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

Simulation-based training in Ebola Personal Protective Equipment for healthcare workers: Experience from King Abdulaziz University Hospital in Saudi Arabia

Background: Millions of Muslims from across the world gather annually to perform pilgrimage. This can import unusual communicable diseases such as Ebola. Communicable diseases with a high risk of mortality necessitate special training to master the required competency to avert transmission of infections. The efficacy of simulation-based training (SBT) has been shown in such circumstances. Objective: We sought to develop an SBT program in Ebola Personal Protective Equipment (PPE) for all healthcare workers (HCWs). Methods: We conducted a quasi-experimental study at the clinical skills and simulation center at the King Abdulaziz University. An interdisciplinary committee was formed to develop this program in three stages. Pre-intervention: Needs assessment “Diagnostic drill”; we conducted in-situ simulation in the emergency department (ED). High-fidelity simulator (HFS) was used as a suspected Ebola case to assess HCWs’ competency of PPE. We used a checklist that was developed in accordance with the national and international guidelines. We then conducted “Train the Trainer in Ebola PPE” course to develop potential instructors. Intervention: PPE competency SBT courses. This involved focusing on trainees to be skilled in Ebola PPE and becoming trained observers using skill stations and Ebola scenario with HFS, followed by debriefing. All courses gathered participants’ evaluations, pre, and post-tests. Post-intervention: In-situ simulation in the ED two months later that was similar to the diagnostic drill. Results: Pre-intervention: 7 HCWs were involved in the drill, the average score was 37% of the checklist items. For train the trainer, 19 potential PPE instructors attended the program; of them, 65% were female and 35% male, and 6 were physicians and 13 nurses. Average pre and post-tests scores were 72% and 86%, respectively. Intervention: 10 PPE courses that were attended by 179 HCWs; of them, 67% were female and 33% male, and 52 were physicians, 112 nurses, and 15 others. Pre and posttests were 67% (57–75%) and 85% (81–91%), respectively, with a p-value < 0.01. Post-intervention: Post Program drill’s average score was 86% of the checklist items (37% in diagnostic drill). Conclusions: Using SBT could be an effective method of developing competent HCWs in Ebola PPE. Keywords: Simulation, Personal Protective Equipment, Training, Ebol

Inflammatory Markers as a Predictor of Postmenopausal Osteoporosis: A cross-sectional study from the Sultan Qaboos University Hospital

Objectives: Postmenopausal osteoporosis is a progressive metabolic bone disease resulting from estrogen deficiency. However, due to the silent nature of the disease, there is an urgent need for a simple, early predictive marker. This study,&nbsp;conducted between January 2017 to December 2019, aimed to assess the potential of three factors—specifically, the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR)—as inflammatory markers of bone mineral density (BMD) loss. Methods: A retrospective cross-sectional study was conducted among 450 postmenopausal Omani women undergoing dual-energy X-ray absorptiometry at the Sultan Qaboos University Hospital, Muscat, Oman. Participants were allocated into groups based on lumbar spine BMD t-score values. A receiver-operating characteristic curve was used to find the area under the curve (AUC). Multivariate logistic regression was performed to identify independent predictors of low BMD. Results: A total of 65 (14.4%), 164 (36.4%), and 221 (49.1%) women were allocated to the control, osteopenia, and osteoporosis groups, respectively. No significant differences in PLR, MLR, and NLR values were observed based on group allocation. BMD t-score values were reversely correlated with age (P = 0.007) and PLR (P = 0.004), and positively correlated with body mass index (BMI) (P &lt;0.001). The AUC was 0.59. However, the only independent predictors of low BMD were age (&gt;65 years) and BMI (&lt;25 kg/m2). Conclusion: None of the three inflammatory biomarkers studied were found to be useful prognostic indicators of bone loss. Further research is recommended to reject or support&nbsp;theories regarding the role of inflammatory status in the pathogenesis. Keywords: inflammatory markers, neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, platelet-to-lymphocyte ratio, Bone mineral density, osteoporosi

Analysis of the nasopharyngeal microbiome and respiratory pathogens in COVID-19 patients from Saudi Arabia

Background: Infection with SARS-CoV-2 may perturb normal microbiota, leading to secondary infections that can complicate the viral disease. The aim of this study was to probe the alteration of nasopharyngeal (NP) microbiota in the context of SARS-CoV-2 infection and obesity and to identify other respiratory pathogens among COVID-19 cases that may affect patients’ health. Methods: A total of 107 NP swabs, including 22 from control subjects and 85 from COVID-19 patients, were processed for 6S amplicon sequencing. The respiratory pathogens causing secondary infections were identified by RT-PCR assay, using a kit that contained specific primers and probes combinations to amplify 33 known respiratory pathogens. Results: No significant (p > 0.05) difference was observed in the alpha and beta diversity analysis, but specific taxa differed significantly between the control and COVID-19 patient groups. Genera of Sphingomonas, Kurthia, Microbacterium, Methylobacterium, Brevibacillus, Bacillus, Acinetobacter, Lactococcus, and Haemophilus was significantly abundant (p < 0.05) in COVID-19 patients compared with a healthy control group. Staphylococcus was found in relatively high abundance (35.7 %) in the COVID-19 patient groups, mainly those treated with antibiotics. A relatively high percentage of Streptococcus was detected in COVID-19 patient groups with obesity or other comorbidities. Respiratory pathogens, including Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Salmonella species, along with Pneumocystis jirovecii fungal species were detected by RT-PCR mainly in the COVID-19 patients. Klebsiella pneumoniae was commonly found in most of the samples from the control and COVID-19 patients. Four COVID-19 patients had viral coinfections with human adenovirus, human rhinovirus, enterovirus, and human parainfluenza virus 1. Conclusions: Overall, no substantial difference was observed in the predominant NP bacterial community, but specific taxa were significantly changed between the healthy control and COVID-19 patients. Comparatively, an increased number of respiratory pathogens were identified in COVID-19 patients, and NP colonization by K. pneumoniae was probably occurring in the local population

Airborne transmission of SARS-CoV-2 is the dominant route of transmission: Droplets and aerosols

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) has become a pandemic worldwide. On a daily basis the number of deaths associated with COVID- 19 is rapidly increasing. The main transmission route of SARS-CoV-2 is through the air (airborne transmission). This review details the airborne transmission of SARS-CoV-2, the aerodynamics, and different modes of transmission (e.g. droplets, droplet nuclei, and aerosol particles). SARS-CoV-2 can be transmitted by an infected person during activities such as expiration, coughing, sneezing, and talking. During such activities and some medical procedures, aerosols and droplets contaminated with SARS-CoV-2 particles are formed. Depending on their sizes and the environmental conditions, such particles stay viable in the air for varying time periods and can cause infection in a susceptible host. Very few studies have been conducted to establish the mechanism or the aerodynamics of virus-loaded particles and droplets in causing infection. In this review we discuss the various forms in which SARS- CoV-2 virus particles can be transmitted in air and cause infections

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)