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.

This study assessed the risk factors driving the epidemic of COVID-19 associated mucormycosis (COVID-Mucor) in Indiathat accompanied the COVID-19 pandemic, particularly the second wave. We analysed the risk factors among 164 participants:132 COVID-Mucor(cases) and 32 non-COVID-Mucor(controls)using the data from a prospective cohort study of mucormycosis over oneyear. Diabetes mellitus remained a pivotal risk factor in both groups (97%) while uncontrolled diabetes mellitus (OR: 4.6; p=0.026)and newly detected diabetes (OR: 3.3; p=0.018), werecommoneramong the cases. Most patients with COVID-Mucor had mild COVID-19. Steroid use, often unwarranted, was highly associated with COVID-Mucorafter adjusting for other risk factors (OR 28.4; P 0.001). Serum ferritin was significantly higher(p=0.041), while C-reactive protein was not, suggesting that alterations in iron metabolism probably predispose to COVID-Mucor. Oxygen was used only in a small minority of patients with COVID-Mucor. The in-hospital mortality in both groups was low. In conclusion, the Indian COVID-Mucorepidemic was likely driven by a convergence of interlinked risk factors –uncontrolled diabetes mellitus, unwarranted steroid use, and perhapsCOVID-19 itself. Appropriate steroid use in patients with severe COVID-19 and screening and optimal control of hyperglycaemia can prevent COVID-Mucor.

Background: Oral and topical corticosteroids, and antibiotics form the mainstay medical treatment of chronic rhinosinusitis (CRS).Clinical outcomes vary depending on the chosen therapy, resident microbiome and disease phenotype. We conducted a doubleblinded, placebo-controlled Randomised Controlled Trial (RCT) to investigate effects of medical therapy on clinical outcomes and associated microbiome shifts.Methodology: Fifty eligible patients (CRS with and without polyps) were treated for 3 weeks after randomisation into 3 arms: namely oral prednisolone, topical budesonide irrigations and oral doxycycline; each with appropriate placebo. Clinical scoring and microbiome swabs were performed on enrolment, at treatment completion and 3-weeks post treatment completion. Microbiome analysis was performed using the llumina-MiSeq next generation sequencing platform and QIME-2 pipeline.Results: Significant improvement in clinical scores was observed in prednisolone and budesonide arms at treatment completion but not with antibiotic. Sub-group analysis showed more pronounced effects in patients with polyposis. Corynebacterium and Staphylococcus species predominated, with variable bacterial relative abundance among different treatments at all time-points.The only significant microbiome finding was an increase in bacterial diversity in topical budesonide group immediately after treatment, which returned to baseline 3-weeks post treatment. Conclusion:Clinical improvement was significant with oral and topical steroid but not empirical antibiotic. Although there were some associated microbiome changes with the various treatments, we could not ascertain the consistency of these and whether they do have a clinical significance at all.

BackgroundMiddle meatal antrostomy (MMA) provides limited access to the anteromedial and inferior aspect of the maxillary sinus (MS) often resulting in residual disease and inflammatory burden. Newer extended procedures, such as mega‐antrostomy (Mega‐A) and extended modified mega‐antrostomy (EMMA), have been developed to address this limitation. This study assesses the effect of varying extent of MS surgery on irrigation penetration and access of instrumentation.MethodsThe MS of 5 fresh‐frozen cadavers were sequentially dissected. Irrigation was evaluated with a squeeze bottle (SB) in different head positions and using different volumes of fluid. Surgical reach and visualization were examined using common sinus instruments and different angled endoscopes. A disease simulation was also performed to check for residual debris after instrumentation and irrigations.ResultsIrrigation penetration improved as antrostomy size increased (p < 0.0001), with a significant difference observed between the extended procedures and MMA. The effect of the volume was significant for SB (p < 0.0001) but head positions appeared irrelevant (p = 0.613). Overall visualization improved for Mega‐A and EMMA. A similar trend was seen for the reach of the instruments to all sinus wall subsites. EMMA facilitated the most removal of “sinus disease” in the disease simulation model when compared with both MMA and Mega‐A, due to its reach of the anteroinferior aspects of the maxillary sinus.ConclusionsHigh‐volume irrigation using SB achieved good sinus penetration, irrespective of head position. Extended MS procedures appear to further increase irrigation penetration as well as surgical access.

A 58-year-old lady, a known diabetic, presented with fever, left facial pain, swelling, and redness of 3 days duration. She reported a similar episode 3 months ago, which subsided with medications. There were no other ENT complaints. There was a notable past history of multiple discharging sinuses over the abdominal wall and around right hip which took few months to heal, several years back. The patient also gave history of undergoing tooth extractions and dental implantation 2 years prior to the current symptoms. On examination, there was diffuse swelling with erythema and tenderness over the left cheek. Rest of the ENT examination was unremarkable except for discharge and debris in left middle meatus on diagnostic nasal endoscopy (DNE). A contrast-enhanced computed tomography of paranasal sinuses (PNS) showed heterogeneous soft tissue density filling left maxilla and ethmoids, with no clear bony erosions (Figure 1). Endoscopic sinus surgery revealed mucopurulent discharge, debris, and underlying unhealthy inflamed mucosa in the left maxillary sinus and ethmoids which were sampled. Histopathology showed nonspecific chronic inflammation and granules with gram-positive thin, branching filamentous organisms. Anaerobic bacterial culture grew Actinomyces spp. She was treated with Co Amoxiclav for 2 weeks but defaulted further treatment till her review 3 months later when a DNE showed granular mucosa with yellow spots in the postoperative cavity. Although she was asymptomatic and repeat debridement and cultures were sterile, she was treated with oral amoxicillin 500 mg 3 times a day for 3 months. On follow-up 9 months later, she was asymptomatic with no endoscopic evidence of recurrence. Actinomycosis is a slowly progressive infection with granulomatous and suppurative features commonly involving the cervicofacial, thoracic, abdominal, and genital areas. 1 Although almost 50% of actinomycosis involve head and neck region, the disease is relatively rare in nose and PNS. 2 Actinomycosis is caused by Actinomyces israelii, a grampositive, anaerobic, saprophytic, human commensal bacterium commonly found in the mouth and aerodigestive tract. The

+31 6 48 934 761 w.horst@student.tue.nl student designer +31 6 48 923 661 t.bunt@student.tue.nl student designer +31 40 247 5980 s.a.g.wensveen@tue.nl probes coach +31 40 247 5390 l.c.cherian@tue.nl project coach ABSTRACTIn this paper we describe how we applied the method of cultural probes to get empathy with and inspiration from families. We illustrate this with a concrete research study in which we applied this method to investigate 'the need to stay in touch' present in different families. Firstly we discuss the problems that emerge when applying this method to a family as opposed to applying it to individuals. Secondly we discuss the design of the package, illustrated with examples, and finally we discuss the translation of the qualitative data into visualised contextual scenarios. We conclude with a reflection on how the research has affected our awareness of the design context.

No abstract