Over the past few years, the international community adopted important policy frameworks to foster an inclusive green economy that acknowledges the value of ecosystem services, protects natural resources and promotes a sustainable future. Without finance in the tune of trillions of dollars annually, all these objectives and commitments will remain on paper. As the COVID-19 pandemic deflected the attention of governments away from long-term sustainability objectives and imposed unparalleled injections of public capital to rescue national economies, the survival of global environmental and socio-economic sustainability priorities becomes more than ever dependent on the private sector. This requires a progressive rather than defensive financial system. One that reinvigorates the sustainability momentum established by the Sustainable Development Goals (SDG), by supporting the best examples of responsible behaviour, circularity, and solidarity that emerged during the health crisis. In turn, this demands a profound rethinking of sustainable finance instruments, practices, metrics and tools in use prior to the crisis, which were clearly failing in their ability to mobilize sufficient public and private capital to accomplish the sustainability transition and convince stakeholders of results achieved. This article provides a review of some of these decision-support tools, focussing in particular on instruments of non-financial disclosure. Its main objective is to highlight key issues and gaps in sustainability assessment practice, which help explain the sustainable finance challenges and failures observed prior to the COVID-19 crisis, while pinpointing some promising examples of novel approaches that could enable a system update & reboot and revive sustainable development ambitions

This paper responds to one by Graham Martin and colleagues, who offered a critique of my previous publications on masks for the lay public in the Covid-19 pandemic. I address their charges that my co-authors and I had misapplied the precautionary principle; drawn conclusions that were not supported by empirical research; and failed to take account of potential harms. But before that, I remind Martin et al that the evidence on mask wearing goes beyond the contested trials and observational studies they place centre stage. I set out some key findings from basic science, epidemiology, mathematical modelling, case studies and natural experiments, and use this rich and diverse body of evidence as the backdrop for my rebuttal of their narrowly-framed objections. I challenge my critics’ apparent assumption that a particular kind of systematic review should be valorised over narrative and real-world evidence, since stories are crucial to both our scientific understanding and our moral imagination. I conclude by thanking my academic adversaries for the intellectual sparring match, but exhort them to remember our professional accountability to a society in crisis. It is time to lay straw men to rest and engage, scientifically and morally, with the dreadful tragedy that is unfolding across the world.

It is currently unclear whether early life stress (ELS) affects males and females differently. However, a growing body of work has shown that sex moderates responses to stress and injury, with important insights into sex-specific mechanisms provided by work in rodents. Unfortunately, most of the ELS studies in rodents were conducted only in males, a bias that is particularly notable in translational work that has used human imaging. Here we examine the effects of unpredictable postnatal stress (UPS), a mouse model of complex ELS, using high resolution diffusion magnetic resonance imaging. We show that UPS induces several neuroanatomical alterations that were seen in both sexes and resemble those reported in humans. In contrast, exposure to UPS induced fronto-limbic hyper-connectivity in males, but either no change or hypoconnectivity in females. Moderated-mediation analysis found that these sex-specific changes are likely to alter contextual freezing behavior in males but not in females.

The main direction of left ventricular (LV) contraction is based on the different architecture of myocardial fibers. Thus, it can be assumed that the specific analysis of different compounds of LV deformation might be a crucial diagnostic tool in patients with infective myocarditis (IM). This case report focusses on conspicuous findings of regional LV deformation in a patient with IM and preserved LV systolic function. Despite unspecific clinical symptoms in IM, e.g. subfebrile temperatures, cough, palpitations, suspect findings of circumferential and rotational deformation can be helpful to initiate further diagnostic procedures to confirm the diagnosis, e.g. cMRI or myocardial biopsy.

Background In ~25% of echo studies discrepant diastolic measurements make the assessment of diastolic function indeterminate. We aimed to assess whether left atrial function may contribute to LV filling evaluation in patients with indeterminate diastolic function (IndtDFx). Methods In our retrospective echocardiography database we found 1674 consecutive patients in sinus rhythm, and EF≥45%. Patients were divided according to the parameters mitral E’, mitral E/E’ ratio , left atrial maximal volume index , and pulmonary pressure. Normal diastolic function (NDFx) was defined as less than 2 abnormal parameters, definite diastolic dysfunction (DDFx) as more than 2 abnormal parameters, and IndtDFx as 2 abnormal parameters. We retrospectively and randomly selected 30 patients from each group for left atrial assessment by speckle tracking echocardiography for off line strain and volumes analysis. Results: sixty seven patients were included in strain analysis. The DDFx group (n=21) and IndtDFx (n=19) were significantly different form NDFx (27) in demographics, cardiovascular risk factors., presentation and echocardiographic parameters. Phasic LA maximal and minimal volume indexes were larger in DDFx and indtDFx groups, and overall and passive LA strains were decreased in DDFx and indtDFx groups compared with NDFx group, while active strain remained in the normal range. Phasic LA minimal volume index was found to be associated with HF symptoms. Conclusion LA phasic function suggests that IndtDFx is similar to DDFx , helping in re- classification of patients with IndtDFx as DDFx. LA minimal volume index correlated with symptoms.

Objectives We aimed to investigate whether uncomplicated type A intramural hematoma (IMHA) patients with type 2 diabetes mellitus (DM) who underwent a “wait-and-watch strategy” and tight glycemic control had similar clinical outcomes as patients without DM who received the same treatment strategy. Methods Between January 2010 and December 2016, uncomplicated IMHA patients with and without diabetes mellitus were included and were propensity score matched to improve balance between the two groups. Cox proportional hazard models were constructed to identify the specific factors associated with aorta-related mortality. The Fine-Gray model for the competing risk analysis was used to estimate the aorta-related and non-aorta-related mortality in different groups during the follow-up period. Results 109 IMHA patients were included in this study, and 66 patients were included after matching. Patients without DM experienced significantly more aorta-related adverse events (51.6% vs 13.3%, P=0.001) and reinterventions than patients in the DM group (29.0% vs 6.7%, P=0.023). Cox regression analysis revealed that a higher matrix metalloproteinase-9 level (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.39-2.09, P<0.001) and larger maximum aortic diameter (HR, 1.41; 95% CI, 1.11-1.80, P=0.005) were associated with higher aorta-related mortality. The competing risk analysis revealed a significantly higher aorta-related mortality during the follow-up period in the no DM group than in the DM group (36.4%; 95% CI, 11.6%-82.3%, P=0.0294). Conclusions Uncomplicated IMHA patients with DM (receiving the “wait-and-watch strategy” and tight glycemic control) may have a lower aorta-related mortality, and rates of aorta-related adverse events and reinterventions than the no DM group.

1. The age range of patients responding to the survey was 28-85 with a mean of 58\(\pm\)12 years with the duration of their disorder less than 5 years in 63% of cases. 2. Patients experience variable treatment, if at all, for post-viral olfactory loss 3. If treatment is given oral and/or intranasal steroids are typically given. 4. Several patients reported receiving imaging despite this not being clinically useful when there is a clear history and normal examination. 5. Over two thirds of patients experience parosmia and up to 5 years of the onset of the problem were still actively seeking a solution.

The screening for IgG subclass donor-specific antibodies (DSAs) in allograft recipients uses IgG1-4 subclass-specific monoclonal antibodies (mAbs) that should be mono-specific. The cross-reactivity discrepancies reported for IgG subclass-specific mAbs warranted a critical cross-reactivity pattern analysis of the IgG subclass-specific mAbs most commonly used to detect DSAs. We tested the reactivity of 2 anti-IgG1-, 3 anti-IgG2-, 1 anti-IgG3-, and 2 anti-IgG4-specific PE-conjugated mAbs against microbeads coated with IgG1-4 proteins separately. Each IgG subclass protein was coated at three densities on the beads (0.5, 1 and 2 µg of protein per 106 beads), and the PE-conjugated mAbs were titrated from 0.04µg/mL to 5µg/mL. The IgG subclass reactivity of the sample was acquired on the Luminex multiplex platform. Among the IgG subclass-specific mAbs, only the anti-IgG3 (clone: HP6050) mAb was mono-specific. All other mAbs tested were binding to IgG subclass proteins other than their respective immunogen, thereby being cross-reactive. IgG subclass cross-reactivity patterns were dependent on the concentration of both IgG subclass-specific mAbs and IgG1-4 protein targets coated onto the beads. With the current IgG subclass mAbs available, 3 of the 15 possible combinations of IgG1-4 subclass protein could be identified. While the remaining 12 unique combinations cannot be distinguished clearly, 6 groups that corresponded to two different unique combinations of IgG1-4 subclass protein could be identified. The dilution of serum samples and IgG subclass-specific mAbs, other than the anti-IgG3 (clone: HP6050), must be further optimized before their implementation of IgG subclass DSA screening in allograft recipients.

Left ventricular outflow tract (LVOT) obstruction is caused by a wide range of different anatomical lesions referred to as subaortic stenosis (SS). SS can be isolated or associated with other heart defects; and tends to evolve and progress over time even though the speed of its progression is very variable and difficult to predict. We present a case of a patient affected by sub aortic membrane undergone to surgical procedure.

Recombinant proteins in Escherichia coli are usually expressed inside the cell. With the growing interest in continuous cultivation, secretion of product to the medium is not only a benefit, but a necessity in future bioprocessing. In this study, we present the X-press strain, a novel E. coli production host for growth decoupled, extracellular recombinant protein production. We investigated the effect of the process parameters temperature and specific glucose uptake rate (qS) on the strain’s growth, productivity, lysis and leakiness, to find the parameter space allowing extracellular protein production. Two model proteins were used, Protein A and a VHH single-domain antibody, and performance was compared to the industrial standard strain BL21(DE3). We show that inducible growth repression in the X-press strain greatly mitigates the effect of metabolic burden under different process conditions. Furthermore, temperature and qS were used to control productivity and leakiness. In the X-press strain, extracellular Protein A and VHH titer reached up to 349 mg/g and 19.6 mg/g, respectively, comprising up to 90% of total soluble product, while keeping cell lysis at a minimum. Our findings demonstrate that the X-press strain constitutes a valuable host for extracellular production of recombinant protein with E. coli.

Aim: To systematically identify studies of implementing risk management measures when prescribing teratogenic medicines for women of child bearing age and studies reporting risk perceptions of teratogenic medications. Methods: MEDLINE, CINAHL, Scopus, EMBASE, and International Pharmaceutical Abstracts were searched. Studies were included in the risk management section if they reported any of the following risk management measures: teratogenic counselling, contraceptive counselling, pregnancy testing before starting treatment, pregnancy testing during treatment, use of contraception before starting treatment, and use of contraception during treatment. Studies were included in the perceptions section if they reported perceived teratogenic risk as numerical value. Results: Fifty-five studies were included in the risk management section and seven studies were included in the perceptions sections. Prevalence of risk management measures varied as follows: teratogenic counselling (9.5-99.3%), contraceptive counselling (6.1-98%), pregnancy testing before starting treatment (0-95.1%), pregnancy testing during treatment (12.7-100%), contraception use before starting treatment (15.7-94%), and contraception use during treatment (1.7-100%). A proper estimation of the teratogenic risk was reported for thalidomide (by general practitioners and obstetric/gynaecologists), for etretinate (by pregnant women), and for misoprostol (by pregnant and non-pregnant women). An under-estimation was reported for warfarin and retinoids (by general practitioners and obstetric/gynaecologists). And over-estimation was reported for thalidomide, valproate, lithium, isotretinoin, phenytoin, warfarin and etretinate by different populations. Conclusion: Considerable variation in the implementation of risk management measures when prescribing teratogenic medicines to women of child bearing age is reported in the literature. A common tendency to over-estimate the risk of teratogenic medications was evident.

In recent years, the use of bioprosthetic valve (BPV) has increased significantly with both surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) due to reasons such as the advantage of not using anticoagulants. Nevertheless major disadvantage of all BPV is the risk of early structural valve deterioration, leading to valve dysfunction, and requires reoperation, which significantly increases the risk of mortality or major morbidity especially after SAVR. There are a limited number of TAV-in-TAV case reports due to TAVI BPV degeneration. In our knowledge this is the second report of TAV-in-TAV implantation wherein a previously implanted transfemoral 25-mm nonmetallic Direct Flow SVD valve treated with ViV TAVI via Edwards Sapien XT.

Background Fractional flow reserve (FFR) is a well-established method for the evaluation of coronary artery stenosis before PCI. However, whether FFR assessment should be routinely used before CABG remains unclear. Our aim was to compare the outcomes of using FFR with that of conventional CAG (coronary angiography) in guiding CABG. Method This systematic review and meta-analysis was performed according to the PRISMA guidelines. Six studies were included, of which four were double-arm (two prospectively randomised) and two single-arm, reporting data on 1931 patients. A meta-analysis was done for double-arm studies, comparing rates of overall death, MACCE, target vessel revascularisation, spontaneous MI and graft patency. The data of all six studies were entered in a pooled analysis for the endpoints of overall death, spontaneous MI and target vessel revascularisation. Results Meta-analysis demonstrated significantly lower death rates in the FFR-guided than the CAG-guided group (p=0.03) and no significant differences in the rates of MACCE, target vessel revascularisation, spontaneous MI and graft patency. In pooled analysis, FFR-guided group was linked with lower rates of overall death and spontaneous MI. Graft occlusion rate was significantly lower after FFR in one retrospective study, however, this difference was lost in meta-analysis (p=0.24). Conclusion In this meta-analysis, FFR-guided CABG was associated with lower overall death rate and was, at least, non-inferior in the endpoints of MACCE, target vessel revascularisation, spontaneous MI and graft patency than CAG-guided CABG. Further randomized trials are needed to define the role of FFR in guiding CABG surgery.

The nascent wave of disruptive competition in the current business environment brought about by the fourth industrial revolution (Fashion 4.0 or Apparel 4.0) is enormous. Therefore, it is paramount important to apparel industry to be flexible enough to respond quickly to the unstable customers’ demand through continuous improvement of their process efficiency and productivity. This study aims at achieving an optimal trouser assembly line balancing using simulation-based optimization via design of experiment. The empirical study is conducted at Southern Range Nyanza Limited (NYTIL) garment facility and a complex trouser assembly line with 72 operations is considered. The discrete event simulation of the trouser assembly line is developed using Arena simulation software. The local optimal solution is obtained from simulation experimentation and is adopted for the optimization process. The OptQuest tool is utilized to solve a single objective function (throughput) optimization problem. The results show that average throughput increases from the existing design (490 pieces per day) to local optimal design (638) and global optimal design (762). Consequently, the line efficiency increases from 61.2% to 79.7% to 95.2% respectively. The high increase in line efficiency and average throughput confirms the suitability assembly line balancing using simulation-based optimization via design of experiment.

During the COVID-19 pandemic, ER visits have drastically decreased for non-COVID conditions such as appendicitis, heart attack and stroke. Patients may be avoiding seeking medical attention for fear of catching the deadly condition or as an unintended consequence of stay-at-home orders. This delay in seeking care can lead to increased morbidity and mortality, which has not been figured in the assessment of the extent of damage caused by this pandemic. This case illustrates an example of “collateral damage” caused by COVID-19 pandemic. What would have been a standard STEMI treated with timely and successful stenting of a dominant right coronary artery occlusion, became a much more dangerous post-infarction VSD; all because of a 2-day delay in seeking medical attention by an unsuspecting patient.

Background and Aim: The optimal duration of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients affected by postcardiotomy cardiogenic shock (PCS) remains controversial. We aimed to investigate the impact of VA-ECMO duration on hospital outcomes. Methods: Data on PCS patients receiving VA-ECMO were retrieved from the multicentre PC-ECMO registry. Patients were stratified according to different duration of VA-ECMO therapy: ≤3 days, 4-7 days, 8-10 days, and >10 days. Results: A total of 725 patients with a mean age of 62.9±12.9 years were included. The mean duration of VA-ECMO was 7.1±6.3 days (range: 0-39 days), and 39.4% patients were supported for ≤3 days, 29.1% for 4-7 days, 15.3% for 8-10 days, and finally 20.7% for >10 days. A total of 391 (53.9%) patients were successfully weaned from VA-ECMO while 134 (34.3%) died prior to discharge. Multivariable logistic regression showed that prolonged duration of VA-ECMO therapy (4-7 days, adjusted rate 53.6%, odds ratio [OR] 0.28, 95% confidence interval [CI] 0.18-0.44; 8-10 days, adjusted rate 61.3%,OR 0.51, 95% CI 0.29-0.87; and >10 days, adjusted rate 59.3%,OR 0.49, 95% CI 0.31-0.81) was associated with lower risk of mortality compared with VA-ECMO lasting ≤3 days (adjusted rate 78.3%). Patients requiring VA-ECMO therapy for 8-10 days (OR 1.96, 95% CI 1.15-3.33) and >10 days (OR 1.85, 95% CI 1.14-3.02) had significantly higher mortality compared to those on VA-ECMO for 4-7 days. Conclusions: PCS patients weaned from VA-ECMO after 4 to 7 days of support had significantly lower mortality compared with those with shorter or longer mechanical support.

Ring species and ring diversification provide good evidence of gradual speciation. Studying differentiation in ring species/ring diversification patterns contributes to understanding the process of speciation. We applied a fine-scale phylogeographic survey to two congeneric small mammals, the South China field mouse (Apodemus draco) and the Chevrier’s field mouse (A. chevrieri), which are endemic to the mountains of Southwest China (MSC), combining mitochondrial (Cytb and COI) and nuclear (microsatellite loci) markers, with dense sampling throughout the range (411 A. draco from 21 sites and 191 A. chevrieri from 22 sites), as well as species distribution modeling, scenario testing of dispersal routes and redundancy analyses of environmental and spatial factors to characterize the population genetic structure and infer the proximate formation mechanism of these patterns. Our results revealed that both A. draco and A. chevrieri clustered into western and eastern lineages, which dispersed clockwise and anticlockwise, respectively, from west to northwest. The two species showed gradually increasing genetic differences with geographic distance and displayed a ring diversification pattern around the Sichuan Basin. The tectonic events of the Qinghai-Tibetan Plateau (QTP) and climatic oscillations during the Quaternary triggered the genetic divergence of A. draco and A. chevrieri by providing environmental heterogeneity and spatial variation, and shaped the ring diversification pattern with the effect of species traits. Our report on the two ring patterns provides supportive evidence for the hypothesis that speciation is a continuous process in nature. Key words: small mammal, phylogeography, speciation, ring species, diversification, mountains of Southwest China

COVID-19, the disease resulting from infection by a novel coronavirus: SARS-Cov2 that has rapidly spread since November 2019 leading to a global pandemic. SARS-Cov2 has infected over 2.8 million people and caused over 180,000 deaths worldwide. Although most cases are mild, a subset of patients develop a severe and atypical presentation of Acute Respiratory Distress Syndrome (ARDS) that is characterised by a cytokine release storm (CRS). Paradoxically, treatment with anti-inflammatory agents and immune regulators has been associated with worsening of ARDS. We hypothesize that the intrinsic circadian clock of the lung and the immune system may regulate individual components of CRS and thus chronotherapy may be used to effectively manage ARDS in COVID-19 patients.

A document by Anjali Maan. Click on the document to view its contents.

A few specific scenarios applied in examples of only five works suggest that the solely use of robust estimators for nonlinear dynamic data reconciliation is able to cope with biased measurements. We present a counterexample to that belief on a dynamic model of two CSTRs that gives rise to wrong transient behaviour. Motivated by this, we introduce and examine an invariant approach to measurement bias. It is based on the location invariance assured by a robust measure of scale used when detecting a sequence of consecutive differences between measured and reconciled values of the same sign. When applied to the counterexample, it can be seen that the procedure has the correct behaviour and shows good results.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder that causes the progressive loss of motoneurons, and unfortunately, there is no effective treatment to stop the disease. Multiple pathological mechanisms are interconnected in the neuropathology of this disorder, including abnormal aggregation of proteins, neuroinflammation and dysregulation of the ubiquitin proteasome system. Such complex mechanisms, together with the lack of reliable animal models of the disease, have hampered drug discovery in the last decades. Protein kinases, key pharmacological targets in several diseases, have been linked to ALS, as they play a central role in numerous of these pathological mechanisms. Therefore, several inhibitors are currently in their way to achieve a clinical proof of concept in ALS patients. In this review we recapitulate the protein kinase inhibitors currently in development for this disease together with their molecular targets and their involvement in the pathobiology of ALS.

Background: High-density automated mapping of complex atrial tachycardias (ATs) requires accurate assessment of activation maps. A new local activation display module (HD Coloring, Biosense Webster®) provides higher map resolution, a better delineation of potential block reducing color interpolation, and a new propagation display. We evaluated the accuracy of a dedicated local activation display compared to standard algorithm. Methods: High density maps from 10 organized atrial tachycardias were collected with a multipolar catheter and were displayed with standard activation or HD Coloring. Six blinded expert operators retrospectively analyzed activation maps and were asked to define (1) the tachycardia mechanism, (2) ablation target, and (3) level of difficulty to interpret those maps. Results: Using HD Coloring, operators were able to reach a correct diagnosis in 93% vs. 63%, p<0.05 compared to standard activation maps. Time to diagnosis was shorter 1.9±1.0 min vs. 3.9±2.1 min, p<0.05. Confidence level would have allowed ablation without necessity for entrainment maneuvers in 87% vs. 53%, p<0.05. Operators would have needed to remap or proceed with multiple entrainments in 3% vs. 13% of cases, p<0.05. Finally, ablation strategy was more accurately identified in 97% vs. 67%, p<0.05. Conclusion: Activation mapping with the new HD Coloring Module allowed a more accurate, reliable, and faster interpretation of complex ATs mechanisms compared to standard activation maps.

Background: In 2019, Ireland extended its Human Papilloma Virus (HPV) vaccine schedule from females of school going age, to include males. Aims: We know that knowledge aids in vaccine acceptability [1], and as such we aimed to assess women’s knowledge of HPV and the vaccine, and if they found the vaccine to be acceptable for both men and women. Methods: This was a questionnaire based study, which took place over a six month period in a general hospital. 100 women attending our gynaecology clinic were asked to complete a 22Q questionnaire, which was based on similar, validated questionnaires. Participants were included if over 18 years, female and capable of consenting. Results: We collected results from n=100 women. Over ¼ (n=26) had never heard of the HPV vaccine. Of these, none knew the risk factors for contracting HPV nor the diseases caused by HPV. Of this subgroup all women responded ‘I don’t know’ when asked if they think boys and girls should receive the vaccine. Of women who had heard of the vaccine (n=74) , 85% believed girls should receive the vaccine, while only 56% believed boys should. Conclusions: Our study highlights the ongoing lack of knowledge surrounding HPV and the HPV vaccine within this community. The importance of knowledge for vaccine acceptability, is highlighted by vaccination considered less acceptable for males, perhaps owing to the lack of education towards this gender. This may affect vaccine uptake within this subgroup and as such we suggest further education be directed towards males

I moved out of our shared bedroom of nearly 10 years on 3/22/2020. It was not a difficult decision as we have two young children and wondered what would happen if both of us became ill at the same time. As a Maternal-Fetal medicine physician in New York City, I was acutely aware of the coming COVID-19 crisis, and its potential ramifications on the health of my family, friends, patients and community. I am trained to function well in emergencies, and in this case, it was a quick and seemingly logical next-step to sleep separately.This decision also comes along with an already in place full-scale decontamination effort that begins as soon as I enter our home. This involves minimizing what jewelry, clothing, food and bags go back and forth between the hospital and my home, 3-shoe changes, stripping off my clothing and placing everything into the wash, and then running to the shower. None of these choices were rooted in years of medical science, given the novelty of the virus, and paucity of data on the SARS-CoV-2 (COVID-19). I used early data regarding transmission as well as anecdotal reports from friends in Asia who seemed to suggest that it was highly contagious and highly transmissible. Thus, when I recently learned that there is a science and a history surrounding how pathogens have shaped human psychological adaptations. As we are forced to confront the longstanding evolutionary pressure of pathogen avoidance regarding what to eat, and touch and who to be intimate with, it no longer feels theoretical.1Looking back at what I’ve gained and what I’m missing over this last month, I am acutely aware of how much less we are touching as a family and in my medical practice, and I miss it. As I say goodnight to my family and retreat to our windowless den, I am both thankful for a place to sleep that is near enough to be able to peek at their beautiful sleeping faces, while sad that I feel less at ease hugging or kissing them. While every health care worker on the front-line of this crisis has drawn different boundaries (some more or less extreme), my decision to sleep in a separate room, create a decontamination routine, and be less physically affectionate with my children was the only way I could feel in control in an uncontrollable situation.Medical professionals know that touch, rooted in the amygdala of the brain, cannot be separated from the expression of empathy and solidarity that it provides.2 In medicine, touch has long been hypothesized to have an impact on health and development over our lifespan. Dr. Cascio and her team at the Vanderbilt Kennedy Center for Human Development describe social touch as “a powerful force in human development, shaping social reward, attachment, cognitive, communication, and emotional regulation from infancy and throughout life.3” Many of the babies of the mothers I care for will begin their lives in the Neonatal Intensive Care Unit where the science surrounding touch as part of healthcare is widely accepted and engrained in the culture. Skin-to-skin and kangaroo care, the act of carrying your child in a pouch-like device, have been shown to improve breastfeeding, bonding, and neurocognitive development4,5 In fact, the World Health Organization currently has an ongoing international trial looking at the benefits of survival on low-birthweight infants of kangaroo care initiated immediately after birth on survival of low birth weight infants.6 Later in life, touch, relationship quality and intimacy continue to drive good health and have been associated with improved cognitive function in the Rotterdam Study7,8and improved cardiovascular outcomes in the National Social Life Health and Aging Project.8 Their findings suggest physical touch may have positive health implications for older adults.Prior to the pandemic, physicians were already sounding alarms about the loss of medical touch in modern medicine. In a 2011 TED talk with over 1.7 million views, renowned author and physician Abraham Verghese discussed the power of physician touch and the physical exam as he tried to revive the culture of bedside medicine.9 With this pandemic all of that has changed. We are all exceedingly careful to prevent transmission and yet try to provide care and solace in new ways. At the bedside, a gloved hand continues to provide care and comfort. I am happily finding ways to connect with patients through smiling eyes behind a mask, and jokes or phrases that now replace touch. I find myself more commonly expressing words of empathy in telemedicine visits to fill in for the gaps that touch might have provided before. I ask many, many questions to understand symptoms if I cannot see the patient in person. Due to the surrounding events, I am undertaking the fulfilling process of learning a new skill in medicine, to express my emotions on a screen and affect patients’ lives in ways similar to that of an in-person visit.As we raise our family in this time of pandemic, I am thankful that my husband is doing “double-duty” in the realm of hugging and kissing, and has always been a physically affectionate father to our children. I try to tell them how much I love them with greater frequency and despite the concerted effort there are days it’s almost impossible to share our apartment without being physically close. The psychological impact this crisis will have on them is yet to be determined. I hope time will find them healthy, more resilient and grateful at the end of this journey.But tonight, as they sleep soundly in their beds for another night, I am still saddened that I’m not doing the usual kissing and hugging as I tuck them into bed, and it feels like a true loss, among the many others. I am not sleeping as soundly these days for a multitude of reasons including the guest bed, the strangeness of being alone after so many years, and the exponential rise in screen time for work and media consumption. I am truly hopeful we will return to a time when we can more freely touch and care for the people we love and the patients we value so much. In the simplest of internet searches, touch has so many definitions. Touch can mean to be in close contact, but it can also mean to affect.10 COVID-19 has affected us in innumerable ways, and as healthcare workers navigate a post-COVID landscape, I’m hopeful we can continue to innovate and find safe ways to incorporate medical touch into a practice that will be forever changed.Acknowledgements : I would like to acknowledge our patients for their immense flexibility in this changing landscape, the support of my division and department, and my family. I’d like to thank Dr. Gwendolyn Quinn and my husband David Lee, for their significant editorial assistance.