American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Critical New Literature: The Science You Need to Know

Thromboembolic Events in COVID-19 Patients

Wright FL, Vogler TO, Moore EE, et al. Fibrinolysis Shutdown Correlates to Thromboembolic Events in Severe COVID-19 Infection. Journal of the American College of Surgeons (2020). doi:

In this retrospective study, 44 critically ill patients with COVID-19 were assessed with conventional coagulation testing as well as D-dimer levels and thromboelastography (TEG). The study found that the combination of elevated D-dimer and fibrinolytic shutdown as reflected by TEG was strongly predictive of thrombotic complications such as renal failure, venous thromboembolism, and stroke. The authors proposed that additional data confirming this pathway as a mechanism for COVID-related thrombotic events may suggest therapy trials with fibrinolytic agents.

COVID-19 Epidemiologic Models

Holmdahl I, Buckee C. Wrong but Useful - What Covid-19 Epidemiologic Models Can and Cannot Tell Us. N Engl J Med. 2020.

Holmdahl and Buckee provide a clear, understandable discussion of the strengths and limitations of the two main statistical models used by epidemiologists to investigate and attempt to understand the behaviors of public health events such as the COVID-19 pandemic. The two approaches discussed are the predictive model and the mechanistic model. They emphasized that predictive models do not account for the dynamics of disease transmission and thus are not useful for long-term prediction. Mechanistic models are adjusted based on evolving knowledge of disease transmission dynamics and can be used to forecast disease spread events based on the use of assumptions in different transmission scenarios. Limitations of mechanistic models depend on the assumptions used. Counting deaths, for example, is an imperfect approach; use of rates of hospitalizations is more dependable but still limited by imperfect knowledge of how the disease spreads. The authors provide a useful table of questions that should be posed before interpreting the statistical models.

Related Interesting article: Courtemanche C, Garuccio J, Le A, Pinkston J, Yelowitz A. Strong Social Distancing Measures In The United States Reduced the COVID-19 Growth Rate. Health Aff (Millwood). 2020:101377hlthaff202000608.

Approaches to Treating Perforated Diverticulitis

Lee YF, Brown RF, Battaglia M, Cleary RK. Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis. J Gastrointest Surg. 2020;24(5):1173-1182.

This retrospective analysis of data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) database compares outcomes for laparoscopic versus open sigmoidectomy for perforated diverticulitis. The authors used propensity scoring to increase the statistical strength of the comparison and to try to overcome the limitations of a retrospective analysis. Outcomes data on nearly 4,000 patients were included. Two comparisons were performed: completed laparoscopic versus open procedures and an intent-to-treat analysis that included both completed laparoscopic procedures and laparoscopic procedures converted to open. The analysis showed no statistically significant difference in operative mortality for the two approaches (7 percent); the laparoscopic group had a lower frequency of complications and a shorter hospital length of stay. Operative time for the laparoscopic approach was longer than for the open approach. The authors concluded that the laparoscopic approach was potentially valuable and encouraged prospective, randomized comparative trials.

Opioid Prescribing in Trauma

Page MG, Kudrina I, Zomahoun HTV, et al. A Systematic Review of the Relative Frequency and Risk Factors for Prolonged Opioid Prescription Following Surgery and Trauma Among Adults. Ann Surg. 2020;271(5):845-854.

This systematic review analyzed data from 35 observational studies. The review disclosed that opioid prescribing for more than three months occurred in 4.6 percent of patients with no preoperative opioid exposure, but this rate increased to more than 50 percent in patients with preoperative exposure. Additional risk factors for prolonged opioid prescribing were tobacco use, alcohol use, history of treatment with antidepressants, and lower income levels. The authors acknowledge that the study is limited by heterogeneity in the included articles as well as the lack of any prospective studies.

Hearing Loss

Dixon PR, Feeny D, Tomlinson G, Cushing S, Chen JM, Krahn MD. Health-Related Quality of Life Changes Associated With Hearing Loss. JAMA Otolaryngol Head Neck Surg. 2020.

This qualitative study, performed from August 1, 2018, to August 1, 2019, in tertiary referral centers, comprised a systematic literature review, focus groups, and semi-structured interviews. The systematic review evaluated studies published from 1982 to August 1, 2018. Focus groups included eight clinical experts experienced in the measurement, diagnosis, treatment, and rehabilitation of hearing loss. Semi-structured interviews included 26 adults with hearing loss recruited from an institutional data set and outpatient hearing aid and otology clinics using stratified convenience sampling to include individuals of diverse ages, urban and rural residency, causes of hearing loss, severity of hearing loss, and treatment experience.

The literature search yielded 2,779 articles, including 45 studies of a total of 1,036 individuals (age range, 18–84 years). The focus group included four audiologists and four otologists. Hour-long semi-structured interviews were conducted with 26 individuals (13 women; median age, 54 years; range, 25–83 years) with a range of hearing loss causes, configurations, and severities. The authors found the association between hearing loss and quality of life is multidimensional and includes subdomains that are not considered in the estimation of health utility by existing measures. The presented comprehensive profile of items can be used to generate or evaluate measures of hearing-related quality of life, including utility measures.

Insights into COVID-19 Immunity and Disparities

JAMA recently published opinion pieces on COVID-19 immunity, disparities, and the limitations of “herd immunity.”

According to the authors of COVID-19 and Postinfection Immunity: Limited Evidence, Many Remaining Questions, limited data on antibody responses to SARS-CoV-2 and related coronaviruses, as well as one small animal model study, suggest that recovery from COVID-19 might confer immunity against reinfection, at least temporarily. However, the immune response to COVID-19 is not fully understood and definitive data on postinfection immunity are lacking.

COVID-19 and Racial/Ethnic Disparities reviews possible reasons for reported excess mortality and poor outcomes in racial/ethnic minority populations with COVID-19 and proposes research, public health, and clinical interventions to decrease health inequities in and beyond the pandemic.

COVID-19 and Health Equity—A New Kind of ‘Herd Immunity’ reflects on the racial/ethnic disparities in COVID-19 infection, testing, and disease burden as a clear reminder that failure to protect vulnerable members of society not only harms them, but also increases the risk of spread of the virus, with devastating health and economic consequences for everyone. The authors say the U.S. should develop a new definition of “herd immunity,” whereby resistance to the spread of poor health in the population occurs when a sufficiently high proportion of individuals, across all racial, ethnic, and social class groups, are protected from and thus “immune” to negative social determinants.

Additional Select Readings

JAMA, Assessment of Deaths From COVID-19 and From Seasonal Influenza

Medscape, COVID-19: What Will Happen to Physician Income This Year?

New Yorker, Amid the Coronavirus Crisis, a Regimen for Reentry

Atul Gawande, MD, MPH, FACS, discusses the need to use a measured, evidence-based approach to reopening states and cities, despite the limitations and burdens associated with these efforts, including requiring people to masks in public and physical distancing.

The Chronicle of Higher Education, How a Department Chair Became America’s COVID-19 Correspondent

Telemedicine and e-Health, Perspective on COVID-19: Finally, Telemedicine at Center Stage