Safety and training of colonoscopies by surgeons. A multicenter study / Seguridad y entrenamiento de las colonoscopias por cirujanos. Estudio multicéntrico

RESUMEN Introducción: la seguridad de la colonoscopia realizada por cirujanos y el tratamiento de sus complica ciones han sido analizados aisladamente y en escasas publicaciones nacionales. Objetivos: el objetivo principal del estudio fue analizar las colonoscopias realizadas por cirujanos co lorrectales, sus complicaciones y resolución. El objetivo secundario fue comparar los resultados entre un hospital universitario y distintos centros del país dotados de cirujanos colorrectales que habían recibido entrenamiento en una residencia posbásica. Material y métodos: estudio multicéntrico, prospectivo a nivel nacional. Se incluyeron las colonosco pias realizadas entre 2011 y 2016 . Se analizaron como variables las complicaciones, edad, sexo, tipo de endoscopia, diagnóstico, tratamiento, sitio de realización y de entrenamiento del cirujano. Se ex presaron en promedios, porcentajes y rangos. El análisis estadístico consistió en el test exacto ordinal, relaciones y proporciones y exacto de Fisher. Se consideró significancia a p < 0,05. Resultados: de 24 907 procedimientos, 17 283 fueron diagnósticos y 17 202 provenían de centros del interior. Hubo 43 complicaciones (0,17%); 35 específicas: perforaciones (19), hemorragias (8), sín drome pospolipectomía (5) y técnicas (3), diagnosticadas y resueltas por el mismo equipo sin mor bimortalidad. No hubo diferencias en las complicaciones según el centro ni tipo de colonoscopia en incidencia o tratamiento. Todos los cirujanos se entrenaron en residencias de posgrado con programas de entrenamiento en colonoscopia. Conclusiones: existen similares resultados entre cirujanos provenientes de instituciones con residen cia posbásica y centros del interior al realizar colonoscopias. La colonoscopia realizada por cirujanos es un procedimiento seguro y posible de ser adquirido como competencia luego de un entrenamiento formal realizado en una residencia posbásica.

ABSTRACT Introduction: The safety of colonoscopies performed by surgeons and the management of their com plications has not been analyzed in depth in the low number of national publications. Objective: The primary endpoint of this study was to analyze the outcomes of colonoscopies perfor med by colorectal surgeons, in terms of complications. and their resolution. The secondary endpoint was to compare the results between a university hospital and different centers nationwide staffed with colorectal surgeons who had received formal training during a residency program in the surgical subspecialty. Material and methods: We conducted a multicenter, prospective and consecutive national study. The colonscopies performed between 2011 and 2016 were included. The variables analyzed included complications, age, sex, type of endoscopy, diagnosis, treatment, location were the procedure was performed and surgeon's training. The results were expressed as mean, percentage and range. The statistical analysis was performed using Fisher's exact test. A p value < 0.05 was considered statistically significant. Results: A total of 24,907 procedures were performed, 17,283 corresponded to diagnostic colonosco pies and 17,202 were made in provincial centers. Forty-four complications were recorded (0.17%), of which 35 were procedure-related complications: 19 perforations, 8 bleeding events, 5 post-polypec tomy syndromes and three related with the technique; all were diagnosed and solved by the same team without morbidity and mortality. There were no differences in the incidence of complications and how they were treated according to the center or type of colonoscopy. All the surgeons received colonoscopy training during a residency program in the surgical subspecialty. Conclusions: The results obtained in colonoscopies performed by surgeons trained in institutions with residency programs in surgical subspecialties are similar t Safe colonoscopies can be performed by surgeons who have been trained in institutions with a residency program in a surgical subspecialty and with a formal training program in colonoscopy.

The utility of the Edmonton Obesity Staging System for the prediction of COVID-19 outcomes: a multi-centre study.

BACKGROUND: Patients with obesity have an increased risk for adverse COVID-19 outcomes. Body mass index (BMI) does not acknowledge the health burden associated this disease. The performance of the Edmonton Obesity Staging System (EOSS), a clinical classification tool that assesses obesity-related comorbidity, is compared with BMI, with respect to adverse COVID-19 outcomes. METHODS: 1071 patients were evaluated in 11 COVID-19 hospitals in Mexico. Patients were classified into EOSS stages. Adjusted risk factors for COVID-19 outcomes were calculated and survival analysis for mechanical ventilation and death was carried out according to EOSS stage and BMI category. RESULTS: The risk for intubation was higher in patients with EOSS stages 2 and 4 (HR 1.42, 95% CI 1.02-1.97 and 2.78, 95% CI 1.83-4.24), and in patients with BMI classes II and III (HR 1.71, 95% CI 1.06-2.74, and 2.62, 95% CI 1.65-4.17). Mortality rates were significantly lower in patients with EOSS stages 0 and 1 (HR 0.62, 95% CI 0.42-0.92) and higher in patients with BMI class III (HR 1.58, 95% CI 1.03-2.42). In patients with a BMI ≥ 25 kg/m2, the risk for intubation increased with progressive EOSS stages. Only individuals in BMI class III showed an increased risk for intubation (HR 2.24, 95% CI 1.50-3.34). Mortality risk was increased in EOSS stages 2 and 4 compared to EOSS 0 and 1, and in patients with BMI class II and III, compared to patients with overweight. CONCLUSIONS: EOSS was associated with adverse COVID-19 outcomes, and it distinguished risks beyond BMI. Patients with overweight and obesity in EOSS stages 0 and 1 had a lower risk than patients with normal weight. BMI does not adequately reflect adipose tissue-associated disease, it is not ideal for guiding chronic-disease management.

Screening for COVID-19 in Children Undergoing Elective Invasive Procedures.

OBJECTIVE: To report the frequency of asymptomatic infection with SARS-CoV-2 in pediatric patients undergoing invasive medical procedures in a tertiary pediatric hospital. METHODS: From June to October 2020, a SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) test was performed for all pediatric patients scheduled to undergo an elective invasive procedure. None of the patients was symptomatic. The cycle threshold (Ct) values of the ORF1ab gene were recorded for all patients. RESULTS: A total of 700 patients were screened for SARS-CoV-2 infection. The median age was 5.7 y old. In total, 46.6% (n = 326) of the patients were male, and 53.4% (n = 374) were female. The most common underlying diseases were hemato-oncological (25.3%), gastrointestinal (24.9%), and genitourinary (10.3%). The main scheduled surgical-medical procedures were surgical treatment for acquired congenital diseases, biopsy sampling, local therapy administration, organ transplantation, and the placement of central venous catheters, among others. The SARS-CoV-2 rRT-PCR test was positive in 9.4% (66), and the median Ct value was 35.8. None of the patients developed COVID-19. CONCLUSIONS: The frequency of asymptomatic SARS-CoV-2 infection was detected in less than 10% of pediatric patients scheduled to undergo an elective invasive procedure in a tertiary hospital. This frequency is higher than those in reports from different countries.

Desempleo juvenil: contribuciones para su disminución desde el emprendimiento

La promoción de nuevos emprendimientos es uno de los pilares básicos y eje estratégico para generar inclusión social, oportunidades laborales, innovación, desarrollo económico y social en las economías latinoamericanas;siendo para muchos jóvenes latinoamericanos la única opción de obtener un ingreso decente. Los niveles de desempleo juvenil en el año 2020, en gran parte de las economías de la región, superan el 20%, por lo que resulta urgente identificar alternativas de generación de empleo, que permitan mejorar la calidad de vida de la población en general y de los jóvenes en particular. El análisis se basa en la revisión documental de las fuentes técnico científico relacionadas con desempleo juvenil y el emprendimiento como alternativa al fenómeno;especialmente con datos de los reportes recientes (entre los años 2018 al 2021). El desempleo en la población joven es un problema generalizado que afecta a los países de la región latinoamericana, lo cual se asentó con la pandemia del COVID-19. El emprendimiento es una herramienta clave para atender directamente la problemática del desempleo y los creados por personas jóvenes están generando fuentes de empleo en los países latinoamericanos.Alternate abstract:The promotion of new ventures is one of the basic pillars and strategic axes to generate social inclusion, job opportunities, innovation, economic and social development in Latin American economies;being for many young Latin Americans the only option to obtain a decent income. The levels of youth unemployment in 2020, in a large part of the economies of the region, exceed 20%, so it is urgent to identify alternatives for generating employment, which allow improving the quality of life of the population in general and of young people. The analysis is based on the documentary review of technical scientific sources related to youth unemployment and entrepreneurship as an alternative to the phenomenon;especially with data from recent reports (between the years 2018 to 2021). Unemployment in the young population is a generalized problem that affects the countries of the Latin American region, which settled with the COVID-19 pandemic. Entrepreneurship is a key tool to directly address the problem of unemployment and those created by young people are generating sources of employment in Latin American countries.

SARS-CoV-2 RNA and antibody detection in breast milk from a prospective multicentre study in Spain.

OBJECTIVES: To develop and validate a specific protocol for SARS-CoV-2 detection in breast milk matrix and to determine the impact of maternal SARS-CoV-2 infection on the presence, concentration and persistence of specific SARS-CoV-2 antibodies. DESIGN AND PATIENTS: This is a prospective, multicentre longitudinal study (April-December 2020) in 60 mothers with SARS-CoV-2 infection and/or who have recovered from COVID-19. A control group of 13 women before the pandemic were also included. SETTING: Seven health centres from different provinces in Spain. MAIN OUTCOME MEASURES: Presence of SARS-CoV-2 RNA in breast milk, targeting the N1 region of the nucleocapsid gene and the envelope (E) gene; presence and levels of SARS-CoV-2-specific immunoglobulins (Igs)-IgA, IgG and IgM-in breast milk samples from patients with COVID-19. RESULTS: All breast milk samples showed negative results for presence of SARS-CoV-2 RNA. We observed high intraindividual and interindividual variability in the antibody response to the receptor-binding domain of the SARS-CoV-2 spike protein for each of the three isotypes IgA, IgM and IgG. Main Protease (MPro) domain antibodies were also detected in milk. 82.9% (58 of 70) of milk samples were positive for at least one of the three antibody isotypes, with 52.9% of these positive for all three Igs. Positivity rate for IgA was relatively stable over time (65.2%-87.5%), whereas it raised continuously for IgG (from 47.8% for the first 10 days to 87.5% from day 41 up to day 206 post-PCR confirmation). CONCLUSIONS: Our study confirms the safety of breast feeding and highlights the relevance of virus-specific SARS-CoV-2 antibody transfer. This study provides crucial data to support official breastfeeding recommendations based on scientific evidence. Trial registration number NCT04768244.

Emergency Tracheal Intubation in Patients with COVID-19: A Single-center, Retrospective Cohort Study.

INTRODUCTION: The objective of this study was to compare airway management technique, performance, and peri-intubation complications during the novel coronavirus pandemic (COVID-19) using a single-center cohort of patients requiring emergent intubation. METHODS: We retrospectively collected data on non-operating room (OR) intubations from February 1-April 23, 2020. All patients undergoing emergency intubation outside the OR were eligible for inclusion. Data were entered using an airway procedure note integrated within the electronic health record. Variables included level of training and specialty of the laryngoscopist, the patient's indication for intubation, methods of intubation, induction and paralytic agents, grade of view, use of video laryngoscopy, number of attempts, and adverse events. We performed a descriptive analysis comparing intubations with an available positive COVID-19 test result with cases that had either a negative or unavailable test result. RESULTS: We obtained 406 independent procedure notes filed between February 1-April 23, 2020, and of these, 123 cases had a positive COVID-19 test result. Residents performed fewer tracheal intubations in COVID-19 cases when compared to nurse anesthetists (26.0% vs 37.4%). Video laryngoscopy was used significantly more in COVID-19 cases (91.1% vs 56.8%). No difference in first-pass success was observed between COVID-19 positive cases and controls (89.4% vs. 89.0%, p = 1.0). An increased rate of oxygen desaturation was observed in COVID-19 cases (20.3% vs. 9.9%) while there was no difference in the rate of other recorded complications and first-pass success. DISCUSSION: An average twofold increase in the rate of tracheal intubation was observed after March 24, 2020, corresponding with an influx of COVID-19 positive cases. We observed adherence to society guidelines regarding performance of tracheal intubation by an expert laryngoscopist and the use of video laryngoscopy.

Postintubation Decline in Oxygen Saturation Index Predicts Mortality in COVID-19: A Retrospective Pilot Study.

BACKGROUND: Acute respiratory failure from COVID-19 pneumonia is a major cause of death after SARS-CoV-2 infection. We investigated whether PaO2/FiO2, oxygenation index (OI), SpO2/FiO2, and oxygen saturation index (OSI), commonly used to assess the severity of acute respiratory distress syndrome (ARDS), can predict mortality in mechanically ventilated COVID-19 patients. METHODS: In this single-centered retrospective pilot study, we enrolled 68 critically ill mechanically ventilated adult patients with confirmed COVID-19. Physiological variables were recorded on the day of intubation (day 0) and postintubation days 3 and 7. The association between physiological parameters, PaO2/FiO2, OI, SpO2/FiO2, and OSI with mortality was assessed using multiple variable logistic regression analysis. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. RESULTS: The ARDS severity indices were not statistically different on the day of intubation, suggesting similar baseline conditions in nonsurviving and surviving patients. However, these indices were significantly worse in the nonsurviving as compared to surviving patients on postintubation days 3 and 7. On intubation day 3, PaO2/FiO2 was 101.0 (61.4) in nonsurviving patients vs. 140.2 (109.6) in surviving patients, p=0.004, and on day 7 106.3 (94.2) vs. 178.0 (69.3), p < 0.001. OI was 135.0 (129.7) in nonsurviving vs. 84.8 (86.1) in surviving patients (p=0.003) on day 3 and 150.0 (118.4) vs. 61.5 (46.7) (p < 0.001) on day 7. OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7. Similarly, SpO2/FiO2 was 130 (90) vs. 210 (90) (p=0.003) on day 3 and 130 (90) vs. 230 (50) (p < 0.001) on day 7, while OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7 in the nonsurviving and surviving patients, respectively. All measures were independently associated with hospital mortality, with significantly greater odds ratios observed on day 7. The area under the receiver operating characteristic curve (AUC) for mortality prediction was greatest on intubation day 7 (AUC = 0.775, 0.808, and 0.828 for PaO2/FiO2, OI, SpO2/FiO2, and OSI, respectively). CONCLUSIONS: Decline in oxygenation indices after intubation is predictive of mortality in COVID-19 patients. This time window is critical to the outcome of these patients and a possible target for future interventions. Future large-scale studies to confirm the prognostic value of the indices in COVID-19 patients are warranted.

The Ventilator Management Team: Repurposing Anesthesia Workstations and Personnel to Combat COVID-19.

The coronavirus disease 2019 pandemic resulted in unprecedented numbers of patients with respiratory failure requiring ventilatory support. The number of patients who required critical care quickly outpaced the availability of intensive care unit (ICU) beds. Consequently, health care systems had to creatively expand critical care services into alternative hospital locations with repurposed staff and equipment. Deploying anesthesia workstations to the ICU to serve as mechanical ventilators requires equipment preparation, multidisciplinary planning, and targeted education. We aim to contextualize this process, highlighting major differences between anesthesia workstations and ICU ventilators, and to share the insights gained from our experiences creating an anesthesia provider-based ventilator management team.