Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: A sequential, prospective meta-analysis.

OBJECTIVE: This sequential, prospective meta-analysis (sPMA) sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to: disease severity, maternal morbidities, neonatal mortality and morbidity, adverse birth outcomes. DATA SOURCES: We prospectively invited study investigators to join the sPMA via professional research networks beginning in March 2020. STUDY ELIGIBILITY CRITERIA: Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area. STUDY APPRAISAL AND SYNTHESIS METHODS: We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a two-stage meta-analysis. RESULTS: We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (pre-existing diabetes, hypertension, cardiovascular disease) versus those without were at higher risk for COVID-19 severity and pregnancy health outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% CI: 1.12, 2.71) more likely to be admitted to the ICU. Pregnant women who were underweight before pregnancy were at higher risk of ICU admission (RR 5.53, 95% CI: 2.27, 13.44), ventilation (RR 9.36, 95% CI: 3.87, 22.63), and pregnancy-related death (RR 14.10, 95% CI: 2.83, 70.36). Pre-pregnancy obesity was also a risk factor for severe COVID-19 outcomes including ICU admission (RR 1.81, 95% CI: 1.26,2.60), ventilation (RR 2.05, 95% CI: 1.20,3.51), any critical care (RR 1.89, 95% CI: 1.28,2.77), and pneumonia (RR 1.66, 95% CI: 1.18,2.33). Anemic pregnant women with COVID-19 also had increased risk of ICU admission (RR 1.63, 95% CI: 1.25, 2.11) and death (RR 2.36, 95% CI: 1.15, 4.81). CONCLUSION: We found that pregnant women with comorbidities including diabetes, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly-known risk factors, including HIV infection, pre-pregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis.

INTRODUCTION: Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. METHODS: We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. RESULTS: We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection-as compared with uninfected pregnant women-were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. CONCLUSIONS: This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol.

Guest editorial

[...]educational institutions quickly declared antiracist action plans: public statements, training workshops, reading lists and reading circles. While we still wait for the coinciding beliefs and actions that Black lives have meaning, the COVID-19 global pandemic continues to ravage the Earth and has taken an (under)estimated 4 million of the Earth's citizens away. Because of global anti-Blackness, a disproportionate amount of Black and Brown people have lost their lives or have been completely engulfed with personal and communal destruction this disease has caused. School buildings were shuttered, and if students did not disappear from the roster all together, they were herded into virtual learning, often revealing how resources that were considered scarce and unaffordable were all of a sudden, plentiful and accessible. Particularly in an anti-Black education system, change often materializes in the s of statements condemning racism and in diversity and inclusion initiatives – more speaker events, more book clubs more workshops. Rarely, if ever, does change from the oppressor requires consistency with the following characteristics: interrogating White supremacy and Whiteness in pedagogical practices and value systems;challenging curricula that harm Black and Brown youth of Color;exposing racial trauma in classrooms;and/or honoring the literacies and full humanity of Black and Brown youth.

Antepartum SARS-CoV-2 infection and adverse birth outcomes in South African women.

Background: SARS-CoV-2 infection in pregnant women has been associated with severe illness in the women and higher rates of premature delivery. There is, however, paucity of data on the impact of the timing of SARS-CoV-2 infection and on symptomatic or asymptomatic infections on birth outcomes. Data from low-middle income settings is also lacking. Methods: We conducted a longitudinal study from April 2020 to March 2021, in South Africa, where symptomatic or asymptomatic pregnant women were investigated for SARS-CoV-2 infection during the antepartum period. We aimed to evaluate if there was an association between antepartum SARS-CoV-2 infection on birth outcomes. SARS-CoV-2 infection was investigated by nucleic acid amplification test (NAAT), histological examination was performed in a sub-set of placentas. Results: Overall, 793 women were tested for SARS-CoV-2 antenatally, including 275 (35%) who were symptomatic. SARS-CoV-2 infection was identified in 138 (17%) women, of whom 119 had symptoms (COVID-19 group) and 19 were asymptomatic. The 493 women who were asymptomatic and had a negative SARS-CoV-2 NAAT were used as the referent comparator group for outcomes evaluation. Women with COVID-19 compared with the referent group were 1.66-times (95% confidence interval (CI) = 1.02-2.71) more likely to have a low-birthweight newborn (30% vs 21%) and 3.25-times more likely to deliver a very low-birthweight newborn (5% vs 2%). Similar results for low-birthweight were obtained comparing women with SARS-CoV-2 confirmed infection (30%) with those who had a negative NAAT result (22%) independent of symptoms presentation. The placentas from women with antenatal SARS-CoV-2 infection had higher percentage of chorangiosis (odds ratio (OR) = 3.40, 95% CI = 1.18-.84), while maternal vascular malperfusion was more frequently identified in women who tested negative for SARS-CoV-2 (aOR = 0.28, 95% CI = 0.09-0.89). Conclusions: Our study demonstrates that in a setting with high HIV infection prevalence and other comorbidities antenatal SARS-CoV-2 infection was associated with low-birthweight delivery.

Active Intrapartum SARS-CoV-2 Infection and Pregnancy Outcomes.

OBJECTIVE: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy has been associated with poor pregnancy outcomes. There is, however, not much information on the impact of the timing of SARS-CoV-2 infection on pregnancy outcomes, and studies from low-middle income settings are also scarce. STUDY DESIGN: We conducted a cross-sectional study from April to December 2020, in South Africa, to assess the association of SARS-CoV-2 infection on a nasal swab at the time of labor with fetal death, preterm birth, low birth weight, or pregnancy-induced complications. When possible, maternal blood, cord blood, and placenta were collected. SARS-CoV-2 infection was investigated by a nucleic acid amplification test (NAAT). RESULTS: Overall, 3,117 women were tested for SARS-CoV-2 on a nasal swab, including 1,562 (50%) healthy women with uncomplicated term delivery. A positive NAAT was detected among 132 (4%) women. Adverse birth outcomes or pregnancy-related complications were not associated with SARS-CoV-2 infection at the time of labor. Among SARS-CoV-2-infected women, an NAAT-positive result was also obtained from 6 out of 98 (6%) maternal blood samples, 8 out of 93 (9%) cord-blood samples, 14 out of 54 (26%) placentas, and 3 out of 22 (14%) nasopharyngeal swabs from newborns collected within 72 hours of birth. Histological assessment of placental tissue revealed that women with SARS-CoV-2 nasal infection had a higher odds (3.82, 95% confidence interval: 1.20, 12.19) of chronic chorioamnionitis compared with those without SARS-CoV-2 infection. CONCLUSION: Our study demonstrates that intrapartum, SARS-CoV-2 infection was not associated with evaluated poor outcomes. In utero fetal and placental infections and possible vertical and/or horizontal viral transfer to the newborn were detected among women with nasal SARS-CoV-2 infection. KEY POINTS: · Intrapartum SARS-CoV-2 infection was not associated with evaluated poor outcomes.. · In utero fetal and placental infections were detected among women with nasal SARS-CoV-2 infection.. · Women with SARS-CoV-2 nasal infection had a higher odds of chronic chorioamnionitis..

End of Life: What Is the Anesthesiologist's Role?

Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.

Maternal-foetal transfer of severe acute respiratory syndrome coronavirus 2 antibodies among women with and those without HIV infection.

In pregnant women, antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein cross the placenta and can be detected in cord-blood at the time of delivery. We measured SARS-CoV-2 full-length antispike IgG in blood samples collected from women living with HIV (WLWHIV) and without HIV when presenting for labour, and from paired cord-blood samples. Antispike IgG was measured in maternal blood at delivery on the Luminex platform. Cord-blood samples from newborns of women in with detectable antispike IgG were analysed. The IgG geometric mean concentrations (GMCs) and the percentage of cord-blood samples with detectable antispike IgG were compared between WLWHIV and without HIV. A total of 184 maternal and cord-blood pairs were analysed, including 47 WLWHIV and 137 without HIV. There was no difference in antispike GMCs between WLWHIV and without HIV [157 binding antibody units (BAU)/ml vs. 187 BAU/ml; P  = 0.17)]. Cord-blood samples from newborns of WLWHIV had lower GMCs compared with those without HIV (143 vs. 205 BAU/ml; P  = 0.033). Cord-to-maternal blood antibody ratio was 1.0 and similar between the two HIV groups. In WLWHIV, those who were 30 years old or less had lower cord-to-maternal blood antibody ratio (0.75 vs. 1.10; P  = 0.037) and their newborns had lower cord-blood GMCs (94 vs. 194 BAU/ml; P  = 0.04) compared with the older women. Independently of maternal HIV infection status, there was efficient transplacental transfer of antispike antibodies. The GMCs in cord-blood from newborns of WLWHIV were lower than those in HIV-unexposed newborns.

Leadership Challenges in Motivating Employees During Covid-19 Pandemic: An Example from Germany

This is a survey-based study to analyze the experiences of office workers in Germany in the second year of the pandemic. The study looked at working from home, work-life balance, perceived organizational support and perceived social support, and tried to understand more about the association between these employees' experiences with their levels of work motivation and their turnover intention or desire to quit their jobs. The study also found differences in relationships between groups, including age, marital status and whether they have dependent children. The practical recommendations and advice given here are based on the results of the study and current literature, aiming to help leaders and managers in navigating the HR issues of the future workplace.

An outbreak of infection due to severe acute respiratory corona virus-2 in a neonatal unit from a low and middle income setting

Introduction The provision of kangaroo mother care (KMC) involving continuous skin-to-skin care (SSC) is an important intervention in neonatal care, which is recommended even when women are infected with severe acute respiratory syndrome coronavirus (SARS-CoV-2). We report on a nosocomial outbreak of SARS-CoV-2 infections in a KMC ward. Methods Contact tracing was conducted following the diagnosis of SARS-CoV-2 in a mother lodging in the KMC ward. All mother-newborn dyads in the KMC and healthcare workers (HCW) were tested for SARS-CoV-2 within 24–72 h of diagnosing the index case. Nasopharyngeal swab samples were obtained and tested from contacts, with a nucleic acid amplification test (NAAT) assay. Next-generation sequencing was done on positive samples. The secondary attack rate (SAR) was calculated assuming that the mother who presented with symptoms was the source of infection. Results Twelve (70.6%) of 17 mothers and 8 (42.1%) of 19 neonates who were in the KMC ward with the index case were found to be positive with SARS-CoV-2. Seven (87.5%) of the 8 neonates who tested positive had mothers who also tested positive. Seventy-five percent (9/12) of the mothers and 62.5% (5/8) of the neonates who tested positive were asymptomatic. Eight (27.6%) of 29 HCW were found to be positive and were all asymptomatic. One neonate died from Acinetobacter baumannii sepsis, and his post-mortem lung histopathology showed features compatible with SARS-CoV-2 pneumonia. The sequencing of 13 specimens, which included 1 mother-newborn dyad, indicated clustering to the same phylogenetic lineage with identical mutations. In assessing for factors contributing to this outbreak, it was found that spaces between beds were less than 1 m and mothers had their meals around the same table at the same time. Conclusion We report on a nosocomial outbreak of SARS-CoV-2 in a KMC ward, affecting a high number of mothers and neonates, and to a lesser extent HCWs. Although it is difficult to point to the index case as the source of this outbreak, as asymptomatic individuals can spread infection, the inadequate adherence to non-pharmaceutical interventions was assessed to have contributed to the spread of infection. This highlights the need for awareness and adherence to mitigation strategies to avoid SARS-CoV-2 outbreaks.

In Vitro Nasal Tissue Model for the Validation of Nasopharyngeal and Midturbinate Swabs for SARS-CoV-2 Testing.

Large-scale population testing is a key tool to mitigate the spread of respiratory pathogens, such as the current COVID-19 pandemic, where swabs are used to collect samples in the upper airways (e.g., nasopharyngeal and midturbinate nasal cavities) for diagnostics. However, the high volume of supplies required to achieve large-scale population testing has posed unprecedented challenges for swab manufacturing and distribution, resulting in a global shortage that has heavily impacted testing capacity worldwide and prompted the development of new swabs suitable for large-scale production. Newly designed swabs require rigorous preclinical and clinical validation studies that are costly and time-consuming (i.e., months to years long); reducing the risks associated with swab validation is therefore paramount for their rapid deployment. To address these shortages, we developed a 3D-printed tissue model that mimics the nasopharyngeal and midturbinate nasal cavities, and we validated its use as a new tool to rapidly test swab performance. In addition to the nasal architecture, the tissue model mimics the soft nasal tissue with a silk-based sponge lining, and the physiological nasal fluid with asymptomatic and symptomatic viscosities of synthetic mucus. We performed several assays comparing standard flocked and injection-molded swabs. We quantified the swab pickup and release and determined the effect of viral load and mucus viscosity on swab efficacy by spiking the synthetic mucus with heat-inactivated SARS-CoV-2 virus. By molecular assay, we found that injected molded swabs performed similarly or superiorly in comparison to standard flocked swabs, and we underscored a viscosity-dependent difference in cycle threshold values between the asymptomatic and symptomatic mucuses for both swabs. To conclude, we developed an in vitro nasal tissue model that corroborated previous swab performance data from clinical studies; this model will provide to researchers a clinically relevant, reproducible, safe, and cost-effective validation tool for the rapid development of newly designed swabs.

An ecological perspective on early educator well-being at the start of the COVID-19 pandemic.

Early educator well-being is increasingly understood as a critical ingredient of high-quality early education and care. The COVID-19 pandemic has threatened educator well-being by exacerbating existing stressors and introducing novel stressors to all aspects of early educators' lives, and early educators have had differential access to resources to cope with these new circumstances. Using survey data collected between April and June 2020 with a sample of 666 early educators in community-based center, family child care, Head Start, and public school prekindergarten programs across Massachusetts, we document the pandemic's initial influence on educators' sense of well-being. Adopting an ecological perspective, we consider educator-, program-, and community-level factors that may be associated with reported changes in well-being. Most educators indicated that their mental and financial well-being had been affected. These changes were not systematically associated with most contextual factors, although there was clear evidence of variability in reported impacts by provider type. These findings underscore the need to support educator well-being, as well as to create policy solutions that meet the heterogeneous needs of this essential workforce.

Correlation of dried blood spots and plasma for quantification of Immunoglobulin (IgG) against Receptor binding domain and full length spike protein of SARS-CoV-2.

We compared plasma and dried blood spots for detection of SARS-CoV-2 IgG antibodies. There was a good correlation between IgG values measured by both sampling methods, r = 0.935 and 0.965 for Receptor Binding Domain and full-length spike protein of SARS-CoV-2. Bland-Altman assessment showed good agreement between two sampling methods. Dried blood spots is a more pragmatic method for collecting samples for sero-epidemiological surveys of SARS-CoV-2 infection.

Employee Job Satisfaction During Remote Work: The Impact of Transformational Leadership

Due to the Covid-19 crisis of 2020-2021, many businesses are being forced to require their employees to work remotely from home, often for the first time. One particular result has been that many leaders have struggled to meet the challenge of managing their remote workers. Previously, it was widely thought that transformational leadership was a consistently positive style for many leaders to adopt. However, this study has found that transformational leadership, although increasing employees' psychological safety, negatively affects employees' job satisfaction. It may weaken employees' job satisfaction in remote work due to a reliance on relational encouragement and caring for individuals in a face-to-face environment. Employees working fewer days at home are significantly less affected compared with those working more days at home. A new form of transformational leadership may now be needed, considering the challenges of remote work, emphasizing a higher degree of empathetic understanding of the issues facing each individual.

Changes in Children's Behavioral Health and Family Well-Being During the COVID-19 Pandemic.

OBJECTIVE: The coronavirus disease 2019 pandemic and associated public health measures have influenced all aspects of life for children and families. In this study, we examine changes in children's behavioral health and families' well-being at the start of the pandemic. METHOD: We used longitudinal data on 2880 children from 1 US state collected over 3 waves to compare family and child well-being before and after a state-wide stay-at-home advisory set in March 2020. We descriptively examined levels and changes in 4 child behavioral health outcomes (externalizing, internalizing, adaptive, and dysregulated behaviors) and 4 family well-being outcomes (parental mental health, parental stress, parent-child relationship conflict, and household chaos) across the preshutdown and postshutdown periods. Fixed effects regression models were used to predict within-child and within-family differences in preshutdown and postshutdown outcomes. RESULTS: Fixed effects analyses showed children's externalizing (0.09 points; 95% confidence interval [CI] 0.05-0.13), internalizing (0.04 points; 95% CI, 0.01-0.08), and dysregulated (0.11 points; 95% CI, 0.06-0.16) behaviors increased after the shutdown, whereas children's adaptive behaviors declined (-0.10 points; 95% CI, -0.15 to -0.05). Parental mental health issues (0.22 points; 95% CI, 0.17-0.27), parental stress (0.08 points; 95% CI, 0.03-0.12), parent-child relationship conflict (0.10 points; 95% CI, 0.04-0.16), and household chaos (0.10 points; 95% CI, 0.05-0.14) all increased relative to preshutdown levels. CONCLUSION: Many children experienced declines in behavioral health and many families experienced declines in well-being in the early months of the public health crisis, suggesting the need for family-focused and child-focused policies to mitigate these changes.

Hypertriglyceridemia during hospitalization independently associates with mortality in patients with COVID-19.

BACKGROUND: Alteration in blood triglyceride levels have been found in patients with coronavirus disease 2019 (COVID-19). However, the association between hypertriglyceridemia and mortality in COVID-19 patients is unknown. OBJECTIVE: To investigate the association between alteration in triglyceride level and mortality in hospitalized COVID-19 patients. METHODS: We conducted a retrospective study of 600 hospitalized patients with COVID-19 diagnosis (ICD10CM:U07.1) and/or SARS-CoV-2 positive testing results between March 1, 2020 and December 21, 2020 at a tertiary academic medical center in Milwaukee, Wisconsin. De-identified data, including demographics, medical history, and blood triglyceride levels were collected and analyzed. Of the 600 patients, 109 patients died. The triglyceride value on admission was considered the baseline and the peak was defined as the highest level reported during the entire period of hospitalization. Hypertriglyceridemia was defined as greater than 150 mg/dl. Logistic regression analyses were performed to evaluate the association between hypertriglyceridemia and mortality. RESULTS: There was no significant difference in baseline triglyceride levels between non-survivors (n = 109) and survivors (n = 491) [Median 127 vs. 113 mg/dl, p = 0.213]. However, the non-survivors had significantly higher peak triglyceride levels during hospitalization [Median 179 vs. 134 mg/dl, p < 0.001]. Importantly, hypertriglyceridemia independently associated with mortality [odds ratio=2.3 (95% CI: 1.4-3.7, p = 0.001)], after adjusting for age, gender, obesity, history of hypertension and diabetes, high CRP, high leukocyte count and glucocorticoid treatment in a multivariable logistic regression model. CONCLUSIONS: Hypertriglyceridemia during hospitalization is independently associated with 2.3 times higher mortality in COVID-19 patients. Prospective studies are needed to independently validate this retrospective analysis.

Using lecture podcasts in the COVID-19 transition to virtual post-secondary education in agriculture

Abstract In the spring 2020 semester SFASU transitioned face-to-face classes to online instruction because of the COVID-19 pandemic. The east Texas region suffers from some of the poorest internet availability in the nation. Thus, limitations exist for streaming lectures or having students download large files. Podcasts are small audio files that can be downloaded from the internet for learning. Research has shown that the use of lecture podcasts have a variety of benefits for both faculty and students. Lecture podcasts provide students small file sizes to download and access and allow them to engage with the course material asynchronously. Therefore, the decision was made to record lecture podcasts for Cultivating Plants, Plant Propagation, and Plant Breeding to deliver educational content for the class. An end of semester survey conducted by the SFASU Agriculture Department indicated that 59% of students who engaged with this type of learning felt it was extremely effective. Additional student comments and semester reflections also provided feedback. This example provides further evidence that lecture podcasts can be a useful tool for educators in an ever-changing world. This article is protected by copyright. All rights reserved

The New Common

This article describes a personal relationship to a common green space in a town in the United Kingdom during the lockdowns prompted by the Covid-19 pandemic in 2020–21. It considers the new meanings that are attaching to ‘commons’ as conceptual spaces and material places;and it links this consideration to the terms in which values and norms are being reassessed in the context of environmental crises.

Reflections of a Healthcare Leader in an Emerging Market in Europe: Leadership Lessons from the Covid-19 Pandemic

The challenges of leading through the Covid-19 crisis have included not just remote staff members and customers but business coming to a standstill. Returning to the workplace has been fraught with restrictions, limitations and safety concerns. Leadership in the healthcare sector has been especially difficult, with pressures on already-limited resources, high infection-rates and death-rates, and increased need for total hygiene. One of our co-authors, experienced in the past as a leader of a large hospital and now advising international healthcare authorities, was facing another war zone. He had to listen to anyone with ideas of how to deal with the crisis;had considered unusual and new paths of action;had to act swiftly and with the conviction that any action was better than no action, with nearly everything based on improvisation, whilst surrounded by terrified patients and families and a lack of clarity from governments and the media.