Point Of Closure Research Articles

Variability of quantitative morphogenetic parameters during early morphogenesis of the loach, Misgurnus fossilis L.

Analysis of normal variation in quantitative morphological characters during the early embryonic development of the loach, based on fixed material and individual developmental trajectories of living embryos, shows that the dorsoventral differentiation of the blastoderm proceeds in two stages. Initially, at the onset of epiboly, the sagittal (short) and transverse (long) blastoderm meridians are marked off, and only then, upon germ ring (GR) formation, differentiation between the opposite poles of the sagittal meridian takes place. The embryonic shield (ES) usually appears in the segment of the blastoderm where the radius of its external curvature reaches a maximum and, therefore, the active surface tension at the blastoderm boundary with the YSL (peri-blast) and yolk is the highest. In this case, the convergence of inner cells toward the future dorsal segment (leading to ES formation) is a mechanical consequence of surface tension anisotropy. The normal course of epiboly is associated with periodic changes in the curvature of the blastoderm external surface, with new structures (the dorsal segment, GR, and ES) are marked off only when the surface curvature becomes maximally uniform. Although the ES in most embryos appears within the initial dorsal segment, individual developmental trajectories have been traced where the GR starts to form at the dorsal pole of the blastoderm but the ES develops on its opposite site, at the point of GR closure. In both cases, GR formation is initiated at the point of convergence of centrifugal cell migration flows that arise in the marginal zone of the blastoderm upon GR initiation or closure.

Simulation Guidance for Calibration of Freeway Lane Closure Capacity

This study provides a methodology for calibrating freeway work zone capacity in a microsimulation environment and guidance for replicating field-observed freeway work zone capacity through simulation. From 81 field observations at 12 U.S. work zone sites, 90 work zone sites from literature archival sources, and a macroscopic capacity model developed in NCHRP Project 03-107, the authors show how to replicate field-observed or forecast capacity in the Vissim simulation tool under various scenarios of freeway work zone lane closure. With guidance from an in-depth literature review, key car-following and lane-changing parameters are proposed as a result of the calibration effort and extensive sensitivity tests of numerous combinations of parameter values. Lane configuration specific guidance is provided for two key car-following parameters in Vissim, cc1 and cc2. During the process of developing the guidance, every tested capacity scenario was verified by using a lane use volume balance that was obtained upstream of the lane closure point in order to replicate realistic freeway work zone conditions. The calibration methodology as well as default parameter guidance developed through this research are useful to practitioners who wish to model freeway work zone impacts accurately through microsimulation.

Scanning curves in wedge pore with the wide end closed: Effects of temperature

The desorption scanning curves within the hysteresis loop of argon adsorbed in a wedge‐shaped pore with its wide end closed have been studied in the temperature range between 60 and 87 K, using grand canonical Monte Carlo simulation. The distinct features are: (1) adsorbate packing follows a sequence of commensurate regions (zones) and incommensurate regions (junctions); (2) the mechanism for evaporation switches from cavitation‐like pore blocking to cavitation when the temperature is increased; as typically observed for ink‐bottle pores. When cavitation is the operating mechanism, the descending scanning curve spans across the loop in two stages: a gradual decrease in density in a zone followed by a sharp evaporation from a junction, and then terminates at the lowest point on the vertical cavitation boundary. The adsorption scanning curve proceeds across the loop in two stages complementary to the desorption scanning‐curve: a gradual change in density at a junction followed by a sharp change through a zone. Conversely, when cavitation‐like pore blocking is operating, the descending curve leaves the adsorption boundary, spans across the hysteresis loop and returns to a different point on the same boundary, rather than to the desorption boundary or to the lower closure point. This feature does not seem to have been recognized in earlier literature and should be considered in the classification of scanning curves. © 2015 American Institute of Chemical Engineers AIChE J, 61: 3936–3943, 2015

Easton's theorem for Ramsey and strongly Ramsey cardinals

We show that, assuming GCH, if κ is a Ramsey or a strongly Ramsey cardinal and F is a class function on the regular cardinals having a closure point at κ and obeying the constraints of Easton's theorem, namely, F(α)≤F(β) for α≤β and α<cf(F(α)), then there is a cofinality-preserving forcing extension in which κ remains Ramsey or strongly Ramsey respectively and 2δ=F(δ) for every regular cardinal δ.

“All That Endures Turns to Dust”: The Melancholy Retrospection of Modern Utopias in Kreisland by Rosa Liksom

Kaikki, mika on pysyvaa, haihtuu polyna ilmaan (Liksom 1996, 177) [All that endures turns to dust] is a quote from Finnish author Rosa Liksom's novel Kreisland, a satirical mapping of Finland's uneasy minuet with three prominent political ideologies of the twentieth century: fascism, communism, and capitalism. This textual image calls to mind another textual image, namely All that is solid melts into air, as evoked by Karl Marx and Friedrich Engels in The Communist Manifesto (1985, 83). According to Marshall Berman, Marx and Engels's image of the ephemerality of the world represents a thoroughly modern experience (Berman 1985, 15). Kreisland's rendering of it discloses the transient sobriety of the novel's protagonist, Impi Agafiina, at the very moment her ideals capsize, as she tries to recover from the loss of one dream and before she becomes intoxicated by a new one. As Germany is losing World War II, Impi Agafiina has to abandon the fascist dream of a Greater Finland, but has not yet found her next mission: communism. The quote captures the mood of utopian thought and its critique in the novel, as seen through the eyes of Impi Agafiina, a modern subject who embarks on a quest to discover utopia, the ideal society, and the means to transform the world into that ideal. While she is caught up in her utopian visions, these visions seem true and enduring. In retrospect, however, the faults and contradictions of the failed utopian projects begin to show, and what is left is a melancholy longing for the utopian impulse itself. Kreisland is the first novel by Rosa Liksom, who is probably best known for her short stories depicting fringe lifestyles and social outcasts in rural peripheries of northern Finland as well as in urban centers. While Liksom's works were initially read by many as authentic depictions of marginalized people, the parody and dark humor in her writing was later acknowledged by critics (see Kantokorpi 1997). Now Liksom is often characterized as a postmodernist--a characterization her quirky public image has no doubt contributed to. In her writing, Liksom employs quick changes in perspectives, vocabularies, styles, and dialects. These nuances are sadly often lost in translation. Kreisland is largely narrated in the dialect of western Lapland and comically juxtaposes the colloquial, northern register of the novel's protagonists with the ideologies (fascism, communism, capitalism) and cultures (German, Soviet, American) they encounter. It has been described as a unique polyphonic mock-epic in a Finnish context (Kirstina 2013a, 40). In a sense, it continues the deconstruction of the myth of the Finnish war hero started by Vaino Linna's Unknown Soldier (1954) and makes similar use of polyphony to challenge official national language, truth, and history (see Kirstina and Turunen 2013, 53). There has been renewed interest in Liksom after she won the Finlandia Prize for her latest novel Hytti nro 6 (2011; Compartment No. 6, 2014). What becomes increasingly audible in Hytti nro 6 is the silence, lyricism, and gentleness that, in previous works, have been overwhelmed by the loudness and irony of Liksom's writing but have nonetheless always been there (Kirstina 2013b, 84). This article attempts to heed the silence behind the loudness in Kreisland, to capture the melancholy in the parody. It stresses the irony of the novel's ending and maintains that it is not a happy and contented point of closure but a point of retrospection. Of the two main protagonists of Kreisland, Impi Agafiina and Juho Gabriel, the former is far more concerned with modernity and the retrospection of it than is the latter. Whereas Impi Agafiina is constantly on the move, Juho Gabriel rarely strays far away from his birthplace, Lapland. He narrates his segments in the present tense and is mostly concerned with present matters and daily chores. In contrast, Impi Agafiina is always making plans for the future, but narrates her story in the past tense. …

The ortho-plastic approach to soft tissue management in trauma.

Fractures with associated soft tissue injuries, or those termed ‘open,’ are not uncommon. There has been much discussion regarding there management, with the guidance from the combined British Orthopaedic Association and British Association and Aesthetic Surgeons teams widely accepted as the gold level of therapy. We aim to discuss the current evidence about the initial management of this group of injuries, taking a journey from arrival in the accident and emergency department through to the point of definitive closure. Other modes of therapy are also reviewed.

246 * A MONITORING AND PHYSIOLOGICAL CONTROL SYSTEM FOR DETERMINING AORTIC VALVE CLOSING

Objectives: Accurate monitoring and assessment of the residual cardiac function of a patient supported by a ventricular assist device (VAD) is critical for better patient management and potential weaning. Information regarding the VAD speed at which the aortic valve remains closed can assist clinicians to maintain appropriate unloading, reduce the risk of aortic insufficiency and potentially reduce the risk of aortic leaflet fusion. Methods: A pressure sensor implanted in the inlet cannula determines the left ventricular (LV) pressure. The area of the LV pressure and motor power is calculated for each heart beat. A feedback signal is monitored at high speed and low speed to determine the change in the system. Small amplitude (<300 rpm) and low frequency (<0.1 Hz) square wave changes to the VAD speed are made. Results: Ten ovine trials have been completed with the DP3 pump (LV to aortic cannulation). The feedback variable (pressure power area) proved to have a peak at the speed of aortic valve closure The gradient (Δ pressure power area) could be measured by using the square wave speed modulation. In both the baseline and beta blocked heart the zero-crossing of gradient occurred at the aortic closure speed. Conclusions: Feedback gives a definite peak around aortic valve closure point and uses pump speed modulation for more accuracy; there is no sensitivity to sensor drift or haematocrit changes, and it provides noninvasive, continuous measurement.

Electronic excitations and metallization of dense solid hydrogen

Theoretical calculations and an assessment of recent experimental results for dense solid hydrogen lead to a unique scenario for the metallization of hydrogen under pressure. The existence of layered structures based on graphene sheets gives rise to an electronic structure related to unique features found in graphene that are well studied in the carbon phase. The honeycombed layered structure for hydrogen at high density, first predicted in molecular calculations, produces a complex optical response. The metallization of hydrogen is very different from that originally proposed via a phase transition to a close-packed monoatomic structure, and different from simple metallization recently used to interpret recent experimental data. These different mechanisms for metallization have very different experimental signatures. We show that the shift of the main visible absorption edge does not constrain the point of band gap closure, in contrast with recent claims. This conclusion is confirmed by measured optical spectra, including spectra obtained to low photon energies in the infrared region for phases III and IV of hydrogen.

Saverio Tomaiuolo, Victorian Unfinished Novels, The Imperfect Page

“The moment of closure is the point at which the events of a story become fully intelligible to the reader”, Catherine Belsey explains about classic realist narratives. For Peter Brooks, “only the end can finally determine meaning, close the sentence as a signifying totality”. Victorian novels moreover favoured a tidy closure (Weiss). What then of these novels that were never completed and therefore never reached the point of closure? These are the texts under study in nineteenth-century spec...

Current Achievements With Topical Negative Pressure to Improve Wound Healing in Dehiscent Ischemic Stumps of Diabetic Patients

Negative pressure wound therapy has been increasingly used either as a primary or as an adjunctive therapeutic measure to treat a variety of recalcitrant wounds during the past years. It is thought to act by creating a local environment that promotes cell proliferation, angiogenesis, and granulation tissue formation, leading to accelerated wound healing to the point of spontaneous closure or reducing the wound size to facilitate significantly further surgical reconstruction. This case series presents our preliminary experience with the use of a Topical Negative Pressure system in the treatment of challenging ischemic wounds of diabetic patients. It aims to underscore its beneficial effects and explore its potential role in the management of ischemic amputated stumps to avoid ipsilateral re-amputation at a higher level.

Precordial acceleration signals improve the performance of diastolic timed vibrations

Background and objectiveThis paper introduces a seismocardiography based methodology of predicting the start and the end of diastole to be used in diastolic timed vibrations (DTV), which provides non-invasive emergency treatment of acute coronary thrombosis by applying direct mechanical vibrations to the patient chest during diastole of heart cycles. It is proposed that seismocardiogram (SCG), in combination with electrocardiogram (ECG), provides a new means of diastole prediction. MethodsAn accelerometer was placed on the sternum of 120 healthy participants and 22 ischemic heart patients to record precordial accelerations created by the heart. The accelerometer signal was used to extract SCG and phonocardiogram (PCG). Two independent trained experts annotated the extracted signals based on the timings of the start and end of diastole. ResultsIn the ischemic heart disease population by using 15 consecutive SCG cycles, the start and end of diastole was predicted in the upcoming cycles with 95 percentile error margin of 10.7ms and 5.8ms, respectively. These error margins were 7.4ms and 3.5ms, respectively, for normal participants. ConclusionThe results provide that prediction of the aortic valve closure point in the SCG signal helps start the vibrator in time to cover most of the isovolumic relaxation period. Also, through prediction of the mitral valve closure point in the SCG signal, safety of the technique can be assessed through prediction of the amount of unwanted vibrations applied during the isovolumic contraction period.

Axillary “Exclusion”—A Successful Technique for Reducing Seroma Formation after Mastectomy and Axillary Dissection

Introduction: A seroma is the commonest complication of breast cancer surgery, and although its consequences most often cause no more than discomfort and anxiety, more important sequelae include flap necrosis and wound breakdown. Infection developing within seroma increases morbidity and often results in the need for re-admission, re-imaging, drainage and antibiotic usage. Numerous methods to reduce post-mastectomy seroma formation have been tried with no consistent success. Methods: 24 consecutive patients undergoing mastectomy and axillary clearance were recruited before and after a departmental change in practice. At the point of skin closure, patients either underwent “axillary exclusion” or not. Total drain outputs were recorded by community district nursing staff for all patients. At the first post-operative visit, the presence and severity of seroma was recorded. Results: 24 patients were included (study group 14, control group 10). Age, size of tumour, and number of positive lymph nodes and laterality were comparable between groups. Mean drain output for the entire group was 471 ml (3 - 1030 ml) over 5.21 days. The control group had a drain output of 763.5 ml (95%CI 674.2 - 852.8) while the study group had a mean drainage of 262.2 ml (95%CI 161.9 - 362.5), a reduction of over 65%, p < 0.001. 15 (62.5%) out of 24 patients developed seroma. 42.9% of the study group and 90% of the control group developed seroma, p < 0.01. Conclusion: Seromas are a common complication following mastectomy and axillary clearance. Our technique of axillary exclusion has resulted in significantly reduced drainage volumes and fewer seromas.

Variation in the schedules of somite and neural development in frogs

The timing of notochord, somite, and neural development was analyzed in the embryos of six different frog species, which have been divided into two groups, according to their developmental speed. Rapid developing species investigated were Xenopus laevis (Pipidae), Engystomops coloradorum, and Engystomops randi (Leiuperidae). The slow developers were Epipedobates machalilla and Epipedobates tricolor (Dendrobatidae) and Gastrotheca riobambae (Hemiphractidae). Blastopore closure, notochord formation, somite development, neural tube closure, and the formation of cranial neural crest cell-streams were detected by light and scanning electron microscopy and by immuno-histochemical detection of somite and neural crest marker proteins. The data were analyzed using event pairing to determine common developmental aspects and their relationship to life-history traits. In embryos of rapidly developing frogs, elongation of the notochord occurred earlier relative to the time point of blastopore closure in comparison with slowly developing species. The development of cranial neural crest cell-streams relative to somite formation is accelerated in rapidly developing frogs, and it is delayed in slowly developing frogs. The timing of neural tube closure seemed to be temporally uncoupled with somite formation. We propose that these changes are achieved through differential timing of developmental modules that begin with the elongation of the notochord during gastrulation in the rapidly developing species. The differences might be related to the necessity of developing a free-living tadpole quickly in rapid developers.

Facial gunshot wound debridement: Debridement of facial soft tissue gunshot wounds

Over the period 1981–1985 the author treated 1486 patients with facial gunshot wounds sustained in combat in Afghanistan. In the last quarter of 20th century, more powerful and destructive weapons such as M-16 rifles, AK-47 and Kalashnikov submachine guns, became available and a new approach to gunshot wound debridement is required. Modern surgeons have little experience in treatment of such wounds because of rare contact with similar pathology. This article is intended to explore modern wound debridement. The management of 502 isolated soft tissue injuries is presented. Existing principles recommend the sparing of damaged tissues. The author's experience was that tissue sparing lead to a high rate of complications (47.6%). Radical primary surgical debridement (RPSD) of wounds was then adopted with radical excision of necrotic non-viable wound margins containing infection to the point of active capillary bleeding and immediate primary wound closure. After radical debridement wound infection and breakdown decreased by a factor of 10. Plastic operations with local and remote soft tissue were made on 14, 7% of the wounded. Only 0.7% patients required discharge from the army due to facial muscle paralysis and/or facial skin impregnation with particles of gunpowder from mine explosions. Gunshot face wound; modern debridement.

Wound Literature Review 2010

Wound Literature Review 2010

Vakuumtherapie bei akuter postoperativer Osteitis

Vacuum-assisted closure is used frequently for the treatment of posttraumatic osteomyelitis of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. However, no objective parameters describe the time point for secondary wound closure. Our thesis was that negative microbiological results from bone specimens can indicate the time for secondary wound closure. Moreover, treatment course and clinical outcome after 3.4 years should be compared to those of other surgical approaches for acute postoperative osteomyelitis from the literature. 43 patients with acute postoperative osteomyelitis of the extremities and the pelvis were treated by serial bone and soft tissue debridements and VAC therapy and analysed prospectively. Debridements were repeated until the wounds were macroscopically free from signs of infection (good granulation/no necrosis). During each revision a bone specimen was taken for microbiological analysis. Number of revisions, bacterial cultures, type of wound closure and recurrence of infection after 3 years and 5 months on average after the last surgery was analysed. 9.8 debridements on average were performed until eradication of infection and secondary wound closure. Despite the absence of macroscopic infection, bacteria were still found in bone samples from 15 of 43 patients. Three biopsies were free of bacteria for the first time right before wound closure, 25 samples had become negative during the treatment. Six recurrences (19.3 %) were noted after 3.4 years on average. Four patients from the group of negative bone biopsies (19 %) and two patients from the group of persisting bacteria before secondary closure (20 %) had a recurrence of infection. In about one third of the bone biopsies bacteria persisted. This bacterial load had no correlation to wound healing and rate of recurrence after over 3 years. In conclusion, microbiological bone samples are not suitable as an indicator for the time point of secondary wound closure. Compared to other treatment options in acute postoperative osteomyelitis from the literature (especially implantation of local antibiotics), no advantage of vacuum-assisted closure could be shown concerning number of debridements and rate of recurrences.

A Recruiting Maneuver Algorithm in Patients with Early Acute Respiratory Distress Syndrome

Objective: to evaluate the efficiency of a recruiting maneuver (RM) and adjustment of positive end-expiratory pressure (PEEP) in patients with early acute respiratory distress syndrome (ARDS). Subjects and methods. The study enrolled 16 patients (14 men and 2 women) aged 46 to 78 years (range 62±5.6 years) with ARDS of various genesis. RM was made, by stepwisely increasing PEEP and inspiratory pressure under the control of dynamic lung compliance and hemodynamic parameters. The values of blood gas composition and hemodynamics were determined during the study. Results. RM caused an increase in oxygenation index (OI) from 153.5±48.3 to 348.5±53.2 mm Hg. Oxygenation values returned to the baseline levels 30—40 min after the PEEP was set at the closure point of +2 cm H2O. If the set PEEP was 8—10 cm H2O higher than the objective, the effect of RM was retained for as long as 24 hours. When RM was performed using the maximum pressure of 50—60 cm H2O, the cardiac index (CI) was lower in all the patients and 30—50% of the baseline values were achieved in all cases, which required the optimization of cardiotonic therapy. The time of this pronounced reduction in cardiac output with RM was not longer than 5 min. After RM, during mechanical ventilation with 18—26 cm H2O PEEP, the CI did not practically differ from the baseline values (3.31±0.41 and 3.37±0.36 l/min/m2, respectively), though the dopamine dose required to maintain normal hemodynamics was somewhat higher (7.5±2.3 and 6.3±2.6 ^g/kg/min). Conclusion. Analysis of the given cases suggests that RM is highly effective in patients at the early stages of acute lung injury. The duration of RM effects may depend on the set PEEP level in individual cases. Setting PEEP at a level of +2—4 cm H2O fails to prevent repeated alveolar derecruitment in a number of patients. In these cases, it is expedient to individually adjust PEEP levels, by taking into account the long-term changes in OI and Cdyn. In this situation, PEEP may be set at a level of +8—10 cm H2O or at the maximum level that causes no hemodynamic disorders. Key words: acute respiratory distress syndrome, recruiting maneuver, alveolar derecruitment, positive end-expiratory pressure.

Vakuumtherapie bei Haut- und Weichgewebsinfektionen der Extremitäten. Nutzen des Wundabstrichs bei der Planung des sekundären Wundverschlusses?

Vacuum-assisted closure is used frequently for the treatment of skin and soft-tissue infections (SSTI) of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. However, no objective parameters describe the time point for secondary wound closure. Our thesis was that negative microbiological results from wound specimens can indicate the time for secondary wound closure. 24 patients with SSTI of the extremities were treated by serial debridements and VAC therapy and analysed prospectively. Debridements were repeated until the wounds were macroscopically free from signs of infection (good granulation/no necrosis). During each revision specimens were taken for microbiological analysis. Moreover, number of revisions, bacterial cultures, type of wound closure and wound status after 3 years and 5 months on average after the last surgery were analysed. 6.3 revisions on average were performed until secondary wound closure was possible. In spite of the absence of macroscopic infection, bacteria were still found in tissue samples from 14 of 24 wounds. 6 wounds were free of bacteria for the first time right before wound closure, 3 wounds had become negative during the treatment. After 3.4 years on average, the wounds of all 18 patients available for examination had healed well and were free from signs of infection. Vacuum-assisted closure resulted in clean, good granulating wounds without necrosis. However, in more than half of the wounds bacteria persisted. This bacterial load had no correlation to wound healing and outcome after over 3 years. In conclusion, microbiological tissue samples are not suitable as indicator for the time point of secondary wound closure in SSTI.

The Timing of Onset of Mechanical Systole and Diastole in Reference to the QRS-T Complex: a Study to Determine Performance Criteria for a Non-Invasive Diastolic Timed Vibration Massage System in Treatment of Potentially Unstable Cardiac Disorders

Our institution is in development of a low frequency, non-invasive Diastolic Timed Vibrator (DTV) for use in emergency treatment of ST Elevation Myocardial Infarction (STEMI). It is preferable to avoid vibration emissions during the IsoVolumetric Contraction Period (IVCP) and at least the majority of mechanical systole thereafter, as systolic vibration may cause a negative inotropic effect in the ischemic heart. Furthermore diastolic vibration should preferably include the IsoVolumetric Relaxation Period (IVRP) which has been shown in clinical studies to improve cardiac performance and enhance coronary flow. Electrocardiographic (ECG) monitoring can be used to enable diastolic tracking, however, the timing of the phases of the cardiac cycle in relation to the ECG waveform must first be verified. The objective of this study was therefore to determine timing of onset of mechanical systole and diastole in reference to the QRS-T Complex. One hundred and twenty-three adult echocardiographic studies were assessed for the point of mitral and aortic valve closure in relation to the QRS complex and T wave in a representative population. We found that onset of mechanical systole occurred on and usually shortly after the peak of a first dominant QRS complex deflection, and onset of diastole occurred at the earliest on and most commonly beyond the peak or midpoint of the T wave. A DTV should ideally be able to stop vibrating on or before the peak of the first dominant deflection of a QRS complex, and begin vibrating near the peak of the T wave. Given early detection of ventricular depolarization can occur 10-20ms prior to R wave peak, it is proposed that a DTV should preferably be able to stop vibrating within 10ms of a triggered stop command. Onset of vibration during peak of T wave could be approximated by a rate adapted Q-T interval regression equation, and then fine tuned by manual adjustment during therapy.

Case Scenario: Perioperative Airway Management of a Patient with Tracheal Stenosis

TRACHEAL stenosis is a rare but a life-threatening condition and is caused by congenital problems, postintubation injury, trauma, tracheal tumor, and compression of the trachea by tumor. Although accurate prevalence of this condition is unknown, an incidence of 4.9 cases per million per year is estimated for postintubation tracheal stenosis. A stenosis commonly occurs at the cuff of the tube (intrathoracic trachea) or at the level of the tracheostomy stoma (extrathoracic trachea). Anesthesia of a patient with tracheal stenosis is challenging for anesthesiologists. Depending on the severity and location of the stenosis and the type of surgical procedure, there may be a variety of choices for perioperative airway management such as a facemask, laryngeal mask airway, an tracheal intubation tube, cardiopulmonary bypass, and extracorporeal membrane oxygenation. The American Society of Anesthesiologists practice guidelines for management of the difficult airway primarily focus airway problems caused at the extrathoracic airway and may not be helpful, particularly for managing patients with intrathoracic tracheal stenosis. In this case scenario, we present a patient with severe intrathoracic tracheal stenosis, who required surgery for a lumbar fracture in the prone position. Various airway management strategies and the actual management used are discussed.