Outcomes of SARS-CoV-2 infection among patients with orthopaedic fracture surgery in the National COVID Cohort Collaborative (N3C).

BACKGROUND: The objective of this study was to investigate the outcomes of COVID-19-positive patients undergoing orthopaedic fracture surgery using data from a national database of U.S. adults with a COVID-19 test for SARS-CoV-2. METHODS: This is a retrospective cohort study using data from a national database to compare orthopaedic fracture surgery outcomes between COVID-19-positive and COVID-19-negative patients in the United States. Participants aged 18-99 with orthopaedic fracture surgery between March and December 2020 were included. The main exposure was COVID-19 status. Outcomes included perioperative complications, 30-day all-cause mortality, and overall all-cause mortality. Multivariable adjusted models were fitted to determine the association of COVID-positivity with all-cause mortality. RESULTS: The total population of 6.5 million patient records was queried, identifying 76,697 participants with a fracture. There were 7,628 participants in the National COVID Cohort who had a fracture and operative management. The Charlson Comorbidity Index was higher in the COVID-19-positive group (n = 476, 6.2 %) than the COVID-19-negative group (n = 7,152, 93.8 %) (2.2 vs 1.4, p<0.001). The COVID-19-positive group had higher mortality (13.2 % vs 5.2 %, p<0.001) than the COVID-19-negative group with higher odds of death in the fully adjusted model (Odds Ratio=1.59; 95 % Confidence Interval: 1.16-2.18). CONCLUSION: COVID-19-positive participants with a fracture requiring surgery had higher mortality and perioperative complications than COVID-19-negative patients in this national cohort of U.S. adults tested for COVID-19. The risks associated with COVID-19 can guide potential treatment options and counseling of patients and their families. Future studies can be conducted as data accumulates. LEVEL OF EVIDENCE: Level III.

Ankle Fracture and Length of Stay in US Adult Population Using Data From the National COVID Cohort Collaborative.

BACKGROUND: The National COVID Cohort Collaborative (N3C) is an innovative approach to integrate real-world clinical observations into a harmonized database during the time of the COVID-19 pandemic when clinical research on ankle fracture surgery is otherwise mostly limited to expert opinion and research letters. The purpose of this manuscript is to introduce the largest cohort of US ankle fracture surgery patients to date with a comparison between lab-confirmed COVID-19-positive and COVID-19-negative. METHODS: A retrospective cohort of adults with ankle fracture surgery using data from the N3C database with patients undergoing surgery between March 2020 and June 2021. The database is an NIH-funded platform through which the harmonized clinical data from 46 sites is stored. Patient characteristics included body mass index, Charlson Comorbidity Index, and smoking status. Outcomes included 30-day mortality, overall mortality, surgical site infection (SSI), deep SSI, acute kidney injury, pulmonary embolism, deep vein thrombosis, sepsis, time to surgery, and length of stay. COVID-19-positive patients were compared to COVID-19-negative controls to investigate perioperative outcomes during the pandemic. RESULTS: A total population of 8.4 million patient records was queried, identifying 4735 adults with ankle fracture surgery. The COVID-19-positive group (n=158, 3.3%) had significantly longer times to surgery (6.5 ± 6.6 vs 5.1 ± 5.5 days, P = .001) and longer lengths of stay (8.3 ± 23.5 vs 4.3 ± 7.4 days, P < .001), compared to the COVID-19-negative group. The COVID-19-positive group also had a higher rate of 30-day mortality. CONCLUSION: Patients with ankle fracture surgery had longer time to surgery and prolonged hospitalizations in COVID-19-positive patients compared to those who tested negative (average delay was about 1 day and increased length of hospitalization was about 4 days). Few perioperative events were observed in either group. Overall, the risks associated with COVID-19 were measurable but not substantial.Level of Evidence: Level III, retrospective cohort study.

Association Between COVID-19 and Mortality in Hip Fracture Surgery in the National COVID Cohort Collaborative (N3C): A Retrospective Cohort Study.

BACKGROUND: This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database. METHODS: This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality. RESULTS: In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period. DICUSSION: We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.

"Seronegative" anti-MUSK positive myasthenia gravis presenting during pregnancy.

Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of the skeletal muscles of the face and extremities. Pregnancy is associated with 19-41% of exacerbations. We present a 19-year-old woman who was seen at the neurology clinic 10 days after her last cesarean section with diplopia and trouble swallowing liquids and solids for the previous 3 months. On examination she had slurred speech, bilateral palpebral ptosis, and mild droop of her shoulders. An arterial blood sample showed a PCO2 of 50 mmHg and a PO2 of 70 mmHg. The tensilon test was positive, Intravenous methylprednisolone and immunoglobulin and oral pyridostigmine effectively relieved her myasthenic signs and symptoms. Five assays for acetylcholine or anti-striational antibodies in her serum were negative. A test for muscle-specific tyrosine kinase antibody was positive. In 10-20% of patients with myasthenia gravis no antibodies to acetylcholine receptors are detectable. Forty percent of this group has an antibody to muscle-specific tyrosine kinase.