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Peer Reviewed Articles by PSEP Faculty
(The articles below relate to the general area of patient
safety, with a focus on nosocomial device-related infections.)
Kim C, Diez Roux A, Hofer TP, Nallamothu BK,
Bernstein SJ, Rogers MAM. Area socioeconomic status and
mortality after coronary artery bypass graft surgery: the role
of hospital volume. American Heart Journal, 2007;154:385-90.
Rogers MAM, Blumberg N, Heal JM, Hicks GL Jr.
Increased risk of infection and mortality in women after cardiac
surgery related to allogeneic blood transfusion. Journal of Women’s
Health, 2007;16:1412-1420.
Nallamothu BK, Rogers MAM, Chernew ME, Krumholz
HM, Eagle KA, Birkmeyer JD. Opening of specialty cardiac hospitals
and use of coronary revascularization in Medicare beneficiaries.
JAMA, 2007;297:962-968.
Flanders SA, Collander HR, Saint S.
Nosocomial pneumonia: State of the science. Am J Infect Control
2006; 34(2):84-93. Just S, Schepers G, Piotrowski MM, Saint S,
Kauffman CA. Improving the safety of intravenous admixtures:
Lessons learned from a Pentostam®overdose. Jt Comm J Qual and Pt
Safety 2006; 32(7):366-372.
Shojania KG, Fletcher KE, Saint S. Graduate
medical education and patient safety: A busy – and occasionally
hazardous – intersection. Ann Intern Med 2006; 145(8):592-598.
Rogers MAM, Langa KM, Kim C, Nallamothu BK, Malani PN, McMahon LF
Jr, Fries BE, Kaufman SR, Saint S. Contribution of infection to
increased mortality in women after cardiac surgery. Archives of
Internal Medicine, 166:437-443, 2006.
Rogers MAM, Blumberg N, Saint SK, Kim C, Nallamothu BK, Langa KM.
Allogeneic blood transfusions explain increased mortality in women
after coronary artery bypass graft surgery. American Heart
Journal, 152:1028-34, 2006.
Saint S, Kaufman SR, Rogers MAM, Baker PD, Ossenkop K, Lipsky
BA. Condom versus indwelling urinary catheters: a randomized
trial. Journal of the American Geriatrics Society, 54:1055-1061,
2006.
Saint S, Kaufman SR, Rogers MAM, Baker PD, Boyko EJ, Lipsky BA.
Risk factors for nosocomial urinary tract-related bacteremia: a
case-control study. American Journal of Infection Control, 34:401-407,
2006.
Nallamothu BK et al. Circulation 2006. Relation between hospital
specialization with primary percutaneous coronary intervention and
clinical outcomes in ST-segment elevation myocardial infarction:
National Registry of Myocardial Infarction-4 analysis.
Circulation. 2006 Jan 17;113(2):222-9. Epub 2006 Jan 9.
Flanders
SA, Kaufman SR, Saint S. Hospitalists as emerging leaders in
patient safety: Targeting a few to affect many. J Patient Safety,
2005;1(2):78-82.
Saint S, Kaufman SR, Thompson M, Rogers MAM, Chenoweth CE. A
reminder reduces urinary catheterization in hospitalized patients. The
Joint Commission Journal on Quality and Patient Safety, 31:455-461,
2005.
Render ML, Kim HM, Deddens J, Sivagenesin S,
Welsh D, Bickel K, Timmons S Johnston J, Connors AF, Wagner D, Hofer
TP. Variation in risk adjusted hospital mortality and length of
stay in Veterans Affairs intensive care units.
Crit Care
Med. 2005 May;33(5):930-9.
Nallomathu, Saint S, Hofer TP, Bernstein SJ Vijan
S, Hospital Volume and Outcome in Coronary Artery Bypass
Grafting: A Risk Paradox?" Arch Intern Med. 2005 Feb
14;165(3):333-7
Nallomathu BK, Shojania KG, Saint S, Hofer TP,
Humes HD, Moscucci M, Bates ER. Is Acetylcysteine Effective for
Prevention of Contrast-Related Nephropathy? A Meta-Analysis. Am. J
Med. 2004 Dec;117(12)938-947
Hofer TP, Zemencuk JK, Hayward RA. When there is
too much to do: How practicing physicians prioritize among recommended
interventions. J Gen Int Med. 2004 June; 19(6):646-53.
Hofer TP, Asch SM, Hayward RA, Rubenstein LV,
Hogan M, Adams J, Kerr EM. Measuring quality of care: is there a
role for peer review? BMC Health Serv Res. 2004 May 19;4(1):9.
Hayward, R.A., Hofer, T.P., Kerr, E.A., and Krein,
S.L. Quality improvement initiatives: issues in moving
from diabetes guidelines to policy. Diabetes Care. 2004;
27(S2):B54-B60
Kerr, E.A., Gerzoff, R.B., Krein, S.L., Selby,
J.V., Piette, J.D., Curb, J.D., Herman, W.H., Marrero, D.G., Narayan,
K.M.V., Safford, and M.M. Mangione, C.M. A Comparison of
Diabetes Care Quality in Veterans Affairs and Commercial Managed
Health Care Systems: Results from the TRIAD Study. Annals of
Internal Medicine. 2004;141(4): 272-281.
Krein, S.L., Klamerus, M.L., Vijan, S., Lee, J.L.,
Fitzgerald, J.T., Pawlow, A., Reeves, P. and Hayward, R.A. Case
management for patients with poorly controlled diabetes: A
randomized trial. American Journal of Medicine.
2004;116(11): 732-739.
Heisler M, Vijan S, Anderson RM, Ubel PA,
Bernstein SJ, Hofer TP. When Do Patients and Their Physicians Agree on
Diabetes Treatment Goals and Strategies, and What Difference Does It
Make? 2003 Dec; J. Gen Int Med.
Lilford RJ, Mohammed MA, Braunholtz D, Hofer TP.
The measurement of active errors: methodological issues. Qual. Saf.
Health Care. 2003 Dec; 12:(ii) 8 - 12.
Saint S, Hofer TP, Rose J, Kaufman SR, McMahon
LF. The use of critical pathways to improve efficiency: a cautionary
tale. Am. J Managed Care. 2003 Nov; 9(11):758-65.
Kachalia A, Shojania K, Hofer TP, Piotrowski M,
Saint S. Does full disclosure of medical errors impact malpractice
liability? The jury is still out. Jt Comm J Qual Saf. 2003 Oct;
29(10):503-11.
Kerr E, Smith DM, Hogan MH, Hofer TP, Krein SL,
Berman M, Hayward RA. Building a better quality measure: Are some
patients with "poor quality" care actually getting good care? Med
Care. 2003 Oct; 41(10):1173-82.
Render ML, Kim HM, Welsh D, Johnston J, Hui S,
Connors AF, Wagner D, Daley J, Hofer TP. Automated Intensive Care Unit
Risk Adjustment: Results from a National VA study. Crit Care Med. 2003
Jun; 31(6): 1638-46.
Rosenberg AL, Hofer TP, Strachan C, Watts CM,
Hayward RA. Accepting critically ill transfer patients: adverse impact
on a referral center's outcome and benchmark measures. Annals of
Internal Medicine. 2003 Jun; 138(11):882-90.
Williams KL, Pladevall M, Fendrick AM,
Elston-Lafata J, McMahon LF. Differences in the Reporting of
Care-Related Patient Injuries to Existing Reporting Systems.
Joint Commission Journal on Quality and Safety; 2003; 29(9):460-467.
Saint S, Higgins LA, Nallamothu BK, Chenoweth C.
Do physicians examine their patients under contact precautions less
frequently? Am J Infect Control 2003;31(6):354-356.
Piotrowski MM. Safety checklist program:
Imbedding a high level of awareness into the delivery of care. Journal
of Quality Health Care, 2003, 2(4):34-36.
Chaiyakunapruk N, Veenstra DL, Lipsky BA,
Sullivan SD, Saint S. Vascular catheter site care: The clinical and
economic benefits of chlorhexidine compared to povidone iodine
solution. Clin Infect Dis. 2003; 38:764-771.
Collard HR, Saint S, Matthay MA. Prevention of
ventilator-associated pneumonia: An evidence-based systematic review.
Ann Intern Med. 2003; 138:494-501.
Cornia PB, Amory JK, Fraser S, Saint S, Lipsky
BA. Computer-based order entry decreases duration of indwelling
urinary catheterization in hospitalized patients. Am J of Medicine.
2003; 144(5): 404-407.
Dezfulian C, Lavelle J, Nallamothu BK, Kaufman
SR, Saint S. Rates of infection in single lumen versus multilumen
central venous catheters: A meta-analysis. Crit Care Med. 2003;
31(9):2385-2390.
Marciante KD, Veenstra DL, Lipsky BA, Saint S.
Which antimicrobial impregnated central venous catheter should we use?
Modeling the costs and outcomes of antimicrobial catheter use. Am J
Infect Control. 2003; 31(1):1-8.
Saint S, Chenoweth CE. Biofilms and catheter
associated urinary tract infections. Infect Dis Clinics North Am.
2003; 17:411-432.
Hofer TP, Hayward RA. Quality Grand Rounds: Are
Bad Outcomes from Questionable Clinical Decisions the Same as Medical
Errors? Annals Intern Med. 2002 Sep; 137: 327-33.
Krein S, Hofer TP, Hayward RA, Kerr E. Whom
should we profile? Examining diabetes care practice variation among
primary care providers, provider teams and healthcare facilities.
Health Serv Res. 2002 Oct;37(5):1159-80
Piotrowski MM, Saint S & Hinshaw DB. Expanding
the avenues for addressing patient safety. Michigan Health &
Hospitals, 2002, 38(5):33.
Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint
S. Chlorhexidine versus povidone-iodine solution for vascular
catheter-site care: a meta-analysis. Annals of Internal Medicine.
2002; 136(11):792-801
Piotrowski MM, Saint S, Hinshaw DB. The safety
case management committee: Expanding the avenues for addressing
patient safety. The Joint Commission Journal on Quality Improvement.
2002; 28 (6):296-305.
Saint S, Savel RH, Matthay MA. Enhancing the
safety of critically ill patients by reducing urinary and central
venous catheter-related infections. American Journal of Respiratory
and Critical Care Medicine. 2002; 165:1475-1479.
Saint S, Goold SD, Lipsky BA. Indwelling urinary
catheters: The one-point restraint? Annals of Internal Medicine. 2002;
137(2):125-27.
Kerr, E. A.; Krein, S. L.; Vijan, S.; Hofer, T.
P., and Hayward, R. A. Avoiding pitfalls in chronic disease quality
measurement: a case for the next generation of technical quality
measures. Am J Manag Care. 2001 Nov; 7(11):1033-43.
Lynch P, Jackson M, Saint S. Research priorities
project, year 2000: Establishing a direction for infection control and
hospital epidemiology. Am J Infect Cont. 2001; 29(2):73-78.
Nallamothu BK, Saint S, Ramsey SD, Hofer TP,
Vijan S, Eagle KA. The role of hospital volume in coronary artery
bypass grafting: is more always better? J Am Coll Cardiol 2001;
38(7):1923-30.
Peer Reviewed Articles by PSEP Faculty ~
(IN PRESS)
Mody L, Langa KM, Saint S, Bradley SF.
Preventing Infections in Nursing homes: A survey of infection
control practices in Southeast Michigan. Am J Infect Control
– in press.
Presentations by PSEP Faculty
(Presentations and conference abstracts provide valuable
early feedback on a line of research as well as providing a useful
method of publicizing the TITRE DCERPS.)
Hofer TP, Hayward RA. “Methods for
Recognizing and Adjusting for Measurement Error.” HSR&D National
Meeting 2005: Improving Care for Chronic Illnesses, Baltimore MD
February 16-18, 2005.
Saint, S. “Enhancing Patient Safety by
Preventing Hospital-Acquired Infection.” Harvard
University/Beth Israel Deaconess Grand Rounds, Boston, MA, January
2005.
Saint, S. “Enhancing Patient Safety by Preventing
Hospital-Acquired Infection.” University of California Davis
Grand Rounds, Sacramento, CA, December 2004.
Krein, SL. “Measuring Outcomes of a Case
Management Program”. Krein SL. Invited presentation, VISN 11
Primary Care Case Management Conference, Kalamazoo, MI, November
4, 2004.
Saint, S. “Translating Nosocomial Infection
Preventive Methods into Practice” – General Medicine Research
Conference, November 2004.
Hofer, TP. “Measurement of Error measurement
theory and the detection of medical errors.” Making Health Care
Safer Conference, October 21-22, 2004 (invited presentation and
session leader), Royal College of Physicians of London.
Piotrowski, MM. “VA Ann Arbor Healthcare System
Safety Checklist Program: Imbedding a High Level of Awareness into the
Delivery of Care.” Presentation at Advancing Patient Safety in
West Virginia, Charleston, WV, October 2004.
Saint, S. “Enhancing Patient Safety by Preventing
Hospital-Acquired Infection.” S. Frederick Rabiner, MD. Visiting
Professorship, Legacy Health System, Portland, OR, October 2004.
Saint, S. “Using Evidence-Based Medicine to
Manage Acute UTI in Women.” S. Frederick Rabiner, MD. Visiting
Professorship, Legacy Health System, Portland, OR, October 2004.
Saint, S. “Preventing Hospital-Acquired Infection.” Medical Grand
Rounds, University of Oklahoma, September 2004.
Saint, S. “Prevention Strategies in the ICU.”
Management of the Hospitalized Patient, University of California San
Francisco, September 2004.
Saint, S. “Translating Nosocomial Infection
Methods Into Practice.” AHRQ 3rd Annual National Patient Safety
Conference, Washington, DC, September 2004.
Saint, S. “The Rise and Rise of Infection
Prevention and Control Programs.” Enhancing Patient Safety:
Successful Strategies and Interventions to Prevent Health
Care-Associated Infection in Mcihgan, St. John Macomb Hospital,
Warren, MI, September 2004.
Saint, S. “Catheter-Related Blood Stream
Infections – Incidence, Impact & Evidence Based Interventions.”
AHRQ Patient Safety Collaborative Kickoff #2, Cincinnati, OH,
September 2004.
Saint, S. “The Economics of Controlling
Infections Associated with Prosthetic Devices.” Fourth Annual
Conference of the Center for Prostheses Infection (CPI) and the
Multidisciplinary Alliance Against Device-Related Infections (MADRI),
San Antonio, TX, August 2004.
Saint, S. “Enhancing Patient Safety by Preventing
Hospital Acquired Infection.” The John Radcliffe
Hospital/1Oxford University, Oxford, England, June 2004.
Hofer, TP. "The Science of Quality Measurement:
Are We Getting It Right?" (invited panelist) Academy Health meeting,
San Diego, June 6-8, 2004.
Saint, S. “Preventing Hospital-Acquired
Infection.” Department of Microbiolioty & Infectious Diseases
Seminar, The John Radcliffe Hospital/Oxford University, Oxford,
England, June 2004.
Mangrulkar, RS. “Targeting and Structuring
Information Resource Use: A Path to Informed Clinical Decisions”,
Invited Plenary Address, CME Congress 2004: Knowledge Translation,
Toronto, Canada, May 16, 2004.
Mangrulkar, RS. “Towards the ideal signout: using
house officer opinion to improve inpatient transitions in care”, The
Society for General Internal Medicine Annual Meeting, Chicago, IL, May
13, 2004.
Mangrulkar, RS. “Integrating Evidence Into
Clinical Decisions”, ½ day workshop, Society for General Internal
Medicine Annual Meeting, May 13, 2004.
Saint, S. “Reducing the Burden of Nosocomial
Urinary Tract Infections Using Antimicrobial-impregnated Urethral
Catheters.” Surgical Infection Society 24th Annual Meeting,
Indianapolis, IN, May 2004.
Piotrowski, MM. “Improving Care for Intensive
Care Unit Patients on Ventilators to Reduce Rate of Ventilator
Associated Pneumonias.” Poster presentation at Infection: Prevention
and Containment, sponsored by Department of Veterans Affairs Employee
Education System, Program Office for Infectious Diseases, Patient Care
Services, and Veterans Affairs Central Office, New Orleans, LA, May
2004, joint presentation with Lisbeth Nordstrom-Lerner.
Saint, S. “From Quality Improvement to Research.”
Society of Hospital Medicine’s 2004 Annual Meeting, New Orleans, LA,
April 2004.
Saint, S. “ICU Prophylaxis.” Society of
Hospital Medicine’s 2004 Annual Meeting, New Orleans, LA, April 2004.
Saint, S. “How Advanced Infection Control
Technologies Can Benefit Both Patients and Hospitals.” Press
Seminar on the Japanese Healthcare System, Tokyo, Japan, March 2004.
Hofer, TP. "Measurement theory and the detection
of medical errors" Department of Public Health and Epidemiology,
University of Birmingham, England. February 2004.
Piotrowski, MM. “Safe Practice at All Costs: Real
Strategies for Today’s Nurse.” Presentation at Nursing Grand Rounds,
Institute for Innovative Nursing Practice, Virginia Commonwealth
University (VCU) Medical Center, Richmond, VA, February 2004.
Hofer, TP. "Quality Measurement through peer
review." Michigan State Medical Society Annual Meeting. Troy,
Michigan. November 5, 2003.
Saint, S. “Catheter-Related Blood Stream
Infections.” AHRQ Patient Safety Collaborative Kickoff,
Cincinnati, OH, November 2003.
Saint, S. “Device-Related Patient Safety.”
Michigan Society for Infection Control, Lansing, MI, November 2003.
Piotrowski, MM. “Imbedding Safety into Patient
Care: An Organizational Mission.” Presentation at Metropolitan Detroit
Medical Library Group meeting. Henry Ford Healthcare System/Wyandotte
Hospital, Wyandotte, MI, November 2003.
Saint, S. "The Use of a Urinary Catheter Reminder
to Reduce Urinary Catheterization in Hospitalized Patients."
International Society for Pharmacoeconomics and Outcomes Research,
Barcelona, Spain, November 2003.
Saint, S. “Using Evidence-Based Medicine to
Manage Acute UTI in Women.” St. Mary Mercy Hospital Grand
Rounds, Livonia, MI, September 2003.
Saint, S. "Enhancing Patient Safety Through
Infection Control." Infection Control Association of the British
Isles, Telford, England, September 2003.
Saint, S. "Enhancing Patient Safety by Reducing
Hospital-Acquired Infection." UCSF Department of Medicine Grand
Rounds, San Francisco, CA, September 2003.
Krein, SL. “Use of Electronic Medical Record Data
and Automated Clinical Databases For System-wide Quality Improvement"
Krein SL. Oral presentation as part of panel session on
Informatics Strategies to Support Evidenced-based Practice at the
Information Technology Conference/ Office of Information, Austin, TX,
August 6, 2003.
Piotrowski, MM. “Safety Checklist Program.
Imbedding High Level Awareness into the Delivery of Care.”
Presentation at The Quality Colloquium at Harvard University,
Cambridge, MA, August 2003.
Borschel, DM. “Does an Antiseptic-coated Central
Venous Catheter Provide Clinical and Economic Benefits in a “Real
World” Setting?" University of Michigan Meet the Investigator, Aug
2003.
Mangrulkar, RS. “Characterization of Information
Exchange Between Residents and Attendings in Internal Medicine
Ambulatory Clinics”, The Society for General Internal Medicine Annual
Meeting, Vancouver, BC, Canada. May 1, 2003.
Saint, S. "Which Site Disinfectant Should We Use
for Vascular Catheter Site Care?" Society for Healthcare Epidemiology
of America, Arlington, VA, April 2003.
Saint, S. "Translating Nosocomial Infection
Prevention into Practice." AHRQ 2nd Annual National Patient Safety
Conference, Washington, D.C., March 2003.
Saint, S. "Clinical Practice Strategies to
Enhance Patient Safety." Chelsea Hospital, Chelsea, MI, March 2003.
Mangrulkar, RS. “Evaluation of Evidence-Based
Medicine Instruction: A Map for the Future”. Director, workshop and
retreat for the Society of General Internal Medicine Evidence-Based
Medicine Task Force Evaluation Cluster, New Orleans, LA. February
23-24, 2003.
Mangrulkar, RS. “Evidence-Based Medicine for the
Practicing Clinician: Education to Change Practice”. Plenary
Presentation at the Alliance for Continuing Medical Education Annual
Meeting, Dallas, TX. January 31, 2003.
Saint, S. "Enhancing Patient Safety by Preventing
Catheter Related Infections." Medical Grand Rounds, Oakwood Hospital &
Medical Center, Dearborn, Michigan, January 2003.
Saint, S. "The University of Michigan's Patient
Safety Enhancement Program: Translating Research into Practice."
Michigan Health and Safety Coalition, South Lyon, Michigan, January
2003.
Krein, SL. “Case Management: Is it Meeting
Expectations?” Krein SL, Klamerus ML, Vijan S, Lee J, Fitzgerald
T, Hayward, RA. Poster presented at the Academy for Health
Services Research and Policy Annual Research Meeting, Washington,
D.C., June, 25, 2002.
Rosenthal M. “Is the Swedish Patient
Insurance Fund a Model for Michigan? Genessee Medical Society
Annual Meeting, May 2, 2002.
Bhalla S, Fine P, Mangrulkar R, Hofer TP.
“Antibiotic Dosing in an Inpatient Elderly Population,” University of
Michigan Department of Internal Medicine, May 2002.
Borschel, DM. “The Effectiveness of an
Antiseptic-Coated Central Venous Catheter in a Real World Setting.”
Oral presentation at APIC (Association of Professionals in Infection
Control) national meeting, May 2002.
Piotrowski, MM. “Techniques and Tools for
Building Your Patient Safety Program – The Safety Checklist Program.”
Presentation at Fostering a Culture of Patient Safety in Michigan,
Dearborn, MI, May 2002.
Borschel, DM. “Does an Antiseptic-Coated Central
Venous Catheter Provide Clinical and Economic Benefits in a Real World
Setting.” Oral plenary presentation NAIP (National Association of
Inpatient Physicians) national meeting, April 2002.
Piotrowski, MM. “Reduction of the Incidence of
Ventilator-Associated Pneumonia (VAP) by Improving the Care of
Ventilator-Dependent SICU Patients.” Poster presentation at the
Twelfth Annual Scientific Meeting of the Society for Healthcare
Epidemiology of America (SHEA), Salt Lake City, UT, April 2002, joint
presentation with Lisbeth Nordstrom-Lerner.
Nallamothu, BK. "Cost-effectiveness of
Radiofrequency Ablation for Paroxysmal Atrial Flutter."
Assessment and Outcome in Cardiovascular Diseases Poster Session of
the National Meeting of the American College of Cardiology.
Atlanta, Georgia, March 2002.
Rosenthal M. “Studying Medical Error:
An Ethnographic Approach.” Emory University School of Public
Health, February 20, 2002.
Krein, SL. “Proactive Diabetes Case Management:
Expectation Versus Reality” Krein SL, Klamerus ML, Vijan S,
Pawlow A, Reeves P, Hayward, RA. Poster presented at the HSR&D
Service 20th Annual Meeting, Washington, D.C., February, 14-15, 2002.
Saint S. “The Clinical and Economic
Benefits of Chlorhexidine Compared to Povidone Iodine Solution.” VA
Health Services Research and Development National Meetings.
Washington, Feb 13-15, 2002.
Zemuncuk JK, Hofer TP, Hayward RA.
“Physician’s understanding and misunderstanding of diabetes care
priorities” Plenary Session, VA Health Services Research and
Development National Meetings. Washington, Feb 13-15, 2002.
Saint S. “Device Associated Adverse Events:
Impact and Prevention.” National Patient Safety Conference
sponsored by the CDC, Baltimore, MD, January 2002.
McMahon LF. “Cancer Screening in the
Elderly: Who, What How? A Tale of Two Cancers.”
Grand Rounds, Oakwood Hospital, Dearborn, MI, December 2001.
Saint S. “Preventing Catheter-related
Urinary Tract Infections: Are Silver Catheters Useful?” 51st Annual
Japanese Urological Association’s Central Section Meeting, Osaka,
Japan, November 2001.
Piotrowski, MM. “Safety Checklist Program: An Act
of Compassion. An Environment of Quality Care.” Presentation at The
Partnership Symposium 2001. Patient Safety – Stories of Success,
Dallas, TX, October 2001.
Piotrowski, MM. “Adverse Events Subcommittee”
Presentation at The Partnership Symposium 2001. Patient Safety –
Stories of Success, Dallas, TX, October 2001.
Saint S. “Quality Grand Rounds: A
Case of Nosocomial Hypoglycemia." Improving Patient Safety and
Decreasing Errors in the Hospital, University of California, San
Francisco, CA, October 2001. (Case presented to David Bates, MD.)
Del Valle J, Chugh R, Goldman E, Hofer TP et.al.
Department of Medicine Grand Rounds – A case of missed diagnosis. |
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