Children born with anatomic or functional "single ventricle" must progress through two or more major operations to sustain life. This management sequence culminates in the total cavopulmonary connection, or "Fontan" operation. A consequence of the "Fontan circulation", however, is elevated central venous pressure and inadequate ventricular preload, which contribute to continued morbidity. We propose a solution to these problems by increasing pulmonary blood flow using an "injection jet" (IJS) in which the source of blood flow and energy is the ventricle itself. The IJS has the unique property of lowering venous pressure while enhancing pulmonary blood flow and ventricular preload. We report preliminary results of an analysis of this circulation using a tightly-coupled, multi-scale computational fluid dynamics model. Our calculations show that, constraining the excess volume load to the ventricle at 50% (pulmonary to systemic flow ratio of 1.5), an optimally configured IJS can lower venous pressure by 3 mmHg while increasing systemic oxygen delivery. Even this small decrease in venous pressure may have substantial clinical impact on the Fontan patient. These findings support the potential for a straightforward surgical modification to decrease venous pressure, and perhaps improve clinical outcome in selected patients.

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OBJECTIVE: To evaluate the appropriateness of proton-pump inhibitor (PPI) prescribing and reduce the number of outpatients on long-term PPI therapy, defined as greater than or equal to one year.<br/> DESIGN: Phase I was retrospective and evaluated the appropriateness of PPI prescribing. Phase II was prospective and involved implementation of a pharmacist-driven PPI step-down protocol.<br/> SETTING: This study was conducted in an outpatient setting at Veterans Affairs Hudson Valley Health Care System.<br/> PATIENTS, PARTICIPANTS: Patients were limited to a single primary care provider and were required to fill an outpatient PPI prescription between August 15, 2015, and August 15, 2016.<br/> INTERVENTIONS: After patients were identified in Phase I as having an inappropriate indication for long-term PPI therapy, they were contacted by a pharmacist to complete the step-down protocol. The patients then received a call two weeks after completing each step.<br/> MAIN OUTCOME MEASURE(S): To determine the number of patients without an indication for long-term PPI therapy that could successfully complete the PPI step-down protocol.<br/> RESULTS: Phase I identified that long-term PPI therapy was not indicated in 68.4% of patients. Phase II implementation demonstrated that 71.4% of patients were able to successfully step-down from PPI therapy in an average of 13 weeks with the use of alternative acid-suppression therapy.<br/> CONCLUSION: This study concluded that a majority of PPI prescriptions were not indicated for a duration of greater than or equal to 1 year. With the implementation of a pharmacist-driven PPI step-down protocol, a majority of patients were able to tolerate the PPI step-down with the use of alternative acidsuppression therapy.

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