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In ARDS patients, the change from supine to prone position generates a more even distribution of the gas–tissue ratios along the dependent–nondependent axis and a more homogeneous distribution of lung stress and strain. The change to prone position is generally accompanied by a marked improvement in arterial blood gases, which is mainly due to a better overall ventilation/perfusion matching. Improvement in oxygenation and reduction in mortality are the main reasons to implement prone position in patients with ARDS. The main reason explaining a decreased mortality is less overdistension in non-dependent lung regions and less cyclical opening and closing in dependent lung regions. The only absolute contraindication for implementing prone position is an unstable spinal fracture. The maneuver to change from supine to prone and vice versa requires a skilled team of 4–5 caregivers. The most frequent adverse events are pressure sores and facial edema. Recently, the use of prone position has been extended to non-intubated spontaneously breathing patients affected with COVID-19 ARDS. The effects of this intervention on outcomes are still uncertain.

Despite long-time awareness of the importance of the location of buds in plant biology, research on belowground bud banks has been scant. Terms such as lignotuber, xylopodium and sobole, all referring to belowground bud-bearing structures, are used inconsistently in the literature. Because soil efficiently insulates meristems from the heat of fire, concealing buds below ground provides fitness benefits in fire-prone ecosystems. Thus, in these ecosystems, there is a remarkable diversity of bud-bearing structures. There are at least six locations where belowground buds are stored: roots, root crown, rhizomes, woody burls, fleshy swellings and belowground caudexes. These support many morphologically distinct organs. Given their history and function, these organs may be divided into three groups: those that originated in the early history of plants and that currently are widespread (bud-bearing roots and root crowns); those that also originated early and have spread mainly among ferns and monocots (nonwoody rhizomes and a wide range of fleshy underground swellings); and those that originated later in history and are strictly tied to fire-prone ecosystems (woody rhizomes, lignotubers and xylopodia). Recognizing the diversity of belowground bud banks is the starting point for understanding the many evolutionary pathways available for responding to severe recurrent disturbances.

During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in prone position until significant clinical improvement was achieved. One center reported extending prone positioning for organizational reasons relying on a predetermined fixed duration. A recent study argued that a clinically driven extension of prone positioning beyond 24 h could be associated with reduced mortality. On a patient level, the main benefit of extending prone positioning beyond 24 h is to maintain a more homogenous distribution of the gas–tissue ratio, thus delaying the increase in overdistention observed when patients are returned to the supine position. On an organizational level, extending prone positioning reduces the workload for both doctors and nurses, which might significantly enhance the quality of care in an epidemic. It might also reduce the incidence of accidental catheter and tracheal tube removal, thereby convincing intensive care units with low incidence of ARDS to prone patients more systematically. The main risk associated with extended prone positioning is an increased incidence of pressure injuries. Up until now, retrospective studies are reassuring, but prospective evaluation is needed. Graphical Abstract

1. We live on a flammable planet yet there is little consensus on the origin and evolution of flammability in our flora. 2. We argue that part of the problem lies in the concept of flammability, which should not be viewed as a single quantitative trait or metric. Rather, we propose that flammability has three major dimensions that are not necessarily correlated: ignitability, heat release and fire spread rate. These major axes of variation are controlled by different plant traits and have differing ecological impacts during fire. 3. At the individual plant scale, these traits define three flammability strategies observed in fire-prone ecosystems: the non-flammable, the fast-flammable and the hot-flammable strategy (with low ignitability, high flame spread rate and high heat release, respectively). These strategies increase the survival or reproduction under recurrent fires, and thus, plants in fire-prone ecosystems benefit from acquiring one of them; they represent different (alternative) ways to live under recurrent fires. 4. Synthesis. This novel framework based on different flammability strategies helps us to understand variability in flammability across scales, and provides a basis for further research.

Background Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave. Methods Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO 2 /FiO 2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position. Results Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p  < 0.001). Overall, prone position induced a significant increase in PaO 2 /FiO 2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders . Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs . 38%, p  = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders . These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs . 37%, p  = 0.189 for Carbon Dioxide Responders and Non-Responders , respectively). Conclusions During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching. Trial registration : clinicaltrials.gov number: NCT04388670

Sudden and unexpected arrest-related deaths are deeply tragic and have generated widespread concern among the public, medical professionals, and law enforcement agencies. One mechanism that has garnered considerable attention is the use of prone restraint, wherein a subject is placed face-down and controlled in this position. The safety and risks of this technique remain subjects of debate within both scientific literature and legal settings. Supporters of prone restraint’s safety frequently cite prospective epidemiologic studies that report no fatalities associated with its use. However, these studies typically involve small cohorts and are conducted over limited timeframes, potentially underestimating rare but serious outcomes. In contrast, retrospective analyses, which assess larger populations over extended periods, have identified multiple cases of fatal outcomes linked to prone restraint. Notably, some of the most comprehensive data on these fatalities come from investigative journalism, which has uncovered patterns and prevalence rates not fully captured in academic or institutional studies. Based on available evidence, we estimate the mortality rate with use of in-custody prone restraint is at approximately 1 per 4.4 million individuals per year, or 0.023 per 100,000 population annually. These findings underscore the need for more rigorous, large-scale, and transparent epidemiological studies to better inform public policy, law enforcement practices, and clinical guidelines. The potential lethality of prone restraint must be recognized, and its use re-evaluated in light of both fatal risk and ethical responsibility. •Prospective studies encompassed an estimated population base of approximately 9.6 million people over a one-year equivalent period and documented 4635 instances of in-custody prone positioning with no deaths reported among individuals restrained in the prone position.•Larger retrospective studies from Ontario, Los Angeles, and the Netherlands, collectively identified 72 prone restraint deaths, yielding an estimated mortality rate of one death per 3.4 million people per year (0.029/100,000/year).•U.S government-based studies and reports have poorly tracked prone restraint deaths.•U.S new agency, the Associated Press performed the most comprehensive investigation in prone restraint deaths finding at least 740 deaths in the United States involving prone positioning with estimated of mortality rate is approximately one death per 4.4 million people per year (0.023/100,000year).•True mortality rate of prone restraint deaths remains unknown. A coordinated effort among medical/forensic communities, law enforcement, public health and policy makers is essential to better study prone restraint deaths.

Background Previous studies suggest that prone positioning (PP) can increase PaO 2 /FiO 2 and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients. Methods This prospective observational cohort study was performed in two teaching hospitals. Non-intubated moderate to severe ARDS patients were included and were placed in PP with NIV or with HFNC. The efficacy in improving oxygenation with four support methods—HFNC, HFNC+PP, NIV, NIV+PP—were evaluated by blood gas analysis. The primary outcome was the rate of intubation. Results Between January 2018 and April 2019, 20 ARDS patients were enrolled. The main causes of ARDS were pneumonia due to influenza (9 cases, 45%) and other viruses (2 cases, 10%). Ten cases were moderate ARDS and 10 cases were severe. Eleven patients avoided intubation (success group), and 9 patients were intubated (failure group). All 7 patients with a PaO 2 /FiO 2  < 100 mmHg on NIV required intubation. PaO 2 /FiO 2 in HFNC+PP were significantly higher in the success group than in the failure group (125 ± 41 mmHg vs 119 ± 19 mmHg, P  = 0.043). PaO 2 /FiO 2 demonstrated an upward trend in patients with all four support strategies: HFNC < HFNC+PP ≤ NIV < NIV+PP. The average duration for PP was 2 h twice daily. Conclusions Early application of PP with HFNC, especially in patients with moderate ARDS and baseline SpO 2  > 95%, may help avoid intubation. The PP was well tolerated, and the efficacy on PaO 2 /FiO 2 of the four support strategies was HFNC < HFNC+PP ≤ NIV < NIV+PP. Severe ARDS patients were not appropriate candidates for HFNC/NIV+PP. Trial registration ChiCTR, ChiCTR1900023564 . Registered 1 June 2019 (retrospectively registered)

Background Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone. Methods Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP. Results A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p  = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days ( p  = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p  = 0.92]. Conclusion In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

PurposeThe objective of this study was to discuss our experience performing LLIF in the prone position and report our complications.MethodsA retrospective chart review was conducted that included all patients who underwent single- or multi-level single-position pLLIF alone or as part of a concomitant procedure by the same surgeon from May 2019 to November 2022.ResultsA total of 155 patients and 250 levels were included in this study. Surgery was most commonly performed at the L4–L5 level (n = 100, 40%). The most common preoperative diagnosis was spondylolisthesis (n = 74, 47.7%). In the first 30 cases, 3 surgeries were aborted to an MIS TLIF. Complications included 3 unintentional ALL ruptures (n = 3/250, 1.2%), and 1 malpositioned implant impinging on the contralateral foramen requiring revision (n = 1/250, 0.4%), which all occurred within the first 30 cases. Out of 147 patients with more than 6-week follow-ups, there were 3 cases of femoral nerve palsy (n = 3/147, 2.0%). Two cases of femoral nerve palsy improved to preoperative strength by the 6th week postoperatively, while one improved to 4/5 preoperative strength by 1 year. There were no cases of bowel perforation or vascular injury.ConclusionOur single-surgeon experience demonstrates the initial learning curve when adopting pLLIF. Thereafter, we experienced reproducibility in our technique and large improvements in our operative times, and complication profile. We experienced no technical complications after the 30th case. Further studies will include long-term clinical and radiographic outcomes to understand the complete utility of this approach.