The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) - the atrial septum's thinnest... more
The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) - the atrial septum's thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 12...
Research Interests:
BackgroundAlthough half of elderly patients with heart failure have preserved left ventricular ejection fraction (LVEF), little is known about predictors of mortality in this group.
Research Interests:
The presentation, natural history, clinical outcomes, and response to therapy in patients with heart failure differ in some ways across populations. Women, older adults, and non-Caucasian racial or ethnic groups comprise a substantial... more
The presentation, natural history, clinical outcomes, and response to therapy in patients with heart failure differ in some ways across populations. Women, older adults, and non-Caucasian racial or ethnic groups comprise a substantial proportion of the overall heart failure population, but they have typically been underrepresented in clinical trials. As a result, uncertainty exists about the efficacy of some guideline-directed medical therapies and devices in specific populations, which may result in the under or over treatment of these patients. Even when guideline-based treatments are prescribed, socioeconomic, physical, or psychological factors may impact non-Caucasian and older adult patient groups to a different extent and impact the application, effectiveness, and tolerability of these therapies. Individualized therapy based on tailored biology (genetics, proteomics, metabolomics), socioeconomic and cultural considerations, and individual goals and preferences may be the optim...
Research Interests:
-Heart failure (HF) is the leading cause for hospital readmission. Hospice care may help palliate HF symptoms but its association with 30-day all-cause readmission remains unknown. -Of the 8032 Medicare beneficiaries hospitalized for HF... more
-Heart failure (HF) is the leading cause for hospital readmission. Hospice care may help palliate HF symptoms but its association with 30-day all-cause readmission remains unknown. -Of the 8032 Medicare beneficiaries hospitalized for HF in 106 Alabama hospitals (1998-2001), 182 (2%) received discharge hospice referrals. Of the 7850 patients not receiving hospice referrals, 1608 (20%) died within 6 months post-discharge (the hospice-eligible group). Propensity scores for hospice referral were estimated for each of the 1790 (182+1608) patients and were used to match 179 hospice-referral patients with 179 hospice-eligible patients who were balanced on 28 baseline characteristics (mean age, 79 years, 58% women, 18% African American). Overall, 22% (1742/8032) died in 6 months, of whom 8% (134/1742) received hospice referrals. Among the 358 matched patients, 30-day all-cause readmission occurred in 5% and 41% of hospice-referral and hospice-eligible patients, respectively (hazard ratio {HR} associated with hospice referral, 0.12; 95% confidence interval {CI}, 0.06-0.24). HRs (95% CIs) for 30-day all-cause readmission associated with hospice referral among the 126 patients who died and 232 patients who survived 30-day post-discharge were 0.03 (0.04-0.21) and 0.17 (0.08-0.36), respectively. Although 30-day mortality was higher in the hospice referral group (43% vs. 27%), it was similar at 90 days (64% vs. 67% among hospice-eligible patients). -A discharge hospice referral was associated with lower 30-day all-cause readmission among hospitalized HF patients. However, most HF patients who died within 6 months of hospital discharge did not receive a discharge hospice referral.
Research Interests: Risk assessment, Multivariate Analysis, Heart Failure, Humans, United States, and 16 moreFemale, Male, Propensity Score, Risk factors, Patient Admission, Registries, Length of Stay, Medicare, Aged, Time Factors, Chi Square Distribution, Risk Factors, Risk Assessment, Hospices, Alabama, and Proportional Hazards Models
We propose that Stage D advanced heart failure be defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Importantly, the progressive... more
We propose that Stage D advanced heart failure be defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Importantly, the progressive decline should be primarily driven by the heart failure syndrome. Formally defining advanced heart failure and specifying when medical and device therapies have failed is challenging, but signs and symptoms, hemodynamics, exercise testing, biomarkers, and risk prediction models are useful in this process. Identification of patients in Stage D is a clinically important task since treatments are inherently limited, morbidity is typically progressive, and survival is often short. Age, frailty, and psychosocial issues impact both outcomes and selection of therapy for Stage D patients. Heart transplant and mechanical circulatory support devices are potential treatment options in select patients. In addition to considering indications, contraindications, cl...
Research Interests:
We report on the discovery of a new potential galaxy threshing system in the COSMOS 2 square degree field using the prime-focus camera, Suprime-Cam, on the 8.2 m Subaru Telescope. This system consists of a giant elliptical galaxy with... more
We report on the discovery of a new potential galaxy threshing system in the COSMOS 2 square degree field using the prime-focus camera, Suprime-Cam, on the 8.2 m Subaru Telescope. This system consists of a giant elliptical galaxy with MV~-21.6 and a tidally disrupted satellite galaxy with MV~-17.7 at a photometric redshift of z~0.08. This redshift is consistent with the
Research Interests:
To determine whether psychological factors differentiate patients with silent versus symptomatic myocardial ischemia, a battery of psychometric tests was administered to 68 patients with positive thallium stress tests. Compared with... more
To determine whether psychological factors differentiate patients with silent versus symptomatic myocardial ischemia, a battery of psychometric tests was administered to 68 patients with positive thallium stress tests. Compared with patients who became symptomatic (n = 25), patients with silent ischemia on the treadmill (n = 24) were less often aware of cardiac and other bodily sensations (p less than 0.005) and were less avoidant of harm or pain in general (p less than 0.05). They did not differ on variables associated with symptom reporting biases. To clarify the relationship between ischemia and symptom reporting, symptomatic patients were subgrouped on the basis of anginal pain latency. Psychologically, the patients with silent ischemia were most similar to patients with the longest pain latencies and most different from those who reported angina before the onset of ST depression. The psychological profile of patients with silent ischemia during exercise testing is consistent wi...
Research Interests:
Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed... more
Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially a...
Research Interests:
This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda. Heart failure contributes significantly to noncommunicable... more
This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda. Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery. Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record. In our study population, the median age ...
Research Interests: Epidemiology, Global Health, Health Policy, Rwanda, Echocardiography, and 7 moreHeart Failure, Decision Trees, Humans, Female, Male, CVD, and Adult
Heart failure (HF) represents the quintessential disorder of cardiovascular aging, reflecting the convergence of age-related changes in the cardiovascular system and other organ systems and the increasing prevalence of cardiovascular... more
Heart failure (HF) represents the quintessential disorder of cardiovascular aging, reflecting the convergence of age-related changes in the cardiovascular system and other organ systems and the increasing prevalence of cardiovascular diseases at older age. The prevalence and incidence of HF increase progressively with advancing age, and HF imposes an enormous burden on society in mortality, morbidity, and associated health care costs. Despite major advances in treatment of HF over the last 25 years, the prognosis remains poor, with median survival rates of less than 5 years in older adults. As the population ages, it is anticipated that the number of older people with HF will increase dramatically over the next several decades.
Research Interests:
BackgroundDepression is associated with an increased risk for cardiac morbidity and mortality in patients with coronary heart disease (CHD). Cardiac autonomic nervous system (ANS) dysregulation, proinflammatory processes, and procoagulant... more
BackgroundDepression is associated with an increased risk for cardiac morbidity and mortality in patients with coronary heart disease (CHD). Cardiac autonomic nervous system (ANS) dysregulation, proinflammatory processes, and procoagulant processes have been suggested as possible explanations.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Findings Of 608 patients with multidrug resistant tuberculosis, 29 (4·8%) patients had baseline XDR tuberculo- sis. Treatment failure was more common in patients with XDR tuberculosis than in those with non-XDR tuberculosis (31% vs 8·5%,... more
Findings Of 608 patients with multidrug resistant tuberculosis, 29 (4·8%) patients had baseline XDR tuberculo- sis. Treatment failure was more common in patients with XDR tuberculosis than in those with non-XDR tuberculosis (31% vs 8·5%, p=0·0008). 48·3% of patients with XDR tuberculosis and 66·7% of patients with non-XDR tuber- culosis had treatment cure or completion (p=0·04). The frequency and management
Research Interests: Treatment Outcome, Russia, Tuberculosis, Humans, Mycobacterium tuberculosis, and 17 moreInfectious Disease, Female, Drug Resistance, Male, Cohort Study, Lancet, Adult, Time Factors, Adverse Event, Retrospective Studies, Combination drug therapy, Quinolines, Oxazolidinones, Fluoroquinolones, Mortality rate, Cohort Studies, and Acetamides
Research Interests:
... High incidence and clinical course of aggressive skin cancer in heart transplant patients: a single-center study. Adamson R, Obispo E, Dychter S, Dembitsky W, Moreno-Cabral R, Jaski B, Gordon J, Hoagland P, Moore K, King J, Andrews J,... more
... High incidence and clinical course of aggressive skin cancer in heart transplant patients: a single-center study. Adamson R, Obispo E, Dychter S, Dembitsky W, Moreno-Cabral R, Jaski B, Gordon J, Hoagland P, Moore K, King J, Andrews J, Rich M, Daily PO. ...
Research Interests:
Research Interests:
Research Interests: Cardiology, Evidence Based Medicine, Obesity, Aging, Quality of Mental Health Care, and 12 moreInflammation, Humans, Hypertension, Reactive Oxygen Species, United States, Preventive Cardiology, Exercise, Aged, Diabetes complications, Cardiovascular Diseases, Caloric Restriction, and Primary Prevention
Research Interests:
Research Interests:
Research Interests: Social Support, Peru, Treatment Outcome, Tuberculosis, Humans, and 14 moreMycobacterium tuberculosis, Female, Drug Resistance, Male, Human immunodeficiency virus, Adult, New England, Adverse Event, Retrospective Studies, Combination drug therapy, Sputum, New England Journalof Medicine, Ambulatory Care, and Drug treatment
Research Interests:
Research Interests:
Research Interests:
Multidrug-resistant tuberculosis (MDR-TB) presents an increasing threat to global tuberculosis control. Many crucial management issues in MDR-TB treatment remain unanswered. We reviewed the existing scientific research on MDR-TB... more
Multidrug-resistant tuberculosis (MDR-TB) presents an increasing threat to global tuberculosis control. Many crucial management issues in MDR-TB treatment remain unanswered. We reviewed the existing scientific research on MDR-TB treatment, which consists entirely of retrospective cohort studies. Although direct comparisons of these studies are impossible, some insights can be gained: MDR-TB can and should be addressed therapeutically in resource-poor settings; starting of treatment early is crucial; aggressive treatment regimens and high-end dosing are recommended given the lower potency of second-line antituberculosis drugs; and strategies to improve treatment adherence, such as directly observed therapy, should be used. Opportunities to treat MDR-TB in developing countries are now possible through the Global Fund to Fight AIDS, TB, and Malaria, and the Green Light Committee for Access to Second-line Anti-tuberculosis Drugs. As treatment of MDR-TB becomes increasingly available in resource-poor areas, where it is needed most, further clinical and operational research is urgently needed to guide clinicians in the management of this disease.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
This study was designed to determine the effect of increasing age on mortality, hospitalizations and digoxin side effects in patients with heart failure (HF), and to determine whether the effect of digoxin on clinical outcomes varies as a... more
This study was designed to determine the effect of increasing age on mortality, hospitalizations and digoxin side effects in patients with heart failure (HF), and to determine whether the effect of digoxin on clinical outcomes varies as a function of age. The incidence and prevalence of HF increase with advancing age, but there are limited data on the clinical course and response to specific therapeutic interventions in elderly patients with HF. The Digitalis Investigation Group (DIG) study was a prospective, randomized clinical trial involving 7,788 patients with HF randomized to digoxin or placebo and followed for an average of 37 months. In the present analysis, patients were stratified into five age categories: <50 years (n = 841), 50 to 59 years (n = 1,545), 60 to 69 years (n = 2,885), 70 to 79 years (n = 2,092) and > or =80 years (n = 425). Interactions between age and the following clinical outcomes were examined: total mortality, all-cause hospitalizations, HF hospitalizations, the composite of HF death or HF hospitalization, hospitalization for suspected digoxin toxicity and withdrawal from therapy because of side effects. Increasing age was an independent risk factor for total mortality, all-cause hospitalization, HF hospitalization, HF death or hospital admission, hospitalization for suspected digoxin toxicity and withdrawal from digoxin therapy (all p < 0.001). However, there were no significant interactions between age and digoxin treatment with respect to any of the major clinical end points. Increasing age is associated with progressively worse clinical outcomes in patients with HF. However, the beneficial effects of digoxin in reducing all-cause admissions, HF admissions, and HF death or hospitalization are independent of age. Thus, digoxin remains a useful agent for the adjunctive treatment of HF due to impaired left ventricular systolic function in patients of all ages.
Research Interests:
Research Interests: Risk, Forecasting, Treatment Outcome, Belgium, Multivariate Analysis, and 43 moreHeart Failure, Canada, Prospective studies, Humans, Enalapril, Diabetes mellitus, Blood Pressure, Cardiovascular Pharmacology, Renin Angiotensin Aldosterone System, United States, Female, Animals, Male, Heart rate, Heart, Follow-up studies, Incidence, Risk factors, Left Ventricular Dysfunction, Enzyme, African Americans, Aged, Middle Aged, Rats, Myocardial Infarction, Public health systems and services research, Sex Factors, Time Factors, Diabetes complications, Survival Rate, Cardiovascular Diseases, European Continental Ancestry Group, Risk Factors, Angiotensin Converting Enzyme, Losartan, Imidazoles, Beta Blockers, Angiotensin Converting Enzyme Inhibitors, ACE Inhibitor, Extended release, Captopril, The American, and Cumulant
Research Interests:
Research Interests:
Research Interests: Cardiology, Communication, Decision Making, Family, Aging, and 16 moreRisk assessment, Research, Continuing Medical Education, Humans, Placenta, Heart, The, Aged, Middle Aged, Public health systems and services research, Advance Directives, Cardiovascular Diseases, Patient Centered Care, Risk Assessment, Older Adult, and Health services for the aged
To determine the feasibility and potential impact of a non-pharmacologic multidisciplinary intervention for reducing hospital readmissions in elderly patients with congestive heart failure. Prospective, randomized clinical trial, with 2:1... more
To determine the feasibility and potential impact of a non-pharmacologic multidisciplinary intervention for reducing hospital readmissions in elderly patients with congestive heart failure. Prospective, randomized clinical trial, with 2:1 assignment to the study intervention or usual care. 550-bed secondary and tertiary care university teaching hospital. 98 patients > or = 70 years of age (mean 79 +/- 6 years) admitted with documented congestive heart failure. Comprehensive multidisciplinary treatment strategy consisting of intensive teaching by a geriatric cardiac nurse, a detailed review of medications by a geriatric cardiologist with specific recommendations designed to improve medication compliance and reduce side effects, early consultation with social services to facilitate discharge planning, dietary teaching by a hospital dietician, and close follow-up after discharge by home care and the study team. All patients were followed for 90 days after initial hospital discharge. The primary study endpoints were rehospitalization within the 90-day interval and the cumulative number of days hospitalized during follow-up. The 90-day readmission rate was 33.3% (21.7%-44.9%) for the patients receiving the study intervention (n = 63) compared with 45.7% (29.2%-62.2%) for the control patients (n = 35). The mean number of days hospitalized was 4.3 +/- 1.1 (2.1-6.5) for the treated patients vs 5.7 +/- 2.0 (1.8-9.6) for the usual-care patients. In a prospectively defined subgroup of patients at intermediate risk for readmission (n = 61), readmissions were reduced by 42.2% (from 47.6% to 27.5%; p = 0.10), and the average number of hospital days during follow-up decreased from 6.7 +/- 3.2 days to 3.2 +/- 1.2 days (p = NS). These pilot data suggest that a comprehensive, multidisciplinary approach to reducing repetitive hospitalizations in elderly patients with congestive heart failure may lead to a reduction in readmissions and hospital days, particularly in patients at moderate risk for early rehospitalization. Further evaluation of this treatment strategy, including an assessment of the cost-effectiveness, is warranted.
Research Interests: General Internal Medicine, Home Care, Multivariate Analysis, University Teaching, Heart Failure, and 21 moreProspective studies, Humans, General, Congestive Heart Failure, Female, Male, Social Services, Follow-up studies, Cost effectiveness, Risk factors, Length of Stay, Clinical Sciences, Aged, Patient Care Team, Time Factors, Randomized Clinical Trial, Risk Factors, Side Effect, Multidisciplinary Approach, Pilot Projects, and Cumulant
Older adults make up an increasing proportion of patients hospitalized with cardiovascular disease. Such patients often have multiple coexisting geriatric syndromes that may affect management and outcomes and are frequently underdiagnosed... more
Older adults make up an increasing proportion of patients hospitalized with cardiovascular disease. Such patients often have multiple coexisting geriatric syndromes that may affect management and outcomes and are frequently underdiagnosed and untreated. To determine the prevalence of geriatric syndromes and incidence of selected adverse events in hospitalized elderly patients with cardiovascular disease. A prospective cohort study. Urban academic medical center. One hundred patients at least 70 years old with cardiovascular disease hospitalized on a cardiology ward. Standard geriatric screens were administered to assess mood, function, and cognitive status. Patients were followed prospectively for adverse events such as falls, urinary tract infection (UTI), and use of restraints. The mean age of the patients was 79.2 +/- 5.5 years, 61% were female, 68% were white, and mean length of stay was 7 days. Geriatric syndromes were prevalent and included functional impairment (35% dependent in >or=1 activity of daily living), cognitive impairment (19% with abnormal results on the Short Blessed Test), and polypharmacy. Thirty-seven percent of patients were prescribed a potentially inappropriate medication on admission or discharge. Patients receiving a Foley catheter were at increased risk for UTI. These findings suggest that geriatric syndromes are prevalent among older patients hospitalized for cardiovascular disease. Further study is needed to determine if interventions designed to increase recognition and treatment of these syndromes can improve outcomes in this patient population.
Research Interests: Geriatrics, Comorbidity, Activities of Daily Living, Malnutrition, Prospective studies, and 23 moreHumans, Weight Loss, Hospitalization, Female, Clinical, Male, Clinical oncology, Missouri, Hospital Medicine, Mental Disorders, Patient Admission, Clinical Sciences, Aged, Prevalence, Patient Care Team, Neoplasms, Cardiovascular Diseases, Geriatric Assessment, Hematologic Diseases, Pilot Projects, Syndrome, Acute Care, and Cohort Studies
The cardiac CT Appropriate Use Criteria (AUC) were updated in 2010 to reflect technical advances, evolving expert consensus, and rapidly expanding clinical evidence. We evaluated the effect of the AUC update on their clinical performance,... more
The cardiac CT Appropriate Use Criteria (AUC) were updated in 2010 to reflect technical advances, evolving expert consensus, and rapidly expanding clinical evidence. We evaluated the effect of the AUC update on their clinical performance, including the completeness and distribution of appropriateness ratings and test outcomes among a consecutive series of patients referred for CT angiography (CTA). The 2006 and 2010 criteria were prospectively applied at the point of service to a consecutive series of patients referred for CTA at a single center (n = 1216). Patient interview and review of available health records were used to determine the CTA indication. The proportions of patients within categories of appropriate (A), uncertain (U), inappropriate (I), and not covered were described and compared between the 2006 and 2010 criteria. The 2010 criteria significantly reduced the proportion of uncertain (30.5%-11.4%), inappropriate (16.0%-12.9%), and no covered (12.1%-4.7%; P < 0.001) indications, while increasing the proportion of appropriate tests from 41.4% to 71%. By the 2010 criteria, appropriate indications were more likely to lead to the detection of coronary artery stenosis (11.5% vs 6.7%; P = 0.03) and complete examinations (95.0% vs 90.8%; P = 0.03). The 2010 cardiac CT AUC update lead to more complete classification and to large shifts in the appropriateness ratings, underscoring the importance of ensuring the periodic revision of AUCs for evolving imaging technologies such that they perform optimally as quality measurement and reimbursement tools.
Research Interests: Prospective studies, Humans, Female, Male, Clinical Sciences, and 12 moreAged, Middle Aged, Coronary Angiography, Adult, Public health systems and services research, Time Factors, Prognosis, Chi Square Distribution, District of Columbia, Coronary Artery Disease, X ray Computed Tomography, and Predictive value of tests
Research Interests: Heart Failure, Humans, Congestive Heart Failure, Female, Renal failure, and 17 moreMale, Cardiac, ROC Curve, Length of Stay, Serum Creatinine, Renal Function, Clinical Sciences, Aged, Middle Aged, Time Factors, Prognosis, Ejection Fraction, Hospital Mortality, Sensitivity and Specificity, Cardiac failure, ACE Inhibitor, and Creatinine
Outpatient care accounts for a significant proportion of total heart failure (HF) expenditures. This observation, plus an expanding list of treatment options, has led to the development of the disease-specific HF clinic. The goals of the... more
Outpatient care accounts for a significant proportion of total heart failure (HF) expenditures. This observation, plus an expanding list of treatment options, has led to the development of the disease-specific HF clinic. The goals of the HF clinic are to reduce mortality and rehospitalization rates and improve quality of life for patients with HF through individualized patient care. A variety of staffing configurations can serve to meet these goals. Successful HF clinics require an ongoing commitment of resources, the application of established clinical practice guidelines, an appropriate infrastructure, and a culture of quality assessment. This consensus statement will identify the components of HF clinics, focusing on systems and procedures most likely to contribute to the consistent application of guidelines and, consequently, optimal patient care. The domains addressed are: disease management, functional assessment, quality of life assessment, medical therapy and drug evaluation, device evaluation, nutritional assessment, follow-up, advance planning, communication, provider education, and quality assessment.