COVID-19 inpatient treatments and outcomes during the conflict in Syria: an observational cohort study.

Background: During the COVID-19 pandemic, countries undergoing conflict have faced difficulties in mounting an effective health response. This observational cohort study describes the treatments and outcomes for inpatients with COVID-19 in the Syrian city of Latakia. Design and methods: A single-centre observational cohort study was conducted at Tishreen University Hospital, involving all patients over 18 admitted between October 1 and December 31, 2021 with a positive RT-PCR test for SARS-CoV-2. Clinical features, investigations, treatments, and outcomes were reported. Results: In total, 149 patients fitted the study criteria. Only one patient was double vaccinated against COVID-19. Oxygen supplementation was required in 87% (n = 130) of participants. Invasive mechanical ventilation was required in 4% (n = 5). Therapeutic anticoagulation was administered in 97.3% (n = 144). Intravenous dexamethasone was received by 97.3% (n = 145) of participants. All patients received empiric antibiotic treatment. In-hospital mortality was 48.4% (n = 72), while only 40.9% (n = 61) were discharged during the study period. Conclusion: The pandemic has placed a compromised Syrian healthcare system under more significant strain. This requires urgent international relief efforts from health agencies in order to aid the pandemic response.

Accelerating the Evolution of Severe Acute Respiratory Syndrome Coronavirus 2: A Risk of Combining Dexamethasone and Tocilizumab for Severe Coronavirus Disease 2019.

Emerging data from open-label randomized trials without placebo controls suggest potential mortality benefits for combining corticosteroids with the interleukin 6 receptor antagonist tocilizumab in severe coronavirus disease 2019. Conversely, dual immunomodulation may weaken antiviral responses and delay viral clearance, allowing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to expand its population and accrue genetic diversity within individual hosts. Generating a pool of hosts with genetically diverse viral populations while introducing new selective pressures in the form of vaccination-induced immunity could accelerate the process of antigenic drift in SARS-CoV-2. However, clinical trials to date have largely disregarded viral outcomes, and data on viral kinetics in response to immunomodulation are scarce. Coadministration of antiviral agents with immunomodulation could serve as a potential strategy to aid viral clearance and reduce the risk of genetic diversification.

Effect of serial awake prone positioning on oxygenation in patients admitted to intensive care with COVID-19.

INTRODUCTION: Awake prone positioning (APP) might benefit patients with COVID-19 by improving oxygenation, but it is unknown whether this improvement can be sustained with serial proning episodes. METHODS: We conducted a retrospective review of adults with COVID-19 admitted to one intensive care unit, in those who underwent APP and controls. Patients in both groups had type 1 respiratory failure requiring oxygen (but not initially intubated), confirmed SARS-CoV-2 PCR by nasopharyngeal swab and findings of multifocal ground-glass opacities on imaging. For the APP group, serial SpO2/FiO2 measurements were recorded after each proning episode. RESULTS: Of 77 patients admitted, 50 (65%) were excluded because they had already been intubated. Another 7 (9%) had undergone APP prior to admission. Of the remaining 20, 10 underwent APP and 10 were controls. Patients in both groups had similar demographics, subsequent intubation and survival. Of those who underwent APP, SpO2/FiO2 was most likely to increase after the first episode (before median: 152, IQR 135-185; after: median 192, IQR 156-234, p=0.04). Half of participants (5) in the APP group were unable to tolerate more than two APP episodes. CONCLUSIONS: Most patients with COVID-19 admitted to the intensive care are not suitable for APP. Of those who are, many cannot tolerate more than two episodes. Improvements in SpO2/FiO2 secondary to APP are transient and most likely in the first episode. Our findings may explain why other studies have failed to show improvements in mortality from APP despite improvements in oxygenation.

The new UK SARS-CoV-2 variant and lockdown - causes and consequences.

The new variant of concern (VOC), B.1.1.7, has a distinct set of mutations in nucleotides encoding the spike (S) protein on the surface of SARS-CoV-2. SARS-CoV-2 previously accumulated mutations at a much slower rate, of 1-2 per month; the sudden appearance of a large cluster of mutations was thought to be unusual. We now suspect that VOC may have arisen from immunosuppressed individuals who shed virus for longer periods. Epidemiological analyses estimate VOC to be more infectious; this is of most concern because these estimates were calculated during periods where many regions of the UK were in high social distancing restrictions. Therefore, the previous 'tiered' system implemented in the UK was ineffective at containing VOC. The most likely reason for this is that previous restrictions, no matter how strict, still allowed for gatherings in certain places. VOC also has implications for the national vaccination programme - a higher proportion of people will need to be vaccinated with a more infectious virus. Prolongation of the second dose of vaccines to increase vaccine uptake has understandably caused concern, but is based on sound immunological principles. There is now an urgent need to monitor the effect of new variants on vaccine efficacy - marking a new chapter in the global fight against COVID-19.

The need for improved discharge criteria for hospitalised patients with COVID-19-implications for patients in long-term care facilities.

In the COVID-19 pandemic, patients who are older and residents of long-term care facilities (LTCF) are at greatest risk of worse clinical outcomes. We reviewed discharge criteria for hospitalised COVID-19 patients from 10 countries with the highest incidence of COVID-19 cases as of 26 July 2020. Five countries (Brazil, Mexico, Peru, Chile and Iran) had no discharge criteria; the remaining five (USA, India, Russia, South Africa and the UK) had discharge guidelines with large inter-country variability. India and Russia recommend discharge for a clinically recovered patient with two negative reverse transcription polymerase chain reaction (RT-PCR) tests 24 h apart; the USA offers either a symptom based strategy-clinical recovery and 10 days after symptom onset, or the same test-based strategy. The UK suggests that patients can be discharged when patients have clinically recovered; South Africa recommends discharge 14 days after symptom onset if clinically stable. We recommend a unified, simpler discharge criteria, based on current studies which suggest that most SARS-CoV-2 loses its infectivity by 10 days post-symptom onset. In asymptomatic cases, this can be taken as 10 days after the first positive PCR result. Additional days of isolation beyond this should be left to the discretion of individual clinician. This represents a practical compromise between unnecessarily prolonged admissions and returning highly infectious patients back to their care facilities, and is of particular importance in older patients discharged to LTCFs, residents of which may be at greatest risk of transmission and worse clinical outcomes.