Putting the squeeze on emergency medicine. The many pressures on today's ED.

Whether it's indigent care, cost containment, transfer laws, financially wary HMOs, overcrowding, reimbursement, or emergency-department inefficiency, the factors "putting the squeeze" on emergency medicine seem to multiply with each new survey. These pressures, the authors feel, are not only weakening the provision of emergency care but also strengthening the argument for a national health plan.

The early repolarization syndrome.

The syndrome of the early repolarization variant is described. This benign ECG phenomenon is noted in 1% to 2% of the adult population and generally occurs in the absence of myocardial disease. The ECG manifestations may mimic acute myocardial injury or pericarditis. Exercise and isoproterenol tend to normalize the RST segment elevation. The presence of "early repolarization" does not preclude diagnosis of exercise-induced myocardial ischemia by treadmill testing, and coronary vaso-occlusive lesions may be demonstrated in some patients with the early repolarization pattern on ECG. The presence of S-T elevation in a patient with chest pain of possible cardiac origin mandates hospitalization and cardiac monitoring even if the ECG may confirm to a classic pattern of early repolarization; in this context, the diagnosis of benign early repolarization is one of exclusion. Recognition of this clinical entity and the use of previous ECGs for comparison would in most cases forestall the administration of thrombolytic agents to patients with S-T segment elevation due to benign early repolarization.

Prospective payment systems: steps to enhance quality, efficiency, and regionalization.

The prospective payment system has many benefits and risks for the hospital industry. A quality-enhancing bidding process can be used to redistribute any unfair windfall profits, and foster quality care, effectiveness, efficiency, and productivity.