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      Post COVID-19: Planning strategies to resume orthopaedic surgery –challenges and considerations

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          Abstract

          The Coronavirus SARS-CoV-2 (COVID-19) pandemic has had a substantial effect on the health care systems around the world. As the disease has spread, many developed and developing countries have been stretched on their resources such as personnel as well as adequate equipment. As a result of resource disparity, in a populous country like India, the elective orthopaedic surgeries stand cancelled whilst trauma and emergency services have been reorganised following Indian Orthopaedic Association and recent urgent British Orthopaedic association guidelines. Though these guidelines provide strategies to deal with trauma and orthopaedic surgery management in the present scenario, once the COVID-19 pandemic stabilizes, restarting elective orthopaedic surgery and managing delayed trauma conditions in evolving health care systems is going to be a profound task. We look at the future challenges and considerations of re-establishing trauma and orthopaedic flow during the post-COVID-19 phase and suggest an algorithm to follow (Fig. 1).

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          Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

          Background The outbreak of 2019 novel coronavirus disease (COVID-19) in Wuhan, China, has spread rapidly worldwide. In the early stage, we encountered a small but meaningful number of patients who were unintentionally scheduled for elective surgeries during the incubation period of COVID-19. We intended to describe their clinical characteristics and outcomes. Methods We retrospectively analyzed the clinical data of 34 patients underwent elective surgeries during the incubation period of COVID-19 at Renmin Hospital, Zhongnan Hospital, Tongji Hospital and Central Hospital in Wuhan, from January 1 to February 5, 2020. Findings Of the 34 operative patients, the median age was 55 years (IQR, 43–63), and 20 (58·8%) patients were women. All patients developed COVID-19 pneumonia shortly after surgery with abnormal findings on chest computed tomographic scans. Common symptoms included fever (31 [91·2%]), fatigue (25 [73·5%]) and dry cough (18 [52·9%]). 15 (44·1%) patients required admission to intensive care unit (ICU) during disease progression, and 7 patients (20·5%) died after admission to ICU. Compared with non-ICU patients, ICU patients were older, were more likely to have underlying comorbidities, underwent more difficult surgeries, as well as more severe laboratory abnormalities (eg, hyperleukocytemia, lymphopenia). The most common complications in non-survivors included ARDS, shock, arrhythmia and acute cardiac injury. Interpretation In this retrospective cohort study of 34 operative patients with confirmed COVID-19, 15 (44·1%) patients needed ICU care, and the mortality rate was 20·5%. Funding National Natural Science Foundation of China.
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            Beware of the second wave of COVID-19

            The outbreak of coronavirus disease 2019 (COVID-19), which began in Wuhan, China, in late 2019, has spread to 203 countries as of March 30, 2020, and has been officially declared a global pandemic. 1 With unprecedented public health interventions, local transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appears now to have been contained in China. Multiple countries are now experiencing the first wave of the COVID-19 epidemic; thus, gaining an understanding of how these interventions prevented the transmission of SARS-CoV-2 in China is urgent. In The Lancet, Kathy Leung and colleagues 2 report their assessment of the transmissibility and severity of COVID-19 during the first wave in four cities and ten provinces in China outside Hubei. The study estimated the instantaneous reproduction number in the selected locations decreased substantially after non-pharmaceutical control measures were implemented on Jan 23, 2020, and has since remained lower than 1. The transmission of SARS-CoV-2 in these locations was mainly driven by imported cases from Hubei until late January, which is, to some extent, similar to the transmission in January in several countries. The epidemics in Chinese provinces outside Hubei were believed to be driven by local transmission dynamics after Jan 31; 3 therefore, the findings of Leung and colleagues' study highlight the fact that the package of non-pharmaceutical interventions in China has the ability to contain transmission—not only imported cases, but also local transmission. The epidemic is accelerating rapidly in multiple countries, indicating shortfalls in preparedness. Given that multiple countries imposed travel restrictions against China in late January, there is a need to model whether earlier implementation of interventions such as social distancing, population behavioural change, and contact tracing would have been able to contain or mitigate the epidemic. Leung and colleagues also modelled the potential adverse consequences of premature relaxation of interventions, and found that such a decision might lead to transmissibility exceeding 1 again—ie, a second wave of infections. The finding is critical to governments globally, because it warns against premature relaxation of strict interventions. However, the effect of each intervention, or which one was the most effective in containing the spread of the virus, was not addressed in the study. While interventions to control the spread of SARS-CoV-2 are in place, countries will need to work toward returning to normalcy; thus, knowledge of the effect of each intervention is urgently required. Air travel data were used to model the effect of travel restrictions on delaying overall epidemic progression, and were found to have a marked effect at the international scale, but only a 3–5 day delay within China. 4 A study 5 focused on the effects of extending or relaxing physical distancing control measures in Wuhan has suggested that if the measures are gradually relaxed in March, a second wave of cases might occur in the northern hemisphere mid-summer. Country-specific models of the effects of travel restrictions and social distancing, as well as the alternative strategies after the relaxation of these interventions, such as the use of face masks, temperature checks, and contact tracing, are now needed. Case fatality rate (CFR) is one of the important unknowns of COVID-19. Leung and colleagues estimated the confirmed CFR (cCFR) outside Hubei was 0·98% (95% CI 0·82–1·16), which was consistent with the report from the Chinese Center for Disease Control and Prevention. 6 Since the epidemics in the studied locations did not overwhelm the health-care capacities, the data on the number of confirmed cases are believed to be reliable. Leung and colleagues also found the cCFR was correlated with provincial per capita gross domestic product and the availability of hospital beds per 10 000. In Wuhan, the CFR was up to 5·08% by March 28, 2020. 7 The remarkable difference in the CFRa between these locations and Wuhan might be attributed to the difference in the degrees of health-care capacity. Therefore, consideration should be given to the variations in health-care capacity when implementing interventions. While the epidemic is growing exponentially, the health-care system will face severe burdens. Governments should act and prepare immediately to ensure that the health-care system has adequate labour, resources, and facilities to minimise the mortality risk of COVID-19. © 2020 Tingshu Wang/Reuters 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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              Is Open Access

              How to risk-stratify elective surgery during the COVID-19 pandemic?

              On March 11, 2020, the World Health Organization (WHO) declared the novel coronavirus disease 2019 (COVID-19) a global pandemic, which classifies the outbreak as an international emergency [1]. At the time of drafting this editorial, COVID-19 has swept through more than 115 countries and infected over 200,000 people around the globe [2–4]. More than 7000 individuals have died during the early phase of the pandemic, implying a high estimated case-fatality rate of 3.5% [2–4]. The rapidly spreading outbreak imposes an unprecedented burden on the effectiveness and sustainability of our healthcare system. Acute challenges include the exponential increase in emergency department (ED) visits and inpatient admission volumes, in conjunction with the impending risk of health care workforce shortage due to viral exposure, respiratory illness, and logistical issues due to the widespread closure of school systems [5]. Subsequent to the WHO declaration, the United States Surgeon General proclaimed a formal advisory to cancel elective surgeries at hospitals due to the concern that elective procedures may contribute to the spreading of the coronavirus within facilities and use up medical resources needed to manage a potential surge of coronavirus cases [6]. The announcement escalated to a nationwide debate regarding the safety and feasibility of continuing to perform elective surgical procedures during the COVID-19 pandemic [7, 8]. Many health care professionals erroneously interpreted the Surgeon General’s recommendation as a “blanket directive” to cancel all elective procedures in the Country [9]. This notion was vehemently challenged in an open letter to the Surgeon General on behalf of United States hospitals [10]. The letter outlined a significant concern that the recommendation could be “interpreted as recommending that hospitals immediately stop performing elective surgeries without clear agreement on how we classify various levels of necessary care “[10]. Notably, the Surgeon General’s recommendation was based on a preceding statement by the American College of Surgeons (ACS) with a call to prioritize appropriate resource allocation during the coronavirus pandemic as it relates to elective invasive procedures. The ACS bulletin stated the following specific recommendations [11]: Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs. Immediately minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators. There are many asymptomatic patients who are, nevertheless, shedding virus and are unwittingly exposing other inpatients, outpatients, and health care providers to the risk of contracting COVID-19. Importantly, the notion to “thoughtfully review all scheduled elective procedures “does not reflect on a presumed imperative to cancel all elective surgical cases across the United States [11]. The uncertainty on the predicted time course of COVID-19 beyond a critical inflection point implies that patients may be deprived of access to timely surgical care likely for many months to come. Arguably, the potential fallout from inconsiderate elective surgery cancellations may have a more dramatic and immeasurable impact on the health of our communities than the morbidity and mortality inflicted by the novel coronavirus disease. For the sake of this discussion, it is imperative to understand that the term “elective “surgery does not mean optional surgery, and rather implies that a procedure is not immediately indicated in response to a limb- or life-threatening emergency. A current estimate suggests that more than 50% of all elective surgical cases have a potential to inflict significant harm on patients if cancelled or delayed [12]. The physiological condition of a vulnerable cohort of patients may rapidly worsen in absence of appropriate surgical care, and the resulting decline in patients‘health will likely make them more vulnerable to a coronavirus infection [12]. A recent publication from the Naval Medical University in Shanghai reported on the inherent risks of delaying surgery for colorectal cancer during the COVID-19 outbreak in China [13]. In addition, impressive anecdotal reports of individual patient stories illustrate the unintended consequences imposed by cancelling scheduled surgery, as exemplified by a woman who stated that she felt like there was a “time bomb” inside her after surgery for early stage cervical cancer had been cancelled and indefinitely postponed [14]. Unequivocally, many elective non-urgent surgeries will become urgent at some point in time, depending on how long the COVID-19 outbreak will prevail. Dr. David Hoyt, a trauma surgeon and executive director of the ACS, recently stated:” Right now, most people are planning for a time period of 4–6 weeks for the peak to hit, but nobody really knows. We’re using our best judgment on the fly.” [11]. In light of all the underlying assumptions and uncertainties, it appears imperative to design and implement clinically relevant and patient safety-driven algorithms to guide the decision-making for appropriate surgical care. Elective procedures can pragmatically be stratified into “essential“, which implies that there is an increased risk of adverse outcomes by delaying surgical care for an undetermined period of time, versus “non-essential “or “discretionary“, which alludes to purely elective procedures that are not time-sensitive for medical reasons. Table 1 provides a suggested stratification by urgency of surgical indications for considering appropriate elective case cancellation. Equivocal surgical cases – which do not fall into either “essential “or “non-essential “categories – appear to have shown an effective self-regulating mechanism in the early phase of the COVID-19 outbreak, driven by patients voluntarily cancelling their scheduled elective procedures and surgeons evaluating appropriate indications on a case-by-case basis [15]. Table 1 Examples of surgical case types stratified by indication and urgency Indication Urgency Case examples Emergent   3 months • Cosmetic surgery • Bariatric surgery • Joint replacement • Sports surgery • Vasectomy / tubal ligation • Infertility procedures In essence, during the current time of widespread anxiety around the COVID-19 pandemic [16], a pragmatic guide based on underlying risk stratification and resource utilization will help support our ethical duty of assuring access to timely and appropriate surgical care to our patients, while maintaining an unwavering stewardship for scarce resources and emergency preparedness. Figure 1 provides a tentative decision-making algorithm based on elective surgical indications and predicted perioperative utilization of critical resources, including the consideration for intra−/postoperative blood product transfusions, estimated postoperative hospital length of stay, and the expected requirement for prolonged ventilation and need for postoperative ICU admission. Fig. 1 Proposed decision-making algorithm for risk-stratification of elective surgical procedures based on the underlying surgical indication and predicted resource utilization during the current COVID-19 pandemic. Abbreviations: ASA, American Society of Anesthesiologists; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; COVID, corona virus disease; ICU, intensive care unit; IP, inpatient; PACU, post-anesthesia care unit; PRBC, packed red blood cells; SNF, skilled nursing facility; SOB, shortness of breath Ultimately, if rationing of healthcare resources in terms of limiting access to surgical care in the United States will never be needed, then these ongoing crucial discussions will have served as an important exercise in nationwide disaster preparedness.
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                Author and article information

                Contributors
                Journal
                J Clin Orthop Trauma
                J Clin Orthop Trauma
                Journal of Clinical Orthopaedics and Trauma
                Elsevier
                0976-5662
                2213-3445
                4 May 2020
                4 May 2020
                Affiliations
                [a ]Trauma and Orthopaedic Surgeon, Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
                [b ]Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
                [c ]Trauma and Orthopaedic Surgeon, Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, 110076, New Delhi, India
                [d ]Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, 110076, New Delhi, India
                [e ]Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India
                [f ]Department of Orthopaedics, Sports Injury Centre, Safdarjung Hospital, New Delhi, India
                Author notes
                []Corresponding author. kartikp31@ 123456hotmail.com
                Article
                S0976-5662(20)30159-4
                10.1016/j.jcot.2020.04.028
                7196552
                32367999
                01b94453-0e50-468a-b10a-49309e0b3557
                © 2020.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 28 April 2020
                : 29 April 2020
                Categories
                Article

                covid-19,pandemic,orthopaedics,health resources,delivery of health care

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