Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Alfa-2 macroglobulina en saliva y su potencial como biomarcador del control metabólico en diabetes mellitus tipo 2

Tesis Magister en Ciencias Odontológicas con Mención en Patología y Medicina OralLa diabetes tipo 2 (DM2) es la enfermedad metabólica más frecuente del mundo. Si no es rigurosamente controlada por parte del sujeto afectado, puede comprometerse la integridad de sistemas y órganos y consecuentemente, derivar en el desarrollo de alteraciones renales, cardiovasculares, neurológicas, orales aumentar la predisposición a infecciones oportunistas. La medición continua de los niveles de hemoglobina glicosilada (HbA1c), es fundamental para prevenir las complicaciones derivadas de la progresión de la enfermedad ya que mide en sangre, el porcentaje de hemoglobina unida a la glucosa en un lapso de 90 días. Este valor en definitiva, representa el grado de control metabólico de la enfermedad. El objetivo de un adecuado control de la DM2, es mantener una HbA1c por debajo de 7% y de esta forma, evitar las complicaciones asociadas. Actualmente los biomarcadores en saliva, son utilizados como método de diagnóstico e indicativos del grado de progresión y control, de diferentes enfermedades tanto orales como sistémicas. Un estudio reciente demostró que los niveles de la proteína α-2-macroglobulina (A2MG) detectados en saliva presentan un incremento significativo en sujetos con DM2 en comparación con aquellos sujetos en estados pre diabético. El objetivo de este estudio fue evaluar la asociación que existe entre A2MG detectada en saliva en sujetos con DM2 y los valores de HbA1. Se reclutaron 120 sujetos con diagnóstico de DM2 a los cuales se les tomó una muestra de saliva para determinar la concentración de A2MG a través de la técnica de ELISA. Posteriormente se correlacionó esta variable con los valores de HbA1 obtenidos en sangre en cada individuo. Además, se asociaron los niveles de A2MG con otras variables, como la velocidad de flujo salival (VFS), pH y concentración de proteínas. El análisis de los resultados muestra una correlación positiva entre A2MG y HbA1. También observamos una correlación positiva entre las variables A2MG y concentración de proteínas en saliva y una correlación negativa entre A2MG y pH salival. Estos resultados sugieren que la determinación de A2MG en saliva es una alternativa de evaluación de control metabólico de la diabetes que eventualmente podría complementar o reemplazar a la HbA1, ya que es un procedimiento más sencillo, no invasivo y de bajo costo que podría favorecer una mayor adherencia a los mecanismos de control de la enfermedad por parte de los sujetos enfermos y mejorar su calidad de vida.Tesis adscrita a proyecto FIOUCH 13-00

Quantitative and qualitative assessment of salivary changes in burning mouth syndrome (systemic condition) and oral squamous cell carcinoma (progression and response to therapies)

Introduction: Saliva as a means of diagnosing oral and systemic diseases has been the object of study in order to add its use as a complementary exam considering the advantages of its use. Oral squamous cell carcinoma (OSCC) is the most common malignant neoplasm of the oral cavity and presents an aggressive and invasive behavior. The early detection of oral potentially malignant disorders (OPMD) is essential to prevent progression to OSCC and the detection of changes in the salivary electrolyte composition could be useful in this regard. In addition, a recent massive sequencing showed that of the mutated genes most associated with the development of OSCC, FAT1 is the only one that encodes a secretory protein, potentially detectable in saliva and usable as a biomarker. Burning mouth syndrome (BMS) is a chronic condition characterized by a burning sensation in the mouth without clinical or laboratory findings that justify this symptom and can dramatically affect the quality of life of those affected. Salivary changes could determine its etiology or reflect the systemic status in the syndrome. The objective of this study was to evaluate the potential use of tissue and salivary FAT1 and the salivary biochemical profile in the progression of OPMD to OSCC and its response to therapies and to trace the salivary profile of women with BMS. Methods: This study was divided into 4 parts 1). Unstimulated saliva (uSRF) was collected from 54 patients, 18 with OSCC (also evaluated 6 months after therapy), 18 with OPMDand 18 without oral lesions. Concentrations of 8 electrolytes were determined using an optical emission spectrometer. These results were complemented with a systematic review of the literature. 2). From this same sample of patients, salivary levels of native FAT1 were determined using the ELISA technique (Enzyme-Linked Immunosorbent Assay) that were associated with tissue levels of aberrant FAT1 (from their respective biopsies), submitted to immunohistochemical technique and evaluated by semi-quantitative analysis and computerized determination. Complementing this analysis, tissue levels of FAT1 were also determined by the immunohistochemical technique in a retrospective study of 72 biopsies (from healthy tissue, high and low risk dysplasias and OSCC). 3). A systematic review was carried out evaluating comparing salivary characteristics of patients with and without BMS. 4). 40 women with BMS and 40 controls were recruited. uSRF, pH, cortisol levels, viscosity and impact profile of SAB on oral health (OHIP-14) were determined. Kruskal-Wallis and Mann-Whitney tests were used for comparisons and the Spearman test for associations between variables. P <0.05 was considered statistically significant. Results: Patients with OPMD had higher levels of salivary Magnesium (Mg). The semiquantitative analysis of the immunohistochemical expression of FAT1 indicated that 2 samples (11%) in the control group and 10 samples (50%) and in the OSCC group, had a score of 4 in the semiquantitative evaluation (staining> 50). Similar results were described by the computerized determination of FAT1 (the results of the two techniques demonstrated a strong and positive association). Saliva from control patients showed higher levels of FAT1 compared to patients with OPMD and OSCC before and after therapy (0.168, 0.162 0.154 and 0.153 nm / mL respectively and p <0.05). A weak negative correlation was observed between the salivary and tissue levels of FAT1. Women with BMS showed, in relation to the control group and with statistically significant differences, lower viscosity (31.1 and 45.01 mPas) lower uSFR (0.35 and 0.61 mL / min) and higher levels of salivary cortisol (0.36 and 0.15 μg / dL), hat were positively associated with higher OHIP-14 scores. Conclusion: 1) Higher levels of salivary Mg are associated with the dysplastic changes seen in OPMDs. 2) The use of native FAT1 as a salivary marker of progression or response to therapy in OSCC is not recommended, according to the methodology used in the present study. The cytoplasmic immunostaining of FAT1, widely more frequent in OSCC, suggests its aberrant phenotype and could be associated with neoplastic characteristics such as aggressiveness. 3) The qualitative salivary analysis points to a multidisciplinary origin in BMS. 4) Salivary changes present in women with BMS such as lower uSRF and lower viscosity could be associated with the pathogenesis of the syndrome and be a reflection of the systemic status of those affected. Higher levels of salivary cortisol reflect the worse quality of life that women with BMS report having.Sem bolsaIntrodução: A saliva como meio de diagnóstico de doenças bucais e sistêmicas tem sido objeto de estudo com o intuito de acrescentar sua utilização como exame complementar, considerando as vantagens do seu uso. O carcinoma espinocelular (CEC) é a neoplasia maligna mais comum da cavidade oral e apresenta um comportamento agressivo e invasivo. A detecção precoce de lesões orais potencialmente malignas (LOPM) é essencial para evitar a progressão para o CEC e a detecção de mudanças na composição electrolítica salivar poderia ser de utilidade neste sentido. Além disso, um recente sequenciamento massivo mostrou que dos genes mutados mais associados com o desenvolvimento de CEC, o FAT1 é o único que codifica uma proteína secretória, potencialmente detectável na saliva e utilizável como biomarcador. A síndrome de ardência bucal (SAB) é uma condição crônica caracterizada por uma sensação de queimação na boca sem achados clínicos ou laboratoriais que justifiquem esse sintoma e pode afetar dramaticamente a qualidade de vida dos afetados. Alterações salivares poderiam determinar a sua etiologia ou refletir o status sistêmico na síndrome. Desta forma, o objetivo deste estudo foi avaliar o potencial uso do FAT1 tecidual e salivar e o perfil bioquímico salivar na progressão de LOPM para o CEC e sua resposta às terapias e traçar o perfil salivar de mulheres com SAB. Métodos: Este estudo foi dividido em 4 partes 1). Saliva não estimulada (uSRF) foi coletada de 54 pacientes, 18 com CEC (avaliados também 6 meses após terapia), 18 com LOPM e 18 sem lesões bucais. Mediante um espectrômetro de emissão óptica foram determinadas concentrações de 8 eletrólitos. Estes resultados foram complementados com uma revisão sistemática da literatura. 2). A partir desta mesma amostra de pacientes, foram determinados os níveis salivares de FAT1 nativo com a técnica ELISA (Enzyme-Linked Immunosorbent Assay) que se associaram com os níveis teciduais de FAT1 aberrante (das suas respectivas biópsias), submetidos à técnica imunoistoquímica e avaliados por análise semi-quantitativa e determinação computadorizada. Complementando esta análise, níveis teciduais de FAT1 também foram determinados pela técnica imunoistoquímica em um estudo retrospectivo de 72 biopsias (de tecido sadio, displasias de alto e baixo risco e CEC). 3). Foi realizada uma revisão sistemática avaliando e comparando caraterísticas salivares de pacientes com e sem SAB. 4). Foram recrutadas 40 mulheres com SAB e 40 controles. Determinaram-se uSRF, pH, níveis de cortisol, viscosidade e perfil de impacto da SAB na saúde bucal (OHIP-14). Testes de Kruskal-Wallis e Mann-Whitney foram utilizados para as comparações e o teste de Spearman para as associações entre as variáveis. P <0,05 foi considerado estatisticamente significante. Resultados: 1) Pacientes com LOPM apresentaram níveis mais altos de Magnésio (Mg) salivar. Informações adicionais sobre o papel dos eletrólitos na progressão do câncer e o seu potencial uso como biomarcadores nesta doença. 2) A análise semiquantitativa da expressão imunoistoquímica de FAT1 indicou que 2 amostras (11%) no grupo controle e 10 amostras (50%) no grupo CEC, tiveram pontuação 4 na avaliação semiquantitativa (coloração > 50). Resultados semelhantes foram descritos pela determinação computadorizada de FAT1 (os resultados das duas técnicas demonstraram associação forte e positiva). Saliva de pacientes controles apresentaram maiores níveis de FAT1 em comparação com pacientes com LOPM e com CEC antes e após terapia (0,168, 0,162 0,154 e 0,153 nm / mL respectivamente e p <0,05). Foi observada uma correlação negativa e fraca entre os níveis salivares e teciduais de FAT1. 3) A Análise salivar qualitativa, segundo a revisão sistemática realizada, aponta que a SAB poderia estar determinada ou refletir a ação de fatores neuropáticos (também sugeridos por alguns eletrólitos salivares), fatores inflamatórios, emocionais, imunológicos e hormonais. 4) Mulheres com SAB apresentaram em relação ao grupo controle e com diferencias estatisticamente significantes, menor viscosidade (31.1 e 45.01 mPas) menor uSFR (0.35 e 0.61 mL / min) e maiores níveis de cortisol salivar (0.36 e 0.15 μg / dL), os que foram associados positivamente com maiores scores de OHIP-14. Conclusão: 1). Maiores níveis de Mg salivar estão assiciados às alterações displásicas vistas nas LOPMs. 2) O uso de FAT1 nativo como marcador salivar da progressão ou da resposta à terapia no CEC não é recomendado, de acordo com a metodologia utilizada no presente estudo. A imunomarcação citoplasmática de FAT1, amplamente mais frequente em CEC sugerem seu fenótipo aberrante e poderia estar associado com caraterísticas neoplásicas como agressividade. 3) A análise salivar qualitativa aponta para uma origem multifatorial na SAB. 4) Alterações salivares presentes em mulheres com SAB como menor uSRF e menor viscosidade poderiam estar associadas com a patogênese da síndrome ou ser reflexo do status sistêmico das afetadas. Maiores níveis de cortisol salivar refletem a pior qualidade de vida que mulheres com SAB relatam ter

Comparación del estado de salud oral entre pacientes diabéticos tipo II y pacientes no diabéticos

Trabajo de investigación requisito para optar al título de Cirujano DentistaLa Diabetes tipo II es una enfermedad crónica que afecta el metabolismo de los hidratos de carbono, lo que determina una serie de complicaciones fisiopatológicas que se manifiestan como alteraciones funcionales y morfológicas. A nivel oral, se ha relacionado con el padecimiento de esta enfermedad con una serie de patologías bucales, entre ellas mayor severidad de enfermedad periodontal, alteraciones en los procesos reparativos y mayor riesgo de infecciones, hiposialia, entre otros. El objetivo de este estudio es evaluar una serie de parámetros indicadores de riesgo para patología orales como también determinar la frecuencia y severidad de éstas, además de analizar composición y flujo salival en pacientes con Diabetes tipo II y en pacientes no diabéticos, con la finalidad de establecer bajo estos parámetros, una comparación entre ambos grupos. Para tal efecto, se examinaron 88 pacientes con Diabetes tipo II y 62 pacientes no diabéticos. Se procedió a tomar muestras de saliva no estimulada con el fin de determinar velocidad de flujo salival y aspectos cualitativos de ella (concentración de proteínas). También se realiza un examen periodontal, evaluación de caries cervicales y un examen de mucosa oral. Además se registran datos referidos a hábitos de salud, presencia de xerostomía y exámenes de laboratorio clínico. Los resultados señalan que el grupo con Diabetes tipo II, presentó mayor frecuencia de HTA, mayor severidad de enfermedad periodontal y mayor número de caries cervicales, mayor frecuencia de xerostomía, un menor flujo salival y una mayor concentración de proteínas en saliva, en comparación con los pacientes no diabéticos

Características salivares podem estar associadas com a síndrome da ardência bucal

Este estudo do tipo caso-controle foi conduzido no sul do Brasil, entre agosto de 2016 e março de 2019

Higher blood vessel density in comparison to the lymphatic vessels in oral squamous cell carcinoma

Artículo de publicación ISIIntroduction: Oral squamous cell carcinoma (OSCC) is characterized by local invasion and the development of cervical metastasis. In the tongue, an association between the invasion of the lymphatic vessels and the development of metastasis in the regional lymph nodes has been demonstrated. Moreover, invasion of the blood vessels is associated with greater recurrence and poorer prognoses. Therefore, the presence and density of lymphatic and blood vessels in intra- and peritumoral tissues should play an important role in the progression, dissemination and metastasis of carcinomas. However, the evidence regarding OSCC is inconclusive. The aim of this study was to determine the comparison and association between the lymphatic (D2-40) and blood vessel (CD34) densities in intratumoral OSCC tissue. Materials and Methods: Thirty-seven cases diagnosed as OSCC between the years 2000 and 2008 were obtained from the Anatomic Pathology Service of the School of Dentistry, University of Chile. The immunohistochemical markers D2-40 and CD34 were used, and the densities (mm2) of lymphatic vessels (LVD) and blood vessels (BVD) in the intratumoral region were determined. The relationship between LVD and BVD values was evaluated. Results: There were significant association between the CD34 and D2-40 expression (rho=0.4, P<0.05) and between the LVD and the location in the tongue (P=0.019). The BVD was greater (128.0 vessels/mm2) than the LVD (42.9 vessels/mm2), and there was a positive correlation between the LVD and BVD. Conclusions: In OSCC, the BVD is greater than the LVD, and there is a moderate correlation between the two quantities.Fondecyt Grant 1120248 FONDEF NaD11/1096 D11I1096 FONDECYT 115102

Perfil demográfico e clínico-histopatológico do carcinoma ex adenoma pleomórfico de glândulas salivares: uma revisão sistemática

Os achados clínicos mais importantes sobre CXAP nesta revisão foram: frequência masculina, sexta década de vida, maior prevalência de T2N0M0, glândulas salivares maiores, sendo a parótida a mais acometida

Relação entre aplicação de bisfosfonatos, câncer de próstata e desenvolvimento de osteonecrose dos maxilares: uma revisão sistematizada da literatura

O objetivo deste estudo é revisar a literatura disponível sobre o uso contínuo de bisfosfonatos no tratamento do câncer de próstata e o impacto da osteonecrose do maxilares em pacientes com essa enfermidade