Naso-pharyngeal discharge as the first symptom of COVID-19 infection is presented in two cases . Appropriate diagnosis and isolation of the patients who may be at risk for covid-19 such as these cases help reduce further transmission.

The incidence of mechanical complications of acute coronary syndromes (ACS) needing cardiac surgery has reduced significantly in the last years due to early diagnosis and treatments. Covid-19 pandemic, however, would generate in the patients a sense of fear regarding access to the ERs so they probably underestimate symptoms such as chest pain or angina equivalents until situation does not became critical. In this way, this behaviour could create a vast pool of patients who will enter the hospital in much more critical situations and with mechanical complications of an evolving ACS needing cardiac surgery treatment.

A global coronavirus (COVID-19) pandemic occurred at the start of 2020 and is already responsible for more than 74,000 deaths worldwide, just over 100 years after the influenza pandemic of 1918. At the center of the crisis is the highly infectious and deadly SARS-CoV-2, which has altered everything from individual daily lives to the global economy and our collective consciousness. Aside from the pulmonary manifestations of disease, there are likely to be several electrophysiologic (EP) sequelae of COVID-19 infection and its treatment, due to consequences of myocarditis and the use of QT-prolonging drugs. Most crucially, the surge in COVID-19 positive patients that have already overwhelmed the New York City hospital system requires conservation of hospital resources including personal protective equipment (PPE), reassignment of personnel, and reorganization of institutions, including the EP laboratory. In this proposal, we detail the specific protocol changes that our EP department has adopted during the COVID-19 pandemic, including performance of only urgent/emergent procedures, afterhours/7-day per week laboratory operation, single attending-only cases to preserve PPE, appropriate use of PPE, telemedicine and video chat follow-up appointments, and daily conferences to collectively manage the clinical and ethical dilemmas to come. We discuss also discuss how we perform EP procedures on presumed COVID positive and COVID tested positive patients in order to highlight issues that others in the EP community may soon face in their own institution as the virus continues to spread nationally and internationally.

As the World Health Organization denies COVID 19 being airborne in nature, there is some research done by the scientific community which differs in this approach. As prevention is always better than cure, it is always safe to give the benefit of doubt to prevention. Even as more data begins to be available regarding COVID, there is proven spread of airborne disease like tuberculosis being transmitted by this route. As the summer months approach, there will be increased use of Air Conditioners in the tropical regions of the world. India, too being in this part of the world sees an active rise in the indoors which are being air conditioned to meet the thermal comfort requirements of the rising urban population which is spending a large chunk of time indoors. This is coupled with the enforced lockdown which encourages people to stay indoors to prevent the spread of infection. In such situations the use of Split air conditioner requires rethinking as they re-circulate the indoor air without any Fresh air supply into the room. To reduce heat gain and save the electric load of the Split AC, people tend to seal the windows further. This requires some rethought by professionals.

This paper provides information and links to resources that address the public and private sector surface transportation impacts of Covid-19.

As the novel coronavirus (Covid-19) globally spreads, the Covid-19 pandemic is straining healthcare workers worldwide. In hospitalized patients with severe Covid-19, endotracheal intubation is one of the most common and indispensable life-saving interventions. For patients in need of long-term endotracheal intubation, tracheostomy may be considered. Some patients with unfavorable neck anatomy, such as short neck, enlarged thyroid, and neck cicatricial contracture, are not suitable for percutaneous tracheostomy, a minimally invasive method1. In these circumstances, conventional open tracheostomy is the primary option for surgeons. However, it is one of the most hazardous procedures, because the direct airway opening and the coughing of patients causes aerosolization of the virus potentially exposing healthcare workers2. To prevent healthcare-associated infections, we are willing to share our modified tracheostomy procedures with other surgeons worldwide.Detailed optimized procedures are illustrated in Figure 1. There are three distinct steps to protect healthcare workers from the virus spreading in the surgical environment during tracheostomy. First, all procedures should under general anesthesia, with deprivation of spontaneous respiration and application of muscle relaxants (Figure 1A), regardless of whether patients had spontaneous breathing or not. This step is to restrain the cough reflex caused by tracheal stimulation. Second, after the cervical trachea is exposed and immediately before an incision is made in the trachea, the endotracheal tube (ETT) is inserted deeper, positioned with the tip close to carina of the trachea (Figure 1B). This step would prevent the ETT cuff leak due to an accidental damage to the cuff when making the tracheal opening. Third, when the opening is complete, brief interruption of the ventilator is essential. Then the ETT is pulled out, and subsequently the tracheostomy tube quickly inserted into the opening (Figure 1C). Almost simultaneously, the tracheostomy tube cuff is inflated and the tube rapidly connected to the ventilator, with immediate resumption of the ventilator (Figure 1D). Suspension of ventilation support was usually not more than 15 seconds, with satisfactory oxygen saturation.This report describes the optimized procedures in tracheostomy for Covid-19 patients. The three major modifications can avoid the aerosolization of secretions, and protect healthcare workers. Thus, we strongly recommend the modified procedures to be a choice for all surgeons when tracheostomy is considered for Covid-19 patients. It is important to protect healthcare workers from coronavirus during the intraoperative period for their own health and for preservation of the healthcare workforce.Figure

On March 27, 2020, the Center for Disease Control reported that 85,356 individuals in the United States were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – exceeding, for the first time, the number of cases in Wuhan, China, where the pandemic began in November, 2019. US federal, state and local agencies are facing an unprecedented public health emergency. The scale of the pandemic has never been seen in US; the way forward uncertain.In 2003, the Hong Kong SAR (HK) healthcare system was thrust into a similar crisis, responding to an outbreak of SARS coronavirus 1 (SARS-CoV-1), that developed in Guangdong Province, China late in 2002. Lessons from how HK physicians adapted their practices to this new disease may hold important lessons for the many countries now facing the pandemic .Based upon experience and evidence from SARS-CoV-1 and early-experience with SARS-CoV-2, we provide our perspective and guidance on mitigating transmission risk during head and neck examination, upper airway endoscopy, and head and neck mucosal surgery including tracheostomy. We set out below, recommendations that every physician performing head and neck examination should consider. The goal is to protect healthcare workers (HCW), caregivers, patients, and the community at large in this Personal Protective Equipment (PPE) limited environment, while conforming to their local guidelines.Early on in the 2003 SARS epidemic, the risk of nosocomial spread of infection to HCW posed a critical challenge. At the Prince of Wales Hospital, HK, a single infected patient caused an outbreak, of which over 50% were HCW, devastating human resources to treat and contain the infection . Seventeen years later HK was inflicted with SARS-CoV-2 late January 2020. A benefit of SARS-COV-1 in HK HCW has been the modus operandi since 2003: including wearing surgical masks in hospital wards, wearing gowns and surgical masks in outpatient clinics and scrubs only in the operating room. The resultant individual and institutional appreciation of infection control measures have served HK well in the current pandemic, relative to other countries, with no HCW COVID-19 nosocomial infections to date 1.In the 2003 SARS-CoV-1 outbreak in HK, an otolaryngologist died after being infected during a routine head and neck examination. In 2020, the first COVID-19 physician fatality was an otolaryngologist in Wuhan, China. Patients with COVID-19 caused by SARS-CoV-2 can carry high viral load in the nasal cavity, nasopharynx, and throat. The anatomic viral distribution of these SARS-CoV viruses in the nasopharynx and mucosal airways, coupled with these disquieting cases, indicate that head and neck examinations and procedures must be approached cautiously with thoughtful preparation and protections. HCW who have these exposures are at heightened risk of transmission.In the outpatient setting, all non-essential clinic visits should be transitioned to virtual “video-visits” or postponed. This will reduce the number of patients in the clinic, minimizing patient flow and potential contamination and freeing up valuable medical resources. On March 18, 2020, the Center for Medicare and Medicaid Services in the US released recommendations to postpone all non-essential dental exams and procedures until further notice.Within the clinic, separate gown up and down areas must be designated to prevent cross-contamination. Visual guides and mirrors for self-visualization in these areas on the steps involved in gowning up and gowning down have, from past experience, proven extremely useful particularly for gowning down, where most HCW self-contaminate (Figure 1). Another critical area is the bedside examination of patients. Currently, there are no CDC guidelines on respiratory and aerosol-generating procedures within the scope of the head and neck surgery, but our experience with SARS-CoV-1 highlights that these are potentially high-risk examinations. Therefore, in HK, there is official guidance for Otolaryngology departments to label several common head and neck examination and procedures as having a potential risk of aerosol generation. This designation carries implications on PPE allocations of as seen in table 1.Anesthetic practices vary but local anesthetic is commonly administered via aerosolized spray in the head and neck examination and procedures. This practice has been abandoned in HK since the SARS-COV-1 epidemic and must be avoided in the current COVID-19 environment. Aerosol spray should be replaced by topical local anesthetic on pledgets or dripped via syringe. Table 1 shows guidelines of PPE use within the outpatient clinic with a dedicated endoscopy room, including flexible laryngoscopy - one of the most common procedures performed in head and neck examination. Unless there is gross contamination there is no need to change the gown, mask or eye protection between each patient.For inpatient rounds, all physicians are recommended to wear a surgical mask and scrubs which are changed daily prior to leaving the hospital. Patient visitors to the hospital should be severely restricted, and visiting hours cut, to minimize people flow and maintain social distancing.For all operative procedures, intubation represents an aerosol-generating procedure as first learned during the 2003 SARS-COV-1 epidemic. Therefore, during intubation anyone in the operating room should have appropriate PPE including a fit-tested N95 mask. This should similarly apply to all open airway procedures such as direct laryngoscopy where they may be a leak during ventilation, tracheostomy, or laryngectomy.Tracheostomies for patients with known COVID-19 should be delayed where possible to minimize viral shedding from the patient, as we know from SARS-COV-1, delaying the tracheostomy does not negatively impact the patient. Guidance for a safe tracheostomy emerged from the 2003 epidemic. The following should be considered for tracheostomies in the COVID-19 pandemic:PPE: AAMI level 3 or waterproof apron on top of AAMI level I isolation gown, N95 mask, face shield, waterproof cap and disposable shoe covers. Powered air purifying respirators (PAPR) may be needed in cases with high viral load.Minimize personnel: One intensivist, one surgeon, one nursing member.Procedure: Use a negative pressure operating room. The patient should be completely paralyzed and preoxygenated. Stop ventilation before tracheotomy and only resume once tracheostomy tube balloon cuff is inflatedPost procedure: Gown down safely, and shower.Ideally, the procedure should be done in a negative pressure operating room with senior personnel and not used as a training procedure. Cautery use should be limited as this can produce small particles that may act as a vehicle for the virus . Again, gowning down following the procedure is of utmost importance and is often overlooked. Dry runs prior to the actual procedure may also help reduce errors and prevent the contamination of HCW.For patients with a tracheostomy they should all be covered with a closed system (Figure 2) identical to when a patient is connected to a mechanical ventilator to minimize the aerosol generated that could cross contaminate the surrounding patients and HCW given the suction requirements of these patients . Humidified tracheostomy collars and nebulized therapies must be avoided. All bedside procedures should be performed in a separate treatment room away from patient cubicles with all HCW wearing PPE. The requirements for PPE will be the same as in the outpatient clinic.In summary, with the use of these broad guidelines which reduces the number of procedures and patients seen, coupled with an appreciation that the head and neck examination cannot be taken lightly in the current pandemic, the risk of exposure and contamination in clinics of patients, HCW and in particular, physicians performing a head and neck examination should be reduced.

Subtitle: A Review of the Literature and Recommendations for Risk ReductionFull author listMaxwell P. Kligerman, MD, MPH1,2; Neelaysh Vukkadala, MD1,2; Raymond K Y Tsang, FRCS Ed (ORL) MS3; John B. Sunwoo, MD1; F. Christopher Holsinger, MD1; Jason Y K Chan, FRCS Ed (ORL)4; Edward J. Damrose, MD, MPH1,2; Ann Kearney, CScD CCC-SLP, BCS-S2; Heather M. Starmer, MA, CCC-SLP, BCS-S11 Division of Head and Neck Surgery, 2 Division of Laryngology Department of Otolaryngology, Stanford University, Palo Alto, California, U.S.A., 3 Department of Otorhinolaryngology—Head and Neck Surgery, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, 4 Division of Otorhinolaryngology – Head and Neck Surgery, Department of Surgery, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR

As Dr. Thomson eloquently notes in his valuable letter [1], underlying respiratory diseases appear to be less of a risk factor for poor outcome in COVID-19 patients than either underlying cardiovascular disease or diabetes. This intriguing finding emerged from several studies that examined underlying medical conditions in COVID-19 patients.In a single-center retrospective analysis of critically ill adults admitted to the intensive care unit of a hospital from China between late December 2019 and January 26, 2020, 22% of the non-survivors had cerebrovascular disease, 22% had diabetes, and 6% had chronic respiratory disease [2]. The analysis of data from patients with laboratory-confirmed COVID-19 from hospitals in China through January 29, 2020 found that 16.2% of those with serious disease had diabetes, 23.7% had hypertension, and 3.5% had chronic obstructive pulmonary disease [3]. A study of electronical medical records of COVID-19 patients admitted between January 16 and February 3, 2020 to a hospital from Wuhan found that hypertension and diabetes mellitus, the most common comorbidities, were present in 37.9%, 13.8%, of the patients with severe disease, respectively, but only in 3.4% of the patients with chronic obstructive pulmonary disease [4]. Finally, an analysis of all COVID-19 cases reported through February 11, 2020, extracted from the Infectious Disease Information System in China, found that case fatality rates in individuals with cardiovascular disease, chronic respiratory disease, and diabetes were 10.5%, 6.3%, and 7.3% respectively, as compared to 0.9% among patients with no comorbidities [5]. In a case series of COVID-19 patients hospitalized in Wuhan, China, ICU patients were more likely to have underlying diabetes than patients that did not receive ICU care (22.2% vs 5.9%) [6].The studies mentioned above did not stratify patients by therapies they were receiving. However, one commonality between cardiovascular disease and diabetes is that they are often treated with angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type-I receptor blockers (ARBs), widely used to inhibit the formation and action of angiotensin II.ACE shares 42% amino acid identity with ACE2 [7], a membrane-bound aminopeptidase [8] extensively expressed on type II human alveolar cells [9]. The genes encoding these two proteins are thought to have emerged by duplication [10]. ACE2 is distributed on many tissues and shows highest expression levels in the heart, kidney, lung, small intestine, and testis [11]. On the apical surface of polarized respiratory epithelial cells, ACE2 is a crucial and primary receptor for the cellular entry of SARS-CoV, the virus that caused the 2002-2003 SARS outbreak [12-16]. SARS-CoV binding to ACE2 mediates entry into human or animal cells [17]. ACE2 is also the receptor for SARS-CoV-2, the etiologic agent of COVID-19 [18]. Structural analyses indicate that SARS-CoV-2 binds the ACE2 receptor with a 10-20-fold higher affinity than SARS-CoV [19, 20].The entry of SARS-CoV and SARS-CoV-2 into their target cells is mediated by the viral spike (S) glycoprotein, which is located on the outer envelope of the virion [21]. The S glycoprotein has two functional subunits, S1, which binds the cellular receptor, and S2, which contains domains required for the fusion between viral and cellular membranes [22, 23]. Viral binding and membrane fusion represent the initial and critical steps during the infection cycle of the coronavirus [24] and the first step in establishing the infection [25, 26]. Binding is followed by internalization of ACE2 and down‐regulation of its activity on the cell surface [27-29].SARS-CoV binds ACE2 through a region of the viral S1 subunit called the minimal receptor-binding domain (RBD) [17]. RBD is the most important determinant of the SARS-CoV host range, and studies about the “species jump” during the 2002-2003 SARS outbreak revealed that changes of only one or two amino acids in this region were sufficient to make the virus “jump” to a new host [26, 30, 31].ACE and ACE2 are two members of the renin angiotensin system that negatively regulate each other [32, 33] and are distinct in their substrate specificity and function [34]. ACE converts angiotensin I to angiotensin II and mediates aldosterone release, vasoconstriction, sodium retention, cell proliferation, and organ hypertrophy [35]. ACE2 cleaves a single residue from angiotensin I to form angiotensin-(1-9), and a single residue from angiotensin II to form angiotensin-(1-7). In humans, ACE2 has a 400-fold higher catalytic efficiency when it uses angiotensin II as a substrate as compared to when it uses angiotensin I [36]. ACE2 and angiotensin-(1-7), through the Mas receptors, oppose ACE and mediate vasodilation and anti-proliferative, anti-hypertrophic, cardioprotective, and reno-protective effects [8, 35, 37]. ACE2 has physiological and pathological importance [25] and its dysregulation was implicated in heart disease, hypertension, and diabetes [36, 38-40]. ACE2 is not inhibited by ACE inhibitors [32] and several studies indicate that the ACE2/Angiotensin-(1-7)/Mas axis has anti-inflammatory effects [41, 42].It was recently hypothesized that treatment with ACE inhibitors and/or ARBs may lead to ACE2 overexpression and this could increase the risk of severe COVID-19 [43], possibly by increasing the internalization of SARS-CoV-2. Several lines of evidence indicate that pharmacological manipulation of the renin-angiotensin-aldosterone pathway could affect ACE2 receptor levels. In animal studies, the selective blockade of angiotensin II synthesis or activity increased cardiac Ace2 gene expression and activity [44, 45], and treatment with ARBs increased the levels of cardiovascular ACE2 receptors [46-49]. While this link is thought-provoking as a possibility, there isn’t currently sufficient evidence to contemplate changing patients’ existing therapeutic regimens in order to minimize their risk of COVID-19 complications. The first clinical evidence exploring this link indicated that the use of ACEI and ARBs appear to improve the clinical outcome of COVID-19 patients with hypertension [50]. We will only learn about any possible associations, along with their magnitude and direction, from carefully conducted and adequately powered clinical trials.It is also important to consider that an increase in ACE2 levels does not necessarily entail a negative impact for the course of COVID-19. ACE2, by forming angiotensin-(1-7) from angiotensin II, could diminish the deleterious effects of angiotensin II and, consequently, it is also possible that ACE inhibitors or ARBs could, in fact, lower the risk of complications [51]. However, increased ACE2 and the formation of angiotensin-(1-7), by inhibiting COX-2, could exert anti-inflammatory effects [52, 53], underscoring the multitude of possible effects and the need to conduct studies to interrogate these connections. Finally, it is not known whether an increase in the expression of ACE2 would also lead to an increased shedding and increased levels of soluble ACE2, which could act as a decoy receptor and lower viral entry into cells [54]. In support of this, recombinant human ACE2 ameliorated the lung injury induced by the avian influenza H5N1 virus in mice [55]. It is also important to consider that from the relatively limited amount of human data, plasma ACE2 activity does not appear to be statistically different between individuals taking ACE inhibitors or ARBs and those not taking these medications, but these results do not reflect the levels of cellular receptors [56]. Structural analyses indicate that the binding of the SARS-CoV spike protein to ACE2 does not occlude the catalytically active site of the receptor [26, 57], and it was hypothesized that angiotensin II binding to ACE2 could induce a conformational change in the receptor, which will no longer be favorable for SARS-CoV-2 binding [54]. The mining of existing datasets, preclinical studies, and clinical trials will help shed light on these complex and sometimes conflicting scenarios.A decrease in the number of ACE2 receptors appears to be involved in acute lung injury and cardiovascular pathology [58, 59], and may be detrimental during coronavirus infection. A mouse Ace2 knockout developed severe cardiac contractility defects and increased angiotensin II levels, and the additional deletion of Ace rescued this phenotype [60]. In acute lung injury models, the loss of Ace2precipitated severe acute lung failure, and this was attenuated by the exogenous recombinant human ACE2 in both Ace2 knock-out and in wild-type mice [59]. Attenuation of the Ace2 catalytic function perturbed the pulmonary renin-angiotensin-aldosterone system and increased inflammation and vascular permeability [61], and Ace2 overexpression decreased lung inflammation in an animal model of acute lung injury [62]. In vitro and in experimental animals, SARS-CoV and the SARS-CoV spike protein downregulated ACE2 expression [12, 28]. In mice with lung injury, injection of the SARS-CoV spike protein worsened the acute lung failure and caused lung edema, increased vascular permeability, and decreased lung function, and this pathology was attenuated by blocking the renin-angiotensin-aldosterone pathway [12]. Thus, animals infected with SARS-CoV or treated with the spike protein resemble Ace2 knockout animals [12]. It is relevant that a pilot study of patients with acute respiratory distress syndrome reported the accumulation of angiotensin I and the decrease of angiotensin-(1-9), indicating decreased ACE2 activity, among non-survivors [63]. Thus, SARS-CoV and SARS-CoV-2 might contribute to severe respiratory symptomatology partly because the viruses, by binding the ACE2 receptors, also deregulate protective pathways in the lungs.Thus, either increased or decreased numbers of pulmonary ACE2 receptors may be detrimental during SARS-CoV or SARS-CoV-2 infection, most likely for distinct reasons. An increased number of ACE2 receptors may lead to a higher viral load and more severe clinical disease. Diabetes increases ACE2 expression, as shown in several experimental models, and the resulting increased viral load might explain the more severe course of COVID-19 in diabetic patients [64, 65]. Interestingly, in a rodent model of diabetes, ibuprofen inhibited the ACE/angiotensin II/angiotensin type 1 receptor axis and enhanced the ACE2/angiotensin-(1-7)/Mas receptor axis [66]. Too few functional ACE2 receptors, which decrease even more as a result of high viral loads and enhanced receptor internalization [67], might exacerbate acute lung injury, increase angiotensin II levels, and alter the balance between pro- and anti-inflammatory responses. It is relevant that in a study on twelve COVID-19 patients from China, plasma angiotensin II levels were markedly elevated as compared to healthy control individuals, and linearly associated with the viral load and with the lung injury [68]. The animal studies that documented an age-dependent decrease in ACE2 expression in the lung and the aortic might also explain, at least in part, the age-dependent increase in the risk of serious COVID-19 complications [69, 70].SARS-CoV can also bind cells through alternative receptors that include the C-type lectins DC-SIGN (dendritic cell-specific intercellular adhesion molecule-3-grabbing non-integrin) and/or L-SIGN (liver/lymph node-SIGN) [14, 71-73]. It will be critical to understand the potential involvement of the same, or alternative receptors in the pathogenesis of COVID-19.It has been less clear why SARS-CoV and SARS-CoV-2 lead to severe lung disease [57], in contrast to other, previously known coronaviruses, which usually result in mild upper respiratory infections and cause pneumonia only rarely, mostly in newborn, the elderly, and immunocompromised individuals [74-77]. One of the possibilities advanced for SARS is that the burden of viral replication and the immune status of the host may both shape the severity of the infection [57, 78, 79]. The same might be true for COVID-19, and further exploring the link between viral burden, chronic medical conditions, long-term medication usage, and the severity of the infection will be critical.An important lesson from SARS and MERS is the association between the incubation period and disease severity. For any infectious disease, the incubation period varies among individuals, even for the same outbreak, and depends on the initial infective dose, the speed of pathogen replication within a host, and host defense mechanisms [80]. During the 2002-2003 SARS outbreak, a study in Hong Kong revealed that patients with shorter incubation times developed more severe disease [81]. The same was found in MERS patients from South Korea, where longer incubation times were associated with a lower risk of death [82]. Interestingly, during the SARS outbreak in Hong Kong, healthcare workers, who have a higher infecting dose, had 34% shorter median incubation times than non-healthcare workers [83]. It will be interesting to examine whether the same is true for SARS-CoV-2, and whether the incubation period is different in COVID-19 patients when they are stratified by age, coexisting morbidities, and therapies they receive for chronic diseases. While the association between the incubation period and mortality might simply indicate that the disease was confirmed earlier in patients with longer incubations, and reflect earlier treatment opportunities [82], it is also plausible that high viral loads might mediate the link between the two.Two factors decisive for the successful control of outbreaks are the ability to isolate asymptomatic individuals and the ability to trace and quarantine their contacts [84, 85]. Several studies reported asymptomatic shedding of SARS-CoV-2, indicating that asymptomatic carriers, or individuals with very mild symptoms, may sustain transmission [86-89]. For example, nearly 18% of the passengers who tested positive for SARS-CoV-2 on the Diamond Princess cruise ship were asymptomatic [88]. Another valuable finding that emerged from the COVID-19 outbreak analysis in Singapore, and has a strong impact on infection control, is that after becoming asymptomatic, some patients continued to shed the virus for up to several days. In one instance, a patient continued to have detectable respiratory shedding, as shown by PCR, for eight consecutive days after becoming asymptomatic [90]. Another study revealed that several children with COVID-19 persistently tested positive for viral RNA on fecal swabs after their nasopharyngeal cultures became negative. Even though replication-competent virus was not detected in the fecal swabs, this finding leaves open the possibility of SARS-CoV-2 fecal-oral transmission [91]. These findings illustrate the challenges in understanding SARS-CoV-2 transmission and in identifying infected individuals, tracing their contacts, and implementing preparedness plans. One of the absolute requirements, to clarify these questions and overcome these obstacles, is ensuring the prompt and large-scale testing of symptomatic individuals and of their asymptomatic contacts. This, together with the social distancing measures, are currently our only available assets in facing a pandemic that, even though it was preceded by multiple warnings in recent years, is unlike any other infectious disease that we experienced in modern history.

Specific therapies in pregnant women are discussedThe health crisis caused by the novel SARS-cov-2 (2019-nCoV) related pandemic requires urgent and necessary therapeutic response. Pregnant women are just as exposed as the general population and should not be excluded, because of their status, from discussions on effective and well tolerated candidate treatments. While in countries that have opted for national containment, daily non-emergency medical and surgical activities are suspended, obstetric services continue to operate relentlessly and are experiencing a surge in so-called ”at-risk” pregnancies. Some countries have now recommended routine screening of all pregnant women 1 but the low availability and performance of the current tests limits their use. Management of an infected pregnant women is essentially conditioned by maternal symptomatology. Women with little or no symptoms do not require routine treatment or in-patient care and simply need to be monitored for up to 15 days for evidence of respiratory deterioration. In the absence of validated specific treatment, the primary approach to therapy is mainly symptomatic and delivery is considered in the event of critical respiratory distress in order to maximize oxygenation and lung capacity2–4 . However, it has been reported that women with respiratory signs may be given antiviral treatment to improve their clinical condition 2,4To date, there is no proven effective strategy, although many teams are working tirelessly to identify an effective treatment. Four molecules are leading in this race:1) Remdesivir is a novel nucleotide analogue prodrug which incorporates into nascent viral RNA chains and results in pre-mature termination. Its effectiveness has been already demonstrated against others coronaviruses such as SARS-Cov and MERS-Cov5, and it has proven to be highly effective on in vitro 2019-nCoV infection6. Compassionate use in human were also reported 7 and phase 3 studies are currently underway.2) (Hydroxy)chloroquine has been known for years because of its effectiveness in the treatment of inflammatory diseases and against malaria. Recent studies have shown antiviral effects of chloroquine and in vitro studies concluded that it was highly effective in the control of 2019-nCoV 6,8. Elevation of endosomal pH and interference with terminal glycosylation of the cellular receptor, angiotensin-converting enzyme 2 conduct to block virus infection. (Hydroxy)chloroquine has been used in 2019-nCoV infected humans with highly controversial restuls9,10 and well-designed randomized studies should be available soon.3) Lopinavir, a viral protease inhibitor, with its pharmacological booster Ritonavir (LPV/R) are commonly used in HIV positive patients. It has already been used for SARS-Cov. Some countries such as China and India approved its use in symptomatic infected patients although a first randomized, controlled, open-label trial showed no benefit of LPV/R over standard care in patients with severe 2019-nCoV disease11.4) Ribavirin, is a guanosine analog that interferes with the replication of RNA and DNA viruses. It has been used for years in the treatment of chronic hepatitis C. Based on its direct anti‐viral activity against 2019‐nCoV in vitro and some evidence for its potential efficacity during the prior SARS-Cov and MERS-Cov outbreaks, it has been suggested as a potential candidate for the treatment of 2019-nCoV diease12. 2019-nCoV infected patients treated with Ribavirin have been reported by Chinese studies4,13but its exact benefit remains to be demonstrated in well designed randomized studies as well.To date, all four drugs are being independently tested in Phase 3 studies, mostly national, to investigate their efficacy and safety in the management of 2019-nCoV disease. Several European countries have also set up, as a result of joint efforts since mid-March, a randomized, multicentre, open-label trial to evaluate and compare the efficacy and toxicity of the first three treatments mentioned above.14With regard to the possibility of treating pregnant patients with these molecules, few data are available for Remdesivir. Only one study reports its use in six pregnant women in a randomized trial during Ebola epidemics. The authors reported no adverse effect15.Many more pharmacological studies on maternal-fetal tolerance of Hydroxy(chloroquine), Lopinavir and Ribavirin are available. The historical use of (hydroxy)chloroquine in antimalarial treatment, but also in connective tissue diseases, has resulted in a well-documented safety and tolerance profile in pregnant women16. Animal studies, undertaken during the Zika virus epidemic, have also suggested that chloroquine may also reduce the risk of viral transplacental transmission to the fetus17. The optimal dosage to be used in pregnant women will have to be specified, but it appears that there is no pharmacokinetic difference between chloroquine and its major metabolite between pregnant and non-pregnant women18. With respect to the use of protease inhibitors during pregnancy, such as Lopinavir, some teams have reported an increased risk of preterm delivery. However, a specific analysis of more than 4,000 pregnant women found a similar incidence and rate of adverse pregnancy outcomes than in controls at all three trimesters of pregnancy, including preterm birth, low birth weight and birth defects19. Significant teratogenic effects have been demonstrated in all animal species exposed to Ribavirin, it is therefore currently contraindicated in pregnant women and in their male sexual partners, although the ribavirin pregnancy registry did not bring evidence of teratogenicity in humans20.The use of antiviral therapy in infected pregnant patients should follow the same indication as in the general population, but some obstetric specificities should be emphasized.1) The main goal should be to slow down and at best stop the clinical progression of the disease, i.e to remain asymptomatic and to avoid progression to acute respiratory distress syndrome in symptomatic cases. In the latter, the obstetrician is often called on to perform an emergency delivery and thus to induce extreme prematurity. Expert consensus provided obstetric guidance, but the management of cases at between 25 and 32 weeks’ remains challenging in the absence of effective antiviral treatment1.2) The second objective would be to rapidly decrease viral load and duration of contagiousness in infected pregnant women. The majority of them are doing well, but the infection can disrupt their obstetrical calendar. Some procedures need to be performed at a specific age, such as first trimester serum markers, ultrasound examinations, chorionic villi sampling (CVS). The same applies to access to termination of pregnancy. All such procedures may indeed be delayed, either to limit contagion, to limit the burden on the health care team (due to reinforced barrier measures…) or in the particular case of CVS/amniocentesis, to limit the theoretical risk of fetal transmission.3) Finally, the third advantage could be to introduce preventive treatment in case of maternal contact with an infected person, similar to what is done for seasonal influenza and oseltamivir21.The use of immunotherapy such as Tocilizumab, plasma of recovered coronavirus patient, Interferons, were not discussed here as they are currently understudy only for critically ill COVID-19 patients. No place for these treatments in a patient who is still pregnant should be considered for the time being, since if the pregnant woman presents a very severe form, the birth will be considered as a priority.The results of the Phase 3 therapeutic studies should be available soon. However, it is unfortunate that infected pregnant women are not included in any appropriate research protocols. Consequently, in this period of pandemic, mutual exchanges of experience between all countries’ maternity hospitals must be carried out in order to ensure the best possible management of infected pregnant women.

Objectives: To investigate the mental status of pregnant women and to describe their obstetrical choices during the outbreak of COVID-19. Design: A cross-sectional study. Setting: Wuhan and Chongqing, two different epidemic areas. Population: A total of 1947 valid questionnaires were received. Methods: We collected information on demographic, pregnancy, and epidemic, along with their attitudes towards the epidemic, anxiety status and obstetrical choices. We described and compared the city-based distribution of all above factors, aiming to explain how anxiety and obstetrical choices existed and differed. Main Outcome Measures: To explore why differences existed, we estimated the impact of the epidemic on women’s anxiety by multivariable analysis. Results: Distribution differences could be seen between cities in employment status, household income, gestational age, fetal number, and exposure history. Women’s attitudes towards COVID-19 in Wuhan were more extreme than that in Chongqing. The anxiety rate was more than double in Wuhan (24.47%) compared to that in Chongqing (10.44%). Generally speaking, obstetrical choices were similar among the 1947 participants, but more obvious in Wuhan. Conclusions: Our study found that the outbreak aggravated prenatal anxiety, and the influence factors could be targets of mental care. Synchronously, vital obstetrical choices changed, followed by pertinent professional advice to prevent irreversible adverse pregnancy outcomes. Online platforms may play crucial roles to address patients’ needs in future PHEs. Funding: National Natural Science Foundation of China (No. 81771614 and No. 81771613), and the National Key Research and Development Program of China (No. 2016YFC1000407). Keywords: COVID-19; Pregnancy; Prenatal Anxiety; Obstetrical Choices.

Testing for COVID-19 has been unable to keep up with the demand. Further, the false negative rate is projected to be as high as 30% and test results can take some time to obtain. X-ray machines are widely available and provide images for diagnosis quickly. This paper explores how useful chest X-ray images can be in diagnosing COVID-19 disease. We have obtained 135 chest X-rays of COVID-19 and 320 chest X-rays of viral and bacterial pneumonia. A pre-trained deep convolutional neural network, Resnet50 was tuned on 102 COVID-19 cases and 102 other pneumonia cases in a 10-fold cross validation. The results were an overall accuracy of 89.2% with a COVID-19 true positive rate of 0.8039 and an AUC of 0.95. Pre-trained Resnet50 and VGG16 plus our own small CNN were tuned or trained on a balanced set of COVID-19 and pneumonia chest X-rays. An ensemble of the three types of CNN classifiers was applied to a test set of 33 unseen COVID-19 and 218 pneumonia cases. The overall accuracy was 91.24% with the true positive rate for COVID-19 of 0.7879 with 6.88% false positives for a true negative rate of 0.9312 and AUC of 0.94. This preliminary study has flaws, most critically a lack of information about where in the disease process the COVID-19 cases were and the small data set size. More COVID-19 case images at good resolution will enable a better answer to the question of how useful chest X-rays can be for diagnosing COVID-19.

The COVID-19 pandemic imposed a major challenge on all health systems on the planet. At the regional level, the state of Ceará (Brazil) differs from other Brazilian regions by an early and rapid onset of its cases, probably due to its high international connectivity by air. Health authorities instituted social isolation measures 3 weeks ago. The authors made a graphical inspection of official data on confirmed cases of COVID-19 in Ceará, São Paulo, Brazil and the USA to search for evidence that can help assess the strategy of local health authorities. Logarithmic scale graphs of new cases per day and cumulative cases indicate a high risk situation for the epidemic in Ceará. The tendency for the pandemic to grow seems to be greater in Ceará than in the state of São Paulo, in the whole of Brazil and even in the USA, the country with the greatest growth of the epidemic recently. The maintenance and even the tightening up of social isolation measures seem a logical conclusion to this panorama.

AbstractThe novel coronavirus, also known as COVID-19, has infected at least 1 million persons worldwide. It has also accounted for a number of deaths. No doubt, it has dealt a drastic blow to businesses and the global economy, leaving behind a huge crisis. Thus, the present study discusses management strategies to counter the short and long-term effects of the COVID-19 pandemic on businesses.IntroductionThe novel coronavirus pneumonia is an acute respiratory disease. In December 2019, this disease emerged in Wuhan, China. The Chinese government called it SARS-CoV-2 which was subsequently named COVID-19 by the World Health Organization (WHO) [1]. In January 2020, WHO confirmed it as a sustained human to human disease [2]. The World Health Organization has declared Covid-19 a full-blown pandemic, which means it's a crisis-level disease outbreak in multiple countries. This disease is extremely rare and its unexpected occurrence has major consequences for just about everybody. Covid-19 is similar to past zoonotic coronaviruses, including SARS. It's less lethal than SARS, but spreads more easily. The death rate is under 2 percent, and for people under the age of 60 under 1 percent.In a bid to control its spread, this disease has led to flight cancellations, border closure, postponement of business meetings and so on. In fact, the impact of this pandemic will take years to be fully quantified. Social distancing -- basically keeping people away from each other (as well as avoiding human physical contact and washing hands) has been one of the mostly talked about method of preventing a full-scale outbreak. However, this has led to severe consequences to businesses and even job losses. This is because business is usually conducted by bringing people together, not keeping them apart. People come to work, have meetings, travel to meet with clients, attend trade conferences and purposefully interact with each other to forward the interests of the organization. Thus, this brings to concern how to keep business alive while keeping people apart. No doubt, the COVID-19 pandemic has led to huge economic and business crisis. For instance, oil prices crashed to an 18-year low of $20.09 a barrel, thereby sending a devastating blow to energy demand. In view of the imminent crisis to businesses, it is imperative that efficient management strategies are adapted to this unusual and unpleasant situation. Thus, the present study highlights these key approaches.Immediate stepsTo prevent further escalation of the situation, the following first steps should be observed. They are as follows:·         Appoint a crisis response team that meets daily.·         Monitor government, medical, industry and local sources for updates for the team.·         Implement a communications plan to transparently inform all employees.·         Develop and implement a comprehensive crisis response.·         Develop or update, then communicate and enforce, a remote-work policy.Long-term actionsScenario planning·         Organizations must act with imperative when developing and implementing enhanced risk management practices, focusing on the opportunities scenario planning offers in creating pre-emptive action plans.·         Scenarios enable organizations to see the bigger picture and make effective trade-off decisions on issues like: how much stock to hold – and where, or how to balance the cost of inventory versus the cost of failing to satisfy customers. Simulations can be run swiftly to identify “sweet spots” between apparently conflicting objectives, based on real-time inventory data, customer demand, and supplier capability. Increasingly enabled by AI and automation, these scenarios can help prescribe rather than just predict.·         By analyzing past events and hypothesizing future threats, organizations are able to identify strategic and concentrated supplies that are at risk in major crises, and most importantly, recognize when current internal risk capacities prove insufficient.Supplier risk management·         Real-time supplier data such as system performance category alerts and geopolitical events helps manage performance and issue resolution.·         When alerted, proactive measures should be taken by organizations to uncover additional exposure levels by reaching out to suppliers (from tier 1, tier 2 and below) outside of affected regions to identify upstream supply dependencies within their supply chains.·         Further, organizations could benefit from balancing supply and demand and working with internal stakeholders as well as critical suppliers to contractually agree on logistic-based costs and necessary buffer stock, so as to reduce sudden price increases in the face of a crisis.Technology upgrades·         In line with the technology-enabled business climate we currently operate in, organizations should rethink the way their employees collaborate with each other and customers - within the office, regionally and globally.·         By investing in internal technology, organizations can teach employees how to effectively leverage powered execution tools such as cloud-office technology and zero-touch models. This will help ensure that not only in times of crisis are teams better equipped to work remotely, but as the business environment continues to shift, employees are able to adapt alongside it and continue serving customers.ConclusionIn conclusion, as the novel coronavirus continues to take its toll on businesses as well as the global economy, hope is not lost for business to bounce back strongly. However, this can only be achieved by ensuring that effective short and long-term management strategies are implemented and followed to the letter.References1.            Chan JF-W, Yuan S, Kok K-H, To KK-W, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;395(10223):514-23.2.            Organization WH. Coronavirus disease 2019 (COVID-19) situation report–34. Geneva, Switzerland: World Health Organization; 2020.

The COVID-19 pandemic has placed an extraordinary demand on the United States healthcare system. Many institutions have cancelled elective and non-urgent procedures to conserve resources and limit exposure. While operational definitions of elective and urgent categories exist, there is a degree of surgeon judgment in designation. In the present commentary, we provide a framework for prioritizing head and neck surgery during the pandemic. Unique considerations for the head and neck patient are examined including risk to the oncology patient, outcomes following delay in head and neck cancer therapy, and risk of transmission during otolaryngologic surgery. Our case prioritization criteria consist of four categories: urgent – proceed with surgery, less urgent – consider postpone > 30 days, less urgent – consider postpone 30–90 days, and case-by-case basis. Finally, we discuss our preoperative clinical pathway for transmission mitigation including defining low-risk and high-risk surgery for transmission and role of preoperative COVID-19 testing.

The 2019 novel coronavirus disease (COVID-19) has presented the world and physicians with a unique public health challenge. In light of its high transmissibility and large burden on the healthcare system, many hospitals and practices have opted to cancel elective surgeries in order to mobilize resources, ration personal protective equipment and guard patients from the virus. Head and neck cancer physicians are particularly affected by these changes given their scope of practice, complex patient population, and interventional focus. In this viewpoint, we discuss some of the many challenges faced by head and neck surgeons in this climate. Additionally, we outline the utility of telemedicine as a potential strategy for allowing physicians to maintain an effective continuum of care.

In December 2019, the world started to face a new pandemic situation, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although COVID-19 clinical manifestations are mainly respiratory, major cardiac complications are being reported. Cardiac manifestations etiology seems to be multifactorial, comprising direct viral myocardial damage, hypoxia, hypotension, enhanced inflammatory status, ACE2-receptors downregulation, drug toxicity, endogenous catecholamine adrenergic status, among others. Studies evaluating COVID-19 patients presenting cardiac injury markers show that it is associated with poorer outcomes, and arrhythmic events are not uncommon. Besides, drugs currently used to treat the COVID-19 are known to prolong the QT interval and can have a proarrhythmic propensity. This review focus on COVID-19 cardiac and arrhythmic manifestations and, in parallel, makes an appraisal of other virus epidemics as SARS-CoV, MERS-CoV, and H1N1 influenza.

Doubling Time (DT) is typically calculated for growth curves that show exponential growth, such as the cumulative number of COVID-19 cases day by day. DT represents the time it takes before the number of COVID-19 cases, in a certain country or area, doubles. Throughout the ongoing COVID-19 outbreak, DT values are continually changing. These changes are influenced by the measures that are recommended by the health authorities and implemented by governments. After the government-imposed shutdowns of Nordic Countries that were announced around the 12th of March 2020, we followed the development of the DT in the region. Governments put in place measures never before experienced during peace time; working from home, closed schools and kindergartens, travel bans and social distancing. We conducted analyses to evaluate the effectiveness of these measures. Does it work? The initial set of results following the shutdown are encouraging, demonstrating a trend towards slower growth; however, this could be reversed if the measures that are in place now are abandoned too early. Premature optimism can be very costly. In this report we describe a method for monitoring the epidemic in real time and evaluating the effectiveness of the implemented measures.

IntroductionPneumonia caused by the 2019 novel coronavirus disease (COVID-19) is a highly infectious disease, which has aroused widespread concern all over the world. COVID-19 pneumonia was first reported in Wuhan, Hubei province, China, in December 2019, followed by an outbreak outside of Hubei province and even the whole country. Because of the great efforts of Chinese government and medical staff, the epidemics of coronavirus has been effectively controlled in China now. As a newly emerged virus, there was a lack of awareness among medical staff in the early stage of the epidemics, so that the initial outbreak in Wuhan has not been well recognized. Pregnant women and newborns are susceptible people, so it is very important to ensure the safety of mothers and infants. In order to prevent the second Wuhan from appearing again in another country, this paper refers to the current guidelines for the management of pregnant women during the epidemic period of COVID-19 in China, and summarizes the clinical experience in the actual diagnosis and treatment of our hospital during the outbreak of the coronavirus epidemics.Because the new coronavirus is particularly infectious, outpatient service is the first window to contact patients with potential virus infection, it is very important to manage the medical staff, pregnant women and their accompanying family members in the outpatient obstetrical department, which is helpful for early detection, early diagnosis, early isolation and early treatment of coronavirus. The effective management of outpatient obstetrical department is one of the key factors to avoid the expansion of the coronavirus epidemics (See figure1).

Objective: To review studies published with pregnant women infected with SARS-CoV-2 and analyze the evolution of them and also of the newborn in order to learn about this pathology in pregnant women. Search strategy: Systematic review in the PUBMED and GOOGLE Scholar databases until March 30, 2020. This research was extended to the references of such articles. Selection criteria: Observational studies that examined maternal and perinatal outcomes of pregnant women with SARS-CoV-2 are published. Data collection and analysis: Data about study characteristics, maternal y perinatal outcomes variable extracted. Main results: We found 14 publications regarding a total of 83 pregnant women with SARS-CoV-2 and results of 84 newborns. The average gestational age was 37 weeks. The most common symptom was fever, and 30% of the pregnant women had lymphopenia on admission to hospital. Cesarean section was performed in 89% of the patients; 70% of them were indicated by SARS-CoV-2. The most common obstetric complication was premature rupture of membranes in 9.6% of them. The need for ventilation support was low. The use of antivirals, corticosteroids, and drugs for the pathology management was scarce, except for antibiotics. Preterm birth was 25%, perinatal mortality was low, and there was no maternal death. There was no evidence of vertical transmission. Conclusion: Maternal and perinatal morbidity-mortality is lower than in other known respiratory diseases. Currently, it appears to be no benefit from antivirals and other drugs, beyond the general support of the disease, and vertical transmission of the virus has not been demonstrated.

Coronavirus disease (COVID-19) with orbital complication in young childCOVID-19 is a current ongoing global health emergencyCoronaviruses cause sinonasal symptoms similar to common cold and loss of smellEndoscopic sinus surgery is an aerosol-generating procedure with high risk of COVID-19 transmissionCOVID-19 infection was related to a case of preseptal orbital cellulitisCovid-19 infection should be suspected in current cases of orbital cellulitis and management plan modified to protect medical professionals

One standout observation regarding the clinical epidemiology in the current COVID-19 pandemic is the relatively low incidence and generally mild presentation of the infections in children (Ludvigsson, 2020)⁠. Indeed, only 230 pediatric cases with 3 neonates have been reported in China through February 6 2020 (Lu & Shi, 2020)⁠ with a total of only 9 infected and hospitalized cases identified between December 8 2019 and February 6 2020 out of a total of 31,211 cases of COVID-19 reported (Wei et al., 2020). Moreover the course in infants and children was mild with infection rarely progressing to lower respiratory tract infections (Hong et al., 2020), and no deaths have been reported in this age group (Lu & Shi, 2020)⁠.Since SARS-CoV-2 is highly contagious, it is anomalous that the infection rate is so low in infants and children given the high risk of inevitable close contact they have with adults. So far, several theories to explain this anomaly include lack of nicotine exposure in children, and reduced expression of ACE2 cell surface receptors needed by SARS-CoV-2 to gain entry to host at younger ages (Song et al., 2012).Here we postulate another possibility for lower incidence and milder disease is high lactoferrin content in breast or some infant formula feedings.Lactoferrin (Lf), which is highly concentrated in human milk as well as often added to modern infant formulas has demonstrable broad-range antiviral properties (Wakabayashi et al., 2014) including against SARS-CoV, which uses the same ACE2 surface receptor to invade hosts as SARS-CoV2 (Lang et al., 2011), thus, it is not inconceivable that nutritional lactoferrin in breast milk or infant formula contributed to reduced incidence as well as milder course of COVID-19 in infants and young children. This intriguing possibility can be assessed by carefully noting the feeding history of pediatric COVID-19 cases.Author list:

Background: This case highlights challenges in the assessment and management of the “difficult airway” patient in the SARS-CoV-2 (COVID-19) pandemic era. Methods: A 60-year-old male with history of recent TORS resection, free flap reconstruction and tracheostomy for p16+ squamous cell carcinoma presented with stridor and dyspnea one month after decannulation. Careful planning by a multidisciplinary team allowed for appropriate staffing and personal protective equipment, preparations for emergency airway management, evaluation via nasopharyngolaryngoscopy, and COVID testing. The patient was found to be COVID negative and underwent imaging which revealed new pulmonary nodules and a tracheal lesion. Results: The patient was safely transorally intubated in the operating room. The tracheal lesion was removed endoscopically and tracheostomy was avoided. Conclusions: This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other “difficult airway” patients during the COVID-19 epidemic.

5 KEY POINTSIn an outbreak, early healthcare personnel segregation should be considered to ensure that the provision of essential services may continue if a single team is quarantinedEstablishing a sustainable PPE usage guideline for healthcare workers early in the outbreak is of paramount importanceDesign and simulation of work processes for emergency airway creation should be considered in every otolaryngology department dealing with the COVID-19 outbreakScreening and postponement of non-urgent patient follow-ups frees up manpower and resourcesThe use of videoconferencing aids in restoring essential department activities and telemedicine may be a useful tool to explore in otolaryngology clinicsWord count: 1494