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3. Handwritten Signature Verification System Using Convolutional Neural Network for Real-Time Applications

Author

Maza-Merchán, Cristian, Cordero, Jorge, Filipe, Joaquim, Editorial Board Member, Ghosh, Ashish, Editorial Board Member, Prates, Raquel Oliveira, Editorial Board Member, Zhou, Lizhu, Editorial Board Member, Botto-Tobar, Miguel, editor, Zambrano Vizuete, Marcelo, editor, Montes León, Sergio, editor, Torres-Carrión, Pablo, editor, and Durakovic, Benjamin, editor

Published
2023
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6. Digoxin Loading Doses and Serum Digoxin Concentrations for Rate Control of Atrial Arrhythmias in Critically Ill Patients

Author

Ahuja, Tania, Saadi, Raghad, Papadopoulos, John, Bernard, Samuel, Pashun, Raymond, Horowitz, James, Yuriditsky, Eugene, and Merchan, Cristian

Abstract

Intravenous (IV) digoxin loading dose (LD) recommendations for rate control of atrial arrhythmias in critically ill patients are not well studied. When using digoxin in the setting of atrial fibrillation/atrial flutter (AF/AFL), a LD in either a fixed-dose regimen, weight-based dose, or pharmacokinetic-based calculation to target a serum digoxin concentration (SDC) of 0.8–1.5 ng/mL is recommended. The objective of this study was to assess the safety and effectiveness of digoxin LD used in critically ill patients for rate control of AF/AFL and to assess the SDC achieved. This single-center retrospective cohort study included patients, who received IV digoxin and had a SDC drawn. The primary endpoint was the median SDC achieved after a digoxin LD. Secondary outcomes included the frequency of SDCs ≥1.5 ng/mL and heart rate control. A total of 92 patients were included. The median total LD of digoxin for the entire cohort was 11 μg/kg (750 μg). For 61% of the cohort, the LD was distributed over 6-hour intervals. The median SDC after completion of the IV digoxin LD was 1.3 ng/mL (0.9–1.7). The incidence of supratherapeutic SDC was 36% for the total cohort. A target heart rate <110 beats per minute within 24 hours from digoxin LD was achieved in 60% of the cohort. In conclusion, a median total digoxin LD of 750 μg in critically ill patients with AF/AFL, targeting a SDC <1.5 ng/mL, may be considered for acute rate control, taking into account drug–drug interactions in the cardiac intensive care unit. Future studies are necessary to confirm our findings.

Published
2025
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10. 2949. Emergency Department (ED) Discharge Antibiotic Prescription Review by Hospital Pharmacists at a Large Academic Medical Center

Author

Dubrovskaya, Yanina, primary, Merchan, Cristian, additional, Marsh, Kassandra, additional, Siegfried, Justin, additional, Major, Vincent J, additional, So, Jonathan, additional, Rodriguez, James, additional, Jhala, Pradyuman, additional, Iturrate, Eduardo, additional, Papadopoulos, John, additional, Mazo, Dana, additional, and Smalley, Samantha, additional

Published
2023
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11. Evaluation of Parenteral Potassium Supplementation in Pediatric Patients

Author

Clouser, Amanda A., Merchan, Cristian D., Bashqoy, Ferras, Tracy, Joanna L., Papadopoulos, John, and Saad, Anasemon

Subjects
Research, Pediatrics, Perinatology and Child Health, Pharmacology (medical)
Abstract

OBJECTIVE The primary objective was to evaluate the effect of parenteral potassium chloride (KCl) supplementation on potassium (K+) concentrations in a non-cardiac pediatric population. Secondary outcomes were to identify variables that may influence response to KCl supplementation (i.e., change in K+ concentration after KCl administration) and assess the incidence of hyperkalemia. METHODS This single-center, retrospective study evaluated infants and children who received parenteral KCl supplementation of 0.5 or 1 mEq/kg between January 2017 and December 2019. RESULTS The study included 102 patients with a median age of 1 year (IQR, 0.4–3.9) and weight of 9.1 kg (IQR, 4.9–14.2) who received 288 parenteral KCl administrations. One hundred seventy-three administrations were in the 1 mEq/kg group, and 115 administrations were in the 0.5 mEq/kg group. The median changes in K+ were 0.8 and 0.5 mEq/L in the 1 mEq/kg and 0.5 mEq/kg groups, respectively. Patients who had a repeat K+ concentration within 4 hours of the end of a 1 to 2–hour infusion had a higher median change in K+ compared with those who had a concentration drawn after this time frame (0.8 vs 0.6 mEq/L; p < 0.01). CONCLUSIONS There is a paucity of data on the correlation between parenteral KCl supplementation and change in K+ concentrations in pediatric patients. Our study demonstrated an association between KCl supplementation doses of 1 and 0.5 mEq/kg and changes in K+ of 0.8 and 0.5 mEq/L, respectively, in non-cardiac pediatric patients, with low observed incidence of hyperkalemia.

Published
2023
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15. Evaluation of the Safety of Slow IV Push Versus Slow IV Infusion Administration of 23.4% Sodium Chloride

Author

Iskaros, Olivia, Arnouk, Serena, Papadopoulos, John, and Merchan, Cristian

Abstract

Background and Purpose Increased intracranial pressure due to cerebral edema is a medical emergency in which 23.4% sodium chloride (23.4% NaCl) may be a lifesaving intervention. Currently, safety data is limited on slow IV push (IVP) administration. The purpose of this study was to evaluate the safety of IVP administration of 23.4% NaCl and determine the number of infusion-related adverse events (IRAEs) compared to slow IV infusion (SIV) administration.Methods We performed a retrospective review of patients who received a dose of 23.4% NaCl at the (removed institution)from January 2015 to June 2020 as either SIV over 30 minutes or IVP over 2-5 minutes.Results In total, 81 patients, 55 in the IVP group and 26 in the SIV group, were included in the analysis. There was a significantly faster time from order entry to dose completion (IVP 25 [13,58] vs SIV 73 [55,113] minutes, P< .001). There was no difference in IRAEs between the groups (IVP 17 [31%] vs SIV 6 [23%], P= .466). Hypotension was most common (IVP 13 [24%] vs SIV 5 [19%], P= .656) followed by bradycardia (IVP 6 [11%] vs SIV 1 [4%], P= .291). There were no extravasations reported.Conclusions Overall, among a cohort of patients with cerebral edema, we found no difference in the incidence of IRAEs between SIV and IVP administration of 23.4% NaCl, and found a faster time to complete administration fssor the latter. In emergent scenarios where time may impact neurologic function, 23.4% NaCl administered IVP may be an alternative to SIV administration.

Published
2024
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21. sj-pdf-1-jao-10.1177_03913988221082686 ��� Supplemental material for Antithrombotic management for Impella�� temporary ventricular assist devices: An analysis of an academic health-system experience

Author

Iskaros, Olivia, Ahuja, Tania, Arnouk, Serena, Toy, Bridget, Lewis, Tyler, Altshuler, Diana, Smith, Deane, Papadopoulos, John, and Merchan, Cristian

Subjects
FOS: Biological sciences, 69999 Biological Sciences not elsewhere classified
Abstract

Supplemental material, sj-pdf-1-jao-10.1177_03913988221082686 for Antithrombotic management for Impella�� temporary ventricular assist devices: An analysis of an academic health-system experience by Olivia Iskaros, Tania Ahuja, Serena Arnouk, Bridget Toy, Tyler Lewis, Diana Altshuler, Deane Smith, John Papadopoulos and Cristian Merchan in The International Journal of Artificial Organs

Published
2022
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39. A Comparison of Prothrombin Complex Concentrate and Recombinant Activated Factor VII for the Management of Bleeding With Cardiac Surgery.

Author

Katz, Alyson, Ahuja, Tania, Arnouk, Serena, Lewis, Tyler C., Marsh, Kassandra, Papadopoulos, John, and Merchan, Cristian

Subjects
HEMORRHAGE, CARDIAC surgery, CRITICAL care medicine, PROTHROMBIN, THROMBOEMBOLISM
Abstract

Bleeding following cardiac surgery that warrants transfusion of blood products is associated with significant complications, including increased mortality at 1 year following surgery. Factor concentrates, such as prothrombin complex concentrate (PCC), or recombinant activated factor VII (rFVIIa) have been used off-label for bleeding in cardiac surgery that is refractory to conventional therapy. The objective of this retrospective study is to assess the hemostatic effectiveness of 4-factor PCC or rFVIIa for bleeding after a broad range of cardiac surgeries. Patients were included if they were at least 18 years of age and had undergone cardiac surgery with bleeding requiring intervention with 4-factor PCC or rFVIIa. There were no differences observed in the number of packed red blood cells (4-factor PCC: 2 units vs. rFVIIa: 2 units), fresh frozen plasma (0 units vs. 1 unit) or platelet (2 units vs. 2 units) transfusions following the administration of 4-factor PCC or rFVIIa. The patients in the rFVIIa group, required more cryoprecipitate than those in the 4-factor PCC group (4-factor PCC: 2 units (range 0-6) vs. rFVIIa: 2 units (range 0-8), p = 0.03). There were no differences in secondary outcomes of chest tube output at 2, 6, 12 and 24 hours, nor was there a difference in re exploration rates or the median length of stay in the intensive care unit. Thromboembolic complications at 30 days were similar between the two groups (4-factor PCC: 13% vs. rFVIIa 26%, p = 0.08). The total median dose requirement for 4-factor PCC was 1000 units (15 units/kg) and 2 mg (20 mcg/kg) for rFVIIa. The results demonstrate feasibility of utilizing the minimum amount of drug in order to achieve a desired effect. Both 4-factor PCC and rFVIIa appear to be safe and effective options for the management of bleeding associated with cardiac surgery. [ABSTRACT FROM AUTHOR]

Published
2022
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46. Antithrombotic management for Impella®temporary ventricular assist devices: An analysis of an academic health-system experience

Author

Iskaros, Olivia, Ahuja, Tania, Arnouk, Serena, Toy, Bridget, Lewis, Tyler, Altshuler, Diana, Smith, Deane, Papadopoulos, John, and Merchan, Cristian

Abstract

The use of acute mechanical circulatory support (MCS) has increased over the last decade. For patients with left-ventricular failure, an Impella®(Abiomed, Danvers, MA) may be used to improve cardiac output. The purpose of this study is to describe Impella®anticoagulation patterns and evaluate the safety and effectiveness of our protocol. This is a retrospective review of all adult patients who required at least 24 h of Impella®support and received a heparin-based purge solution. In total, 109 patients were included in the final analysis. The most common indication for Impella®device insertion was cardiogenic shock (76%) with the remaining patients receiving a device for a high-risk procedures; typically coronary artery bypass grafting or percutaneous coronary intervention. A total of 9 thrombotic events occurred among 8 (7%) patients and 50 bleeding events occurred among 43 (39%) patients, with the most common classification being BARC 3a (60%). A univariate analysis revealed that patients were more likely to bleed if they were less than 65 years old, had an indication of cardiogenic shock for Impella®, inserted the device peripherally, were on dual antiplatelet therapy, or had an intra-aortic balloon pump prior to Impella®insertion, the latter of which was confirmed with a multivariate analysis (OR 2.5 [1.072–5.830]; p= 0.034). For those monitored by anti-Xa, the presence of two or more values greater than 0.40 IU/mL was a risk factor for bleeding (p= 0.037). Our study identifies risk factors for bleeding in patients receiving temporary MCS with an Impella®.

Published
2022
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48. Intravenous push versus intravenous piggyback beta‐lactams for the empiric management of gram‐negative bacteremia.

Author

Marsh, Kassandra, Dubrovskaya, Yanina, Jen, Shin‐Pung (Polly), Ahmed, Nabeela, Decano, Arnold, Siegfried, Justin, Papadopoulos, John, and Merchan, Cristian

Subjects
MEROPENEM, ESCHERICHIA coli, VASOCONSTRICTORS, INTRAVENOUS therapy, BETA lactam antibiotics, RETROSPECTIVE studies, CEFEPIME, HOSPITAL mortality, GRAM-negative bacterial diseases
Abstract

What is known and objective: Nationwide shortages of small‐volume parenteral solutions (SVPS) compelled hospitals to develop strategies including the use of intravenous push (IVP) administration of antibiotics to reserve SVPS for absolute necessities. It is unknown if administration of beta‐lactam antibiotics (BL) via IVP results in worse clinical outcomes compared to intravenous piggyback (IVPB) due to the potential inability to achieve pharmacodynamic targets. Methods: Our health‐system implemented a mandatory IVP action plan for BL from October 2017 to September 2018. This was a retrospective study of adult patients with GNB who received empiric therapy with IVPB (30 minutes) or IVP (5 minutes) cefepime (FEP) or meropenem (MEM) for at least 2 days. Endpoints included clinical response, microbiological clearance and mortality. All data are presented as n (%) or median (interquartile range). Results: The final cohort included 213 patients (IVPB n = 105, IVP n = 108). The primary source of bacteremia was urinary, with Escherichia coli being the primary pathogen. Escalation of therapy was similar between groups (15 [14%] vs 11 [10%], P =.36) at a median of 3 days (P =.68). No significant differences were observed in any secondary endpoints including microbiological clearance, bacteremia recurrence, time to defervescence, WBC normalization, vasopressor duration or in‐hospital mortality. What is new and conclusion: Our findings suggest no differences in clinical response with the use of IVP compared to IVPB FEP and MEM for treatment of GNB. This form of administration may be considered as a fluid conservation strategy in times of shortage. [ABSTRACT FROM AUTHOR]

Published
2021
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49. 1345

Author

Patel, Mitulkumar, primary, Lewis, Tyler, additional, Merchan, Cristian, additional, Arnouk, Serena, additional, Altshuler, Diana, additional, and Papadopoulos, John, additional

Published
2019
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