Intraoperative Pedal Pressure Changes Offers Another Quantitative Assessment for Revascularization.

BACKGROUND: Lower extremity angiography is one of the most prevalent vascular procedures performed, generally via the contralateral common femoral artery. The use of retrograde pedal artery access to perform angiography has long been reserved as a "bail-out" technique to help cross chronic total occlusions that were not amenable from an antegrade approach. Recently, there have been reports and discussions involving increased utilization of pedal access for primary revascularization. The purpose of this study is to describe the outcomes of pedal access as a primary approach and to propose a novel evaluation of distal perfusion changes associated with interventions using direct pressure measurements. METHODS: A retrospective observational study evaluating all patients who underwent lower extremity angiography via retrograde pedal access between December 1, 2020, and June 30, 2021, within a single health-care system spanning 3 hospitals was performed. Demographics, comorbidities, procedural indications, and details were all recorded. Hemodynamic measurements were obtained and recorded upon initial pedal access and post intervention with a pressure transducer connected directly to the access sheath. Outcomes were analyzed with paired t-test. RESULTS: Twenty-eight angiograms using primary pedal access for endovascular intervention were performed during the study period. Most patients were African American (75%) females (57.1%) with hypertension (89.3%), hyperlipidemia (78.6%), diabetes (85.7%), coronary artery disease (64.3%), and current tobacco users (57.1%). The most prevalent indication for angiography was nonhealing wounds (67.9%). Pedal access was mostly achieved via the anterior tibial artery (79%). Sixty-three vessels were treated during the 28 angiograms (averaging 2.3 vessels per angiogram), most commonly the superficial femoral (27%), anterior tibial (25%), and popliteal (22%) arteries. Balloon angioplasty with or without stenting (98.5%) was predominately performed with an overall technical success rate of 94%. The mean preintervention and postintervention pressures were 36.5 mm Hg (standard deviation [SD] 25.7) and 83.4 mm Hg (SD 19.5), respectively. The mean change in pressure after intervention was 46.9 mm Hg (SD 23.3) (Table 3). There was a statistically significant difference detected between preintervention and postintervention pressure (P < 0.001) (Figure 1). There were no major amputations or adverse cardiovascular events at a mean first follow-up duration of 89 days. Six of the total 28 patients (21.4%) underwent repeat endovascular intervention on the ipsilateral extremity within a median of 45 (interquartile range 22.5-62.3) days. CONCLUSIONS: Primary pedal access is a viable option for performing lower extremity angiographic interventions. A significant increase in pedal artery pressure can be observed after angiographic intervention from retrograde pedal artery access. Further studies are necessary to define the clinical prognostic importance of these findings in relation to wound healing rates.

Restricted Albumin Utilization Is Safe and Cost Effective in a Cardiac Surgery Intensive Care Unit.

BACKGROUND: Volume expansion is often necessary after cardiac surgery, and albumin is often administered. Albumin's high cost motivated an attempt to reduce its utilization. This study analyzes the impact limiting albumin infusion in a cardiac surgery intensive care unit. METHODS: This retrospective study analyzed albumin use between April 2014 and April 2015 in patients admitted to a cardiac surgery intensive care unit. During the first 9 months, there were no restrictions. In January 2015, institutional guidelines limited albumin use to patients requiring more than 3 L crystalloid in the early postoperative period, hypoalbuminemic patients, and to patients considered fluid overloaded. Albumin utilization was obtained from pharmacy records and compared with outcome quality metrics. RESULTS: In all, 1,401 patients were admitted over 13 months. Albumin use, mortality, ventilator days, patients receiving transfusions, and length of stay were compared for 961 patients before and 440 patients after guidelines were initiated. After restrictive guidelines were instituted, albumin utilization was reduced from a mean of 280 monthly doses to a mean of 101 monthly doses (p < 0.001). There was also a trend toward reduced ventilator days. Mortality, length of stay, and transfusion requirements demonstrated no significant change. Based on an average wholesale price and an average monthly reduction of 180 albumin doses, the cardiac surgery intensive care unit demonstrated more than $45,000 of wholesale savings per month after restrictions were implemented. CONCLUSIONS: Albumin restriction in the cardiac surgery intensive care unit was feasible and safe. Significant reductions in utilization and cost with no changes in morbidity or mortality were demonstrated. These findings may provide a strategy for reducing cost while maintaining quality of care.

Scope of contemporary pharmacy practice: roles, responsibilities, and functions of pharmacists and pharmacy technicians.

OBJECTIVE: To provide an overview of the current context and scope of pharmacy practice, the range of professional services offered by pharmacists, and the supporting role of pharmacy technicians. DATA SYNTHESIS: A synopsis of the current state of pharmacy practice as it relates to the spectrum of professional roles and responsibilities, the diversity of patient populations served, the complexities of patient services provided, and various aspects of emerging pharmacy practice is provided. The current work focuses on patient care services provided by pharmacists; it does not address all possible activities of pharmacists, such as administration and general management. This is a descriptive analysis. It does not take a position regarding future changes but is intended to serve as a foundation for understanding the relationship and alignment between the profession's various mandatory and voluntary credentials and the scope of practice continuum. The key educational and credentialing standards for pharmacists and pharmacy technicians are summarized and referenced. CONCLUSION: The evolutions in health care and pharmacy practice are presenting many new opportunities for pharmacists to perform functions and provide services not considered as traditional roles. The profession of pharmacy is working to achieve a pervasive model and standard of care determined only by the needs of patients and populations. The Council on Credentialing in Pharmacy hopes that the material presented herein, including the framework for credentialing in pharmacy practice, will allow audiences to gain a better understanding of where pharmacy is today and what future pharmacy practice will look like.

Beyond idealism and realism: Canadian NGO/government relations during the negotiation of the FCTC.

The Framework Convention on Tobacco Control (FCTC) marks a unique point in the history of global health governance. This convention produced the first legally binding treaty under the auspices of the World Health Organization. Another first was the extent to which non-governmental organizations (NGOs) participated in the negotiation process. This article explores the relationship between one group of NGOs and their respective government during the negotiation of the FCTC. Documentary analyses and 18 individual in-depth interviews were conducted with both government and NGO representatives. In contrast to the polar perspectives of idealism (NGOs as unique and autonomous) and realism (NGOs as funded arms of the government), our findings suggest that neither opposition nor conformity on the part of the NGOs characterize the relationship between the NGOs and government. While specific to the case under study (the FCTC), our findings nonetheless indicate the need for a nuanced view of the relationship between governments and NGOs, at least during the process of multilateral health policy negotiations.