Inadvertent Treatment of a Vertical Banded Gastroplasty Stricture With a LAMS for Two Years

Introduction: Lumen-apposing metal stents (LAMS) are innovative endoscopic devices representing the next significant advancement in stent technology. LAMS have demonstrated success, most notably with improving drainage of pancreatic fluid collections. Other clinical indications for using LAMS include biliary drainage, gastroenterostomy, or the managment of luminal tract strictures. The stent has a larger lumen diameter than previously created stents as well as a unique "dumbbell" shape to limit migration. Studies have demonstrated advantages such as shorter procedure times and overall reduced repeat endoscopic procedures. As LAMS has gained notoriety, there have been increasing studies demonstrating potential complications of the device. Most common consequences of LAMS include bleeding, biliary stricture, and buried LAMS syndrome. As the anatomical design has decreased migration risk, prompt removal is recommended to prevent buried LAMS syndrome, where the stent is embedded in the wall of the gastric mucosa and can eventually not be visualized endoscopically. In this case, we will present a patient with an endoscopically placed LAMS, which was successfully removed with minimal complications after two years in place. Case Description/Methods: Our patient is a 68 year old female with a Vertical Banded Gastroplasty Stricture. She had required multiple repeat endoscopies for dilation therapy but the stricture was refractory to dilation, as a result, she underwent LAMS placement Due to the onset of the COVID pandemic, patient was lost to follow up. On a repeat EGD two years after placement, the stent remained in its original location. There were signs of mild gastric tissue overgrowth at the right lateral side of the LAMS. The stent was then removed easily with no signs of bleeding. After removal, the stricture remained dilated as the scope could be passed without difficulty. Over course of COVID she ate better than she had in years. (Figure) Discussion: LAMS have demonstrated significant success in a variety of endoscopic interventions. Their potential complications are well documented in various studies. This case is unique in regards to the length of time in which the LAMS remained in position. From a literature review, no study has demonstrated a LAMS in place as long as two years for stricture management. More remarkable is the lack of complications from the stent such as no bleeding with removal and no true buried LAMS syndrome as there was minimal tissue overgrowth. (Figure Presented).

Food supply chains and resilience to shocks: Evidence from India's COVID-19 lockdown

We study the disruption of food supply to households and reduced farm-to-market arrivals in India's food supply chain during the COVID-19 lockdown. We focus on the relationship between logistics quality (and performance) and the intensity of disruptions across India's states. We find four policy-relevant findings: (1) Food consumption expenditure was higher in states with better logistics quality;(2) These states recovered more quickly from farm-to-market disruptions with higher agricultural market arrivals in the later phases of the lockdown;(3) Rural food supply chains turned out to be as vulnerable as urban ones;and (4) Expenditure on cereals and pulses faced large reductions. © 2023 Agricultural & Applied Economics Association.

Myasthenia gravis amidst COVID-19

Purpose: The aim is to review immunological triggers as well as beneficial treatment regimens and their considerations in managing Myasthenia Gravis patients with varying severity of COVID-19. Methods: A systematic review was performed on 63 articles through an extensive search of PubMed, Science Direct, Google scholar, JAMA, and Scopus databases from the onset of COVID-19 to date using keywords, 'COVID-19,' 'Myasthenia Gravis,' 'Neuromuscular disease,' 'Immunosuppressants,' and 'Immunomodulators.' We excluded other neuromuscular disorders and included 18 articles of COVID-19 patients with Myasthenia Gravis. No exclusions were made for age, sex, or geographical regions. Results: During this COVID-19 pandemic, we need to be watchful for neuromuscular complications that may be directly or indirectly related to coronavirus infection. Coronavirus, through molecular mimicry, forms autoantibodies against the neuromuscular junction that might trigger immune-mediated disorders such as Myasthenia Gravis (MG). MG patients on immunosuppressive or immunomodulatory therapy are predisposed to COVID- 19, manifesting severe complications. Steroids have varied effects on COVID-19 patients depending on their stage of infection, not effective in earlier infection but beneficial in ARDS by inhibiting chemokine production. IL-6 is an inflammatory marker found in COVID-19 and MG patients, which can be associated with a higher mortality rate. Experimental therapies for COVID-19, such as combined use of azithromycin and hydroxychloroquine, may trigger a myasthenic exacerbation or crisis. Hydroxychloroquine is known to result in potential neuromuscular side effects. Diaphragm hemiparesis was possibly induced secondary to the myasthenic crisis in the setting of a viral illness and azithromycin's recent use. Conclusions: Routine treatment for MG should be tailored depending on the COVID-19 severity. Steroids and immunomodulators should be used with caution in MG patients. However, limited data exist on how COVID-19 affects people with Myasthenia Gravis.