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1.
Liver Transpl ; 27(10): 1479-1489, 2021 10.
Article in English | MEDLINE | ID: covidwho-1487507

ABSTRACT

Cirrhosis has a significant and growing impact on public health and patient-reported outcomes (PROs). The increasing burden of cirrhosis has led to an emphasis on the quality of care with the goal of improving overall outcomes in this high-risk population. Existing evidence has shown the significant gaps in quality across process measures (eg, hepatocellular carcinoma screening), highlighting the need for consistent measurement and interventions to address the gaps in quality care. This multistep process forms the quality continuum, and it depends on clearly defined process measures, real-time quality measurement, and generalizable evaluative methods. Herein we review the current state of quality care in cirrhosis across the continuum with a focus on process measurement methodologies, developments in PRO evaluation on quality assessment, practical examples of quality improvement initiatives, and the recent emphasis placed on the value of primary prevention.


Subject(s)
Liver Transplantation , Quality Improvement , Humans , Liver Cirrhosis/diagnosis , Liver Cirrhosis/therapy , Patient Reported Outcome Measures , Quality of Health Care
2.
Endocrinol Metab (Seoul) ; 36(4): 800-809, 2021 08.
Article in English | MEDLINE | ID: covidwho-1367944

ABSTRACT

BACKGROUND: Based on recent evidence on the importance of the presence of diabetes mellitus (DM) and fibrosis-4 (FIB-4) index in coronavirus disease 2019 (COVID-19) mortality, we analyzed whether these factors could additively predict such mortality. METHODS: This multicenter observational study included 1,019 adult inpatients admitted to university hospitals in Daegu. The demographic and laboratory findings, mortality, prevalence of severe disease, and duration of quarantine were compared between patients with and without DM and/or a high FIB-4 index. The mortality risk and corresponding hazard ratio (HR) were analyzed using the Kaplan-Meier method and Cox proportional hazard models. RESULTS: The patients with DM (n=217) exhibited significantly higher FIB-4 index and mortality compared to those without DM. Although DM (HR, 2.66; 95% confidence interval [CI], 1.63 to 4.33) and a high FIB-4 index (HR, 4.20; 95% CI, 2.21 to 7.99) were separately identified as risk factors for COVID-19 mortality, the patients with both DM and high FIB-4 index had a significantly higher mortality (HR, 9.54; 95% CI, 4.11 to 22.15). Higher FIB-4 indices were associated with higher mortality regardless of DM. A high FIB-4 index with DM was more significantly associated with a severe clinical course with mortality (odds ratio, 11.24; 95% CI, 5.90 to 21.41) than a low FIB-4 index without DM, followed by a high FIB-4 index alone and DM alone. The duration of quarantine and hospital stay also tended to be longer in those with both DM and high FIB-4 index. CONCLUSION: Both DM and high FIB-4 index are independent and additive risk factors for COVID-19 mortality.


Subject(s)
COVID-19/diagnosis , COVID-19/mortality , Diabetes Mellitus/diagnosis , Diabetes Mellitus/mortality , Liver Cirrhosis/diagnosis , Liver Cirrhosis/mortality , Adult , Aged , COVID-19/therapy , Diabetes Mellitus/therapy , Female , Humans , Liver Cirrhosis/therapy , Male , Middle Aged , Retrospective Studies , Risk Factors , Treatment Outcome
4.
Scand J Gastroenterol ; 56(4): 453-457, 2021 04.
Article in English | MEDLINE | ID: covidwho-1085400

ABSTRACT

OBJECTIVES: Coronavirus disease 2019 (COVID-19) is an ongoing major health emergency, but its occurrence and clinical impact on patients withliver cirrhosis is unknown. Therefore, we conducted a population-based study of 2.6 million Danish citizens investigating the occurrence and impact of COVID-19 in patients with liver cirrhosis. MATERIALS AND METHODS: A prospective population-based cohort study was conducted in the Capital Region of Denmark and Region Zealand in the study period between 1 March 2020 up until 31 May 2020, with the only eligibility criteria being a reverse-transcriptase polymerase chain reaction for presence of viral genomic material confirming COVID-19. The patients were subsequently stratified according to presence of pre-existing liver cirrhosis. RESULTS: Among 575,935 individuals tested, 1713 patients had a diagnosis of cirrhosis. COVID-19 occurredsignificantly lessamongpatients with cirrhosis (n = 15; 0.9%, p < .01) compared with the population without cirrhosis (n = 10,593; 1.8%). However, a large proportion (n = 6;40.0%) required a COVID-19 related hospitalization which was correlated with higher values of alanine aminotransferase (p < .01) and lactate dehydrogenase (p = .04). In addition, one-in-three (n = 2; 13.3%) required intensive therapy. Four patients died (26.7%) and mortality was associated with higher MELD scores, co-existing type 2 diabetes, and bacterial superinfections. CONCLUSION: In conclusion, patientswith cirrhosis may have a lower risk of COVID-19; but a higher risk of complications hereto and mortality.


Subject(s)
COVID-19 , Liver Cirrhosis , Liver Function Tests , SARS-CoV-2/isolation & purification , Alanine Transaminase/blood , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Nucleic Acid Testing/statistics & numerical data , Cohort Studies , Denmark/epidemiology , Female , Hospitalization/statistics & numerical data , Humans , L-Lactate Dehydrogenase/blood , Liver Cirrhosis/blood , Liver Cirrhosis/epidemiology , Liver Cirrhosis/therapy , Liver Function Tests/methods , Liver Function Tests/statistics & numerical data , Male , Middle Aged , Mortality , Risk Assessment , Risk Factors
5.
J Intensive Care Med ; 36(5): 511-523, 2021 May.
Article in English | MEDLINE | ID: covidwho-1029763

ABSTRACT

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.


Subject(s)
Acute-On-Chronic Liver Failure , COVID-19 , Critical Care , Echocardiography/methods , Liver Cirrhosis , Point-of-Care Systems , Remote Consultation , Shock , Acute-On-Chronic Liver Failure/etiology , Acute-On-Chronic Liver Failure/physiopathology , Acute-On-Chronic Liver Failure/therapy , COVID-19/epidemiology , COVID-19/prevention & control , Cardiology/trends , Critical Care/methods , Critical Care/organization & administration , Critical Illness/therapy , Delayed Diagnosis/prevention & control , Hemodynamic Monitoring/instrumentation , Hemodynamic Monitoring/methods , Humans , Infection Control , Liver Cirrhosis/complications , Liver Cirrhosis/physiopathology , Liver Cirrhosis/therapy , Organizational Innovation , Remote Consultation/instrumentation , Remote Consultation/methods , Remote Consultation/organization & administration , SARS-CoV-2 , Shock/diagnosis , Shock/etiology , Shock/therapy
7.
J Viral Hepat ; 28(1): 4-11, 2021 01.
Article in English | MEDLINE | ID: covidwho-944757

ABSTRACT

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a novel coronavirus causing coronavirus disease 19 (COVID-19), with an estimated 22 million people infected worldwide so far although involving primarily the respiratory tract, has a remarkable tropism for the liver and the biliary tract. Patients with SARS-CoV-2 infection and no antecedent liver disease may display evidence of cytolytic liver damage, proportional to the severity of COVID-19 but rarely of clinical significance. The mechanism of hepatocellular injury is unclear and possibly multifactorial. The clinical impact of SARS-CoV-2 infection in patients with underlying chronic liver disease, a cohort whose global size is difficult to estimate, has been assessed appropriately only recently and data are still evolving. Patients with cirrhosis are at higher risk of developing severe COVID-19 and worse liver-related outcomes as compared to those with non-cirrhotic liver disease. OLT patients have an intermediate risk. Specific interventions in order to reduce the risk of transmission of infection among this high-risk population have been outlined by international societies, together with recommendations for modified treatment and follow-up regimens during the COVID-19 pandemic. When a vaccine against SARS-CoV-2 becomes available, patients with fibrotic liver disease and those with OLT should be considered as prime targets for prophylaxis of COVID-19, as all other highly susceptible subjects.


Subject(s)
COVID-19/complications , Liver Diseases/complications , Liver/injuries , SARS-CoV-2/pathogenicity , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/therapy , COVID-19 Vaccines/administration & dosage , Chronic Disease , Humans , Liver/virology , Liver Cirrhosis/complications , Liver Cirrhosis/epidemiology , Liver Cirrhosis/therapy , Liver Diseases/epidemiology , Liver Diseases/therapy , Risk
8.
Dig Liver Dis ; 52(9): 937-941, 2020 09.
Article in English | MEDLINE | ID: covidwho-641652

ABSTRACT

BACKGROUND: The COVID-19 pandemic had a huge impact on national and regional health systems. The impact of SARS-CoV-2 on the quality of care for patients with liver disease is still unknown. AIMS: The Italian Association for the Study of the Liver (AISF) conducted a survey to assess the impact of SARS-CoV-2 on hepatology units activities in Italy. METHODS: A prospective web-based survey was proposed to all AISF active members. The survey was available online from April 8 2020, to May 3 2020, (lockdown phase in Italy). RESULTS: 194 AISF members answered the questionnaire, most of whom were specialists in Gastroenterology (41%) or Internal Medicine (28%), and worked in Northern Italy (51%). 26% of hepatology wards had been converted into COVID-19 wards, and 33% had bed reductions. All hepatological activities, including the management of patients with decompensated liver disease, liver transplant and HCC had been significantly reduced/stopped. The number of physicians answering that their practices had not been modified ranged between 0.6% (for chronic hepatitis) to 47% (for the execution of paracentesis). The recorded answers were consistent among different regions, and did not show any north-south gradient CONCLUSION: COVID-19 outbreak significantly impacted on hepatological clinical activity. This survey can serve as a basis to compare the impact of future measures aimed at delivering an acceptable level of liver care during a national pandemic or crisis.


Subject(s)
Ambulatory Care/statistics & numerical data , Coronavirus Infections/epidemiology , Gastroenterology/statistics & numerical data , Hospitalization/statistics & numerical data , Liver Diseases/therapy , Pneumonia, Viral/epidemiology , Antiviral Agents/therapeutic use , Betacoronavirus , COVID-19 , Carcinoma, Hepatocellular/therapy , Chronic Disease , Esophageal and Gastric Varices/diagnosis , Esophageal and Gastric Varices/surgery , Hepatitis B, Chronic/drug therapy , Hepatitis C, Chronic/drug therapy , Humans , Italy/epidemiology , Liver Cirrhosis/therapy , Liver Neoplasms/therapy , Liver Transplantation/statistics & numerical data , Mass Screening , Pandemics , Paracentesis/statistics & numerical data , Quality of Health Care , SARS-CoV-2 , Surveys and Questionnaires
9.
Rev Gastroenterol Mex (Engl Ed) ; 85(3): 303-311, 2020.
Article in English, Spanish | MEDLINE | ID: covidwho-610946

ABSTRACT

The novel SARS-CoV-2 coronavirus is responsible for the infectious disease caused by coronavirus 19 (COVID-19). The current pandemic is growing worldwide and could affect 50-60% of the world population in the months to come. The most severe disease manifestations are atypical pneumonia and sepsis, but the gastrointestinal tract, particularly the liver, has recently been reported to be affected by SARS-CoV-2. Therefore, the aim of the present work was to review the literature available on the topic and provide information about COVID-19, in both healthy and diseased livers, and issue recommendations. The incidence of liver injury specifically associated with COVID-19 varies from 14.8-53%. The majority of case series have reported altered ALT and AST, elevated total bilirubin, and low serum albumin and liver compromise has been associated with the most severe cases of COVID-19. Cirrhosis of the liver has a recognized immune dysfunction status that includes immunodeficiency and systemic inflammation, making it reasonable for those patients to be more susceptible to SARS-CoV-2 infection. The recommendations for those patients, in addition to the general measures of physical distancing and handwashing for all persons, include social, medical, and psychologic support during the period of home quarantine to prevent lapses in treatment. Patients should be made aware that they need to keep abreast of changes in recommendations and social policies.


Subject(s)
Coronavirus Infections/complications , Coronavirus Infections/physiopathology , Liver Cirrhosis/therapy , Liver Diseases/etiology , Liver Diseases/physiopathology , Liver/physiopathology , Pneumonia, Viral/complications , Pneumonia, Viral/physiopathology , COVID-19 , Coronavirus Infections/prevention & control , Coronavirus Infections/therapy , Humans , Incidence , Liver Cirrhosis/complications , Liver Cirrhosis/epidemiology , Liver Cirrhosis/physiopathology , Liver Diseases/therapy , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Pneumonia, Viral/therapy
10.
Ann Saudi Med ; 40(4): 273-280, 2020.
Article in English | MEDLINE | ID: covidwho-612198

ABSTRACT

In December 2019, a novel coronavirus was identified in patients in Wuhan, China. The virus, subsequently named severe acute respiratory syndrome coronavirus-2, spread worldwide and the disease (coronavirus disease 2019 or COVID-19) was declared a global pandemic by the World Health Organization in March 2020. Older adults and individuals with comorbidities have been reported as being more vulnerable to COVID-19. Patients with chronic liver disease (CLD) have compromised immune function due to cirrhosis and are more susceptible to infection. However, it is unclear if patients with CLD are more vulnerable to COVID-19 and its complications than other populations. The high number of severe cases of COVID-19 has placed an unusual burden on health systems, compromising their capacity to provide the regular care that patients with CLD require. Hence, it is incredibly crucial at this juncture to provide a set of interim recommendations on the management of patients with CLD during the current COVID-19 outbreak.


Subject(s)
Coronavirus Infections/epidemiology , Liver Diseases/epidemiology , Pneumonia, Viral/epidemiology , Adenosine Monophosphate/adverse effects , Adenosine Monophosphate/analogs & derivatives , Adrenal Cortex Hormones/adverse effects , Alanine/adverse effects , Alanine/analogs & derivatives , Amides/adverse effects , Antiviral Agents/therapeutic use , Azetidines/adverse effects , Betacoronavirus , Biopsy/methods , COVID-19 , Carcinoma, Hepatocellular/epidemiology , Carcinoma, Hepatocellular/therapy , Comorbidity , Coronavirus Infections/drug therapy , Coronavirus Infections/prevention & control , Drug Combinations , Drug Interactions , Enzyme Inhibitors/adverse effects , Hepatitis, Autoimmune/epidemiology , Hepatitis, Autoimmune/therapy , Hepatitis, Viral, Human/epidemiology , Hepatitis, Viral, Human/therapy , Humans , Hydroxychloroquine/adverse effects , Immunosuppressive Agents/therapeutic use , Janus Kinase Inhibitors/adverse effects , Liver Cirrhosis/epidemiology , Liver Cirrhosis/therapy , Liver Diseases/therapy , Liver Neoplasms/epidemiology , Liver Neoplasms/therapy , Liver Transplantation , Lopinavir/adverse effects , Non-alcoholic Fatty Liver Disease/epidemiology , Non-alcoholic Fatty Liver Disease/therapy , Pandemics/prevention & control , Pneumonia, Viral/drug therapy , Pneumonia, Viral/prevention & control , Purines , Pyrazines/adverse effects , Pyrazoles , Ritonavir/adverse effects , SARS-CoV-2 , Saudi Arabia/epidemiology , Sulfonamides/adverse effects , Ultrasonography/methods
12.
Hepatol Int ; 14(4): 478-482, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-327354

ABSTRACT

BACKGROUND: The clinical characteristics and disease course in COVID-19 patients with pre-existing decompensated cirrhosis has not been described so far. METHODS: In this case series, we report three patients with confirmed COVID-19 and pre-existing decompensated cirrhosis from three hospitals in Hubei, the epicenter of the outbreak in China. RESULT: Patient 1 was a 53-year-old man with hepatitis B virus-related cirrhosis, portal hypertension, and ascites. Though receiving intensive support, he died of irreversible multiple organ dysfunction syndrome 48 days after the onset of the illness. Patient 2 was a 75-year-old woman with a history of schistosomiasis-related cirrhosis, portal hypertension, and ascites. Her family members requested that invasive rescue measures not be undertaken, and she died of acute respiratory distress syndrome 40 days after presenting with COVID-19 infection. Patient 3 was an 87-year-old man with alcohol-related cirrhosis, portal hypertension, and esophageal variceal hemorrhage. He was discharged from the hospital 29 days after illness onset. CONCLUSION: The case series raise the possibility that decompensated cirrhosis may be a risk factor for a poor outcome in patients with COVID-19.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/therapy , Liver Cirrhosis/therapy , Pneumonia, Viral/complications , Pneumonia, Viral/therapy , Aged , Aged, 80 and over , COVID-19 , China , Coronavirus Infections/diagnosis , Female , Humans , Liver Cirrhosis/diagnosis , Liver Cirrhosis/etiology , Male , Middle Aged , Pandemics , Pneumonia, Viral/diagnosis , SARS-CoV-2
14.
J Hepatol ; 73(2): 441-445, 2020 08.
Article in English | MEDLINE | ID: covidwho-164705

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has shattered the meticulously developed processes by which we delivered quality care for patients with cirrhosis. Care has been transformed by the crisis, but enduring lessons have been learned. In this article, we review how COVID-19 will impact cirrhosis care. We describe how this impact unfolds over 3 waves; i) an intense period with prioritized high-acuity care with delayed elective procedures and routine care during physical distancing, ii) a challenging 'return to normal' following the end of physical distancing, with increased emergent decompensations, morbidity, and systems of care overwhelmed by the backlog of deferred care, and iii) a protracted period of suboptimal outcomes characterized by missed diagnoses, progressive disease and loss to follow-up. We outline the concrete steps required to preserve the quality of care provided to patients with cirrhosis. This includes an intensification of the preventative care provided to patients with compensated cirrhosis, proactive chronic disease management, robust telehealth programs, and a reorganization of care delivery to provide a full service of care with flexible clinical staffing. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic is challenging. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm. Change is needed.


Subject(s)
Betacoronavirus , Coronavirus Infections/prevention & control , Delivery of Health Care/trends , Liver Cirrhosis/therapy , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Quality of Health Care/trends , COVID-19 , Carcinoma, Hepatocellular/diagnosis , Carcinoma, Hepatocellular/etiology , Clinical Decision-Making/methods , Coronavirus Infections/virology , Humans , Liver Cirrhosis/complications , Liver Cirrhosis/mortality , Liver Neoplasms/diagnosis , Liver Neoplasms/etiology , Patient Care Team , Pneumonia, Viral/virology , SARS-CoV-2 , Telemedicine/methods
15.
Singapore Med J ; 61(12): 619-623, 2020 12.
Article in English | MEDLINE | ID: covidwho-145282

ABSTRACT

In this paper, we aim to provide professional guidance to clinicians who are managing patients with chronic liver disease during the current coronavirus disease 2019 (COVID-19) pandemic in Singapore. We reviewed and summarised the available relevant published data on liver disease in COVID-19 and the advisory statements that were issued by major professional bodies, such as the American Association for the Study of Liver Diseases and European Association for the Study of the Liver, contextualising the recommendations to our local situation.


Subject(s)
COVID-19/complications , Liver Diseases/therapy , COVID-19/epidemiology , Carcinoma, Hepatocellular/complications , Carcinoma, Hepatocellular/therapy , Chronic Disease , Hepatitis B, Chronic/complications , Hepatitis B, Chronic/therapy , Hepatitis C, Chronic/complications , Hepatitis C, Chronic/therapy , Humans , Liver Cirrhosis/complications , Liver Cirrhosis/therapy , Liver Diseases/etiology , Liver Neoplasms/complications , Liver Neoplasms/therapy , Liver Transplantation , Singapore/epidemiology
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