COVID-19 has definitely had a very significant impact on medical travel, and for a short period, it completely stopped around the world. When the pandemic hit and halted outbound medical travel, domestic medical tourism did get traction, but now the interest is shifting back overseas, highlighted Jonathan Edelheit, CEO of the Medical Tourism Association.

In an interview with Omnia Health Magazine, he shared: “Some countries were able to bounce back quickly and are now doing the same or more business than they did pre-pandemic. There’s a lot of optimism with the vaccine coming around. We see a lot more bookings and investment, and companies are moving forward with medical tourism.”

Vaccine tourism

Related: 1 in 5 healthcare organisations confident in medical tourism recovery

One of the recent buzzwords has been vaccine tourism. This involves travelling to countries where people can quickly get access and make an appointment to get a vaccine shot.

Edelheit said: “One of the biggest challenges with the COVID-19 vaccine is that it is not available everywhere in the world. There are a lot of countries that don’t have access to it. Also, people are looking to get a specific vaccine. For instance, there has been a lot of demand for Pfizer and Moderna vaccines.”

Related: Medical Travel Special 2021

He explained that medical travellers visiting the U.S. could get an appointment for Pfizer or Moderna almost immediately. Previously the wait time was between four to eight weeks, but as most people in the U.S. have been vaccinated now, a vaccine appointment is available almost immediately. “I think that more people would travel to get vaccines to different countries if they had the confidence and know that they can visit the country of their choice and book an appointment through a trusted source,” he added.

Vaccine passports

Another term that has been doing the rounds is vaccine passports or COVID-19 testing passports that airlines are using now, which will play a key role in boosting medical travel. He said: “Vaccine passports will be a game-changer to really get medical travel back up and running.”

Boosting medical travel

Some other strategies that can be applied to reviving medical travel include employing technology and building confidence, safety, trust, and accreditation. Edelheit shared the example of the Global Healthcare Accreditation organisation that accredits top hospitals globally in terms of the international patient experience they offer and factors such as transparency, pricing, and other areas. “I think accreditations like these are essential,” he emphasised.

Typically, medical travel does not make it easy for patients to connect with doctors and hospitals. As COVID-19 saw an accelerated adoption of telemedicine, hospitals or governments offering medical travel services will have to consider the technology that is at their disposal and ensure it can be implemented easily. It is also essential for telemedicine to eliminate the frustration that bureaucratic processes can cause and break down the barriers.

Interestingly, he shared that during the pandemic, a lot of plastic surgery was being done. However, there is a lot of pent-up demand for patients who require complex care but have been putting it off. “For patient’s that require complex care, we’re going to see a lot of it move through medical tourism, as more patients become vaccinated,” he concluded.

In an Omnia Health survey of 1,600 healthcare respondents worldwide, titled the Voice of the Healthcare Industry Market Outlook 2021, only 20 per cent of respondents believe that medical travel is likely to pick up in the next 12 months (as of May 2021), with the highest confidence shown to be in the Americas and GCC (both 28 per cent), putting it behind other projected trends.

Healthcare organisations based in Asia, where there has been a COVID-19 resurgence in formerly ‘safe’ territories including Taiwan and Singapore, are much more pessimistic, identifying medical travel’s recovery as the least likely trend in the year ahead.

Related: Medical Travel Special 2021

There is slightly more hope for digital passports, however, with 24 per cent of overall survey participants backing the trend, on par with the regulation of health misinformation.

European respondents to the survey put digital passports second behind value-based healthcare among anticipated trends in the coming months (41 per cent), with respondents in the Americas not far behind (32 per cent).

Related: What does the road to recovery for international medical travel look like?

In Europe, a provisional consensus on an EU COVID travel pass means that the EU Digital COVID Certificate will allow for travel restrictions to lift across all 27 member states. The pass will be available for specific non-EU countries too.

In the Americas, meanwhile, Panama has become the first nation in the region to accept the IATA Travel Pass, an app approved as a digital travel credential for passengers to store their COVID-19 test result – a current requirement for entry into the country.

Digital passports may yet unlock a path to medical tourism’s revival.

Unsurprisingly perhaps, clinics/medical practices show most confidence in medical travel’s recovery in the coming 12 months, selected by one in three, with consultancies the least optimistic.

Growing optimism in the United States

Increased consumer confidence in the United States might account in part for renewed optimism in the Americas.

According to the US Cooperative for International Patient Programs (USCIPP) and parent organisation National Center for Healthcare Leadership, global consumer confidence in the U.S. will recover faster than previously expected, pointing to three insights in particular.

First, the U.S. has administered vaccines to more people than any other country in the world, barring China. As of early June 2021, nearly 300 million doses have been administered, with a little more than half of the population vaccinated and 41 per cent fully vaccinated. Ahead of the U.S. in vaccinations by country worldwide are smaller nations that include the likes of Aruba, Bahrain and Malta.

Second, the United States may become the engine of global economic growth in 2021, according to a new IMF forecast. In its World Economic Outlook from April 2021, the IMF expected the U.S. economy to grow 6.4 per cent in 2021, faster than the 5.1 per cent it had earlier projected in the year and nearly double its October 2020 forecast. This is ahead of the Euro Area, Japan, United Kingdom, Canada and indeed other advanced economies.

The IMF attributed this to the rapid rollout of vaccines in the United States in addition to relief spending amounting to trillions of dollars.

Third, Anthony Fauci predicted the U.S. will ‘approach some degree of normality by the end of summer 2021. Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, and Chief Medical Advisor to U.S. President Biden, revealed in a March 2021 interview that the United States can gradually ease its restrictions, while risking another surge if it pulls back too fast.

Technology is being used as a catalyst to deliver sustainable and repeatable benefits for patients, clinicians, and hospital systems across the globe. Torbay and South Devon NHS Foundation Trust in the UK is one such example.

The CONNECTPlus app which is described in this article is a platform for managing patients with multiple conditions. In England, it is being used to reduce demand and cost.

Related: How technology is facilitating transformation of the healthcare industry

But for medical tourism destinations such as the UAE, it offers a single digital health platform to manage patients' health journeys, from pre and post-treatment.

By using CONNECTPlus the patient’s treatment journey begins as soon as they book their treatment. The app enables health services to provide patients with condition-specific information and guidance wherever they are in the world. It provides them with the information they need to help them prepare and rehabilitate and can enable them to capture information about their condition to aid the diagnosis and post-procedure treatment programmes.

Related: Digital Innovations set in motion a new age for healthcare

As one of the first integrated care organisations in the UK Torbay and South Devon NHS Foundation Trust provides high quality, personalised acute, elective, specialist, social and community care services to a resident population of over 290,000 people, plus about 100,000 visitors at any one time during the summer holiday season. They employ over 6,500 staff including frontline health and social care staff, such as nurses, occupational therapists, social workers, consultants, and physiotherapists who work in people’s homes and community settings.

The challenge

The hospital, like almost all trusts in the UK, faces multiple challenges of budgetary constraints, shortages of health staff and yet growing demand from an ageing population. In South Devon, the population is on average around 10 years older than the UK general population and within the footprint, there are also towns with very high levels of deprivation. These factors bring increased pressures and demands to the health of the population and in turn the hospital.

In addition, COVID-19 has added to the pressures on the system, increasing the backlog of patients needing elective care and outpatient appointments. For example, the usual throughput of hip and knee replacement procedures is 600 per annum and the waiting list has now risen to around 1100. Approximately 75,000 people received treatment in their Emergency Department each year, and 41,000 treated in the Minor Injury Units. There are around 500,000 face-to-face contacts with service users and carers in their homes and communities each year.

The role of digital

The trust believes that digital health has a major role to play in addressing these challenges and, it will mean:

• Increasing capacity with limited resources

• Improving safety and quality

• Empowering citizens, patients, and carers

• Being data-driven

• Saving money

Their overarching digital strategy is a transformation strategy for outpatients which focuses on the following objectives:

• Reducing the number of outpatient appointments required by 30 per cent

• Shortening remaining outpatient appointments and facilitating the delivery of remote virtual consultations (target 50 per cent of outpatient appointments)

• Enabling staff to operate at top of their licence

The solution

To enable them to scale their use of digital resources, principally video and apps to support and transform their pathways of care to support patients and reduce demand, they formed a joint venture with an independent company, HCI.

HCI, with support from the Trust, has designed a unique, multiple long-term conditions app CONNECTPlus and the Trust has selected it as one of its principal digital tools to enable them to deliver the digital health strategy and achieve the transformation objectives for outpatients.

Designed with patients and clinicians, CONNECTPlus is an app that helps people with multiple health conditions. It gives them the information they need to help them manage all their conditions so that they can look after themselves better at home and reduce their demand on the health system.

They can keep a record of how their symptoms progress, the appointments and treatment activities they book and the medications they take so that they can take control of their conditions and are better able to get on with their lives and need fewer appointments.

When patients do need an appointment the trend data they can provide enable more remote and virtual consultations reducing the number of face-to-face appointments.

The impact

The early evaluation showed a reduction in rheumatology related appointments of up to 50 per cent and seven hours of weekly nursing time released from the rheumatology education programme for patients being prescribed new medications. Within six months, the waiting times for MS clinics were reduced significantly. These early results gave a strong enough indication of the impact of CONNECTPlus to support the delivery of the objectives set for the outpatient transformation programme.

The hospital has shorter waiting lists and can focus their resources on the people that really need their help and offer better ways of supporting people to manage their conditions and live their lives more independently.

Adel Jones, Director of Transformation and Partnerships at Torbay and South Devon NHS Trust says of the app: ‘I have real confidence in the product because actually, it's been designed by patients and clinicians so that it meets their needs’.

Adel Jones

Patients have also responded positively to the use of the app saying: “I believe this app is a tool for empowerment. It is actually something that encourages you to be resilient, it gives you the tools to work with the information, and notice some progress for yourself and think yea, I can do this, I can cope,” Valerie Bailey, App user and MS patient.

As a result of the successes achieved at Torbay and South Devon NHS Trust, HCI now provides services to multiple trusts across the UK. It has the largest library of health and care videos in the UK, now standing at around 1,000 videos and is the provider of the National Video Library to NHSx, part of NHS England www.healthandcarevideos.uk. This library supports the patients of secondary and primary care right across England.

Next steps

2021 brings an accelerated approach to the implementation of CONNECTPlus in the hospital with 15 additional conditions being added across multiple pathways including multiple conditions in Cardiology, Ophthalmology, Gastroenterology, Respiratory and Diabetes, plus a pilot programme in planned care for Hip and Knee replacement where the app will be used for preoperative education, to create a remote joint school, and post-operative monitoring to reduce post-procedure appointments by 80 per cent and achieve savings of £216,000 each year.

Richard Wyatt-Haines

Musculoskeletal tumours provide a very challenging group of clinical problems that require extensive clinical experience to treat. A thorough knowledge of a diagnostic and treatment algorithms are needed in their evaluation as well. Bone and soft tissue tumours present in many ways when located in the musculoskeletal system. This article will outline the challenges associated with the presentation of both entities.

Benign bone tumours often present in asymptomatic fashion. They are often found serendipitously after an injury or during a screening study in children. In this instance, as long as they are not painful, they are followed clinically. Typically, they will have very well-defined borders and a sclerotic rim. If there are any concerns about the aggressiveness of the lesion, short interval radiographic and clinical follow-up versus advanced imaging is indicated. Malignant bone tumours often cause pain and swelling. Sometimes after an injury, it can be difficult to determine whether radiographic imaging is warranted. The pain is associated with an injury should subside over a couple of days to a couple of weeks. If the pain does not subside plain radiographs of the affected bone should be obtained. Typical symptoms associated with aggressive/malignant bone tumours include night pain that awakens the patient from sleep, pain that is unrelieved by rest, and pain which is constant.

The presence of constant pain is more commonly a worrisome finding. Neoplastic soft tissue musculoskeletal pain is not often increased with activity and is not relieved by rest. Plain radiographs are the first imaging modality that should be obtained upon presentation for a bone lesion. Benign lesions often have a geographic pattern where all borders of the tumour are fully delineated on plain x-ray alone. Malignant tumours have destructive patterns of behaviour characterised by a moth-eaten pattern or permeative pattern of bone destruction.

Both of these patterns of bone destruction do not allow complete delineation of the borders of the tumour and necessitate further evaluation when present. If there any concerns on plain radiographs about the aggressiveness of the lesion, advanced imaging is required. MRI delineates the bone characteristics as well as the surrounding soft tissue characteristics better than CT scan and is the preferred imaging modality. When an MRI demonstrates aggressive findings, referral to a specialist in musculoskeletal tumours should occur.

Benign soft tissue masses are extremely common. Malignant soft tissue masses are outnumbered by benign masses by greater than 100-1. The exact incidence of benign soft tissue masses is unknown as many of these are asymptomatic and often undetected. The characteristics of benign soft tissue masses are size less than 4-5 cm, superficial to fascia, softer than muscle, and mobility when palpated. Benign soft tissue masses are painful much more frequently than malignant soft tissue masses. Post traumatic injuries can mimic soft tissue masses and need to be followed closely. Stability of size is also a characteristic of a benign soft tissue mass. Pain is a misconstrued characteristic of a soft tissue mass that is malignant. Malignant soft tissue masses most commonly present as a painless mass. The characteristics of malignant soft tissue masses are size greater than 5 cm, deep to fascia, firmer than muscle, fixed to fascia, and those that are rapidly growing. Malignant soft tissue masses in the extremities are most often soft tissue sarcomas. If the presence of any of the characteristics associated with malignant soft tissue masses are present, an MRI with and without contrast is indicated.

Heterogeneity of signal intensity on MRI is also concerning if the lesion is correlated with other findings for malignancy. If there are concerning findings on the MRI, referral to a specialist in musculoskeletal tumours is needed.

Once findings of a potentially aggressive soft tissue or a bone tumour are demonstrated, systemic staging is indicated. Malignant musculoskeletal tumours most commonly metastasize to the lungs and therefore a chest CT is warranted. A technetium whole-body bone scan is utilised for bone tumours to see if the lesion is isolated or multifocal. In patients over 40 years of age where metastatic disease is a concern and abdomen pelvis CT scan should be performed to evaluate for primary tumour sites. A PET-CT scan is also a potential option to evaluate the entire body for metabolically active areas. This test is more expensive and has a higher false-positive rate than CT and bone scan. Therefore, the clinical care team needs to evaluate the utilisation of a PET-CT carefully.

Systemic problems such as infection can mimic both bone lesions and soft tissue masses. Unexplained extremity pain that does not go away within a couple of weeks should have plain radiographs. Unless the bone and/or soft tissue lesion can be confirmed to be benign on plain x-ray or exam, advanced imaging is often required. Sometimes trauma can also mimic bone and soft tissue masses.

Myositis ossificans is a reactive, posttraumatic bone-forming lesion that demonstrates ossification in the soft tissues. Clinical correlation must be used with the appropriate imaging studies to confirm diagnosis. Biopsy of this lesion should be avoided if at all possible since the histology can be confused for a malignant lesion by an inexperienced pathologist.

Trauma can also cause bleeding into either cystic structures such as a Baker’s cyst or the creation of a hematoma. Sometimes advanced imaging can have a difficult time telling the difference between hemorrhagic changes and malignancy as they both can be heterogeneous in signal intensity on MRI. In this case, serial imaging done in short intervals and/or biopsy may be needed to rule out an aggressive lesion.

Musculoskeletal neoplasms are a challenging group of diagnoses for even experienced clinicians. Using the above-outlined algorithm, non-specialist physicians can appropriately evaluate these patients. Whenever the clinical and radiographic evaluation brings a concern for musculoskeletal malignancy, the patient should be referred to a musculoskeletal oncology expert with experience in management of these challenging problems.

Dr Joel Mayerson

At Arab Health, Fujifilm Middle East was participating to spotlight its acquisition of Hitachi’s Diagnostic Imaging-related business to expand its healthcare business further.

In an interview, Michio Kondo, Managing Director, Fujifilm Middle East FZE, said that the acquisition was completed on April 1, and their presence at Arab Health was to show how these companies are collaborating with each other. Excerpts:

What has been the impact of COVID-19 on the medical imaging industry?

Related: AI has arrived in medical imaging

COVID-19 has impacted medical imaging in a big way. All of the investment now has shifted towards medical preparation towards prevention. We have put in a lot of effort to prevent COVID-19. But we recognise that patients will be hesitant now to come into the hospitals due to the pandemic and, therefore, some products and businesses have been impacted.

At the show, we are showcasing solutions in the diagnostic area and are displaying products, such as mobile X-ray and chest-X ray, which are helping in the prevention of COVID-19. We are also working with a pharmaceutical company, who are carrying out the R&D process, and we are supporting the production of the COVID-19 vaccines.

What has been the impact of AI in medical imaging?

Related: The 2021 Medical Imaging Report

We aim to incorporate AI in all our X-ray products. Currently, most of our products have already been combined with an AI function. We are also working towards incorporating these in CT and MRI. These functionalities are going a long way in helping radiologists.

How, in your opinion, can companies continue to operate in the new normal?

COVID-19 has accelerated the adoption of technology, which is excellent. But having physical contact is also essential. Thanks to the vaccine, people are ready to travel and have that physical connection again, which is a big motivation. So, we have to prepare for servicing the anticipated demand.

Are there any future plans you would like to highlight?

The partnership between Fujifilm and Hitachi is quite substantial, and the companies have now merged. We will continue to invest in the healthcare growth business. We are working towards exploring the synergy between the companies.

What did AMS showcase at Arab Health?

AMS is an American nutraceutical company. We specialise in the development and manufacturing of all-natural vitamins, minerals, and other healthcare products. We mainly specialise in fertility supplements. But over the years, we have branched out into different categories within the vitamins sector, which we showcased at the show.

How did AMS respond to the increase in demand for vitamins due to the COVID-19 crisis? 

Due to the pandemic, we saw significant demand for immunity boosters and immunity supporting products such as zinc, vitamin C, and other unique immunity blends. We weren’t expecting this demand, and it came as a surprise. But with the support of our team and network of suppliers, vendors, and customers, we have managed to fulfil and meet this demand. We did experience a slowdown in our fertility range, but that’s picked up as well now.

How, in your opinion, can businesses continue to operate in the new normal?

If it weren’t for businesses uniting, we wouldn’t have made it out of COVID, whether as corporations or individuals. We saw how companies’ cooperation allowed for the mass production of masks and other types of protective equipment and vaccines. COVID has allowed us to think outside the box about cooperating and working together to deliver better quality products to customers and better services. The ecosystem and the landscape of healthcare have grown.

Are there any future plans that you would like to highlight? 

We have a few plans in the pipeline but will announce these maybe at the next Arab Health! Our goal has always been to serve our customers better, cater to their needs, and ensure they get their vitamins and supplements most conveniently. We are delighted to be at Arab Health. It’s exciting for us as this is the first show we are attending post the pandemic. It’s been nice to see the attendance and see that people are getting comfortable with being around one another again. It’s nice to know that exhibitions can still happen the way they used to happen before.

COVID-19 has mostly been discussed in the context of severe or fatal cases, however, recent investigations reveal that a growing number of patients with initially mild COVID-19 may develop long-term symptoms. During the onset of the pandemic, patients recognised themselves as “Long-Haulers” and the prolonged health concerns as “Long COVID”. There have been limited findings on Long COVID due to a lack of systematic studies, and according to a study published by The Lancet, information is scarce on “the symptom profile and severity, projected clinical course, impact on daily functioning, and expected recovery to baseline health.”

However, new research is surfacing to help healthcare professionals better understand Long COVID to implement specialised treatments that can alleviate symptoms. Dr. Brian O'Connor, Consultant in Respiratory Medicine at Cromwell Hospital discusses findings that led to the initiation of its Long COVID Clinic, and how a multi-disciplinary approach to treatment is ensuring positive patient outcomes.

Source: Cromwell Hospital, https://www.cromwellhospital.com/

COVID-19 compromises the immune system significantly. What percentage of patients experience long-term effects after being tested negative?

The current statistics in the UK indicate that around 15% of people who have had an acute COVID infection, even if it's a mild infection, go on to develop what we call Long COVID. Patients experiencing Long COVID can still have symptoms that relate to the original COVID infection, 12 weeks after they first test positive.

Long COVID symptoms vary for each individual, they range from being related to the heart or the lungs. Many patients suffer from breathlessness, and chest pain, palpitations, dizziness, and they continue with the sensation of not being able to take a deep breath. The other constant symptom is profound fatigue. In addition, they have problems with what we call brain fog, or poor concentration, where they are unable to focus or get tired very easily. They are unable to complete mental tasks and to process complex information, particularly when back at work. Significant joint pains are also a symptom many patients continue to experience.

As well as physical symptoms, mental health is also impacted by Long COVID, for example, sleep patterns become poor or irregular, with some patients sleeping more hours or others have insomnia. We also have seen a lot of patients reporting anxiety and depression since having the virus.

What are physicians doing to accurately diagnose Long Covid symptoms?

By definition, a patient can be only diagnosed with Long COVID when other illnesses have been excluded. There can be an instance when a patient comes back for a checkup after three months of recovering from COVID or even longer. If they have the mentioned symptoms, we need to rule out that they don’t have any other underlying problems unrelated to COVID-19.  These can be autoimmune diseases, lung abnormalities, neurological conditions, or heart disease issues. Every patient undergoes a very extensive range of investigations before you can conclude that they have Long COVID.

How does long covid impact patients and what are the ramifications of these symptoms being misdiagnosed?

Initially, healthcare professionals did not expect patients to suffer from the long-lasting effects of COVID-19. In the first wave, between March and September of last year, there was an attitude among the healthcare community, and doctors, that this was a virus from which you recover and can continue with your normal lifestyle. Patients were being poorly advised to resume full activity too quickly. We didn’t realise the devastating impact of COVID-19 on the immune system.

Patients have been frustrated that they’re not recovering from the virus as quickly as they originally thought. We’re tending to see people presenting with Long COVID who have tried to return to a busy lifestyle too quickly. These patients tend to work full time, exercise regularly, and have childcare responsibilities.

 

Can you tell us about the Long Covid Clinic at Cromwell Hospital?

15 percent of patients who had COVID-19, have developed Long COVID. Therefore, a staggering number of the UK population are suffering from the long last effects of COVID-19. In the private sector, Cromwell Hospital is one of the UK’s leading private hospitals that receive a huge range of inquiries from people with symptoms. In our clinic, these patients undergo a series of tests, inclusive of various blood tests to exclude autoimmune disease, lung function tests, echocardiogram, ECG, seven-day ECG monitoring, heart monitoring, a CT scan to analyse their lung functions depending on their case, a brain MRI, tests on muscle function, and nerve conduction studies. As well as a huge range of blood tests. From our findings, we’ve also noticed several patients who suffer from Long COVID have a Vitamin D deficiency.

When specialists are concerned about the cardiac status of a patient, particularly the palpitations, lightheadedness, and ongoing chest pain, even in the instance of a normal echo, patients undergo a cardiac MRI. A cardiac MRI is a much more sophisticated test to identify abnormalities.  The multidisciplinary team at Cromwell Hospital encompasses of consultants from different specialties, including hospital consultants in respiratory medicine, neurology, and cardiology. In addition, we have and physiotherapists, psychiatrists as well as access when necessary to a rheumatologist.

Do genetics, immunity, and pre-existing conditions play a role in patients being more susceptible to experiencing Long Covid?

One of the striking aspects about Long COVID has been the majority of patients we’ve diagnosed with it tend to be individuals from their late 20s to their early 50s, 75 percent of them being female. Several of them are very high achieving with extremely busy lives pre-COVID-19. They can be successful entrepreneurs or those with incredibly stressful family lives. These are caretakers, who also have multiple projects in their personal lives, outside work. These patients tend to be extremely busy people who find it very difficult to cope with being ill with COVID-19, and they don't give themselves enough time for their bodies to recover.

Our findings related to Long Covid ever-changing and how will this impact patient care in the future? 

One of the key factors in Long COVID patient care is reassurance. Telling our patients that they will recover, and encouraging them is crucial. Testing them to ensure that results indicate their heart and brain functionality is normal is important. They require as much support as possible and need to have access to not just physical therapists, but also psychologists or psychiatrists to help with the mental health implications of the virus.

The most critical aspect of recovery from Long COVID is physiotherapy and rehabilitation. Patients should not try and rush back to doing full activity. Patients who suffer the most from Long COVID are those who try and do too much, too soon without allocating enough time to recover from the initial infection

 

 

Over 4.5 million people in 213 countries have been affected by COVID-19, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Confirmed a pandemic by the World Health Organization on March 11, 2020, SARS-CoV-2 is spread largely by direct touch or droplets. There have also been instances of SARS-CoV-2 being found in biopsies and stool specimens, with the possibility of fecal-oral transmission being speculated. According to the World Journal of Gastrointestinal Endoscopy, Gastrointestinal symptoms have been observed in 17.6% of COVID-19 patients, and transmission by gastrointestinal secretions is a possibility in this group.

Asymptomatic carriers or individuals with viral shedding during the incubation stage can potentially transmit the virus. As endoscopists and endoscopy workers come in close contact with patients during these aerosol-generating procedures, endoscopic procedures may offer considerable risks of transmission, even if they are not directly confirmed COVID-19 cases. This might result in an infection being transmitted inadvertently during the endoscopy. According to the basic concept, elective cases should be individually examined and reviewed, and elective non-urgent situations should be delayed. Cases considered to be of greater priority, such as those with a suspected time-sensitive diagnosis, such as cancer, should still undergo endoscopic investigation based on risk assessment since a delay might have a fat impact on patient outcomes.

The rationale underlying this approach is the need to balance the medical urgency of procedures, as a delay in the procedure may result in a delay in diagnosis and appropriate treatment, potentially leading to complications of disease or disease progression, with the risk of infection and the use of potentially limited resources. However, different organisations and societies have varied definitions of an elective case that should proceed — this reflects the fact that different locations have different COVID-19 occurrences and hence diverse capacity for doing semi-urgent endoscopy. Emergent patients are treated immediately, whereas outpatient elective cases are evaluated on a case-by-case basis and may be postponed. During this time, direct-access endoscopy is not easily accessible.

All organisations agree that all members of the endoscopy team should wear proper personal protective equipment (PPE) throughout all operations, which often includes a N95 or surgical mask, eye shield/goggles, face shield, water-resistant gown, and gloves. For all operations, the AGA and ASGE recommend using a N95 mask. ESGE, CAG, and GESA, on the other hand, exclusively utilise the N95 mask for high-risk operations. AGA also recommends using two sets of gloves, rather than one set, for all operations, but CAG and ESGE recommend using two sets of gloves exclusively for high-risk procedures. This helps in the prevention of viral organisms being transferred from PPE to clothing or the rest of the body when the PPE is removed. These discrepancies are most likely due to varying availability and practical rationing to save scarce PPE resources in the face of conflicting demands. Endoscopy personnel should be educated in appropriate dressing and removal of PPE, and stringent hand hygiene procedures should be followed.

Endoscopy rooms and equipment should be cleaned and disinfected regularly. Standardised reprocessing techniques are used to reprocess endoscopes and endoscopic equipment. Endoscopes are manually cleaned by disassembling the components and immersing the endoscope and its components in a detergent that is suitable for the endoscope. To eliminate any residue, all accessible passages are flushed and brushed. Endoscopes and their components are then disinfected at a high level using automated endoscope reprocessing equipment.

Used endoscopes and endoscopic equipment should be disinfected on-site for confirmed or suspected COVID-19 infections. Used scopes should be packed in biohazard bags, double bagged, and brought back to the endoscopy center for additional cleaning and reprocessing, which will be done separately from other endoscopic equipment. PPE should be worn by all endoscopy specialists involved in disinfecting and reprocess

The peak of the COVID-19 pandemic may have subsided, with many nations implementing techniques like social distancing to reduce SARS-CoV-2 infection rates. Now the focus is on how to safely reintroduce routine activities and services. The American Gastroenterological Association (AGA), the Digestive Health Physicians Association (DHPA), the American Society of Gastroenterology (ASGE), and the British Society of Gastroenterology (BSG) have published guidelines on the resumption of endoscopy during the COVID-19 epidemic. The frequency of COVID-19 cases in the local community and the availability of equipment and staff should dictate the timing of beginning elective surgeries.

Snoring has a ‘hidden threat’ within itself, and although it is a fairly prevalent disorder, it can often lead to serious medical problems and should not be ignored. Snoring is the first indication of the sleep apnoea disorder that is hidden. If left undiagnosed, extreme cases of sleep apnoea can cause a patient to slip into a medical complication such as high blood pressure, irregular heartbeat, heart attack, chronic lung disease, stroke, diabetes or even an increase in road traffic and work accidents.

ENT Consultant, Dr Abdul Ghani Siddique, who is based at Dubai London Clinic, Nakheel Mall on the Palm Jumeirah, explains that Yale University studied the link between snoring and diabetes. According to their research, those who snore regularly have greater changes in their body metabolism, which can then lead to diabetes. The study showed that sleep apnoea is significantly associated with the risk of Type 2 diabetes independent of other risk factors such as age, race, sex or weight.

How are sleep apnoea and diabetes connected?

Related: A lens on sleep apnoea

“Severity of snoring they say is directly associated with a raised risk of diabetes,” he said. “Looking at the study, it is important that people who snore should get themselves assessed by an ENT specialist for the severity of their snoring, possibility of sleep apnoea and management of these two conditions to try and prevent the development of diabetes.”

He added that from this study, one could infer that snoring and sleep apnoea can directly lead to the development of diabetes type 2. “Both these conditions - sleep apnoea, snoring and diabetes - can lead to wide varieties of medical problems such as high blood pressure, serious cardiac disease, and strokes apart from a long list of other health complications,” Siddique added.