Immediate and Contributory Causes of Death in Patients Hospitalized with Covid-19

Background: Accurate determination of the immediate and contributory causes of death in patients with COVID-19 is important for optimal care and instituting mitigation strategies. Method(s): All deaths in Qatar between March 1, 2020 and August 31, 2022 flagged for likely relationship to COVID-19 by were evaluated by two independent reviewers trained to determine and assign the most likely immediate underlying cause of death. Each decedent's electronic medical records was comprehensively reviewed, and the cause of death was assigned based on the most plausible underlying event that triggered the event(s) that led to death based on clinical documentation and a review of laboratory, microbiology, pathology, and radiology data. After cause assignment, each case was categorized into major diagnostic groups by organ system, syndrome, or disease classification. Result(s): Among 749 deaths flagged for likely association with COVID-19, the most common admitting diagnoses were respiratory tract infection (91%) and major adverse cardiac event (MACE, 2.3%). The most common immediate cause of death was COVID pneumonia (66.2%), followed by MACE (7.1%), hospital associated pneumonia (HAP, 6.8%), bacteremia (6.3%), disseminated fungal infection (DFI, 5.2%), and thromboembolism (4.5%). The median length of hospital stay was 23 days (IQR 14,38). COVID pneumonia remained the predominant cause irrespective of the time from admission, though the proportion dropped with increasing length of stay in the hospital. Other than COVID pneumonia, MACE was the predominant cause of death in first two weeks but declined thereafter. No death occurred due to bacteremia, HAP, or DFI in the first week after hospitalization, but became increasing common with increased length of stay in the hospital accounting for 9%, 12%, and 10% of all deaths after 4 weeks in the hospital respectively. The majority of deaths (86%) occurred in the intensive care unit setting. COVID pneumonia accounted for approximately two-thirds of deaths in each setting. MACE and HAP were approximately equally represented in both settings while bacteremia and disseminated fungal infection were more common in the intensive care unit setting. Conclusion(s): Nearly one-third of patients with COVID infection die of non- COVID causes, some of which are preventable. Mitigation strategies should be instituted to reduce the risk of such deaths. (Figure Presented).

A Single Center Experience of Simultaneous Heart-Kidney Transplantation

Purpose: Currently there are no UNOS guidelines regarding the selection criteria required for simultaneous heart-kidney transplant recipients (SHKT). As of 2018 our center has begun performing these dual transplants for appropriate candidates. We report on the criteria devised to guide SHKT candidate selection at our institution and the subsequent clinical outcomes. Method(s): This is a single center, retrospective study of 26 patients who received SHKT at our institution from Dec 2018 to Oct 2021. A multidisciplinary team composed of heart and kidney transplant medical and surgical members determined appropriate recipient-donor SHKT candidate pairs. Selection criteria for SHKT was established by our kidney transplant group and included an evaluation for chronic kidney disease (CKD) or evidence of acute kidney injury (AKI) with a prolonged course or requiring renal replacement therapy (RRT). The surgery was conducted according to our institution's standardized protocols. The majority of patients received IL2-RA and methylprednisolone induction therapy, and all patients received triple immunosuppression therapy with prednisone, mycophenolate mofetil and tacrolimus. Adjustments in long term therapy were made in collaboration between the heart and kidney transplant teams. Result(s): From Dec 2018 to Oct 2021, 26 patients underwent SHKT at our institution. 24 patients (92%) carried a diagnosis of chronic kidney disease (CKD) as defined as an eGFR <60 ml/min/1.73m2 for at least 90 days on at least two separate tests. Clinical risk factors for CKD, the presence of proteinuria, and renal imaging data were also taken into consideration when determining a diagnosis of CKD. Two patients (8%) carried a diagnosis of stage III AKI for at least 4 weeks and required renal replacement therapy during their hospital course. Of our 26 patients, one patient received a DCD donor and 12 patients (46%) received hepatitis C donors. 25 patients (96%) received induction therapy with IL2-RA. During the first 3 months post-transplant, the only patient who received ATG had 7 severe infections;11 patients (44%) and 13 patients (52%) who received IL2 -RA had no infections and <= 4 mild infections, respectively. One patient died due to COVID 19 pneumonia complicated by multisystem organ failure. For a median follow up period of 410 (187-707) days, 8% patients in the IL2-RA induction cohort experienced a 2R/3A heart rejection, 8% patients remained on HD due to primary kidney graft nonfunction, and the survival rate was 96%. Conclusion(s): UNOS guidelines regarding selection criteria for SHKT are an important next step in the care of heart transplant candidates with kidney disease, particularly as the number of SHKT performed yearly increase. Compared to the literature, our data supports the use of standardized criteria for SHKT selection and the use of IL2- RA as an induction strategy with excellent patient survival.

Interleukin - 2 Receptor Antagonists Induction Therapy in Simultaneous Heart - Kidney Transplantation

SRTR data currently suggests that induction therapy in simultaneous heart-kidney transplantation (SHKT) with rabbit antithymoglobulin (ATG) provides survival advantage compared to interleukin-2 receptor antagonist (IL2-RA). We are reporting the outcomes of recipients with SHKT treated with IL2-RA as induction therapy. This is a single center, retrospective study of 26 patients who received SHKT at our institution from Dec 2018 to Oct 2021. A multidisciplinary team composed of heart and kidney transplant medical and surgical members determined appropriate recipient-donor SHKT candidate pairs. The majority of patients received IL2-RA induction therapy, and all patients received triple immunosuppression therapy with prednisone, mycophenolate mofetil and tacrolimus. Adjustments in long term therapy were made in collaboration between the heart and kidney transplant teams. From Dec 2018 to Oct 2021, 26 patients underwent SHKT. 23 patients (88%) were male, the median age was 57 years, and 5.4% were ≥ 65 years. 18 patients (69%) had non ischemic cardiomyopathy and 24 patients (92%) had CKD (mean GFR ≤ 35%). 18 patients were listed Status 2 and 2 patient Status 5. One patient received a DCD donor and 12 patients (46%) received hep C donors. 25 patients (96%) received induction therapy with IL2-RA. During the first 3 months post-transplant, the only patient who received ATG had 7 severe infections;11 patients (44%) and 13 patients (52%) who received IL2 -RA had no infections and ≤ 4 mild infections, respectively. One patient died due to COVID 19 pneumonia complicated by multisystem organ failure. For a median follow up period of 410 (187-707) days, 8% patients in the IL2-RA induction cohort experienced a 2R/3A heart rejection, 8% patients remained on HD due to primary kidney graft non-function, and the survival rate was 96%. Compared with present literature, our data support the use of IL2- RA as an induction strategy in SHKT with excellent patient survival. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Steps and Challenges in Creating and Managing Quarantine Capacity During a Global Emergency ? Qatar?s Experience

Background: COVID-19 pandemic has exposed the lack of adequate and appropriate quarantine capacity globally. Most countries lack the knowledge and/or capacity to set up and manage quarantine facilities at a national scale. Methods: The State of Qatar developed a systematic plan to create and manage quarantine facilities for persons with confirmed or suspected COVID-19 infection or returning travelers and residents. A checklist was developed to streamline the process and to help other institutions requiring such guidance. Results: Three distinct stages were identified: acquisition, commissioning and active operations. Steps required for each stage were identified and added to the checklist. Conclusion: We share our experience and a checklist for setting up new quarantine capacity at a national level. Such checklists can serve as a critical tool to quickly and efficiently ramp up capacity in this setting. (c) 2021 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).

A robust and hybrid cryptosystem for identity authentication

With the progressive development of a wide range of applications, interconnect things and internet of things (IoT) became an imperative required trend by industries and academicians. IoT became a base infrastructure for remote access or control depending on internet protocol (IP) networks, especially after the COVID‐19 pandemic. The huge application domain’s infrastructure, which depends on IoT, requires a trusted connection to guarantee security and privacy while transferring data. This paper proposes a hybrid identity authentication pipeline that integrates three schemes, namely, an elliptic curve cryptography (ECC) scheme is integrated with the Ong, Schnorr, and Shamir (OSS) signature scheme and chaotic maps. The latter satisfies both security and guarantee criteria. The novelty of the proposal is in using chaotic mapping and a cyclic group to deduce a substitution box (S‐Box) and a reversible matrix as a portion of the OSS signature equation. The ECC‐based security part is an efficient public key cryptography mechanism with less computational cost, which makes it the most convenient to be used in IoT devices for authentication and privacy. The strength of the proposed scheme relies on combining the discrete logarithm problem (DLP) and integer factorization problem (IFP). The proposed approach was simulated using Lab‐View and compared with other state‐of‐the art schemes. Extensive simulation results and analysis of the security and time rendering results confirmed its durability against different types of attacks, such as linear and differential attacks. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

Hospital admission rates, length of stay, and in-hospital mortality for common acute care conditions in COVID-19 vs. pre-COVID-19 era.

OBJECTIVES: The impact of COVID-19 upon acute care admission rates and patterns are unknown. We sought to determine the change in rates and types of admissions to tertiary and specialty care hospitals in the COVID-19 era compared with pre-COVID-19 era. METHODS: Acute care admissions to the largest tertiary care referral hospital, designated national referral centers for cardiac, cancer and maternity hospital in the State of Qatar during March 2020 (COVID-19 era) and January 2020 and March 2019 (pre-COVID-19 era) were compared. We calculated total admissions, admissions for eight specific acute care conditions, in-hospital mortality rate, and length of stay at each hospital. RESULTS: A total of 18,889 hospital admissions were recorded. A sharp decline ranging from 9% to 75% was observed in overall admissions. A decline in both elective and non-elective surgeries was observed. A decline of 9%-58% was observed in admissions for acute appendicitis, acute coronary syndrome, stroke, bone fractures, cancer, and live births, whereas an increase in admissions due to respiratory tract infections was observed. Overall length of stay was shorter in the COVID-19 period possibly suggesting lesser overall disease severity, with no significant change in in-hospital mortality. Unadjusted mortality rate for Qatar showed marginal increase in the COVID-19 period. CONCLUSIONS: We observed a sharp decline in acute care hospital admissions, with a significant decline in admissions due to seven out of eight acute care conditions. This decline was associated with a shorter length of stay but not associated with a change in in-hospital mortality rate.