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

Definitions for keratoconus progression and their impact on clinical practice

Abstract: Purpose: There is currently no consensus on which keratoconus need cross-linking nor on how to establish progression. This study assessed the performance of diverse progression criteria and compared them with our clinical knowledge of keratoconus evolution.Methods: This was a retrospective, longitudinal, observational study. Habitual progression criteria, based on (combinations of) keratometry (K-MAX ), front astigmatism (A(F)), pachymetry (P-MIN ), or ABCD progression display, from 906 keratoconus patients were analyzed. For each criterion and cutoff, we calculated %eyes flagged progressive at some point (R-PROG), individual consistency C-IND (%examinations after progression detection still considered progressive), and population consistency C POP (% eyes with C-IND >66%). Finally, other monotonic and consistent variables, such as front steep keratometry (K-2F), mean radius of the back surface (R-mB), and the like, were evaluated for the overall sample and subgroups.Results: Using a single criterion (e.g., triangle K-MAX >1D) led to high values of R-PROG. When combining two, (K-MAX and A F ) led to worse C POP and higher variability than (K-MAX and P-MIN); alternative criteria such as (K-2F and R-mB) obtained the best C POP and the lowest variability ( P <0.0001). ABC, as defined by its authors, obtained R-PROG of 74.2%. Using wider 95% confidence intervals (95% CIs) and requiring two parameters over 95CI reduced R-PROG to 27.9%.Conclusion: Previous clinical studies suggest that 20% to 30% of keratoconus cases are progressive. This clinical R-PROG value should be considered when defining KC progression to avoid overtreatment. Using combinations of variables or wider margins for ABC brings R PROG closer to these clinical observations while obtaining better population consistency than current definitions