Macrolides in critically ill patients with Middle East Respiratory Syndrome.

OBJECTIVES: Macrolides have been reported to be associated with improved outcomes in patients with viral pneumonia related to influenza and other viruses, possibly because of their immune-modulatory effects. Macrolides have frequently been used in patients with Middle East Respiratory Syndrome (MERS). This study investigated the association of macrolides with 90-day mortality and MERS coronavirus (CoV) RNA clearance in critically ill patients with MERS. METHODS: This retrospective analysis of a multicenter cohort database included 14 tertiary-care hospitals in five cities in Saudi Arabia. Multivariate logistic-regression analysis was used to determine the association of macrolide therapy with 90-day mortality, and the Cox-proportional hazard model to determine the association of macrolide therapy with MERS-CoV RNA clearance. RESULTS: Of 349 critically ill MERS patients, 136 (39%) received macrolide therapy. Azithromycin was most commonly used (97/136; 71.3%). Macrolide therapy was commonly started before the patient arrived in the intensive care unit (ICU) (51/136; 37.5%), or on day1 in ICU (53/136; 39%). On admission to ICU, the baseline characteristics of patients who received and did not receive macrolides were similar, including demographic data and sequential organ failure assessment score. However, patients who received macrolides were more likely to be admitted with community-acquired MERS (P=0.02). Macrolide therapy was not independently associated with a significant difference in 90-day mortality (adjusted odds ratio [OR]: 0.84; 95% confidence interval [CI] :0.47-1.51; P=0.56) or MERS-CoV RNA clearance (adjusted HR: 0.88; 95% CI:0.47-1.64; P=0.68). CONCLUSIONS: These findings indicate that macrolide therapy is not associated with a reduction in 90-day mortality or improvement in MERS-CoV RNA clearance.

Surgical resection of type III juvenile angiofibroma without preoperative embolization.

OBJECTIVES/HYPOTHESIS: To evaluate the outcome of surgical resection of type III juvenile angiofibroma without preoperative embolizationo in 20 young male patients. PATIENTS AND METHODS: Twenty young male patients with type III JAF (based on Fisch classification by CT/MRI or both), were operated on by endoscopic-assisted midfacial degloving approach without preoperative embolization. The surgical technique is described in details. RESULTS: Apart from a case developed cerebrospinal fluid rhinorrhea (CSF) intraoperatively there were neither major operative nor postoperative complications. CSF leak was repaired through the same approach successfully in the same set. Eighteen patients had complete tumor clearance with no residual or recurrence during the follow up period which ranged from 6 months to 10 years. Recurrence was detected early by endoscopic examination in two cases (3 and 8 months postoperatively) and confirmed by CT and MRI. Endoscopic transnasal removal of the recurrent JAF was done successfully under local anesthesia in the first patient and under general anesthesia in the second with no recurrence during the follow up period. CONCLUSIONS: Surgical resection of stage III JAF without embolization through endoscopic assisted midfacial degloving approach can be used as an adequate surgical technique with acceptable intraoperative blood loss and low rate of recurrence.