Prevalence and epidemiological trends in mortality due to COVID-19 in Saudi Arabia

OBJECTIVES

This article describes the prevalence and epidemiological trends of COVID-19 mortality in the largest registry in the Kingdom of Saudi Arabia (KSA).

STUDY DESIGN

A prospective epidemiological cohort study using data from all healthcare facilities in KSA collected between March 23, 2020, and April 30, 2022. Data on the number of daily deaths directly related to COVID-19 were gathered, analyzed, and reported.

METHOD

Data analysis was carried out using national and regional crude case fatality rate and death per 100,000 population. Descriptive statistics using numbers and proportions were used to describe age, gender, nationality, and comorbidities. The mortality trend was plotted and compared with international figures. In addition, the most common comorbidities associated with mortality and the proportion of patients who received COVID-19 vaccine were reported.

RESULTS

The total reported number of deaths between March 23, 2020, and April 30, 2022, was 9085. Crude case fatality rate was 1.21%, and death per 100,000 population was 25.38, which compared favorably to figures reported by several developed countries. The highest percentages of deaths were among individuals aged between 60 and 69 years, males (71%), and individuals with diabetes (60%). Only 2.8% of mortalities occur in patients who received COVID-19 vaccine. Diabetes, hypertension, and heart failure had the highest attributable risk of mortality among patients who died due to COVID-19.

CONCLUSION

Case fatality rate and death per 100,000 population in KSA are among the lowest in the world due to multiple factors. Several comorbidities have been identified, namely, diabetes, hypertension, obesity, and cardiac arrhythmias.

The toll of noninfected CRS patients to the COVID-19 pandemic

Social distancing with the aim of avoiding infections and pre-serve critical care capacities during the COVID-19 pandemic has been implemented in Germany according to World Health Organization (WHO) recommendations from early March onwards. Limitations of physical contacts to reduce exposure to SARS-CoV-2 infected individuals were handled strictly, particularly in medical centers dealing with airway diseases, like rhinology and pneumology clinics. Such measures and reluctance to visit out- and inpatient services resulted in a 82% decrease in consultations to the 12 German oto-rhino-laryngological (ORL) centres forming our database during the 50 days following March 09 in 2020 if compared to the same period in 2019. Our data on CRS care underline reports on undertreatment of non-COVID-19 individuals with several different diseases during the current pandemic. We should try to reduce the toll these patients have to pay as much as possible. We established telemedicine, e-Health and artificial intelligence-supported triage for selecting the right patients for onsite-consultations and to advise patients in several demands.

OSAS and upper pharynx surgery: Does basilingual collapsus always rhyme with failure?

OBJECTIVE

Drug-induced-sedation endoscopy (DISE) has proved superior to awake clinical examination for diagnosis of upper-airway obstruction sites and surgical planning. Our question is: does multilevel obstruction on DISE systematically entail failure for surgery limited to the upper pharynx?

MATERIAL & METHODS

We conducted a retrospective single-center study in patients with obstructive sleep apnea syndrome (OSAS) treated by single-level surgery of the upper pharynx (tonsillectomy with or without pharyngoplasty). Preoperative assessment included polysomnography (PSG) and DISE. Surgical efficacy was assessed on postoperative PSG. Treatment response was defined by postoperative apnea-hypopnea index (AHI) <20 events/h with 50% reduction, and cure by AHI <10 (patients with preoperative AHI ≤10 being excluded). Efficacy was compared between groups without (group A) and with basilingual or laryngeal collapsus on DISE (group B).

RESULTS

We analyzed 63 patients, with mean preoperative AHI 33.8±17.9 events/h. The two groups (A, n=36; B, n=27) were clinically comparable. Postoperative PSG took place at a mean 8.5 ± 11.5 months. The success rate was 66.7% in group A (mean reduction in AHI, 57.3±36.2%) and 59.3% in group B (mean reduction, 53.9±39.2%). Cure rates were respectively 48.5% and 48.1%. There was no statistically significant difference between the two groups (P>0.1).

CONCLUSIONS

Oropharyngeal surgery can alleviate associated obstructive sites found on DISE in the lower pharynx, and step-by-step treatment shows efficacy equal to that of single-step multilevel surgery.

Experience With Ceftolozane-Tazobactam for the Treatment of Serious Pseudomonas aeruginosa Infections in Saudi Tertiary Care Center

Introduction:

Multidrug-resistant Pseudomonas aeruginosa isolates have multiple resistance mechanisms, and there are insufficient therapeutic options to target them. Ceftolozane-tazobactam is a novel antipseudomonal agent that contains a combination of an oxyimino-aminothiazolyl cephalosporin (ceftolozane) and a β-lactamase inhibitor (tazobactam).

Methods:

A single-center retrospective observational study between January 2017 and December 2018 for patients who had been diagnosed with carbapenem-resistant P aeruginosa infections and treated with ceftolozane-tazobactam for more than 72 hours. We assessed clinical success based on microbiological clearance as well as the clinical resolution of signs and symptoms of infection.

Results:

A total of 19 patients fit the inclusion criteria, with a median age was 57 years, and 53% were female. The types of infections were nosocomial pneumonia, acute bacterial skin, and skin structure infections; complicated intra-abdominal infections; and central line–associated bloodstream infections. All of the isolates were resistant to both meropenem and imipenem. The duration of therapy was variable (average of 14 days). At day 14 of starting ceftolozane-tazobactam, 18 of 19 patients had a resolution of signs and symptoms of the infection. Only 14 of 19 patients (74%) had proven microbiological eradication observed at the end of therapy. During therapy, there was no adverse event secondary to ceftolozane-tazobactam, and no Clostridium difficile infection was identified. The 30-day mortality rate was 21% (4/19).

Conclusions:

Multidrug-resistant P aeruginosa infection is associated with high mortality, which would potentially be improved using a new antibiotic such as ceftolozane-tazobactam. Studies are required to explain the role of combination therapy, define adequate dosing, and identify the proper duration of treatment.

Reduced NFAT1 protein expression in human umbilical cord blood T lymphocytes

Umbilical cord blood (UCB) stem cells from related and unrelated allogeneic donors have emerged as novel treatment for patients with hematologic malignancies. The incidence and severity of acute graft-versus-host disease (GVHD) after UCB transplantation compares favorably with that observed in recipients of matched unrelated donor allogeneic grafts, but remains a major cause of morbidity and mortality. It has been shown that stimulated lymphocytes from UCB have reduced production of cytokines including interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha), which play a role in GVHD pathophysiology. We investigated the molecular mechanisms underlying this reduced cytokine production by analyzing expression of nuclear factor of activated T cells-1 (NFAT1) in UCB T cells. We detected no constitutive expression of NFAT1 protein in unstimulated UCB T cells compared with adult T cells. Moreover, although NFAT1 expression in UCB T cells was upregulated after prolonged (40 hours) T-cell stimulation, it was only partially upregulated when compared with adult controls. Our observation of minimal NFAT1 expression after stimulation correlated with reduced cytoplasmic IFN-gamma and TNF-alpha production in UCB T cells studied simultaneously. Reduced NFAT1 expression may blunt amplification of donor UCB T-cell alloresponsiveness against recipient antigens, thereby potentially limiting GVHD incidence and severity after allogeneic UCB transplantation.

Regulation of bFGF expression and ANG II secretion in cardiac myocytes and microvascular endothelial cells

Basic fibroblast growth factor (bFGF; fibroblast growth factor-2) and angiotensin II (ANG II), among other peptide signaling autacoids (cytokines), are known to regulate the phenotypic adaptation of cardiac muscle to physiological stress. The cell type(s) in cardiac muscle responsible for ANG II synthesis and secretion and the role of endogenous cytokines in the regulation of bFGF induction remain unclear. With the use of confluent, serum-starved, low-passage cultures of cardiac microvascular endothelial cells (CMEC), ANG II could be detected in cellular lysates and in medium conditioned by these cells with the use of high-performance liquid chromatography followed by radioimmunoassay. The secretion of angiotensins by individual CMEC could be detected with a cell-blot assay technique. ANG II secretion was decreased by brefeldin A, an agent that interrupts constitutive and regulated secretory pathways for peptide autacoid/ hormone synthesis, suggesting de novo synthesis, activation, and secretion of angiotensins by CMEC. In primary isolates of adult rat ventricular myocytes (ARVM) and CMEC, ANG II, acting at ANG II type 1 receptors in both cell types, was found to increase bFGF mRNA levels measured by ribonuclease protection assay. Endothelin-1 (ET-1), which is known to be synthesized by CMEC, and bFGF itself, which has been detected in both ARVM and CMEC, increased bFGF transcript levels in both cell types. Interleukin-1beta (IL-1beta), which like ANG II and ET-1 is known to activate mitogen-activated protein kinases in both ARVM and CMEC, increased bFGF mRNA levels only in cardiac myocytes. Thus cytokines such as ANG II, ET-1, bFGF, and IL-1beta locally generated by cellular constituents of cardiac muscle, including CMEC, regulate bFGF mRNA levels in a cell type-specific manner.

Regulation of heparin-binding epidermal growth factor-like growth factor mRNA levels by hypertrophic stimuli in neonatal and adult rat cardiac myocytes

Heparin-binding epidermal growth factor-like growth factor (HB-EGF) is a recently characterized member of the EGF family of peptide signaling factors that acts as an early response gene to growth stimuli in vascular smooth muscle cells, as well as being a potent mitogen for these cells. As many of these growth stimuli also induce a hypertrophic response in heart muscle, we examined the regulation of HB-EGF mRNA abundance and function in primary cultures of neonatal rat ventricular myocytes and adult rat ventricular myocytes (ARVM). HB-EGF mRNA levels increased 40- and 6-fold in neonatal rat ventricular myocytes and ARVM, respectively, following a 2-4-h exposure to the alpha-adrenergic agonist phenylephrine, a known hypertrophic stimulus for these cells. Phenylephrine had no effect on HB-EGF mRNA stability, and induction of HB-EGF could be blocked completely by actinomycin D. HB-EGF mRNA abundance was also increased 15-fold in ARVM maintained in defined medium that had been induced to contract at 3 Hz by continual uniform electric field stimulation, a mechanical stimulus that we have shown preserves contractile function and induces cell growth in vitro. To determine whether cardiac myocytes would respond to exogenous HB-EGF, quiescent ARVM were exposed to defined medium conditioned by transfected COS MT cells overexpressing HB-EGF. These myocytes exhibited nearly a 2-fold increase in protein content at 24 h compared with unstimulated control ARVM exposed to medium conditioned by COS cells transfected with the plasmid vector alone. Thus, neonatal and adult cardiac muscle cells respond to both neurohumoral and mechanical growth stimuli with a marked increase in HB-EGF mRNA, which may act as an early response gene to facilitate hypertrophic growth in these cells.