Intra-Abdominal Hemorrhage Triggering Inappropriate Therapy From a Subcutaneous Defibrillator.

The SMART Pass filter (Boston Scientific) aims to reduce inappropriate shocks (IASs) from subcutaneous implantable cardioverter-defibrillators by filtering out low-frequency signals such as T waves. However, this filter is deactivated in the presence of diminished R-wave sensing. We describe a case of IAS in the setting of extensive intra-abdominal hemorrhage.

Remote monitoring in patients with heart failure with cardiac implantable electronic devices: a systematic review and meta-analysis.

BACKGROUND: Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is now the standard of care, but whether the demonstrated benefits of RM translate into improvements in heart failure (HF) management is controversial. This systematic review addresses the role of RM in patients with HF with a CIED. METHODS AND RESULTS: A systematic search of the literature for randomised clinical trials in patients with HF and a CIED assessing efficacy/effectiveness of RM was performed using MEDLINE, PubMed and Embase. Meta-analysis was performed on the effects of RM of CIEDs in patients with HF on mortality and readmissions. Effects on implantable cardiac defibrillator (ICD) therapy, healthcare costs and clinic presentations were also assessed.607 articles were identified and refined to 10 studies with a total of 6579 patients. Implementation of RM was not uniform with substantial variation in methodology across the studies. There was no reduction in mortality or hospital readmission rates, while ICD therapy findings were inconsistent. There was a reduction in patient-associated healthcare costs and reduction in healthcare presentations. CONCLUSION: RM for patients with CIEDs and HF was not uniformly performed. As currently implemented, RM does not provide a benefit on overall mortality or the key metric of HF readmission. It does provide a reduction in healthcare costs and healthcare presentations. PROSPERO REGISTRATION NUMBER: CRD42019129270.

Rapidly expanding saphenous vein graft myoctic aneurysm causing ST-elevation myocardial infarction: a case report.

BACKGROUND: Mycotic aneurysms of coronary vein grafts are rare and associated with high mortality. They are most commonly a result of surgical or percutaneous intervention, and present with complications including myocardial infarction (MI), infective endocarditis. A recent literature review identified 97 cases of mycotic coronary aneurysms in total. CASE SUMMARY: A 49-year-old man with a history of coronary artery bypass grafting and septic arthrithis presented with chest pain and fevers and ST elevation on electrocardiogram. Urgent angiogram showed an aneurysmal saphenous vein graft from the PL branch to PDA-no acute intervention was performed due to concern about bacteraemia. Methicillin-sensitive Staphylococcus aureus was grown in urine and blood but no focus of infection was identified. Despite treatment with antibiotics and antiplatelets, the patient returned with evidence of expansion of the SVG aneurysm requiring surgical resection. DISCUSSION: This case highlights the difficulty in treating acute coronary syndromes involving mycotic aneurysms. Multimodal imaging approaches are useful to identify suspected infection, but false negatives occur. Due to high risk of rupture or haemorrhage, there are limited options for urgent reperfusion in cases of MI with mycotic aneurysm, demonstrating the need for an individualized approach and close follow-up.

Effect of Recruitment of Acute Coronary Collaterals on In-Hospital Mortality and on Left Ventricular Function in Patients Presenting With ST Elevation Myocardial Infarction.

Recruitment of the coronary collateral circulation is frequently observed during ST elevation myocardial infarction (STEMI) and is of uncertain significance. The aim of this study was to identify and determine the predictors and prognostic implications of the presence of robust collaterals during STEMI. All patients presenting to a large tertiary centre with a STEMI undergoing percutaneous coronary intervention from 2010 to 2018 were reviewed. Patients with poor collateral recruitment were defined as those with Rentrop grade 0 or 1 collaterals, whilst patients with robust collateral recruitment were defined as Rentrop grade 2 or 3. A total of 1,625 patients were included in the study, with 1,280 (78.8%) patients having poor collateral recruitment and 345 patients (21.2%) having robust collateral recruitment. Patients with robust collaterals were younger (63.1 vs 65.1 years, p < 0.05), had a longer ischemic time (628.5 minutes vs 433.1 minutes, p < 0.0001), and more likely to have a chronic total occlusion of a noninfarct related artery (10.4% vs 5.3%, p < 0.001). The presence of robust collaterals was associated with higher rates of normal or mildly impaired left ventricular function (83.5% vs 63.2%, p < 0.0001) and lower in-hospital mortality (2.1% vs 7.6%, p < 0.0001). After correcting for left ventricular function, collateral recruitment was not an independent predictor of mortality. In conclusion, in patients presenting with STEMI, the presence of robust coronary collaterals appears to be associated with improved left ventricular function. Further research is required to identify mechanisms of collateral maturation and recruitment.

An international capstone experience for pharmacy students.

This report describes the experiences of the University of Tennessee College of Pharmacy over 20 years with an international capstone educational experience for students. Although the university provides reciprocal opportunities to international students, this report focuses on the experiences of the college's pharmacy students who have participated in the program. This capstone course is offered as an elective course in the advanced pharmacy practice experience (APPE) component of the college's experiential program. Goals of the program and a brief description of its organizational structure are provided. Results of a structured student satisfaction survey and a survey covering the most recent 3 years of the program are presented. This program has greatly broadened participants' cultural horizons and expanded their global view and understanding of the contributions of pharmacy to health care.

Education and training of pharmacists: comments on sustaining continuous improvement.

OBJECTIVE: To examine three approaches to improving the education and training of pharmacists and their interrelationships. DATA SOURCES: American Association of Colleges of Pharmacy, American Society of Health-System Pharmacists, National Center for Education Statistics, and peer-reviewed pharmacy literature. SUMMARY: The education of pharmacists continues to change based on a paradigm of continuous quality improvement and broad agreement that many newly graduated pharmacists are not ready to practice in all practice settings. This commentary looks at three avenues for change: increased prepharmacy coursework up to a baccalaureate degree, more clinical experience during the professional Doctor of Pharmacy program, and postgraduate professional residencies. The three avenues are examined in terms of feasibility, unanswered questions, and interrelationships among the variables. CONCLUSION: The interrelationships among the three approaches for change suggest a coordinated approach in which progress in each area informs the others. Requiring additional prepharmacy coursework up to a baccalaureate degree is feasible and likely sustainable relative to total number of awarded and projected baccalaureate degrees. Higher undergraduate academic expectations can provide "space" in the pharmacy curriculum for more clinical education. The space makes more clinical education possible, with the caveat that more clinical education will require many more residency-trained pharmacists to serve in faculty positions. Residency growth could generate needed additional qualified faculty members and preceptors. Further evolution in pharmacist education and training should be driven by the goal of advancing the profession's leadership in improving the safety and quality of the medication-use process.

Unmet needs in the medication use process: perceptions of physicians, pharmacists, and patients.

OBJECTIVES: To explore the perception of unmet needs in the medication use process from the perspectives of three of the principal participants in the process--physicians, pharmacists, and patients--and to identify the individual(s) or strategy(ies) perceived to be the best or most likely candidate(s) to resolve the problems identified. PARTICIPANTS: Physicians (primary care, cardiology, oncology, and obstetrics/gynecology specialties), pharmacists (community and health-system settings), and patients from four medium-sized U.S. cities. The survey instrument was modified for each group. MAIN OUTCOME MEASURES: The medication use process was divided into nine steps, based on a previous study. A two-part question was framed for each step. In part A, respondents were asked to indicate their level of agreement (on a 5-point scale) about whether the step was being conducted appropriately. In part B, those who disagreed with a statement in part A were asked their opinions on the best possible candidate or strategy for improving that step. RESULTS: Both physicians and pharmacists identified four areas of unmet needs: timing of physician visit, patient counseling, patient use of medications, and patient monitoring. Each group held itself primarily responsible for the resolution of most of these problems. Patients did not identify any unmet needs from the survey. In responses to open-ended questions, however, they cited medication cost, appropriateness, access, and convenience as problems. CONCLUSION: Providers and patients reported substantially different perspectives on medication use problems and on improving the process. Addressing the unmet needs identified in this study will require better understanding, communication, and collaboration among physicians, pharmacists, and patients.