The Role of Convalescent Plasma and Tocilizumab in the Management of COVID-19 Infection: A Cohort of 110 Patients from a Tertiary Care Hospital in Oman.

AIM: As Coronavirus Disease-2019 (COVID-19) pandemic continues to evolve, the search for safe and effective therapeutic interventions remain essential. METHODS: We conducted a retrospective cohort study on patients hospitalized with laboratory confirmed severe acute respiratory syndrome coronavirus-2 infection, comparing standard of care along with Convalescent Plasma with or without Tocilizumab (CP vs. CPT). RESULTS: A total of 110 patients were enrolled with an overall mean age of 50 ± 16 years. Patients on CPT were more likely to have had acute respiratory distress syndrome (77% vs. 42%; p < 0.001), sepsis (9.7% vs. 0; p = 0.036), chest X-ray abnormalities (71% vs. 44%; p = 0.004), intensive care unit admission (84% vs. 56%; p = 0.001) as well as being on mechanical ventilation (79% vs. 48%; p = 0.001). After CPT treatment, all measured inflammatory markers, except interleukine-6, showed an overall steady decline over time (all p-values <0.05) and the ventilatory parameters showed significant improvement of PaO2/FiO2 ratio from 127 to 188 within 7 days (p < 0.001). Additionally, 52% (32/62) of the patients had favorable outcome, either as improvement of ventilatory parameters or extubation within 14 days of hospitalization. However, mortality rate in those on CPT was higher than those who received CP alone (24% vs. 8.3%; p = 0.041). CONCLUSION: In patients with severe COVID-19 infection, using tocilizumab with convalescent plasma is associated with improvement in inflammatory and ventilatory parameters but no effect on mortality. These findings require validation from randomized clinical trials.

Transplant tourism and invasive fungal infection.

BACKGROUND: Deceased and live-related renal transplants (RTXs) are approved procedures that are performed widely throughout the world. In certain regions, commercial RTX has become popular, driven by financial greed. METHODS: This retrospective, descriptive study was performed at the Royal Hospital from 2013 to 2015. Data were collected from the national kidney transplant registry of Oman. All transplant cases retrieved were divided into two groups: live-related RTX performed in Oman and commercial-unrelated RTX performed abroad. These groups were then divided again into those with and without evidence of fungal infection, either in the wound or renal graft. RESULTS: A total of 198 RTX patients were identified, of whom 162 (81.8%) had undergone a commercial RTX that was done abroad. Invasive fungal infections (IFIs) were diagnosed in 8% of patients who had undergone a commercial RTX; of these patients, 76.9% underwent a nephrectomy and 23.1% continued with a functioning graft. None of the patients with RTXs performed at the Royal Hospital contracted an IFI. The most common fungal isolates were Aspergillus species (including Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, and Aspergillus nigricans), followed by Zygomycetes. However, there was no evidence of fungal infection including Aspergillus outside the graft site. Computed tomography (CT) findings showed infarction of the graft, renal artery thrombosis, aneurysmal dilatation of the external iliac artery, fungal ball, or just the presence of a perigraft collection. Of the total patients with IFIs, 23.1% died due to septic shock and 53.8% were alive and on hemodialysis. The remaining 23.1% who did not undergo nephrectomy demonstrated acceptable graft function. CONCLUSIONS: This is the largest single-center study on commercial RTX reporting the highest number of patients with IFI acquired over a relatively short period of time. Aspergillus spp were the main culprit fungi, with no Candida spp being isolated. A high index of suspicion might be the most reasonable means to reduce the possible very poor outcomes. Improving legal transplant programs and strengthening the associated laws could prevent commercial transplant tourism.

Mode of presentation and progress of childhood diabetes mellitus in the Sultanate of Oman.

We surveyed the clinical presentation, initial management and subsequent course of a prospectively registered cohort of 60 children with insulin-dependent diabetes mellitus (IDDM) diagnosed before age 15 years in the Sultanate of Oman between January 1990 and December 1993. Clinical details from the time of diagnosis were available on all the children. At diagnosis 9 (15 per cent) presented with severe ketoacidosis (DKA) with pH less than 7.1 or plasma bicarbonate less than 10 mmol/l, and 16 (27 per cent) had mild to moderate ketoacidosis with pH 7.1-7.35 or plasma bicarbonate 10-18 mmol/l. During DKA electrolyte disturbances included: hypokalemia (K < 3.5 mmol/l) 25 per cent), hyperkalemia (K > 5.5 mmol/l) (18 per cent) and hyponatremia (Na < 130 mmol/l) (40 per cent). Serum creatinine concentrations were high in 25 per cent of children with DKA. Within the first year of diagnosis, 17 of the 60 children (28 per cent) experienced symptomatic hypoglycaemia, which in six (10 per cent) led to one or more admissions. Re-admission for unstable glycaemic control, excluding acute hypoglycaemia occurred at least once in six children (10 per cent) within 1 year of diagnosis and in 10 (17 per cent) within 2 years. Statural growth velocity (GV) and GVSDS (6.9 +/- 0.85 cm/year and 0.75, respectively) were significantly higher in the group of children with good glycaemic control (HbA1C = 7.9 +/- 0.4 per cent) compared to those children (3.7 +/- 0.44 cm/ year and -1.6, respectively) with bad glycaemic control (HbA1C = 12.5 +/- 1.5 per cent). Insulin-like growth factor-I (IGF-I) concentrations were significantly higher (260 +/- 21 ng/ml) in the group with good glycemic control v. the group with bad control (149 +/- 15 ng/ml). In summary, greater public and medical awareness of the presenting features of diabetes in young children is needed to reduce the frequency of DKA at presentation, and improvement of patient and family education is necessary to reduce the incidence of DKA and hypoglycaemia in children with IDDM.

Epidemiology of childhood insulin-dependent diabetes mellitus in the Sultanate of Oman.

This study assessed the updated incidence of IDDM in 0 to 14-year-old children in the Sultanate of Oman, which is located in the southern-eastern part of the Arabian peninsula. Incident cases were recorded prospectively from January 1993 to the end of December 1994. Incidence rates were standardized on the basis of the National Population Census. The degree of ascertainment was above 96% from the primary source. During two full calendar years, 31 new cases of IDDM in children were diagnosed in Oman (10 health regions). The standardized incidence rates were 2.45 and 2.62/100,000 per year during 1993 and 1994, respectively. The sex-specific rates among males and females were 3.23 and 1.99/100,000, respectively, in 1993 and 2.91 and 1.95/100,000, respectively in 1994. The age-specific incidence rates during the 2 years were higher in the 10-14 age group (3.69 and 4.22/100,000, respectively) vs those in the 5-9 age group (2.32 and 2.79/100,000, respectively) and 0.4 age group (1.54 and 0.97/100,000 respectively). The number of new cases/month was markedly higher in the relatively cooler months (September through March) of the year. The incidence rate of IDDM in children under the age of 15 years in Oman was lower than the reported incidence in Kuwait (another gulf country located north-west to Oman) which might reflect the north-south gradient reported in several previous studies. However this incidence rate was higher than those reported for many countries in Asia.

BCG vaccination as a cause of osteomyelitis and subcutaneous abscess.

Ten patients with osteomyelitis and three with a subcutaneous abscess, all caused by BCG vaccination, are described. All patients were less than 3 years old and had as newborns been vaccinated intracutaneously in the left gluteal or hip area. Pain, limping, or a slightly tender subcutaneous induration were the primary symptoms. The sites of predilection of osteomyelitis were the metaphysis or epiphysis of the femur, these being affected in five out of 10 cases. All three subcutaneous abscesses were in the thoracic region. Prolonged (up to 30 months) combined tuberculostatic medication, in addition to appropriate surgical procedures, resulted in healing, but two cases of arthritis and two of secondary abscesses developed. In addition, sequestrectomy and two late operations, for coxa valga and hip subluxation, were deemed to be necessary. Radiographs showed femoral overgrowth of up to 1 cm in two symptomless patients three to seven years after the first discharge. We conclude that the benefits of BCG vaccination should be weighed against the risk of complications, especially in countries with a low incidence of tuberculosis.

An epidemic due to sulphonamide-resistant group A meningococci in the Helsinki area (Finland). Epidemiological and clinical observations.

An epidemic due to sulphonamide-resistant group A meningococci started in Finland in January 1973. By the end of 1974 the number of cases exceeded 1300. This report describes epidemiological and clinical observations in 370 patients treated in Helsinki 1973-1974. The incidence was about 65 per 100 000 per year in children under 7 years of age and about 10 per 100 000 in adults. More than one case occurred in 3.8% of the families and in 36% of the lodging-houses of the lowest social group. The fatality rate of patients treated in hospital was 4.1%. Persistent neurological damage was noticed in 4.6%.