Timing of elective surgery and risk assessment after SARS-CoV-2 infection: an update

The impact of vaccination and new SARS-CoV-2 variants on peri-operative outcomes is unclear. We aimed to update previously published consensus recommendations on timing of elective surgery after SARS-CoV-2 infection to assist policymakers, administrative staff, clinicians and patients. The guidance remains that patients should avoid elective surgery within 7 weeks of infection, unless the benefits of doing so exceed the risk of waiting. We recommend individualised multidisciplinary risk assessment for patients requiring elective surgery within 7 weeks of SARS-CoV-2 infection. This should include baseline mortality risk calculation and assessment of risk modifiers (patient factors; SARS-CoV-2 infection; surgical factors). Asymptomatic SARS-CoV-2 infection with previous variants increased peri-operative mortality risk three-fold throughout the 6 weeks after infection, and assumptions that asymptomatic or mildly symptomatic omicron SARS-CoV-2 infection does not add risk are currently unfounded. Patients with persistent symptoms and those with moderate-to-severe COVID-19 may require a longer delay than 7 weeks. Elective surgery should not take place within 10 days of diagnosis of SARS-CoV-2 infection, predominantly because the patient may be infectious, which is a risk to surgical pathways, staff and other patients. We now emphasise that timing of surgery should include the assessment of baseline and increased risk, optimising vaccination and functional status, and shared decision-making. While these recommendations focus on the omicron variant and current evidence, the principles may also be of relevance to future variants. As further data emerge, these recommendations may be revised.     

Can bedside needle arthroscopy of the ankle be an accurate option for intra-articular delivery of injectable agents?

BACKGROUNDBedside needle arthroscopy of the ankle under local anesthesia has been proposed for intra-articular delivery of injectable agents. Accuracy and tolerability of this approach in the clinical setting–including patients with end-stage ankle pathology and/or a history of prior surgery–is not known.AIMTo assess clinical accuracy and tolerability of bedside needle arthroscopy as a delivery system for injectable agents into the tibiotalar joint.METHODSThis was a prospective study that included adult patients who were scheduled for an injection with hyaluronic acid to the tibiotalar joint. In our center, these injections are used as a last resort prior to extensive surgery. The primary outcome was injection accuracy, which was defined as injecting through the arthroscopic cannula with intra-articular positioning confirmed by a clear arthroscopic view of the joint space. Secondary outcome measures included a patient-reported numeric rating scale (NRS, 0-10) of pain during the procedure and willingness of patients to return for the same procedure. NRS of ankle pain at rest and during walking was collected at baseline and at 2-wk follow-up. Complications were monitored from inclusion up to a 2-wk control visit.RESULTSWe performed 24 inspection-injections. Eleven (46%) participants were male, and mean age was 46.8 ± 14.5 years. Osteoarthritis was the indication for injection in 20 (83%) cases, of which 8 (33%) patients suffered from osteoarthritis Kellgren-Lawrence grade IV, and 10 (42%) patients from Kellgren-Lawrence grade III. An osteochondral defect was the indication for injection in 4 (17%) cases. A history of ankle surgery was present in 14 (58%) participants and a history of multiple ankle surgeries in 11 (46%) participants. It was possible to confirm accuracy in 21 (88%) procedures. The 3 (12%) participants where needle arthroscopy did not reach a clear view of the joint space all suffered from Kellgren-Lawrence grade IV osteoarthritis. Pain during the procedure was reported with a median of 1 [interquartile ranges (IQR): 0–2]. Willingness to return was 100%. Pain in rest decreased from a median NRS of 4 (IQR: 2–7) at baseline to a median of 3 (IQR: 1–5) at follow-up (P < 0.01). Pain during walking decreased from a median NRS of 8 (IQR: 6–9) to a median of 7 (IQR: 4–8) (P < 0.01). Infections or other complications were not encountered.CONCLUSIONClinical accuracy and tolerability of bedside needle arthroscopy of the ankle as a delivery system for injectable agents are excellent. Accuracy was 100% in patients without total ventral joint obliteration.     

Autologous bone marrow transplantation in children with acute lymphoblastic leukemia

We report 25 children with acute lymphoblastic leukemia (ALL) treated with purged autologous bone marrow transplantation (ABMT) at a single center. Two children with high-risk ALL were transplanted in first remission and 23 with relapsing ALL were transplanted in second (n = 21) or third (n = 2) remission. There was no procedure-related mortality. The median time to engraftment (i.e. to reach a polymorphonuclear cell count of 0.5 x 10(9)/l) was 25 days (range 16-45 days). Seven children relapsed, four within five months after ABMT: 18 of 25 children (72%) are in continuous complete remission after a median follow-up period of 50 months (range 5-71 months). The predicted long-term disease-free survival is 65% in the whole group and 61% in those transplanted after relapse. Relapse-free children returned to normal activities within three months after ABMT. The major side effects were development of cataract and gonadal insufficiency. We consider the results promising, but our data do not allow comparison with results reported from treatment with chemotherapy alone, since some of our patients were referred from other centers and represent a selected patient group. Long-term follow-up of well-defined patient populations is necessary to evaluate the effect of ABMT.     

Fetus-placenta-newborn

OBJECTIVE: Our purpose was to determine whether third-trimester maternal serum α-fetoprotein predicts adverse perinatal outcome and whether use of both second- and third-trimester maternal serum α-fetoprotein enhances the positive predictive value for various abnormal outcomes.STUDY DESIGN: A cohort study with obstetric outcome assessed by chart analysis after delivery was performed at Regional Medical Center (Memphis, Tennessee), a hospital staffed by university-based physicians saving a large urban population with many indigent patients. A total of 650 women attending prenatal clincis in the above setting with a singleton pregnancy without a neural tube defect, contributing a maternal blood samples in both the second and third trimesters, and delivered in the above hospital participated. Various pregnancy outcomes were correlated with maternal serum α-fetoprotein levels in the second the third trimesters and in both.RESULTS: In the third trimester no significant associations were found between maternal serum α-fetoprotein elevations and pregnancy complications. In the second trimester elevation (≥2.0 multiples of the median) were, by contrast, significantly associated with preterm premature rupture of the membranes, preterm birth, and low birth weight. No association was found with certain other complications. When second-trimester data were grouped according to the types of complications occurring in individual women, only preterm premature rupture of the membrane proved statistically significant.CONCLUSIONS: Second-trimester but not third-trimester maternal serum α-fetoprotein is significantly elevated with preterm premature rupture of the membranes, preterm birth, and low birth weight; in this conhort study no association was found with preeclampsia, oligohydramnios, or polyhydramnios.     

Efficacy of outpatient induction with low-dose intravaginal prostaglandin E2: A randomized, double-blind, placebo-controlled trial

OBJECTIVE: Our purpose was to determine whether a protocol for outpatient induction is safe and effective for initiating labor.STUDY DESIGN: A randomized, double-blind, a placebo-controlled trial was performed with 100 low-risk patients having well-dated pregnancies. Women with a Bishop score ≤6 at 38 to 40 weeks' gestation were administered either 2 mg of intravaginal prostaglandin E₂ gel or placebo for 5 consecutive days as outpatients while undergoing fetal monitoring.RESULTS: The median interval from randomization to delivery was 4 days in the prostaglandin E₂ group (range 0 to 28 days) and versus 10 days in the placebo group (range 0 to 26 days, p = 0.002). Twenty-seven of 50 patients (54%) in the prostaglandin E₂ group were admitted for labor during the dosing interval compared with 10 placebo-treated patients (20%, p = 0.001). The mean gestational age at delivery was significantly reduced in the treatment group (39.9 ± 1.0 weeks vs 40.5 ± 0.99 weeks, p = 0.003) as was the incidence of postdates pregnancy (40% vs 66%, p = 0.016). Hyperstimulation was observed in one prostaglandin E₂-treated patient, but no intervention was required.CONCLUSIONS: Outpatient low-dose prostaglandin E₂ gel administration is effective for initiating labor in patients with an unfavorable cervix and appears safe if performed with adequate monitoring.     

Incisional bowel herniations after operative laparoscopy: A series of nineteen cases and review of the literature

Objectives: The objectives of this report were (1) to identify all cases of incisional bowel herniations noted after operative laparoscopy in 11 participating institutions and (2) to report the clinical details of such patients.Study Design: A retrospective case review was performed.Results: Nineteen cases of incisional bowel herniation were identified. The average age of the patients was 50.5 years. Initial laparoscopic procedures varied and included laparoscopically assisted vaginal hysterectomy (six Patients), laparoscopically assisted vaginal hysterectomy with lymphadenectomy (five patients), oophorectomy (two patients), adhesiolysis (two patients), myomectomy (two patients), lymphadenectomy alone (one patient), and ovarian cystectomy (one patient). The averge time to reoperation was 8.5 days.Conclusions: Incisional bowel herniation is a serious complication of operative laparoscopy. Herniations occur through ports ≥ 10 mm in size at both umbilical and extraumbilical sites. New techniques are needed to avoid this serious complication.