Ex-vivo percutaneous bypass: Limb perfusion in the setting of occlusive large bore sheath.

Successful cardiac catheterization procedure begins with safe vascular access and ends with effective hemostasis after equipment removal. These new and advanced technologies in the cath lab require large-bore arterial accesses. Large-bore sheaths are associated with blood flow obstruction resulting in limb ischemia. In this case we present a 48-year-old woman was admitted NSTEMI and cardiogenic shock requiring mechanical circulatory support. Selective left common iliac angiography demonstrated obstructive flow at the level of the left CFA (access site). Therefore, ipsilateral bypass circuit was done. The current case illustrates the utility of a temporary ex-vivo bypass circuit to preserve limb perfusion in the presence of an occlusive large bore sheath. The technique permits sufficient hemodynamic support while maintaining limb perfusion and can be used for any occlusive large bore sheath.

Penicillin plus Ceftriaxone versus Ampicillin plus Ceftriaxone Synergistic Potential against Clinical Enterococcus faecalis Blood Isolates.

Penicillin plus ceftriaxone is a promising alternative to ampicillin plus ceftriaxone for the treatment of Enterococcus faecalis infective endocarditis. Limited data is available supporting the utilization of penicillin plus ceftriaxone. A total of 20 E. faecalis isolates; one wild-type strain (JH2-2) and 19 clinical blood strains were assessed for penicillin plus ceftriaxone and ampicillin plus ceftriaxone synergy using a 24-h time-kill experiment. Susceptibility was determined by broth microdilution. Differences in bactericidal, bacteriostatic, or inactivity, as well as synergy between treatments were assessed by chi-square or Fisher exact test. All E. faecalis isolates were considered susceptible to ampicillin and penicillin. Ampicillin plus ceftriaxone versus penicillin plus ceftriaxone similarly demonstrated synergy. Bactericidal activity was more commonly observed for ampicillin plus ceftriaxone versus penicillin plus ceftriaxone. Among isolates with a penicillin MIC of 4 µg/mL (n = 7), synergistic activity for both combinations was less common compared to isolates with a penicillin MIC ≤ 2 µg/mL (n = 13). Ampicillin plus ceftriaxone and penicillin plus ceftriaxone demonstrate similar synergistic potential against E. faecalis clinical blood isolates, but strains with higher penicillin and ceftriaxone MICs less frequently demonstrated synergy. Further research is warranted to determine the role of the penicillin plus ceftriaxone therapy and the penicillin MIC in clinical practice. IMPORTANCE Penicillin plus ceftriaxone demonstrates similar synergistic activity against Enterococcus faecalis to ampicillin plus ceftriaxone. Isolates with a penicillin MIC of 4 mg/L and a ceftriaxone MIC of 512 or higher, lack penicillin plus ceftriaxone synergy despite the penicillin susceptibility MIC breakpoint of 8 mg/L.

Medical home visit programs during COVID-19 state of emergency.

Elderly, homebound individuals comprise a vulnerable segment of society who have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic through a myriad of unique challenges. There is a significant amount of fear of acquiring COVID-19 by seeking health care services, which has adversely affected patients by worsening fixable situations. Another challenge is the decrease in diagnostic support for evaluating patients compared with a pre-COVID-19 world. Agencies providing at-home phlebotomy, portable radiology, and support services have had to limit their home visits due to an inability to access personal protective equipment. This loss of diagnostic and therapeutic support has had an emotional toll on patients and their caregivers. COVID-19 has had a tremendous impact on the health and finances of home health aides and their patients. Loss of long-term home health aides has adversely affected younger patients with ailments like Down syndrome as well as older patients with dementia. COVID-19 has also increased pressure on end-of-life decision making. Patients and their families are increasingly opting for palliative care and hospice programming to avoid separation. Families are being forced to consider advance directives under an increased emotional strain as patients become "persons under investigation" for COVID-19. Technology has allowed for the provision of services through telehealth, and changes to policy by CMS have aided widespread implementation of telemedicine. We anticipate continuing to be nimble in the face of challenge and to provide timely and meaningful care for those who depend on our efforts.

Perspective: What a Difference a Disaster Makes: The Telehealth Revolution in the Age of COVID-19 Pandemic.

Despite the existence of telemedicine since the late 1950s and early 1960s, it took a pandemic to bring this technology mainstream. The critical urgency of the pandemic drove an auspicious alignment of policy, economics, and technology to facilitate the widespread implementation of telehealth. It is imperative that this synchronicity be maintained in the post-COVID era in order to optimize our health care system to be ready for the next threat to the health of the United States.

Contrast-induced acute kidney injury following coronary angiography in patients with end-stage liver disease.

Background: Contrast-induced acute kidney injury (CIAKI) following coronary angiography is frequently observed in the general population. End-stage liver disease (ESLD) patients are at a particularly increased risk for development of CIAKI following coronary angiography due to preexisting renal hypoperfusion. Methods: We performed a retrospective study of 544 consecutive cardiac catheterizations in ESLD patients from December 2003 to May 2013 to calculate the incidence of CIAKI post-coronary angiography and to identify risk factors for CIAKI. CIAKI was defined as a serum creatinine increase of either ≥ 25% or ≥ 0.5 mg/dL from baseline within 72 hours. Multivariable and Cox regression analysis was performed for development of CIAKI and all-cause mortality, respectively. Results: Overall, 179 cases of coronary angiography were included in the final analysis. CIAKI occurred in 23% of patients. All-cause mortality was 52% in the CIAKI group and 37% in the non-CIAKI group, with a mean follow-up of 2.2 ± 3.8 years. Multivariable analysis identified intensive care unit admission (OR 2.72, CI 1.05-7.01, p < 0.05) and baseline estimated glomerular filtration rate (OR 1.02, CI 1.002-1.035, p < 0.05) as independent predictors of CIAKI. Cox regression analysis identified pre-angiography beta-blocker use (HR 2.13, CI 1.04-4.38, p < 0.05), international normalized ratio (HR 1.37, CI 1.05-1.78, p < 0.05) and Mehran risk score (HR 1.13, CI 1.02-1.25, p < 0.05) as independent predictors of all-cause mortality. Conclusions: CIAKI in ESLD patients undergoing coronary angiography occurs at a moderately elevated rate when compared to the general population.