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Introduction: Croatian National Cancer Registry of Croatian Institute for Public Health reported that in year 2020 lung cancer was the second most common cancer site diagnosed in men with 16% and the third most common in women with 10% incidence among all cancer sites. Unfortunatelly lung cancer has the highest mortality in both men and women. Haematological malignancies had 7% share in all malignancies in both male and female cances cases. In 2020 190 newly diagnosed cases of lymphatic leukemia in men and 128 cases in women were reporeted, meaning 1.5 and 1.2% of all malignancies, respectively. Chronic lymphatic leukemia (CLL) is an advanced age disease and incidence increases with age. Impaired immunity, T and B cell dysfunction in CLL, chromosomal aberations, long-term immunosuppressive therapy and genetic factors can all cause secondary malignancies. Co- occurence of solid tumors and CLL is very rare. Although patiens with CLL have an increased risk of developing second primary malignancies including lung carcinoma, the data about their clinical outcomes are lacking. Parekh et al. retrospectively analyzed patients with simultaneous CLL and lung carcinoma over a 20-year period, and they found that ~2% of patients with CLL actually developed lung carcinoma. The authors claimed that up to 38% of patients will also develop a third neoplasm more likely of the skin (melanoma and basal cell carcinoma), larynx (laryngeal carcinoma) or colon. Currently there are no specific guidelines for concurrent CLL and non-small cell lung carcinoma (NSCLC) treatment. Usually, when the tumors are diagnosed simultaneously, treatment is based to target the most aggressive malignancy, as the clinical outcomes depend on the response of the tumor with the poorest prognosis. For this reason, a multidisciplinary approach is mandatory. Case report: A patient with history of coronary heart disease, myocardial infarction and paroxysmal atrial fibrillation was diagnosed in 2019 (at the age of 71) with B chronic lymphocytic leukemia with bulky tumor (inguinal lymph nodes 8x5 cm), stage B according to Binet, intermediate risk. He was treated with 6 cycles of chemoimmunotherapy (rituximab/cyclofosfamid/fludarabine). In 10/2019 remission was confirmed, but MSCT described tumor in the posterior segment of upper right lung lobe measuring 20x17 mm and bilateral metastases up to 11 mm. Bronchoscopy and biopsy were performed, and EGFR neg, ALK neg, ROS 1 neg, PD-L1>50% adenocarcinoma was confirmed. He was referred to Clinical Hospital Center Osijek where monotherapy with pembrolizumab in a standard dose of 200 mg intravenously was started in 01/2020. Partial remission was confirmed in October 2020. Immunotherapy was discontinued due to development of pneumonitis, dysphagia and severe weight loss (20kg), but without radiologically confirmed disease progression. At that time he was referred to our hospital for further treatment. Gastroscopy has shown erosive gastritis with active duodenal ulcus, Forrest III. Supportive therapy and proton pump inhibitor were introduced. After complete regression of pneumonitis, improvement of general condition and resolution of dysphagia, no signs of lung cancer progression were found and pembrolizumab was reintroduced in 12/2021. Hypothyroidism was diagnosed in 01/2021 and levothyroxine replacement ther apy was started. In 03/2021 he underwent surgical removal of basal cell carcinoma of skin on the right temporal region with lobe reconstruction. From 02/2021, when pembrolizumab was reintroduced, regression in tumor size was continously confirmed with complete recovery of general condition. He was hospitalized for COVID 19 infection in 09/2021, and due to complications pembrolizumab was discontinued till 11/2021. Lung cancer immunotherapy proceeded till 11/2022, when Multidisciplinary team decided to finish pembrolizumab because of CLL relapse. CLL was in remission till August 2022 when due to B symptoms, lymphcytosis, anemia and generalized lymphadenopathy, hematological workup including biopsy of cervical lymph node was performed and CLL/SLL relapse was confirmed. Initially chlorambucil was introduced, but disease was refractory. Based on cytogenetic test results (IGHV unmutated, negative TP53) and due to cardiovascular comorbidity (contraindication for BTK inhibitors) venetoclax and rituximab were started in 01/2023. After just 1 cycle of treatment normal blood count as well as regression of B symptoms and peripheral lymphadenopathy occured, indicating the probability of complete disease remission. In our patient with metastatic lung adenocarcinoma excellent disease control is achieved during 41 month of treatment in first line setting. Furthermore, relapsed/refractory CLL/SLL is currently in confirmed remission. Conclusion(s): Successful treatment of patients with multiple primary malignancies is based on multidisciplinarity, early recognition and management of side effects, treatment of comorbidities with the aim of prolonging life, controlling symptoms of disease and preserving quality of life.
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The most common causes of acute hepatitis in children are hepatitis A and autoimmune hepatitis. Hepatitis in the course of Wilson's disease is sporadically registered in adolescents. An increase of activity of aminotransferases both in the course of multisystem inflammatory syndrome in children (MIS-C) and in the course of COVID-19 has been observed. Hepatitis is common in children with MIS-C and is associated with a more severe presentation and persistent elevation of liver function tests. To date, no cases of acute hepatitis in children due to COVID-19 have been reported. We present 2 cases of acute hepatitis in children where the only cause seems to be a previous asymptomatic SARS-CoV-2 infection.Copyright © 2023 Termedia Publishing House Ltd.. All rights reserved.
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Summary Background Objectives Methods Results Main limitations Conclusion The natural progression of equine glandular gastric disease (EGGD) in the absence of treatment has not yet been described in the literature, nor has the prevalence in a teaching herd population been reported.The aims of this study were to determine the prevalence of disease in a teaching population over the study period (2019–2021) and to observe the changes over time in disease severity of naturally occurring diseases (not experimentally induced) without medical intervention.Twenty‐one horses underwent an initial gastroscopy and a repeat gastroscopy between 14 and 731 days later. Gastroscopy data were graded quantitatively and described qualitatively. Prevalence and 95% confidence intervals (CI) were calculated. The changes over time were determined by comparing initial and repeat gastroscopies.The prevalence from initial, repeat and total number of gastroscopies was 62% (95% CI: 40.8–79.3), 71% (95% CI: 50.0–86.2) and 67% (95% CI: 51.6–79), respectively. The changes over time included worsening of disease in 29% of horses (95% CI: 13.8–50.0), improvement of disease to a lower grade in 24% (95% CI: 10.6–45.1), no change in grade in 38% (95% CI: 20.8–59.1), and complete resolution of disease to grade 0 in 10% (95% CI: 2.7–28.9).Limitations included a maximum of two gastroscopies per horse given COVID‐19 restrictions on data collection, and highly varied interval times between initial and repeat gastroscopies.In conclusion, there is a high prevalence of disease in this teaching herd. The changes over time in naturally occurring diseases without medical intervention might include worsening, improvement, no change or resolution of disease. [ FROM AUTHOR] Copyright of Equine Veterinary Education is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
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Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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Background: COVID-19 has significantly disrupted cancer care. This has impacted on staging, management and survival of gastric cancer as health services worldwide had to adapt. Responding to the pandemic, the UK government declared a national lockdown on 23 March 2020. Our aim was to determine the impact of COVID-19 and socio-economic deprivation on patients with newly diagnosed gastric cancers. Method(s): This was a retrospective cohort study. Consecutive new patients presenting in NHS Scotland to five regional OG cancer MDTs covering 93.2% of the Scottish population between October 2019 and September 2020 were identified. Gastric cancers were included and electronic health records were reviewed. Patient's residential address was used to calculate Scottish Index of Multiple Deprivation (SIMD). Patients were divided into two groups: Most deprived (SIMD 1-5) and least deprived (SIMD 6-10) and results compared. The study period was divided into pre- and post-lockdown, based on the first UK national lockdown of 23 March 2020. Result(s): 269 patients were diagnosed with gastric cancer;4 (1.5%) were excluded due to unrecognised postcode. 173 (65.3%) were male and the median age was 73 years (range 29-94). 143 (54.0%) were in most deprived and 122 (46.0%) were in least deprived group. Deprivation and lockdown: Age, sex, ECOG performance status and route of referral were not significantly different. No clinically meaningful difference in median time to gastroscopy was observed (16.5 vs 17 days). Stage 4 cancer were more commonly observed in most deprived group (60.8% vs 52.1%). In whole cohort, the palliative care intent was higher post-lockdown (70% vs 83.2%, p=0.033). Palliative intent treatment increased in the most deprived group from 74.3% to 81.2% and in least deprived from 65.2% to 85.7% (p=0.092). The median survival for the whole cohort decreased post-lockdown (9.0 vs 6.9 months, p=0.14), but did not reach statistical significance. The medial survival did not change for the most deprived group (7.6 vs 7.1 months, p=0.840), however it decreased significantly for the least deprived group post-lockdown (11 vs 6.7 months, p=0.014). A test of heterogeneity between lockdown period and SIMD group supported the suggestion that the least deprived cohort did worse post-lockdown (HR 1.72, p=0.055). Conclusion(s): This national study highlights that the least deprived patients had survival advantage pre-lockdown, which has been completely lost post COVID-19 national lockdown. This disproportional impact on the least deprived patients could be because early cancers were not diagnosed in the least deprived population.
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Background: COVID-19 has significantly disrupted cancer care. This has impacted on staging, management and survival of oesophageal cancer as health services worldwide had to adapt. Responding to the pandemic, the UK government declared a national lockdown on 23rd March 2020. Our aim was to determine the impact of COVID-19 and socio-economic deprivation on patients with oesophageal cancers. Method(s): Thiswas a retrospective cohort study.Consecutivenewpatients presenting in NHS Scotland to five regional OG cancer MDTs covering 93.2% of the Scottish population between October 2019 and September 2020 were identified. Electronic health records were reviewed. Patient's residential address was used to calculate Scottish Index of Multiple Deprivation (SIMD). Patients were divided into two groups: Most deprived (SIMD 1-5) and least deprived (SIMD 6-10) and results compared. The study period was divided into pre- and post-lockdown, based on the first UK national lockdown on 23rd March 2020. Result(s): 728 patients with were identified, 5 were excluded due to unrecognised postcode. 365 (50.5%) were in the more deprived and 358 (49.5%) were in least deprived group. 488 (67.0%) were male and the median age was 71 years (range 25-95). Deprivation and lockdown: Age, sex, WHO performance status and route of referral was not significantly different. No clinically meaningful difference in median time to gastroscopy was observed. Palliative intent treatment increased in the most deprived from 67.0% to 71.4% and in least deprived from 54.0% to 74.0% (p=0.002). The overall survival for the whole cohort decreased post-lockdown (11.3 vs 7.8 months, p=0.001). Pre-lockdown the median survival for most deprived group was 8.9 vs 15 months for the least deprived group (p=0.001). Post-lockdown the median survival was similar irrespective of socioeconomic status (7.8 vs 6.9 months, p=0.99). The medial survival did not changed post-lockdown for the most deprived group (8.9 vs 7.8 months, p=0.480). However, the median survival for the least deprived group significantly decreased post lockdown (15 vs 6.9 months, p<0.001). A test of heterogeneity between lockdown period and SIMD group supported the suggestion that least deprived group did worse post-lockdown (HR 1.45, p=0.035). Conclusion(s): This national study highlights that the least deprived patients had survival advantage pre-lockdown, which has been completely lost due to the lockdown. This disproportionate impact on the least deprived patients could be because early cancers were not diagnosed in the least deprived population.
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Introduction: Pandemic restrictions delayed endoscopic Barrett's surveillance programmes with a risk of late or missed dysplasia and cancer diagnoses. We established a new Cytosponge service and surveillance pathway to address this risk and aid triage of patients to timely gastroscopy alongside gastroscopic assessment for higher risk patients. Aims & Methods: East and North Hertfordshire NHS Trust covers a population of 600,000 people. We have 700 patients on our Barrett's surveillance database.All patients due or overdue surveillance from November 2020 to January 2022 were offered Cytosponge instead of gastroscopy unless contraindicated, or previous history of Dysplasia or oesophageal cancer. Contraindications included strictures, varices and fundoplication - as such, patients with these conditions, as well as those declining or failing Cytosponge, were offered gastroscopy.TFF3 was used as a biomarker for intestinal metaplasia (IM). P53 positivity and atypia were biomarkers for potential dysplasia.33 patients were also included in the DELTA study. Result(s): 230 patients were included in the study.152 patients successfully swallowed Cytosponge with adequate cytology. 78 patients had gastroscopy as a primary surveillance method. Of the Cytosponge group, 115/152 (76%) patients had positive biomarkers - 97(64%) were solely TFF3 positive (suggesting non dysplastic Barrett's oesophagus). 18 (12%) had atypia and/or p53 positive (suggesting dysplasia). 37 (24%) were TFF3 negative and are described elsewhere. Confirmed dysplasia at endoscopy was found in 8/18 patients with atypia/p53 positivity on Cytosponge. 2 patients were found to have evidence of high grade dysplasia, 5 has evidence of low grade dysplasia, and one sample was 1indefinite for dysplasia.5% overall confirmed dysplasia. Of the gastroscopy group, 8/78 (10%) were found to have dysplasia, 2 patients had high grade dysplasia, 2 had low grade displasia and 4 were indefinite for dysplasia. In total, 16/230 (7%) had histologically confirmed dysplasia during the pandemic. Conclusion(s): We were able to prevent delayed Barrett's surveillance during the COVID-19 pandemic using Cytosponge in most patients and reduce unnecessary gastroscopy. Using a combination of Cytosponge in low risk and gastroscopy in higher risk patients for Barrett's surveillance during the pandemic allowed identification of dysplasia.Further stratification of risk using Barrett's length, Male sex and age have been identified from the recently reported DELTA study which may further improve dysplasia detection by identifying those in the Cytosponge group who need more frequent surveillance. Comparison with non-pandemic years going forward will also be important to evaluate this strategy.
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P55 Figure 1Patient survival to 90 days in precovid year compared with covid year[Figure omitted. See PDF]DiscussionAlthough the overall mortality of patients presenting with UGIVB to UHNM was high, there was no significant difference in the mortality between the pre-COVID and the COVID year. This finding contrasts with the previously published data from London. Several factors may have contributed to this difference including variations in patient characteristics, availability of endoscopy services during the periods of lockdown and the variations in the overall burden of COVID pandemic on the hospitals in different parts of the country.
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Background: In recent years, there has been an increase in automated interventions in medicine. The COVID-19 outbreak has further fueled this rise. In response to the pandemic, Healthcare systems have developed a multitude of technological strategies for case identification and contact tracing. It is in this evolving digital landscape, that a PAtient-guided Complication Tracking System (PACTS) was launched. PACTS allows clinics to track complications using the Short Message Service (SMS). This program also offers opportunities to augment medical services and support patients having complications. Before PACTS can be widely implemented in clinics, research needs to be conducted to investigate its potential as a complication tracking software. Aims: To assess the outcomes of an automated follow-up program implemented at St. Paul's Hospital in Vancouver, BC. Methods: A prospective study was designed to contact outpatients one-week post-procedure using PACTS. This program was delivered in two phases. Stage 1 ran from November 2019-March 2020. During this pilot stage, patients having a colonoscopy or gastroscopy were asked to participate in the study. Stage 2 ran from August 2020-August 2021. For this phase, patients having a colonoscopy, gastroscopy or flexible sigmoidoscopy were automatically enrolled in the study. An independent t-test was completed to assess response rate differences between stages. SMS responses were recorded and patients having unplanned events were contacted by phone to categorize complications. Adverse events (AE) were defined as side-effects requiring telehealth follow-up or emergency room visitation. Severe adverse events (SAE) were classified as complications requiring admission to hospital (>24 hrs). Results: SMS prompts were sent to 6975 patients and the overall mean response rate was 89%. The mean response rates from Stages 1 and 2 were 92% and 88% respectively. The independent t-test revealed a statistically significant difference in response rates between phases, two-sample t(174) = 4.56, p = 9.58 x 10-6. 498 (8%) of SMS respondents reported having unplanned events. Of these patients, 372 (75%) were reached by phone and 257 (69%) were confirmed to have had a side effect. 65 of these complications were AEs and of these, 3 cases were SAEs. The most common AEs were abdominal pain (37%), bleeding (35%), nausea and vomiting (14%). Conclusions: The high response rates achieved during this study provide further evidence for the use of automated follow-up systems in medicine. This study also demonstrates the potential of PACTS as a complication tracking software. Future research should devise strategies to optimize the collection of complication data using an SMS-based service. (Table Presented).
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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.
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Background: A 50 years old woman, a medical doctor, came to our department with symmetrical proximal muscular weakness, several months after Covid-19 infection and three weeks after a second dose of Covid-19 mRNA vaccine. The patient had no prior or family history of autoimmune diseases and take no medicines. In the past she undergone an operation for double-kidney with frequent urinary infections. Objective fndings have shown symmetrical proximal muscular weakness and classic sings of dermatomyositis-Gottron's papules, shawl and holster signs, periungual vasculitis. Objectives: We present a case of a 50 old woman with clinical and laboratory proven dermatomyositis, starting three weeks after a second dose of a Covid1-19 mRNA vaccine without other reasons. Methods: The laboratory tests showed elevated CPK, lactate dehydroge-nase, aspartate aminotransferase and alanine aminotransferase, high ANA-1:1280 and myositis specifc autoantibodies-anti-NXP2 and anti-Mi-2-beta. The electromyography showed myopathic changes and the muscle MRI-symmetrical edema of mm.obturator and mm.adductor brevis. We exclude diseases that may mimic infammatory myopathies. We made a cancer screening-whole body MRI, colonoscopy, gastroscopy, mammography and gynecological exam, immunoblot for detection of paraneoplastic syndrome-associated neuronal antibodies, with no detection of cancer. Muscle biopsy of m.vastus lateralis showed attenuating muscle infammation with advancing muscle atrophy and fbrosis. Results: The diagnose dermatomyositis was made according Bohan and Peter criteria and we start a high dose (1mg/kg/day) glucocorticoid therapy with good initial clinical and laboratory effect. Two months after starting a therapy muscle weakness worsened together with difficulty of swallowing. We excluded steroid myopathy after second EMG and lack of improvement when tapering the GS dose. Methotrexate 20 mg/weekly was added as a steroid sparing drug with good response, but was stopped because fare of pyelonephritis. Accordning to the opinion of dermatologist hydroxychloroquine was started for a couple of weeks, because of active skin manifestations. Muscle weakness worsened on the background of treatment, which was stopped. We started a therapy with intravenous immunoglobulins and considered therapy with cyclophosphamide or azathio-prine after urinary infection. Because the patient was infected for a second time with covid-19, although vaccine, we continued only with glucocorticoids and anti-osteoporotic therapy. Conclusion: The etiology and pathogenesis of infammatory myopathies are not fully clarifed so far. We speculate that the infection with Covid-19 as well as mRNA vaccine trigger infammatory myopathy and compromise the patient's immunity for poor treatment response with glucocorticoids and immunosuppres-sives. On the other hand advanced muscle atrophy and fbrosis within a short period show that suspected triggering factors could be a reason for difficult to treat such type of dermatomyiositis.
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Introduction Endoscopy training has been significantly impacted by the COVID-19 pandemic. The Joint Advisory Group on GI Endoscopy issued guidance for the recovery of endoscopy training. This provided us with an opportunity to improve endoscopy training with a peer-led programme. Methods The programme involved a group of trainees using the EndoVault® endoscopy system to scrutinise endoscopy lists to establish their suitability for training. A senior trainee was tasked to allocate the endoscopy lists based on trainee availability and current training objectives. The allocations were made on a 2-weekly cycle. We analysed the number of procedures over a 4-month period (1st March-30th June) for 2019, 2020 and 2021. Trainee satisfaction for 2021 was assessed pre- and post-intervention using a Likert scale based survey. Results There was a significant increase in the number of training procedures performed by trainees, comparing 2019 (pre-pandemic) and 2021 (post-intervention) - 21.7% vs. 59.8%, p<0.0001. The greatest increase was access to training in colonoscopy (297%), with also increased access for gastroscopy (270%) and flexible sigmoidoscopy (242%), represented as the change in the proportion of available training procedures performed by trainees comparing 2019 to 2021. Furthermore, trainees performed more independent procedures. Table 1 summarises the number of endoscopic procedures identified and performed by trainees during 2019, 2020 and 2021 (with∗Denotes p<0.001 relative to 2019 data and +denotes p<0.001 relative to 2020 data for comparator proportions represented). The survey showed an improvement in satisfaction of trainees' access to endoscopy with 100% of all responding trainees (n=16) being satisfied (25% pre-intervention). 87.5% of all trainees advised the programme helped them to meet their endoscopy training objectives. Conclusions This programme, devised by trainees for trainees, had a significant improvement in access to endoscopy training. This was further reflected in the results of the satisfaction survey. This programme could easily be applied at other hospital trusts as a model of training delivery.
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Introduction During the COVID-19 pandemic gastroscopy was halted with large burden on recovery and risk of late diagnosis. We established an early diagnosis service using Cytosponge to triage patients to timely gastroscopy and management Methods 2 patient cohorts were used: 1. Barrett's oesophagus (BO) on endoscopic surveillance 2. Patients with symptoms of gastro-oesophageal reflux referred for routine gastroscopy. Exclusions were patients with dysplasia on last gastroscopy, fundoplication, pregnancy and patient preference. Triage of patients on the waiting list was from endoscopy referrals, Barrett's surveillance database and telephone triage. 2 research nurses and 2 clinical nurse specialists were trained in delivering Cytosponge. A patient satisfaction survey was completed. All cytology specimens were analysed by Cyted. Results were relayed to patients within 4 weeks by consultant led nurse-run teleclinic and letter. Clinical triage was according to the table below. TFF3+ was used as a marker for intestinal metaplasia (IM), P53+ve and atypia for potential dysplastic change. Results 470 patients agreed to Cytosponge over 14 months November 2020-January 2022. 22 cancelled-mostly COVID related. 34 failed to swallow (5.5% of Barrett's, 8.9% reflux). of those successfully swallowing the sponge 6% were inadequate samples in Barrett's and 9% reflux. No major adverse events occurred. Conclusion We report on the largest single site series of Cytosponge in non-specialist clinical practice in England and its pragmatic use in patients management and pandemic recovery. Significant benefits in the Barrett's cohort were timely identification of dysplasia and those longer requiring surveillance. Benefits in the reflux group include identification of new BO, avoiding unnecessary gastroscopy and early discharge. Overall reduced endoscopy resulted in reduced cost, lower carbon footprint and improved patient experience. Careful follow up and longer-term outcomes will provide confidence to continue this new technique in routine clinical practice.
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Introduction Bowel cancer screening age extension, 'faster diagnosis' and COVID-related backlog all increase demand on endoscopy services. A competent workforce is central to endoscopy delivery but service pressure, lack of dedicated training time, and poor/unrefined trainer skills may be barriers to effective staff training. Immersive training programmes have improved nurse training in other settings1 and achieved success in the training of endoscopists.2 We, therefore, instituted a novel 4-week immersive nurse training programme for new starters to prepare workforce members for tasks in diagnostic luminal endoscopy. Methods Newly appointed registered nurses in Endoscopy commenced a dedicated, ring-fenced 4-week hybrid programme of didactic and supported practical teaching for 3 days per week. Trainees completed pre-training, midpoint, end of training and post-training online questionnaires utilising Likert scales where appropriate. Recorded feedback included indicators on trainee knowledge of endoscopy, confidence, and anxiety level on caring for patients in admission, procedure room, recovery, and discharge. Results Due to staggered commencement dates, preceding time in endoscopy varied (62% no exposure, 38% some exposure in preceding 6 months). Pre-course 62.2% and 66.7% of responses showed low confidence levels in undertaking the tasks of admitting, room preparation, endoscopy assistant roles, recovery and discharge of gastroscopy and colonoscopy patients respectively. In contrast at completion 74.3% and 75.6% of responses showed confidence or high confidence in these competencies. Further data at 6 months post training noted confidence to be sustained with 98.5% of responses describing no anxiety undertaking above tasks and 1.5% minor anxiety. Additionally 60% of trainees felt able train others and all had commenced GI bleed on-call work. Conclusions Rapid and agile re-skilling of the workforce to meet staff learning needs and importantly patient safety outcomes is heralded by HEE in other nurse groups. Our pilot results indicate immersive training meets the learning needs of Endoscopy nurses and correlates with confidence in job roles. Further work will correlate JAG workforce competencies and look at implementation to a wider, multi-site training group.
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In the highly contagious coronavirus disease 2019 pandemic, aerosol-generating procedures (AGPs) are associated with high-risk of transmission. Upper gastrointestinal endoscopy is a procedure with the potential to cause dissemination of bodily fluids. At present, there is no consensus that endoscopy is defined as an AGP. This review discusses the current evidence on this topic with additional management. Prevailing publications on coronavirus related to upper gastrointestinal endoscopy and aerosolization from the PubMed and Scopus databases were searched and reviewed. Comparative quantitative analyses showed a significant elevation of particle numbers, implying that aerosols were generated by upper gastrointestinal endoscopy. The associated source events have also been reported. To reduce the dispersion, certain protective measures have been developed. Endoscopic unit protocols are recommended for the concerned personnel. Therefore, upper gastrointestinal endoscopy should be classified as an AGP. Proper practices should be adopted by healthcare workers and patients.
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Background-During the COVID-19 pandemic all routine and surveillance gastroscopy was halted or delayed in the UK with considerable burden on recovery and risk of late diagnosis of significant pathology. We established an early diagnosis service using CytospongeR minimally invasive cell sampling device to help triage patients to timely gastroscopy and identify patients who could be managed without endoscopy. Methods-2 patient cohorts were identified: 1. Known Barrett's oesophagus on endoscopic surveillance 2. Patients with symptoms of gastrooesophageal reflux referred for routine gastroscopy. Exclusions were previous dysplasia of any grade on last gastroscopy, previous fundoplication, pregnancy and patient preference. Triage of patients on the waiting list was done initially from referrals to endoscopy and those on the Barrett's surveillance database, and then telephone clinic. 2 research nurses and 2 clinical nurse specialists were fully trained in delivering CytospongeR . All patients provided informed consent. All Cytology specimens were analysed by Cyted. Results were relayed to patients within 4 weeks of the procedure by consultant led nurse-run teleclinic or by letter for the Barrett's surveillance cohort. Clinical triage was according to the table below. TFF3+ was used as a marker for intestinal metaplasia, P53+ve and atypia for potential dysplastic change. Results-408 patients agreed to CytospongeR over 12 months November 2020-2021. 157 for Barrett's surveillance. 251 for Investigation of reflux. 28 failed to swallow (5% of Barrett's, 7.5% reflux). In the Barrett's Cohort 148 patients successfully swallowed, 139 for analysis 8 inadequate (5.4%) first samples. In the reflux cohort 232 successfully swallowed, 200 for analysis 32 inadequate first samples (13.8%) Discussion-Overall 205 (60.5%) of patients had low risk CytospongeR findings (no Barretts/short segment not requiring surveillance under BSG guidance) were managed symptomatically without initial gastroscopy, 114 (33.6%) had evidence of non dysplastic Barrett's and could be managed on a routine pathway. 20 (5.9%) had high risk findings suggesting dysplasia and had urgent gastroscopy. Conclusion-We report the largest single site series of CytospongeR in clinical practice in England and its pragmatic use in patients management and service recovery during the Pandemic. Notable benefits in the Barrett's cohort were timely identification of high numbers of potential dysplasia and also of those no longer requiring surveillance. Identification of new potential Barrett's for surveillance and the avoidance of unnecessary gastroscopy and early discharge were notable benefits in the Reflux cohort. Careful follow up and long-term outcomes of these patients will provide more data and safety netting for adoption of this new technique into routine clinical practice and help avoid unnecessary gastroscopy. (Table Presented)Table 1. CytospongeR findings and triage pathways in Barrett's oesophagus and gastrooesophageal reflux
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OBJECTIVES: In Morocco, in order to prepare health facilities for the upcoming influx of COVID-19 patients, it was necessary to minimize non-COVID-19 related activities, which led to a significant reduction of non-urgent procedures. The aim of the study was to describe the impact of the COVID-19 pandemic on the digestive endoscopic activity in our department by comparing it to the previous year. Study design: This was a retrospective study. METHODS: We performed a retrospective study, comparing endoscopic procedures performed (excluding emergencies) in both 2019 and 2020, especially the periods from March 20 to June 30 (lockdown period). Statistical analysis was performed by SPSS 21.0 software. RESULTS: 5018 endoscopy procedures were performed in 2019 and 2020, but only 1869 performed in 2020. For the lockdown period, a large decrease in the number of patients undergoing endoscopy was seen in 2020 compared with 2019 (179 vs 863). Gastroscopy, colonoscopy, and rectosigmoidoscopy volumes experienced a 59%, 53%, and 67% reduction, respectively. A reduction of 50% in the number of echo-endoscopy was also seen, especially during the lockdown period 11 versus 21 in 2019 (p = 0.006), whereas the number of ERCPs remained relatively unchanged, with 22 during the lockdown period versus 29 in 2019 (p < 0.001). We also compared the different endoscopy procedures performed during the post-lockdown period compared to the same period in 2019. CONCLUSION: The COVID-19 pandemic had a significant impact on endoscopy services, its staff and especially on patients following the reduction and limitation of endoscopy indications and procedures.