Outcomes of early versus late irrigation and debridement of pediatric open long bone fractures

BACKGROUND Open long bone fractures are a major concern for pediatric patients due to the risk of surgical site infection(SSI).Early studies have recommended irrigation and debridement of open fractures within 6 hours-8 hours for the prevention of SSI.According to the American College of Surgeons(ACS)Best Practice Guidelines,in 2015,irrigation and debridement should be done within 24 hours.AIM To identify whether early irrigation and debridement,within 8 hours,vs late,between 8 hours and 24 hours,for pediatric open long bone fractures impacts rate of SSI.METHODS Using retrospective data review from the National Trauma Data Bank,Trauma Quality Improvement Project(TQIP)of 2019.TQIP database is own by the ACS and it is the largest database for trauma quality program in the world.Propensity matching analysis was performed for the study.RESULTS There were 390 pediatric patients with open long bone fractures who were incl-uded in the study.After completing propensity score matching,we had 176 patients in each category,irrigation and debridement within 8 hours and irrigation and debridement between 8 hours and 24 hours.We found no significant differences between each group for the rate of deep SSI which was 0.6%for patients who received surgical irrigation and debridement within 8 hours and 1.1%for those who received it after 8 hours[adjusted odd ratio(AOR):0.5,95%CI:0.268-30.909,P>0.99].For the secondary outcomes studied,in terms of length of hospital stay,patients who received irrigation and debridement within 8 hours stayed for an average of 3.5 days,and those who received it after 8 hours stayed for an average of 3 days,with no significant difference found,and there were also no sig-nificant differences found between the discharge dispositions of the patients.CONCLUSION Our findings support the recommendation for managing open long bone fractures from the ACS:Complete surgical irrigation and debridement within 24 hours.

Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure

Objective:Secondary pyeloplasty for recurrent ureteropelvic junction obstructions may be a safe and feasible surgical option for patients.This study aimed to demonstrate outcomes of utilizing a non-transecting buccal mucosa graft ureteroplasty for management of recurrent ureteropelvic junction obstruction after prior failed pyeloplasty.Methods:We performed a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery database for all consecutive patients who underwent buccal mucosa graft ureteroplasty between April 2012 and June 2022 for management of recurrent ureteropelvic junction obstructions after prior failed pyeloplasty.The primary outcome included surgical success which was defined as the absence of flank pain and no obstruction on imaging.Results:Overall,ten patients were included in our analysis.The median stricture length was 2.5(interquartile range[IQR]1.8-4.0)cm.The median operative time was 230.5(IQR 199.5-287.0)min and median estimated blood loss was 50.0(IQR 28.8-102.5)mL.At a median follow-up of 10.3(IQR 6.2-14.8)months,80%of patients were surgically successful and there were no major(ClavieneDindo Grade>2)complications.Conclusion:Buccal mucosa graft ureteroplasty is a valuable non-transecting surgical option for patients with recurrent ureteropelvic junction obstructions who failed prior pyeloplasty and has comparable outcomes to the literature regarding standard transecting techniques.

Global geoepidemiology of gastrointestinal surgery rates in Crohn’s disease

BACKGROUND Data regarding the worldwide gastrointestinal surgery rates in patients with Crohn’s disease(CD)remains limited.AIM To systematically review the global variation in the rates of surgery in CD.METHODS A comprehensive search analysis was performed using multiple electronic databases from inception through July 1,2020,to identify all full text,randomized controlled trials and cohort studies pertaining to gastrointestinal surgery rates in adult patients with CD.Outcomes included continent based demographic data,CD surgery rates over time,as well as the geoepidemiologic variation in CD surgery rates.Statistical analyses were conducted using R.RESULTS Twenty-three studies spanning four continents were included.The median proportion of persons with CD who underwent gastrointestinal surgery in studies from North America,Europe,Asia,and Oceania were 30%(range:1.7%-62.0%),40%(range:0.6%-74.0%),17%(range:16.0%-43.0%),and 38%respectively.No clear association was found regarding the proportion of patients undergoing gastrointestinal surgery over time in North America(R^(2)=0.035)and Europe(R^(2)=0.100).A moderate,negative association was seen regarding the proportion of patients undergoing gastrointestinal surgery over time(R^(2)=0.520)in Asia.CONCLUSION There appears to be significant inter-continental variation regarding surgery rates in CD.Homogenous evidencebased guidelines accounting for the geographic differences in managing patients with CD is prudent.Moreover,as a paucity of data on surgery rates in CD exists outside the North American and European continents,future studies,particularly in less studied locales,are warranted.

Traumatic Lower Extremity Reconstruction in a Patient with Significant Vascular Comorbidities

Limb salvage after devastating traumatic injuries, cancer extirpation, and intrinsic disease is a complex decision-making process. Although several scoring and evaluation tools have been created to attempt to apply algorithmic decision-making to the process, thoughtful clinical decision-making remains the most important standard. When limb salvage is deemed appropriate, selection of a tissue flap for limb reconstruction is dependent on the size and location of the defect, patient comorbidities, nicotine dependence, mechanism of injury to the limb, patient lifestyle, occupation, and ambulatory status. This case involves a male trauma patient with significant comorbidities and a large lower extremity wound requiring multiple operations to attempt limb reconstruction with a rectus abdominis free flap. This patient’s complex injury and comorbidities made the risk of flap failure high, illustrating that the importance of patient- and case-specific factors cannot be overstated when planning for a limb reconstruction. This extreme resort of limb reconstruction, where limb loss is the only other option and a likely consequence of even heroic efforts, is aptly called “limb salvage”.

Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide.With the widespread reliance on endoscopic retrograde cholangiopancreatography(ERCP)for the management of pancreaticobiliary conditions,post-ERCP pancreatitis(PEP)has come to represent an important etiology of acute pancreatitis.Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder,findings have been heterogeneous,and considerable variation in clinical practice exists.Herein,we review the literature regarding PEP with the goal to raise awareness of this entity,discuss recent data,and present evidence-based best practices.We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.

Disparities in colonoscopy utilization for lower gastrointestinal bleeding in rural vs urban settings in the United States

BACKGROUND Lower gastrointestinal bleeds(LGIB)is a very common inpatient condition in the United States.Gastrointestinal bleeds have a variety of presentations,from minor bleeding to severe hemorrhage and shock.Although previous studies investigated the efficacy of colonoscopy in hospitalized patients with LGIB,there is limited research that discusses disparities in colonoscopy utilization in patients with LGIB in urban and rural settings.AIM To investigate the difference in utilization of colonoscopy in lower gastrointestinal bleeding between patients hospitalized in urban and rural hospitals.METHODS This is a retrospective cohort study of 157748 patients using National Inpatient Sample data and the Healthcare Cost and Utilization Project provided by the Agency for Healthcare Research and Quality.It includes patients 18 years and older hospitalized with LGIB admitted between 2010 and 2016.This study does not differentiate between acute and chronic LGIB and both are included in this study.The primary outcome measure of this study was the utilization of colonoscopy among patients in rural and urban hospitals admitted for lower gastrointestinal bleeds;the secondary outcome measures were in-hospital mortality,length of stay,and costs involved in those receiving colonoscopy for LGIB.Statistical analyses were all performed using STATA software.Logistic regression was used to analyze the utilization of colonoscopy and mortality,and a generalized linear model was used to analyze the length of stay and cost.RESULTS Our study found that 37.9%of LGIB patients at rural hospitals compared to approximately 45.1%at urban hospitals received colonoscopy,(OR=0.730,95%CI:0.705-0.7,P>0.0001).After controlling for covariates,colonoscopies were found to have a protective association with lower inhospital mortality[OR=0.498,95%CI:0.446-0.557,P<0.0001],but a longer length of stay by 0.72 d(95%CI:0.677-0.759 d,P<0.0001)and approximately$2199 in increased costs.CONCLUSION Although there was a lower percentage of LGIB patients that received colonoscopies in rural hospitals compared to urban hospitals,patients in both urban and rural hospitals with LGIB undergoing colonoscopy had decreased in-hospital mortality.In both settings,benefit came at a cost of extended stay,and higher total costs.

Atherosclerotic cardiovascular disease in inflammatory bowel disease:The role of chronic inflammation

Inflammatory bowel disease(IBD)causes systemic vascular inflammation.The increased risk of venous as well as arterial thromboembolic phenomena in IBD is well established.More recently,a relationship between IBD and atherosclerotic cardiovascular disease(ASCVD)has been postulated.Systemic inflammatory diseases,such as rheumatoid arthritis and systemic lupus erythematosus,have well characterized cardiac pathologies and treatments that focus on prevention of disease associated ASCVD.The impact of chronic inflammation on ASCVD in IBD remains poorly characterized.This manuscript aims to review and summarize the current literature pertaining to IBD and ASCVD with respect to its pathophysiology and impact of medications in order to encourage further research that can improve understanding and help develop clinical recommendations for prevention and management of ASCVD in patients with IBD.

Retrospective analysis of anti-inflammatory therapies during the first wave of COVID-19 at a community hospital

BACKGROUND Our understanding of the severe acute respiratory syndrome coronavirus 2 has evolved since the first reported cases in December 2019,and a greater emphasis has been placed on the hyper-inflammatory response in severely ill patients.The purpose of this study was to determine risk factors for mortality and the impact of anti-inflammatory therapies on survival.AIM To determine the impact of various therapies on outcomes in severe coronavirus disease 2019 patients with a focus on anti-inflammatory and immune-modulating agents.METHODS A retrospective analysis was conducted on 261 patients admitted or transferred to the intensive care unit in two community hospitals between March 12,2020 and June 17,2020.Totally 167 patients received glucocorticoid(GC)therapy.Seventythree patients received GC alone,94 received GC and tocilizumab,28 received tocilizumab monotherapy,and 66 received no anti-inflammatory therapy.RESULTS Patient survival was associated with GC use,either alone or with tocilizumab,and decreased vasopressor requirements.Delayed administration of GC was found to decrease the survival benefit of GC therapy.No difference in survival was found with varying anticoagulant doses,convalescent plasma,tocilizumab monotherapy;prone ventilation,hydroxychloroquine,azithromycin,or intravenous ascorbic acid use.CONCLUSION This analysis demonstrated the survival benefit associated with anti-inflammatory therapy of GC,with or without tocilizumab,with the combination providing the most benefit.More studies are needed to assess the optimal timing of anti-inflammatory therapy initiation.

Epidemiologic risk factors for patients admitted with chronic pancreatitis and pancreatic ductal adenocarcinoma in the United States

BACKGROUND Epidemiological studies of chronic pancreatitis(CP)and its association with pancreatic ductal adenocarcinoma(PDAC)are limited.Understanding demographic and ethno-racial factors may help identify patients at the highest risk for CP and PDAC.AIM To evaluate the ethno-racial risk factors for CP and its association with PDAC.The secondary aim was to evaluate hospitalization outcomes in patients admitted with CP and PDAC.METHODS This retrospective cohort study used the 2016 and 2017 National Inpatient Sample databases.Patients included in the study had ICD-10 codes for CP and PDAC.The ethnic,socioeconomic,and racial backgrounds of patients with CP and PDAC were analyzed.RESULTS Hospital admissions for CP was 29 per 100000,and 2890(0.78%)had PDAC.Blacks[adjusted odds ratio(aOR)1.13],men(aOR 1.35),age 40 to 59(aOR 2.60),and being overweight(aOR 1.34)were significantly associated with CP(all with P<0.01).In patients with CP,Whites(aOR 1.23),higher income,older age(aOR 1.05),and being overweight(aOR 2.40)were all significantly associated with PDAC(all with P<0.01).Men(aOR 1.81)and Asians(aOR 15.19)had significantly increased mortality(P<0.05).Hispanics had significantly increased hospital length of stay(aOR 5.24)(P<0.05).CONCLUSION Based on this large,nationwide analysis,black men between 40-59 years old and overweight are at significantly increased risk for admission with CP.White men older than 40 years old and overweight with higher income were found to have significant associations with CP and PDAC.This discrepancy may reflect underlying differences in healthcare access and utilization among different socioeconomic and ethno-racial groups.

Gastric Perforation after Cesarean Delivery: An Unintended Consequence of the Opioid Epidemic

30 year old female now para 1 presented to the Emergency Department with nausea, vomiting, and abdominal pain 6 days after an uncomplicated primary cesarean delivery. She did not respond to conservative management and underwent exploratory laparotomy for worsening pain, pneumoperitoneum and intraabdominal fluid collections. Gastric perforations required repair via gastrojejunostomy. Postoperative course was unremarkable. The anti-opioid campaign has altered the approach to postoperative pain management in both positive and negative ways. It has sparked new interest in alternative approaches to postoperative pain management, which include an increased role for non-steroidal anti-inflammatory drugs (NSAIDs). We present a case of a woman who had a significant complication due to the reliance of non-opioid pain medications after cesarean delivery.

Changes in trends of orthopedic services due to the COVID-19 pandemic: A review

As of June 10,2022,the World Health Organization has recorded over 532 million documented coronavirus disease 2019(COVID-19)[(Coronavirus)SARS-CoV-2]cases and almost 6.3 million deaths worldwide,which has caused strain on medical specialties globally.The aim of this review is to explore the impact that COVID-19 has had on orthopedic practices.Providers observed a rapid decline in the number of orthopedic patients’admissions due to cancellation of elective procedures;however,emergent cases still required treatment.Various observational studies,case reports,and clinical trials were collected through a PubMed database search.Additional sources were found through Google.The search was refined to publications in English and between the years of 2019 and 2021.The keywords used were“COVID-19”and/or“Orthopedic Injuries”.Thirty-seven studies were retained.The pandemic brought on significant changes to the mechanism of injury,number of admissions,type of injuries,and patient outcomes.Mortality rates significantly increased particularly amongst patients with hip fractures and COVID-19.Road traffic injuries remained a common cause of injury and domestic injuries became more prevalent with lockdown.Social isolation negatively affected mental health resulting in several orthopedic injuries.Telehealth services and separation for COVID-positive and COVID-negative patients benefited both patients and providers.While hospitals and medical facilities are still facing COVID-19 case surges,it is important to understand how this pandemic has impacted preparation,care,and opportunities for prevention education and ongoing care.

Papillary Thyroid Cancer Association with the Use of Infertility Drugs Case Report and Literature Review

Recently, the incidence of papillary thyroid cancer increases rapidly than any other type of cancer worldwide, without the age and gender discrimination. Environmental or therapeutic exposure of radiation is main culprit of papillary thyroid cancer, but there is limited research available to support that to the usage of infertility drug associated with papillary thyroid cancer. We presented the rare and interesting case of papillary thyroid cancer while patient was on clomiphene citrate for the management of infertility. We found few studies which showed pathophysiology connection between in CC and papillary cell carcinoma.

Surgical management of facial dog bite trauma:A contemporary perspective and review

Objective:To perform a review evaluating management of and complications stemming from dog bite trauma sustained to the head and neck over the past decade.Data Sources:PubMed and Cochrane Library.Methods:The authors searched the PubMed and Cochrane Library databases for relevant published literature.A total of 12 peer-reviewed canine-exclusive series inclusive of 1384 patient cases describing facial dog bite trauma met inclusion criteria.Wounds including fractures,lacerations,contusions,and other soft-tissue injuries were evaluated.Demographics related to clinical course and management,operating room requirements,and antibiotic usage were compiled and analyzed.Initial trauma and surgical management complications were also assessed.Results:75.5%of patients sustaining dog bites required surgical intervention.Of these patients,7.8%suffered from postsurgical complications,including hypertrophic scarring(4.3%),postoperative infection(0.8%),or nerve deficits and persistent paresthesias(0.8%).Prophylactic antibiotics were administered to 44.3%of patients treated for facial dog bites and the overall infection rate was 5.6%.Concomitant fracture was present in 1.0%of patients.Conclusion:Primary closure,often in the OR may be necessary,with few cases requiring grafts or flaps.Surgeons should be aware that the most common complication is hypertrophic scarring.Further research is needed to elucidate the role of prophylactic antibiotics.

Overview of juvenile localized scleroderma and its management

Background Juvenile localized scleroderma(JLS)is a rare pediatric disease characterized by inflammation and skin thick ening.JLS is associated with deep tissue and extracutaneous involvement that often results in functional impairment and growth disturbances.This article provides an overview of the disease with a focus on active features and treatment.Data sources We searched databases including PubMed,Elsevier and MedLine and Wanfang,reviewing publications from 2013 to 2019.Selected earlier publications were also reviewed.Results Linear scleroderma is the most common JLS subtype.Several lines of evidence suggest that JLS is an autoimmune disease.Extracutaneous involvement is common and can present before the onset of skin disease.Multiple skin features are associated with disease activity,and activity can also manifest as arthritis,myositis,uveitis,seizures,and growth impairment.Systemic immunosuppressive treatment,commonly methotrexate with or without glucocorticoids,greatly improves outcome and is recommended for treating JLS patients with active disease and moderate or higher severity.Long term monitoring is needed because of the disease's chronicity and the high frequency of relapses off of treatment.Conclusions JLS is associated with a risk for disabling and disfiguring morbidity for the growing child.Identifying active disease is important for guiding treatment,but often difficult because of the paucity of markers and lack of a universal skin activity feature.More studies of JLS pathophysiology are needed to allow the identification of biomarkers and therapeutic targets.Comparative effectiveness treatment studies are also needed to work towards optimizing care and outcome.

SRSF1 plays a critical role in invariant natural killer T cell development and function

Invariant natural killer T(iNKT)cells are highly conserved innate-like T lymphocytes that originate from CD4^(+)CD8^(+)double-positive(DP)thymocytes.Here,we report that serine/arginine splicing factor 1(SRSF1)intrinsically regulates iNKT cell development by directly targeting Myb and balancing the abundance of short and long isoforms.Conditional ablation of SRSF1 in DP cells led to a substantially diminished iNKT cell pool due to defects in proliferation,survival,and TCRαrearrangement.The transition from stage 0 to stage 1 of iNKT cells was substantially blocked,and the iNKT2 subset was notably diminished in SRSF1-deficient mice.SRSF1 deficiency resulted in aberrant expression of a series of regulators that are tightly correlated with iNKT cell development and iNKT2 differentiation,including Myb,PLZF,Gata3,ICOS,and CD5.In particular,we found that SRSF1 directly binds and regulates pre-mRNA alternative splicing of Myb and that the expression of the short isoform of Myb is substantially reduced in SRSF1-deficient DP and iNKT cells.Strikingly,ectopic expression of the Myb short isoform partially rectified the defects caused by ablation of SRSF1.Furthermore,we confirmed that the SRSF1-deficient mice exhibited resistance to acute liver injury uponα-GalCer and Con A induction.Our findings thus uncovered a previously unknown role of SRSF1 as an essential post-transcriptional regulator in iNKT cell development and functional differentiation,providing new clinical insights into iNKT-correlated disease.

Post-traumatic thrombotic microangiopathy: What trauma surgeons need to know?

Thrombotic microangiopathy(TMA)is characterized by systemic microvascular thrombosis,target organ injury,anemia and thrombocytopenia.Thrombotic thrombocytopenic purpura,atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs.Traditionally,TMA is encountered during pregnancy/postpartum period,malignant hypertension,systemic infections,malignancies,autoimmune disorders,etc.Recently,the patients presenting with trauma have been reported to suffer from TMA.TMA carries a high morbidity and mortality,and demands a prompt recognition and early intervention to limit the target organ injury.Because trauma surgeons are the first line of defense for patients presenting with trauma,the prompt recognition of TMA for these experts is critically important.Early treatment of post-traumatic TMA can help improve the patient outcomes,if the diagnosis is made early.The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion.This article familiarizes trauma surgeons with TMA encountered in the context of trauma.Besides,it provides a simplified approach to establishing the diagnosis of TMA.Because trauma patients can require multiple transfusions,the development of disseminated intravascular coagulation must be considered.Therefore,the article also provides different features of disseminated intravascular coagulation and TMA.Finally,the article suggests practical points that can be readily applied to the management of these patients.

Ectopic Tcf1 expression instills a stem-like program in exhausted CD8^(+) T cells to enhance viral and tumor immunity

Exhausted CD8^(+)T(Tex)cells are dysfunctional due to persistent antigen exposure in chronic viral infection and tumor contexts.A stem cell-like Tex(Tex-stem)subset can self-renew and differentiate into terminally exhausted(Tex-term)cells.Here,we show that ectopic Tcf1 expression potently promoted the generation of Tex-stem cells in both a chronic viral infection and preclinical tumor models.Tcf1 overexpression diminished coinhibitory receptor expression and enhanced polycytokine-producing capacity while retaining a heightened responses to checkpoint blockade,leading to enhanced viral and tumor control.Mechanistically,ectopically expressed Tcf1 exploited existing and novel chromatin accessible sites as transcriptional enhancers or repressors and modulated the transcriptome by enforcing pre-existing expression patterns in Tex-stem cells,such as enhanced suppression of Blimp1 and Bim and acquisition of new downstream genes,including Mx1,Tox2,and Runx3.These findings reveal a pronounced impact of ectopic Tcf1 expression on Tex functional restoration and highlight the therapeutic potential of harnessing Tcf1-enforced transcriptional programs.

Pharmacological targeting EZH2 to modulate chronic graft-versus-host disease

In a recent issue of Blood(Blood 139,2022),Zaiken et al 1 reported that in vivo administration of the EZH2 inhibitor JQ5 effectively reduces chronic graft-versus-host disease(cGVHD),a life-threatening complication that occurs in 30%–70%of patients after allogeneic hematopoietic stem cell transplantation(allo-HSCT).

Incidence, mortality, and risk factors of immunotherapy-associated hepatotoxicity: A nationwide hospitalization analysis

Background and aims Anti-neoplastic immunotherapy has revolutionized cancer management;however,its safety profile with respect to liver-related injury remains largely unexplored.Herein,we analyzed a United States national database to determine the incidence,mortality,and predictors of hepatotoxicity in the setting of anti-neoplastic immunotherapy.Methods This was a nationwide retrospective study of hospital encounters from 2011 to 2014 using the National Inpatient Sample(NIS)database.We utilized the International Classification of Diseases,Ninth Revision(ICD-9)coding system to identify all adult patients who underwent anti-neoplastic immunotherapy during hospitalization.The primary outcome was the incidence of hepatotoxicity during the same hospitalization.Secondary outcomes included in-hospital mortality as well as socioeconomic and ethno-racial predictors of hepatotoxicity.Analyses were performed using IBM SPSS Statistics 23.0.Results The sample included 3002 patients who underwent inpatient anti-neoplastic immunotherapy.The incidence of hepatotoxicity was 10.1%,which was significantly higher as compared to a matched inpatient population(adjusted odds ratio(aOR)4.93,95%confidence interval(CI):3.80–6.40,P=0.001).No significant mortality difference was seen in those that developed hepatotoxicity compared to those who did not(aOR 0.47,95%CI:0.03–8.03,P=0.612).Age under 60(aOR 1.56,95%CI:1.23–1.78,P=0.050)and white race(aOR 1.85,95%CI:1.35–2.04,P<0.010)were independent risk factors for developing immunotherapy-associated hepatotoxicity.Conclusions In this large,nationwide database analysis,we found that anti-neoplastic immunotherapy was associated with a nearly five-fold risk of in-hospital hepatotoxicity as compared to a matched inpatient population,though without an associated mortality difference.Additionally,younger age and white race were identified as predictors of immunotherapy-associated hepatotoxicity.Heightened vigilance and prospective investigation of the risk factors and liver-related adverse effects of anti-neoplastic immunotherapy are warranted.

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID- 19 pandemic

Background During the COVID-19 pandemic,decreased volumes of stroke admissions and mechanical thrombectomy were reported.The study’s objective was to examine whether subarachnoid haemorrhage(SAH)hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.Methods We conducted a cross-sectional,retrospective,observational study across 6 continents,37 countries and 140 comprehensive stroke centres.Patients with the diagnosis of SAH,aneurysmal SAH,ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases,10th Revision,codes.The 3-month cumulative volume,monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before(1 year and immediately before)and during the pandemic,defined as 1 March-31 May 2020.The prior 1-year control period(1 March-31 May 2019)was obtained to account for seasonal variation.Findings There was a significant decline in SAH hospitalisations,with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic,representing a relative decline of 22.5%(95%CI−24.3%to−20.7%,p<0.0001).Embolisation of ruptured aneurysms declined with 1170-1035 procedures,respectively,representing an 11.5%(95%CI−13.5%to−9.8%,p=0.002)relative drop.Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations,a 24.9%relative decline(95%CI−28.0%to−22.1%,p<0.0001).A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1%(95%CI 32.3%to 50.6%,p=0.008)despite a decrease in SAH admissions in this tertile.Interpretation There was a relative decrease in the volume of SAH hospitalisations,aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic.These findings in SAH are consistent with a decrease in other emergencies,such as stroke and myocardial infarction.