Left Bundle Branch Area Pacing From a Femoral Approach in a Patient Without Superior Access.

Limited venous access and lateral left ventricular scar are impediments to traditional cardiac resynchronization therapy. We present a case where placement of an implantable cardioverter-defibrillator from a femoral approach while using left bundle branch area pacing led to clinical improvement. (Level of Difficulty: Intermediate.).

Low lateral thoracic site for cardiac implantable electronic device implantation: A viable alternative in patients with limited access options after infected device extraction.

BACKGROUND: Device reimplantation after extraction because of cardiac implantable electronic device (CIED) infection in pacemaker-dependent patients can be challenging in individuals with limited access options. OBJECTIVE: The purpose of this study was to describe a straightforward, low lateral thoracic implantation technique for patients with a patent axillary vein but unavailable bilateral pectoral sites. METHODS: Nine pacemaker-dependent patients (mean age 70 ± 13 years, 7 male) who underwent CIED extraction and low lateral thoracic reimplantation in whom bilateral pectoral sites were unavailable were included in the study. RESULTS: Extraction was performed a median of 10 (interquartile range [IQR] 8-13) days before CIED reimplantation (4 dual-chamber, 3 single-chamber, 2 cardiac resynchronization therapy). The new generator was implanted in the low lateral thoracic region ipsilateral to the extracted generator in 7 patients (78%) and contralateral in 2 patients (22%), via a subcutaneous pocket in 6 (67%) and submuscular pocket in 3 (33%). Median procedure duration was 85 (IQR 61-116) minutes, median fluoroscopy time was 7.2 (IQR 5.7-10.9), minutes and median fluoroscopy exposure was 26.0 (IQR 10.0-110.5) mGy. No acute complications occurred. Over median follow-up of 92 (IQR 31-131) days, 1 patient experienced right atrial lead dislodgment (122 days postimplantation) requiring lead revision. No patients experienced recurrent device infection. CONCLUSION: In pacemaker-dependent patients with limited prepectoral and vascular access options, a low lateral thoracic implantation site is a viable alternative to surgical epicardial or femoral pacing systems. This simple implantation technique is a safe and effective option in selected patients who require a single-chamber, dual-chamber, or biventricular pacemaker or implantable cardioverter-defibrillator.

Patient knowledge and perception of upper respiratory infections, antibiotic indications and resistance.

BACKGROUND AND OBJECTIVE: The misuse of antibiotics is not a harmless practice; rather, it can render future antibiotic treatments ineffective. This study looked to determine patient knowledge and perception of upper respiratory infections and indicated treatment. METHODS: The authors developed and administered a questionnaire to 98 patients visiting affiliated family medicine clinical sites. Participants were selected randomly, either while sitting in the waiting room, or after being seen by the clinician. RESULTS: While more than half the respondents recognized that treatment for colds did not require antibiotics, 70% erroneously indicated that viruses require antibiotic treatment. Additionally, almost 90% of respondents thought that yellow nasal discharge or coughing up yellow mucous requires antibiotic treatment. It was interesting to note that 95% of patients reported satisfaction when advised by their physician that antibiotic treatment wasn't necessary, even if they initially thought they needed antibiotics. CONCLUSIONS: Primary care providers have the greatest opportunity to curb inappropriate antibiotic use by both prescribing appropriately and educating their patients about proper antibiotic use when indicated.