Respiratory Morbidity and Mortality of Traumatic Cervical Spinal Injury.

BACKGROUND: Traumatic cervical spinal injuries can severely affect respiratory function and cause significant morbidity and mortality. The typical respiratory morbidity in cervical spine injury is Atelectasis, Ventilator-associated pneumonia, acute respiratory distress syndrome and delayed weaning, etc. The study aims to see the prevalence of respiratory morbidity as well as mortality associated with cervical spine injury. METHODS: Cross sectional study based on retrospective data was conducted on the X Sciences with the existing hospital record during the period of 3 years to find out the prevalence respiratory morbidity like Ventilatory Associated Pneumonia, delayed weaning, ARDS, atelectasis of traumatic cervical spine injury, determine the prevalence, type, and impact of respiratory morbidity and mortality in this population. RESULTS: Total no 76 patients data meeting the inclusion criteria included in study. Male patients were more prone to develop traumatic cervical spinal injuries (SCI). The prevalence of respiratory morbidity in term of VAP(57.89), delayed weaning(46.05) and Atelectasis(22.36) was high. Patients with Asia A Neurology has higher association for VAP and delayed weaning, while Asia E Neurology patients had no respiratory morbidity. The study found a significant positive association between respiratory morbidity with hospital stay, and ventilator days (p-value: 0.019 and 0.048). A total of 15 patients died, 28.95% were discharged on request and 40.8% leaving the hospital against medical advice. CONCLUSIONS: The prevalence of respiratory morbidity higher in cervical spine injury. Furthermore, it has associated with prolonged ICU and ventilator days and increase in mortality.

Clinical Outcome for Lumbar Disc Herniation Treatment with Intradiscal Oxygen-ozone Therapy.

BACKGROUND: Low back pain due to disc herniation is a common problem causing frequent hospital visits and loss of working days with major socio-economic impact. Conservative treatments like analgesics, physiotherapy do not work in all patients. Surgical treatment has been the mainstay of treatment when indicated but is associated with anesthetic and surgical complications. Intradiscal oxygen-ozone chemonucleolysis is a minimally invasive procedure done under local anesthesia and has promising role in shrinking the bulged disc and reducing nerve root compression and related symptoms. This retrospective study was done to see how intradiscal oxygen-ozone chemonucleolysis reduces pain severity in patients with discogenic low back pain. METHODS: Retrospective data were retrieved of those patients who underwent fluoroscopy guided intradiscal oxygen-ozone chemonucleolysis with 5-6 ml of an O2-O3 mixture (concentration of 30 microgram/ml) during a period of two years in Nepal pain care and research center. Numerical pain scale (NRS) at various follow ups were compared to preprocedural NRS. RESULTS: Preprocedural NRS was 8± 13. NRS at three hours, one week, one month, three months and six months were 2± 13 (73 percent reduction), 2± 53 (68 percent reduction), 2± 27 (72 percent reduction), 1± 08 (77 percent reduction) and 1± 67 (79 percent reduction) respectively. CONCLUSIONS: Intradiscal oxygen-ozone chemonucleolysis can be a useful modality of treatment for discogenic low back pain in patients who fail to respond to conservative management and in whom surgery is not indicated.

Co-constructing collaboration: An evidence-based approach to advance and evaluate equitable global public health research partnerships.

Equitable global health partnerships are essential to promote innovative research and strengthen research capacity to address critical public health challenges, but how to optimally evaluate such collaborations is unclear. This was a sequential, multi-method study that utilized an electronic survey informed by the literature followed by semi-structured interviews to comprehensively evaluate the experience of participating in a global research-capacity building collaboration between Nepal and U.S. clinicians and investigators. De-identified quantitative survey were analyzed to calculate descriptive and summary statistics, along with crosstabs of each variable by group. Groups were defined based on country-of-origin and Chi Square statistics calculated to assess for statistically significant differences (p<0.05) between groups. Interviews were analyzed using a descriptive qualitative approach to develop an overall thematic map. 22 survey responses (52.4% response rate) were analyzed; 13 (59.1%) from Nepal, 9 (40.9%) from the U.S. Eight participants (4 Nepal; 4 U.S.) were interviewed. Over the course of the project, all participants reported gaining experience and confidence with research. The majority of participants "strongly agreed" there was a shared understanding of goals, priorities and strategies (Nepal, 58.3%, n = 7; U.S., 88.9%, n = 8;) and that power was shared equally (Nepal, 58.3%, n = 7; U.S., 55.6%, n = 5). The over-arching theme that emerged from the interviews was the importance of 'establishing community' which participants discussed within the broader context of COVID-19. Overall, team members reported strong bi-directional benefit and a greater emphasis on perceived benefits versus challenges. Our survey tool and interview guide, designed to holistically evaluate the impact of a global partnership across various levels of the Social Ecological Model, with particular attention to power dynamics and equity, can be adapted and used by others engaged in similar research capacity collaborations.

Management and Leadership Development in Healthcare Professionals.

In the healthcare system, leadership has never been more crucial. Initiatives to improve health care in underdeveloped nations frequently fail, not for lack of clinical and public health understanding, but rather for lack of management ability. However, there are currently few possibilities for thorough leadership development at any level of career. This short communication highlights the success of the International Public Health Management Development Program by the Nepal Medical Association in conjunction with the Indian Embassy in Nepal, financed by the Ministry of External Affairs under the Indian Technical Education Corporation. Keywords: leadership; Nepal; public health; training activities.

How positive deviants helped in fighting the early phase of COVID-19 pandemic? A qualitative study exploring the roles of frontline health workers in Nepal.

Positive deviance is an approach wherein learnings from persons who fare better than their peers under similar circumstances are used to enable behavioral and social change. Such behaviors and solutions are likely affordable, acceptable, sustainable, and fit into the socio-cultural milieu. Despite the wide use of positive deviance in many public health programs and research, it has yet to be used to study frontline workers in the context of COVID-19. Therefore, this study aimed to explore the positive deviance traits among frontline health workers during the early days of the COVID-19 pandemic in Nepal. This qualitative study followed a grounded theory approach. The data was collected through in-depth interviews among the 17 identified participants representing different cadres of the health workforce, types of health facilities, and regions across Nepal purposively. The findings are structured around four major themes: challenges, finding solutions and innovations, positive lessons, and motivations. The personal challenges included fear and anxiety about the uncertainties. The professional challenges included stigma, infection control, and changing work style with the use of personal protective equipment. Despite the challenges, they managed available resources and innovated low-cost, technological, and practice-based solutions. They were able to reflect upon the positive lessons learned, such as self-sustainability, teamwork, and policy direction and research, and self-reflection of personal growth and patient care. The intrinsic motivation included their inherent value system, and the extrinsic motivation included appreciation and acknowledgment, family and social support, psychosocial support from peers, and support from higher authorities. This study provides insights into how the positive deviance approach can help identify the solution amid the most challenging circumstances, such as the COVID-19 pandemic in low-resource settings. However, more extensive studies are warranted to explore deeper into positive deviance and its long-term effects in bringing positive outcomes during the pandemic.

Building a 'Virtual Library': continuing a global collaboration to strengthen research capacity within Nepal and other low- and middle-income countries.

To fill the gap in health research capacity-building efforts, we created the 'Virtual Library' (VL) - a web-based repository of context-relevant resources for health researchers in low- and middle-income countries (LMICs). This paper describes the participatory process used to systematically develop the VL, and describes how our interprofessional team - representing both an LMIC (Nepal) and a high-income country (HIC) (USA, US) - engaged in shared meaning-making. A team of researchers and clinicians representing a range of subdisciplines from Nepal and the US created a replicable search strategy and standardized Resource Screening Guide (RSG) to systematically assess resources to be included within the VL. Descriptive methods were used to summarize findings from the RSG and lessons learned from the collaborative process. Collectively, 14 team members reviewed 564 potential resources (mean = 40, SD = 22.7). Mean RSG score was 7.02/10 (SD = 2). More than 76% of resources met each of the four quality criteria (relevant; reputable, accessible; understandable). Within the published VL, 298 resources were included, organized by 15 topics and 45 sub-topics. Of these, 223 resources were evaluated by the RSG; 75 were identified by team member expertise. The collaborative process involved regular meetings, iterative document revisions, and peer review. Resource quality was better than expected, perhaps because best practices/principles related to health research are universally relevant, regardless of context. While the RSG was essential to systematize our search and ensure reproducibility, team member expertise was valuable. Pairing team members during peer-review led to bi-directional knowledge sharing and was particularly successful. This work reflects a highly collaborative global partnership and offers a model for future health research capacity-building efforts. We invite engagement with the Virtual Library as one supportive pillar of infrastructure to develop individual and institutional research capacity.

Clinical Characteristics and outcome analysis of SARS-CoV-2 patients admitted to different Critical Care Units in Nepal.

BACKGROUND: The clinical presentation, biochemical characteristics, and outcomes of patients infected with SARS-CoV-2 can vary in different populations. The purpose of the study is to assess the clinical presentation and identify predictors of mortality among patients with severe acute respiratory distress syndrome admitted to different critical care units in Nepal. METHODS: An observational study was conducted among the confirmed SARS-CoV-2 patients admitted to different critical care units in seven provinces of Nepal. Retrospective data was collected for the period of three months (April 14, 2021 to July 15, 2021) in relation to the peak of the second wave of COVID-19 pandemic in Nepal. Clinical, biochemical and mortality data were collected from the admitted patients of different critical care units. Univariate logistic regression analysis was done among the selected variables at 5% significance. Final predictor variables were identified after multiple regression analysis. RESULTS: Out of total of 646 patients admitted to critical care units of different provinces of Nepal, there was a male predominance 420 (65%). A total of 232(35.91 %) patients were non-survivors with the majority of mortality occurring in patients > 50 years of age. Cough (72.3 %), shortness of breath (70.9%) and fever (56 %) were the most common presenting clinical features. Increasing age, presence of comorbidity, critical COVID-19 cases, respiratory rate, temperature, serum urea and alanine aminotransferase were identified as predictors of mortality after multiple regression analysis. CONCLUSIONS: Approximately 36 % of the confirmed SARS-CoV-2 patient admitted to critical care units did not survive. There was a male preponderance with most casualties occurring in patients more than 50 years of age. Cough, shortness of breath and fever were the most common presenting features. After multiple regression analysis of the identified clinical and biochemical factors, age, presence of comorbidity, respiratory rate, temperature, severity grade as per the World Health Organization classification, serum urea and alanine aminotransferase were identified as the predictors of mortality.

Ultrasound Guided Nerve Blocks for Anterior Cutaneous Nerve Entrapment Syndrome an Overlooked Cause of Chronic Abdominal Pain: A Case Series.

Entrapment abdominal neuropathy is not a common diagnosis in our context. Chronic Abdominal wall pain is often mistaken for gastritis, gynecological issue, thoracic spinal radiculopathy, rectus sheath hematoma, abdominal muscle injury or psychiatric disorder. Anterior cutaneous nerve entrapment syndrome is one of the frequent causes of abdominal wall pain occurring due to trapped thoracic intercostal nerves between abdominal muscles. History and bedside Carnett's sign can elicit the diagnosis. Injection of the local anesthetics with steroids in the junction between the rectus sheath and abdominal muscle under ultrasound guidance can provide sustained pain relief. We should consider Anterior cutaneous nerve entrapment syndrome as a differential diagnosis while evaluating the abdominal wall pain. Keywords: ACENE; carnett's test; chronic abdominal pain; entrapment neuropathy; hydrodissection.

Performance of custom made videolaryngoscope for endotracheal intubation: A systematic review.

INTRODUCTION: Videolaryngoscope is regarded as the standard of care for airway management in well-resourced setups however the technology is largely inaccessible and costly in middle and low-income countries. An improvised and cost-effective form of customized videolaryngoscope was proposed and studied for patient care in underprivileged areas however there were no distinct conclusions on its performances. METHOD: The study follows PRISMA guidelines for systematic review and the protocol in International Prospective Register for Systematic Reviews. The primary aim was to assess the first attempt success of customized videolaryngoscope for endotracheal intubation. The secondary objective was to evaluate the number of attempts, laryngoscopic view in terms of Cormack Lehane score and Percentage of glottic opening, use of external laryngeal maneuver and stylet and, the airway injuries after the endotracheal intubation. RESULT: Five studies were analyzed for risk of bias using the National Institute of Health Quality Assessment Tool for cross-sectional studies. Most of the studies had a poor to a fair level of evidence with only one study with a good level of evidence. Certainty of evidence was "very low" for all eligible studies when graded using the Grading of Recommendation, Assessment, Development and Evaluation approach for systematic review. CONCLUSIONS: The certainty of the evidence regarding performance of custom-made videolaryngoscope compared to conventional laryngoscope was very low and the study was performed in small numbers with fair to the poor risk of bias. It was difficult to establish and do further analysis regarding whether the customized form of videolaryngoscope will improve the first attempt success rate for tracheal intubation, reduce the number of attempts, improve the laryngoscopic view, require fewer external aids and reduce the incidences of airway injury with the given low-grade evidence. Some properly conducted randomised clinical trials will be required to further analyze the outcome and make the strong recommendations.

Outcome of Cervical Spine Trauma Patients Admitted to the Intensive Care Unit at a Tertiary Government Referral Trauma Center in Nepal.

STUDY DESIGN: Retrospective study. OBJECTIVES: Cervical spinal cord injury (SCI) is a devastating event for patient and family. It has a huge impact on society because of intensive resources required to manage the patient in both acute and rehabilitation phases. With the limited resource setting in underdeveloped countries like Nepal, questions are often raised regarding whether the outcome justifies the expenses of their care. The objective was to assess the outcomes of cervical SCI patients admitted to intensive care unit (ICU). METHODS: All cervical SCI admitted in ICU during May 2017 to August 2018 were included in this study. Demographic details, mode, morphology, and neurological level of injury, intervention performed and outcomes of ICU stay were analyzed. RESULTS: Out of 48 patients, 36 (75%) were male and 12 female with mean age 43.9 ± 15.9 years. Fall injury was the commonest mode of injury (83.3%). Most patients presented within 1 to 3 days of injury and C5-C6 (33.3%) was the most common involved level and 75% presented with ASIA A neurology. Mechanical ventilation was required in 95.8% of the patients and 22 patients were operated upon. The average stay in ICU was 15 days and 13 patients died in the ICU. CONCLUSIONS: Majority of cervical SCI with complete motor paraplegia required ICU care. Inspite of the intensive care, a subset of these patients succumbed to the complications of the injury. Therefore, it is essential to establish trauma ICU care with specific protocols on managing cervical spine injuries.

Experiences of COVID-19 patients admitted in a government infectious disease hospital in Nepal and its implications for health system strengthening: A qualitative study.

INTRODUCTION: The COVID-19 pandemic has affected the health systems in many ways. It has put unprecedented strain on health systems worldwide and exposed gaps in public health infrastructure. A health system comprises all institutions and resources working towards improving and maintaining health. Among the different aspects of health system strengthening, a patient's experiences and expectations play a crucial role in determining how well the health facilities function. This study aims to explore health system strengthening's implications based on experiences and feedback provided by COVID-19 patients admitted to a government tropical and infectious disease hospital in Nepal. METHODS: In this qualitative study, we collected the voluntary handwritten feedback by the admitted COVID-19 patients to document the feedback and experiences from a book, maintained by the hospital. We performed thematic content analysis using the World Health Organization's six building blocks of health system as a theoretical framework which included service delivery, health workforce, information, leadership and governance, financing, and access to medicines. RESULTS: Most patients in this study had positive experiences on service delivery and health workforce. Some also highlighted the gaps in infrastructure, cleanliness, and hygiene. Many suggested positive experiences on other dimensions of the health system such as financing, governance and leadership, and access to medicines reflected upon by the patients' thankfulness to the hospital and the government for the treatment they received. The responses also reflected the inter-connectedness between the different building blocks of health system. CONCLUSION: This study approached a unique way to strengthen the health system by exploring patients' feedback, which suggested an overall positive impression on most building blocks of health system. However, it also highlighted certain gaps in infrastructure, cleanliness, and hygiene. It reinforces the hospital management and government's role to continue its efforts to strengthen the health system.

Ethical Characteristics of Research Proposals Related to COVID-19 Pandemic in Nepal: A Retrospective Review.

BACKGROUND: Public health emergency is vulnerable time where maintaining ethical principles is obligatory while doing research, on the other hand, it is the same time when breach in ethics is much likely whenever a researcher is unaware, unprepared or hastens to do research. The aim of this study was to assess ethical issues of the coronavirus disease 2019 (COVID-19) related research proposals submitted during the early stages of pandemic in Nepal. METHODS: Retrospective analysis of COVID-19 related research proposals and their informed consent document submitted to the ethical review board at Nepal Health Research Council was done for the study. The analysis was done as per the National Ethical Guidelines, Standard Operating Procedure for Health Research in Nepal and World Health Organization guidelines for infectious disease outbreak, 2016 under ethically relevant headings. Descriptive data were analyzed in SPSS v24. RESULTS: The major issues were observed in the informed consent documents where 55% were lacking principal investigator's contact information, 68% not having participant selection criteria, 70% without clear informed consent taking process, 57% without explanation of possible risks. Similarly, 68% of the interventional studies' consent form didn't mention possible adverse events and mitigation mechanisms. CONCLUSIONS: Most of the research proposals related to COVID-19 were devoid of major ethical elements which took longer time for receiving approval and eventually delayed the opportunity for evidence generation in critical time. More attention is needed to increase awareness and to develop capacity of researchers, reviewers, ethics committees and relevant stakeholders at the time of health emergencies.

Clinical Outcome of Cooled Radiofrequency Ablation in Chronic Knee Pain Osteoarthritis: An Initial Experience from Nepal.

BACKGROUND: Cooled Radiofrequency ablation is a newer technique for management of chronic knee pain in osteoarthritis. The aim of the study is to evaluate the clinical outcomes in patients with chronic osteoarthritis in terms of pain scores for first six months of cooled radiofrequency ablation using ultrasound guidance. METHODS: A cross-sectional study with retrospective review of database was evaluated to analyze the change in the Numerical Rating Scale from baseline scores at 1 day, 1 month and 6 months after the Cooled Radiofrequency ablation of genicular nerves around knee in patients with chronic knee osteoarthritis. RESULTS: Median age was 71 years [ 61-73 years (IQR: 25-75)] with more female preponderance. Numerical Rating Scale (Mean ± S.D.) was significantly less at 1 day (1.87 ± 1.22), 1 month (3.03 ± 0.99) and 6 months (3.37 ± 1.098) from baseline values (6.77 ± 1.00). No soreness and numbness were noted. CONCLUSIONS: Cooled Radiofrequency using Ultrasound guidance for management of knee pain in chronic osteoarthritis is promising and reduces Numerical Rating Score significantly from baseline at 1 month and 6 months respectively.

Comparison of Fentanyl-Propofol and Ketamine-Propofol Combination in Induction and Maintenance with Intravenous Anesthesia for Short Surgical Procedures at Moderate Elevations.

BACKGROUND: The aim of the study is to evaluate the efficacy of Ketamine-Propofol compared to Fentanyl-Propofol combination during induction and maintenance of total intravenous anesthesia for short surgical procedures at moderate elevation. METHODS: A prospective pilot study was done comparing between Fentanyl (1.2 mcg/kg)- Propofol and Ketamine (0.5mg/kg)-Propofol with 30 in each group at moderate altitude of approximately 2514 meters for the requirement of positive pressure ventilation, changes in heart rate and mean arterial pressure intraoperatively, total Propofol consumption and time to attain Modified Steward Score of 6. RESULTS: Requirement for positive pressure ventilation was significantly high in Fentanyl-Propofol group 18 (60%) compared to Ketamine-Propofol 1 (0.03%) [P = 0.00]. Fall in oxygen saturation was significant at 2 minute of Ketamine or Fentanyl [95% CI, 3.10-5.76, P = 0.00], after induction with Propofol [95% CI, 2.30-4.03, P = 0.00], 5 minute [95% CI, 1.66-3.54, P = 0.00], 10 minutes [95% CI, 0.55-2.32, P = 0.02], 15 minutes [95% CI, 0.50-2.09, P = 0.00] and 20 minutes [95% CI, 0.43-2.23, P = 0.00] respectively after study drug between the groups. Total Propofol consumption was significantly higher [95% CI, 0.19-0.43, P = 0.00] in KP (1.55±0.27mg/kg) compared to FP (1.23±0.16 mg/kg). CONCLUSIONS: At moderate elevations of 2514 meters, during the induction and maintenance of intravenous anesthesia, Ketamine-Propofol causes significantly less fall in oxygen saturation in the first 20 minutes requiring lesser need of positive pressure ventilation with comparable least fall in heart rate and mean arterial pressure with higher total Propofol consumption when compared to Fentanyl-Propofol. It took a significantly longer time to recovery with Modified steward score of maximum 6 with Ketamine-Propofol.

Anaesthesia for Antenatal Diagnosed Duodenal Atresia with Undiagnosed Persistent Pulmonary Hypertension of Neonate.

Conversion of fetal circulation to adult-type occurs immediately after birth but neonates with problems in the development of pulmonary vasculature are prone to revert back to fetal circulation. This phenomenon is known as flip-flop circulation which may be induced perioperatively and as such anesthesiologist are central to its management. We report a case of term neonate planned for repair of duodenal atresia that despite having no respiratory symptom preoperatively developed severe hypoxemia under anesthesia that was even unresponsive to 100% oxygen. The intraoperative hemodynamics of the neonate was managed along with supportive care successfully. A postoperative echocardiogram confirmed the evidence of persistent pulmonary hypertension of the newborn. Keywords: Duodenal atresia; flip flop circulation; neonates; persistent pulmonary hypertension of newborn.

Clinical Anesthesia, South Asian Edition: A Book Review.

Local practices, contextual issues and the therapeutic challenges of South Asian perspectives are generally overlooked in standard Clinical Anesthesia textbooks with more relevance to western scenarios. The South Asian Editors of this book, have made a tremendous painstaking effort to consider these issues and present the content as per the need of the local scenarios in an evidence-based manner.

Ultrasound-Guided Interscalene Brachial Plexus Block for Pathological Humerus Fracture due to Multiple Myeloma with Systemic Manifestation: Useful Option for Management in Low-Income Countries.

Anesthetic management of pathological fracture due to multiple myeloma with systemic manifestation poses a perioperative challenge especially in low-resource setups like Nepal. Regional anesthesia using ultrasound-guided block can improve the accuracy, reduce complications, and improve overall perioperative management of pathological fractures due to malignancy with systemic spread in resource-deprived setups. We present a case of a 53-year-old lady with pathological fracture of left humerus shaft, a diagnosed case of multiple myeloma with compression fracture of multiple lumbar spine with chest wall metastasis with resolving acute kidney injury with chest infections. Ultrasound-guided interscalene brachial plexus block with sedation was done for open reduction internal fixation of humerus shaft fracture taking in consideration the overall high perioperative risk of patient. Intraoperative hemodynamic was uneventful, with no neurological sequelae and good recovery status perioperatively. Ultrasound-guided interscalene brachial plexus block if done cautiously can be a very useful alternative technique for better perioperative outcome in patients with malignancy with systemic spread in areas where expertise is scarce and resource is limited.

Perspective of Doctors for COVID-19 Pandemic Readiness in Government Hospitals of Nepal.

BACKGROUND: The study assesses the perspective of doctors working in government hospitals of Nepal regarding hospital preparedness for infection prevention measures, isolation services provisions, critical care service readiness, and training of staff for COVID-19 pandemic management. METHODS: This cross-sectional study was done in central, provincial, and local level health centers of the Government of Nepal to assess the perspective of medical doctors regarding COVID-19 pandemic readiness in their facility. Nonprobability sampling was used to collect 56 responses from doctors working in different hospitals of Nepal. An online survey was performed using a questionnaire tool, which was adapted from the guidelines of the World Health Organization and the Centers for Disease Control and Prevention. RESULTS: Most of the participants were medical officers with an MBBS degree (32) followed by anesthesiologists (10). Thirteen participants worked in central hospitals (23.2%), 24 in provincial hospitals (42.8%) and 19 in local health centers (33.92%). The availability of adequate facemask was 84% in central hospitals, which was higher than provincial hospitals (66.7%), and local level health centers (77.8%). There were only 53.8% trained critical care providers in central hospitals and 29.2% in provincial hospitals. Nearly 38.5% (5) of central hospitals had measures for airborne isolation in place, whereas this was only found in 8.3% (2) of provincial hospitals surveyed for critical care facilities. Overall, only 2 hospitals had the provision of a negative pressure room with air exchanges. Only 8 participants working in central hospitals (61.5%) and 14 working in provincial hospitals (58.3%) had performed hands-on training for donning and doffing personal protective equipment. CONCLUSIONS: The majority of medical doctors working in government hospitals of Nepal perceive that provision of facemask distribution, airborne isolation rooms, critical care preparedness, and hands-on training to staff were not adequate.

Let Us Fight Together against COVID-19 Pandemic.

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