Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Based on EHR documentation, obesity is under coded and generally not identified as a significant problem in primary care. Physicians are more likely to document obesity in the patient record for those with higher BMI scores who are morbidly obese. Moreover, physicians more frequently provide exercise than diet counseling for the documented obese.

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

Zika virus (ZKV) is an arbovirus of the Flaviviridae family, which includes West Nile, dengue fever, yellow fever, and Japanese encephalitis virus. It is transmitted by the Aedes genus of mosquitoes. Before 2015, ZKV outbreaks occurred in areas of Africa, the Pacific Islands, and Southeast Asia. The current large outbreak, which began in Brazil, has also emerged throughout a large part of South/Central America, a number of islands in the Caribbean, including Puerto Rico, the Virgin Islands, and Mexico. A sudden rise in the numbers of infants reported born with microcephaly in Brazil, and the detection of the single-stranded positive RNA virus in the amniotic fluid of affected newborns, has captured medical, mainstream media, and global political attention, causing considerable concern in a post-Ebola global community considerably more focused on the threat of internationally transmissible diseases. The goal of this article is to provide an overview of ZKV for clinicians, with the emphasis on pathogenesis, clinical manifestations, diagnosis, and treatment/preventive measures.

Previous literature on the impact of scribe programs varies and has mostly been reported from academic institutions or other clinics. We report the implementation of the scribe program in the emergency room of a community hospital and its impact on patient throughput, physician productivity, and patient satisfaction. We performed a quasi-experimental, before-and-after study measuring patient throughput metrics, physician productivity, and patient satisfaction. The intervention measuring the scribe implementation was divided into pre- and post-implementation periods. Patient throughput metrics were (1) door-to-room time, (2) room-to-doc time, (3) door-to-doc time, (4) doc-to-disposition time, and (5) length of stay for discharged/admitted patients. Our secondary outcome was physician productivity, which was calculated by measuring total patients seen per hour and work relative value units per hour. Additionally, we calculated the time-motion analysis in minutes to measure the emergency department physician's efficiency by recording the following: (1) chart preparation, (2) chart review, (3) doctor-patient interaction, (4) physical examination, and (5) post-visit documentation. Finally, we measured patient satisfaction as provided by Press Ganey surveys. Data analysis was conducted in 12,721 patient encounters in the pre-scribe cohort, and 13,598 patient encounters in the post-scribe cohort. All the patient throughput metrics were statistically significant (p< 0.0001). The patients per hour increased from 2.3 ± 0.3 pre-scribe to 3.2 ± 0.6 post-scribe cohorts (p < 0.001). Total work relative value units per hour increased from 241(3.1 ± 1.5 per hour) pre-scribe cohort to 336 (5.2 ± 1.4 per hour) post-scribe cohort (p < 0.001). The pre-scribe patient satisfaction was high and remained high in the post-scribe cohort. There was a significant increase in the clinician providing satisfactory feedback from the pre-scribe (3.9 ± 0.3) to the post-scribe (4.7 ± 0.1) cohorts (p < 0.01). We describe a prospective trial of medical scribe use in the emergency department setting to improve patient throughput, physician productivity, and patient satisfaction. We illustrate that scribe use in community emergency department is feasible and results in improvement in all three metrics.