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.
case report E544Cite as: Can Urol Assoc J 2013;7(7-8):e544-6. http://dx.doi.org/10.5489/cuaj.175 Published online August 19, 2013. AbstractThe incidence of prostate cancer in transsexual patients is very low with only few reported cases. Many years before presenting with prostate cancer, these patients receive hormone ablation as a part of their gender therapy. Their disease is already defined as castrate resistant, and the treatment and follow-up of such patients remains a challenge. We report a case of a male-to-female transgender woman who was diagnosed with metastatic prostate cancer, 31 years post-feminization. Case reportIn 1970, a 45-year-old woman underwent male-to-female sex reassignment surgery, including bilateral orchidectomy. Since then she had started feminizing estrogen therapy, which included conjugated estrogen tablets 1.25 mg daily with no other hormone manipulation therapy. She had no documented family history of prostate cancer.At the age of 75, she presented with obstructive voiding urinary symptoms and was found to have a serum prostatespecific antigen (PSA) level of 13.5 ng/mL; no previous PSA level had been measured (Fig. 1). Her testosterone value was in the castrate range. She underwent a transurethral resection of the prostate and the histology revealed a Gleason 7 prostatic adenocarcinoma. Staging scans did not reveal any evidence of gross metastatic disease. In July 2000, the patient completed a course of external beam radiotherapy (20 fractions of 55.00 Gy) with curative intent. Treatment was well-tolerated. For 18 months following radiotherapy, her PSA values stabilized to about 20 ng/mL. Two years later, her PSA has risen to 37 ng/mL, at which time antiandrogen therapy was initiated (flutamide 250 mg, three times a day) and her estrogen replacement therapy was converted to diethylstilboestrol (1 mg once a day). Four months later, her repeat PSA value decreased to 20 ng/mL. At the end of the same year, diethylstilboestrol had been replaced with ethinyl estradiol (150 mcg once a day), which did not seem to have an effect on future PSA values. At that time a restaging bone scan was done which revealed a suspicion of single metastasis in the proximal femur. She remained asymptomatic. Fourteen months later, her PSA level increased to 40 ng/mL and a repeat bone scan demonstrated significant progression of osseous metastatic disease. At that time palliative chemotherapy was initiated. The patient was treated with mitoxatrone every 21 days and with prednisone 5 mg orally twice daily. She was given 6 cycles of chemotherapy with no toxic side effects. Her PSA initially rose from 53 ng/mL at the start of chemotherapy to 75 at the third cycle and reached plateau at 78 ng/mL after the sixth cycle. Repeated bone and computed tomography scan during chemotherapy showed stable appearances. On August 27, 2005, she was admitted to hospital with general deterioration in health. The next day, the patient died of thromboembolic event. DiscussionThe development of prostate adenocarcinoma in feminized tr...
Heterotopic ossification (HO) is a recognised complication of total hip arthroplasty (THA). This study aims to correlate demographics, surgical approach and type of arthroplasty to the incidence of HO in an attempt to quantify patient risk. A total of 920 primary THAs in 893 patients were performed between 2006 and 2008 in a single arthroplasty centre. Radiographic evaluation was conducted and all cases of HO were classified using the Brooker classification. Age, sex, arthroplasty type and surgical approach were all considered as variables. Arthroplasty type was classified into four groups; total cemented (TC), total uncemented (TU), hybrid (H) and reverse hybrid (RH). Two-level logistic regression analysis was conducted. The overall incidence of HO was 24%. Male sex [OR=3.57, 95% CI (1.79-7.10); p=0.001], lateral approach [OR=2.47, (95% CI 1.23-4.95); p=0.001] and total cemented implants [OR=3.14, (95%CI 1.37-7.23); p=0.007] were significantly associated with HO. The intra-class correlation coefficient was 0.52 [95% CI (0.21, 0.81); p=0.004], demonstrating that patients with previous HO to one THA were very likely to suffer HO in subsequent THA. The results demonstrate very large effects for sex, surgical approach, and implant type on HO incidence. This raises a three arm hypotheses that reaming of the femoral canal for the insertion of cemented implants contaminates the surgical field with bone marrow increasing the risk of HO, whereas modern cementless implants generally employ impaction broaching. In addition surgical insult to the hip abductors during exposure, particularly in males due to higher muscle mass, may also predispose to HO.
Cancer and its treatment are recognized risk factors for VTE. Compliance rate with published VTE prophylaxis guidelines is low. Decision on when to offer prophylaxis for hospitalized cancer patients is difficult to make. This paper describes current clinical practice in offering VTE prophylaxis to hospitalized cancer patients. Prophylaxis rate and rate of VTE will be correlated with the risk level. We prospectively followed all consecutive adult cancer patients admitted to medical units over a 5-month period. Caprini risk assessment model, with some modifications, was utilized to determine risk of VTE. Six hundred and six patients (51% males, median age 52 years, range 18-91) were included. Reasons for admission included infections (25%), chemotherapy (22%) and palliative care (10%). In addition to cancer, the most frequently encountered risk factors for VTE were: Immobilization (35%), age > 60 years (31%) and body mass index > 30 in (20%). Patients were grouped according to their total risk score: low (9%), moderate (44%) and high risk (47%). VTE prophylaxis rate was 55.1% for the whole study group. Following discharge, patients were followed for 60 days. The incidence of VTE was 3.4% in the moderate and 4.2% in the high risk groups, while none in the low risk group developed VTE. Many additional risk factors for VTE are usually encountered in hospitalized cancer patients. Cancer alone may not be an enough reason for VTE prophylaxis. Risk assessment model able to stratify patients into different risk categories will simplify decision making and enhance VTE prophylaxis rate.
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