Elimination of early rehospitalization in a randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure population: the potential contributions of specialist care, clinical stability and optimal angiotensin-converting enzyme inhibitor dose at discharge.

BACKGROUND: Despite a growing body of data demonstrating the benefits of multidisciplinary care in heart failure, persistently high rates of readmission, especially within the first month of discharge, continue to be documented. AIMS: As part of an ongoing randomized study on the value of multidisciplinary care in a high risk (NYHA Class IV), elderly (mean age 69 years) heart failure population, we examined the effects of this intervention on previously high (20%) 1-month readmission rates. METHODS: Unlike previous studies of this approach, both multidisciplinary (MC) and routine care (RC) populations were cared for by the cardiology service, complied with adherence to clinical stability criteria prior to discharge (100% of patients) and received at least target dose angiotensin-converting enzyme (ACE) inhibition with perindopril prior to discharge (94% of indicated patients). We analysed death and unplanned readmission for heart failure at 1 month. RESULTS: This early report from the first 70 patients (67% male, 71% systolic dysfunction with a mean ejection fraction of 31.0+/-6.7%) enrolled in this study demonstrates elimination of 1-month hospital readmission in both RC and MC groups. This unexpected result represents a dramatic improvement both for this patient cohort (20% 30-day readmission rate prior to enrollment reduced to 0% following the index admission in both care groups) and in comparison with available data. CONCLUSIONS: Critical contributors to this improvement appear to be specialist cardiology care, adherence to clinical stability criteria prior to discharge and routine use of target or high-dose ACE inhibitor therapy prior to discharge. Widespread application of this approach may have a dramatic improvement in morbidity of CHF while limiting the escalating costs of this condition.

Occupational asthma in a technologist exposed to glutaraldehyde.

BACKGROUND: Occupational asthma can be caused by several sterilizing agents, including glutaraldehyde, which has been shown to cause irritation of the eyes and upper respiratory tract and skin rash. We report a case of occupational asthma that was caused by exposure to glutaraldehyde. METHODS: To document the diagnosis of occupational asthma in a respiratory technologist, the following tests were performed: preshift and postshift spirometry, serial measurements of peak expiratory flow rate and nonspecific bronchial hyperresponsiveness, and workplace challenge test. RESULTS: Monitoring of peak expiratory flow rate showed improvement when the subject was away from the workplace. Improvements in forced expiratory volume in 1 second (FEV1) and provocative concentration causing a 20% fall in FEV1 were also observed. A workplace challenge test showed a progressive fall in FEV1 when the subject was exposed to glutaraldehyde in a sterilizing agent used to clean bronchoscopes at her workplace. After the diagnosis of occupational asthma was confirmed, the subject continued to assist with bronchoscopy but no longer cleaned the bronchoscopes. CONCLUSIONS: This case study illustrates the usefulness of a workplace challenge test in confirming the diagnosis of occupational asthma. It also indicates the importance of preventing or reducing exposure to sterilizing agents such as glutaraldehyde by means of effective ventilation and proper storage and enclosure during use.