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Introduction and Objectives: Limited healthcare access and resource inequities pose significant barriers to care, all of which have been amplified during the COVID-19 pandemic. DFUs represent an especially challenging medical problem to prevent and treat due to the resource intensive care required. We sought to evaluate the feasibility of multidisciplinary, mobile, DFU outreach clinics to improve access to care. Method(s): Our clinic model focused on creating mobile diabetic foot clinics staffed by volunteer clinical providers who specialize in Vascular Surgery, Diabetes, and Podiatry. We recruited volunteer healthcare providers from an academic medical center. We partnered with local community centers with established programs providing services to unhoused individuals. Result(s): Between June 2020 and August 2022, a total of 130 unhoused individuals were seen at four mobile clinics set up at different locations. Diabetic foot care was provided by volunteers from seven departments: Endocrinology/Diabetes, Vascular Surgery and Vascular Lab, Podiatry, Addiction Medicine, Smoking Cessation, and Financial. On average, 32 healthcare provider volunteers participated at each clinic. Services provided include: vitals, blood glucose, HgA1c, lipid panel testing, ankle-brachial index, podiatric exam, wound care, medical education, COVID vaccination/booster, insurance enrollment, and new socks and shoes. Of 130 unhoused patients, 29% had hypertension (38), 34% had abnormal ABI (44), and 14% had diabetes (18). Fifteen patients were further identified as high risk for developing DFU-associated amputation (12%) and were provided with ambulatory follow-ups. Conclusion(s): In our pilot experience, it is feasible to provide consistent comprehensive DFU care through mobile outreach clinics. By using the infrastructure of partner organizations and healthcare expertise of an academic center, our clinics could integrate into existing community services. [Formula presented]Copyright © 2022
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Background: Neuropathy in diabetic foot is the onset of diabetic foot complications. The COVID-19 pandemic has caused changes in the health service system. The lockdown decision can make it difficult for patients to get medication and consult with health workers due to physical activity restrictions. This research aimed to analyze the factors that contribute to peripheral neuropathy in diabetic foot during the COVID-19 pandemic. Materials and Methods: The research is a cross-sectional study with a sample of 122 patients with type 2 diabetes mellitus who participated in the Chronic Disease Management Program at community health centers in Malang, Indonesia, and was selected using a purposive sampling method. Data were analyzed using multivariate linear regression. Results: Variables that contributed to the development of neuropathy were ankle-brachial index of the right foot (ß = 7.35, p = 0.06), irregular exercise (ß = 2.01, p = 0.07), glycated hemoglobin A (HbA1c) (ß = 0.97, p < 0.001), and Low-Density Lipoprotein (LDL) (ß = 0.02, p = 0.06). Meanwhile, the variables that contributed to reducing neuropathy were ankle-brachial index of the left foot (ß = -1.62, p = 0.73) and being female (ß = -2.62, p = 0.02). The regression model could explain the variation in the scores of neuropathy in diabetic foot during the COVID-19 pandemic (R2 = 20.10%). Conclusion: The factors that contributed to the incidence of neuropathy in diabetic foot during the COVID-19 pandemic were ankle-brachial index, exercise for diabetes, LDL, HbA1c, and sex.
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SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Covid 19 virus has impacted nearly 450 million people across the globe;ranging from an asymptomatic carrier state to respiratory symptoms, cardiovascular symptoms, hematologic manifestations and multiorgan failure to death. Thrombotic events are one of its devastating complications. CASE PRESENTATION: A 66 year old man with a history of diabetes mellitus, hypertension and 30 pack years smoking history presented to the emergency room with hypoxia and altered mental status. On exam, his GCS was 8/15 and oxygen saturation was 85% on room air. He was subsequently intubated. CTA chest demonstrated bilateral diffuse ground glass opacities and left pulmonary embolism (PE). CT abdomen and pelvis showed multifocal infarcts in the right kidney with findings suggestive of renal artery thrombosis. Initial platelet count was 80,000/ul with creatinine of 3.9 mg/dl and creatine kinase (CK) of 3977 u/l. His INR was 1.4. Patient was not a candidate for thrombolysis given his thrombocytopenia. He was started on intravenous (IV) heparin and given IV hydration. On day 3 of his admission, he developed dry gangrene of the toes. Ankle brachial index of the right lower extremity (LE) was 1.16 and left LE was 0. Duplex ultrasonography of left LE showed mid to distal popliteal artery thrombus occluding below knee popliteal and tibial arteries. Echocardiogram showed ejection fraction of 55% and bubble study was negative for any intra atrial or pulmonary shunting. On day 4 of his admission, he developed oliguria and his gangrene got worse. His platelet counts decreased to 36,000/ul. Other pertinent labs showed INR 1.2, PT 15.3, PTT 34, D dimer 14.82, fibrinogen 498, CK 6434 mg/dl, hemoglobin 13.2 g/dl, haptoglobin 243 mg/dl and LDH 1041 U/l. Given his poor prognosis in the setting of ventilator dependent respiratory failure, multiple thrombosis and kidney failure requiring hemodialysis, the family decided to withdraw care. DISCUSSION: There are multiple hypotheses of thrombus formation in Covid 19 infection such as interleukin 6 and other cytokines induced endothelial injury, angiogenesis and elevated prothrombotic factors such as factor VIII and fibrinogen. Our patient had PE, renal artery thrombosis and popliteal artery thrombosis. Despite being on full dose anticoagulation, he developed gangrene of the toes. His lab results were not consistent with disseminated intravascular coagulation, thrombotic thrombocytopenic purpura and he was not known to have any baseline hypercoagulable disorder. He did not have any intra cardiac shunts. Hence, it is most likely Covid 19 induced multiple arterial and venous thrombosis. CONCLUSIONS: The treatment of Covid 19 related thrombosis has become very challenging especially in the setting of multiple clots. It is crucial to have large multicenter studies to investigate vascular complications of Covid-19 and to formulate management strategies to ensure good patient outcomes. Reference #1: https://www.nejm.org/doi/full/10.1056/nejmoa2015432 Reference #2: https://journal.chestnet.org/article/S0012-3692(21)01126-0/fulltext DISCLOSURES: No relevant relationships by Devashish Desai No relevant relationships by Swe Swe Hlaing no disclosure on file for Jean Marie Koka;No relevant relationships by Hui Chong Lau No relevant relationships by Subha Saeed No relevant relationships by Anupam Sharma No relevant relationships by Muhammad Moiz Tahir
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Objectives: Paraplegia is known to complicate extensive iliocaval and lower extremity deep vein thrombosis (DVT) in rare instances. The most common pathophysiology is ischemia from severe venous hypertension in phlegmasia cerulea dolens. Less understood, however, is paresis or paraplegia in the absence of ischemia. We present a case of paraplegia in extensive iliocaval and lower extremity DVT without ischemia, which was successfully treated by percutaneous pharmacomechanical therapy. Methods: A 46-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, indwelling inferior vena cava filter since 2005, and recent coronavirus disease 2019 diagnosis, presented with acute abdominal pain with severe bilateral lower extremity edema, pain, and paresis. She was found to have bilateral iliocaval to tibial DVT (Fig 1). The patient was noted to have multiphasic arterial waveforms on ankle-brachial index and duplex ultrasound examination. Paresis quickly progressed to flaccid bilateral lower extremity paralysis. Neurologic workup was unrevealing. Despite her symptoms, thrombolytic therapy was delayed due to severe menstrual bleeding requiring a blood transfusion. Therapeutic anticoagulation was initiated. Results: On hospital day 10, the patient underwent 24-hour catheter-directed thrombolysis via bilateral popliteal vein access. Bilateral mechanical thrombectomy was then performed, achieving recanalization of the bilateral lower extremities, iliac veins, and inferior vena cava with minimal residual thrombus (Fig 2). The patient's edema and sensorimotor function immediately improved and never incurred lower extremity tissue ischemia. She was discharged on lifelong rivaroxaban. With physical therapy, the patient ambulated independently at 1 month postoperatively. Venous duplex ultrasound examination revealed continued iliocaval and lower extremity patency at 6 months postoperatively. Conclusions: We postulate that this patient suffered lower extremity paralysis secondary to cauda equina syndrome. Pharmacomechanical thrombectomy is a pragmatic means that reestablishes venous patency and relieves venous hypertension. This pathophysiology and its treatment should be considered in extensive iliocaval DVT and lower extremity neurologic compromise despite duration of paralysis. [Formula presented] [Formula presented]
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Background: Convalescent plasma (CP) transfusion is one of the suggested treatments for Coronavirus disease 2019 (COVID-19) especially in critically ill patients. Objectives: This study aimed to investigate the efficacy and safety of CP transfusion were investigated in severe/critically ill COVID-19 patients. Methods: This study was performed on 50 consecutive COVID-19 patients with severe/critically ill disease. Severe disease was defined as having at least one of the following symptoms: shortness of breath, respiratory frequency ≥ 20/min, blood oxygen saturation ≥ 93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 300, lung infiltrates > 50% within the last 24-48 h. Critically ill disease was identified by intensive care unit admission, respiratory failure, septic shock, or multiple organ dysfunction or failure. Primary outcomes included the safety of CP transfusion, 14-day and 30-day survival rate, and change in lung computed tomography (CT) scan score. Several other clinical and laboratory features were evaluated as the secondary outcomes. Results: Based on the results, 21 out of 50 consecutive patients were on mechanical ventilation at the time of CP transfusion. In total, 32 patients (64%) survived 30 days after CP transfusion. The survival rates were 74% and 44% in patients who received CP < 7 and ≥ 7 days after admission, respectively. While 92% of patients without mechanical ventilation survived, the survival rate of patients on mechanical ventilation was 29%. Moreover, the CT scan score and some other clinical features were improved in the group that received CP transfusion, and no adverse effects were observed. Conclusion: The CP transfusion is a safe and effective treatment in severe/critically ill COVID-19 patients. The best outcome can be achieved in patients who are not on mechanical ventilation, especially early in the disease course.