Disease Course and Outcomes of COVID-19 Among Hospitalized Patients With Gastrointestinal Manifestations

BACKGROUND & AIMS

Our understanding of outcomes and disease time course of COVID-19 in patients with gastrointestinal (GI) symptoms remains limited. In this study we characterize the disease course and severity of COVID-19 among hospitalized patients with gastrointestinal manifestations in a large, diverse cohort from the Unites States.

METHODS

This retrospective study evaluated hospitalized individuals with COVID-19 between March 11 and April 28, 2020 at two affiliated hospitals in New York City. We evaluated the association between GI symptoms and death, and also explored disease duration, from symptom onset to death or discharge.

RESULTS

Of 2804 patients hospitalized with COVID-19, the 1,084 (38.7%) patients with GI symptoms were younger (aOR for age ≥75, 0.59; 95% CI, 0.45-0.77) and had more co-morbidities (aOR for modified Charlson comorbidity score ≥2, 1.22; 95% CI, 1.01-1.48) compared to those without GI symptoms. Individuals with GI symptoms had better outcomes, with a lower likelihood of intubation (aHR, 0.66; 95% CI, 0.55-0.79) and death (aHR, 0.71; 95% CI, 0.59-0.87), after adjusting for clinical factors. These patients had a longer median disease course from symptom onset to discharge (13.8 vs 10.8 days, log-rank p = .048; among 769 survivors with available symptom onset time), which was driven by longer time from symptom onset to hospitalization (7.4 vs 5.4 days, log-rank P < .01).

CONCLUSION

Hospitalized patients with GI manifestations of COVID-19 have a reduced risk of intubation and death, but may have a longer overall disease course driven by duration of symptoms prior to hospitalization.

International cost-effectiveness analysis evaluating endoscopic screening for gastric cancer for populations with low and high risk

BACKGROUND

Gastric cancer remains one of the 3 most common causes of cancer death worldwide. Understanding the health and economic factors that affect screening cost-effectiveness in different countries will help address when and where it makes most sense to screen for gastric cancer.

METHODS

We performed a cost-effectiveness analysis using a Markov model to compare screening and surveillance strategies for gastric cancer in Brazil, France, Japan, Nigeria, and the United States. Primary outcome was the incremental cost-effectiveness ratio. We then performed a sensitivity analysis to determine how each variable affected the overall model.

RESULTS

In all countries, the most cost-effective strategies, measured by incremental cost-effectiveness ratio relative to no screening, were screening every 10 years, surveillance of high- and low-risk patients every 5 and 10 years, respectively, and screening every 5 years. Only Japan had at least one cost-effective screening strategy. The most important variables across different screening strategies and countries were starting age of screening, cost of endoscopy, and baseline probability of local gastric cancer at time of diagnosis.

CONCLUSIONS

Our model suggests that screening for gastric cancer is cost-effective in countries with higher incidence and lower costs of screening, but screening may still be a viable option in high-risk populations within low incidence countries.

Functional Outcomes after Fracture-Dislocation of the Ankles

Category:

Ankle, Trauma

Introduction/Purpose:

Fracture-dislocation of the ankle represents a substantial injury to the bony and soft tissue structures of the ankle. Although there is a wealth of reported outcome after operative treatment of ankle fractures, there has been a limited focus on functional outcome of surgically treated ankle fracture-dislocations. The purpose of this study is to compare short-term functional outcome after open reduction and internal fixation (ORIF) in ankle fractures with and without dislocation.

Methods:

A retrospective chart review of ankle fractures surgically treated by ORIF over a three year period was performed. All ankle fracture patients 18 years or older with a minimum of 12 months follow-up were included. Demographic data, type of injury (bimalleolar, trimalleolar, etc.), operative time, complications, and functional outcomes were recorded. Functional outcome was determined by Foot and Ankle Outcome Score (FAOS) at the latest follow up visit. Comparison of demographic variables and the subcategories of FAOS including symptoms, pain, activities of daily living (ADL), sport activity and quality of life (QOL) were performed in ankle fractures with dislocation and without dislocation. A total of 62 patients were eligible for analysis, 38 (61.3%) were female. Twenty patients (32.3%) were fracture-dislocations and 42 (67.7%) had no dislocation. Mean age of patients was 48.44 ± 17.89 years (range, 19-85 years). Mean follow-up time is 39.79 ± 13.53 months (range, 12-76 months).

Results:

The fracture-dislocation cohort demonstrated worse FAOS than the nondislocation cohort (symptoms 73 vs 79, pain 75 vs 85, ADL 80 vs 88, Sport 63 vs 76 and QOL 54 vs 60, respectively), although none of these differences were statistically significant. Patients with ankle fracture-dislocation had more bony injury (i.e. more bimalleolar and trimalleolar injuries) (P = .007) and had a higher rate of subsequent hardware removal (11.9% vs 35%, P = .031) There was no statistically significant difference in patient demographics or the rate of complications.

Conclusion:

Fracture-dislocations of the ankle presented with more bimalleolar and trimalleolar fractures, although there was no statistically significant difference in terms of functional outcome. Subsequent surgery for hardware removal was higher in the dislocation cohort. Although our data showed no difference in outcome, there was a trend towards worse outcomes in the dislocation cohort that a larger study may be able to discern.

Timing of Open Reduction and Internal Fixation of Ankle Fractures

Category:

Ankle, Trauma

Introduction/Purpose:

Unstable ankle fractures are typically treated with open reduction and internal fixation (ORIF) for stabilization in an effort to ultimately prevent post-traumatic arthritis. It is not uncommon for operative treatment to be performed as an outpatient in the ambulatory surgery setting several days to a couple weeks after the injury to facilitate things from a scheduling perspective. It is unclear what effect this delay has on functional outcome. The purpose of this study is to assess the impact of delayed operative treatment by comparing the functional outcomes for groups of patients based on the amount of time between the injury and surgery.

Methods:

A retrospective chart review of 122 ankle fracture patients who were surgically treated by ORIF over a three year period was performed. All ankle fracture patients older than 18 years with a minimum of 24 months of follow-up were included. A total of 61 patients were included for this study. Three patients were excluded; 2 patients had an open injury and 1 patient presented with a delayed union. Demographic data, comorbidities, injury characteristics, duration from injury to surgery, operative time, length of postoperative stay, complications and functional outcomes were recorded. Functional outcome was determined by Foot and Ankle Outcome Score (FAOS) at the latest follow-up visit. Comparison of demographic variables and the subcategory of FAOS including symptoms, pain, activities of daily living (ADL), sport activity and quality of life (QOL) was performed between patient underwent ORIF less than 14 days after injury and 14 days or greater.

Results:

A total of 58 patients were included in this study. Thirty-six patients (62.1%) were female. The mean age of patients was 48.14 ± 16.84 years (19-84 years). The mean follow-up time was 41.48 ± 12.25 months (24-76 months). The duration between injury and operative fixation in the two groups was 7 ± 3 days (<14 days) and 18 ± 3 days (>14 days), respectively. There was no statistically significant difference in demographic variables, comorbidities, injury characteristics, or length of operation. Each subcategory of FAOS demonstrated no statistically significant difference between these two groups. (Table 1) Additionally, further analysis for the delayed fixation more than 7 days and 10 days also revealed no significant difference of FAOS.

Conclusion:

Open reduction and internal fixation of ankle fracture more than 14 days does not significantly diminish functional outcome according to FAOS. Delay of ORIF for ankle fractures does not play a significant role in the long-term functional outcome.

Long-term failure of Amplatzer plugs in the treatment of aortic pathology

We present two cases of Amplatzer® device deployment that exhibited long-term failure necessitating surgical correction. The first case illustrates recanalization of a ruptured Valsalva aneurysm with worsening aortic insufficiency after percutaneous repair with the Amplatzer Vascular Plugs and Amplatzer duct occluder, while the second case illustrates recanalization after deployment of the Amplatzer septal occluder in a patient with a pseudoaneursym in a bovine aorta after type I aortic dissection repair. These two cases illustrate the potential long-term complications and limitations in durability with these devices.