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We report the perioperative management of a patient with melanoma. Surgical intervention was withheld at multiple institutions because of the presence of metastases; the patient was undergoing experimental immunotherapy and had responded everywhere except in the liver. She underwent hepatic right trisegmentectomy to improve her quality of life and to allow resumption of immunotherapy. Dyspnea because of heart compression, pleural effusion, lung collapse, and pulmonary emboli improved. She died of late complications. This case highlights physiologic and ethical considerations.

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Universal precautions mandate that health care workers wear gloves to prevent the unintended spread of bloodborne pathogens. Gloves may affect manual dexterity, generally delaying task completion. Our previous study showed that wearing the wrong size latex surgical glove degraded manual dexterity. The use of non-sterile and non-latex gloves may limit certain risks and be more cost-effective. However, such gloves may produce different results. We hypothesized that ambidextrous vinyl examination gloves would degrade manual dexterity compared with bare hands. We studied 20 random subjects from a medical environment. Subjects performed a standard battery of Grooved Pegboard tasks while bare-handed, wearing ambidextrous non-sterile vinyl gloves that were their preferred size, a size too small, and a size too large. The order was randomized with a Latin Square design to minimize the effects of time, boredom, and fatigue on the subjects. Subjects were also invited to comment on the fit of different size gloves. Wearing vinyl gloves of both the preferred size and a size up or down failed to affect manual dexterity vs. bare hands on time to insert pegs, and pegs dropped during insertion or removal. In contrast, the time to remove pegs was reduced by wearing preferred size vinyl gloves compared with performing the task with bare hands (P<0.05). Subjects reported a generally poor fit in all sizes. Vinyl gloves that were too small caused significant hand discomfort. Vinyl gloves surprisingly do not degrade manual dexterity even when worn in ill-fitting sizes. Wearing a preferred size vinyl glove vs. bare hands may improve dexterity in selected tasks. Choosing a comfortable, large size seems the best strategy when the preferred size is unavailable. Thinner vinyl gloves may improve grip and may not degrade touch as much as latex surgical gloves and may thus represent a reasonable choice for selected tasks.

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Anesthesia for liver transplantation (ALT) requires extensive preparation and rapid recognition of changing clinical conditions. Owing to the proliferation of transplant centers, greater number of anesthesia providers need training in specific skills required to treat these patients. These cases are no longer limited to few transplant centers; therefore, reduction of cases in individual centers has created a need for simulation training to prepare and supplement clinical experience. We have developed an ALT simulation course for senior anesthesia residents which combines didactic sessions with live-patient-based and mannequin-based simulation. Outcomes have been measured using pre- and post-simulation course quizzes as well as a survey given at the end of the month-long ALT rotation. Twenty-four senior anesthesiology residents (n = 24) have completed the ALT simulation course. Residents had an average score of 75% ± 10% on the pre-simulation quiz, which increased to 92% ± 6.5% on the post-simulation quiz (p < 0.001). Furthermore, survey scores indicated that residents noted that the course provided an improvement in their preparedness, confidence, anticipation, and understanding of the importance of communication skills in the care of this patient population. The ALT simulation course provided a standardized in-depth exposure to clinical issues involved in the perioperative care of liver transplant patients.

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End-stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52-year-old man had end-stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double-lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re-exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT.

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Universal precautions mandate that health care workers wear gloves when dealing with patients, often in situations requiring a high level of technical skill. Although it seems obvious that wearing the wrong size gloves could impair or prolong tasks involving manual dexterity, the issue has not been formally studied. We tested the hypothesis that wearing the wrong size gloves impairs manual dexterity. We administered a grooved pegboard test to 20 healthy, paid, volunteer health care workers. The subjects performed the test with bare hands and while wearing their preferred size of latex surgical gloves, gloves that were a full size smaller, and gloves that were a full size larger. Each subject did three runs with each size glove and three runs with bare hands. The time necessary to insert pegs was measured with a stopwatch. Peg insertion time was not affected by wearing preferred size gloves (vs. bare-handed) but was increased 7-10% by gloves that were either too small or too large (both effects: P < 0.05 vs. preferred size; both P < 0.001 vs. bare-handed). The subjects reported that the too-small gloves limited hand motion or hurt their hands, whereas the too-large gloves were clumsy but comfortable. Health care workers should wear gloves that fit properly when doing tasks that require manual dexterity. If the preferred size is unavailable, wearing gloves that are too large seems the best alternative.

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BACKGROUND: During cardiopulmonary resuscitation (CPR), mouth-to-mouth ventilation (MTM) is only effective if rescuers are willing to perform it. METHODS: To assess the degree of willingness or reluctance in performing MTM, a survey including 17 hypothetical scenarios was created. In each scenario health hazards for the rescuer needed to be balanced against the patient's need for MTM. Respondents were recruited from health care workers attending courses at a medical simulation center. Respondents reported their willingness or reluctance to perform MTM for each scenario using a 4 point scale. RESULTS: The questionnaire had responses by 560 health care workers. Reluctance to perform MTM varied with the scenario. Some health care workers refused to ventilate patients who could benefit from MTM. In all scenarios even when resuscitation was both futile and potentially hazardous, some health care workers were willing to perform MTM. Age and level of experience tend to reduce the propensity to engage in MTM. Parental propensity to ventilate one's own child was stronger than any other motivator. CONCLUSIONS: HIV infection is not the only condition for which rescuers hesitate to perform MTM. Bag-valve-mask devices for mechanical ventilation should be available in all locations where health care workers may be called upon to resuscitate apneic patients making the decision to perform MTM moot.

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