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

Occurrence and Concentrations of Caffeine in Seawater from the Oregon Coast and Potential Effects on the Dominant Mussel, Mytilus californianus

Caffeine, a biologically active drug with many known molecular targets, is recognized as a contaminant of aquatic systems including marine systems. Although the concentrations of caffeine reported from aquatic systems are low (ng/L to μ/L), harmful ecological effects not detected by traditional toxicity tests could occur as a result of caffeine contamination. The goals of this thesis project were to: 1) quantify concentrations of caffeine occurring in the coastal ocean off of the Oregon Coast and to determine if higher levels were correlated with proximity to caffeine pollution sources; and 2) investigate the sub-lethal cellular toxicity of environmentally relevant concentrations of caffeine on Mytilus californianus, an intertidal mussel that is one of the dominant species of the Oregon Coast. Caffeine was analyzed at 14 locations in the coastal ocean off of the Oregon Coast. Sampling locations were stratified between populated areas identified as having sources of caffeine pollution and sites located in sparsely populated areas not in proximity to major caffeine pollution sources. Caffeine concentrations were also measured in the major water body discharging near sampling locations. Caffeine was detected in water from the coastal ocean off of the Oregon Coast at concentrations ranging from below the reporting limit to 44.7 ng/L. The occurrence and concentrations of caffeine in the coastal ocean did not correspond well with pollution threats from population density and point and non-point sources, but did correspond with a storm event occurrence. Caffeine concentrations in rivers and estuaries draining to the coast ranged from below the reporting limit to 152.2 ng/L. Hsp70, a molecular biomarker of cellular stress, was used to investigate the sub-lethal toxicity of environmentally relevant concentrations of caffeine to the mussel M. californianus. Hsp70 concentrations in the gill and mantle tissue of mussels exposed to 0.05, 0.2, and 0.5 μ/L of caffeine for 10, 20, and 30 days were compared to basal levels in control mussels. Hsp70 in the gill tissue of M. californianus had an initial attenuation of the stress protein followed by a significant albeit moderate up-regulation relative to controls in all but the 0.5 μ/L treatment. Hsp70 in the mantle tissue of mussels exposed to caffeine did not differ from control mussels. This Study confirms the presence of caffeine in Oregon\u27s coastal ocean and provides laboratory evidence that environmentally relevant concentrations of caffeine can exert an effect on M. californianus gill tissue at the molecular-level

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)