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

Evidencias geol\uf3gicas, geomorfol\uf3gicas y geof\uedsicas de deformaci\uf3n asociada a la falla Cerritos y su implicaci\uf3n en el peligro s\uedsmico de Morelia, Michoac\ue1n, M\ue9xico

The Cerritos fault is located SW of Morelia city, in the state of Michoac\ue1n, M\ue9xico. The fault belongs to the western part of the Morelia-Acambay Fault System, an area with several active segmented faults that form various grabens and half-grabens. In this area, faulting affects Miocene to Holocene lithologies; some of these faults even control the distribution of regional monogenetic volcanoes. This work is an interdisciplinary approach to characterize the Cerritos fault, an important structure with a high seismic hazard potential. The Cerritos fault is a 12 km-long oblique fault (normal-left lateral) with a 130\ub15 m-high topographic relief (100 m of surface displacement + 30 m of subsurface displacement estimated from the inverted resistivity study). This fault is ENE-WSW oriented (255\ub0), with a 76\ub0 NNW dip. In a well\u2010exposed cross section of the Cerritos fault, a few meters from the master fault trace, a colluvial wedge with organic material was identified, yielding a radiocarbon age of 3.37-3.21 cal ka BP. Our geologic and geomorphological analyses indicate that the Cerritos fault is a young, tectonically-active fault, especially in its eastern part. The vertical and horizontal linearity of the fault scarp and the accumulation of lake deposits in the down-thrown block suggest active vertical motion (uplift and subsidence, respectively) along this fault. Geophysical surveys, including seismic refraction, terrestrial magnetometry, and electrical resistivity tomography, show the subsurface geometry of the fault to be characterized by a main listric fault plane and a damage zone in the footwall block, extending as far as 75 m from the main scarp. The damage zone is characterized by secondary, synthetic, and antithetic faults, forming roll-over anticlines and two crestal collapse grabens that accumulate colluvial material. Paleoseismic estimates of activity and seismic hazard potential indicate that the Cerritos fault has a slip-rate of 0.03\ub10.01 mm/yr, with mean vertical displacements of 0.5 m per event and a mean recurrence interval of 16 700 years. The Cerritos fault can generate single-segment ruptures with magnitudes of MW 6.2 to 6.6. Still, in a worst-case scenario, it could also rupture with the subparallel and adjacent Morelia and Cointzio faults, generating earthquake magnitudes up to MW 6.9

Geomorphic characterization of faults as earthquake sources in the Cuitzeo Lake basin, central Mexico

The Trans-Mexican Volcanic Belt is an active continental volcanic arc characterized by several arc-parallel Miocene-Holocene tectonic lake basins, such as the Cuitzeo, Zacapu, Chapala, and Zacoalco. Normal faults and related continental seismicity shape these basins. In the central part of this volcanic arc, the Cuitzeo Lake basin presents neotectonic fault activity, accommodating oblique extension through ENE-striking normal fault zones of the Morelia-Acambay Fault System and transfer faulting. Specific faults have been described in the basin, and various geological and structural studies have outlined its kinematics and structural geometry. However, these fault zones have not been fully characterized. Characterizing earthquake sources in the Cuitzeo Lake basin is essential to constrain the regional potential seismic hazard, aiming toward better territory planning. This study presents the first regional fault compilation in the Cuitzeo Lake basin that characterizes 21 fault zones from geomorphic data. We integrated previous volcanic and tectonic studies with new geomorphic and paleoseismic evaluations to assess potential seismic sources in the Cuitzeo Lake basin. Furthermore, we evaluate fault zone segmentation, fault slip distribution, transtensional partitioning, seismic hazard implications, and basin development. We improved the current understanding of the basin\u2019s transformation, subsidence, and sedimentation with all this information. Here, fault zones present a mean vertical slip-rate of 0.17 \ub1 0.27 mm/yr for 1 Ma, capable of generating Mw 6.2 to 7.0 earthquakes and average single-event displacements from 0.2 to 1.2 m. Multi-fault ruptures could be up to 63 km-long, capable of generating Mw 7.0 to 7.2 earthquakes, representing an important regional seismic hazard

Silent pulmonary embolism in patients with proximal deep vein thrombosis in the lower limbs

BACKGROUND: One in every three patients with deep vein thrombosis (DVT) in the lower limbs may have silent pulmonary embolism (PE), but its clinical relevance has not been thoroughly studied. METHODS: We used the RIETE Registry data to study patients with proximal DVT and no PE symptoms, but with a systematic search for PE. We compared the outcome of DVT patients with silent PE and those with no PE. RESULTS: Of 2375 patients with DVT, 842 (35%) had silent PE and 1533 had no PE. During the first 15 days of anticoagulation, patients presenting with silent PE had a higher incidence of symptomatic PE events than those with no PE (0.95% vs. 0.13%; P = 0.015), with a similar incidence of major bleeding (0.95% vs. 1.63%; P = 0.09). In patients with silent PE, the incidence of PE events during the first 15 days was equal to the incidence of major bleeding (eight events each), but in those with no PE the incidence of PE events was eight times lower (3 vs. 25 bleeding events). Multivariate analysis confirmed that DVT patients with silent PE had a higher incidence of symptomatic PE events during the first 15 days than those with no PE (odds ratio, 4.80; 95% CI, 1.27-18.1), with no differences in bleeding. CONCLUSIONS: DVT patients with silent PE at baseline had an increased incidence of symptomatic PE events during the first 15 days of anticoagulant therapy. This effect disappeared after 3 months of anticoagulation

Influence of recent immobilization and recent surgery on mortality in patients with pulmonary embolism

BACKGROUND: The influence of recent immobilization or surgery on mortality in patients with pulmonary embolism (PE) is not well known. METHODS: We used the Registro Informatizado de Enfermedad TromboEmb\uf3lica (RIETE) data to compare the 3-month mortality rate in patients with PE, with patients categorized according to the presence of recent immobilization, recent surgery, or neither. RESULTS: Of 18,028 patients with PE, 4169 (23%) had recent immobilization, 2212 (12%) had recent surgery, and 11,647 (65%) had neither. The all-cause mortality was 10.0% (95% confidence interval [CI] 9.5-10.4), and the PE-related mortality was 2.6% (95% CI 2.4-2.9). One in every two patients who died from PE had recent immobilization (43%) or recent surgery (6.7%). Only 25% of patients with immobilization had received prophylaxis, as compared with 65% of the surgical patients. Fatal PE was more common in patients with recent immobilization (4.9%; 95% CI 4.3-5.6) than in those with surgery (1.4%; 95% CI 1.0-2.0) or those with neither (2.1%; 95% CI 1.8-2.3). On multivariate analysis, patients with immobilization were at increased risk for fatal PE (odds ratio 2.2; 95% CI 1.8-2.7), with no differences being seen between patients immobilized in hospital or in the community. CONCLUSIONS: Forty-three per cent of patients dying from PE had recent immobilization for 654 days. Many of these deaths could have been prevented

A clinical prognostic model for the identification of low-risk patients with acute symptomatic pulmonary embolism and active cancer.

BACKGROUND: Physicians need a specific risk-stratification tool to facilitate safe and cost-effective approaches to the management of patients with cancer and acute pulmonary embolism (PE). The objective of this study was to develop a simple risk score for predicting 30-day mortality in patients with PE and cancer by using measures readily obtained at the time of PE diagnosis. METHODS: Investigators randomly allocated 1,556 consecutive patients with cancer and acute PE from the international multicenter Registro Informatizado de la Enfermedad TromboEmb\uf3lica to derivation (67%) and internal validation (33%) samples. The external validation cohort for this study consisted of 261 patients with cancer and acute PE. Investigators compared 30-day all-cause mortality and nonfatal adverse medical outcomes across the derivation and two validation samples. RESULTS: In the derivation sample, multivariable analyses produced the risk score, which contained six variables: age > 80 years, heart rate 65 110/min, systolic BP < 100 mm Hg, body weight < 60 kg, recent immobility, and presence of metastases. In the internal validation cohort (n = 508), the 22.2% of patients (113 of 508) classified as low risk by the prognostic model had a 30-day mortality of 4.4% (95% CI, 0.6%-8.2%) compared with 29.9% (95% CI, 25.4%-34.4%) in the high-risk group. In the external validation cohort, the 18% of patients (47 of 261) classified as low risk by the prognostic model had a 30-day mortality of 0%, compared with 19.6% (95% CI, 14.3%-25.0%) in the high-risk group. CONCLUSIONS: The developed clinical prediction rule accurately identifies low-risk patients with cancer and acute PE

The Gaia-ESO Survey: Calibrating the lithium-age relation with open clusters and associations. I. Cluster age range and initial membership selections

Previous studies of open clusters have shown that lithium depletion is not only strongly age dependent but also shows a complex pattern with other parameters that is not yet understood. For pre- and main-sequence late-type stars, these parameters include metallicity, mixing mechanisms, convection structure, rotation, and magnetic activity. We perform a thorough membership analysis for a large number of stars observed within the Gaia-ESO survey (GES) in the field of 20 open clusters, ranging in age from young clusters and associations, to intermediate-age and old open clusters. Based on the parameters derived from the GES spectroscopic observations, we obtained lists of candidate members for each of the clusters in the sample by deriving RV distributions and studying the position of the kinematic selections in the EW(Li) versus Teff plane to obtain lithium members. We used gravity indicators to discard field contaminants and studied [Fe/H] metallicity to further confirm the membership of the candidates. We also made use of studies using recent data from the Gaia DR1 and DR2 releases to assess our member selections. We identified likely member candidates for the sample of 20 clusters observed in GES (iDR4) with UVES and GIRAFFE, and conducted a comparative study that allowed us to characterize the properties of these members, as well as identify field contaminant stars, both lithium-rich giants and non-giant outliers. This work is the first step towards the calibration of the lithium-age relation and its dependence on other GES parameters. During this project we aim to use this relation to infer the ages of GES field stars, and identify their potential membership to young associations and stellar kinematic groups of different ages

Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE registry

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have a modified clinical presentation of venous thromboembolism (VTE) but also a worse prognosis than non-COPD patients with VTE. As it may induce therapeutic modifications, we evaluated the influence of the initial VTE presentation on the 3-month outcomes in COPD patients. METHODS: COPD patients included in the on-going world-wide RIETE Registry were studied. The rate of pulmonary embolism (PE), major bleeding and death during the first 3 months in COPD patients were compared according to their initial clinical presentation (acute PE or deep vein thrombosis (DVT)). RESULTS: Of the 4036 COPD patients included, 2452 (61%; 95% CI: 59.2-62.3) initially presented with PE. PE as the first VTE recurrence occurred in 116 patients, major bleeding in 101 patients and mortality in 443 patients (Fatal PE: first cause of death). Multivariate analysis confirmed that presenting with PE was associated with higher risk of VTE recurrence as PE (OR, 2.04; 95% CI: 1.11-3.72) and higher risk of fatal PE (OR, 7.77; 95% CI: 2.92-15.7). CONCLUSIONS: COPD patients presenting with PE have an increased risk for PE recurrences and fatal PE compared with those presenting with DVT alone. More efficient therapy is needed in this subtype of patients

Unsuspected pulmonary embolism in patients with cancer

BACKGROUND: The natural history of unsuspected pulmonary embolism (PE) in patients with cancer has not been thoroughly studied. METHODS: We used the RIETE Registry data to compare the clinical characteristics, treatment strategies and outcome in cancer patients with unsuspected PE and in those presenting with symptomatic, acute PE. RESULTS: Up to December 2011, 78 cancer patients with unsuspected PE and 1,994 with symptomatic PE had been enrolled. Patients with unsuspected PE more likely had colorectal cancer than those with symptomatic PE (28% vs. 13%), and less likely had prostate (3.8% vs. 10%) or hematologic (1.3% vs. 6.4%) cancer, or prior venous thromboembolism (3.8% vs. 12%). While the patients were receiving anticoagulant therapy, the incidence of PE recurrences (0% vs. 1.9%) or major bleeding (2.6% vs. 4.8%) were similar. After completion of anticoagulation, recurrent PE developed in 2.6% vs. 1.4% of patients, and major bleeding in 0% vs. 0.4%, respectively. CONCLUSIONS: Our findings suggest that the clinical characteristics and outcome in cancer patients with unsuspected PE are quite similar to those in patients with symptomatic PE