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

American College of Rheumatology Provisional Criteria for Clinically Relevant Improvement in Children and Adolescents With Childhood-Onset Systemic Lupus Erythematosus

10.1002/acr.23834ARTHRITIS CARE & RESEARCH715579-59

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p < 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Use of liposomal amphotericin B and other drugs for the treatment of patients presenting with mucosal leishmaniasis: analysis of the experience in a referenced institute for the treatment of leishmaniasis, 2000-2015

Introdução: As leishmanioses são antropozoonoses que constituem um grave problema de saúde pública por apresentarem um complexo espectro clínico de manifestações e relevante diversidade epidemiológica. Aproximadamente 5% dos pacientes com leishmaniose cutânea não tratada adequadamente irão desenvolver a leishmaniose mucosa (LM). As principais opções terapêuticas disponíveis para esta apresentação da doença são os antimoniais pentavalentes, a pentamidina e as anfotericinas B. As formulações lipídicas da anfotericina B tem sido desenvolvidas na tentativa de melhorar a eficácia e a tolerabilidade das anfotericinas, entretanto, ainda há escassez de estudos que avaliem eficácia, dose e segurança da anfotericina B lipossomal (AFBL) no tratamento da LM. Objetivo: Relatar a experiência do ambulatório e da enfermaria de um hospital escola com medicamentos usados no tratamento da leishmaniose mucosa, comparando a eficácia e a segurança da anfotericina B lipossomal com as outras drogas. Métodos: Foram avaliados os prontuários de todos os pacientes do Ambulatório de Leishmanioses do Departamento de Moléstias Infecciosas e Parasitárias do HC-FMUSP com diagnóstico confirmado de LM e tratados no período de janeiro de 2000 a julho de 2015. Dados clínicos e epidemiológicos foram descritos, e também avaliados os efeitos adversos e os desfechos com o uso das principais drogas para LM. Resultados: Foram avaliados 71 pacientes com leishmaniose mucosa e um total de 106 tratamentos. A maioria dos pacientes era do sexo masculino (60,6%) e da Região Nordeste do Brasil (50%). Observou-se associação de flebite (46,2%) e de tremor (30,8%) com o grupo que recebeu anfotericina B complexo lipídico e maior desenvolvimento de artralgia (16%) no grupo que recebeu o antimonial. Os pacientes tratados com anfotericina B desoxicolato apresentaram a maior taxa de insuficiência renal aguda (57,10%) em relação aos demais grupos de drogas. O grupo que usou antimonial pentavalente foi o único que desenvolveu alterações nas enzimas pancreáticas (28%) e alterações eletrocardiográficas (20%). Dos pacientes que usaram anfotericina B desoxicolato, 85,7% precisaram interromper definitivamente o tratamento, o que contribuiu para a pior taxa de cicatrização final (14,3%), enquanto a AFBL apresentou a melhor taxa (81,3%) quando comparada aos demais tratamentos, OR= 4,971 [1,829-13,508] (p= 0,001). O uso de itraconazol mostrou alta taxa de recidiva (63,6%). A dose média de AFBL usada no tratamento de LM foi 1907mg e 28,91mg/kg. Quando comparadas as drogas com a AFBL, a pentamidina foi a única que não apresentou diferença estatisticamente significante em relação aos desfechos de tratamento. Conclusão: A pentamidina e a AFBL mostraram-se, neste estudo, as melhores opções terapêuticas no tratamento da LM, sendo que a AFBL foi a droga com a maior taxa de cicatrização. Com base neste estudo e em outras experiências da literatura até o momento, o intervalo de dose compreendido entre 30 e 35 mg/kg é o que parece alcançar eficácia próxima a 100%. Sugerimos, portanto, uma dose cumulativa de 30 mg/kg para o tratamento da LM. Este estudo amplia a experiência com o uso do itraconazol e da pentamidina, e é o primeiro a descrever o uso da ABCL na LM. Apresenta, ainda, a maior casuística que conhecemos na literatura com o uso da AFBL, além de ser o primeiro estudo a compará-la com as demais drogas no tratamento da LMCROIntroduction: Leishmaniases are anthropozoonoses that constitute a severe problem of public health as they present with a complex spectrum of manifestations and relevant epidemiologic diversity. Approximately 5% of patients with untreated cutaneous leishmaniosis will develop mucosal leishmaniasis (ML). The main treatment options for this presentation are: pentavalent antimonials, pentamidine, and amphotericins B. The lipid formulations of amphotericin B have been developed to improve efficacy and tolerability, however, there are few studies that evaluate efficacy, dosage, and safety of liposomal amphotericin B (LAB) for treatment of ML. Objective: To report outpatient and inpatient experience of a hospital school with medications used for treatment of mucosal leishmaniasis by comparing the efficacy and safety of liposomal amphotericin B with other drugs. Methodology: The medical records of all patients of the Leishmaniasis Outpatient Clinic of the Department of Infectious and Parasitic Diseases of the Hospital das Clínicas of University of São Paulo were assessed. The patients had diagnosis of ML and were treated between January 2000 and July 2015. Epidemiologic and clinical data were described, as well as adverse effects and outcomes of the main drugs for treatment of ML. Results: Seventy-one patients with ML and a total of 106 treatments were assessed. The majority of the patients were male (60.6%) and from the Northeast of Brazil (50%). There was an association of phlebitis (46.2%) and tremor (30.8%) to the group that received amphotericin B lipid complex (ABLC). There was a higher development of arthralgia (16%) in the group that received the antimonial. Patients treated with deoxycholate amphotericin B presented with the highest level of acute kidney injury (57.1%) when compared to other drugs. The group who received pentavalent antimonial was the only one to develop pancreatic enzymes abnormalities (28%) and electrocardiographic abnormalities (20%). Within the patients who used deoxycholate amphotericin B, 85.7% had to discontinue the treatment, contributing to the worst healing rate (14.3%). LAB presented with the best healing rate (81.3%) when compared to the other treatments, OR = 4.971 [1,829-13,508] (p=0,001). The use of itraconazole showed high recurrence rate (63.6%). The mean dosage of LAB for the treatment of ML was 1,907 mg and 28.91 mg/kg. When LAB was compared to other drugs, pentamidine was the only one with no statistical significance related to the outcomes of the treatment. Conclusion: In this study, pentamidine and LAB were the best therapeutic options for the treatment of ML; LAB was the drug with better healing rate. Based on this study and other references in the literature, the dosage interval between 30 and 35 mg/kg appears to reach efficacy close to 100%. Therefore, our recommendation is the use of a cumulative dosage of 30 mg/kg for the treatment of ML. This study enhances the experience of itraconazole and pentamidine, and it is the first one to describe the use of ABLC for the treatment of ML. In addition, it presents the largest casuistic known in the literature with the use of LAB, and it is a pioneer in comparing this drug with other drugs in the treatment of M

Use of liposomal amphotericin B and other drugs for the treatment of patients presenting with mucosal leishmaniasis: analysis of the experience in a referenced institute for the treatment of leishmaniasis, 2000-2015

Introdução: As leishmanioses são antropozoonoses que constituem um grave problema de saúde pública por apresentarem um complexo espectro clínico de manifestações e relevante diversidade epidemiológica. Aproximadamente 5% dos pacientes com leishmaniose cutânea não tratada adequadamente irão desenvolver a leishmaniose mucosa (LM). As principais opções terapêuticas disponíveis para esta apresentação da doença são os antimoniais pentavalentes, a pentamidina e as anfotericinas B. As formulações lipídicas da anfotericina B tem sido desenvolvidas na tentativa de melhorar a eficácia e a tolerabilidade das anfotericinas, entretanto, ainda há escassez de estudos que avaliem eficácia, dose e segurança da anfotericina B lipossomal (AFBL) no tratamento da LM. Objetivo: Relatar a experiência do ambulatório e da enfermaria de um hospital escola com medicamentos usados no tratamento da leishmaniose mucosa, comparando a eficácia e a segurança da anfotericina B lipossomal com as outras drogas. Métodos: Foram avaliados os prontuários de todos os pacientes do Ambulatório de Leishmanioses do Departamento de Moléstias Infecciosas e Parasitárias do HC-FMUSP com diagnóstico confirmado de LM e tratados no período de janeiro de 2000 a julho de 2015. Dados clínicos e epidemiológicos foram descritos, e também avaliados os efeitos adversos e os desfechos com o uso das principais drogas para LM. Resultados: Foram avaliados 71 pacientes com leishmaniose mucosa e um total de 106 tratamentos. A maioria dos pacientes era do sexo masculino (60,6%) e da Região Nordeste do Brasil (50%). Observou-se associação de flebite (46,2%) e de tremor (30,8%) com o grupo que recebeu anfotericina B complexo lipídico e maior desenvolvimento de artralgia (16%) no grupo que recebeu o antimonial. Os pacientes tratados com anfotericina B desoxicolato apresentaram a maior taxa de insuficiência renal aguda (57,10%) em relação aos demais grupos de drogas. O grupo que usou antimonial pentavalente foi o único que desenvolveu alterações nas enzimas pancreáticas (28%) e alterações eletrocardiográficas (20%). Dos pacientes que usaram anfotericina B desoxicolato, 85,7% precisaram interromper definitivamente o tratamento, o que contribuiu para a pior taxa de cicatrização final (14,3%), enquanto a AFBL apresentou a melhor taxa (81,3%) quando comparada aos demais tratamentos, OR= 4,971 [1,829-13,508] (p= 0,001). O uso de itraconazol mostrou alta taxa de recidiva (63,6%). A dose média de AFBL usada no tratamento de LM foi 1907mg e 28,91mg/kg. Quando comparadas as drogas com a AFBL, a pentamidina foi a única que não apresentou diferença estatisticamente significante em relação aos desfechos de tratamento. Conclusão: A pentamidina e a AFBL mostraram-se, neste estudo, as melhores opções terapêuticas no tratamento da LM, sendo que a AFBL foi a droga com a maior taxa de cicatrização. Com base neste estudo e em outras experiências da literatura até o momento, o intervalo de dose compreendido entre 30 e 35 mg/kg é o que parece alcançar eficácia próxima a 100%. Sugerimos, portanto, uma dose cumulativa de 30 mg/kg para o tratamento da LM. Este estudo amplia a experiência com o uso do itraconazol e da pentamidina, e é o primeiro a descrever o uso da ABCL na LM. Apresenta, ainda, a maior casuística que conhecemos na literatura com o uso da AFBL, além de ser o primeiro estudo a compará-la com as demais drogas no tratamento da LMCROIntroduction: Leishmaniases are anthropozoonoses that constitute a severe problem of public health as they present with a complex spectrum of manifestations and relevant epidemiologic diversity. Approximately 5% of patients with untreated cutaneous leishmaniosis will develop mucosal leishmaniasis (ML). The main treatment options for this presentation are: pentavalent antimonials, pentamidine, and amphotericins B. The lipid formulations of amphotericin B have been developed to improve efficacy and tolerability, however, there are few studies that evaluate efficacy, dosage, and safety of liposomal amphotericin B (LAB) for treatment of ML. Objective: To report outpatient and inpatient experience of a hospital school with medications used for treatment of mucosal leishmaniasis by comparing the efficacy and safety of liposomal amphotericin B with other drugs. Methodology: The medical records of all patients of the Leishmaniasis Outpatient Clinic of the Department of Infectious and Parasitic Diseases of the Hospital das Clínicas of University of São Paulo were assessed. The patients had diagnosis of ML and were treated between January 2000 and July 2015. Epidemiologic and clinical data were described, as well as adverse effects and outcomes of the main drugs for treatment of ML. Results: Seventy-one patients with ML and a total of 106 treatments were assessed. The majority of the patients were male (60.6%) and from the Northeast of Brazil (50%). There was an association of phlebitis (46.2%) and tremor (30.8%) to the group that received amphotericin B lipid complex (ABLC). There was a higher development of arthralgia (16%) in the group that received the antimonial. Patients treated with deoxycholate amphotericin B presented with the highest level of acute kidney injury (57.1%) when compared to other drugs. The group who received pentavalent antimonial was the only one to develop pancreatic enzymes abnormalities (28%) and electrocardiographic abnormalities (20%). Within the patients who used deoxycholate amphotericin B, 85.7% had to discontinue the treatment, contributing to the worst healing rate (14.3%). LAB presented with the best healing rate (81.3%) when compared to the other treatments, OR = 4.971 [1,829-13,508] (p=0,001). The use of itraconazole showed high recurrence rate (63.6%). The mean dosage of LAB for the treatment of ML was 1,907 mg and 28.91 mg/kg. When LAB was compared to other drugs, pentamidine was the only one with no statistical significance related to the outcomes of the treatment. Conclusion: In this study, pentamidine and LAB were the best therapeutic options for the treatment of ML; LAB was the drug with better healing rate. Based on this study and other references in the literature, the dosage interval between 30 and 35 mg/kg appears to reach efficacy close to 100%. Therefore, our recommendation is the use of a cumulative dosage of 30 mg/kg for the treatment of ML. This study enhances the experience of itraconazole and pentamidine, and it is the first one to describe the use of ABLC for the treatment of ML. In addition, it presents the largest casuistic known in the literature with the use of LAB, and it is a pioneer in comparing this drug with other drugs in the treatment of M