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Effects of Multidisciplinary Care of Heart Failure Patients at High Risk for Hospital AdmissionHeart failure (HF) is a complex clinical syndrome in whichthe heart is unable to deliver adequate cardiac output at normal fillingpressures. There are proven pharmacological and clinical management strategiesthat can improve care and reduce associated health care costs, but these areunderutilized. The Advanced Heart Failure Program (AHFP) was developed at theDorn Veterans Administration Medical Center to provide a comprehensivemultidisciplinary management approach to persons with advanced HF. Beforeenrollment in the AHFP, the average annual all-cause hospital admission rate was3.2 for the 217 HF patients. After enrollment in the AHFP and stabilization, themean all-cause hospital admission rate was 1.2. HF patients had an averageannual hospitalization cost of $28,936.32 before enrollment in the AHFP. Afterenrollment, average hospitalization cost dropped to $10,851.12 per patient.Taking into account the 50-week cost of $3036.14 for a patient enrolled in theclinic, participation in the AHFP was associated with a significant decrease inthe number of HF-related admissions, saving an average of $15,049.06 perpatient. (Drug Benefit Trends. 2008;20:54-59)
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HIV Infection: Clues to Timely DiagnosisEarly diagnosis enables patients to derive maximum benefit from highly active antiretroviral therapy (HAART). Primary care practitioners can play a key role in the timely identification of HIV infection.
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Economic Evaluation of a Prior Authorization Program for Biologic Response ModifiersSpecialty medications constitute the fastest-growing segment of drug spending under the pharmacy benefit. This study evaluated the impact of a specialty pharmacy prior authorization (PA) program on prescription drug costs for biologic response modifiers (BRMs) used in the treatment of persons with rheumatoid arthritis, juvenile rheumatoid arthritis, Crohn disease, ankylosing spondylitis, psoriatic arthritis, psoriasis, and other spondyloarthropathies. A retrospective, case-control, one-to-one matching approach based on patient age, sex, and client characteristics was used. Case clients were enrolled in the specialty pharmacy PA program from January 1 through December 31, 2005. The control group consisted of clients who were not enrolled in the program during this time. The average costs per eligible member per month (PMPM), for the total, plan, and member were $1.32, $1.29, and $0.03, respectively, in the case group, and $1.44, $1.41, and $0.03, respectively, in the control group. Clients who implemented the specialty pharmacy PA program for BRMs saved an estimated total cost of $0.12 PMPM. Implementing a specialty pharmacy PA program reduced BRM costs. (Drug Benefit Trends. 2008;20:26-31)
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Streptococcal Toxic Shock SyndromeA 44-year-old man presented to the emergency department (ED) with pain and swelling of the left ankle and a petechial rash in the pretibial area that developed the night before. He also reported "fluttering" in his chest.
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Thrombocytopenia: How Best to Determine the CauseABSTRACT: A scheme-based approach, supported by a simple mnemonic, can narrow the broad differential diagnosis of thrombocytopenia. This approach uses findings from the complete blood cell count and the peripheral smear to organize the possible causes of thrombocytopenia into those that affect only platelet count, those that produce both a low platelet count and hemolytic anemia, and those that produce disturbances in all 3 blood cell lines. Causes of isolated thrombocytopenia include viral infections, immune-mediated platelet destruction, congenital diseases, gestational thrombocytopenia, conditions in which splenomegaly is a prominent feature, antiphospholipid antibody syndrome, infectious diseases of bacterial origin, and drugs. Causes of thrombocytopenia in conjunction with hemolytic anemia include hemolytic uremic syndrome, thrombotic thrombocytopenia purpura, and disseminated intravascular coagulation. Disorders that produce disturbances in all 3 blood cell lines include aplastic anemia, myeloproliferative syndromes, myelodysplasia (both primary and secondary), myelofibrosis, myelophthisis, and several other diseases in which splenomegaly is prominent.
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What caused this patient's cough and mild hemoptysis?The authors describe a previously healthy patient who required surgical resection of a large mucoid tumor lined with atypical columnar epithelium. The diagnosis was mucinous cystadenocarcinoma, a rare type of pulmonary cancer that is difficult to identify.
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Blue NevusWorsening episodes of pain and bleeding from the lesion on the dorsum of her foot brought a 16-year-old girl to her physician's office. The spot had gradually enlarged since she first noticed it about 3 years earlier.
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Lactic Acidosis in an Infant Receiving HIV ProphylaxisZidovudine is safe and effective in reducing transmission of HIV from mother to infant but rare serious side effects do occur. Is it worth the risk?
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Diabetic Nephropathy: Early Clues, Effective ManagementNephropathy develops in about 30% of patients with diabetes. Screen for albuminuria at the time type 2 diabetes is diagnosed and within 5 years of diagnosis of type 1 diabetes.
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Trust Your Instincts When Treating Patients: Healthcare Career InsightsMust reads about the latest news and trends in healthcare careers. . .
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A Rash of Rough Spinous Patches on a Young GirlThe rash has been present for 2 years. Originally on the trunk and extremities it has now spread to her face and hands. She has been diagnosed as having and been unsuccessfully treated for nummular eczema and tinea corporis. What's your Dx?
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Hepatitis C: ABCs for PatientsHere, in plain language, a list of the most common questions you may hear about HCV and the answers, in brief.
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The Benefits and Challenges of Health Care ReformThe pharmaceutical industry aggressively supported efforts to pass health care reform, even pledging to trim drug costs by $80 billion.1 In addition, it pumped millions of dollars into lobbying and ad campaigns to push the legislation to a successful conclusion, even joining with groups such as Families USA, which ironically spent years attacking drug makers in the early part of the decade.2
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A Retrospective Diagnosis of Ventricular TachycardiaVentricular versus supraventricular tachycardia? This case offers diagnostic and treatment strategies when the diagnosis is uncertain.
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An apical cavitary lesion in a 51-year-old manA 51-year-old man with a long history of alcohol abuse and heavy cigarette smoking presented to our hospital with worsening of a chronic cough, which had become productive of thick green sputum and was associated with posttussive emesis. He denied fevers and chills but had a recent and unintentional weight loss of about 5 kg. He had a history of squamous cell carcinoma of the right tonsil, which remained in remission for more than 4 years after chemotherapy, radiation therapy, and resection. There was no recent history of travel or any occupational exposures or known contacts with tuberculosis or animals (wild or domestic).
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Case ReportA 49-year-old white man, in whom HIV infection had been newly diagnosed (CD4+ cell count, 25/µL; HIV-1 RNA level, 274,000 copies/mL), was transferred to our hospital for further workup and treatment of multiple neurologic deficits. He had presented to another hospital with a 4-day history of left-sided weakness and numbness, left-sided facial droop, dysphonia, and dysphagia that led to the initial diagnosis of an acute stroke.
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Microsoft Enters Health Information Domain with HealthVaultWASHINGTON -- Computer giant Microsoft is surfing into the health-care information field with a free service that allows consumers to store their medical information online.
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Nonsustained Ventricular TachycardiaAn 8-year-old boy was brought to his pediatrician for well-child care. On physical examination, an irregularly irregular heart rate was detected.
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Cytomegalovirus InfectionCough, fever, diarrhea, and weight loss had disturbed a 52-year-old woman for 1 month. AIDS had been diagnosed 5 years earlier, but she had declined medical treatment. The patient's vital signs were stable when she was admitted to the hospital. Physical examination results were unremarkable except for thrush and mild, diffuse abdominal tenderness.
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Diabetes Care: Are We Asking the Right Questions?ABSTRACT: Many patients with diabetes are anxious or fearful about the disease. These negative emotions stem in part from the fact that the patient is responsible for many facets of diabetes management, such as exercise, dietary modification, and blood glucose measurement. For example, failure to adhere to a regimen may engender guilt. Up to 30% of patients with diabetes are depressed, and hemoglobin A1c levels are higher in such patients. Even patients with good metabolic control may not be doing well psychologically. It is thus essential to ask about patients' concerns and fears, identify their psychosocial needs, and provide emotional support.
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Chilaiditi SyndromeDull, intermittent, midepigastric abdominal pain of 1 day's duration prompted a 73-year-old man to seek medical attention. He had no other symptoms.
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Diabetic Foot Problems: Keys to Effective, Aggressive PreventionABSTRACT: A 4-pronged approach that includes patient education, skin and nail care, appropriate footwear, and proactive surgeries can effectively prevent diabetic foot problems. Teach patients with diabetes to examine their feet daily to detect new onset of redness, swelling, breaks in the integrity of the skin, blisters, calluses, and macerated areas. Have them follow a daily foot care regimen that includes warm water soaks and lubrication, and have them keep toenails properly trimmed. Recommend that patients select shoes that fit properly and have sufficient padding and toe box space; have them use inserts, lifts, orthoses, or braces--as recommended-to correct abnormal gait patterns. Finally, if deformities develop, simple proactive surgical procedures can correct these problems before they result in the development of wounds.
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Phrenic Nerve ParalysisPhrenic nerve paralysis can present with chest wall pain, cough, and exertional dyspnea mimicking cardiac dyspnea. Fluoroscopy is the most reliable way to document diaphragmatic paralysis, and the sniff test confirms that abnormal hemidiaphragm excursion is due to paralysis rather than unilateral weakness.
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Allergic Reactions: Anaphylaxis Presenting as MacroglossiaThree days after having eaten fish, a 66-year-old woman with a known allergy to fish and a history of schizophrenia was brought to the emergency department because of macroglossia--a presentation of anaphylaxis.
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Case In Point: Recognizing allergic bronchopulmonary aspergillosisA 28-year-old man presented with chest pain, hemoptysis, and wheezing. He had a history of intermittent shortness of breath that occurred at least 3 times a year in the past 3 years; fever; and loss of appetite associated with headache, vomiting, and weakness. His medical history also included asthma, chronic gastritis, and more than 5 episodes of pneumonia since 1996. A test for hepatitis C virus (HCV) had yielded positive results.
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Pseudomyxoma PeritoneiA 67-year-old man presented with right lower quadrant pain of 3 days' duration. CT findings suggested acute appendicitis with ascites and omental caking. Laparotomy revealed a ruptured appendix, which was removed, and numerous gelatinous deposits throughout the abdomen.
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Emphysematous Pancreatitis in a 61-Year-Old ManEmphysematous pancreatitis is a rare form of necrotizing pancreatitis. Free air within the pancreatic parenchyma is typically attributed to infection.
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Congenital Nevomelanocytic NevusThis darkly pigmented lesion on the left arm of a 27-year-old man had been present since birth and had slowly enlarged over the past 2 months. Two days earlier, another physician had diagnosed a wart and treated the lesion with liquid nitrogen, which caused erythema of the surrounding skin.
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Chemical Colitis From Hydrogen Peroxide EnemaA 61–year–old man presented to the emergency department with diffuse lower abdominal pain, nausea, and severe diarrhea (20 episodes within the past 12 hours). His symptoms began the night before and had gradually worsened. He denied fever. His medical history was significant for hypertension.
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Older Woman With Dyspnea and Large Abdominal EcchymosisTHE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.
