ABSTRACT
Background: Given the COVID-19 pandemic, international travel restrictions have been in effect since March 2020 in Canada. As a result, some patients requiring international travel for medical care have experienced delays. Therefore, innovative techniques were required to provide care that would not routinely be performed in Canada, as in the case of Orbera® gastric balloon retrieval. Aims: To describe an approach to gastric balloon retrieval amidst COVID-19 related travel restrictions Methods: Case review of three cases of gastric balloon retrieval was performed Results: 1: A 41-year-old (yo) woman had an Orbera® gastric balloon placement in Washington state in September 2019. She lost 42lbs. Retrieval was scheduled for March 2020, but was delayed due to COVID-19 restrictions. In May 2020, she developed symptoms of balloon dysfunction. The patient was referred to a Canadian tertiary care centre. Gastroscopy was performed under conscious sedation. The Orbera® balloon was in the distal gastric body. The balloon was punctured with a 19G EUS FNA needle;600cc of blue tinted liquid was aspirated. The emptied balloon was retrieved successfully using rat tooth forceps. 2: A 35-yo woman had an Orbera® gastric balloon placed in October 2019 in Toronto at a private health facility. She lost 20lbs. Retrieval of the balloon was scheduled for March 2020, but due to COVID-19 restrictions, it was not possible at the original facility. She did not have symptoms related to the balloon. Gastroscopy was performed under general anesthesia (GA) on October 8, 2020. The balloon was intact in the distal gastric body. The balloon was punctured with a 19G Cook Echotip Needle and vacuum suction applied;400cc of blue tinted fluid was removed. Alligator forceps were used to create holes in the underside of the balloon, allowing excess fluid to be expelled as the balloon was pulled up against the GEJ. Once the balloon was deflated, it was removed successfully through the mouth. 3: A 38-yo man had an Orbera® gastric balloon placed in his native Columbia in March 2020. He did not achieve weight loss. Due to COVID-19 restrictions, he was unable to return for planned removal. He did not have symptoms related to the balloon. Gastroscopy was performed under GA on October 8, 2020. The balloon was intact in the distal gastric body. The balloon was punctured with a 19G Cook Echotip Needle and vacuum suction applied;600cc of blue tinted fluid was removed. Alligator forceps were used in retroflexion to tear the underside of the flattened balloon to ensure all liquid and air had escaped from the balloon. Once the balloon was deflated, it was removed successfully through the mouth. Conclusions: Although Orbera® gastric balloon retrieval is not routinely performed in Canada, we demonstrate that gastroscopy with balloon puncture and forcepsretrieval is a safe option.
ABSTRACT
Background: Given the social distancing measures employed to reduce the transmission of SARS-CoV-2, tele-health has rapidly expanded and is now routinely used in new patient encounters and in follow up appointments across Canada. Aims: To determine the patient and physician perspective towards tele-health in a gastroenterology outpatient setting. Methods: An anonymous voluntary online survey was distributed to patients who had previously undergone at least one tele-health visit in a tertiary care gastroenterology outpatient setting. A separate online survey was distributed to gastroenterologists practising across Canada. Results: A total of 181 patients from British Columbia (59.8% female) completed the survey. The tele-health appointment was the first visit for 21.8% of patients. Appointments occurred by phone call alone (61.4%) or by video and audio software (38.6%) and started within 5 minutes of the scheduled time in 75% of visits. Patient satisfaction with the tele-health visit was high (8.54 on a scale of 0-10;0 completely dissatisfied, 10 extremely satisfied;IQR 8-10). Most patients did not perceive a difference in likelihood of compliance compared to a non-tele-health visit (90.6%), were not concerned about the lack of physical exam during a tele-health visit (82.4%) and did not with-hold information they would have revealed in person (88.7%). After the COVID-19 pandemic, some patients would prefer tele-heath visits (39.2%), whereas others would prefer in office visits (28.5%) and the remainder were indifferent (32.3%). Post-pandemic, most patients would prefer tele-health for follow up visits (68.4%), over tele-health for all possible visits (27.9%) or no tele-health visits (3.8%). A total of 25 Canadian gastroenterologists (28.0% female;60% academic practice, 40% community practice) completed a separate survey. Regarding the lack of physical exam in tele-health, 44% of physicians believed this did not affect the quality of their assessment, whereas some physicians believed it had either minimally (48%) or greatly (8%) impaired the quality of their assessment. Almost all physicians (96%) perceived that patients either appreciate tele-health as much as or more than in office visits. Post-pandemic, most physicians (96%) supported a hybrid model of both tele-health and in office visits. Appointments for follow up of benign endoscopic pathology results (96%), follow up visits (92%), consultations prior to endoscopy (76%) were deemed to be most appropriate for tele-health. Follow up of malignant pathology results (24%) and consultations for new patients (32%) were thought to be less appropriate for tele-health visits. Conclusions: Patient and physician satisfaction with tele-health in a Canadian outpatient gastroenterology setting is high. Most patients and physicians wish for telehealth to remain available in the post-pandemic setting.
ABSTRACT
Background: With the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has increased. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology despite burden of chronic diseases such as inflammatory bowel disease (IBD). Aims: To assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various GI conditions. Methods: Retrospective chart analysis of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate. Results: A total of 241 patients were identified who were provided prescriptions during visit with their gastroenterologists. 128 patients were seen through in-person visit during pre-pandemic period. 113 patients were seen through telehealth appointment during COVID pandemic. The mean age of patients in telehealth cohort was 42 years (57% male). On average patients had 10 prior visits with their gastroenterologists before index appointment, used for adherence assessment. 92% of patients were seen in follow-up, while 8% were seen in initial consultation. The majority of the patients in the telehealth cohort had IBD (89%), while the remaining 11% had various diagnoses, including functional GI disorder, gastroesophageal reflux disease, viral hepatitis, or hepatobiliary disorders. Biologic therapy was the most commonly prescribed medication (66.4%). 45 patients were provided either new medication or dose change, and 68 patients had prescription refill to continue their current medications. It took a mean of 18 days (SD = 16.2) for patients to fill their prescriptions. Prescription fill rate for patients seen through telehealth and in-person visit were 98.2% and 89.1% (P = 0.004) respectively. Patients seen through telehealth were 6.8 times more likely to fill their prescriptions compared to the in-person counterparts (OR 6.82, CI 1.51 - 30.68, P = 0.004). When we compared adherence rate while excluding biologic therapies, the prescription fill rate was 94.7% in telehealth group and 81.4% in in-person group (OR 4.11, CI 0.88 - 19.27, P = 0.056). Due to high level of adherence, statistical analysis comparing adherent and non-adherent groups was performed but yielded insignificant results. Conclusions: Medication adherence rate for patients seen through telehealth was higher compared to patients seen through in-patient visit in this study. Telehealth is a viable alternative for outpatient care especially for patients with chronic GI conditions such as IBD.
ABSTRACT
Objective: Angiotensin converting enzyme 2 (ACE2) is the cellular entry point for severe acute respiratory syndrome coronavirus (SARS-CoV-2)-the cause of COVID-19 disease. However, the effect of RAS-inhibition on ACE2 expression in human tissues of key relevance to blood pressure regulation and COVID-19 infection has not previously been reported Design and method: We examined how hypertension, its major metabolic cophenotypes and antihypertensive medications relate to ACE2 renal expression using information from up to 436 patients whose kidney transcriptomes were characterised by RNA-sequencing. We further validated some of the key observations in other human tissues and/or a controlled experimental model Results: Our data reveal increasing expression of ACE2 with age in both human lungs and the kidney. We show no association between renal expression of ACE2 and either hypertension or common types of RAS inhibiting drugs. We demonstrate that renal abundance of ACE2 is positively associated with a biochemical index of kidney function and show a strong enrichment for genes responsible for kidney health and disease in ACE2 co-expression analysis Conclusions: Our results indicate that neither hypertension nor antihypertensive treatment are likely to alter the expression of the key entry receptor for SARSCoV-2 in the human kidney. Our data further suggest that in the absence of SARSCoV-2 infection, kidney ACE2 is most likely nephro-protective but the age-related increase in its expression within lungs and kidneys may be relevant to the risk of SARS-CoV-2 infection.