Severe COVID-19-associated sepsis is different from classical sepsis induced by pulmonary infection with carbapenem-resistant klebsiella pneumonia (CrKP)

PurposeCOVID-19 is also referred to as a typical viral septic pulmonary infection by 2019-nCoV. However, little is known regarding its characteristics in terms of systemic inflammation and organ injury, especially compared with classical bacterial sepsis. This article aims to investigate the clinical characteristics and prognosis between COVID-19-associated sepsis and classic bacterial-induced sepsis.MethodsIn this retrospective cohort study, septic patients with COVID-19 in the intensive care unit (ICU) of a government-designed therapy center in Shenzhen, China between January 14, 2020 and March 10, 2020, and septic patients induced by carbapenem-resistant klebsiella pneumonia (CrKP) admitted to the ICU of the Second People's Hospital of Shenzhen, China between January 1, 2014 and October 30, 2019 were enrolled. Demographic and clinical parameters including comorbidities, critical illness scores, treatment, and laboratory data, as well as prognosis were compared between the two groups. Risk factors for mortality and survival rate were analyzed using multivariable logistic regression and survival curve, respectively.ResultsA total of 107 patients with COVID-19 and 63 patients with CrKP were enrolled. A direct comparison between the two groups demonstrated more serious degrees of primary lung injury following 2019-nCoV infection (indicated by lower PaO₂/FiO₂), but milder systemic inflammatory response, lower sequential organ failure assessment score and better functions of the organs like heart, liver, kidney, coagulation, and circulation. However, the acquired immunosuppression presented in COVID-19 patients was more severe, which presented as lower lymphocyte counts (0.8×10⁹/L vs. 0.9×10⁹/L). Moreover, the proportion of COVID-19 patients treated with corticosteroid therapy and extracorporeal membrane oxygenation was larger compared with CrKP patients (78.5% vs. 38.1% and 6.5% vs. 0, respectively) who required less invasive mechanical ventilation (31.6% vs. 54.0%). The incidence of hospitalized mortality and length of ICU stay and total hospital stay were also lower or shorter in viral sepsis (12.1% vs. 39.7%, 6.5 days vs. 23.0 days and 21.0 days vs. 33.0 days, respectively) (all p < 0.001). Similar results were obtained after being adjusted by age, gender, comorbidity and PaO2/FiO2. Lymphocytopenia and high acute physiology and chronic health evaluation II scores were common risk factors for in-hospital death. While the death cases of COVID-19 sepsis mostly occurred at the later stages of patients’ hospital stay.ConclusionCritical COVID-19 shares clinical characteristics with classical bacterial sepsis, but the degree of systemic inflammatory response, secondary organ damage and mortality rate are less severe. However, following 2019-nCoV infection, the level of immunosuppression may be increased and thus induce in more death at the later stage of patients’ hospitalstay.     

COVID-19 patients with obesity at risk for worse outcomes despite younger age and fewer inflammatory derangements

BackgroundCoronavirus disease 2019 (COVID-19) is a viral pulmonary infection that can progress to cytokine storm syndrome because of widespread dysregulated inflammatory response. Many patients at risk for severe COVID-19 manifestation have been identified as those with preexisting conditions of pulmonary origin, as well as conditions that impair appropriate immune response, such as obesity.ObjectivesThe aim of this study is to describe the manifestation, clinical course, and inflammatory biomarker milieu of COVID-19 in patients with obesity.SettingUniversity Hospital Philadelphia, Pennsylvania.MethodsIn this retrospective cohort study, 600 patients who were positive for COVID-19 were stratified by World Health Organization (WHO) obesity class and their presenting symptoms, disease biomarkers, demographics, and outcomes (intubation rate, intensive care unit [ICU] admission, length of stay [LOS], and mortality) were investigated.ResultsAge was inversely related to obesity class; patients of obesity class III presented 12.9 years younger than patients of normal weight (P < .0001). Initial ferritin lab values were negatively correlated with increasing obesity class (P = .0192). Normal or near-normal lymphocyte profile was noted in patients with obesity compared with patients without obesity (P = .0017). Patients with obesity had an increased rate of ICU admission (P = .0215) and increased length of stay (P = .0004), but no differences in intubation rate (P = .3705) or mortality (P = .2486).ConclusionPatients with obesity were more likely to present to the hospital at a younger age, with reduced levels of COVID-19 related biomarker disturbances, and increased LOS and ICU admission rates, although were not at increased risk for mortality.     

COVID-19 in hemodialysis patients: a single-center experience in Istanbul

Objective

Coronavirus disease 2019 (COVID-19) causes a wide spectrum of symptoms, from asymptomatic conditions to severe inflammatory response. Hemodialysis (HD) patients have a higher risk for developing severe COVID-19 because of older age, multiple co-morbid conditions, and impaired immune system compared to the general population. As little is known about these special groups, we evaluated the clinical characteristics and outcomes of HD patients with COVID-19.

Methods

All hospitalized HD patients with COVID 19 between March 11, 2020 and May 31, 2020 were included in the study. The composite end-points consisted of admission to the intensive care unit (ICU), discharging or death were analysed. Demographic, clinical, laboratory, and treatment data were retrieved and compared between survivors and nonsurvivors.

Results

A total of 45 patients (median age 65.33?±?12.22, 24 female, 53.96?±?40.68) were enrolled and of whom 14 were admitted to ICU and overall 14 (31.1%) have died. Hypertension was the most common comorbidity and fever (60%), dyspnea (55.6%) and cough (53.3%) were predominant symptoms at admission. 8.8% of patients developed severe complications (acute respiratory distress syndrome, macrophage activation syndrome) and secondary infection was observed in 51.1% of the patients. Elevation in the level of inflammatory markers, lactate dehydrogenase, liver enzymes, troponin, creatine kinase, and decrease in lymphocyte count and serum albumin level were observed in non-survivors compared with survivors throughout the clinical course. No significant difference was observed in the score of chest CT performed on the day of hospitalization for the survivors and non-survivors.

Conclusion

Mortality of COVID-19 in HD patients is high and follow up of certain laboratory parameters can help to predict the prognosis of the patients.

     

Pacientes críticos COVID-19 atendidos por anestesiólogos en el Noroeste de España: estudio multicéntrico,prospectivo, observacional

Background and objectivesThere are limited information on outcome, complications and treatments of critically ill COVID-19 patients requiring admission to an intensive care unit (ICU). The aim of this study is to describe the clinical ICU course, treatments used, complications and outcomes, of critically ill COVID-19 patients admitted in seven ICU in Galicia region during the 2020 March-April pandemic peak.MethodsBetween March 21 and April 19, 2020, we evaluated critically ill COVID-19 patients admitted to the ICU of Anesthesia of seven hospitals in Galicia, northwestern Spain. Outcome, complications, and treatments were monitored until May 6, 2020, the final date of follow-up.ResultsA total of 97 critically ill COVID-19 patients were included. During ICU stay, mechanical ventilation became necessary in 80 (82.5%) patients, and tracheostomy in 22 (22.7%) patients. Prone position was used frequently in both intubated (67.5%) and awake (27.8%) patients. Medications consisted of antivirals agents (92.7%), corticosteroids (93.8%), tocilizumab (57.7%), and intermediate or high doses of anticoagulants (83.5%). The most frequent complications were ICU-acquired infection (52.6%), thrombosis events (16.5%), and reintubation (9.3%). After a median follow-up of 42 (34-45) days, 15 patients (15.5%) deceased, 73 patients (75.2%) had been discharged from ICU, and nine patients (9.3%) were still in the ICU.ConclusionsA high proportion of our critically ill COVID-19 patients required mechanical ventilation, prone positioning, antiviral medication, corticosteroids, and anticoagulants. ICU complications were frequent, mainly infections and thrombotic events. We had a relatively low mortality of 15,5%.     

Bariatric surgery and COVID-19 outcomes: a systematic review and meta-analysis

BackgroundObesity and its associated complications have a negative impact on human health. Metabolic and bariatric surgery (MBS) ameliorates a series of clinical manifestations associated with obesity. However, the overall efficacy of MBS on COVID-19 outcomes remains unclear.ObjectivesThe objective of this article is to analyze the relationship between MBS and COVID-19 outcomes.SettingA meta-analysis.MethodsThe PubMed, Embase, Web of Science, and Cochrane Library databases were searched to retrieve the related articles from inception to December 2022. All original articles reporting MBS-confirmed SARS-CoV-2 infection were included. Outcomes including hospital admission, mortality, intensive care unit (ICU) admission, mechanical ventilation utilization, hemodialysis during admission, and hospital stay were selected. Meta-analysis with fixed or random-effect models was used and reported in terms of odds ratios (ORs) or weighted mean differences (WMDs) along with their 95% confidence intervals (CIs). Heterogeneity was assessed with the I² test. Study quality was assessed using the Newcastle-Ottawa Scale.ResultsA total of 10 clinical trials involving the investigation of 150,848 patients undergoing MBS interventions were included. Patients who underwent MBS had a lower risk of hospital admission (OR: .47, 95% CI: .34–.66, I² = 0%), mortality (OR: .43, 95% CI: .28–.65, I² = 63.6%), ICU admission (OR: .41, 95% CI: .21–.77, I² = 0%), and mechanical ventilation (OR: .51, 95% CI: .35–.75, I² = 56.2%) than those who did not undergo surgery, but MBS did not affect hemodialysis risk or COVID-19 infection rate. In addition, the length of hospital stay for patients with COVID-19 after MBS was significantly reduced (WMD: −1.81, 95% CI: −3.11–.52, I² = 82.7%).ConclusionsOur findings indicate that MBS is shown to improve COVID-19 outcomes, including hospital admission, mortality, ICU admission, mechanical ventilation, and hospital stay. Patients with obesity who have undergone MBS infected with COVID-19 will have better clinical outcomes than those without MBS.     

Hypophosphatemia is an independent risk factor for AKI among hospitalized patients with COVID-19 infection

BackgroundThis study sought to investigate incidence and risk factors for acute kidney injury (AKI) in hospitalized COVID-19.MethodsIn this retrospective study, we enrolled 823 COVID-19 patients with at least two evaluations of renal function during hospitalization from four hospitals in Wuhan, China between February 2020 and April 2020. Clinical and laboratory parameters at the time of admission and follow-up data were recorded. Systemic renal tubular dysfunction was evaluated via 24-h urine collections in a subgroup of 55 patients.ResultsIn total, 823 patients were enrolled (50.5% male) with a mean age of 60.9 ± 14.9 years. AKI occurred in 38 (40.9%) ICU cases but only 6 (0.8%) non-ICU cases. Using forward stepwise Cox regression analysis, we found eight independent risk factors for AKI including decreased platelet level, lower albumin level, lower phosphorus level, higher level of lactate dehydrogenase (LDH), procalcitonin, C-reactive protein (CRP), urea, and prothrombin time (PT) on admission. For every 0.1 mmol/L decreases in serum phosphorus level, patients had a 1.34-fold (95% CI 1.14–1.58) increased risk of AKI. Patients with hypophosphatemia were likely to be older and with lower lymphocyte count, lower serum albumin level, lower uric acid, higher LDH, and higher CRP. Furthermore, serum phosphorus level was positively correlated with phosphate tubular maximum per volume of filtrate (TmP/GFR) (Pearson r = 0.66, p < .001) in subgroup analysis, indicating renal phosphate loss via proximal renal tubular dysfunction.ConclusionThe AKI incidence was very low in non-ICU patients as compared to ICU patients. Hypophosphatemia is an independent risk factor for AKI in patients hospitalized for COVID-19 infection.     

Prior bariatric surgery in COVID-19–positive patients may be protective

BackgroundPatients infected with novel COVID-19 virus have a spectrum of illnesses ranging from asymptomatic to death. Data have shown that age, sex, and obesity are strongly correlated with poor outcomes in COVID-19–positive patients. Bariatric surgery is the only treatment that provides significant, sustained weight loss in the severely obese.ObjectivesExamine if prior bariatric surgery correlates with increased risk of hospitalization and outcome severity after COVID-19 infection.SettingUniversity hospitalMethodsA cross-sectional retrospective analysis of a COVID-19 database from a single, New York City–based, academic institution was conducted. A cohort of COVID-19–positive patients with a history of bariatric surgery (n = 124) were matched in a 1:4 ratio to a control cohort of COVID-19–positive patients who were eligible for bariatric surgery (BMI ≥40 kg/m² or BMI >35 kg/m² with a co-morbidity at the time of COVID-19 diagnosis) (n = 496). A comparison of outcomes, including mechanical ventilation requirements and deceased at discharge, was done between cohorts using χ² test or Fisher’s exact test. Additionally, overall length of stay and duration of time in intensive care unit (ICU) were compared using Wilcoxon rank sum test. Conditional logistic regression analyses were done to determine both unadjusted (UOR) and adjusted odds ratios (AOR).ResultsA total of 620 COVID-19–positive patients were included in this analysis. The categorization of bariatric surgeries included 36% Roux-en-Y gastric bypass (RYGB, n = 45), 36% laparoscopic adjustable gastric banding (LAGB, n = 44), and 28% laparoscopic sleeve gastrectomy (LSG, n = 35). The body mass index (BMI) for the bariatric group was 36.1 kg/m² (SD = 8.3), which was significantly lower than the control group, 41.4 kg/m² (SD = 6.5, P < .0001). There was also less burden of diabetes in the bariatric group (32%) compared with the control group (48%) (P = .0019). Patients with a history of bariatric surgery were less likely to be admitted through the emergency room (UOR = .39, P = .0001), less likely to require a ventilator during the admission (UOR=.42, P = .028), had a shorter length of stay in both the ICU (P = .033) and overall (UOR = .44, P = .0002), and were less likely to be deceased at discharge compared with the control group (OR = .42, P = .028).ConclusionA history of bariatric surgery significantly decreases the risk of emergency room admission, mechanical ventilation, prolonged ICU stay, and death in patients with COVID-19. Even when adjusted for BMI and the co-morbidities associated with obesity, patients with a history of bariatric surgery still have a significant decrease in the risk of emergency room admission.     

Patients With Previous COVID-19 Infection Can Safely Undergo Primary Total Joint Arthroplasty

BackgroundThe COVID-19 virus is believed to increase the risk of diffusing intravascular coagulation. Total joint arthroplasty (TJA) is one of the most common elective surgeries and is also associated with a temporarily increased risk of venous thromboembolism (VTE). However, the influence of a history of COVID-19 infection on perioperative outcomes following TJA remains unknown. Therefore, this study sought to determine what effect a history of COVID-19 infection had on outcomes following primary TJA.MethodsA retrospective case-control study using the national database was performed to identify all patients who had a history of COVID-19 and had undergone TJA, between 2019 and 2020. Patients who had a history of both were 1:1 matched to those who did not have a history of COVID-19, and 90-day outcomes were compared. A total of 661 TKA and 635 THA patients who had a history of COVID-19 were 1:1 matched to controls. There were no differences in demographics and comorbidities between the propensity-matched pairs in both TKAs and THAs studied. Previous COVID-19 diagnosis was noted in 28.3% of patients 5 days within TJA and in 78.6%, 90 days before TJA.ResultsPatients who had a previous diagnosis of COVID-19 had a higher risk of pneumonia during the postoperative period for both THA and TKA (6.9% versus 3.5%, P < .001 and 2.27% versus 1.21%, P = .04, respectively). Mean lengths of stay were also greater for those with a previous COVID-19 infection in both cohorts (TKA: 3.12 versus 2.57, P = .027, THA: 4.52 versus 3.62, P < .001). Other postoperative outcomes were similar between the 2 groups.ConclusionCOVID-19 infection history does not appear to increase the risk of VTE following primary TJA, but appears to increase the risk of pneumonia in addition to lengths of stay postoperatively. Individual risk factors should be discussed with patients, to set reasonable expectations regarding perioperative outcomes.     

Características,evolución clínica y factores asociados a la mortalidad en UCI de los pacientes críticos infectados por SARS-CoV-2 en España: estudio prospectivo,de cohorte y multicéntrico

BackgroundThe clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported.ObjectiveThis study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients.MethodsProspective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12^th to May 26^th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients.ResultsA total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO₂ with non-rebreather mask, 90 (IQR 83 to 93) vs. 91 (IQR 87 to 94); P<.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5 to 9) vs. 4 (IQR 3 to 7); P<.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs. 89%; P=.009), acute kidney injury (AKI) (58% vs. 24%; P<10^-16), shock (42% vs. 14%; P<10^-13), and arrhythmias (24% vs. 11%; P<10^-4). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs. 25%; P=.03, 33% vs. 23%; P=.01 and 15% vs. 3%, P=10^-7), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1 to 10, P=.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), P=.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), P<10^-4)], cardiac arrest [OR: 11.099 (3.389, 36.353), P=.0001], and septic shock [OR: 3.224 (1.486, 6.994), P=.002] had an increased risk-of-death.ConclusionsOlder COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades ii or iii and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.     

Clinical characteristics of deceased hemodialysis patients affected by COVID-19

Background

The recent outbreak of Coronavirus Disease 2019 (COVID-19) is a public health emergency of international concern. In China, Wuhan, Hubei Province was the epicenter. The disease is more severe in patients with high comorbidities and dialysis patients fall into this category.

Methods

In this report, we reviewed the whole course of the epidemic emerged in the HD center of Wuhan NO.1 Hospital by 28 February 2020. We compared the differences on the epidemiological characteristics and clinical features between patients surviving from COVID-19 and patients who died.

Result

In this hospital, at time of the present report, 627 patients were on chronic hemodialysis and the prevalence of affected cases was 11.8% (74/627).The median age of the COVID-19-positive patients was 63 years (range 31–88), with an almost even gender distribution (females accounted for 54.4%).The most frequent presenting symptom was cough (41.9%), followed by fatigue (24.2%), fever (17.2%) and dyspnea (14.8%); 22.4% of the cases were and asymptomatic. Fourteen of the 74 patients died (19%), as for presenting symptoms, cough was more frequent in patients who died (P?<?0.05). Surviving patients had higher levels of phosphate and albumin, and lower levels of C-reactive protein (CRP). Chest CT scan was positive in all cases, including in asymptomatic ones, and revealed in about three fourths of the cases bilateral (76.2%) lesions; in each lung lesions were multiple in about half of the cases of the cases (52.3%). After diagnosis, median time to death was 7 days in the 14 patients who died, with a range between 4 and 18 days.

Conclusion

This preliminary, single Center study identifies hemodialysis patients as a population at high risk of severe, and deadly COVID-19 infection. While classic baseline clinical conditions, including age, kidney disease and gender, are not significantly associated with survival in COVID-19 infected hemodialysis, our study also suggests a significant association between risk of and death, poor nutritional status and less than optimal metabolic balance.

     

Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era

BACKGROUNDHip fractures are the most common reason for inpatient orthopaedic trauma admission. Urgent surgical intervention for hip fractures has remained a clinical priority throughout the coronavirus disease 2019 (COVID-19) pandemic. Despite this, there is a paucity of clinical guidance addressing the informed consent process for hip fracture surgery in COVID-19 positive patients. This is of paramount medicolegal importance in a high-risk patient population.AIMTo quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery and provide clinicians with an evidence-based framework to establish an informed consent process.METHODSTwo hundred and fifty nine consecutive patients undergoing surgical intervention for hip fractures in four hospitals in the United Kingdom were recruited. 51 patients were confirmed positive for COVID-19. Predefined outcomes were analyzed over a 30-d postoperative period. COVID-19 positive and COVID-19 negative patients were compared after adjustment for confounding factors.RESULTSCOVID-19 positive patients had more intensive care admissions (27% vs 5%, P < 0.001), longer inpatient stays (median 23 d vs 9 d, P < 0.001) and a higher 30-d mortality (29% vs 10%, P = 0.001) than COVID-19 negative patients. Postoperative complications were evident in 74.5% of COVID-19 positive patients. 35.3% of COVID-19 positive patients suffered postoperative lower respiratory tract infections with 13.7% developing acute respiratory distress syndrome (ARDS) and 9.8% experiencing symptomatic thromboembolic events.CONCLUSIONThe COVID-19 pandemic has created uncertainty in the medical community worldwide and poses unique challenges in providing informed consent for surgery. COVID-19 positive patients undergoing hip fracture surgery should be consented for the additional risk of postoperative complications (including lower respiratory tract infection, ARDS, deep vein thrombosis and pulmonary embolism), increased requirement for intensive care admission, longer inpatient stay and higher risk of mortality. Further, clinicians must be transparent about the potential for unknown risks as research into the long-term surgical outcomes of COVID-19 positive patients continues to evolve.     

How COVID-19 Patients Were Moved to Speak: A Rehabilitation Interdisciplinary Case Series

Background

Up to 36% of patients admitted to the ICU for COVID-19 require tracheostomy. While the literature recommends the use of multidisciplinary teams in the management of patients with tracheostomy for other diseases, little is known on the collaborative administration of physical therapy and speech language pathology services in the COVID-19 population.

Purpose

We sought to determine the outcomes of a collaboration between physical therapy (PT) and speech language pathology (SLP) in the treatment of patients who underwent tracheostomy placement as part of their treatment for COVID-19 at our facility.

Methods

We conducted a retrospective case series on patients with COVID-19 who had a tracheostomy. We included patients who had undergone mechanical ventilation for 14 days or longer, had a surgical tracheostomy, been discharged from intensive care to a medical unit, and received PT and SLP referrals. We compiled retrospective data from electronic medical records, analyzing days from tracheostomy to achievement of PT and SLP functional milestones, including mobility, communication, and swallowing. Of six critically ill patients with COVID-19 who had tracheostomy placement at our facility, three met inclusion criteria: patient 1, a 33-year-old woman; patient 2, an 84-year-old man; and patient 3, an 81-year-old man. For all patients, PT interventions focused on breathing mechanics, secretion clearance, posture, sitting balance, and upper and lower extremity strengthening. SLP interventions focused on cognitive reorganization, verbal and nonverbal communication, secretion management, and swallowing function. Intensity and duration of the sessions were adapted according to patient response and level of fatigue.

Results

We found that time to tracheostomy from intubation for the three patients was 23 days, 20 days, and 24 days, respectively. Time from tracheostomy insertion to weaning from ventilator was 9 days for patient 1, and 5 days for patient 2 and patient 3. Regarding time to achieve functional PT and SLP milestones, all patients achieved upright sitting with PT prior to achieving initial SLP milestone of voicing with finger occlusion. Variations in progression to swallowing trials were patient specific and due to respiratory instability, cognitive deficits, and limitations in production of an effortful swallow. Patient participation in therapy sessions improved following establishment of oral verbal communication.

Conclusion

Interdisciplinary cooperation and synchronized implementation of PT and SLP interventions in three COVID-19 patients following prolonged intubation facilitated participation in treatment and achievement of functional milestones. Further study is warranted.

     

Outcomes of orthopaedic trauma patients undergoing surgery during the peak period of COVID-19 infection at a UK major trauma centre

BackgroundTo review the clinical outcomes of all patients undergoing emergency orthopaedic trauma surgery at a UK major trauma centre during the first 6 weeks of the COVID-19 related lockdown.MethodsA retrospective review was performed of all patients who underwent emergency orthopaedic trauma surgery at a single urban major trauma centre over the first six-week period of national lockdown. Demographics, co-morbidities, injuries, injury severity scores, surgery, COVID-19 status, complications and mortalities were analysed.ResultsA total of 76 patients were included for review who underwent multiple procedures. Significant co-morbidity was present in 72%. The overall COVID-19 infection rate of the study population at any time was 22%. Sub-group analysis indicated 13% had active COVID-19 at the time of surgery. Only 4% of patients developed COVID-19 post surgery with no mortalities in this sub-group. The overall mortality rate was 4%. The overall complication rate was 14%. However mortality and complications rates were higher if the patients had active COVID-19 at surgery, if they were over 70 years and had sustained life-threatening injuries.ConclusionThe overall survival rate for patients undergoing emergency orthopaedic trauma surgery during the COVID-19 peak was 96%. The rate of any complication was more significant in those presenting with active COVID-19 infections who had sustained potentially life threatening injuries and were over 70 years of age. Conversely those without active COVID-19 infection and who lacked significant co-morbidities experienced a lower complication and mortality rate.     

Perioperative use of intra-articular steroids during the COVID-19 pandemic

Purpose

There are growing concerns with the widely used glucocorticoids during the Coronavirus disease-19 (COVID-19) pandemic due to the associated immunosuppressive effects, which may increase the risk of COVID-19 infection and worsen COVID-19 patient outcome. Heavily affecting orthopaedics, the pandemic led to delay and cancellation of almost all surgical cases, and procedures including perioperative intra-articular corticosteroid injections (ICIs) saw similar decreases. However, the benefits of ICI treatments during the pandemic may outweigh these potential risks, and their continued use may be warranted.

Methods

A literature search was conducted, and all relevant articles including original articles and reviews were identified and considered in full for inclusion, and analysed with expert opinion. Epidemiological statistics and medical guidelines were consulted from relevant authorities.

Results

ICIs allow a targeted approach on the affected joint and are effective in reducing pain while improving functional outcome and patient quality-of-life. ICIs delay the requirement for surgery, accommodating for the increased healthcare burden during the pandemic, while reducing postoperative hospital stay, bringing significant financial benefits. However, ICIs can exert systemic effects and suppress the immune system. ICIs may increase the risk of COVID-19 infection and reduce the efficacy of COVID-19 vaccinations, leading to important public health implications.

Conclusion

Perioperative ICI treatments may bring significant, multifaceted benefits during the pandemic. However, ICIs increase the risk of infection, and perioperative COVID-19 is associated with mortality. The use of ICIs during the COVID-19 pandemic should therefore be considered carefully on an individual patient basis, weighing the associated risks and benefits.

     

Bariatric surgery in patients with previous COVID-19 infection

BackgroundThe process of reintroducing bariatric surgery to our communities in a COVID-19 environment was particular to each country. Furthermore, no clear recommendation was made for patients with a previous COVID-19 infection and a favorable outcome who were seeking bariatric surgery.ObjectivesTo analyze the risks of specific complications for patients with previous COVID-19 infection who were admitted for bariatric surgery.SettingEight high-volume private centers from 5 countries.MethodsAll patients with morbid obesity and previous COVID-19 infection admitted for bariatric surgery were included in the current study. Patients were enrolled from 8 centers and 5 countries, and their electronic health data were reviewed retrospectively. The primary outcome was to identify early (<30 d) specific complications related to COVID-19 infection following bariatric surgery, and the secondary outcome was to analyze additional factors from work-ups that could prevent complications.ResultsThirty-five patients with a mean age of 40 years (range, 21–68 yr) and a mean body mass index of 44.3 kg/m² (±7.4 kg/m²) with previous COVID-19 infection underwent different bariatric procedures: 23 cases of sleeve (65.7 %), 7 cases of bypass, and 5 other cases. The symptomatology of the previous COVID-19 infection varied: 15 patients had no symptoms, 12 had fever and respiratory signs, 5 had only fever, 2 had digestive symptoms, and 1 had isolated respiratory signs. Only 5 patients (14.2 %) were hospitalized for COVID-19 infection, for a mean period of 8.8 days (range, 6–15 d). One patient was admitted to an intensive care unit and needed invasive mechanical ventilation. The mean interval time from COVID-19 infection to bariatric surgery was 11.3 weeks (3–34 wk). The mean hospital stay was 1.7 days (±1 d), and all patients were clinically evaluated 1 month following the bariatric procedure. There were 2 readmissions and 1 case of complication: that case was of a gastric leak treated with laparoscopic drainage and a repeated pigtail drain, with a favorable outcome. No cases of other specific complications or mortality were recorded.ConclusionMinor and moderate COVID-19 infections, especially the forms not complicated with invasive mechanical ventilation, should not preclude the indication for bariatric surgery. In our experience, a prior COVID-19 infection does not induce additional specific complications following bariatric surgery.     

Rheumatic Disease-Related Symptoms During the Height of the COVID-19 Pandemic

Background

Systemic rheumatic diseases are characterized by diverse symptoms that are exacerbated by stressors.

Questions/Purposes

Our goal was to identify COVID-19-related stressors that patients associated with worsening rheumatic disease symptoms.

Methods

With approval of their rheumatologists, patients at an academic medical center were interviewed with open-ended questions about the impact of COVID-19 on daily life. Responses were analyzed with qualitative methods using grounded theory and a comparative analytic approach to generate categories of stressors.

Results

Of 112 patients enrolled (mean age 50 years, 86% women, 34% non-white or Latino, 30% with lupus, 26% with rheumatoid arthritis), 2 patients had SARS-CoV-2 infection. Patients reported that coping with challenges due to the pandemic both directly and indirectly worsened their rheumatic disease symptoms. Categories associated with direct effects were increased fatigue (i.e., from multitasking, physical work, and taking precautions to avoid infection) and worsening musculoskeletal and cognitive function. Categories associated with indirect effects were psychological worry (i.e., about contracting SARS-COV-2, altering medications, impact on family, and impact on job and finances) and psychological stress (i.e., at work, at home, from non-routine family responsibilities, about uncertainty related to SARS-CoV-2, and from the media). Patients often reported several effects coalesced in causing more rheumatic disease symptoms.

Conclusion

Coping with the COVID-19 pandemic was associated with rheumatic disease–related physical and psychological effects, even among patients not infected with SARS-CoV-2. According to patients, these effects adversely impacted their rheumatic diseases. Clinicians will need to ascertain the long-term sequelae of these effects and determine what therapeutic and psychological interventions are indicated.

     

Effect of COVID-19 Pandemic on Patients Who Have Undergone Liver Transplantation Because of Hepatocellular Carcinoma

Background and AimMany clinical studies have shown that the COVID-19 case fatality rate is higher in older patients, those with comorbidities, those with immunosuppressive conditions, and those who stay in the intensive care unit. This study aims to evaluate the clinical outcomes of 66 liver transplant (LT) patients with primary liver cancer who were exposed to COVID-19 infection.MethodsDemographic and clinical data of 66 patients with primary liver cancer (hepatocellular carcinoma = 64, hepatoblastoma = 1, cholangiocarcinoma = 1) who underwent LT in our institute and were exposed to COVID-19 infection between March 2020 and November 2021 were analyzed in this cross-sectional study. The following data of the patients were recorded: age, sex, body mass index (kg/m²), blood group, underlying primary liver disease, smoking, tumor characteristics, post-transplant immunosuppressive agents, COVID-19 symptoms, hospitalization, intensive care unit stay, intubation, and other clinical features.ResultsThere were 55 (83.3%) male and 11 (16.7%) female patients, with a median age of 58 years. Sixty-four patients were exposed to COVID-19 only once, whereas the remaining 2 patients were exposed 2 and 4 times, respectively. After exposure to COVID-19, it was determined that 37 patients used antiviral drugs, 25 were hospitalized, 9 were followed in the intensive care unit, and 3 were intubated. One intubated patient was under hospital follow-up because of biliary complications before exposure to COVID-19, and this patient died from sepsis.ConclusionThe low mortality rate of LT patients with primary liver cancer exposed to COVID-19 infection can be attributed to background immunosuppression that prevents cytokine storm. However, it is appropriate to support this study with multicenter studies to make strong comments on this issue.     

30-Day Mortality Rate in Hip Fractures Among the Elderly with Coexistent COVID-19 Infection: A Systematic Review

PurposeHip fractures in the elderly require a multi-disciplinary approach and are associated with increased morbidity and mortality. The current COVID-19 pandemic has affected substantially this high-risk population group. This present review was done to ascertain whether or not the pandemic has affected the 30-day mortality and outcomes of hip fracture in the elderly.Research QuestionDoes the coexistence of COVID-19 infection and hip fractures in the elderly increase the mortality rates?MethodologyA systematic review and meta-analysis were conducted using three databases (PubMed, EMBASE and SCOPUS) to compare the mortality rates between COVID-19 positive/suspect and COVID-19 negative patients. The secondary outcomes included comparison of in-hospital mortality, complication rate and length of hospital stay. Risk of bias assessment was done using the MINORS tool.ResultsThe present review included 20 studies. Primary outcome: A significantly higher 30 day mortality rate was seen in COVID-19 positive/suspect patients with an Odds ratio of 6.09 (95% CI 4.75–8.59, p < 0.00001). Secondary outcome: We observed significantly higher rates of inpatient mortality [OR 18.22, (95% CI 7.10–46.75], complication rate (OR 9.28, 95% CI 4.46–19.30), and length of hospital stay (MD: 4.96, 95% CI 2.86–7.05) in COVID-19 positive/suspect patients as compared to COVID-19 negative patients.ConclusionCOVID-19 has deteriorated the outcomes in elderly patients with hip fractures and associated with higher rates of mortality in the short term. A multidisciplinary approach is needed to contain this “pandemic within a pandemic” and improve the overall outcome to survival.