Early Prone versus Supine Positioning in Moderate to Severe Coronavirus Disease 2019 Patients with Acute Respiratory Distress Syndrome.

Objectives: This study sought to determine whether early prone positioning of patients with moderate to severe COVID-19-related acute respiratory distress syndrome (ARDS) lowers the mortality rate. Methods: We conducted a retrospective study using data from intensive care units of two tertiary centers in Oman. Adult patients with moderate to severe COVID-19-related ARDS with a PaO2/FiO2 ratio < 150 on FiO2 of 60% or more and a positive end-expiratory pressure of at least 8 cm H2O who were admitted between 1 May 2020 and 31 October 2020 were selected as participants. All patients were intubated and subjected to mechanical ventilation within 48 hours of admission and placed in either prone or supine position. Mortality was measured and compared between the patients from the two groups. Results: A total of 235 patients were included (120 in the prone group and 115 in the supine group). There were no significant differences in mortality (48.3% vs. 47.8%; p =0.938) and discharge rates (50.8% vs. 51.3%; p =0.942) between the prone and supine groups, respectively. Conclusions: Early prone positioning of patients with COVID-19-related ARDS does not result in a significant reduction in mortality.

Superior vena cava syndrome-induced hemoptysis.

Superior vena cava (SVC) syndrome resulting from obstruction of the blood flow to the superior vena cava is rarely reported to present with life-threatening hemoptysis. The pathogenesis and the underlying mechanism are still not well described in the literature. We report a unique case of a 27-year-old man known to have end-stage kidney disease (ESKD) on hemodialysis that presented with shortness of breath and life-threatening hemoptysis that developed during the dialysis session. Computerized tomography with contrast (CTPA) confirmed the presence of a large, calcified thrombus within the SVC along with the formation of multiple collaterals which was diagnostic for SVC syndrome. Attempts for revascularization and stenting failed, and the patient had a prolonged and stormy course while admitted, including difficult alternative dialysis access that unfortunately resulted in death eventually. Here we are highlighting the importance of recognition of hemoptysis as a presentation of SVC syndrome by explaining the underlying pathogenesis and possible management options.

Therapeutic plasma exchange: A potential therapeutic modality for critically ill adults with severe acute respiratory syndrome coronavirus 2 infection.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 infection can be severe and fatal due to cytokine storm. Therapeutic plasma exchange (TPE) potentially mitigates the harmful effects of such cytokines. We investigated the use of TPE, as rescue therapy, in patients with severe Coronavirus disease 2019 (COVID-19) infection. STUDY DESIGN AND METHODS: A retrospective analysis on COVID-19 patients admitted to the intensive care unit and treated with TPE from April 17, 2020 to July 2, 2020. This group was compared with COVID-19 patients who received standard therapy without TPE. The following outcomes were analyzed: changes in laboratory parameters, length of hospital stay (LOS), days on mechanical ventilation, mortality at days 14 and overall mortality. RESULTS: A total of 95 patients were included, among whom 47% (n = 45) received TPE. Patients who received TPE had reductions in C-reactive protein (P = .002), ferritin (P < .001) and interleukin-6 (P = .013). After employing entropy-balancing matching method, those on TPE were also more likely to discontinue inotropes (72% vs 21%; P < .001). However, they were more likely to be associated with longer LOS (23 vs 14 days; P = .002) and longer days on ventilatory support (14 vs 8 days; P < .001). Despite marginal mortality benefit at 14-days (7.9% vs 24%; P = .071), there was no significant differences in overall mortality (21% vs 31%; P = .315) between the groups. CONCLUSIONS: TPE was effective in reducing inflammatory markers in patients with severe COVID-19 infection, however, further research is warranted.

COVID-2019 Pneumonia: Severity and distribution of lung changes observed on the initial chest X-ray as an indicator of final outcomes.

Objectives: This study aimed to assess the correlation between the severity of the initial chest x-ray (CXR) abnormalities in patients with a confirmed diagnosis of COVID-19 and the final outcomes. Methods: This retrospective study was conducted at the Royal Hospital, Oman between mid-March and May 2020 and included patients who had been admitted with a confirmed diagnosis of COVID-19 and had a final outcome. Serial CXRs were identified and examined for presence, extent, distribution and progression pattern of radiological abnormalities. Each lung field was divided into three zones on each CXR and a score was allocated for each zone (0 is normal and 1-4 is mild-severe). The scores for all six zones per CXR examination were summed to provide a cumulative chest radiographic score (range: 0-24). Results: A total of 64 patients were included; the majority were male (89.1%) and the mean age was 50.22 ± 14.86 years. The initial CXR was abnormal in 60 patients (93.8%). The most common finding was ground glass opacity (n = 58, 96.7%) followed by consolidation (n = 50, 83.3%). Most patients had bilateral (n = 51, 85.0%), multifocal (n = 57, 95.0%) and mixed central and peripheral (n = 36, 60.0%) lung abnormalities. The median score of initial CXR for deceased patients was significantly higher than recovered patients (17 versus 11; P = 0.009). Five CXR evolution patterns were identified: type I (initial radiograph deteriorates then improves), type II (fluctuate), type III (static), type IV (progressive deterioration) and type V (progressive improvement). Conclusion: A higher baseline CXR score is associated with higher mortality rate and poor prognosis in those with COVID-19 pneumonia.

Corrigendum to "A fatal case of COVID-19 due to metabolic acidosis following dysregulate inflammatory response (cytokine storm)" [ID Cases 21 (2020) e00829].

[This corrects the article DOI: 10.1016/j.idcr.2020.e00829.].

Chest Radiography Findings of COVID-19 Patients: Differences between the Intubated and Non-intubated Groups.

OBJECTIVES: We sought to identify the chest radiography differences at presentation between two groups of hospitalized confirmed COVID-19 patients; intubated group compared to non-intubated group. METHODS: We retrospectively collected the data of confirmed hospitalized COVID-19 patients at the Royal Hospital, Muscat, Oman, from March to April 2020. Radiographic and clinical data were collected from the hospital and radiology information systems and compared between two groups based on intubation status. RESULTS: Twenty-six patients confirmed to have COVID-19 by reverse-transcriptase polymerase chain reaction test were included in the study; 15/26 were non-intubated, and 11/26 were intubated. Overall, 88.5% were males in the intubated group. Respiratory symptoms were the most common presentation (84.6%) followed by fever (76.9%), with no statistical difference between the two groups. There was a statistically significant difference in having diabetes mellitus (p = 0.020) in which 8/11 and 4/15 were recorded to have diabetes mellitus in the intubated and non-intubated groups, respectively. Other comorbidities showed no statistically significant difference. The radiographic analysis redemonstrates the peripheral lower zone distribution but no statistically significant difference among the two groups. There were no differences between the intubated and non-intubated chest radiography in laterality involvement, central and peripheral distribution, and lesions type. However, upper zones involvement was more noted in the intubated group with 10/11 (90.9%) compared to 7/15 (46.7%) in non-intubated cases (p = 0.036). There were higher numbers of zone involvement in intubated cases than non-intubated cases: 9/11 (81.8%) of intubated patients had 10-12 areas of involvement on chest radiographs compared to 3/15 (20.0%) in the non-intubated group. Half of the cases were discharged home; 3/11 from the intubated group and 10/15 from the non-intubated group. Five patients died from the intubated group (5/11) versus 3/15 from the non-intubated group. Five patients are still hospitalized (three from the intubated group and two from the non-intubated group). CONCLUSIONS: The radiographic findings among intubated and non-intubated hospitalized COVID-19 patients demonstrate differences in the number of zones involved. More upper zone involvement was noted in the intubated group. Male sex and diabetes mellitus carried a poorer prognosis and were more associated with the intubated group.

Serum Calcium and Vitamin D levels: Correlation with severity of COVID-19 in hospitalized patients in Royal Hospital, Oman.

INTRODUCTION: Studies have revealed hypocalcemia and low vitamin D levels in severe covid-19 that warrant further research. OBJECTIVE: Our study investigates the correlation between calcium levels at presentation as a primary endpoint and pre-existing calcium levels as a secondary endpoint to the severity of disease presentation and progression. METHOD: Observational cohort study in adults admitted with COVID-19 from March utill September 2020. Multiple clinical scales and laboratory parameters were used to correlate corrected calcium and vitamin D associations with risk factors and outcomes. RESULTS: Four hundred and forty five patients were included in the study. Hypocalcemic patients had more abnormal laboratory parameters and longer hospitalization duration. Hypocalcemia was in 60-75% of all age groups (p-value 0.053), for which 77.97% were ICU admissions (p-value 0.001) and 67.02% were diabetic (p-value 0.347). There were non-significant correlations between Vitamin D and almost all the parameters except for chronic respiratory diseases, which had a P-value of 0.024. CONCLUSION: It can be concluded that hypocalcemia is a significant and reliable marker of disease severity and progression regardless of underlying comorbidities. Vitamin D levels fail to reflect correlation with severity of COVID-19 infections.

Clinical characteristics and outcomes of the first 63 adult patients hospitalized with COVID-19: An experience from Oman.

INTRODUCTION: To identify the clinical characteristics and outcomes of hospitalized patients with COVID-19 in Oman. METHODS: A case series of hospitalized COVID-19 laboratory-confirmed patients between February 24th through April 24th, 2020, from two hospitals in Oman. Analyses were performed using univariate statistics. RESULTS: The cohort included 63 patients with an overall mean age of 48±16 years and 84% (n=53) were males. A total of 38% (n=24) of the hospitalized patients were admitted to intensive care unit (ICU). Fifty one percent (n=32) of patients had at least one co-morbidity with diabetes mellitus (DM) (32%; n=20) and hypertension (32%; n=20) as the most common co-morbidities followed by chronic heart and renal diseases (12.8%; n=8). The most common presenting symptoms at onset of illness were fever (84%; n=53), cough (75%; n=47) and shortness of breaths (59%; n=37). All except two patients (97%; n=61) were treated with either chloroquine or hydroxychloroquine, while the three most prescribed antibiotics were ceftriaxone (79%; n=50), azithromycin (71%; n=45), and the piperacillin/tazobactam combination (49%; n=31). A total of 59% (n=37), 49% (n=31) and 24% (n=15) of the patients were on lopinavir/ritonavir, interferons, or steroids, respectively. Mortality was documented in (8%; n=5) of the patients while 68% (n=43) of the study cohort recovered. Mortality was associated with those that were admitted to ICU (19% vs 0; p=0.009), mechanically ventilated (31% vs 0; p=0.001), had DM (20% vs 2.3%; p=0.032), older (62 vs 47 years; p=0.045), had high total bilirubin (43% vs 2.3%; p=0.007) and those with high C-reactive protein (186 vs 90mg/dL; p=0.009) and low corrected calcium (15% vs 0%; p=0.047). CONCLUSIONS: ICU admission, those on mechanical ventilation, the elderly, those with high total bilirubin and low corrected calcium were associated with high mortality in hospitalized COVID-19 patients.

Therapeutic plasma exchange in adults with severe COVID-19 infection.

OBJECTIVE: To evaluate the therapeutic use of plasma exchange in COVID-19 patients compared to controls. METHODS: A case series of critically ill adult men and non-pregnant women, ≥18 years of age, with laboratory-confirmed COVID-19, was studied at the Royal Hospital, Oman, from April 17 to May 11, 2020. Therapeutic plasma exchange (TPE) was performed on patients admitted to the intensive care unit (ICU) with confirmed or imminent acute respiratory distress syndrome (ARDS) or severe pneumonia. The analysis was performed using univariate statistics. RESULTS: A total of 31 COVID-19 patients were included with an overall mean age of 51±15 years (range: 27-76 years); 90% (n=28) were males, and 35% (n=11) of the patients had TPE as a mode of treatment. The TPE group was associated with higher extubation rates than the non-TPE cohort (73% versus 20%; p=0.018). Additionally, patients on TPE had a lower 14 days (0 versus 35%; p=0.033) and 28 days (0 versus 35%; p=0.033) post plasma exchange mortality compared to patients not on TPE. However, all-cause mortality was only marginally lower in the TPE group compared to the non-TPE group (9.1% versus 45%; p=0.055; power=66%). Laboratory and ventilatory parameters also improved post TPE (n = 11). CONCLUSIONS: The use of TPE in severe COVID-19 patients has been associated with improved outcomes, however, randomized controlled clinical trials are warranted to draw final, conclusive findings.

A fatal case of COVID-19 due to metabolic acidosis following dysregulate inflammatory response (cytokine storm).

The ongoing outbreak of COVID-19 has been expanding worldwide. As of 17 April 2020, the death toll stands at a sobering 147,027 and over two million cases, this has been straining the health care systems all over. Respiratory failure has been cited as the major cause of death but here we present a case about a patient who instead succumbed to severe metabolic acidosis with multiple organ failure.