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• Concurrent charge feedback has gained widespread acceptance as a method of minimizing hospitals' losses under the Medicare prospective payment system despite the fact that its effect on patient outcomes, physician behavior, or charges has not been studied in depth. In a controlled trial on two medical wards in an academic medical center, the effect of daily charge feedback on charges was studied. Sixty-eight house staff and 16 teaching attending physicians participated during a 35-week period, taking care of 1057 eligible patients. No significant differences in charges were seen when all patients were included. Since 45% of patients had planned protocol admissions (diagnostic workups or protocol treatment) on which the house staff had little chance to impact, a subgroup analysis was performed, excluding these patients. In the remaining patients, a highly significant reduction in mean total charges (17%), length of stay (18%), room charges (18%), and diagnostic testing (20%) was found. In-hospital mortality and preventable readmission within 30 days were similar on the two wards. It was concluded that charge feedback alone is effective in a teaching hospital for decreasing charges.(Arch Intern Med 1989;149:426-429)

A data bank containing our clinical experience with more than 3,000 patients with suspected and documented ischemic heart disease is being used to expand our ability to care for patients. This report describes how the experience is documented, stored, and retrieved so that it can be used in patient management. Data acquisition is integrated with patient care by means of forms that are part of the patient record. Follow-up information is obtained at six months, one year, and yearly thereafter. All data are stored in a computer information system that allows the doctor to recall the experience of patients like his new patient. Prognostic information is available on each new patient both on-line and in the form of a printed laboratory report. The data bank represents an initial chapter of a computer textbook of medicine.

To examine whether different septal pacing sites could be distinguished by their epicardial activation patterns, six to eight stimulating electrodes were placed throughout the septum in seven open chest dogs. Unipolar electrograms were obtained from 52 epicardial electrodes during pacing from each stimulating electrode and isochronous epicardial maps were constructed. The location of each stimulating electrode was found by dissection, and its distance from the overlying epicardium was measured. To allow comparison among epicardial maps, the septum was conceptually subdivided into nine regions to which stimulating electrodes were assigned. Epicardial activation patterns from the same region were similar and these patterns allowed the region containing a stimulating electrode to be identified in many cases.

CLOSED-CHEST cardiac massage has been used successfully to resuscitate patients since 1960, when the method was introduced by Kouwenhoven et al.1 Because the technique is easily accomplished, anyone in medicine or allied fields can learn to do this emergency procedure. Closed cardiac massage, like open massage, is not without complications. Those reported have included separation of the costochondral junction, fractured ribs, laceration of the inferior vena cava, and lungs with hemothorax and pneumothorax as well as laceration of the aorta, spleen, liver, stomach, and colon.26The purpose of this communication is to report the pathological findings following unsuccessful cardiac resuscitation and to add to the list of complications rupture of the heart. REPORT OF A CASE A 69-year-old woman was admitted for evaluation and treatment of severe and progressive congestive heart failure. Seven years previously a by-pass Dacron prosthesis had been inserted from the left femoral to popliteal

Urinary excretion of norepinephrine and epinephrine was measured in 30 patients with myocardial infarction for five days after admission to a cardiac care unit. Patients with uncomplicated hospital courses or those with primary ventricular fibrillation or complete atrioventricular block showed a similar pattern, ie, high initial levels with a slope to normal range over the five-day period. Patients with multiple complications, particularly of a hemodynamic nature, showed lower initial levels and a different slope over the five-day period. Some instances of catechol elevation at time of psychological stress are presented.

A series of 14 patients with myocardial infarction hospitalized on a Coronary Care Unit and then transferred to a general medical ward were studied by clinical observation and measurement of urinary catecholamine excretion. Emotional changes were frequent and correlated temporally with urinary catecholamine changes at the time of transfer. The incidence of cardiovascular complications was reduced in patients prepared for transfer and followed by a nurse and physician throughout their hospitalization. The findings reaffirm the importance of continuity of care in the treatment of patients with myocardial infarction.