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

Should physical features discrimination be prohibited?

© 2019 Liam MeagherThis paper commences by outlining a framework for determining when the moral underpinnings of discrimination laws on ‘traditional grounds’ (such as race, sex, disability and age) can be applied to justify further prohibited grounds of discrimination. Applying this framework, and drawing on the psychological literature and experience in the only Australian jurisdictions with physical features discrimination laws (Victoria and the Australian Capital Territory), it considers whether physical features discrimination should be prohibited. It argues, first, for prohibiting discrimination on the ground of physical features that are ‘immutable’, in the sense they are not chosen and are difficult to change. Second, it argues against prohibiting discrimination on the ground of chosen physical features generally. Third, it argues for also prohibiting discrimination on the ground of physical features that represent attributes already protected by discrimination laws

Whistleblower Laws: the other employment law

© 2018 Liam MeagherWhile there has been a considerable amount of research and writing on enhancing whistleblower laws to encourage whistleblowing and protect whistleblowers, little has been written on these laws’ impact on employers’ ability to manage employees. This paper, first, outlines how whistleblower laws impose restrictions and duties on employers dealing with employees’ alleged misconduct. Second, it critically evaluates these restrictions and duties, and advocates for changes. It argues for reforms to some public sector whistleblower laws to enable employers to discipline employees for making deliberately false and misleading disclosures. More importantly, however, it argues that requirements on employers in public sector whistleblower laws to investigate employee disclosures inappropriately interfere with employers’ ability to respond to allegations of employee misconduct. These requirements force employers to go through an ‘investigation’ process where other forms of management action are preferable; may discourage employees reporting wrongdoing; and impose substantial administrative costs. Alternatives models are considered

Refining consultants' evidence : deciding the best interests of the child

One role of family consultants is to provide expert evidence to the court on what is in a child’s best interests when making parenting orders. Yet deciding a child’s best interests is a complex and value-laden determination, on which legislation provides considerable guidance. Rational Choice Theory may be used to disaggregate the best interests question into four stages: outlining the options of the court, determining possible outcomes for a child within these options, determining the likelihood these outcomes will occur and placing value on these outcomes. The last stage in this process involves a subjective value judgement as to what is ‘best’ for a child, which family consultants have no expertise in addressing. The author argues that family consultants should cease the practice of making recommendations to the court on what orders are in a child’s best interests, as such recommendations exceed the boundaries of their knowledge base, misrepresent their knowledge base, engender a likely conflict with the legislation and lead to the possibility of institutionalising expert biases within the court system. Despite this, a considerable amount of evidence should continue to be provided by family consultants. Guidelines are suggested to help ensure the quality of this evidence.18 page(s

Regulation of a multigenic invasion programme by the transcription factor, AP-1: re-expression of a down-regulated gene, TSC-36, inhibits invasion

The transcription factor AP-1 (activator protein-1) is required for transformation by many oncogenes, which function upstream of it in the growth factor-ras signal transduction pathway. Previously, we proposed that one role of AP-1 in transformation is to regulate the expression of a multigenic invasion programme. As a test of this proposal we sought to identify AP-1 regulated genes based upon their differential expression in 208F rat fibroblasts transformed by FBR-v-fos (FBR), and to determine if they functioned in the invasion programme. Subtracted cDNA libraries specific for up- or down-regulated genes in FBRs compared to 208Fs were constructed and analysed. Northern analysis revealed that the cDNAs in both libraries represented differentially expressed genes. Nucleic acid sequence analysis of randomly selected cDNA clones from each library coupled with searches of nucleic acid and amino acid sequence databases determined that many of the cDNAs represented proteins that function in various aspects of the invasion process. Functional analysis of one the down-regulated genes, TSC-36/follistatin-related protein (TSC-36/Frp), which has not previously been associated with invasion, demonstrated that its expression in FBRs inhibited in vitro invasion. These results support the proposal that AP-1 in transformed cells regulates a multigenic invasion programme