Development and Validation of a Low-Cost, High-Fidelity Simulation Model for Robotic Internal Mammary Artery Harvest Using the da Vinci Xi Robot.

Objective: We created and validated a low-cost simulation model for robotic internal mammary artery (IMA) takedown.

Methods: The simulation model utilized a calf fetus thorax cavity stented open internally and secured to a table. The simulation model was validated at a 2-day robotic cardiac surgery workshop.

Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure.

Background: The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals.

Objectives: The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF.

Vascular Access Management in Complex Percutaneous Coronary Interventions.

Vascular access is a crucial step, which every interventional cardiologist needs to be skilled with to consistently achieve excellent periprocedural outcomes. Some operators argue that it is the most important aspect of the entire intervention. Hence, careful planning of vascular access in an individualized fashion - based on the patient's clinical status, anatomy, and technical requirements of the intervention - is the first step in securing optimal procedural safety and successful results.

Effects of S-Allylcysteine-Rich Garlic Extract and Dietary Inorganic Nitrate Formula on Blood Pressure and Salivary Nitric Oxide: An Open-Label Clinical Trial Among Hypertensive Subjects.

Introduction:  The conversion of dietary inorganic nitrate (NO3-) to nitric oxide (NO) is a non-canonical pathway that plays an important role in NO biology, especially under pathological conditions. Inorganic NO3- supplementation is a proven method for controlling mild hypertension. Recent reports have suggested that another gaseous transmitter, hydrogen sulfide (H2S), influences NO biosynthesis and metabolism.

Using a Standardized Rounding Tool to Improve the Incidence of Spontaneous Awakening and Breathing Trials.

Background: Spontaneous awakening and breathing trials have been associated with shorter durations of mechanical ventilation and intensive care unit lengths of stay.

Local Problem: Inconsistent spontaneous awakening trials and spontaneous breathing trials, mechanical ventilation weaning strategies, and interdisciplinary rounding processes contributed to prolonged mechanical ventilation duration and length of stay in a 44-bed adult medical intensive care unit. Methods A standardized rounding tool that focused on coordinating spontaneous awakening and breathing trials, and on their outcomes, was integrated into daily multidisciplinary rounds in a medical intensive care unit.

Catheter ablation for atrial fibrillation can be safely performed without invasive hemodynamic monitoring: A multi-center study.

Background: Arterial invasive monitoring is the most common method in the USA for hemodynamic monitoring during atrial fibrillation (AF) ablation. Although studies have shown favorable comparison between non-invasive and invasive hemodynamic monitoring (IHM) in non-cardiac procedures under general anesthesia, limited data is available for complex cardiac procedures such as AF ablation in the USA. With progressive improvement in AF ablation procedural safety, particularly with routine use of intracardiac echocardiography (ICE) to monitor for pericardial effusion, it is unclear if invasive hemodynamic monitoring provides any advantage over non-invasive methods.

Echocardiographic parameters associated with in-hospital adverse outcomes in patients with Takotsubo syndrome.

Introduction: Takotsubo syndrome (TTS) is an acute heart failure syndrome that leads to significant morbidity and mortality. We sought to evaluate the association of cardiac mechanics on presentation with in-hospital adverse outcomes in patients with apical TTS.

Methods: We retrospectively identified 468 patients with TTS based on ICD-9/10 codes between 2006 and 2017.

Efficacy and safety of dapagliflozin in acute heart failure: Rationale and design of the DICTATE-AHF trial.

Background: Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, reduces cardiovascular death and worsening heart failure in patients with chronic heart failure and reduced ejection fraction. Early initiation during an acute heart failure (AHF) hospitalization may facilitate decongestion, improve natriuresis, and facilitate safe transition to a beneficial outpatient therapy for both diabetes and heart failure.

Objective: The objective is to assess the efficacy and safety of initiating dapagliflozin within the first 24 hours of hospitalization in patients with AHF compared to usual care.

Critical Care Considerations in Adult Patients With Influenza-Induced ARDS.

Topic: Acute respiratory distress syndrome is a complex respiratory disease that can be induced by influenza virus infection. Critical care providers are uniquely positioned to manage this pathological progression in adult patients through evidence-based practice.

Clinical Relevance: Influenza and subsequent acute respiratory distress syndrome are associated with extremely high morbidity and mortality in adult patients in the United States.

Common, Difficult Questions about Providing Nutrition at End of Life: Bedside Application of Catholic Moral Teaching.

There is much confusion surrounding how to interpret provision of artificial nutrition and hydration (ANH) at the bedside in complicated clinical circumstances. The specific scenario that prompted these questions was a request by a patient and her family to remove a feeding tube that had become, in the patient's eyes and opinion, disproportionately burdensome in her particular set of clinical circumstances. This clinically relevant article can be viewed as a bedside interpretation of Catholic bioethical teachings on provision of ANH to the dying patient.

How to Be a Friend Who Is a Physician Without Being a Physician Friend.

As physicians, we are often asked for advice when loved ones become ill. Sometimes, the request advice is explicit; often, it is more supportive in nature and this may blur the boundary between being a friend and being a physician. Through various excerpts from social medial exchange, this narrative discusses the experience with a friend who was diagnosed with head and neck cancer during my Palliative Medicine Fellowship.

Piperacillin-Tazobactam Versus Carbapenems for the Treatment of Nonbacteremic Urinary Tract Infections due to Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae.

Carbapenems are the drug of choice for treatment of infections due to extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. Current evidence regarding piperacillin-tazobactam (PTZ) as an effective treatment alternative remains controversial. The purpose of this study was to determine the efficacy of PTZ versus carbapenems for treatment of nonbacteremic urinary tract infections (UTIs) due to ESBL-producing Enterobacteriaceae.

Outcome Study after Nasal Alar/Peri-alar Subunit Reconstruction: Comparing Paramedian Forehead Flap to Nasolabial Flap.

Objective: Contours of the lower nasal third are unique and present challenges in surgical reconstruction. The nasal alar intricate curved anatomy makes the area easily compromised after Mohs surgery. Managing patient and surgeon expectations with regard to aesthetics and functionality remains the reconstructive goal.

Treatment of Alcohol Withdrawal Syndrome: Phenobarbital vs CIWA-Ar Protocol.

Background: Benzodiazepine-based therapy for alcohol withdrawal is associated with agitation and respiratory depression. Treatment can be complicated by a need for adjunctive therapy to control these symptoms and in patients requiring mechanical ventilation. Strong evidence for the effectiveness of alternative treatment modalities is lacking, despite the availability of promising pharmacological agents such as phenobarbital.

Successful use of extracorporeal membrane oxygenation support in severe septic shock with associated acute cardiomyopathy.

A 24-year-old female presented with sepsis and cardiogenic shock 4 days after vaginal delivery. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) therapy was used for cardiovascular support as a bridge for recovery. The use of VA ECMO in patients with cardiogenic shock secondary to sepsis is reviewed.

Optimizing proton pump inhibitor therapy for treatment of nonvariceal upper gastrointestinal bleeding.

Purpose: The pharmacology, rationale, and dosing optimization strategies of proton pump inhibitors (PPIs) for the treatment of upper gastrointestinal bleeding (UGIB) are discussed.

Summary: In combination with endoscopic therapy, PPIs are the treatment of choice for UGIB. While the advent of PPIs has improved patient outcomes, controversy still exists over optimal PPI therapy for UGIB.

Use of social media to engage membership of a state health-system pharmacy organization.

Purpose: The influence of targeted strategies implemented to increase member engagement on a social media page of a professional pharmacy organization was studied.

Methods: The Ohio Society of Health-System Pharmacists (OSHP) implemented posting strategies to increase member engagement with its social media page in late 2013. Data were collected retrospectively for a nine-month period in 2013 (preimplementation) and a matching nine-month period in 2014 (postimplementation).

Iliopsoas: Pathology, Diagnosis, and Treatment.

Disorders of the iliopsoas can be a significant source of groin pain in the athletic population. Commonly described pathologic conditions include iliopsoas bursitis, tendonitis, impingement, and snapping. The first-line treatment for iliopsoas disorders is typically conservative, including activity modification, physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections.

Impact of Postoperative Intravenous Acetaminophen on Opioid Requirements and Pain Scores Following Gynecologic Procedures.

Objective: This study aims to assess the impact of postoperative intravenous (IV) acetaminophen on opioid requirements and pain scores in patients following gynecologic procedures.

Study Design: A retrospective cohort study of patients undergoing gynecologic procedures was conducted to assess the impact of adding scheduled IV acetaminophen to postoperative analgesic regimens. The control group consisted of patients admitted prior to formulary addition of IV acetaminophen; the study group consisted of patients admitted after formulary addition of IV acetaminophen who received scheduled IV acetaminophen for at least the first 24 hours postoperatively.

Postoperative atrial fibrillation: role of inflammatory biomarkers and use of colchicine for its prevention.

Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery, occurring in up to 65% of cardiac surgical patients. It is a condition associated with increased morbidity, increased length of hospital stay, and increased health care costs. One of the many potential causes of POAF is postsurgical inflammation, as demonstrated by increased levels of inflammatory biomarkers such as C-reactive protein and interleukin-6.