Acute Pancreatitis Following a Lower Extremity Angioplasty

Introduction: Acute pancreatitis affects a significant population globally. Usual etiologies are gallstones, alcohol, hypertriglyceridemia, medications;less frequent are trauma, hypercalcemia, infections, toxins, ischemia, anatomic anomalies, vasculitis, and idiopathic. Pancreatitis post coronary intervention is an uncommon cause with only 19 published cases in the last two decades. Being cognizant of this etiology is important given the increasing number of patients undergoing angiography. Case Description/Methods: An 81-year-old female with hypertension, diabetes, peripheral arterial disease, prior cholecystectomy underwent left lower extremity angioplasty at an outside center. Within a few hours, she started having severe epigastric pain radiating to her back, nausea, vomiting and loose bloody stool. She presented to the emergency department 24 hours after symptom onset. Epigastric tenderness was present on exam. Labs revealed leukocytosis (24,450/muL), elevated lipase (1410 U/L), elevated creatinine (1.3 mg/dL), lactate (3.1 mmol/L), calcium 9.4 mg/dL and triglycerides 161 mg/dL. Incidentally, found to be positive for COVID-19. Normal common bile duct diameter seen on sonogram. CT angiogram of the abdomen/pelvis showed acute pancreatitis, duodenal and central small bowel enteritis (Figure). She was not on any medications known to cause pancreatitis and denied alcohol use. Patient improved with analgesics and intravenous fluids. She had no recurrence of bloody stools and hemoglobin remained stable. On day 4, she was able to tolerate a regular diet, and leukocyte count and creatinine normalized. Patient did not have any COVID respiratory symptoms, and was discharged. Discussion(s): Given the temporal association to angioplasty and no other identifiable cause, acute pancreatitis was presumed to be due to the contrast used during angioplasty. Other possibilities included cholesterol embolism but no peripheral signs of cholesterol embolism were seen. Patient was an asymptomatic COVID-19 case. Although, there are case series of pancreatitis due to COVID, those were found in very sick symptomatic patients. On review of literature, cholesterol embolism was identified as a definite cause only on autopsy or laparotomy (Table). Other possible mechanisms are: high viscosity of the contrast media leading to ischemia and necrosis, contrast causing NF-kB activation followed by epithelial damage, and vasospasm. Pancreatitis after coronary angiography is rare, nonetheless, an important differential especially if there is a temporal relationship.

Comprehensive medication management services provided via telehealth or hybrid models: A scoping review

Comprehensive medication management (CMM) is increasingly provided by health care teams through telehealth or hybrid modalities. The purpose of this scoping literature review was to assess the published literature and examine the economic, clinical, and humanistic outcomes of CMM services provided by pharmacists via telehealth or hybrid modalities. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. Randomized controlled trials (RCTs) and observational studies were included if they: reported on economic, clinical, or humanistic outcomes;were conducted via telehealth or hybrid modalities;included a pharmacist on their interprofessional team;and evaluated CMM services. The search was conducted between January 1, 2000, and September 28, 2021. The search strategy was adapted for use in Medline (PubMed);Embase;Cochrane;Cumulative Index to Nursing and Allied Health Literature;PsychINFO;International Pharmaceutical s;Scopus;and grey literature. Four reviewers extracted data using a screening tool developed for this study and reviewed for risk of bias. Authors screened 3500 articles, from which 11 studies met the inclusion criteria (9 observational studies, 2 RCTs). In seven studies, clinical outcomes improved with telehealth CMM interventions compared to either usual care, face-to-face CMM, or educational controls, as shown by the statistically significant changes in chronic disease clinical outcomes. Two studies evaluated and found increased patient and provider satisfaction. One study described a source of revenue for a telehealth CMM service. Overall, study results indicate that telehealth CMM services, in select cases, may be associated with improved clinical outcomes, but the methods of the included studies were not homogenous enough to conclude that telehealth or hybrid modalities were superior to in-person CMM. To understand the full impact on the Quadruple Aim, additional research is needed to investigate the financial outcomes of CMM conducted using telehealth or hybrid technologies.Copyright © 2022 Pharmacotherapy Publications, Inc.

The Effect of the Different Waves of COVID-19 Pandemic on the Outcome of Diabetic Foot Ulcers

Objective: Diabetic foot ulcers (DFUs) are complications of diabetes mellitus. COVID-19 pandemic has massively impacted human health. We studied effect of COVID-19 on outcome of DFUs. Method(s): We recruited 483 people with DFU from June 2020-April 2022 (pandemic group) together with a matched group of 227 people with DFU from March 2019-March 2020 (pre-pandemic group). Matching was done with respect to glycemic control (Average HbA1c in pandemic group 9.15%;pre-pandemic group 8.92%), and renal status. Primary endpoint was outcome of ulcers- healed or undergone amputation. Primary outcome was further sub analyzed in the 3 waves of COVID-19 Secondary endpoint was healing of individual types of DFUs. Basic anthropometric data with site, nature and Wegner's grading of DFUs were collected. Diagnosis of peripheral neuropathy was done by monofilament testing and peripheral arterial disease by handheld Doppler and ABI. Standardized treatment protocol including glycemic control, infection control, debridement, dressing, offloading was provided. All patients were monitored for >6 months. Result(s): In pandemic cohort of 483 patients 323(66.9%) patients had healed ulcers, 70(14.5%) had minor amputation, 11(2,2%) had major amputation, 29(6%) lost to follow up, 22(4.6%) had not healed and 28 are in follow up (5.8%). Rate of healing of DFU in pandemic group was higher (66.9%) than control group (53.5%). Similarly, rate of amputation in pandemic group was less (16.7%) than pre-pandemic group (23.4%). Among healed ulcers in pandemic group, non-infected neuropathic ulcers healed better (77.8%;199/256) than other types (54.6%;124/227) [p< 0.00001]. Similarly, rate of amputation (major/minor) in ischemic and neuroischemic ulcers in pandemic group was more (32.3%;11/34) than other types (15.6%;70/449) [p= 0.011]. Rate of healing of foot ulcers in 1st wave was 65.4% (53/81), 2nd wave 75.2% (158/210), 3rd wave 58.3% (112/192). Neuropathic ulcers though less prevalent in first two waves (49.8%;145/291) than 3rd wave (57.8%;111/192) healing rate was more in first two (79.3%;115/145 vs 75.6%;84/111). [p=0.488 (statistically not significant]. Ischemic and neuroischemic ulcers were more in 3rd wave (7.8%;15/192) than first two waves (6.5%;19/291) and undergone more amputation (46.7%;7/15 vs 15.7%;3/19). [p=0.58 (statistically not significant;due to small sample size]. Discussion/Conclusion: COVID-19 pandemic (mainly first two waves) accounted for travel restrictions contributing to better healing of neuropathic ulcers whereas ischemic and neuroischemic ulcers worsened and underwent more amputation as patients could not seek intervention. Conversely, in third wave withdrawal of COVID restrictions lead to worsening of DFUs leading to less healing and more amputation.Copyright © 2023

Telemedicine technologies in improving the effectiveness of followup monitoring of patients with lower extremity peripheral artery disease during the COVID19 pandemic.

Aim. To evaluate the effectiveness of a novel approach to followup monitoring of patients with lower extremity peripheral artery disease (PAD) using telemedicine technologies. Material and methods. The study included 175 patients (mean age, 68, 1+/-7, 7 years). Two following groups of patients were formed: the main group (n=86), which used an optimized monitoring program using telemedicine techniques, and the control group (n=89), which assumed traditional monitoring by a cardiologist and a vascular surgeon. The mean followup period was 11, 77+/-1, 5 months. The optimized monitoring program included the implementation of audio communication with patients by an employee with a secondary medical education with an assessment of the current health status according to original unified questionnaire, with the definition of personalized management tactics. At the primary and final stages, the patient underwent an assessment of clinical and anamnestic data, mental and cognitive status, and compliance. Results. At the final stage, uncompensated hypertension was revealed in 36, 0% and 49, 4% (p=0, 0001), smoking - in 30, 6% and 42, 9% (p=0, 05) in the main and control group, respectively. In the main group, a greater painfree walking distance was revealed - 625, 8+/-395, 3 m (control group - 443+/-417 m (p=0, 013)). The average systolic blood pressure was 125, 2+/-10, 2 mm Hg and 138, 8+/-15, 8 mm Hg (p=0, 0001) in the main and control group, respectively. In the control group, a greater number of patients with a high level of personal and situational anxiety were revealed (p=0, 05). In the main group, a higher level of adherence to therapy was established at the final study stage (p=0, 001). Conclusion. The optimized monitoring program for patients with limited mobility is effective and can be implemented in practical healthcare for patients with lower extremity PAD.Copyright © 2023 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved.

Peripheral Artery Disease Causes More Harm to Patients than COVID-19

Background: To optimize our strategic planning, we aimed to investigate the impact of the COVID-19 pandemic on the treatment of patients with peripheral artery disease (PAD) at our tertiary care hospital. Method(s): We performed a prospective single-center cohort study at a large tertiary care hospital. In total, 1,210 patients have been included: 611 patients admitted between March and December 2020, compared with retrospective data from 599 patients from the same period in 2019. Result(s): Emergency admissions involving patients with advanced stage PAD increased significantly during the pandemic period of 2020 (n = 79;13%) compared with the same period in 2019 (n = 50;8%;p < 0.0098). This increase was accompanied by increased limb amputations performed during first lockdown (n = 14;15%), post-lockdown (n = 26;6%), and second lockdown 2020 (n = 3;6%) compared with respective time periods in 2019 (n = 3;2%;p < 0.0003, n = 5;1%;p < 0.0004, and n = 2;4%;p = 1). The 30-day mortality rate of patients with PAD increased to 3% during the COVID-19 pandemic period of 2020 compared with 2% in the same period in 2019. No SARS-CoV-2 infection was observed among patients with PAD during the observation period. Conclusion(s): Delayed treatment for PAD due to changes in clinical practice protocols caused more harm to PAD patients than SARS-CoV-2 infection during the COVID-19 pandemic. Strict lockdown protocols adversely affected the care of PAD patients, with persisting aftereffects, including increased emergency admission with unsuccessful revascularization attempts leading to limb amputation even after the peak of the pandemic had passed. We believe that creating standards to simplify patient access to health care facilities, and providing continuous care to PAD patients, even in times of global pandemics, will prevent the unfavorable outcomes observed during the COVID-19 pandemic in 2020.

Appraising SARS-CoV-2 infections after full mRNA COVID-19 vaccination in patients with systemic lupus erythematosus (SLE)

The 2019 Coronavirus disease (COVID-19) vaccine is a major weapon in the fight against the severe acute respiratory syndrome brought about by coronavirus 2 (SARS-CoV-2). The vaccine significantly reduces the risk and severity of infection by SARS-CoV-2. Patients with systemic lupus erythematosus (SLE) need protection from vaccine-preventable diseases including COVID-19. SLE patients have higher rates of severe infections due to immunosuppressive therapies and multiple immunologic defects - both of which are capable of blunting the immune responses after vaccination. In the management of COVID-19, recommendations have been developed to guide adjustments and/or continuation of immunosuppressive therapies for an effective immune response following vaccination with mRNA-based or viral vector-delivered vaccines. Monoclonal antibodies have also become available since December 2021. Here we present three cases of SLE patients who contracted COVID-19 after vaccination. One was managed in ambulatory settings and two required inpatient hospital admission.Copyright © 2022

Multifactorial Benefits of Radial Access in Endovascular Interventions to Treat Peripheral Arterial Disease-Critical Limb Threatening Ischemia

Background A paradigm shift appears to be occurring with overwhelming evidence of trans-radial access (TRA) being a safe and feasible approach for peripheral interventions compared to trans-femoral access (TFA). Our study explores the additional, multifactorial benefits of TRA regarding perioperative times, radiation, contrast administration, and cost-savings for patients and hospitals during Covid era. Methods A retrospective review of all peripheral interventions were performed over two years to outline the advantages and limitations of TRA compared to TFA approach. Patient demographics, procedural time, contrast usage, and radiation dose were recorded and analyzed. Hospital discharges and bed utilization were also studied. Results Total of 170 procedures performed via radial access were evaluated and compared to a control population of n=20 femoral access procedures. Procedural success rate for all interventions was 100% with 10% of cases presenting with acute limb ischemia and 90% presenting with chronic limb ischemia. A two-fold decrease in procedural time for TRA was evident in our analysis compared to the procedures conducted via TFA (81 +/- 43 mins vs. 164 +/- 36 mins, respectively). Furthermore, contrast usage and radiation absorption in TRA procedures decreased dramatically, adding to the potential cost-saving and safety measures for the patient and hospital system. Conclusion While current TRA limitations include operator experience, length of devices, and sheath sizes, the overall benefits of TRA over traditional TFA management cannot be ignored. TRA approach is undoubtedly a safe, feasible, efficient, and cost-saving route for peripheral interventions. It is here to stay as the present and future of diagnosing and treating peripheral arterial disease.Copyright © 2023 American College of Cardiology Foundation

Arterial thromboembolism (ATE) and mortality among COVID-19 patients in the intensive care unit (ICU): prevalence and risk factors

Objective: To investigate the prevalence of arterial thromboembolic (TE) complications including stroke, peripheral arterial disease (PAD) and myocardial infarction (MI) and mortality among COVID-19 patients admitted to an ICU at a single centre hospital in the area of Klang Valley, Malaysia. The proportions of patients with ATE complication who died, and factors associated with the occurrence of ATE were explored. Method(s): Patients admitted to a single centre ICU with PCR confirmed of SARS-CoV-2 virus and received adequate thromboprophylaxis within February 2020-2021 were included in this retrospective Malaysian cohort study. ATE event is a combination of >=1 stroke, PAD and MI. Result(s): Mean (SD) age 56.6 (13.7), 63.5% were male, 61.6% Malays, median (IQR) 7 (3-14) days of ICU admission, 64.2%, 53.2 % and 20.9% had underlying hypertension, diabetes and obesity respectively. Of 534 patients, 21 (3.9%) developed stroke, 39 (7.3%) MI, 1(0.2%) PAD and 22.8% died despite adequate thromboprophylaxis. In total, only 58 (10.9%) developed ATE event during their ICU admission. Significantly higher proportions of COVID-19 patients admitted to ICU who developed complications of stroke (12.3% vs. 1.5;p<0.001) and MI (16.4% vs. 4.6%;p<0.001) died. Age, duration of ICU admission, proportion of underlying hypertension, stroke, IHD, diabetes, kidney disease, troponin, D-Dimer were significantly greater among those with ATE events. Predictors of ATE event on multivariate logistic regression analysis were duration of ICU admission [OR 1.0 (95% CI 1.00-1.04)] and troponin [OR 1.3 (95% CI 1.1-1.4)] level. Conclusion(s): The overall prevalence of ATE complication among the severely ill COVID-19 patients was low (10.9%) with the overall mortality of 22.8% despite adequate thromboprophylaxis. Key predictors of ATE events included increased troponin level and duration of ICU admission. Perhaps a more aggressive preventive strategies can be undertaken to prevent further increase in the prevalence of arterial thromboembolism and death.

The arrhythmic events and short-term cardiovascular outcomes in patients hospitalized with COVID-19 infection in Taiwan

Objective: The aim of this study is to investigate the arrhythmic events and short-term cardiovascular (CV) outcomes in patients hospitalized with COVID-19 infection in a single Taiwan tertiary center. Method(s): A retrospective study was carried out on 186 confirmed COVID-19 infection patients admitted to our hospital between May, 2021 and September, 2021. We investigate their CV symptoms, vital signs, laboratory examinations, arrhythmic events, and major adverse cardiovascular events (MACE), including ischemic stroke or systemic embolism, myocardial infarction, CV death, and heart failure (HF) during hospitalization. Result(s): During the hospitalization, 29.6% of patients had an elevation of cardiac enzymes, 67.2% had an elevation of d-dimer level, and 7.5% had abnormal NT-pro BNP level. The most common recorded arrhythmia is sinus tachycardia (22%), followed by atrial arrhythmia (12.4%, including atrial fibrillation 7.0%), sinus bradycardia (3.2%), ventricular arrhythmia (1.6%), and paroxysmal supraventricular tachycardia (1.1%). A total of 68 patients (36.6%) had arrhythmic events during hospitalization. During the mean follow-up of 2.8 months, 17 patients (9.1%) developed MACE, including 6 ischemic strokes, one pulmonary embolism, one peripheral artery occlusive disease, 3 HF, and 7 CV death. The total mortality rate is 19.9%. The hospitalized patients with arrhythmic events were associated with a higher incidence of intubation (32% vs 15%, p = 0.0062), MACE (22% vs 2%, p < 0.001), and mortality (37% vs 10%, p < 0.001) than those without arrhythmic events. Conclusion(s): The patients hospitalized with COVID-19 infection were associated with higher CV manifestations and arrhythmic events in Taiwan. Those patients with arrhythmic events were associated with higher morbidity and mortality.

The Impact of the Covid19 Pandemic on Patients with Peripheral Artery Disease

Background The impact of COVID-19 on major adverse lower extremity (MALE) and cardiovascular events (MACE) in patients with peripheral artery disease (PAD) is unknown. Methods Using the VA Corporate Data Warehouse, Veterans with PAD were identified. Rates of MALE (amputation or lower extremity revascularization [LER]), and MACE (death, MI, or coronary revascularization) were assessed in pre-pandemic (3/11/2019-3/10/2020), early-pandemic (3/11/2020-3/10/2021), and late-pandemic (3/11/2021-3/10/2022) periods. Outcomes were compared using Kaplan-Meier method. Results Of 418,042 Veterans (mean age 72 yrs) with PAD, 76.7% were white and 96.8% male. Furthermore, 89.2% had HTN, 60.4% diabetes, 49.3% CAD, 21.6% heart failure, and 20.5% atrial fibrillation. From 3/11/2019 to 3/10/2022, 3,100 had amputation, 8,187 had LER, & 2,229 had MACE. Amputation rates declined and continued to decline in early- and late-pandemic period (306 to 268 to 235;p<0.001;rates per 100k). Rates of LER declined initially and stabilized in late-pandemic period (951 to 587 to 609;p < 0.001;rates per 100k). MACE did not change significantly. (215 to 168 to 202;p<0.001;rates per 100k). Conclusion Amputation rates in Veterans with PAD did not increase despite a clinically significant decline in LER. Given the known efficacy of noninvasive therapies in PAD, these data suggest that there is a need to re-evaluate appropriate indications for LER and amputation. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Contribution of Cardiovascular Disease to Adverse Hospital Outcomes in Covid-19 Hospitalizations: Results from National Inpatient Sample

Background It is a well-established fact that cardiovascular disease (CVD) adversely affects COVID-19 outcomes. However, the extend of the burden posed by CVD on hospitalized COVID-19 patients in the United States is unknown. In this study, using a national database, we estimated the effects CVD on COVID-19 hospitalizations in the United States. Methods This study is a retrospective analysis of National Inpatient Sample data, collected during 2020. Patients >=18 years of age, admitted with primary diagnosis of COVID-19 were included in the analysis. CVD was defined as presence of coronary artery disease, myocardial infarction, heart failure, sudden cardiac arrest, conduction disorders, cardiac dysrhythmias, cardiomyopathy, pulmonary heart disease, venous thromboembolic disorders, pericardial diseases, heart valve disorders, or peripheral arterial disease. The primary outcomes of the study were in-hospital mortality rate, prolonged hospital length of stay, mechanical ventilation, and disposition other than home. Multivariable logistic regression analysis was done to examine the association between presence of CVD and primary outcomes. Results During 2020 there were 1,050,040 COVID-19 hospitalizations in the United Sates. Of these 454650 (43.3%) had CVD. COVID-19 patients with CAD were older, males, and had higher comorbidity burden. The odds of in-hospital mortality (OR, 3.40;95% CI: 3.26-3.55), prolonged hospital length (OR, 1.71;95% CI: 1.67-1.76) and mechanical ventilation use (OR, 3.40;95% CI: 3.26-3.55), and disposition other than home (OR, 2.11;95% CI: 2.06-2.16) were significantly higher for COVID-19 hospitalizations with CAD. Mean hospitalization costs were also significantly higher among COVID-19 patients with CAD ($24,023 versus $15,320, P<0.001). The total cost of all COVID-19 hospitalizations during 2020 was $19.9 billion - $10.9 billion for those with CAD and $9.0 billion for those without CVD. Conclusion Cardiovascular disease was present in a substantial proportion of COVID-19 patients hospitalized in the United States and contributed to considerable adverse hospital outcomes and significantly higher hospitalization cost.Copyright © 2023 American College of Cardiology Foundation

CSM 2023 Cardiovascular and Pulmonary Platform Abstracts

The proceedings contain 63 papers. The topics discussed include: the CAT is significantly correlated to DLCO and 6-minute walk test in patients with long-COVID;cardiac and non-cardiac pain and sleep in patients participating in outpatient cardiac rehabilitation;the PEM/PESE activity questionnaire: a novel health-related quality of life measure for post-exertional disablement;comparison of AM-PAC and FSS-ICU in patients recovering from open heart surgery in ICU;assessment of physical therapy students' self-efficacy and accuracy measuring blood pressure using a task trainer;functional improvements observed in long-covid patients following participation in pulmonary rehabilitation;effects of a virtually-delivered program on breathing strength and lung function - a retrospective study;the influence of kinesiology tape on posture and breathing mechanics in healthy individuals;is there a role for increasing daily lifestyle walking bouts in asymptomatic peripheral arterial disease?;and impact of standard vs. modified sternal precautions on function following median sternotomy: a systematic review.

Editor's Choice - Outcomes of Surgery for Patients with Peripheral Arterial Disease During the COVID-19 Pandemic in the United Kingdom: A Population Based Study.

OBJECTIVE: There is limited information on changes in the patterns of care and outcomes for patients who had vascular procedures after the first wave of the COVID-19 pandemic. The aim of this population based study was to examine the patterns of care and outcomes for vascular lower limb procedures in the UK during the COVID-19 pandemic. METHODS: Lower limb revascularisations and major amputations performed from January 2019 to April 2021 in the UK and entered in the National Vascular Registry were included in the study. The primary outcome was in hospital post-operative death and secondary outcomes were complications and re-interventions. The study was divided into Pre-pandemic (1 January 2019 - 29 February 2020), Wave 1 (1 March - 30 June 2020), Respite (1 July - 31 October 2020), Wave 2/3 (1 November 2020 - 30 April 2021). RESULTS: The study included 36 938 procedures (7 245 major amputations, 16 712 endovascular, 12 981 open revascularisations), with 15 501 procedures after March 2020, a 27.7% reduction compared with pre-pandemic. The proportion of open surgical procedures performed under general anaesthetic was lower in Wave 1 and after compared with pre-pandemic (76.7% vs. 81.9%, p < .001). Only 4.6% of patients in the cohort had SARS-CoV-2 infection (n = 708), but their in hospital post-operative mortality rate was 25.0% (n = 177), six times higher than patients without SARS-CoV-2 (adjusted odds ratio 5.88; 95% CI 4.80 - 7.21, p < .001). The in hospital mortality rate was higher during the pandemic than pre-pandemic after elective open and endovascular revascularisation (respectively 1.6% vs. 1.1%, p = .033, and 0.9% vs. 0.5%, p = .005) and after major amputations (10.4% during Wave 2/3 vs. 7.7% pre-pandemic, p = .022). CONCLUSION: There was excess post-operative mortality rate for patients undergoing lower limb vascular procedures during the pandemic, which was associated with SARS-CoV-2 infections. Further research should be conducted on long term outcomes of patients operated on during the COVID-19 pandemic period.

The Link Between Reproductive History, Cardiovascular Disease, and Peripheral Arterial Disease in Women: Implications for Practice

The average life expectancy in the United States fell for the second straight year. Attributed mostly to COVID-19 and unintentional injuries (driven by drug overdoses), the third most prevalent cause of death is heart disease. Peripheral arterial disease (PAD) is an often-unrecognized global pandemic affecting more than 220 million. Since early 2000, the incidence of PAD has increased by 25% globally, Once considered a male-dominated disease, PAD is a significant cause of morbidity and mortality among women. This article provides a comprehensive review of the sex-linked risk factors for PAD that pose additional threats for women. Implications for practice are provided.

Anaplastic thyroid tumor as an embolic source of metastasis.

Tumor-based arterial thromboembolism in patients with cancer is a poorly described concept that lacks evidence for surgical indications owing to its unusual occurrence. The study and understanding of this condition's etiology is, however, essential because it could constitute the initial presentation or determine the prognosis of oncologic disease. In the present report, we have described the case of a 77-year-old female patient with multiple cerebral, splenic, and upper limb arterial embolic episodes. Embolectomy for acute upper limb ischemia revealed the histopathologic diagnosis of an anaplastic thyroid tumor.

Vitamin D: The Missing Nutrient Behind the Two Deadly Pandemics, COVID-19 and Cardiovascular Diseases.

The coronavirus (COVID-19) pandemic is claiming millions of lives and creating an additional burden on health care, which is already affected by the rise of non-communicable diseases (NCDs). The scientific community, on the other side, is enormously engaged with studies to best identify the characteristics of the virus and minimize its effect while supporting the fight to contain NCDs, mainly cardiovascular diseases (CVDs), which are contributing hugely to the global death toll. Hence, the roles of vitamin D in COVID-19 immunity and cardiovascular health are gaining traction recently.  This literature review will mainly focus on summarizing pertinent studies and scientific publications which highlight the association of vitamin D levels with the various outcomes of COVID-19 and CVDs. It will also address how low vitamin D correlates with the epidemiology of CVDs and the inflammatory mechanisms attributed to COVID-19 severity. We believe that our review may open up hindsight perspectives and further discussions among the physicians in tapping the potential of vitamin D supplementation to tackle the morbidity, mortality, and health care cost of the two deadly diseases, COVID-19 and CVDs.

Rivaroxaban with Aspirin Versus Aspirin for Peripheral Arterial Disease and Intermittent Claudication. Rationale and Design of the COMPASS CLAUDICATION Trial.

BACKGROUND: The COMPASS trial demonstrated that in patients with peripheral arterial disease, the combination of rivaroxaban and aspirin compared with aspirin reduces the risk of major adverse limb events, but it is not known whether this combination can also improve symptoms in patients with intermittent claudication. The primary objective of this study is to evaluate the effect of the combination on claudication distance. STUDY DESIGN: Eighty-eight patients with intermittent claudication will be randomized to receive rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily or aspirin 100 mg once daily for 24 weeks. The primary outcome is the change in claudication distance from the baseline to 24 weeks, measured by 6 min walking test and treadmill test. The primary safety outcome is the incidence of major bleeding and clinically relevant non-major bleeding according to the International Society on Thrombosis and Hemostasis criteria. SUMMARY: The COMPASS CLAUDICATION trial will provide high-quality evidence regarding the effect of the combination of rivaroxaban and aspirin on claudication distance in patients with peripheral arterial disease.

Treating Peripheral Arterial Occlusive Disease and Acute Limb Ischemia During a COVID-19 Pandemic in 2020.

BACKGROUND: For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on the care for patients with peripheral arterial disease (PAOD) and acute limb ischemia (ALI). METHODS: A retrospective analysis of the vascular practices of 2 major teaching hospitals in the Netherlands was performed. All interventions and outpatient visits for PAOD or ALI in 2020 were included. Patients treated in 2018 and 2019 were to serve as a control group. Data were analysed using descriptive statistics. RESULTS: In 2020, a total of 1513 procedures were performed for PAOD or ALI. This did not differ significantly from previous years. Overall, Fontaine 2 and 4 were the most frequent indications for intervention. A significant increase in the number of major amputations was observed in 2020 compared to 2018 (P< 0.01). This was mainly due to patients suffering from PAOD Fontaine 4. Inversely, a reduction in the number of femoro-popliteal bypasses was observed between 2020 and 2018. The number of outpatient visit due to Fontaine 2 was significantly lower in 2020 compared to 2018. CONCLUSIONS: The vascular practices of our hospitals were minimally influenced by the measures taken due to the outbreak of SARS-CoV-2. There was an increase in the number of amputation but an enormous surge in patients presenting with critical limb ischemia was not observed.

Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit.

INTRODUCTION: To determine the current (pre-COVID-19) provision of supervised exercise training (SET) for patients with peripheral arterial disease (PAD) in UK Vascular Centres. METHODS: Hospital Trusts delivering vascular care to patients with PAD were identified from the National Vascular Registry and asked to complete an online questionnaire on their provisions for SET. If a centre offered SET, they were asked questions to determine whether the programme was compliant with NICE guidelines and the difficulties they faced delivering the service. If centres did not offer SET, they were asked what obstacles prevented them implement SET. RESULTS: Of the 78 UK vascular centres, 59 (76%) responded and were included in the audit. Of these, 27 (46%) were able to offer SET but only 21 (36%) could offer it to all their patients with PAD. Only four (6.8%) offered SET that was fully compliant with current NICE guidelines. Reasons identified included insufficient funding, lack of resource and poor patient compliance. CONCLUSIONS: The benefits of SET are well established yet the availability of the service in the UK is poor. The reasons for this are readily identified but have not yet been overcome. Research on novel methods of delivering supervised exercise that mitigates existing barriers, such as home exercise with remote monitoring, should be prioritised to facilitate optimal management for our patients with PAD.