Chest
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The coronavirus pandemic has disrupted clinical practice, health-care organizations, and life. In the context that "a crisis is a terrible thing to waste," as disruptive as the pandemic has been to traditional practices-both clinically and educationally-opportunities have also presented. Clinical benefits have included the propulsion of clinical innovation, including such items as the development of novel vaccines and accelerated understanding of multiplex ventilation. ⋯ Although the obvious disadvantages (weaknesses) regard the loss of face-to-face interaction with all of its consequences (eg, isolation, risks to camaraderie, loss of hands-on training opportunities, and loss of in-person celebratory events like graduations and end-of-training celebrations), there are clearly offsetting strengths. These include growing experience with virtual teaching and virtual learning strategies, the invitation to codify best virtual teaching practices, a tightening of alignment between undergraduate and graduate medical education (eg, around virtual interview strategies), and opportunities for both self-reflection and a commitment to act virtuously. On balance, the pandemic has created the opportunity, indeed the necessity, to innovate in practice and in education, making the landscape ripe for creative practice, new mastery, and the concomitant benefits to learners and to educators.
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Multicenter Study Observational Study
Angiotensin II Infusion for Shock: A Multicenter Study of Post-Marketing Use.
Vasodilatory shock refractory to catecholamine vasopressors and arginine vasopressin is highly morbid and responsible for significant mortality. Synthetic angiotensin II is a potent vasoconstrictor that may be suitable for use in these patients. ⋯ In postmarketing use for vasopressor-refractory shock, 67% of angiotensin II recipients demonstrated a favorable hemodynamic response. Patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II. Patients who responded to angiotensin II experienced reduced mortality.
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A right heart catheterization with measurements of pulmonary artery wedge pressure (PAWP) may be necessary for the diagnosis of left heart failure as a cause of pulmonary hypertension or unexplained dyspnea. Diagnostic cutoff values are a PAWP of ≥ 15 mm Hg at rest or a PAWP of ≥ 25 mm Hg during exercise. However, accurate measurement of PAWP can be challenging and heart failure may be occult. ⋯ The procedure is simple and does not take much catheterization laboratory time. Combining echocardiography with invasive measurements may increase the diagnostic accuracy of diastolic dysfunction. Cardiac output after a fluid challenge may be of prognostic relevance.