Coronavirus disease 2019 (COVID-19), a respiratory tract infection caused by a novel human coronavirus, the severe acute respiratory syndrome coronavirus 2, leads to a wide spectrum of clinical manifestations ranging from asymptomatic cases to patients with mild and severe symptoms, with or without pneumonia. Given the huge influence caused by the overwhelming COVID-19 pandemic affecting over three million people worldwide, a wide spectrum of drugs is considered for the treatment in the concept of repurposing and off-label use. There is no knowledge about the diagnosis and clinical management of the drug hypersensitivity reactions that can potentially occur during the disease. This review brings together all the published information about the diagnosis and management of drug hypersensitivity reactions due to current and candidate off-label drugs and highlights relevant recommendations. Furthermore, it gathers all the dermatologic manifestations reported during the disease for guiding the clinicians to establish a better differential diagnosis of drug hypersensitivity reactions in the course of the disease.

Cardiac resynchronization therapy with His-bundle pacing (His-CRT) is evolving rapidly as a viable cardiac device strategy for the treatment of severe chronic heart failure. The success of this technique in patients with congenital heart disease is facilitated by advanced integrated imaging modalities. We report a case of His-CRT pacing for the management of a patient with heart failure with severely reduced ejection fraction, left bundle branch block and congenital heart disease characterized by Scimitar syndrome with cardiac dextroposition. We highlight the contribution of integrated imaging modalities to guide accurate lead positioning.

The effect of interactions of Li+, Na+ and K+ cations with two configuration of the A–G mispairs, AantiGanti and AsynGanti, on the geometries and hydrogen bond energies have been studied at the MP2/6-311++G(d,p) level of theory. For each ion type, the most stable complex in AantiGanti and AsynGanti configurations are related to binding cation to N3 atom of guanine and N1 atom of adenine, respectively. The AantiGanti configuration is higher in the absolute values of binding energy than the AsynGanti configuration, indicating that AantiGanti configuration is more stable than AsynGanti ones. The results indicate that the strength of hydrogen bonds depends on the type and position of cations in considered systems. The values of hydrogen bonding energies estimated by the EML formula in AantiGanti mismatch are higher than AsynGanti case. The influences of cations binding in hydrogen bond strength are confirmed by the results of natural bond orbital (NBO) and atoms in molecules (AIM) analyses

1. Data on reproductive features of temperate terrestrial isopods species is well-known, for some species this knowledge is still incipient. Armadillidium tunisiense is a newly discovered and endemic Tunisian with an only recent study concerning its breeding patterns. 2. Seen the interspecific and intraspecific variations due to local variations in environmental conditions. We decided to describe the main characteristics of A. tunisiense’s life cycle from the Chambi mountain, the highest point in Tunisia, by determining the population structure; the reproduction dynamics, the sex ratio and fertility. 3. The breeding patterns and the reproductive cycle of A. tunisiense were studied on 2908 individuals collected on regular bias from July 2009 to July 2011 from the Chambi mountain. Our specimens were divided into six categories. Where females were followed from the day of collection until their death. An in-depth study of a well-defined number (35 specimens) of reproductive females were desiccated to define the fertility by counting the eggs contained in the marsupium. 4. We found that A. tunisiense from the Chambi mountain is a semelparous species with a seasonal reproductive pattern, characterized by a reproduction period followed by a sexual rest. Also, we could’ve confirmed the positive relationship between the sizes of ovigerous females and fertility. With 5 eggs recuperated in a 5.2 mm female while 33 eggs were encountered in an 8 mm female. As well as for the sex ratio which characterized by fluctuation (0.49-1.12), but mainly in favor of females over that of males. 5. The combined results of the previous study and ours maintain on the role of environmental conditions that interfere to explain the interspecific variations were observed for the launch and the duration of the reproduction period. Thus, altitude might confirm the intraspecific variations between both studied populations of A. tunisiense.

Rationale: Whether asthma constitutes a risk factor for COVID-19 is unclear. Here we aimed to assess whether asthma, the most common chronic disease in children, is a risk factor for COVID-19 in pediatric populations. Methods: We performed a systematic literature search in three stages: First, we reviewed PubMed, EMBASE and CINAHL for systematic reviews of SARS-CoC-2 and COVID-19 in pediatric populations, and reviewed their primary articles; second, we searched PubMed for studies on COVID-19 or SARS-CoV-2 and asthma/wheeze, and evaluated whether the resulting studies included pediatric populations; third, we repeated the second search in BioRxiv.org and MedRxiv.org to find pre-prints that may have information on pediatric asthma. Results: In the first search, eight systematic reviews were found, of which five were done in pediatric population; after reviewing 67 primary studies we found no data on pediatric asthma as a comorbidity for COVID-19. In the second search, we found 34 results in PubMed, of which five reported asthma in adults, but none included data on children. In the third search, 23 pre-prints in MedRxiv were identified with data on asthma, but again none with pediatric data. We found only one report by the U.S. CDC stating that 40/345 (~11.5%) children with data on chronic conditions had “chronic lung diseases including asthma”. Conclusion: There is scarcely any data on whether childhood asthma (or other pediatric respiratory diseases) constitute risk factors for SARS-CoV-2 infection or COVID-19 severity. Studies are needed that go beyond counting the number of cases in the pediatric age range.

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A mixed immunotherapy-chemotherapy treatment protocol is developed for cancer treatment. Immunotherapy alters the dynamics of the system by affecting on the parameters of the system, and then chemotherapy pushes the trajectory of the system toward the tumor-free equilibrium point. The chemotherapy protocol is derived using the pseudo-spectral controller. In this method, an infinite-horizon optimal control problem is proposed for a nonlinear cancer model. Then, the infinite-horizon optimal control of cancer is transformed into a nonlinear programming (NLP) problem. The efficient Legendre pseudo-spectral (LPS) scheme is suggested to solve the proposed problem. Moreover, to restrict the upper limit of the chemo-drug dose based on the age of the patients a Mamdani fuzzy system is designed. Simulation results on three cases; i.e. young, middle-aged and old patients, show the efficiency of the proposed treatment strategy. In each case the dynamics of the system is modified by immunotherapy, and then chemotherapy guides the trajectory of the system toward the tumor-free equilibrium point. After stopping the treatment, the trajectory of the system converges to this point due to the correction in the dynamics of the system.

The aim of this paper is to apply the Differential Transformation Method (DTM) to analyze and obtain the solution for the mathematical model described by the system of non-linear ordinary differential equations which describe the epidemiology of the most threatening virus called \textbf{Corona-virus} later labeled as COVID-19. Finally, the present study may help you to examine the wild class of real-world models and also aid to predict their behavior with respect to parameters considered in the model. The purpose of this study is to estimate the effectiveness of preventive measures, predicting future outbreaks, and potential control strategies using the mathematical model.

The problem of finding minimal spanning tree is a famous combinatorial optimization problem for which polynomial time algorithms exits. The problem of finding minimal spanning tree appears in different engineering and service applications, particularly in designing computers, telecommunication, transportation and water supply network. In addition it has a number of computational applications such as clustering a data point in a plane, handwriting recognition and providing approximate solution for the travelling salesman problem. Some recent applications include cell nuclei segmentation, Alzheimer's classification, water looped network equilibrium and characterizing local urban patterns. In this article we are finding minimal path of a network problem by converting that problem in linear programming and integer programming using TORA and MATLAB. We also find the minimal spanning tree using these computer software and check that which one is more efficient and less time consuming.

CDC recommends the use of N-95 respirator or surgical mask (if N-95 masks are not available) when taking care of the COVID-19 suspected or positive patients. N-95 respiratory mask should be used instead of a face-mask when present or carrying out aerosol-generating procedures such as intubation, bronchoscopy1. WHO has also recommended to wear a mask in simple encounters with COVID-19 patients and reserve the N-95 respirators for aerosol producing procedures2. CDC reports that the spread of the virus is mainly from person to person in the form of respiratory droplets when the infected COVID 19 patient sneezes or coughs3. WHO reported the transmission of the virus between people through droplets and contact and not through airborne precautions4. However, there are recent experimental studies that suggest the plausibility of aerosol transmission of COVID-19. We describe a case of an emergency health care worker acquiring COVID-19 in a short encounter with an index COVID-19 positive patient (patient X) in the hospital despite the use of a surgical mask and gloves.

Integrated pest management(IPM) has been promoted as an environmentally friendly pest control approach. It utilizes a combination of control methods to control pest populations in agricultural and forestry systems. In this paper, we propose an IPM pest-predator model with impulses and stage structure on predator population, where the predator population is divided into two stages, a juvenile stage and a mature stage. The mature predator’s predation conversion for production of new predators. This kind of stage-structured pest-predator model has been omitted in the mathematical models for integrated pest management. The dynamical properties for the pest-extinction solution and permanence of system $(2.1)$ are established. The simulations are employed to support the proofs. Our results provide a good balance between the biological control and chemical control for integrated pest management.

There is currently scant data on COVID-19 related death cases among physicians with different medical specialties. Mortality data among physicians in Italy show that General Practitioners (GPs) are the most affected group. They currently represent the 43% of the total COVID-19 related death cases among physicians, whereas the estimated proportion of GPs compared to other doctors is of 15%. This high number among GPs is attributable to a work-related contagion happened massively during the first weeks of the epidemic, but constantly continuing also in the weeks following the national lock-down. There are various reasons for these higher contagion rates: GPs use to daily perform a lot of medical examinations in close contacts with patients, and in addition it should be considered that SARS-CoV-2 can resist on the clinics’ surfaces for several hours and it can be transmitted also at distances longer than two meters, persisting in the air after an aerosolization process. Furthermore, especially at the beginning of the epidemic GPs might have scant information on specific safety procedures for the prevention of COVID-19 transmission (e.g. there was scant knowledge on the possibility of contagions from asyntomatic patients) and, morever, the availability of personal protective equipment was insufficient. Following these observations, and considering the high tribute in term of lives from the GPs, Covid-19 pandemic will probably revolutionize the approach to patients in the general practice. Clear and effective guidelines are absolutely and urgently needed, for the refinement of adequate measures to prevent SARS-CoV-2 infections among GPs.

The black soil region of northeast China is one of the most productive regions of the world. The depth of A horizon is rapidly decreasing due to excessive erosion. A strategy for erosion hazard evaluation and soil conservation planning has been proposed and tested on the region. Climate, geomorphology, DEM, soil, landuse, runoff plot and corn yield data were compiled. Soil erosion rate, A horizon thickness and corn yield under six conservation scenarios during 2020~2200 was predicted. The six scenarios include Present (continue present practices), Contour (contour tillage), Straw (straw incorporated in tillage layer), Combo 1 (contour tillage and terracing etc.), No-till (no-till farming) and Combo 2 (partially Combo 1 and partially No-till). Current soil life expectancy of A horizon (SLEA), which is the time until a critical horizon thickness needed for sustaining crop production is reached, was calculated for each scenario. Erosion hazard degrees were determined with SLEA. Croplands with SLEA of <0 a, 0 a~20 a, 20 a~100 a, 100 a~1000 a and ≥1000 a, were classified as “Damaged”, “High hazard”, “Moderate hazard”, “Low hazard” and “No hazard”, respectively. Current area ratio of “Damaged” and “High hazard” and “Moderate hazard” was found to be 8%, 5%, and 22%, respectively. The optimum conservation practice was found to be No-till for “Damaged”, “Combo 2” for “High hazard”, “Moderate hazard” and “Low hazard” and Present for “No hazard”. An optimum conservation schedule was also suggested for each township to maintain all soils to have an A horizon above 20 cm.

Identifying candidate drugs effective in the new coronavirus disease 2019 (Covid-19) is crucial, pending a vaccine against SARS-CoV2. We suggest the hypothesis that Cannabidiol (CBD), a non-psychotropic phytocannabinoid, has the potential to limit the severity and progression of the disease for several reasons: 1) High-CBD Cannabis Sativa extracts are able to downregulate the expression of the two key receptors for SARS-CoV2 in several models of human epithelia 2) CBD exerts a wide range of immunomodulatory and anti-inflammatory effects and it can mitigate the uncontrolled cytokine production featuring Acute Lung Injury 3) Being a PPARΥ agonist, it can display a direct antiviral activity 4) PPARΥ agonists are regulators of fibroblast/myofibroblast activation and can inhibit the development of pulmonary fibrosis, thus ameliorating lung function in recovered patients. We hope our hypothesis, corroborated by several preclinical evidence, will inspire further targeted studies to test CBD as a support drug against the COVID-19 pandemic.

Background and Purpose: The role of peripheral mu-opioid receptors (MOPs) in chronic pain conditions is not well understood. Here, we used a combination of mouse genetics, behavioral assays, and pharmacological interventions to investigate the contribution of MOPs on primary afferent neurons to nociceptive, inflammatory, and neuropathic pain as well as to opioid analgesia. Experimental Approach: We generated conditional knockout mice in which MOPs were selectively deleted in primary sensory neurons. Inflammatory and neuropathic pain states were induced in mutant and control wild-type mice and their behavioral responses to noxious stimuli compared. Gross motor function was also evaluated. Immunohistochemistry was used to assess MOP expression in the dorsal root ganglia, periaqueductal gray, and small intestine. Behavioral assays and whole-cell patch-clamp recordings were used to evaluate the inhibitory effects of mu-opioid agonists, DALDA and morphine, on pain behavior and neurophysiologic effects in DRG neurons, respectively. Key Results: Conditional MOP knockouts and control mice exhibited similar behavioral responses to acute nociceptive stimuli and developed similar inflammation-induced hypersensitivity. Nerve injury in animals lacking peripheral MOPs induced enhanced, bilateral mechanical allodynia. DALDA administered subcutaneously was unable to decrease the hypersensitivity induced by inflammation and nerve injury in MOP knockout animals, and morphine’s antinociceptive effects were significantly attenuated in the absence of peripheral MOPs. Conclusion and Implication: MOPs in primary sensory neurons contribute to the modulation of neuropathic pain behavior and opioid analgesia. Our observations highlight the clinical potential of peripherally acting opioid agonists in the management of chronic inflammatory and neuropathic pain.

The overarching goal of this study is to test innovative monitoring strategies for agricultural properties at watershed towards effectively locating erosions and correcting them, through the implementation of changes in soil management strategies. The purpose is to recover and restore degraded areas, and promote conservation agriculture. The results are, assessed by remote sensing and water quality indicators. In 2019, twelve years were completed of inspection/monitoring at Rio do Peixe watershed. From 2007 to 2017, 14,076 ha, were inspected at Vera Cruz sector, using the Conventional CDA methodology, with 94 properties having been notified. In Ocauçu, a total of 82 properties were notified, in a total surface of 9,027 ha. In Marília, the Innovative CDA Methodology was used, which allowed the inspection and rehabilitation of 52 properties, across 27,775 ha, from 2017 to 2018. After the notifications, the owners presented the conservationist technical projects for each property, which were, implemented using conservation practices, such as: improvement of vegetation cover and crop rotation, to control laminar erosion; and agricultural terracing, divergent channels and containment basin, to control gullies erosions. This work promoted a transformation from degrading agriculture to conservation agriculture, with degraded pastures having been altered into agricultural areas, with the implementation of the No-tillage. Pastures were recovered through the Integrated Crop-Livestock System, and occupancy rate was increased by 31%. This work has demonstrated to benefit Watershed farmers, by increasing their productivity and consequently the profit, as well as the local communities, improving the quality of water that supplies the region.

Background The Corona virus disease 2019 (COVID-19), evolving into a pandemic, resulted in medical resources being shifted to crisis management. Anecdotal evidence suggests that treatment of retinoblastoma, the most common intraocular cancer, is compromised by policy changes during the pandemic, risking children’s lives. Procedure The Global Retinoblastoma Study Group that comprises most retinoblastoma treatment centers across the world conducted a survey focusing on the impact of COVID-19 on retinoblastoma management from March 29 to April 4 2020. Data on COVID-19, including number of positive cases and reported deaths, in the same period were retrieved from the World Health Organization. Results Overall, 194 retinoblastoma centers from 94 countries and 6 continents representing nearly half of the estimated global annual incidence of retinoblastoma participated. As of April 4 2020, the number of COVID-19 positive patients and reported deaths in the participating countries were 1,165,380 and 63,720, respectively, representing over 95% of the global burden. Forty-two percent of the centers reported that families were restricted from travelling to them, and 38% reported disruption to retinoblastoma management from shortage or reallocation of personnel or equipment. Enucleation was still available in 90% and intravenous chemotherapy in 97% of the centers, but 54% of them reported that changes and restrictions outside or within the center were potentially affecting the lives of retinoblastoma patients. Conclusions Shift in health care resources and pandemic policies at a national level may be hazardous for children with retinoblastoma.

Background: Reduced intensity conditioning followed by allogeneic hematopoietic stem cell transplantation can often be curative for the treatment of hemoglobinopathies. Procedure: This is a prospective IRB-approved (NCT02435901) clinical trial, reporting the possible impact of “late” alemtuzumab (administered on days -10 to-8) versus “early” alemtuzumab (-19 to -17) with respect to engraftment and acute/chronic graft-vs-host disease (GvHD) in a group of 35 pediatric patients with sickle cell disease (SCD) or thalassemia undergoing bone marrow transplantation (BMT) following conditioning with alemtuzumab, fludarabine and melphalan. The first 9 patients with SCD received “late” alemtuzumab followed by BMT from HLA matched siblings (MSD). The next 26 patients (21 with SCD and five thalassemia major) received “early” alemtuzumab. Of the 26 patients, 17 received transplant from MSD and nine from matched unrelated donors (MUD). Results: In the “late” group, one patient (11%) developed acute GvHD, six (67%) achieved sustained engraftment. Three patients (33%) ultimately experienced graft rejection, leading to early termination of enrollment of patients on this regimen. In the “early” alemtuzumab group, acute and chronic GvHD developed in 50% and 34% patients, respectively none of the patients experienced graft rejection. Three patients died, 2 due to GvHD-related complications and 1 from sepsis. Five patients developed stable mixed chimerism while 14 demonstrated 100% donor chimerism at one year post-transplant and beyond. Conclusions: These results suggest a benefit with respect to engraftment of administering “early” vs “late” alemtuzumab in this RIC regimen but with the possible cost of an increase in acute, and possibly chronic GvHD.

Increasing treatment intensity for pediatric Ewing sarcoma (ES) has improved survival, but comes with an increased incidence of secondary malignancy. Here, we describe a case of therapy-related mixed phenotype acute leukemia (t-MPAL), T-myeloid type, in a pediatric patient four years after completion of therapy for ES. Genomic evaluation revealed a novel and likely pathogenic RUNX1-TAF3 fusion. This patient did not respond to T-cell leukemia-directed therapy, and while he initially responded to myeloid leukemia-directed therapy, he never achieved complete remission and died of disease 10 months after diagnosis. Here, we present this case and review prior literature regarding t-MPAL.

Background: Trials postulate that analysis of pre-ejection velocities is closely sensitive to blood supply. Tissue velocities declines with reduced regional perfusion and recover on reperfusion. Accordingly, tissue doppler imaging (TDI) can predict myocardial function recovery after revascularization. Purpose: To assess the value of Tissue Doppler Imaging echocardiography in predicting recovery of myocardial function after percutaneous coronary revascularization in patients with coronary artery disease (CAD). Methods: 27 patients with CAD based on coronary angiography were prospectively studied. Echocardiography with 2D measurements, global systolic function and longitudinal myocardial velocities; (IVCPv, S wave, AT, IVCT, CT and IVRT) of the affected segments were recorded 24 hours before revascularization and 6 months after revascularization. Functional recovery was defined as increase in LVEF by ≥5 %. Results: All patients underwent PCI. Most of TDI parameters changed significantly with revascularization, however only mean IVCPv and S wave of dysfunctional segments at rest correlated significantly with recovery of global systolic function. Mean IVCPv> 2.8 cm/sec and mean S wave > 4.6 cm/sec at baseline are an objective indicator of global systolic function recovery with sensitivity, specificity and accuracy for IVCPv (85%, 70%, 79% respectively) and PPV was estimated to be 80% (AUC=0.789, CI=0.603 -0.975, P value=0.02), while for S wave (87%, 77%, 83% respectively) and PPV was 87% (AUC=0.833, CI=0.664 -1.000, P value=0.007). Conclusions: The resting pattern of IVCPv & S wave by TDI accurately predicts the recovery of global systolic function with high PPV but not the regional function after revascularization in patients with CAD.

Background: - The term pure red cell aplasia (PRCA) entails a group of congenital/acquired blood disorders characterized by anemia, reticulocytopenia, and insufficiency of erythroid precursors in an otherwise normo-cellular marrow. Procedures: All children diagnosed as PRCA from 2013 to 2019 at the Pediatric Hematology and Oncology Division at LTMGH, were included and their clinical profile, investigations and treatment details were analyzed. Results: Total 11 patients were diagnosed as PRCA during the study. Mean age of presentation for congenital PRCA was 8.5 months and acquired PRCA was 13.5 years. The acquired cases were patients of aplastic anemia post allogenic HSCT, with major ABO incompatibility, developing PRCA on an average of day +89 post transplant. Most common presentation was pallor in both groups. Mean hemoglobin, MCV and reticulocyte count at diagnosis was 2.7 gm%, 91.06 fL, 0.2% for congenital group and 6 gm%, 128.1 fL, 0.05% for acquired group. Erythroid hypoplasia was seen in bone marrow analysis of all children. In congenital group, NGS confirmed DBA in 2 children (22%); Parvovirus was isolated in 1 child (11%). These children were given steroid trial for a mean duration of 9 months. Four ended up on chronic transfusion program, 2 are transfusion independent, 1 is on steroid trial and 2 children were lost to follow up. Children with acquired PRCA post HSCT were treated with multiple treatment modalities with satisfactory results. Conclusion: - PRCA is a multi-faceted disease with many clinico-hematological presentations. All diagnosticpossibilities must be considered in children with a strong clinical suspicion.

Recent microsatellite studies of two African buffalo (Syncerus caffer) populations in South Africa indicated a high genetic load due to genome-wide high-frequency occurrence of deleterious alleles. These alleles have a negative effect on two male traits: body condition and bovine tuberculosis resistance. Here, we study the occurrence of these male-deleterious alleles throughout most of the buffalo’s range using previously published microsatellite data (2-17 microsatellite loci genotyped on 1676 animals from 34 localities). We uncovered a continent-wide frequency cline of microsatellite alleles associated with male-deleterious traits, with frequencies decreasing from 25 °S to 5 °N (adjusted R2 = 0.87). Further, there was a continent-wide presence of linkage disequilibrium (LD) between male-deleterious-trait-associated alleles at five linked locus pairs (interlocus distance: 0.5-28 Megabase). The fraction of positive interlocus associations among these locus pairs was 0.65 (95% CI: 0.52-0.77; expected fraction with free recombination: 0.5), indicating that many male-deleterious alleles co-occur in haplotypes. We argue that the allele-frequency cline and LD likely result from genome-wide balancing selection of male-deleterious alleles with equilibrium allele and haplotype frequencies determined by the activity of a sex-chromosomal gene-drive system, the latter which was indicated in earlier studies and seemingly originated in southern Africa. The selection pressures involved must be high to prevent destruction of the allele-frequency cline and haplotypes by LD decay. Since most buffalo populations are stable, our results indicate that natural mammal populations can withstand a high genetic load. Nevertheless, we expect that a high genetic load makes many buffalo populations relatively sensitive to environmental stresses.

Conductive tissues are main routes of resource transport, that are crucial for the growth of fleshy fruit. Yet, very few quantitative data of xylem and phloem areas are available and their variabilities are unknown. This study aimed at better understanding and quantifying the structural and functional properties of the conductive tissues in tomato pedicel. 11 contrasting genotypes were described and the impact of water deficit was studied depending on stress intensity and stage of application. In parallel, MRI was used to assess the proportion and size of active xylem vessels in the stem. Results were implemented in a Virtual Fruit model to assess the potential contribution of pedicel conductive tissues in the variability of fruit fresh and dry masses. On their whole, results suggested that variations in the properties of conducting tissues are involved in the genotypic and environmental variations of fruit mass. The study also highlights the interest to combine methods and to integrate knowledge to better understand plant functioning, and finally to improve plant models. Flow-MRI was shown to be an easy non-destructive method to measure the functional properties of conducting tissues such as the proportion of active vessels and their diameter.

COVID outbreak has incapacitated the healthcare system around the world. Existing resources and manpower are being redirected to take care of the COVID-19 disease patients. People with head and neck cancers with the need of post ablative reconstruction are in difficult situation owing to multiple factors like poor general condition, disease progression and potential chance of getting an infection of COVID -19 in a health care facility as well as doubt regarding treatment completion i.e. adjuvant treatment. Appropriate reconstruction following ablative surgery, especially in advanced disease, facilitates functional recovery and thus adding to the quality of life of the patients.The reconstructive procedures are resource-intensive, requiring long hours of surgery, trained manpower, and multiple team members. However, if adequate surgical excision demands the reconstructive procedure, then it should not be a hindrance for the standard treatment.  We need to review our approach in the face of the devastating COVID-19 pandemic. We are presently working in resource constraints like limited availability of staff and limited availability of personal protective equipment especially in plastic surgery procedures which requires the use of loupes and microscope. Thus, the challenge is to ensure proper reconstruction with limited available resources and maintaining safety standards for the staff in the operation theatre. This work is based on our experience and evidence from the literature.