Catheter ablation is the current standard of care for the management of symptomatic atrial fibrillation (AFib) refractory to pharmacological therapy. One of the complications of this procedure is thermal injury to the esophagus due to its anatomical proximity to the posterior wall of the left atrium (1). Rarely (<1%), an atrioesophageal fistula can form connecting the lumen of damaged esophagus to the atrial chamber (2). This complication is almost always fatal and can result in exsanguination, air embolism, and sepsis (3, 4). With a growing number of catheter ablations being performed each year, the rate of atrioesophageal fistulas is only expected to rise (5). Other more frequent complications include esophageal wall erosions and ulcers (47%), and thermal injury to the vagus nerve plexus leading to esophageal dysmotility and gastroparesis (17%) (6, 7). Therefore, protecting the esophagus from thermal injuries is paramount in ablative procedures and several strategies have been devised to help mitigate this risk. Many physicians monitor the luminal esophageal temperature (LET) [ as a surrogate for intramural esophageal tissue temperature] with a single sensor or multisensor temperature probe and interrupt energy delivery when LET reaches 38°C or 39°C during radiofrequency ablation. However, this technique significantly impacts the procedural workflow due to the waiting periods for LET to return to baseline. Alternative strategies involve cooling of the esophagus with ice water or reducing the ablation lesion power, contact force and/or duration but this strategy may increase the chances for pulmonary vein reconnection (8). To that end, there has been a growing interest in mechanical devices capable of deflecting the esophagus away from the atrium protecting it from thermal injury.In the current issue of the Journal of Cardiovascular Electrophysiology, Houmsse et al. introduce a novel device capable of mobilizing the esophagus laterally to protect it from injury when performing catheter ablation for AFib. Although other devices have been developed and/or used for this purpose (such as the transesophageal echocardiography probe, endotracheal stylet, Esosure stylet and DV8 shaped balloon retractor), this is the only one to operate using vacuum suction allowing it to latch onto the esophageal wall. The device consists of four main components: outer extrusion, inner stacking plates, deflecting arm and control handle. The outer extrusion is inserted via a trochanter or a bougie into the esophagus and is the only portion of the retractor that comes in contact with the surrounding tissues. Small perforations at the distal end allow for vacuum suction to adhere to the esophagus and for a radiocontrast agent to be delivered to delineate the esophageal contour. The inner stacking plates are then introduced through the outer extrusion and are designed to allow movement of the deflecting arm in the medio-lateral plane only. The deflecting arm is connected to the distal end of the stacking plates through a pivot point and can be steered using the control handle. The authors have evaluated the effectiveness and safety of the device on canine and swine animal models by measuring the distance and direction of displacement of the esophagus, examining the cellular architecture after prolonged suction, measuring the LET, and assessing compatibility of device with electroanatomical mapping systems. A total of 68 deviations were performed on four canine models. The average rightward deflection was equal to 26.6 ± 2.5mm compared to 18.7 ± 2.3mm for the direct leftward deflection (p<0.001), and 96% of deviations did not have an esophageal trailing edge. With the exception of one study, the average distance displaced using the suction retractor was superior to other devices (9-13). The substantial distance of deflection and the minimal esophageal trailing edge significantly decreased the rise in LET from baseline (mean increase of 0.2°C vs 2.5°C without deflection). Examination of the esophageal tissue integrity following one hour of continuous suctioning revealed no change in the esophageal cellular architecture, and only minimal circular areas of hyperemia in mucosa due to the suction ports without injury to the muscularis layer. Finally, the retractor did not interfere with the electroanatomical mapping systems used (CARTO and EnSite).Despite its interesting findings, this study has several limitations that should be acknowledged. First, the study was performed on swine and canine animal models, which are known to have an anatomy close to humans; however, the safety profile of the device and its effectiveness in displacing the esophagus may not translate in humans. Second, subjects may exhibit symptoms secondary to extreme deviation of the esophagus in the absence of distortion of the cellular architecture. Clinical studies are needed to assess the safety profile and side effects of this esophageal retractor. Third, it is unclear whether these results would be reproducible under monitored anesthesia care. Finally, the fluoroscopic equipment tools lacked electronic caliper capabilities, and the measurements were performed using radiopaque rulers.Overall, the authors should be commended on their efforts to introduce and evaluate an inexpensive and innovative tool for esophageal protection during AFib ablation. This retractor addresses the limitations of other products that serve a similar purpose. In fact, the suctioning power of the product minimizes the trailing edge of the esophagus that could not be managed with other devices which left esophageal tissue in the ablation field (10, 13). In addition, the control handle offers significant flexibility in device manipulation allowing physicians to choose the site of angulation and the angle of deflection depending on the patient’s anatomy. Future studies should focus on evaluating the safety and effectiveness of this device in humans. Given the growing number of esophageal retracting devices, studies should also aim to determine the device that produces the best esophageal protection and most desirable outcomes of ablation.REFERENCES1. Chung MK, Refaat M, Shen WK, Kutyifa V, Cha YM, Di Biase L, Baranchuk A, Lampert R, Natale A, Fisher J, Lakkireddy DR. Atrial Fibrillation: JACC Council Perspectives. J Am Coll Cardiol. Apr 2020; 75 (14): 1689-1713.2. D’Avila A, Ptaszek LM, Yu PB, Walker JD, Wright C, Noseworthy PA, Myers A, Refaat M, Ruskin JN. Left Atrial-Esophageal Fistula After Pulmonary Vein Isolation. Circulation May 2007; 115(17): e432-3.3. Aryana A, Arthur A, O’ Neill PG, D’Avila A. Catastrophic manifestations of air embolism in a patient with atrioesophageal fistula following minimally invasive surgical ablation of atrial fibrillation. Journal of cardiovascular electrophysiology. 2013;24(8):933-4.4. Stöckigt F, Schrickel JW, Andrié R, Lickfett L. Atrioesophageal fistula after cryoballoon pulmonary vein isolation. Journal of cardiovascular electrophysiology. 2012;23(11):1254-7.5. Oral H, Siontis KC. Prevention of Atrioesophageal Fistula After Catheter Ablation: If the Esophagus Cannot Stand the Heat (Cold), Can It Be Moved to the Sidelines? : JACC: Clinical Electrophysiology; 2017.6. Shah D, Dumonceau J-M, Burri H, Sunthorn H, Schroft A, Gentil-Baron P, et al. Acute pyloric spasm and gastric hypomotility: an extracardiac adverse effect of percutaneous radiofrequency ablation for atrial fibrillation. Journal of the American College of Cardiology. 2005;46(2):327-30.7. Schmidt M, Nölker G, Marschang H, Gutleben K-J, Schibgilla V, Rittger H, et al. Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation. Europace. 2008;10(2):205-9.8. Tran VN, Kusa S, Smietana J, Tsai W-C, Bhasin K, Teh A, et al. The relationship between oesophageal heating during left atrial posterior wall ablation and the durability of pulmonary vein isolation. Ep Europace. 2017;19(10):1664-9.9. Mateos JCP, Mateos EIP, Peña TGS, Lobo TJ, Mateos JCP, Vargas RNA, et al. Simplified method for esophagus protection during radiofrequency catheter ablation of atrial fibrillation-prospective study of 704 cases. Brazilian Journal of Cardiovascular Surgery. 2015;30(2):139-47.10. Bhardwaj R, Naniwadekar A, Whang W, Mittnacht AJ, Palaniswamy C, Koruth JS, et al. Esophageal Deviation During Atrial Fibrillation Ablation: Clinical Experience With a Dedicated Esophageal Balloon Retractor. JACC Clin Electrophysiol. 2018;4(8):1020-30.11. Herweg B, Johnson N, Postler G, Curtis AB, Barold SS, Ilercil A. Mechanical esophageal deflection during ablation of atrial fibrillation. Pacing and clinical electrophysiology. 2006;29(9):957-61.12. Palaniswamy C, Koruth JS, Mittnacht AJ, Miller MA, Choudry S, Bhardwaj R, et al. The extent of mechanical esophageal deviation to avoid esophageal heating during catheter ablation of atrial fibrillation. JACC: Clinical Electrophysiology. 2017;3(10):1146-54.13. Parikh V, Swarup V, Hantla J, Vuddanda V, Dar T, Yarlagadda B, et al. Feasibility, safety, and efficacy of a novel preshaped nitinol esophageal deviator to successfully deflect the esophagus and ablate left atrium without esophageal temperature rise during atrial fibrillation ablation: The DEFLECT GUT study. Heart Rhythm. 2018;15(9):1321-7.

We read with great interest the article by Khashkhusha TR et al “ACE inhibitors and COVID-19: We don’t know yet”. The authors discuss whether the use of angiotensin-converting enzyme (ACE) inhibitors (ACEIs) in novel coronavirus disease‐19 (COVID‐19) patients is beneficial or harmful. ACEIs and angiotensin receptor antagonists (ARBs) both upregulate ACE2 levels. We believe that ARBs should be preferred since, unlike ARBs, ACEIs may increase angiotensin II through the chymase pathway. We would like to discuss potential harms ACEI may cause through secondary bradykinin-chymase pathways.

Purpose: To evaluate the prognostic factors affecting surgical margin and recurrence in patients who underwent partial nephrectomy for renal masses. Materials and Methods: Data of 125 patients who underwent open or laparoscopic partial nephrectomy due to renal mass between January 2006 and January 2019 were analyzed retrospectively. Demographic data, habits, additional diseases, clinical and laboratory findings, operational data, the morphology of the tumor in computerized tomography or magnetic-resonance imaging and follow-up data were scanned and acquired via our hospital’s system and archive. Results: Average age was 54.4, male-female ratio was 1.55 and average tumor size was 3.31 cm. 104 patients had malignant pathology and 21 was benign. Positive surgical margin rate was 5.6% and recurrence rate was 3.2%. Average follow-up was 47.4 months. Pathological size of the tumor was larger (p=0.006), warm-ischemia period was lower (p=0.003), and PADUA score was higher (p=0.015) in open technique. Tumor size and tumor stage were statistically higher in patients with recurrence (p=0.009, p<0.001 respectively). No statistically significant difference was observed between surgical margin positivity and tumor size, Fuhrman grades, PADUA scores, R.E.N.A.L. scores, and C-index. (p>0.05) Conclusion: Surgical margin positivity after partial nephrectomy is not significantly associated with tumor characteristics and anatomical scoring systems. Tumor size and stage after partial nephrectomy are valuable parameters in evaluating the recurrence risk. Keywords: nephrectomy, recurrence, margins of excision, prognosis

Background and Aim: Despite transrectal ultrasound (TRUS) being regarded as gold-standard for prostate volume estimation, concerns have been raised in literature concerning its accuracy especially in men with above-average prostate volumes. We aimed to evaluate the performance of TRUS for prostate volume estimation in a cohort of sub-Saharan African men since they are known to have relatively large mean prostate volumes. Methods: This was a prospective study of 77 sub-Saharan African men who had open simple prostatectomy for Benign Prostate Hyperplasia (BPH). Pre-operative TRUS determined total prostate volume (TPV) and transition zone volume (TZV). Following surgical enucleation, the adenoma was weighed (EPW) and its volume (EPV) also determined by fluid displacement. TRUS was repeated six weeks post-operatively to calculate the TRUS-estimated specimen volume (TESV). Results: The mean EPV, EPW, TRUS-estimated TZV, TRUS-estimated TPV and TESV were 79.1 ± 62.9mls, 79.1 ± 62.9g, 53.3 ± 28.5mls, 93.1 ± 48.9mls and 69.9 ± 44.6mls respectively. Pearson’s correlation showed perfect relationship between EPW and EPV with no difference in their mean values (r=1.000; P<0.001). Pearson’s correlation between TRUS-estimated TPV vs EPV, TRUS-estimated TZV vs EPV, and between TESV vs EPV were 0.932, 0.865 and 0.930 respectively (p = 0.0000). TRUS significantly under-estimated the TZV and TESV by 25.8ml and 9.2ml respectively; unrelated to severity of prostate enlargement. Conclusion: TRUS underestimates prostate volume, independent of prostate size. We propose simple formulae that could be used to improve the prostate volume determination from TRUS, especially if magnetic resonance imaging is not readily available or contraindicated.

The coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 infections has led to substantial unmet need for treatments, many of which will require testing in appropriate animal models of this disease. Vaccine trials are already underway, but there remains an urgent need to find other therapeutic approaches to either target SARS-CoV-2 or the complications arising from viral infection, particularly the dysregulated immune response and systemic complications which have been associated with progression to severe COVID-19. At the time of writing, in vivo studies of SARS-CoV-2 infection have been described using macaques, cats, ferrets, hamsters, and transgenic mice expressing human angiotensin I converting enzyme 2 (ACE2). These infection models have already been useful for studies of transmission and immunity, but to date only partially model the mechanisms implicated in human severe COVID-19. There is therefore an urgent need for development of animal models for improved evaluation of efficacy of drugs identified as having potential in the treatment of severe COVID-19. These models need to recapitulate key mechanisms of COVID-19 severe acute respiratory distress syndrome and reproduce the immunopathology and systemic sequelae associated with this disease. Here, we review the current models of SARS-CoV-2 infection and COVID-19-related disease mechanisms and suggest ways in which animal models can be adapted to increase their usefulness in research into COVID-19 pathogenesis and for assessing potential treatments.

Quantitative systems pharmacology (QSP) is a relatively new discipline within modelling and simulation that has gained wide attention over the past few years. The application of QSP models spans drug-target identification and validation, through all drug development phases as well as clinical applications. Due to their detailed mechanistic nature, QSP models are capable of extrapolating knowledge to predict outcomes in scenarios that have not been tested experimentally making them an important resource in experimental and clinical pharmacology. However, these models are complicated to work with due to their size and inherent complexity. This makes many applications of QSP models for simulation, parameter estimation and trial design computationally intractable. A number of techniques have been developed to simplify QSP models into smaller models that are more amenable to further analyses while retaining their accurate predictive capabilities. Different simplification techniques have different strengths and weaknesses and hence different utilities. Understanding the utilities of different methods is essential for selection of the best method for a particular situation. In this paper, we have created an overall framework for model simplification techniques that allows a natural categorisation of methods based on their utility. We provide a brief description of the concept underpinning the different methods and example applications. A summary of the utilities of methods is intended provide a guide to modellers in their model endeavours to simplify these complicated models.

Stroke is a devastating complication following coronary artery bypass grafting, which thankfully occurs with low incidence. The role of preoperative carotid ultrasound remains unclear. Whilst it is a cheap and reliable way of diagnosing carotid stenosis, it is unclear if and how this knowledge should impact on subsequent patient management. The evidence overall suggests that patients with severe carotid stenosis are likely to have an increased incidence of postoperative stroke -- however, the prevalence of severe carotid stenosis is low, and even in this cohort of patients, the incidence is not particularly high. In screened patients identified to have severe carotid stenosis, there appears to be a generally low appetite for undertaking carotid intervention internationally either prior to or concurrently with the coronary artery bypass grafting. Putting this all together, the widespread screening of asymptomatic patients would appear to not be justified.

Techniques such as micro-tomography (µCT) and nuclear magnetic resonance (NMR) methods have been used to characterize porous media for decades. Magnetic Resonance Imaging (MRI) offers direct visualization of pore architecture through a vast number of pulse sequences. In this work, we tested the MRI pulse sequence Zero Echo Time (ZTE) in the study of sandstone and carbonate. ZTE has been used previously to image highly porous geological material with relative success. In this research, ZTE was used to study porous systems tighter than those previously reported. We show that ZTE can resolve not only pore systems, but also a combination of fractures and pores simultaneously. Additionally, Pore Cluster Analysis (PCA), combined with ZTE, can be used to analyze connectivity of relatively large volume core plugs. By combining Time-Domain NMR pore-size analysis and PCA, we show that careful selection of resolution is necessary to understand transport in porous media.

Diverse engineering fields request flash calculations like isothermal flash, isenthalpic flash, and isentropic flash. They can be cast as minimization of a thermodynamic state-function and solved by Michelsen’s Q-function approach. Flash calculations for open systems, i.e. systems where chemical potentials are specified instead of the mole numbers for some components, also belong to this scope. By analyzing the construction of Q-functions through Legendre transforms, we extend this approach to the flash for open systems in the absence or presence of chemical reactions, resulting in general formulations for various specifications. For systems without reactions, the classical framework using mole numbers as independent variables is employed; for those with reactions, the modified-RAND framework is employed. We present examples for open systems at constant temperature and pressure. Using the Q-function minimization, we can solve multicomponent non-reactive or reactive systems at a specified chemical potential with quadratic convergence over a wide range of conditions.

This article concerns with the thermoelastic corner-edge type system with singular potential function on a wedge manifold with corner singularities. First, we introduce weighted $p-$Sobolev spaces on manifolds with corner-edge singularities. Then, we prove the corner-edge type Sobolev inequality , Poincar$\acute{e}$ inequality and Hardy inequality and obtain some results about the compactness of embedding maps on the weighted corner-edge Sobolev spaces. Finally, as an application of these results, we apply the potential well theory and the Faedo-Galerkin approximations to obtain the global weak solutions for the thermoelastic corner-edge type system.

Environmental DNA metabarcoding is becoming a key tool for biodiversity monitoring over large geographical or taxonomic scales and for elusive taxa like soil organisms. Increasing sample sizes and interest in remote or extreme areas often require the preservation of soil samples and thus deviations from optimal standardized protocols. However, we still ignore the impact of different methods of soil sample preservation on the results of metabarcoding studies and there is no guidelines for best practices so far. Here, we assessed the impact of four methods of soil sample preservation commonly used in metabarcoding studies (preservation at room temperature for 6h, preservation at 4°C for three days, desiccation immediately after sampling and preservation for 21 days, and desiccation after 6h at room temperature and preservation for 21 days). For each preservation method, we benchmarked resulting estimates of taxon diversity and community composition of three different taxonomic groups (bacteria, fungi and eukaryotes) in three different habitats (forest, river bank and grassland) against results obtained under optimal conditions (i.e. extraction of eDNA right after sampling). Overall, the different preservation methods only marginally impaired results and only under certain conditions. When rare taxa were considered, we detected small but significant changes in MOTU richness of bacteria, fungi and eukaryotes across treatments, while the exclusion of rare taxa led to robust results across preservation methods. The differences in community structure among habitats were evident for all treatments, and the communities retrieved using the different preservation conditions were extremely similar. We propose guidelines on the selection of the optimal soil sample preservation conditions for metabarcoding studies, depending on the practical constraints, costs and ultimate research goals.

We treated PR3-ANCA positive vasculitis patient with bilateral ischemic peroneal nerve paralysis accompanying rheumatoid arthritis. Pathology showed mild vasculitis. With PR3-ANCA amelioration, the level of complement 3, anti-CCP and neurological disability normalized simultaneously responding to rituximab. This result means the shared pathogenic pathway of PR3-ANCA vasculitis and rheumatoid arthritis.

To study the genetic diversity and structure of the forest species Pterocarpus erinaceus Poir., seventeen polymorphic nuclear microsatellite markers were isolated and characterized, using Illumina MiSeq sequencing technology. Three hundred and sixty five (365) individuals were analysed within fifteen (15) West Africa populations. The alleles’ number for these loci varied from 4 to 30 and 0.23 to 0.82 for the heterozygosity. The seventeen primers designed here will be useful to analyse ecology population and mechanisms of population differentiation of this threaten species.

1. Accurate differential expression of microbial metatranscriptomes based on Next Generation Sequencing depends partly on the depth of the libraries used to perform the analysis. Therefore, estimating the sequencing depth required to sample the metatranscriptome of interest using RNA-seq effectively is an essential first step to both obtain robust results in further analysis and avoiding over-expending once the information contained in the library reaches saturation. 2. Here we present a method to calculate the effort in saturation curves and a priori genes prediction using a simulated series of metatranscriptomic/metagenomic matrices. This method is based on the extrapolation rarefaction curve using a Weibull growth model to estimate the maximum number of genes/OTUs as a function of sequencing depth using a machine learning approach. This approach allows us to compute the effort at different confidence intervals and to obtain an approximate a priori effort using based on an initial fraction of sequences. 3. The accuracy of the results obtained with simulations and real samples (15 datasets of metatranscriptomes from the oral cavity, RNA sequences consist of vectors of 105-1.5x107 reads depth with a 10000 and 600000 genes size) allows one to use an initial shallowly sequenced sample (in this case 20% of the total amount of reads sampled; accuracy R2>0.99 simulated samples and 60-93% for real samples) to estimate the expected sequencing effort needed to cover the whole metatranscriptome/ metagenome from the same sample, so can be used to estimate the estimate the sample size. The algorithm containing the proposed method was saved as a function for R. 4. This proposed method of estimation of the maximum number of gene/OTUs, reads to reach 90, 95 and 99% of maximum number of gene/OTUs, is efficient to help researchers to know if the sampling is sufficient or otherwise need to be increased.

As the hydrodesulfurization (HDS) of diesel achieves ultra-deepness, our understanding of its kinetics is still far from in-depth. Therefore, herein, two lumped kinetic models for the ultra-deep hydrodesulfurization (UHDS) and hydrodenitrogenation (HDN) are established based on experiments under a wide range of operating conditions. Meanwhile, a four-lump kinetic model of the aromatic hydrosaturation (AHS) is erected. Our kinetic models disclose thermodynamic decisiveness in UHDS, which is unreachable beyond a temperature upper limit or a pressure lower limit. We also reveals the unexpected temperature dependence of nitrogen inhibition to HDS, for less than 300℃ the nitrogen inhibition becomes even more potent despite nitrogen removal by HDN reactions. Subsequently, the HDS kinetics of total sulfur are deciphered as multi stages exist in the whole reaction coordinate. Accordingly, a four-stage conceptual model involving mechanism and rate laws is proposed to offer a better understanding of nitrogen inhibition, thermodynamics and kinetics in UHDS.

The COVID-19 pandemic has substantial implications on almost every aspect of life. Its ongoing influence on health care, as well as other financial, social, psychological, educational and emotional aspects are yet to be fully recognized. Although the COVID-19 outbreak emerged in China at the end of December 2019, the first patient arrived in Israel on February 21st. This nearly two month gap enabled the Israeli health system to implement preparations at a both national and institutional level. Every hospital established an isolated internal medicine ward, which was assigned to treat only COVID-19 patients. Since there was no previous experience or recommended published guidelines, on a national level the Ministry of Health instructed each hospital to convert at least one standard internal medicine ward into a specialized isolated COVID 19 unit, usually within a few days. Although several series of protocols to treat critical COVID-19 patients in ICUs have been proposed, similar recommendations for treatment in internal medicine wards are scarce (1,2). Hence, we would like to summarize our experience in the organizational aspects of managing COVID-19 patients in an isolated internal medicine ward of a tertiary medical center.Minimal exposure . The major concept of working in the isolation ward is minimal exposure to the pathogen. The medical and nursing staff are essential resources and it is crucial to minimize their risk of SARS-COV-2 infection. The staff are also instructed to minimize social contacts outside of working hours to avoid infection risk outside of the hospital. The ward’s staff is divided into two separate ”capsules”, each capsule with consistent personnel (nursing and medical staff) that work at separate shifts without physical interaction between the shifts. In this manner, if one member is accidently infected, only one capsule is isolated instead of the entire staff.Minimal exposure concept is facilitate in the following methods:Medical staff enter the ward the least as possible – usually once for morning rounds and later only for new admissions or for deteriorating patients.Every entrance to the ward is carried out only with the minimal staff needed (e.g. two physicians and two nurses). Communication with the remaining team situated outside of the isolation unit is continuous.Every entrance is planned ahead and equipment (e.g. PCR swabs, fluids) are prepared a priori.We conduct minimal procedures and only on an as-need bases.We use point-of-care ultrasound for lung and heart physical examination instead of stethoscope use(3)Situation room. We facilitate a situation room (SR) manned 24/7 by a physician or nurse. Patients’ vital signs and medical follow-up are transmitted from the isolated ward to the SR. The are multiple communication channels for facilitating transmission of medical data to and from the SR. In addition, the SR is connected to other units inside and outside of the hospital who used as needed.Telemedicine. Telemedicine devices allow the staff to monitor patients with little SARS COV 2 exposure(4). The ward is interconnected with cameras which broadcast to the SR, allowing continued monitoring of the patients. In a addition, mobile sensors are attached to the patients, which wirelessly transmit vital signs, via wifi, to the SR. A remote control mobile robot with a screen, microphone and camera, can be remotely moved around the isolated ward, allowing constant communication with the patients.Patients examination. Due to the use of personal protective equipment (PPE) the routine physical examination of COVID 19 patients is limited. Instead, we recommend focusing on appreciating the general condition of the patients, his/her speech flow, mobility level and in mild to moderate cases on POCUS of the lungs.Inter-disciplinary approach. The significance of inter-disciplinary cooperation cannot be more emphasized. During rounds physicians assist nursing staff in their routine tasks: e.g. measuring vital signs, feeding patients and replacing bed ridden patient’s diaper. We also are aided by social workers with routine talks with patients and family members for daily updates and for psychological support (5). In addition, a physiotherapist is involved to perform respiratory and ambulatory physiotherapy as needed.Research. We initiated several small-scale studies in our ward. Data of the admitted COVID 19 patients are collected to evaluate possible association with demographical and clinical characteristics. We also evaluate several compounds with minimal adverse evets, which were recently reported to have possible positive effect on disease progression, such as hydroxychloroquine, Zinc, vitamin C and N-acetyl-cysteine(6,7).In conclusion, treating COVID-19 patients create unique clinical and institutional challenges. These challenges can be managed with minimal exposure to the medical staff, but without losing the therapeutic Continuum. Notwithstanding, the basic concept of internal medicine remain the same: maximal treatment with minimal risk for the patients (Primum non nocere), but also to the treating team. More studies are needed to investigate the functioning of the isolated COVID-19 wards in larger scales, and the preparedness of health systems to this pandemic at national levels.All authors declare no conflict of interest(1) Xie J, Tong Z, Guan X, Du B, Qiu H, Slutsky AS. Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Med 2020:1-4.(2) Wang H, Wang S, Yu K. COVID-19 infection epidemic: the medical management strategies in Heilongjiang Province, China. Crit Care 2020 Mar 18;24(1):107-020-2832-8.(3) Peng QY, Wang XT, Zhang LN, Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med 2020 Mar 12.(4) Wendelboe AM, Amanda Miller J, Drevets D, Salinas L, Miller E, Jackson D, et al. Tabletop exercise to prepare institutions of higher education for an outbreak of COVID-19. Journal of Emergency Management 2020;18(2):1-20.(5) Lima CKT, de Medeiros Carvalho, Poliana Moreira, Lima, Igor de Araújo Silva, de Oliveira Nunes, José Victor Alexandre, Saraiva JS, de Souza RI, et al. The Emotional Impact Of Coronavirus 2019-Ncov (New Coronavirus Disease). Psychiatry Res 2020:112915.(6) Matthay MA, Aldrich JM, Gotts JE. Treatment for severe acute respiratory distress syndrome from COVID-19. Lancet Respir Med 2020 Mar 20.(7) Razzaque M. COVID-19 Pandemic: Can Maintaining Optimal Zinc Balance Enhance Host Resistance? 2020.

Mini-commentary on BJOG- 19-1590.R1: Obstetric outcomes of twin pregnancies presenting with a complete hydatidiform mole and coexistent normal fetus: A systematic review and meta-analysis

Dear Editor, We would like to thank Dr. Lamont and colleagues for their interesting commentary.1 The authors point out very pressing topics that deserve more attention than we could provide in the original manuscript.They expressed concerns in their letter towards the heterogeneity of the data that were used in our meta-analysis. If incidences differ between regions and populations, absolute numbers on colonisation and neonatal infections might not be comparable. However, new policies were implemented in various settings, where differences in outcomes were measured under the same local circumstances. So as rightly mentioned by Lamont et al, data from the US cannot and should not be used as a blueprint for other parts of the world.1 Yet the general trend in developed countries that we observed, might shed some new light on the respective effectiveness of the strategies currently available.