Impact of patient-centered medical home assignment on emergency room visits among uninsured patients in a county health system.

The Medical Services Initiative program--a safety net-based system of care--in Orange County included assignment of uninsured, low-income residents to a patient-centered medical home. The medical home provided case management, a team-based approach for treating disease, and increased access to primary and specialty care among other elements of a patient-centered medical home. Providers were paid an enhanced fee and pay-for-performance incentives to ensure delivery of comprehensive treatment.

Haemodynamic effects of verapamil administration after large doses of fentanyl in man.

Thirteen patients with good left ventricular function undergoing coronary artery revascularization were studied to determine the cardiovascular effects of verapamil, 75-150 micrograms X kg-1, after a large dose (100 micrograms X kg-1) of fentanyl, with pancuronium for muscle relaxation. The patients were continued on their usual cardiovascular medications until the time of surgery, which included nitrates, beta adrenergic blockers, and nifedipine. Anaesthesia with fentanyl was associated with decreases in mean arterial blood pressure, systemic vascular resistance, left ventricular stroke work index, and circulating catecholamine levels.

Thrombolytic therapy for superior vena caval thrombosis following superior vena cava-pulmonary artery anastomosis.

Immediate postoperative thrombosis of left superior vena cava-left pulmonary artery anastomosis in a modified Fontan procedure for single ventricle and pulmonary artery stenosis is described. Before thrombolytic therapy with streptokinase is initiated, confirmation of thrombosis by venography is mandatory to lessen the risk of cardiac tamponade or hemothorax. By this technique major surgical intervention is avoided, but close attention to the dose of streptokinase and the coagulation profile is essential.

Surgical correction of pulmonary atresia and ventricular septal defect with large systemic-pulmonary collaterals.

A two-stage surgical procedure was performed in a young adult with pulmonary atresia and a ventricular septal defect with upper lobe pulmonary artery flow from confluent central pulmonary arteries and lower lobe pulmonary blood flow originating from two large systemic-pulmonary collaterals. Initially a Dacron Y graft was anastomosed between the ascending aorta and the collaterals and a graft to the left pulmonary artery. At the second operation, continuity was established between the right ventricle and the Y graft by using a valved Dacron conduit and the ventricular septal defect was closed.