Effects of Post COVID-19 Pneumonia on the Prognosis of Trauma Patients undergoing Treatment in a Tertiary Care Hospital

Background: In the light of post severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) Pneumonias playing a role in the long-term respiratory complications in patients subsequently involved in trauma, a study was conducted to assess the post COVID-19 Pneumonias on the prognosis of trauma patients in a Tertiary care Hospital of Telangana. Aim of the Study: To identify the post COVID-19 pneumonia and respiratory complications, their severity, factors affecting the management of trauma patients and the long-term sequelae. Materials: 42 patients categorized on American Association for the Surgery of Trauma (AAST) injury scoring scales were included. Patients aged between 18 and 70 years were included. Patients with previous history of post COVID-19 lung disease for 09 months or above were included. Pulmonary function tests like FEV1, FVC, TLC and DLCO were performed and analyzed. The CT scan signs were based on the involvement of the lung parenchyma as: Normal CT (no lesion), minimal (0-10%), moderate (11-25%), important (26-50%), severe (51-75%), and critical (>75%). Result(s): 42 patients with trauma with either COVID-19 disease affecting the lungs or RTPCR positive were included. There were 29 (69.04%) male patients and 13 (30.95%) female patients with a male to female ratio of 2.23:1. The mean age among the men was 41.55+/-3.25 years and 38.15+/-4.10 years in female patients. There were 33/42 patients with positive RTPCR test and 09/42 were negative for RTPCR test for COVID-19. Conclusion(s): Recovery from COVID-19 disease especially with lung parenchyma changes during the active state has shown to affect adversely the morbidity of post trauma surgeries. Preoperative assessment of Lung function tests such as FEV1, FVC, TLC and DLCO would guide the surgeon and the anesthetist in the surgical management of such patients.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Application of a Novel Swallowable Telemetric Device for Real Time Luminal Blood Detection to Guide Timing of Enteroscopy in a Patient with Obscure-Occult Gastrointestinal Bleeding: A Case Report

Background and aim: Gastrointestinal (GI) bleeding is deemed "obscure" when upper and lower GI endoscopy reveal no bleeding site. While the term "overt" is used in cases where visible blood passage is observed or reported, cases without macroscopic bleeding stigmata are defined "occult". Although small bowel origin accounts for only about 5% of all GI bleedings, it makes up the majority of obscure GI bleedings. Diagnostic work-up and treatment of small bowel GI bleedings can be challenging, especially when overt bleeding symptoms are absent. Material(s) and Method(s): We report the case of a frail patient with multiple comorbidities and evidence of bleeding small bowel angiodysplastic lesions on videocapsule assisted enteroscopy (VCE). Device assisted enteroscopy (DAE), planned in order to treat the bleeding lesions, was delayed after the patient contracted SARSCoV- 2 infection. Eight weeks after, in the absence of clinical signs of bleeding, a device for real time luminal blood detection (HemoPillR acute, Ovesco) was applied to guide timing of enteroscopy. Result(s): The 71 year old male patient was on dual anti platelet therapy and had persistent clinical features of iron deficiency anemia (Hemoglobin 8,0g/dl). Upper and lower GI endoscopy were negative for potential bleeding sources. VCE showed three small lesions suspect for angiodysplasia within 1 to 13 minutes after pylorus passage. Upon recovery from SARS-CoV-2 infection and congestive heart failure with respiratory insufficiency, we administered HemoPillRacute orally, without previous bowel preparation. The measurement showed a peak HemoPillR-Index (HI max) at 1h 47min after capsule administration (Fig. 1) and was therefore indicative of a small bowel bleeding site, best approachable by antegrade oral route, in keeping with the prior VCE findings. On subsequent DAE, performed through spiral enteroscopy, the small bowel angiodysplastic lesions were successfully treated. [Figure presented] Conclusion(s): Our case report illustrates how a novel telemetric blood detection measurement was able to confirm luminal blood presence and successfully guide timing of therapeutic DAE in a patient with obscure-occult GI bleeding, without the need for repetition of VCE.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Surgery for Stage IVA Metastatic Thymoma Found Incidentally Post-COVID-19

Background: Thymic epithelial tumours (TET) are rare thoracic cancers with reported annual incidence of 1.3-3.2 per million. TETs are histologically classified as thymomas or thymic carcinomas. Thymomas are slow-growing tumours that comprise the majority of lesions found in the anterior mediastinum. They can be associated with autoimmune disorders such as Myasthenia Gravis. Contrast CT is the standard for diagnosis. Surgery is treatment of choice depending on resectability of the tumour. The Masaoka-Koga staging system is correlated with overall survival and is utilised post-surgical resection to guide adjuvant treatment. Case Presentation: A 50-year-old male presented with cough, shortness of breath, myalgia, sore throat, and reduced sense of smell that was diagnosed as COVID-19. CT chest and abdomen showed a large heterogeneous mediastinal mass (11cm) invading the innominate vein and left upper lobe with two left pleural deposits, and diaphragmatic disease. CT biopsy confirmed thymoma. MDT recommended surgery due to patient age and resectability of tumour with post-operative chemotherapy. The sites of disease necessitated a left thoracotomy and median sternotomy. The pleural and diaphragmatic deposits were resected, followed by left upper lobe anatomical dissection enbloc with invaded pericardium, phrenic and vagus nerve, followed by median sternotomy to resect the thymic mass along with the innominate vein. Final staging was stage IVA thymoma (B2 and B3) (T3N0M1aR0). A CT scan at 1 year showed no recurrence despite patient declining adjuvant chemotherapy. Conclusion: Surgical resection is a viable treatment option for patients with stage IVA thymoma who present with resectable primary and metastatic disease.

Single center experience with left atrial pressure remote monitoring in advanced heart failure patients

Background: Advanced heart failure (HF) is a complex clinical syndrome with scarce therapeutic options. Despite growing body of research in the field, no alternative end-stage solution is available for those individuals who are not eligible for heart transplant and mechanical circulatory support. The efficacy of implantable hemodynamic monitoring is currently being tested. Clinical manifestations of congestive HF appear late in the progression to acute decompensation, whereas intracardiac pressures rise gradually and can anticipate, even by weeks, the symptoms onset, thus offering a sweet spot to timely face an incipient acute decompensation. To date, the only implantable monitoring systems which received the regulatory agencies approval is a PAP sensor allowing PAP-guided management in symptomatic patients with reduced left ventricular ejection fraction (LVEF <35%). Although right-sided pressures data have proved their usefulness, they do not always correlate with left heart chambers pressures, so that PAP indirect estimation of left ventricular filling pressure can be misleading in some clinical contexts. Purpose. The V-LAP system is the latest-generation device, capable of monitoring the left atrial pressure (LAP) directly, by an intracardiac leadless sensor, transmitting LAP data wirelessly to an external reader. It is designed to offer a continuously updated status of the left-sided hemodynamics in order to improve the outcomes of advanced chronic HF-patient by reducing HF-related hospitalizations. Methods: In our center, V-LAP was implanted in five NYHA class III HF patients, not eligible for heart transplant, with a history of frequent hospital readmission and recurrently elevated proBNP levels. After confirmation of the device reliability, LAP trends have been remotely monitored over time in order to guide therapy optimization. Results: Over a median follow-up time of 18 months, LAP - driven therapy adjustments succeeded in noticeably reducing LAP and no HF-related hospitalization occurred in all patients considered. Morover, functional capacity improved in three out of five patients (NYHA class from III to II), and this was paralleled by an increase in the perceived quality of life as indicated by the KCCQ summary score (67.01±15.95 at baseline vs 83.21±11.94 at latest follow-up). The overall compliance of our patients to daily LAP measurements was > 90%, attesting a remarkable patient usability and acceptance. Conclusion: Preliminary data from V-LAP application at our institution expressed optimistic efficacy, along with remarkable reliability and ease of use, encouraging patients to adhere with a high compliance rate. In covid-19 era, VLAP revealed to be an excellent tool to control HF patients avoiding medical contacts and in-hospital exposure. While further study is needed, heart failure patient management guided by the V-LAP system may have the potential to significantly improve clinical outcomes.

Enhancing Ambulatory Care - Caring through crisis and cancellations through Covid-19

Introduction: At a time of massive service downturn and heightened public anxiety, we sought to develop, enhance and maintain an ambulatory service to provide specialist care to Urology patients throughout the Covid-19 pandemic. The aim was to divert Urology patients from attending Emergency Departments (ED) and reduce inpatient stays. To allow patients access to specialist services and reduce multiple hospital attendances where possible. Patients and Methods: Two Specialty Doctors and a Ward Manager re-opened an inactive ward with a new purpose, to respond to the growing need for an alternative route for patients who required Urology attention. An outline of emergency urology pathways were devised as a guide for ED and on-call surgical colleagues disseminated by Trust email, initially providing a guide for referral to the service. Results: Over 16 months, 1400 patients attended ambulatory appointments. 424 were diverted from attending ED, 160 hospital admissions were prevented and 382 patients removed from waiting lists for outpatients or day procedure. Patient satisfaction was excellent and wholly positive feedback collected. Conclusions: Despite particularly challenging circumstances, staff shortages and increasing pressure on the health system, we were able to rapidly put together a substantial and sustainable service. With a patient-centered approach and considerable benefits to the hospital, came great professional satisfaction. In a time of crisis came opportunity, which led to significant service development with a lot of team work and dedication.

The Impact of the COVID-19 pandemic on a regional Cleft Lip and Palate Surgery Service in the United Kingdom;A review of case-load prioritisation and lessons learned

Background/Purpose: Cleft Surgery in our centre is delivered by a single specialist surgeon in a regional Burns and Plastic service. We see 35-45 cleft-affected births per annum and, prior to the COVID-19 pandemic, ran 6 theatre lists per month, conducting 170-180 cleft procedures annually. The pandemic severely hindered elective operating in even tertiary centres, due to the redeployment of theatre staff and resources to manage the emergency care load. Cleft surgery was suspended entirely during the first wave (March-June 2020), before efforts in collaboration with the RCPCH (UK) to conserve the cleft pathway restored it as a priority. Primary palatine reconstruction is recommended at 6-9 months of age to optimise velopharyngeal function and speech proficiency by 5 years (Slater et al 2019). Our service was restarted at 1-2 ad hoc lists a month, which was both insufficient to manage ongoing demands and deal with rising outstanding cases. We faced a major challenge in safely distributing scarce surgical time and capacity across the entire cleft surgical burden. Therefore, we aim to examine our response to these limitations in the face of rising cases and time pressures, illustrating our methods in prioritising cleft procedures. Methods/Description: We reviewed the current literature to determine which of the main cleft procedures were most time critical, and compiled a cleft priority document with a broad evidence basis. Babies with palate involvement were top priority, in light of the strong evidence advocating primary palate repair by 13 months of age (CRANE 2020), after which there is a risk of speech delay (Shaffer et al 2020). Primary lip +/- alveolar involvement were prioritised lower and performed later (∼1 year), as cosmesis during infancy was deemed less detrimental, although there remained the psychological impact on the parent (Grollemund et al 2020). Secondary speech surgery was next, the lack of which can inhibit education and require intensive speech therapy to support patients (Baillie and Sell 2020). This was followed by alveolar bone grafting, ideally performed prior to canine eruption at ∼8-9 years to limit further dental reconstructions (Vandersluis et al 2020). As per national consensus, all adult cleft surgery was suspended to accommodate higher priorities. Focusing on early palate repair helped restart the cleft pathway and prevent functional delay as well as further interventions and schoolage support. However, late lip repair saw a rise in complications - two cases of dehiscence were associated with self-inflicted toddler trauma. This is in addition to the psychosocial implications of cosmesis, including early maternal interactions (Montirosso et al 2011), stigmatisation by peers (Bous et al 2021), and parental anxiety (Bous et al 2020). We recommend isolated lip reconstructions are also undertaken within 9 months. Long-term physical and psychosocial impacts of delay in surgery should guide resource allocation in the event of future operating limitations.

Scoring System to Triage Patients for Spine Surgery in the Setting of Limited Resources

INTRODUCTION: As ofMay 04, 2020, the COVID-19 pandemic has affected over 3.5 million people and touched every inhabited continent. Accordingly, it has stressed health systems the world over leading to the cancellation of elective surgical cases and discussions regarding healthcare resource rationing. It is expected that rationing of surgical resources will continue even after the pandemic peak, and may recur with future pandemics, creating a need for a means of triaging emergent and elective spine surgery patients. METHODS: Using a modified Delphi technique, a cohort of 16 fellowship-trained spine surgeons from 10 academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. Three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. Sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-priority elective, or low-priority elective scheduling. RESULTS: The devised scoring system included 8 independent components: neurological status, underlying spine stability, presentation of a highrisk post-operative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. The resultant calculator was deployed as a freely-available web-based calculator: https://jhuspine3.shinyapps. io/SpineUrgencyCalculator/ CONCLUSION: Here we present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. We believe that our scoring system, while not all-encompassing, has potential value as a guide for triaging spine surgical cases during the COVID pandemic and post-COVID period.

OUR EXPERIENCES IN A NEUROSURGICAL OPERATING ROOM DURING THE COVID-19 PANDEMIC

Objective: The COVID-19 pandemic has led to many compulsory alterations at health system. Emergency surgery is an area that is facing the need for many adaptations in health system.We aimed to evaluate the emergency cases accepted the neurosurgery operating room during the pandemic period and to determine the adequacy of the measures we took and if any, our deficiencies. Methods: We examined the 135 patients who were urgently operated in the neurosurgery operating room during the pandemic period (between March 15 and June 1, 2020). Demographic features and the way they applied to our clinic were recorded. Our study includes the results of the PCR tests before and after the surgery, chest x-rays, chest CT findings, laboratory results. The patients were called on the phone and asked whether they were diagnosed with COVID-19 in the postoperative period 1st month. Results: COVID-19 infection was detected in 3 of 135 patients who had an emergency surgery. All three patients with the infection were children. Preoperative PCR tests were carried out in only one of the three positive patients. In the other two patients, postoperative test results were positive. No infection was detected in our anesthesia and surgical personnel in our units period. Conclusion: If we organize our surgery programs with the precautions suggested by the guides, we will ensure the safety of both our patients and healthcare professionals.

Reintubation during COVID-19 pandemic: a simple self-made guiding device facilitates reintubation and minimizes transmission

Consensus guidelines to protect airway managers during COVID-19 were developed to encourage safe, accurate and swift performance in intubation and extubation, but reintubation was not considered. With the massive surge of patients requiring mechanical ventilation in this COVID-19 pandemic, great incidence of difficult airways may necessitate reintubation. Equipments could be used now in extubation and reintubation are either too expensive and time-consuming in decontamination, or have not gained wide acceptance. Here, we adapted an extubation device from an intubating stylet, which is provided as accessory of endotracheal tube. Such stylet could provide safe access for expediting reintubation both during and after the COVID-19 pandemic, which is inexpensive, single-use, readily available, straightforward to handle, and well-tolerated, thereby benefiting both the patients and healthcare providers.