Treatment speed and high load in the Emergency Department—does staff quality matter?

Research in the field of operations management and medicine analyzed how workload affects productivity and patient outcomes. However, staff quality has largely been neglected, and if staffing information has indeed been included, then it takes the form of quantitative measures like staff–to–patient ratios. We therefore seek to analyze how education and experience are directly associated with effort. How do responses to workload differ with respect to education and experience? By analyzing a single hospital unit, we are able to establish a link between staff quality and patient outcomes, allowing us to demonstrate empirically that knowledge and experience are highly relevant in staff members’ responses to increasing system load. The systematic aligning of staffing with expected system load should therefore consider not only staffing quantity but also staffing quality. Provided with a reliable prediction of system load, this knowledge would allow managers to generate savings since they can assign high-quality staff more effectively.     

In Vitro Alveolar Macrophage Viability

A simple, rapid method was developed for the determination of in vitro alveolar macrophage viability after exposure to gases. Air pollutants such as ozone, sulfur dioxide, and oxides of nitrogen killed alveolar macrophages, as determined by the dye exclusion test. Ozone (O₃) was effective at very low concentrations. Other gases such as carbon dioxide (CO₂), carbon monoxide (CO), methane (CH₄), methyl chloride (CH₃Cl), acrolein, acetaldehyde, acetone, isoprene, benzene, and hydrocyanic acid (HCN) had no effect on cell viability.     

Comparison of Celsior and UW solution in experimental pancreas preservation

BACKGROUND: The University of Wisconsin solution (UW) is the gold standard for pancreas preservation. Celsior (CEL) was formulated specifically for heart preservation. Recently, experimental and clinical experience has been reported on the application of CEL to abdominal organs. In this animal study, pancreas preservation with CEL was compared with that in UW solution. PATIENTS AND MATERIALS: Heterotopic, allogeneic pancreaticoduodenal transplantation was performed in female G?ttingen Minipigs (n = 12 donors, n = 12 recipients). The grafts were flushed and stored for 6 h at 4 degrees C in UW or CEL. The recipients were randomized into two groups receiving either UW (n = 6)- or CEL (n = 6)-preserved grafts with a follow-up of 5 days. Blood flow (laser Doppler), partial oxygen tension, histological changes, endothelin-1 (plasma, immunohistochemistry), lipase, amylase, trypsinogen activation peptide, and C-reactive protein (CRP) were measured. RESULTS: Partial oxygen tension was lower in the CEL group (P < 0.05). However, blood flow did not differ between UW- and CEL-preserved organs. The histomorphologic analysis of the pancreatic grafts revealed significantly less edema in the UW-preserved organs. Serum levels of amylase, lipase, CRP, and TAP taken from the central venous blood were comparable in the two groups, except for higher amylase values 36 h after reperfusion in the CEL group compared to the UW group (P < 0.05). Likewise, TAP taken from the portal venous effluent of the graft was found to be higher in the CEL group than in UW (P < 0.05). Endothelin-1 serum levels rose significantly during reperfusion without differences between the two groups. ET-1 immunohistochemistry revealed increased local ET-1 during reperfusion in all grafts. However, the ET-1 immunostaining in the CEL group was more pronounced than that in the UW group (P < 0.05). CONCLUSIONS: Our results suggest that CEL solution is not as effective in preventing pancreatic ischemia/reperfusion damage as the standard UW solution in experimental pancreas transplantation. Increased ET-1 immunostaining and reduced p(ti)O(2) in the CEL group indicate increased microcirculatory damage in the CEL group.     

Alport syndrome associated with diffuse leiomyomatosis: COL4A5-COL4A6 deletion associated with a mild form of Alport nephropathy.

BACKGROUND: The X-linked Alport syndrome (AS) is an inherited nephropathy due to mutations in the COL4A5 gene, encoding the alpha5 chain of type IV collagen, a major component of the glomerular basement membrane (GBM). Here, we report a new kindred with the rare association of X-linked AS and diffuse leiomyomatosis (DL), which is a tumourous process involving smooth muscle cells of the oesophagus, the tracheobronchial tree and, in females, the genital tract. For this syndrome, an almost constant association of large COL4A5 rearrangements with a severe juvenile form of nephropathy has been described for male patients. METHODS: DNA rearrangement at the COL4A5-COL4A6 locus was studied in several members of this family using polymerase chain reaction and pulsed field gel electrophoresis. Furthermore, immunohistochemical staining of tumour and skin samples was performed. RESULTS: The affected patients in this family carry a 120 kb deletion by which the COL4A5 exon 1 and COL4A6 exons 1, 1', and 2 are removed. Immunohistochemical investigation of a skin biopsy of an affected male patient confirmed the absence of both the alpha5 and the alpha6 chains of type IV collagen in the basement membrane of the skin. Surprisingly, both affected male patients had a rather mild renal phenotype. CONCLUSIONS: This report shows that, contrary to what has been reported to date, patients suffering from AS associated with DL can be associated with a late onset renal failure (adult) form of nephropathy.     

Stand-alone 3D-ultrasound navigation after failure of conventional image guidance for deep-seated lesions

Image guidance has proven to be an important tool in surgery for deep-seated or eloquently located cavernomas. However, neuronavigation depending on preoperative images can fail. Thus, the displayed anatomy might be distorted already during the approach. This report demonstrates the use of three-dimensional intraoperative ultrasound (3D-US) as a rescue tool, when conventional navigation is erroneous. Two patients with symptomatic cavernomas, the one located subcortically in the right peritrigonum, the other in the left thalamus, were operated in our clinic via an image-guided approach. An integrated ultrasound-navigation system was used for neuronavigation. In both cases, navigation based on preoperative MRI failed after the craniotomy because patient-to-image registration was lost. In both cases, a simple registration of the patient’s orientation was performed. Then a 3D-US volume was acquired and navigation was performed using the 3D-US data set. This is accurate as image acquisition and navigation are done in the same system. The cavernoma was visualized without difficulties in both cases. It could be reached directly via the ultrasound-guided approach. Patients’ symptoms improved postoperatively and a complete resection could be documented. Two cavernomas were successfully resected using 3D-US guidance. In our experience, stand-alone 3D-US navigation is an effective option if conventional MRI-based navigation fails.     

Current Issues of Targeted Therapy in Metastatic Triple-Negative Breast Cancer

Patients with triple-negative breast cancer are characterized by a poor prognosis compared with patients with other breast cancer subtypes. The angiogenesis inhibitor bevacizumab is effective in the palliative treatment of patients with triple-negative breast cancer as well as in other breast cancer subtypes. PARP inhibitors represent the first group of targeted agents to be developed under the particular aspect of treating patients with hereditary and triple-negative breast cancer. In addition, an increasing number of studies have demonstrated a significant and clinically relevant change in phenotype between primary tumor and metastasis. Consequently, it should be an essential component of the design of modern clinical trials of targeted agents in metastatic breast cancer to determine the relevant tumor phenotype and, depending on the clinical situation, confirm the presence of the therapeutic target in metastatic lesions.     

Surgical therapy for malignant pleural effusions

Symptomatic malignant pleural effusions are common in patients with neoplastic disease (50 %). Frequently, they are a sign of advanced disease. These patients have an average life expectancy of 3 to 12 months. The therapeutic aim should be an efficient treatment with a short hospital stay. Chest tube drainage gives rapid relief of symptoms and information on the expansion of the lungs. When complete expansion of the lung is possible, VATS insufflation of talc is recommended. Talc is the most effective sclerosant (80 %) followed by doxycycline (70 %). VATS pleurodesis has a higher complication rate but is more effective than a talc slurry instilled through the chest tube. When the lung is trapped, long-term indwelling pleural drainage and pleuroperitoneal shunts are alternatives.     

Management of hemorrhage and perforation following endoscopic sphincterotomy]

Bleeding and perforation are rare but dangerous complications of diagnostic and therapeutic ERCP and endoscopic sphincterotomy (EST). To evaluate the clinical outcome of patients treated for complicated EST in our surgical department, data were collected prospectively between 1/1995 and 3/2000. A total of 9 patients were admitted to our department, 7 women and 2 men, average age 60 (range 41-72) years. 5 patients were treated for severe hemorrhage, all of them underwent laparotomy following duodenotomy and oversewing of the sphincterotomy site. In average 10 hours (range 4-20) after endoscopy. One of these patients died due to multiple organ failure. In 4 additional patients a retroperitoneal perforation was discovered, 2 of these patients underwent laparotomy and drainage of the retroperitoneal cavity. The other two patients were sufficiently treated by percutaneous drainage. One of the patients, who underwent surgical drainage for retroperitoneal perforation died.In conclusion for severe hemorrhage duodenotomy and oversewing of the bleeding site is recommended in combination with common bile duct T-drain or other draining procedures. The treatment for perforation should depend on the clinical finding. A laparotomy seems not always to be necessary.     

A Simple Geometric Validation Approach to Assess the Basic Behaviour of Space‐ and Time‐ Distributed Models of Epidemic Spread – An Example Using the Ontario Rabies Model

Dynamic mathematical modelling and stochastic simulation of disease–host systems for the purpose of epidemiological analysis offer great opportunities for testing hypotheses, especially when field experiments are impractical or when there is a need to evaluate multiple experimental scenarios. This, combined with the ever increasing computer power available to researchers, has contributed to the development of many mathematical models for epidemic simulations, such as the individual‐based model (IBM). Nevertheless, few of these models undergo extensive validation and proper assessment of intrinsic variability. The Ontario rabies model (ORM) will be used here to exemplify some advantages of appropriate model behaviour validation and to illustrate the use of a simple geometric procedure for testing directional bias in distributed stochastic dynamic model of spread of diseases. Results were obtained through the comparison of 10 000 epizootics resulting from 100 epidemic simulations started using 100 distinct base populations. The analysis results demonstrated a significant directional bias in epidemic dispersion, which prompted further verification of the model code and the identification of a coding error, which was then corrected. Subsequent testing of the corrected code showed that the directional bias could no longer be detected. These results illustrate the importance of proper validation and the importance of sufficient knowledge of the model behaviour to ensure the results will not confound the objectives of the end‐users.