The Impact of the COVID-19 Pandemic on a Dedicated Vascular Emergency Clinic.

BACKGROUND: Vascular Emergency Clinics (VEC) improve patient outcomes in chronic limb-threatening ischemia (CLTI). They provide a "1 stop" open access policy, whereby "suspicion of CLTI" by a healthcare professional or patient leads to a direct review. We assessed the resilience of the outpatient VEC model to the first year of the coronavirus disease (COVID-19) pandemic. METHODS: A retrospective review of a prospectively maintained database of all patients assessed in our VEC for lower limb pathologies between March 2020 and April 2021 was performed. This was cross-referenced to national and loco-regional Governmental COVID-19 data. Individuals with CLTI were further analysed to determine Peripheral Arterial Disease-Quality Improvement Framework compliance. RESULTS: Seven hundred and ninety one patients attended for 1,084 assessments (Male n = 484, 61%; Age 72.5 ± standard deviation 12.2 years; White British n = 645, 81.7%). In total, 322 patients were diagnosed with CLTI (40.7%). A total of 188 individuals (58.6%) underwent a first revascularization strategy (Endovascular n = 128, 39.8%; Hybrid n = 41, 12.7%; Open surgery n = 19, 5.9%; Conservative n = 134, 41.6%). Major lower limb amputation rate was 10.9% (n = 35) and mortality rate was 25.8% (n = 83) at 12 months of follow-up. Median referral to assessment time was 3 days (interquartile range: 1-5). For the nonadmitted patient with CLTI, the median assessment to intervention was 8 days (interquartile range: 6-15) and median referral to intervention time of 11 days (11-18). CONCLUSIONS: The VEC model has demonstrated strong resilience to the COVID-19 pandemic with rapid treatment timelines maintained for patients with CLTI.

Clinical outcome of a quadrifocal (trifocal) intraocular lens in Chinese patients: prospective, observational case series.

PURPOSE: To report the visual outcomes and quality of vision and life after bilateral implantation of a single-piece trifocal intraocular lens (IOL) in Chinese patients. SETTING: Hong Kong Sanatorium & Hospital, Hong Kong, China. DESIGN: Prospective, observational case series. METHODS: Patients with bilateral implantation of AcrySof IQ PanOptix multifocal IOL were included. Distance, intermediate (60 cm), and near (40 cm) visual acuities (VAs) and contrast sensitivity (CS), defocus curve, preoperative higher-order aberration (HOA), dysphotopsia (0 to 5), satisfaction (1 to 5), spectacle independence, and quality of life were evaluated. The association between preoperative HOA and postoperative halos was also assessed. RESULTS: 54 eyes of 27 patients were included. The mean binocular distance, intermediate, and near uncorrected VA was -0.05 ± 0.06 (20/18), 0.06 ± 0.10 (20/23), and 0.04 ± 0.05 (20/22), respectively. No eyes lost more than 1 line of vision. Binocular CS was comparable with the monocular population norm of older adults. The defocus curve demonstrated that the binocular VA of 20/25 or better was achieved at a power of -3.00 to +0.50 diopters. The mean scores for halos, glare, and starbursts were 2.4 ± 1.4, 0.2 ± 0.8, and 1.4 ± 1.4 (of 5), respectively. The mean satisfaction score was 4.3 ± 0.7 (of 5). All the patients (100%) reported total spectacle independence. The mean vision-targeted composite score of the vision-related quality-of-life questionnaire was 97.2 ± 9.7 (of 100). Preoperative HOA was not associated with postoperative halos. CONCLUSIONS: Implantation of the trifocal IOL provided satisfactory visual outcomes and quality of vision and life, which resulted in a high rate of spectacle independence.

Effect of high-pain versus low-pain structured exercise on walking ability in people with intermittent claudication: meta-analysis.

BACKGROUND: The aim was to determine the comparative benefits of structured high-pain exercise, structured low-pain exercise, and usual-care control, to identify which has the largest effect on walking ability in people with intermittent claudication (IC). METHODS: A network meta-analysis was undertaken to assess two outcomes: pain-free walking ability (PFWA) and maximal walking ability (MWA). Nine electronic databases were searched. Trials were included if they were: RCTS; involved adults with IC; had at least two of the following arms-structured low-pain exercise, structured high--pain exercise or usual-care control; and a maximal or pain-free treadmill walking outcome. RESULTS: Some 14 trials were included; results were pooled using the standardized mean difference (MD). Structured low-pain exercise had a significant large positive effect on MWA (MD 2.23, 95 percent c.i. 1.11 to 3.35) and PFWA (MD 2.26, 1.26 to 3.26) compared with usual-care control. Structured high-pain exercise had a significant large positive effect on MWA (MD 0.95, 0.20 to 1.70) and a moderate positive effect on PFWA (0.77, 0.01 to 1.53) compared with usual-care control. In an analysis of structured low- versus high pain exercise, there was a large positive effect in favour of low-pain exercise on MWA (MD 1.28, -0.07 to 2.62) and PFWA (1.50, 0.24 to 2.75); however, this was significant only for PFWA. CONCLUSION: There is strong evidence in support of use of structured high-pain exercise, and some evidence in support of structured low-pain exercise, to improve walking ability in people with IC compared with usual-care control (unstructured exercise advice).

Toric intraocular lenses for astigmatism correction after keratoplasty in phakic and pseudophakic eyes.

Residual astigmatism and anisometropia significantly affect patients' vision and quality of life even in clear grafts after corneal transplant. This study reviewed and summarized the role of toric intraocular lenses (IOLs) in phakic and pseudophakic eyes after penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty in correcting residual astigmatism. 342 eyes from 20 studies with iris-clipped toric IOL, ciliary sulcus toric implantable collamer lens, piggyback sulcus toric IOL, or posterior chamber toric IOL implantations for phakic, pseudophakic, or eyes undergoing cataract surgery after keratoplasty were included. Visual, refractive, and predictability outcomes were encouraging. Secondary realignment rate and complications were low. Endothelial cell loss secondary to phakic toric IOLs might be a concern over the long-term, particularly in iris-clipped IOLs in PKP eyes. Toric IOLs represent a viable option in the treatment of residual astigmatism in postkeratoplasty eyes, resulting in improved visual acuity and reduced anisometropia.

Effect of time since primary laser-assisted in situ keratomileusis on flap relift success and epithelial ingrowth risk.

PURPOSE: To assess the association of time since primary laser-assisted in situ keratomileusis (LASIK) with flap relift success and risk for epithelial ingrowth (EI) in eyes undergoing flap relift after primary LASIK. SETTING: Hong Kong Sanatorium & Hospital, Hong Kong Special Administrative Region. DESIGN: Retrospective observational case series. METHODS: 73 eyes with flaps relifted for refractive enhancement LASIK were included. Main outcome measures included rate of relift success and EI; associations of time since primary LASIK, sex, age at relift, year of relift, and flap creation method in primary LASIK with relift success and EI. RESULTS: Of the 73 eyes included, relifting was successful in 71 eyes (97.3%). Among the successfully relifted eyes, 12 (16.9%) developed EI, of which 3 (4.2%) were clinically significant. No eyes lost more than 1 line of corrected distance visual acuity. The time since primary LASIK (up to 22 years), sex, age at relift, year of relift, and flap creation method in primary LASIK were not associated with relift success or EI. CONCLUSIONS: With the described surgical technique, flaps could be successfully relifted without much difficulty up to 22 years after primary LASIK with a low incidence of EI.

Understanding variations in reported epidemiology of major lower extremity amputation in the UK: a systematic review.

OBJECTIVE: Estimate the prevalence/incidence/number of major lower extremity amputations (MLEAs) in the UK; identify sources of routinely collected electronic health data used; assess time trends and regional variation; and identify reasons for variation in reported incidence/prevalence of MLEA. DESIGN: Systematic review and narrative synthesis. DATA SOURCES: Medline, Embase, EMcare, CINAHL, The Cochrane Library, AMED, Scopus and grey literature sources searched from 1 January 2009 to 1 August 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Reports that provided population-based statistics, used routinely collected electronic health data, gave a measure of MLEA in adults in the general population or those with diabetes in the UK or constituent countries were included. DATA EXTRACTION AND SYNTHESIS: Data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Instruments were performed by two reviewers independently. Due to considerable differences in study populations and methodology, data pooling was not possible; data were tabulated and narratively synthesised, and study differences were discussed. RESULTS: Twenty-seven reports were included. Incidence proportion for the general population ranged from 8.2 to 51.1 per 100 000 and from 70 to 291 per 100 000 for the population with diabetes. Evidence for trends over time was mixed, but there was no evidence of increasing incidence. Reports consistently found regional variation in England with incidence higher in the north. No studies reported prevalence. Differences in database use, MLEA definition, calculation methods and multiple procedure inclusion which, together with identified inaccuracies, may account for the variation in incidence. CONCLUSIONS: UK incidence and trends in MLEA remain unclear; estimates vary widely due to differences in methodology and inaccuracies. Reasons for regional variation also remain unexplained and prevalence uninvestigated. International consensus on the definition of MLEA and medical code list is needed. Future research should recommend standards for the reporting of such outcomes and investigate further the potential to use primary care data in MLEA epidemiology. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020165592.

Does the Introduction of a Vascular Limb Salvage Service Improve One Year Amputation Outcomes for Patients with Chronic Limb-Threatening Ischaemia?

OBJECTIVE: Vascular limb salvage services are recommended by the Global Vascular Guidelines to help improve outcomes for patients with chronic limb-threatening ischaemia (CLTI), although their description within the literature is limited. This study reports the 12 month outcomes for an outpatient based vascular limb salvage (VaLS) clinic. METHODS: An analysis of a prospectively maintained database, involving all consecutive patients diagnosed with CLTI within the VaLS clinic from February 2018-February 2019, was undertaken. Data were compared with two comparator cohorts, identified from coding data: 1) patients managed prior to the clinic, between May 2017 and February 2018 (Pre-Clinic [PC]); and 2) patients managed outside of clinic, between February 2018 and February 2019 (Alternative Pathways [AP]). Freedom from major amputation at 12 months was the primary outcome. Kaplan-Meier plots and adjusted Cox's proportional hazard models (aHR) were used to compare outcomes. RESULTS: Five hundred and sixty-six patients (VaLS 158, AP 173, PC 235) were included (median age 74 years). Patients managed within the VaLS cohort were statistically significantly more likely to be free from major amputation (90.5%) compared with both the AP (82.1%, aHR 0.52, 95% confidence interval [CI] 0.28 - 0.98, p = .041) and the PC (80.0%; aHR 0.50, 95% CI 0.28 - 0.91, p = .022) cohorts at 12 months, after adjustment for age, disease severity, and presence of diabetes. CONCLUSION: This study supports the recommendations of the Global Vascular Guidelines that vascular limb salvage clinics may improve the rate of major amputation. Furthermore, the study provides a reproducible service model that delivers timely vascular assessment in an ambulatory setting. Further evaluation is required to assess longer term outcomes.

Prevalence of Cognitive Impairment in Individuals with Vascular Surgical Pathology: a Systematic Review and Meta-Analysis.

OBJECTIVE: A significant proportion of vascular surgery patients may have undiagnosed cognitive impairment; however, its true prevalence and impact on outcomes are unknown. The aim of this review was to estimate the prevalence of cognitive impairment among individuals with clinically significant vascular surgical pathology and investigate its associations with post-operative outcomes in those undergoing vascular surgery. METHODS: MEDLINE, EMBASE, EMCare, CINAHL, PsycINFO, and Scopus were searched for relevant studies. Included studies assessed cognitive function among individuals with either symptomatic vascular surgical pathology, or disease above threshold for intervention, using a validated cognitive assessment tool. The primary outcome measure was prevalence of cognitive impairment. Secondary outcomes included incidence of post-operative delirium (POD). Two reviewers independently extracted relevant study data and assessed risk of bias (ROBINS-E or RoB 2 tool). Prevalence (%) of cognitive impairment was calculated for individual studies and presented with 95% confidence intervals (CI). Prevalence data from comparable studies were pooled using the Mantel-Haenszel method (random effects model) for separate vascular disease types. Certainty of effect estimates was assessed using the GRADE criteria. RESULTS: Twenty-four studies (2 564 participants) were included in the systematic review, and nine studies (1 310 participants) were included in the meta-analyses. The prevalence of cognitive impairment was 61% (95% CI 48 - 74; 391 participants; low certainty) in studies including multiple vascular surgical pathologies, 38% (95% CI 32 - 44; 278 participants; very low certainty) in carotid artery disease, and 19% (95% CI 10 - 33; 641 participants; low certainty) in those with intermittent claudication. Lower cognitive assessment scores were associated with POD (five studies; 841 participants), but data were not suitable for pooling. CONCLUSION: Screening elective vascular surgery patients for cognitive impairment may be appropriate given its high prevalence, and the association of worse cognition with POD, among individuals with clinically significant vascular surgical pathology.

Experimental evaluation of nickel and cobalt release from tools and self-reported prevalence of nickel and cobalt allergy in the German hairdressing trade.

BACKGROUND: Nickel release from some metal tools in the hairdressing trade has been sporadically evidenced, whereas data about cobalt release from metal tools in the hairdressing trade are lacking. OBJECTIVES: To screen metal tools for nickel and cobalt release and to estimate the prevalence of nickel allergy and cobalt allergy in the German hairdressing trade. METHODS: Four hundred seventy-five metal tools in the hairdressing trade were tested in three North German states with a nickel spot test for nickel release and with a cobalt spot test for cobalt release. Seventy hairdressers were surveyed with a standardized questionnaire to collect data about the tested metal tools as well as the prevalence of nickel allergy and cobalt allergy. RESULTS: One hundred thirty-one of 475 metal tools (27.6%) - 60 of 60 hair clips (100%), five of five crochet hooks (100%), 24 of 40 tweezers (60.0%), 33 of 75 sectioning clips (44.0%), five of 32 straight razors (15.6%), and four of 45 tail combs (8.9%) - released nickel and 10 of 475 metal tools (2.1%) - three of 40 tweezers (7.5%), four of 60 hair clips (6.7%), one of 32 straight razors (3.1%), and two of 75 sectioning clips (2.7%) - released cobalt. Eight of 63 female hairdressers (12.7%) suffered from nickel allergy and two of 63 female hairdressers (3.2%) suffered from cobalt allergy. CONCLUSIONS: Metal tools in the German hairdressing trade - with which a prolonged skin contact is intended - release nickel and cobalt in allergologically relevant amounts and thus should be taken into account as occupational sources of exposure to nickel and cobalt.

Global evidence on occupational sun exposure and keratinocyte cancers: a systematic review.

Individual studies have suggested that the association between occupational exposure to solar ultraviolet radiation (UVR) and the development of keratinocyte cancers (KCs) may only be valid in populations of European ancestry living in certain geographical regions. Comparative global data are scarce and so this review aimed to summarize current evidence on the association between occupational exposure to solar UVR and the development of KCs, with a specific focus on geographical location and skin colour. Ovid MEDLINE, PubMed, Embase and Web of Science were searched for potentially relevant records. Extracted data were summarized by study, country and region. We included one prospective cohort study and 18 case-control studies (n = 15 233) from 12 countries in regions where the majority of the population is white skinned (Americas, Europe and Oceania). Eighteen of the 19 studies reported effect estimates suggesting an increased risk of basal cell carcinoma (BCC) and/or squamous cell carcinoma (SCC) among outdoor workers. Only 11 studies found a significantly increased risk and many had imprecise estimates. There was a significantly increased risk of BCC and SCC in individual studies in North America, Latin America and the Caribbean, Western Europe and Southern Europe, but not across regions or countries. Overall, 95% of studies reported higher risks among outdoor workers, although the increases in risk were statistically significant in just over half of the studies. Well-designed and sufficiently powered occupational case-control and cohort studies with adequate adjustment for confounding factors and other risk factors are required to provide more accurate risk estimates for occupational KC.

Improved protection of outdoor workers from solar ultraviolet radiation: position statement.

The vast majority of non-melanoma skin cancer (NMSC) is attributable to excessive exposure to ultraviolet radiation (UVR). Outdoor workers are exposed to an UVR dose at least 2 to 3 times higher than indoor workers and often to daily UVR doses 5 times above internationally recommended limits. The risk of UVR workplace exposure is vastly neglected, and the evident future challenges presented in this statement are contrasted with the current situation regarding legal recognition, patient care and compensation. While prevention is crucial to reduce cancer risks for outdoor workers, it is as much of relevance to better protect them through legally binding rules and regulations. Specific actions are outlined in five recommendations based on a Call to Action (table 1). The role of health professionals, including dermatologists, in this context is crucial.

Basal cell carcinoma risk and solar UV exposure in occupationally relevant anatomic sites: do histological subtype, tumor localization and Fitzpatrick phototype play a role? A population-based case-control study.

BACKGROUND: A two-fold risk increase to develop basal cell carcinoma was seen in outdoor workers exposed to high solar UV radiation compared to controls. However, there is an ongoing discussion whether histopathological subtype, tumor localization and Fitzpatrick phototype may influence the risk estimates. OBJECTIVES: To evaluate the influence of histological subtype, tumor localization and Fitzpatrick phototype on the risk to develop basal cell carcinoma in highly UV-exposed cases and controls compared to those with moderate or low solar UV exposure. METHODS: Six hundred forty-three participants suffering from incident basal cell carcinoma in commonly sun-exposed anatomic sites (capillitium, face, lip, neck, dorsum of the hands, forearms outside, décolleté) of a population-based, case-control, multicenter study performed from 2013 to 2015 in Germany were matched to controls without skin cancer. Multivariate logistic regression analysis was conducted stratified for histological subtype, phototype 1/2 and 3/4. Dose-response curves adjusted for age, age2, sex, phototype and non-occupational UV exposure were calculated. RESULTS: Participants with high versus no (OR 2.08; 95% CI 1.24-3.50; p = 0.006) or versus moderate (OR 2.05; 95% CI 1.15-3.65; p = 0.015) occupational UV exposure showed a more than two-fold significantly increased risk to develop BCC in commonly UV-exposed body sites. Multivariate regression analysis did not show an influence of phototype or histological subtype on risk estimates. The restriction of the analysis to BCC cases in commonly sun-exposed body sites did not influence the risk estimates. The occupational UV dosage leading to a 2-fold increased basal cell carcinoma risk was 6126 standard erythema doses. CONCLUSION: The risk to develop basal cell carcinoma in highly occupationally UV-exposed skin was doubled consistently, independent of histological subtype, tumor localization and Fitzpatrick phototype.

The evolving field of Dermato-oncology and the role of dermatologists: Position Paper of the EADO, EADV and Task Forces, EDF, IDS, EBDV-UEMS and EORTC Cutaneous Lymphoma Task Force.

BACKGROUND: The incidence of skin cancers has been increasing steadily over the last decades. Although there have been significant breakthroughs in the management of skin cancers with the introduction of novel diagnostic tools and innovative therapies, skin cancer mortality, morbidity and costs heavily burden the society. OBJECTIVE: Members of the European Association of Dermato-Oncology, European Academy of Dermatology and Venereology, International Dermoscopy Society, European Dermatology Forum, European Board of Dermatovenereology of the European Union of Medical Specialists and EORTC Cutaneous Lymphoma Task Force have joined this effort to emphasize the fundamental role that the specialist in Dermatology-Venereology has in the diagnosis and management of different types of skin cancer. We review the role of dermatologists in the prevention, diagnosis, treatment and follow-up of patients with melanoma, non-melanoma skin cancers and cutaneous lymphomas, and discuss approaches to optimize their involvement in effectively addressing the current needs and priorities of dermato-oncology. DISCUSSION: Dermatologists play a crucial role in virtually all aspects of skin cancer management including the implementation of primary and secondary prevention, the formation of standardized pathways of care for patients, the establishment of specialized skin cancer treatment centres, the coordination of an efficient multidisciplinary team and the setting up of specific follow-up plans for patients. CONCLUSION: Skin cancers represent an important health issue for modern societies. The role of dermatologists is central to improving patient care and outcomes. In view of the emerging diagnostic methods and treatments for early and advanced skin cancer, and considering the increasingly diverse skills, knowledge and expertise needed for managing this heterogeneous group of diseases, dermato-oncology should be considered as a specific subspecialty of Dermatology-Venereology.