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Background: The global spread of the novel strain of coronavirus referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in the continuous rise in the hospitalization of people suffering from COVID-19 in various parts of the world. The predominant symptoms experienced by patients diagnosed with SARS-CoV-2 infection include pneumonia and acute respiratory distress syndrome (ARDS). These symptoms have contributed to the high mortality rate of COVID-19 patients across the globe. Recent studies have indicated that nebulized unfractionated heparin (UFH) can be employed in the treatment of pneumonia and acute respiratory distress syndrome (ARDS) in hospitalized patients who have been diagnosed with SARS-CoV-2 infection. Case description: The case study for this investigation was a 37-year-old Saudi woman who had muscular dystrophy, bronchial asthma, and diabetes mellitus. This hospitalized patient who was a wheelchair bound was admitted to the intensive care unit (ICU) due to the onset of severe COVID-19 related pneumonia and ARDS. The patient was intubated and placed on high mechanical ventilation support with protective lung strategy (low tidal volume and high PEEP level), prone positioning, administering inhaled nitric oxide therapy, and the intravenous infusion methylprednisolone together with antiviral agents and empiric antibiotics for seven days. Despite the administration of this maximal therapy, she continued to have refractory hypoxemia and severe ARDS. As a result, a high dose of UFH was administered to the patient through nebulization. After administering nine different doses of nebulized UFH, the patient’s oxygenation and inflammatory markers have remarkably improved, then she had a very smooth course and successfully weaned off mechanical ventilation. Conclusion: This treatment strategy resulted in a significant improvement in the P/F ratio, a remarkable reduction in the bilateral lung infiltrates and inflammatory markers and eventually weaning of mechanical ventilation in the COVID-19 patient. This case suggests that nebulized UFH has a strong scientific and biological basis to test its use as a therapy for COVID-19 pneumonia and ARDS as it may offer huge clinical benefit across the time course of the disease as well may prevent progression of infection If administered early at the onset of symptoms, and may finally prevent the needs for mechanical ventilation. Learning points: Randomized controlled trials should be carried out to investigate the clinical impacts of nebulized UFH in both prevention and treatment of COVID-19 pneumonia/AERDS.

This study aimed to explore the association of turnover-attachment motive with socio-demographic data among Saudi and foreign nurses in a hospital in the Eastern Province of Saudi Arabia.A cross-sectional correlation study was conducted among n = 180 registered Saudi and foreign nurses working at a private tertiary hospital in the Eastern Province, Saudi Arabia. The turnover-attachment motive survey was used to evaluate the eight motivational forces. Data were analysed using JASP version 16 statistical software and Orange 3 version 3.26.0. The data were subjected to correlation analysis and multiple linear regression.Only 8% of participants were identified with a high intention to leave driven by alternative, behavioural, normative and constitutive forces. Younger healthcare workers tend to have higher intentions to quit the job; the 29-33 age group has a statistically significant negative effect, increasing intention to leave. It was found that those with 5-6 years of clinical experience at Dr. Sulaiman Al Habib Hospital, Al Khobar and no experience abroad had statistically significantly lower intention to leave.This study presented the factors influencing nursing staff to stay or leave work in a hospital in the Eastern Province of Saudi Arabia that can be a basis for reviewing existing policies and procedures to improve nurses' working conditions.

Background: Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was first discovered in December 2019 and turned to be pandemic in early March 2020. We aimed to describe the dominant ABO group and outcomes of critically ill patients (respiratory failure requiring mechanical ventilation and mortality) in a Saudi Arabian setting. Methods: We conducted an observational, analytic cross-sectional, retrospective study in a tertiary care hospital. Around 90 candidates tested positive for COVID-19 were enrolled in this study during admission to critical care unit between May 2020 and September 2020. Blood group was detected in all patients included in the study during admission to critical care unit. Results: In this study, data of 90 patients with COVID-19 admitted to critical care unit were collected. Some prevalent medical conditions were collected, in which hypertension (64.2%) and diabetes mellitus (58.9%) were the most reported comorbidities among patients and there was no significant difference between groups. Most of the sample had blood group of O (45.6%), while the least group was AB (5.6%). Patients with blood group of A/AB showed the highest mortality vs. group O/B (32% vs. 18.5%) with significant P value of 0.001. Patients of groups A/AB had higher risk for intubation than O/B groups (52.0% and 49.2%, respectively; confidence interval of 0.44 - 2.8 with insignificant P value of 0.055). Length of stay in critical care unit was significantly higher in group A/AB with a mean course of 18.20 days in comparison to group O/B with a mean course of 12.63 days (P = 0.033). Conclusion: Our data indicate that critically ill patients with COVID-19 with blood group A/AB are at increased risk of mortality and length of stay in critical care unit, with insignificant requirement of mechanical ventilation when compared with patients with blood group O/B. Future larger studies are needed to validate and understand the underlying mechanisms. J Hematol. 2021;10(2):64-70 doi: https://doi.org/10.14740/jh821

Background: COVID-19 is a pandemic disease that has no definite treatment or preventive medication until late 2020 when vaccines were developed. Vaccines are a very useful new tool against COVID-19 that stimulate the immune system after recognition of viruses or their parts. Complications post vaccination could happen and they depend on the types, vaccine mechanism of action as well as some other patients' factors. Case report: We are reporting a 39 years old lady who is known as allergic to a strawberry and kiwi, otherwise medically free. She presented to the outpatient unit with a ten-days history of palms of the hands and soles of the feet itchiness that is associated with occasional redness after receiving the first dose of COVID-19 vaccination. There were no skin rashes or pruritis at any other sites. The patient was treated conservatively by antihistamine and the symptoms gradually resolved within five days. Conclusion: Allergic reaction is one of the expected complications post any COVID-19 or non-COVID-19 vaccination. Although the type, distributions and severity of allergic reactions are variable from person to another, yet isolated itching to palms and soles could be a rare side effect post first dose of COVID-19 vaccination (Pfizer-BioNTech) which is worth reporting. This presentation could be a type of allergic reaction which may require holding further doses, debate is there for further case reporting, research or evaluation.Learning points: • Isolated itching to palms and soles could be one of the side effects of COVID-19 vaccination (Pfizer-BioNTech) which is worth reporting.

Sickle cell disease (SCD) is a group of hereditary diseases, inherited as autosomal recessive disorder, which causes mutation in the β-globin gene. As a result, there is a change in the sixth amino acid from glutamic acid to valine. The affected red blood cell is then prone to polymerization and sickling crisis under conditions of low oxygen tension. One of the major causes of mortality in SCD is acute chest syndrome (ACS). On the other hand, coronavirus disease 2019 (COVID-19) is a pandemic disease that carries significant mortality and morbidity worldwide with unknown outcomes in the affected SCD population. This study was created for that reason.We report a case series of ten SCD patients who were affected by COVID-19 and required admission between May 1, 2020, and October 30, 2020, at a tertiary care hospital in Dhahran, eastern region of Saudi Arabia. Historical data were obtained retrospectively from electronic records. MS Excel was used for data entry, and SPSS version 23 was used for data analysis.The mean age of the patients involved in the study was 32 years, and the mean duration of symptoms was 5.7 days. None required critical care admission, and there was no mortality. All patients were discharged from hospital in good condition with no requirement of home oxygen.Although we expected a fatal outcome of SCD patients affected by COVID-19 infection, our limited case series showed favorable disease behavior and outcome, with a suspicion of underlying unclear protective mechanism from serious complications. However, further studies are required to better understand COVID-19 behavior in SCD patients.

Introduction Crohn's disease (CD) is an idiopathic inflammatory disorder of unknown etiology with genetic, immunologic, and environmental influences. Infliximab is a treatment modality for fistulated Crohn's disease. Infliximab induced hemolysis is rare and very few cases reported before in Ulcerative colitis (UC) but not in Crohn's disease. Case presentation We are reporting a 63 years old gentleman who was diagnosed as Crohn's disease and started on Tumor necrosis factor Inhibitor (TNF) -α i.e. (infliximab - Remsima) infusion. The course was complicated by Coomb's negative hemolytic anemia which is suggestive of non-immune drug induced hemolysis. Our patient was treated with steroid and conservative measures. Upon following up, his hemoglobin level as well as all hemolytic markers showed dramatic improvement. Adalimumab was used to treat this patient as an alternative choice without relapse of hemolysis. Clinical discussion Drug induced Hemolysis is not a well-known complication post receiving Tumor necrosis factor Inhibitor (TNF) -α infusion in patients with Crohn's disease. Coombs negative hemolysis keeps in favor of non-immune drug induced rather than other differentials in our case scenario. Conclusion Although cross-reactivity is expected between one biological agent to another, in our case the use of Adalimumab as alternative choice post Tumor necrosis factor Inhibitor (TNF) -α (Remsima infliximab) induced hemolysis did not cause hemolysis or any type of reaction., Highlights • Crohn's disease is one of the Inflammatory bowel diseases (IBD) that can affect any part of gastrointestinal tract as well as extraintestinal organs. • Tumor necrosis factor Inhibitor (TNF) -α i.e. (infliximab - Remsima) is a treatment modality for fistulated Crohn's disease. • Drug induced Hemolysis is one of the complications that is not well-known post receiving Tumor necrosis factor Inhibitor (TNF) -α (Remsima) infusion.

Essential thrombocythemia is one of the famous diseases under the category of myeloproliferative disorder. It is an end result of a genetic mutation of one or more of the most frequent oncogenes such as Janos kinase 2 (JAK2), MPL proto-oncogene, thrombopoietin receptor (MPL), and calreticulin (CALR). However, negative genetic markers, so-called (triple negative disease), can happen in the presence of other uncommon types of mutation. TET2 (ten-eleven translocation 2) positive as isolated genetic marker in triple negative essential thrombocythemia is uncommon genetic presentation. For that, we are reporting a 22-year-old lady who presented with a feature of dyspepsia and accidentally found to have persistently high platelet count, even after treating her mild iron deficiency anemia with no other secondary causes. Further investigations and bone marrow biopsy supported the diagnosis of isolated TET2 positive in triple negative essential thrombocythemia. We treated her conservatively with good hydration and low dose of aspirin. In conclusion, isolated TET2 positive in triple negative essential thrombocythemia at presentation is uncommon with no clear management or risk stratification guideline. However, it is hypothesized that TET2 mutation precedes JAK2; therefore, the detection of isolated TET2 in a triple negative essential thrombocythemia case should be closely followed for clonal evolution in long term. Further study and guidelines required in this area.

Background Thrombotic thrombocytopenic purpura (TTP) is an uncommon haematological disease which can occur at any age and may present with COVID-19. This case describes a COVID-19 complication associated with a presentation resembling TTP. Case description A 51-year-old man who had received a kidney transplant and was on immunosuppressant medication, was admitted to a critical care unit with severe COVID-19 pneumonia/acute respiratory distress syndrome (ARDS) which required intubation, mechanical ventilation and inotropic support. The course was complicated by the classic pentad of thrombocytopenia, intravascular haemolysis, acute kidney injury, neurological symptoms and fever, which prompted the diagnosis of probable TTP. After five sessions of therapeutic plasma exchange, the patient's general status improved, he was weaned off mechanical ventilation and his renal panel and haemolytic markers normalized. Conclusion TTP is a life-threatening condition which requires urgent management with therapeutic plasma exchange. This case highlights some possible complications of COVID-19 generally and in immunocompromised patients specifically. The potential role of plasma exchange in COVID-19 patients without a positive diagnosis of TTP (the so-called 'TTP resembling presentation') is an area of further research. Learning points COVID-19 can manifest as a picture of thrombotic thrombocytopenic purpura (TTP) which requires therapeutic plasma exchange as in other cases of TTP.Further research is required on the use of therapeutic plasma exchange in severe COVID-19 with cytokine storm.

BACKGROUND: Sickle cell disease is a genetic condition frequently found in Africa and the Arabian Peninsula. Uncommon complications include subgaleal haematoma (soft head syndrome) and periorbital oedema. CASE PRESENTATION: A 17-year-old male patient presented with body aches and progressive right parieto-temporal and frontal head swelling. Physical examination revealed puffiness of the right eye that progressed rapidly to reddish periorbital oedema sparing the extraocular muscle and pupil response to light. CT and MRI of the brain suggested multiple subgaleal haematomas (soft head syndrome) and right periorbital oedema. CONCLUSION: Subgaleal haematoma (soft head syndrome) and periorbital oedema are uncommon complications of sickle cell disease. Management is conservative rather than surgical. LEARNING POINTS: Subgaleal haematoma concurrently with periorbital oedema is a rare presentation of sickle cell disease. There are no guidelines on treatment, but the conditions in our patient resolved with conservative management.