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

Quelles sont les modifications apportées ou à apporter à la prise en charge des blessures de guerre par le médecin généraliste militaire lors des conflits actuels ? (analyse bibliographique rétrospective des blessures de guerre d Irak et d Afghanistan entre 2001 et 2012 à propos de cette thématique)

Introduction : War injuries occurred in combat in Iraq and Afghanistan have new features. We can therefore ask whether the management of these injuries has been modified or should be. We studied the war wounds of soldiers engaged in Afghanistan and Iraq since 2001. The objective was to identify current issues related to the management of pre hospital wounded combatants by military doctors.Method : This is a retrospective literature.Results: The physician's role in terms of prevention, screening, education and care has evolved with the Afghan and Iraqi conflicts particularly in regard to the control of bleeding, resuscitation, analgesia and control of infection.Discussion : Training to Combat Rescue Levels 1, 2 and 3 as well as the new individual fighter kits and basic medical kits are adapted to the new challenges posed by the wounds of war.Conclusion : This work lists the skills that all physicians must have in external operations, some are new and tend to change. Health Service of the Armed French Forces has adapted both in terms of training and in terms of the staffing of medical equipment. Prophylaxis against infection remains to be determined precisely. It seems important to establish a medical registery similar to JTTRIntroduction : Les blessures de guerre d'Irak et d'Afghanistan présentent de nouvelles caractéristiques. La prise en charge de ces blessures a-t-elle par conséquent été modifiée ou doit-elle l'être ? Nous avons étudié les blessures de guerre des militaires engagés dans ces pays depuis 2001. L'objectif était d'identifier les problématiques pré hospitalières liées à la prise en charge des combattants blessés par les médecins généralistes militaires.Méthode : Il s'agit d'une synthèse bibliographique. Résultats : Le rôle de prévention, de dépistage, d'enseignant et de soignant du médecin d'unité a évolué avec les conflits afghan et irakien notamment en ce qui concerne le contrôle hémorragique, la réanimation, l'antalgie et la maîtrise du risque infectieux.Discussion : Les formations de Sauvetage au Combat de niveaux 1, 2 et 3 ainsi que les nouvelles Trousses Individuelles du Combattant et trousses médicales de base sont adaptées aux récents défis imposés par les blessures de guerre. Conclusion : Ce travail liste les compétences requises par tout médecin d'unité en opérations extérieures ; certaines sont nouvelles et tendent à se modifier. Le Service de Santé des Armées français a su s'adapter en termes de formation et de dotation du matériel médical. La prophylaxie anti infectieuse reste à déterminer précisément. Il paraît important de mettre en place un registre médical semblable au JTTR.PARIS12-Bib. électronique (940280011) / SudocPARIS-Bib. Serv.Santé Armées (751055204) / SudocSudocFranceF

Could the orthopaedic surgeon deployed in austere setting perform flaps on the leg?

The orthopaedic military surgeons deployed in operations are led to perform soft tissue coverage on the lower limb. The purpose of this study was to evaluate if flaps performed by surgeons’ non-specialist in reconstructive surgery are associated with good outcome. All patients operated for a flap on the leg in French Forward Surgical Team deployed in theatre of operations between 2003 and 2013 were retrospectively reviewed. Forty-nine patients were included, for a total of 54 flaps’ procedures.  Indications were open fractures in 25 cases and osseous infections in 29 cases. No flap was performed on French soldiers. All the flaps were pedicle. Outcome was favourable for more than 90% of flaps with no statistical difference between muscular and fasciocutaneous flap and with regard to the indication. In conclusion, an orthopaedic surgeon deployed in austere setting with significant good outcome can perform reconstructive surgery with legs’ flaps

Traumatismes du membre supérieur en contexte de guerre : expérience de l'hôpitalmédico-chirurgical de l'aéroport international de Kaboul

Few epidemiologic studies have been published about the surgical management of wartime upper extremity injuries (UEIs). The purpose of the present report was to analyze upper extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the Kabul International Airport Combat Support Hospital. A retrospective study was conducted using the French surgical database OpEX (French military health service) from June 2009 to January 2013. During this period, 491 patients with a mean age of 28.7 ± 13 years were operated on because of an UEI. Among them, 244 (49.7%) sustained CRIs and 247 (50.3%) sustained NCRIs. A total number of 558 UEIs were analyzed. Multiple UEIs and associated injuries were significantly more common in the CRIs group. Debridement was the most common procedure in both groups. External fixator application, delayed primary closure and flap coverage were predominant in the CRIs group, as well as internal fracture fixation and tendon repair in the NCRIs group. The overall number of surgical episodes was significantly higher in the CRIs group. Due to the high frequency of UEIs in the theatres of operations, deployed orthopedic surgeons should be trained in basic hand surgery. Although the principles of CRIs treatment are well established, management of hand NCRIs remains controversial in this setting.Peu d'études épidémiologiques ont été consacrées à la prise en charge chirurgicale des traumatismes du membre supérieur en contexte de guerre. L'objectif de ce travail était d'analyser les lésions du membre supérieur, liées à des agents vulnérants de guerre ou à des traumatismes de pratique civile, traitées au sein de l'hôpital médico-chirurgical de l'aéroport international de Kaboul. Une étude rétrospective a été menée en utilisant la banque de données française OpEX (service de santé des armées) entre juin 2009 et janvier 2013. Durant cette période, 491 patients d'âge moyen 28,7 ± 13 ans ont été opérés d'un traumatisme du membre supérieur. Parmi eux, 244 (49,7 %) avaient subi un traumatisme de guerre et 247 (50,3 %) un traumatisme de pratique civile, pour un total de 558 lésions analysées. Les lésions multiples du membre supérieur et les lésions associées étaient significativement plus nombreuses dans le groupe des traumatismes de guerre. Le parage était le geste le plus fréquemment pratiqué dans les deux groupes. La fixation externe, la fermeture secondaire des plaies et la couverture par lambeaux pédiculés étaient prédominantes pour le traitement des lésions de guerre, tout comme la fixation osseuse interne et les réparations tendineuses pour les lésions de pratique civile. Le nombre total d'interventions était significativement plus élevé dans le groupe des lésions de guerre. Du fait de la grande fréquence des lésions du membre supérieur sur les théâtres d'opérations, les chirurgiens orthopédistes déployés doivent avoir une formation minimale en chirurgie de la main. Si le traitement des lésions de guerre est bien codifié, la prise en charge des traumatismes de la main de pratique civile reste discutée dans ce contexte

Outcomes of talar dome osteochondral defect repair using osteocartilaginous autografts: 37 cases of Mosaicplasty (R)

International audienceBackground: The indications of osteochondral autograft implantation using the Mosaicplasty (R) technique were only recently extended to osteochondral lesions of the talus (OLT), a site for which no medium- or long-term outcome data are available. Our objective here was to evaluate medium-term outcomes in case-series of patients who underwent Mosaicplasty (R) for OLT repair. Hypothesis: Mosaicplasty (R) provides good medium-term outcomes with low morbidity when used for OLT repair. Patients et methods: We retrospectively reviewed cases of Mosaicplasty (R) for OLT repair, performed in combination with malleolar osteotomy on the side of the OLT, at either of two centres, between 1997 and 2013. Pre-operative clinical data were collected from the medical records and all patients were re-evaluated. We studied 37 patients with a mean age of 33 years. Results: Mean follow-up at re-evaluation was 76 months. Mean AOFAS score at re-evaluation was 83( range, 9-100). A work-related cause to the OLT was associated with significantly poorer outcomes( P = 0.01). AOFAS values were significantly better in patients whose OLT size was 0.5 to 1 cm(2). The Ogilvie-Harris score at last follow-up was good or excellent in 78% of patients. No patient experienced morbidity related to the malleolar osteotomy. Persistent patellar syndrome was noted in 6 patients. Discussion: In our case-series, Mosaicplasty (R) for OLT repair provided good medium-term outcomes in 78% of patients. Nevertheless, the donor-site morbidity should be borne in mind. Mosaicplasty (R) deserves to be viewed as a reference standard method for OLT repair. (C) 2014 Elsevier Masson SAS. All rights reserved

How to reconstruct an upper full-thickness abdomen wall defect in austere environment? Interests of the pedicled myofascial latissimis dorsi flap

Upper abdominal wall defects secondary to trauma are not amenable to immediate closure in most cases. After a primary coverage, the definitive reconstruction can be done at a later date, using prosthetic mesh or flap. The majority of these complex procedures is, however, not available in the austere environment. The authors report a clinical case of upper full-thickness defects of the abdominal wall secondary to an explosion in Afghanistan. The patient was managed by a French Forward Surgical Team. The defect was immediately reconstructed in a one-stage surgery using a pedicled myofascial latissimus dorsi flap with good functional results. The pedicled latissimus dorsi flap is commonly used for coverage of both extrathoracic and intrathoracic defects. It is, therefore, possible to extend the harvesting of the muscle to the thoracolumbar fascia and the posterior third of the iliac crest. It provides a very large flap to cover an upper full-thickness abdomen wall defect. The harvest technique is simple, short, and largely accessible to a general surgeon. It provides immediate and definitive closure with a short hospital stay, what is clearly adapted in austere environment

The impact of sudden cold waves over Europe on future viticulture practices

Poster. 21st GiESCO International Meeting "A Multidisciplinary Vision towards Sustainable Viticulture", 2019 Jun. 23-28, Thessaloniki, Greec

Impact of a SPG convection collapse on the European viticulture

Poster. EGU, 2018 Apr. 8-13, Vienna, Austri

Climate change impacts and adaptations of wine production.

International audienceClimate change is affecting grape yield, composition and wine quality. As a result, the geography of wine production is changing. In this Review, we discuss the consequences of changing temperature, precipitation, humidity, radiation and CO2 on global wine production and explore adaptation strategies. Current winegrowing regions are primarily located at mid-latitudes (California, USA; southern France; northern Spain and Italy; Barossa, Australia; Stellenbosch, South Africa; and Mendoza, Argentina, among others), where the climate is warm enough to allow grape ripening, but without excessive heat, and relatively dry to avoid strong disease pressure. About 90% of traditional wine regions in coastal and lowland regions of Spain, Italy, Greece and southern California could be at risk of disappearing by the end of the century because of excessive drought and more frequent heatwaves with climate change. Warmer temperatures might increase suitability for other regions (Washington State, Oregon, Tasmania, northern France) and are driving the emergence of new wine regions, like the southern United Kingdom. The degree of these changes in suitability strongly depends on the level of temperature rise. Existing producers can adapt to a certain level of warming by changing plant material (varieties and rootstocks), training systems and vineyard management. However, these adaptations might not be enough to maintain economically viable wine production in all areas. Future research should aim to assess the economic impact of climate change adaptation strategies applied at large scale

Agric. for. metereol.

Tardive frosts, i.e. frost events occurring after grapevine budburst, are a significant risk for viticultural practices, which have recently caused substantial yield losses over different winegrowing regions of France, e.g. in 2016 and 2017. So far, it is unclear whether the frequency of late frosts events is destined to increase or decrease under future climatic conditions. Here, we assess the risk of tardive frosts for the French vineyards throughout the 21st century by analyzing temperature projections from eight climate models and their statistical regional down scaling. Our approach consists in comparing the statistical occurrences of the last frost (day of the year) and the characteristic budburst date for nine grapevine varieties as simulated by three different phenological models. Climate models qualitatively agree in projecting a gradual increase in temperature all over the France, which generally produces both an earlier characteristic last frost day and an earlier characteristic budburst date. However, the latter notably depends on the specific phenological model, implying a large uncertainty in assessing the risk exposure. Overall, we identified Alsace, Burgundy and Champagne as the most vulnerable regions, where the probability of tardive frost is projected to significantly increase throughout the 21st century for two out of three phenological models. The third phenological model produces opposite results, but the comparison between simulated budburst dates and observed records over the last 60 years suggests its lower reliability. Nevertheless, for a more trustworthy risk assessment, the validity of the budburst models should be accurately tested also for warmer climate conditions, in order to narrow down the associated large uncertainty