Improving management of hospitalised patients with COVID-19: algorithms and tools for implementation and measurement.

BACKGROUND: The COVID-19 pandemic represents an unprecedented challenge to healthcare systems and nations across the world. Particularly challenging are the lack of agreed-upon management guidelines and variations in practice. Our hospital is a large, secondary-care government hospital in Kuwait, which has increased its capacity by approximately 28% to manage the care of patients with COVID-19. The surge in capacity has necessitated the redeployment of staff who are not well-trained to manage such conditions. There was a great need to develop a tool to help redeployed staff in decision-making for patients with COVID-19, a tool which could also be used for training. METHODS: Based on the best available clinical knowledge and best practices, an eight member multidisciplinary group of clinical and quality experts undertook the development of a clinical algorithm-based toolkit to guide training and practice for the management of patients with COVID-19. The team followed Horabin and Lewis' seven-step approach in developing the algorithms and a five-step method in writing them. Moreover, we applied Rosenfeld et al's five points to each algorithm. RESULTS: A set of seven clinical algorithms and one illustrative layout diagram were developed. The algorithms were augmented with documentation forms, data-collection online forms and spreadsheets and an indicators' reference sheet to guide implementation and performance measurement. The final version underwent several revisions and amendments prior to approval. CONCLUSIONS: A large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly, algorithm-based toolkit for the management of patients with COVID-19. This toolkit can be used for training and decision-making to improve the quality of care provided to patients with COVID-19.

Clinical significance of elevated alpha-foetoprotein (AFP) in patients with chronic hepatitis C without hepatocellular carcinoma in upper EGYPT.

BACKGROUND AND STUDY AIMS: Egypt has the highest prevalence of hepatitis C in the world. Alpha-foetoprotein (AFP) is important in the diagnosis of hepatocellular carcinoma (HCC), but elevated AFP levels have also been observed in chronic hepatitis C (CHC) without HCC. We evaluated the clinical correlation between elevated AFP levels and CHC. We analysed data from a population-based cohort of patients with hepatitis C virus (HCV) infection to assess the prevalence of elevated serum AFP, to determine its association with clinical and virologic parameters and with clinical outcomes. PATIENTS AND METHODS: From December 2009 to April 2011, 121 patients with no evidence of HCC with regular abdominal ultrasound or other imaging studies (multislice computed tomography (MSCT) or magnetic resonance imaging (MRI)) were controlled by a chart review. RESULTS: The prevalence of elevated AFP ≥10ngml(-1) was 11.6%. Univariate analysis revealed that fibrosis stage III/IV, alanine aminotransferase (ALT) more than 45IUl(-1) and platelet count less than 150×10(9) l(-1) were significantly associated with elevated AFP. Multivariate analysis revealed that the independent variable associated with elevated serum AFP was fibrosis stage III/IV, p=0.015. Multivariate analysis also revealed that AST>45IUl(-1) and AFP ≥10 ngml(-1) were associated with advanced fibrosis using a cut-off AFP value >10 ngml(-1). The sensitivity and specificity of diagnosing fibrosis score III/IV were 26.1% and 97.3%, respectively. CONCLUSIONS: Elevated AFP levels were observed in 11.65% of patients with CHC. Elevated AFP levels correlated positively with fibrosis stage III/IV; ALT elevation, thrombocytopenia and AFP ≥10 ngml(-1) were associated with advanced fibrosis.

Alpha(2)-blocker helps to avoid systemic to pulmonary shunt in a prostaglandin dependent infant with critical pulmonary valve stenosis.

A 27 days old newborn with critical pulmonary valve stenosis remained prostaglandin (PGE(1)) dependent for 2 weeks after successful balloon valvuloplasty. Only the introduction of Phentolamine in his medication regimen, allowed PGE(1) to be weaned off within days of this therapy. The medication was continued for 4 days and replaced by angiotensin converting enzyme inhibitor (Captopril). Few weeks after the discharge, the patient remained clinically stable with acceptable saturation.