaries based on the best-fit conditional regression GAMMs were then adjusted for variable sample size using the predicted estimated marginal means approach113. The phylogenetic signal or constraint is a simple metric that reflects the apparent effect of shared evolutionary history or ancestry on the specific trait or attribute state being evaluated114.We estimated the model-specific phylogenetic signal as the mean posterior proportion (with 95% HDI) of the summed group-level variances attributable to the phylogenetic group-level component—this approach assumes a Brownian diffusion or genetic drift process of character evolution for a continuous species-specific traitRhat statistic32. We also used leave-one-out cross-validation (LOOcv) metrics and Bayesian stacking116 to explore any comparative difference in expected predictive accuracy between models fitted with or without a specific predictor such as for instance body form, ventilation mode or phylogenetic correlation structure. Further evaluation of the best-fit-model was then assessed using graphical posterior predictive checks117. All inference was then made using the best-fit model and the posterior predictive samples118.All models were fit with 4 Markov chains with 10,000 iterations per chain after a warm-up of 2000 iterations. Model convergence was assessed using parameter-specific diagnostics such as multiple chain rank plots, bulk and tail effective sample size metrics and a rank-based Manta (Mobula) birostris, Pteroplatytrygon violacea) and two Squaliformes species .We modelled the effect of potential informative predictors on AVM rates for each of the following four species using a similar Bayesian GAMM modelling approach but without phylogenetic adjustment as no phylogenetic structure was relevant for this small subset of species—two Myliobatiformes species  effects used in the Bayesian GAMMs. Metafor cannot directly fit a binomial-Normal GAMM (or GLMM) with phylogenetic structure, so we used the multivariate parameterization form of a meta-regression model in metafor122 with logit transformed AVM response to mimic a GLMM and specifically accommodate in metafor the more complex forms of random-effect structures used here including the phylogenetic tree structure33.We explored potential publication biasSupplementary Information.


Direct laryngoscopy (DL) and videolaryngoscopy (VL) have been the most commonly used airway management modalities in the last several decades. Meanwhile, various optional airway tools  have been used for alternative rescue modalities when anticipated or unexpected difficulties in airway management has occurred. In recent decades, optical stylets and video-assisted intubating stylets have become another option for difficult airway scenarios. In contrast to other approaches, we have adopted the Shikani video-assisted intubating stylet technique (VS) for both routine and difficult airway management scenarios. In this case series report, we present the video-twin technique, combining a videolaryngoscope with a video-assisted intubating stylet in various clinical case scenarios. We propose that such a combination is easy to learn and employ and is particularly beneficial in situations where an expected difficult airway (EDA) is encountered. Conventional direct laryngoscopy (DL) has been the mainstream intubation tool for the last century. In 2010, videolaryngoscopy (VL) shifted the paradigm of airway management from providing direct vision to indirect vision ,5,6,7,8.With a VS, the airway operator uses his/her non-dominant hand (the thumb) to lift up patient’s chin and mandible in order to open the airway A. When nThe idea of using laryngoscopy to facilitate other airway management tools  is not new. In numerous reports, either DL or VL has been used to assist fiberoptic bronchoscopy (FOB) in various clinical scenarios ,29,30,31We have a unique clinical experience with VS in our institutions, both for routine and difficult airways. We also adopted VS a video-twin technique, combining VL with VS in selected cases with EDA. In this report, several VL and VS were used as follows: (1) UE rigid laryngoscope and TRS video stylet, Zhejiang UE Medical Corp., Taizhou, 317300, China; (2) C-MAC-VS (Video Stylet), KARL STORZ SE & Co. KG, Tuttlingen, Germany; (3) TuoRen Kingtaek Video Intubating stylet, TuoRen, Henan Tuoren Medical Device Co., Xinxiang, Henan, 453401, China; (4) Trachway video Intubating stylet, Markstein Sichtech Medical Corp., Taichung, 407, Taiwan; (5) McGRATH™ MAC Video Laryngoscope, Medtronic, Minneapolis, MN, 55432-5604, USA.2) underwent laparoscopic cholecystectomy and duodenorrhaphy. His past medical history included type II diabetes mellitus, esophageal reflux, and gall stones. Intraoperatively, standard American Society of Anesthesiologists (ASA) monitoring was applied, including non-invasive blood pressure (NIBP), electrocardiogram (ECG), end-tidal CO2 (EtCO2), pulse oximeter (SpO2), and peripheral temperature monitor. General anesthesia was induced with intravenous medications, including lidocaine (20 mg), fentanyl (1 µg/kg), propofol (1.5 mg/kg) and rocuronium (0.6 mg/kg). The tracheal intubation was performed using combined technique with VS and VL. Briefly, the operator inserted a videolaryngoscope with his non-dominant hand (left hand) and localized the glottis. Then, the operator applied video-assisted intubating stylet with his dominant hand. Using this technique, the access of the stylet into the airway was swift and glottis view was clear and full  was 8 s. Anesthesia was maintained with sevoflurane, fentanyl, and rocuronium. The whole procedure was uneventful.A 64-year-old man  25.0 kg/mand full . The end2) was admitted for laryngeal microsurgery (LMS). He was diagnosed with right hypopharyngeal squamous cell carcinoma  three years ago and completed concurrent chemoradiotherapy (CCRT). This time, he was found to have right aryepiglottic folds (AE fold) granulation and underwent laryngeal biopsy (suspected dysplasia squamous papilloma). American Society of Anesthesiologists standard monitoring was applied. General anesthesia was induced with intravenous glycopyrrolate, lidocaine, fentanyl, midazolam, and propofol. Muscle paralysis was induced by succinylcholine for tracheal intubation . The combined VS with VL technique facilitated by videolaryngoscopy was applied. The intubating time (from lip to trachea) was 8 s  underwent augmentation enterocystoplasty. Her past medical history included cervical spinal cord injury (C5–C7 injuries with complete paraplegia five years previously), urinary incontinence and frequent urinary tract infection, and autonomic dysreflexia (neurogenic voiding dysfunction and detrusor sphincter dyssynergia). Standard peri-operative vital signs monitorings were performed. General anesthesia was induced with lidocaine, ketamine, propofol, and rocuronium. Anesthesia was maintained with desflurane and cis-atracurium and supplementary fentanyl. Tracheal intubation was performed using the combined VS with VL  underwent total thyroidectomy and right central cervical lymph node dissection due to papillary thyroid carcinoma. Her past medical history included esophageal squamous cell carcinoma , arrhythmia, DM, and hypertension. Intraoperative neuromonitoring (IONM) was used for bilateral lymph node exploration and to confirm the functional integrity of the recurrent laryngeal nerve (RLN) as well as facilitates identification of the RLN before visualization during operations. Standard peri-operative vital signs monitoring was performed. General anesthesia was induced with lidocaine, fentanyl, propofol, and rocuronium. Anesthesia was maintained with sevoflurane. Tracheal intubation was performed using the combined VS with VL technique  underwent tongue biopsy, trans urethral removal of bladder tumour (TURBT), ureterorenoscopic manupilation (URS-M), and insertion of double-J stents. The patient was diagnosed with chronic obstructive pulmonary disease (COPD), urinary bladder urothelial cancer  and tongue cancer. General anesthesia was induced with lidocaine, glycopyrrolate, fentanyl, propofol and rocuronium. He was diagnosed with COVID-19 with positive PCR results. The anesthesia staff were equipped with full-gear personal protective equipment (PPE). Anesthesia was maintained with sevoflurane. Tracheal intubation was performed using the combined VS with VL technique  underwent left percutaneous nephrolithotomy (PCNL) and left ureterorenoscope stone manipulation (URS-SM). Standard peri-operative vital signs monitors were applied. General anesthesia was induced with lidocaine, glycopyrrolate, fentanyl, midazolam, propofol and rocuronium. Anesthesia was maintained with sevoflurane. Tracheal intubation was performed using the combined VS with VL technique  for tracheal intubation in six cases . While bAlthough from our unique clinical experiences the Shikani VS technique seems to be superior to DL or VL, there are nevertheless some potential technical obstacles that still need to be overcome, especially for novice trainees. Similar to other optical devices, airway secretions, mucus, saliva or blood may obstruct the view of the lenses or chip at the end of the stylet. In addition, the airway soft tissues and structures may collapse, block the view, and leave little space for the stylet to advance. Unless an EDA is encountered, it has been our experience that most elective airway intubations can be successfully accomplished by a single airway operator. It is imperative to clearly understand potentially difficult airways and how to prepare for the optimal working environment for intubation and decide whether to use VS or the video-twin technique combining VS with VL. During nasotracheal intubation using fiberoptic bronchoscopy (FOB), it was found that DL performed almost as well as an adjunct maneuver as jaw thrust for laryngeal visualization and intubation time, and it provided significantly better airway clearance at the level of the soft palate (instead of the larynx) than jaw thrust . The useThe authors have had clinical experience with the Shikani VS technique for routine tracheal intubation since 2016 ,51,52,53In most cases, the classic Shikani VS technique using one hand to lift chin is manageable and easily done by a single airway operator . OccasioHigh body mass index, severe obstructive sleep apnea;Severe head and neck trauma, tumor, restricted cervical spine motion;Narrow oropharynx ;Very anterior larynx, Cormack-Lehane grade 3/4, droopy/floppy epiglottis that prevent the scope from seeing the glottis;Bleeding, heavy secretions, vomits (obstructs the view of the stylet and requires continuous suctioning).


Combined pulmonary fibrosis and emphysema (CPFE) is an underrecognized syndrome that involves simultaneous restrictive-obstructive lung disease. The prognosis is poor, and it frequently occurs with comorbidities. Heavy or former smoking is a major risk factor, and computed tomography (CT) typically shows lower zone fibrosis and upper zone emphysema. Chronic respiratory failure, pulmonary hypertension, and lung carcinoma are major causes of mortality. Diagnosis of CPFE should be combined with palliative care due to the high mortality of the condition, especially in the case of delayed diagnosis. We present the case of a 73-year-old male with a history of non-small cell lung cancer, 50 pack-year smoking, and cervical spine injury (CSI) with a late diagnosis of CPFE. After presenting to the emergency department for an acute exacerbation of dyspnea and hypoxia, he was initially treated with a congestive heart failure protocol. Further examination showed mixed pulmonary function tests as well as digital clubbing, and a CT scan showed changes indicative of advanced bullous emphysema diffusely throughout both lungs with an upper lobe predominance and basilar fibrosis. He was diagnosed with CPFE and immediately treated for both restrictive and obstructive lung diseases with supplemental oxygen, albuterol, ipratropium, corticosteroids, systemic antibiotics, as well as provided with palliative consultation. His previous history and CSI delayed diagnosis, as his lung restriction was likely assumed to be from impaired chest wall mobility rather than CPFE. This case highlights the presentation of a relatively rare disease that was confounded by comorbidities.  Combined pulmonary fibrosis and emphysema (CPFE) is a rare condition comprised of a combination of restrictive and obstructive lung disease. The most common predisposing risk factor is exposure to cigarette smoke. Clinical symptoms most often include dyspnea due to upper lobe emphysema and lower lobe fibrosis leading to abnormalities in gas exchange . AlthougCPFE is generally categorized as interstitial lung disease. The American Thoracic Society and the European Respiratory Society classification of interstitial pneumonia in 2013 listed three main categories of idiopathic interstitial pneumonia: major idiopathic interstitial pneumonia, rare idiopathic interstitial pneumonia, and unclassified idiopathic interstitial pneumonia. CPFE falls into the latter "unclassified" category and was first described in 2005 [The prevalence of this condition is not completely understood, likely due to the rarity of this condition. The pathogenesis has been unclear as well; however, there is a strong association with smoking and other environmental exposures such as mineral dust and agricultural and industrial compounds . There iMost authors have suggested that CPFE can be thought of as a combination of chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). The clinical symptoms are primarily cough and dyspnea, which are nonspecific and overlap with more common symptoms of long-term smoking, such as those seen with COPD or IPF. However, there are some subtle differences . COPD geDiminished diaphragmatic motion during deep breathing can also be an initial presentation of CPFE. With such a diverse array of presentations, the CPFE syndrome has a poor prognosis with a five-year survival of approximately 50-60%, depending on comorbidities and extent of pulmonary disease. There are currently no specific treatments or established guidelines for CPFE . General2) of 50-60% was required to keep his oxygen saturation above 88%. Physical examination was notable for bilateral digital clubbing, bibasilar crackles, and bilateral leg swelling. Other relevant laboratory findings such as troponins, electrocardiogram (ECG), and a metabolic panel were within normal limits. However, a chest X-ray displayed changes indicative of cardiomegaly without any patterns suspicious of pneumonia. After stabilization, treatment was initiated for a presumed congestive heart failure exacerbation, including diuresis with furosemide. An echocardiogram was notable for right ventricular hypertrophy  and septal dyskinesia.A 73-year-old male with an extensive medical history of a cervical spine injury (leading to quadriplegia), non-small cell lung cancer treated with lobectomy eight years prior, COPD, hypertension, type 2 diabetes mellitus, 50 pack-year smoking, post-traumatic stress disorder (PTSD), and peripheral neuropathy was brought to the emergency department for acute-onset hypoxia. His caretaker reported that his oxygen saturation was approximately 75%, and he had been experiencing progressive dyspnea. He usually relied on a two-liter nasal cannula but was experiencing respiratory distress even with the supplemental oxygen. He was afebrile and had no other major complaints, such as chest pain, diarrhea, nausea, and vomiting. Upon arrival at the emergency department, he was provided with a six-liter nasal cannula which initially resolved his dyspnea. His dyspnea progressively worsened over the next four hours, and he was initiated on a high flow nasal cannula at 35 L/minute, and a fraction of inspired oxygen  demonstrated reduced forced expiratory volume in one second , reduced diffusion of carbon monoxide (DLCO) at 14 mL/mmHg/min , and an overall mixed pattern of restriction and obstruction. FEV1 to forced vital capacity (FVC) ratio was 87% of expected (Table A computed tomography (CT) of the chest was performed and showed moderate to advanced pulmonary interstitial edema, fibrosis, and a small left pleural effusion Figure .Additionally, changes indicative of advanced bullous emphysema were present diffusely throughout both lungs with an upper lobe predominance Figure .A subsequent CT chest with pulmonary angiography confirmed the lack of pulmonary emboli as well as prominent cardiomegaly, severe pulmonary fibrosis, and mediastino-hilar lymphadenopathy. After examination of the history, PFTs, and CT findings, it was determined that our patient's clinical presentation best fit the diagnosis of CPFE syndrome. Palliative care was consulted, owing to the high risk of mortality in this patient. His CPFE was further managed by approaching the obstructive and restrictive aspects separately. Bronchodilators , antibiotics (amoxicillin-clavulanate), supplemental oxygen, and corticosteroids were used to manage the obstructive symptoms, whereas judicious fluid management helped manage the restriction. His condition improved over the next few days, whereby he was able to be weaned down to one-liter supplemental oxygen. Palliative experts were also consulted and separately evaluated the patient. He opted to continue medical management of his CPFE, understanding the prognosis of his disease.Based on the clinical and imaging criteria, our patient with combined restrictive and obstructive lung disease had CPFE. Since the most accurate confirmatory test is a chest CT, the combined pattern of upper lobe fibrosis and lower lobe bullous emphysema was key in establishing the diagnosis. This patient, who was paraplegic due to his cervical spine injury, was also expected to have a restrictive lung disease secondary to decreased chest wall mobility. The delay in diagnosis could have been due to the fact that an extensive smoking history combined with a recalcitrant chest wall could also create a combined restrictive-obstructive clinical picture. Additionally, the lack of confirmatory CT findings would also lead to a delay in finding the root cause. Even with a diagnosis such as CPFE, treatment is in the form of managing symptoms individually . For exaMost patients suffering from CPFE have a mixed pattern in pulmonary function testing. They also display marked reductions in diffusing capacity of carbon monoxide (DLCO) . PerhapsFindings on CT for CPFE are generally heterogeneous and exist on the spectrum both in terms of the characteristics of the findings as well as the severity . PulmonaThis rare case demonstrates a rare condition that can easily be confused with other disease processes, especially in the case of an extensive medical history such as our patient. The exact prevalence of CPFE is not known. Some estimates state that in asymptomatic smokers, roughly 3% of patients may have findings indicative of CPFE . AlthougThe decision to pursue purely comfort measures is often seen in CPFE patients due to their decreased life expectancy and often the presence of comorbidities. By some estimates, the five-year survival rate of patients diagnosed with CPFE is between 35-80%, with aggressive treatment marginally improving mortality while also significantly decreasing quality of life and comfort . PatientCombined pulmonary fibrosis and emphysema (CPFE) is an under-documented disease with a characteristic restrictive-obstructive presentation. It is a combination of emphysematous changes in the upper lungs and fibrotic changes in the basilar lung fields. It has a strong association with smoking, and complications can include pulmonary hypertension, lung cancer, and respiratory insufficiency. Due to the severity of the disease, the prognosis is poor, and newly diagnosed patients should be counseled on palliative or hospice care. Comorbidities such as cervical spine injuries can act as confounders and delay the diagnosis of CPFE due to the inherent disruption of chest wall function. Keeping CPFE on the differential may be appropriate in patients with respiratory exacerbations and a history of smoking. Pulmonary function tests and computed tomography are the most accurate confirmatory studies for this condition. Physical examination findings like digital clubbing are associated with a worse prognosis.


The stiffness of composite laminates is easily affected by wrinkle defects. In this paper, a new effective analytical model was proposed to predict the three-dimensional equivalent elastic properties of multidirectional composite laminates with wrinkle defects. Firstly, a geometric model was established according to the microscopic characteristics of wrinkle defects. Then, based on the classical laminate theory and homogenization method, the constitutive equation and flexibility matrix of the wrinkle region were established. Finally, the equivalent stiffness parameters of unidirectional and multidirectional laminates were derived, and the effects of different wrinkle parameters and ply-stacking sequences on the stiffness of unidirectional and multidirectional laminates were studied by using the analytical model. The results show that the mechanical properties of the lamina and laminates are affected by the out-of-plane angle and in-plane angle of the wrinkle defects. The accuracy of the analytical model has been verified by the numerical model and other theoretical models, and it has the characteristics of few parameters and a high efficiency. The analytical model can be used to predict the stiffness of composite structures with wrinkle defects simply, effectively, and quantitatively. It can also be used as a tool to provide the mechanical response information of laminates with wrinkle defects. Fiber-reinforced composites have been widely used in the aerospace, marine, automobile, and chemical industries in recent years; this is mainly due to their high specific strength and stiffness, good functional designability for anisotropy, corrosion resistance, and fatigue resistance, etc. However, composite structures are prone to be affected by initial defects in the manufacturing process. A wrinkle is one of the most common initial defects of fiber-reinforced composite structures ,2,3, andWrinkle defects are usually divided into the in-plane and out-of-plane wrinkle types. An in-plane wrinkle mainly refers to fiber fluctuations in the plane, which describes the fiber deviation from the specified direction in the thin plate plane ,14,15. FWith the increasing emphasis on structural integrity, studies on the influence of wrinkle defects on structural mechanical properties have been gradually carried out. Hsiao  proposedThe finite element method is used to quantitatively study the mechanical response behavior of composite structures with wrinkle defects. Garnich  establisAs mentioned above, these studies mainly focused on the wrinkle defects with the two-dimensional analysis method. However, due to the spatial geometric characteristics of wrinkle defects and the anisotropy of composite materials, the mechanical response generated by wrinkles often shows three-dimension elastic characteristics. In addition, although some examples in the literature ,10,21 usThe aim of this work is to establish an effective analytical model to estimate the three-dimensional equivalent stiffness of multidirectional composite laminates with wrinkle defects. The triangle wrinkle model is used to improve the cosine wrinkle model which is already widely used. Based on the classic laminate theory and micromechanics, the equivalent elastic stiffness was proposed through the homogenization method. The accuracy of the analytical model was examined by RVE (Representative Volume Element) simulation and other published approaches from the literature. In addition, the effect of wrinkle defects on the equivalent properties of unidirectional and cross-ply laminates was evaluated by the analytical model, and it was found that there were some differences in the effect of wrinkle defects on the Young’s modulus and shear modulus under different ply stacking sequences.The microphotographs of wrinkle defects are shown in XOZ plane and extend along the X, Y, and Z principal axes, respectively, where X is the length direction, Y is the width direction, and Z is the thickness direction. Secondly, due to a small proportion in the whole wrinkle length, the arc length of the ply at the deflection corner of the wrinkle could be replaced by linear segments, as shown in Before the homogenization of laminates with wrinkle regions, some assumptions were made. Firstly, the wrinkles only fluctuate in the A uniform wrinkle, as shown in The subscript “Based on the classical laminate theory, the constitutive equation under the plane stress state condition is expressed as:Specially, when the coupling stiffness matrix For orthotropic composite materials, the stress-strain relationship is expressed as:The elements in the matrix XOY plane and the X-axis of the global coordinate system. The second step is the deflection between the fiber ply in the XOZ plane and the X-axis of the global coordinate system. If the declination angle between the fiber bundle in the plane XOY and the X-axis of the global coordinate system is φ, the first compliance transformance matrix T” represents the transposition of the matrix, Different from the methods to separate the stiffness of out-of-plane and in-plane wrinkles in other examples of the literature ,10, a unessed as :(7)S ply stacking sequences decrease with the increase of wp,wp2]S laminate is the smallest and the effect on [0wp6]S is the greatest. Therefore, it can be found that the orthogonal plies and The relationship between the effective elastic stiffness, wp/90wp]S3 and S laminates decreases with the increase of wp6]S laminate doesn’t change with wp,wp2]S laminate, the significant least effect on the wp/90wp]S3 laminate, and no effect on the wp6]S laminate.The relationship between the effective elastic stiffness, wp/90wp]S3 and S laminates decreases with the increase of wp6]S laminate increases with the increase of The relationship between the effective elastic stiffness, wp6]S, [0wp/90wp]S,3 and S laminates increase with the increase of wp/90wp]S3 is smallest.The relationship between the shear stiffness, wp6]S, [0wp/90wp]S,3 and S increase with the increase of wp6]S ply stacking sequence is greater than that of laminates with the other two ply-stacking sequences. Therefore, the wrinkle defect has a greater effect on the shear stiffness, The relationship between the shear stiffness, wp6]S, [0wp/90wp]S,3 and S ply stacking sequences decrease with the increase of wp,wp2]S ply stacking sequence and a slight weakening effect on the shear stiffness, The relationship between the shear stiffness, H/L; is 0 to 0.1, the maximum decrease percentages of A new three-dimensional analytical model for multidirectional composite laminates with wrinkle defects was proposed to study the equivalent stiffness of wrinkle regions of laminates. The analytical model in this paper was compared with the results of the RVE model and other studies’ analytical and finite element models, and good accuracy and consistency were obtained. The results of the present model show that the effect of the wrinkle on the six effective elastic mechanical parameters of the single ply are different. When The analytical model established in present paper can quantitatively evaluate the effect of wrinkle defects on the stiffness performance of the laminates. It has the advantages of few parameters, good precision, and high efficiency. In future research, the difference of the angles between the fiber direction and the primary axis of the material coordinate system on the two wrinkles’ surface should be studied, which would be helpful to further improve the accuracy of the present model for predicting the effect of the wrinkle defects on the stiffness of multidirectional laminates.