Safety measures for COVID-19: a review of surgical preparedness at four major medical centres in Saudi Arabia.

In view of the worldwide coronavirus disease 2019 (COVID-19) pandemic, hospitals need contingency planning. This planning should include preparation for an unexpected patient surge. This measure is evolving concomitantly with the implementation of the needed infection control rules. Here, we present our experience in contingency planning at four large tertiary hospitals in Saudi Arabia during this global pandemic, with a focus on dealing with COVID-19 patients who need to undergo surgery. The planning covers response measures required in the operating room and supporting units, including the administrative department, intensive care unit, and different sections of the surgical department. Furthermore, it covers the role of education and simulation in preparing health care providers and ensuring smooth workflow between all sections. We additionally discuss the guidelines and policies implemented in different surgical specialties. These measures are necessary to prevent the transmission of COVID-19 within healthcare facilities. Throughout the COVID-19 pandemic, the healthcare system should develop a comprehensive pandemic plan and set guidelines addressing the management of urgent and malignant cases. The guidelines should be in concordance with internal guidelines.

Atypical hemolytic-uremic syndrome due to complement factor I mutation.

Atypical hemolytic-uremic syndrome (aHUS) is a rare disease of complement dysregulation leading to thrombotic microangiopathy (TMA). Renal involvement and progression to end-stage renal disease are common in untreated patients. We report a 52-year-old female patient who presented with severe acute kidney injury, microangiopathic hemolytic anemia, and thrombocytopenia. She was managed with steroid, plasma exchange, and dialysis. Kidney biopsy shows TMA and renal cortical necrosis. Genetic analysis reveals heterozygous complement factor I (CFI) mutation. Eculizumab was initiated after 3 mo of presentation, continued for 9 mo, and stopped because of sustained hematologic remission, steady renal function, and cost issues. Despite this, the patient continued to be in hematologic remission and showed signs of renal recovery, and peritoneal dialysis was stopped 32 mo after initiation. We report a case of aHUS due to CFI mutation, which, to the best of our knowledge, has not been reported before in Saudi Arabia. Our case illustrates the challenges related to the diagnosis and management of this condition, in which a high index of suspicion and prompt treatment are usually necessary.

A pragmatic randomized controlled trial comparing pathway-based versus usual care in community-acquired acute kidney injury.

Clinical pathways have shown conflicting evidence in improvement of several patient-centered outcomes across different clinical settings. However, the effectiveness of clinical pathway in management of acute kidney injury (AKI) has not been reported. Therefore, we aimed to assess the length of hospital stay (LOS) and patient-centered outcomes in community acquired AKI and compared pathway care (PC) versus usual care (UC). The CHAMP-Path AKI Trial is a pragmatic, parallel, single-blind randomized controlled trial. Physicians were randomized to provide either UC or PC. Patients were randomized through a computer-generated sequence. Allocation was concealed. Patients presenting to the emergency department with AKI and hemodynamic stability, who were over 14 years with a serum creatinine greater than 1.5 times the baseline were eligible. Patients with chronic kidney disease stages 4 or 5, kidney transplantation recipients, those admitted with obstructive uropathy, suspected glomerular or interstitial disease, and pregnant women were excluded. Thirty-eight patients were enrolled from March 2012 to December 2013. The primary outcome was LOS. Secondary outcomes included: 30-day readmission, in-hospital mortality, determinants of LOS, and patient-centered outcomes. Eighteen patients were randomized to PC, and 20 to UC. Baseline characteristics were comparable in both groups. Using an intention-to-treat analysis, the median LOS was 4.96 [interquartile range (IQR) 6.57] and 4.80 days (IQR 6.84) for PC and UC, respectively (P = 0.770). Of the five readmissions, none were for AKI. No in-hospital mortality was reported. The CHAMP-Path AKI pragmatic trial demonstrated that PC was not different than UC in reducing LOS. There was no difference in 30-day re- admission, in-hospital mortality, and patient-centered outcomes.

A case of Legionnaires' disease with extensive concurrent deep vein thrombosis.

A previously healthy 37-y-old male presented with community-acquired pneumonia and extensive upper limb deep vein thrombosis. The diagnosis of Legionella pneumonia was made based on a positive direct immunofluorescence of the bronchial wash. An extensive investigation for hypercoagulable states was negative. The possible association between Legionella infection and deep vein thrombosis is highlighted.