Surgical or radiological treatment for varicoceles in subfertile men.

BACKGROUND: Varicoceles are associated with male subfertility; however, the mechanisms by which varicoceles affect fertility have yet to be satisfactorily explained. Several treatment options exist, including surgical or radiological treatment, however the safest and most efficient treatment remains unclear.  OBJECTIVES: To evaluate the effectiveness and safety of surgical and radiological treatment of varicoceles on live birth rate, adverse events, pregnancy rate, varicocele recurrence, and quality of life amongst couples where the adult male has a varicocele, and the female partner of childbearing age has no fertility problems. SEARCH METHODS: We searched the following databases on 4 April 2020: the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL. We also searched the trial registries and reference lists of articles. SELECTION CRITERIA: We included randomised controlled trials (RCTs) if they were relevant to the clinical question posed and compared different forms of surgical ligation, different forms of radiological treatments, surgical treatment compared to radiological treatment, or one of these aforementioned treatment forms compared to non-surgical methods, delayed treatment, or no treatment. We extracted data if the studies reported on live birth, adverse events, pregnancy, varicocele recurrence, and quality of life. DATA COLLECTION AND ANALYSIS: Screening of abstracts and full-text publications, alongside data extraction and 'Risk of bias' assessment, were done dually using the Covidence software. When we had sufficient data, we calculated random-effects (Mantel-Haenszel) meta-analyses; otherwise, we reported results narratively. We used the I2 statistic to analyse statistical heterogeneity. We planned to use funnel plots to assess publication bias in meta-analyses with at least 10 included studies. We dually rated the risk of bias of studies using the Cochrane 'Risk of bias' tool, and the certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS: We identified 1897 citations after de-duplicating the search results. We excluded 1773 during title and abstract screening. From the 113 new full texts assessed in addition to the 10 studies (11 references) included in the previous version of this review, we included 38 new studies, resulting in a total of 48 studies (59 references) in the review providing data for 5384 participants. Two studies (three references) are ongoing studies and two studies are awaiting classification. Treatment versus non-surgical, non-radiological, delayed, or no treatment Two studies comparing surgical or radiological treatment versus no treatment reported on live birth with differing directions of effect. As a result, we are uncertain whether surgical or radiological treatment improves live birth rates when compared to no treatment (risk ratio (RR) 2.27, 95% confidence interval (CI) 0.19 to 26.93; 2 RCTs, N = 204; I2 = 74%, very low-certainty evidence). Treatment may improve pregnancy rates compared to delayed or no treatment (RR 1.55, 95% CI 1.06 to 2.26; 13 RCTs, N = 1193; I2 = 65%, low-certainty evidence). This suggests that couples with no or delayed treatment have a 21% chance of pregnancy, whilst the pregnancy rate after surgical or radiological treatment is between 22% and 48%. We identified no evidence on adverse events, varicocele recurrence, or quality of life for this comparison. Surgical versus radiological treatment We are uncertain about the effect of surgical versus radiological treatment on live birth and on the following adverse events: hydrocele formation, pain, epididymitis, haematoma, and suture granuloma. We are uncertain about the effect of surgical versus radiological treatment on pregnancy rate (RR 1.13, 95% CI 0.75 to 1.70; 5 RCTs, N = 456, low-certainty evidence) and varicocele recurrence (RR 1.31, 95% CI 0.82 to 2.08; 3 RCTs, N = 380, low-certainty evidence). We identified no evidence on quality of life for this comparison. Surgery versus other surgical treatment We identified 19 studies comparing microscopic subinguinal surgical treatment to any other surgical treatment. Microscopic subinguinal surgical treatment probably improves pregnancy rates slightly compared to other surgical treatments (RR 1.18, 95% CI 1.02 to 1.36; 12 RCTs, N = 1473, moderate-certainty evidence). This suggests that couples with microscopic subinguinal surgical treatment have a 10% to 14% chance of pregnancy after treatment, whilst the pregnancy rate in couples after other surgical treatments is 10%. This procedure also probably reduces the risk of varicocele recurrence (RR 0.48, 95% CI 0.29, 0.79; 14 RCTs, N = 1565, moderate-certainty evidence). This suggests that 0.4% to 1.1% of men undergoing microscopic subinguinal surgical treatment experience recurrent varicocele, whilst 1.4% of men undergoing other surgical treatments do. Results for the following adverse events were inconclusive: hydrocele formation, haematoma, abdominal distension, testicular atrophy, wound infection, scrotal pain, and oedema. We identified no evidence on live birth or quality of life for this comparison. Nine studies compared open inguinal surgical treatment to retroperitoneal surgical treatment. Due to small sample sizes and methodological limitations, we identified neither treatment type as superior or inferior to the other regarding adverse events, pregnancy rates, or varicocele recurrence. We identified no evidence on live birth or quality of life for this comparison. Radiological versus other radiological treatment One study compared two types of radiological treatment (sclerotherapy versus embolisation) and reported 13% varicocele recurrence in both groups. Due to the broad confidence interval, no valid conclusion could be drawn (RR 1.00, 95% CI 0.16 to 6.20; 1 RCT, N = 30, very low-certainty evidence). We identified no evidence on live birth, adverse events, pregnancy, or quality of life for this comparison. AUTHORS' CONCLUSIONS: Based on the limited evidence, it remains uncertain whether any treatment (surgical or radiological) compared to no treatment in subfertile men may be of benefit on live birth rates; however, treatment may improve the chances for pregnancy. The evidence was also insufficient to determine whether surgical treatment was superior to radiological treatment. However, microscopic subinguinal surgical treatment probably improves pregnancy rates and reduces the risk of varicocele recurrence compared to other surgical treatments. High-quality, head-to-head comparative RCTs focusing on live birth rate and also assessing adverse events and quality of life are warranted.

Hormone replacement therapy after surgery for epithelial ovarian cancer.

BACKGROUND: Women who have undergone surgical treatment for epithelial ovarian cancer (EOC) may develop menopausal symptoms due to immediate loss of ovarian function following surgery and chemotherapy. Women may experience vasomotor symptoms, sleep disturbance, difficulty concentrating, sexual dysfunction, vaginal symptoms and accelerated osteoporosis. Although hormone replacement therapy (HRT) is the most effective treatment to relieve these symptoms, its safety has been questioned for women with EOC. OBJECTIVES: To assess the safety and efficacy of HRT for menopausal symptoms in women surgically treated for EOC. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6), MEDLINE via Ovid (1946 to 12 June 2019) and Embase via Ovid (1980 to 2019, week 23). We also handsearched conference reports and trial registries. There was no language restriction. SELECTION CRITERIA: We included randomized controlled trials (RCTs) with participants of any age and menopausal status who had undergone surgery for EOC and, after diagnosis and treatment, used any regimen and duration of HRT compared with placebo or no hormone therapy. We also included trials comparing different regimens or duration of administration of HRT. DATA COLLECTION AND ANALYSIS: Two review authors independently identified studies that met the inclusion criteria. They used Covidence to extract study characteristics, outcome data and to assess methodological quality of the included studies. MAIN RESULTS: Our search strategy identified 2617 titles, of which 2614 titles were excluded. Three studies, involving 350 women, met our inclusion criteria. Two of the studies included pre and postmenopausal women, and the third only included premenopausal women. The overall age range of those women included in the studies was 20 to 89.6 years old, with a median follow-up ranging from 31.4 months to 19.1 years. The geographical distribution of participants included Europe, South Africa and China. All stages and histological subtypes were included in two of the studies, but stage IV disease had been excluded in the third. The three included studies used a variety of HRT regimens (conjugated oestrogen with or without medroxyprogesterone and with or without nylestriol) and HRT administrations (oral, patch and implant), In all studies, the comparisons were made versus women who had not received HRT. The studies were at low or unclear risk of selection and reporting bias, and at high risk of performance, detection and attrition bias. The certainty of the evidence was low for overall survival and progression-free survival, and very low for quality-of-life assessment, incidence of breast cancer, transient ischaemic attack (TIA), cerebrovascular accident (CVA) and myocardial infarction (MI). Meta-analysis of these studies showed that HRT may improve overall survival (hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.54 to 0.93; 350 participants, 3 studies; low-certainty evidence). Quality-of-life assessment by use of the EORTC-C30 questionnaire was performed only in one study. We are uncertain whether HRT improves or reduces quality of life as the certainty of the evidence was assessed as very low (mean difference (MD) 13.67 points higher, 95% CI 9.26 higher to 18.08 higher; 1 study; 75 participants; very low-certainty evidence). Likewise, HRT may make little or no difference to progression-free survival (HR 0.76, 95% CI 0.57 to 1.01; 275 participants, 2 studies; low-certainty evidence). We are uncertain whether HRT improves or reduces the incidence of breast cancer (risk ratio (RR) 2.00, 95% CI 0.19 to 21.59; 225 participants, 2 studies; very low-certainty evidence); TIA (RR 5.00, 95% CI 0.24 to 102.42; 150 participants, 1 study; very low-certainty evidence); CVA (RR 0.67, 95% CI 0.11 to 3.88; 150 participants, 1 study; very low-certainty evidence); and MI (RR 0.20, 95% CI 0.01 to 4.10; 150 participants, 1 study; very low-certainty evidence). The incidence of gallstones was not reported in the included studies. AUTHORS' CONCLUSIONS: Hormone replacement therapy may slightly improve overall survival in women who have undergone surgical treatment for EOC, but the certainty of the evidence is low. HRT may make little or no difference to quality of life, incidence of breast cancer, TIA, CVA and MI as the certainty of the evidence has been assessed as very low. There may be little or no effect of HRT use on progression-free survival. The evidence in this review is limited by imprecision and incompleteness of reported relevant outcomes and therefore the results should be interpreted with caution. Future well-designed RCTs are required as this is an important area to women experiencing menopausal symptoms following surgical treatment for ovarian cancer, especially as doctors are often reluctant to prescribe HRT in this scenario. The evidence in this review is too limited to support or refute that HRT is very harmful in this population.

How to address SARS-CoV-2 airborne transmission to ensure effective protection of healthcare workers? A review of the literature.

SARS-CoV-2 mainly infects the respiratory tract, and presents significantly higher active replication in the upper airways. To remain viable and infectious, the SARS-CoV-2 virion must be complete and integral, which is not easily demonstrated in the environment by positive reverse transcriptase PCR results. Real-life conditions in healthcare settings may be conducive to SARS-CoV-2 RNA dissemination in the environment but without evidence of its viability and infectiveness in air. Theoretically, SARS-CoV-2 shedding and dissemination nonetheless appears to be air-mediated, and a distinction between "air" and "droplet" transmission is too schematic to reflect the reality of the respiratory particles emitted by patients, between which a continuum exists. Airborne transmission is influenced by numerous environmental conditions that are not transposable between different viral agents and situations in healthcare settings or in the community. Even though international guidelines on "droplet" versus "air" precautions and personal protective equipment (surgical versus respirator masks) are under discussion, the existing literature underscores the effectiveness of "droplet" precautions as a means of protecting healthcare workers. Differentiation in guidelines between healthcare venues, community settings and, more generally, confined environments is of paramount importance, especially insofar as it underlines the abiding pandemic-related need for systematic mask wearing by the general population.

Analysis of Neurosurgical Cases Before and During the Coronavirus Disease 2019 Pandemic from a Tertiary-Care Centre in India.

OBJECTIVE: We present the unique administrative issues as well as specific patient-related and surgeon-related challenges and solutions implemented while treating neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic vis-à-vis pre-COVID-19 times at our tertiary-care center. METHODS: This is a retrospective study comparing the outcome of the neurosurgical patients treated from the beginning of lockdown in India on March 25, 2020 to November 30, 2020 with that of same period in the previous year, 2019. RESULTS: There were 687 neurosurgery admissions during the study period compared with 2550 admissions in 2019. The total number of surgeries performed in neurosurgery also showed a similar trend, with only 654 surgeries in 2020 compared with 3165 surgeries in 2019. During COVID-19 times, 474 patients were operated on including both trauma and nontrauma cases. Of the 50 patients with suspected/indeterminate COVID-19 who were operated on, 5 turned out to be positive for COVID-19. Significant differences were seen in the mortality (P < 0.01) and morbidity (P < 0.01) among patients with trauma on comparing COVID and pre-COVID periods. Similarly, a significant difference was observed in the mortality (P < 0.001) and morbidity (P < 0.001) in patients who did not have trauma. CONCLUSIONS: The higher mortality and morbidity during the COVID pandemic is primarily attributable to poorer baseline clinical status. Our experience from this COVID period might not only help us in tackling subsequent waves but also help other institutions in the developing world to be better prepared for similar circumstances.

Trend of emergency general surgery procedures during COVID-19 pandemic.

BACKGROUND: In early 2020, the novel coronavirus infection (COVID-19) spread rapidly throughout the whole world, causing a massive response in terms of health resource disposal. Moreover, lockdowns were imposed in entire countries. This study aims to assess whether there was a downward trend in emergency general surgery (EGS) procedures accomplished throughout the COVID-19 pandemic and to determine patients' and diseases' characteristics. METHODS: This is a multicentric retrospective observational cohort analysis conducted on patients who underwent EGS procedures during the lockdown and the same period of the previous year in the three Third Level Hospitals of Friuli Venezia Giulia, Italy. RESULTS: During the study period, 138 patients underwent EGS procedures versus the 197 patients operated on in 2019, meaning a 30.0% decrease in the number of surgeries performed. The incidence rate for EGS procedures was 2.5 surgeries per day during the COVID-19 pandemic compared to 3.5 surgeries per day in 2019 (P<0.001). The characteristics of patients operated on in 2020 were comparable to those of patients who underwent EGS in 2019, except for the higher prevalence of male patients during the COVID-19 pandemic (76.8 vs. 55.8; P<0.001). No difference was recorded in disease severity between the two study periods. CONCLUSIONS: During the COVID-19 pandemic, a significant reduction in EGS procedures carried out was recorded. However, no clear explanation can be given to elucidate this fact.

A nationwide survey on the impact of COVID-19 pandemic on minimal invasive surgery in urology practice.

OBJECTIVE: The beta-coronavirus (COVID-19) pandemic has changed the clinical approach of 93% of urologists worldwide, and this situation has affected the use of laparoscopic and robot-assisted laparoscopic methods, which are known as minimally invasive surgery (MIS). This study aimed to determine the effects of the COVID-19 pandemic on MIS in urology practice at national level. DESIGN, SETTING AND PARTICIPANTS: A total of 234 urologists in Turkey participated in an online survey between August 22 and September 23, 2020. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistical analyses were conducted to determine the participants' demographic characteristics and responses to multiple-choice questions. RESULTS: While 54% of urologists stated that they were concerned about the possibility that the patients planned to undergo MIS were carrying COVID-19 or false-negative for the virus, 51% considered that open surgery was safer than MIS in this regard. The pandemic led to a difference in the preferences of 40% of the urologists in relation to open or MIS methods, and during the pandemic, 39% of the urologists always directed their patients to open surgery. It was determined that during the pandemic, there was a statistical decrease in the intensity and weekly application of MIS methods among all surgical procedures compared to the pre-pandemic (P < .001 and P < .001, respectively). MIS was preferred for oncological operations by 97.3% of the urologists during the pandemic, with the most performed operation being radical nephrectomy (90.7%). Among oncological operations, radical prostatectomy was most frequently postponed. To prevent virus transmission during MIS, 44% of the urologists reported that they always used an additional evacuation system and 52% took additional precautions. There were a total of 27 healthcare workers who took part in MIS and tested positive for COVID-19 after the operation. CONCLUSIONS: Although the number of operations has decreased during the ongoing pandemic, MIS is a method that can be preferred due to its limited contamination and mortality in urology practice provided that safety measures are taken and guideline recommendations are followed.

Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study.

Introduction The COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. Method All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. Results  Fifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). Conclusions COVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

Efficacy of Bioshell Calcium Oxide Water as Disinfectants to Enable Face Mask Reuse.

Bioshell calcium oxide (BiSCaO) is derived from scallop shells and after heat treatment exhibits broad microbicidal activity. BiSCaO Water is a disinfectant prepared by collecting the aqueous layer after adding BiSCaO powder to water, is colorless and transparent, and has a pH of 12.8. We compared the utility of commercially available BiSCaO Water, ethanol, sodium hypochlorite, hypochlorous acid and hydrogen peroxide solutions as sterilization agents to enable the reuse of surgical and N95 face masks. The microbicidal efficacy of each disinfectant was evaluated using pieces of surgical and N95 face masks contaminated with normal bacterial flora. The results suggest that BiSCaO Water has excellent disinfection activity toward contaminated polypropylene masks and has minimal adverse effect on the structure of non-woven masks.

The Effect of the COVID-19 Pandemic on Hip and Knee Arthroplasty Patients in the United States: A Multicenter Update to the Previous Survey.

BACKGROUND: In March 2020, elective total hip and knee arthroplasty (THA and TKA) were suspended across the United States in response to the COVID-19 pandemic. We had previously published the results of a survey to the affected patients from 6 institutions. We now present the results of a larger distribution of this survey, through May and June 2020, to electively scheduled patients representing different regions of the United States. METHODS: Fifteen centers identified through the American Association of Hip and Knee Surgeons Research Committee participated in a survey study of THA and TKA patients. Patients scheduled for primary elective THA or TKA but canceled due to the COVID-19 elective surgery stoppage (3/2020-5/2020) were included in the study. Descriptive statistics along with subgroup analysis with Wilcoxon rank were performed. RESULTS: In total, surveys were distributed to 2135 patients and completed by 848 patients (40%) from 15 institutions. Most patients (728/848, 86%) had their surgery postponed or canceled by the surgeon or hospital. Unknown length of surgical delay remained the highest source of anxiety among survey participants. Male patients were more likely to be willing to proceed with surgery in spite of COVID-19. There were minimal regional differences in responses. Only 61 patients (7%) stated they will continue to delay surgery for fear of contracting COVID-19 while in the hospital. CONCLUSION: Similar to the previous study, the most anxiety-provoking thought was the uncertainty, over if and when the canceled joint replacement surgery could be rescheduled. Patients suffering from the daily pain of hip and knee arthritis who have been scheduled for elective arthroplasty remain eager to have their operation as soon as elective surgery is allowed to resume.

Utilizing Outpatient Pelvic Reconstructive Surgery in the Era of the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has created a significant strain on the medical system, creating resource scarcity. We sought to demonstrate the reduction in hospital room utilization after implementation of outpatient pelvic reconstructive surgery. METHODS: We included all minimally invasive reconstructive surgical procedures in this retrospective cohort study within a large managed care organization of 4.5 million members (2008-2018). We queried the system-wide medical record for Current Procedural Terminology (CPT), International Classification of Diseases, Ninth Revision (ICD-9), and International Classification of Diseases, Tenth Revision (ICD-10) codes for all included procedures and patient perioperative data. Categorical variables were compared using χ2 test for categorical variables and the Kruskal-Wallis test for continuous variables. RESULTS: Of the 13,445 patients undergoing pelvic reconstructive surgery, 5,506 were discharged the same day, whereas 7,939 were discharged the next day. Over the 10-year period, patients without hysterectomy had outpatient surgery rates increase from 31.2% to 76.4% (+45.2%), whereas those with hysterectomy increased from 3% to 56.4% (+53.4%). Hospital room utilization decreased by 45,200 room days/100,000 reconstructive procedures without hysterectomy and 53,400 room days/100,000 reconstructive procedures with hysterectomy. When compared to 2008, in 2018 after more widespread adoption of outpatient elective surgery, for the 738 patients undergoing surgery without hysterectomy, 334 less room days were used, whereas 335 less room days were used among the 640 patients who had a surgical procedure with hysterectomy. CONCLUSIONS: The implementation of outpatient pelvic reconstructive procedures leads to a significant reduction in hospital room utilization. Same-day discharge decreases hospital resource utilization, therefore improving hospital access, which may be essential for the delivery of routine care during times of resource scarcity such as the COVID-19 pandemic.

Epidemiology of hand traumas during the COVID-19 confinement period.

INTRODUCTION: hand injuries are a common emergency mainly caused by domestic accidents or sport injuries. During the COVID-19 pandemic confinement period, with a cut off in transportation as well as in occupational and physical activities, we observed a decrease in medical and elective surgical activities but emergency cases of upper limb and hand surgery increased. MATERIALS AND METHODS: we conducted a retrospective epidemiological study to analyze two periods between the same dates in 2019 and 2020, for all the duration of the confinement period. We compared the numbers of consultations in the emergency department, elective surgeries, hand and upper limb emergency cases in our center and urgent limb surgeries in the nearby hospital. Then we compared the mechanisms and severity of injuries and the type of surgery. RESULTS: between 2019 and 2020 there was a decrease of consultations in the emergency department in our institution of 52%, a decrease of total elective surgeries of 75%, a decrease in surgeries for urgent peripheral limb injuries of 50%, whereas the hand and upper limb emergency remained stable or even increased by 4% regard to occupational and domestic accidents. There was a significant difference in the mechanism of injury with an increase of domestic accident and a decrease of occupational, road traffic and sport accidents. Severity of the injuries increased, with augmentation of the number of tissues involved and longer expected time of recovery. CONCLUSION: during the confinement period of the COVID-19 pandemic, despite an important reduction of medical activities, the amount and severity of hand emergency cases increased. A specific plan regarding duty shift organization for hand trauma should be maintained regardless of the sanitary situation.

Comparison of surgical smoke between open surgery and laparoscopic surgery for colorectal disease in the COVID-19 era.

BACKGROUND: Surgical smoke during operation is a well-known health hazard for medical staff. This study aimed to investigate the dynamics of surgical smoke during open surgery or laparoscopic surgery for colorectal disease. METHODS: This study quantitated particulate matter (PM) counts as part of surgical smoke in 31 consecutive patients who underwent colectomy at the Niigata City General Hospital using a laser particle counter. Particles were graded by size as ≤ 2.5 µm PM (PM2.5) or > 2.5 µm PM (large PM). Operative procedures were categorized as either open surgery (n = 14) or laparoscopic surgery (n = 17). RESULTS: The median patient age was 72 (range 41-89) years and 58.1% were male. The total PM2.5, PM2.5 per hour, and maximum PM2.5 per minute counts during operation were significantly higher in open surgery than in laparoscopic surgery (P = 0.001, P < 0.001, and P = 0.029, respectively). Large PM counts (total, per hour, and maximum per minute) were also higher in the open surgery group than in the laparoscopic surgery group. The maximum PM2.5 concentration recorded was 38.6 µm/m3, which is considered "unhealthy for sensitive groups" according to the U.S. Environment Protection Agency air quality index standards, if it was a 24-h period mean value. CONCLUSION: Exposure to surgical smoke is lower during laparoscopic surgery than during open surgery for colorectal diseases.

Early Intervention for the Treatment of Acute Laryngeal Injury After Intubation.

Importance: Patients with laryngeal injury after endotracheal intubation often present long after initial injury with mature fibrosis compromising cricoarytenoid joint mobility and glottic function. Objective: To compare functional outcomes between early and late intervention for intubation-related laryngeal injury. Design, Setting, and Participants: This retrospective cohort study involved 29 patients with laryngeal injury resulting from endotracheal intubation who were evaluated at a tertiary care center between May 1, 2014, and June 1, 2018. Ten patients with intubation injury to the posterior glottis who received early treatment were compared with 19 patients presenting with posterior glottic stenosis who received late treatment. Statistical analysis was performed from May 1 to July 1, 2019. Exposures: Early intervention, defined as a procedure performed 45 days or less after intubation, and late treatment, defined as an intervention performed greater than 45 days after intubation. Main Outcomes and Measures: Patient-specific and intervention-specific covariates were compared between the 2 groups, absolute differences with 95% CIs were calculated, and time to tracheostomy decannulation was compared using log-rank testing. Results: The 2 groups had similar demographic characteristics and a similar burden of comorbid disease. Ten patients who received early intervention (7 women [70%]; median age, 59.7 years [range, 31-72 years]; median, 34.7 days to presentation [IQR, 1.5-44.8 days]) were compared with 19 patients who received late intervention (11 women [58%]; median age, 53.8 years [range, 34-73 years]; median, 341.9 days to presentation [IQR, 132.7-376.3 days]). Nine of 10 patients (90%) who received early intervention and 11 of 19 patients (58%) who received late interventions were decannulated at last follow-up (absolute difference, 32%; 95% CI, -3% to 68%). Patients who received early treatment required fewer total interventions than patients with mature lesions (mean, 2.2 vs 11.5; absolute difference, 9.3; 95% CI, 6.4-12.1). In addition, none of the patients who received early treatment required an open procedure, whereas 17 patients (90%) with mature lesions required open procedures to pursue decannulation. Conclusions and Relevance: This study suggests that early intervention for patients with postintubation laryngeal injury was associated with a decreased duration of tracheostomy dependence, a higher rate of decannulation, and fewer surgical procedures compared with late intervention. Patients who underwent early intervention also avoided open reconstruction. These findings may bear relevance to the management of patients requiring extended durations of endotracheal intubation during recovery for critical illness related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Comparing the fit of N95, KN95, surgical, and cloth face masks and assessing the accuracy of fit checking.

INTRODUCTION: The COVID-19 pandemic has made well-fitting face masks a critical piece of protective equipment for healthcare workers and civilians. While the importance of wearing face masks has been acknowledged, there remains a lack of understanding about the role of good fit in rendering protective equipment useful. In addition, supply chain constraints have caused some organizations to abandon traditional quantitative or/and qualitative fit testing, and instead, have implemented subjective fit checking. Our study seeks to quantitatively evaluate the level of fit offered by various types of masks, and most importantly, assess the accuracy of implementing fit checks by comparing fit check results to quantitative fit testing results. METHODS: Seven participants first evaluated N95 and KN95 respirators by performing a fit check. Participants then underwent quantitative fit testing wearing five N95 respirators, a KN95 respirator, a surgical mask, and fabric masks. RESULTS: N95 respirators offered higher degrees of protection than the other categories of masks tested; however, it should be noted that most N95 respirators failed to fit the participants adequately. Fit check responses had poor correlation with quantitative fit factor scores. KN95, surgical, and fabric masks achieved low fit factor scores, with little protective difference recorded between respiratory protection options. In addition, small facial differences were observed to have a significant impact on quantitative fit. CONCLUSION: Fit is critical to the level of protection offered by respirators. For an N95 respirator to provide the promised protection, it must fit the participant. Performing a fit check via NHS self-assessment guidelines was an unreliable way of determining fit.

Aerosol generation during routine rhinologic surgeries and in-office procedures.

OBJECTIVE: Cadaveric simulations have shown endonasal drilling and cautery generate aerosols, which is a significant concern for otolaryngologists during the COVID-19 era. This study quantifies aerosol generation during routine rhinologic surgeries and in-office procedures in live patients. METHODS: Aerosols ranging from 0.30 to 10.0 µm were measured in real-time using an optical particle sizer during surgeries and in-office procedures. Various mask conditions were tested during rigid nasal endoscopy (RNE) and postoperative debridement (POD). RESULTS: Higher aerosol concentrations (AC) ranging from 2.69 to 10.0 µm were measured during RNE (n = 9) with no mask vs two mask conditions (P = .002 and P = .017). Mean AC (0.30-10.0 µm) were significantly higher during POD (n = 9) for no mask vs a mask covering the patient's mouth condition (mean difference = 0.16 ± 0.03 particles/cm3, 95% CI 0.10-0.22, P < .001). There were no discernible spikes in aerosol levels during endoscopic septoplasty (n = 3). Aerosol spikes were measured in two of three functional endoscopic sinus surgeries (FESS) with microdebrider. Using suction mitigation, there were no discernible spikes during powered drilling in two anterior skull base surgeries (ASBS). CONCLUSION: Use of a surgical mask over the patient's mouth during in-office procedures or a mask with a slit for an endoscope during RNE significantly diminished aerosol generation. However, whether this reduction in aerosol generation is sufficient to prevent transmission of communicable diseases via aerosols was beyond the scope of this study. There were several spikes in aerosols during FESS and ASBS, though none were associated with endonasal drilling with the use of suction mitigation. LEVEL OF EVIDENCE: 4.

Aerosol Transmission of SARS-CoV-2: Physical Principles and Implications.

Evidence has emerged that SARS-CoV-2, the coronavirus that causes COVID-19, can be transmitted airborne in aerosol particles as well as in larger droplets or by surface deposits. This minireview outlines the underlying aerosol science, making links to aerosol research in other disciplines. SARS-CoV-2 is emitted in aerosol form during normal breathing by both asymptomatic and symptomatic people, remaining viable with a half-life of up to about an hour during which air movement can carry it considerable distances, although it simultaneously disperses. The proportion of the droplet size distribution within the aerosol range depends on the sites of origin within the respiratory tract and on whether the distribution is presented on a number or volume basis. Evaporation and fragmentation reduce the size of the droplets, whereas coalescence increases the mean droplet size. Aerosol particles containing SARS-CoV-2 can also coalesce with pollution particulates, and infection rates correlate with pollution. The operation of ventilation systems in public buildings and transportation can create infection hazards via aerosols, but provides opportunities for reducing the risk of transmission in ways as simple as switching from recirculated to outside air. There are also opportunities to inactivate SARS-CoV-2 in aerosol form with sunlight or UV lamps. The efficiency of masks for blocking aerosol transmission depends strongly on how well they fit. Research areas that urgently need further experimentation include the basis for variation in droplet size distribution and viral load, including droplets emitted by "superspreader" individuals; the evolution of droplet sizes after emission, their interaction with pollutant aerosols and their dispersal by turbulence, which gives a different basis for social distancing.

The Impact of the COVID-19 Pandemic on General Surgery Acute Admissions and Urgent Operations: A Comparative Prospective Study.

BACKGROUND: As part of the effort to control the coronavirus disease-19 (COVID-19) outbreak, strict emergency measures, including prolonged national curfews, have been imposed. Even in countries where healthcare systems still functioned, patients avoided visiting emergency departments (EDs) because of fears of exposure to COVID-19. OBJECTIVES: To describe the effects of the COVID-19 outbreak on admissions of surgical patients from the ED and characteristics of urgent operations performed. METHODS: A prospective registry study comparing all patients admitted for acute surgical and trauma care between 15 March and 14 April 2020 (COVID-19) with patients admitted in the parallel time a year previously (control) was conducted. RESULTS: The combined cohort included 606 patients. There were 25% fewer admissions during the COVID-19 period (P < 0.0001). The COVID-19 cohort had a longer time interval from onset of symptoms (P < 0.001) and presented in a worse clinical condition as expressed by accelerated heart rate (P = 0.023), leukocyte count disturbances (P = 0.005), higher creatinine, and CRP levels (P < 0.001) compared with the control cohort. More COVID-19 patients required urgent surgery (P = 0.03) and length of ED stay was longer (P = 0.003). CONCLUSIONS: During the COVID-19 epidemic, fewer patients presented to the ED requiring acute surgical care. Those who did, often did so in a delayed fashion and in worse clinical condition. More patients required urgent surgical interventions compared to the control period. Governments and healthcare systems should emphasize to the public not to delay seeking medical attention, even in times of crises.

Operation and Management of Seoul Metropolitan City Community Treatment Center for Mild Condition COVID-19 Patients.

BACKGROUND: In response to the disaster of coronavirus disease 2019 (COVID-19) pandemic, Seoul Metropolitan Government (SMG) established a patient facility for mild condition patients other than hospital. This study was conducted to investigate the operation and necessary resources of a community treatment center (CTC) operated in Seoul, a metropolitan city with a population of 10 million. METHODS: To respond COVID-19 epidemic, the SMG designated 5 municipal hospitals as dedicated COVID-19 hospitals and implemented one CTC cooperated with the Boramae Municipal Hospital for COVID-19 patients in Seoul. As a retrospective cross-sectional observational study, retrospective medical records review was conducted for patients admitted to the Seoul CTC. The admission and discharge route of CTC patients were investigated. The patient characteristics were compared according to route of discharge whether the patient was discharged to home or transferred to hospital. To report the operation of CTC, the daily mean number of tests (reverse transcription polymerase chain reaction and chest X-ray) and consultations by medical staffs were calculated per week. The list of frequent used medications and who used medication most frequently were investigated. RESULTS: Until May 27 when the Seoul CTC was closed, 26.5% (n = 213) of total 803 COVID-19 patients in Seoul were admitted to the CTC. It was 35.7% (n = 213) of 597 newly diagnosed patients in Seoul during the 11 weeks of operation. The median length of stay was 21 days (interquartile range, 12-29 days). A total of 191 patients (89.7%) were discharged to home after virologic remission and 22 (10.3%) were transferred to hospital for further treatment. Fifty percent of transferred patients were within a week since CTC admission. Daily 2.5-3.6 consultations by doctors or nurses and 0.4-0.9 tests were provided to one patient. The most frequently prescribed medication was symptomatic medication for COVID-19 (cough/sputum and rhinorrhea). The next ranking was psychiatric medication for sleep problem and depression/anxiety, which was prescribed more than digestive drug. CONCLUSION: In the time of an infectious disease disaster, a metropolitan city can operate a temporary patient facility such as CTC to make a surge capacity and appropriately allocate scarce medical resource.

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World.

OBJECTIVES: (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Masks for Prevention of Respiratory Virus Infections, Including SARS-CoV-2, in Health Care and Community Settings : A Living Rapid Review.

BACKGROUND: Recommendations on masks for preventing coronavirus disease 2019 (COVID-19) vary. PURPOSE: To examine the effectiveness of N95, surgical, and cloth masks in community and health care settings for preventing respiratory virus infections, and effects of reuse or extended use of N95 masks. DATA SOURCES: Multiple electronic databases, including the World Health Organization COVID-19 database and medRxiv preprint server (2003 through 14 April 2020; surveillance through 2 June 2020), and reference lists. STUDY SELECTION: Randomized trials of masks and risk for respiratory virus infection, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and observational studies of mask use and coronavirus infection risk were included. New evidence will be incorporated by using living review methods. DATA EXTRACTION: One reviewer abstracted data and assessed methodological limitations; a second reviewer provided verification. DATA SYNTHESIS: 39 studies (18 randomized controlled trials and 21 observational studies; 33 867 participants) were included. No study evaluated reuse or extended use of N95 masks. Evidence on SARS-CoV-2 was limited to 2 observational studies with serious limitations. Community mask use was possibly associated with decreased risk for SARS-CoV-1 infection in observational studies. In high- or moderate-risk health care settings, observational studies found that risk for infection with SARS-CoV-1 and Middle East respiratory syndrome coronavirus probably decreased with mask use versus nonuse and possibly decreased with N95 versus surgical mask use. Randomized trials in community settings found possibly no difference between N95 versus surgical masks and probably no difference between surgical versus no mask in risk for influenza or influenza-like illness, but compliance was low. In health care settings, N95 and surgical masks were probably associated with similar risks for influenza-like illness and laboratory-confirmed viral infection; clinical respiratory illness had inconsistency. Bothersome symptoms were common. LIMITATIONS: There were few SARS-CoV-2 studies, observational studies have methodological limitations, and the review was done by using streamlined methods. CONCLUSION: Evidence on mask effectiveness for respiratory infection prevention is stronger in health care than community settings. N95 respirators might reduce SARS-CoV-1 risk versus surgical masks in health care settings, but applicability to SARS-CoV-2 is uncertain. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.