Prioritisation of lower gastrointestinal endoscopy during the COVID-19 pandemic: outcomes of a novel triage pathway.

Objective: The 2-week-wait (2ww) referral pathway is used in England to fast-track patients with suspected colorectal cancer (CRC). A two-stage triage pathway was used to prioritise lower gastrointestinal (LGI) endoscopy for suspected CRC during the COVID-19 pandemic. Method: All patients referred for an LGI endoscopy via a 2ww referral pathway between March 2020 and July 2020 were assessed. The first stage triaged patients to high, standard or low risk of CRC based on symptoms and faecal immunochemical test (FIT), and offered CT scans to those at high risk. The second stage, endoscopy prioritisation (EP), incorporated the CT results, FIT and symptoms to triage into four groups, EP1-EP4; with EP1 being the most urgent and EP4 the least. The primary outcome measure was CRC detection. Results: 514 patients were included. The risk of CRC was triaged as high in 190/514 patients (37%), standard in 274/514 patients (53%) and low in 50/514 (10%) patients. 422/514 patients (82%) underwent endoscopy with triage to EP1 in 52/422 (12%), EP2 in 105/422 (25%), EP3 in 210/422 (50%) and EP4 in 55/422 (13%). CRC was detected in 23 patients (5.4%). CRC was significantly more frequent in the EP1 group (23.1%, relative risk (RR)=16.2) and EP2 group (6.7%, RR=4.7) compared with EP3 group (1.4%). All CRC lesions were identified by CT imaging when performed prior to LGI endoscopy. Conclusion: This triage pathway designated 83% of patients with CRC to either EP1 or EP2. During a period of limited endoscopy provision, this pathway effectively prioritises endoscopy for those at greatest risk of CRC.

Prevalence of paediatric chronic suppurative otitis media and hearing impairment in rural Malawi: A cross-sectional survey.

OBJECTIVE: To estimate the prevalence of World Health Organization-defined chronic suppurative otitis media (CSOM) and mild hearing impairment in a population representative sample of school-entry age children in rural Malawi. A secondary objective was to explore factors associated with CSOM in this population. METHODS: We performed a community-based cross-sectional study of children aged 4-6 years in Chikhwawa District, Southern Malawi, utilising a village-level cluster design. Participants underwent a structured clinical assessment, including video-otoscopy and screening audiometry. Diagnoses were made remotely by two otolaryngologists who independently reviewed clinical data and images collected in the field. Hearing impairment was classified as failure to hear a pure tone of 25dB or greater at 1, 2 or 4kHz. RESULTS: We recruited 281 children across 10 clusters. The prevalence estimates of CSOM, unilateral hearing impairment and bilateral hearing impairment were 5.4% (95%CI 2.2-8.6), 24.5% (95%CI 16.3-30.0), and 12.5% (95%CI 6.2-16.9) respectively. Middle ear disease was seen in 46.9% of children with hearing impairment. A trend towards increased risk of CSOM was observed with sleeping in a house with >2 other children. INTERPRETATION: We found a high burden of middle ear disease and preventable hearing impairment in our sample of school-entry age children in rural Malawi. There are important public health implications of these findings as CSOM and hearing impairment can affect educational outcomes, and may impact subsequent development. The identification and management of middle ear disease and hearing impairment represent major unmet needs in this population.

Clinical presentation, biochemical, and haematological parameters and their association with outcome in patients with Ebola virus disease: an observational cohort study.

BACKGROUND: Clinical management of Ebola virus disease remains challenging. Routine laboratory analytics are often unavailable in the outbreak setting, and few data exist for the associated haematological and biochemical abnormalities. We aimed to assess laboratory and clinical data from patients with Ebola virus disease to better inform clinical management algorithms, improve understanding of key variables associated with outcome, and provide insight into the pathophysiology of Ebola virus disease. METHODS: We recruited all patients, alive on arrival, with confirmed Ebola virus disease who were admitted to the Kerry Town Ebola treatment centre in Sierra Leone. At admission, all patients had clinical presentation recorded and blood taken for Ebola confirmation using reverse-transcriptase-PCR (RT-PCR) and for haematological and biochemical analysis. We studied the association between these and clinical outcome. The primary outcome was discharge from the Ebola treatment centre. FINDINGS: 150 patients were admitted to the treatment centre between Dec 8, 2014, and Jan 9, 2015. The mean age of patients was 26 years (SD 14·7). Case fatality rate was 37% (55/150). Most patients presented with stage 2 (gastrointestinal involvement, 72/118 [61%]) and stage 3 (severe or complicated, 12/118 [10%]) disease. Acute kidney injury was common (52/104 [50%]), as were abnormal serum potassium (32/97 [33%]), severe hepatitis (54/92 [59%]), and raised C-reactive protein (21/100 [21%]). Haematological abnormalities were common, including raised haematocrit (15/100 [15%]), thrombocytopenia (47/104 [45%]), and granulocytosis (44/104 [42%]). Severe acute kidney injury, low RT-PCR cycle threshold (<20 cycles), and severe hepatitis were independently associated with mortality. INTERPRETATION: Ebola virus disease is associated with a high prevalence of haematological and biochemical abnormalities, even in mild disease and in the absence of gastrointestinal symptoms. Clinical care that targets hypovolaemia, electrolyte disturbance, and acute kidney injury is likely to reduce historically high case fatality rates. FUNDING: None.