Gaurav S Desai*Department of Obstetrics and GynecologyBandra Bhabha Municipal General HospitalMumbai, IndiaCorresponding AuthorGaurav S Desai MS FCPSDepartment of Obstetrics and GynecologyBandra Bhabha Municipal General HospitalMumbai, India+91-8169936775Running title: COVID 19 in pregnancyAuthor contributions: GSD was responsible for this manuscript

In December 2019, the new acute respiratory syndrome coronavirus 2 (SARS-Cov-2) emerged in Wuhan, China, with an infection of pandemic proportions. Data from Wuhan showed that mortality from coronavirus disease 2019 (COVID-19) is strongly associated with cardiovascular diseases. Similar to SARS-Cov-1, which was responsible for the SARS epidemic from 2002 to 2004, SARS-Cov-2 also utilizes the host protein angiotensin II-converting enzyme (ACE2) as a coreceptor to gain intracellular entry. Hence, upregulation of ACE2 has been proposed as a potential factor in infectivity and a higher risk of harmful outcomes of COVID-19. In this context, data obtained from experimental models of hyperthyroidism have demonstrated increased cardiac ACE2, which can theoretically facilitate SARS-Cov-2 entry. However, there is currently no consistent scientific research on how COVID-19 specifically affects hyperthyroid patients, and more clinical and experimental evidence is urgently required to clarify this point. In this review, we highlight important known and unknown features of COVID-19 related to ACE2 and hyperthyroidism.

Objective: Surgical/anesthetic management of patients undergoing surgical tracheostomy for Covid-19 pneumonia aiming at minimizing the risk of health care workers (HCWs) infection. Design, Setting and Paticipants: Twenty-three Caucasian patients, mean age 67 years, with long-term orotracheal intubation for severe acute respiratory syndrome Covid-19 pneumonia were submitted to surgical tracheostomy, between February 3rd and March 22nd 2020, according to our specific procedure. Main outcomes and Measures: Air exposure time (AET) and frequency of infection in HCWs. Results: No complication, in terms of bleeding or tracheostomy cannula displacement, was observed. No HCWs involved in the procedures contracted Covid-19. Conclusions: The tracheostomy technique we describe minimizes the risk of surgeon’s exposure to patient’s aerosol drops/expired air and the possibility of HCWs infection during the procedure carried out in patients with Covid-19 pneumonia. The details and advantages of our approach with respect to “standard” tracheotomy and percutaneous procedures are discussed.

AbstractThe human microbiome, especially the microbiomes of the gastrointestinal and respiratory tracts, are potentially important in determining susceptibility to COVID-19 and the immunopathology that leads to severe disease. Data is beginning to be gathered on the risk factors for severe disease in the coronavirus disease of 2019 (COVID-19). This data will be discussed in connection with some highlights of what is being learned about the human microbiome and its relationship with viral illnesses and inflammation-related chronic diseases. In particular, possible roles for diet, lifestyle, and microbiota manipulation as means of reducing rates of severe viral disease will be explored. Some potential pharmaceutical approaches to treating severe COVID-19 disease, involving the microbiome, mast cells and hypersensitivity responses, are also discussed. It is proposed that chronic low-grade infections and/or dysbiosis may underlie the age-related diseases that are risk factors for severe disease from SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). It is also suggested that the connection between these chronic diseases and COVID-19 may have implications for understanding some of the reasons for the severity of COVID-19 in a proportion of patients. Whether or not the hypothesis of a causal role for dysbiosis or prior infection is correct, some of the suggested treatment approaches might still be worth investigating.Keywords: microbiome, COVID-19, Westernized diet, exercise, stress, mast cells, cytokine storm, IL-6, plant-based diet, inflammation, dysbiosisIntroductionResearchers are rapidly gaining knowledge about COVID-19 to help address the current global pandemic, with a focus on treatment and prevention of the spread of the disease[1–3]. This article has two primary aims. The first aim is to examine the characteristics of the disease and the individuals who are most susceptible to severe disease to see if they can help reveal how humans can become less susceptible. A second aim is to explore whether these considerations might suggest treatment approaches that have potential to help at least some of those who are already suffering from severe disease. It is hoped that this review will be able to suggest areas of research that could be helpful in dealing with both the current pandemic and with other similar diseases or future epidemics.The emphasis here will be on the human microbiome and the diet, lifestyle and medical intervention factors that often affect it. This emphasis arises from the increasing research showing the profound impact of the human microbiome on immune function and many aspects of diverse disease processes[4,5]. The human genetic makeup is certainly important; however, the microbiotas inhabiting different parts of the human body are increasingly being shown to be crucial factors. It has been estimated that there are as many bacterial cells in the human body as human cells[6], and numerous microbial metabolites from the microbiome reach the blood stream and are increasingly being investigated[7]. This has led to the human microbiome being called the second genome[8]. One advantage of focusing on this second genome is that studies are showing that it can be altered much more easily than the human genome, apparently with beneficial effects, such as in the treatment of antibiotic-associated diarrhea due to Clostridiodes dificile infection using fecal microbiota transplants[9].The rapid changes in diet, lifestyle, environmental exposures and medical interventions in the last 75 years has led to changes in the human microbiome that may not be optimally compatible with our evolved immune responses to pathogens. This perspective is closely related to the hygiene hypothesis[10] and its newer forms, such as the altered microflora hypothesis[11] and an extension of these earlier hypotheses that focuses on the potentially pathogenic microbes within the post-hunter-gatherer era microbiota (PHM)[12]. Throughout this review, attention will be paid to factors that might lead to the establishment of these potentially pathogenic microbes, which include environmental microbes that are less coevolved with their human hosts and thus could have greater immune suppressing/dysregulating potential.

KEYPOINTSCOVID-19 patients often require prolonged mechanical ventilation, and tracheostomy is a common choice.Shared guidelines for intensive care unit patient tracheostomies for COVID-19 patients do not exist.Our survey indicates the timing and technique of COVID-19 tracheostomies vary considerably among hospitals in Lombardy, Italy.Otolaryngologists are seldom involved with decision-making regarding tracheostomies for intensive care unit COVID-19 patients.Evidence-based interventions are essential for providing the best care to invasively ventilated COVID-19 patients.KEYWORDSSARS-Cov-2; COVID-19; coronavirus; tracheostomy; percutaneous tracheotomy; surgical tracheostomy; intubation; ventilation.INTRODUCTIONAfter identifying the first Italian COVID-19 infected patient on 20 February 2020, a rapidly escalating infection cluster was discovered. On 21 February, a response coordinated by a governmental task force progressively led to a countrywide lockdown beginning on 9 March. Italy became the first Western country to address COVID-19, which on 20 March, the World Health Organization declared a pandemic.Although pneumology, infectious disease, and intensive care units (ICUs), as well as emergency departments, have carried the heaviest healthcare burden during this outbreak,1 other departments must also address the increased infectious risk while meeting patient needs. Given the number of COVID-19 patients requiring long-term invasive ventilation, a surge in tracheostomies have ensued. Otolaryngologists have quickly become involved in patient management, despite previously having been ’second-line’ specialists during infectious outbreaks.2 This unprecedented need for tracheostomies reopened decades-old debates about ICU patient tracheostomy timing, techniques and operators: supporters of late versus early tracheostomies, percutaneous tracheostomies (PTs) versus open surgical tracheostomies (STs) and otolaryngologists versus anaesthesiologists.This unprecedented situation similarly affected all hospitals in the region, overburdening ICUs and inpatient units. Our study aimed to illustrate the COVID-19 healthcare situation and investigate ICU tracheostomy management decisions.MATERIALS AND METHODSWe prepared a 13-item questionnaire asking the following: the number of COVID-19 patients treated, ICU dedicated beds, tracheostomies performed and their timing, preferred tracheostomy techniques with reasons for choosing PT or ST. The questionnaire was sent to each otolaryngology department in the Lombardy region, during the first week of April 2020. Department directors, instructed to collect data by collaborating directly with their respective ICUs, responded by phone the following week.

Recently (2019), a novel coronavirus (SARS-CoV-2) first reported in Wuhan, China has been declared a pandemic by the World Health Organization and is rapidly spreading throughout the globe which is associated with high morbidity and mortality, especially in the elderly and those with existing chronic conditions. SARS-CoV-2 infects cells through interaction of its surface glycoprotein with the human angiotensin converting enzyme 2 (ACE-2). This study conducted a analysis of mutation frequency in the surface glycoprotein of 796 sequenced SARS-CoV-2 isolates from different geographical locations in the GISAID and GenBank databases. Multiple sequence alignment analysis of the surface glycoprotein identified 64 different mutations at the protein level spanning multiple geographic locations globally. A cluster of mutations was identified in the receptor binding domain (RBD) of the surface glycoprotein. Significantly, the analysis showed that 68.5% of the isolates contain a D614 residue compared to 31.5% which contain a G614 suggesting virus is spreading in two forms. Furthermore, our investigation found that one isolate from Belgium had acquired 5 cumulative mutations in the surface glycoprotein indicating possible antigenic drift. The findings of this study are of critical importance for the design of vaccines and novel drugs against this severe acute respiratory syndrome coronavirus.

CaseA 35-year-old pregnant woman, 34 weeks gestation, was admitted to a tertiary hospital after 3 hours of clear vaginal fluid discharge. Labor occurred spontaneously on that day, and a healthy female baby was delivered with no evidence of infection (SARS-CoV-2 negative upon throat swab). This was the mother’s second pregnancy and delivery. On the second day after vaginal delivery, the patient presented with persistent low fever and dry cough. Laboratory investigations showed white blood cell count (WBC) 7.1×\(10^{9}\)/L (reference range 3.5-9.5), neutrophil ratio (N%) 84.7% (reference range 40-75), lymphocyte count (L#) 0.69×\(10^{9}\)/L (reference range 1.1-3.2), and C-reactive protein (CRP) 73.63 mg/L (reference range 0.0-0.4). Throat swabs from the patient tested positive for SARS-CoV-2 by real-time RT-PCR assays, and the chest CT scan showed multiple infiltrations of different sizes in both lungs and a small amount of fluid on both sides of the chest. Considering these findings, the patient was diagnosed with SARS-CoV-2 and isolated. She had no other history of comorbidities, and was treated with i.v. antibiotics and hormones, and was administered oxygen through a nasal catheter (Figure 1). The patient experienced dyspnea and cyanosis on the following day. Considering her critical condition, she was transferred to the intensive care unit (ICU) for further treatment.After transferring to the ICU, she quickly developed severe acute respiratory distress syndrome (ARDS), and her symptoms did not improve after she was given a non-invasive ventilator. The CT scan showed a density shadow and a large-scale ground-glass opacity in both lungs, which had progressed in severity compared with the scan on Day 2 post-delivery. She required tracheal intubation on the 14th day of hospitalization. Gram-positive and gram-negative bacteria (Acinetobacter baumannii, Klebsiella pneumoniae) were positively cultured in her sputum. Antibiotics were administered according to the results of a drug sensitivity test. Empirical antifungal treatment was also given. Antiviral, nutritional and symptomatic treatments were also performed simultaneously. After 11 days of ICU treatment, the patient’s condition significantly improved. Tracheal intubation was removed and replaced with non-invasive ventilator. The patient was changed to high-flow humidified oxygen several days later, and she was transferred to the general ward for treatment. Her symptoms and primary treatment strategy are illustrated as shown in Figure 1.

Two papers in this issue, on births to Covid-19 infected mothers, are important additions to this rapidly evolving literature. They are both broadly reassuring.The paper from Lombardy, the epicentre of the pandemic in Italy, is the first detailed report of pregnancies from this large region (Ferrazzi et al. BJOG 2020 xxxx). Among 42 affected women, 19 developed pneumonia, of whom seven required oxygen and four critical care. Eighteen babies were delivered by Caesarean, although in eight the indication was unrelated to Covid-19. Three babies tested positive for SARS-COV-2. Two to women who had developed Covid-19 postnatally and had breast-fed without a mask; the presumed source was the mother. One baby who delivered vaginally and did not breast-feed, developed respiratory symptoms requiring one day’s ventilation and tested positive. No mothers or babies died.The paper from China reports SARS-COV-2 viral tests in a range of body fluids from mothers and babies with COVID-19, cared for at Renmin Hospital of Wuhan University (RHWU) (Yanting Wu et al. BJOG 2020 xxxx). This hospital appears on the Global Research Identifier Database (GRID) here https://grid.ac/institutes/grid.412632.0. Readers should know that the GRID database reports that RHWU has the following English aliases “People’s Hospital of Wuhan University”, “Hubei Provincial People’s Hospital”, “First Affiliated Hospital of Wuhan University”, “Wuhan University Renmin Hospital” and “Hubei General Hospital”. This raises the possibility that some or all of the cases may have been reported previously.With this proviso, the detailed information that 1/9 stool samples, 0/13 vaginal samples, and 1/3 breast milk samples were positive is important. Of the five babies who have delivered, none tested positive for Covid-19, although two, both preterm, had pneumonia diagnosed on chest x ray. Apart from one biochemical pregnancy in the first trimester in which a serum human chorionic gonadotrophin of 25.9 IU/L reverted to negative, no mothers or babies died.Taken together with other accumulating data, it is already clear that Covid-19 is less severe in pregnancy than the two previous coronavirus infections, Severe Acute Respiratory Syndrome-related coronavirus (SARS) and Middle East Respiratory Syndrome-related coronavirus (MERS). Nevertheless, four of the mothers from Lombardy required critical care, and there have been other reports of both mother and baby deaths in association with Covid-19. It remains an important disease in pregnancy, which should be taken seriously.No disclosures. A completed disclosure of interest form is available to view online as supporting information.

The emergence and outbreak of coronavirus disease 2019 (COVID-19) poses great challenges to our society, economy, and public health, and has already become an international public health emergency. The prevention and control of COVID-19 requires early detection and the timely and effective control of virus dissemination. Front-line medical personnel in the outpatient and emergency departments of hospitals, quarantine centers, and entry and exit ports are key to the early detection and control of COVID-19. Based on experiences in the prevention and control of other new and recurrent infectious diseases, epidemiologists previously proposed the concept of “vital sign zero” and the “Identify-Isolate-Inform” (3I) system for the detection and control of infectious diseases. The use of “vital sign zero” and the “3I system” for COVID-19 will facilitate the prevention and control of new infections, provide more timely treatment and effective isolation of patients, and protect the safety and health of medical workers. These concepts will also prevent the spread of COVID-19 and help to ensure public health and safety.

In December 2019, an unknown pneumonia-disease outbreak emerged in in Wuhan, China. The incriminated causative pathogen, later termed SARS-CoV-2, was found to be a novel lineage of betacoronavirus, belonging to subgenus sarbecovirus. Although China has roughly controlled the epidemic, but the situation in the rest of the world is becoming less and less optimistic. Scientists and pharmaceutical companies around the world are actively looking for treatment options. Till now, there are couple of drugs undergo the clinical trial including convalescent plasma, which possess valid methods of treating or preventing the disease. And since considerable studies had already been carried out based on the analysis of SARS-CoV-2’s genome sequence and its comparison with that of the other SARS-like virus, let us review in detail and, hopefully, they might provide us with some key features for answering some of the crucial questions relating to its origin, epidemiology, and treatment to better contain the virus. Basing on that, clues on how to develop a fast and accurate viral diagnostic method and the way of treating it may also be provided. Up to now, the treating option constrained only in a few drugs (Remdesivir, Chloroquine, Hydroxychloroquine, Favipiravir etc.), in addition to the Chinese herb as well as convalescent plasma. More drugs are only roughly screened by virtual screening, and they are still far from not achieving the minimum standards for clinical treatment application. Also, the expected vaccine was reported but it just started the very first trial and still needs time to apply on a large scale. Although the very origin of this virus has been determined to be bats, but till now we still can’t determine what kind of animal plays the role of the intermediate host, leaving an issue that needs a further investigation.

SARS-CoV-2 has infected millions of people around the world, with most cases recorded among adults. The cases reported among children have been acknowledged to be minimal in comparison to adults. Nevertheless, COVID-19 has been reported to affect children at all ages, including newborns. The symptoms among children have also been identified to be similar to those observed among adults, although pediatric patients have been noted to display spectrum of clinical features ranging from asymptomatic through mild to moderate symptoms. Despite ample publications on the ongoing pandemic, the literature is only replete with guidelines on treating SARS-CoV-2 infection among older people. In this narrative review, comprehensive updates on the infection in children have been discussed. The latest information on the spread of the disease among children around the world, the clinical features observed among the pediatric population, as well as recommended pharmaceutical treatments of COVID-19 among this special group of patients have been covered. Further, expert consensus statements regarding the management of this highly contagious disease among pregnant women and neonates have been discussed. It is believed that this comprehensive review will provide updated information on the epidemiology and clinical features of the ongoing pandemic among pediatric patients. Additionally, the guidelines for handling SARS-CoV-2 among pregnant women and children, as reviewed in this article, are anticipated to be useful to frontline clinicians battling this fatal disease around the globe.

Background : Critically ill patients with coronavirus disease 2019（COVID-19）was surging and far outnumbered existing beds. Aims :  To describe how to rapidly convert general wards to intensive care units for critically ill patients with COVID-19. Materials & Methods :  Comprehensive assessment and analysis of available resources and standard requirements. Results : The ICUs were successfully assembled in four days. The conversion included environment reconstruction, configuration and management of equipment, information system construction and human resource allocation. A total of 172 critically ill patients had been admitted to the contemporary ICUs and none medical staff was infected. Discussion :  The epidemic situation of COVID-19 poses a great challenge to various management departments of the hospital, especially for critically ill patients with high mortality rate. To save more critically ill patients, the conversion of a general ward to a quarantine ICU ward must be completed in a short time, and the optimal allocation of resources must be appropriate to ensure that the medical team works effectively and is of high quality. In face of the overloaded medical system, the ideal non-negative pressure ward is hard to achieve. However, we have demonstrated with evidence that our conversions are effective in both providing care to the critical patients and protecting the safety of our staff. Conclusion:  The conversion is successful and the running experience would be a reference for hospitals in other areas nationally or globally.

Acute respiratory distress syndrome (ARDS) is the main cause of morbidity and mortality in Coronavirus disease 19 (Covid-19) for which as of now there is no effective treatment. ARDS is caused and sustained by an uncontrolled inflammatory activation characterized by a massive release of cytokines (cytokine storm), diffuse lung edema, inflammatory cell infiltraton and disseminated coagulation. Macrophage and T lymphocyte dysfunction plays a central role in this syndrome. In several experimental in vitro and in vivo models, many of these pathophysiological changes are triggered by stimulation of the P2X7 receptor. We hypothesize that this receptor might be an ideal candidate to target in Covid-19-associated ARDS.

Aims 1. To systematically review the currently available evidence investigating the association between olfactory dysfunction (OD) and the novel coronavirus (COVID-19). 2. To analyse the prevalence of OD in patients who have tested positive on Polymerase Chain Reaction (PCR) for COVID-19. 2. To perform a meta-analysis of patients presenting with olfactory dysfunction, during the pandemic, and to investigate the Positive Predictive Value for a COOVID-19 positive result in this population. 3. To assess if olfactory dysfunction could be used as a diagnostic marker for COVID-19 positivity and aid public health approaches in tackling the current outbreak. Methods We systematically searched MedLine (PubMed), Embase, Health Management Information Consortium (HMIC), Medrxiv, the Cochrane Library, the Cochrane COVID-19 Study Register, NIHR Dissemination centre, Clinical Evidence, National Health Service Evidence and the National Institute of Clinical Excellence to identify the current published evidence which associates coronaviridae or similar RNA viruses with anosmia. The initial search identified 157 articles. 145 papers were excluded following application of our exclusion criteria. The 12 remaining articles, that presented evidence on the association between COVID-19 and olfactory dysfunction, were critically analysed. Results OD has been shown to be the strongest predictor of COVID-19 positivity when compared to other symptoms in logistic regression analysis. In patients who had tested positive for COVID-19 there was a prevalence of 62% of OD. In populations of patients who are currently reporting OD there is a positive predictive value of 61% for a positive COVID-19 result. Conclusion Our review has shown that there is already significant evidence which demonstrates an association between OD and the novel coronavirus – COVID-19. It is unclear if this finding is unique to this coronavirus as individual viral phenotypes rarely present in such concentrated large numbers. We have demonstrated that OD is comparatively more predictive for COVID-19 positivity compared to other associated symptoms. We recommend that people who develop OD during the pandemic should be self-isolate and this guidance should be adopted internationally to prevent transmission.

Hundreds of researchers are working on developing a vaccine or testing drugs to mitigate COVID-19 worldwide. If novel compounds are found, geopolitical and economic variables will determine their introduction to communities. Therefore, finding low-cost and accessible substances for prevention or treatment of COVID-19 would be ideal.Earlier in April, a new hope emerged when the antiviral effect of ivermectin, a known anti-parasite drug, upon SARS-CoV-2 was published. Caly et al unveiled that 5uM ivermectin induces a profound reduction (~5000 fold) in SARS-CoV-2 replication (RNA levels) in cultured human cells 1. The authors suggested that this drug could reduce viral load in infected patients, with a potential effect on disease progression and spread. Amidst fear of the pandemic, the public and some physicians may be tempted to use ivermectin as prophylaxis, or as a coadjuvant, for COVID-19. These actions have motivated cautionary statements from institutions such as the FDA against the use of pharmaceutical formulations of ivermectin, intended for animals, as therapeutics in humans 2.It is vital to be careful with the translation of molecular findings into clinical outcomes, and it is especially important to understand the pharmacokinetic profile of drugs that could be repurposed for COVID-19, in order to design optimal dosing regimens3. There is no evidence that the concentration of ivermectin used in this study can be achieved in humans. Multiple teams have evaluated the pharmacokinetics of ivermectin in humans 4-6 (fig 1), and protocols using the highest doses (approx. 1800 µg/kg and about 10 times the usual dose), have achieved maximum plasma concentrations of about 0.28 µM 6. Therefore, the highest concentration reached is 17.5 times lower than what is required to reduce the replication of SARS-CoV-2. Consequently, although ivermectin may have anin vitro antiviral effect, it probably will not effectivein vivo . Pharmacokinetics may explain lack of effectiveness of ivermectin (400 µg/kg for 3 days) for treatment of viral infections such as dengue fever 7.These results should not discourage us. We do not know what the ceiling concentration of ivermectin in humans is, and administering higher doses of ivermectin may be useful, but could also increase the risk of adverse effects. Besides, some more potent ivermectin analogs may also have an antiviral effect on SARS-CoV-2, although this idea requires further study. In summary, it is crucial to be cautious and consider the clinical pharmacokinetics of potential treatments for COVID-19 before initiating off-label therapies in communities and health care workers.

A recent commentary published in BJCP used lopinavir/ritonavir as an example to highlight the importance of the clinical pharmacology principles in the repurposing of old drugs for therapeutic use against Coronavirus disease 19 (COVID-19).1 Here, we provide another example to support this point.A recent study found that ivermectin, an FDA-approved anti-parasitic drug, has inhibitory effects on the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).2 Ivermectin has broad anti-viral activity through inhibition of viral proteins including importin α/β1 heterodimer and integrase protein.3 In the in vitro study reported by Caly and colleagues, the addition of ivermectin at a concentration of 5 micromolar (μM) (twice the reported IC50) to Vero-hSLAM cells 2 hours post infection of with SARS-CoV-2 resulted in a reduction in the viral RNA load by 99.98% at 48 hours.2Large trials of mass drug administration of ivermectin in adults and children have shown that ivermectin is well tolerated.4 Even at doses that are 10 times greater than the highest FDA-approved dose of 200 μg/kg, central nervous system toxicity has not been reported.5 However, following the oral administration of supra-therapeutic doses of ivermectin (i.e. 120 mg) the maximum plasma concentration achieved was 0.28 ± 0.18 (standard deviation) μM, a value 18 times lower than the reported 5 μM ivermectin concentration used by Caly et al in their SARS-CoV-2 experiment.5 To date, the clinical effects of ivermectin at a concentration of 5 μM range are unknown, but likely to be toxic. Furthermore, ivermectin is only commercially available as a 3 mg oral tablet.6 These factors hinder our ability to immediately repurpose ivermectin in its current form for the treatment of COVID-19.While the findings by Caly and colleagues provide some promise, viral suppression was not seen at concentrations observed with standard doses in humans. Further preclinical in vivo studies should evaluate the pharmacokinetics and pharmacodynamics to determine the kill pattern of ivermectin. A potential alternate solution may be to develop an inhaled formulation of ivermectin to efficiently deliver a high local concentration in the lung, whilst minimising systemic toxicity. As therapeutic agents to tackle the COVID-19 pandemic are urgently sought, careful consideration of the pharmacokinetics of these drugs should be considered to guide in vitro testing.

IntroductionThe rapid spread of coronavirus disease 2019 (COVID-19) worldwide raised concerns about its heavy impact on the health care delivery system and forced significant changes in the realities of the clinical practice we are accustomed to. With these changes comes a need for a different approach to outpatient evaluation of common otolaryngology complaints in patients with new symptoms.Recently published set of guidelines for evaluation of head and neck during the COVID-19 pandemic recommended to postpone the management of benign disease including benign salivary or thyroid gland disease.1 In order to limit the chance of COVID-19 infection among patients or health care workers, surveying patients via telephone or telemedicine visit was advised, reserving in-person evaluation for the patients at risk for significant negative outcomes. The challenge is that these measures can only be applied in clear-cut clinical scenarios, when the disease process is most likely benign and the care delivery can be postponed.In cases with a high degree of uncertainty based on available clinical information, many physicians will have to decide how to proceed after initial telemedicine encounter. Clinicians will have to consider how to balance a potential delay in diagnosis, including cancer diagnosis, against the risk of COVID-19 exposure, and may need to exercise their best judgement knowing that for head and neck cancer the risk of progression with cancer care delay is high.2 In this communication, we present our approach to triaging and evaluation of patients with complaints concerning for salivary gland disease.

As this ever-evolving pandemic lays itself, more of its impact is being understood. Until recently, most guidelines were reported to aid in managing and treating suspected or confirmed cases. Research institutions around the world are responding with a sense of confusion. Some are continuing routinely, especially those who are overseeing clinical trials that could offer life-saving therapies, particularly against the novel coronavirus. Since research must continue even in the face of a shutdown, we aim to collate the currently available recommendations from various organizations and provide guidance to head and neck researchers across the world during these trying times.

The 2019 novel coronavirus disease (COVID-19) pandemic has been spreading worldwide at an alarming rate. Healthcare workers have been confronted with the challenge of not only treating patients with the virus, but also managing the disruption of healthcare services caused by COVID-19. In anticipation of outbreak, clinic sessions and operation theatre lists have been actively cut back since February 2020 to reduce hospital admissions and clinic attendances. This has severely disrupted healthcare services, leading to accumulating clinic caseload and substantial delays for operations. The head and neck cancer service has been faced with the difficult task of managing the balance between infection risk to healthcare providers and the risk of disease progression from prolonged waiting times. We share our experience in Hong Kong on the mitigation of head and neck cancer service disruption through telehealth and multi-institution collaboration.

BackgroundOutpatient telemedicine consultations are being adopted to triage patients for head and neck cancer. However, there is currently no established structure to frame this consultation.MethodsFor suspected cancer referrals, we adapted the Head and Neck Cancer Risk Calculator (HaNC-RC)-V.2, generated from 10,244 referrals with the following diagnostic efficacy metrics: 85% sensitivity, 98.6% negative predictive value and area under the curve of 0.89. For follow up patients, a symptom inventory generated from 5,123 follow-up consultations was used. A customised Excel Data Tool was created, trialled across professional groups and made freely available for download at www.entintegrate.co.uk/entuk2wwtt, alongside a user guide, protocol and registration link for the project. Stakeholder support was obtained from national bodies.ResultsNo remote consultations were refused by patients. Preliminary data from 511 triaging episodes at 13 centres show that 77.1% of patients were discharged directly or have had their appointments deferred.DiscussionSignificant reduction in footfall can be achieved using a structured triaging system. Further refinement of HaNC-RC V.2 is feasible and the authors welcome international collaboration.

The global pandemic of 2019 Novel Coronavirus Disease (COVID-19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the healthcare system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID-19 may last longer than SARS in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and healthcare personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS-CoV-2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the non-instrumental swallowing evaluation, appropriate use of PPE, and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID-19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies.

Background The global COVID-19 pandemic brings new challenges to otolaryngology resident education. Surgical volume and clinic visits are curtailed, personal protective equipment for operating room participation is restricted, and the risk of COVID-19 disease transmission during heretofore routine patient care is the new norm. Methods We describe a small-team “cohorting” protocol including guidelines for faculty and resident in common clinical scenarios with attention paid to the risk of common otolaryngologic procedures. Results A rotating small-team approach was implemented at each clinical site, limiting interaction between Department members but providing comprehensive coverage. Faculty were involved at the earliest phase of clinical interactions. Guidelines delineated faculty and resident roles based on risk stratification by patient COVID status and anticipated procedures. Special consideration was given to high-risk procedures such as endoscopy and tracheotomy. Conclusions A small-team based approach with guidelines for faculty/resident roles may mitigate risk while optimizing patient care and maximizing education.

As an aerosol and droplets generating procedure, tracheostomy increases contamination risks for health workers in the coronavirus disease context. To preserve the health care system capacity and to limit virus cross-transmission, protecting caregivers against coronavirus infection is of critical importance. We report the use of external fixator equipment to set up a physical interface between the patient’s neck and the caregiver performing a tracheostomy in COVID-19 patients. Once the metal frame set in place, it is wrapped with a single-use clear and sterile cover for surgical C-arm. This installation is simple, easy and fast to achieve and can be carried out with inexpensive material available in every hospital. This physical interface is an additional safety measure that prevents the direct projection of secretions or droplets. It should, of course, only be considered as a complement to strict compliance with barrier precautions and personal protective equipment.

Dear Editor,Since December 2019, coronavirus 2019 (COVID-19) has spread worldwide.1 Some data have suggested that the prevalence and mortality of COVID-19 are different among races. 2However, this analysis did not account for potential confounding factors.Since chronic kidney disease (CKD) is common, the number of COVID-19 patients with CKD will increase. However, there are scarce data about outcomes in CKD patients. We herein investigated the outcomes from COVID-19 in AAs compared to those in whites.We analyzed Mount Sinai Health System (MSHS) medical records up to April 5, 2020, using Epic SlicerDicer software. We extracted data from patients who had positive for the COVID-19 reverse-transcription polymerase chain reaction (RT-PCR) test. Sex, age, race, and comorbidities (hypertension, diabetes mellitus, ischemic heart disease, heart failure, and atrial fibrillation) were extracted using the 10th revision of the International Statistical Classification of Diseases code. Mortality and intensive care unit (ICU) admission were tracked through April 12, 2020. Relative risks (RR) and 95 % confidence interval (CI) in each race stratified by age groups and comorbidities were calculated using a Fisher’s exact test. MSHS waived Institutional Review Board approval since this research used only deidentified, aggregate-level data.During the study period, 1,269 AAs COVID-19 patients with 105 CKD patients and 1,450 whites COVID-19 patients with 80 CKD patients were detected. AAs were younger (median 66, IQR 55-76) than whites (median 75, IQR 65-83) (p< 0.001). There was no significant difference in mortality between AAs and whites (0.65 [0.36-1.15]). This tendency was observed after stratification by age and medical conditions. Similarly, AAs did not have an increased risk of ICU admission (0.84 [0.6-1.18])) even after stratification by age and comorbidities (Table).To the best of our knowledge, this is the first study that compared the risk of severe outcomes among races in CKD patients. Although it has been suggested that there might be racial disparity in COVID-19, our study did not show any significant differences in outcomes, even after stratifying patients by age and comorbidities. Our data suggested that we do not need to stratify these patients by race.The racial and ethnic diversity in NYC enabled us to investigate differences in outcomes among races in the same cohort. However, our study has several limitations. First, the number of patients was relatively small. Second, we did not access individual data, which prevented us from performing multivariate analyses. The fact that AAs were younger might mask differences among races.In conclusion, AAs with CKD did not have a higher risk of mortality or ICU admission than whites with CKD. This trend was consistent after stratification by age, sex, or comorbidities.Acknowledgements: noneConflict of Interest Disclosures: TY reports no conflict of interest. TM reports no conflict of interest. NC reports no conflict of interest. HM reports no conflict of interest. SC repots no conflict of interest. SM reports no conflict of interest.Reference1. Team CC-R. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 - United States, February 12-March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382-386.2. Health N. Age adjusted rate of fatal lab confirmed COVID-19 cases per 100,000 by race/ethnicity group as of April 6, 2020 (Accessed Aprio 12, 2020). 2020.