Spontaneous pulmonary herniation in COVID-19.

Spontaneous pulmonary hernia (SPH) is a rare condition. We report a case secondary to extreme coughing and COVID-19 infection. The patient displayed several clinical features typical of this diagnosis; difficult to manage pain on coughing, flank haematoma and bulging of the chest wall on coughing. Clinicians should be aware of the risk factors and clinical features of SPH to aid diagnosis of this rare condition.

Ecological and socioeconomic factors associated with the human burden of environmentally mediated pathogens: a global analysis.

BACKGROUND: Billions of people living in poverty are at risk of environmentally mediated infectious diseases-that is, pathogens with environmental reservoirs that affect disease persistence and control and where environmental control of pathogens can reduce human risk. The complex ecology of these diseases creates a global health problem not easily solved with medical treatment alone. METHODS: We quantified the current global disease burden caused by environmentally mediated infectious diseases and used a structural equation model to explore environmental and socioeconomic factors associated with the human burden of environmentally mediated pathogens across all countries. FINDINGS: We found that around 80% (455 of 560) of WHO-tracked pathogen species known to infect humans are environmentally mediated, causing about 40% (129 488 of 359 341 disability-adjusted life years) of contemporary infectious disease burden (global loss of 130 million years of healthy life annually). The majority of this environmentally mediated disease burden occurs in tropical countries, and the poorest countries carry the highest burdens across all latitudes. We found weak associations between disease burden and biodiversity or agricultural land use at the global scale. In contrast, the proportion of people with rural poor livelihoods in a country was a strong proximate indicator of environmentally mediated infectious disease burden. Political stability and wealth were associated with improved sanitation, better health care, and lower proportions of rural poverty, indirectly resulting in lower burdens of environmentally mediated infections. Rarely, environmentally mediated pathogens can evolve into global pandemics (eg, HIV, COVID-19) affecting even the wealthiest communities. INTERPRETATION: The high and uneven burden of environmentally mediated infections highlights the need for innovative social and ecological interventions to complement biomedical advances in the pursuit of global health and sustainability goals. FUNDING: Bill & Melinda Gates Foundation, National Institutes of Health, National Science Foundation, Alfred P. Sloan Foundation, National Institute for Mathematical and Biological Synthesis, Stanford University, and the US Defense Advanced Research Projects Agency.

One year experience of a newly established super green ERAS pathway for performing oesophago-gastric cancer resections during the Covid-19 pandemic

Background Surgical oncology services in the UK have been impacted by the COVID-19 pandemic.  Various strategies have been employed in an attempt to continue cancer resectional surgery   during the pandemic.  This study examined our institution’s experience and outcomes with a newly established Super Green ERAS pathway for oesophago-gastric (OG) cancer resections during the pandemic. Methods A retrospective cohort study of consecutive patients who had a resection for OG cancer performed over a 12-month period beginning from the date of the first UK National Lockdown of 23 March 2020.  Barring two intervals each lasting 3 weeks, urgent elective cancer surgery continued on our mixed hot and cold site through the establishment of a Super Green ERAS pathway. Patients were confirmed COVID-19 negative within 72 hours pre-admission and retested  72-hourly post-op. 14 days self-isolation pre-admission was mandated.  Patients not complying had their surgery postponed. Transhiatal oesophagectomy was the preferred approach for oesophagectomy during the pandemic.  Results 45 resections (33 oesophagectomies, 10 gastrectomies and 2 trial of dissections) were performed.  37 (82.2%) patients were male with a median age of 64 (IQR 58-71) years.   3 patients were postponed due to non-adherence with self-isolation. No patients tested positive for COVID-19 post-operatively, hence, there was no COVID-19-related morbidity. Nine patients developed pneumonia. Seven patients had an anastomotic leak, all of whom were successfully rescued. One patient required a clamshell thoracotomy due to intra-operative mediastinal bleeding followed by a return to theatre for reconstruction 48hrs later.  Median length of stay was 12 (IQR 9-18) days. There was no in-hospital mortality. Conclusions OG cancer resections can be performed safely despite COVID-19, with favorable clinical outcomes when a Super Green ERAS pathway is strictly adhered to.   Implementation of such pathways will enable surgical oncology services, including OG cancer resections, to continue to ensure best possible outcomes for cancer patients despite any future waves of the COVID-19 pandemic.

Stage Migration in Newly Diagnosed Oesophago-gastric Cancer during the first wave of COVID-19 Pandemic

Background Covid-19 has significantly disrupted elective and emergency health care provision including cancer care within the UK. The aim of the study was to investigate the impact of the pandemic on the staging of oesophago-gastric cancers at presentation, determine the time delay in performing gastroscopy and the multidisciplinary team (MDT) treatment outcomes. Methods A retrospective cohort study of all newly diagnosed oesophago-gastric cancers (adenocarcinoma and squamous cell carcinoma) in a single regional MDT was performed between 1st October 2019 and 30th September 2020. Electronic records were interrogated and patients dichotomised into two groups with those presenting before the introduction of the UK national lockdown of 23rd March 2020 compared to those presenting post-lockdown. Results 349 new oesophago-gastric cancer patients were discussed in the MDT (192 pre-lockdown versus 157 post-lockdown). Demographics were evenly matched between the two groups. More patients presented as an emergency admission post-lockdown (28.0% vs 12.5%, p < 0.001). Median waiting time for gastroscopy was longer post-lockdown (23 vs 14 days, p = 0.035). Metastatic disease at presentation was more frequent post-lockdown (47.8% vs 33.3%, p = 0.008). Overall, more patients had a palliative rather than curative treatment intent post-lockdown (71.3% vs 57.8%, p = 0.005). Conclusions The Covid-19 pandemic has had a significant negative effect on the stage of oesophago-gastric cancers at presentation. This has translated into more patients receiving palliative treatment and ultimately having a poorer prognosis. This study highlights the importance of maintaining cancer services during the Covid-19 pandemic.

Mitigating Coronavirus Induced Dysfunctional Immunity for At-Risk Populations in COVID-19: Trained Immunity, BCG and "New Old Friends".

The novel, highly contagious coronavirus SARS-CoV-2 spreads rapidly throughout the world, leading to a deadly pandemic of a predominantly respiratory illness called COVID-19. Safe and effective anti-SARS-CoV-2 vaccines are urgently needed. However, emerging immunological observations show hallmarks of significant immunopathological characteristics and dysfunctional immune responses in patients with COVID-19. Combined with existing knowledge about immune responses to other closely related and highly pathogenic coronaviruses, this could forebode significant challenges for vaccine development, including the risk of vaccine failure. Animal data from earlier coronavirus vaccine efforts indicate that elderly people, most at risk from severe COVID-19 disease, could be especially at risk from immunopathologic responses to novel coronavirus vaccines. Bacterial "new old friends" such as Bacille Calmette-Guérin (BCG) or Mycobacterium obuense have the ability to elevate basal systemic levels of type 1 cytokines and immune cells, correlating with increased protection against diverse and unrelated infectious agents, called "trained immunity." Here we describe dysfunctional immune responses induced by coronaviruses, representing potentially difficult to overcome obstacles to safe, effective vaccine development for COVID-19, and outline how trained immunity could help protect high risk populations through immunomodulation with BCG and other "new old friends."