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.

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.

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Traumatic 'degloving' injury to the ascending colon This is a case of a seldom published degloving injury to the caecum in a 21-year-old man following a motor vehicle accident. He was the restrained backseat passenger in a car that lost traction at 60 km/h and rolled three times. He was assisted out of the vehicle by the uninjured passengers and brought to hospital by ambulance. He had minimal recollection of the accident but was alert and orientated to person, place and time. He expressed pain over the anterior lower chest wall and entire abdomen. He was examined with a heart rate of 80 beats/min, temperature of 37.3 C, blood pressure of 125/61 mmHg, GCS 15 and respiratory rate of 16 breaths/min with an oxygen saturation of 99% on room air. His abdomen was generally tender, distended and guarded, with focal percussion tenderness over the right hemi-abdomen and right renal angle. He had tenderness to palpation over the lumbar spine but no sensorimotor changes in the lower limbs, genitals or pelvis. He had a 1.5-cm shallow laceration on the forehead without tenderness or bleeding. He had full range of motion in all limbs, without sensory or motor abnormalities. An eFAST scan was attempted but abandoned due to pain; however, brief views elicited free fluid in the abdomen.His admission blood tests revealed a white cell count of 16.3 × 10 9 /L (4.0-11.0 × 10 9 ), haemoglobin 149 g/L (130-175), venous lactate 3.2 mmol/L (0-1.9) and venous pH of 7.32 (7.30-7.4). Initial management included intravenous fluid resuscitation, nasal prong oxygen and analgesia. He underwent a full body

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This article describes the challenge of addressing indigenous health leadership to reduce ethnic disparity in modern healthcare. The indigenous New Zealand population, Māori, are disadvantaged across many health domains including the socioeconomic determinants of health. The Treaty of Waitangi, considered New Zealand’s founding document, outlines Māori autonomy and leadership, and can be applied to a model of health equity. Leadership frameworks in this sense must incorporate ethical and servant leadership styles across a shared, distributive leadership model to develop safe and equitable health environments where Indigenous ways of being and knowing are not subjugated. This is a shift from traditional hierarchical paradigms of the past and acknowledges Māori as having the autonomy to lead and maintain equitable health outcomes.

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