The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section

BACKGROUND: The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU). METHODS: The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations. RESULTS: The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. CONCLUSION: The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available

Black widow spider bites experience from tertiary care center in Saudi Arabia

Introduction: Black widow spiders are one of the most poisonous species to humans; there are more than 30 species of widow spiders in the globe but good thing that not all of them are dangerous. Some of these spiders produce toxic venoms, which cause broad spectrum of clinical manifestations including skin lesions, neurotoxicity, cardiac toxicity and death in some occasions. In Saudi Arabia there were no much reports of black widow spider bites apart from the case series by BUCUR and his group in ALBAHA region. Settings: In 2 years period a total of 8 patients were presented to the emergency departments diagnosed to have black widow spider bites based on description by the patients. Results: 100 % of the cohort were males, aged between 25-58 years. The time between bite and presentation to emergency room was one hour in average (30 min to 4 hours). 75% occured during summer season. All of them 100% had one bite only and reported the bite to be at nighttime in 75% of the times. The average pain score at presentation was 4 /10.100% of the bites were in the lower extremities and almost all progressed to have lower back pain. Three patients had gastrointestinal tract manifestation in form of abdominal cramps and nausea. One had bilateral ptosis, none of them had cardiac or pulmonary complications. The outcome was excellent in all patients and the average of hospital stay was 2.5 days (1-5)

An Overview of Clinical Manifestations of Dermatological Disorders in Intensive Care Units: What Should Intensivists Be Aware of?

Acute skin failure is rarely the primary diagnosis that necessitates admission to an intensive care unit. Dermatological manifestations in critically ill patients, on the other hand, are relatively common and can be used to make a key diagnosis of an adverse drug reaction or an underlying systemic illness, or they may be caused by factors related to a prolonged stay or invasive procedures. In intensive care units, their classification is based on the aetiopathogenesis of the cutaneous lesion and, in the meantime, distinguishes critical patients. When evaluating dermatological manifestations, several factors must be considered: onset, morphology, distribution, and associated symptoms and signs. This review depicts dermatological signs in critical patients in order to lay out better recognition

Computed tomography pulmonary angiogram in a poly-trauma patient undergoing veno venous extracorporeal membrane oxygenation: our experience in diagnosing pulmonary embolism

Abstract Extracorporeal membrane oxygenation (ECMO) is an adapted form of the heart–lung machine that provides cardiopulmonary bypass life support for critically ill patients with acute cardiac and/or respiratory failure who are unresponsive to standard medical and surgical therapies. Although ECMO therapy has advanced significantly, complications like thrombosis and bleeding continue to be substantial, necessitating rapid transport of patients to the radiology suite to reveal crucial findings for further treatment plans or care. Even though the low flow rate for veno-arterial ECMO (VA-ECMO) support during contrast-enhanced CT is well known, the flow rate for veno-venous ECMO support during CT, especially computed tomography pulmonary angiography, is not well understood. Our case emphasizes that CTPA can be performed safely in trauma patients with ECMO runs and any suspected complications during ECMO runs may delay or worsen the clinical prognosis therefore immediate radiological verdicts may reveal significant findings to plan the treatment accordingly. Also, there were no complications associated with our examinations or transport. Our case highlights that VV-ECMO like VA-ECMO induces flow-dependent alterations in the patient’s circulation due to contrast injections, which might lead to an incorrect interpretation of CTPA. However, CTPA is safe, and bringing down the VV-ECMO flow rate of zero with vigilant monitoring of vitals and ventilation support helps radiologists to predict and interpret the contrast flow based on injection and cannula sites in the diagnosing and evaluation of pulmonary embolism patients with acute respiratory failure during ECMO

Clinical Relevance and Antimicrobial Profiling of Methicillin-Resistant Staphylococcus aureus (MRSA) on Routine Antibiotics and Ethanol Extract of Mango Kernel (Mangifera indica L.)

Methicillin-resistant Staphylococcus aureus (MRSA) is known for serious health problems. Testing new inexpensive natural products such as mango kernel (Mangifera indica L., Anacardiaceae) may provide alternative and economically viable anti-MRSA drugs. In the current study, we screened clinical isolates from Aseer Central Hospital, Saudi Arabia, during 2012–2017 for MRSA and tested an ethanolic extract of mango kernel for anti-MRSA activity. Brief confirmation of MRSA was performed by the Vitek 2 system, while antibiotic sensitivity of strains was tested for their clinical relevance. The In vitro disc diffusion method was used to test the anti-MRSA activity of the ethanolic mango kernel extract. The antimicrobial activity of mango kernel was compared to that of standard drugs (oxacillin and vancomycin). Of the identified 132 S. aureus strains, 42 (31.8%) were found to be MRSA and their prevalence showed a clear increase during the last two years (2016-2017; p<0.001). MRSA strains showed 100% sensitivity to vancomycin, teicoplanin, linezolid, tetracycline, daptomycin, tigecycline, and tobramycin and 100% resistance to ampicillin and 98% to penicillin. The ethanolic extracts of mango kernel were found active against both S. aureus and the MRSA strains. Inhibitory activities (mean ± SE) were achieved at concentrations of 50 mg/mL (20.77 ± 0.61), 5 mg/mL (16.18 ± 0.34), and 0.5 mg/mL (8.39 ± 0.33) exceeding that of vancomycin (p=0.0162). MRSA strains were sensitive to mango kernel extracts when compared to vancomycin. Therefore, ethanolic extracts of mango kernel can be escalated to animal model studies as a promising leading anti-MRSA drug candidate and can be an economic alternative to high-priced synthetic antibiotics

Physicians’ Characteristics Associated with Their Attitude to Family Presence during Adult Cardiopulmonary Resuscitation

Healthcare providers have disparate views of family presence during cardiopulmonary resuscitation; however, the attitudes of physicians have not been investigated systematically. This study investigates the patterns and determinants of physicians’ attitudes to FP during cardiopulmonary resuscitation in Saudi Arabia. A cross-sectional design was applied, where a sample of 1000 physicians was surveyed using a structured questionnaire. The study was conducted in the southern region of Saudi Arabia for over 11 months (February 2014–December 2014). The collected data was analyzed using the Pearson chi-square test. Spearman’s correlation analysis and chi-square test of independence were used for the analysis of physicians’ characteristics with their willingness to allow FP. 80% of physicians opposed FP during cardiopulmonary resuscitation. The majority of them believed that FP could lead to decreased bedside space, staff distraction, performance anxiety, interference with patient care, and breach of privacy. They also highlight FP to result in difficulty concerning stopping a futile cardiopulmonary resuscitation, psychological trauma to family members, professional stress among staff, and malpractice litigations. 77.9% mostly disagreed that FP could be useful in allaying family anxiety about the condition of the patient or removing their doubts about the care provided, improving family support and participation in patient care, or enhancing staff professionalism. Various concerns exist for FP during adult cardiopulmonary resuscitation, which must be catered when planning for FP execution

Application of temperature-dependent and steered molecular dynamics simulation to screen anti-dengue compounds against Marburg virus

Marburg virus infections are extremely fatal with a fatality range of 23% to 90%, therefore there is an urgent requirement to design and develop efficient therapeutic molecules. Here, a comprehensive temperature-dependent molecular dynamics (MD) simulation method was implemented to identify the potential molecule from the anti-dengue compound library that can inhibit the function of the VP24 protein of Marburg. Virtual high throughput screening identified five effective binders of VP24 after screening 484 anti-dengue compounds. These compounds were treated in MD simulation at four different temperatures: 300, 340, 380, and 420 K. Higher temperatures showed dissociation of hit compounds from the protein. Further, triplicates of 100 ns MD simulation were conducted which showed that compounds ID = 118717693, and ID = 5361 showed strong stability with the protein molecule. These compounds were further validated using ΔG binding free energies and they showed: −30.38 kcal/mol, and −67.83 kcal/mol binding free energies, respectively. Later, these two compounds were used in steered MD simulation to detect its dissociation. Compound ID = 5361 showed the maximum pulling force of 199.02 kcal/mol/nm to dissociate the protein-ligand complex while ID = 118717693 had a pulling force of 101.11 kcal/mol/nm, respectively. This ligand highest number of hydrogen bonds with varying occupancies at 89.93%, 69.80%, 57.93%, 52.33%, and 50.63%. This study showed that ID = 5361 can bind with the VP24 strongly and has the potential to inhibit its function which can be validated in the in-vitro experiment. Communicated by Ramaswamy H. Sarma</p

Genetic Variants and Protective Immunity against SARS-CoV-2

The novel coronavirus-19 (SARS-CoV-2), has infected numerous individuals worldwide, resulting in millions of fatalities. The pandemic spread with high mortality rates in multiple waves, leaving others with moderate to severe symptoms. Co-morbidity variables, including hypertension, diabetes, and immunosuppression, have exacerbated the severity of COVID-19. In addition, numerous efforts have been made to comprehend the pathogenic and host variables that contribute to COVID-19 susceptibility and pathogenesis. One of these endeavours is understanding the host genetic factors predisposing an individual to COVID-19. Genome-Wide Association Studies (GWAS) have demonstrated the host predisposition factors in different populations. These factors are involved in the appropriate immune response, their imbalance influences susceptibility or resistance to viral infection. This review investigated the host genetic components implicated at the various stages of viral pathogenesis, including viral entry, pathophysiological alterations, and immunological responses. In addition, the recent and most updated genetic variations associated with multiple host factors affecting COVID-19 pathogenesis are described in the study