Abstract Background Veno-Venous Extracorporeal Membrane Oxygenation (ECMO) technology provides as a alternative approach in the intensive care of patients with respiratory failure due to varied causes who are not responsive to conventional treatment. As per the 2014 Extracorporeal Life Support Organization (ELSO) guidelines, in order to to maintain circuit patency and minimize thromboembolic complications, anticoagulation is used, but the optimal strategy remains to be defined. Activated clotting time (ACT) is the most utilized bedside test to adjust anticoagulation. Therefore, we performed an extended analysis of all published studies on the incidence of thromboembolic and bleeding events in patients with acute respiratory distress syndrome who were put on ECMO. Methods A comprehensive search of several databases from inception to November 25, 2020, limited to English language and excluding animal studies, was conducted. The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The studies were classified into low anticoagulation target (ACT<180) or high anticoagulation target (ACT>180). A meta-analysis was performed of all eligible studies with the data on the incidences of thromboembolic and bleeding complications in patients with ARDS on VV-ECMO during different intensities of anticoagulation. Results A total of 6 eligible studies (4 retrospective and 2 case series) were identified, including in total 190 patients for 100 patient years. Our study showed that there is two times higher chances of bleeding when ACT goal is >180 versus a lower ACT range of <180 (Risk ratio 2.07, 95% CI 1.23-3.46, P 0.0056). The incidence of thrombosis did not change in the two group (Risk ratio 1.17, 95% CI 0.45-3, P 0.7516). Conclusions Currently there is a lack of data for anticoagulation strategies during VV-ECMO for patients in respiratory failure. Our study aimed to find an appropriate anticoagulation target for this patient group. The results show that although anticoagulation is required for circuit patency, there is an increased risk of bleeding when higher anticoagulation targets are set. Disclosures No relevant conflicts of interest to declare.

Heart failure with preserved ejection fraction (HFpEF) is the presence of clinical signs and/or symptoms of heart failure with a left ventricular ejection fraction (LVEF) ≥50%. Risk factors associated with this disease include hypertension, hyperlipidemia, atrial fibrillation (AF), obesity, diabetes and coronary artery disease (CAD). Despite the multiple risk factors identified for this condition, treatment and management remain challenging and a subject of ongoing research. Since a treatment approach that alters the natural course or lowers mortality for this disease has not been found, treating co-morbidities and symptom management is essential. From the comorbidities, hypertension is identified as the main risk factor for disease development. Thus, after congestive symptom control with diuretics, blood pressure (BP) management is considered one of the most important preventive measures and also a target for treatment. Amongst antihypertensives, angiotensin receptor blockers (ARBs) and aldosterone antagonists are the therapeutic agents used that have a role in reducing hospitalizations. Implantable monitoring devices have also been shown to reduce hospitalizations in comparison to standard heart failure therapies by allowing to tailor diuretic therapy based on ongoing hemodynamic data. In this manuscript we discuss pharmacologic strategies for HFpEF patients by risk factors, including those with and without a potential role.

The need to quantify blood flow through the heart has led to the development of different techniques for its measurement. The 3 main approaches are the Fick method, dye dilution, and thermodilution techniques. The latter 2 are based on the use of indicators that indirectly quantify blood flow. These have slowly been developed over centuries, from the concept of measuring blood flow, to a technique, and its clinical utility. Thermodilution is the most popular dilution method used for measuring cardiac output (CO) in the clinical setting. The information obtained during this procedure is relevant in the process of clinical decision making in patients with critical illness, valvular heart disease, and congestive heart failure. The technique increased in popularity in the early 1970’s after Swan and Ganz invented the pulmonary artery catheter that simplified thermodilution enough to utilize it as a bedside procedure. This was only possible with simple yet clever engineering methods that are not commonly known in the medical community. Despite these advancements, the concept of measuring CO by dilution techniques is one where its optimal use in the clinical setting continues to be an area of investigation. The thermodilution concept and the mechanism of measuring CO will be discussed in the following review.

Primary cardiac tumors are rare, and atrial myxomas represent about half of the benigntumors encountered. When found, definitive treatment is surgical resection. Followingresection of these tumors, recurrence is possible, and these patients need regular follow-up.In the case of recurrence, repeat surgical intervention is feasible, but the potential for moredisruption in atrial anatomy has to be considered. This could contribute to cardiac arrhythmias,and anticipation of these events is necessary to optimize patient care. We present the caseof a woman with a recurrent left atrial myxoma who developed sinus node dysfunction afterresection and discuss her clinical management.

Objectives: To describe our single center experience with the use of laser endartherectomy assisted balloon angioplasty in popliteal and infrapopliteal arterial disease.Background: Peripheral arterial disease (PAD) carries significant morbidity to patients. Some patients may have multiple comorbid conditions potentially limiting therapeutic options for PAD. Endovascular interventions are aimed at decreasing arterial disease symptoms, improve wound healing and ultimately limb salvage. There is limited data on below the knee PAD and simultaneous laser endartherectomy use in this anatomic location.Methods: The cohort comprised 41 patients that underwent laser assisted balloon angioplasty from 2010 to 2013. All patients had popliteal and infrapopliteal arterial disease. Outcomes evaluated were limb salvage and symptom relief 12 months following the procedure. A comparison between the patients that underwent amputation and those with limb salvage was also performed.Results: All the patients had TASC II (Trans Atlantic Inter-Society Consensus) type D lesions. Most patients reported persistent PAD symptoms by six months, with 17% remaining symptom free by 12 months. Affected limb salvage was 69%. Five patients (12%) died and one third of the patients had a new peripheral angiogram. In the repeat angiogram, most patients showed initial target vessel occlusion. No statistically significant differences were found between the patients that preserved their limb to those who underwent amputation.Conclusions: Laser assisted balloon angioplasty use for complex popliteal and infrapopliteal arterial disease is a therapeutic option when limb salvage is the goal. Despite this, symptom recurrence and the need for repeated angiography continue to be high. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

The FloTrac®/Vigileo device uses arterial pressure waveform analysis to calculate stroke volume and cardiac output; it does not require calibration against an independent measurement of cardiac output. Consequently, it provides a method to determine hemodynamic status, changes in the clinical course and responses to therapeutic interventions in patients who have arterial catheters in place. These devices perform relatively well in stable patients undergoing surgery and having an acceptable percentage error in differences between the FloTrac® device and invasive monitoring using pulmonary catheters. However, in patients with septic shock and other clinical states associated with low systemic vascular resistances, such as cirrhosis, the FloTrac® does not provided acceptable correlation with independent measurements with pulmonary artery catheters. FloTrac® measurements often underestimate the cardiac output and have unacceptably high percent error, which ranges from 30% to 60%. There is a moderate correlation with changes in cardiac output after fluid administration, but a poor correlation with changes in cardiac output after increases or decreases in norepinephrine administration. The bias between measurements increases as the systemic vascular resistance decreases. Consequently, cardiac output measurements using the FloTrac® device are not accurate enough for use in patients with septic shock, advanced liver disease and other medical conditions associated with decreased vascular tone.

Pneumopericarditis describes a clinical scenario where fluid and air are found within the pericardial space. Although infrequent, pneumopericarditis should be considered in patients presenting with acute chest pain as a differential diagnosis. This is relevant in patients with history of upper gastrointestinal (GI) surgery, as this may lead to a fistula communicating the GI tract and the pericardium. We report a 42-year-old man with history of numerous surgical interventions related to a Nissen fundoplication that presented with acute chest pain and inferior lead ST segment elevations. Emergent coronary angiography was negative for coronary vascular disease but fluoroscopy revealed air in the pericardial space. Subsequent radiographic studies helped confirm air in the pericardial space with a fistulous communication to the stomach. Ultimate treatment for this defect was surgical closure.

Case report publications introduce new information into the current body of medical information and provide trainees with an opportunity to develop skills that enhance patient care. However, opportunities for publication are limited because journals often have other editorial priorities and some journals do not want to publish articles that might decrease their impact factors. Using PubMed and Google Scholar, we identified the case report articles published by our residents who completed training between 2008 and 2013. Sixty-one residents published 55 case reports and/or letters. Twenty-five of these publications had 87 citations in the years of publication and up 5 years after publication. Most of these citations occurred in other case reports (36) or in review articles (24). In conclusion, publishing case reports by residents has important benefits for the individual resident and the residency program and provides another resource for medical care.

Sickle cell intrahepatic cholestasis (SCIC) is a rare but fatal complication of sickle cell disease. It is found mainly in homozygous sickle cell disease. To date, there are no standard diagnostic criteria or well-established therapeutic approaches to this condition. Herein, we report this case of a 48-year-old man with sickle cell anemia and a total bilirubin of 78.5 mg/dL without evidence of extrahepatic biliary obstruction or viral hepatitis. The patient had a hemoglobin S level of 87.9%, acute renal failure, and mild coagulopathy. Despite the disease severity, he refused exchange transfusion (ET) with packed red blood cells. He was transfused with 2 units of blood and treated mainly with supportive measures. His total bilirubin levels trended down to normal days after discharge. Multiple studies have shown a significant decrease in the mortality rate in SCIC after ET. To date, only two reported adult cases have survived SCIC without aggressive treatment. Our case is the third case that demonstrates recovery of severe SCIC without ET.

The diagnosis of acute pancreatitis requires clinical, biochemical, and occasionally imaging information. Biochemical criteria include serum lipase levels, which are considered both sensitive and specific for the diagnosis of acute pancreatitis. Patients with diabetic ketoacidosis often have abdominal pain that may be related to the ongoing metabolic derangement or to precipitating intra-abdominal pathology. The pain severity in diabetic ketoacidosis helps determine whether abdominal disease should be further investigated. We present a patient with diabetic ketoacidosis and acute pancreatitis who had no significant elevation of amylase and lipase. The patient had abdominal pain that persisted despite ongoing treatment with intravenous insulin for ketoacidosis. The pain was initially located in the epigastrium and then migrated to the right lower quadrant. An abdominal computed tomography scan was obtained to exclude acute appendicitis, and this study revealed peripancreatic fluid consistent with acute pancreatitis that extended into the right lower quadrant anterior to the psoas muscle. A literature review of previous case reports and possible explanations for normal lipase levels are discussed. In conclusion, normal lipase levels do not exclude the diagnosis of acute pancreatitis and imaging criteria may be needed. It is also important to recognize that laboratory studies have limitations, and these should be taken into account when confirming a diagnosis.

A 26-year-old previously healthy man presented with fever, urinary retention, nuchal rigidity, and hyperreflexia but with a clear sensorium. His initial spinal fluid results were consistent with aseptic meningitis from West Nile virus infection, and this was confirmed by serological studies on blood and cerebrospinal fluid. Computed tomography and magnetic resonance imaging studies were unremarkable. He received supportive care and urinary catheterization to prevent bladder injury from overdistension. He was discharged home without recurrence of urinary retention after five days of hospitalization. Therefore, this case report describes the first case of West Nile virus meningitis in a patient with the meningitis-retention syndrome.