A document by Xiaomei Peng, written on Authorea.

Aim: To evaluate the pathogenesis, risk factors, diagnosis and management strategies in pregnant women suspected or confirmed with COVID-19 infection. Methods: A literature review of published articles was carried out using keywords of corona virus (and its root derivatives), pregnancy, vertical transmission and childbirth in Medline, Cochrane, CINAHL, Clinicaltrials.gov and Web of Sciences. Clinical articles including case-control, case reports, case series and reviews published between 2019 and 2020, in English language were included. Editorials and Letter to Editors were not included. Two independent authors reviewed title and abstract of the articles and another set of two independent authors screened full text. A total of 22 articles were shortlisted for addition into the final manuscript Results: A total of 403 pregnancies were considered in the study with most of the patients in the third trimester of pregnancy. There was no maternal mortality reported in the literature, however 1.49% fetal mortality has been reported. Conclusion: The ideal management revolves around, rapid detection, prompt diagnosis and effective isolation.

Many articles have reported that cancer patients are more susceptible to COVID-19 pneumonia and cancer patients with COVID-19 seem to be more often tend to develop severe events. In these studies of infected cancer patients, factors associated with a higher risk of developing severe events included age, baseline fragility, and anti-tumor treatment. However, specific reasons regarding why infected patients with cancer have a higher probability of severe events compared to non-cancer infected patients remain unclear. Thus, we sought to study one particular factor to determine a potential associative effect: differences in Computed tomography (CT) findings. In our study,we found that cancer patients represent a special population which multiple lobes of the lungs were more susceptible to infection by the SARS-CoV-2, and thus were more likely to be transferred from mild illness to severe, should be deserved more intensive attention during the SARS-CoV-2 pandemic.

Purpose: The COVID-19 pandemic has presented an international health crisis of a scope not seen in our lifetime. While much attention has been paid to health workers in critical care and acute areas, nurses working outside of hospitals are also significantly affected. This study sought to investigate the experience of nurses working in Australian primary health care during the COVID-19 pandemic. In particular, it sought to understand the implications on their employment status, role and access to personal protective equipment.Design and Method: Nurses employed in primary health care across Australia were invited to participate in a cross-sectional online survey through social media and professional organisations. The survey tool was comprised of demographics, questions about the nurses’ employment and work role and access to personal protective equipment.Findings: Of the 637 responses received, nearly half (43.7%) reported a decrease in hours, threatened or actual loss of employment. While most respondents felt that they had sufficient knowledge about COVID-19, they expressed concern about work-related risks to themselves and their family. Most respondents described never or only sometimes having sufficient personal protective equipment in their workplace. Just over half of respondents (54.8%) felt well supported by their employer. A third of respondents (34%) perceived that care provided in their workplace was significantly or slightly worse than before the pandemic.Conclusions: This is the first study of primary health care nurses experiences during the COVID-19 pandemic. The study findings have highlighted a concerning level of insecurity around primary health care nursing employment, as well as issues with the availability of personal protective equipment for these nurses. The perception that the pandemic has resulted in reduced quality of care needs further exploration to ensure that those with chronic conditions are supported to maintain and promote health.Clinical Relevance: Understanding the implications of COVID-19 on the primary health care nursing workforce is vital to ensure staff retention and care quality. Ensuring that the community remain healthy and supported at home is vital to both reduce the burden on the health system and reduce secondary mortality.

Background: Diagnosis of Severe Acute Respiratory Coranavirus-2 (SARS-CoV-2) infection is currently based on Real-Time PCR (RT-PCR) performed on either nasopharyngeal (NPS) or oropharyngeal (OPS) swabs; saliva specimen collection can be used, too. Diagnostic accuracy of these procedures is suboptimal, and some procedural mistakes may account for it.Methods and results: The video shows how to properly collect secretions from the upper airways for non-serologic diagnosis of COVID-19 by nasopharyngeal swab (NPS), oropharyngeal swab (OPS), and deep saliva collection after throat-cleaning manoeuvre, all performed under videoendoscopic view by a trained ENT examiner.Conclusions: We recommend to perform NPS after elevation of the tip of the nose in order to reduce the risk of contamination from the nasal vestible, and to let it flow over the floor of the nasal cavity in parallel to the hard palate in order to reach the nasopharynx. Then the tip of the swab should be left in place for few seconds, and then rotated in order to achieve the largest absorption of nasopharyngeal secretions. Regards OPS, gentle anterior tongue depression should be used to avoid swab contamination from the oral cavity during collection of secretions from the posterior pharyngeal wall. These procedural tricks would enhance diagnostic reliability.

Steroids treatment has been studied in influenza, SARS, MERS, COVID-19 and ARDS, but no clear guidelines or recommendations are available regarding the dose and the duration. In this review we summarize the studies available on steroids and influenza, SARS, MERS, COVID-19 and evaluated them according to the steroid dose, duration and beneficial and harmful effects. Steroids were not much useful in influenza infection, but have shown beneficial effects in SARS and COVID-19. Intimidate and high doses for a short duration in SARS is beneficial, especially if used after the viral replication phase. Methyl prednisolone is the preferred steroid compared to hydrocortisone and can be combined with intravenous immunoglobulin, ribavirin, quinolone plus azithromycin. Limited studies are available for COVID-19 and steroids to provide recommendations and steroids use can be harmful in critically ill patients. Delayed viral clearance, secondary bacterial infections, cardiovascular events due to fluid retention, psychosis, diabetes, avascular necrosis and osteoporosis can be side effects of steroid use.

Bats are a natural reservoir of many pathogenic and non-pathogenic viruses with the chance of spill over via the intermediate host and/ directly to human. The number of zoonotic and deadly viruses especially RNA viruses originated from bats is remarkable. The recent outbreak of COVID 19 or SARS-Cov-2 is the novel or new version of continuation of virus spill over the last few decades. The previous outbreaks as such MERS, SARS predominantly infect human respiratory systems with limited human to human transmission capability. The human interface with wildlife along with deforestation, urbanization, overgrown population, bush meat hunting, wildlife trade significantly increase the reassortment of bat originated virus with other intermediate host to jump in to human species. In this review, we discussed the history of bat borne pathogen and the triggering factors that impose their spill over to human for generating current and future pandemics.

Viruses, including the recent, COVID-19-causing SARS-CoV-2 rely on their host for re-production. Here, we made use of genomic and structural information from SARS-CoV-2 and related viruses to create a biomass function capturing the stoichiometric amino and nucleic acid requirements of SARS-CoV-2. By incorporating this function into a stoichiometric metabolic model of the human cell and applying metabolic flux balance analysis, we identified host-based metabolic perturbations inhibiting SARS-CoV-2 reproduction. Our results highlight reactions in the central metabolism, as well as amino acid and nucleotide biosynthesis pathways. By incorporating host cellular maintenance into the model based on available protein expression data from human lung cells, we find that only few of these metabolic perturbations are able to selectively inhibit virus reproduction without significantly affecting host maintenance. Key reactions that are able to do so are found in metabolic junctions in amino acid biosynthesis pathways and in mitochondrial metabolite shuttles. We note that some of the catalysing enzymes of such reactions have demonstrated interactions with existing drugs, which can be used for experimental testing of the presented predictions. The developed computational approach offers a platform for rapid, experimentally testable generation of drug predictions against existing and emerging viruses based on their biomass requirements and their host’s metabolism.

Background: In light of the COVID-19 pandemic, there has been a rapid increase in telemedicine visits. Otolaryngology patient satisfaction with these visits has not yet been extensively studied using a validated survey. Methods: All patients who had telemedicine visits with three head and neck surgeons, by phone or video-based platform, between March 25, 2020 and April 24, 2020. Retrospective chart reviews were conducted to determine demographic, disease and treatment information. Patients who had a video visit were contacted by telephone and, if they could be reached and consented, were administered the Telehealth Usability Questionnaire (TUQ).Results: 100 surveys were completed. The average score across all questions was 6.01 on a scale from 1-7, where 7 indicated the highest level of patient agreement. The highest scores were for questions related to satisfaction with telehealth (6.29), while the lowest were related to reliability (4.86). Conclusions: Patients are generally highly satisfied with telemedicine.

Much has been discussed about the curve of COVID-19 as it ravages through our countries, our cities, our homes. Politicians readily refer to it in addressing the various nations of the world. They ask us to “flatten the curve to save lives” 1,2. Effectively, the way to flatten the curve is to abide by social distancing measures.Nevertheless, even among medical specialists, there are common misconception about the curve and how it affects population outcomes. Understanding the fundamental characteristics of a problem can allow us to see the problem with more clarity. Herein, I aim to provide a simple understanding of the various population dynamics at play. We will review how principles such as the area under the curve and thethreshold of capacity can be conceptualized.The discussion will begin as rudimentary. However, it will add gentle layers of complexity. Hopefully, by the end, it will provide the reader a sense of insight.

A local outbreak of initially unknown cause pneumonia was detected in Wuhan (Hubei, China) in December 2019 and a novel coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was quickly found to be causing it. Since then, the epidemic has spread to all of China’s mainland provinces as well as 58 other countries and territories, with more than 87,137 confirmed cases around the globe, including 79,968 from China, 7,169 from other countries as of 1 March 2020, as stated by the World Health Organization (WHO) in the COVID-19 situation report - 41. In response to this current public health emergency, this study done a statistical analysis and visualized reported cases of coronavirus disease 2019 (COVID-19) based on the open data collection provided by Johns Hopkins University. Where the location and number of confirmed infected cases have been shown, there have also been deaths, recovered cases and comparisons of the growth rates between the Globe countries. This was intended to provide researchers, public health officials and the general public with exposure to the epidemic.

SARS-CoV-2 has claimed more than 300,000 lives while infecting 4 million individuals worldwide. There are no specific treatments for COVID-19. Symptoms vary from very mild/asymptomatic to severe, including admission to ICU. Strong sex-bias in COVID-19 have been noted with males showing more than double the odds of requiring ICU admission and higher mortality. Reproductive steroids, including estrogens, progesterone and its physiologically-active metabolite, allopregnanolone exert anti-inflammatory actions and influence the immune system. Intriguingly, pregnant women with COVID-19 appear to experience milder symptoms. In some pregnant women escalated symptoms severity is observed immediately postpartum in coincidence with the rapid hormonal drop associated with parturition. This finding suggests that reproductive steroids’ anti-inflammatory effects and their role in reshaping competence of immune cells may protect during pregnancy. The hypothesis that estradiol, progesterone may provide a treatment against COVID-19 in men and in postmenopausal women is discussed.

The global pandemic from Sars-cov-2 has down caused thousands of deaths worldwide, triggering a health crisis in the various countries involved, with few precedents in history. To date there are no vaccines for prophylaxis, and there are no antivirals directed against the virus. Among the therapeutic options that have shown effectiveness is passive immunization with immune plasma from convalescent patients cured of the infection. Plasma collected from patients cured of Sars-cov-2 infection is rich in antibodies that neutralized the pathogen. Plasma therapy has already demonstrated its efficacy in other epidemics, such as Sars-Cov and MERS. To date, there are limited data for its use in sars-Cov-2 infection, both for prophylaxis and treatment, but the few existing data bode well for the scientific world. Many questions are still unresolved, when to administer it? At what dosage? When is it most appropriate to take the plasma from the cured patient? Are there different answers depending on gender and age? Certainly in view of the high number of patients infected and cured by Sars-Cov-2, there could be a high amount of plasma from donor patients. In this article we want to give an overview on a current and important topic in the perspective of the battle against the new Sars-Cov-2, analysing the therapeutic successes in past epidemics, the clinical data currently available, the future prospect and an expert opinion.

Background Recent epidemiologic data has indicated coronavirus to be highly contagious with high risk of person-to-person transmission. On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. With the increasing number of confirmed cases and the accumulating clinical data, the cardiac manifestations induced by COVID-19 have generated great concern. COVID-19 was also associated with cardiac arrest, acute-onset heart failure, and myocarditis. COVID-19 has not been reported as the cause of abnormalities of cardiac conduction system. Case Presentation Our patient was transferred from a long-term care facility with history of new onset bradycardia and fall. Patient had no classical symptoms of viral infection, including fever, dyspnea or any classical radiological finding like bilateral ground glass opacities. Initial EKG was noted for 3rd degree AV and heart rate 30 BPM. He was taken to cardiac catheterization lab for an emergent temporary transvenous pacemaker. Patient subsequently had permanent pacemaker implanted electively. Discussion and Conclusions This case represents cardiac conduction abnormality requiring therapeutic pacing as a presenting symptom of SARS-CoV-2 Health care professionals need to be vigilant about atypical, noval presentation of this disease in patients belonging to risk groups such as over 60 years age, immunocompromised, residents of long-term facilities, and with medical conditions such as heart disease, lung disease, diabetes, stroke, renal disease, cirrhosis, and diabetes. Currently there is no proven treatment for this infection and individuals in these at-risk groups are susceptible to higher morbidity and mortality.

During the SARS-Cov-2 pandemic, it is essential to identify the risk factors that can cause a higher probability of infection and, therefore, worsen the patient's health. In fact, the known risk factors include already existing diseases and associated pharmacological treatments. A patient with multiple sclerosis takes immunomodulatory drugs and certainly has a high risk. Evidence and literature have shown that SARS-Cov-2 infection causes severe lung damage due to a poorly functioning immune system and overexpression of cytokines. Therefore the management of multiple sclerosis treatments in immunomodulating therapy must be carefully monitored. This article on the one hand analyzes and recalls the safety profile of all drugs for multiple sclerosis, on the other the recommendations adopted by different countries are highlighted, trying to understand if the suspension of MS treatment must actually materialize in order not to incur lethal covid pneumonia.

In March 2020 a pandemic was declared due to a novel coronavirus strain. The virus can create a hypercoagulable state. This case is one of the first to report the development of a pulmonary embolism in an infected patient with no known risk factors in an outpatient setting.

The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has made widespread impact recently. We aim to investigate the clinical characteristics of COVID-19 children with different severities and allergic status. Pediatric COVID-19 patients tended to have a mild clinical course. Patients with pneumonia had higher proportion of fever and cough and increased inflammatory biomarkers than those without pneumonia. There was no difference between allergic and non-allergic COVID-19 children in aspects of incidence, clinical features, laboratory and immunological findings. Allergy was not a risk factor for developing and severity of SARS-CoV-2 infection and hardly influenced the disease course of COVID-19 in children.

In December 2019, Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is widely spread and causes a critical threat to clinical burden and public healthcare. The outbreak of COVID-19 has aroused widespread concern in the rheumatology community.

A new epidemic caused by SARS-CoV-2 has affected millions of people around the world with high rate of mortality. In this article, an insight into the mechanism of inactivation of some conronaviruses by formaldehyde and glutaraldehyde is presented, based on analysis of previous observations during electron microscopic examination of several members of the orthocoronavirinae subfamily, including the new virus SARS-CoV-2. A new prophylactic and therapeutic measure is suggested. However, it needs to be tested experimentally before consideration to be used solely or in adjunction to other therapies. Also, a preconditioning step against the cytokine storm of COVID-19 is proposed and a new line of research is proposed to find a broad spectrum antivirus against several members of of this subfamily.

Objective: To analyze covid-19-associated test results and optimize screening procedure for obstetrics and gynecology outpatients Design: Single center retrospective study. Setting: Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei province, P.R. China. Population or Sample: A total of 1,051 obstetrics and gynecology outpatients were included in the study from March 12 to April 26, 2020. Methods: We collected medical records, COVID-19-associated test results and reported the visit procedure for obstetrics and gynecology outpatients. Main outcome(s) and measure(s): We analyzed covid-19-associated test results and followed up the patients. Results: After reviewing the visit procedure, a total of 1051 obstetrics and gynecology outpatients were included in the study, and a series of COVID-19 tests were conducted, which included the SARS-CoV-2 nucleic acid test, chest CT scan and SARS-CoV-2-specific serological test. The SARS-CoV-2 nucleic acid test was negative in all 1051 patients. None of the patients admitted to the hospital experienced SARS-CoV-2 infections during hospitalization. Seventy-six cases were diagnosed with abnormal uterine bleeding-related disease (excluding endometrial malignancy), 2019-nCoV antibody positive rate was 6.579%, which is greater than the average positive rate of 3.974%, and the positive rate among patients with other diseases. No nucleic acid positivity was found in the follow-up of 9 IgM+ (and IgG+) patients. Conclusions: As the peak of the epidemic has passed, a more optimized screening procedure is required to avoid hospital infections.

Objective:To compare maternal and fetal consequences of Covid-19-infected pregnancies with non-infected pregnancies. Design: Prospective cohort study Setting: Iran Population: Pregnant women who were hospitalized from March 1 to April 20 2020 Methods: Participants were divided into three groups: Women with positive Covid-19 PCR test and/or positive CT scan findings in the presence of very typical clinical symptoms were classified as confirmed group,women with typical clinical symptoms along with two or more oflaboratory findings were classified as probable group and women who hadno clinical symptom of infection were classified as a control group.In order to minimize the presence of asymptomatic individuals in the control group, we used very precise exclusion criteria. Main Outcome Measures: Maternal, neonatal and pregnancy outcomes. Results:One hundred and eighty-two women enrolled including37 and 12 and 133 women inconfirmed, probable andcontrol groups respectively.Caesarean Section was carried outin total 96 women (52.74%,95%CI:45.22,68.31).Nosignificant association was found between COVID-19 infection and preterm labour(aRR:0.75,95%CI:0.30,1.87,P=0.546),low birth weight(aRR:1.15,95%CI:0.49,2.73,P=0.737), gestational diabetes(aRR:0.78,95%CI:0.26,2.33,P=0.669), preeclampsia (aRR:2.07,95%CI:0.50,8.47,P=0.310) intrauterine growth restriction(aRR:0.30, 95%CI:0.02,3.27,P= 0.327) preterm rupture of membrane(aRR:0.38,95%CI:0.04,3.30,P=0.383), stillbirth (aRR: 1.53,95%CI:0.15,14.71,P=0.712), postpartum haemorrhage (aRR:0.80,95%CI:0.11,5.57,P=0.829), neonatal intensive care unit admission (aRR:1.48,95%CI:0.38,5.78,P=0.568), neonatal sepsis(aRR:1.23,95%CI:0.68,2.20,P= 0.481) Conclusion:Given the effect of many potential factors, such as the severity of maternal infection, the time interval between the onset of symptoms in mother and childbirth, and many other factors on the effect of the virus on pregnancy outcomes, we suggest conductingmore extensive prospective studies in this field.

Coronavirus disease 2019 (COVID-19) was first described in December 2019 in Wuhan, the capital of China’s Hubei province. 1,2. On March 11, 2020, WHO declared COVID-19 as a pandemic3. The first confirmed case of COVID-19 in Egypt was reported on February 14, 2020. As of May 10, 2020, there have been 8,964 confirmed cases, 2,002 recovered and 514 deaths4.

Gynecology in the Time of CoronavirusJennifer O. Howell3009 Old Clinic BuildingCampus Box 7570Chapel Hill, NC 27599919-966-5280 (p)johowell@med.unc.eduHealthcare delivery has undergone a rapid transformation as we grapple with reality in the time of the novel coronavirus. I daresay, regardless of specialty, we are all adapting new models to care for our patients, mitigate contagion, and preserve resources. Every day we structure a measured response to the number of new cases, the amount of personal protective equipment on hand, as well as the projections of lost revenue. The response of modern medicine to this pandemic is astounding. The sheer volume of e-mail memoranda, power point presentations, web-based tools, and other electronic weapons amassed against this disease cannot be underestimated. Indeed, we have a duty to treat. Can we fulfill this duty as obstetrician/gynecologists in present times without further endangering our patients, or depleting the healthcare workforce?To answer this question, it may be useful to reflect on the practice of our vocation during past pandemics. In the 14thcentury, the Black Plague caused by the bacillus Yersinia Pestiskilled twenty million people in Europe. Those who cared for the sick had only crude treatments such as bloodletting, burning incense, and bathing brows in rosewater or vinegar. Doctors commonly refused the care of patients, priests avoided burying the dead, and family members were forced to abandon their loved ones in desperation. The cause was unknown, but divine retribution was suspected. Thus, instead of advocating wearing facemasks in public, displays of self-flagellation were encouraged as protective.During the influenza pandemic of 1918, fifty million people perished worldwide. While we then understood the concepts of antisepsis and microbiology, we had little but ourselves to offer. There were still no diagnostic tests, no antibiotics, no effective vaccines, nor mechanical ventilators. There was basic ‘PPE’ to don while administering aspirin, epinephrine, and oxygen by face mask. Fortunately, the healthcare ethical code during the 1918 pandemic was robust. Patient welfare came first, even in the face of a serious risk to physician health. Public health measures such as mass closures, quarantines, and masks were in effect. There is documentation of doctors, hospitals, and morgues being overwhelmed in certain ‘hot spots,’ but there are no stories of the medical establishment closing shop. This was still the age when doctors came to your house – and by all accounts, they continued to do this work.In our work as OBGYNs, we treat many hidden conditions which require relatively invasive exams to properly assess and diagnose. Surely, there must be something in our technologic armamentarium that will allow us to persevere in the digital pandemic age. While I may not know what it was like to be healer during the Black Plague, or a doctorduring the “Spanish” flu, I am learning quickly how to be ahealth care provider during COVID-19. I introduce to you a new framework that will be adopted in the OBGYN department at our institution. I welcome all to adapt as you see fit in your local facilities. We simply must marry safety and duty. And while naturally money is a secondary concern, we simply must keep our fiscal heads above water. Our patients depend on us.______________________________________________________________________________VIRTUAL Gynecologic visitsDocument for workflow in the Ambulatory Environment.Approved by the Sub-committee of Ambulatory Operations, the Taskforce for Increasing Virtual Visits, and the Gynecology Working Group.As many of you have now heard the good news, reimbursements for “virtual” visits will be at the same rate as “in-person” appointments during COVID-19. Therefore, effective immediately please adopt this new 9-step protocol.Patients may now obtain a speculum for home use with a provider’s prescription. An updated e-tip sheet will be forthcoming on the durable goods pharmacies that are providing this service including the 10 easy steps you must follow for getting this equipment mailed to our patients.Must use only approved electronic platforms for these transactions given the sensitive patient information to be transmitted. Providers and nurses must watch an e-learning module entitled “Oh Yes We Can: Handling Sensitive Information 2.0 - Privacy Concerns, Questions, and the Law”Action item: It is expected you will watch the module in the next 24 hours!Schedulers will call the patient and inform them of their “virtual speculum tutorial.” This is a new visit type available on the last update of our EMR – called SPEC TUT, 20-minute slot. Write in notes section on the schedule tab – “patient agrees to home speculum teaching.”Patient instructed to sign up for ‘MyChart’ app and message provider directly when home equipment has arrived. We understand that many of our patients speak other languages and this may be difficult. Thanks for the incredible work you do. Kudos to our Personnel Support Managers for putting together this helpful resource entitled “My speculum has arrived” in 19 languages – click this hyperlinkmi espéculo casero ha llegado to access.Nurses will then call the patient from a private location and perform a demonstration using the ‘MySpeculum’ app which can be downloaded in 5 easy steps. An e-tip sheet from your EEP (Embedded Electronic Medical Record Professional) will be forthcoming. Nurse will then write in Notes section: “patient successful” initials, date, timeOn the day of the video pelvic exam visit, there will be a light-up speculum icon on the schedule that will turn green when your patient is “checked in” for the visit. Click the wrench icon on the schedule bar to get this notification column to appear if you do not see it. E-tip sheet coming – stay tuned.Providers – Be on time for your visit, introduce yourself, and make sure you know your patient’s location. They must be in a state, province, county, district, and territory where your medical license is valid. This is changing rapidly so in order to protect you from litigation we ask you to go to this website to check on licensing reciprocity www.incredibleamountsofbureaucracy.com. In addition, you must ensure patient location is not a fast-food drive through before connecting the camera.After the patient has placed the speculum and positioned the camera correctly – be sure to use the verbiage: “I am all done looking now.” The patient will then know they can take the speculum out.As always, be sure to properly document and use this e-smart phrase which has all the billing embedded: .COVIDDIDVIRTUALPAP______________________________________________________________________________By now the astute reader has guessed that this ‘modest proposal1’ for virtual pelvic exams is not for implementation. Instead this perspective is offered as a wry critique of our increasingly technocratic response to the crisis. A response, which I believe, has drastically changed the standard of care in our field. We must recognize that we are delaying or divorcing needed care from the laying on of hands unencumbered by evidence that this will result in acceptable outcomes. When I think of something as ludicrous as a virtual gynecologic assessment, I am haunted by yet one other epidemic not yet mentioned.Whether justified or not, the mythology of the medical establishment’s early response to HIV is not flattering. Reports abound of medical professionals dodging the ‘duty to treat’ ethos. Physicians and nurses were assured transmission would be unlikely with a bloodborne pathogen. Yet, anxious perceptions kindled debate over the long-embraced professional code of self-sacrifice. Ultimately, our better selves prevailed. Medical societies worldwide issued guidance in the 1990’s reaffirming our obligation to care for contagious patients. And now we find ourselves in an ever more bureaucratic and entrepreneurial healthcare landscape. Just how will history view our retrenchment to care via computer screen for a virus spread by droplets? Surely, the spread between two masked individuals taking proper precautions during a medical visit must be quite low. Shall we stand by our commitment to care with a human (gloved) touch and a physical exam as the gold standard? Indeed, I stand ready to wipe my patient’s brow with rosewater and vinegar, however ineffectual.If perhaps you smiled as you recognized your institution in this satire’s looking glass, then I am satisfied. Presently, it may be that humor is the best medicine we have. Perhaps laughter will lower the viral transmission rate. I will wager it is at least as effective as self-flagellation, and better than bloodletting. I will end this reflection to return to my screen with a sense of urgency – there are workflows and memos to attend to. Afterall, leadership expects this protocol to be in place next week to achieve our triple aim: reduced exposure, maximum reimbursement, and operational efficiency in these unprecedented times. You are all heroes. Thank-you for all that you do. Stay safe!

Keeping up with the surgical training might be difficult during the time of COVID-19 pandemic: with most of the health care resources dedicated to face this reality, trainees can improve themselves deep diving in scientific literature, study, Telemedicine and Social Media professional platforms. Moreover, they might be directly involved in COVID patient care, facing a still a still elusive disease with a high lethality rate. Often the frustration of having no valid treatment and a poor incisiveness on the natural course of the COVID19 could lead to a blue mood or a burnout. Eventually, the natural adaptability and the survival instinct prevail and teach us the real meaning of resilience. Every trainee has to be prepared for the second phase, when the new normality will force everyone to cohabit with the virus. Even the obvious teething troubles, this could be the right moment for all the Residents to “grow-up” and develop their own future Character.