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1.
Foundations of Data Science ; 3(3):479-541, 2021.
Article in English | Scopus | ID: covidwho-2080575

ABSTRACT

The disparity in the impact of COVID-19 on minority populations in the United States has been well established in the available data on deaths, case counts, and adverse outcomes. However, critical metrics used by public health officials and epidemiologists, such as a time dependent viral reproductive number (Rt), can be hard to calculate from this data especially for individual populations. Furthermore, disparities in the availability of testing, record keeping infrastructure, or government funding in disadvantaged populations can produce incomplete data sets. In this work, we apply ensemble data assimilation techniques which optimally combine model and data to produce a more complete data set providing better estimates of the critical metrics used by public health officials and epidemiologists. We employ a multi-population SEIR (Susceptible, Exposed, Infected and Recovered) model with a time dependent reproductive number and age stratified contact rate matrix for each population. We assimilate the daily death data for populations separated by ethnic/racial groupings using a technique called Ensemble Smoothing with Multiple Data Assimilation (ESMDA) to estimate model parameters and produce an Rt(n) for the nth population. We do this with three distinct approaches, (1) using the same contact matrices and prior Rt(n) for each population, (2) assigning contact matrices with increased contact rates for working age and older adults to populations experiencing disparity and (3) as in (2) but with a time-continuous update to Rt(n). We make a study of 9 U.S. states and the District of Columbia providing a complete time series of the pandemic in each and, in some cases, identifying disparities not otherwise evident in the aggregate statistics. © American Institute of Mathematical Sciences.

2.
Lung Cancer ; 165:S76, 2022.
Article in English | EMBASE | ID: covidwho-1996678

ABSTRACT

Introduction: It is rare for pulmonary SCLC to present as a cavitating lesion unlike non-small-cell-cancer (NSCLC). Hence, if a cavitating lesion is found with histo-pathology showing SCLC, it is important to rule out alternate diagnosis e.g., infection [1]. Case: We present the case of a 41-year-old-male of Bangladeshorigin. He was referred on 2ww-pathway to UHL Glenfield hospital lung cancer team for haemoptysis. Clinical assessment (05/12/2019) revealed that he had 4kg weight loss/haemoptysis/anorexia/fatigue. He was a current smoker (10 pack-years) with no significant past/ family history. He worked in a restaurant. Clinical examination was unremarkable. Chest x-ray showed left-hilar-mass. CT scan revealed 3.2cm mass with peripheral cavitation and mild focal enhancement without calcification/mediastinal-lymphadenopathy. Differentials included cancer/rheumatoid arthritis/infection. Bloods including ANCA/ANA/rheumatoid factor and bronchial-washings microbiology/cytology were unremarkable. He was given antibiotics. He did not attend subsequent 2 out-patient-appointments. Repeat CT scan (March 2020) showed growing lesion with focally dilated vessel. CT-guided biopsy was advised but he declined it due to COVID19 pandemic. In May 2020, he agreed to undergo CT-guided biopsy. However, pre-procedure CT scan showed possible pseudoaneurysm. CT-guided biopsy was deemed high-risk and not attempted. Lung cancer MDT advised lobectomy given diagnostic dilemma. Patient declined surgery. CT in November 2020 showed progressive lesion. Patient still was not keen for surgery. He was admitted in June 2021 with haemoptysis. CT scan showed progressive cavitating disease with necrotic left hilar/mediastinal lymph nodes. He underwent EBUS-TBNA that confirmed SCLC. Given cavitating lesion and long history, left lower lobe lesion was deemed unlikely to be due to SCLC. He was referred to infectious disease (ID) clinic. Blood parasitology screen revealed positive Hydatid ELISA. He did not attend subsequent outpatient appointments in Oncology/ID clinics and has been discharged. Learning points: There were two pathologies: hydatid cyst (Fig. 1a);SCLC developed between November 2020 and June 2021 (Fig. 1b). 1) To look for cause of a cavitating lesion even if SCLC is diagnosed. 2) To consider hydatidcyst in lung-cavity differentials.(Figure Presented) Fig. 1

3.
Cancer Research ; 82(12), 2022.
Article in English | EMBASE | ID: covidwho-1986509

ABSTRACT

African Americans (AA) have higher incidence and mortality rates for several cancer types in comparison to their European American (EA) counterparts. Increasing participation in clinical research and patient registries, related to precision cancer medicine, will significantly improve cancer health equity. Many AA cancer patients are treated in community oncology clinics. Unfortunately, these health systems have limited access to Clinical Laboratory Improvement Amendments (CLIA) next generation sequence (NGS) germline and somatic DNA and RNA testing that are used to inform oncologists on the best treatment and/or clinical trial options for cancer patients. Indeed, AA CLIA NGS sample sets are poorly represented, which could presumably result in incomplete knowledge of genomic variants that could affect their treatment and overall outcomes. Hence, it is crucial to implement CLIA NGS efforts for all cancer patients. To address these disparities, Morehouse School of Medicine has formed the Comprehensive Approach to Reimagine health Equity Solutions (CARhES) consortium with Tuskegee University that has engaged community oncology practices in Alabama and Georgia - two of five Black Belt states. The CARhES consortium aims to implement precision cancer medicine to underserved and underrepresented communities that will improve the standard of cancer care by providing access to CLIA NGS testing, clinical trials, and personalized cancer care. Here we describe the first proof of concept of this approach with community oncology partners, i.e., Grady Health System, Wellstar Health System, Georgia Urology, Midtown Urology, and Maui Memorial Medical Center. At the time of consent, saliva, buccal, and tumor samples were collected from participants. Germline and somatic CLIA NGS was performed, and medical reports were returned to practitioners within 14 days. Prior to the COVID pandemic, the study enrolled over 880 patients with a 88% consent rate (n = 1000) in the first 11months of the program. At the start of the COVID pandemic, recruitment efforts were suspended for four months with a slow restart by June 2020. A decrease in the number of staff, office visits (67% reduction), and increase in COVID cases significantly limited recruitment efforts. During this slowdown, we established and improved eConsenting capabilities, which exist today. Community anxiety, due to the pandemic and SARS-CoV-19 vaccine efforts, resulted in a significant reduction in consent rates (88% to 60%). Nevertheless, this study began in April of 2019 and consented 1,750 participants in less than 2 years. Taken together, our study shows that a community-focused precision medicine approach requires meeting people where they are and providing them with access and understanding the benefit of clinical trial participation. The approximate 2,000 clinically annotated genomic AA datasets will greatly contribute to our understanding of cancer health disparities and among the first steps to democratize precision medicine.

4.
BMJ Global Health ; 7:A7, 2022.
Article in English | EMBASE | ID: covidwho-1968251

ABSTRACT

Introduction The onset of the COVID-19 pandemic in early 2020 triggered reorganisation of hospital departments around the world as resources were configured to prioritise critical care. In spring 2020, NHS England issued national guidance proposing acceptable time intervals for postponing different types of surgical procedures for patients with cancer and other conditions. The 'Consider-19' study sought to investigate prioritisation decisions in practice, with in-depth examination of colorectal cancer surgery as a case-study, given recommendations that these procedures could be delayed by up to 12 weeks. Methods Twenty-seven semi-structured interviews were conducted with healthcare professionals between June - November 2020. A key informant sampling approach was used, followed by snowballing to achieve maximum regional variation across the UK. Data were analysed thematically using the constant comparison approach. Results Interviewees reported a spectrum of perceived disruption to colorectal cancer surgery services in the early phase of the pandemic, with some services reporting greater scarcity of resources than others. Nonetheless, all reported a need to prioritise patients based on local judgments. Prioritisation was framed by many as unfamiliar territory, requiring significant deliberation and emotional effort. Whilst national guidance provided a framework for prioritising, it was largely left to local teams to devise processes for prioritising within surgical specialities and then between different specialities, resulting in much local variation in practice. Discussion The pandemic necessitated a significant change in practice as surgeons, in a tense and uncertain situation, found themselves having to navigate clinically, emotionally, and ethically- charged decisions about how best to use limited surgical resources. Whilst unavoidable, many felt uncomfortable with the task and the consequences for their patients. The findings point to a need to better support surgeons tasked with prioritising patients and raise questions about who should be involved in this activity.

5.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925139

ABSTRACT

Objective: To assess adaptive immunity to SARS-CoV-2 in anti-CD20 treated individuals with mRNA vaccination as it relates to spike binding IgG, neutralizing antibody titers, and T cell response. Background: Anti-CD20 therapies attenuate humoral responses to vaccines. Their effect on T cell responses is unclear. We examined B and T cell responses with COVID-19 vaccination in patients receiving anti-CD20 therapy for multiple sclerosis (MS) and other autoimmune inflammatory neurologic diseases (AINDs). Design/Methods: Patients on anti-CD20 therapies were prospectively enrolled for longitudinal analysis of antibody and T cell responses before and after COVID-19 vaccination. Serum antibodies against the receptor-binding domain of the S1 spike protein (RBD-S1 IgG), neutralizing antibodies, and SARS-CoV-2 CD4 and CD8 T cell levels responses using activation-induced markers and INF-gamma release assay were measured at various time points including pre-vaccination, less than 12 weeks and greater than 12 weeks post initial vaccination series, and 4 and 12 weeks after 3rd “booster” vaccination. Results: Twenty-five MS and AIND participants are enrolled as of 10/11/21 with projected enrollment complete by December 2021 (50-60 total). Preliminary results for 17 of these patients (mean age 44 years-old, 83% female, 16 Pfizer, 1 Moderna) demonstrated attenuated RBD IgG antibody responses. However, CD8 T cell response is robust compared to non-immunosuppressed, age-matched controls (n=22) less than 12 weeks after two dose series (p value = 0.0069) and sustained long-term (>12 weeks) in all eight anti-CD20 patients tested thus far. Additional analysis will include comparison between pre and post 3rd vaccination at 4- and 12-week timepoints. Conclusions: Early results suggest that patients treated with anti-CD20 therapy generate a robust CD8 T cell response to SARS-CoV-2 mRNA post initial series of vaccination but remain with attenuated humoral immune responses. Our observational study will provide important data to guide vaccine management in patients on or anticipating anti-CD20 therapy.

6.
NPJ Vaccines ; 7(1): 57, 2022 May 26.
Article in English | MEDLINE | ID: covidwho-1864747

ABSTRACT

The response by vaccine developers to the COVID-19 pandemic has been extraordinary with effective vaccines authorized for emergency use in the United States within 1 year of the appearance of the first COVID-19 cases. However, the emergence of SARS-CoV-2 variants and obstacles with the global rollout of new vaccines highlight the need for platforms that are amenable to rapid tuning and stable formulation to facilitate the logistics of vaccine delivery worldwide. We developed a "designer nanoparticle" platform using phage-like particles (PLPs) derived from bacteriophage lambda for a multivalent display of antigens in rigorously defined ratios. Here, we engineered PLPs that display the receptor-binding domain (RBD) protein from SARS-CoV-2 and MERS-CoV, alone (RBDSARS-PLPs and RBDMERS-PLPs) and in combination (hCoV-RBD PLPs). Functionalized particles possess physiochemical properties compatible with pharmaceutical standards and retain antigenicity. Following primary immunization, BALB/c mice immunized with RBDSARS- or RBDMERS-PLPs display serum RBD-specific IgG endpoint and live virus neutralization titers that, in the case of SARS-CoV-2, were comparable to those detected in convalescent plasma from infected patients. Further, these antibody levels remain elevated up to 6 months post-prime. In dose-response studies, immunization with as little as one microgram of RBDSARS-PLPs elicited robust neutralizing antibody responses. Finally, animals immunized with RBDSARS-PLPs, RBDMERS-PLPs, and hCoV-RBD PLPs were protected against SARS-CoV-2 and/or MERS-CoV lung infection and disease. Collectively, these data suggest that the designer PLP system provides a platform for facile and rapid generation of single and multi-target vaccines.

7.
British Journal of Surgery ; 109:1, 2022.
Article in English | Web of Science | ID: covidwho-1799462
9.
British Journal of Surgery ; 109(SUPPL 1):i44, 2022.
Article in English | EMBASE | ID: covidwho-1769184

ABSTRACT

Introduction: Routine operative treatment of appendicitis was temporarily interrupted during the COVID-19 pandemic. Non-operative management in suspected appendicitis makes a definitive diagnosis difficult. This study investigated diagnostic outcomes of suspected appendicitis patients before and during COVID-19. Method: A retrospective review of patients aged 16-45 undergoing treatment for suspected appendicitis pre-COVID-19 (1st January 2019- 1st January 2020) and during the COVID-19 pandemic (1st March 2020 to 31st June 2020) was performed. Patients were followed up for one year (31st June 2021) to explore diagnostic outcomes. Results: At one year follow up, 206 patients were identified in the pre-COVID-19 cohort with 100% (n=206) undergoing an appendicectomy. On histopathological examination 77.2% (n=159) had appendicitis;10.7% (n=22) another pathology;2.9% (n=6) neuroendocrine tumour. There were 62 patients in the COVID-19 cohort in which 79% (n=49) underwent appendicectomy (56% (n=35) immediate appendicectomy;23% (n=13) interval appendicectomy). On histopathological examination 61% (n=38) had appendicitis;13% (n=8) another pathology;5% (n=3) neuroendocrine tumour. Of the remaining 13/62 patients, one had undergone a CT scan and colonoscopy for gastrointestinal symptoms demonstrating signs of chronic caecal inflammation treated conservatively. One underwent a CT scan alone for gastrointestinal symptoms finding no pathology. The remaining 11/62 patients had no further reported symptoms or diagnostics. Conclusions: This study demonstrates that the risk of appendiceal malignancy and chronic inflammation is important in non-operative management of suspected appendicitis and establishing consistent follow up pathways is essential.

10.
Open Forum Infectious Diseases ; 8(SUPPL 1):S191-S192, 2021.
Article in English | EMBASE | ID: covidwho-1746727

ABSTRACT

Background. Multiple studies have shown that antibiotic utilization increased during the COVID-19 pandemic. However, the impact of this increased utilization has not been well established. The aim of this study is to describe the trends in minimum inhibitory concentrations for various antibiotics against common gram-negative pathogens observed since the start of the COVID-19 pandemic as compared to previous years. Methods. This retrospective study was conducted at the Memphis VA. All respiratory, urine, and blood culture MicroScan results run from October 2017-March 2021 were analyzed. Only inpatient and emergency department data was included. The MIC50 and MIC90 of seven antibiotics for four of the most common pathogens were trended by quarterly intervals. Results. MIC50 and MIC90 were compared using standardized breakpoints. As compared to previous years, Pseudomonas aeruginosa was noted to have the most sustained increase in MIC90 across various antibiotics. In the last 3 quarters of the study time frame, piperacillin-tazobactam mean MIC90 increased from 32 to 64, cefepime from 8 to > 16, and meropenem from 4 to > 8. Escherichia coli had a sustained increase in ceftriaxone MIC90 from < 1 to > 8 in the final quarter of 2020 and beginning of 2021. Klebsiella pneumonia was also found to have a sustained increase in cefepime mean MIC90 from < 1 to > 16 during the year of 2020, with return to previous MIC90 the following quarters. Conclusion. Previous studies have clearly demonstrated a widespread increase in antibiotic utilization during the COVID era. Our study demonstrates how even short-term increases in antibiotic use can lead to shifts in MIC, if not outright resistance. This was demonstrated across multiple common gram-negative pathogens and to various broad-spectrum antibiotics which were commonly used more frequently during COVID-19. Further analysis will be needed to determine whether these trends continue or whether the decrease in antibiotic utilization in the recent months will lead to similar decrease in MIC.

12.
British Journal of Surgery ; 108:1, 2021.
Article in English | Web of Science | ID: covidwho-1537487
13.
British Journal of Surgery ; 108:1, 2021.
Article in English | Web of Science | ID: covidwho-1535628
14.
British Journal of Surgery ; 108:148-148, 2021.
Article in English | Web of Science | ID: covidwho-1535314
15.
Diseases of the Esophagus ; 34(SUPPL 1):67, 2021.
Article in English | EMBASE | ID: covidwho-1501063

ABSTRACT

Esophageal leaks present a significant management challenge, especially in patients with delayed presentation and established sepsis. Endoluminal vacuum therapy (EVT) is an emerging treatment strategy which may reduce morbidity and mortality compared to traditional treatments in this patient group. We report the outcomes for patients with esophageal leaks from a range of different causes that were treated with EVT in a tertiaryUKhospital over a 10-year period. Methods: Between April 2011 and March 2021, 45 patients with a median age of 67 years (31-92) who had an esophageal leak were treated with EVT. All patients were treated with an ad-hoc endoluminal vacuum device (EVD) constructed using V.A.C GRANUFOAMTM (KCI) and a standard nasogastric (Ryles) tube. The median Apache II score for patients at the time of leak diagnosis was 20 (6-36). The cause of the leak was anastomotic in 16 patients (36%), iatrogenic in 14 patients (31%), spontaneous in 14 patients (31%), and traumatic in 1 patient (2%). Information related to treatment and outcome was recorded prospectively. Results: Successful resolution of the leak was achieved in 39 (87%) patients. The median number of EVD changes required to heal the leak was 6 (1- 17). There were no complications related to insertion of the EVD. The median length of hospital stay was 49 days (1-108). Six (13%) patients died during treatment. Six (13%) patients had complications during treatment requiring further intervention;2 (4%) had a significant bleed requiring angiography and aortic stent placement, 1 (2%) had a stroke, 1 (2%) had a pulmonary embolism, 1 (2%) had a myocardial infarction, and 1 (2%) contracted COVID-19. Conclusion: EVT is a safe and effective treatment that can be used successfully to treat esophageal leaks froma disparate range of leak causes in selected critically unwell patients. Further studies are required to develop a standardized procedure and management pathway which will enable broader adoption of EVT in this group of patients.

16.
Multiple Sclerosis Journal ; 27(2 SUPPL):158-160, 2021.
Article in English | EMBASE | ID: covidwho-1495981

ABSTRACT

Introduction: Inebilizumab is approved in the USA and Japan for aquaporin 4 immunoglobulin (Ig)G seropositive neuromyelitis optica spectrum disorder (NMOSD). Objective: Report final safety and efficacy data from the N-MOmentum trial of inebilizumab in NMOSD. Methods: Participants with NMOSD (aged 18+, EDSS score of ≤8, recent history of attacks) were randomized 3:1 to inebilizumab or placebo monotherapy for 28 weeks or up to attack occurrence;the randomized controlled period (RCP). Primary outcome was time to adjudicated attack. Participants could then enter the inebilizumab open label period (OLP). Final study data are presented, including attack risk and safety outcomes. Results: Of the 230 participants randomized and dosed, 216 (93.9%) entered and 174 (80.6%) completed the OLP. In the RCP, 87.0% were attack free with inebilizumab and 59.9% with placebo (72.8% risk reduction, p<0.001). In the OLP, 87.7% were attackfree in those continuing inebilizumab and 83.4% in those switched from placebo. Regardless of randomization, 225 participants received inebilizumab. Mean (SD) treatment duration was 3.2 (1.4) years;36.8% were treated for >4 years (maximum of 5.5 years). Total exposure was 730.36 person-years (py) with an annualized attack rate of 0.092;40/63 (63.5%) attacks occurred in the first year. Treatment-emergent adverse events (AE) were reported by 89 (39.6%) participants, most frequently urinary tract infection (26.2%), nasopharyngitis (20.9%) and arthralgia (17.3%). Infusion-related reactions with inebilizumab occurred in 28 (12.9%) participants (rate per 100-py: whole study, 11.1;RCP, 37.6). The rate (95% confidence interval) of infections per 100-py did not increase with continued treatment: year 1, 116.3 (102.4-131.6);year 2, 68.1 (57.2-80.6);year 3, 61.9 (50.3-75.5);year 4, 55.1 (41.7-71.4). 105 participants had transient low IgG (<700 mg/dL) during treatment, but no correlations were found between the worst IgG, IgM or IgA levels recorded and the occurrence of any infection or an infection ≥ grade 3 (Fisher exact test, all p>0.05). Three trial participants died: one from complications of NMOSD attack, one from a CNS event of unclear etiology and one due to COVID-19, after 9, 224 and 1225 days of inebilizmab treatment, respectively. Conclusions. During the 5.5 years of N-MOmentum, the risk of attack in participants receiving inebilizumab remained low with no evidence of unexpected serious adverse events, including serious infection.

17.
biorxiv; 2021.
Preprint in English | bioRxiv | ID: ppzbmed-10.1101.2021.11.08.467648

ABSTRACT

The response by vaccine developers to the COVID-19 pandemic has been extraordinary with effective vaccines authorized for emergency use in the U.S. within one year of the appearance of the first COVID-19 cases. However, the emergence of SARS-CoV-2 variants and obstacles with the global rollout of new vaccines highlight the need for platforms that are amenable to rapid tuning and stable formulation to facilitate the logistics of vaccine delivery worldwide. We developed a designer nanoparticle platform using phage-like particles (PLPs) derived from bacteriophage lambda for multivalent display of antigens in rigorously defined ratios. Here, we engineered PLPs that display the receptor binding domain (RBD) protein from SARS-CoV-2 and MERS-CoV, alone (RBD-SARS-PLPs, RBD-MERS-PLPs) and in combination (hCoV-RBD PLPs). Functionalized particles possess physiochemical properties compatible with pharmaceutical standards and retain antigenicity. Following primary immunization, BALB/c mice immunized with RBD-SARS- or RBD-MERS-PLPs display serum RBD-specific IgG endpoint and live virus neutralization titers that, in the case of SARS-CoV-2, were comparable to those detected in convalescent plasma from infected patients. Further, these antibody levels remain elevated up to 6 months post-prime. In dose response studies, immunization with as little as one microgram of RBD-SARS-PLPs elicited robust neutralizing antibody responses. Finally, animals immunized with RBD-SARS-PLPs, RBD-MERS-PLPs, and hCoV-RBD PLPs were protected against SARS-CoV-2 and/or MERS-CoV lung infection and disease. Collectively, these data suggest that the designer PLP system provides a platform for facile and rapid generation of single and multi-target vaccines.

18.
BJS Open ; 5(SUPPL 1):i6, 2021.
Article in English | EMBASE | ID: covidwho-1493696

ABSTRACT

Background: During the Covid-19 pandemic, non-operative management for acute appendicitis (AA) was implemented in the UK. Aim of this study was to determine the efficacy and outcomes of conservative versus surgical management of AA during the pandemic. Materials & Methods: We conducted an observational study in a tertiary referral centre. Data was collected from patients (≥16 years) with a diagnosis of AA between 1st November 2019 to 10th March 2020 (pre-COVID period) and 10th March 2020 to 5th July 2020 (COVID period). Results: A total of 116 patients in the pre-COVID period were included versus 91 in the COVID period. 43.1% (n=50) of patients pre-COVID were classified as ASA 2 compared to 26.4% (n=24) during the COVID period (p-value =0.042). 72.5% (n=66) of the patients during the COVID period scored as high risk using the Alvarado score compared to 24.1% (n=28) in the pre-COVID period (p-value<0.001).We observed a significant increase in radiological evaluation, 69.8% versus 87.5% of patients had a CT in the pre-COVID and COVID periods respectively (p-value=0.008). 94.9% of patients were managed operatively in the pre-COVID period compared to 60.4% in the COVID period (p-value<0.001). We observed more open appendicectomies (37.3% versus 0.9%;p-value<0.001) during the COVID period compared to the pre-COVID period. More abscess formation and free fluid were found intraoperatively in the COVID period (p-value= 0.021 and 0.023 respectively). Re-attendance rate due to appendicitis-related issues was significantly higher in the COVID period (p=0.027). Conclusion: Radiological diagnosis of AA was more frequent during the COVID period. More conservative management for AA was employed during the COVID-19 pandemic, and for those managed operatively an open approach was preferred. Intra-operative findings were suggestive of delayed presentation during the COVID period without this affecting the length of hospital stay.

19.
United European Gastroenterology Journal ; 9(SUPPL 8):878, 2021.
Article in English | EMBASE | ID: covidwho-1490918

ABSTRACT

Introduction: Upper gastrointestinal (UGI) leaks present a significant management challenge, especially in patients with delayed presentation and established sepsis. Traditional treatment strategies such as surgery are associated with high mortality rates. Endoluminal vacuum therapy (EVT) is an emerging treatment option which may reduce morbidity and mortality compared to traditional treatments in this group of patients. We report the outcomes for patients with UGI leaks treated with EVT in a tertiary UK hospital over a 10-year period. Aims & Methods: Between April 2011 and April 2021, 66 patients with UGI leaks from different causes were treated with EVT using an ad-hoc endoluminal vacuum device (EVD). The EVD was constructed using a piece of open cell foam sutured around the distal end of a nasogastric tube, and placed endoscopically either through the perforation and into the extra-luminal leak cavity or intraluminally depending on the morphology of the leak cavity. Continuous negative pressure (125 mmHg) was applied. Endoscopic re-evaluation of the leak cavity with a change of the EVD was performed every 48-120h depending on the patients clinical condition. Patients were fed enterally, and treated with broad-spectrum antibiotics and anti-fungal medication until healing was complete. Information related to treatment and outcome was recorded prospectively. Results: Patients had a median age of 67 years (range 25-92), and mean Apache II score of 21 (range 6-36) at the time of leak diagnosis. Fifty-one (77%) leaks were oesophageal, 12 (18%) gastric, 2 (3%) duodenal, and 1 (2%) pharyngeal. The cause of the leak was anastomotic in 24 patients (36%), iatrogenic in 21 patients (32%), spontaneous in 20 patients (30%), and traumatic in 1 patient (2%). The median number of EVD changes required to heal the leak was 6 (range 1-27), and the median length of hospital stay was 44 days (range 1-196). Successful resolution of the leak occurred in 58 (88%) patients. Eight (12%) patients died during treatment. There were no complications related to insertion of the EVD. Nine (14%) patients had complications during treatment which required further intervention including bleeding in 4 patients (6%), a cerebrovascular accident in 1 patient (2%), a pulmonary embolism in 1 patient (2%), a myocardial infarction in 1 patient (2%), and COVID-19 infection in 2 patients (3%). Following resolution of the leak, one patient (2%) developed a stricture which required endoscopic dilation. Conclusion: EVT is a safe and effective treatment for UGI leaks, and can be used successfully to treat a disparate range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to improve the ease with which EVT can be delivered, and enable broader adoption of EVT for this group of patients.

20.
Journal of the American College of Surgeons ; 233(5):e62-e63, 2021.
Article in English | EMBASE | ID: covidwho-1466563

ABSTRACT

Introduction: Management of upper gastrointestinal (UGI) leaks is challenging, especially in patients with delayed presentation and established sepsis. Endoluminal vacuum therapy (EVT) is an emerging treatment strategy which may reduce morbidity and mortality compared to traditional treatments in this patient group. We report the outcomes for patients with UGI leaks treated with EVT in a tertiary UK hospital over a 10-year period. Methods: Between April 2011 and February 2021, 63 patients with UGI leaks from different causes were treated with EVT using an ad-hoc endoluminal vacuum device (EVD). Information related to treatment and outcome was recorded prospectively. Results: Patients had a median age of 67 years (25-92), and mean Apache II score of 20.7 (6-36) at the time of leak diagnosis. The cause of the leak was anastomotic (n=23;37%), iatrogenic (n=20;32%), spontaneous (n=19;30%), and traumatic (n=1;2%). Forty-seven (75%) leaks were oesophageal, 12 (19%) gastric, 2 (3%) duodenal, and 1 (2%) pharyngeal. The median number of EVD changes required to heal the leak was 9 (1-27), and median length of hospital stay was 31 days (1-196). Successful resolution of the leak occurred in 55 (87%) patients. Eight (13%) patients died during treatment. There were no complications related to insertion of the EVD. Eight (13%) patients had complications during treatment which required further intervention including bleeding (n=4;6%), stroke (n=1;2%), pulmonary embolus (n=1;2%), myocardial infarction (n=1;2%) and COVID-19 (n=1;2%). Conclusion: EVT is safe, and can be used to successfully treat UGI leaks from a disparate range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to enable broader adoption of EVT in this group of patients.

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