Baricitinib Versus Tocilizumab for the Treatment of Moderate to Severe Covid-19

INTRODUCTION: The dysregulated inflammatory response to SARS-CoV-2 plays a crucial role in the pathogenesis of Coronavirus Disease 2019 (COVID-19). The National Institutes of Health (NIH) guidelines recommend adding a second immunomodulatory agent, tocilizumab (TCZ) or baricitinib (BARI), to dexamethasone in patients with rapidly increasing oxygen requirements and systemic inflammation. As of July 2022, these guidelines do not recommend one agent over the other. This study aims to compare the progression rates to mechanical ventilation and in-hospital mortality for TCZ vs. BARI in patients with moderate to severe COVID-19. METHOD(S): This was a single-center, retrospective, cohort study of patients treated with TCZ or BARI for COVID-19 between August 24, 2021, and December 31, 2021. The primary endpoint was a composite outcome of progression to mechanical ventilation or in-hospital mortality. Secondary endpoints included components of the composite outcome, progression to a higher level of care, duration of mechanical ventilation, hospital length of stay (LOS), and intensive care unit (ICU) LOS. Safety endpoints included the incidence of infection and thrombosis. RESULT(S): One-hundred-seventy-six patients were included, of which 61 (34.7%) received TCZ and 115 (65.3%) received BARI. The primary outcome was not significant between groups (52.5% TCZ vs. 44.3% BARI, p=0.305). There were no statistically significant differences noted between TCZ and BARI in regards to progression to mechanical ventilation (36.1% vs 28.7%, p=0.315), inhospital mortality (50.8% vs 41.7%, p=0.249), progression to higher level of care (18% vs 17.4%, p=0.926), duration of mechanical ventilation (median 9 days vs 6 days, p=0.311), hospital LOS (median 8 days vs 14 days, p=0.193), or ICU LOS (median 7 days vs 8 days, p=0.964). For safety outcomes, there was no difference in the infection rate (36.1% vs. 26.1%, p=0.167), but the rate of thrombosis was higher in the TCZ group (11.5% vs. 3.5%, p=0.042). CONCLUSION(S): There was no significant difference in the composite outcome of progression to mechanical ventilation or in-hospital mortality in patients who received TCZ of BARI for the treatment of COVID-19. However, this primary outcome occurred more frequently in the TCZ group, and a larger study may be able to detect this difference.

Difficulties in managing acute gallstone disease at a Tertiary Referral Centre admist COVID-19

Background: Acute Biliary disease, a surgical emergency, is predominantly treated conservatively initially. Specialist units aim to follow guidelines set by The Royal College of Surgeons and NICE to provide a cholecystectomy within a set time. Clinical practice at St Thomas' Hospital was reviewed along with The difficulties during The COVID-19 pandemic. Aim(s): Reassess practice at a specialist unit failing to meet guidelines during The start of COVID-19. Prospective data collection, on patients booked for a laparoscopic cholecystectomy (LC) after Emergency attendances. Method(s): Initial retrospective data analysis, reviewing pre-COVID (PC19) practice (03/19-02/20), initial COVID-19 (IC19) management (03/20-12/20). Prospective data (01/21-11/21) after implementing changes (AC19). Identifying demographics, pathology, length of stay during acute admission, average wait for Surgery and readmission rate prior to surgery. Patients receiving Surgery within 6 weeks, which has been set by our Trust as an acceptable standard. Result(s): Patients with acute presentation (acute cholecystitis, gallstone pancreatitis, cholangitis) 162 (PC19), 80 (IC19), 145 (AC19). Gender Ratio M:F 1:2 for all groups. Average wait to Surgery 93 (PC19), 44 (IC19), 69 (AC19) days. Patients receiving Surgery within 6 weeks 24.7% (PC19), 32.5% (IC19), 51.7% (AC19). Patients who were still awaiting Surgery at The end of each time frame 49% (PC19), 51% (IC19), 48% (AC19). Mean length of surgical stay 1.75 (AC19) days. Conclusion(s): Further changes are required, as guidelines are still not being met, with average wait times significantly above The recommended wait to undergo laparoscopic cholecystectomy.

Comparing Mortality and Morbidity of COVID-19 Omicron Variant vs. Other Variants in a Hemodialysis Population in Qatar

Background: Patients on dialysis are more susceptible to COVID-19 infection, with higher mortality and morbidity. In December 2021 the state of Qatar witnessed a surge in COVID 19 cases solely due to omicron variant. We compare the effect of omicron Vs pre-omicron variants COVID infection on hemodialysis patients in terms of incidence, severity and mortality. Method(s): This is an observational, analytical, retrospective, nationwide study. COVID-19 PCR was the method of diagnosis. During the Omicron wave, Rapid Antigen Test was accepted by Ministry of Health in Qatar as a diagnostic test. Our study followed patients for duration from 3/2020 to 1/2022. All positive results from 1st of December 2021 were assigned to the omicron group as per national genomic surveillance. Cases before that were assigned to the pre-omicron group. Primary outcome was to compare the incidence of omicron infections in haemodialysis patient compared to pre-omicron era. Secondary outcomes were to assess the mortality, ICU admissions, length of stay in ICU and need for ventilatory support in omicron vs pre-omicron phase. Patient demographics and clinical features were collected from a national electronic medical record. Result(s): 274 haemodialysis patients were diagnosed with COVID-19 during the omicron wave (2 months period) vs174 patients in the pre-omicron period (21 months). The incidence in omicron wave was 30.3%, which is significantly higher than preomicron waves of 18.7% (p <0.001). Omicron variant has lower mortality rate 2.4%, compared to other variants grouped together 15.5% (p <0.001). ICU admissions rate during the omicron wave was significantly less than pre-omicron waves (4.9% Vs 26.4% (p <0.001)), and there was less need for ventilatory support (0.01% Vs 0.16% (p <0.001)). ICU length of stay was not significantly different (16.7+/-8 days Vs 14.2 +/-17.5 days (p = 0.34)). Conclusion(s): This is the 1st national study to compare the outcome of omicron vs non-omicron COVID-19 variants infection among hemodialysis patients. The incidence of omicron variant was higher than pre-omicron variants, while mortality and ICU admission were significantly lower in the omicron era compared to pre-omicron era. ICU length of stay was not significantly different.