COVID-19 in patients with rheumatological diseases in the Eastern Province of Saudi Arabia.

The severity of the 2019 coronavirus disease (COVID-19) and its effects remain unpredictable. Certain factors, such as obesity, hypertension, and type 2 diabetes mellitus, may increase the severity of the disease. Rheumatology experts suggest that patients with active autoimmune conditions and controlled autoimmune diseases on immunosuppressive therapy may be at higher risk of developing severe COVID-19. In this retrospective observational study, we aimed to examine the patterns of COVID-19 in patients with underlying rheumatological diseases and their association with disease severity and hospital outcomes. A total of 34 patients with underlying rheumatological diseases who tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by polymerase chain reaction (PCR) were included between March 2020 and April 2021 at King Fahd Hospital of the University. The study population consisted of 76.47% female and 23.53% male patients, with a mean age ranging from 20 to 40 years. Female gender (p=0.0001) and younger age (p=0.004) were associated with milder disease. The most frequent rheumatological disease was systemic lupus erythematosus (SLE) (38.24%), which was associated with a milder infection (p=0.045). Patients treated with mycophenolate mofetil (MMF) had a milder disease course (p=0.0037). Hypertension was significantly associated with severe COVID-19 disease (p=0.037). There was no significant relationship between SLE and the need for ICU admission. Patients on hydroxychloroquine and MMF tended to develop milder disease, and there was no association between the severity of the infection and the treatment with steroids.

Hepatobiliary manifestations of COVID-19 and their impact on severity and outcomes in a single center in Saudi Arabia.

Recognizing hepatic manifestations of COVID-19 and their impact on the severity and outcome is crucial in managing this emerging pandemic. However, we lack such reported data in Saudi Arabia regarding this clinical entity. This is a retrospective observational study conducted on 387 patients with COVID-19 disease who were hospitalized at King Fahad Hospital of the University from March-September 2020. The total cohort was divided into two groups: liver and non-liver involvement. Then, the frequency of hepatic manifestations was determined, followed by comparing severity and outcome among the two study groups. A total of 387 patients were included, of which 72.87% had hepatic manifestations. The most prevalent abnormalities were high LDH in 308 (79.58%) followed by AST 205 (52.97%), GGTP 124 (31.26%), ALT 74 (19.12%), PT/INR 66 (17.05%), direct bilirubin 51 (12.40%), total bilirubin 46 (11.88%), and low albumin 48 (12.4%). Univariate analyses showed that liver involvement was significantly associated with severe (31.91%) and critical (34.75%) presentation (P<0.001). Multivariate regression analysis showed that the presence of liver involvement was an independent risk factor for severe or critical COVID-19 disease (OR 2.44; P<0.001), longer hospitalization (OR 2.27; P=0.001), and ICU admission (OR 2.27; P=0.006). The current study showed that liver involvement is common in the setting of COVID-19 disease. Such patients had a higher disease severity and a worse clinical outcome.

The impact of obesity on hospitalized patients with COVID-19 infection in the Eastern Province of Saudi Arabia.

This study aimed to assess the association of obesity with the severity and outcome of COVID-19 infection. A retrospective observational study was performed from March to September 2020 in Saudi Arabia. Baseline and laboratory data were collected from the inpatient health record system. The cohort was divided into three groups based on body mass index. Following this, the severity and outcome of COVID-19 disease were analyzed between the three groups. Of the 502 COVID-19 cases included, 244 (48.5%) were obese. Obesity was significantly associated with severe (53.5%) or critical (28%) COVID-19 infection (P<0.001) and a higher need for ICU admission (35.8%, P=0.034). Multivariate analysis showed that overweight/obesity was an independent risk factor of severe (P<0.001) as well as critical COVID-19 infection (P=0.026, respectively) and a predictor of a higher risk of ICU admission (P=0.012). Class I obesity was associated with severe-critical COVID-19 disease (33.6%, P=0.042) compared to other obesity classes. Obesity is an independent risk factor for severe-critical COVID-19 infection and a higher risk of ICU admission. Clinicians should give special attention to such populations and prioritize vaccination programs to improve outcomes.

Gastrointestinal manifestations of COVID-19 in a single center in the Eastern Province of Saudi Arabia.

Background: Several gastrointestinal (GI) symptoms have been associated with novel coronavirus disease-2019 (COVID-19). Their prevalence and relation to the severity and hospital outcome of COVID-19 have not been well reported in the Middle East and Saudi Arabia. We aimed to examine the GI manifestations of COVID-19 and their association with the severity and hospital outcome of COVID-19 infection. Methods: We conducted a retrospective observational study of hospitalized COVID-19 patients who had a positive SARS-COV2 PCR test and were admitted at a university hospital in Saudi Arabia, from March to September 2020. The primary objective of the study was to describe the GI manifestations of COVID-19. The secondary objective was to investigate the association of GI manifestations with severity and outcome of COVID-19 infection. Results: We included 390 patients, of which 111 (28.5%) presented with GI manifestations. The most common presentation was diarrhea followed by nausea, vomiting, and abdominal pain. Patients without GI manifestations had a higher risk of severe-critical COVID-19 infection evident by the development of lung infiltration in more than 50% of lung fields within 24-48 h, acute respiratory distress syndrome, altered mental status, multiorgan failure, and cytokine storm syndrome (P < 0.05). These patients had a higher mortality rate compared to patients with GI manifestations (P = 0.01). A lower odds of death was seen among patients with GI symptoms (AOR 0.36; 95% CI, 0.158-0.82; P = 0.01). Conclusion: COVID-19 infection presents commonly with GI manifestations. Patients with GI manifestations have less severe COVID-19 disease and lower mortality rates.

The Impact of Vitamin D Level on the Severity and Outcome of Hospitalized Patients with COVID-19 Disease.

PURPOSE: The world is experiencing a life-altering and extraordinary situation in response to the COVID-19 pandemic. There are limited data and controversies regarding the relationship between vitamin D (Vit D) status and COVID-19 disease. Thus, this study was designed to investigate the association between Vit D levels and the severity or outcomes of COVID-19 disease. METHODS: A cross-sectional observational study was conducted in the Eastern province of Saudi Arabia from January to August 2021. All the admitted patients who were diagnosed with COVID-19 infection were distributed into three groups depending on their Vit D levels: normal, insufficiency, and deficiency. For the three groups, demographic data, and laboratory investigations as well as data regarding the severity of COVID-19 were collected and analysed. RESULTS: A total of 203 diagnosed cases of COVID-19 were included in this study. The Vit D level was normal (>30) in 31 (15.3%) cases, insufficient in 45 (22.2%) cases and deficient in 127 (62.6%) cases. Among the included cases, 58 (28.6%) were critical cases, 109 (53.7%) were severe and 36 (17.7%) had a mild-moderate COVID-19 infection. The most prevalent comorbidity of patients was diabetes mellitus 117 (57.6%), followed by hypertension 70 (34.5%), cardiac disease 24 (11.8%), chronic kidney disease 19 (9.4%) and chronic respiratory disease in 17 (8.4%) cases. Importantly, the current study did not detect any significant association between Vit D status and COVID-19 severity (p-value=0.371) or outcomes (hospital stay, intensive care units admission, ventilation, and mortality rate) (p-value > 0.05), even after adjusting the statistical model for the confounders. CONCLUSION: In hospital settings, Vit D levels are not associated with the severity or outcomes of COVID-19 disease. Further, well-designed studies are required to determine whether Vit D status provides protective effects against worse COVID-19 outcomes.

The Impact of Diabetes Mellitus and Hyperglycemia on the Severity and Outcome of Patients with COVID-19 Disease: A Single-Center Experience.

PURPOSE: Diabetes mellitus (DM) has been reported to be associated with a  worse outcome of COVID-19 infection. The evidence is scarce in the Middle East and Saudi Arabia. We aimed to evaluate the impact of diabetes mellitus and hyperglycemia in non-diabetic individuals on the severity and outcome of COVID-19 infection. METHODS: This is a retrospective observational study, which included patients with confirmed COVID-19 infection [RT-PCR positive for SARS-CoV2] who were admitted to King Fahd Hospital of the University-Khobar-Eastern Province-Saudi Arabia from March to September 2020. Baseline demographic data, laboratory investigations, and markers of the severity of COVID-19 were analyzed. The collected data were categorized according to the Saudi Arabian Ministry of Health COVID-19 infection severity criteria. Patients were divided into three groups as follows: patients in Group 1 had pre-existing DM, patients in Group 2 did not have DM but were documented to have hyperglycemia at presentation, and patients in Group 3 were neither diabetics nor hyperglycemics at presentation and served as the control group. The severity and outcome of the control group were compared with the other two groups. The effect of risk factors on the severity and outcome of COVID-19 infection was studied in the DM group. RESULTS: A total of 414 patients were included (70.5% males and 29.5% females). The mean age (SD) of patients was 52.3 (±15.5) years. Compared to the control group, pre-existing DM was found to be significantly associated with severe (OR 3.61), critical disease (OR 4.32), intensive care unit (ICU) admission (OR 2.0), and death (OR 2.0) from COVID-19 infection. Hyperglycemia without known DM was also found to be associated with critical COVID-19 pneumonia (P 0.001), and had longer duration of hospitalization (P 0.014), higher ICU admission, mechanical ventilation, and death from COVID-19 infection (P < 0.0001). CONCLUSION: Diabetes mellitus and hyperglycemia at presentation, even in the absence of pre-existing DM, are independent risk factors for disease severity and worse outcome of COVID-19 infection. These patients should be identified and managed accordingly. The COVID-19 vaccination program should also target those populations to improve their outcomes.

Determinants of time-to-disposition in patients who underwent CT for pulmonary embolism: a retrospective study.

BACKGROUND: Pulmonary embolism (PE) is a common life-threatening medical emergency that needs prompt diagnosis and management. Providing urgent care is a key determinant of quality in the emergency department (ED) and time-based targets have been implemented to reduce length of stay and overcrowding. The study aimed to determine factors that are associated with having a time-to-disposition of less than 4 h in patients with suspected PE who underwent computed tomography pulmonary angiography (CT-PA) to confirm the diagnosis. METHODS: After obtaining approval from the ethics committee, we conducted a retrospective observational study by examining CT-PA scans that was performed to rule out PE in all adult patients presenting at the ED between January 2018 and December 2019. Demographic information and clinical information, as well as arrival and disposition times were collected from electronic health records. Multivariable regression analysis was used to identify the independent factors associated with meeting the 4-h target in the ED. RESULTS: In total, the study involved 232 patients (76 men and 156 women). The median length of stay in the ED was 5.2 h and the 4-h target was achieved in 37% of patients. Multivariable logistic regression analysis revealed that a positive CT-PA scan for PE was independently associated with meeting the four-hour target in the ED (odds ratio [OR]: 2.2; 95% CI: 1.1-4.8). Furthermore, Hemoptysis was the only clinical symptom that served as an independent factor associated with meeting the 4-h target in the ED (OR: 10.4; 95% CI: 1.2-90.8). CONCLUSION: Despite the lower number of staff and higher volume of patients on weekends, patients who presented on weekends had shorter stays and were more likely to meet the 4-h target. Careful clinical assessment, prior to requesting a CT-PA scan, is crucial, since negative CT-PA scans may be associated with failure to meet the 4-h target.

Clinical and imaging profiles of pulmonary embolism: a single-institution experience.

BACKGROUND: Pulmonary embolism (PE) is a common life-threatening condition with non-specific clinical presentations. The diagnosis of PE depends highly on imaging studies, which may also provide prognostic information. This study aimed to describe the clinical and imaging profiles of patients with PE, emphasizing the differences between central and peripheral PE. METHODS: After ethics review board approval, this retrospective observational study examined the non-negative results in adult patients who underwent computed tomography pulmonary angiography (CT-PA) at our hospital between May 2016 and December 2019. Demographic and clinical information and imaging findings were collected from the electronic medical records. RESULTS: The study included 85 cases that were identified after re-interpreting the 103 non-negative CT-PA scans. Six cases were excluded for incomplete data and 12 cases were false-positive. Central PE was found in 63.5% of the cases. Obesity was the most common risk factor seen in 37.6% of the cases. Furthermore, 9.4% of the patients had sickle cell disease, which tended to be associated with peripheral PE. There was no difference between the peripheral and central PE in most clinical and imaging parameters evaluated (P > 0.05). However, patients with isolated subsegmental PE were more likely to develop hemoptysis (P = 0.04). CONCLUSION: This study suggests that patients with obesity and sickle cell disease constitute an important proportion of all PE cases. Furthermore, the clinical and imaging profiles in patients with peripheral PE are similar to those in patients with central PE. Future research should focus on the clinical value of peripheral PE in patients with sickle cell disease.

Predictors of positive computed tomography pulmonary angiography results.

PURPOSE: Computed tomography pulmonary angiography (CT-PA) is the diagnostic modality used for pulmonary embolism (PE). This study aimed to estimate the positive CT-PA rate and identify the predictors of positive CT-PA results. METHODS: A retrospective observational study was conducted by examining the CT-PA data for ruling out PE in all adult patients who visited the King Fahd Hospital of Imam Abdulrahman Bin Faisal University. The data regarding background demographic information, clinical information, and CT-PA findings were collected from electronic health records. Data were analyzed descriptively using the chi-squared test. Multivariate regression analysis was used to identify the predictors of positive CT-PA results. RESULTS: In total, 548 patients (209 male, 339 female) who underwent CT-PA scans were included. The positive CT-PA rate was 18.8%. The Charlson Comorbidity Index was not significantly associated with positive CT-PA results (p = 0.456). Multivariate logistic regression analysis revealed that smoking (odds ratio [OR] 4.96; 95% confidence interval [95% CI] 2.05-12.02) was an independent factor associated with positive CT-PA results. The CT-PA scans performed in winter and spring were 43% (OR 0.43; 95% CI 0.22-0.84) and 52% (OR 0.52; 95% CI 0.28-0.97) less likely to show positive results compared with those performed in autumn, respectively. CONCLUSION: The positive CT-PA rate varied significantly between seasons. Smoking was a predictor of positive CT-PA results. These findings may assist in developing interventions for improving the utilization of CT-PA scans to avoid unnecessary exposure of patients to radiation. CLINICAL TRIAL REGISTRATION: N/A.

The use of clinical decision rules for pulmonary embolism in the emergency department: a retrospective study.

BACKGROUND: Pulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation. Computed tomography pulmonary angiography (CT-PA) has been the diagnostic modality of choice, but its use is not without risks. Clinical decision rules have been established for the use of diagnostic modalities for patients with suspected PE. This study aims to assess the adherence of physicians to the diagnostic algorithms and rules. METHODS: A retrospective observational study examining the utilization of CT-PA in the Emergency Department of King Fahd Hospital of Imam Abdulrahman Bin Faisal University for patients with suspected PE from May 2016 to December 2019. The electronic health records were used to collect the data, including background demographic data, clinical presentation, triage vital signs, D-dimer level (if ordered), risk factors for PE, and the CT-PA findings. The Wells score and pulmonary embolism rule-out (PERC) criteria were calculated retrospectively without knowledge of the results of D-dimer and the CT-PA. RESULTS: The study involved a total of 353 patients (125 men and 228 women) with a mean age of 46.7 ± 18.4 years. Overall, 200 patients (56.7%) were classified into the "PE unlikely" group and 153 patients (43.3%) in the "PE likely" group as per Wells criteria. Out of all the CT-PA, 119 CT-PA (33.7%) were requested without D-dimer assay (n = 114) or with normal D-dimer level (n = 5) despite being in the "PE unlikely" group. Only 49 patients had negative PERC criteria, of which three patients had PE. CONCLUSIONS: The study revealed that approximately one-third of all CT-PA requests were not adhering to the clinical decision rules with a significant underutilization of D-dimer assay in such patients. To reduce overutilization of imaging, planned interventions to promote the adherence to the current guidelines seem imperative.

Diabetic Ketoacidosis Revealing Severe Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD-D) Deficiency with Methemoglobinemia: A Case Report.

BACKGROUND Glucose-6-phosphate dehydrogenase deficiency (G6PD-D) is the most common red blood cell enzymopathy disorder. Severe hemolysis due to G6PD-D may rarely manifest as methemoglobinemia. Although acute hemolytic crises are usually induced by the exposure to certain oxidative stresses, diabetic ketoacidosis may also elicit hemolytic reactions in G6PD deficient persons. CASE REPORT A 17-year-old male with type 1 diabetes mellitus presented with diabetic ketoacidosis and features of hemolytic anemia which turned to be G6PD-D related. Interestingly, the arterial blood gas of the patient showed an elevated methemoglobin level (8.1%). CONCLUSIONS G6PD-D induced hemolysis is conventionally caused by oxidative stress, however, we report here a case of G6PD-D induced methemoglobinemia as a complication of diabetic ketoacidosis that has not been, as far as we know, previously reported.

Antiepileptic drugs toxicity: A case of toxic epidermal necrolysis in patient with phenytoin prophylaxis post-cranial radiation for brain metastases.

BACKGROUND: Treatment of epilepsy with antiepileptic drugs (AED) is effective and remains the principal mode of management. A group of adverse effects and drug toxicity can develop immediately or later in the course of treatment. AEDs also have the potential of precipitating idiosyncratic adverse effects including serious cutaneous, hematological and hepatic events. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe cutaneous adverse reactions are related to or caused by a variety of medications including AEDs, they carry a high mortality and morbidity rate, accurate diagnosis and rapid treatment may improve the prognosis. OBJECTIVE: To characterize the clinical features and methods of differentiating Stevens-Johnson syndrome from toxic epidermal necrolysis using a case study and to identify other factors that may contribute to this critical illness. CONCLUSION: Clinical knowledge of potential sever adverse reaction of AEDs is essential and may overcome treatment failure with major impact on health-related quality of life in people with epilepsy.