Impact of COVID-19 on surgical emergencies: nationwide analysis

Background

The COVID-19 pandemic has had a major impact on healthcare in many countries. This study assessed the effect of a nationwide lockdown in France on admissions for acute surgical conditions and the subsequent impact on postoperative mortality.

Methods

This was an observational analytical study, evaluating data from a national discharge database that collected all discharge reports from any hospital in France. All adult patients admitted through the emergency department and requiring a surgical treatment between 17 March and 11 May 2020, and the equivalent period in 2019 were included. The primary outcome was the change in number of hospital admissions for acute surgical conditions. Mortality was assessed in the matched population, and stratified by region.

Results

During the lockdown period, 57 589 consecutive patients were admitted for acute surgical conditions, representing a decrease of 20.9 per cent compared with the 2019 cohort. Significant differences between regions were observed: the decrease was 15.6, 17.2, and 26.8 per cent for low-, intermediate- and high-prevalence regions respectively. The mortality rate was 1.92 per cent during the lockdown period and 1.81 per cent in 2019. In high-prevalence zones, mortality was significantly increased (odds ratio 1.22, 95 per cent c.i. 1.06 to 1.40).

Conclusion

A marked decrease in hospital admissions for surgical emergencies was observed during the lockdown period, with increased mortality in regions with a higher prevalence of COVID-19 infection. Health authorities should use these findings to preserve quality of care and deliver appropriate messages to the population.

Retinal Photocoagulation for Proliferative Sickle Cell Retinopathy: A Prospective Clinical Trial with New Sea Fan Classification

Purpose

To compare the clinical outcome of stage III proliferative sickle cell retinopathy (PSR) treated by peripheral retinal scatter photocoagulation to natural course disease.

Methods

Long-term follow-up of 101 patients enrolled in a prospective trial of photocoagulation for PSR has been completed. Among 202 eyes of 101 patients enrolled at the University Eye Clinic of Créteil, 73 eyes showed a stage III PSR, which the authors further divided into five new grades (A, B, C, D, E) considering size, hemorrhage, fibrosis, and visible vessels. Grading was based on a three-mirror fundus examination, 360° color photographs, and fluorescein angiography. Mean follow-up was 4 years.

Results

Thirty-eight treated eyes and 35 untreated eyes were included in this study. The evolution was not statistically significant between treated and untreated groups concerning flat sea fan p<1 MPS disc area (grade A) or elevated sea fan with partial fibrosis (grade C). Progression and regression were compared between the two groups for grade B, resulting statistically significant (pp<0.05). Nine complications (13%) were observed, which only occurred in untreated patients with elevated sea fan and hemorrhage (grade B) or complete fibrosed sea fan with well defined vessels (grade E) (pp<0.05).

Conclusions

These data suggest that patients with grade A or C new sea fan classification should not be initially treated but observed.

[Ranibizumab and exudative age-related macular degeneration: 5-year multicentric functional and anatomical results in real-life practice]

PURPOSE

The goal of this study was to evaluate five year functional and anatomical outcomes of wet AMD patients treated with ranibizumab according to a pro re nata (PRN) regimen in real-life practice.

METHODS

A retrospective, multicentric chart review of 201 eyes of 201 patients who underwent their first ranibizumab intravitreal injection (IVT) between January 1, 2007 and December 31, 2008 was performed. Best-corrected visual acuity (BCVA), central macular thickness (CMT) on SD-OCT, number of IVT and follow-up visits were collected at baseline and during the entire follow-up period of 5 years.

RESULTS

Mean BCVA at baseline was 52.3±16.5 letters. Mean BCVA change from baseline was respectively +2.8, +2.5, +1.8, -0.6 at 1, 2, 3, 4 years of follow-up. At year 5, 43% of eyes had a stable or improved letter score (≥0 letter gain), whereas 29% declined by 15 letters or more, with an overall significant mean decline of 2.8 letters (P<0.05). No correlation was observed between final visual outcome and age, baseline BCVA, type of neovascularization, naive status, number of IVT or number of follow-up visits. On SD-OCT, mean CMT was 293±96μm at baseline and was significantly reduced compared to baseline at each year end-point (P<0.005). The mean number of IVT was 15±10.4 at year 5, with 55% of eyes still being under active treatment.

CONCLUSION

PRN ranibizumab in real-life practice improved or stabilized visual acuity over 4 years. During the 5th year, progressive decline of visual acuity was observed.

[Review and expert opinion in age related macular degeneration. Focus on the pathophysiology, angiogenesis and pharmacological and clinical data]

Age related macular degeneration (AMD) is a pathological aging of the macula, brought about by the interaction of genetic and environmental factors. It induces geographic atrophy of the retina and/or choroidal neovascularization. In the latter, abnormal vessels develop from the choriocapillaris, with the involvement of VEGF (vascular endothelial growth factor). The VEGF family includes several factors, including VEGF-A, B, C, D, F and PlGF (placental growth factor). Their biological properties and their affinities to the VEGFR1, VEGFR2 and VEGFR3 receptors found on endothelial cells differ. Exudative AMD involves mainly VEGF-A and VEGF-R2. Anti-VEGF agents used in ophthalmology (ranibizumab, bevacizumab and aflibercept) are designed to primarily target this pathway. In vitro, all have sufficient affinity to their ligands. Their therapeutic efficacy must therefore be judged based on clinical criteria. In clinical practice, the minimum number of injections required for a satisfactory result appears to be comparable with all the three. The few available studies on therapeutic substitutions of anti-VEGF compounds suggest that some patients may benefit from substituting the anti-VEGF in cases of an unsatisfactory response to an initial molecule. Although local side effects, including increased risk of geographic atrophy, and systemic effects, including vascular accidents, have been suggested, these risks remain low, specially compared to the benefits of the treatment. Differences in safety between anti-VEGF are theoretically possible but unproven.

[Evolving intravitreous injection technique]

The technique of intravitreous injections has been well documented for several years. Recently, a descriptive article on the intravitreous injections procedure was published in the Journal Français d'Ophtalmologie, and the AFSSAPS (French agency for drug safety) released recommendations concerning this matter on the occasion of commercial launch of pegaptanib. Since that time, the number of intravitreal injections has considerably increased, because anti-VEGF drugs had been made available to ophthalmologists, and several teams have performed a large number of procedures, allowing them to better comprehend intravitreous injections. The present paper describes our current practice of intravitreous injections. Several specialists have exchanged their experiences and issued a common synthesis. Detailed modifications of the initial recommendations have been suggested, with such basic changes such as abandoning preoperative pupil dilatation and easing postsurgical monitoring. Follow-up examinations should be adapted to each patient rather than being systematic. The suggested modifications do not change the procedure of intravitreous injections substantially, but they simplify many steps and detail the various procedures when consensus is lacking.