Large differences in COVID‐19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage were associated with low death rates in European countries. SARS‐CoV‐2 binds to its receptor, the angiotensin converting enzyme 2 (ACE2). As a result of SARS‐Cov‐2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT 1 R) axis associated with oxidative stress. This leads to insulin resistanceas well as lung and endothelial damage, two severe outcomes of COVID‐19. The nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) is the most potent antioxidant in humans and can block the AT 1 R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are given: Kimchi in Korea, westernized foods and the slum paradox. It is proposed that fermented cabbage is a proof‐of‐concept of dietary manipulations that may enhance Nrf2‐associated antioxidant effects helpful in mitigating COVID‐19 severity.

Rheumatoid arthritis is an autoimmune disease in which probiotics appears to have an immune modulating action along with decreased inflammatory process. Therefore, we aim to investigate the efficacy of probiotics as an adjuvant therapy for rheumatoid arthritis. A comprehensive literature search was performed using nine databases including PubMed and Web of Science. Interesting data was extracted and meta-analyzed. We assessed the risk of bias using Cochrane Collaboration's tool. The protocol was registered in PROSPERO (CRD 42016036769). We found nine studies involving 361 patients who met our eligibility criteria. Our meta-analysis indicated that pro-inflammatory cytokine IL-6 was significantly lower in the probiotics compared with the placebo group (standardized mean difference = - 0.708; 95% confidence interval (CI) - 1.370 to 0.047, P = 0.036). However, there was no difference between probiotics and placebo in disease activity score (mean difference 0.023; 95% CI - 0.584 to 0.631, P = 0.940). Probiotics lowered pro-inflammatory cytokines IL-6 in RA; however, its clinical effect is still unclear. Hence, many high-quality randomized controlled trials (RCTs) are still needed to prove this effect.

BackgroundLittle research addresses how medical students develop their choice of specialty training in crisis and resource-poor settings. The newly graduated medical students determine the future of the healthcare system. This study aims to elucidate the factors influencing Syrian medical students’ specialty selection and students’ intentions to study abroad.MethodsA cross-sectional study carried out at the universities of Damascus, Al-Kalamoon and the Syrian Private University in Syria using self-administered questionnaire to investigate medical students’ specialty preferences and plans for career future. The questionnaire included questions about students’ demographic and educational characteristics, intention to train abroad, the chosen country for training.ResultsRandomly selected 450 students completed the questionnaire. The two most common specialties selected were general surgery (27.6%) and internal medicine (23.5%). The most influencing factors on their decision were ‘flexibility of specialty’ (74.8%) and ‘Better work opportunities after specializing’ (69.1%). Most participants stated that they are interested in specializing abroad outside Syria (78.7%). The two most common countries of choice were Germany (35.5%) and the United States of America (24.6%). Acquiring a visa to the foreign country was the most common obstacle of specializing abroad (n = 186, 53.6%). Male gender, having a previous clinical training abroad, and having friends or relatives living abroad were significant factors in predicting students’ interest in specializing abroad.ConclusionInternal medicine and surgery are the most reported specialties of choice in this study and most of the participants reported intentions to study abroad. Their specialty preferences are influenced by both familiar epidemiological and war-driven factors. These data can be useful to design further cohort study to understand the war-related affecting factors on students’ plans for their career in the effort of improving the balance of healthcare system in Syria.Electronic supplementary materialThe online version of this article (10.1186/s12909-018-1146-x) contains supplementary material, which is available to authorized users.

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