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Mody K.P.,Columbia University | Lyons J.J.,Vassar Brothers Medical Center | Jorde U.P.,Montefiore Medical Center | Uriel N.,University of Chicago
Circulation | Year: 2015

A 35-year-old woman with no past medical history presented to her local emergency room with 2 days of fevers, chills, and myalgias. She was febrile with a temperature of 102°F, blood pressure of 95/60 (72) mm Hg, heart rate of 110 bpm, respiratory rate of 20 breaths per minute, and an oxygen saturation of 100% on 2 L oxygen. The physical examination was notable for cool extremities, clear lungs, and tachycardic heart sounds with no s3, s4, or friction rub. The patient decompensated quickly and developed hypotension, requiring rapid uptitration of norepinephrine to 12 μg · kg-1•min-1. The ECG (Figure 1) showed sinus tachycardia with ST-segment elevation in the inferolateral leads. Laboratory results were notable for cardiac troponin of 3.89 ng/mL (normal range, 0-0.08 ng/mL), venous lactate of 3.5 mmol/L (normal range, 0.50-2.20 mmol/L), white blood cell count of 17.0×109 per 1 L (normal range, 3.5-9.1×109 per 1 L), and hemoglobin of 12.4 g/dL (normal range, 13.3-16.2 g/ dL) with preserved hepatic and renal function. © 2015 American Heart Association, Inc.

Ali I.,The University of Oklahoma Health Sciences Center | Ahmad S.,The University of Oklahoma Health Sciences Center | Alsbou N.,University of Oklahoma | Lovelock D.-M.,Sloan Kettering Cancer Center | And 2 more authors.
Journal of X-Ray Science and Technology | Year: 2011

Purpose: To investigate image artifacts caused by a standard treatment couch on cone-beam CT (CBCT) images from a kV on-board imager and to develop an algorithm based on spatial domain filtering to remove image artifacts in CBCT induced by the treatment couch. Methods: Image artifacts in CBCT induced by the treatment couch were quantified by scanning a phantom used to quantify CT image performance. This was performed by scanning the phantom setup on a regular treatment couch and in air with the kV on-board imager. An algorithm was developed to filter image artifacts from the treatment couch by processing of cone-beam radiographic projections using two scans: one scan of the phantom and treatment couch and a second scan of the treatment couch only. This algorithm is based on a pixel-by-pixel removal of beam attenuation due to the treatment couch from each projection of the phantom and couch scan. The net couch-filtered projections were then used to reconstruct CBCT. Results: We found that the treatment couch causes considerable image artifacts: CT number uniformity is degraded and varies as much as 15%, and noise in CBCT scans with phantom plus couch (3.5%) is higher than for the phantom in air (1.5%). The spatial domain filtering technique reduces noise by more than 1.5%, improves uniformity by a factor of 2, and removes ringing and streaking artifacts related to the standard treatment couch in CBCT reconstructed from couch-filtered projections. This filtering technique was tested successfully to filter other hardware objects such as a patient immobilization body-fix frame. Conclusions: The standard treatment couch causes image artifact in CBCT from kV on-board imaging systems. The spatial domain filtering technique developed in this work improves image quality of CBCT by preprocessing the projections prior to CBCT reconstruction. This technique might be useful to filter other hardware objects from CBCT which may contribute to the degradation of image quality. © 2011-V IOS Press and the authors. All rights reserved.

St. Vincent's Catholic Medical Centers of New York initiated a study in 2009 to assess the health needs of residents of New York City (NYC) municipal housing at the Robert Fulton public housing complex in Manhattan. The aim of this project was to provide valid data on perceived health services needs of the residents of a NYC housing project. These data may also be used to support hospital and community collaborative strategic decisions for developing resident-appropriate health and social services and would be valuable for use in formulating policies and programs by other interested nonprofit health and social services organizations and government. We designed a 28-item instrument and pilot tested it with our research team and members of the population under study. The English and Spanish surveys were designed as an inperson surveyor-administered instruments addressing four domains: demographics, access and barriers to health care services, risk behaviors, and perceived health needs. The sampling was an apartment-level stratified random sampling. A 20%, 188 apartment sample was drawn from the population of 944 housing units. Our response rate was 92% (173/188 apartments). Background, methods, and demographic results are reported in this article. A second article will report on the needs assessment results. © 2013 Springer Publishing Company.

Kiernan M.S.,Tufts University | Joseph S.M.,University of Washington | Katz J.N.,University of North Carolina at Chapel Hill | Kilic A.,Ohio State University | And 12 more authors.
Circulation: Heart Failure | Year: 2015

Implant center clinical resources are becoming taxed by the growing volume of ambulatory LVAD patients and the rapid growth of this unique population has led to the emergence of MCS shared-care centers. The successful sharing of care with local MCS providers is necessary to allow the continued expansion of this technology to a broader patient population that may otherwise lack adequate access to this life-saving technology. These satellite partnerships facilitate the care of LVAD patients who may be unduly burdened by the distance separating their homes from the implanting centers. This model also allows for a more confident transition from hospital to home. Sharing of care, however, is unlikely to end at the ambulatory level. Because clinical experience grows, common inpatient diagnoses may eventually be comfortably managed by local sites. Implanting centers that develop a solidified partnership with an experienced shared-care center could be anticipated to increasingly promote specialized care such as endoscopy services being delivered locally, thus avoiding unnecessary readmissions. Providing these resources in closer proximity to home would be expected to improve both patient and caregiver's quality of life. Collaborative efforts are necessary to monitor outcomes to ensure that these assumptions are correct. Pivotal to the success of any shared-care relationship is transparent communication that allows identification of potential barriers to care and facilitates the shared objective of improving outcomes. Commitment to a shared-care model by all parties, including patients/caregivers, local providers, and the implanting team, empowers a model of patient-centered, advanced heart failure care focused on quality of life in addition to quality of care. © 2015 American Heart Association, Inc.

Hurewitz A.N.,Winthrop University | Khan S.U.,Vassar Brothers Medical Center | Groth M.L.,Winthrop University | Patrick P.A.,Winthrop University | And 2 more authors.
Journal of General Internal Medicine | Year: 2011

BACKGROUND: Aggressive weight-based dosing guidelines help achieve prompt therapeutic anticoagulation in patients with venous thromboembolism (VTE). While obese patients with VTE face an increased risk of recurrence, physicians typically resist prescribing doses two to three times the usual dose because of concern about bleeding complications. OBJECTIVE: To examine the use of unfractionated heparin in obese patients with VTE at an academic teaching hospital in order to document the extent and pattern of underprescribing in this high-risk patient population. DESIGN: Three-year, cross-sectional consecutive case series. PATIENTS: Adult inpatients with VTE and a body mass index ≥30 kg/m 2 who were treated with unfractionated heparin. MEASUREMENTS: Time to achievement of therapeutic anticoagulation (activated partial thromboplastin time >60 s) and gap between recommended and prescribed heparin doses. RESULTS: Time to attainment of therapeutic anticoagulation exceeded 24 h in 29% of study patients (n=84) and exceeded48 h in 14% ofpatients. In 75 patients (89%), the prescribed bolus dose fell below the recommended dose of 80 units/kg, and in 64 patients (76%) the initial continuous infusion fell more than 100 units/h below - in some cases more than 1000 units/h below - the recommended dose of 18 units/kg/h. There was a significant correlation between time to therapeutic anticoagulation and initial infusion dose (Spearman r=-0.27; p<0.02). Each decrease of 1 unit/kg/h translated to a delay ranging from about 0.75 h to 1.5 h over the range of prescribed doses (6 to 22 units/kg/h). CONCLUSIONS: A substantial proportion of obese patients treated with unfractionated heparin experienced a delay >24 h in achieving adequate anticoagulation, and the vast majority received an inadequate heparin bolus or initial continuous infusion (or both) according to current dosing guidelines. © 2010 Society of General Internal Medicine.

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