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1.  Exercise Hemodynamics and Quality of Life after Aortic Valve Replacement for Aortic Stenosis in the Elderly Using the Hancock II Bioprosthesis 
Background and Aim. While aortic valve replacement for aortic stenosis can be performed safely in elderly patients, there is a need for hemodynamic and quality of life evaluation to determine the value of aortic valve replacement in older patients who may have age-related activity limitation. Materials and Methods. We conducted a prospective evaluation of patients who underwent aortic valve replacement for aortic stenosis with the Hancock II porcine bioprosthesis. All patients underwent transthoracic echocardiography (TTE) and completed the RAND 36-Item Health Survey (SF-36) preoperatively and six months postoperatively. Results. From 2004 to 2007, 33 patients were enrolled with an average age of 75.3 ± 5.3 years (24 men and 9 women). Preoperatively, 27/33 (82%) were New York Heart Association (NYHA) Functional Classification 3, and postoperatively 27/33 (82%) were NYHA Functional Classification 1. Patients had a mean predicted maximum VO2 (mL/kg/min) of 19.5 ± 4.3 and an actual max VO2 of 15.5 ± 3.9, which was 80% of the predicted VO2. Patients were found to have significant improvements (P ≤ 0.01) in six of the nine SF-36 health parameters. Conclusions. In our sample of elderly patients with aortic stenosis, replacing the aortic valve with a Hancock II bioprosthesis resulted in improved hemodynamics and quality of life.
PMCID: PMC4269201  PMID: 25544931
2.  Continuity in a VA Patient-Centered Medical Home Reduces Emergency Department Visits 
PLoS ONE  2014;9(5):e96356.
One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED).
To characterize continuity under the Veterans Health Administration’s PCMH model – the Patient Aligned Care Team (PACT), at one large Veterans Affair’s (VA’s) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits.
Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012.
The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011.
Main Measures
Our exposure variable was continuity of care –a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit.
The patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care – at least one visit with their assigned PCP – had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (p = 0.001). Compared to patients with low continuity (<33% of visits), individuals with medium (33–50%) and high (>50%) continuity were less likely to utilize the ED.
Strong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services.
PMCID: PMC4035271  PMID: 24867300
3.  Reasons for readmission in an underserved high-risk population: a qualitative analysis of a series of inpatient interviews 
BMJ Open  2013;3(9):e003212.
To gather qualitative data to elucidate the reasons for readmissions in a high-risk population of underserved patients.
We created an instrument with 27 open-ended questions based on current interventions.
Yale-New Haven Hospital.
Patients at the Yale Adult Primary Care Center (PCC).
We conducted semi-structured qualitative interviews of patients who had four or more admissions in the previous 6 months and were currently readmitted to the hospital.
We completed 17 interviews and identified themes relating to risk of readmission. We found that patients went directly to the emergency department (ED) when they experienced a change in health status without contacting their primary provider. Reasons for this included poor telephone or urgent care access and the belief that the PCC could not treat acute illness. Many patients could not name their primary provider. Conversely, every patient except one reported being able to obtain medications without undue financial burden, and every patient reported receiving adequate home care services.
These high-risk patients were receiving the formal services that they needed, but were making the decision to go to the ED because of inadequate access to care and fragmented primary care relationships. Formal transitional care services are unlikely to be adequate in reducing readmissions without also addressing primary care access and continuity.
PMCID: PMC3780332  PMID: 24056478
Primary Care; Qualitative Research
4.  Diagnostic Accuracy of Point-of-Care Testing for Diabetic Ketoacidosis at Emergency-Department Triage 
Diabetes Care  2011;34(4):852-854.
In the emergency department, hyperglycemic patients are screened for diabetic ketoacidosis (DKA) via a urine dipstick. In this prospective study, we compared the test characteristics of point-of-care β-hydroxybutyrate (β-OHB) analysis with the urine dipstick.
Emergency-department patients with blood glucose ≥250 mg/dL had urine dipstick, chemistry panel, venous blood gas, and capillary β-OHB measurements. DKA was diagnosed according to American Diabetes Association criteria.
Of 516 hyperglycemic subjects, 54 had DKA. The urine dipstick had a sensitivity of 98.1% (95% CI 90.1–100), a specificity of 35.1% (30.7–39.6), a positive predictive value of 15% (11.5–19.2), and a negative predictive value of 99.4% (96.6–100) for DKA. Using the manufacturer-suggested cutoff of >1.5 mmol/L, β-OHB had a sensitivity of 98.1% (90.1–100), a specificity of 78.6% (74.5–82.2), a positive predictive value of 34.9% (27.3–43), and a negative predictive value of 99.7% (98.5–100) for DKA.
Point-of-care β-OHB and the urine dipstick are equally sensitive for detecting DKA (98.1%). However, β-OHB is more specific (78.6 vs. 35.1%), offering the potential to significantly reduce unnecessary DKA work-ups among hyperglycemic patients in the emergency department.
PMCID: PMC3064039  PMID: 21307381
5.  Test Characteristics of Urine Dipstick for Identifying Renal Insufficiency in Patients with Diabetes 
To evaluate the test characteristics of the urine dipstick as a screening tool for elevated serum creatinine in patients with uncontrolled diabetes mellitus in the emergency department (ED).
Patients with diabetes over the age of 18 who presented to the ED for any complaint over a three-month study period were considered eligible for participation in this study. A finger-stick blood glucose of ≥250 mg/dL at triage was used to confirm the diagnosis of uncontrolled diabetes. After obtaining written consent, each patient had a urine dip performed and a chemistry panel drawn. Any level of proteinuria on the urine dip was considered to be a positive test. Based on the laboratory and clinical guidelines at our institution, renal insufficiency was defined as creatinine concentration of greater than 1.3 mg/dL.
Three Hundred ninety-three confirmed patients with uncontrolled diabetes were enrolled in this study, and 49 of these (12.5%) were found to have renal insufficiency. The sensitivity and specificity of the urine dip for predicting renal insufficiency were 69.4% (95% confidence interval [CI] 54.6–81.7%) and 57.8% (95%CI 52.4–63.1%) respectively. The positive predictive value was 19% (95%CI 13.5–25.5%), and the negative predictive value was 93% (95%CI 88.7–96%). The positive likelihood ratio was 1.65 (95%CI 1.32–2.06) and the negative likelihood ratio was 0.53 (95%CI 0.34–0.81).
In this cohort of patients with uncontrolled diabetes, the test characteristics of the urine dipstick make it a poor screening tool for renal insufficiency in the ED.
PMCID: PMC3099618  PMID: 21691537
6.  Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis: A Natural History 
Case Reports in Medicine  2010;2010:168408.
Mycotic aneurysms are a rare cause of intracranial aneurysms that develop in the presence of infections such as infective endocarditis. They account for a small percentage of all intracranial aneurysms and carry a high-mortality rate when ruptured. The authors report a case of a 54-year-old man who presented with infective endocarditis of the mitral valve and acute stroke. He subsequently developed subarachnoid hemorrhage during antibiotic treatment, and a large intracranial aneurysm was discovered on CT Angiography. His lesion quickly progressed into an intraparenchymal hemorrhage, requiring emergent craniotomy and aneurysm clipping. Current recommendations on the management of intracranial Mycotic Aneurysms are based on few retrospective case studies. The natural history of the patient's ruptured aneurysm is presented, as well as a literature review on the management and available treatment modalities.
PMCID: PMC2946581  PMID: 20885918

Results 1-6 (6)