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Heparin-free hemodialysis is often warranted in postoperative states, bleeding diathesis, and critically ill patients. this website Conventionally, this is achieved through normal saline flushes or regional citrate anticoagulation. An 87-year-old white man with end-stage renal disease and atrial fibrillation, who was taking warfarin and using maintenance home hemodialysis (HHD) with an NxStage machine, underwent laparoscopic appendicectomy. The procedure was complicated by intra-abdominal abscess, sepsis, and tamponade from a bloody pericardial effusion. He needed emergent therapeutic pericardiocentesis. Warfarin was promptly discontinued. He was discharged home with heparin-free HHD. Prior heparin anticoagulation for HHD was an initial bolus of 4000 units of heparin. He continued to clot his extracorporeal system with resultant very high venous pressures and compromised HHD. Heparin anticoagulation was still contraindicated. Flushes with 250-500 mL normal saline, delivered in aliquots every 15-30 minutes, failed to prevent the frequent clotting. The first author, our HD Senior Technician, had astutely observed that the horizontally placed hemodialysis filter exhibited early "clot" formation at the 12-o'clock position, despite the saline flushes. Through trial and error, he discovered that rotating the horizontally placed hemodialysis filter along its long axis, 60 degrees clockwise for 15 minutes, return to the neutral position for 15 minutes, rotating the filter another 60 degrees counterclockwise for 15 minutes, with this repeated cycle of rotations "did the trick." It promptly and consistently resolved the clotting problem. The lines stopped clotting, and he has not needed saline flushes for smooth heparin-free HHD for more than 7 months. To our knowledge, this is the first such report. Further study is justified. We have hypothesized a mechanism and have named this the "Locke-Onuigbo Maneuver."Pulmonary hypertension (PH) has been described in myeloproliferative disorders; monoclonal plasma cell disorder such as polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome; and plasma cell dyscrasias such as multiple myeloma and amyloidosis. We describe 4 cases of PH likely due to pulmonary vascular involvement and myocardial deposition from light chain deposition disease, amyloidosis, and multiple myeloma. On the basis of our clinical experience and literature review, we propose screening for plasma cell dyscrasia in patients with heart failure with preserved ejection fraction, unexplained PH, and hematological abnormalities. We also recommend inclusion of cardiopulmonary screening in patients with monoclonal gammopathy of undetermined significance.Musculoskeletal injury is an uncommon but usually self-limited complication of vaccine administration. We present a case of progressive inflammatory monoarthritis of the shoulder characterized by bone erosion, bursitis, and severe synovitis caused by an influenza vaccine administered to the ipsilateral deltoid region. Clinical symptoms began within 2 hours of vaccination, with progressive decline in function over 6 weeks. Magnetic resonance imaging examinations performed 5 months apart demonstrated progressive erosive changes of the greater tuberosity, rotator cuff injury, and extensive enhancing synovitis of the glenohumeral joint and subacromial/subdeltoid bursa. After the exclusion of septic arthritis and osteomyelitis, the patient underwent nonoperative treatment and experienced near-complete recovery at 32 months. Although inflammatory arthritis of the shoulder following vaccination is rare, there have been previous reports of it. Clinicians and radiologists need to be aware of this potential complication to ensure an accurate diagnosis.Cardiovascular disease (CVD) risk factors cluster in an individual. Exercise is universally recommended to prevent and treat CVD. Yet, clinicians lack guidance on how to design an exercise prescription (ExRx) for patients with multiple CVD risk factors. To address this unmet need, we developed a novel clinical decision support system to prescribe exercise (prioritize personalize prescribe exercise [P3-EX]) for patients with multiple CVD risk factors founded upon the evidenced-based recommendations of the American College of Sports Medicine (ACSM) and American Heart Association. To develop P3-EX, we integrated (1) the ACSM exercise preparticipation health screening recommendations; (2) an adapted American Heart Association Life's Simple 7 cardiovascular health scoring system; (3) adapted ACSM strategies for designing an ExRx for people with multiple CVD risk factors; and (4) the ACSM frequency, intensity, time, and time principle of ExRx. We have tested the clinical utility of P3-EX within a university-based online graduate program in ExRx among students that includes physicians, physical therapists, registered dietitians, exercise physiologists, kinesiologists, fitness industry professionals, and kinesiology educators in higher education. The support system P3-EX has proven to be an easy-to-use, guided, and time-efficient evidence-based approach to ExRx for patients with multiple CVD risk factors that has applicability to other chronic diseases and health conditions. Further evaluation is needed to better establish its feasibility, acceptability, and clinical utility as an ExRx tool.Endoscopic lung volume reduction is now included in the guidelines for treatment in severe chronic obstructive pulmonary disease. Since December 2018, 2 valve systems have been approved by the US Food and Drug Administration (FDA). To date, there is no head-to-head trial comparing both valve systems and no clear benefit of one over the other. This article provides an overview of the two largest prospective trials performed with the FDA-approved valve systems.

To assess the impact of the COVID-19 crisis on physician stress and mental health.

The 10-item Coping With COVID survey assessed stress among 2373 physicians from April 4 to May 27, 2020. A stress summary score with 4 items (a single-item [overall] stress measure, fear of exposure, perceived anxiety/depression due to COVID, and work overload, each scored 1-4) ranged from 4 to 16. Hypothesized stress mitigators included enhanced purpose and feeling valued by one's organization. Multilevel linear regression tested associations of variables with overall stress and stress summary scores.

In 2373 physicians in 17 organizations (median response rate of 32%), mean stress summary score was 9.1 (SD 2.6). Stress was highest among women (stress summary score, 9.4 [SD 2.5] vs 8.7 [SD 2.6] in men;

<.001), inpatient physicians (stress summary score, 9.4 [SD 2.8] vs 8.9 [SD 2.5] in outpatient physicians;

<.001), early- and mid-career physicians (stress summary score, 9.5 [SD 2.6] vs 8.6 [SD 2.5] in late-career physicians;

<.001), and physicians in critical care (stress summary score, 10.8), emergency departments (10.2), and hospital medicine (10.1). Increases in perceived anxiety/depression (regression coefficient, 0.30), workload (0.28), and fear (0.14) were associated with higher overall stress (

values <.001). Increases in feeling valued were associated with lower stress summary scores (regression coefficient,-0.67;

<.001) and explained 11% of stress summary score variance at the physician level and 31% of variance at the organizational level.

Mental health support, modulation of workload, and noting physicians' organizational value should be explored as means to reduce COVID-related stress.

Mental health support, modulation of workload, and noting physicians' organizational value should be explored as means to reduce COVID-related stress.

To evaluate whether

(formerly

)

contaminated stethoscope diaphragms remained aseptic by the placement of an aseptic diaphragm barrier.

On November 1, 2019, fresh cultures of

were diluted to 10

colony-forming units (CFU)/mL and used to inoculate 16 stethoscope diaphragms; 8 had an aseptic diaphragm barrier applied and 8 served as nonbarrier controls. Contaminated stethoscopes were anaerobically incubated, then swabbed at 15 and 30 minutes, 2 and 4 hours, and 1, 2, 3, and 7 days after inoculation and subsequently plated onto blood, chocolate, and cycloserine-cefoxitin fructose agar. Plates were incubated for 48 hours and on November 9, 2019, the resulting colonies were manually counted. Statistical analyses (RStudio, version 1.0.153) used analysis of variance with post hoc Tukey honestly significant difference.

Overall, mean colony count was 33 CFU on stethoscopes without barriers vs zero on those with barriers (

≤.05). Growth was greatest at 48 hours, with colony counts as high as 160 CFU. The presence of the barrier resulted in no growth in 100% of stethoscope diaphragms for up to 1 week.

We found that stethoscope diaphragm barriers provide an aseptic patient contact point, thus reducing the potential for transmission of

during the physical examination. In critical care environments, in which many hospitals use acoustically inferior disposable stethoscopes, the option of a disposable aseptic stethoscope barrier may allow high-quality auscultation while reducing the potential for pathogen transmission.

We found that stethoscope diaphragm barriers provide an aseptic patient contact point, thus reducing the potential for transmission of C difficile during the physical examination. In critical care environments, in which many hospitals use acoustically inferior disposable stethoscopes, the option of a disposable aseptic stethoscope barrier may allow high-quality auscultation while reducing the potential for pathogen transmission.

To evaluate usability of a quality improvement tool that promotes guideline-based care for patients with peripheral arterial disease (PAD).

The study was conducted from July 19, 2018, to August 21, 2019. We compared the usability of a PAD cohort knowledge solution (CKS) with standard management supported by an electronic health record (EHR). Two scenarios were developed for usability evaluation; the first for the PAD-CKS while the second evaluated standard EHR workflow. Providers were asked to provide opinions about the PAD-CKS tool and to generate a System Usability Scale (SUS) score. Metrics analyzed included time required, number of mouse clicks, and number of keystrokes.

Usability evaluations were completed by 11 providers. SUS for the PAD-CKS was excellent at 89.6. Time required to complete 21 tasks in the CKS was 4 minutes compared with 12 minutes for standard EHR workflow (median,

= .002). Completion of CKS tasks required 34 clicks compared with 148 clicks for the EHR (median,

= .002). Keystrokes for CKS task completion was 8 compared with 72 for EHR (median,

= .004). link2 Providers indicated that overall they found the tool easy to use and the PAD mortality risk score useful.

Usability evaluation of the PAD-CKS tool demonstrated time savings, a high SUS score, and a reduction of mouse clicks and keystrokes for task completion compared to standard workflow using the EHR. Provider feedback regarding the strengths and weaknesses also created opportunities for iterative improvement of the PAD-CKS tool.

Usability evaluation of the PAD-CKS tool demonstrated time savings, a high SUS score, and a reduction of mouse clicks and keystrokes for task completion compared to standard workflow using the EHR. link3 Provider feedback regarding the strengths and weaknesses also created opportunities for iterative improvement of the PAD-CKS tool.