Toxic shock syndrome (TSS) is caused by toxic bacteria and has been associated with prolonged, continual use of high-absorbency tampons. This article documents the first case of TSS associated with the use of a menstrual cup in a 37-year-old woman. The authors also discuss the history of TSS associated with tampon use and the mechanisms by which menstrual cups may also lead to the syndrome.

Objective The worldwide pandemic involving the novel respiratory syndrome (COVID-19) has forced healthcare systems to delay elective operations, including abdominal aortic aneurysm (AAA) repair, to conserve resources. This study provides a structured analysis of the decision to delay AAA repair and quantify the potential for harm. Methods A decision tree was constructed modeling immediate repair of AAA relative to an initial non-operative (delayed repair) approach. Risk of COVID-19 contraction and mortality, aneurysm rupture, and operative mortality were considered. A deterministic sensitivity analysis for a range of patient ages (50 to >80), probability of COVID-19 infection (0.01%-30%), aneurysm size (5.5->7cm), and time horizons (3-9 months) was performed. Probabilistic sensitivity analyses (PSA) were conducted for three representative ages (60, 70, 80). Analyses were conducted for endovascular aortic aneurysm repair (EVAR) and open surgical repair (OSR). Results Patients with aneurysms 7cm or greater demonstrated a higher probability of survival when treated with immediate EVAR or OSR, compared to delayed repair, for patients under 80 years of age. When considering EVAR for aneurysms 5.5-6.9cm, immediate repair had a higher probability of survival except in settings with high probability of COVID-19 infection (10-30%) and advanced age (70-85+ years). A non-operative strategy maximized the probability of survival as patient age or operative risk increased. Probabilistic sensitivity analyses demonstrated that patients with large aneurysms (>7cm) faced a 5.4-7.7% absolute increase in the probability of mortality with a delay of repair of 3 months. Young patients (60-70 years) with 6-6.9cm aneurysms demonstrated an elevated risk of mortality (1.5-1.9%) with a delay of 3 months. Those with 5-5.9cm aneurysms demonstrated an increased survival with immediate repair in young patients (60), however this was small in magnitude (0.2-0.8%). The potential for harm increased as length of surgical delay increased. For elderly patients requiring OSR, in the context of endemic COVID-19, delay of repair improves probability of survival. Conclusion The decision to delay operative repair of AAA should consider both patient age and local COVID-19 prevalence in addition to aneurysm size. EVAR should be considered when possible due to a reduced risk of harm and lower resource utilization.

Objective: The novel respiratory syndrome coronavirus disease 2019 has forced healthcare systems to delay elective abdominal aortic aneurysm (AAA) repair. The present study provides a structured analysis of the decision to delay AAA repair and quantify the potential for harm.Methods: A decision tree was constructed modeling immediate AAA repair relative to an initial nonoperative (delayed repair) approach. The risk of COVID-19 contraction and mortality, AAA rupture, and operative mortality were considered. We performed a deterministic sensitivity analysis for a range of patient ages (50 to >80 years), probability of COVID-19 infection (0.01%-30%), AAA size (5.5 to >7cm), and time horizons (3-9 months). We then performed a probabilistic sensitivity analysis for three representative ages (60, 70, 80 years). Analyses were conducted for endovascular aortic aneurysm repair (EVAR) and open surgical repair (OSR).Results: Patients with AAAs >7 cm demonstrated a greater probability of survival with immediate EVAR or OSR compared with delayed repair for patients <80 years old (Fig) . When considering EVAR for AAAs 5.5 to 6.9 cm, immediate repair had a greater probability of survival, except in settings with a high probability of COVID-19 (10%-30%) infection and advanced age (70-85+ years). Probabilistic sensitivity analysis demonstrated that patients with large AAAs (>7 cm) had a 5.4% to 7.7% absolute increase in the probability of mortality with a 3-month delay of repair. Young patients (age, 60-70 years) with 6-to 6.9-cm AAAs demonstrated an elevated risk of mortality (1.5%-1.9%) with a 3-month delay. For 60year-old patients with 5-to 5.9-cm AAAs, immediate repair improved survival; however, the improvement was small in magnitude (0.2%-0.8%). For OSR, in the context of endemic COVID-19, delay of repair improves the probability of survival when patients are old and COVID-19 prevalence is high.Conclusions: The decision to delay repair of AAAs should consider patient age, local COVID-19 prevalence and aneurysm size. EVAR should be considered when possible owing to the reduced risk of harm and lower resource usage.