SARS-CoV-2 infection in adult liver transplantation recipients: a systematic review of risk factors for mortality and immunosuppression role.

OBJECTIVE: Data on mortality, immunosuppression, and vaccination role regarding liver transplant (LT) recipients affected by COVID-19 are still under debate. This study aims to identify risk factors for mortality and the role of immunosuppression in COVID-19 LT recipients. MATERIALS AND METHODS: A systematic review of SARS-CoV-2 infection in LT recipients was performed. The primary outcomes were risk factors for mortality, the role of immunosuppression and vaccination. A meta-analysis was not performed as there was a different metric of the same outcome (mortality) and a lack of a control group in most studies. RESULTS: Overall, 1,343 LT recipients of 1,810 SOT were included, and data on mortality were available for 1,110 liver transplant recipients with SARS-CoV-2 infection. Mortality ranged between 0-37%. Risk factors of mortality were age >60 years, Mofetil (MMF) use, extra-hepatic solid tumour, Charlson Comorbidity Index, male sex, dyspnoea at diagnosis, higher baseline serum creatinine, congestive heart failure, chronic lung disease, chronic kidney disease, diabetes, BMI >30. Only 51% of 233 LT patients presented a positive response after vaccination, and older age (>65y) and MMF use were associated with lower antibodies. Tacrolimus (TAC) was identified as a protective factor for mortality. CONCLUSIONS: Liver transplant patients present additional risk factors of mortality related to immunosuppression. Immunosuppression role in the progression to severe infection and mortality may correlate with different drugs. Moreover, fully vaccinated patients have a lower risk of developing severe COVID-19. The present research suggests safely using TAC and reducing MMF use during the COVID-19 pandemic.

Perioperative morbidity and readmission rate in all spine patients in the COVID era

Introduction: The coronavirus (COVID-19) pandemic has presented healthcare workers with one of the most significant global health crises to date. Prior studies have not identified an increase in complications or readmissions in COVID-19 negative patients undergoing emergency or essential surgery during the pandemic. Similar findings have been found in the urgent and elective surgery population. However, no study has shown the risks of all spine surgeries during this time period. Therefore, the purpose of this study is to measure the rates of complications and readmissions for all patients who underwent spine procedures (elective, urgent, and emergent) since the beginning of the COVID-19 pandemic compared to historical averages. Material and Methods: A retrospective review was performed on patients who underwent any spine procedure performed by one of our fellowship-trained spine surgeons at a single tertiary academic center from January 1st, 2019 to June 22nd, 2021. Patients were split into Pre-COVID or Post-COVID cohorts based on the timing of their surgery. March 23, 2020 was designated as the bifurcation based on the first issuance of a Stay at Home Order for COVID-19 in our city. Inpatient complications, 90-day readmission, and inpatient mortality were compared between the two cohorts. Secondary analysis included multiple logistic regression to determine independent predictors of inpatient complications, 90-day readmission, and inpatient mortality. Results: A total of 2,978 patients were included in the final analysis with 1,702 patients receiving designation as Pre-COVID and 1,276 as Post-COVID. The two groups differed with regards to lower Elixhauser scores (1.47 vs 1.65, p = 0.001), lower preoperative diagnoses of stenosis (57.8% vs 62.5%, p = 0.010) and radiculopathy (23.7% vs 31.2%, p < 0.001), fewer revision surgeries (16.8% vs 21.9%, p < 0.001), and fewer patients discharged home (84.5% vs 88.2%, p = 0.011) in the Pre-COVID cohort. The two cohorts had similar inpatient complications (36.6% vs 36.3%, p = 0.893) and inpatient mortality (0.1% vs 0.2%, p = 0.193). The Post-COVID cohort had fewer 90-day readmission (6.1% vs 3.9%, p = 0.008). On regression, being a Post-COVID patient was an independent predictor of decreased 90-day readmission (OR 0.63, p = 0.011). Similarly, surgery in the cervical region was associated with decreased readmission (ref: lumbar, OR 0.28, p = 0.001). Elixhauser (OR 1.12, p = 0.032), fusion surgeries (ref: decompression, OR 1.80, p = 0.027), and being discharged to an inpatient rehab facility (ref: home, OR 1.87, p = 0.021) were all associated with increased 90-day readmissions. Age (OR 1.01, p = 0.036), female sex (OR 1.33, p = 0.001), Elixhauser (OR 1.11, p < 0.001), length of stay (OR1.24, p < 0.001), anterior approach (ref: posterior, OR 2.33, p < 0.001), and combined approach (ref: posterior, OR 1.52, p < 0.001) were independent predictors of increased inpatient complications. Conclusion: Since COVID-19, patients undergoing spine surgery have an increased number of medical comorbidities, but a similar rate of inpatient complications and mortality. Patients are also being readmitted less frequently during the COVID-19 pandemic.

The unexpected decrease of Kawasaki syndrome during the second COVID-19 wave: the report from the COVASAKI survey

Introduction: During the first pandemic wave, Tuscany reported the fifth Italian highest number of COVID-19 cases in Italy even if this prevalence was lower if compared to other high-prevalence regions in the North of Italy. From September 2020, Tuscany situation has deeply changed with a significant increase of SARS CoV-2 positive cases, currently standing almost 234,000. Objectives: The Pediatric Tuscany Network continued the COVASAKI survey with the aim to track children who received a Kawasaki Syndrome (KS) or Multisystem Infalmmatory syndrome (MIS-C) diagnosis during the second vawe of COVID-19 pandemic. Methods: We retrospectively collected demographics, clinical findings, treatment and outcome of KS and MIS-C children between November 1st, 2020 to April 30th,2021 and compared the number of KS cases during this period to the number of reported KS children in the first pandemic vawe and in the previous five years in the same region. Results: 14 MIS-C children were admitted to 5 Paediatric Units (incidence 2.3/month), 10 boys and 4 girls (mean age of 9.6 years [IQR] 8.8-12). 11/14 patients required intensive care unit admission: 10 needed amines and 3 underwent mechanical ventilation. Echocardiography revealed a reduced left ventricular ejection fraction in 8/14. A diffuse coronary artery ectasia was found in 1. All children completely recovered with a timely immunomodulatory treatment with intravenous immunoglobulins, steroids and, in case of severe cardiac involvement, anakinra. Nasopharyngeal swabs and serological test for SARS CoV-2 resulted positive in 5/13 and 14/14 respectively. The MIS-C incidence rate, adjusted for the 5,170 children hospitalized, resulted 0.27% and represented the 13.9 % of paediatric COVID 19- related hospital admissions in Tuscany. Conversely, the number of observed KS significantly reduced comparing to the first six months of COVASAKI survey: 3 cases, 0.5 incidence/month vs 11 cases, 1.8 incidence/ month (p <0.03, RR 0.27, 95% CI 0.06 to 0.92). Comparing the 2.7 incidence/month of the 165 diagnosed KS from 1st January 2015 to 31th January 2020, a statistically significant difference has been detected (p <0.0005, RR 0.24, 95% CI 0.07 to 0.59). The same result has been found limiting the analysis to the 92 children with KS diagnosed during the same corresponding 6 months of the last 5 years: 3.0 versus 0.7 incidence/month (p <0.0002, RR 0.21, 95% CI 0.06 to 0.53). Conclusion: Our results seem in accordance with the hypothesis of an infectious trigger in KS pathogenesis. The stay-home imposed by pandemic and the extensive adoption of barrier protection devices have concomitantly reduced the incidence of respiratory infections among general and paediatric population. At this regard, the massive drop in the number of influenza and Syncytial Virus infections during the winter months results emblematic. From this point of view, it could be hypothesized that, in contrast to what had been previously reported in the early stages of its outbreak, the SARS CoV-2 pandemic could lead to a reduction rather than a substantial increase in the number of KS cases. Although indirectly, the behavioural measures adopted to contain the contagion or maybe further mechanisms not yet identified might be the reason.