Abstract-Allopurinol, an inhibitor of xanthine oxidase, increases myofilament calcium responsiveness and blunts calcium cycling in isolated cardiac muscle. We sought to extend these observations to conscious dogs with and without pacing-induced heart failure and tested the prediction that allopurinol would have a positive inotropic effect without increasing energy expenditure, thereby increasing mechanical efficiency. In control dogs (nϭ10), allopurinol (200 mg IV) caused a small positive inotropic effect; (dP/dt) max increased from 3103Ϯ162 to 3373Ϯ225 mm Hg/s (ϩ8.3Ϯ3.2%; Pϭ0.01), but preload-recruitable stroke work and ventricular elastance did not change. In heart failure (nϭ5), this effect was larger; (dP/dt) max rose from 1602Ϯ190 to 1988Ϯ251 mm Hg/s (ϩ24.4Ϯ8.7%; Pϭ0.03), preload-recruitable stroke work increased from 55.8Ϯ9.1 to 84.9Ϯ12.2 mm Hg (ϩ28.1Ϯ5.3%; Pϭ0.02), and ventricular elastance rose from 6.0Ϯ1.6 to 10.5Ϯ2.2 mm Hg/mm (Pϭ0.03). Allopurinol did not affect myocardial lusitropic properties either in control or heart failure dogs. In heart failure dogs, but not controls, allopurinol decreased myocardial oxygen consumption (-49Ϯ4.6%; Pϭ0.002) and substantially increased mechanical efficiency (stroke work/myocardial oxygen consumption; ϩ122Ϯ42%; Pϭ0.04). Moreover, xanthine oxidase activity was Ϸ4-fold increased in failing versus control dog hearts (387Ϯ125 versus 78Ϯ72 pmol/min ⅐ mg -1 ; Pϭ0.04) but was not detectable in plasma. These data indicate that allopurinol possesses unique inotropic properties, increasing myocardial contractility while simultaneously reducing cardiac energy requirements. The resultant boost in myocardial contractile efficiency may prove beneficial in the treatment of congestive heart failure. (Circ Res. 1999;85:437-445.)

Background Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results. Methods We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre– and post–patient blood management time periods. Results Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts. Conclusions Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.

Provider education and reminders can reduce the frequency of daily blood tests ordered by providers for hospitalized patients. This can decrease health care costs and may reduce the risk of complications such as anemia.

BACKGROUND:In caring exclusively for inpatients, hospitalists are expected to perform hospital procedures. The type and frequency of procedures they perform are not well characterized. OBJECTIVES:To determine which procedures hospitalists perform; to compare procedures performed by hospitalists and non-hospitalists; and to describe factors associated with hospitalists performing inpatient procedures. DESIGN:Cross-sectional survey.PARTICIPANTS: National sample of general internist members of the American College of Physicians. METHODS:We characterized respondents to a national survey of general internists as hospitalists and nonhospitalists based on time-activity criteria. We compared hospitalists and non-hospitalists in relation to how many SHM core procedures they performed. Analyses explored whether hospitalists' demographic characteristics, practice setting, and income structure influenced the performance of procedures.RESULTS: Of 1,059 respondents, 175 were classified as "hospitalists". Eleven percent of hospitalists performed all 9 core procedures compared with 3% of non-hospitalists. Hospitalists also reported higher procedural volumes in the previous year for 7 of the 9 procedures, including lumbar puncture (median of 5 by hospitalists vs. 2 for non-hospitalists), abdominal paracentesis (5 vs. 2), thoracenteses (5 vs. 2) and central line placement (5.5 vs. 3). Performing a greater variety of core procedures was associated with total time in patient care, but not time in hospital care, year of medical school graduation, practice location, or income structure. Multivariate analysis found no independent association between demographic factors and performing all 9 core procedures. CONCLUSIONS:Hospitalists perform inpatient procedures more often and at higher volumes than nonhospitalists. Yet many do not perform procedures that are designated as hospitalist "core competencies."