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

Independent and combined influence of the components of physical fitness on academic performance in youth

Objective: To examine the independent and combined associations of the components of physical fitness with academic performance among youths. Study design: This cross-sectional study included a total of 2038 youths (989 girls) aged 6-18 years. Cardiorespiratory capacity was measured using the 20-m shuttle run test. Motor ability was assessed with the 4 × 10-m shuttle run test of speed of movement, agility, and coordination. A muscular strength z-score was computed based on handgrip strength and standing long jump distance. Academic performance was assessed through school records using 4 indicators: Mathematics, Language, an average of Mathematics and Language, and grade point average score. Results: Cardiorespiratory capacity and motor ability were independently associated with all academic variables in youth, even after adjustment for fitness and fatness indicators (all P ≤ .001), whereas muscular strength was not associated with academic performance independent of the other 2 physical fitness components. In addition, the combined adverse effects of low cardiorespiratory capacity and motor ability on academic performance were observed across the risk groups (P for trend < .001). Conclusion: Cardiorespiratory capacity and motor ability, both independently and combined, may have a beneficial influence on academic performance in youth

Maternal physical activity before and during the prenatal period and the offspring's academic performance in youth. The UP & DOWN study

Objective: To examine the association of maternal physical activity before and during pregnancy with academic performance in youth. Methods: This study included 1868 youth (6–18 years) and their mothers. Mothers recalled their physical activity before and during pregnancy. Mothers were categorized into four groups: “remained active”, “became inactive”, “became active” and “remained inactive”. Academic performance was assessed through school records. Results: Boys whose mothers practiced physical activity before or during pregnancy had significantly higher scores in academic performance indicators independently of physical activity, fitness, current body mass index (BMI) and birthweight than those whose mothers did not practice physical activity before or during pregnancy (all p  <  0.05). In addition, boys whose mothers remained active had higher scores in all academic indicators (ranging from +0.358 to +0.543) than boys whose mothers remained inactive. Boys whose mothers remained active had higher scores in Language (score +0.546; 95% CI, 0.150–0.940), average of Math and Language (score +0.468; 95% CI, 0.100–0.836) and grade point average (GPA) (score +0.368; 95% CI, 0.092–0.644) than boys whose mothers became active. Conclusions: Maternal physical activity before and during pregnancy may positively influence youth's academic performance. Continuing maternal physical activity practice during pregnancy may have greater benefits for youth's academic performance

Maternal physical activity before and during the prenatal period and the offspring's academic performance in youth. The UP&DOWN study

Objective: To examine the association of maternal physical activity before and during pregnancy with academic performance in youth. Methods: This study included 1868 youth (6–18 years) and their mothers. Mothers recalled their physical activity before and during pregnancy. Mothers were categorized into four groups: “remained active”, “became inactive”, “became active” and “remained inactive”. Academic performance was assessed through school records. Results: Boys whose mothers practiced physical activity before or during pregnancy had significantly higher scores in academic performance indicators independently of physical activity, fitness, current body mass index (BMI) and birthweight than those whose mothers did not practice physical activity before or during pregnancy (all p  <  0.05). In addition, boys whose mothers remained active had higher scores in all academic indicators (ranging from +0.358 to +0.543) than boys whose mothers remained inactive. Boys whose mothers remained active had higher scores in Language (score +0.546; 95% CI, 0.150–0.940), average of Math and Language (score +0.468; 95% CI, 0.100–0.836) and grade point average (GPA) (score +0.368; 95% CI, 0.092–0.644) than boys whose mothers became active. Conclusions: Maternal physical activity before and during pregnancy may positively influence youth's academic performance. Continuing maternal physical activity practice during pregnancy may have greater benefits for youth's academic performance

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care