Determinants of Quality of Life in Patients with Post-Thrombotic Syndrome.

BACKGROUND: Chronic post-thrombotic syndrome (PTS) may develop in up to 50% of patients after deep vein thrombosis (DVT), and may reduce patients' quality of life (QoL). We aimed to evaluate the association of PTS severity with QoL in patients with proximal DVT submitted for medical treatment and also to identify modifiable and non-modifiable risk factors related to PTS. METHODS: Patients with iliac or femoropopliteal DVT observed in Vascular Surgery consultation in our institution from 1 year period with unilateral DVT were selected. Patients with total vein recanalization were excluded. Villalta scale was applied to assess PTS degree and VEINES-QoL/Sym questionnaire was used as a disease-specific QoL measure. Correlation between PTS degree and VEINES-QoL/Sym score and predictors of PTS were determined. RESULTS: Fifty-six patients were accepted to enter the study. From those, 66.1% were female, 64.3% (n = 36) had iliac and 35.7% (n = 20) femoropopliteal DVT. PTS was present in 52.8% of iliac and 65.0% of femoropopliteal DVT patients observed for consultation (P = 0.41). There was a significant correlation with PTS degree and both VEINES-QoL and VEINES-Sym scores (P < 0.01). Major depression (odds ratio OR = 5.63, P = 0.04) and regular wear of compressing stockings (OR = 4.69, P = 0.04) were the only independent factors associated with PTS. Patients with depression had lower QoL scores, while patients with PTS who wear compression stockings had similar QoL scores compared to patients without PTS. Ultrasound alterations (OR = 3.28, P = 0.17), age, gender, iliac DVT, multiple DVT and time after DVT (P > 0.20) were not associated with PTS syndrome. CONCLUSIONS: VEINES-QoL/Sym had moderate inverse correlation with PTS degree. Depression was associated with both PTS and lower QoL scores. Patients with PTS criteria compliant to wearing compressing stockings had similar QoL scores to patients without PTS.

Abdominal Aortic Aneurysms and Q Fever: An Odd Connection to Keep in Mind.

Abdominal aortic aneurysms (AAAs) secondary to Coxiella burnetii infections are rare but carry important implications. The diagnosis is difficult due to unspecific symptoms. To the authors' knowledge, this is the first AAA caused by chronic Q fever treated with an endoprosthesis.

Prognostic Value of Charlson Comorbidity Index in Acute Embolic Lower Limb Ischaemia Patients.

INTRODUCTION: Charlson Comorbidity Index (CCI) is commonly used in outcome studies to adjust for patient comorbid conditions but has not been specifically validated for use in acute embolic lower limb ischaemia (AELLI). OBJECTIVES: The aim of this study was to access whether a high CCI score unadjusted (CCIu) and adjusted (CCIa) by age relates to major amputation and mortality after a first episode of AELLI. METHODS: The last 100 patients presenting with the first event of AELLI submitted to embolectomy at our Vascular Surgery Department were retrospectively evaluated. Patient characteristics, pre- and post-operative period variables were collected and CCIu and CCIa calculated. Survival predictors were analyzed using Cox regression. The area under the curve of the receiver operating characteristic curves was calculated to validate and determine the discriminating ability of CCIu and CCIa in predicting amputation rate and 30-day mortality. Youden index was used to determine the critical value. Survival analysis was performed with Kaplan-Meier method and differences between survival curves were tested with Log-Rank test. A P value of <0.05 was considered statistically significant. RESULTS: The mean age was 80.03±10.776 years and the mean follow-up 19.28±7.929 months. Amputation rate was 16%, 30-day mortality 21% and long-term mortality 42%. Patients with CCIu≥3 compared with patients with CCIu<3 had higher amputation rate (37.5% vs. 1.7%; OR:35.400), 30-day mortality (47.5% vs. 3.3%; OR:35.400) and global mortality (P=0.00). Also, patients with CCIa≥6 compared with patients with CCIa<6 had higher amputation rate (34.1% vs. 1.8%; OR:28.488), 30-day mortality (47.7% vs. 0.0%) and global mortality (P=0.00). Multivariate analysis showed that both CCIu and CCIa were independent predictors of amputation rate and 30-day mortality. CONCLUSION: CCIu and CCIa have proven to be good predictors of amputation rate and survival, thus being a valuable prognostic factor in patients presenting with the first event of AELLI.

Impact of Total Psoas Area and Lean Muscular Area on Mortality after Endovascular Aortic Aneurysm Repair.

BACKGROUND: Sarcopenia has assumed growing relevance as a morbimortality predictor after major abdominal surgery. The aim of this study is to access total psoas muscle area (TPA) and lean muscle area (LMA) impact in morbimortality after elective endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Asymptomatic patients submitted to aortic endoprosthesis implantation between January 1, 2014 and December 31, 2018 at our vascular surgery department were retrospectively evaluated. After exclusion criteria were applied, 105 patients were included in the study; preoperative computed tomography scans were evaluated using OSIRIX software (Bernex, Switzerland). Two observers independently calculated TPA at the most caudal level of the L3 vertebra and respective density, therefore calculating LMA. Patients were separated by tertiles with the lowest being considered sarcopenic and with higher muscle steatosis and compared with the higher tertiles. Patient demographics and intraoperative and postoperative period variables were collected. Charlson comorbidity index was calculated and surgical complications classified according to Clavien-Dindo. The intraclass correlation coefficient and Bland-Altman plot were made to characterize interobserver variability. Survival analysis was performed with the Kaplan-Meier method, and differences between survival curves were tested with the log-rank test. The effect of sarcopenia on patient survival was assessed using Cox proportional hazard models. RESULTS: Considering TPA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.03), whereas multivariate analyses showed increased likelihood of mortality (P = 0.039, hazard ratio (HR) 3.829). For LMA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.013), whereas multivariate analyses showed increased likelihood of mortality (P = 0.026, HR 4.153). When analyzing patients in the lowest tertile of both TPA and LMA, both univariate (P = 0.002) and multivariate (P = 0.018, HR 4.166) analyses reveled inferior survival. CONCLUSIONS: Our study reveals reduced survival in patients with low TPA and low LMA submitted to elective EVAR; these factors should probably be taken into consideration in the future for preoperative risk evaluation and surgical planning.

Is There an Impact of COVID-19 on Admission of Patients to the Emergency Department for Vascular Surgery?

BACKGROUND: On March 2020, the World Health Organization declared the coronavirus disease 2019 outbreak a pandemic. During this period, surgical activity and admission to the Emergency Department (ED) decreased globally. The aim of this article is to understand how the admission of a patient to the ED for vascular surgery changed in our center in Portugal and if this situation prevented urgent surgical procedures. METHODS: Through a retrospective study, we compared the volume of patients admitted to the ED during the emergency state (ES) in Portugal with the same period in 2019. In addition, we analyzed the urgent surgical activity during the ES and in the correspondent period of the previous 10 years, regarding limb acute ischemia, acute aortic pathology, and vascular trauma. Two groups of patients were formed-patients operated during the ES and during the non-ES, for control. Statistical analysis was performed using IBM SPSS® Statistics, version 25. RESULTS: In the ES, 115 patients were observed at the ED and 179 in the 2019 corresponding period. During the ES, patients significantly recurred less to the ED directly from home (P < 0.001) and were less referred to the ED by primary care doctors (P < 0.001). Patients observed at the ED were significantly more urgent-required urgent surgery or were admitted to the department-than those in 2019 (40% vs. 24%). However, there were no differences when only considering urgent surgery (14% in ES vs. 10% in 2019). In the ES, 38% of patients observed at the ED were discharged with no follow-up related to vascular surgery against 60% in 2019, although this difference was not significant. Compared with the preceding 10 years, there are not significant differences in the number of patients who underwent urgent surgery in both ES and non-ES periods. In patients with acute limb ischemia, we did not find an increase in the time between onset of symptoms and ED admission, during the ES. CONCLUSIONS: Fewer patients were admitted at the ED during the ES, and those admitted were significantly more urgent. We did not find a decrease in the number of urgent surgeries when compared with the preceding 10 years. Therefore, we cannot assume that coronavirus pandemic precluded urgent surgical procedures.

Bullous Pemphigoid in a Patient with Longstanding Hailey-Hailey Disease Complicated by Eczema Herpeticum: Managing the Coexistence of Three Different Blistering Conditions.

Hailey-Hailey disease (HHD), or chronic benign familial pemphigus, is a rare inherited acantholytic dermatosis, characterized by chronic, recurrent vesicles, erosions, and maceration in intertriginous sites. We present a case of a male patient with longstanding HHD who presented with an acute exacerbation characterized by the worsening of pre-existing lesions but also with the appearance of new large, tense bullae on an erythematous base in the areas of the groin (i.e., inguinal region), trunk, and arms, associated with intense pruritus. Blood work revealed eosinophilia. Histopathology and direct immunofluorescence were compatible with the diagnosis of bullous pemphigoid (BP). Indirect immunofluorescence showed positivity for autoantibodies to BP antigen 180. We started oral methylprednisolone, oral antihistamines, and local care with potassium permanganate baths, a potent corticosteroid, and fusidic acid, with resulting improvement of the lesions. The case was further complicated by the occurrence of eczema herpeticum, which was successfully treated with acyclovir. At the time of discharge from the hospital, the patient was medicated with a low dose of oral steroid and oral doxycycline. During a later examination, the lesions had totally disappeared, but the skin had some residual hyperpigmented patches and excoriated papules. This case was a diagnostic challenge due to the simultaneous occurrence of three distinct bullous diseases with different etiopathogeneses. To our knowledge, there are no other reports of the coexistence of HHD and BP in the literature.

The clinical spectrum of dermatomyositis and the new autoantibodies - with regard to two clinical cases with distinct associations.

Dermatomyositis is a rare idiopathic inflammatory myopathy associated with different autoantibodies (anti-MDA5, anti-TIF1-γ) which are linked with typical and distinct phenotypes of dermatomyositis. We describe two cases that illustrate these diverse cutaneous and systemic manifestations.