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Coronavirus disease (COVID) toes are pernio-like skin lesions associated with severe acute respiratory syndrome coronavirus 2. We observed pernio-like skin findings presenting after a Pfizer BioNTech vaccine, which significantly worsened after an infusion of rituximab. This suggests that the mechanism for COVID toes is interferon activation. Military providers may avoid unnecessary referrals for this self-limiting condition by anticipating this adverse effect.

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Introduction: Preoperative cardiac testing is common prior to bariatric surgery despite the low incidence of postoperative cardiac events. We sought to determine what proportion of patients who underwent preoperative cardiac testing and evaluation prior to laparoscopic bariatric surgery were at low cardiac risk. Methods: We reviewed preoperative cardiac testing and evaluations performed for patients undergoing laparoscopic bariatric surgery at Hershey Medical Center from January 1 st 2015 through December 31 st 2019. Cardiac risk was evaluated using the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest risk calculator (NSQIP MICA). Patients with a RCRI score ≤1, or a NSQIP MICA cardiac risk estimate less than 1%, were considered to be at low cardiac risk. Results: 1,134 patients underwent laparoscopic bariatric surgery during the study time period, of which 1,093 (96.4%) were low cardiac risk by RCRI and 1,133 (99.9%) were low cardiac risk by NSQIP MICA. 587 patients (51.8%) were referred to cardiology for preoperative evaluation. 643 patients (56.7%) underwent one or more preoperative cardiac tests (see figure for breakdown of cardiac risk for each cardiac evaluation). Out of 1,134 patients, 1 (0.1%) had myocardial infarction within 30 days of surgery. There were 0 patients with either cardiac arrest or death within 30 days of surgery. Conclusions: A large majority of patients undergoing cardiac evaluation and testing prior to laparoscopic bariatric surgery were at low cardiac risk, regardless of whether cardiac risk was assessed by the RCRI or by the NSQIP MICA. Preoperative cardiac testing and evaluation were common despite excellent cardiac outcomes. Use of tools such as the RCRI or NSQIP MICA to identify patients at low cardiac risk at the time of bariatric enrollment may help to reduce the overuse of preoperative cardiac evaluation and testing in low risk patients.