Success of intravenous immunoglobulin and steroids in managing severe COVID-19 following lung transplantation:A case report

BACKGROUND Coronavirus disease 2019(COVID-19)pneumonia with severe septic shock and acute respiratory distress syndrome(ARDS)are critical illnesses for patients following transplant.Intravenous immunoglobulin(IVIG)plays a role in both immune support and inflammation control,especially in immunocompromised patients.This case report describes the first successful experience using IVIG and pulse steroids to manage this critical condition following lung transplantation.CASE SUMMARY A 65-year-old male patient reported a history of chronic obstructive pulmonary disease and poor lung function and received bilateral sequential lung transplantations.Postoperatively,he developed COVID-19 pneumonia,severe septic shock,and ARDS.He recovered from this critical condition after empirical antibiotics administration and veno-venous extracorporeal membrane oxygenation,in addition to IVIG and pulse steroids.CONCLUSION IVIG is a valuable adjunct in managing severe sepsis in lung transplant recipients after COVID-19 infection.We aim,for the first time,to report the success of such a management approach for COVID-19 ARDS and sepsis in the post-lung transplant setting.With further investigations,this is a starting point for wider analysis of such an approach in this setting and consequently helps guide clinical practice for such a challenging patient population moving forward.

Beyond conventional care:The therapeutic potential of hemoperfusion in severe COVID-19

BACKGROUND Hemoperfusion(HP)is an extracorporeal blood purification modality utilized to remove small-to medium-sized molecules,such as toxins and cytokines,that are difficult to remove by conventional hemodialysis.In clinical practice,HP has been successfully used as a salvage therapy for drug overdose and occasionally in patients with liver failure and sepsis.AIM To summarize the clinical outcomes of a series of patients with severe coronavirus disease 2019(COVID-19)who received HP.METHODS Here,we summarize the clinical outcomes of a series of 18 patients with severe COVID-19 who received HP in our institution during the COVID-19 pandemic.A review of the literature was also performed.RESULTS HP was well-tolerated,and after an average of three sessions,respiratory and cardiovascular parameters as well as blood inflammatory markers improved in most patients.Ten patients were discharged alive.Our literature search identified a total of 20 studies(873 patients)in which HP was used for COVID-19.Nine studies reported improvements in respiratory parameters,and 13 studies(438 patients in total)reported better survival rates in patients undergoing HP.CONCLUSION HP was well-tolerated in patients with severe COVID-19,and most studies reported improved clinical parameters,including better survival rates,when HP was used in patients with severe COVID-19.Further research,especially prospective studies,is needed to evaluate the utility of HP as an early and supportive therapy for critically ill patients due to infectious diseases,such as those with COVID-19 or severe sepsis.

Prevalence and outcomes of neonates with severe COVID-19:An observational study at Children’s Hospital 1 in Ho Chi Minh City,Vietnam

Objective:To evaluate the impact of the severe COVID-19 pandemic on neonates and develop strategies to improve their outcomes.Methods:We conducted an observational cross-sectional study at Children's Hospital 1(CH1)from July 25,2021,to May 31,2022.All neonates who had fever or respiratory symptoms or were born from mothers with COVID-19 and had a positive RT-PCR SARS-CoV-2 result would be included.We classified neonates with COVID-19 into 2 groups:mild/moderate and severe for analysis.Differences between groups were analyzed using Fisher's exact test/Chi-square test for categorical variables and Student's t-test/Wilcoxon Rank Sum test for continuous variables.Results:This study included 88 newborns who had positive RT-PCR SARS-CoV-2 results.The severity COVID-19 rate among neonatal cases was found to be 13.6%(12/88),with a corresponding mortality rate of 1.1%(1/88).All severe cases showed lung abnormalities as evident on chest X-ray images.In addition to respiratory symptoms,a higher incidence of gastrointestinal manifestations,such as vomiting and diarrhea,was observed in the severe group,indicating a compelling association.The administration of anticoagulant and anti-inflammatory drugs in the study group resulted in a satisfactory outcome with no significant complications.Conclusions:The COVID-19 pandemic has had a substantial impact on the well-being of neonates.The management of COVID-19 in this population presents significant challenges.

Effect of Prone Position in Severe Covid-19 Patients in a Referral Center: A Cohort Retrospective Study

Introduction: Covid-19 is defined as a pandemic disease by WHO, in November 2023, WHO recorded 772.1 million confirmed cases and 6.9 million deaths, including 68,382 confirmed cases and 1426 deaths in Madagascar. The management of severe cases of Covid-19 remains a challenge for the healthcare system in a resource-limited country, due to the consumption of human resources, the shortage of medical resources and the lack of capacity in resource-limited countries. Prone position (PP) improves survival in acute respiratory distress, and numerous studies have shown that during Covid-19, it reduces mortality rates at 28 and 90 days, and increases the number of days without mechanical ventilation. However, data on the beneficial effects of PP remain limited in low-income countries. In this context, our study aims to evaluate the benefits of the prone position for severe Covid-19 patients in a referral center in Madagascar. Method: This is a retrospective cohort study, during the 2nd and 3rd waves of COVID-19, over a period of 11 months in two wards managing COVID-19 cases. We included all patients aged 15 and over with severe forms of COVID-19 who required 6 l/min of oxygen therapy. Results: We enrolled 123 patients, including 40 in the prone position and 83 in the supine position, with a mean age of 60.5 ± 12 years. The prone position (DV) reduced the risk of probable complications of COVID-19 with a strong association in terms of use of respiratory assistance (OR = 0.15;95% CI = 0.05 - 0.47), respiratory deterioration (OR = 0.22;95% CI = 0.09 - 0.58), shock (OR = 0.30;95% CI = 0.11 - 0.79) and hemodynamic instability (OR = 0.33;95% CI = 0.12 - 0.95). Univariate analysis of the effect of prone position on SpO2 showed improvement with significant associations with SpO2 at Day 1- Day 3, D4 - D7, D8 - D14, and persisting even at D15 - D21, D3 and D2 before discharge, and at discharge. In the overall population, the mean length of hospital stay was 22.8 ± 22.1 days, with extremes of 1 and 67 days. Univariate analysis of the effect of the prone position showed a reduction in length of hospital stay with a strong association (p = 0.001) and a mean difference of 14 days. The prone position reduced mortality with a significant association (OR = 0.44;95% CI = 0.20 - 0.98). Conclusion: Awake prone position prevents complications of COVID, improves SPO2 even up to hospital discharge and reduces hospital stay. This practice is simple, less costly and suitable in low income countries.

Overcoming Adversity:The Severe COVID-19 Illness Experience

This viral outbreak of the novel SARS-CoV-2 has profoundly disrupted lives globally and has placed unparalleled burdens on individual physical and psychological health.It is imperative to comprehend the psychological journey of COVID-19 patients to provide them with effective care.This study aimed to explore the psychological illness experience of severe COVID-19 survivors from the first symptoms,to hospitalization,recovery,and post-discharge adjustment.Semi-structured interviews were conducted from November 2022 to April 2023,with 30 Romanian former COVID-19 patients.Thematic analysis of transcribed interviews identified four major themes:(1)a distant threat;(2)the tipping point;(3)the turning point;and(4)readjustment and growth.Some participants faced denial or uncertainty early on,misattributing symptoms and delaying seeking care.Hospitalization as a last resort brought anxiety,isolation,and closer confrontations with mortality perception.As symptoms improved,and participants received supportive care from both healthcare professionals and family members,hope and optimism appeared.Despite health improvements and feelings of safety,lingering anxiety persisted.Post-discharge adjustment involved managing lasting effects and selectively resuming activities.For some of the participants,reflection afterward prompted greater self-understanding,empathy and connection,and motivation for self-care.The results have implications for healthcare practitioners,policymakers,and researchers.

Liver dysfunction as a cytokine storm manifestation and prognostic factor for severe COVID-19

patients with or without preexisting liver disorders,posing a significant complication and mortality risk.During coronavirus disease 2019(COVID-19),abnormal liver function is typically observed.However,liver injury may occur because of the treatment as well.Ischemia,cytokine storm,and hypoxia were identified as the three major factors contributing to liver damage during COVID-19.Indeed,raised liver enzymes during hospitalizations may be attributed to medications used,as well as sepsis and shock.As a result,the proportion of hospitalized patients afflicted with COVID-19 and pathological liver biomarkers varies from 14%to 53%.Aminotransferases and bilirubin are found most often elevated.Usually,increased gamma-glutamyltransferase,alkaline phosphatase,and decreased serum albumin levels are demonstrated.Additionally,although there is no specific treatment for COVID-19,many of the drugs used to treat the infection are hepatotoxic.In this mini-review,we focus on how liver dysfunction can be one of the features associated with the COVID-19 cytokine storm.Furthermore,data show that liver injury can be an independent predictor of severe COVID-19,the need for hospitalization,and death.

Nomogram for prediction of fatal outcome in patients with severe COVID-19:a multicenter study

Background:To develop an effective model of predicting fatal outcomes in the severe coronavirus disease 2019(COVID-19)patients.Methods:Between February 20,2020 and April 4,2020,consecutive confirmed 2541 COVID-19 patients from three designated hospitals were enrolled in this study.All patients received chest computed tomography(CT)and serological examinations at admission.Laboratory tests included routine blood tests,liver function,renal function,coagulation profile,C-reactive protein(CRP),procalcitonin(PCT),interleukin-6(IL-6),and arterial blood gas.The SaO2 was measured using pulse oxygen saturation in room air at resting status.Independent high-risk factors associated with death were analyzed using Cox proportional hazard model.A prognostic nomogram was constructed to predict the survival of severe COVID-19 patients.Results:There were 124 severe patients in the training cohort,and there were 71 and 76 severe patients in the two independent validation cohorts,respectively.Multivariate Cox analysis indicated that age≥70 years(HR=1.184,95%CI 1.061–1.321),panting(breathing rate≥30/min)(HR=3.300,95%CI 2.509–6.286),lymphocyte count<1.0×109/L(HR=2.283,95%CI 1.779–3.267),and interleukin-6(IL-6)>10pg/ml(HR=3.029,95%CI 1.567–7.116)were independent high-risk factors associated with fatal outcome.We developed the nomogram for identifying survival of severe COVID-19 patients in the training cohort(AUC=0.900,95%CI 0.841–0.960,sensitivity 95.5%,specificity 77.5%);in validation cohort 1(AUC=0.811,95%CI 0.763–0.961,sensitivity 77.3%,specificity 73.5%);in validation cohort 2(AUC=0.862,95%CI 0.698–0.924,sensitivity 92.9%,specificity 64.5%).The calibration curve for probability of death indicated a good consistence between prediction by the nomogram and the actual observation.The prognosis of severe COVID-19 patients with high levels of IL-6 receiving tocilizumab were better than that of those patients without tocilizumab both in the training and validation cohorts,but without difference(P=0.105 for training cohort,P=0.133 for validation cohort 1,and P=0.210 for validation cohort 2).Conclusions:This nomogram could help clinicians to identify severe patients who have high risk of death,and to develop more appropriate treatment strategies to reduce the mortality of severe patients.Tocilizumab may improve the prognosis of severe COVID-19 patients with high levels of IL-6.

Level of Acceptance of COVID-19 Vaccine and Its Determinants among High Risk Groups for Severe COVID-19 Infection Living in Mogadishu Somalia

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, which is widely referred to as “COVID-19”, has been infecting more than 5.5 million over 144 countries. A vaccine is considered to be the most awaiting intervention and hundreds of global R&D institutions engaged in unprecedented speed to develop the vaccine. The availability of COVID-19 vaccines may not translate into its uptake. Although governments will provide the vaccines, their uptake is voluntary. Objective: This study was carried out to evaluate the level of acceptance of COVID-19 vaccine and it’s determinants among high risk groups for severe COVID-19 infection living in Mogadishu Somalia. Methods: The study was cross-sectional, descriptive analysis conducted to obtain reliable information about the acceptance of COVID-19 vaccine and it is determinants among high-risk groups living in Mogadishu, Somalia. The calculated sample size was 404 using Cochran’s formula = Z2p(1 − p)/d2 and addition of 5% non-respondent rate. According to PESS population estimate in 2020, there are 17 districts. We grouped them into 2 strata and through simple random sampling one district was selected from each strata. After randomly selecting the two districts, three sub districts were randomly selected from each and then every second house (1, 3, 5) in the main roads will be selected. If target population were not found in the second selected house, the next house will be taken until sample size is obtained. Results: 59.4% of respondents were willing to accept and take vaccination while 40.6% of them were not accepting the vaccination. Being afraid of the side effect was the most common reason for not accepting the vaccine Conclusion: More than one third of respondents (40.6%) were not willing to accept the vaccination, knowledge towards COVID-19 was strongly associated with acceptance level of COVID-19 vaccine. Recommendation: Multi-sector organized awareness campaigns involving FMH as well as local authorities and civil society to enhance level of knowledge of community towards COVID-19.

Hypotheses and facts for genetic factors related to severe COVID-19

Genome-wide association analysis allows the identification of potential candidate genes involved in the development of severe coronavirus disease 2019(COVID-19).Hence,it seems that genetics matters here,as well.Nevertheless,the virus's nature,including its RNA structure,determines the rate of mutations leading to new viral strains with all epidemiological and clinical consequences.Given these observations,we herein comment on the current hypotheses about the possible role of the genes in association with COVID-19 severity.We discuss some of the major candidate genes that have been identified as potential genetic factors associated with the COVID-19 severity and infection susceptibility:HLA,ABO,ACE2,TLR7,ApoE,TYK2,OAS,DPP9,IFNAR2,CCR2,etc.Further study of genes and genetic variants will be of great benefit for the prevention and assessment of the individual risk and disease severity in different populations.These scientific data will serve as a basis for the development of clinically applicable diagnostic and prognostic tests for patients at high risk of COVID-19.

Insight into molecular mechanisms underlying hepatic dysfunction in severe COVID-19 patients using systems biology

BACKGROUND The coronavirus disease 2019(COVID-19),a pandemic contributing to more than 105 million cases and more than 2.3 million deaths worldwide,was described to be frequently accompanied by extrapulmonary manifestations,including liver dysfunction.Liver dysfunction and elevated liver enzymes were observed in about 53%of COVID-19 patients.AIM To gain insight into transcriptional abnormalities in liver tissue of severe COVID-19 patients that may result in liver dysfunction.METHODS The transcriptome of liver autopsy samples from severe COVID-19 patients against those of non-COVID donors was analyzed.Differentially expressed genes were identified from normalized RNA-seq data and analyzed for the enrichment of functional clusters and pathways.The differentially expressed genes were then compared against the genetic signatures of liver diseases including cirrhosis,fibrosis,non-alcoholic fatty liver disease(NAFLD),and hepatitis A/B/C.Gene expression of some differentially expressed genes was assessed in the blood samples of severe COVID-19 patients with liver dysfunction using qRT-PCR.RESULTS Analysis of the differential transcriptome of the liver tissue of severe COVID-19 patients revealed a significant upregulation of transcripts implicated in tissue remodeling including G-coupled protein receptors family genes,DNAJB1,IGF2,EGFR,and HDGF.Concordantly,the differential transcriptome of severe COVID-19 liver tissues substantially overlapped with the disease signature of liver diseases characterized with pathological tissue remodeling(liver cirrhosis,Fibrosis,NAFLD,and hepatitis A/B/C).Moreover,we observed a significant suppression of transcripts implicated in metabolic pathways as well as mitochondrial function,including cytochrome P450 family members,ACAD11,CIDEB,GNMT,and GPAM.Consequently,drug and xenobiotics metabolism pathways are significantly suppressed suggesting a decrease in liver detoxification capacity.In correspondence with the RNA-seq data analysis,we observed a significant upregulation of DNAJB1 and HSP90AB1 as well as significant downregulation of CYP39A1 in the blood plasma of severe COVID-19 patients with liver dysfunction.CONCLUSION Severe COVID-19 patients appear to experience significant transcriptional shift that may ensue tissue remodeling,mitochondrial dysfunction and lower hepatic detoxification resulting in the clinically observed liver dysfunction.

Efficacy and Safety of Washed Microbiota Transplantation to Treat Patients with Mild-to-Severe COVID-19 and Suspected of Having Gut Microbiota Dysbiosis: Study Protocol for a Randomized Controlled Trial

Objective:Coronavirus disease 2019(COVTD-19)is often accompanied by gastrointestinal symptoms,which are related to gut microbiota dysbiosis(GMD).Whether washed microbiota transplantation(WMT)is an effective treatment for COV1D-19 patients suspected of having GMD by restoring the gut microbiota is unknown.This study is designed to explore the efficacy and safety of WMT in COVID-19 patients suspected of having GMD.Methods:This is a randomized,multicenter,single-blind prospective study.COVID-19 patients suspected of having GMD will be randomly divided to receive routine treatment only or to receive routine treatment and WMT.The frequency of WMT will be once a day for three consecutive days.Laboratory and imaging examinations will be performed at admission,1 and 2 weeks after treatment,and on the day of discharge.Then a telephone follow-up will be conducted at 1st week,2nd week,and 6th month after discharge.The clinical efficacy and safety of WMT in COVD-19 patients suspected of having GMD and the effects of WMT on the organ function,homeostasis,inflammatory response,intestinal mucosal barrier function,and immunity of the patients will be evaluated.Results:By following the proposed protocol,WMT is expected to be efficacious and safe for the treatment of COVID-19 patients suspected of having GMD,and the therapeutic effect is expected to be associated with improvement of the intestinal mucosal barrier function,inflammatory response,and immunity.Conclusion:The findings from this study may offer a new approach for the prevention and treatment of COVID-19 patients suspected of having GMD.

Clinical, laboratory and radiological features and outcomes of moderate to severe COVID-19 patients: A descriptive retrospective study

Objective:To describe the clinical,laboratory and radiological characteristics and outcomes of moderate-to-severe coronvirus disease 2019(COVID-19)patients.Methods:We retrospectively analyzed 43 RT-PCR confirmed moderate-to-severe COVID-19 patients who were admitted to a tertiary care center.The primary composite outcomes were admission to intensive care unit,requirement of mechanical ventilation,and death.Results:The median age of the patients was 50 years,and 62.8%of the patients were male.Out of 43 patients,15(34.88%)were categorized as severe.A total of 26(60.47%)patients had 1 or more comorbidities[diabetes(34.88%)and hypertension(30.23%)].The median duration from the onset of symptoms to admission was 3 days,and the most common symptoms were dyspnoea(90.7%),cough(79.07%),fever(69.77%),and body ache(46.51%).Leucopenia was presented in 14(32.56%)patients,lymphopenia in 26(60.47%)patients,and monocytosis in 7(16.28%)patients.Besides,40(93.02%)patients had bilateral patchy nodular or interstitial infiltration on chest X-ray.The primary outcomes occurred in 20 patients(46.5%),among whom 8 required mechanical ventilation.The patients who had met the primary outcomes were older.They were prone to have at least 1 comorbidity(P=0.004),diabetes(P=0.01),hypertension,higher sequential organ failure assessment score,more tachycardia,lower SpO2,lower PaO2/FiO2,more thrombocytopenia,and more pancytopenia.Conclusions:This retrospective study identified several risk factors for poor outcomes in adults with COVID-19.In particular,older age,tachycardia,high SOFA score,low SpO2,low PaO2/FiO2,presence of comorbidities in form of diabetes and hypertension,thrombocytopenia,and pancytopenia at admission were associated with higher odds of ICU admission,a requirement of mechanical ventilation and in-hospital death.

Clinical outcomes of moderate to severe COVID-19 patients receiving invasive vs. non-invasive ventilation

Objective:To evaluate the in-hospital outcome of moderate to severe COVID-19 patients admitted in High Dependency Unit(HDU)in relation to invasive vs.non-invasive mode of ventilation.Methods:In this study,the patients required either non-invasive[oxygen≤10 L/min or>10 L/min through mask or nasal prongs,rebreather masks and bilevel positive airway pressure(BiPAP)]or invasive ventilation.For analysis of 30-day in hospital mortality in relation to use of different modes of oxygen,Kaplan Meier and log rank analyses were used.In the end,independent predictors of survival were determined by Cox regression analysis.Results:Invasive ventilation was required by 15.1%patients while 84.9%patients needed non-invasive ventilation.Patients with evidence of thromboembolism,high inflammatory markers and hypoxemia mainly required invasive ventilation.The 30-day in hospital mortality was 72.7%for the invasive group and 12.9%for the non-invasive group(1.8%oxygen<10 L/min,0.9%oxygen>10 L/min,3.6%rebreather mask and 4.5%BiPAP).The median time from hospital admission to outcome was 7 days for the invasive group and 18 days for the non-invasive group(P<0.05).Age,presence of co-morbidities,number of days requiring oxygen,rebreather,BiPAP and invasive ventilation were independent predictors of outcome.Conclusions:Invasive mechanical ventilation is associated with adverse outcomes possibly due to ventilator associated lung injury.Thus,protective non-invasive ventilation remains the necessary and safe treatment for severely hypoxic COVID-19 patients.

Factors Predicting Progression to Severe COVID-19: A Competing Risk Survival Analysis of 1753 Patients in Community Isolation in Wuhan, China

Most studies of coronavirus disease 2019(COVID-19)progression have focused on the transfer of patients within secondary or tertiary care hospitals from regular wards to intensive care units.Little is known about the risk factors predicting the progression to severe COVID-19 among patients in community iso-lation,who are either asymptomatic or suffer from only mild to moderate symptoms.Using a multivari-able competing risk survival analysis,we identify several important predictors of progression to severe COVID-19—rather than to recovery—among patients in the largest community isolation center in Wuhan,China from 6 February 2020(when the center opened)to 9 March 2020(when it closed).All patients in community isolation in Wuhan were either asymptomatic or suffered from mild to moderate COVID-19 symptoms.We performed competing risk survival analysis on time-to-event data from a cohort study of all COVID-19 patients(n=1753)in the isolation center.The potential predictors we inves-tigated were the routine patient data collected upon admission to the isolation center:age,sex,respira-tory symptoms,gastrointestinal symptoms,general symptoms,and computed tomography(CT)scan signs.The main outcomes were time to severe COVID-19 or recovery.The factors predicting progression to severe COVID-19 were:male sex(hazard ratio(HR)=1.29,95%confidence interval(CI)1.04–1.58,p=0.018),young and old age,dyspnea(HR=1.58,95%CI 1.24–2.01,p<0.001),and CT signs of ground-glass opacity(HR=1.39,95%CI 1.04–1.86,p=0.024)and infiltrating shadows(HR=1.84,95%CI 1.22–2.78,p=0.004).The risk of progression was found to be lower among patients with nausea or vomiting(HR=0.53,95%CI 0.30–0.96,p=0.036)and headaches(HR=0.54,95%CI 0.29–0.99,p=0.046).Our results suggest that several factors that can be easily measured even in resource-poor set-tings(dyspnea,sex,and age)can be used to identify mild COVID-19 patients who are at increased risk of disease progression.Looking for CT signs of ground-glass opacity and infiltrating shadows may be an affordable option to support triage decisions in resource-rich settings.Common and unspecific symptoms(headaches,nausea,and vomiting)are likely to have led to the identification and subsequent community isolation of COVID-19 patients who were relatively unlikely to deteriorate.Future public health and clinical guidelines should build on this evidence to improve the screening,triage,and monitoring of COVID-19 patients who are asymtomatic or suffer from mild to moderate symptoms.

Effectiveness of adjunctive corticosteroid therapy in patients with severe COVID-19:A retrospective cohort study

BACKGROUND The effectiveness of adjunctive corticosteroid use in patients with coronavirus disease 2019(COVID-19)remains inconclusive.AIM To investigate the effectiveness of adjunctive corticosteroid therapy in patients with severe COVID-19.METHODS We conducted a retrospective analysis of the difference in several outcomes between patients with severe COVID-19 who received corticosteroid therapy(the corticosteroid group)and patients with severe COVID-19 who did not receive corticosteroid therapy(the non-corticosteroid group).RESULTS Seventy-five patients were included in this study.Of these,47 patients were in the corticosteroid group and 28 patients were in the non-corticosteroid group.There were no differences between the two groups in the total length of hospital stay,the length of intensive care unit stay,high-flow oxygen days,non-invasive ventilator days,invasive ventilation days,and mortality rate.Total lesion volume ratio,consolidation volume ratio and ground-glass opacity volume ratio in the corticosteroid group decreased significantly on day 14,while those in the noncorticosteroid group did not show a significant decrease.CONCLUSION Our results show that adjunctive corticosteroid use did not significantly improveclinical outcomes in severe COVID-19 patients,but might promote the absorptionof pulmonary lesions.Larger multicenter randomized controlled studies may beneeded to confirm this.

Outcome of patients with severe COVID-19 pneumonia treated with high-dose corticosteroid pulse therapy:A retrospective study

Objective:To assess the effectiveness of high-dose corticosteroid pulse therapy and evaluate possible factors associated with 28-day mortality in hospitalised patients with severe COVID-19 pneumonia.Methods:We conducted a single-centre retrospective cohort study on hospitalised patients with clinical,epidemiological,and/or radiologically confirmed and suspected COVID-19 at Bitlis Tatvan State Hospital in Turkey between December 1,2020 and June 1,2021.All data of the study participants were recorded,and all patients received intravenous high-dose corticosteroid pulse therapy.The Ordinal Scale for Clinical Improvement(OSCI),Charlson Comorbidity Index and Total Severity Score were calculated.Univariate and multivariate Cox regression models were performed to evaluate the clinical and laboratory parameters that may affect the 28-day mortality.Results:A total of 126 patients were included in the analysis.The 28-day mortality rate of the patients was 22.2%.Laboratory and clinical improvement were observed in 77.8%(98/126)of patients after high-dose corticosteroid pulse therapy.There was a statistically significant difference between the survivors and non-survivors in terms of age,platelet count,neutrophil/lymphocyte ratio,and OSCI,Charlson Comorbidity Index,and Total Severity Score(P<0.001).Multivariate Cox regression analysis revealed that age[HR 1.047(95%CI 1.01-1.08)],use of prophylactic anticoagulation[HR 0.838(95%CI 0.79-0.89)],and bacterial co-infection[HR 3.966(95%CI 1.40-11.21)]were significant determinants of mortality.Early C-reactive protein(CRP)response,decreased oxygen requirement,and improving respiratory rate/OSCI scores after administration of high-dose corticosteroid pulse therapy could contribute to clinical improvement.Conclusions:CRP response,needed oxygen and OSCI scores can be used as prognostic factors to select patients who will benefit from high-dose corticosteroid pulse therapy.

Clinical diagnosis of severe COVID-19:A derivation and validation of a prediction rule

BACKGROUND The widespread coronavirus disease 2019(COVID-19)has led to high morbidity and mortality.Therefore,early risk identification of critically ill patients remains crucial.AIM To develop predictive rules at the time of admission to identify COVID-19 patients who might require intensive care unit(ICU)care.METHODS This retrospective study included a total of 361 patients with confirmed COVID-19 by reverse transcription-polymerase chain reaction between January 19,2020,and March 14,2020 in Shenzhen Third People’s Hospital.Multivariate logistic regression was applied to develop the predictive model.The performance of the predictive model was externally validated and evaluated based on a dataset involving 126 patients from the Wuhan Asia General Hospital between December 2019 and March 2020,by area under the receiver operating curve(AUROC),goodness-of-fit and the performance matrix including the sensitivity,specificity,and precision.A nomogram was also used to visualize the model.RESULTS Among the patients in the derivation and validation datasets,38 and 9 participants(10.5%and 2.54%,respectively)developed severe COVID-19,respectively.In univariate analysis,21 parameters such as age,sex(male),smoker,body mass index(BMI),time from onset to admission(>5 d),asthenia,dry cough,expectoration,shortness of breath,asthenia,and Rox index<18(pulse oxygen saturation,SpO2)/(FiO2×respiratory rate,RR)showed positive correlations with severe COVID-19.In multivariate logistic regression analysis,only six parameters including BMI[odds ratio(OR)3.939;95%confidence interval(CI):1.409-11.015;P=0.009],time from onset to admission(≥5 d)(OR 7.107;95%CI:1.449-34.849;P=0.016),fever(OR 6.794;95%CI:1.401-32.951;P=0.017),Charlson index(OR 2.917;95%CI:1.279-6.654;P=0.011),PaO2/FiO2 ratio(OR 17.570;95%CI:1.117-276.383;P=0.041),and neutrophil/lymphocyte ratio(OR 3.574;95%CI:1.048-12.191;P=0.042)were found to be independent predictors of COVID-19.These factors were found to be significant risk factors for severe patients confirmed with COVID-19.The AUROC was 0.941(95%CI:0.901-0.981)and 0.936(95%CI:0.886-0.987)in both datasets.The calibration properties were good.CONCLUSION The proposed predictive model had great potential in severity prediction of COVID-19 in the ICU.It assisted the ICU clinicians in making timely decisions for the target population.

Ocular manifestations and SARS-CoV-2 detection in tears and conjunctival scrape from non-severe COVID-19 patients

AIM:To explore the ocular features of corona virus disease(COVID)-19 and severe acute respiratory syndrome coronavirus(SARS-CoV)-2 detection in tears and conjunctival scrapes in non-severe COVID-19 patients.METHODS:This is a multicenter observational clinical study with no intervention conducted from Jan 25th to March 1st,2020.Clinical data and samples of tears and conjunctival scraping were collected in consecutive laboratory-confirmed,non-severe COVID-19 patients from three hospitals.COVID-19 virus was analyzed by real-time reverse transcriptase polymerase chain reaction(RT-PCR)kits.RESULTS:Totally 255 laboratory-confirmed,non-severe COVID-19 patients were recruited for ocular manifestation investigation.Of them,54.9%were females,with a mean age of 49.4 y.None of the patients has evidence of uveitis;11 patients(4.3%)complained of mild asthenopia;2(0.8%)had mild conjunctival congestion and serous secretion.Twenty-five of them had performed tears and conjunctival scrape for COVID-19 virus detection,with 4 yield possible positive results in the nucleoprotein gene.One of them were asymptomatic with normal chest CT and positive pharyngeal swab result.CONCLUSION:Ocular manifestations are neither common nor specific in non-severe COVID-19 patients.Meanwhile,COVID-19 virus nucleotides can be detected in the tears and conjunctival scrape samples,warranting further research on the transmissibility by the ocular route.

Bedside ultrasonic localization of the nasogastric tube in a patient with severe COVID-19:A case report

BACKGROUND The indwelling nasogastric tube is commonly used for supplying enteral nutrition to patients who are unable to feed themselves,and accurate positioning is essential in the indwelling nasogastric tube in the body of the aforementioned patients.In clinical practice,abdominal radiography,auscultation,and clinical determination of the pH of the gastric juice are routinely used by medical personnel to determine the position of the tube;however,those treatments have proved limitations in specific cases.There are few case reports on the precise positioning of the nasogastric tube in patients with coronavirus disease 2019(COVID-19),for whom a supply of necessary nutrition support is significant throughout the process of treatment.CASE SUMMARY A 79-year-old patient,diagnosed with COVID-19 at the stage of combined syndromes with severe bacterial lung infection,respiratory failure,multiple comorbidities,and a poor nutritional status,was presented to us and required an indwelling nasogastric tube for enteral nutrition support.After pre-treatment assessments including observation of the patient’s nasal feeding status and examination of the nasal septal deviation,inflammation,obstruction,nasal leakage of cerebrospinal fluid,and other disorders that might render intubation inappropriate,we measured and marked the length of the nasogastric tube to be placed and delivered the tube to the intended length in the standard manner.Then further scrutiny was conducted to ensure that the tube was not coiled in the mouth,and gentle movements were made to avoid damage to the esophageal mucosa.However,back draw of the gastric juice using an empty needle failed,and the stethoscope could not be used for auscultation due to the specific condition presented by the internal organs of the patient,and the end of the tube was placed in saline with no bubbles spilling out.Therefore,it was not possible to determine whether the nasogastric tube was placed exactly in the stomach and no nutrient infusion was performed for the time being.Subsequently,the ultrasound probe was utilized to view the condition of the patient’s stomach,where the nasogastric tube was found to be translucent and running parallel to the esophagus shaped as“=”.The pre-conditions were achieved and 100 mL nutritional fluid was fed to the patient,who did not experience any discomfort throughout the procedure.His vital signs were stable with no adverse effects.CONCLUSION We achieved successfully used ultrasound to position the nasogastric tube in a 79-year-old patient with COVID-19.The repeatable ultrasound application does not involve radiation and causes less disturbance in the neck,making it advantageous for rapid positioning of the nasogastric tube and worthy of clinical promotion and application.

Dapsone: A Century-Old Medicine and a New Hope for Severe COVID-19

Background: The 2020 pandemic of COVID-19 infection, which has already lasted more than 22 months, is not subsiding. Despite the available vaccinations, the infection is still claiming many lives throughout the world, especially among the unvaccinated people. The newly discovered and fast spreading Omicron variant also raises the concern if vaccination alone will be sufficient to win this battle. Purpose: In this concept paper, we examine the possible use dapsone, a century-old and safe medication, to treat patients with severe cases of pulmonary COVID-19 infection. Methods: We aim to delineate the similarities between IgA-mediated neutrophil-directed blistering skin diseases and the severe pulmonary COVID-19 infection by reviewing the relevant medical literatures, in order to compare the pathological mechanisms of these two different clinical situations. Results: Analysis of published reports reveals strong evidence pointing to the involvement of IgA and neutrophils in both clinical situations. In addition, results of a small clinical trial showed efficacy of dapsone in patients suffered with severe COVID-19 infection. Conclusions: Since dapsone is effective in treating IgA-mediated skin diseases by blocking the binding of neutrophils to the tissue site, it could also be an effective treatment for severe cases of COVID-19 lung injury, which has a similar pathological mechanism.