Renal transplantation during the SARS‐CoV‐2 pandemic in the UK: Experience from a large‐volume center

There is uncertainty about the safety of kidney transplantation during the SARS‐CoV‐2 pandemic due to the risk of donor transmission, nosocomial infection and immunosuppression use. We describe organ donation and transplant practice in the UK and assess whether kidney transplantation conferred a substantial risk of harm. Data from the UK transplant registry were used to describe kidney donation and transplant activity in the UK, and a detailed analysis of short‐term, single‐center, patient results in two periods: during the pre‐pandemic era from 30th December 2019 to 8th March 2020 (“Pre‐COVID era”) and the 9th March 2020 to 19th May 2020 (“COVID era”). Donor and recipient numbers fell by more than half in the COVID compared to the pre‐COVID era in the UK, but there were more kidney transplants performed in our center (42 vs. 29 COVID vs. pre‐COVID respectively). Overall outcomes, including re‐operation, delayed graft function, primary non‐function, acute rejection, length of stay and graft survival were similar between COVID and pre‐COVID era. 6/71 patients became infected with SARS‐CoV‐2 but all were discharged without critical care requirement. Transplant outcomes have remained similar within the COVID period and no serious sequelae of SARS‐CoV‐2 infection were observed in the peri‐transplant period.     

SARS‐CoV‐2 infection in two patients following recent lung transplantation

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) that causes coronavirus disease 2019 (COVID‐19) has become a global health problem with pandemic character. Lung transplant recipients may be particularly at risk due to the high degree of immunosuppression and the lung being the organ primarily affected by COVID‐19. We describe a 16‐year‐old male and a 64‐year‐old female recently lung transplanted patients with COVID‐19 during inpatient rehabilitation. Both patients were receiving triple immunosuppressive therapy and had no signs of allograft dysfunction. Both patients had close contact with a person who developed COVID‐19 and were tested positive for SARS‐CoV‐2. Subsequently, both patients underwent systematic screening and SARS‐CoV‐2 was ultimately detected. Although the 16‐year‐old boy was completely asymptomatic, the 64‐year‐old woman developed only mild COVID‐19. Immunosuppressive therapy was unchanged and no experimental treatment was initiated. No signs of graft involvement or dysfunction were noticed. In conclusion, our report of patients with asymptomatic SARS‐CoV‐2 infection and mild COVID‐19, respectively, may indicate that lung transplant recipients are not per se at risk for severe COVID‐19. Further observations and controlled trials are urgently needed to study SARS‐CoV‐2 infection in lung transplant recipients.     

Salivary detection of SARS‐CoV‐2 (COVID‐19) and implications for oral health‐care providers

The coronavirus disease 2019 (COVID‐19) pandemic has become a major public health crisis. The diagnostic and containment efforts for the disease have presented significant challenges for the global health‐care community. In this brief report, we provide perspective on the potential use of salivary specimens for detection and serial monitoring of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), based on current literature. Oral health‐care providers are at an elevated risk of exposure to COVID‐19 due to their proximity to nasopharynx of patients, and the practice involving the use of aerosol‐generating equipment. Here, we summarize the general guidelines for oral health‐care specialists for prevention of nosocomial transmission of COVID‐19, and provide specific recommendations for clinical care management.     

Management of dysphagia in the patient with head and neck cancer during COVID‐19 pandemic: Practical strategy

The global pandemic of 2019 novel coronavirus disease (COVID‐19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the health care system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID‐19 may last longer than severe acute respiratory syndrome (SARS) in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and health care personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS‐CoV‐2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the noninstrumental swallowing evaluation, appropriate use of personal protective equipment (PPE), and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID‐19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies.     

Recent progress on the diagnosis of 2019 Novel Coronavirus

Coronavirus disease 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has become a global pandemic. Therefore, convenient, timely and accurate detection of SARS‐CoV‐2 is urgently needed. Here, we review the types, characteristics and shortcomings of various detection methods, as well as perspectives for the SARS‐CoV‐2 diagnosis. Clinically, nucleic acid‐based methods are sensitive but prone to false‐positive. The antibody‐based method has slightly lower sensitivity but higher accuracy. Therefore, it is suggested to combine the two methods to improve the detection accuracy of COVID‐19.     

There is no routine head and neck exam during the COVID‐19 pandemic

Head and neck examinations are commonly performed by all physicians. In the era of the COVID‐19 pandemic caused by the SARS‐CoV‐2 virus, which has a high viral load in the upper airways, these examinations and procedures of the upper aerodigestive tract must be approached with caution. Based on experience and evidence from SARS‐CoV‐1 and early experience with SARS‐CoV‐2, we provide our perspective and guidance on mitigating transmission risk during head and neck examination, upper airway endoscopy, and head and neck mucosal surgery including tracheostomy.     

COVID‐19 in a high‐risk dual heart and kidney transplant recipient

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is rapidly infecting people worldwide, resulting in the infectious disease coronavirus disease 19 (COVID‐19) that has been declared a pandemic. Much remains unknown about COVID‐19, including its effects on solid organ transplant (SOT) recipients. Given their immunosuppressed state, SOT recipients are presumed to be at high risk of complications with viral infections such as SARS‐CoV‐2. Limited case reports in single SOT recipients, however, have not suggested a particularly severe course in this population. In this report, we present a dual‐organ (heart/kidney) transplant recipient who was found to have COVID‐19 and, despite the presence of a number of risk factors for poor outcomes, had a relatively mild clinical course.     

How did we get here? Short history of COVID‐19 and other coronavirus‐related epidemics

The COVID‐19 epidemic was not the first coronavirus epidemic of this century and represents one of the increasing number of zoonoses from wildlife to impact global health. SARS CoV‐2, the virus causing the COVID‐19 epidemic is distinct from, but closely resembles SARS CoV‐1, which was responsible for the severe acute respiratory syndrome (SARS) outbreak in 2002. SARS CoV‐1 and 2 share almost 80% of genetic sequences and use the same host cell receptor to initiate viral infection. However, SARS predominantly affected individuals in close contact with infected animals and health care workers. In contrast, CoV‐2 exhibits robust person to person spread, most likely by means of asymptomatic carriers, which has resulted in greater spread of disease, overall morbidity and mortality, despite its lesser virulence. We review recent coronavirus‐related epidemics and distinguish clinical and molecular features of CoV‐2, the causative agent for COVID‐19, and review the current status of vaccine trials.     

Anesthetic concerns for pediatric patients in the era of COVID‐19

After a novel human coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), was reported in China in December 2019, the disease quickly reached pandemic level. On January 30, 2020, the World Health Organization (WHO) declared that the SARS‐CoV‐2 outbreak constituted a Public Health Emergency of International Concern. The caseload has increased exponentially, with WHO reporting 182 000 global cases by March 17, 2020, and over 2.6 million by 23 April. The clinical situation is complex, with children presenting different clinical features compared to adults. Several articles with recommendations on the anesthetic management of adult patients with COVID‐19 have been published, but no specific recommendations for pediatric anesthesiologists have been made yet. This article addresses specific concerns for the anesthetic management of the pediatric population with COVID‐19.     

Pediatric anesthetic implications of COVID‐19—A review of current literature

Pediatric anesthetists have an important role to play in the management of patients suspected or confirmed to have COVID‐19. In many institutions, the COVID‐19 intubation teams are staffed with anesthetists as the proceduralists working throughout the hospitals also in the ICU and Emergency Departments. As practitioners who perform aerosol generating procedures involving the airway, we are at high risk of exposure to the virus SARS‐CoV‐2 and need to ensure we are well prepared and trained to manage such cases. This article reviews the relevant pediatric literature surrounding COVID‐19 and summarizes the key recommendations for anesthetists involved in the care of children during this pandemic.     

Head and neck survivorship care in the times of the SARS‐CoV‐2 pandemic

With the arrival of the coronavirus disease (SARS‐CoV‐2) in the United States, care practice paradigms have drastically changed. Data from China suggest that the new virus poses additional risks as case fatality of patients with cancer was higher at 5.6% compared to 2.3% of the general population. There are three proposed major strategies to address care for patients with cancer in this SARS‐CoV‐2 pandemic with postponing treatment for those with stable cancer, increasing personal protection provisions for patients with cancer, and increasing monitoring if a patient becomes infected with SARS‐CoV‐2. In this present commentary, we discuss the unique mental health challenges and burdens of patients with head and neck cancer in the times of the SARS‐CoV‐2 pandemic and approaches to mitigate these stressors through telemedicine to reduce future burdens to the patient and the health care system.     

Assistência perioperatória de paciente com infecção pelo SARS‐CoV‐2 (COVID‐19) submetido a ressecção de tumor de hipófise urgente. Relato de caso e diretrizes para manejo de via aérea

The 2020 pandemic caused by the novel coronavirus, COVID‐19, had its headquarters in China. It causes Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) and presents a broad spectrum of clinical manifestations, ranging from entirely asymptomatic through severe acute respiratory failure and death. Presuming a significant quantity of ventilator‐dependent patients, several institutions strategically delayed elective surgeries. Particularly procedures performed involving the nasal mucosa, such as a transsphenoidal approach of the pituitary gland, considering the tremendous level of viral shedding. Nevertheless, critical cases demand expeditious resolution. Those situations are severe pituitary apoplexy, declining consciousness level, or risk of acute visual loss. This case presents a successful urgent perioperative management of a 47 year‐old male COVID‐19 positive patient who presented to the Emergency Department with a left frontal headache that culminated with diplopia, left eye ptosis, and left visual acuity loss after 5 days. Transsphenoidal hypophysectomy was uneventfully performed, and the patient was discharged from the hospital on postoperative day four. It additionally describes in detail the University of Mississippi Medical Center airway management algorithm for patients infected with the novel coronavirus who need emergent surgical attention.     

Managing head and neck cancer patients with tracheostomy or laryngectomy during the COVID‐19 pandemic

Head and neck cancer patients with tracheostomies and laryngectomies, as well as their healthcare providers, face unique challenges in the context of the current COVID‐19 pandemic. This document consolidates best available evidence to date and presents recommendations to minimize the risks of aerosolization and SARS‐CoV‐2 exposures in both the inpatient and outpatient settings. The cornerstones of these recommendations include the use of closed‐circuit ventilation whenever possible, cuffed tracheostomy tubes, judicious use of heat moisture exchange units, appropriate personal protective equipment for providers and patients, meticulous hand hygiene, and minimal manipulation of tracheostomy tubes.     

Utilization of deceased donors during a pandemic: argument against using SARS‐CoV‐2–positive donors

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has rapidly become an unprecedented pandemic that has impacted society, disrupted hospital functions, strained health care resources, and impacted the lives of transplant professionals. Despite this, organ failure and the need for transplant continues throughout the United States. Considering the perpetual scarcity of deceased donor organs, Kates et al present a viewpoint that advocates for the utilization of coronavirus disease 2019 (COVID‐19)–positive donors in selected cases. We present a review of the current literature that details the potential negative consequences of COVID‐19–positive donors. The factors we consider include (1) the risk of blood transmission of SARS‐CoV‐2, (2) involvement of donor organs, (3) lack of effective therapies, (4) exposure of health care and recovery teams, (5) disease transmission and propagation, and (6) hospital resource utilization. While we acknowledge that transplant fulfills the mission of saving lives, it is imperative to consider the consequences not only to our recipients but also to the community and to health care workers, particularly in the absence of effective preventative or curative therapies. For these reasons, we believe the evidence and risks show that COVID‐19 infection should continue to remain a contraindication for donation, as has been the initial response of donation and transplant societies.     

Clinical features of patients undergoing hemodialysis with COVID‐19

Hemodialysis patients are susceptible to coronavirus disease 2019 (COVID‐19). The aim of this study was to describe the epidemiological, clinical characteristics, and mortality‐related risk factors for those who undergoing hemodialysis with COVID‐19. We conducted a retrospective study. A total of 49 hemodialysis patients with COVID‐19 (Group 1) and 74 uninfected patients (Group 2) were included. For patients in Group 1, we found the median age was 62 years (36‐89 years), 59.3% were male, and the median dialysis vintage was 26 months. Twenty‐eight patients (57%) had three or more comorbidities and two patients (4%) died. The most common symptoms were fever (32.7%) and dry cough (46.9%), while nine patients (18.4%) were asymptomatic. Blood routine tests indicated lymphocytopenia, the proportion of lymphocyte subsets was generally reduced, and chest CT scans showed ground‐glass opacity (45.8%) and patchy shadowing (35.4%). However, these findings were not specific to hemodialysis patients with COVID‐19, and similar manifestations could be found in patients without SARS‐CoV‐2 infection. In conclusion, for hemodialysis patients with COVID‐19, lymphocytopenia and ground‐glass opacities or patchy opacities were common but not specific to them, early active treatment and interventions against nosocomial infection can significantly reduce the mortality and the risk of SARS‐CoV‐2 infection.     

Tracheostomy time‐out: New safety tool in the setting of COVID‐19

Tracheostomy procedures have a high risk of aerosol generation. Airway providers have reflected on ways to mitigate the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) transmission risks when approaching a surgical airway. To standardize institutional safety measures with tracheostomy, we advocate using a dedicated tracheostomy time‐out applicable to all patients including those suspected of having COVID‐19. The aim of the tracheostomy time‐out is to reduce preventable errors that may increase the risk of transmission of SARS‐CoV‐2.     

COVID‐19 pneumonia in a kidney transplant recipient successfully treated with tocilizumab and hydroxychloroquine

Coronavirus disease 2019 (COVID‐19) pneumonia has been poorly reported in solid organ transplanted patients; prognosis is uncertain and best management unclear. We describe the case of a 61‐year‐old kidney transplant recipient with several comorbidities who was hospitalized and later received a diagnosis of COVID‐19 pneumonia; the infection was successfully managed with the use of hydroxychloroquine and a single administration of tocilizumab, after immunosuppression reduction; the patient did not require mechanical ventilation. During the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic, transplant clinicians should be readily informed about new cases of COVID‐19 pneumonia in solid organ transplant recipients, with focus on therapeutic strategies employed and their outcome.     

COVID‐19 pneumonia in lung transplant recipients: Report of 2 cases

Coronavirus disease 2019 (COVID‐19) has been declared pandemic since March 2020. In Europe, Italy was the first nation affected by this infection. We report anamnestic data, clinical features, and therapeutic management of 2 lung transplant recipients with confirmed COVID‐19 pneumonia. Both patients were in good clinical condition before the infection and were receiving immunosuppression with calcineurin inhibitors (CNI), mycophenolate mofetil, and corticosteroids. Whereas mycophenolate mofetil was withdrawn in both cases, CNI were suspended only in the second patient. The first patient always maintained excellent oxygen saturation throughout hospitalization with no need for additional oxygen therapy. He was discharged with a satisfactory pulmonary function and a complete resolution of radiological and clinical findings. However, at discharge SARS‐CoV‐2 RNA could still be detected in the nasopharyngeal swab and in the stools. The second patient required mechanical ventilation, had a progressive deterioration of his clinical conditions, and had a fatal outcome. Further insight into SARS‐CoV‐2 infection is eagerly awaited to improve the outcome of transplant recipients affected by COVID‐19 pneumonia.     

COVID‐19 pandemic: Effects and evidence‐based recommendations for otolaryngology and head and neck surgery practice

The 2019 novel coronavirus disease (COVID‐19) is a highly contagious zoonosis produced by SARS‐CoV‐2 that is spread human‐to‐human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities. There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists, and otolaryngologists. Health workers represent between 3.8% and 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter). All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55 to 65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases, and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Health care facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case‐by‐case basis for patients with cancer. For those who are working with COVID‐19 infected patients' isolation is compulsory in the following settings: (a) unprotected close contact with COVID‐19 pneumonia patients; (b) onset of fever, cough, shortness of breath, and other symptoms (gastrointestinal complaints, anosmia, and dysgeusia have been reported in a minority of cases). For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (eg, rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is strongly recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves. The procedures described are essential in trying to maintain safety of health care workers during COVID‐19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID‐19 positive subjects, and their protection should be considered a priority in the present circumstances.     

Early COVID‐19 infection after lung transplantation

COVID‐19, the clinical syndrome caused by the novel coronavirus, SARS‐CoV‐2, continues to rapidly spread, leading to significant stressors on global healthcare infrastructure. The manifestations of COVID‐19 in solid organ transplant recipients are only beginning to be understood with cases reported to date in transplant recipients on chronic immunosuppression. Herein, we report the first case of COVID‐19 in a lung transplant recipient in the immediate posttransplant period, and we describe the epidemiologic challenges in identifying the source of infection in this unique situation.