Objective: To assess the knowledge and attitude toward coronavirus disease-2019 (COVID-19) among Syrian community pharmacists. Methods: A cross-sectional study was performed between March 17th and April 10th, 2020 among practicing community pharmacists in Syria. Systematic random sampling strategy was used, and data was collected through an online questionnaire covering pharmacists’ knowledge and attitude towards COVID-19. Descriptive analysis was used to describe participants’ demographics, knowledge and attitude mean score. For inferential statistics, t-test, ANOVA and Spearman’s correlation were used to evaluate the relationship between study variables. Results: Of the 1236 randomly selected practicing community pharmacists, 427 completed the questionnaire (35%). Our participants primary sources of knowledge were social media and foreign health authorities’ websites. They achieved a mean good score of knowledge and attitude, of 7.17±1.3 and 1.84±0.5, respectively. Around two-thirds of the participants were able to identify all symptoms associated with COVID-19, while over 90% knew the different ways of disease transmission. Our participants had mixed answers about the times that COVID-19 can stay on different surfaces and the distance required to achieve physical distancing. Over 80% of our participants expressed positive attitude towards the emerging pandemic. A negative correlation between knowledge and attitude scores (r=-0.21, p<0.001) was noted. Conclusions: Syrian pharmacists expressed good knowledge and positive attitude towards COVID-19. This can provide a good support to the challenged Syrian healthcare system. The study showed a need to provide reliable and updated resource for knowledge for pharmacists that is administered by Syrian health authorities.

This study aimed to evaluate the physicochemical composition, the lipid profile, and the technological and nutritional impact of Brazilian margarines. Thirteen margarine samples were characterized for fatty acid composition, technological properties, and thermal stability. The margarines presented total fat from 20 to 82% and low trans fatty acids (TFA) levels, except for two samples (5-7% of elaidic acid), allowing labels to declare “zero trans-fat”, according to the current Brazilian legislation (Resolution 54 of November 12, 2012). All margarines had similar fatty acids composition, with predominance of linoleic (23-46%), oleic (20-46%) and palmitic acids (7-14%), probably from soy and palm-based fats. The saturated fat content ranged from 23 to 31%. All lipid phases had a similar fat solid profile, with a melting point between 22 and 28 °C. The margarines with higher lipid content and saturated fatty acids (SFA) showed greater hardness and lower spreadability, and the presence of TFA provided greater plasticity. Changes in the lipid profile of this product are still necessary, as there is a global transition scenario aimed at healthy aspects with the elimination of TFA and reduction of SFA intake to reduce deaths from coronary heart disease.

Background: Primary headache associated with sexual activity is a rare type of headache mostly seen in male gender and initiates at the 3rd decade. Even though the pathophysiology is still unknown, it is a benign type of headache and must be reminded on the differential diagnosis of the secondary headache. Materials&Methods: Thirteen patients diagnosed as primary headache associated with sexual activity were evaluated by their clinical and demographic data. Results:Ten male and three female patients were evaluated. The mean age was 37.07± 7.67. Headache was usually localized at bilateral occipital area or diffuse, starting with a severe ache and sudden explosive intensity in association with preorgasm in 8 patients and orgasm in 5 patients with a mean VAS score of 7.8±1.2. The mean duration was 21.53± 15.32 minutes. Five of the patients had a history of migraine, 3 had arteriel hypertension and two were diagnosed as primary thunderclap headache with sudden beginning and high intensity ache. Conclusion: Herein we presented our cases to highlight the importance of differential diagnosis. Patients may have difficulty of explaining the problem therefore their sexual activity could be limited.Apart from pharmacological prevention, counselling and facilitation plays important role in managing.

The aim of this meta-analysis is to investigate the effectiveness of chloroquine in treating coronavirus, in general not only novel coronavirus (COVID¬-19), by pooling the results of randomized controlled clinical trials (RCTs). Only 28 publications were identified; none of which was a RCT. Identified studies were published between 1987 and March 15, 2020. Of these 28 publications, 7 were published in 2020 and discussed the effectiveness of chloroquine against COVID-19. In conclusion, this meta-analysis could not prove that chloroquine is an effective treatment against coronavirus in general or COVID-19 in particular. Expanded access trials should be encouraged especially that chloroquine is available, cheap and relatively safe drug.

Pollen coat lipids form an outer barrier to protect pollen itself and play essential roles in pollen-stigma interaction. However, the precise molecular mechanisms underlying pollen coat lipids production, deposition, regulation and function during anther development remain largely elusive. 3-ketoacyl-coenzyme A synthases (KCS) are involved in fatty acid elongation or very long chain fatty acid (VLCFA) synthesis. Here, we identified six members of Arabidopsis KCS family expressed in anther. Of them, KCS7, KCS15 and KCS21 express in tapetal cells at stages 8-10. Further analysis demonstrated that they act downstream of Male sterility1 (MS1), a regulator for late tapetum development. The kcs7/15/21 triple-mutant is fertile. Both cellular observation and lipid staining showed pollen coat lipid was decreased in triple mutant. After landing on stigma, the wild-type pollen was hydrated in about 5 min while the triple mutant pollen took about 10 min. Pollen tube growth of the triple mutant was also delayed. These results demonstrate the pathway in tapetum to produce pollen coat lipid, and reveal the roles of tapetal-derived pollen coat lipid for pollen-stigma interaction.

This paper presents the application of multi-objective genetic programming in engineering issues. An evolutionary symbolic implementation was developed based on a case study on prediction of the shear strength of slender reinforced concrete beams without stirrups including 1942 set of published test results. In the implementation of the MOGP model, the non-dominated sorting genetic algorithm II with adaptive regression by mixing algorithm with considering the optimization of mean-square error as the fitness measure and the subtree complexity was used. The developed MOGP model was compared to previously developed GP models, different building codes, and additional machine learning-based approaches. It is clearly shown that the MOGP model outperformed the other algorithms applied in this database and can be a general solution to any engineering problems with the main advantage of prediction equations without assuming the prior form of the relevance among the input predictor variables.

Ecosystems worldwide depend on habitat-forming foundation species that engage in facultative mutualisms. Global change, however, is causing rapid declines of foundation species-structured ecosystems, often typified by sudden collapse. Although disruption of obligate mutualisms involving foundation species is known to precipitate collapse (e.g. coral bleaching), how facultative mutualisms (i.e. context-dependent, non-binding reciprocal interactions) affect ecosystem resilience is uncertain. Here, we synthesize recent advancements, and combine this with model analyses supported by real-world examples, to propose that facultative mutualisms may pose a double-edged sword for foundation species. We suggest that by amplifying self-facilitative feedbacks by foundation species, facultative mutualisms can increase foundation species resistance to global change stressors. Simultaneously, however, mutualism-dependency can generate or exacerbate bistability, implying a potential for sudden collapse when the mutualism’s buffering capacity is exceeded, while recovery requires conditions to improve beyond the initial collapse point (hysteresis). Thus, our work emphasizes the importance of acknowledging facultative mutualisms for conservation and restoration of foundation species-structured ecosystems, but highlights the potential risk of relying on mutualisms in the face of global change. We argue that significant caveats remain regarding the determination of these feedbacks, and suggest empirical manipulation across stress gradients as a way forward to identify related nonlinear responses.

IIntroduction Physician empathy has been correlated with several outcomes in outpatient settings, demonstrating better prognosis in patients followed by highly empathetic doctors. Aim To correlate empathy of Internal Medicine ward physicians with readmission rates of patients they took care of. Methods We extracted readmission data of all patients discharged from Internal Medicine wards at our hospital between January 1st, 2011 and May 31st, 2017. Patients discharged to other institutions (nursing homes, rehabilitation units, other hospitals) were excluded. The 30-day readmission rate was recorded for each doctor. We measured the empathy of physicians who discharged more than 100 patients during that period, using the Jefferson Scale of Empathy (JSE) and the Empathy Components Questionnaire (ECQ). Correlation between empathy scores and readmission rate was weighted for the number of patients followed by each physician and adjusted for sex, age and relative cost weight of patients, as well as the doctor’s age. The same correlation was calculated in the subgroup of index patients discharged with Diagnosis Related Group 127 (DRG 127, Heart Failure and Shock). Results A total of 4280 index discharge events were identified, 383 of which (8.9%) were readmitted within 30 days. JSE scores were found out to be inversely correlated with readmission rates (coefficient -0.027, R2 0.181, p<0.001) whereas ECQ correlation was not significant after adjustment. A significant inverse correlation was also observed considering only the DRG 127 patients, with both Empathy scales (JSE and ECQ, coefficient -0.032 and -0.098, R2 0.303 and 0.326, p=0.050 and p<0.001, respectively). Conclusion Empathy of Internal Medicine physicians correlates with readmission rates of the patients they cared for, especially heart failure patients for whom this is a relevant outcome.

Little information is available about the effects of different species of shrubs on the composition of the soil seed bank (SSB) in semiarid regions. We determined the role of three dominant shrub species on SSB characteristics and evaluated their potential for their possible use in rangeland restoration projects. Fifteen sites, each containing three shrub species (Amygdalus scoparia, Daphne mezereum and Ebenus stellata) and a herbaceous patch (control) in close proximity, were sampled and their SSB density, species richness and diversity at 0-10 cm depth were determined. The results showed that the density of the SSB was highest under A. scoparia (1133 seeds per m2) and lowest in herbaceous vegetation (110 seeds per m2). Species richness and diversity of the SSB was significantly greater under E. stellata than under the other shrubs and control. This study revealed that the extent to which vegetation affected SSB characteristics did not only depend on the presence of shrubs, but also on the species of shrub. These different roles of different species of shrubs on SSB are advised to be considered in the restoration of degraded areas through planting of shrubs in semiarid regions. Planting and the extension of E. stellata cover in degraded sites could be of priority due to its prominent role in herbaceous SSB reservoir and species diversity and richness.

Narrow QRS tachycardia with atrial and ventricular cycle length wobbling – What is the mechanism?

Abstract Recent evidence suggests that stressed plants employ epigenetic mechanisms to transmit acquired resistance to their progeny. However, little is known about the evolutionary and ecological significance of this transgenerational acquired resistance (TAR). In this study, we have used a full factorial design to study the specificity, costs and stability of TAR following exposure of Arabidopsis thaliana to increasing stress intensities by a biotrophic pathogen, a necrotrophic pathogen, and soil salinity. All stresses incrementally reduced parental growth, while salt stress additionally impacted reproductive success. Biotrophic and necrotrophic pathogens, but not salt, increased resistance of progeny against the stress experienced by their parents (i.e., in matched environments). In mis-matched environments, however, pathogen-elicited TAR was associated with costs from increased susceptibility to other stresses. Furthermore, the stability of pathogen-elicited TAR over one stress-free generation and its associated costs were proportional to parental disease severity, suggesting that plants use stress intensity as an environmental proxy to adjust TAR investment. We conclude that pathogen-elicited TAR is an adaptive and deterministic parental effect that is associated with ecological costs. Accordingly, our study provides evolutionary and ecological context to the epigenetic TAR response. Key words: Adaptive parental effects; Arabidopsis; Phenotypic plasticity; Plant stress; Transgenerational acquired resistance.

The incidence of thrombotic complications among critically ill patients with COVID-19 is high despite thromboprophylaxis. We describe a case of a young, otherwise healthy patient admitted to our intensive care unit with COVID-19-associatred acute respiratory distress syndrome (ARDS). Despite an initial uncomplicated course, he suffered cardiopulmonary arrest with a right ventricular clot in transit (CIT) identified on point-of-care ultrasound (POCUS) and redemonstrated on transesophageal echocardiography (TEE). We highlight the association between COVID-19 and thrombosis as well as the utility of TEE during cardiac arrest for both diagnostic and therapeutic purposes.

Aim & Objective: Silent information Regulators (SIRT1) gene stimulates the expression of antioxidants and repairs damaged cells. It affects the mitochondrial activity within the oocytes to overcome the oxidant stress. We aimed to assess an association of SIRT1 polymorphism (Tag SNPs rs10509291 and rs12778366) with fertility, and assess serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, manganese superoxide (MnSOD) and SIRT1. Material and Methods: In this cross-sectional study, 207 fertile and 135 infertile subjects between the ages of 18-45 year were recruited. Polymerase chain reaction (PCR) was performed; products were electrophoresed in a 2% agarose gel. Descriptive analysis of continuous variables was expressed as mean ± standard deviation. Mann-Whitney test was performed for comparison of groups, p value <0.001 was considered significant. Single Nucleotide Polymorphism (SNP) data was analyzed by applying chi-squared statistics. Results: All subjects were age matched (p = 0.896). SIRT1 levels were significantly lower in infertile females when compared with fertile subjects (p<0.001). AA (rs10509291) and CC (rs12778366) variant frequency was higher in the infertile than fertile subjects (p<0.01). Similarly, the frequency of A allele (rs10509291) and C allele (rs12778366) was higher in infertile subjects (p<0.001). Infertile females (29%) showed existence of SNP rs10509291 while 49% demonstrated genetic variation of rs12778366. MnSOD and SIRT1 levels were found to be lower in these subjects. Conclusion: Presence of SIRT1 genetic variants (rs10509291 and rs12778366) apparently disturbs the expression of SIRT1 deteriorating mitochondrial antioxidant function within the oocytes, instigating oxidative stress within. Their probable effect on modulating oocyte maturation may be the cause of infertility in females.

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Coronavirus is a new virus that takes control over the immune system making it lose its ability to differentiate between the healthy and infected cells. After enervating its host’s capacity to fight, the virus now replicates and transmits to look for other susceptible hosts. Due to this hollowing out of the immune system there are noticeable effects in the health of the people. Mass transmission of this virus leads the disease caused by it, called COVID-19, to take the form of a pandemic. In this study, we aim to underline the importance of carrying out the studies of other diseases with similar symptoms, of different animals carrying the virus and medications used in preceding pandemics. Certain species have been observed to be immune to the disease. The steroid, Hydroxychloroquine (C18H26ClN3O.H2SO4) which is an anti-parasitic drug that has been showing promising results in COVID-19, creates an intriguing fact wherein an antidote for Malaria is proving promising against a Coronavirus. Here, we intend to reflect on the importance of an interdisciplinary study across biochemistry, medical sciences and molecular sciences so that we can stay prepared beforehand for an epidemic.

SARS-CoV-2 infection is characterized by a protean clinical picture that can range from asymptomatic patients to life threatening conditions. Severe COVID-19 patients often display a severe pulmonary involvement and develop neutrophilia, lymphopenia, and strikingly elevated levels of IL-6. There is an over-exuberant cytokine release with hyperferritinemia leading to the idea that COVID-19 is part of the hyperferritinemic syndromes spectrum. Indeed, very high levels of ferritin can occur in other diseases including hemophagocytic lymphohistiocytosis, macrophage activation syndrome, adult onset Still's disease, catastrophic antiphospholipid syndrome and septic shock. Numerous studies have demonstrated the immunomodulatory effects of ferritin and its association with mortality and sustained inflammatory process. High levels of free iron are harmful in tissues, especially through the redox damage that can lead to fibrosis. Iron chelation represents a pillar in the treatment of iron overload. In addition, it was proven to have an anti-viral and anti-fibrotic activity. Herein, we analyse the pathogenic role of ferritin and iron during SARS-CoV-2 infection and propose iron depletion therapy as a novel therapeutic approach in COVID-19 pandemic.

Despite the current presumption that SARS-CoV-2 is transmitted by droplets, the reported evidence of the presence of the virus in air suggests that droplets dry fast producing clusters of virus, which are most penetrative through commonly available fabric filters to the public.   We consider droplets corresponding to a typical bimodal distribution of droplets of sneeze and calculate the time taken for them to evaporate to their ultimate size for two virus loadings.  The dry virus clusters resulting from fine droplets of the first mode have a size distribution comparable to cigarette smoke. There are currently no masks available to the public which can filter these aerosols efficiently, and even FFP grade masks have low filtration efficiency for these particle sizes.The implications are that safe distance is considerably greater than the generally-recommended two metres, as the virus remains fully suspended in the air.  Secondly, mask filters available to the public are inefficient in preventing SARS-CoV-2 spreading, as it could penetrate through them. The rapid spread of the virus is indicative of the ease with which it spreads through the air, and apart from wearing a high efficiency mask, the only safe prevention is to self-isolate at home.

Background: Physical activity (PA) reduces significantly in active women during pregnancy and in postpartum. Objectives: To synthesise the evidence on the effectiveness of PA interventions delivered to active pregnant and postpartum women and to explore the perceptions of active women on being active during pregnancy. Search Strategy: Five databases were searched from inception up until 12th of May 2019. Selection Criteria: We included studies where a PA intervention was used to promote or prevent decline in PA levels in active pregnant and/or postpartum women, and either PA outcomes or participants’ views on physical activity were reported. Data Collection and Analysis: Data were extracted using structured data extraction forms. A narrative synthesis of quantitative and qualitative data was produced. Main Results: Three studies with a total of 2,1426 participants were included. Quantitative studies used face-to-face sessions, goal setting, and multimedia provision to exercise at home as interventions. Different methods were used to assess change in PA with both studies reporting significant positive changes in physical activity. Qualitative data suggested that already active women are enthusiastic about continuing PA during and after pregnancy. They see health benefits and empowerment as an enabler and overcoming peer judgement and stereotypes as a barrier. Conclusion: Available evidence shows that PA interventions in already active women tend to be successful in increasing physical activity levels and foster a positive perception. These findings should inform the design and delivery of successful PA interventions in already active pregnant and postpartum women. Keywords: Physical activity; Already active; Pregnant; Postpartum.

The host-associated microbiome plays a significant role in health. However, the roles of factors such as host genetics and microbial interactions in determining microbiome diversity remain unclear. We examined these factors using amplicon-based sequencing of 175 Thoropa taophora frog skin swabs collected from a naturally fragmented landscape in southeastern Brazil. Specifically, we examined (1) the effects of geography and host genetics on microbiome diversity and structure; (2) the structure of microbial eukaryotic and bacterial co-occurrence networks; and (3) co-occurrence between microeukaryotes with bacterial OTUs known to affect growth of the fungal frog pathogen Batrachochytrium dendrobatidis (including anti-Bd bacteria commonly referred to as “antifungal”). Microbiome structure correlated with geographic distance, and microbiome diversity varied with both overall host genetic diversity and diversity at the frog MHC IIB immunity locus. Our network analysis showed the highest connectivity when both eukaryotes and bacteria were included, implying that ecological interactions occur among Domains. Lastly, anti-Bd bacteria did not demonstrate broad negative co-occurrence with fungal OTUs in the microbiome, indicating that these bacteria are unlikely to be broadly antifungal. Our findings emphasize the importance of considering both Domains in microbiome research, and suggest that probiotic strategies for amphibian disease management should be considered with caution.

Since the outbreak of SARS-CoV-2 virus more than 2 800 000 cases have been reported worldwide. Patients suffering from diabetes and other comorbidities are particularly susceptible to severe forms of the COVID-19, which might result in chronic complications following recovery. Dipeptidyl peptidase-4 inhibitors exert beneficial effects in the prevention/treatment of pulmonary fibrosis, heart, and kidney injury, and since they may be a long-term consequence caused by COVID-19, it is reasonable to expect that DPP-4 inhibitors might be beneficial in alleviating long-term consequences of COVID-19. With that in mind, we would like to voice our concerns over chronic implications following recovery from COVID-19 especially in diabetic, but also in non-diabetic patients, and to indicate that some preventive measures could be undertaken by application of DPP-4 inhibitors.

Angiotensin-Converting Enzyme 2 (ACE2) is cell surface receptor responsible for SARS-CoV-2 entry highly expressed in maternal-fetal interface including placenta cells e.g. stromal cells, prevascular cells of deciduas, cytotrophoblast, syncytotrophoblast. Several studies reported lack of transplacental transmission of SARS-CoV-2 from a COVID-19 positive mother to fetus suggests that the SARS-CoV-2 may not be transmitted from mother to her child due to some placenta barriers but may be replicating inside the placenta. Our earlier studies demonstrated that human placenta organ culture supports the replication of Japanese Encephalitis(JE) virus indicating their susceptibility and possibility to support propagation of other viruses. Based on our previous experience and present work, we propose that human Placental organ culture will be an ideal in vitro model for propagation of COVID-19 as it has the requisite receptors and tissue architecture needed for virus replication and vaccine development.

For centuries it has been humankind’s instinct to cover the mouth and nose when coughing or sneezing. Common sense would dictate this instinctively reduces the dispersion of aerosol and droplets and thus the spread of contact and airborne infections.Aerosol generating procedures (AGPs) have become a new byword for procedures that put clinicians at increased risk of contracting COVID-19. Whilst the title suggests the risk is simply in aerosols, the science is much more interesting. Droplets and aerosols are different, with the distinction between them based on size. Whilst experts disagree on the absolute size when an aerosol becomes a droplet, the general acceptance is that anything bigger than 50 microns (0.05mm) is a droplet and those smaller are aerosols.In most contagious respiratory infections, the principal transmission agents are droplets (1). This is due to the relatively high viral load in a droplet, purely due to its large size, and also the fact that large droplets have weight, and so gravity pulls them down onto surfaces that others can touch – so passing it on. This is why washing hands is so effective against droplet spread.Aerosol transmission is thought to be a much less frequent cause of transmission, mainly due to the very small viral load (given the aerosol itself is by definition very small). However, it is clearly more concerning as these very small, and therefore very light particles, can travel large distances on air currents and can be directly inhaled. That said, it is thought to only play a minor role in transmission compared to droplet spread.During the COVID-19 pandemic PHE (Public Health England) updated guidance on what it considers (AGPs) Aerosol Generating Procedures. Included within this list were examinations of the upper aerodigestive tract in ENT. Any procedure enacting air over a fluid mucosal surface therefore poses a risk of viral dispersion within both droplets and aerosol. Healthcare workers were recommended to reduce endoscopy of the nose and throat. Any essential examination had to be performed using high level PPE including an respirator (N95 or FFP3)(2).Anfinrud et al (3) graphically represented a visual reduction in aerosol production by creating light sheet from a 532-nm green LASER. Comparisons were made between a person talking with and without a cover for the mouth, in their instance, a slightly dampened wash cloth. Light flashes were recorded to evaluate the number of droplets ranging between 5-200 microns. They showed that by covering the mouth, virtually no light flashes were seen. This observation supports the well-known concept that covering the mouth does indeed reduce droplet production.On impact with smooth surfaces droplets disperse to smaller sizes and can aerosolise. Similarly impact onto soft surfaces absorbs droplets reducing their projection as well as the tendency to aerosolise (3).As the pandemic plateaus in countries across the world various strategies are to be considered to return to a new normal. This would facilitate the resumption of diagnostic services whilst maintaining the protection to healthcare workers. One suggestion is the use of facemasks to help reduce the risk of inadvertent droplet dispersion (2). Despite the ‘soft surface’ barrier masks create, in the ENT setting, facemasks obscure access to the nasal cavity thus preventing nasoendoscopy.The ‘SNAP’ (Safe Nasoendoscopic Airway Procedure) developed by endoscope-i Ltd (West Midlands, UK) is a single-use, valved endoscopic port, retrofitted to any surgical mask (Figure 1), permitting entry of a 4mm flexible and rigid endoscope to examine the naso and pharyngolarynx. The valve, a 10.9 mm cylindrical tube truncated by two opposing 45 degree inclined membranes 700 microns thick, approaches a point but terminates in a 700 micron thick and 500 micron wide plateau, creating a ‘duck bill’ formation The valves are formed using a FFF (fused filament fabrication) 3D printing technique with a Flashforge Creator Pro 3D printer. The plateau atop the valve serves to provide a reference for introducing a slit using a hardened steel razor blade that is 400 microns thin. The blade is mounted in a jig to ensure angle, penetration depth and position are controlled as it is driven through the membrane. These measures ensure that the valve opening is observably consistent and less than 50 microns. Once the SNAP is fitted to a surgical mask, any cough or sneeze generated during the procedure is caught within the mask. The valve is configured such that pressure from the patient side will serve to collapse the walls of the valve membrane thereby further sealing the slit in the valve. This seal has been in vitro tested with aerosolised fluorescein(figure 2). The 45-degree angle of the valve walls from the non-patient side similarly allows the blunt tip of the nasoendoscope to deform the valve walls with ease. The cylindrical form of the walls encourages the valve membranes to return to their original flat shape following withdrawal of the endoscope.During the COVID-19 pandemic our tertiary head and neck cancer referral centre managed 120 urgent 2ww cases. Using the Tikka et al calculator (4) 40% of referrals were redirected back to the GP. The remaining 60% either went direct for imaging or underwent endoscopy. In total 40 cases were endoscoped, 9 of which using the SNAP. All 9 cases scoped with the SNAP were completed without any adverse effect. No cough or sneeze was elicited during any of the examinations and observations between the two groups were identical. Subsequently one consultant lead FEES examination was performed under controlled conditions. Again, the procedure was completed without any complications. The patient self-remarked on the comfort of the endoscopy as a result of the stability provided by the SNAP device in the alar region the prevented inadvertent movement during the chin tuck and head turn exercises.Our observations demonstrate the SNAP device is a practical and safe tool to aid reduction in droplet dispersion whilst performing nasoendoscopy. We hope to see the inclusion of such a device in recovery guidelines by national bodies in order to facilitate the return of safe nasoendoscopy in the post COVID Pandemic era.

Objective: Antibiotic stewardship remains a significant challenge in sub-Saharan Africa, with paucity of systematic data on antimicrobial use in surgical care. We characterise antibiotic prescribing practices for women who delivered via caesarean section (c-section) in rural Rwanda. Design: Nested retrospective cohort study. Setting: Kirehe District, rural Eastern Rwanda. Population: All women aged > 18 years who delivered by c-section between November 2017 and February 2018. Methods: Data on antibiotic use, including name, indication, dose/frequency/route, time, and duration of administration were extracted from patient charts. Prescribing practices statistics were summarised by the timing and type. Main Outcome Measures: Pre-operative and post-operative antibiotic prescriptions, by time, name and dose. Results: A total of 506 patients were enrolled. 80.8% received a pre-operative antibiotic, with 67.4% receiving an antibiotic within one hour of incision. The most prevalent pre-operative antibiotics prescribed were Ceftriaxone (83.3%) and Ampicillin (15.0%). Post-operatively during hospitalisation, 95.7% of patients received two antibiotics, most commonly Ampicillin (99.2%) in combination with Gentamicin (98.5%). For all but one, antibiotics were prescribed without indication of infection. At discharge, while 27.8% of patients were not prescribed any additional antibiotics, 72.2% were prescribed at least one antibiotic. Conclusions: Large deviations in antibiotic prescribing practices as compared to international prophylaxis guidelines were observed. Further studies to understand the rationale for these deviations and the effects of over-prescription on infection prevention and antibiotic resistance are needed to support context-appropriate guidelines in Rwanda and in comparable settings. Funding: NIH R21EB022369 Keywords: Antimicrobial use, sub-Saharan Africa, global surgery

Acute respiratory distress syndrome (ARDS) is the key cause for the morbidity and mortality due to COVID-19 infections. Recent clinical evidences suggest chronic release of pro-inflammatory cytokines as a prominent etiological factor. Adult stem cells are known to secrete potent immunomodulatory and bioactive compounds. We propose a nebulizer assisted treatment of Mesenchymal Stem Cells (MSCs) Secretome as a therapy which will counterbalance the COVID-19 induced cytokine storm as well as promote the regeneration of alveolar tissue attributed to the intrinsic cytokines and growth factor present in the Secretome. Intranasal administration of Secretome will not only protect against the COVID-19 associated complications but also bring down the necessity of the ventilator reducing the burden on health care infrastructure.