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Item A Case Series of Severe Hospitalized COVID-19 Patients Treated with Tocilizumab and Glucocorticoids: A Report from Saudi Arabian Hospital(Atlantis Press, 2021-01-22) Al Bahrani, Salma Yassin; Al-Tawfiq, Jaffar A.; Alshaer, Abdulaziz R.; Shilash, Amal; Alswefy, Khalid; Al-Zayer, Razan Salamah; Abouelela, Amr Mohamed; Medicine, School of MedicineBackground: The clinical spectrum of COVID-19 is variable and ranges from asymptomatic, mildly symptomatic, moderately severe and severe disease. A small proportion might develop severe disease and may have cytokine storm. One of the therapeutic options to treat such cases is Tocilizumab (TCZ). In this study, we present cases of severe COVID-19 treated with TCZ and glucocorticoids and discuss the treatment responses. Methods: This is a retrospective observational study of severe COVID-19 cases treated with TCZ and glucocorticoids. The case series examined the characteristics and outcome of those patients. Results: This study included 40 Severe Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) confirmed patients who received TCZ and glucocorticoids. The mean age of the included patients was 57.55 (±Standard deviation 12.86) years. There were 34 (85%) males, 19 (47.5%) were obese (BMI >30), 13 (32.5%) over weight, and five (12.5%) normal weight. The mean days from positive SARS-CoV-2 polymerase chain reaction (PCR) test to admission was 1.641 (±3.2) days. Of the patients, 18 (45%) had diabetes mellitus, 14 (35%) had hypertension. The mean days from hospital admission to ICU was 1.8 (±2.6), 20 (50%) required mechanical ventilation, 39 (97.5%) had received prone position, seven (17.5%) had renal replacement therapy, 13 (32.5%) required inotropes, four (10%) had plasmapheresis, one (2.5%) had intravenous immunoglobulin, all patients received steroid therapy, and the majority 31 (77.5%) did not receive any anti-viral therapy. Of all the patients, six (15%) died, 28 (70%) were discharged and six (15%) were still in hospital. Conclusion: The overall mortality rate was lower than those cited in meta-analysis. As our understanding of the COVID-19 continues, the approach and therapeutics are also evolving.Item Clinical characteristics of asymptomatic and symptomatic COVID-19 patients in the Eastern Province of Saudi Arabia(Elsevier, 2021-01-01) AlJishi, Jumana Mansour; Alhajjaj, Alya Hassan; Alkhabbaz, Fatimah Lateef; AlAbduljabar, Taaweel Hussain; Alsaif, Ahmad; Alsaif, Hussain; Alomran, Kawther Saeed; Aljanobi, Ghada Ali; Alghawi, Zainab; Alsaif, Mohammed; Al-Tawfiq, Jaffar A.; Medicine, School of MedicineBackground: The first case of COVID-19 infection in Saudi Arabia was reported in Qatif on March 2nd, 2020. Here, we describe the clinical characteristics of the initial COVID-19 patients in that area. Methods: This is an observational study describing the clinical presentation, radiographic and laboratory data of COVID-19 cases. Results: From March 1st, 2020 to April 5th, 2020 we identified a total of 82 adult COVID-19 patients. The median age of the patients was 50 years, with a range of 30 to 60 years and most of patients were female 54 (65.9%). Of all the patients, 29 (35.4%) were contacts and 43 (52.4%) were returning travelers, mainly from Iraq (65% of the total returning travelers). Comorbidities were present in 50% of patients, G6PD deficiency in 33%, hypertension in 27%, and diabetes mellitus in 26%. Chest radiographs were abnormal in 46% of symptomatic and 15.5% of asymptomatic patients (P value = 0.0035). Of all patients, 4 (4.87%) required intensive care admission. There was no significant difference in time to negative RT-PCR with mean days to negativity of 13.6 and 16.9 for asymptomatic and symptomatic group, respectively (P value = 0.42). Conclusions: In the initial Epicenter of the COVID-19 in Saudi Arabia, the majority of the patients were asymptomatic and were returning travelers. Comorbidities were present in nearly half of the patients.Item Delirium Incidence, Duration and Severity in Critically Ill Patients with COVID-19(Indiana Medical Student Program for Research and Scholarship (IMPRS), 2020-12-15) Hammes, Jessica; Khan, Sikandar; Lindroth, Heidi; Khan, Babar; Department of Medicine, IU School of MedicineBackground: COVID-19 is associated with severe respiratory failure and high mortality in critically ill patients. Neurologic manifestations of the disease, including delirium and coma, may also be associated with poor clinical outcomes. Delirium is associated with prolonged mechanical ventilation and mortality. This study sought to describe the rates, duration, and severity of delirium in patients admitted to the ICU with COVID-19. Methods: A retrospective, observational study was conducted from March 1st to April 27th, 2020, at Indiana University Health Methodist and Eskenazi Health Hospitals. The delirium measurements were extracted in the first 14 days of the ICU stay, using the Richmond Agitation and Sedation Scale (RASS) and the CAM-ICU and CAM-ICU7, for those with a positive COVID-19 diagnosis. The primary outcomes were delirium rates and duration; the secondary outcome was delirium severity. Descriptive statistics and median group comparisons were done using SAS v9.4. Results: Of 144 patients in the study, 73.6% experienced delirium and 76.4% experienced delirium or coma. The median delirium or coma duration was 7 days (IQR: 3-10), and the median delirium duration was 5 days (IQR: 2-7). The median CAM-ICU-7 score was 6 (IQR: 2-7) signifying severe delirium. Mechanical ventilation was associated increased risk of developing delirium (OR: 22.65, 95% CL: 5.24-97.82). Mortality was also more likely in patients experiencing delirium: 26.4% compared to 15.8% in patients without delirium. Conclusion: Of the 144 patients included, 73.6% experienced delirium lasting on average 5 days: the median delirium score being severe. Mechanical ventilation was also associated with greater odds of developing delirium. Because Covid-19 is associated with high rates of delirium, leading to increased rates of functionality disability, more resources and attention are needed to prevent and manage delirium in patients.Item Hemophagocytic Lymphohistiocytosis in the Medical ICU: A Single-Institution Cohort Study on Acute Liver Failure and Mortality(Wolters Kluwer, 2021-01-08) Al Nasrallah, Nawar; Al-Hader, Ahmad; Samala, Niharika; Sears, Catherine R.; Medicine, School of MedicineHemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory disorder that is associated with high morbidity and mortality in the ICU. It has also been associated with acute liver failure. Design: Retrospective observational study. Setting: Tertiary-care medical ICU. Patients: Thirty-one patients critically ill with hemophagocytic lymphohistiocytosis. Interventions: None. Measurements and main results: We performed a comprehensive review of critically ill hemophagocytic lymphohistiocytosis patients admitted to a tertiary-care medical ICU from January 2012 to December 2018. Most patients presented with constitutional symptoms and elevated liver enzymes and thrombocytopenia were common upon hospital admission. ICU admission laboratory and clinical variables were used to calculate Acute Physiology and Chronic Health Evaluation II, hemophagocytic syndrome diagnostic score, and model for end-stage liver disease. Mean age of the cohort was 48.1 years, and 45% were male. The mortality rate was 65% at 28 days and 77% at 1 year. About 28-day survivors were younger, had lower mean Acute Physiology and Chronic Health Evaluation II score (16.5 vs 23.0; p = 0.004), and higher mean hemophagocytic syndrome diagnostic score (249.1 vs 226.0; p = 0.032) compared with nonsurvivors. Survivors were less likely to receive mechanical ventilation, renal replacement therapy, or vasopressor support and were more likely to receive chemotherapy for hemophagocytic lymphohistiocytosis. In this ICU cohort, 29% were diagnosed with acute liver failure, of whom only 22% developed acute liver failure early during their hospital stay. Acute liver failure was associated with a higher model for end-stage liver disease score upon hospital admission. Available histology in those that developed acute liver failure showed massive hepatic necrosis, or histiocytic or lymphocytic infiltrates. Conclusions: Patients admitted to the ICU with hemophagocytic lymphohistiocytosis have a high mortality. Those who survived had lower Acute Physiology and Chronic Health Evaluation scores, had higher hemophagocytic syndrome diagnostic scores, are more likely to receive hemophagocytic lymphohistiocytosis specific chemotherapy, and are less likely to have organ failure. Hemophagocytic lymphohistiocytosis can be associated with acute liver failure especially when model for end-stage liver disease score is elevated upon admission.Item Intermittent viral shedding in respiratory samples of patients with SARS-CoV-2: observational analysis with infection control implications(Elsevier, 2020-09-10) AlJishi, J.M.; Al-Tawfiq, Jaffar A.; Medicine, School of MedicineSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a global health concern since December 2019. It was feared that intermittent positive cases may indicate a reinfection as there were a number of patients who had positive reverse-transcriptase–polymerase-chain-reaction (RT-PCR) after an initial negative test. Here, we describe the occurrence of intermittent positive PCR and the duration of viral PCR positivity in patients with SARS-CoV-2 infection in patients admitted to Qatif Central Hospital, Saudi Arabia.