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Design to installation
’Measure twice and cut once’ is perhaps the oldest saying in any design or construction business, the thing is, it is as true today as when the first craftsman said it, probably to a young or inexperienced colleague.
Of course, with the modern CAD processes that we use here at Churchill Interiors, the measurements are always precise, and in this way we can make sure that not only will everything fit where it is supposed to, but that we will be making optimum use of every available millimetre of space.
Our team of fitters are hugely experienced craftsmen that take pride in their work and place their reputation on the line with every pencil mark and detail. It is not enough to make the job look good, it also has to perform well, a beautiful looking door means nothing if the opening action is off.
Do we still stand by ‘measure twice and cut once’?
You bet we do.
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Why not pop into our showroom in Camberley have a tea or coffee and take a look at some of the bedrooms on offer
Home Design Visit
One of our experienced bedroom designers will come and visit you in your home and design your new bedroom
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every upgrade tested • Eurogamer.net
It’s a big, big improvement over PS4 Pro.
Announced several months ago, the next generation upgrade for Marvel’s Avengers lands today and Digital Foundry had the opportunity to check out the campaign element on PlayStation 5 in a near-final build – and the results are impressive. Developer Nixxes delivers a 60fps performance mode with improved graphics compared to PlayStation 4 Pro, upping the ante for the next-gen quality mode, and utilising the new console’s advanced storage capabilities to provide a revelatory improvement in loading times.
Showing is perhaps better than telling, so I’d recommend digging into the video embedded below, but the bottom line is that the performance mode is arguably the best way to play. Just like PS4 Pro, it’s running at 2160p checkerboard with a dynamic resolution window that extends as far as it needs to in order to sustain the crucial 60fps target. Essentially, the more mayhem you unleash, the lower typical resolution is likely to be – expect values in the 1800p range in the heat of the action, dropping to 1440p when all hell truly breaks loose.
Regardless, there are visual improvements on top of the frame-rate boost if you compare the game running up against PS4 Pro’s quality mode. This starts with significantly superior texture assets on PS5, along with a mild boost to texture filtering quality and a more dramatic speed-up in texture streaming. Particle effects and alpha transparencies also operate at a significantly higher resolution up against Pro at its best, which adds a great deal to the look of the game bearing in mind how omni-present these elements are. On top of that, water rendering also gets a significant boost – the flat plane effect on last-gen water is replaced with a proper geometric surface with undulation and deformation on PS5.
A visual breakdown of the PlayStation 5 upgrades for Marvel’s Avengers.
It’s not a complete improvement in all areas though – that’s reserved for the next-gen quality mode. So, shadow quality remains mostly unchanged and post-processing quality on elements such as depth of field and motion blur is also much as it was on PS4 Pro. But the point is that 60 frames per second is promised and aside from some minor blips, that is what is delivered for the most part, with only the most intense destruction seeing any kind of fleeting frame-rate hit during gameplay. Yes, there’s also a performance mode on the last-gen machines, but resolution is low and there’s a sometimes crippling CPU limitation – PlayStation 5 looks good and runs great, certainly in the campaign we tested thoroughly (we’ll return to the online component when it’s up and running).
The quality mode removes checkerboard rendering in favour of native rendering, aiming to deliver a 4K30 presentation, but again, the title leans into dynamic resolution to ensure that frame-rate is rock solid – and it is, as I discovered over hours of play. DRS changes are minimal to the point where an almost unnoticeable 2088p was the lowest pixel count I could find. Beyond switching to native resolution rendering and running with a much tighter DRS window, the quality mode ups shadow quality and filtering significantly, adds screen-space shadows for extra depth and improves the quality of screen-space reflections. View distance improvements are also made; these were subtle where I could spot them, but welcome nonetheless. The final improvement to the quality mode is my favourite: improved destruction effects. Particle effects are improved, debris is more dense and less prone to disappearing into the ether, while physics are applied too. It makes those impressive Hulk rampages even more of an event.
In summary, what we’ve played of Marvel’s Avengers so far on PS5 is impressive – and aside from the huge improvements to both quality and performance modes, the loading times also deserve mention as Nixxes really is tapping into the software APIs here, not just relying on the basic hardware upgrade. In just one example, a four-second load on PlayStation 5 takes one minute and two seconds on PlayStation 4 Pro – an astonishing boost. This is the kind of improvement we really wanted to see and it’s remarkable to see the side-by-sides play out.
We’ve still got to put the online component through its paces, and we’re also keen on examining the new Xbox versions. Our understanding is that native resolution rendering replaces checkerboarding on the Series X performance mode, with the 4K60 target dropping to 4K30 on the quality mode. Meanwhile, on Series S, 1440p30 is the aim for the higher fidelity mode, dropping to 1080p for the 60fps performance alternative. Naturally, expect dynamic resolution scaling to be in play on Xbox systems too, which will be fascinating to stack up against the checkerboard rendering on PS5. We’re also told that Nixxes taps into the new DirectStorage API, so we should also see some impressive loading time improvements on Xbox consoles too. We’ll be looking at the Series versions of the game as soon as we can.
Best Digital Cameras For Beginners 2021: Nikon, Canon, Sony Reviews
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You don’t have to be a professional photographer to want to want to take better quality, well-lit, blur-free photos. Smartphone photography is certainly a convenient way to snap a quick pic on the go, but you’re only limited to certain settings, and they falter when it comes to grainy zoom and fixed shutter speeds.
Want to ditch the Camera app and really boost your photography game? The best beginner digital cameras are not only incredibly versatile, their advanced features and interchangeable lenses allow for easy upgrade swaps once you’re no longer a beginner too.
Don’t settle for cheaper, bulky cameras with no features just because you’re still learning—once you get the basic controls, commands, and settings down, a quality camera will be worth the investment to shoot consistently clear and crisp photos (and video recordings too) long after your skills start picking up.
Whether you’re looking to pick up a new photo hobby, or just want better pictures for Instagram than what you can shoot on your phone, here are our top beginner camera picks for when you’re just starting out.
What Are the Best Digital Cameras For Beginners?
There’s an almost overwhelming amount of choices out there, but we recommend going with DSLRs, mirrorless, or point and shoots. Here’s what else to keep in mind when shopping for a starter digital camera.
Lenses: Some digital cameras will let you switch out lenses, like most DSLRs, so you can get the best picture possible based on your lighting and angle (although standard is 18-35 mm). Others only have a fixed lens which can’t be changed, though they still offer a higher photo and zoom quality than most smartphone cameras.
Ease-of-Use: This will ultimately depend on your goals for what you want to achieve with the camera. But things like Auto-Zoom, built-in flash, touch screen capabilities, and an outward display make all the difference when you’re learning, since you’ll probably still want some automatic settings at first.
Photo and Video Quality: Note how many megapixels your sensor has (though a good lens is just as important for image quality). You may be tempted to spring for 20mp (megapixels) or higher, but even a 15mp sensor is just fine for beginners. If you care more about video, get a camera that can record full HD (1080P) video, or shoot in 4K.
Modes: Just like your smartphone camera probably has settings like “night mode” and “portrait mode”, so too should your digital camera. While you’re adjusting to a wide arrange of adjustments, things like HDR, portrait, night mode, and different resolutions for videography on the touch screen can be helpful tools for creating high-quality images without fiddling around too much.
Mirrorless vs. DSLR: With a mirrorless camera, the light passes right through the lens, so what you see on the viewfinder or the LCD screen is what you get. DSLRs often feature more interchangeable lenses, though both are pretty even in terms of photo accuracy.
1.Panasonic Lumix G85 Mirrorless 4K Digital Camera
This mirrorless camera is a true hybrid, with interchangeable lenses like a DSLR, but with half the bulk. Panasonic Lumix G85 is the perfect transitional camera, with enough features to start shooting light and fast, without too much manual clutter.
The dual image stabilization is a fantastic feature, especially if you’re interested in videography. You can get crystal clear 4K video with a handheld shot, even in the darkest settings.
You’ll be able to shoot in 16mp with a low-pass filter at 30fps, and the photo details are pretty true to life. You can also adjust the focus after you shoot with a handy Post Focus mode, if you’re indecisive.
Reviews say that all the options and settings can feel a little intimidating for newbies, while being bit too limiting for pros. But once you get a hand of the creative controls, anyone can shoot sharp sharp photos and videos with this top choice.
Buy: Panasonic Lumix G85 Digital Camera at $699.99
2. Sony Alpha a6000 Mirrorless Digital Camera
Sony’s Alpha a6000 is super quick on the draw, and can shoot up to 11 photos per second, all in clear 24.2mp detail. It also has one of the fastest autofocus functions we’ve ever seen, so tracking moving objects (like pets, or sports teams) is no problem.
It’s a mirrorless DSLR camera, but it’s fairly compact and easy-to-use, with two quick-access dials that let you change settings on the fly. Despite its small size, you’ll have everything you need to shoot like a pro, with seven customizable buttons that can be assigned up to 474 functions.
But the best way to learn is to experiment with all the settings available, and the variety is unparalleled here. One bonus for beginners is the electronic viewfinder, which lets you display the various camera settings before you take the picture.
Sharing your photos has also never been easier, with WiFi connectivity to the PlayMemories app. You can transfer files fast, and even control the camera’s shutter from your phone.
Buy: Sony Alpha a6000 Mirrorless Camera at $648.00
3. Canon PowerShot G9 X Mark II Digital Camera
We’ve said it before and we’ll say it again, Canon’s PowerShot G9 X Mark II is one of the best point-and-shoot cameras for photographers just getting started.
It has a fast capture (up to 8.2 fps), so you can take advantage of any moment for a great photo. The camera has manual photo settings too, but for newbies, the eight built-in presets, which include effects and photo styles, but the 20.1mp sensor alone works as a solid baseline of high-quality photos to experiment off of.
What we like: it’s Bluetooth-enabled, so you can send your photos over to the Camera Connect App for easy storage. Features like autofocus, time-lapse, and a 3X optical zoom gives you enough to play with that you won’t feel too restricted, though you may grow out of them fast.
One of the benefits to its ultra slim build is that the camera is lightweight, so you can throw it in a bag and take it anywhere with you. Even with a fixed lens, the PowerShot G9 X Mark II is a good choice if you’re looking for a starter camera with just a few quality controls you want to master.
Buy: Canon PowerShot G9 X Mark II Camera at $449.004. Nikon D3500 DSLR Camera
Nikon has been a trusted brand by photographers for decades, and it only makes sense that this D3500 would be the gold standard of digital cameras, a reliable yet infinitely customizable choice for those new to the world of photography.
As easy to use as a point and shoot camera for a DSLR of its kind, it has a crisp 24.3mp sensor, which is 15 times larger than your average smartphone camera.
It syncs to Bluetooth, where you can use Nikon’s SnapBridge app to transfer files, or edit them right in the app. But you should always get an extra SD card to store you photos and videos on, anyways.
We recommend the 18-55mm and a 70-300mm hard kit lenses, which is great for portraits, landscapes, videos and other wide shots. The camera also features 11 different autofocus points across the frame, so you can keep your subject in focus at all times.
This is a camera that knows it’s beginner friendly, and the LCD screen offers a handy “Guide Mode” which gives you on-screen tips on how to get the best shot possible. When you get a hand of the basics, the camera will graduate with you—the specialty effects and exposure modes will give you total control when you know exactly what you want.
Buy: Nikon D3500 DSLR at $595.99
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20 Strong Gen 3 Pokemon That Break The Game (And 10 Who Are Ridiculously Weak)
The introduction to the Pokemon franchise, for many people, began in Gen 3 with Pokemon Ruby and Sapphire. With an exciting new region on new hardware featuring so many new creatures, there was a lot of buzz about these games, and it led to them becoming some of the best-selling games on the Game Boy Advance.
RELATED: The 10 Weakest Hoenn Pokemon, Ranked
While this generation contained several of the most beloved Pokemon of the series, not all of them were equally useful. Many of these species are still considered the best Gen 3 Pokemon and continued to be the best Omega Ruby & Alpha Sapphire options, while others have remained pointless in every game they appear in.
Updated April 4, 2021 by Gene Cole: With so much time having passed the original Hoenn games, we’ve seen tons of Gen 3 Pokemon remain just as powerful in Pokemon Sword & Shield, and many differ from the between the best Pokemon in Ruby, Sapphire, & Emerald compared to the best Pokemon in Omega Ruby and Alpha Sapphire. There are several that can demolish opponents in your Galar adventures, but only a few can crush your opponents especially well in the original and remade Hoenn games.
30 Strong: Breloom
Breloom was a remarkably unique Pokemon compared to other early game Grass-types. It had an excellent move pool and Attack stat to go with its risky Grass and Fighting-type combination, making it an immediate threat on the battlefield. It lacked quite a lot of speed, but it often made up for this by having utility moves like Spore to put foes to sleep with great accuracy.
It’s remained as a powerful option in every Hoenn game, and it’s a sorely missed competitive favorite from Pokemon Sword & Shield since it was one of few Pokemon to learn its highly efficient sleep move. Unless you went with Treeko and already had a Grass-type, Breloom was essentially the perfect Grass-type option early in the game.
29 Strong: Manectric
Manectric is somewhat of an underrated Electric-type among the series, having a somewhat goofy appearance due to its thick lightning-bolt head and an oddly blue body. This has led people to not often be familiar with its stats, which is a shame because it actually has one of the most impressive combinations of Speed and Special Attack in any non-Legendary Pokemon from the Hoenn games.
RELATED: The 10 Best Pure Electric-Type Pokemon
This made it an absolute all-star if your team needed an Electric-type to deal with the later Water-type experts of the game. Manectric is perhaps also one of the best Pokemon in Emerald because of this, as the final champion is replaced by the Water-type pro Wallace and can be destroyed instantly with some fast Electric-type strikes.
28 Weak: Seviper
Pokemon Sapphire really ended up with the short end of the stick when it came to version exclusives, as many of the worst Pokemon in Sapphire are only obtainable in this edition. This is especially evident with Seviper, a thicker version of the Poison-type Arbok with a far stranger stat spread.
It definitely had some solid all-around Attack and Special Defense stats, but most of the moves it learned were far too weak to make a dent in the original game. It got slightly better in Pokemon Alpha Sapphire thanks to a wider variety of Poison-type moves like Venoshock and Poison Jab, but it still never had the speed or defense to make its offense worthwhile.
27 Strong: Zangoose
Pokemon Ruby had a much better selection of version exclusives, with its parallel to Seviper being easily one of the best Normal-types in the game. Zangoose has all the physical offense of Seviper with a significantly higher speed, making it a quick dasher who could inflict Normal and Dark-type moves on opponents before they could make a move.
This Pokemon only got better in Pokemon Omega Ruby, where it had access to a more diverse set of Fighting-type moves and a wider selection of TMs. It’s hardly competitive compared to the strongest Pokemon in the series, but it’ll do a great job dealing with any opponent who isn’t a Rock or Steel-type.
26 Strong: Swampert
Most people will always think to counter Water-type Pokemon with Electric-type Pokemon. Being a Water and Ground-type, though, Swampert is immune to all Electric attacks, giving it a serious advantage in battle that none of the other Hoenn starters have. Since there’s no Grass-type Gym Leader to give it trouble, this means Swampert will almost never encounter a Super Effective attack in any of your playthroughs.
RELATED: Pokémon: 10 Amazing Works Of Gen III Starter Fan Art You Have To See
This dual typing also gives Swampert a range of moves like Surf and Earthquake that can affect multiple Pokemon at a time, which makes it even more useful in the various new Double Battles throughout the Hoenn games. It was arguably the least-used of all the starters, but it still made a splash in the meta.
25 Weak: Delcatty
Fans of cute Pokemon will be disappointed to hear that Ruby and Sapphire aren’t the games for them. There are plenty of cute Pokemon in the Hoenn region, but none of them are particularly useful in battle, and this is especially true of Skitty and its evolution Delcatty.
Despite its Normal typing giving it access to many different moves, Delcatty doesn’t have the stats to support any casual or competitive strategy. Even a Pokemon without a type advantage would be able to get rid of it with a single move, and evolving it requires maximizing its friendship stat, making Delcatty a huge investment with zero payoff.
24 Strong: Sceptile
Where many Grass-type Pokemon were focused on healing and defense in the first few Pokemon games, Sceptile was one of the first ones that prioritized speed and attack. Introducing the Leaf Blade attack to the game, Sceptile became one of the strongest Grass-types in the entire franchise.
Players who went with the other Hoenn starters likely didn’t miss it thanks to other Grass-types like Breloom and Ludicolo, but Sceptile became much more useful when it was given a Mega Evolution that added a Dragon-type. From there, Sceptile’s impressive stats grew absurdly high, and it essentially became the strongest starter Pokemon in Omega Ruby & Alpha Sapphire.
23 Strong: Blaziken
Blaziken is easily the most popular fully-evolved Hoenn starter, and that’s no surprise given just how strong it can be. Having the dual typing of Fire and Fighting-type, along with mixed offensive stats, Blaziken could easily be made into a quick sweeper in both casual and competitive play.
RELATED: Pokemon: 5 Starters That Are Overrated (& 5 That Are Severely Underrated)
Its popularity likely is why it got the first mega evolution of the three starters in Pokemon X & Y, raising its offensive stats even higher and adding a Speed Boost ability to grant it fifty percent more Speed at the end of each turn. It’s remained just as powerful as when it first debuted, and is another sorely missed competitive staple left out of Pokemon Sword & Shield.
22 Weak: Swalot
Swalot has often been labeled a shameless copy of Muk, and it’s appropriately just as worthless as the original ball of sludge. Poison-type Pokemon don’t have a lot of decent coverage and leave themselves open to many more popular type matchups, particularly since they’re weak to the strongest moves in Gen 3 like Earthquake and Psychic.
Furthermore, Swalot doesn’t have any good moves to damage opponents besides Sludge Bomb, which it learns at the late level of 37 in Pokemon Omega Ruby & Alpha Sapphire and the even higher level of 48 in Pokemon Ruby & Sapphire. Simply put, it’s better to just leave this one absent from any team.
21 Strong: Metagross
In each generation, there are pseudo-legendary Pokemon introduced that are often the best choices in the mix. Gen 3 had two of them, one being Metagross. This Steel and Psychic-type has excellent stats, being a champion in both offensive and defensive strategies with a Clear Body ability to avoid any troubling stat changes.
Coupled with great coverage through moves like Meteor Mash and Psychic to give it Super Effective moves against nearly every type of Pokemon, Metagross remains one of the best Pokemon in both casual and competitive play to date. It was made an even more viable pick with its overpowered Mega Evolution in Omega Ruby and Alpha Sapphire, which only gave it higher stats and made up for its concerning number of weaknesses.
20 Strong: Salamence
Alongside Metagross, the other pseudo-legendary Pokemon from Gen 3 is Salamence. This dragon type has all the right stats and moves to make it one of the best picks in the game. It was extremely hard to train, not evolving from a Shelgon until level 55, but extremely worth your time, and it only got stronger with its Mega Evolution in the remakes.
RELATED: Pokémon: The 15 Best Dragon-Type Legendaries, Ranked
Much like Metagross, though, it had a slight downside in that you couldn’t actually obtain one easily before the Elite 4. This meant Salamance was reserved more for the post-game events like the Battle Frontier instead of your main story, but that hasn’t stopped Salamance from being one of the best competitive Dragon-types in the series.
19 Weak: Luvdisc
Luvdisc is one of the most universally-hated Pokemon to date. On top of its slightly awkward-looking (though romantic) design, Luvdisc isn’t useful in combat on any level. There was almost no reason to have one in a team if players wanted to defeat any impressive trainers, let alone using it in a competitive match.
Without any decent stats or access to any good moves, Luvdisc fell through the tiers, leaving it one of the most useless Pokemon in the entire generation. The only reason it was ever useful was to farm Heart Scale items, which could be sold to the Move Relearner to learn old moves, but those have now become free services in Pokemon Sword & Shield and Luvdisc has returned to obscurity.
18 Strong: Milotic
When Milotic was introduced in Ruby and Sapphire, it left quite an impact on the metagame thanks to a terrifyingly balanced set of stats for a pure Water-type. It was one of the bulkier Pokemon in the mix, having the proper stats and abilities to keep it from taking a lot of damage outside of Super Effective attacks.
Furthermore, moves like Recover and Refresh allowed it to stay in battle longer, making it frustrating to take down if you didn’t have enough damage to kill it in one or two fast hits. That said, Milotic became less viable as the series continued, and while it still shows up in competitive play and is great for your runs of any Gen 3 game, there have been several more Pokemon introduced in recent games that can handle it.
17 Strong: Gardevoir
Gardevoir was a decent Pokemon in Ruby and Sapphire, having a nice move pool and decent stats to allow it an advantage against its opponents. However, things changed when it got an additional Fairy-type trait and Mega Evolution in Pokemon X & Y, as it then became an absolute menace that few Psychic or Fairy-type Pokemon could match.
RELATED: 10 Pokémon You Forgot Were Fairy-Type
Some online battling forums ended up banning it due to its utility, having amazing type coverage to deal with the game’s strongest Dragon-type and Dark-type opponents. It seems like just a little change, but it helped this popular Pokemon go from pretty good in the original games to outright overpowered after Gen 6.
16 Weak: Armaldo & Cradily
It’s extremely rare that any Fossil Pokemon is good, but Pokemon Ruby & Sapphire’s pair of fossils may be some of the worst in series history. Armaldo is especially tragic, as this unique Rock and Bug-type had more weaknesses than most other Pokemon and very few worthwhile moves to make up for this vulnerability.
Cradily was only slightly better, but being Rock and Grass-type meant it shared most of the same weaknesses. It managed to be slightly more relevant in competitive play in recent games thanks to interesting hidden abilities and new moves, but both of these similar Pokemon ended up being too slow and unimpactful compared to any other Pokemon of the same type in all of Hoenn.
15 Strong: Altaria
Altaria is a glamorous example of a bird Pokemon, but underneath the surface lies the face of a monster in battle. Much of its power comes in its rare typing, as there are few Dragon-types that are available early in the Hoenn games and it can resist a massive number of common moves among Hoenn’s Gym Leaders.
However, its Mega Evolution gave it a risky Dragon and Fairy dual typing, making it extremely versatile in both moves and coverage. Altaria can function just about any role, but its defensive potential is where it really shines, and maxing its physical defense with Cotton Guard in Omega Ruby & Alpha Sapphire can help you win almost any battle against a physical foe.
14 Strong: Hariyama
Hariyama doesn’t have great defensive stats, but what it lacks in those areas, it more than accommodates with its HP and attack. Hariyama is a mean Pokemon, boasting moves like Fake Out to stall your poisoned or burned opponents and Knock Off to get rid of any pesky berries or items they might be taking advantage of.
RELATED: The 10 Best Pure Fighting-Type Pokemon
Beyond that, it also had a move pool that allowed it to properly counter a lot of Pokemon that would’ve been untouchable otherwise, particularly Fire-types thanks to a good set of Rock and Ground-type options. It’s become irrelevant against more exciting Fighting-types in recent games, but it’s hardly a bad choice in any of the Hoenn games if you don’t have a Blaziken on its way to fill your Fighting-type role.
13 Weak: Masquerain
In a game where better Bug-types exist, there is almost no reason to choose Masquerain. Its typing would be interesting if it had the stats to properly use it, but like most Bug and Flying-type combinations, Masquerain suffers from a shallow movepool and poor stats that result in every attack annihilating it instantly.
Even worse are its offensive stats, which are too low to use anything that would make Masquerain potentially interesting. It has a few surprising rare moves like Hydro Pump at its disposal, but you’re better off using nearly any other Pokemon if you want to make a serious impact on an opponent with stronger Pokemon.
12 Strong: Dusclops
Unlike the past example of a version exclusive, Pokemon Ruby’s Dusclops isn’t that much better than Pokemon Sapphire’s Banette. Both are quite slow and defensive Ghost-type threats that lean more on physical damage stats, which is quite a blessing in the original games since Ghost-type attacks only dealt physical damage.
What puts Dusclops above Banette is its immense defensive stats, which can make it almost impossible to defeat. With moves like Pain Split to restore its health further, it’s remained incredibly dominant in Pokemon Sword & Shield as a competitive tank, and can carry your team in any Hoenn game with just as much ease.
11 Strong: Latios & Latias
While the majority of Gen 3 legendaries have always been restricted to temporary events related to movies or pre-order bonuses, Latios & Latias ended up becoming an automatic inclusion in Pokemon Omega Ruby & Alpha Sapphire. You gain access to one only mid-way through the game, and as a speedy Dragon and Psychic-type Pokemon they can easily outclass nearly every other Pokemon on your team.
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This was an odd choice for the game, as it made things almost unfairly easy by having this effective legendary at no cost to the player. They aren’t necessarily the strongest Pokemon in the game, but it’s clear that these two are the greatest example of Pokemon that can break the game and change how it’s played if you include it in your team.
10 Weak: Mightyena
There were several new Dark-types in Gen 3, most of which were extremely viable, but Mightyena was unfortunately not one of them. While its Intimidate ability was useful in battle, its poor stats hinder it more than enough to make it an easy target for Fighting types, which were numerous and common throughout every Gen 3 game.
Mightyena has never had a lot of options to regain its low maximum health, and even fewer that can deal any serious damage. At best, it can use Roar to force another Pokemon out, but that’s only if it hasn’t been knocked out first, and it’s usually better to just toss it into battle to use Intimidate before swapping it with another ally.
9 Strong: Whiscash
If you wanted an unfair type combination and skipped out on Mudkip as your starter, you might want to consider one another underrated Pokemon from the later oceans of Hoenn. This would be Whiscash, another Water and Ground-type combination to match up with the beloved powerful Swampert.
Whishcash is hardly as powerful in terms of stats, but this type combination means it can still resist all kinds of moves while hitting all opponents in Double Battles with powerful strikes like Surf and Earthquake. It might be the best Pokemon you aren’t including on your team, and could easily make most team combinations impossible to beat.
8 Strong: Flygon
While not as impressive as Salamence, Flygon was more than a viable pick in Ruby and Sapphire. Its Ground and Flying-type combination along with Levitate meant that it was immune to both Ground and Electric attacks, making some NPCs in the game totally unable to deal damage to it.
RELATED: Pokémon: The 10 Deadliest Ground-Types
Outside of regular playthroughs, this easy-to-train Dragon-type was able to counter many popular picks back in the day, having the move pool to properly deal with most common threats like starters. It has decent stats as well, but later Pokemon in the franchise received much better stats and Flygon has significantly fallen in the ranks.
7 Weak: Tropius
Tropius is very possibly the most useless Pokemon to have ever been created in recent years. From its massive size and unusual Grass and Flying-type combination, you’d expect it to be a monstrous threatening dinosaur with a loving exterior, but it ends up just being a pile of weaknesses that couldn’t hurt a fly.
As lovely as that sounds, it leads to an inability to even participate in most battles. Its Speed, defenses, and even maximum health are hardly fitting for its great size, and by the time you encounter Tropius in the wild you’ll have encountered several better Grass-type options.
6 Strong: Absol
Absol was a scary Pokemon in Ruby and Sapphire thanks to its high attack stat, Dark typing, and wide move pool. However, its lack of speed made it sometimes frustrating to use. Still, it was at the top of the meta, and its stylish look made it a fan-favorite for several years. Once it got its own Mega Evolution in Pokemon X & Y, though, Absol was able to run wild.
This boost of stats made it a much more viable choice in Omega Ruby & Alpha Sapphire than it was in the original games, as it had the potential to put up a fight against top physical fighters like Blaziken and Sceptile. When combined with a Super Luck ability in later games to raise its Critical Hit rate, this Pokemon has remained a monster even without this Mega Evolution.
5 Strong: Rayquaza
As a fitting last package of Pokemon, the Gen 3 Legendary Pokemon are some of the best. At the top of the list is Rayquaza. Not only are its stats impressive, but by boasting moves like Extremespeed, and getting a Mega Evolution in Omega Ruby and Alpha Sapphire that creates its own unique weather effect, Rayquaza remains impossibly powerful.
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Unfortunately, only players of Pokemon Emerald are able to use it in their run, as the other Hoenn games only let you catch it after you’ve beaten the Elite 4. Nonetheless, its legacy is still remarkable and its power is unmatched by nearly any other Gen 3 Pokemon.
4 Weak: Exploud
With the huge supply of Normal-types in Gen 3, it made sense that one with a three-evolution chain like Exploud would be strong. However, that couldn’t be further from the truth, as it hardly learns any moves that can use its Special Attack stat and its Speed is low enough to be slower than almost every opponent you’ll encounter.
It can learn lots of new attacks with TMs, but by being a Normal-type it’s not able to use these moves to the fullest extent of its strength. Furthermore, its stats are downright laughable, making it one of the worst Pokemon in Gen 3 and a huge waste of time when you could be grinding starter Pokemon or legendaries.
3 Strong: Groudon
Groudon, another legendary Pokemon from Gen 3, is one of the best Pokemon in the game. It was always an oddity as a Ground-type despite its weather supporting Fire-type moves, but its Primal Form and access to some unique elemental attacks made it significantly more relevant for most players.
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As a result, it was especially best in Pokemon Omega Ruby, but as a physically aggressive tank it could still pull its weight in the original Pokemon Ruby. Building sun teams around its Drought ability also helped make many Fire and Grass-types much more relevant and powerful than they were on their own.
2 Strong: Kyogre
Rayquaza and Groudon are some of the strongest Pokemon in Gen 3, so it comes as no surprise that the immense and menacing Water-type Kyogre is also an impressive pick. Having great coverage with both Water and Ice-type moves, Kyogre becomes one of the best water types in the mix. With its addition of a Primal Form, Kyogre was given Primordial Rain to have a stronger version of rain.
The main reason Kyogre’s remained more powerful than the others is how it matches up against the remaining foes, as it can easily gain Super Effective attacks against most of the Elite 4 and especially Steven. This makes it easily the best Pokemon in Sapphire and Alpha Sapphire, and even in Pokemon Sword & Shield it can often be unmatched.
1 Weak: Plusle & Minun
Plusle and Minun were introduced as the Gen 3 counterparts to Pikachu. Unlike the other quirky Pika-clones, these two were designed to help each other in Double Battles thanks to their Plus and Minus ability. However, it may not surprise you to hear that Pikachu is infinitely more viable in combat than they are.
Plusle and Minun have extremely poor stats, lacking any potential to take a punch or dish anything out. Their abilities give each other a boost, but they only add to their offense and it’s not significant enough to help them stand against any tough opponents. They’ve never received any stronger moves or boosts, simply being left in the PC since their debut.
Next: 10 Strongest Competitive Pokemon In Gen One
Next Dark Souls 3: The 10 Most Unique Weapons In The Game, RankedAbout The Author Joshua Olivieri (195 Articles Published)
I am an entertainment writer with a strong passion for all things gaming. I’m a huge fan of the Nintendo Switch and have poured hours into games like Zelda and Mario Kart.More From Joshua Olivieri
Could Caleb Farley fall out of Round 1 amid health concerns?
Leading up to the 2021 NFL draft, which starts April 29, Yahoo Sports will count down our top 100 overall prospects. We’ll count them down in groups of five for Nos. 100-51, followed by more in-depth reports on our top 50 players, with help from our scouting assistant, Liam Blutman. We reserve the right to make changes to players’ grades and evaluations based on injury updates, pro-day workouts or late-arriving information from NFL teams.
Previous prospect rankings: Nos. 100-96 | 95-91 | 90-86 | 85-81 | 80-76 | 75-71 | 70-66 | 65-61 | 60-56 | 55-51 | 50. OT Liam Eichenberg | 49. WR Terrace Marshall Jr. | 48. LB Chazz Surratt | 47. EDGE Joe Tryon | 46. OT-OG Alex Leatherwood | 45. CB Asante Samuel Jr. | 44. DL Levi Onwuzurike | 43. LB Jabril Cox | 42. DT Daviyon Nixon | 41. EDGE Ronnie Perkins | 40. LB Nick Bolton | 39. CB Ifeatu Melifonwu | 38. WR Elijah Moore | 37. OT Jalen Mayfield | 36. EDGE Carlos Basham Jr. | 35. CB Elijah Molden | 34. RB Travis Etienne | 33. WR Kadarius Toney | 32. EDGE Jayson Oweh | 31. LB Zaven Collins | 30. DT Christian Barmore | 29. QB Mac Jones
Here’s how we use our prospect grades for the 2021 NFL draft. (Albert Corona/Yahoo Sports)
28. Virginia Tech CB Caleb Farley
6-foot-2, 207 pounds
Yahoo Sports draft grade: 6.01 — possible immediate starter
TL;DR scouting report: Press-CB prototype with exciting ball skills and upside whose worrisome medical evaluation clouds his landing spot
Games watched: Notre Dame (2018), Boston College (2019), Notre Dame (2019), Miami (2019), North Carolina (2019)
The skinny: A 4-star Rivals recruit, Farley committed to the Hokies and redshirted during the 2017 season after suffering a knee injury during preseason camp. He’d been working at wide receiver that year (after playing QB in high school) before switching to cornerback in the spring of 2018. That season Farley played in 13 games (starting 12) and made 36 tackles, one sack, two interceptions and seven passes defended. In 2019, he logged 20 tackles, four interceptions (one returned for a TD) and an ACC-best 16 pass breakups despite missing two games with a back injury. Farley opted out of the 2020 season and declared early for the 2021 draft. He didn’t work out at Tech’s pro day after having back surgery three days prior to repair a herniated disc.
Upside: Ideal combination of size and athleticism to fit the modern press-CB prototype. Stands a shade under 6-foot-2, with long arms (33 3/8 inches) and a respectable wingspan (76 1/4 inches). Extremely fast — reportedly was running in the 4.3s for his 40-yard dash training prior to undergoing surgery.
Natural coverage ability is stunning for such a new player to the position. Gets low in his stance and flips hips well. Good recovery speed to handle vertical threats who gain a step on him. Good short-area quickness to adjust to quick stuff underneath. Fluid transitions.
Football instincts have translated from high school QB to lockdown corner. Tracks the ball extremely well. Terrific production (six INTs, 23 PDs in two seasons) in smaller sample size. Allowed only 29 catches and two TDs (on 69 targets) in his final 18 college games.
The 2019 UNC game was a teaching tape in coverage — ran the routes for the receivers, glued himself to them, offered no space to operate and seemingly batted down every ball thrown his way (although he strangely didn’t face off with either of the Tar Heels’ best receivers, Dyami Brown or Dazz Newsome, often in the game).
Virginia Tech CB Caleb Farley looks like an ideal NFL press corner, but his medical evaluation will be crucial. (AP Photo/Lynne Sladky)
Shows a willingness to support the run. Snappy reaction time to click and close on routes once the ball is in the air. Handled matchups nicely against bigger, more physical receivers and could even be tried as a tight end eraser. Experience playing the left (2019) and right (2018) sides extensively. Also lurks as an overhang defender and isn’t out of place close to the box.
Rapid, impressive improvement in a short time — if this is the starting point, he could be great in time with coaching and patience. Has the traits, production and tape to be great in the NFL if the medical evaluation is favorable.
Humble, willing learner. Plays with confidence. Believes every ball has his name on it. Aggressive, alpha corner who has a taste for taking on the toughest matchups. Displayed mental and physical toughness his first two years on campus, losing his mother to cancer, suffering a torn ACL and playing nearly the entire 2018 season through back pain following a preseason weight-lifting injury.
Evaluators have told Yahoo Sports that they are confident that Farley’s decision to opt out was a more-than-reasonable one considering he already lost one parent and was fearful of losing another.
Downside: Concerning injury history — 2017 ACL tear, chronic back spasms in 2019 and multiple back procedures, including a March microdiscectomy that could leave him out for summer workouts and possibly cut into the start of training camp. Compound medical worries could scare off teams.
Opted out in 2020 — no recent tape. Last game was in November 2019 after missing final two games of that season. Very limited experience — only 24 career games and two years’ experience at cornerback over the past four years. Came in 10 pounds below (197) his listed weight of 207 at pro-day measurements. Small hands (8 3/4 inches), although it hasn’t appeared to affect his ability to make plays on the ball.
Tackling concerns remain unanswered. Will take poor angles in run support and fly by tackle attempts — will lunge and lead with shoulder too often. Got better at it in 2019 but remains raw in this area. Wasn’t utilized much as a blitzer despite logging his only career sack in his first college game.
Fits press-man template but wasn’t asked to do it that often in a zone-heavy system. Can mistime his jab and get beaten off the line. Doesn’t harness his great length well enough yet in press. Overaggressive to a fault at times — will squat on routes and get jumpy on double moves. Flagged five times in 2019 — including twice for pass interference vs. Old Dominion.
Still learning the finer points of the position. Doesn’t appear comfortable in zone coverage yet — needs better feel for passing off receivers and handling switches in coverage. Unnatural in his backpedal. Can lose phase on longer-developing routes and get handsy downfield — inklings of panic once in a while.
Notre Dame’s Chase Claypool stressed him more than once in the 2019 outing. Limited special teams experience and utility. Stayed on an island — never asked to follow opponents’ best receivers. Very limited slot experience.
Best-suited destination: Farley’s projection has changed dramatically following his second back procedure. Prior to that, he was viewed as the possible CB1 in this class. Now his status remains up in the air.
If healthy, he likely fits best in a press-man/Cover 3 systems where his length, athleticism and playmaking ability can be weaponized, although his inexperience can’t be overlooked. The team that drafts Farley must be confident in his health as well as patient with his development at a relatively new position.
Did you know: Farley was an all-state dual-threat QB who reportedly ran a sub-4.3 40 in high school.
Player comp: Byron Jones.
Expected draft range: A once no-doubt first-rounder, Farley’s cloudy medical picture could cause him to fall — perhaps similar to Sidney Jones, who slid to the 43rd overall pick in 2017 following an Achilles injury.
More from Yahoo Sports:90,000 Slow economic growth and the threat of new sanctions hinder the development of Russia
Already imposed sanctions and the threat of new ones continue to pose risks to economic growth, Eric Arispe, senior director of the analytical group for sovereign ratings at Fitch, warned on Tuesday. At the same time, the current slowdown in the growth rate of GDP, as well as foreign investment in Russia, is already negatively affecting the country’s rating.
A balanced monetary policy, reduced dependence of the ruble exchange rate and the budget on oil prices allowed Fitch to raise the country’s rating in August from BBB- to BBB with a stable outlook.Another achievement of the Russian authorities is the level of public debt, which remains the lowest among countries with the same rating, analysts of the agency point out and warn that the inflow of foreign investment, on the contrary, is still the lowest among them, and GDP growth is lower than in comparable countries. Russian oil exporters.
In the first half of 2019, the economic growth rates significantly slowed down compared to the same period in 2018 (growth by 0.7% versus 2.3% in the first half of 2018). Domestic demand and business activity remain weak – in June the PMI index dropped to 49.2, however, in July it again surpassed the 50 mark (values above 50 indicate an increase in activity, below – about a decline).
The fundamental weakness of domestic demand is evidenced by a rapid slowdown in inflation, the Ministry of Economic Development pointed out in its forecast of socio-economic development until 2024.From March 2019 to August, inflation slowed down from 5.3% to 4.3% in annual terms, and by the end of 2019 year, according to the forecast of the Ministry of Economic Development, may decrease to 3.8%.
The economy may be supported by an increase in budget spending in the second half of 2019, as well as a recovery in private consumption and external demand, Fitch analysts say.This will ensure economic growth of 1.2% in 2019, they say. In 2020–2022 the economy will accelerate to 1.9%, but GDP is unlikely to grow above 2%. This is significantly below the median forecast for countries with the same BBB rating (3.1%). Structural factors restraining economic growth – the delay in the implementation of investment projects, low growth rates of private investment, as well as a decrease in uncertainty and the role of the state in the economy, Fitch analysts list.
The Ministry of Economic Development also expects that in 2019the economy will grow by a modest 1.3%. But already from 2021, GDP will grow by more than 3% until 2024. Economists surveyed by the Higher School of Economics are not sure about such an acceleration of the economy. Neither the achievement of inflation of 4% and the expected rate cut, nor the implementation of national projects will be able to warm up the economy to rates at least close to 3%, it follows from a survey of 25 economists. Only one of them hopes for 3% GDP growth, and then only in 2024–2025.
Spending funds from the National Welfare Fund (NWF) will also be able to accelerate the economy.In 2020, it can amount to 8.5% of GDP, the Finance Ministry expects. And already in the second half of 2020, the fund’s funds can begin to be invested, the government official noted. “We plan to invest these funds in new projects next year, we are talking about the largest projects,” said First Deputy Prime Minister and Finance Minister Anton Siluanov in September. But how exactly to spend the funds of the NWF – to invest them in foreign assets or in Russian investment projects and in which ones – the authorities have not yet decided.
Uncertainty about the future of the fund’s assets could in itself become a risk, economists warned. Only one of the five possible options for investing this money does not carry economic and inflationary risks, the Central Bank warned in the main directions of monetary policy for 2020-2022: if officials decide to invest in foreign financial instruments, and not in Russian infrastructure projects or loans foreigners for the purchase of Russian goods. In the short term, this may accelerate economic growth, but then it will slow down (if new tied loans do not constantly grow), and in the medium term, growth may turn out to be even lower than now if the volatility of the ruble exchange rate increases.
Fitch analysts do not see such risks in the baseline forecast. The scale of domestic investment funded by the NWF will not lead to a decrease in macroeconomic stability and will not increase the impact of oil price volatility on the economy.
Sanctions risks have now receded into the background and it is not clear exactly when the new wave will take place, but the structural problem of increasing economic growth rates will definitely have to be solved, says Natalia Orlova, chief economist of Alfa-Bank.
It’s not enough just to spend money, you need to spend it efficiently, says Alexandra Suslina from the Economic Expert Group.Really stimulating government spending should lead the economy to a new growth curve, which is higher than the previous one, but so far the growth in spending provides only a short-term recovery, she says. If national projects affect infrastructure, education and medicine, the costs may be effective, argued Oleg Shibanov, director of the Skolkovo-NES financial center. But the economy can be stimulated in a different way, including by reducing the tax burden on business, he says.
Efficient spending is still hampered by the lack of institutions, a high-quality judicial system, protection of property rights, corruption, lack of confidence in the future, Suslina lists.While 71% of entrepreneurs consider the conditions for doing business in Russia unfavorable, every second believes that the situation will only get worse in the next five years, the VTsIOM poll showed in the summer. Businesses are forced to focus on risks, not opportunities, which leads to a narrowing of the planning horizon and the abandonment of the game for a long time, says Suslina.90,000 main threats to Russia in 2021
The coming year is likely to pass with a plus sign for the country’s GDP, but there are still many unknowns in the formula.
In 2020, epidemiology has almost become part of the economy. Such is the current crisis: without taking into account the incidence curve, it will not be possible to correctly predict the change in GDP. The experience of the Spanish flu pandemic in 1918-1919 reminds that the probability of a third wave in the spring is still high, but it can be mitigated by population immunity and mass vaccination.What kind of virus is it? Global financial market in 2021 Finance
What kind of virus is it? Global financial market in 2021
“The Russian economy, whatever the waves of the crisis, will end the first half of the year with a result of 1.5 to 2% of GDP growth,” says Alexander Shirov, director of the Institute for Economic Forecasting of the Russian Academy of Sciences.“The whole drama will unfold in the second half of the year, where, depending on how effective the government policy is, we will be able to see either an acceleration of economic growth up to 3% by the end of the year, or will remain at levels of about 2%.”
Surprises are also possible. In December, stock exchanges crashed when news of a new strain of coronavirus emerged that was spreading 70% faster. These kinds of black swans may still be on the horizon, but they are almost impossible to predict.
Prices in question
If the waves of the virus recede, inflation will become the main macroeconomic intrigue.Tons of liquidity have been printed around the world: the assets of the leading central banks, reflecting the amount of cash injections into the financial sector and the real economy, by November 2020 grew by 41.5% on an annualized basis and reached $ 27.9 trillion. The lion’s share of this money has so far gone to the stock market, but as it returns from lockdowns, it will flow into the consumer sector. The word “stagflation” from the 70s has already returned to economic discourse, but so far – exclusively as a “horror story”. In reality, the US Fed is still proceeding from an inflation forecast of 1.2%, which is even lower than the 2% target.
Russia differs from the rest of the world in this, since in our country inflation already exceeded the targets at the end of 2020, and the president personally drew attention to food prices. Alfa-Bank believes that the government’s policy will already become a disinflationary factor.
“We expect that the government will respond to this situation in 2021 by increasing pressure on producers,” writes Natalia Orlova, chief economist of Alfa-Bank. and faster growth in supply should put disinflationary risks on the agenda. “
The question of inflation is a key issue for the value of money in the country. The Central Bank rate of 4.25% is a historical record for Russia, but the issue of a decrease is paused until April-May. This is not the end of the monetary cycle, but experts are no longer expecting revolutionary changes either. According to experts of the rating agency “National Credit Ratings”, by spring the key rate may be reduced to 4%, but by the end of the year the Central Bank may raise it to 4.5%. Analysts build their forecast based on a scenario in which the ruble remains stable and no tough sanctions have been introduced against Russia.But that’s another unknown in the 2021 equation.Everything goes according to plan? The specter of techno-communism haunts Europe Economy
Everything goes according to plan? The specter of techno-communism haunts Europe
Old New Sanctions
The victory of the Democrats in the US elections has increased nervousness over the sanctions pressure on Russia.Hackers, Belarus, chemical weapons, Nord Stream – there would only be a desire, and there are enough reasons. Nevertheless, for now, experts assess the risk of extremely strict restrictions as insignificant.
“For Russia, the most significant sanctions are on the market as a whole – the secondary Eurobond market or the primary or secondary OFZ market,” says Sofya Donets, economist at Renaissance Capital for Russia and the CIS. “We estimate the likelihood of such sanctions being introduced at about 5 % and do not consider this a baseline scenario, although in this case we see the possibility of the ruble weakening against the US dollar by 15-25%. “
On the other hand, there is also a long-term effect of the sanctions, which is pointed out by Denis Sokolov, Head of Research and Analytics for Eastern Europe at Cushman & Wakefield. “Calibrated sanctions, perhaps, do not strike at the moment, but they deprive us of the future,” the expert believes. “Here is an example in our real estate: without sanctions, the annual market volume was 7-8 billion euros, and under sanctions – 3 billion euros. , that is, more than half of the market “took out.” And this is money not received by developers, low asset valuation, decrease in multipliers, and so on. “
In addition to sanctions, the determining factors for the ruble may be oil prices, as well as the recovery of outbound tourism. In 2020, the closure of the borders helped Russia to reduce the demand for foreign currency in the amount of $ 30 billion. If it returns, for the trade balance it will be equivalent to a decrease in the oil price by $ 10 per barrel, calculated in Alfa-Bank.
It is worth keeping an eye on bank balances as well. In 2020, Russia was able to partially compensate for the fall in the extractive sectors with growth in the financial sector.However, in 2021, it is banks that may be the source of the main risks, according to the World Bank. The fact is that so far, for the financial sector, there have been concessions in relation to loan reserves for individuals and small or medium-sized businesses. But by July 1, 2021, these reserves should be formed in full.
“Thus, a more realistic picture of the impact on the banking system will begin to emerge only towards the middle of the year,” the bank’s survey says. “Retail lending, which experienced double-digit growth in 2018-2019, could become another hotbed of vulnerability, as household incomes are falling, unemployment is rising, and affected citizens are applying for credit vacations and loan restructuring. “
The mortgage market is already giving the first SOS signals. The Central Bank estimated the increase in overdue debt in May-October by the Central Bank at 5%, describing it as “significant” and calling it “an indicator of potential risks.”
On the other hand, the government’s reserves cannot but inspire optimism. Gold and foreign exchange reserves cover 30 months of our imports, and the reserves of the NWF will suffice for at least 12 years of cheap oil.
Already the state banks have to patch up the holes in 2021 – it should definitely be enough.Georgy Vermishev All articles of the author
January 29, 2021 06:49 am 3826
Select the fragment with the error text and press Ctrl + Enter90,000 Alfa-Bank economist saw the threat of rising unemployment – Frank RG
Large companies will cut costs, which will negatively affect household income and unemployment ratephoto: pxhere
Russian retail trade turnover decreased by 19.2% YoY in May, which came as no surprise given the continued quarantine measures.Growth in nominal wages by 1% y / y in April and unemployment at 6.1% in May were better than expected; this supports our surprise at the decision of the Central Bank of the Russian Federation to cut the rate at once by 100 bp. The possibility of a pause in the cycle of rate cuts, which is now indicated by the Central Bank, and the strong ruble exchange rate leave large Russian companies in a state of high uncertainty, which may force them to focus on cutting costs in 2H20.
Retail turnover declined 19.2% YoY in May, in line with our expectations for a 19% YoY decline .Retail turnover fell 19.2% YoY in May, below market expectations (-17% YoY), but in line with our expectations for a 19% YoY decline. The figure for May indicates some recovery amid a 23.2% y / y drop in April, but the dip remained deep due to the continued quarantine in Moscow and several regions in May.
Passenger car sales declined 52% y / y in May, which remains in line with the 72% y / y decline in April. Another important observation in terms of retail trade turnover is related to the fact that during the quarantine period, the share of food in the total food and non-food consumer basket jumped to 55% in May against an average of 48% in 2019 – it is difficult to say whether this was a shift in the direction of food is a temporary phenomenon or indicates an increase in poverty.
The dynamics of wages in April and unemployment at 6.1% in May were a positive surprise for . The released statistics on consumption is positive not only because the scale of the recession coincided with our expectations, but also because the unemployment rate for May turned out to be better than our forecast. Although we did not rule out that this indicator could grow to 6.5-7%, since the number of officially registered unemployed continues to increase by 0.7 million per month, in fact Rosstat reported that unemployment was only 6.1% y / y – this is a very low rate compared to 13% in the United States.
Another positive surprise is related to the fact that nominal wages in April continued to grow by 1% y / y, which led to a decrease in real wages by only 2% y / y. Overall, the impression is that income dynamics are in line with our expectations of a 5% YoY decline in real disposable income in 2020, which, in our view, is a positive sign.
Industrial production in May fell by 9.6% y / y, despite the growth of budget expenditures by 26% y / y .The decline in industrial production deepened compared to the 6.6% y / y decline in April, which came as a negative surprise. We believe that the weak May result is mainly due to the new OPEC + agreement to cut production, which resulted in a 13.5% YoY decrease in mining production in May, compared with a 3.2% decline. in April.
Statistics on the topic
Mortgage debts of the population in the regions of RussiaIn the manufacturing sector, output fell by 7.2% y / y in May against a 10% y / y decline in April.On the other hand, the recession deepened amid accelerated growth in federal budget spending to 26% y / y in 5M20 from 24% y / y in 4M20, which is a bad sign. In addition, electricity consumption is also giving a bad signal, which declines by 6% y / y in June versus a decline of 5% y / y in May and 3% y / y in April, which indicates a possible deepening of the industrial downturn in this sector. month.
Cost optimization by large companies is the main risk for Russia in 2H20 . According to the Ministry of Economic Development, Russian GDP fell by 10.9% y / y in May after falling by 12% y / y in April.This indicates that GDP will decline by about 9% YoY in 2Q20, which is broadly in line with our estimate of the impact of two months of quarantine. However, 2H20 horizons now look worse than we originally expected. This is due to the fact that, firstly, hopes for additional stimulation from the authorities have disappeared: the Central Bank pointed out to the market a possible pause in the rate cut cycle last Friday.
Besides, the ruble exchange rate turned out to be much stronger in comparison with what we expected for the summer.In addition, concerns about the outbreak of a second wave of the pandemic are growing in the markets and in the real sector. As a result, we fear that the high level of uncertainty will force large companies to optimize costs, which will put additional pressure on household incomes and unemployment in 2H20. While at the beginning of the pandemic, it was mainly SMEs that were at risk, now we do not exclude that the economic recovery may be delayed due to the fact that large corporations will pay increased attention to reducing costs.
Author – Chief Economist of Alfa-Bank Natalia Orlova
The text is published with the permission of the copyright holder
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Laboratory diagnostics of the threat of atherosclerosis
The information in this section cannot be used for self-diagnosis and self-medication. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For a diagnosis and correct prescription of treatment, you should contact your doctor.Atherosclerosis is a chronic disease characterized by specific lesions of elastic and muscular-elastic arteries.In their walls, the proliferation of connective tissue occurs in combination with lipid (fatty) infiltration of the inner membrane. This leads to organ and general circulatory disorders. Atherosclerosis is the main disease of the cardiovascular system, which is the cause of angina pectoris (angina pectoris), myocardial infarction, stroke and death.
It is a mistake to think that this disease is for the elderly. Alas, more and more often atherosclerosis affects young people and even children. It is difficult to treat severe atherosclerosis.But, unfortunately, its symptoms often appear only when atherosclerotic plaques have already affected the coronary vessels of the heart and brain, arteries of the kidneys, pancreas and sensory organs.
The leading factor in the pathogenesis of atherosclerosis is metabolic disorders of lipoproteins (proteins associated with fats). Disorders of their metabolism are called dyslipoproteinemia (DLP). Their identification and detailed analysis are the basis for laboratory diagnosis of early “preclinical” stages of atherosclerotic lesions.The detection of even small violations of lipoprotein metabolism is an indication for research and other laboratory and physiological parameters.
Accurate diagnosis of DLP is based on the determination of a number of biochemical parameters, such as triglycerides, cholesterol, HDL cholesterol, LDL cholesterol. In the INVITRO form, they are deciphered under the corresponding numbers. thirty, 31, 32, 33
It is very important that not all lipoproteins contribute to the development of atherosclerosis.Some of them, the so-called high-density lipoproteins (HDL), have anti-atherosclerotic effects. It is the ratio of various indicators included in the system of lipid (fat) metabolism that makes it possible to predict the danger of atherosclerosis development and choose the best methods for its prevention and treatment.
DLP can be hereditary. But their significant part depends on the influence of many factors of lifestyle, diet, and other diseases. It should be remembered that the type of hyperlipoproteinemia (HLP) in a patient can change from one type to another under the influence of diet, changes in body weight and treatment.
According to the classification of the World Health Organization (WHO), 5 types of HLP are distinguished: I, IIa, IIb, III, IV, V, which are distinguished by a violation of the metabolism of certain lipoproteins. In practice, the doctor often has to meet with types IIa, IIb, IV, which are considered in more detail.
Type II: hyper-b-lipoproteinemia
Hyper-b-lipoproteinemia (synonyms: familial hypercholesterolemia, multiple lumpy xanthoma) is divided into two subtypes IIa and IIb.
Hyperlipoproteinemia IIa is characterized by an increased content of LDL (b-LP) with a normal content of very low density lipoproteins (VLDL) – pre-b-LP. It is caused by slowing down the metabolism of LDL and the elimination of cholesterol from the body. It is manifested by early atherosclerosis (coronary sclerosis, myocardial infarction), xanthomatosis, coagulopathy.
The content of cholesterol (CS) in blood plasma in patients reaches 13.0 mmol / l.
It is relatively common.Its secondary form can be caused by an excess of fats (cholesterol) in the diet, hypothyroidism, liver diseases, nephrotic syndrome, hypercalcemia, porphyria.
Hyperlipoproteinemia IIb is characterized by an increased content of LDL and VLDL. The diagnosis is made when an increased content of cholesterol, triglycerides, b- and pre-b-LP, reduced glucose tolerance is found. May accompany diabetes mellitus and liver disease as a secondary form.
Type IV: hyper-pre-b-lipoproteinemia (synonyms: familial essential hyperlipemia, carbohydrate-induced lipemia).It is characterized by an increased level of VLDL (pre-b-LP) with normal or reduced LDL levels and the absence of chylomicrons. Differs in hyperinsulinism and an excess of carbohydrates in the diet, causing intensive synthesis of triglycerides in the liver. It is common, manifested by atherosclerosis of the coronary and peripheral vessels, decreased glucose tolerance and hyperuricemia. Eruptive xanthomas are formed when the TG content in the blood is more than 17.0 mmol / l, they are easily absorbed when the TG level is normalized.
Hyperlipemia is often associated with diabetes. As a secondary form, it accompanies glycogenosis, gout, alcoholism, Cushing’s syndrome, pituitary hypofunction, diabetes, pancreatitis, lipid digestion disorders. It is diagnosed by laboratory with an increased content of pre-b-lipoproteins and triglycerides, the content of b-lipoproteins is not changed or reduced.
Other types of DLP should, of course, be investigated, especially the following:
Hyper-b-lipoproteinemia (synonym: hyper-alpha cholesterolemia).
It is characterized by an increased content of HDL with a normal content of the remaining fractions of LP and is found among individuals with normal blood lipids. This is a variant of a favorable ratio of lipoprotein fractions of blood in terms of the development of atherosclerosis and life expectancy.
Hypo-b-lipoproteinemia (synonym: hypoalpha-cholesterolemia).
It is characterized by a low content of HDL with a normal concentration of the remaining fractions of LP.An unfavorable decrease in HDL cholesterol is an increased risk factor for the development of atherosclerosis and coronary heart disease, independent of other lipid parameters.
Table 1 presents the main characteristics of the most common hyperlipidemias.
|GPL type||Cholesterol||Triglycerides||The severity of atherosclerosis||Clinic|
|IIa||++++||Norm, + or ++||Pronounced and occurs early||Ischemic heart disease, corneal dystrophy (early)|
|IIb||++++||Pronounced and occurs early||Ischemic heart disease|
|IV||Norm or +||+++||Common in adults||
Hepato- and splenomegaly,
diabetes, pancreatitis, ischemic heart disease,
peripheral vascular disease
To assess the risk of developing atherosclerosis based on the determination of total cholesterol and beta-lipoprotein cholesterol, the cholesterol coefficient of atherogenicity proposed by A.N. Klimov according to the formula:
|Cholesterol total – HDL cholesterol|
|K (coefficient) =||————————————————–|
This coefficient in newborns is “ideal”: it is equal to 1.In healthy women under the age of 30, it is approximately 2.2, and in men 2.5. After 40 years in healthy people it does not exceed 3.5, and in people with manifestations of coronary heart disease or other manifestations of atherosclerosis (see table) it exceeds 4, often reaching 5, 6 and higher.
Thus, laboratory studies of the main indicators of lipid metabolism (especially in combination with indicators of carbohydrate metabolism and liver function) make it possible to determine the degree of risk of developing atherosclerosis, coronary heart disease and outline ways of prevention and therapy.
See also: Cholesterol, Cholesterol – HDL, Cholesterol – LDL, Triglycerides.
The information in this section cannot be used for self-diagnosis and self-medication.In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For a diagnosis and correct prescription of treatment, you should contact your doctor.
The beta subunit of human chorionic gonadotropin (beta-hCG)
The beta subunit of human chorionic gonadotropin is one of the subunits of a specific hormone molecule – chorionic gonadotropin, which is formed in the membrane of the human embryo.The analysis is carried out in order to diagnose pregnancy early, identify its complications and diagnose diseases associated with impaired hCG secretion.
Beta subunit of HG.
Human Chorionic Gonadotropin, hCG, b-HCG, Quantitative hCG; Beta hCG, Total hCG, Total beta hCG.
Electrochemiluminescence immunoassay (ECLIA).
Detection range: 0.1 – 1,000,000 IU / L.
IU / L (international unit per liter).
Which biomaterial can be used for research?
How to properly prepare for the study?
- Do not smoke within 30 minutes prior to examination.
General information about the study
Human chorionic gonadotropin (hCG) is a hormone that is produced in the fetal membrane of the human embryo.It is an important indicator of the development of pregnancy and its deviations. It is produced by the cells of the chorion (shell of the embryo) immediately after it is attached to the wall of the uterus (this happens only a few days after fertilization). The embryo at this stage of pregnancy is a microscopic fluid-filled vesicle, the walls of which are composed of rapidly multiplying cells. From one part of these cells, the unborn child (embryoblast) develops, while from the cells outside the embryo, the trophoblast is formed – that part of the ovum, with the help of which it attaches to the wall of the uterus.Subsequently, a chorion is formed from the trophoblast.
Chorion performs the function of feeding the embryo, being an intermediary between the body of the mother and the child. In addition, it produces chorionic gonadotropin, which, on the one hand, affects the formation of the child, on the other hand, it affects the mother’s body in a specific way, ensuring the successful course of pregnancy. The appearance of this hormone in the body of the expectant mother at the initial stage of pregnancy explains the importance of the test for early diagnosis of pregnancy.
Chorionic gonadotropin stimulates the secretory function of the corpus luteum of the ovaries, which should produce the hormone progesterone, which maintains the normal state of the inner lining of the uterine wall – the endometrium. The endometrium provides reliable attachment of the ovum to the mother’s body and its nutrition with all the necessary substances.
Due to a sufficient amount of chorionic gonadotropin, the corpus luteum, which normally exists for only about 2 weeks during each menstrual cycle, with a successful conception does not undergo resorption and remains functionally active throughout the entire period of pregnancy.Moreover, it is in pregnant women under the influence of chorionic gonadotropin that it produces very large amounts of progesterone. In addition, hCG stimulates the production of estrogens and weak androgens by ovarian cells and promotes the development of the functional activity of the chorion itself, and later the placenta, which is formed as a result of the maturation and proliferation of chorionic tissue, improving its own nutrition and increasing the number of chorionic villi.
Thus, the role of chorionic gonadotropin consists in a specific and multifaceted effect on the body of a woman and a fetus in order to achieve a successful pregnancy.Based on the analysis for chorionic gonadotropin, the presence of chorionic tissue in a woman’s body is determined, and hence pregnancy.
In terms of chemical structure, chorionic gonadotropin is a combination of protein and complex carbohydrates, consisting of two parts (subunits): alpha and beta. The alpha subunit of chorionic gonadotropin is completely identical to the alpha subunits of luteinizing, follicle-stimulating and thyroid-stimulating hormones of the pituitary gland, which perform functions that are largely similar to that of chorionic gonadotropin, but not during pregnancy.The beta subunit of chorionic gonadotropin is unique, which, on the one hand, determines the specificity of its action, and on the other hand, makes it possible to identify it in biological media. In this regard, this test is called “beta-subunit of human chorionic gonadotropin (beta-hCG)”.
Knowing the level of beta-hCG in the blood, it is possible to diagnose pregnancy already on the 6-8th day after conception (in the urine, the concentration of beta-hCG reaches the diagnostic level 1-2 days later). Normally, during pregnancy, between the 2nd and 5th weeks, the amount of beta-hCG doubles every 1.5 days.With multiple pregnancies, it increases in proportion to the number of fetuses. The hCG level reaches a maximum at 10-11 weeks, and then gradually decreases. This is due to the fact that from the beginning of the 2nd third of pregnancy, the placenta is able to independently produce enough estrogens and progesterone, with the participation of which the endometrium functions normally regardless of the secretion of hormones in the corpus luteum of the ovaries. At the same time, the concentration of CG in the blood of a pregnant woman gradually decreases, and the corpus luteum can function without the influence of CG.During this period, the role of the hormone is to stimulate the production of testosterone in the fetus, which is necessary for the normal development of the external genital organs of the embryo.
Thus, during pregnancy, the level of beta-hCG in the blood first increases and then decreases. By this indicator, one can judge the successful course of pregnancy and identify fetal developmental disorders. The HCG blood test is the most reliable method for determining early pregnancy. CG appears in a woman’s body from 6-8 days after fertilization.A common rapid pregnancy test that every woman can use at home is also based on the measurement of hCG in the urine.
Levels of the hormone below normal at various stages of fetal development suggest an ectopic pregnancy, a delay in fetal development, the threat of spontaneous abortion, missed pregnancy, or failure of placenta function. The reason for the increased content of beta-hCG can be toxicosis, diabetes mellitus, or an incorrectly established pregnancy period.A high hormone level after a mini-abortion indicates a progressive pregnancy.
Determination of the level of hCG is included in a triple test study, according to the results of which it is possible to judge about some anomalies in the development of the fetus, but an accurate diagnosis cannot be made. The study only allows a woman to be attributed to a risk group for this pathology. In this case, further examination is necessary. In non-pregnant women, hCG is normally absent, but it can be secreted by some abnormal tissues originating from the chorion (cystic drift, chorionepithelioma) and some other tumors.
What is the research used for?
- For the diagnosis of pregnancy, including multiple, ectopic and non-developing.
- For monitoring the course of pregnancy.
- To identify delays in the development of the fetus, the threat of spontaneous abortion, failure of the placenta.
- For the diagnosis of amenorrhea.
- To monitor the effectiveness of induced abortion.
- As part of a comprehensive examination to identify fetal malformations.
- For diagnostics of tumors producing hCG.
When is the study scheduled?
- If you suspect pregnancy, in particular multiple pregnancy.
- When monitoring the course of pregnancy.
- When there is an assumption of a complication during pregnancy: delayed fetal development, the threat of spontaneous abortion, undeveloped or ectopic pregnancy, chronic insufficiency of the placenta function.
- If necessary, confirm successful induced abortion.
- With a comprehensive examination to identify fetal malformations.
- When finding out the reason for the absence of menstruation (amenorrhea).
- When is the diagnosis of HCG-producing tumors carried out.
What do the results mean?
Week of pregnancy (since conception)
Less than 5 IU / L
5.8 – 71.2 IU / L
9.5 – 750 IU / L
217 – 7138 IU / L
158 – 31795 IU / L
3697 – 163563 IU / L
32065 – 149571 IU / L
63803 – 151410 IU / L
46509 – 186977 IU / L
27832 – 210612 IU / L
13950 – 62530 IU / L
12039 – 70971 IU / L
9040 – 56451 IU / L
8175 – 55868 IU / L
8099 – 58176 IU / L
Less than 5 IU / L
Reasons for an increase in beta-hCG levels
If there is no pregnancy, the beta-hCG test result must be negative.The detection of beta-hCG suggests that at least 5-6 days have passed since fertilization. Between the 2nd and 5th weeks of pregnancy, in its normal course, the level of beta-hCG doubles every 1.5 days and soon reaches its maximum. Then it starts to descend slowly. The results of the analysis are compared with the indicators of the norm for each stage of pregnancy. For a correct interpretation of the results, it is necessary to know exactly when conception occurred.
In pregnant women:
- multiple pregnancies (the indicator increases in proportion to the number of fetuses),
- prolonged pregnancy,
- maternal diabetes mellitus,
- fetal malformations,
- intake of synthetic hormones.
Not in pregnant women:
- tumors producing hCG,
- surgical abortion (first 4-5 days after the procedure),
- taking hCG drugs.
Reasons for a decrease in the level of beta-hCG (during pregnancy):
- ectopic or non-developing pregnancy,
- fetal growth retardation,
- threat of spontaneous abortion,
- chronic placental insufficiency,
- fetal death (in the 2-3rd trimester of pregnancy).
What can influence the result?
- When diagnosing pregnancy, performing the test too early — less than 5 days after conception — can lead to a false negative result.
Who orders the study?
General practitioner, obstetrician-gynecologist, oncologist.
- Handbook of Clinical Laboratory Testing During Pregnancy, edited by Ann M.Gronowski. Springer-Verlag LLC, New York, 2004
- Prenatal Diagnosis in Obstetric Practice. M. J. J. Whittle, Blackwell Publishers 1995
- Endocrinology of Pregnancy. Fuller W. Bazer, Humana Press 1998
- Blood Biochemistry. N J Russell, G M Powell, J G Jones, P J, Winterburn and J M Basford, Croom Helm, London and Canberra, 1982
- Blood Chemistry and CBC analysis-Clinical Laboratory Testing from a Functional Perspective.Rychard Weatherby N.D and Scott Fergusson, N.D., Bear Mounting Publishing, 2002
- Tietz Clinical Guide to Laboratory Tests. Alan H. B. Wu, Saunders / Elsevier, 2006
- Laboratory and Diagnostic Tests. Joyce LeFever Kee – Pearson, Prentice Hall, 8th Edition 2010
- District Laboratory Practice in Tropical Countries. Monica Cheesbrough, Cambridge University Press, second edition, 2005
- Clinical Chemistry. A Laboratory Perspective.Wendy L. Arneson, Jean M. Brickell, F. A. Davis Company, 2007
- Clinical Chemistry. Michael L. Bishop, Edward P. Fody, Larry E. Schoef, Lippincott Williams & Wilkins 2005
Climactic threat: vitamin D will reduce stress and prolong fertility | Articles
Russian doctors have created a new method for correcting the negative manifestations of menopause in women. First of all, this concerns the prevention and correction of psychoemotional disorders. Scientists have conducted animal studies that have shown that the combination of hormone therapy with individualized dosages of vitamin D3 significantly reduces depression and anxiety, as well as other negative manifestations of menopause, but this requires individually selected high doses.Also, according to indications, such therapy was carried out to a number of women with especially severe problems – it turned out that new combination therapy can prolong the period of fertility.
Not a sad age
Climax is a long period in a woman’s life associated with the gradual cessation of ovarian estrogen production and the completion of reproductive function. Its onset occurs after the age of 50. Pathological manifestations of menopause negatively affect the professional activities of women, their social activity and interpersonal relationships, which affects the quality of life.For many, menopause occurs with a whole complex of vegetative-vascular, mental and metabolic-endocrine disorders. Such problems are observed in 30-60% of women.
Scientists of the Institute of Physiology named after I.P. Pavlova RAS, with the support of the Russian Science Foundation, are developing a new method for correcting negative manifestations of menopause. First of all, this concerns the prevention and correction of psychoemotional disorders. As the leading researcher of the laboratory of neuroendocrinology of the Institute of Physiology named after I.P. Pavlova Yulia Fedotova, during the research, scientists have established a relationship between low levels of vitamin D3 (cholecalciferol) in the body and a predisposition to the onset and development of affective disorders in women during menopause.
Photo: Global Look Press / imago-images / Julia Pfeifer
– Studies have shown that the level of vitamin D3 in women can be one of the predictors of the development of anxiety-depressive disorders during the initial stage of menopause.At the same time, the prevention of a deficiency of this substance can play a leading role in preventing the development of psychopathologies, the specialist explained.
From 2016 to 2018, scientists performed two parts of the study: preclinical (on animals) and clinical (on volunteers). Now the work continues.
Case in the dose
Previously, all doses and treatment methods were worked out on rats . The experiment involved females of different ages: young (2.5-3 months), middle-aged (12-14 months) and old (16-18 months).They recreated an experimental model of menopause: the animals had their ovaries removed, and then they waited three months for hormone levels to roughly match those of menopause in women. Then, all three groups of rats of different age were injected with vitamin D3 in three different doses: low, medium and high. The vitamin was administered alone or in combination with a low dose of the hormone estradiol (similar to hormone therapy in women).
In some cases it was possible to achieve a strong antidepressant effect, and in some it did not work at all.That is, it turned out that therapy with vitamin D3 is effective only in the case of an individual approach, taking into account age and hormonal status.
Photo: TASS / Petr Kovalev
Then the scientists conducted clinical trials on women of different ages, including those who had menopause ahead of schedule (33 years). Clinical studies have confirmed the effectiveness of the combined use of hormone therapy in combination with vitamin D3 in different doses, depending on the age of the patients.
– In parallel, we found that the appointment of vitamin D3 helps restore hormonal levels in young women with premature menopause, thereby increasing the likelihood of conceiving a child in conditions of depleted ovaries , – noted Yulia Fedotova. – It can be used in preparation for in vitro fertilization.
Reception under supervision
Scientists have prescribed an algorithm for choosing drug doses and treatment tactics for different age groups.The authors of the work emphasize that the main thing in such therapy is compliance with dosages depending on the woman’s age and her hormonal background.
Director of the Institute of Biology and Biomedicine at Lobachevsky University Maria Vedunova told Izvestia that the role of vitamin D in the functioning of the body, especially the female, both in the reproductive and age aspects, is extremely difficult to overestimate.
– Vitamin D is a necessary participant in the synthesis of female hormones, especially estrogens. For a long time in clinical practice, there have been approaches that actively use vitamin D to correct hormonal and age-related changes in the female body. This therapy was not always effective, most likely, this was due to the difficulty of controlling the absorption of vitamin , she noted.
Photo: TASS / YAY
Vadim Tseilikman, director of the SUSU Higher Medical and Biological School (a university that participates in the 5-100 project), is confident that the proposed therapy can be effective.
– Undoubtedly, Professor Fedotova’s research deserves attention and support. At present, the attention of researchers in various countries is drawn to vitamin D as a promising antidepressant . Its biological effect is not limited to bone tissue, he said. – In many internal organs there are receptors for the vitamin, and its biological action is similar to that of hormones. These properties served as the basis for studies of its effect on behavioral activity.
Previously, scientists from the United States conducted a major study in which they showed that daily intake of 400 IU of vitamin D (as recommended by the US Institute of Medicine) in combination with 1 mg of calcium does not reduce the risk of depression. At the same time, the authors note that in order to determine whether the vitamin may be useful in prevention and treatment in specific populations, more studies are required using higher doses. This was done by Russian scientists, who confirmed that much higher dosages are required for women in menopause.However, the vitamin should be used under the supervision of the attending physician, and in case of normalization of its level, a break should be taken between courses to avoid an overdose.
Historically established technological paradigm of mechanical ventilation as a threat to national security
The coronavirus pandemic has shown the critical vulnerability of national health systems to the risk of respiratory disasters.
Respiratory disaster – the sudden appearance of a large number of victims with respiratory failure due to biological, chemical or radiation damage.
The COVID-19 pandemic is not the first nor the last respiratory disaster:
- 50s polio pandemic
- UnionCarbide chemical plant accident in Bhopal, 1984
- Chernobyl accident (mass radiation pneumonitis), 1986
- hostage-taking at the Moscow theater center on Dubrovka, 2002
- SARS (SARS, mortality up to 50%), 2003
- Middle East respiratory syndrome (MERS, mortality up to 50%), 2012-2019
Similarly, today the COVID-19 pandemic has led to a massive appearance of patients with respiratory failure and the need for mechanical ventilation (ALV).Up to 31% of hospitalized patients diagnosed with COVID-19 need mechanical ventilation, and among those who are admitted to intensive care units – from 47 to 71% [1, 2]. Hence the shortage of ventilators and personnel, which de facto demanded to suspend planned care and re-profile many hospitals specializing in high-tech care for the treatment of COVID-19. At the same time, with a high degree of probability, many of the surviving patients will face the problem of “weaning” from the ventilator and will need respiratory rehabilitation or long-term respiratory support.
However, COVID-19 is far from the first case of such a respiratory disaster. Poliomyelitis pandemic in the 50s of the last century, hostage-taking at the Moscow Theater Center on Dubrovka in 2002, SARS outbreak in 2003, h2N1 influenza pandemic in 2009 – even people far from medicine remember these cases a sudden increase in the need for mechanical ventilation.
It seems that the risk and social cost of such tragic accidents will increase as urbanization, urban expansion, the construction of huge office, shopping and entertainment complexes and the development of the transportation system.The risk of wars and terrorist attacks using biological, chemical and nuclear weapons cannot be ruled out. Finally, these are “breakthroughs” into the human population of dangerous infectious agents. Thus, cases of human infection with the “bird flu” H7N9 are regularly recorded. If we proceed from the available data on the mortality rate of this disease (up to 38%), then in the event of its epidemic spread, the COVID-19 pandemic will be remembered as an insignificant incident .
How prepared is our civilization for this threat? Today, the mobilization potential of mechanical ventilation is critically low, even in developed countries, which obviously dooms a significant (if not most) part of the sick and injured to death.A recent study by the Johns Hopkins Center for Health Security showed that even if the resources of ventilators (including anesthesia equipment and strategic reserves) are fully mobilized, the United States is not able to guarantee mechanical ventilation even for 0.5% of the population . What about the staff? A simulation of the need for mechanical ventilation in the USA in 2005 in the event of a large-scale epidemic of h2N1 influenza showed that the shortage of qualified specialists will outstrip the shortage of devices . It seems that the results of this study can, with certain assumptions, be extrapolated to the COVID-19 pandemic.
Therefore, both in order to confront the COVID-19 pandemic now and in future cases of a sudden mass appearance of patients with a therapeutic profile (affected by infectious, chemical or radiation agents) with respiratory failure, a mechanical ventilation method is required with the following set of characteristics.
A) High level of patient safety.
B) Efficacy for the treatment of respiratory failure in this disease.
B) Low risk of personnel contamination.
D) Minimum stress and deprivation of patients. E) The minimum period of “weaning” is
patients from the device.
E) Affordability: low cost of the device and minimal operating costs for mechanical ventilation.
G) Taking into account the scarcity of resources in any catastrophe, the highest cost-utility indicator (Cost / QALY).
H) Mobilization potential: the possibility of creating significant strategic reserves, the rapid organization of mass production of equipment and personnel training, the use of the method in ordinary wards by personnel without special training.
I) In case of mass admission of patients, the method should not turn into a critical limitation (“bottleneck”)
health care systems, limiting the provision of medical care to other categories of patients.
K) Mobilization costs should bring maximum benefit after the end of a respiratory disaster: the ability to use the method for respiratory rehabilitation and long-term support of surviving patients, including at home.
Alas, this method cannot be recognized as a conventional ventilation technology using the positive pressure ventilation (PPV) method, which, within the framework of the historically established ventilation paradigm, replaced the older NPV (negative pressure ventilation) method.Unlike normal breathing and NPV (where air passively moves into the lungs following an increase in chest volume), PPV works on the “antiphysiological” principle of actively blowing breathing gas into the lungs under pressure.
With undeniable advantages in surgery, PPV has brought tremendous advances in surgical technology. However, with regard to therapeutic (including infectious) patients with acute and chronic respiratory failure, the PPV method has serious medical, economic, mobilization and ethical disadvantages.In the context of the COVID-19 pandemic, the following are the most significant.
A) Harm and low safety of long-term PPV for patients . The pathological physiology of PPV is the reason that it is a method of mechanical ventilation that is harmful to the health of patients and is dangerous with a large number of complications, which causes damage to the patient’s body, which is directly proportional to the duration of use. If PPV lasts more than 5 days, then the predicted mortality increases by 50% regardless of the diagnosis and ventilation mode .For those who survived after long-term PPV, the prognosis of long-term survival and delayed mortality is unfavorable: the proportion of those who die within the first year after discharge reaches 55% .
“Antiphysiological” PPV mode, on the one hand, affects the lungs themselves: deterioration of the drainage function of the tracheobronchial tree, decreased production and activity of surfactant, impaired water exchange and local immunity, ventilator-induced lung injury, ventilator-associated pneumonia, barotrauma, volumotrauma, atelectasis [8, 9].On the other hand, the negative extrapulmonary effects of the PPV method on blood circulation, liver, kidneys, hemostasis, immunity, gastrointestinal tract, endocrine and nervous systems are well known . The pathogenetic mechanisms of PPV extrapulmonary effects are multicomponent and mediated.
The most significant for the treatment of patients with COVID-19 is the fact that mechanical ventilation itself causes the release of cytokines from the lungs (tumor necrosis factor, IL-1, IL-8, etc.), which enter the systemic circulation, damaging other organs and tissues [11-13], thereby intensifying the “cytokine storm”, which today is given a leading role in the pathogenesis of COVID-19 .
B) Low efficacy (possibly harmful) of invasive PPV in the treatment of respiratory failure in patients with COVID-19. The use of invasive PPV for the treatment of covid patients has resulted in very high (up to 78% and more) mortality , giving doctors the impression that this method is more harmful than beneficial. Hence the recommendation to avoid invasive PPV while treating COVID-19 or to delay its use as much as possible using mask ventilation and other forms of non-invasive respiratory support [16-18].However, 90,085 masked PPV is impossible for 20-30% of patients for various reasons [22, 23]. At the same time, it seems that, by protecting the lungs from damage to PPV, refusal from mechanical ventilation or postponement of this method in the event of severe hypoxia threatens severe or irreversible damage to other organs and tissues (“vicious circle”).
Available data suggest that high mortality is the result of an unfavorable synergy between the specificity of COVID-19 and the pathological physiology of PPV: atypical lung disease  is exacerbated by ventilation injury from the ventilator, and the “cytokine storm” of COVID-19 is enhanced by the extrapulmonary effects of PPV. the release of cytokines and damage to internal organs.
B) PPV increases the risk of COVID-19 infection of personnel. PPV invasive ventilation requires tracheal intubation or tracheostomy, open airway debridement, and periodic service depressurization of the breathing circuit. These are manipulations with a high risk of infection with COVID-19 [20, 21], which make the work of workers in intensive care units (ICU) similar to the work of sappers in a minefield, require protective equipment and a number of techniques that reduce the risk of infection, limiting labor productivity and increasing sanitary (including irrecoverable) personnel losses.
D) PPV inflicts psychological trauma on patients already in a state of severe situational stress . Respiratory failure, the emergency nature of hospitalization and the conditions of stay in the intensive care room (high noise level, movement and conversations of people, painful manipulations, often – the deterioration of the condition of neighbors and their death) are in themselves a difficult test for the patient. Stress is increased when a patient is transferred to non-invasive PPV (using a mask), which causes severe discomfort, claustrophobia and panic in many patients.Including for psychological reasons, 20–30% of patients with acute respiratory failure cannot use the PPV mask method [22, 23]. In turn, invasive PPV (through an endotracheal tube or tracheostomy) requires deprivation of patients and inflicts severe mental trauma on them: the inability to communicate with others, the realization of one’s helplessness, dependence and loneliness, often multiple experiences of one’s own impending death .
E) PPV requires prolonged “weaning from the apparatus.” PPV suppresses the natural mechanisms of respiration regulation, requires the use of sedatives, often drug coma and artificial muscle paralysis. Therefore, long-term PPV requires a complex process of “weaning from the apparatus” of those who survived. For this, in developed countries, special “weaning” centers are being created, which release expensive technological facilities and ICU personnel from convalescents . There are no such centers in Russia, and ICU doctors are engaged in “weaning from the apparatus” in parallel with their main work.Under normal conditions, this reduces the efficiency of the ICU, and under conditions of mass admission of patients, it exacerbates the shortage of resources and threatens complications due to the accelerated “weaning from the apparatus” of those who are not yet ready for spontaneous breathing.
E) PPV is an expensive method with low financial availability. A natural consequence of the pathological physiology of PPV, its danger and risks is the high cost of mechanical ventilation based on this method. On the one hand, this is expensive equipment, on average from $ 20,000 to $ 45,000.USA for one device. On the other hand, there is a high level of costs for maintenance, consumables and depreciation of fixed assets. Modern PPV requires a large number of disposable medical devices, specialized rooms supplied with medical gases, vital signs monitoring devices and other expensive equipment. Finally, these are the colossal costs of skilled labor required to control complex and dangerous technology, to care for immobilized patients, to prevent pressure ulcers and contractures, and to treat mechanical ventilation complications.Therefore, the main contribution to the variable costs of PPV in the United States is made by the labor of sisters: in this country it is accepted
nurse-patient ratio on extended ventilation is 1: 1, in other developed countries this ratio ranges between 1: 1 and 1: 2 . As a result, patients who require more than 7 days of mechanical ventilation make up, on average, about 10% of the total number of ICU patients, consuming up to 40% of ICU resources . In 2005, in the United States, patients on long-term mechanical ventilation ranked third in total inpatient costs and first in diagnostic costs per patient .
G) Low cost-benefit PPV in the context of the COVID-19 pandemic. There is no available information on attempts to assess the cost-effectiveness of mechanical ventilation for patients with COVID-19. However, the high mortality rate when PPV is used to treat COVID-19 patients suggests a low Cost / QALY. Therefore, in the event of a long-term pandemic, the total costs of mechanical ventilation using the PPV method may turn out to be unaffordable even for developed countries with their low efficiency in terms of the number of lives saved.
H) Mobilization potential of PPV seems to be critically low even for developed countries [39, 41]. On the one hand, this is due to the high price of PPV equipment and the specifics of its production. PPV devices for long-term ventilation are complex (on average 1.5 thousand parts) devices, the reliability requirements of which are comparable to those of the aerospace industry. Therefore, their manufacture requires large-scale investments, a high production culture, a strong scientific base, well-trained personnel and suppliers with guaranteed reliability.If there are no such competencies in the country, attempts to quickly establish mass production of such devices are associated with a high risk of accidents.
On the other hand, an increase in the park of PPV devices automatically requires an increase in the area of specially equipped premises and the number of qualified personnel. In conditions of time pressure, the problem of premises can only be solved by re-profiling hospitals, reducing the availability of care for patients with “ordinary” diseases, which we see today in Russia.In turn, the long process of training qualified employees to work with PPV obviously loses the rate of growth of the car park – all the more taking into account contamination, sanitary losses, layoffs, official movements and natural retirement of personnel.
I) In case of mass admission of patients with respiratory failure, PPV turns mechanical ventilation into a critical technological limitation of the health care system, and in the event of a respiratory epidemic, it threatens to destabilize society as a whole. The COVID-19 pandemic has allowed the public to see the high technological vulnerability of national health systems due to PPV. Medical, economic and mobilization shortcomings of this method in conditions of mass admission of patients with respiratory failure lead to a shortage of ventilators, catastrophic overload and an increasing shortage of personnel, forced triage of patients to “promising” and “unpromising” and blocking the intensive care service – a key link in the provision of modern medical care.Hence the drop in the availability of care for both COVID-19 patients and patients with “ordinary” diseases, who, moreover, are forced to postpone seeking medical attention because of the fear of not getting help in case of infection and because of the low efficiency of mechanical ventilation in case of respiratory failure. This fear spreads to the entire society, destroying its economy and institutions.
K) Low potential to use mobilization costs for PPV after the end of the pandemic. Having spent colossal resources on the purchase of a huge number of expensive and, as it turned out, ineffective for the treatment of COVID-19 PPV devices, national health systems doom themselves to the problem: what to do with the grown fleet of these devices after the pandemic? It is impossible to use PPV devices for respiratory rehabilitation outside intensive care units – in ordinary wards and at home.Therefore, with a high degree of probability, a significant part of this park will be utilized, and the colossal costs of its creation will be written off, increasing poverty in society.
Thus, PPV technology, which is ideally suited for surgery, does not meet any of the criteria that must be met by a mechanical ventilation method for situations of mass emergence of patients with respiratory failure of a therapeutic profile – infected with an infection, poisoned by chemical agents or affected by radiation sickness.
However, the historically established technological paradigm of mechanical ventilation provides that there is no alternative to PPV, postulating it by a conventional method, which should be used in all cases of respiratory failure, regardless of the patient profile. The natural result of this paradigm in the context of the COVID-19 pandemic is, on the one hand, the paralysis of national health systems and an increase in mortality from preventable causes from both coronavirus infection and common diseases. On the other hand, this is an ineffective use of colossal resources and a threat to the stability of both the health care system and other social institutions and the economy.It seems that if the pandemic turns out to be prolonged, then the persistent maintenance of the course towards no alternative to PPV may indirectly lead to difficult-to-predict consequences for society.
The way out is seen in a new paradigm of respiratory therapy, built on a balanced (each case has its own method) complementary use of two methods, both PPV and the now half-forgotten ventilation technology using negative pressure – NPV, negative pressure ventilation, “Iron Lung”. Each of these methods has strengths and weaknesses that have different implications for different patient groups.
Unlike “antiphysiological” PPV (which causes an abnormal increase in intrathoracic pressure during inspiration), the mechanics of ventilation in NPV mimics the physiology of normal breathing. The essence of this technology is placing the patient’s chest or his entire body (except for the head) in a sealed reservoir (there are various options: “tank”, “cuirass”, “fan jacket”), in which an external pump creates a vacuum. The resulting negative pressure causes expansion of the chest and a decrease in pleural and alveolar pressures, creating a pressure gradient for air that moves from the airways to the alveoli.After the pressure in the reservoir increases and becomes atmospheric or higher, exhalation occurs passively due to the elastic response of the respiratory system. Negative pressure is created by bellows or rotary pumps, which are controlled by a microprocessor and provide specified modes of pressure change. After “exhalation”, the pumps maintain a set value of subatmospheric pressure around the chest wall, preventing collapse of the lungs. As in PPV, tidal volume during NPV is a complex function of the applied (this time negative) pressure and its rate of approach to target pressure, available inspiratory time and breathing resistance with end-expiratory positive internal pressure – PEEP .
Thus, NPV, like PPV, solves the problem of reducing the oxygen price of respiration and improves gas exchange – but at the same time does not require tracheal intubation and medical coma, retains the patient’s consciousness and activity, and is devoid of the damaging effect of PPV on the lungs and its extrapulmonary negative effects (Fig. one).
Modern modifications of NPV devices allow the use of five modes: intermittent negative pressure, alternating negative / positive pressure, continuous negative pressure (CNEP), mode with negative end-pressure expiratory pressure and high-frequency ventilation.At “standard” intermittent negative pressure, the NPV generates a target subatmospheric pressure for the selected inspiratory time. The pressure around the chest becomes atmospheric during exhalation, which occurs passively due to the elastic response of the respiratory system. By alternating negative and positive pressures, the device generates a predetermined extrathoracic subatmospheric pressure during inspiration and a predetermined extrathoracic positive pressure during expiration. This combination has been found to increase tidal volume more than intermittent negative pressure, decreasing end-expiratory volume of the respiratory system.In addition, this mode helps the patient to cough in case of profuse sputum production. With continuous negative pressure, the ventilator maintains a constant sub-atmospheric pressure throughout the breathing cycle and the patient breathes spontaneously. In negative expiratory end pressure mode, the ventilator generates a predetermined subatmospheric pressure during inspiration and maintains a predetermined negative pressure throughout expiration. Finally, high-frequency ventilation according to the NPV method is possible with the so-called “cuirass” version of the apparatus, allowing oscillations to be applied to the baseline of negative pressure .
The “physiological” nature of NPV determined the advantages of this method for patients with a therapeutic profile with preserved consciousness. The relevance of its benefits in the context of the COVID-19 pandemic is beyond doubt.
A) High level of NPV safety and minimum number of complications. The experience of using NPV has shown that this method does not threaten the lungs and has little effect on other organs and systems of the body; therefore, unlike PPV, it can be safely used for long-term mechanical ventilation even for many decades [27–33].
B) There is evidence to suggest that NPV may improve respiratory outcomes in COVID-19 patients. A number of studies report a higher efficacy of NPV in the treatment of acute and chronic respiratory failure compared to PPV [34–38]. Moreover, there are data that inspire restrained optimism regarding the use of NPV in the case of acute respiratory distress syndrome (ARDS) [39–45], including in combination with PPV . When used in pediatrics, NPV is not inferior to PPV in its effectiveness in the treatment of “hyaline membrane disease”  – diffuse damage to the alveoli with the formation of hyaline membranes also occurs in COVID-19 .Available data suggest that the use of NPV may improve treatment outcomes for respiratory failure in COVID-19, enabling early transfer of patients with respiratory failure to mechanical ventilation, avoiding both severe hypoxia and ventilation damage to the lungs and extrapulmonary effects of ventilation associated with the release of cytokines. …
NEGATIVE PRESSURE VENTILATION (NPV)
Lungs “suck in” air through open airways
The walls of the chest and abdomen collapse naturally and air escapes through the free airways
Fig.1. Schematic diagram of the device NPV
B) NPV is a non-invasive technology that can reduce the risk of personnel infection.
NPV preserves the consciousness of patients, their inhalation and exhalation are carried out in a natural way, the ability to cough is preserved. Therefore, in the majority of conscious patients, this method, as a rule, does not require tracheal intubation, tracheostomy and open airway sanation – situations with the maximum risk of personnel infection [20, 21].This makes it possible to count on a reduction in the risk of infection for personnel when using NPV, all the more taking into account the possibility of “mechanical” breathing of patients through a regularly changed protective mask.
D) NPV technology is humane, minimizes psychological stress, spares the psyche and personality of patients. NPV does not require a ventilation mask, tracheal intubation, medical coma and artificial myoplegia. Patients remain conscious, they can communicate with relatives on the phone and help staff with care.The ethical benefits of NPV enable many
patients to adapt to the conditions of mechanical ventilation, even if it continues for many decades or for life [48–50].
E) NPV allows you to shorten the duration of mechanical ventilation and facilitate “weaning from the device”.
The data indicate that in the treatment of acute and chronic respiratory failure in therapeutic patients, the use of NPV reduces the duration of mechanical ventilation (including “weaning from the apparatus”) compared with PPV . There is encouraging information on the combined use of these methods: the use of NPV for accelerated weaning after prolonged PPV .
E) NPV is a relatively inexpensive method. Cost reduction is due, on the one hand, to the simple design and the minimum number of moving parts of NPV devices – hence their low price, reliability, long service life, simplicity and low cost of repair and maintenance. On the other hand, NPV allows mechanical ventilation outside of expensive ICUs in regular wards by non-specialized personnel or at home. At the same time, a high level of safety of the method, preservation of consciousness in patients and their active assistance during care can reduce the workload on staff and / or increase their service standards.
G) The medical and economic characteristics of NPV make it possible to count on an increase in the cost-benefit indicator of mechanical ventilation in the context of the COVID-19 pandemic. Given the high cost of conventional PPV and its low efficacy for the treatment of COVID-19, the low price of NPV makes it possible to expect an increase in Cost / QALY, even if this method does not meet expectations in terms of effectiveness. The utility rate will grow and due to the fact that the NPV method will take over some of the victims of a respiratory catastrophe) – thereby freeing up the resources of the “invasive” PPV to help “ordinary” patients, thereby reducing mortality from other diseases.
H) High mobilization potential of NPV.
The experience of the poliomyelitis pandemic has shown that the production of simple NPV devices can be quickly organized even in fairly simple technological conditions. At the same time, the ability to use this method by non-specialized personnel in ordinary wards and at home by the forces of relatives removes the need to automatically increase specially prepared rooms and the number of qualified ventilators in accordance with the growth of the ventilator fleet.The relatively low price of NPV devices makes it possible to significantly increase the mobilization reserves of ventilators in case of military conflicts, disasters and emergencies, to provide assistance in rural areas and outside settlements.
I) If the pandemic turns out to be prolonged, the use of NPV seems to be the only real opportunity to restore the health system, blocked by the technological limitations of PPV. It seems that simplicity of technology, low price of devices, the ability to quickly organize their mass domestic production and conduct mechanical ventilation in ordinary wards by non-specialized employees will help to quickly overcome the shortage of mechanical ventilation.
K) There are already large groups of consumers to use the NPV fleet after a pandemic. After the end of the COVID-19 pandemic, the NPV machine fleet can be used as it was used after the polio pandemic – to solve the problem of prolonged (including life-long) ventilation at home in patients with central and peripheral respiratory disorders, as well as for patients with chronic obstructive pulmonary disease (COPD) . For Russia, this problem is extremely urgent.With the “catching up” development of NPV, we should expect the expansion of the use of this method in general medical practice, primarily in patients with a therapeutic profile.
Thus, the proven and perceived benefits of NPV allow us to expect that this method can make an important contribution to the fight against the COVID-19 pandemic and its consequences (especially if the course of the pandemic proves to be prolonged and vaccines are ineffective) and will create reserves of mechanical ventilation for future respiratory disasters. – tab.
Why was this simple, safe, humane and well-proven technology with excellent medical and economic characteristics and great mobilization potential removed from wide medical practice? How did the current paradigm of mechanical ventilation come about, which postulated that there was no alternative to PPV?
NPV technology flourished in the middle of the twentieth century, when the polio pandemic required the organization of extended mechanical ventilation for tens of thousands of children and adolescents who (temporarily or permanently) lost the ability to breathe independently.To save them, in the shortest possible time, mass production of relatively inexpensive, easy-to-use, safe and reliable devices NPV (“iron lungs”) was launched, which could even be serviced by relatives of patients without medical education. These devices could work without medical oxygen and even with a power outage – in this case, a mechanical drive was provided. Thanks to the simplicity, safety and effectiveness of NPV, a huge number of non-respiratory polio victims have been able to live and work for many decades.
NPV technology dominated up to
in the mid-70s, when it was ousted from clinical practice by the “explosive” development of surgery, in which PPV has unconditional advantages, and in some cases (for example, in operations on the chest), it really has no alternative. It is important to take into account that, unlike therapy (where prolonged ventilation is more common), surgery usually involves short-term use of PPV – anesthesia during surgery and prolonged ventilation in the early postoperative period.
Comparison of medico-economic, mobilization and ethical qualities of PPV and NPV technologies in the choice of a mechanical ventilation method for rendering assistance in conditions of a respiratory catastrophe during the rational period.In other words, in surgery, the harm of PPV is usually negligible compared to the value of the surgical treatment. On the contrary, NPV is practically impossible to use in surgery: its size is inconvenient for the operating room, lack of access to the chest and abdomen, inability to ventilate under conditions of pneumothorax, etc. In addition, due to the technological underdevelopment of NPV in the middle of the twentieth century. perhaps the erroneous conclusion was made about the low effectiveness of this method in the case of “hard lung syndrome” – ARDS, which often complicates the course of illness and injury.In this condition, the lungs lose their elasticity and do not “stretch” well following the expansion of the chest – from which it was concluded that PPV air injection is more effective than “iron lungs” in the case of ARDS.
|Proven efficacy for the treatment of respiratory distress||+||+|
|Reducing the risk of personnel contamination||–||+|
|Patient safety, low risk of complications||–||+|
|A short period of “weaning from the device” and / or the possibility of continuing ventilation in a normal ward or at home||–||+|
Economic and mobilization criteria
|Low cost of the device and low operating costs for mechanical ventilation||–||+|
|The ability to create significant stocks of devices, their mass production and rapid training of personnel||–||+|
|Possibility of operation in ordinary wards without medical gases by unqualified personnel||–||+|
|With a massive admission of victims, the method does not turn into a critical limitation of the provision of assistance||–||+|
|High potential for usefulness in the mobilization costs of mechanical ventilation after a disaster: use at home and in hospices||–||+|
|Preservation of consciousness, the possibility of communication with doctors, communication and psychological support of relatives||–||+|
|Low level of deprivation and fear of patients||–||+|
|Reducing the risk of triage of patients on “promising” and “unpromising”||–||+|
It seems that due to some of these reasons, the NPV method was pushed to the sidelines of medical practice, and resources for its development were practically not allocated.As a result, NPV technologies are now far behind PPV in developed countries. Its use is currently limited to a small number of medical centers. The main area of application today is acute and chronic respiratory failure in COPD, acute hypercapnic respiratory failure, outpatient care for central and peripheral breathing disorders. NPV is also successfully used in patients with acute respiratory failure, in whom a face mask cannot be used due to facial anatomy, claustrophobia or excessive secretions in the airways, as well as in pediatrics, including after cardiac surgery .Scientific articles and reviews devoted to this method are regularly published, companies that serially produce this equipment, for example, Hayek Medical (https://www.hayekmedical.com) and Dima Italia (https://www.dimaitalia.com) (Fig. 2, 3).
Fig. 2. Negavent modern negative pressure ventilator – Pegaso Vent connected to a Gore-Tex® poncho respirator (manufactured by Dima Italia)
Source: https: // www.dimaitalia.com/en/5363/
Fig. 3. Modern “cuirass” ventilator of negative pressure Hayek RTX (manufactured by Hayek Medical)
In our country, the NPV method is unfamiliar to doctors. Thanks to the cooperation of the Soviet virologist M. Chumakov and the American scientist A. Seibin, the Soviet Union escaped the polio epidemic and did not face the need for mechanical ventilation for a huge number of patients, the development of mechanical ventilation in the USSR (and then in Russia) almost immediately went within the framework of PPV technology, and about Russian doctors today know the NPV method only by hearsay, treating it as an anachronism.
In the context of the COVID-19 pandemic, interest in NPV is growing in developed countries. On the one hand, this is due to the low efficiency (possibly even harm) of the PPV method in the treatment of COVID-19, which led to high mortality . On the other hand, this is the discovery of the atypical nature of ARDS in this disease. It turned out that in this disease, the affected lungs remain soft, retaining almost normal elasticity  – this has removed the objections of those who consider NPV ineffective in ARDS.As a result, the official websites of NPV device manufacturers inform about the loading of orders and queues, as well as start initiatives aimed at restoring the production of previously released models (for example, the release by HESS SERVICES of a modern replica of a full-size version of “iron lungs”) and the “catch-up” development of this technology (fig. 4). For example, this is the British project Exovent (official website www.exovent.info), which involves a number of researchers, practitioners, the National Health Service, the Marshall Aerospace and Defense Group and the University of Warwick.In April, a prototype of the lightweight mobile (weighing about 4 kg) NPV EXOVENT apparatus was created, and in May its clinical trials began, which is financed by the Stephen Hawking Family Foundation. EXOVENT developers do not oppose NPV to PPV devices, seeing its place in a single technological chain of respiratory support. The stated goal of the EXOVENT project is not to make a profit, but to make the new device widely available in all countries of the world at affordable prices to combat both COVID-19 and other diseases requiring respiratory support (Fig.five). To do this, the project is looking for partners (influential persons, doctors, engineers and manufacturers) in each country, ready to provide them with medical and technical information for the development and certification of local versions of the NPV apparatus, assistance in organizing production using local materials and equipment and creating conditions for innovation …
Thus, there is reason to believe that the medical, economic, ethical, mobilization and production advantages of NPV technology can be useful to Russia both during the pandemic and after its completion, in the long term.For this, it is necessary to change the paradigm of respiratory therapy, which provides for the uncontested use of the PPV method, even where the benefits of NPV have long been proven.
It is not necessary to oppose PPV and NPV, one should see in them not alternative, but complementary methods of ventilation in a single technological chain of respiratory therapy. Each of these methods has advantages, disadvantages and a range of possibilities that can be used in their combined use.However, today NPV lags far behind PPV in its development: the number of publications on NPV is negligible in comparison with the potential of research, knowledge, technological solutions and innovations accumulated by PPV. Relatively speaking, if PPV today is a supercar, then NPV, due to its oblivion, has largely remained at the level of a steam engine. Therefore, the first step towards a new paradigm is to stop seeing NPV as an anachronism and provide this technology with an accelerated “catching up” development: to fund scientific research on this direction, create pilot production and conduct clinical trials, including (taking into account the lack of our own specialists) using the available foreign experience.
Fig. 4. Modern replica of full-size “iron lungs”, April 2020, manufactured by Hess Services, Inc. (USA)
Source: https: //www.ksn.com/news/health/coronavirus/coronavirus-in-kansas/one-kansas-company-isswitching-gea …
Fig. 5. EXOVENT prototype, May 2020, UK
Source: https: // twitter.com / exovent1 / status / 1258803188708278272? s = 20
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