The gold medal; recognition as "being first" is an icon of western (Post Hellenic) culture. However just behind the victor are concepts and forces that presaged victory, discovery or complete insight.

The field of pharmacy and the role of pharmacists have expanded remarkably within the past thirty years. Clinical pharmacists' postgraduate educational training has prepared them to be competent in patient-centered care and pharmacy operational services that can be applied to any practice setting including specialized fields of clinical pharmacy such as infectious diseases and anticoagulation. Studies have also revealed the impact of clinical pharmacists on medication error reduction within the pediatric and adult critical care units, improved nutritional status in hematopoietic stem cell transplant patients, and reduced readmission rates of patients with heart failure. Highlights of selected literature showcase the role clinical pharmacists' play within the multidisciplinary team and its significant impact on both clinical and economical outcomes.

The principles of airway control, breathing and circulation maintenance provide the starting point of care for patients with thoracic injury. Intravenous access, thoracostomy tube insertion and balanced resuscitation can address most of the issues seen. Endovascular techniques have altered the course of care for patients with blunt aortic injury. Rib plating holds promise regarding enhanced recovery from a flail chest. This article reviews the basic principles and highlights the changing landscape in thoracic trauma.

Objective: Some earlier studies have suggested that cocaine use in African-Americans (AAs) results in higher defibrillation thresholds. We are therefore reviewing our own experience with this racial group for comparison. Materials and Methods: We retrospectively reviewed the medical records of AA patients who had placement by a single operator of implantable cardioverter defibrillator (ICD) at an inner city hospital from January 2006 to December 2015. Results: Seventy-four patients, mean age 59.2 ± 12.9 years, comprising 37 (50.0%) males, underwent ICD implantation of which 67.6% were single chamber and 32.4% dual chamber devices. Diagnosis was nonischemic cardiomyopathy in 68.9% and indication for device therapy was primary prevention in 87.8%. Sixty-six (89.2%) patients were noncocaine users, whereas 8 (10.8%) were cocaine abusers. The mean age, ejection fraction, and defibrillation threshold between the noncocaine and cocaine users were 60.2 ± 12.8 versus 51.3 ± 12.4 (P = 0.642), 21.6 ± 8.3 versus 16.1 ± 4.6 (P = 0.0704), and 23.5 ± 5.0 versus 25.0 ± 8.4 (P = 0.447), respectively. Biotronik device patients had complete follow-up and they had an all-cause mortality of 28.8% (15/52), while 27.0% (10/37) of the survivors had at least one or more antitachycardia pacing or high voltage shock therapies. Conclusion: There was no statistically significant difference in defibrillation threshold testing observed in AA patients in our series between noncocaine and cocaine users as previously seen in some earlier small reviews. Larger studies or meta-analysis of several studies to accumulate a substantial number of AAs using cocaine may be required for a definitive answer to the question.

Objective: There are conflicting data on the influence of race and gender on the outcome of patients undergoing coronary artery bypass graft surgery (CABG), with blacks and females showing higher operative mortality (OM) in some series and not others. Materials and Methods: The medical records of 176 black patients undergoing isolated CABG by a single surgeon from 2000 to 2014 were retrospectively reviewed. The mean age was 61.9 ± 11.2 years and majority 93 (52.8%) were males. Identified risk profiles were peripheral vascular disease 53 (30.1%) patients, insulin-dependent diabetes mellitus 49 (27.8%), end-stage renal disease (ESRD) 27 (15.3%), chronic obstructive pulmonary disease 27 (15.3%), cerebrovascular disease 24 (13.6%), and HIV/AIDS 5 (2.8%). One hundred and forty (79.5%) had severe triple vessel disease, 30 (17.0%) left main disease, and ejection fraction mean 43.0 ± 14.3. Results: One hundred and twenty-eight patients (72.7%) underwent on-pump and 48 patients (27.3%) off-pump coronary artery bypass graft (OPCAB), with 150 (85.2%) urgent surgeries. EuroSCORE-II (ES-II) score was 3.86 ± 3.18 while observed OM was 6.81% (12/176). There was no difference in OM between males and females 6.45% versus 7.22% (P = 0.924) and on-pump and OPCAB 7.81% versus 4.16% (P = 0.604). Univariate analysis identified ESRD and ES as predictors but on multivariate analysis only ESRD with odds ratio 4.630 (95% CI: 1.321-16.229, P = 0.017). The society of thoracic surgeons (STS) quality measurement task force major complications were acute kidney injury 6.81%, prolonged ventilation 6.81%, stroke 3.40%, deep sternal wound infection 2.27%, and reoperation 1.70%. Overall 1 and 5 years survival was 90.0% and 73.9%, respectively, with no significant difference between males and females 92.4% and 75.0% versus 86.4% and 70.9%, respectively, when P = 0.764. Conclusion: The observed/expected 1.76 ratio may partly be due to higher number of urgent and ESRD patients of 85.2% and 15.3% compared to 27.9% and 2.36-7.90%, respectively, in the STS database. Our ESRD patients had 4΍ times odds of death than non-ESRD. Despite males having slightly higher risk profiles, long-term survival was similar with females and overall 1 and 5 years survival comparable to blacks in other series.

The rhythm after valve surgery has been shown to impact on long-term outcome with increased thromboembolic risk in patients with persistent atrial fibrillation (AF) despite anticoagulation. Concomitant Cox maze IV (CMPIV) or pulmonary vein isolation using bipolar radiofrequency ablation has been demonstrated to reduce stroke risk when successful in restoring stable sinus rhythm. We report the case of a 27-year-old male with rheumatic mitral stenosis, persistent AF, and left atrial thrombus who underwent concomitant CMPIV radiofrequency ablation during mechanical mitral valve replacement and has subsequently remained in sinus rhythm and free from thromboembolism 10 years postoperatively. Strategies aimed at addressing AF and the left atrial appendage at the time of valve surgery may be beneficial in reducing embolic stroke and should be part of the contemporary surgeons armamentarium. Concomitant ablation when the capacity and expertise is locally available should therefore be considered in low-risk patients without severe left ventricular dysfunction or severe pulmonary hypertension during valve surgery in patients with persistent AF. When ablation is not feasible or equipment unavailable, consideration should then be given at a minimum to excision or exclusion of the left atrial appendage which is the most common source of emboli in AF as an alternative stroke reduction strategy.

A 36-year-old male motorcyclist involved in a motor vehicle accident (MVA) with loss of consciousness and sustained multiple orthopedic injuries and a traumatic ventricular septal defect (VSD) which was hemodynamically stable. He then underwent emergency orthopedic surgery and was discharged after 5 weeks to rehabilitation. Subsequently, 6 months later, he underwent an elective repair of a 1.5 cm apical septal defect with uneventful recovery. A meta-analysis of 61 other reports of traumatic VSD revealed MVA as the most common etiology in 57.8%, predominantly males in 85.5% and younger age group <30 years in 87.5%. The midmuscular septum was involved in 43.6%, and patch closure was used in the majority of patients performed through a right or left ventriculotomy. Operative mortality was zero with elective versus 27.3% for emergency repairs, which also had a 27.3% VSD recurrence. 28.6% of the patients required concomitant cardiac surgical procedures while two patients (4.1%) both with perimembranous VSD required a permanent pacemaker. Less invasive transcatheter closure was successfully deployed in three patients without any complications, and it is an alternative in patients with a suitable anatomy and no associated cardiac injuries requiring surgery. Conservative therapy as a mainstay of treatment should be reserved for asymptomatic small defects with hemodynamically insignificant shunts.