BackgroundElectronic collection of patient-reported outcomes (e-PROM) allows accurate recording of data. They also enable the visualization of longitudinal trends in domain-specific scores for a patient, and may improve patient-physician communication. Several commercial offerings are available but deploying them in countries like India is challenging due to language barriers and literacy levels. Additionally, costs involved remain a major problem. We propose to develop an open-source tool to serve the same purpose.Material and MethodsAfter an exhaustive requirement analysis for a minimum viable product, we decided to proceed with developing the system using an open-source content management system. Additional contributed modules like Webform and Media were used to provide additional functionality. Three tiers of user roles with role-specific privileges were defined. A preliminary user experience testing was done for the patient role.ResultsAll requirements identified in the requirement analysis section have been met. The system allows users with a patient role to fill in questionnaires presented to them. To ensure that diverse groups of patients can be accommodated, patients are grouped according to disease groups. Health care workers can visualize the results of the questionnaire as well as develop new questionnaires using a graphical interface. Initial user experience testing shows that 93.5% of the users (playing the role of patients) were able to use the website without additional help. ConclusionAn open-source system to collect electronic PROM has been developed with localization in Indian languages. We aim to continue developing, validating and extending the system in the future.

Full author listEric Adjei Boakye, PhD, MA1,2, Wiley Jenkins, PhD, MPH1,2, Arun Sharma, MD, MS2,31Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois2Simmons Cancer Institute at SIU, Southern Illinois University School of Medicine, Springfield, Illinois3Department of Otolaryngology – Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois

BackgroundIn the face of the COVID-19 pandemic, cancer care has had to adapt rapidly given the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons (ACS) issuing recommendations to postpone non-urgent surgeries. MethodsAn institutional multidisciplinary group of Head and Neck Surgical Oncology, Surgical Endocrinology, and Medical Endocrinology devised Surgical Triaging Guidelines for Endocrine Surgery during COVID-19, aligned with phases of care published by the ACS.ResultsPhases of care with examples of corresponding endocrine cases are outlined. Most cases can be safely postponed with active surveillance, including most differentiated and medullary thyroid cancers.  During the most acute phase, all endocrine surgeries are deferred except thyroid tumors requiring acute airway management.ConclusionsThese guidelines provide context for endocrine surgery within the spectrum of surgical oncology, with the goal of optimal individualized multidisciplinary patient care, and the expectation of significant resource diversion to care for COVID-19 patients.

Background and Methods: There is an added level of complexity in the management of head and neck cancer patients with underlying immunosuppressive disorders during the COVID-19 pandemic. Head and neck oncologists are tasked with balancing the dual risks of cancer progression in the setting of impaired tumor immunity and increased susceptibility to life-threatening complications from exposure to viral infection for patients and providers. Through two cases of immunocompromised patients with newly diagnosed head and neck malignancies, we aim to provide guidance to clinicians struggling with how to best counsel and manage this unique subset of patients under these difficult circumstances. Results: After careful consideration of the options, we took different approaches in the care of these two patients. Conclusions: Ultimately, there is no uniform set of rules to apply to this heterogeneous group of immune-compromised patients. We provide some general principles to help guide patient management during the current pandemic.

The Coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world, placing unprecedented strain on the healthcare system. Healthcare resources including hospital beds, ICUs, as well as personal protective equipment (PPE) are becoming increasingly rationed and scare commodities. In this environment, the laryngectomee (patient having previously undergone a total laryngectomy) continues to represent a unique patient with unique needs. Given their surgically altered airway, they pose a challenge to manage for the otolaryngologist within the current COVID-19 pandemic. In this brief report, we present special considerations and best practice recommendations in the management of total laryngectomy patients. We also discuss recommendations for laryngectomy patients and minimizing community exposures.

Triazole fungicides have a broad fungicidal activity spectrum through inhibiting the sterol biosynthesis, which damages the cell membrane function. In addition, triazoles also regulate phytohormone synthesis. Chiral pesticides have different fungicidal activities, environmental fate, and toxicities. In this study, four optical isomers and racemates of metconazole (a chiral triazole fungicide) were used to seed-coat wheat seeds (2.5 g/100 kg seed) before germination. The results showed that cis-1S,5R-metconazole treatment inhibited seedling emergence, which could be impeded by adding exogenous gibberellin3(GA3). Seedling morphology identified the stereoselectivity of metconazole isomers. Plants exposed to cis-1S,5R-metconazole had shorter and thicker appearance, while plants treated with trans-1S,5S-metconazole were taller and thinner, compared with the control plants. Furthermore, the effects of metconazole on plant hormones, gibberellins (GAs), and Jasmonic acid (JA) were investigated. Related enzyme activity and gene RT-qPCR results showed that trans-1S,5S-metconazole treatment upregulated the activity of related enzyme and gene expression in GAs biosynthesis. cis-1S,5R-metconazole caused down-regulation of GAs biosynthesis, and upregulation of JA synthetase activity. Moreover, all metconazole treatments increased antioxidant enzyme activity, especially trans-1S,5S-metconazole, trans-1R,5R-metconazole, and rac-metconazole. Generally, cis-1R,5S-metconazole treatment showed minimum interference of the growth of wheat seedlings, thus cis-1R,5S-metconazole may be a safer metconazole seed-coating application.

Electron Beam Melting (EBM) is one of a few additive manufacturing technologies capable of making full-density functional metallic parts realized from raw materials in the form of powders. The ability of direct fabrications of metallic parts can accelerate product designs and developments in a wide range of metallic-part applications, especially for complex components, which are difficult to make by conventional manufacturing means. To capitalize on these benefits, it must be shown that the mechanical performances of parts produced by EBM can meet design requirements. In this research an intensive mechanical characterization aimed at determining static and fatigue performance of the alloy Ti6Al4V processed by EBM has been performed. The effect of both postprocessing treatments (HIP and surface finish) on the mechanical behavior was evaluated by mechanical testing, microstructural study, computed tomography analysis and fracture surface investigation.

Birds have been observed to have dietary preferences for unsaturated fatty acids (FAs) during migration. Polyunsaturated fatty acids (PUFAs) increase the exercise performance of migrant birds; however, PUFAs are also peroxidation prone and might therefore incur increased costs in terms of enhanced oxidative stress in migratory individuals. To shed light on this potential constraint, we analysed plasma FA composition and estimated the susceptibility to peroxidation of migrants and residents of the partially migratory common blackbird (Turdus merula) at a stop-over site during autumn migration. As predicted, migrant birds had higher relative and absolute levels of PUFAs compared to resident birds. This included the strictly dietary ω-3 PUFA α-linoleic acid, suggesting a dietary preference for these fatty acids in migrants. Interestingly, the FA unsaturation index, which is an index of lipid peroxidation susceptibility, did not differ between migrants and residents. These findings suggest a mechanism where birds alter their levels of metabolic substrate to increase exercise performance without simultaneously increasing the risk of lipid peroxidation and oxidative stress. In summary, our results are in line with the hypothesis of increased exercise performance being constrained by oxidative stress during migration, which is manifested in changes in the composition of key FAs to retain the unsaturation index constant despite the increased levels of peroxidizable PUFAs.

The Food and Agriculture Organizations’ (FAO) PenmanMonteith reference evapotranspiration (ET0) index is a key parameter in hydrological and meteorological studies. Temporal and spatial variations in ET0 from 1981–2017 were investigated in the topographical rapid change zone in the Hengduan Mountains, China. The results showed a change point around the year 2000 in the area-averaged annual ET0 series. ET0 decreased and increased significantly by 3.103 mm/yrmm/year (p < 0.05) from 1981–2000 and by 3.591 mm/yrmm/year (p < 0.05) from 2001–2017, respectively. The contribution analysis shows that reduction in wind speed (Ws) was the primary driving force for the decrease in ET0 during 1981–2000 in spring, autumn, and winter, and annually, while net solar radiation (Rn) was the dominant force in summer. Reduction in relative humidity (RH) was responsible for the increase in ET0 in all seasons and for the annual scale in 2001–2017. The sensitivity analysis shows that ET0 was most sensitive to Rn, followed by RH, and air temperature (Ta) was the least sensitive of the variables. The trends of ET0 were also found to increase with elevation; we denote this as the elevation-dependence of ET0 changes. The elevation-dependence was also noted for the trends of Ws, RH, and Rn, with higher elevations showing larger changes in these parameters. In addition, the sensitivities of Rn, RH, and Ta decreased with elevation, while that of Ws increased with elevation. A comprehensive investigation into the trends of these climatic variables and their sensitivities revealed complex trends of ET0 along the elevation gradient, with typical increases with elevation over the annual scale despite the large differences in seasons. A more detailed exploration of the mechanisms causing this pattern is required.

In this Article, we consider quantum dots with different structures and solve the Schrödinger equations for them by finite difference time-domain method and obtain the Eigenfunction’s and the Eigenvalue’s of these points.The FDTD method have an analysis that demonstrates the high accuracy of this method for solving quantum equations.The FDTD method is a suitable method for simulating electromagnetic phenomena, in this Article we present a simple formulation for the Schrödinger equation in FDTD. In fact, we get help from the idea of FDTD and solve quantum equations. The most important structures we have simulated with this method are cubic quantum dot, spherical quantum dot, elliptical quantum dot and partial truncate-shaped quantum dots on the wetting layer. It is very difficult to solve the Schrödinger equation analytically for these structures, but by using the numerical method we obtain the Eigenfunction’s and Eigenvalue’s in a simpler way.

Co-gasification of coal and renewable biomass is a promising technique to reduce greenhouse gas emission from coal gasification alone. The co-gasification performance of pine bark (PB) biomass and Bangladeshi bituminous coal (BBC) have been assessed using a high-temperature entrained flow gasifier under CO2 atmosphere. Results show that increasing biomass concentration increases the carbon conversion, syngas quality and cold gas efficiency (CGE), while reduces emission. Using 20% CO2 as the reactant gas, an addition of 20% biomass with coal increased the carbon conversion by 21.5, 10.6 and 4.5%-point at temperatures of 1000, 1200 and 1400 °C compared to that of coal respectively. Increasing biomass in the blend from 20% to 80% increased the yield of CO by 36%, 21% and 11% with increasing temperature, while the concentration of H2 remained nearly constant. Also, the CGE, fragmentation index and alkali and alkaline earth minerals in ash were increased with increasing biomass ratio.

The novel coronavirus 2019 (COVID-19) pandemic is rapidly advancing across the globe despite drastic public and personal health measures. Antivirals and nutritional supplements have been proposed as potentially useful against SARS-CoV-2 (virus that causes COVID-19), but few have been clinically established. Lactoferrin (Lf) is a naturally occurring and non-toxic glycoprotein that is orally available as a nutritional supplement and has established in vitro anti-viral efficacy against a wide range of virus including SARS-CoV, a closely related corona virus to SARS-CoV-2 (virus that causes COVID-19). Furthermore, Lf possesses unique immunomodulatory and anti-inflammatory effects that may be especially relevant to the pathophysiology of severe COVID-19 cases. We review the underlying biological mechanisms of Lf as antiviral and immune regulator, and propose its unique potential as a preventative and adjunct treatment for COVID-19. We hope that further research and development of Lf nutritional supplementation would establish its role for COVID-19.

Tick-borne encephalitis virus (TBEV) is responsible for the most serious human viral tick-borne disease in Europe. A greater knowledge of the natural foci of TBEV and their fluctuating characteristics is essential to better assess the temporal variations of TBEV cycle’s epidemiological risks. To describe the seasonal and inter-annual variations of the TBEV-cycle epidemiological parameters related to TBEV nymph-to-larva transmission, exposure of small mammals to TBEV and tick aggregation on small mammals, a longitudinal survey was conducted over a 3-year period to monitor a TBEV focus in a mountain forest in Alsace, eastern France. We trapped small mammals and collected questing ticks five times per year from 2012 to 2014. TBEV prevalence in questing nymphs was lower in 2013 than in 2012 and 2014, probably because small mammals (Myodes glaerolus and Apodemus flavicollis) were more abundant in 2012, reducing tick aggregation and co-feeding transmission between ticks. This prevalence was higher in autumn than spring, which suggests that nymph-to-larva transmission of TBEV mainly occurs in spring. Despite these variations in prevalence, the density of infected questing nymphs was constant over time, leading to a constant risk for humans. The seroprevalence of small mammals was also constant over time although the proportion of small mammals harbouring ticks varied between years and seasons. Our results draw attention to the importance of considering the complex relationship between small mammal densities, tick aggregation on small mammals, density of infected questing nymphs and prevalence of infected nymphs in order to forecast the risk of TBEV for humans.

Dystrophic epidermolysis bullosa (DEB) is a inherited blistering disorder, characterized by affected dermis-epidermis conjunction. COL7A1 encodes collagen VII protein, which is responsible for dermis-epidermis conjunction. We report several mutations of COL7A1 in Iranian families, which result in DEB and expands the mutation spectrum of COL7A1 mutations for further molecular studies

Coronavirus disease 2019 (COVID-19) is a remarkably challenging health issue that provoked all the health-care providers to contemplate some measures about the situation. All the health-care workers frontline (esp. emergency service, pulmonologists, infection disease specialist and anesthesiologist) have produced recommendations on prevention and taking care of COVID-19 patient (1,2). Whereas, at the second line another important issue is the ongoing healthcare for the continual disease situations.There are two main critical issues on cardiovascular surgery in this pandemic. Firstly, to delay the elective surgeries is essential to sustain the health-care service. Elective case triage is trickier for cardiovascular procedures which are relatively progressive conditions. Definitive decision to defer a procedure should be made regarding firstly to the capacity of health-care system, and then availability of surgical/anesthesia staff, intensive care unit beds, need for isolation beds, ventilators, cardiopulmonary bypass machine, extracorporeal membrane oxygenator, supplies such as sutures, grafts, valves and blood and blood product availability. The patient status should be taken into account to defer or to perform the procedure, as well. Therefore, we developed “Level of Priority” (LoP) statement for cardiovascular procedures (3). Elective cases are defined as LoP I that may be postponed as much as possible. LoP II to IV cases should be reconsidered by individual basis by “Heart Team”. The situations that can be managed by percutaneous coronary intervention, endovascular procedures and etc. may be handled by non-operative manners.The second one is the personal protection equipment and infection measures while dealing with a suspected / confirmed COVID-19 patient. It is obvious that a suspected / confirmed COVID-19 patient ought to be assessed with specific measures for any medical or surgical intervention. Personal protection equipment (PPE) is the most crucial measure during the pandemic. It is recognized that many centers are facing PPE shortages and there are recommendations to re-sterile the masks to be effective for reuse.(4) More measures should be taken into consideration for sterile environment such as surgical procedures. Some added measures such as face shield may be recommended for surgical procedures. The surgical team who scrubbed in, must wear extra equipment such as surgical coat and double gloves. It may be recommended to fix the long-sleeve gloves to the surgical coat by adhesive drapes (3). It is obvious that this kind of working environment with all this equipment is challenging, sometimes irritating and disquieting. One other big problem is the fraught feeling of health-care providers to be diseased or to be contagious for their family. Therefore, health-care providers may need enormous support for burnouts during the pandemic.The other measures such as preparation of the operating room (OR), anesthesiologic management, transportation of patients and disinfection of OR were discussed in the referring article (3).In conclusion, it is important to assess the “Level of Priority” for surgical procedures to support the service of health-care facility. More than that, whole surgical team should be protected by adequate PPE and should take the time to get full protected.

In mid-February 2018, a 29-yeal old male patient with Marfan’s syndrome, a history of mitral valve repair in 2007, valve-sparing aortic root replacement in 2017 and aortic valve replacement with a St Jude mechanical heart valve inside the valve sparing aortic root graft in 2018 presented with a sudden onset of palpitations and New York Heart Association Class III symptoms. Computed tomography demonstrated a large, 7 x 4 x 9 cm mediastinal haematoma arising from a long vertical incisional defect in the anterior wall of the Dacron graft. During surgery, hypothermic cardiopulmonary bypass (CPB) was established and after cooling the patient to 16° C, a partial redo sternotomy was performed. During this process, the haematoma was entered, resulting in profuse bleeding. Circulatory arrest was immediately initiated, sternotomy was opened with a chest retractor and mediastinal blood evacuated. A 4.0 x 2.5 cm vertical defect in the Bentall graft with fragments of 4-0 polypropylene sutures were found at its edges. The defect was closed with a Dacron patch, then the graft was de-aired and CPB resumed. After rewarming the patient to 34° C temperature, a direct current shock was applied to convert ventricular fibrillation into sinus rhythm. On fully rewarming the patient, he was uneventfully weaned from CPB and decannulated. In our opinion, long vertical incisional defects in the Bentall Dacron graft should be closed with a synthetic patch. A postoperative mediastinal haematoma after aortic root replacement can be successfully operated on in deep hypothermic circulatory arrest with CPB.

Double orifice mitral valve (DOMV) is an unusual finding, most commonly seen with atrioventricular canal defect (AVCD). Due to the varied anatomical types, hemodynamic effects and co existence of other malformations, the surgical management of this anomaly can be challenging. Achieving a compromise between residual regurgitation and new stenosis, should be the aim of surgical intent. We present a case report of DOMV detected incidentally during surgery in a case of AVCD with severe MR.

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

Objective: To evaluate the accuracy of concentrations of gingival crevicular fluid (GCF) placental alkaline phosphatase (PLAP) during early pregnancy in identifying women at risk of subsequently developing preeclampsia (PE). Design: Prospective cohort study. Setting: Hospital Sotero del Río, Santiago, Chile. Population: Pregnant women recruited at 11-14 weeks of gestation. Methods: Maternal obstetric and periodontal histories were obtained. GCF samples were collected for PLAP determination by ELISA assay. Multiple logistic regression models estimated the association between GCF-PLAP concentrations, maternal variables, and PE development. The accuracy performance of the prediction model was established. Results: 460 women were recruited into the study, and 412 completed their pregnancy follow–up visit. 18 (4.3%) women developed PE. GCF-PLAP concentrations and systolic blood pressure measurements were significantly higher in women who developed PE (p=0.015 and p<0.001, respectively). An association between first-trimester systolic blood pressure, GCF-PLAP, and PE were established. The predictive model had a sensitivity of 83%, specificity of 72%, a positive predictive value (PPV) of 12%, and a negative predictive value (NPV) of 99%. The positive and negative likelihood ratios were 2.9 and 0.3, respectively, thus classifying correctly 72% of women who subsequently developed PE. The area under the receiver operating characteristic curve was 0.77 for PE and 0.85 for preterm PE. Conclusions: An algorithm that includes PLAP concentrations in GCF and blood pressure during early pregnancy may aid in the identification of women at risk of developing PE. Funding: FONDEF IDeA: ID16I10452. NICHD/NIH/DHHS: HHSN275201300006C. Keywords: a cohort study, gestation, hypertension, placental biomarkers, risk prediction model.

Objective. To externally validate five approaches to predict ectopic pregnancy (EP) in pregnancies of unknown location (PUL): the M6P and M6NP risk models, the two-step triage strategy (2ST, which incorporates M6P), the M4 risk model, and beta human chorionic gonadotropin ratio cut-offs (BhCG-RC). Design. Secondary analysis of a prospective cohort study.Setting. Eight UK early pregnancy assessment units.Population. Women presenting with a PUL and BhCG >25 IU/L.Methods. Women were managed using the 2ST protocol: PUL were classified as low risk of EP if presenting progesterone ≤2 nmol/L; the remaining cases returned two days later for triage based on M6P. EP risk ≥5% was used to classify PUL as high risk. Missing values were imputed, and predictions for the five approaches were calculated post hoc. We meta-analysed centre-specific results. Main outcome measures. Discrimination, calibration and clinical utility (decision curve analysis) for predicting EP.Results. Of 2899 eligible women, the primary analysis excluded 297 (10%) women who were lost to follow-up. The area under the ROC curve for EP was 0.89 (95% confidence interval 0.86-0.91) for M6P, 0.88 (0.86-0.90) for 2ST, 0.86 (0.83-0.88) for M6NP, and 0.82 (0.78-0.85) for M4. Sensitivities for EP were 96% (M6P), 94% (2ST), 92% (N6NP), 80% (M4), and 58% (BhCG-RC); false positive rates were 35%, 33%, 39%, 24%, and 13%. M6P and 2ST had the best clinical utility and good overall calibration, with modest variability between centres.Conclusions. 2ST and M6P performed best to predict and triage PUL.Funding. Research Foundation – Flanders (FWO; G0B4716N), Internal Funds KU Leuven (C24/15/037), NIHR Collaboration for Leadership in Applied Health Research & Care, NorthWest London (RDIP033), NIHR Biomedical Research Centre based at Imperial College Healthcare NHS Trust. Keywords Pregnancy of unknown location, ectopic pregnancy, beta human chorionic gonadotrophin (BhCG) ratio, progesterone, prediction model, prediction model validation 

Objective: To investigate whether live birth rate (LBR) following frozen-thawed embryo transfer in tamoxifen -stimulated cycles (T-FET) differs from hormone replacement treatment FET (HRT- FET) in women with thin endometrium. Design: Retrospective cohort study. Setting: Tertiary-care academic medical center. Participant(s): A total of 671 patients with thin endometrium who fulfilled the inclusion criteria were involved in the period from January 2016 till February 2019. Methods In the group of T-FET, 20 mg TAM per day was giving from day 5 of the menstrual cycle for 5 days. Day-3 ET was performed four days after ovulation while blastocyst transfer was performed six days after ovulation. In the group of HRT- FET, estradiol val¬erate was taken 6 mg/d from menstrual cycle day 2-3. 12 to 14 days later progesterone 40 - 60 mg/d was given. Embryo transfer was performed 3 or 5 days later for day-3 embryos or blastocysts respectively. Main Outcome Measure(s): LBR per embryo transfer was the primary outcome. The secondary end points included ongoing and clinical pregnancy rate, cancellation rate, endometrial thickness and pregnancy loss rate. Multivariable logistic regression analysis was performed to adjust for potential confounders. Result(s): LBR was significantly higher in T-FET group than HRT-FET group. Moreover, the clinical and ongoing pregnancy rate also higher in the T-FET group than in the HRT-FET group. Conclusion(s): In patients with thin endometrium undergoing FET, tamoxifen use for endometrial preparation was associated with higher LBR compared with HRT cycles. Funding: No external funding was used.

Design: Qualitative research Setting: Two University Hospitals and one District Hospital in Ireland Population: Participants interviewed ranged from first year trainees to consultant obstetricians. Methods: Interviews using open ended questions. Interviews were recorded on audio and later transcribed. Main outcome measures: Thematic analysis was performed until saturation. Results: 35 obstetricians were interviewed. The median number of years of experience was 5 years (range 3-20 years). The median number of OVD was 200 (range 20-1000+). Vacuum was the preferred choice amongst junior trainees. Preference shifted to forceps with increasing clinical experience. Seven clear themes emerged. Three themes were common to all participants: firstly, that all clinicians reported respect for the primiparous OVD in anticipation of possible complications, secondly the wish for senior midwifery support and finally the importance of clinical experience and exposure. Four themes were common to trainees only. Female clinicians in training reported significant self-doubt in their ability to perform an OVD and had concerns about causing harm. Clinicians in training wished to be trained by consultants during their first year on the labour ward. Experience was important. The final theme was a wish for more training in forceps OVD by clinicians in training. Conclusion: This qualitative study identified factors that can be used to design education and training in OVD in order to improve care for the woman and baby.

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

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