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 (740%) had emergency surgery and 280 (248%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (261%) patients. 30-day mortality was 238% (268 of 1128). Pulmonary complications occurred in 577 (512%) of 1128 patients; 30-day mortality in these patients was 380% (219 of 577), accounting for 817% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 175 [95% CI 128-240], p<00001), age 70 years or older versus younger than 70 years (230 [165-322], p<00001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (235 [157-353], p<00001), malignant versus benign or obstetric diagnosis (155 [101-239], p=0046), emergency versus elective surgery (167 [106-263], p=0026), and major versus minor surgery (152 [101-231], p=0047). 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

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Anatomical and physiological studies of organogenesis in vitro of Passiflora cincinnata MAST.

O avanço da cultura do maracujazeiro no país impulsionado pela agroindústria de suco e a crescente demanda de fruta fresca, acarretou o surgimento de problemas, principalmente de ordem fitossanitária, doenças causadas por fungos, bactérias e vírus. A espécie Passiflora cincinnata Mast. por apresentar resistência à doença da parte aérea causada pela ba ctéria Xanthomonas campestris f. sp. passiflorae e, potencial para a comercialização constitui um genótipo de interesse em programas de melhoramento. Visto que a cultura de tecidos tem sido ferramenta importante nesses programas, o presente projeto visa o estudo aspectos anatômicos e fisiológicos da organogênese in vitro dessa espécie. Os explantes utilizados: segmentos radiculares, discos foliares e a própria plântula, obtidos da germinação de sementes in vitro, foram inoculados em meio contendo diferentes concentrações de 6-BA (6-benziladenina) e acrescido de 5% de água de coco, a fim de estabelecer os protocolos de regeneração de plantas in vitro. A concentração de 0,5 mg.L -1 de 6-BA foi a mais adequada para os três explantes, porém, o tempo e a via (direta/indireta) de formação da gema diferiu para cada tipo de explante. Os eventos histológicos que levaram a formação de um novo órgão, via meristemóides (centros meristemáticos) foram descritos. Nos discos foliares a origem foi indireta, com formação de calo a partir das células subepidérmicas das camadas de parênquima clorofiliano. Nos segmentos de raiz e nas raízes das plântulas, a organogênese direta apresentou duas origens, a partir do periciclo, nas raízes com início da estrutura secundária, e a partir do câmbio vascular, nas raízes com estrutura secundária já estabelecida. Também nos segmentos de raiz observou-se a via indireta, esta a partir da proliferação do periciclo.The progress of passionfruit culture in the country stimulated by the juice agroindustry and due to an increased demand of fresh fruit have brought phytosanitary problems, such as, diseases caused by fungis, bacterium and virus. The Passiflora cincinnata Mast. a resistant specie to Xanthomonas campestris f. sp. Passiflora bacterium shows a potential for commercialization creating an interest genotype in breedings programs. Whereas the tissue culture has been an important instrument for those programs, object of this program is to study the anatomical and physiologycal aspects of organogenesis "in vitro" of this specie. The explants used were: root segments, leaf discs and the seedlings obtained from germination of seeds "in vitro". They were placed in different solutions of 6-BA (benzyladenine) and with 5% of coconut water, in order to establish protocol for plant regeneration "in vitro". The concentration of 0,5 mg.L- 1 of 6-BA was the most adequate for all three explants, but the time and nourishement source (direct/indirect) to the shoots formation differed to each kind of explants. The histological events had lead the formation of a new organ, by meristemoids (meristematic centers) were described. In the leaf discs the indirect origin, was observed in which callus were formatted by the layer of chlorophyll parenchyma subepidermis cells. In the root segments and in the root plantets, the direct organogenesis showed two origins (source), from the pericycle, on the roots that starts at the secondary structure and from vascular cambium, on the roots that had already been established secondary structure. Also the root segments was seen by the indirect way, which callus were formatted by the pericycle proliferation

Functional study of a regeneration rg1 locus from Solanum peruvianum, a wild species related to tomato

A regeneração in vitro é bastante utilizada em processos biotecnológicos. No entanto, pouco se conhece sobre os mecanismos envolvidos na aquisição de competência para formação de novos órgãos. Em tomateiro (S. lycopersicum), a alta capacidade de regeneração in vitro é atribuída ao alelo Rg1, vinda de Solanum peruvianum, e que está presente na cv MsK (S. lycopersicum x S. peruvianum). Os genes de nanismo da cv Micro-Tom (MT) foram passados para MsK, obtendo-se, após 8 gerações de autofecundação (F8), a cv Micro-MsK. No presente estudo, após 6 gerações de retrocruzamentos (BC6Fn), criou-se MT-Rg1, com Rg1 isogênico a MT. Testes de regeneração in vitro mostraram que a formação de gemas caulinares adventícias para MT-Rg1 e Micro-MsK são equivalentes, evidenciando que a alta capacidade de regeneração de Micro-MsK é basicamente devido ao Rg1. Plantas MTRg1 apresentam freqüente formação de 3 cotilédones, excesso de ramificações caulinares e senescência atrasada, características ausentes nos parentais. Esses efeitos pleiotrópicos de Rg1 coincidem com aqueles descritos para alterações no hormônio citocinina. Testes de sensibilidade à citocinina e de tempo de senescência realizados por nós, bem como dosagem desse hormônio feita por outras equipes, descartaram essa hipótese. Enxertias recíprocas evidenciaram que a promoção da ramificação caulinar por Rg1 não é um sinal translocável, mas parece ser uma característica intrínseca do tecido. Rg1 também promoveu uma maior formação de raízes adventícias em estacas ex vitro, sugerindo que ele afeta o processo de competência para formação de órgãos em geral, e não somente a indução específica de gemas caulinares. Duplos mutantes entre Rg1 e mutantes com alteração na sensibilidade/metabolismo hormonal (dgt, brt e pro), ausência de ramificações caulinares (ls) e senescência acelerada (l) foram obtidos e testados quanto ao padrão de ramificações e à capacidade de regeneração in vitro. Além desses parâmetros, a presença de Rg1 suprimiu o fenótipo de folhas pouco recortadas do mutante hipersensível a giberelina (pro) e recuperou o sistema radicular pouco desenvolvido do mutante com baixa sensibilidade à auxina (dgt). Rg1 também foi capaz de reverter a ausência de ramificações laterais de ls, sendo que a mutação Me, o qual representa uma superexpressão de um gene do tipo KNOX, não foi capaz. Esse resultado sugere que Rg1 não é um gene do tipo KNOX, embora esses genes sejam considerados os principais controladores da competência. Analisando diferentes tipos de explantes em experimentos independentes, contatou-se que, em geral, as mutações brt (baixa sensibilidade a citocinina), dgt e ls diminuíram a capacidade de regeneração de Rg1, enquanto l aumentou. Rg1 mostrou-se particularmente epistático à mutação pro, revertendo o fenótipo de baixa formação de gemas caulinares desse mutante. Surpreendentemente, Rg1 provou ser mais sensível à auxina em testes de alongamento de segmentos de hipocótilos, sendo capaz de reverter o fenótipo do mutante dgt nesse mesmo teste. Em conjunto, esses resultados confirmam o papel de Rg1 na fase de aquisição da competência e sugerem uma interação dos hormônios giberelina e auxina nesse processo.The In vitro regeneration process is widely used in plant biotechnology. However, the mechanisms involved in the acquisition of competence for organ formation are hitherto unknown. In tomato (S. lycopersicum), the high capacity for in vitro regeneration is attributed to the Rg1 allele from S. peruvianum, which is present in the cv MsK (S. lycopersicum x S. peruvianum). The dwarfism genes of the cv Micro-Tom (MT) were transferred to MsK, and, after 8 generations of selfing (F8), the cv Micro-Msk was obtained. Here, after 6 generations of backcrosses (BC6Fn), we created the MT-Rg1, which has Rg1 isogenic to MT. Tests of in vitro regeneration showed that shoot formation in MT-Rg1 and Micro-MsK are equivalent, suggesting that the high capacity of regeneration of Micro-MsK is basically due to Rg1. Comparing MT-Rg1 with the control MT, we noticed a high frequency of 3 cotyledon formation, increased shoot branching and late senescence, which are absent in the parentals. These pleiotropic effects of Rg1 coincide with those described for plants with alterations in the hormone cytokinin. Tests of sensitivity for cytokinin and senescence behavior carried out by us, as well as dosage of that hormone made by other researches, discarded that hypothesis. Reciprocal grafting showed that the promotion of shoot branching by Rg1 is not a transmissible signal, but seems to be an inherent characteristic of the tissue. Rg1 also increases adventitious roots formation of ex vitro cuttings, suggesting that it affects the process of competence, which is common for shoots and roots, instead of the specific induction of shoots. Double mutants between Rg1 and mutants with alteration in the sensitivity/metabolism of plant hormones (dgt, brt and pro), as well as mutants with absence of shoot branching (ls) and accelerated senescence (l) were obtained and tested for the capacity of in vitro regeneration. The presence of Rg1 suppressed the phenotype of less dissected leaves of the mutant hypersensitive to gibberrellin (pro) and rescued the phenotype of poor developed root system of the mutant with low auxin sensitivity (dgt). Rg1 was also able to revert the absence of axillary shoot formation in ls, whereas the mutant Me, which represents an over expression of a KNOX gene was not. This result suggests that Rg1 is not a KNOX gene, although those genes are considered the main controllers of the competence. Analyzing different types of explants in independent experiments, it was verified that, in general, the mutations brt (low sensibility to cytokinin), dgt and ls decreased the regeneration capacity of Rg1, while l increased it. Rg1 was particularly epistatic to the pro mutation, reverting the phenotype of little shoot formation of that mutant. Surprisingly, Rg1 proved to be more sensitive to auxin in the hypocotyl segment elongation test, being able to revert the phenotype of the mutant dgt in the same test. Together, these results confirm the role of the Rg1 in the process of acquisition of the competence and suggest an interaction of the hormones gibberellin and auxin in this process