Potential gaps in congestive heart failure management in a rural hospital.

INTRODUCTION: Congestive heart failure (CHF) is increasingly recognized as an important cause of morbidity and mortality. Previous studies in urban settings have shown that patients frequently are not receiving recommended therapy. There is a paucity of studies that have evaluated CHF management in a rural setting. We therefore reviewed hospital and outpatient care in this setting as an initial step toward improving CHF care. METHOD: A retrospective chart review was used to examine the care of all 34 patients hospitalized for CHF from 2000-2001 in a small rural hospital, to assess the need for improved CHF management. RESULTS: The median age of the patients was 78 yr, and a number of them had many co-morbid cardiovascular risks. Similar to other studies, only 23% of patients were prescribed recommended doses of angiotensin-converting enzyme (ACE) inhibitors. Use of beta-blockers was far below expected rates. Although there was follow-up care for nearly all patients (97%), few patients had echocardiography performed (38%) or had their medications altered in the outpatient setting. CONCLUSION: There is a need for improved management of CHF in the rural setting. Approaches to improving CHF care should use the continuity of care advantage provided by primary care physicians to optimize outpatient medical treatment regimens and improve access to diagnostic services such as echocardiography.

Identifying and managing adverse environmental health effects: 6. Carbon monoxide poisoning.

Carbon monoxide poisoning is an enigmatic illness. The symptoms are often non-specific or masked by an exacerbation of an underlying illness, such as congestive heart failure, that has been triggered by carbon monoxide inhalation. The effects can range from mild, annoying symptoms relieved by removal of the source to severe morbidity with profound central nervous system dysfunction, acute complications and delayed sequelae. Estimates suggest that about one-third of nonfatal cases of carbon monoxide poisoning go undetected and undiagnosed. We present a case of residential carbon monoxide poisoning to illustrate these points and to demonstrate the usefulness of a simple tool based on the CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs) that physicians can use to obtain an environmental exposure history. We outline the clinical management of carbon monoxide poisoning and provide strategies and resources to prevent exposure.

Identifying and managing adverse environmental health effects: 3. Lead exposure.

Lead levels in North American children and adults have declined in the past 3 decades, but lead persists in the environment in lead paint, old plumbing and contaminated soil. There are also a number of occupations and hobbies that carry a high risk of lead exposure. There is no evidence for a threshold below which lead has no adverse health effects. Blood lead levels previously considered safe are now known to cause subtle, chronic health effects. The health effects of lead exposure include developmental neurotoxicity, reproductive dysfunction and toxicity to the kidneys, blood and endocrine systems. Most lead exposures are preventable, and diagnosing lead poisoning is relatively simple compared with diagnosing health effects of exposures to other environmental toxins. Accurate assessment of lead poisoning requires specific knowledge of the sources, high-risk groups and relevant laboratory tests. In this article we review the multiple, systemic toxic effects of lead and provide current information on groups at risk, prevention, diagnosis and clinical treatment. We illustrate how the CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs) and specific screening questions are useful tools for physicians to quickly obtain an environmental exposure history and identify patients at high risk of lead exposure. By applying effective primary prevention, case-finding and treatment interventions for lead exposure, both the individual patient and the larger community reap the benefits of better health.

Identifying and managing adverse environmental health effects: 4. Pesticides.

Pesticide exposure can cause many different health effects, from acute problems such as dermatitis and asthma exacerbation to chronic problems such as chronic obstructive pulmonary disease and cancer. The resulting clinical presentations are undifferentiated, and specific knowledge of the links to environmental exposures is often required for effective diagnosis. In this article we illustrate the use of the CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Drugs and Diet), a history-taking tool that assists physicians in quickly identifying possible environmental exposures. We also provide clinical information on the epidemiology, clinical presentations, treatment and prevention of pesticide exposures.

Identifying and managing adverse environmental health effects: 5. Persistent organic pollutants.

Concern and awareness is growing about the health effects of exposures to environmental contaminants, including those found in food. Most primary care physicians lack knowledge and training in the clinical recognition and management of the health effects of environmental exposures. We have found that the use of a simple history-taking tool - the CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs) - can help physicians identify patients at risk of such health effects. We present an illustrative case of a mother who is concerned about eating fish and wild game because her 7-year-old son has been found to have learning difficulties and she is planning another pregnancy. Potential exposures to persistent organic pollutants (POPs) and mercury are considered. The neurodevelopmental effects of POPs on the fetus are reviewed. We provide advice to limit a patient's exposure to these contaminants and discuss the relevance of these exposures to the learning difficulties of the 7-year-old child and to the planning of future pregnancies.

Identifying and managing adverse environmental health effects: 1. Taking an exposure history.

Public concern and awareness are growing about adverse health effects of exposure to environmental contaminants. Frequently patients present to their physicians with questions or concerns about exposures to such substances as lead, air pollutants and pesticides. Most primary care physicians lack training in and knowledge of the clinical recognition, management and avoidance of such exposures. We have found that it can be helpful to use the CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs) as a tool to identify a patient's history of exposures to potentially toxic environmental contaminants. In this article we discuss why it is important to take a patient's environmental exposure history, when and how to take the history, and how to interpret the findings. Possible routes of exposure and common sources of potentially toxic biological, physical and chemical substances are identified. A case of sick-building syndrome is used to illustrate the use of the mnemonic.

Identifying and managing adverse environmental health effects: 2. Outdoor air pollution.

Air pollution contributes to preventable illness and death. Subgroups of patients who appear to be more sensitive to the effects of air pollution include young children, the elderly and people with existing chronic cardiac and respiratory disease such as chronic obstructive pulmonary disease and asthma. It is unclear whether air pollution contributes to the development of asthma, but it does trigger asthma episodes. Physicians are in a position to identify patients at particular risk of health effects from air pollution exposure and to suggest timely and appropriate actions that these patients can take to protect themselves. A simple tool that uses the CH2OPD2 mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs) can help physicians take patients' environmental exposure histories to assess those who may be at risk. As public health advocates, physicians contribute to the primary prevention of illness and death related to air pollution in the population. In this article we review the origins of air pollutants, the pathophysiology of health effects, the burden of illness and the clinical implications of smog exposure using the illustrative case of an adolescent patient with asthma.