Implementación de paquete de medidas de conductas perinatales en recién nacidos con gastrosquisis congénita / Implementation of a perinatal bundles measures in newborns with congenital gastroschisis / ¿Implementação de um pacote de medidas comportamentais perinatais em recém-nascidos com gastrosquise congénita

Introducción: la gastrosquisis congénita (GC) es una patología con creciente demanda asistencial. Atentos a esto, en el Centro Hospitalario Pereira Rossell (CHPR) se implementó un protocolo de cuidados llevado adelante por un equipo multidisciplinario. En este trabajo nos proponemos evaluar el impacto en la sobrevida y morbilidad a partir de su aplicación. Material y método: estudio comparativo tipo antes y después de pacientes portadores de GC (n = 47), 29 de una cohorte histórica (GH) y 18 de una cohorte posaplicación de protocolo (GP). Con edad gestacional ≥ 36 semanas y peso al nacer ≥ 2500 g, asistidos en el CHPR entre los años 2016 y 2021. Resultados: no se observaron diferencias perinatales entre ambos grupos, ni en la incidencia de GQ complicadas. En el GP se observó mayor incidencia de cierre abdominal precoz (p < 0,01), menor necesidad de realización de silo quirúrgico (p < 0,01), menor tiempo de administración de ventilación mecánica (p = 0,03), de uso total de opioides (p < 0,01), de administración de nutrición parenteral (p = 0,03), e inicio más temprano de la alimentación enteral (p = 0,03). Sin diferencias en la sobrevida al egreso hospitalario. Conclusiones: la aplicación de un protocolo estandarizado se asoció a una reducción significativa en el tiempo de cierre abdominal, de ventilación mecánica, nutrición parenteral y de opioides, con inicio más precoz de la nutrición enteral.

Introduction: congenital gastroschisis is an increasingly demanded pathology, therefore a care protocol was implemented at the Pereira Rossell Pediatric Hospital (CHPR), and it has been carried out by a multidisciplinary team. In this paper, we aim at assessing the morbidity and mortality impact of survival and morbidity of this application. Materials and Methods: comparative before and after study of a historical cohort (GH, n=29) versus a post-protocol application cohort (GP, n=18), in patients with a gestational age ≥36 weeks and birth weight ≥2500 grams assisted in CHPR between 2016-2021. Results: no perinatal differences were observed between both groups or in the incidence of complicated GQ. In the GP, a higher incidence of early abdominal closure was decreased (GH 3.4% vs GP 67%, p<0.01), less need to perform a surgical silo (GH 100% vs GP 33%, p<0.01 ), shorter mechanical ventilation administration time (GH 2 days vs GP 0.5 days, p=0.03), total use of opioids (GH 3.5 days vs GP 7 days, p<0.01) , of administration of parenteral nutrition (GH 24.5 days vs GP 20 days, p=0.03), and earlier start of enteral feeding (GH 11 days vs GP 7 days, p=0.03). No differences in survival after hospital discharge (93% vs 89%, p=0.63). Conclusions: the application of a standardized protocol was linked to a significant reduction in the time of abdominal closure, mechanical ventilation, parenteral nutrition, and opioids, with earlier initiation of enteral nutrition.

Introdução: a gastrosquise congênita (GC) é uma patologia com demanda crescente de atendimento e, porém, foi implementado um protocolo de atendimento por equipe multidisciplinar no Centro Hospitalar Pediátrico Pereira Rossell (CHPR). Neste trabalho propomos avaliar o impacto na mortalidade e morbidade depois de sua aplicação. Material e Métodos: estudo comparativo antes e depois de pacientes com CG (n=47), sendo 29 de uma coorte histórica (GH) e 18 de uma coorte pós-aplicação de protocolo (GP). Idade gestacional ≥ 36 semanas e peso ao nascer ≥ 2.500 gramas atendidos no CHPR entre os anos de 2016-2021. Resultados: não foram observadas diferenças perinatais entre os dois grupos ou na incidência de QG complicada. No GP observou-se maior incidência de fechamento abdominal precoce (p<0,01), menor necessidade de silos cirúrgicos (p<0,01), menor tempo de administração de ventilação mecânica (p=0,03) e uso total de opioides. (p<0,01), administração de nutrição parenteral (p=0,03) e início mais precoce da alimentação enteral (p=0,03). Não houve diferenças na sobrevivência até a alta hospitalar. Conclusões: a aplicação de protocolo padronizado foi associada à redução significativa do tempo de fechamento abdominal, ventilação mecânica, nutrição parenteral e opioides, com início mais precoce da nutrição enteral.

Implementation Science Perspectives on Implementing Telemedicine Interventions for Hypertension or Diabetes Management: Scoping Review.

BACKGROUND: Hypertension and diabetes are becoming increasingly prevalent worldwide. Telemedicine is an accessible and cost-effective means of supporting hypertension and diabetes management, especially as the COVID-19 pandemic has accelerated the adoption of technological solutions for care. However, to date, no review has examined the contextual factors that influence the implementation of telemedicine interventions for hypertension or diabetes worldwide. OBJECTIVE: We adopted a comprehensive implementation research perspective to synthesize the barriers to and facilitators of implementing telemedicine interventions for the management of hypertension, diabetes, or both. METHODS: We performed a scoping review involving searches in Ovid MEDLINE, Embase, CINAHL, Cochrane Library, Web of Science, and Google Scholar to identify studies published in English from 2017 to 2022 describing barriers and facilitators related to the implementation of telemedicine interventions for hypertension and diabetes management. The coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research. RESULTS: Of the 17,687 records identified, 35 (0.2%) studies were included in our scoping review. We found that facilitators of and barriers to implementation were dispersed across the constructs of the Consolidated Framework for Implementation Research. Barriers related to cost, patient needs and resources (eg, lack of consideration of language needs, culture, and rural residency), and personal attributes of patients (eg, demographics and priorities) were the most common. Facilitators related to the design and packaging of the intervention (eg, user-friendliness), patient needs and resources (eg, personalized information that leveraged existing strengths), implementation climate (eg, intervention embedded into existing infrastructure), knowledge of and beliefs about the intervention (eg, convenience of telemedicine), and other personal attributes (eg, technical literacy) were the most common. CONCLUSIONS: Our findings suggest that the successful implementation of telemedicine interventions for hypertension and diabetes requires comprehensive efforts at the planning, execution, engagement, and reflection and evaluation stages of intervention implementation to address challenges at the individual, interpersonal, organizational, and environmental levels.

Manejo del paciente anticoagulado en una cirugía dental / Management of the anticoagulated patient in dental surgery / Gerenciamento do paciente anticoagulado em cirurgia odontológica

Introducción: una adecuada hemostasia es crucial para el éxito del tratamiento odontológico invasivo, ya que los problemas de sangrado pueden dar lugar a complicaciones asociadas a una importante morbimortalidad. El tratamiento odontológico de pacientes que tienden a un mayor riesgo de sangrado debido al uso de fármacos anticoagulantes plantea un desafío en la práctica diaria de los profesionales de la odontología. El conocimiento adecuado de los mecanismos subyacentes a la hemostasia y el manejo optimizado de estos pacientes son, por lo tanto, cuestiones muy importantes. Se realiza un estudio de los fármacos anticoagulantes actualmente disponibles en el mercado, evaluando los riesgos y beneficios de suspender dicho fármaco previo a un tratamiento odontológico invasivo. Además, se hace una revisión de los protocolos de manejo actuales que se utilizan en estos pacientes. Material y métodos: se realizó una búsqueda bibliográfica en las bases de datos Epistemonikos y Medline/PubMed; en el portal Timbó y en la biblioteca virtual Scielo. Abarcando todos los estudios publicados en los últimos 15 años en inglés y español. Se encontraron 30 artículos, se seleccionaron 15 en primera instancia para finalizar con 11 artículos. En dicha selección el filtro fue que los demás artículos se referían a otros anticoagulantes que no eran parte de este trabajo. Resultados: se han desarrollado múltiples protocolos de manejo, aunque en todos los casos se requiere una historia clínica completa, junto con pruebas hemostáticas complementarias para minimizar los riesgos derivados del tratamiento odontológico. Discusión: muchos autores consideran que la medicación de los pacientes indicada para el tratamiento de una enfermedad de base no debe ser alterada o suspendida a menos que así lo indique el médico prescriptor. Se ha demostrado que las medidas hemostáticas locales son suficientes para controlar los posibles problemas de sangrado derivados del tratamiento dental.

Introduction: Adequate hemostasis is crucial for the success of invasive dental treatment, since bleeding problems can lead to complications associated with significant morbidity and mortality. The dental treatment of patients who are prone to an increased risk of bleeding due to the use of anticoagulant drugs poses a challenge in the daily practice of dental professionals. Adequate knowledge of the mechanisms underlying hemostasis and optimized management of these patients are therefore very important issues. A review is made of the anticoagulant drugs currently available on the market, evaluating the risks and benefits of suspending such a drug prior to invasive dental treatment. In addition, a review is made of the current management protocols used in these patients. Material and methods: A bibliographic search was carried out in the Epistemonikos and Medline/PubMed databases; in the Timbo portal and in the Scielo virtual library. All the studies published in the last 15 years in English and Spanish were included. Thirty articles were found, 15 were selected in the first instance to end up with 11 articles. In this selection, the filter was that the other articles referred to other anticoagulants that were not part of this work. Results: multiple management protocols have been developed, although in all cases a complete clinical history is required, together with complementary hemostatic tests to minimize the risks derived from dental treatment. Discussion: many authors consider that the patient's medication indicated for the treatment of an underlying disease should not be altered or suspended unless so indicated by the prescribing physician. It has been shown that local hemostatic measures are sufficient to control possible bleeding problems derived from dental treatment.

Introdução: A hemostasia adequada é crucial para o sucesso do tratamento dentário invasivo, pois problemas de sangramento podem levar a complicações associadas a uma morbidade e mortalidade significativas. O tratamento odontológico de pacientes que são propensos a um risco maior de sangramento devido ao uso de drogas anticoagulantes representa um desafio na prática diária dos profissionais da odontologia. O conhecimento adequado dos mecanismos subjacentes à hemostasia e o gerenciamento otimizado desses pacientes são, portanto, questões muito importantes. É realizada uma revisão dos anticoagulantes atualmente disponíveis no mercado, avaliando os riscos e benefícios de descontinuar tal medicamento antes do tratamento dentário invasivo. Além disso, é feita uma revisão dos protocolos de gerenciamento atuais usados nesses pacientes. Material e métodos: Foi realizada uma pesquisa bibliográfica nas bases de dados Epistemonikos e Medline/PubMed; no portal Timbo e na biblioteca virtual Scielo. Todos os estudos publicados nos últimos 15 anos, em inglês e espanhol, foram incluídos. Trinta artigos foram encontrados, 15 foram selecionados em primeira instância para acabar com 11 artigos. Nesta seleção, o filtro foi que os outros artigos se referiam a outros anticoagulantes que não faziam parte deste trabalho. Resultados: foram desenvolvidos múltiplos protocolos de gerenciamento, embora em todos os casos seja necessário um histórico clínico completo, juntamente com testes hemostáticos complementares para minimizar os riscos derivados do tratamento odontológico. Discussão: muitos autores consideram que a medicação os pacientes indicada para o tratamento de uma doença subjacente não deve ser alterada ou descontinuada, a menos que o médico que a prescreve dê instruções nesse sentido. Medidas hemostáticas locais demonstraram ser suficientes para controlar potenciais problemas de sangramento resultantes do tratamento odontológico.

Management of DOAC in Patients Undergoing Planned Surgery or Invasive Procedure: Italian Federation of Centers for the Diagnosis of Thrombotic Disorders and the Surveillance of the Antithrombotic Therapies (FCSA) Position Paper.

Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. About a quarter of the anticoagulated patients require temporary cessation of direct oral anticoagulants (DOACs) or vitamin K antagonists for a planned intervention within 2 years from anticoagulation inception. Several clinical issues about DOAC interruption remain unanswered: many questions are tentatively addressed daily by thousands of physicians worldwide through an experience-based balancing of thrombotic and bleeding risks. Among possible valuable answers, the Italian Federation of Centers for the diagnosis of thrombotic disorders and the Surveillance of the Antithrombotic therapies (FCSA) proposes some experience-based suggestions and expert opinions. In particular, FCSA provides practical guidance on the following issues: (1) multiparametric assessment of thrombotic and bleeding risks based on patients' individual and surgical risk factor, (2) testing of prothrombin time, activated partial thromboplastin time, and DOAC plasma levels before surgery or invasive procedure, (3) use of heparin, (4) restarting of full-dose DOAC after high risk bleeding surgery, (5) practical nonpharmacological suggestions to manage patients perioperatively. Finally, FCSA suggests creating a multidisciplinary "anticoagulation team" with the aim to define the optimal perioperative management of anticoagulation.

Effect of electronic medication reconciliation at the time of hospital discharge on inappropriate medication use in the community: an interrupted time-series analysis.

BACKGROUND: It is unclear if enhanced electronic medication reconciliation systems can reduce inappropriate medication use and improve patient care. We evaluated trends in potentially inappropriate medication use after hospital discharge before and after adoption of an electronic medication reconciliation system. METHODS: We conducted an interrupted time-series analysis in 3 tertiary care hospitals in London, Ontario, using linked health care data (2011-2019). We included patients aged 66 years and older who were discharged from hospital. Starting between Apr. 13 and May 21, 2014, physicians were required to complete an electronic medication reconciliation module for each discharged patient. As a process outcome, we evaluated the proportion of patients who continued to receive a benzodiazepine, antipsychotic or gastric acid suppressant as an outpatient when these medications were first started during the hospital stay. The clinical outcome was a return to hospital within 90 days of discharge with a fall or fracture among patients who received a new benzodiazepine or antipsychotic during their hospital stay. We used segmented linear regression for the analysis. RESULTS: We identified 15 932 patients with a total of 18 405 hospital discharge episodes. Before the implementation of the electronic medication reconciliation system, 16.3% of patients received a prescription for a benzodiazepine, antipsychotic or gastric acid suppressant after their hospital stay. After implementation, there was a significant and immediate 7.0% absolute decline in this proportion (95% confidence interval [CI] 4.5% to 9.5%). Before implementation, 4.1% of discharged patients who newly received a benzodiazepine or antipsychotic returned to hospital with a fracture or fall within 90 days. After implementation, there was a significant and immediate 2.3% absolute decline in this outcome (95% CI 0.3% to 4.3%). INTERPRETATION: Implementation of an electronic medication reconciliation system in 3 tertiary care hospitals reduced potentially inappropriate medication use and associated adverse events when patients transitioned back to the community. Enhanced electronic medication reconciliation systems may allow other hospitals to improve patient safety.

AHA/ACC vs ESC Guidelines for Management of Adults With Congenital Heart Disease: JACC Guideline Comparison.

The American Heart Association and American College of Cardiology published practice guidelines for the management of adult congenital heart disease in 2018 and the European Society of Cardiology published analogous guidelines in 2020. Although there are broad areas of consensus between the 2 documents, there are important differences that impact patient management. This review discusses key areas of agreement and disagreement between the 2 guidelines, with discussion of possible reasons for disagreement and potential implications.

Targeting Higher Intraoperative Blood Pressures Does Not Reduce Adverse Cardiovascular Events Following Noncardiac Surgery.

BACKGROUND: Intraoperative arterial hypotension is strongly associated with postoperative major adverse cardiovascular events (MACE); however, whether targeting higher intraoperative mean arterial blood pressures (MAPs) may prevent adverse events remains unclear. OBJECTIVES: This study sought to determine whether targeting higher intraoperative MAP lowers the incidence of postoperative MACE. METHODS: This single-center randomized controlled trial assigned adult patients at cardiovascular risk undergoing major noncardiac surgery to an intraoperative MAP target of ≥60 mm Hg (control) or ≥75 mm Hg (MAP ≥75). The primary outcome was acute myocardial injury on postoperative days 0-3 and/or 30-day MACE/acute kidney injury (AKI) (acute coronary syndrome, congestive heart failure, coronary revascularization, stroke, AKI, and all-cause mortality). The secondary outcome was 1-year MACE. RESULTS: In total, 458 patients were randomized (intention-to-treat population: 451). The cumulative intraoperative duration with MAP <65 mm Hg was significantly shorter in the MAP ≥75 group (median 9 minutes [interquartile range: 3 to 24 minutes] vs 23 minutes [interquartile range: 8-49 minutes]; P < 0.001). The primary outcome incidence was 48% for MAP ≥75 and 52% for control (risk difference -4.2%; 95% CI: -13% to +5%), the primary contributor being AKI (incidence 44%). Acute myocardial injury occurred in 15% (MAP ≥75) and 19% (control) of patients. The secondary outcome incidence was 17% for MAP ≥75 and 15% for control (risk difference +2.7; 95% CI: -4% to +9.5%). CONCLUSIONS: These findings do not support universally targeting higher intraoperative blood pressures to reduce postoperative complications. Despite a 60% reduction in hypotensive time with MAP <65 mm Hg, no significant reductions in acute myocardial injury or 30-day MACE/AKI could be found. (Biomarkers, Blood Pressure, BIS: Risk Stratification/Management of Patients at Cardiac Risk in Major Noncardiac Surgery [BBB]; NCT02533128).

Care management in a French cohort with Down syndrome from the AnDDI-Rares/CNSA study.

Down syndrome (DS) is a genetic neurodevelopmental disorder. In individuals with DS, a multidisciplinary approach to care is required to prevent multiple medical complications. The aim of this study was to describe the rehabilitation, medical care, and educational and social support provided to school-aged French DS patients with varying neuropsychological profiles. A mixed study was conducted. Quantitative data were obtained from a French multicentre study that included patients aged 4-20 years with diverse genetic syndromes. Qualitative data were collected by semi-structured face-to-face interviews and focus groups. Ninety-five DS subjects with a mean age of 10.9 years were included. Sixty-six per cent had a moderate intellectual disability (ID) and 18.9% had a severe ID. Medical supervision was generally multidisciplinary but access to medical specialists was often difficult. In terms of education, 94% of children under the age of six were in typical classes. After the age of 15, 75% were in medico-social institutions. Analysis of multidisciplinary rehabilitation conducted in the public and private sectors revealed failure to access physiotherapy, psychomotor therapy and occupational therapy, but not speech therapy. The main barrier encountered by patients was the difficulty accessing appropriate facilities due to a lack of space and long waiting lists. In conclusion, children and adolescents with DS generally received appropriate care. Though the management of children with DS has been improved considerably, access to health facilities remains inadequate.

Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics.

OBJECTIVE: Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. METHODS: A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. RESULTS: One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. CONCLUSIONS: Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.

Management of the major complications of cirrhosis: Beyond guidelines.

Along with a growing understanding of the pathophysiology of cirrhosis and its complications, new therapies and management strategies have emerged in recent years. Many of these advances have helped inform the current EASL clinical practice guidelines1 on the management of some of the key complications of cirrhosis, such as ascites, variceal bleeding and infection. However, there are still some aspects of management where the evidence base is less clear, and/or where opinions amongst practitioners remain divided. Some of these more controversial areas are explored in this section, wherein we present evidence culminating in a suggested management approach based on expert opinion and extending beyond the current guidelines.

The TIMI Study Group's Contributions to the Advancement of Cardiology -With Focus on Atherosclerotic Cardiovascular Disease.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality across the world, warranting continuous research in this field. The elucidation of the atherogenesis mechanism is considered one of the most relevant scientific accomplishments of the last century. This has led to the clinical development of various novel therapeutic interventions for patients with or at risk of ASCVD, in which randomized clinical trials played a crucial role.The Thrombolysis in Myocardial Infarction (TIMI) Study Group was initially established to conduct a clinical trial studying thrombolysis for treatment of myocardial infarction. However, over the years, the TIMI Study Group has expanded their research interests to include antithrombotic therapy, lipid lowering, anti-diabetes, anti-obesity, and even heart failure. By leading large-scale, international, randomized, controlled trials of novel therapeutics, the TIMI Study Group has helped shape the very practice of cardiovascular medicine for over a quarter of a century, and decades of research continue to provide future promise for further advancement. Through a mutual goal to improve the care of ASCVD patients, the Japanese scientific community has become one of the important contributors to the TIMI Study Group's clinical research.In this review article, the authors aim to summarize major research lead by the TIMI Study Group in the ASCVD field.

A Snapshot of Lipid-Reporting Practices in Canadian Clinical Laboratories: An Urgent Need for Harmonisation.

To effectively implement the Canadian Cardiovascular Society (CCS) guidelines for dyslipidemia management into clinical laboratories, clear recommendations for lipid reporting are essential. In this study, the Canadian Society of Clinical Chemists Working Group on Reference Interval Harmonisation surveyed Canadian laboratories on adult lipid reporting practices to set a foundation for the development and implementation of harmonised lipid reporting across Canada. Key aspects of the survey asked laboratories: what reporting parameters were in place to assess lipid results; what interpretative comments were provided; whether nonfasting lipids were permitted and, if so, what strategy was used to document fasting status; and whether there was interest in implementing a harmonised lipid report. A total of 101 laboratories were represented by 24 respondents, as many responses were submitted by laboratory networks that included more than 1 laboratory. There was at least 1 response from 9 Canadian provinces and representation across 5 testing platforms. Upper and lower limits for lipid parameters and referenced source of limits varied substantially across laboratories, with only 56% of laboratories (9 respondents) referencing the 2016 CCS guidelines. Eighty-six percent of laboratories (19 respondents) report nonfasting lipids, although the method of documenting nonfasting status varied. Overall, 36% of laboratories (8 respondents) reported interest in implementing a harmonised lipid report. Assessment of current lipid-reporting practices supports the need for harmonised lipid reporting across Canada. Development of a harmonised lipid report for the adult population, consistent with up-to-date Canadian guidelines, will improve continuity of lipid test interpretation across Canada and improve clinical decision making.

Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease.

Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery.Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.