Percutaneous tracheostomy in head and neck oncology surgery: How Covid-19 changed our practice

Enhanced experience in performing percutaneous tracheostomies during the COVID-19 pandemic resulted in changes to airway management protocol for patients undergoing major head and neck reconstructive surgery within our department. Most patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy. The aim of this study was to review our experience in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. All consecutive patients undergoing free flap reconstructive surgery for head and neck cancer between June 2020 and November 2021 were included, with 56 patients receiving a percutaneous tracheostomy. Data across a range of variables including age, BMI, comorbidities and complications was compared with 56 surgical tracheostomies performed for the same group of patients before the COVID-19 pandemic and resultant protocol changes. In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group;28.57% and 30.35% respectively. Analysis of the 16 patients who experienced complications in the percutaneous group led to development of selection criteria to identify appropriate patients to receive a percutaneous tracheostomy in future, based on factors such as BMI, bleeding risk and positioning deformities. The COVID-19 pandemic has offered a multitude of learning experiences for healthcare professionals to change our practice. In our unit, this has involved modifying the routine tracheostomy procedure used for airway management intra- and post-operatively in major head and neck reconstruction surgery.Copyright © 2023 The Authors

The Percutaneous Tracheostomy in Head and Neck Oncology Surgery

Introduction/Aims: Enhanced experience in performing percutaneous dilatational tracheostomies (PDT) during the COVID-19 pandemic resulted in changes to airway management for patients undergoing head and neck reconstructive surgery at Queen Elizabeth Hospital Birmingham. All patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy (ST), unless contraindicated. This ambispective case series aimed to review experiences in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. In addition, we propose a selection criteria for identifying patients suitable for PDT. Material(s) and Method(s): All patients undergoing free flap reconstruction for head and neck cancer treatment between June 2020-November 2021 were included, with 56 patients receiving PDT. This was compared with data of 56 ST performed before the COVID-19 pandemic. Results/Statistics: In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group;28.57% and 30.35% respectively. Although not statistically significant, time to decannulation was slightly lower in PDT group (5.8 days) compared to ST group (7.3 days). An additional observed advantage included quicker tracheostomy wound healing with PDT. Analysis of the 16 patients who experienced complications with PDT aided development of the selection criteria for identifying patients for percutaneous tracheostomy. This selection criteria considers BMI, ASA, bleeding risk and positioning deformities. Conclusions/Clinical Relevance: This study has demonstrated PDT to be an equally safe and successful technique with a similar complication rate to ST in head and neck cancer reconstruction surgery. Moving forward, further studies with larger sample sizes would be recommended to draw conclusions. Copyright © 2022

Elevated Cytokine Levels in Plasma of Patients with SARS-CoV-2 Do Not Contribute to Pulmonary Microvascular Endothelial Permeability.

The vascular endothelial injury occurs in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, but the mechanisms are poorly understood. We sought to determine the frequency and type of cytokine elevations and their relationship to endothelial injury induced by plasma from patients with SARS-CoV-2 versus controls. Plasma from eight consecutively enrolled patients hospitalized with acute SARS-CoV-2 infection was compared to controls. Endothelial cell (EC) barrier integrity was evaluated using ECIS (electric cell-substrate impedance sensing) on human lung microvascular EC. Plasma from all SARS-CoV-2 but none from controls decreased transendothelial resistance to a greater degree than that produced by tumor necrosis factor-alpha (TNF-α), the positive control for the assay. Thrombin, angiopoietin 2 (Ang2), and vascular endothelial growth factor (VEGF), complement factor C3a and C5a, and spike protein increased endothelial permeability, but to a lesser extent and a shorter duration when compared to SARS-CoV-2 plasma. Analysis of Ang2, VEGF, and 15 cytokines measured in plasma revealed striking patient-to-patient variability within the SARS-CoV-2 patients. Pretreatment with thrombin inhibitors, single, or combinations of neutralizing antibodies against cytokines, Ca3 and C5a receptor antagonists, or with ACE2 antibody failed to lessen the SARS-CoV-2 plasma-induced EC permeability. The EC barrier destructive effects of plasma from patients with SARS-CoV-2 were susceptible to heat inactivation. Plasma from patients hospitalized with acute SARS-CoV-2 infection uniformly disrupts lung microvascular integrity. No predicted single, or set of, cytokine(s) accounted for the enhanced vascular permeability, although the factor(s) were heat-labile. A still unidentified but potent circulating factor(s) appears to cause the EC disruption in SARS-CoV-2 infected patients. IMPORTANCE Lung vascular endothelial injury in SARS-CoV-2 patients is one of the most important causes of morbidity and mortality and has been linked to more severe complications including acute respiratory distress syndrome (ARDS) and subsequent death due to multiorgan failure. We have demonstrated that in eight consecutive patients with SARS-CoV-2, who were not selected for evidence of endothelial injury, the diluted plasma-induced intense lung microvascular damage, in vitro. Known endothelial barrier-disruptive agents and proposed mediators of increased endothelial permeability in SARS-CoV-2, induced changes in permeability that were smaller in magnitude and shorter in duration than plasma from patients with SARS-CoV-2. The effect on endothelial cell permeability of plasma from patients with SARS-CoV-2 was heat-labile. The main plasma factor that causes the increased endothelial permeability remains to be identified. Our study provides a possible approach for future studies to understand the underlying mechanisms leading to vascular injury in SARS-CoV-2 infections.

Correlation between CT chest severity score (CT-SS) and ABO blood group system in Egyptian patients with COVID-19

Background: The 2019 coronavirus disease (COVID-19) has become a global health crisis. CT chest is considered as an important investigation for early diagnosis as well as assessment of severity of COVID-19 pneumonia. Several articles reported that there is a correlation between ABO blood group system and susceptibility as well as prognosis of the disease. In our study we correlated the CT severity score (CT-SS) and the ABO blood group in patients with COVID-19 infection. This study involved 547 symptomatic patients with pathologically proven COVID-19 infection (positive PCR);non contrast CT chest was done for all cases and CT severity score (CT-SS) was calculated followed by its correlation with the patients’ ABO blood group. Aim of the work was to evaluate the relation between CT-SS and the ABO blood groups in Egyptian patients with COVID-19 infection. Results: The mean CT-SS in patients with blood group A patients (n = 153;28%) was 13.7 (moderate severity), while in patients with blood group O (n = 227;41.5%) the mean CT-SS was 6.7 (mild severity). In blood group B patients (n = 139;25.4%) the mean CT-SS was 9.1 (mild to moderate severity) and in blood group AB patients (n = 28;5.1%) the mean CT-SS was 9.7 (mild to moderate severity). Conclusion: COVID-19 patients with blood group A are more prone to aggressive CT findings (higher CT-SS) and consequently may be susceptible to increased risk of mortality compared to the patients with other blood groups;however, patients with blood group O are suggested to have the least CT-SS and appear to be relatively protected.

Demographics, management and outcomes of inpatients with newly diagnosed diabetes in acute covid-19 infection

Aim: To investigate the demographics, management and outcomes of patients with newly diagnosed diabetes in covid-19 infection admitted to Queen Elizabeth Hospital, Birmingham. Methods: All patients with a new diagnosis of diabetes on their admission with covid-19 pneumonia (pre-dexamethasone use) between March and June 2020 were examined. Demographics, comorbidities, medication history, investigations, management and outcomes were analysed. Results: Twelve patients were identified. Demographic analysis revealed (all median [IQR]);Age 59.5 [51.5-69.3] years, body mass index 27.4 [26.0-28.9] kg/m2 and length of admission 21.5 [7.5-28.8] days. The majority of patients were male (9/12) and most were diagnosed with type 2 diabetes (9/12). Seven patients had no diabetes symptoms prior to admission and positive family history was uncommon (1/12). Median glucose reading on admission was 16.0 [10.0-29.0] mmol/l, HbA1c 62.5 [47-104] mmol/mol. During admission, median percentage of glucose in target (5-15 mmol/l) for individual patients was 71.6 [46.4-91.0]% and median percentage of glucose levels in hypoglycaemic range (<4 mmol/l) was 0.8 [0.0-2.6]%. Intravenous insulin was required by half of patients (6/12). 5/12 (41.7%) patients were admitted to the critical care unit versus 69/497 (13.8%) patients with pre-existing diabetes and covid-19, median length of stay was 18.5 [13.3-23.0] days versus 7 [3-13] days. 3/12 patients died during admission (25.0%) versus 112/497(23%) patients with pre-existing diabetes and covid-19. Of the nine patients discharged, six required long-term antidiabetes therapy;five with insulin and one with oral diabetic treatment. Conclusion: A new diagnosis of diabetes in combination with covid-19 infection is associated with high rates of complication relating to glucose control and need for intensive care during admission.

In Silico Mining of Terpenes from Red-Sea Invertebrates for SARS-CoV-2 Main Protease (M^pro) Inhibitors

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent for the COVID-19 pandemic, which generated more than 1.82 million deaths in 2020 alone, in addition to 83.8 million infections. Currently, there is no antiviral medication to treat COVID-19. In the search for drug leads, marine-derived metabolites are reported here as prospective SARS-CoV-2 inhibitors. Two hundred and twenty-seven terpene natural products isolated from the biodiverse Red-Sea ecosystem were screened for inhibitor activity against the SARS-CoV-2 main protease (M^pro) using molecular docking and molecular dynamics (MD) simulations combined with molecular mechanics/generalized Born surface area binding energy calculations. On the basis of in silico analyses, six terpenes demonstrated high potency as M^pro inhibitors with DELTAG_binding <= -40.0 kcal/mol. The stability and binding affinity of the most potent metabolite, erylosides B, were compared to the human immunodeficiency virus protease inhibitor, lopinavir. Erylosides B showed greater binding affinity towards SARS-CoV-2 M^pro than lopinavir over 100 ns with DELTAG_binding values of -51.9 vs. -33.6 kcal/mol, respectively. Protein-protein interactions indicate that erylosides B biochemical signaling shares gene components that mediate severe acute respiratory syndrome diseases, including the cytokine- and immune-signaling components BCL2L1, IL2, and PRKC. Pathway enrichment analysis and Boolean network modeling were performed towards a deep dissection and mining of the erylosides B target-function interactions. The current study identifies erylosides B as a promising anti-COVID-19 drug lead that warrants further in vitro and in vivo testing.

Reentry to Metabolic and Bariatric Surgery During the COVID19 Pandemic.

Patients with obesity and diabetes have higher risk for severe complications and mortality from COVID19 infection. In addition, unexpected mortalities were reported in a small series of asymptomatic COVID19-positive patients undergoing metabolic and bariatric surgery (MBS). Several organization including IFSO and the American College of Surgeons (ACS) endorsed recommendations to suspend elective nonessential surgery including MBS during the peak period of COVID19. However, both recommendations have no clear guidelines on how to prioritize MBS patients after the peak of COVID19 cases has passed, but there remain patients with asymptomatic COVID19 in the community. We present a tiered approach to restart MBS during the COVID19 pandemic once the peak of new cases has passed or the curve of new COVID19 cases has flattened.