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As the focus of the COVID-19 crisis is gradually taken away from emergency healthcare needs, increased attention is warranted on the psychological impact of the pandemic on a global level. Existing guidance on managing the COVID-19 related distress needs to be better informed by upcoming larger-scale research. Applying e-Health can be useful in dealing with the immediate psychological needs, while developing strategies to identify vulnerable populations and shifting the provision of mental health and social care to community services need to be prioritised when looking at the future. Focusing on global mental health during this universal crisis is an opportunity for promoting a more compassionate and less discriminating society.

There is ongoing scientific interest regarding comorbidities associated with the metabolic syndrome (MeTS). MeTS comprises a combination of parameters that predispose individuals to the development of type 2 diabetes and cardiovascular disease (CVD). Three or more of the following criteria are necessary: fasting glucose > 110 mg/dl (5.6 mmol/l), hypertriglyceridemia > 150 mg/dl (1.7 mmol/l), HDL levels 130/85 mmHg, waist circumference (values for Mediterranean populations > 94 cm (men)/> 89 cm (women). In this review we attempted to summarize relevant data by searching dermatological literature regarding associations between various skin conditions and MeTS. A multitude of studies was retrieved and a further goal of the present article is to present plausible mechanistic connections. The severity of skin conditions like psoriasis has been linked with MeTS. Parameters of MeTS like insulin resistance are present in patients with early onset androgenic alopecia, hidradenitis suppurativa acne and rosacea. Since MeTS can lead to CVD and type 2 diabetes early detection of patients would be very important. Also therapeutic intervention on MeTS could lead to improvement on the severity of skin conditions. This reciprocal relationship between skin diseases and MeTS in our opinion holds great interest for further investigation.

Coronary arteriovenous fistulae are a coronary anomaly, presenting in 0.002% of the general population. Their etiology can be congenital or acquired. We present a review of recent literature related to their epidemiology, etiology, pathophysiology, clinical presentation, diagnostic approach, and therapeutic management.

We read with interest the manuscript by Wu and Chen and we would like to comment on the surgical complications of intracardiac pacemaker implantation [1]. The use of permanent pacemakers (PPM) and implantable cardioverter-defibrillators (ICD) is increasing due to the expansion of indications and aging of the population. As a consequence, cardiologists and cardiothoracic surgeons have to deal with a broad spectrum of complications, which are sometimes under-estimated and life-threatening. The surgical complications of PPM and ICD may occur during the immediate or early post-operative period and can be related to venous access process (pneumothorax, hemothorax, air embolism, haematoma, arterial puncture, wound healing problems, infection, pain), to the pacemaker lead (cardiac perforation, tamponade, malposition or dislodgement of the lead), or to the generator device. In addition, other complicationed that may occur during the late post-operative period are related to infections, thrombosis, endocarditis, pulmonary embolism, superior vena cava (SVC) syndrome (due to thrombus formation and/or fibrosis of the pacing wires within the SVC) and pericarditis [2-5]. Ostovan and Aslani have reported on the successful treatment of massive pulmonary air embolism during a PPM implantation with air suctioning by the guide catheter inserted into main pulmonary artery via the left femoral vein. Treatment for air embolisms includes oxygen treatment, haemodynamic support and prevention of further air entry in the systemic circulation. The left lateral decubitus position can prevent the air obstruction of the pulmonary outflow tract (air can be moved toward the right ventricular apex) [2]. Aggarwal et al. found no difference in the incidence of intraoperative and early postoperative complications (up to two months after implantation) between single and dual chamber pacing systems [3]. Sohail et al., in their retrospective review of 189 patients with pacemaker related infections, found out that the most common clinical presentations were generator pocket infection (69%) and device-related endocarditis (23%). The leading pathogens were Coagulase-negative Staphylococci and Staphylococcus aureus, in 42% and 29% of cases, respectively. There was a broad spectrum of related complications such us septic arthritis, sternal or vetebral or femoral osteomyelitis, and abscesses in lung, spleen, liver, brain and perinephric area. Twenty-two (11.6%) patients had thrombosis of the subclavian vein or superior vena cava and 6 of them developed clinical manifestations of pulmonary embolism. Ninety-eight percent of patients underwent complete device removal combined with antibiotic treatment and 96% of patients were treated successfully [4]. Nineteen patients had lead extraction via a median sternotomy and the rest underwent percutaneous lead extraction. Interventional complications were more common in patients with a history of multiple device-related procedures and were related to tricuspid valve failure, laceration of subclavian vein, hemothorax, haematoma, fracture of lead tip, ventriculotomy and bleeding [4]. Right atrial thrombosis and pulmonary embolism are infrequent complications (0.6%-3.5%) and its therapeutic modalities include anticoagulation, thrombolysis and or surgery [5]. In conclusion, the knowledge of all potential complications of the PPM/ICD and its multidisciplinary approach is very important for its prevention and definitive treatment. Conflict of interest: none declared

We read with interest the article by Thekkudan and associates regarding the tricuspid valve chordal rupture due to blunt injury and we agree with their comment that the timing of the surgical intervention in the heart valve depends on the patient's general clinical condition [1]. Cardiac valvular injuries are quite uncommon after blunt thoracic trauma and the tricuspid valve is perhaps the more vulnerable because of the proximity of the right ventricle to the sternum [2]. Bailey et al. have highlighted that even a moderate blunt chest injury can provoke a significant injury of cardiac valves [2]. The major causes of injury are related to motor vehicle accidents followed by falls from one or more stories, falls off a horse or bus and compressed air explosions [2, 3]. Van Son et al. have reported on their experience with the surgical management of thirteen patients with tricuspid insufficiency due to blunt chest trauma (twelve cases were related to motor vehicle accidents and one to an explosion of a tank of compressed air). The median duration between trauma and surgical treatment was 17 years (range, 1 month to 37 years) and the primary cause of tricuspid insufficiency was flail of the anterior leaflet because of chordae tendinea rupture (n = 9), rupture of anterior papillary muscle (n = 3), or tear in the anterior leaflet (n= 1). In one patient, the septal leaflet was missing and in another it was retracted and adherent to the ventricular septum. Eight patients underwent tricuspid valve replacement and four tricuspid valve repair. No early or late deaths occurred at a median follow-up of 12 years [3]. Choi and Kim have reported on the successful management of simultaneous rupture of mitral and tricuspid valve with left ventricular rupture due to blunt chest injury. Their brief review of the relevant literature found that only eight patients had simultaneous rupture of the atrioventricular valves [4]. The diagnostic and therapeutic approach is a real challenge for these complex cases. When cardiac trauma is suspected after blunt chest trauma, transthoracic echocardiography can facilitate its appropriate management. However, the atrioventricular valve rupture can be missed due to cardiac tamponade and resultant ventricular collapse or due to other significant thoracic injuries [4]. In controversial cases or in extremely unstable patients transesophageal echocardiography (preoperative and/or intraoperative) can establish the definitive diagnosis [2]. Post-traumatic tricuspid and mitral valve repair has to be considered very carefully because these patients are haemodynamically unstable and there are anatomic valvular difficulties such as myocardial contusion, focal endocardial ischaemia, friable endocardium and necrotic papillary muscle. Because the right heart is a low-pressure system and the septomarginal trabecula is thick, the ruptured anterior papillary muscle can be reattached to its primary position with the use of the native chordae or neochordae with pledgeted sutures [1, 4]. In conclusion, the experience of valve repair in blunt chest trauma is limited however, especially for the tricuspid valve this therapeutic modality can be effective.

We would like to comment on the case report by Kim and colleagues concerning the surgical treatment of a gastrointestinal stromal tumour in the posterior mediastinum [1]. Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract (5000 new cases per year in the United States) [2]. They can be found in patients with a median age of 60 y, with frequent occurrence (70%) in the muscular wall of the stomach, followed by small bowel (10-20%), oesophagus, omentum, mesentery and retroperitoneum [2,3]. GISTs can range from small benign tumours to sarcomas at all sites of occurrence. Tumours that have metastasized at presentation have a very poor prognosis. The 5-year survival in patients with malignant GISTs is less than 40% [2]. There are three key prognostic factors: mitotic rate, tumour size, and site. Tumours that are small (=2 cm) and show mitotic activity not exceeding 5 mitoses per 50 high-power fields, have an excellent prognosis. This prognosis probably is independent of site, although this has not been shown specifically for all sites. In the stomach, most epithelioid GISTs are benign. However, we have to bear in mind that a small proportion of tumours apparently lacking mitotic activity do metastasize [2,3]. GISTs in association with paragangliomas and pulmonary chondromas constitute the Carney triad. In fact, the ‘Carney triad’ is a multiple neoplasia syndrome affecting mostly females. This syndrome - or Carney complex - predisposes to a variety of tumours including adrenocortical adenomas (unilateral or bilateral) that are usually non-functioning [2,4]. Carney and Stratakis, in 2002, distinguished the inherited GISTs with paraganglioma syndrome from the Carney triad as an autosomal dominant condition in adult patients. This condition has been called Carney-Stratakis syndrome [5]. These two syndromes, even though quite rare, have entered the realm of multiple endocrine neoplasias in the last years. Carney-Stratakis syndrome is probably more frequent and may be prevalent amongst patients with GISTs that are negative for KIT/PDGFRA mutations [2]. A high index of suspicion is required by surgeons who are dealing with patients with isolated or sporadic GISTs or paragangliomas. They have to be aware of the Carney and Carney-Stratakis syndromes. A multidisciplinary diagnostic approach regarding the medical and family history of the patients is of paramount importance (especially in the younger patient with KIT or PDFGRA mutation-negative GISTs) [2]. Conflict of Interest: None declared

Memetoglu and Kalkan, in their well-written manuscript have reported on the successful percutaneous treatment of an aneurysm in a patient with Behcet's disease [1]. We agree with the consideration of a percutaneous therapeutic modality instead of conventional surgical treatment for the management of aneurysms in Behcet's disease and would like to add a brief comment from a historical perspective. In 1956, the ophthalmologist Feigenbaum highlighted the first description of Behcet's syndrome by Hippocrates of Kos [2,3]. According to Feigenbaum, Hippocrates wrote in his third “Epidemion” book; case 7, “But there were also other fevers, as it will be described. Many had their mouths affected with aphthous ulcerations. There were also many defluxions about the genital parts, and ulcerations, boils (phymata), externally and internally about the groins. Watery ophthalmies of a chronic character, with pains; fungous excrescences of the eyelids, externally and internally, called fici, which destroyed the sight of many persons…”[2,3]. Zouboulis and Keitel, in their well-documented historical review, showed that the Greek ophthalmologist Benediktos Adamantiades (1875-1962) brought the ocular signs, genital ulcers and the arthritis in connection with a single disease [3]. On 15th of November 1930, Adamantiades presented a case report entitled “A case of relapsing iritis with hypopyon” at the annual meeting of the Medical Association of Athens and this presentation was published in the Proceedings of the Medical Society of Athens [3,4]. The case report was related to a 20 year old male, whose first clinical symptoms were edema and ulcerations of his left leg with a primary diagnosis of thrombophlebitis. In a two years follow-up, the patient developed recurrent iritis with hypopyon in both eyes, resulting in blindness and atrophy of the optic nerve, scrotal ulcers, oral aphthous ulcers, and sterile arthritis of both knees. The last three signs were recurrent and the bacterial cultures of the knees and eyes were negative [3,4]. Adamantiades went on to publish this case report in the French journal Annales d'Oculistique in 1931 [5]. In 1946, Adamantiades reported on two further patients and defined thrombophlebitis as a fourth sign of the disease [3]. In 1953, he presented the first classification of the disease and proposed the first diagnostic criteria and in 1958, his last work regarding its neurologic complications [3] was published. On 11th of May 1937, Hulsi (Hulusi) Behcet (1889-1948) presented a case report of a 34 year old female with a seven-year history of recurrent oral aphthous ulcers, genital ulcers, and ocular lesions at a meeting of the Dermatological Association of Istanbul [3]. This case report with the addition of a similar one was published in 1937 [3]. Behcet published three more manuscripts from 1938 to 1940, drawing medical attention [3]. He was aware of the publications by Adamantiades and included these in his references. Even though the current World Health Organization/ICD-10 standard is Behcet's disease, we believe that the term Adamantiades-Behcet's disease honors both first describers (in the modern era) for their contributions [3]. Conflict of Interest: None declared

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a huge public health burden associated with significant morbidity and mortality. For decades an increasing number of patients have undergone surgical treatment of AF, mainly during concomitant cardiac surgery. This has sparked a drive for conducting further studies and researching this field. With the cornerstone Cox-Maze III “cut and sew” procedure being technically challenging, the focus in current literature has turned towards less invasive techniques. The introduction of ablative devices has revolutionised the surgical management of AF, moving away from the traditional surgical lesions. The hybrid procedure, a combination of catheter and surgical ablation is another promising new technique aiming to improve outcomes. Despite the increasing number of studies looking at various aspects of the surgical management of AF, the literature would benefit from more uniformly conducted randomised control trials.

We have read the article by O'Sullivan et al. and we would like to add a comment on the complications of this pathological entity [1]. Aortic coarctation (AC) carries an incidence of 4 per 10 000 live births (5-8% of all congenital heart disease) and it can occur in association with patent ductus arteriosus, ventricular septal defect, bicuspid aortic valve (present in nearly two-thirds of patients with coarctation), concomitant hypoplastic aortic arch as well as parachute mitral valve stenosis, circle of Willis cerebral aneurysms and other congenital heart diseases (transposition of the great vessels, Taussig-Bing anomaly, hypoplastic left heart syndrome etc). Finally, AC is the commonest cardiac anomaly present in females with Turner syndrome [2, 3]. More importantly, the mean survival without treatment is 35 years and the vast majority of patients (90%) die before their 50s [2]. The choice of treatment has to be decided by a multi disciplinary team meeting with relevant specialists (Recommendation Class I, Level of Evidence C) [3]. Despite successful outcomes of its surgical treatment, late survival is compromised. For patients who are operated at a mean age of 16 years, the 10-, 20- and 30-year survival rates are 91%, 84% and 72% respectively [2]. Late complications can be subdivided into 8 categories namely: (i) re-coarctation, (ii) aortic aneurysm formation/aortic dissection, (iii) related to coexisting bicuspid aortic valve, (iv) endocarditis, (v) premature coronary atherosclerosis, (vi) strokes secondary to cerebrovascular aneurysms, (vii) systemic hypertension, and (viii) aortobronchial or aorto-oesophageal fistulas [2]. Re-coarctation is usually treated with primary balloon angioplasty with or without stent or surgical intervention. The probability of re-coarctation after surgery may be as high as 44% in neonates and 11% in older children, while adults carry a much lower risk (0-9%) [2]. About 9% of surgically-treated patients can develop aneurysms or pseudoaneurysms while those treated with balloon dilatation carry a much higher risk (20%) [2]. Those with coexisting bicuspid aortic valves are at an additional risk of developing aortic root dilatation [2]. Endocarditis can occur at the site of repair or at the coexisting bicuspid aortic valve and antibiotic prophylaxis is recommended subsequently according to the American Heart Association Guidelines [2, 3]. Premature atherosclerosis is usually the commonest cause of late death (25-37% of cases), leading to an increased risk of myocardial infarction and sudden death [2]. Circle of Willis aneurysms are present in 3-5% of patients and may cause cerebral haemorrhages even in normotensive individuals [2]. Systemic hypertension is found in 20-40% of patients followed-up 10 to 20 years after treatment and it represents a big challenge for the screening of either pregnant women or those with exercise-induced hypertension [2]. Aortobronchial fistulas are a rare though lethal complication and they can be safely managed with TEVAR [1, 2, 4]. All patients with treated AC should have lifelong close follow-up (at least yearly - Recommendation Class I, Level of Evidence C), magnetic imaging resonance/computed tomography should be repeated at intervals of 5 years at least (depending on anatomic findings) and management of blood pressure (Recommendation Class I, Level of Evidence B) and other risk factors should be applied [1, 3].

We read with great interest the best evidence topic by Shaikhrezai and colleagues regarding retained temporary epicardial pacing wires (TEPWs) in cardiac surgery and we agree with their recommendations [1]. TEPWs are used routinely in the postoperative period following cardiac surgery and its use is associated with low morbidity and mortality [1, 2]. Significant predictors for pacing in the postoperative period include diabetes mellitus, preoperative arrhythmias and need for pacing during the operation (coming off cardiopulmonary bypass, etc). If patients with these risk factors were excluded, only 2.6% patients of coronary artery bypass graft (CABG) surgery will require pacing [2]. The incidence of major complications following TEPWs removal is 0.04% [2]. The risk of complications is higher in redo cardiac surgery and anti-coagulated patients [2]. Patients' vital signs should be monitored following the removal of TEPWs to allow early and prompt identification of related potential complications [2]. Retained TEPWs rarely cause problems [1, 2]. Chung and Smith have reported on two cases of delayed presentation of anterior mediastinal foreign body reaction secondary to retained TEPWs [3]. The first case was related to a 59-year-old man who had CABG and six years later, presented with an abscess in the lower third of his sternotomy incision, which was treated with debridement and removal of the underlying sternal wires. Even though the wound had healed well, a mid-sternal swelling combined with right subcostal sinus eventually developed [2]. A computed tomography scan showed a retrosternal, ill-defined area of soft tissue extending into the superior mediastinum containing the retained TEPWs. The patient was treated successfully with opening of the sinus, removal of the TEPWs and remaining sternal wires with healing of the wounds by secondary intention [3]. The second case was quite similar to the first one and was related to a 64-year old woman who had CABG and five years later was presented with abscess in the lower third of the sternotomy scar. The same approach with the first case was used successfully after confirmation with a CT scan of the retrosternal collection associated with retained TEPWs [2]. Lyons et al., in 1986, have reported on four cases with infection and bacteraemia due to retained TEPWs [3]. The authors illustrated that the failure of removal of the TEPWs should be considered as a real surgical complication and not just a trivial event [4]. In conclusion, because it is suggested that off-pump CABG may be associated with reduced requirement of TEPWs, its routine insertion might be considered carefully [2, 5]. In the case of retained TEPWs, the patient has to be aware of any related potential complication, the incident has to be documented in the patient records and its inclusion in the differential diagnosis of any relevant postoperative complication is of paramount importance [1]. Conflict of interest: none declared

Yamamoto and colleagues have described the successful surgical treatment of a patient with bilateral coronary-to-pulmonary artery fistulas [1]. We agree with their decision of opening the main pulmonary artery (PA) under CPB and closure of both orifices with a suture [1]. We reported this additional manoeuvre of opening the PA for the direct identification of the entry points of all the fistulas into the PA plus the securing of its closure with a patch of autologous pericardium, sealed with Bioglue for the avoidance of recurrence and it seems to be a very helpful technique [2]. Biorck and Crafoord, on the 22nd of July 1946, in the Surgical Clinic I at Sabbatsberg Hospital in Stockholm, performed the first successful surgical ligation of a pulmonary-to-coronary artery fistula. The patient was a 15-year-old male who was referred due to exertional dyspnoea, fatigue and a ‘continuous’ murmur over the pulmonary area. The primary diagnosis after radiographic and phonocardiographic findings was of a case of patent ductus arteriosus Botalli [3]. For this reason the patient underwent left postero-lateral thoracotomy by the method of Crafoord (according to the authors) with a removal of the fifth rib [3]. However, in the area of ductus arteriosus no thrill was palpable and further exploration revealed an arteriovenous aneurysm on the PA which was consistent with an arteriovenous communication between an aneurysm of an aberrant branch of the left coronary artery and the PA [3]. The authors applied and tightened a silk ligature for 3–4 minutes around the abnormal artery centrally to the aneurysm for observation of the reaction of the heart. No abnormalities in the cardiac function were noted and the silk ligature was tied. On direct auscultation with a sterile stethoscope the murmur had then decreased significantly. The authors applied another silk ligature distally now to the aneurysm and, thereafter, the continuous murmur disappeared. The pericardium and chest were closed with no drains and the patient had an uneventful recovery with significant improvement in his functional status (no dyspnoea on moderate exertion) when he was reviewed in November 1946 [3]. According to Angelini and colleagues, coronary artery anomalies (including coronary arteriovenous fistulas) appear quite frequently in the practice of cardiologists and cardiac surgeons. In addition, the coronary artery anomalies display a variety of anatomic variants, sizes, and clinical symptoms with different implications in all spectrums of ages [4]. It is very important to bear in mind that, according to the Sudden Death Committee of the American Heart Association, a 19% of deaths in athletes is related to coronary artery anomalies [5]. The multidisplinary approach is of paramount importance for all these patients. The type of treatment of most of the subgroups of coronary artery anomalies is not supported by evidence-based guidelines [4]. A careful assessment is needed to clarify who of those patients should be under close follow-up and who will be treated in the catheterization laboratory (use of vascular plugs, umbrella devices, covered stents or coils) or in the theatre (TOE, on/off CPB, plus/minus CABG). Conflict of interest: none declared.

The retrospective study by Vos et al. has reported on the superiority of VAC-therapy compared to open packing in patients with post-sternotomy mediastinitis (PM) [1]. We have reviewed our experience regarding the management of deep sternal wound infections (also commonly called PM) in 85 patients over a period of 11 years (2000–2010) where the in-hospital mortality rate for this specific group was 7% vs. 3% . The higher logistic EuroSCORE for these patients (10.2% vs. 7.9%) indicates the higher rate of preoperative co-morbidities [2]. Our therapeutic approach is consistent with immediate application of VAC-therapy plus systemic antibiotics even when there is no clear distinction of whether there is an infective deep sternal wound or not [2]. This approach may improve the wound healing process through the early removal of the infective tissues and reduction of dead space. In case of sternal dehiscence, further surgical revision is required. Upon resolution of acute infection and confirmation of wound cultures as negative, a primary sternal closure technique is applied followed by insertion of closed irrigation - suction drains [2]. Bilateral myocutaneous pectoral flap reconstruction can be performed when necessary with particular emphasis on the preservation of its vascular supply. Six percent of these patients required a further plastic intervention [2]. In 2003, Luckraz et al. found that VAC-therapy combined with primary closure or myocutaneous flap is superior to VAC-therapy alone in patients with PM (VAC duration 13.5 days vs. 8 days, healed scar 77% vs. 64%, mortality rate 7.7% vs. 28.6%) [3]. The overall cost of the VAC-therapy per patient was regarded as nearly $4000 cheaper per patient than the single use of a closed irrigation system [3]. Pectoralis flaps can frequently be used for the definitive treatment of PM and the final sternal reconstruction. These flaps, as described by Jurkiewicz et al., allow early closure and healing of sternal wounds and are currently the conventional treatment for PM [4]. Alternatively, omental flaps can also be used for the treatment of PM specifically in the case of replacement of the ascending aorta with a prosthetic graft [4]. In 2007, Raja and Berg published their meta-analysis regarding the routine use of VAC-therapy in all patients with deep sternal wound infections post cardiac surgery. The authors identified 13 papers (out of 198) representing the best evidence in the use of VAC-therapy [5]. All the studies were retrospective or small cohort and the largest one was by Agarwal et al. with 103 patients (64% had the definitive diagnosis of PM) [5]. According to Agarwal et al., all the patients were treated with VAC-therapy (average period 11 days/patient) of whom 68% had definitive chest closure. The overall mortality rate was 28%, however, no deaths were related to VAC-therapy. Four deaths were due to PM sepsis [5]. This meta-analysis illustrates that VAC-therapy is a safe and effective additional method for the surgical management of PM. However, a prospective double-blinded randomized controlled trial is essential in order to validate the effectiveness, cost effectiveness and improvement of quality of life of patients undergoing VAC-therapy [5]. Conflict of interest: none declared.