Reducing readmissions for congestive heart failure.

Hospital admission for congestive heart failure is extremely common and quite expensive, although it is frequently preventable. New drugs and therapies have been reported to reduce admissions, decrease morbidity and mortality, and improve the quality of life for these patients. Patients with an ejection fraction less than 40 percent (decreased systolic function) should be treated with medication to improve symptoms and prevent progression of heart failure. Angiotensin-converting enzyme (ACE) inhibitors are a mainstay of treatment in patients who can tolerate them; in patients who cannot take these drugs, angiotensin II receptor blocking agents offer an alternative. Patients with New York Heart Association class II or III heart failure should also receive a beta blocker (metoprolol, carvedilol or bisoprolol). Recent research has shown that treatment with spironolactone improves mortality and hospital readmission rates. An exercise program should also be recommended for all patients with heart failure unless their condition is unstable.

Severe systemic reactions attributed to the acetone-inactivated parenteral typhoid vaccine.

Typhoid vaccine is recommended for people traveling to areas where they may be exposed to contaminated food and/or water. Two different parenteral forms of the vaccine have been utilized. We report five active duty patients with severe systemic reactions to the acetone-inactivated form of typhoid vaccine. The patients presented with very similar physical exam findings and laboratory abnormalities. Alternative typhoid vaccines that are less reactogenic are now available for use.

Linking cost control measures to health care services by using activity-based information.

Canada's health care institutions are under pressure to limit expenditures, maintain or increase productivity, and assimilate new technology. Even though more than 75% of hospital operating expenditures are controllable, according to a study by the Economic Council of Canada, cost systems are needed to provided essential management information. The new Canadian Management Information System (MIS) Guidelines for health care are designed to provide accurate cost measurement of patient treatment and to help managers evaluate the impact of planned program changes on areas of operational responsibility. Other potential benefits of implementing the MIS guidelines include correcting dysfunctional funding of health care units with benchmarking and setting high reporting standards for resource use at the patient level (MIS, 1991). This paper focuses on one important aspect of bringing these costs under control by examining the relation between cost deviations (variances) and underlying cost drivers. Our discussion will lead to the conclusion that incompatibility of DRG methodology and traditional cost accounting models may be an important source of cost variability within diagnostically-related disease groupings.

M marinum infections in a Chesapeake Bay community.

Their proximity to Eastern Virginia's abundant waterways has given the authors experience in managing the destructive tenosynovitis and deep tissue infections caused by M marinum. They present nine cases, discuss diagnosis and treatment, review the literature, and urge urban physicians to be on the alert for the disease in patients recently returned from fishing trips.

Severe neutropenia due to sustained-release procainamide.

With increased use of sustained-release forms of procainamide in treating common cardiac arrhythmias, more and more cases of severe neutropenia and occasional deaths have been reported. It is unclear whether all sustained-release procainamide preparations are implicated. I recommend that a complete blood count be done every two weeks for the first three months of treatment with these drugs. Any patient who has an unexplained fever or a toxic reaction while taking one of these preparations should have a complete blood count done.

Ovarian cancer associated with the nephrotic syndrome.

A 65-year-old woman was found to have the nephrotic syndrome eight months before the onset of a new left neck mass. Biopsy specimen of the mass showed metastatic adenocarcinoma, which was subsequently found to be from an ovarian primary. Operation and triple chemotherapy has markedly diminished the degree of proteinuria. Although uncommon, ovarian carcinoma must be considered in the differential diagnosis of cancer-related nephrotic syndrome.