The challenge of maintaining necessary vascular and endovascular services at a referral center in Northern Italy during the COVID-19 outbreak.

OBJECTIVES: The Padova Hospital Vascular Surgery Division is located in Veneto, one of the area of the Northern Italy most hit by the Coronavirus disease 2019 outbreak. The aim of this paper is to describe the protocols adopted and to evaluate their impact during the acute phase of Coronavirus spread, focusing on the management of elective and urgent/emergent surgery, outpatients activity, and also health staff preservation from intra-hospital Coronavirus disease 2019 infection. METHODS: Several measures were progressively adopted in the Padova University Hospital to front the Coronavirus disease 2019 outbreak, with a clear strong asset established by 9 March 2020, after the Northern Italy lockdown. Since this date, the Vascular Surgery Unit started a "scaled-down" activity, both for elective surgical procedures and for the outpatient Clinical activities; different protocols were developed for health preservation of staff and patients. We compared a two months period, 30 days before and 30 days after this time point. In particular, emergent vascular surgery was regularly guaranteed as well as urgent surgery (to be performed within 24 h). Elective cases were scheduled for "non-deferrable" pathology. A swab test protocol for COVID-19 was applied to health-care professionals and hospitalized patients. RESULTS: The number of urgent or emergent aortic cases remained stable during the two months period, while the number of Hospital admissions via Emergency Room related to critical limb ischemia decreased after national lockdown by about 20%. Elective vascular surgery was scaled down by 50% starting from 9 March; 35% of scheduled elective cases refused hospitalization during the lockdown period and 20% of those contacted for hospitalization where postponed due to fever, respiratory symptoms, or close contacts with Coronavirus disease 2019 suspected cases. Elective surgery reduction did not negatively influence overall carotid or aortic outcomes, while we reported a higher major limb amputation rate for critical limb ischemia (about 10%, compared to 4% for the standard practice period). We found that 4 out of 98 (4%) health-care providers on the floor had an asymptomatic positive swab test. Among 22 vascular doctors, 3 had a confirmed Coronavirus disease 2019 infection (asymptomatic); a total of 72 swab were performed (mean = 3.4 swab/person/month) during this period; no cases of severe Coronavirus disease 2019 (deaths or requiring intensive care treatment) infection were reported within this period for the staff or hospitalized patients. CONCLUSIONS: Elective vascular surgery needs to be guaranteed as possible during Coronavirus disease 2019 outbreak. The number of truly emergent cases did not reduce, on the other side, Emergency Room accesses for non-emergent cases decreased. Our preliminary results seem to describe a scenario where, if the curve of the outbreak in the regional population is flattened, in association with appropriate hospitals containment rules, it may be possible to continue the activity of the Vascular Surgery Units and guarantee the minimal standard of care.

Changes in red blood cell transfusion practice during the past two decades: a retrospective analysis, with the Mayo database, of adult patients undergoing major spine surgery.

BACKGROUND: Others have reported significant changes in red blood cell (RBC) transfusion practice during the past two decades during knee, hip, prostate, and carotid surgery. Similar data for patients undergoing major spine surgery, however, are not available. STUDY DESIGN AND METHODS: After institutional review board approval, adult patients undergoing elective major spine surgery were stratified into one of two transfusion-related groups: 1) 1980 to 1985 (i.e., before human immunodeficiency virus screening, early practice group; n = 699) or 2) 1995 to 2000 (i.e., late practice group; n = 610). RESULTS: Patients in the late practice group were older, had greater numbers of preoperative coexisting diseases (e.g., hypertension, cardiac dysrhythmias, coronary artery disease, prior myocardial infarction, diabetes mellitus, renal disease, cerebrovascular disease, and asthma), and were exposed to longer operations (p < 0.01 for each variable). Over time, allogeneic RBC administration significantly decreased, whereas autologous and intraoperative autotransfusion significantly increased. Compared to the early practice group, all perioperative Hb concentrations were significantly lower than the late practice group, yet no significant difference in major morbidity or mortality was observed between groups. CONCLUSION: In this retrospective analysis, significantly lower acceptable perioperative Hb concentrations were observed in older patients having substantially worse baseline comorbidity and exposed to longer major spine operations, without significant change in the incidence of perioperative morbidity or mortality.

A 15-year longitudinal analysis of trends in elective urological surgery - an evidence base for Modernising Medical Careers.

INTRODUCTION: The impact of Modernising Medical Careers on the differential need for consultant urologists and urological surgeons is as yet unknown. This study's aim was to determine what changes there had been in operative urological activity so as to predict the need for urological surgeons in the future. MATERIALS AND METHODS: A retrospective study of all elective operative urological surgery over a 15-year period was performed. The absolute numbers of patients presenting for different grades of surgery were aggregated and analysed using the Spearman's rank correlation test. RESULTS: Aggregated data from 27,839 procedures demonstrated no change in the number of operations (r 0.01; NS) or the number of diagnostic endoscopic procedures (r 0.21; NS) carried out over the study period. There was a decrease in endoscopic surgery related to a 70% reduction in trans-urethral resection of the prostate (TURP) (r -0.89; P = <0.0001) and an increase in ureteroscopic interventions (r 0.82; P = 0.0002) for stone disease. There was no change in the amount of major surgery carried out (r -0.43; NS) over the 15 years. CONCLUSIONS: There have been changes to the pattern of surgery urologists have provided over the last 15 years but the need for complex surgical interventions has not altered. This suggests there will be as great a need for operating surgeons in the future, as currently exists.

Diez años de experiencia en autotransfusión de predepósito en cirugía electiva / Ten years experience on predeposit autologous transfusion in elective surgery

Se presenta la metodología utilizada para la selección de casos, preparación, obtención, análisis, preservación, almacenaje, custodia, transportación y aplicación de la sangre obtenida en el preoperatorio para ser transfundida días después al mismo donador durante algún procedimiento quirúrgico. Se hace énfasis en los beneficios que se obtienen con la práctica de la autotransfusión en cirugía electiva sangrante al mencionar el menor tiempo de recuperación y de incapacidad que tienen los pacientes sometidos a este procedimiento comparativamente con los que sufren una cirugía similar sin efectuarles la autotransfusión. Se menciona además, en una experiencia de 212 casos la ausencia de complicaciones y la exactitud con que se puede planear la cantidad de sangre de que se debe disponer así como la estimulación de la eritropoyesis preoperatoria