Perioperative leaders' experience of COVID-19 in Aotearoa: a qualitative interview study.

AIMS: Once it became apparent that COVID-19 would reach Aotearoa New Zealand, perioperative services responded urgently to contain viral spread, keep staff safe and maintain patient care. We aimed to understand how perioperative leaders around the country responded to the pandemic, their experiences, reflections and the lessons learnt. Our goal is to inform future pandemic responses. METHODS: We undertook a qualitative study with thematic analysis of semi-structured interviews. We recruited perioperative leads involved in the COVID-19 response using snowball sampling, following initial contact with anaesthetic and surgical department heads. RESULTS: We interviewed 33 perioperative leads from 16 of the country's 20 district health boards, with representation across hospitals of different sizes and the professional groups working in operating theatres. Four main themes were identified from data. These were: "no one source of truth," with prolific, constantly changing information, limited initial support from hospital senior executives, and siloed approaches and tensions between departments and professional groups; resourcing challenges attributed to limited baseline preparedness and increased workload; deficiencies in PPE and physical facilities; staff stress and anxiety, and the impact this had on workforce capacity; ongoing preparedness for future waves; and reflections on "lessons learnt". These lessons focused strongly on communication, caring for staff, collaboration, downtime to enable preparation, and a need for external, potentially national co-ordination and resources to facilitate planning. CONCLUSIONS: Perioperative leaders' experiences and reflections of COVID-19 paint a picture of limited prior preparation or planning for a pandemic, requiring an immediate pivot from routine care to emergency response. In an environment of uncertainty, information overload and staff stress hospital leaders worked to obtain resources, maintain staff safety and engagement, develop new systems and in some cases, create new facilities. Sharing the experiences and lessons learned about communication and collaboration, policy development and staff training may go some way to facilitate a smoother implementation of a pandemic response the next time around.

Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery.

Background: Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. Objective: To evaluate benefits and harms of perioperative aspirin in patients with prior PCI. Design: Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet randomization was done between 2010 and 2013. Patients, clinicians, data collectors, and outcome adjudicators were blinded to treatment assignment. (ClinicalTrials.gov: NCT01082874). Setting: 135 centers in 23 countries. Patients: Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery. Intervention: Aspirin therapy (overall trial, n = 4998; subgroup, n = 234) or placebo (overall trial, n = 5012; subgroup, n = 236) initiated within 4 hours before surgery and continued throughout the perioperative period. Of the 470 subgroup patients, 99.9% completed follow-up. Measurements: The 30-day primary outcome was death or nonfatal myocardial infarction; bleeding was a secondary outcome. Results: In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% [95% CI, 0.4% to 10.5%]; hazard ratio [HR], 0.50 [CI, 0.26 to 0.95]; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% [CI, 1.0% to 10.8%]; HR, 0.44 [CI, 0.22 to 0.87]; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% [CI, -2.6% to 5.2%]). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% [CI, 0.1% to 1.6%]; HR, 1.22 [CI, 1.01 to 1.48]; P for interaction = 0.50). Limitation: Nonprespecified subgroup analysis with small sample. Conclusion: Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI. Primary Funding Source: Canadian Institutes of Health Research.

Analyses of expressed sequence tags from apple.

The domestic apple (Malus domestica; also known as Malus pumila Mill.) has become a model fruit crop in which to study commercial traits such as disease and pest resistance, grafting, and flavor and health compound biosynthesis. To speed the discovery of genes involved in these traits, develop markers to map genes, and breed new cultivars, we have produced a substantial expressed sequence tag collection from various tissues of apple, focusing on fruit tissues of the cultivar Royal Gala. Over 150,000 expressed sequence tags have been collected from 43 different cDNA libraries representing 34 different tissues and treatments. Clustering of these sequences results in a set of 42,938 nonredundant sequences comprising 17,460 tentative contigs and 25,478 singletons, together representing what we predict are approximately one-half the expressed genes from apple. Many potential molecular markers are abundant in the apple transcripts. Dinucleotide repeats are found in 4,018 nonredundant sequences, mainly in the 5'-untranslated region of the gene, with a bias toward one repeat type (containing AG, 88%) and against another (repeats containing CG, 0.1%). Trinucleotide repeats are most common in the predicted coding regions and do not show a similar degree of sequence bias in their representation. Bi-allelic single-nucleotide polymorphisms are highly abundant with one found, on average, every 706 bp of transcribed DNA. Predictions of the numbers of representatives from protein families indicate the presence of many genes involved in disease resistance and the biosynthesis of flavor and health-associated compounds. Comparisons of some of these gene families with Arabidopsis (Arabidopsis thaliana) suggest instances where there have been duplications in the lineages leading to apple of biosynthetic and regulatory genes that are expressed in fruit. This resource paves the way for a concerted functional genomics effort in this important temperate fruit crop.