A case of ultra-prolonged intra-aortic balloon pump support via sheathless femoral access.

Background: An intra-aortic balloon pump (IABP) is a mechanical circulatory support platform with a relatively low complication rate. Axillary access is increasingly utilized to allow rehabilitation. Case summary: We present a case of femoral IABP inserted into the femoral artery percutaneously via a sheathless technique that allowed the patient to ambulate and physically rehabilitate over 102 days until cardiac transplantation. The patient was able to progress with the protocolized rehabilitation programme to up to 3500 ft walking distance. The IABP was removed at the time of transplantation without any vascular complications. Discussion: While axillary IABP offers an opportunity to rehabilitate, it has an unacceptably high complication rate, often resulting in vascular injury that adds morbidity to an acutely ill cohort. In this case, we found that sheathless femoral IABP access offered stability for a prolonged time while avoiding pain, bleeding, infection, and vascular injury. We hypothesize that this is due to less indwelling prosthetic material usage and also device flexibility, allowing conformation to the natural course of the femoral artery. We are encouraged by this case to use a sheathless access approach for patients expected to require prolonged IABP support.

Integration of the Verbatim Exercise into a Hospice and Palliative Medicine Fellowship.

One of the more challenging aspects of specialty level training in any medical fellowship is learning to communicate mindfully and effectively with patients and families in the face of serious illness. For the past five years, our accredited Hospice and Palliative Medicine (HPM) fellowship program has been integrating the "verbatim"-an exercise with a long and integral history in the training of health care chaplains. Verbatims are word-for-word accounts of a clinician's encounter with a patient and/or the patient's family. The verbatim serves as a formative educational exercise offering a method to hone one's clinical skills and competencies, while providing a unique space to practice self-awareness and self-reflection. Although sometimes difficult and intense for the fellow, we have found this to be a helpful exercise in improving the fellow's ability to make meaningful connections with patients and leading to improved outcomes of communication episodes. This potential growth in self-awareness supports both resiliency and mindfulness, which are essential skills for longevity and reduction of burnout risk in the field of HPM. The verbatim invites all participants to reflect on their own participation in facilitating whole person care to patients and families. Out of the six HPM milestone metrics for fellowship training, the verbatim exercise supports achievement in at least three of the milestones. We present survey data over the past five years of our fellowship in support of the utility of this exercise and for consideration to include this exercise in a palliative medicine fellowship. We offer additional suggestions for further study of this formative tool. This article delineates the verbatim technique and its specific integration into our accredited ACGME Hospice and Palliative Medicine fellowship training program.

Review of novel therapeutics in cardiac arrest (ReNTICA): systematic review protocol.

INTRODUCTION: Cardiac arrest remains a common and devastating cause of death and disability worldwide. While targeted temperature management has become standard of care to improve functional neurologic outcome, few pharmacologic interventions have shown similar promise. METHODS/ANALYSIS: This systematic review will focus on prospective human studies from 2015 to 2020 available in PubMed, Web of Science and EMBASE with a primary focus on impact on functional neurologic outcome. Prospective studies that include pharmacologic agents given during or after cardiac arrest will be included. Study selection will be in keeping with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. If sufficient data involving a given agent are available, a meta-analysis will be conducted and compared with current evidence for therapies recommended in international practice guidelines. ETHICS AND DISSEMINATION: Formal ethical approval will not be required as primary data will not be collected. The results will be disseminated through peer-reviewed publication, conference presentation and lay press. PROSPERO REGISTRATION NUMBER: International Prospective Register for Systematic Reviews (CRD42021230216).

Sinus bradycardia with haemodynamic compromise following lithium intoxication.

Lithium is a well-established treatment for mood disorders and considered first-line pharmacological therapy for bipolar disorder as per the American Psychiatric Association guidelines. However, lithium is associated with significant toxicity. Cardiotoxicity including sinus node dysfunction is a rare but clinically significant presentation of lithium intoxication. This case report describes an adult male presenting with unstable sinus bradycardia in the setting of acute kidney injury and elevated serum lithium levels. The patient required temporary management with inotropic support and transcutaneous pacing. The patient's heart rate and hypotension improved in parallel with resolution of his acute kidney injury and elevated serum lithium level after treatment with intravenous fluids. Given the prevalence of bradycardia in both the outpatient and inpatient settings, a high index of suspicion is necessary for the prevention and identification of this clinical entity to guide appropriate management.

Incisional hernia risk after hand-assisted laparoscopic surgery.

Hand-assisted laparoscopic surgery (HALS) bridges traditional open surgery and pure laparoscopy. The HALS technique provides the necessary site for organ retrieval, reduces operative time, and realizes the postoperative benefits of laparoscopic techniques. Although the reported rates of incisional hernia should be theoretically low, we sought to determine our incidence of hernia after HALS procedures. A retrospective review of all HALS procedures was performed from July 2006 to June 2011. All patients who developed postoperative incisional hernias at the hand port site were confirmed by imaging or examination findings. Patient factors were reviewed to determine any predictors of hernia formation. Over the 5 years, 405 patients undergoing HALS procedures were evaluated: colectomy (264), nephrectomy (107), splenectomy/pancreatectomy (18), and ostomy reversal (10). The overall incidence of incisional hernia was 10.6 per cent. There were three perioperative wound dehiscences. The mean body mass index was significantly higher in the hernia group versus the no hernia cohort (32.1 vs 29.2 kg/m(2); P = 0.001). The hernia group also had a higher incidence of renal disease (18.6 vs 7.2%; P = 0.018). Mean time to hernia formation was 11.4 months (range, 1 to 57 months). Follow-up was greater than 12 months in 188 (46%) of patients, in which the rate of incisional hernia was 17 per cent. The rate of incisional hernia formation after hand-assisted laparoscopic procedures is higher than the reported literature. Because the mean time to hernia development is approximately 1 year, it is important to follow these patients to this end point to determine the true incidence of incisional hernia after hand-assisted laparoscopy.