Orthopedic Surgery in Ambulatory Surgery Centers During the COVID-19 Pandemic: Low Incidence of Infection Among Patients, Surgeons, and Staff.

Background and objective The coronavirus disease 2019 (COVID-19) pandemic has presented tremendous challenges to the healthcare systems worldwide. Consequently, ambulatory surgery centers (ASCs) have been forced to find new and innovative ways to function safely and maintain operations. We conducted a study at a large United States (US) private orthopedic surgery practice, where a universal screening policy and testing protocol for COVID-19 was implemented for patients and ASC personnel including surgeons, in order to examine the incidence of COVID-19 in patients scheduled for orthopedic surgery in ASC settings as well as the incidence among the surgeons and ASC personnel. Methods The universal screening protocol was implemented in the ASCs of the facility during the early stage of the pandemic for an eight-month period from April 28, 2020, to December 31, 2020. All ASC personnel including surgeons had their symptoms tracked daily and were rapid-tested every two weeks. All patients were screened and tested before they entered the ASC. Results A total of 70 out of 12,115 patients and 41 out of 642 ASC personnel tested positive for COVID-19, resulting in infection rates of 0.6% and 6.4%, respectively. Individual symptoms, age, the American Society of Anesthesiologists (ASA) scores, and comorbidities were documented, and no single factor was found to be common among positive (+) tests. Conclusions The implementation of universal screening and symptom-reporting procedures was associated with a very low rate of infections among ASC patients, staff, and surgeons, and it offers a reproducible framework for other facilities to continue to provide orthopedic outpatient operations in ASC settings during the ongoing iterations of the COVID-19 pandemic.

COVID-19 and ST elevations-keep an open mind: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been associated with a range of cardiovascular manifestations, including myocardial injury and thrombo-embolism. Pulmonary embolism (PE) causing anteroseptal/anterior ST elevations that mimic myocardial infarction have previously been described. This phenomenon is thought to be related to right ventricular injury from large emboli. CASE SUMMARY: A 48-year-old woman with history of type 2 diabetes mellitus and hypertension presented to her local hospital with fever, cough, nausea, and dyspnoea. A test for SARS-CoV-2 was taken, and she was discharged with instructions to self-quarantine. She was subsequently notified of a positive SARS-CoV-2 result. Three days later, she re-presented with worsening dyspnoea and respiratory failure requiring intubation. On hospital Day 6, she became acutely hypoxic and hypotensive. Telemetry was noted to have ST changes, prompting ECG that revealed sinus tachycardia with prominent new ST elevations in her precordial leads. Transthoracic echocardiogram showed normal left ventricular function; however, the right ventricle was moderately dilated with positive McConnell's sign. Due to her unstable clinical state and high suspicion for PE, she was treated with tenecteplase 50 mg i.v. with complete resolution of her ST elevations and improved oxygenation. DISCUSSION: Given the high rates of thrombo-embolic events in COVID-19 patients, PE should be in the differential diagnosis of ST elevation, particularly in younger patients with few risk factors for coronary artery disease.

Coccidioidomycosis among persons undergoing lung transplantation in the coccidioidal endemic region.

BACKGROUND: Coccidioidomycosis, an endemic fungal infection, is more likely to be symptomatic and severe among those receiving allogeneic transplants. While several case series have been published for various transplanted organs, none has described the incidence and outcomes in those receiving lung transplants within the coccidioidal endemic region. METHODS: Patients receiving a heart-lung, single-lung, or bilateral-lung transplantation at the University of Arizona between 1985 and 2009 were retrospectively reviewed. RESULTS: Coccidioidomycosis occurred post transplantation in 11 (5.8%) of 189 patients. All but one patient was diagnosed with pulmonary coccidioidomycosis and only one had a history of prior coccidioidomycosis. Two patients received transplants from donors found to have coccidioidomycosis at the time of transplantation and one death was directly attributed to coccidioidomycosis. The risk of developing active coccidioidomycosis was significantly higher if the patient did not receive some type of antifungal therapy post transplantation (P<.001). CONCLUSION: Within the coccidioidal endemic region, post-transplantation coccidioidomycosis was a definable risk among lung transplant recipients. Use of antifungals appeared to reduce this incidence of disease. Almost all cases resulted in pulmonary disease, suggesting that the lung is the primary site of infection.

Tuberculosis in liver transplant recipients: a systematic review and meta-analysis of individual patient data.

Mycobacterium tuberculosis (MTB) causes substantial morbidity and mortality in liver transplant recipients. We examined the efficacy of isoniazid latent Mycobacterium tuberculosis infection (LTBI) treatment in liver transplant recipients and reviewed systematically all cases of active MTB infection in this population. We found 7 studies that evaluated LTBI treatment and 139 cases of active MTB infection in liver transplant recipients. Isoniazid LTBI treatment was associated with reduced MTB reactivation in transplant patients with latent MTB risk factors (0.0% versus 8.2%, P = 0.02), and isoniazid-related hepatotoxicity occurred in 6% of treated patients, with no reported deaths. The prevalence of active MTB infection in transplant recipients was 1.3%. Nearly half of all recipients with active MTB infection had an identifiable pretransplant MTB risk factor. Among recipients who developed active MTB infection, extrapulmonary involvement was common (67%), including multiorgan disease (27%). The short-term mortality rate was 31%. Surviving patients were more likely to have received 3 or more drugs for MTB induction therapy (P = 0.003) and to have been diagnosed within 1 month of symptom onset (P = 0.01) and were less likely to have multiorgan disease (P = 0.01) or to have experienced episodes of acute transplant rejection (P = 0.02). Compared with the general population, liver transplant recipients have an 18-fold increase in the prevalence of active MTB infection and a 4-fold increase in the case-fatality rate. For high-risk transplant candidates, isoniazid appears safe and is probably effective at reducing MTB reactivation. All liver transplant candidates should receive a tuberculin skin test, and isoniazid LTBI treatment should be given to patients with a positive skin test result or MTB pretransplant risk factors, barring a specific contraindication. Liver Transpl 15:894-906, 2009. (c) 2009 AASLD.

Role of bronchoalveolar lavage diagnostics in fungal infections.

Although a biopsy may need to be performed in complicated patients, bronchoalveolar lavage (BAL) is an important adjunct to the diagnosis of pulmonary and disseminated fungal infections. Culture is the gold standard for diagnosis in many instances, but cytologic and morphologic analysis is often diagnostic. Although newer molecular and antigen techniques may be applied to BAL samples, the role of such tests is yet to be defined for many pathogens.

Advances in the management of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death, seems to be increasing in worldwide prevalence, and carries with it a significant health and economic burden. Smoking cessation is the only available intervention proven to halt disease progression. The authors discuss the role of the newly approved agent, varenicline, in promotion of smoking cessation. The remainder of presently available therapies treat the symptoms of COPD, but do not impact progression of disease. As the understanding of the pathogenesis of COPD improves, new targets for therapies are emerging. Given the large number of potential targets and the results of recent studies, it seems unlikely that a single new agent will result in a cure. Rather, management of COPD should involve a multi-pronged approach including smoking cessation, bronchodilators, treatment of infection, and eventual targeting of inflammatory pathways and genetic predispositions. In this article, the authors discuss presently available therapies as well as agents under development.

Fluid management in hospitalized patients.

Intravenous fluid administration is critical to the care of hospitalized patients. Despite the lack of a clear consensus on fluid administration, one may use the principles in this article to develop an organized framework for patient care.

A sequence-based map of Arabidopsis genes with mutant phenotypes.

The classical genetic map of Arabidopsis contains 462 genes with mutant phenotypes. Chromosomal locations of these genes have been determined over the past 25 years based on recombination frequencies with visible and molecular markers. The most recent update of the classical map was published in a special genome issue of Science that dealt with Arabidopsis (D.W. Meinke, J.M. Cherry, C. Dean, S.D. Rounsley, M. Koornneef [1998] Science 282: 662-682). We present here a comprehensive list and sequence-based map of 620 cloned genes with mutant phenotypes. This map documents for the first time the exact locations of large numbers of Arabidopsis genes that give a phenotype when disrupted by mutation. Such a community-based physical map should have broad applications in Arabidopsis research and should serve as a replacement for the classical genetic map in the future. Assembling a comprehensive list of genes with a loss-of-function phenotype will also focus attention on essential genes that are not functionally redundant and ultimately contribute to the identification of the minimal gene set required to make a flowering plant.