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

The parasitism of Ixodes luciae (Acari: Ixodidae) on marsupials and rodents in Peruvian Amazon

In this work the infestation with I. luciae on Didelphimorphia and Rodentia in different environments of Peruvian Amazon was studied. Didelphimorphia was represented by the family Didelphidae. Specimens belonging to Caluromys lanatus, Didelphis marsupialis, Marmosops sp.2, Metachirus nudicaudatus, Philander andersoni and Philander opossum were infested with adults I. luciae and one Micoureus sp. was infested with larvae. In Rodentia, the infestation with I. luciae nymphs was restricted to Hylaeamys perenensis, Hylaeamys yunganus and Oligoryzomys microtis, while one Oecomys bicolor (all Cricetidae) was infested with larvae of this species. The few larvae were found on rodents captured in primary forest. The only significant difference (P < 0.05) in prevalence of adult ticks on Didelphimorphia was between P. andersoni and M. nudicaudatus (chi-square distribution). Adult tick distribution was significant different in P. andersoni in comparison with M. nudicaudatus, P. opossum and D. marsupialis (Kruskal-Wallis test). No significant effect of month or environment was detected in relation to adult tick infestation on Didelphimorphia. The prevalence of nymphal infestation as well as tick distribution showed that H. perenensis and H. yunganus were significantly more prone to be infested with nymphs of I. luciae than O. microtis. Prevalence of nymph infestation was higher in primary and secondary forest than rural areas while abundance was higher in secondary forest when compared with rural areas (P < 0.05). Kruskal-Wallis test showed differences (P < 0.05) for nymphal infestation during December in relation to January, March, April and June. The natural cycle of I. luciae appeared to be continuous, bound to adult tick infestation on Philander and nymphal infestation on Hylaeamys in forested environs

Cauquenes-INIA, Nuevo Cultivar de Hualputra Chilena (Medicago Polymorpha) Para Areas de Secano Mediterraneo

Cauquenes-INIA is the first cultivar of burr medic ( Medicago polymorpha ), released by the Cauquenes Experimental Center of the National Agricultural Research Institute (INIA). It was selected from a collection of germoplasm obtained from an expedition through the Mediterranean zone of central Chile, between La Serena (29\uba 55' S lat.) and Temuco (38\uba 47' S lat.), in 1988. It is an annual forage legume, for subhumid and humid Mediterranean zones, especially appropriate for farming systems where the pasture is rotated with cereals (ley farming systems). It is a semi-precocious cultivar (approximately 100 days from emergence to first flower), with semi-erect growth, yellow flowers, spineless pods and a high percentage of hard seeds. Dry matter production (6570 and 6350 kg DM ha -1 ) and seed yield (82 and 88 kg ha -1 ) proved to be similar or superior to Australian cultivars of burr medic available in the national market.Cauquenes INIA es el primer cultivar de hualputra ( Medicago polymorpha L.), liberada por el Centro Experimental Cauquenes del Instituto de Investigaciones Agropecuarias (INIA). Fue seleccionado desde una colecci\uf3n de germoplasma que obtenida en una expedici\uf3n a trav\ue9s de la zona Mediterr\ue1nea de Chile, entre La Serena (29\uba 55' lat. S) y Temuco (38\uba 47' lat. S), en 1988. Es una leguminosa forrajera anual, para zonas de secano mediterr\ue1neo subh\ufamedo y h\ufamedo, especialmente apropiada para sistemas agr\uedcolas donde la pradera va en rotaci\uf3n con cereales ("ley farming systems"). Es un cultivar semiprecoz, de h\ue1bito de crecimiento semi-erecto, flores de color amarillo, gloqu\ueddeos sin espinas, y alto porcentaje de semillas duras. La producci\uf3n de materia seca (6570 y 6350 kg MS ha -1 ) y de semillas (82 y 88 kg ha -1 ) resultaron ser iguales o superiores a las variedades australianas disponibles en el mercado nacional

Combarbala-INIA, un Cultivar Precoz de Hualputra (Medicago PolymorphaL.) Para Areas de Secano Mediterraneo

Combarbal\ue1-INIA is a new cultivar of burr medic ( Medicago polymorpha L.), selected from a great number of accessions collected in Chile, between La Serena (29\uba 55' lat. S) and Temuco (38\uba 47' lat. S). It is an annual forage legume, precocious (71-83 days from emergence to first flowering), adequate for dryland areas of the arid, semiarid and subhumid Mediterranean zones, gbetween the IV and VI Regions of Chile. It has prostrate growth, yellow flowers and spineless pods. It is well adapted to ley farming systems, since it produces a large number of hard seeds. Dry matter production and seed yield was greater than Australian cultivars of burr medic available in the market.Combarbal\ue1-INIA es un nuevo cultivar de hualputra ( Medicago polymorpha L.), seleccionado entre un gran n\ufamero de accesiones colectadas en Chile, entre La Serena (29\uba 55' lat. Sur) y Temuco (38\uba 47' lat. Sur). Es una leguminosa forrajera anual, precoz (71 - 83 d\uedas desde emergencia a primera flor), apta para \ue1reas de secano de la zona mediterr\ue1nea \ue1rida, semi\ue1rida y subh\ufameda, es decir, entre la IV y VI Regiones de Chile. Presenta un h\ue1bito de crecimiento postrado, flores de color amarillo, y los gloqu\ueddeos no tienen espinas. Se adapta muy bien a sistemas de rotaci\uf3n con cereales ("ley farming system"), ya que produce una gran cantidad de semillas duras impermeables al agua. La producci\uf3n de fitomasa y de semillas es superior a la de cultivares australianos de hualputra, disponibles en el mercado

Aspiration risk factors, microbiology, and empiric antibiotics for patients hospitalized with community-acquired pneumonia

Background: Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. Research question: What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? Study design and methods: This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. Results: We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P = .021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P 50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. Interpretation: Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage

Risk for Major Bleeding in Patients Receiving Ticagrelor Compared With Aspirin After Transient Ischemic Attack or Acute Ischemic Stroke in the SOCRATES Study (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes)

Abstract: Background: Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)\u2013defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). Methods: An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. Results: A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52\u20131.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. Conclusions: Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994720.Abstract: BACKGROUND: Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)-defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). METHODS: An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. RESULTS: A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52-1.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. CONCLUSIONS: Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs