Timing of elective surgery and risk assessment after SARS-CoV-2 infection: 2023 update: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, Federation of Surgical Specialty Associations, Royal College of Anaesthetists and Royal College of Surgeons of England: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, Federation of Surgical Specialty Associations, Royal College of Anaesthetists and Royal College of Surgeons of England

Guidance for the timing of surgery following SARS-CoV-2 infection needed reassessment given widespread vaccination, less virulent variants, contemporary evidence and a need to increase access to safe surgery. We, therefore, updated previous recommendations to assist policymakers, administrative staff, clinicians and, most importantly, patients. Patients who develop symptoms of SARS-CoV-2 infection within 7 weeks of planned surgery, including on the day of surgery, should be screened for SARS-CoV-2. Elective surgery should not usually be undertaken within 2 weeks of diagnosis of SARS-CoV-2 infection. For patients who have recovered from SARS-CoV-2 infection and who are low risk or having low-risk surgery, most elective surgery can proceed 2 weeks following a SARS-CoV-2 positive test. For patients who are not low risk or having anything other than low-risk surgery between 2 and 7 weeks following infection, an individual risk assessment must be performed. This should consider: patient factors (age; comorbid and functional status); infection factors (severity; ongoing symptoms; vaccination); and surgical factors (clinical priority; risk of disease progression; grade of surgery). This assessment should include the use of an objective and validated risk prediction tool and shared decision-making, taking into account the patient's own attitude to risk. In most circumstances, surgery should proceed unless risk assessment indicates that the risk of proceeding exceeds the risk of delay. There is currently no evidence to support delaying surgery beyond 7 weeks for patients who have fully recovered from or have had mild SARS-CoV-2 infection.

Postoperative mortality and complications in patients with and without pre-operative SARS-CoV-2 infection: a service evaluation of 24 million linked records using OpenSAFELY

Surgical decision-making after SARS-CoV-2 infection is influenced by the presence of comorbidity, infection severity and whether the surgical problem is time-sensitive. Contemporary surgical policy to delay surgery is informed by highly heterogeneous country-specific guidance. We evaluated surgical provision in England during the COVID-19 pandemic to assess real-world practice and whether deferral remains necessary. Using the OpenSAFELY platform, we adapted the COVIDSurg protocol for a service evaluation of surgical procedures that took place within the English NHS from 17 March 2018 to 17 March 2022. We assessed whether hospitals adhered to guidance not to operate on patients within 7 weeks of an indication of SARS-CoV-2 infection. Additional outcomes were postoperative all-cause mortality (30 days, 6 months) and complications (pulmonary, cardiac, cerebrovascular). The exposure was the interval between the most recent indication of SARS-CoV-2 infection and subsequent surgery. In any 6-month window, < 3% of surgical procedures were conducted within 7 weeks of an indication of SARS-CoV-2 infection. Mortality for surgery conducted within 2 weeks of a positive test in the era since widespread SARS-CoV-2 vaccine availability was 1.1%, declining to 0.3% by 4 weeks. Compared with the COVIDSurg study cohort, outcomes for patients in the English NHS cohort were better during the COVIDSurg data collection period and the pandemic era before vaccines became available. Clinicians within the English NHS followed national guidance by operating on very few patients within 7 weeks of a positive indication of SARS-CoV-2 infection. In England, surgical patients' overall risk following an indication of SARS-CoV-2 infection is lower than previously thought.

High Psychosocial Burden Relates to Poorer Antiretroviral Treatment Adherence Among Black/African American People with HIV

Black/African American communities continue to be disproportionately impacted by HIV with Black people with HIV (PWH) exhibiting poorer outcomes along the HIV treatment cascade. Psychosocial burden may, in part, explain these health disparities among PWH. We implemented a culturally adapted intervention [individualized Texting for Adherence Building (iTAB)] to improve ART adherence among 89 Black PWH in San Diego, CA. We aimed to (1) characterize psychosocial risk factors (depression, negative life events, discrimination, medical mistrust) hypothesized to be barriers to HIV outcomes among Black PWH and (2) determine if these factors influence intervention engagement, HIV outcomes, and self-reported physical and mental health. We identified three levels of psychosocial burden (low, moderate, high) through hierarchical cluster analysis. Participants in the high burden cluster (n = 25) experienced the highest levels of depression, negative life events, and discrimination, in addition to the poorest intervention outcomes, HIV outcomes, and physical and mental health compared to low and moderate burden clusters. Participants in the low (n = 29) burden cluster had less medical mistrust than the moderate (n = 34) and high burden clusters, but low and moderate clusters did not differ on any outcomes. Overall, self-reported ART adherence was 83%, which is above estimates of ART adherence in the Western region of the United States. The iTAB intervention shows promise in improving HIV-related outcomes among Black PWH with low to moderate psychosocial burden; however, additional supports may need to be identified for those with high psychosocial burden.

Aerosol precautions and airway complications: a national prospective multicentre cohort study

The perceived risk of transmission of aerosolised viral particles from patients to airway practitioners during the COVID-19 pandemic led to the widespread use of aerosol precautions, including personal protective equipment and modifications to anaesthetic technique. The risk of these aerosol precautions on peri-operative airway complications has not been assessed outside of simulation studies. This prospective, national, multicentre cohort study aimed to quantify this risk. Adult patients undergoing general anaesthesia for elective or emergency procedures over a 96-hour period were included. Data collected included use of aerosol precautions by the airway practitioner, airway complications and potential confounding variables. Mixed-effects logistic regression was used to assess the risk of individual aerosol precautions on overall and specific airway complications. Data from 5905 patients from 70 hospital sites were included. The rate of airway complications was 10.0% (95%CI 9.2-10.8%). Use of filtering facepiece class 2 or class 3 respirators was associated with an increased risk of airway complications (odds ratio 1.38, 95%CI 1.04-1.83), predominantly due to an association with difficult facemask ventilation (odds ratio 1.68, 95%CI 1.09-2.61) and desaturation on pulse oximetry (odds ratio 2.39, 95%CI 1.26-4.54). Use of goggles, powered air-purifying respirators, long-sleeved gowns, double gloves and videolaryngoscopy were not associated with any alteration in the risk of airway complications. Overall, the use of filtering facepiece class 2 or class 3 respirators was associated with an increased risk of airway complications, but most aerosol precautions used during the COVID-19 pandemic were not.

Timing of elective surgery and risk assessment after SARS-CoV-2 infection: an update: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, Centre for Perioperative Care, Federation of Surgical Specialty Associations, Royal College of Anaesthetists, Royal College of Surgeons of England

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.

Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.

SARS-CoV-2 infection, COVID-19 and timing of elective surgery: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England

The scale of the COVID‐19 pandemic means that a significant number of patients who have previously been infected with SARS‐CoV‐2 will require surgery. Given the potential for multisystem involvement, timing of surgery needs to be carefully considered to plan for safe surgery. This consensus statement uses evidence from a systematic review and expert opinion to highlight key principles in the timing of surgery. Shared decision‐making regarding timing of surgery after SARS‐CoV‐2 infection must account for severity of the initial infection; ongoing symptoms of COVID‐19; comorbid and functional status; clinical priority and risk of disease progression; and complexity of surgery. For the protection of staff, other patients and the public, planned surgery should not be considered during the period that a patient may be infectious. Precautions should be undertaken to prevent pre‐ and peri‐operative infection, especially in higher risk patients. Elective surgery should not be scheduled within 7 weeks of a diagnosis of SARS‐CoV‐2 infection unless the risks of deferring surgery outweigh the risk of postoperative morbidity or mortality associated with COVID‐19. SARS‐CoV‐2 causes either transient or asymptomatic disease for most patients, who require no additional precautions beyond a 7‐week delay, but those who have persistent symptoms or have been hospitalised require special attention. Patients with persistent symptoms of COVID‐19 are at increased risk of postoperative morbidity and mortality even after 7 weeks. The time before surgery should be used for functional assessment, prehabilitation and multidisciplinary optimisation. Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS‐CoV‐2 infection of other patients and staff. National vaccine committees should consider whether such patients can be prioritised for vaccination. As further data emerge, these recommendations may need to be revised, but the principles presented should be considered to ensure safety of patients, the public and staff.

A Culturally Adapted SMS Text Messaging Intervention to Promote Antiretroviral Therapy Adherence Among African Americans: Protocol for a Single-Arm Trial

Background

African Americans are disproportionally affected by HIV and have poorer rates of antiretroviral therapy (ART) adherence compared to other racial or ethnic groups in the United States. Factors associated with poor HIV disease outcomes are commonly associated with sociostructural barriers that prevent engagement with and retention in HIV care. SMS text messaging interventions to promote ART adherence among predominantly non-Hispanic White persons with HIV (PWH) have been shown to be efficacious; however, limited research has been devoted to culturally tailoring interventions for underrepresented racial/ethnic groups. Considering African Americans show poorer engagement along the HIV care continuum, we developed an individualized and culturally tailored two-way SMS text messaging intervention to improve ART adherence and associated virologic suppression among African American PWH.

Objective

In this paper we describe the protocol of a culturally tailored individualized Texting for Adherence Building (iTAB) intervention in a 24- to 48-week, single-arm study.

Methods

We developed a culturally tailored iTAB intervention, which we are implementing in a 24- to 48-week, single-arm study. Participants were recruited from the Family Health Centers of San Diego (FHCSD), a federally qualified health center. Patient inclusion criteria were (1) receiving care at the FHCSD, (2) living with HIV, (3) self-identification as Black, African American, or of African ancestry, (4) English speaking, (5) age 18 or older, (6) currently on ART, and (7) able to provide informed consent. Study enrollment began in November 2017 and closed in July 2019. A total of 90 participants from the FHCSD enrolled in the iTAB intervention, and we anticipate completing data collection in July 2020. Participants were assisted in individualizing and customizing their SMS text message preferences at the baseline study visit. Self-assessment measures are collected at baseline, interim, and final study visits. Problems related to sending/receiving SMS text messages and barriers to ART adherence are assessed at each interim study visit. The FHCSD staff monitors and tracks participants’ daily SMS text message responses to ART adherence reminders using a clinical dashboard.

Results

We hypothesize that the proportion of individuals achieving HIV virologic suppression (viral load <40 copies/mL) will be greater at the end of the intervention period compared to the proportion prior to study implementation. Additionally, we anticipate that rates of virologic suppression at the end of the intervention among participants receiving iTAB will be comparable to those among the general FHCSD non-African American population who did not receive iTAB. Finally, we anticipate a high response rate to iTAB SMS text messages as well as positive participant feedback at the end of the intervention with regard to the acceptability of, satisfaction with, and perceived efficacy of iTAB.

Conclusions

The iTAB intervention is a novel individualized two-way SMS text messaging intervention that has been culturally tailored for use among African Americans with HIV. We anticipate that iTAB will demonstrate efficacy in future randomized control trials and will be supportive of medication adherence among other populations facing health disparities.

International Registered Report Identifier (IRRID)

DERR1-10.2196/21592

Tailoring a mobile health text-messaging intervention to promote antiretroviral therapy adherence among African Americans: A qualitative study

African Americans are disproportionately affected by HIV and socio-structural barriers that impact antiretroviral (ART) adherence. Two-way text-messaging interventions have shown promise in supporting adherence in US studies of mostly White people living with HIV (PLWH). However, culturally-appropriate tailoring is necessary to maximize intervention effectiveness among other racial/ethnic groups. Thus, to refine an existing text-messaging intervention, we examined barriers and facilitators to ART adherence among African Americans and perspectives on features to integrate into the extant intervention. Three focus groups, two with African American PLWH (n = 5 and n = 7) and one with providers of care (n = 11) were conducted; transcripts of audio-recordings were thematically analyzed. Adherence supports operated at individual, interpersonal, and structural/environmental levels (e.g., using reminders and pill organizers, wanting to protect partners from HIV, and positive interactions with providers). Adherence barriers also operated at multiple ecological levels (e.g., poor mental health, fear of disclosure of HIV status, and unstable housing). Participant-suggested features for refinement included: i) matching content to participants’ comfort with receiving messages referencing HIV or medication-taking, ii) culturally-tailoring content for African Americans, iii) tracking adherence, and iv) encouraging adherence interactions between patients and providers. Feedback from both patients and providers is foundational to designing effective ART interventions among African American PLWH.

Functional outcome assessment after open tennis elbow release: what are the predictor parameters?

INTRODUCTION

Open surgical release remains the gold standard for treatment of recalcitrant lateral epicondylitis (tennis elbow). We aimed to evaluate the potential impact of perioperative factors on outcome after open surgical release for tennis elbow.

METHODS

All patients without elbow dislocation who underwent open surgical release for tennis elbow from January 2000 to June 2006 were included in the study. Comorbidities and associated pathologies of the upper limb as well as postoperative pain score, range of motion, evidence of instability, recurrence and other complications were noted.

RESULTS

There were 37 female and 24 male patients aged 22-60 (44.95 +/- 7.34) years. Five (8.1 percent) patients had diabetes mellitus. The mean duration of symptoms before surgery was 16.8 +/- 15.3 (range 2-84) months. The average duration of follow-up was 23.0 +/- 34.5 (range 0.4-206) months. Overall, 59 (96.7 percent) patients reported improvement of symptoms post surgery. Median grip strength on the operated and unoperated sides were 25.5 +/- 9.0 (range 10.5-44.0) KgN and 23.7 +/- 9.1 (range 9.3-41.5) KgN, respectively. Patients with diabetes mellitus had significantly higher pain scores (2.80 versus 0.36, p-value less than 0.01, 95 percent confidence interval [CI] 1.2-3.7), reduced grip strength (0.91 KgN versus 1.06 KgN, p-value is 0.038, 95 percent CI 0.29-0.01) and higher recurrence rates (40 percent versus 7.7 percent, p-value is 0.018).

CONCLUSION

Diabetes mellitus has a negative effect on surgical outcome in terms of pain scores, grip strength ratio and recurrence rate. This should be reiterated during preoperative counselling.

The prevalence of psychological and psychiatric sequelae of cancer in the elderly - how much do we know?

INTRODUCTION

Ageing is the greatest single risk factor for cancer but there is a dearth of systematically reviewed data on the psychological and psychiatric sequelae in elderly cancer patients. The aim of this paper is to review the current literature on these issues.

MATERIALS AND METHODS

Multiple searches using Medline (1970 to 2003), PsycInfo (1970 to 2003), CINAHL (1982 to 2003), EMBASE Psychiatry (1992 to 2003) and Cochrane Research Database were carried out. Additional searches were made using the reference lists of published papers and chapters.

RESULTS

Most of the studies were cross-sectional in nature. The few longitudinal studies had fairly short follow-up periods. Overall, the available evidence suggests that up to a third of elderly cancer patients may experience psychological distress. The psychological impact of cancer on the elderly was less adverse or similar compared with younger patients. There were only limited studies that specifically addressed the prevalence of psychiatric disorders in elderly cancer patients, which suggested that the prevalence for clinically significant depression could range from 3% to 25%. Organic mental disorders were more prevalent in the older group.

CONCLUSIONS

This review suggests that the psychological impact of cancer is less negative in the elderly compared to younger patients. As for the prevalence of psychiatric disorders in elderly cancer patients, this review suggests that it is an unanswered question with a dearth of published data, with most work either based only on clinical or hospital samples or not solely on the elderly.

A 20-year follow-up study on schizophrenia in Singapore

OBJECTIVE

To assess the outcome and predictors of patients with schizophrenia 20 years later.

METHOD

The patients, aged 15-39 years, with diagnosis of schizophrenia and first admitted to a national mental hospital in Singapore in 1975 were included. In 1980, 1985, 1990 and 1995, their hospital records were examined and the patients were interviewed to determine their working and treatment status. Possible predictors of good outcome and suicide data were determined.

RESULTS

A total of 402 patients were included. Over 20 years, there was lower percentage of patients working full time and proportionately more patients were receiving out-patient treatment. Overall, about two-third of the patients had a good/fair outcome. Shorter illness duration before admission was significantly associated with a good outcome. The suicide rate was the highest in the first 10 years.

CONCLUSION

Most patients with schizophrenia had a good/fair outcome at 20 years.

Stabilization of coiled-coil peptide domains by introduction of trifluoroleucine

Substitution of leucine residues by 5,5,5-trifluoroleucine at the d-positions of the leucine zipper peptide GCN4-p1d increases the thermal stability of the coiled-coil structure. The midpoint thermal unfolding temperature of the fluorinated peptide is elevated by 13 degrees C at 30 microM peptide concentration. The modified peptide is more resistant to chaotropic denaturants, and the free energy of folding of the fluorinated peptide is 0.5-1.2 kcal/mol larger than that of the hydrogenated form. A similarly fluorinated form of the DNA-binding peptide GCN4-bZip binds to target DNA sequences with affinity and specificity identical to those of the hydrogenated form, while demonstrating enhanced thermal stability. Molecular dynamics simulation on the fluorinated GCN4-p1d peptide using the Surface Generalized Born implicit solvation model revealed that the coiled-coil binding energy is 55% more favorable upon fluorination. These results suggest that fluorination of hydrophobic substructures in peptides and proteins may provide new means of increasing protein stability, enhancing protein assembly, and strengthening receptor-ligand interactions.

A comparative mental health literacy survey of psychiatrists and other mental health professionals in Singapore

OBJECTIVE

The objectives of this study are, first, to replicate and extend an Australian approach to assessing mental health literacy by studying a sample of Singapore mental health professionals, and to focus on differences between judgements made by the psychiatrists in comparison with the other mental health professionals. Second, to compare the psychiatrists' judgements with those of Australian psychiatrists.

METHOD

The Australian questionnaire, assessing responses in relation to vignettes of major depression and to schizophrenia was extended by adding a third vignette of mania, and by the addition of several region-specific response options. Nearly 500 questionnaires were distributed to representative staff (psychiatrists, nurses and allied health) of a large psychiatric institution in Singapore, with a response rate of 81%. Psychiatrists' judgements were compared with all other hospital staff, and with Australian psychiatrists' judgements.

RESULTS

The two principal contrast groups (Singapore psychiatrists and other Singapore mental health professionals) differed slightly in terms of diagnostic accuracy. The psychiatrists differed in favouring a more professionally focused model of intervention, while both professional groups viewed traditional healers and their practices as distinctly unhelpful. Direct comparison of psychiatrist ratings generated in Singapore and in Australia revealed quite similar response profiles.

CONCLUSIONS

In addition to generating data of some intrinsic importance, comparison with Australian survey data allows the potential impact of regional and cultural differences, as well as of varying psychiatric practices, to be identified. Responses identified more similarities than differences in the judgements of the psychiatrists from the two countries.

Mental health literacy in Singapore: a comparative survey of psychiatrists and primary health professionals

OBJECTIVES

To assess the beliefs amongst health professionals in Singapore about management of 3 major mental disorders, comparing psychiatrists and a sample of primary care physicians, and so identify target areas for the education of primary health professionals.

MATERIALS AND METHOD

A questionnaire earlier distributed to psychiatrists at Woodbridge Hospital was posted to both Singapore general practitioners and polyclinic doctors. The questionnaire assessed the capacity of respondents to identify vignettes of depression, schizophrenia or mania, and then assessed respondents' views about the likely helpfulness of a number of interventions.

RESULTS

The psychiatrists and primary health professionals differed little in terms of diagnostic accuracy for depression and schizophrenia; however, only half the general practitioners and three-quarters of the polyclinic doctors correctly diagnosed mania, which was consistently diagnosed by the psychiatrists. A number of distinct differences were identified between the groups concerning the likely helpfulness and disorder specificity of various psychotropic drugs. The primary health physicians were more likely to favour non-specific management approaches, whilst the psychiatrists generally supported a focused biological approach to treatment, especially for the psychotic disorders. Some of the differences in beliefs about mental health management may well be contributed by the different patients treated by each group of clinicians.

CONCLUSIONS

The findings have important clinical implications in terms of diagnosing common psychiatric conditions accurately and giving us professionals' views about a range of interventions for such conditions, while also assisting review of educational programmes for identifying and managing major mental disorders.