Potential drug-drug interactions in a multi-center study of death cases of COVID-19: The significance of appropriate drug choice.

OBJECTIVES: The prevalence, types, severity, risk ratings, and common pairs of involved drugs, and the most important potential drug-drug interactions (pDDIs) in coronavirus disease 2019 (-COVID-19) deceased cases were evaluated. MATERIALS AND METHODS: We reviewed the medical records of 157 confirmed COVID-19 deceased cases hospitalized in 27 province-wide hospitals. Patients' demographics and clinical data (including comorbidities, vital signs, length of in-hospital survival, electrocardiograms (ECGs), medications, and lab test results) were extracted. The online Lexi-interact database and Stockley's drug interactions reference were used to detect pDDIs retrospectively. The QTc interval and total Tisdale risk score were also calculated. Descriptive analysis, analysis of variance, Fisher exact test, and multivariate analysis were conducted for data analysis. RESULTS: Of 157 study cases, 63% were male, had a mean age of 68 years, and 55.7% had one or more underlying diseases. All patients had polypharmacy, with 69.2% having ≥ 15 drugs/day. We detected 2,416 pDDIs in patients' records, of which 658 (27.2%) were interactions with COVID drugs. Lopinavir/ritonavir among -COVID drugs and fentanyl among non-COVID drugs were commonly involved in the interactions. pDDIs was significantly higher in the polypharmacy group of ≥ 15 medications (p < 0.001). A majority (83%) had received drug(s) with the QTc prolongation effect, of whom 67% had actual QTc prolongations in their ECGs. The regression analysis showed that by increasing 6.7% in polypharmacy, one day increase in-hospital survival can be expected. Moreover, an increase of 2.3% in white blood cells or 10.5% in serum potassium level decreased in-hospital survival by 1%. CONCLUSION: The findings underscored the importance of careful drug choice, especially in the hectic search for early treatments in pandemics of novel diseases. Close monitoring of patients' drug choice is warranted for reducing pDDIs and their adverse effects in any new disease outbreak.

Effect of guided imagery on anxiety, muscle pain, and vital signs in patients with COVID-19: A randomized controlled trial.

BACKGROUND: COVID-19 can lead to anxiety due to its high mortality rate. Patients with COVID-19 may suffer from muscle pain. This study aimed to determine the effect of guided imagery on anxiety, muscle pain, and vital signs in patients with COVID-19. METHODS: 110 patients with COVID-19 were recruited and randomly assigned to two control and intervention groups. Data were collected using the Spielberger Anxiety Inventory, the McGill Pain Questionnaire, and the Visual Analogue Scale. The intervention group received ten training sessions of guided imagery. RESULTS: The results indicated a significant difference in the mean scores of state (t = -3.829, p < .001), trait anxiety (t = -2.946, p = .004), pain quality (t = -4.223, p < .001), pain intensity (t = -3.068, p = .003), and heart rate, systolic blood pressure, and oxygen saturation (p < .001) between the two groups after the intervention. CONCLUSIONS: Guided imagery as a cost-effective method of complementary medicine is recommended to manage anxiety and pain in patients with COVID-19.

Evaluation of epidemiology, clinical features, prognosis, diagnosis and treatment outcomes of patients with COVID-19 in West Azerbaijan Province.

BACKGROUND: COVID-19 is considered a widespread concern in global public health. Diagnoses of COVID-19 in some cases are necessary because of severe prognosis. In this study, epidemiologies, clinical and demographic characteristics of patients with COVID-19 were studied in Taleghani Hospital, Urmia, Iran. METHODS: This descriptive-analytical cross-sectional study was carried out on 215 patients with COVID-19 during March and April 2020. Approved COVID-19 case was considered as a person with a positive respiratory sample performed by at least one of two RT-PCR methods or genetic sequencing. ANOVA repeated measure, independent t-test and logistic regression were done. A P < .05 was considered significant. RESULTS: The mean age of patients was 50.93 ± 17.92 years. Regarding gender, there were 91 females (42.3%) and 124 males (57.7%). The mean hospital stay, the temperature at admission, and onset of symptoms were 4.91 ± 3.68 days, 37.40 ± 0.96°C and 5.88 ± 4.80 days, respectively. Close contact with suspected people was found in 10.2% of patients. Additionally, 44 patients (20.5%) were smokers. Shortness of breath and cough were found in 62.8% and 49.3% of patients. Diabetes mellitus and hypertension were the most common comorbidities of patients. Regarding lung involvement, 33 patients (33%) were normal, most of the patients (n = 71) had 5%-25% involvement in their lung and a minority of patients (n = 13) had a severe condition of 50%-75% lung involvement. The association between smoking and mortality was tested using chi-square showing no significant difference (X2 :2.959, P = .085). There was no significant difference between AST, ALT, ALP, total, direct Bilirubin, lung involvement and suffering from fever (P > .05). High Spo2 can increase the chance of recovery by 24% with each unit reduction. Kidney involvement increases the chance of death by about 80% (95% CI: 0.104-0.013). The odds ratio of spo2 for recovery of COVID-19 was 1.24 (95% CI: 1.014-1.528; P = .037). Kaletra with odds ratio of 31.960 had the most highest effect on recovery following COVID-19 (P = .043). CONCLUSION: COVID-19 involves different organs of the body with different severity. In the meantime, smoking was not a risk factor for the virus or associated with severe manifestations of the disease. Patients with high creatinine and CPK, pulmonary involvement above 25%, and hypoxemia had a higher mortality rate. Increase of Spo2 by 1% can improve the patients by 24%. The results indicated that Kaletra had the most highest effect on improvement following COVID-19.

Correction to: The use of intravenous immunoglobulin gamma for the treatment of severe coronavirus disease 2019: a randomized placebo-controlled double-blind clinical trial.

An amendment to this paper has been published and can be accessed via the original article.

The use of intravenous immunoglobulin gamma for the treatment of severe coronavirus disease 2019: a randomized placebo-controlled double-blind clinical trial.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has infected people in many countries worldwide. Discovering an effective treatment for this disease, particularly in severe cases, has become the subject of intense scientific investigation. Therefore, the objective of this study was to evaluate the efficacy of intravenous immunoglobulin (IVIg) in patients with severe COVID-19 infection. METHODS: This study was conducted as a randomized placebo-controlled double-blind clinical trial. Fifty-nine patients with severe COVID-19 infection who did not respond to initial treatments were randomly assigned into two groups. One group received IVIg (human)-four vials daily for 3 days (in addition to initial treatment), while the other group received a placebo. Patients' demographic, clinical, and select laboratory test results, as well as the occurrence of in-hospital mortality, were recorded. RESULTS: Among total study subjects, 30 patients received IVIg and 29 patients received a placebo. Demographics, clinical characteristics, and laboratory tests were not statistically different (P > 0.05) between the two groups. The in-hospital mortality rate was significantly lower in the IVIg group compared to the control group (6 [20.0%] vs. 14 [48.3%], respectively; P = 0.022). Multivariate regression analysis demonstrated that administration of IVIg did indeed have a significant impact on mortality rate (aOR = 0.003 [95% CI: 0.001-0.815]; P = 0.042). CONCLUSIONS: Our study demonstrated that the administration of IVIg in patients with severe COVID-19 infection who did not respond to initial treatment could improve their clinical outcome and significantly reduce mortality rate. Further multicenter studies with larger sample sizes are nonetheless required to confirm the appropriateness of this medication as a standard treatment. TRIAL REGISTRATION: A study protocol was registered at the Iranian Registry of Clinical Trials ( www.IRCT.ir ), number IRCT20200501047259N1 . It was registered retrospectively on May 17th, 2020.

Clinical and radiological characteristics of pediatric patients with COVID-19: focus on imaging findings.

PURPOSE: CT imaging has been a detrimental tool in the diagnosis of COVID-19, but it has not been studied thoroughly in pediatric patients and its role in diagnosing COVID-19. METHODS: 27 pediatric patients with COVID-19 pneumonia were included. CT examination and molecular assay tests were performed from all participants. A standard checklist was utilized to extract information, and two radiologists separately reviewed the CT images. RESULTS: The mean age of patients was 4.7 ± 4.16 (mean ± SD) years. Seventeen patients were female, and ten were male. The most common imaging finding was ground-glass opacities followed by consolidations. Seven patients had a single area of involvement, five patients had multiple areas of involvement, and four patients had diffuse involvement. The sensitivity of CT imaging in diagnosing infections was 66.67%. Also, some uncommon imaging findings were seen, such as a tree-in-bud and lung collapse. CONCLUSION: CT imaging shows less involvement in pediatric compared to adult patients, due to pediatric patients having a milder form of the disease. CT imaging also has a lower sensitivity in detecting abnormal lungs compared to adult patients. The most common imaging findings are ground-glass opacities and consolidations, but other non-common imaging findings also exist.

A rare case of brucellosis with dermatomal pattern of cutaneous manifestation.

Brucellosis is a systemic disease which may involve any organ or system of the body, and is listed in the differential diagnosis of many diseases. In spite of described cutaneous involvements, skin manifestations are not common in brucellosis, particularly papulonodular lesions with dermatomal patterns that may overlap with dermatomal skin lesions. This may prevent correct diagnosis and treatment in practice, harming patients' health and leading to financial costs to the health system and patient. In this case, at first, due to left thigh and buttock skin lesions and dermatomal pattern, the patient was diagnosed with Herpes zoster infection. After medical treatment and no improvement of lesions, the patient was referred to the infectious clinic with low back pain; magnetic resonance imaging (ordered by a neurosurgeon) suggested infectious spondylodiscitis. At the infectious ward, brucellosis spondylitis was diagnosed and a biopsy was taken from dermatomal lesions. The patient's follow-up after 1, 2, and 3 months revealed that treatment of brucellosis had led to healing of lesions. Surprisingly, the histopathological assessment of the biopsy suggested psoriasis vulgaris. This was a rare case of manifestation of cutaneous brucellosis which could not even be diagnosed by histopathological assessment.

Neutrophil-to-lymphocyte ratio in patients with gram-negative sepsis admitted to intensive care unit.

INTRODUCTION: Several studies have investigated the role of Neutrophil to Lymphocyte Ratio (N/L ratio) in the early diagnosis of infection, which had different results. We assessed this ratio in early diagnosis of Gram-negative sepsis admitted to ICU. METHODS: This cross sectional study was approved by ethics committee of Urmia University of Medical Sciences and conducted during 2015. All patients with gram negative sepsis admitted to general intensive care unit (GICU) were enrolled. Demographic characteristics, APACHE II score, duration of mechanical ventilation and ICU length of stay, average neutrophil, lymphocyte count, and their ratio on the first, second and third day of hospitalization, and mortality were recorded. P < 0.05 was significant. RESULTS: One hundred and thirty nine patients were studied during one year with mean age 68.29 ±17. 4 years. 136 patients received mechanical ventilation with mean 13.85 ±2.07 days. The mean white blood cells count on the first day of hospitalization was 11776.04±5789.60,and on the second and third days was 12446±2101.16 and 13241.01 ± 7077.17, respectively. The ratio of neutrophil to lymphocyte on the day of hospitalization was 11.38±1.02. This ratio on the second and third days was 11.98±0.99 and 12.94±1.3, respectively. Furthermore, 46.8% of patients died. According to the T-test, significant difference was seen between two groups in term of APACHEII score, count of neutrophil, WBC and N/L ratio on the second and third days (p < 0.05). CONCLUSION: Blood cell analysis and N/L ratio can be used as a predictor for severity of gram negative sepsis along with other diagnostic procedures.

Postsplenectomy Kawasaki disease in a 17-year-old male.

Kawasaki disease (KD) is characterized with an acute systemic vasculitis of the medium- and small-sized vessels. This disease mainly involves children within the age of 6 months to 5 years and it is often self-limited and patients seem to recover well; however, it may lead to devastating and fatal cardiovascular complications such as coronary artery aneurysm. Thus, early diagnosis and appropriate management of this disease have a significant effect on improving the prognosis and preventing its serious complications. Adult-onset KD (AKD) is rare and often misdiagnosed. Here we report a rare case of KD that occurred in a 17-year-old young adult who presented 4 weeks post splenectomy, with clinical signs and symptoms consistent with AKD. This may potentially highlight the association of AKD with infectious etiologies.

Evaluation of 30 cases of mucormycosis at a university hospital in Iran.

Mucormycosis is a deadly invasive fungal infection and mainly affects immunocompromised patients. To investigate the clinical features of patients who developed mucormycosis and to determine the parameters, which influenced the outcome following mycotic infection. The current investigation retrospectively evaluated the demographic characteristics, clinical features, therapeutic data, as well as the outcomes of treatment in all cases of proven and probable mucormycosis diagnosed from 2002 until 2016 in our hospital. A total of thirty cases were recorded. Rhizopus spp. was the predominant pathogen among the identified Mucorales (26.7%). Diabetes mellitus (46.7%) and haematological malignancy (40%), were the most common underlying diseases. With regard to predisposing factors, neutropenia (43.3%) and chemotherapy (40%) were the leading concomitant parameters. The most frequent sites of infection were lung (30%) and sinus (26.7%), whereas disseminated infection was also found in nine of 30 patients (30%). Neutropenia remained the only independent factor associated with mortality (Relative Risk=3.557, 95% CI=1.365-9.271, P=.009). Diagnostic delay -either due to delayed presentation of patients to our centre or insufficient awareness about invasive fungal infection among our clinicians- is a likely explanation for such a high mortality rate in our series.