Sometimes Late Is Better Than Never: Implantation of a Cardioverter Defibrillator Years after an Acute Myocardial Infarction - Case Report

Sustained ventricular arrhythmias that occur early post-myocardial infarction (MI) are generally considered epiphenomena of the MI and are not consistently associated with long-term prognosis. The lack of association with long-term prognosis is more clearly established for early ventricular fibrillation (VF) and polymorphic ventricular tachycardia (PVT). Sustained monomorphic ventricular tachycardia (SMVT), even when it occurs early, however, may reflect a permanent arrhythmic substrate1. Patients with COVID-19 have a high risk of thromboembolic events, and the virus has also been shown to have extensive effects on the cardiovascular system2,3,4. A 62-year-old woman, recently hospitalized for COVID-19 pneumonia, was brought to the emergency department with pulseless SMVT having been successfully resuscitated in the prehospital setting. The patient has a history of an old MI treated with thrombolysis and percutaneous coronary intervention (PCI) that was complicated with early SMVT, but with preserved left ventricular function and without heart failure. The patient underwent implantation of a cardioverter defibrillator (ICD). During the hospitalization, she developed dyspnea and was diagnosed with minor pulmonary embolism. It may be appropriate to consider early SMVT as a predictor of adverse late outcomes that would necessitate rigorous follow-up and maybe an early invasive primary prevention strategy. This case also reflects the possibility of long-term cardiac involvement and increased thromboembolic risk in patients recovering from COVID-19. © 2022 Maria Zamfirescu et al., published by Sciendo.

Telemedicine for Optimizing Secondary Prevention in Coronary Artery Bypass Grafting Patients during COVID-19 Pandemic.

(1) Background: The COVID-19 pandemic has introduced a major disruption to the delivery of secondary prevention measures in patients with established atherosclerotic cardiovascular disease (CVD). It required a rapid and widespread adoption of new medical services, including the use of telemedicine. This study aimed to examine the impact of COVID-19 on secondary prevention in patients with coronary artery bypass grafting (CABG) and to evaluate the effectiveness of the telemedicine application for the implementation of lifestyle change measures, remote monitoring, and treatment regimen adjustment; (2) Methods: This prospective study on 194 CABG patients evaluated three consecutive years between 2019 and 2022 in the pre-pandemic period by face-to-face visits and during the pandemic by teleconsultations or hybrid follow-up. Variables of interest were compared between four periods: pre-pandemic-pre-P (1 March 2019-29 February 2020), lockdown-Lock (1 March-31 August 2020), restrictive-pandemic-Restr-P (1 September 2020-28 February 2021), and relaxed-pandemic-Rel-P (1 March 2021-1 March 2022). (3) Results: The average values of the lipidogram, blood sugar, and uric acid increased during Lock and Restr-P, but, through the use of teleprevention, they returned to the pre-pandemic level or even below this level. The exception was blood sugar, which remained high in Rel-P. The number of newly diagnosed patients with diabetes also increased, with most of them having moderate forms of COVID. During Lock and Res-P, the percentage of obese, smoking, or hypertensive patients increased, but, through the use of teleprevention, we managed to reduce it, although it remained slightly higher than the pre-pandemic level. Physical activity decreased in the first year of the pandemic, but, in Rel-P, CABG patients became more active than before the pandemic (4) Conclusions: The use of telemedicine for cardiovascular secondary prevention allowed us to not only continue seeing CABG patients but, also, to adjust their medication and to expand cardiovascular preventive counseling and testing with favorable results, especially during the second year of the pandemic.

Takotsubo Cardiomyopathy Triggered by Emotional Stress From the Russia-Ukraine War.

Stress-induced cardiomyopathy presents like acute coronary syndrome and is triggered by emotional stress or critical illness. Increased incidence has been reported during the COVID-19 pandemic and natural disasters. We describe a case of stress-induced cardiomyopathy as an indirect consequence of the Russia-Ukraine war. (Level of Difficulty: Beginner.).

Characteristics and correlates of disease-related knowledge and exercise self-efficacy among cardiac patients attending virtual cardiac rehabilitation during the first COVID-19 lockdown in Peru

Background Government responses and restrictions due to the COVID-19 pandemic (e.g., limits to non-urgent health care services, including non-urgent outpatient appointments) led to the suspension of center-based (in-person) cardiac rehabilitation (CR), with many programs switching to virtual delivery. This study aimed to understand the characteristics and correlates of disease-related knowledge and exercise self-efficacy in a group of patients attending a virtual CR program during the first COVID-19 lockdown in Peru. Methods In this prospective observational study, 240 patients receiving virtual CR care (exercise instructions and patient education) between August/2020 and December/2021 completed questionnaires pre- and post-CR assessing disease-related knowledge (CADE-Q SV questionnaire) and self-efficacy (SE;Bandura's Exercise SE scale). Paired t tests were used to investigate changes pre/post-CR and Pearson correlation coefficients were used to determine the association between knowledge/SE and patients' characteristics. Results Participants were mainly comprised of men, with a cardiac diagnosis of stable coronary artery disease, who underwent percutaneous coronary intervention or had a known diagnosis of hypertension and with at least one cardiovascular risk factor (95.8%). Mean total knowledge scores improved significantly at post-CR (12.9±2.4 to 15.6±2.0/20;p<0.001), as well as in 4/5 knowledge areas (cardiovascular risk factors, exercise, nutrition, and psychosocial risk;p<0.001). Mean SE scores improved significantly at post-CR (1.9±0.9 to 3.0±0.9/5;p=0.01). Post-CR knowledge and SE were significantly correlated with cardiac diagnosis and surgical procedures (r=0.17, p =0.02 and r=0.27, p=0.02, respectively). Conclusions The virtual CR program improved disease-related knowledge and SE of cardiac patients during the first months of the COVID-19 pandemic. Post-CR outcomes were correlated with cardiac diagnosis and surgical procedures and more research with other characteristics is warrantied.

The effectiveness of secondary prevention of malignant neoplasms during the COVID-19 pandemic.

Objective. To evaluate the effectiveness of the detection of malignant neoplasms (MNPs) when implementing secondary preventive measures against cancer in municipal healthcare facilities during the COVID-19 pandemic. Material and methods. The model of the Volga Federal District (VFD) of Russia was used to conduct analytical and statistical studies of the rates of active detection of MNPs in the municipal healthcare facilities in 2019-2020. The demographic indicators and state statistics data, which were publicly available on the Internet, on the official websites of the territorial health authorities, oncology dispensaries of the VFD subjects, were comparatively analyzed. A database (State Registration Certificate of the Russian Federation under No. 2021621834/01.09.21) was used to evaluate the effectiveness of secondary preventive measures against cancer during the COVID-19 pandemic in 2020. Results. Compared to 2019, the COVID-19 pandemic caused a 2.1% expansion in the network of patients' examination rooms mainly due to an increase in the number of male rooms by 5.6% and mixed-type rooms by 6.3%. The number of mid-level healthcare workers that provided the functioning of patients' examination rooms rose by 5.2%;the proportion of specialists trained in the area of oncology decreased by 20% (85% in 2019 and 68.1% in 2020). The introduction of restrictive measures determined a statistically significant (p<0.05) decline in the proportion of people who had undergone a primary medical examination in the male (32.9%), female (35.6%), and general (34.7%) populations. The mean frequency of detected MNPs in 2019 and 2020 was 0.91 and 0.76, respectively (a 16.5% decrease). There was an increase in the incidence of lung cancer (LC) (a 4.2% increase) and a reduction in that of breast cancer (BC) (a 56.6% decrease). A comparative assessment of changes in the rate of active detection of MNPs in healthcare facilities at all health levels revealed a negative increase in its mean value in 2020 versus 2019 for colorectal cancer (CRC) (-25.6%), LC (-25.0% ), BC (-11.6%), cervical cancer (CC) (-12.4%), and prostate cancer (PC) (-2.1%). The prognosis of the number of actively detected MNP cases during the pandemic shows that, provided that the effectiveness of MNP detection rates remains the same as in 2019;there were no CRC (n = about 1100 cases), LC (n=1050), BC (n=1470), CC (n=300), and PC (n=300) cases in the VFD in 2020. An analysis of the effectiveness of secondary preventive measures against LC and BC in the VFD showed that among the number of newly diagnosed cases of a disease in 2019, there were LC (92.3%) and BC (75.1%) cases in the municipal healthcare facilities;there were LC (100%) and BC (60.9%) cases during the COVID-19 pandemic. Conclusion. The COVID-19 pandemic led to a decline in the number of participants in preventive activities. Considering the uneven territorial spread of COVID-19, the development of a methodology for the preventive measures adapted to a pandemic, mainly in the municipal healthcare facilities, is an extremely important area of preventive healthcare activities.Copyright © 2022, Media Sphera Publishing Group. All rights reserved.

The impact of the COVID-19 pandemic on the diagnosis of malignant neoplasms during preventive medical examinations.

The restrictive social distancing strategy during the COVID-19 pandemic in the healthcare system has led to a reduction in measures for the active detection of malignant neoplasms (MNs). Objective. To evaluate the impact of a temporary stop the measures for the secondary prevention of MNs on the frequency of detected cases of the disease during preventive medical examinations (PMEs). Materials and methods. The efficiency of active MN detectability in 2020 versus the pre-COVID-19 period (2018-2019) was com-paratively analyzed in 17 regions of the Central Federal District (CFD) of Russia. Information on the coverage of the population with PMEs and on the frequency of detected cancer cases when using fluorographic, mammographic, and cytological studies was obtained from the study of the data contained in the information project <<Passport of an Oncology Dispensary>> of the P.A. Herzen Moscow Oncology Research Institute, as well as those available in the public domain on the Internet and on the official websites of regional health authorities. Results. The comparative analysis of the results of PMEs did not reveal significant differences in their efficiency in the studied regions of the Central Federal District of Russia in 2018 and 2019. Compared to the pre-COVID-19 period in 2020, there was a sta-tistically significant decline in the population coverage with primary care, which was 33.2+/-2.3% among both sexes (p<0.01), 25.8+/-2.3 for males (p<0.05) and 39.7+/-3.0% females (p<0.01). The frequency of detected cancer cases was 1.0 in the general population, 0.6 for males and 1.2 for females. There was an increase in the number of detected cases during fluorographic (+27.1%) and mammographic (+22.9%) studies and a decrease in the proportion of cytologically detected MNs (-33.2%). At the same time, due to a decline in the number of the surveyed population in 2020, there was a decrease in the number of detected cancer cases of the lung (-34.8%), breast (-37.1%), as well as tumors diagnosed cytologically (-65.9%). Conclusion. This investigation may suggest that at least 1.065 lung cancer cases and 1.875 breast ones were not diagnosed due to the temporary reduction in PMEs in the regions studied.Copyright © 2021, Media Sphera Publishing Group. All rights reserved.

Multivessel Epicardial Coronary Artery Thrombosis after Heart Transplantation

Introduction: Although cardiac allograft vasculopathy (CAV) remains one of the leading causes of graft failure after heart transplantation (HTx), simultaneous thrombosis of multiple epicardial coronary arteries (CA) is an uncommon finding. Case Report: A 43-year-old male patient with non-ischemic dilated cardiomyopathy underwent successful HTx in 2019. The first two years after HTx were uneventful, surveillance endomyocardial biopsies (EMB) did not reveal any rejection episodes, coronary CTA revealed only minimal non-calcified CA plaques. The patient was admitted to hospital due to fever and chest pain in 2021. Immunosuppressive therapy consisted of tacrolimus, mycophenolate-mofetil and methylprednisolone. ECG verified sinus rhythm. Laboratory test revealed elevated hsTroponin T, NT-proBNP and CRP levels. Cytomegalovirus, SARS-CoV-2-virus and hemoculture testing was negative. Several high-titre donor-specific HLA class I and II antibodies (DSAs;including complement-binding DQ7) could have been detected since 2020. Echocardiography confirmed mildly decreased left ventricular systolic function and apical hypokinesis. EMB verified mild cellular and antibody-mediated rejection (ABMR) according to ISHLT grading criteria. Cardiac MRI revealed inferobasal and apical myocardial infarction (MI);thus, an urgent coronary angiography was performed. This confirmed thrombotic occlusions in all three main epicardial CAs and in first diagonal CA. As revascularization was not feasible, antithrombotic therapy with acetylsalicylic acid, clopidogrel and enoxaparin was started for secondary prevention. Tests for immune system disorders, thrombophilia and cancer were negative. Patient suddenly died ten days after admission. Necropsy revealed intimal proliferation in all three main epicardial CAs, endothelitis, thrombosis, chronic pericoronary fat inflammation, fat necrosis, and subacute MI. CA vasculitis owing to persistent high-titre DSAs, chronic ABMR and acute cellular and antibody-mediated rejection led to multivessel CA thrombosis and acute multiple MI. ABMR after HTx may be underdiagnosed with traditional pathological methods. Pathologies affecting coronary vasculature of HTx patients with DSAs, unique manifestations of CAV lesions and occlusive thrombosis of non-stenotic, non-atherosclerotic lesions should be emphasized.Copyright © 2023

Weekly screening of youth male football players: a 14-week longitudinal investigation of interactions between groin pain and long lever adductor squeeze strength.

OBJECTIVES: To explore relationships between groin pain and adductor squeeze strength in male academy football players over a 14-week period. DESIGN: Longitudinal cohort study. METHODS: Weekly monitoring of youth male football players consisted of reporting groin pain and testing long lever adductor squeeze strength. Players who reported groin pain at any time during the study period were stratified into the "groin pain" group while players who did not report pain remained in the "no groin pain" group. Baseline squeeze strength was retrospectively compared between groups. Players that developed groin pain were examined via repeated measures ANOVA at four timepoints: baseline, last squeeze before pain, pain onset, and return to pain-free. RESULTS: 53 players were included (age 14.4 ±â€¯1.6 years). Baseline squeeze strength was not different between players in the "groin pain" (n = 29, 4.35 ±â€¯0.89 N/kg) versus "no groin pain" group (n = 24, 4.33 ±â€¯0.90 N/kg, p = 0.83). At a group level, players with no groin pain maintained similar adductor squeeze strength throughout 14 weeks (p > 0.05). Compared to baseline (4.33 ±â€¯0.90 N/kg), players with groin pain had decreased adductor squeeze strength at the last squeeze before pain (3.91 ±â€¯0.85 N/kg, p = 0.003) and at pain onset (3.58 ±â€¯0.78 N/kg, p < 0.001). Adductor squeeze strength at the point where pain subsided (4.06 ±â€¯0.95 N/kg) was not different from baseline (p = 0.14). CONCLUSIONS: Decreases in adductor squeeze strength manifest one-week prior to groin pain onset and further decrease at pain onset. Weekly adductor squeeze strength may be an early detector for groin pain in youth male football players.

Impact Analysis of Aspirin over the Cardiac Activity

Cardiovascular disease (CVD) is the leading cause of death in most developed countries, including the United States, with a significant economic impact. Lifestyle changes and the administration of antiplatelet medication, like aspirin, may significantly contribute to the secondary prevention of CVD in adults. For years, aspirin has been utilized for both secondary and primary cardiovascular disease prevention. Aspirin has been extensively used because of the belief that it may have a positive impact on primary prevention, despite the debate surrounding its usage. This study briefly examines usage patterns and discusses the potential variables and factors that can decrease the ability of aspirin to prevent cardiovascular disease. The present study also explore the key studies of aspirin use in the context of recent recommendations. The risk of bleeding has been observed to significantly rise, although large randomized clinical studies have demonstrated a reduction or absence of CVD events. Prevention strategies for cardiovascular disease with low-dose aspirin are no longer advised for persons at intermediate risk. To determine whether taking aspirin is worth the potential dangers, the benefits must be evaluated.Copyright © 2022 Novyi Russkii Universitet. All rights reserved.

Secondary Prevention of Stroke or Transient Ischaemic Attack: An Investigation of Patient Experience of a Novel Dietetic Service

Introduction: Patients who have had a stroke or transient ischaemic attack (TIA) are at high risk of recurrent events. Around 90% of strokes are associated with ten modifiable risk factors. The prevalence of modifiable risk factors is high, with 89% of stroke clinic patients at Guy's and St. Thomas' Hospital having at least one. This study aimed to explore the patient experience of a novel virtual dietetic secondary prevention service, between November and December 2020, developed in response to the COVID-19 pandemic. Method(s): A questionnaire was developed to explore patients' experience of receiving virtual consultation with the Specialist Stroke Dietitian for the secondary stroke or TIA prevention. The questionnaire, informed by a literature review, was piloted with dietitians and patients. The Questionnaire was used to develop a topic guide for structured in-depth telephone interviews. Patients (n=8) who completed a telephone consultation with the Stroke Dietitian were invited to participate in a structured telephone interview with the researcher. The Framework method was used for thematic analysis. Result(s): Six patients aged 30-69 years discussed their experience of secondary prevention dietetic consultations. Thematic analysis suggests that new knowledge obtained, nutrition education provided, and the Dietitian's interpersonal communication style were key factors that improved confidence, facilitated behaviour change and contributed to a positive patient experience. Participants expressed a preference for telephone appointments rather than face-to-face or video. Conclusion(s): Exploration of patient experience is central to the design of novel clinical services. Our pilot questionnaire can be modified for use in future stroke service development.

Epidemiology, risk factors, and prevention of colorectal cancer.

Background: Colorectal cancer remains the fourth most common malignancy in Korea, and has been ranked as the third leading cause of cancer deaths in 2020. This study aims to describe the epidemiologic status of colorectal cancer in Korea, and provide basic data for effective primary and secondary prevention methods by summarizing risk factors and screening tools. Current Concepts: Although colorectal cancer incidence and mortality have decreased in recent years in Korea, it still poses a significant public health burden. From the early 1990s until the mid-2000s, the 5-year relative survival of patients with colorectal cancer in Korea continuously increased. This can be attributed to the successful introduction of the government-led screening program;development of improved surgical techniques, anticancer drugs, and adjuvant treatment;and advances medical resources and infrastructure along with economic growth. However, since the late 2000s, the improvement in survival has stagnated. The coronavirus disease 2019 outbreak has reduced hospital visits and screenings, which is assumed to cause delays in diagnosis, leading to a worse prognosis in the patients. To overcome these obstacles, it is essential to explore modifiable environmental risk factors and appropriate screening test methods in Korea. Discussion and Conclusion(s): Primary prevention through risk factor modification and secondary prevention using suitable screening programs can reduce the incidence and mortality rates of colorectal cancer.Copyright © Korean Medical Association.

Preventing Psychopathology in Different Stages of Development: Comparing Experiences

Preventing psychopathology and promoting well-being have always been objecting of concern in many fields of psychology and psychiatry. Prevention is a form of intervention aimed at preventing the onset of a symptom, disorder, and psychological and/or social distress. The symposium intends to compare prevention in various contexts and different developmental stages of life, through the presentation of 4 contributions: (a) "Coping strategies and mental health during the covid-19 pandemic: an Italian survey". The study aims to evaluate mental health starting from individual characteristics and to explore which coping strategies are effective in enhancing the Italian population's well-being in dealing with covid-19;(b) "The role of several aspects of personality in the construction of transversal competencies in a sample of young adults". The study aims to assess the role that self-criticism, dependency and efficacy play in enhancing the young adult's transversal skills to facilitate more adaptive and satisfying life trajectories;(c) "Mentalization and attachment representation in mother-child and teacher-student relationships". The study has two aims: the first is to evaluate the relationship between the mentalization abilities and the attachment representation of both mother and her child and the teacher and her/his pupils. The second is to verify whether the adult's (mother and teacher) mentalization abilities impact the child's mentalization abilities;(d) 'Psychopathological symptoms and mentalizing capabilities in adolescents with anorexia nervosa before and during COVID-19 pandemic. This study aims to compare Covid-Period vs. NON-Covid Period adolescent patients affected by Anorexia Nervosa (AN) considering their psychopathological symptoms and their mentalizing capabilities. In the symposium, three types of prevention are focused: primary, secondary, and tertiary. The primary aim is to avoid or minimise the risk of occurrence. Secondary prevention intervenes early on the problem to reduce its negative effects. A clear example is an early diagnosis, which is even more important when dealing with childhood disorders as it increases treatment opportunities, effectiveness, and positive outcomes. Tertiary prevention relates to preventing complications and reducing the risk of relapse. The symposium's objective is to compare various typologies of prevention in different contexts focusing on specific samples. The four contributions illustrate once again the greatest importance of prevention and how it can be broadly applied, in clinical, social, and developmental contexts.

HPV-Based Self-Sampling in Cervical Cancer Screening: An Updated Review of the Current Evidence in the Literature.

Identifying and reaching women at higher risk for cervical cancer is all-important for achieving the ambitious endpoints set in 2020 by the WHO for global cervical cancer control by 2030. HPV-based (vaginal) self-sampling (SS) represents a cost-effective screening strategy, which has been successfully implemented during the last decade both in affluent and constrained settings. Among other advantages, SS strategies offer convenience, diminished costs, flexibility to obtain a sample in the office or home, avoiding a pelvic exam and uncomfortable appointment with a healthcare professional, as well as social and cultural acceptability. SS implementation has been globally boosted during the COVID-19 pandemic. In pragmatic terms, social distancing, local lockdowns, discontinuation of clinics and reallocation of human and financial resources challenged established clinician-based screening; self-collection strategies apparently surpassed most obstacles, representing a viable and flexible alternative. With time, sufficient reassuring data has accumulated regarding specially designed SS devices, aspects of sample preparation, transport and storage and, importantly, optimization of validated PCR-based HPV testing platforms for self-collected specimens. Suboptimal rates of clinical follow-up post-SS screening, as well as overtreatment with reliance solely on molecular assays, have both been documented and remain concerning. Therefore, effective strategies are still required to ensure linkage to follow-up testing and management following positive SS results by trained health professionals with knowledge of HPV biology and management algorithms. Because of the prolonged SS screening intervals, implementation data are limited regarding subsequent screening rounds of SS-screened individuals; however, these are accumulating gradually. With further refinement of assays and validation of novel biomarkers in self-collected samples, there is a clear potential for increasing SS accuracy and PPV. The potential differentiation of self-collection protocols for vaccinated versus non-vaccinated individuals also represents an open issue. In conclusion, HPV-based self-collection techniques can effectively address limited uptake alongside other conventional cervical screening drawbacks; however, assays, logistics and infrastructures need further optimization to increase the efficacy, effectiveness and cost-effectiveness of SS approaches.

CLINICAL RESEARCH IN LATIN AMERICA: FROM SPONSORED TO INVESTIGATOR INITIATED RESEARCH

Latin American clinical researchers had participated in many controlled clinical trials in the 80 s and 90 s sponsored initiated that confirmed the place of calcium channel blockers and RAS blockade in hypertension treatment. Later, non-inferiority or superiority trials like ONTARGET, Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial and VALUE, Valsartan Antihypertensive Long-term Use Evaluation were performed worldwide including Latin-American countries. In the last decade, the absence of new drugs in the pipeline and sponsors portfolios at one side, and the recommendation of fixeddose combination as initial treatment tool at the other could be supposed as main causes of a dramatic reduction in sponsored hypertension research. At the same time, a huge increase in investigator initiated research was observed. Scientific national and regional societies in many cases fueled this increase. In this scenario, the Cardiovascular Risk Factor Multiple Evaluation in Latin America, CARMELA study was the first large-scale population-based study that assessed cardiovascular risk factor prevalence in 7 Latin American cities and its relationship to hypertension mediated organ damage. CARMELA is an example of an epidemiological study investigator initiated supported by a sponsor in Latin America The FOCUS study, Fixed-Dose Combination Drug for Secondary Cardiovascular Prevention was another example of an investigator initiated research supported by a private company. FOCUS was funded by the 7th Framework Programme European Commission Consortium with the participation of the Centro Nacional De Investigaciones Cardiovasculares CNIC Madrid, Spain, World Heart Federation, Federación Argentina De Cardiología, and some European research organizations, supported by FERRER Internacional. FOCUS help to understand the reasons of treatment non-adherence in Latin American countries and also to recognize the potential benefits of fixed-dose combinations in secondary prevention. More recently, the Interamerican Society of Cardiology SIAC developed the CorCOVID Latam study which aim was to study changes in lifestyle habits, treatment adherence, and mental health status in patients with cardiometabolic disease, but no clinical evidence of COVID-19 during the pandemic. This study is a good example of the feasibility of non-sponsored research in Latam supported by a regional scientific society structure and members. Five publications related to gender differences in the impact of the pandemic in Latam, Influenza and Pneumococcal vaccination during the pandemic, and the psychological impact in more than 4 thousand patients were the fruit of this society research initiative.

Epidemiology, risk factors, and prevention of colorectal cancer

Background: Colorectal cancer remains the fourth most common malignancy in Korea, and has been ranked as the third leading cause of cancer deaths in 2020. This study aims to describe the epidemiologic status of colorectal cancer in Korea, and provide basic data for effective primary and secondary prevention methods by summarizing risk factors and screening tools. Current Concepts: Although colorectal cancer incidence and mortality have decreased in recent years in Korea, it still poses a significant public health burden. From the early 1990s until the mid-2000s, the 5-year relative survival of patients with colorectal cancer in Korea continuously increased. This can be attributed to the successful introduction of the government-led screening program;development of improved surgical techniques, anticancer drugs, and adjuvant treatment;and advances medical resources and infrastructure along with economic growth. However, since the late 2000s, the improvement in survival has stagnated. The coronavirus disease 2019 outbreak has reduced hospital visits and screenings, which is assumed to cause delays in diagnosis, leading to a worse prognosis in the patients. To overcome these obstacles, it is essential to explore modifiable environmental risk factors and appropriate screening test methods in Korea. Discussion and Conclusion: Primary prevention through risk factor modification and secondary prevention using suitable screening programs can reduce the incidence and mortality rates of colorectal cancer.

A Series of Catastrophic Events

Case report - Introduction: Catastrophic antiphospholipid syndrome (CAPS) is a rare, life-threatening disease occurring in up to 1% of antiphospholipid syndrome (APS) cases. It was first defined in 1992 and remains a difficult to treat entity with a mortality rate of 37%. We describe a patient with systemic lupus erythematosus (SLE) and CAPS presenting with simultaneous multi-organ injuries who was successfully managed with 'triple' therapy including cyclophosphamide. Case report - Case description: A 42-year-old female presented to her local hospital with chest pain and worsening vision. She had a background of SLE, triple antibody-positive APS (previous DVT, pregnancy loss and strokes), hypertension, a metallic mitral valve, a previous myocardial infarction and pre-existing visual impairment due to a prior intra-cerebral bleed related to anticoagulation. Examination revealed a faint malar rash, cortical blindness and long tract neurological signs. Her ECG showed ischaemic changes and the admission troponin was significantly raised (3773ng/L). An echocardiogram showed new left ventricular dysfunction and a subsequent cardiac MRI was in keeping with coronary artery disease. Investigations showed an acute kidney injury, newly deranged liver function tests and a raised INR (>11, with no bleeding). Complement was normal with a low dsDNA titre. Urinalysis revealed proteinuria and a protein creatinine ratio measured 176mg/mmol. MRI diffusion weighted brain imaging showed acute bilateral occipital and left fronto-parietal infarcts. She had symptoms of a lupus flare with arthralgia and a butterfly facial rash. COVID-19 PCR tests were negative and she had not been recently vaccinated. She was diagnosed with CAPS and transferred to St Thomas' hospital intensive care. On arrival, she received 1mg intravenous vitamin K followed by triple therapy for CAPS: an unfractionated heparin infusion, oral prednisolone 40mg daily, 5 days of plasma exchange and, given her background of SLE, she was treated with intravenous cyclophosphamide (according to the EUROLUPUS regimen). Intravenous methylprednisolone was avoided due to a previous hypertensive encephalopathy reaction. She responded rapidly. Her troponin fell from a peak of 5054 to 294ng/ L, her creatinine settled at a new baseline (232umol/L) and her liver function normalised. She was switched back to warfarin due to her metallic valve and started on aspirin for cardiovascular secondary prevention. She required physical and occupational therapy due to her strokes but recovered well. Case report - Discussion: According to the 2003 criteria, CAPS can be classified as definite when there is evidence of: -3 organs involved, development of manifestations simultaneously or within a week, confirmation by imaging and/or histopathology of small vessel occlusion and positive antiphospholipid antibodies. Probable CAPS is when 3 out of the 4 criteria are present. In this case, three organs were confirmed to be involved with imaging showing cerebral and cardiac ischaemia. Her creatinine rose from a base of 190 to 289umol/L coupled with a high protein creatinine ratio confirming renal involvement. A Budd-Chiari syndrome was also suspected due to deranged liver function tests and INR, though imaging performed after therapy did not confirm this. A biopsy of any of these four organs was not feasible given the severity of her presentation and coagulopathy. There are no randomised controlled trials but data from the CAPS registry guides treatment and management follows a logical approach: anticoagulation to treat thrombosis, glucocorticoids for inflammation and plasma exchange (or IVIG) to remove the circulating autoantibodies. Triple therapy was associated with a reduced mortality compared to no treatment (28.6% versus 75%, respectively). Following analyses from the CAPS registry we also chose to treat with cyclophosphamide, which is associated with improved survival in patients with SLE. This decision was based on the clinical features of an SLE flare as opposed to serological grounds. There have b en reports of rituximab and eculizumab being used successfully in CAPS, though generally as a last resort. As complement activation is seen in animal models of antiphospholipid syndrome thrombosis and rituximab is often used in refractory SLE, they may prove to be promising agents for refractory CAPS. Case report - Key learning points: 1. Prompt recognition and early treatment is vital in managing CAPS 2. Triple therapy with anticoagulation, glucocorticoids and plasma exchange / IVIG is associated with better survival in CAPS 3. Cyclophosphamide is associated with better survival in patients with CAPS and concomitant SLE.

Impact of Early COVID-19 Waves on Cardiac Rehabilitation Delivery in Australia: A National Survey.

BACKGROUND: The novel coronavirus disease of 2019 (COVID-19) pandemic significantly disrupted health care, especially outpatient services such as cardiac rehabilitation (CR). We investigated the impact of early COVID-19 waves on the delivery of Australian CR programs, comparing this time period with usual practice prior to the pandemic (2019) and current practice (2021) once the early waves had subsided. Specifically, we aimed to understand how the delivery of programs during COVID-19 compared to usual practice. METHODS: An anonymous online cross-sectional survey of Australian CR program staff was conducted, comprising three sections: program and respondent characteristics, COVID-19 impact on program delivery, and barriers to, and enablers of, program delivery. Respondents were asked to consider three key timepoints: 1) Pre-COVID-19 (i.e. usual practice in 2019), 2) Early COVID-19 waves (March-December 2020), and 3) Currently, at time of survey completion post early COVID-19 waves (May-July 2021). RESULTS: Of the 314 Australian CR programs, 115 responses were received, of which 105 had complete data, representing a 33% response rate. All states and territories were represented. During early COVID-19 waves programs had periods of closure (40%) or reduced delivery (70%). The majority of programs reported decreased CR referrals (51.5%) and decreased participation (77.5%). The two core components of CR-exercise and education-were significantly impacted during early COVID-19 waves, affecting both the number and duration of sessions provided. Exercise session duration did not return to pre-pandemic levels (53.5 min compared to 57.7 min, p=0.02). The majority of respondents (77%) reported their CR program was inferior in quality to pre-pandemic and more organisational support was required across information technology, staffing, administration and staff emotional and social support. CONCLUSION: Australian CR programs underwent significant change during the early COVID-19 waves, consistent with international CR reports. Fewer patients were referred and attended CR and those who did attend received a lower dose of exercise and education. It will be important to continue to monitor the long-term impacts of the COVID-19 pandemic to ensure CR programs return to pre-pandemic functioning and continue to deliver services in line with best practice and evidence-based recommendations.

Exploration of Cardiology Patient Hospital Presentations, Health Care Utilisation and Cardiovascular Risk Factors During the COVID-19 Pandemic.

OBJECTIVES: COVID-19 and the lockdowns have affected health care provision internationally, including medical procedures and methods of consultation. We aimed to assess the impact of COVID-19 at two Australian hospitals, focussing on cardiovascular hospital admissions, the use of community resources and cardiovascular risk factor control through a mixed methods approach. METHODS: Admissions data from the quaternary referral hospital were analysed, and 299 patients were interviewed from July 2020 to December 2021. With the admissions data, the number, complexity and mortality of cardiology hospital admissions, prior to the first COVID-19 lockdown (T0=February 2018-July 2019) were compared to after the introduction of COVID-19 lockdowns (T1=February 2020-July 2021). During interviews, we asked patients about hospital and community health resource use, and their control of cardiovascular risk factors from the first lockdown. RESULTS: Admission data showed a reduction in hospital presentations (T0=138,099 vs T1=128,030) and cardiology admissions after the lockdown period began (T0=4,951 vs T1=4,390). After the COVID-19-related lockdowns began, there was an increased complexity of cardiology admissions (T0=18.7%, 95% CI 17.7%-19.9% vs T1=20.3%, 95% CI 19.1%-21.5%, chi-square test: 4,158.658, p<0.001) and in-hospital mortality (T0=2.3% of total cardiology admissions 95% CI 1.9%-2.8% vs T1=2.8%, 95% CI 2.3%-3.3%, chi-square test: 4,060.217, p<0.001). In addition, 27% of patients delayed presentation due to fears of COVID-19 while several patients reported reducing their general practitioner or pathology/imaging appointments (27% and 11% respectively). Overall, 19% reported more difficulty accessing medical care during the lockdown periods. Patients described changes in their cardiovascular risk factors, including 25% reporting reductions in physical activity. CONCLUSION: We found a decrease in hospital presentations but with increased complexity after the introduction of COVID-19 lockdowns. Patients reported being fearful about presenting to hospital and experiencing difficulty in accessing community health services.