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PubMed1994

Reducing pacemaker costs while preserving choice: a partnership that worked.

Over the last ten years, separate and repeated attempts by Cardiology Management, Materials Management, and physicians to effectively reduce pacemaker costs had led to limited successes of short duration. Issues of physician choice, clinical application of advancing technology and long-term relationships with a variety of vendor representatives had usually conspired to overwhelm any incremental inroads into manufacturers' pricing structures. A collaborative review of past practices resulted in the creation of a multi-disciplinary task force charged with two goals: maintain physician choice and reduce costs. In the resulting process, no manufacturer was eliminated, vendors accepted all of the risks and received no guarantees of market share, and device specifications were matched to clinical indications in a preferred device matrix. The task force met both of its goals as evidenced by a 18.9% decrease in annual expenditures for pacemakers and by a 27% shift in device use based upon physician choice.

Cardiology Service, Hospital↗
PubMed1976

[Enrichment of wheat flour with sunflower and soya flour for bakery products].

In order to improve the nutritive value of wheat protein, with a wheat flour, defated soybean flour and sunflower seed flour were mixed on the basis of their amino acid composition. The highest nutritive value, 86 expressed as CS, was obtained with 60% wheat flour + 28% defatted soybean flour + 12% defatted sunflower seed flour. The mixture was used to prepare: a) sea-biscuits, baked in a traditional bakery oven, and b) crackers, baked in an electric endless oven. Similar products, baked with wheat flour alone, were studied as controls. Chemical composition, total lysine, methionine, cystine, threonine and available lysine content were determine on the raw flours and mixture. Protein, fats and available lysine were determined on the bakery products. The nutritive value of the latter was assessed by their NPUop from which NPUst was calculated. The results showed an increase in the protein content of the enriched bakery products up to 60% over the controls. The nutritive value of the products was lower than the calculated figure for the raw mixture. Products b had the highest NPUst (56.4), surpassing the figures for the control (33.3) and also for product a (53.5). These values agreed with the figures for lysine availability which decreased with heat according to the cooking process. These data and the good acceptability of the crackers suggest that their enrichment with soybean and sunflowers seed concentrates asayed, could help to fulfill protein requirements in children.

Amino Acids↗
PubMed1999

Integrated knowledge-based functions in a hospital cancer registry--specific requirements for routine applicability.

The background of the presented work is the design, realization, and routine use of integrated knowledge-based functions in the context of a hospital cancer registry. The first field of application was supporting registrars to detect data inconsistencies and incompleteness timely during the documentation process. Especially, we focused on the acceptance of the administrator of the underlying information system and on the phenomenon of duplicate and outdated messages. These aspects are specific for integrated knowledge based functions and a precondition for obtaining a routine applicability and acceptance.

Artificial Intelligence↗
PubMed1975

The evaluation of continuing medical education.

To use the limited time available for the most benefit, practising doctors need presentations of maximal educational effectiveness. This effectiveness can be assessed by methods which are practical and acceptable. We can evaluate the educational process itself by assessing each presentation using selected criteria, by examining the appropriateness of programme content, and by obtaining the opinions of participants. We can evaluate changes in the knowledge of participants by seeking opinions from them and by building evaluation into educational sessions. We can look at patient-outcome in relation to education by seeking the opinions of informed observers and by building evaluation into clinical work.

Attitude of Health Personnel↗
PubMed1999

[Medical education at the dawn of the 21st century: a challenge for the French Units of Education and Investigation].

In the incoming 21st century, traditional medical schools are facing major challenges, if medical education wants to sustain educating physicians capable of answering continuous increasing health care needs of populations they should serve. Institutions should be willing to accept the necessity to modify instructional processes to favor student autonomy and to manage knowledge explosion. A new approach should guide schools in determining undergraduate program content and objectives, in favoring a learning process centered on student and oriented towards community needs, as well as in investing into faculty development in pedagogy. This approach triggers medical schools to establish with their students a new social contract intended to educate them as responsible and autonomous future medical citizens.

Curriculum↗
PubMed1999

Overview of clinical trials with MIT-MANUS: a robot-aided neuro-rehabilitation facility.

We are applying robotics and information technology to assist, enhance, and quantify neuro-rehabilitation. Our goal is a new class of interactive, user-affectionate clinical devices designed not only for evaluating patients, but also-for delivering meaningful therapy via engaging "video games". Notably, the novel robot MIT-MANUS has been designed and programmed for clinical neurological applications, and has undergone extensive clinical trials for more than four years at Burke Rehabilitation Hospital - White Plains, NY. This paper will review results of the first clinical trial of 20 patients, which showed that: - Stroke patients treated daily with additional robot-aided therapy during acute rehabilitation had improved outcome in motor activity at hospital discharge, when compared to a control group that received only standard acute rehabilitation treatment. - This improved outcome was sustained after three years. - The neuro-recovery process continued far beyond the commonly accepted 3 months post-stroke interval.

Double-Blind Method↗
PubMedDate not supplied

Recommendations for uniform reporting of data following major trauma--the Utstein Style: an initiative. International Trauma Anaesthesia and Critical Care Society (ITACCS)

Basic and advanced care of trauma patients always has been an important aspect of prehospital and immediate in-hospital Emergency Medicine, involving a broad spectrum of disciplines, specialties, and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources, and operation. This complex background, at least in part, has hindered the development of a uniform pattern or set of criteria and definitions. This in turn, has rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be evaluated or compared readily with acceptable validity. Guided by previous consensus processes evolved by the ERC, the AHA, and other International Organisations represented in ILCOR--on Uniform Reporting of Data following Out-of-hospital and In-hospital Cardiac Arrest--the Utstein Style, an international working group of ITACCS, has drafted a document, Recommendations for Uniform Reporting of Data following Major Trauma--the Utstein Style. The reporting system is based on the following considerations: 1) A structured reporting system based on an "Utstein style template" that would permit the compilation of data and statistics on major trauma care, facilitating and validating independent or comparative audit of performance, and quality of care (and enable groups to challenge performance statistics that did not take account of all relevant information); 2) The Recommendations and Template should encompass both out-of-hospital and in-hospital trauma care; 3) The Recommendations and Template should permit further intra- and inter-system evaluation to improve the quality of delivered care and identification of the relative benefits of different systems and innovative initiatives; and 4) The Template should facilitate studies setting out to improve epidemiological understanding of trauma; for example, such studies might focus on the factors that determine survival. The document is structured along the lines of the original Utstein Style Guidelines publication on "prehospital cardiac arrest". It includes a glossary of terms used in the prehospital and early hospital phase as definitions, time points, and time intervals. The document uses an almost identical scheme for illustrating the different process time clocks--one for the patient, one for the dispatch centre, one for the ambulance, and finally, one for the hospital. For clarity, data should be reported as core data (i.e., always obtained) and optional data (obtained under specific circumstances). In contrast to the graphic approach used for the Utstein Template for pre- or in-hospital cardiac arrest, respectively, the present Template introduces, for the time being, at least, a number of terms and definitions and a semantic rather than a graphic report form. The document includes the following sections: I. INTRODUCTION AND BACKGROUND: II. TRAUMA DATA STRUCTURE DEVELOPMENT: A general outline of the development of structured data using object-oriented modelling (which will be discussed in due course) and includes a set of explanatory illustrations; III. TERMS AND DEFINITIONS: Outlines terms and definitions in trauma care, describing different types of trauma (blunt, penetrating, long bone, major/combined, multiple/polytrauma, and predominant trauma); IV. FACTORS RELATING TO THE CIRCUMSTANCES OF THE INJURY: Describes the following items: a) Cause of injury e.g., type of injury (blunt or penetrating), burns, cold, crush, laceration, amputation, radiation, multiple, etc.; b) Severity of Injury--e.g., prehospital basic abbreviated injury score developed by the working group. The score contains anatomical and physiological disability data, with the anatomical scale ranging ordinally from "1" = head to "9" = external; the physiological disability scale ranges ordinally from "0"; c) Mechanism of injury--recording for transportation incidents etc; e.g., the type of impact, possible restraining devices,

Anesthesiology↗
PubMed2000

"Recommendations for uniform reporting of data following major trauma--the Utstein style" (as of July 17, 1999). An International Trauma Anaesthesia and Critical Care Society (ITACCS).

Basic and advanced care of trauma patients has always been an important aspect of prehospital and immediate in-hospital emergency medicine, involving a broad spectrum of disciplines, specialties and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources and operation. This complex background has, at least in part, hindered the development of a uniform pattern or set of criteria and definitions. This in turn has hitherto rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be readily evaluated or compared with acceptable validity. Guided by previous consensus processes evolved by the ERC, the AHA and other International Organizations--represented in ILCOR--on 'Uniform reporting of data following out-of-hospital and in-hospital cardiac arrest--the Utstein style' an international working group of ITACCS has drafted a document, 'Recommendations for uniform reporting of data following major trauma--the Utstein style'. The reporting system is based on the following considerations: A structured reporting system based on an "Utstein style template" which would permit the compilation of data and statistics on major trauma care, facilitating and validating independent or comparative audit of performance and quality of care (and enable groups to challenge performance statistics which did not take account of all relevant information). The recommendations and template should encompass both out-of-hospital and in-hospital trauma care. The recommendations and template should further permit intra- and inter-system evaluation to improve the quality of delivered care and identification of the relative benefits of different systems and innovative initiatives. The template should facilitate studies setting out to improve epidemiological understanding of trauma; for example such studies might focus on the factors that determine survival. The document is structured along the lines of the original Utstein Style Guidelines publication on 'prehospital cardiac arrest'. It includes a glossary of terms used in the prehospital and early hospital phase and definitions, time points and intervals. The document uses an almost identical scheme for illustrating the different process time clocks--one for the patient, one for the dispatch centre, one for the ambulance and, finally, one for the hospital. For clarity, data should be reported as core data (i.e. always obtained) and optional data (obtained under specific circumstances). In contrast to the graphic approach used for the Utstein template for pre- or in-hospital cardiac arrest, respectively, the present template introduces, for the time being, at least, a number of terms and definitions and a semantic rather than a graphic report form. The document includes the following sections: The Section Introduction and background The Section on Trauma Data Structure Development: presents a general outline of the development of structured data using object-orientated modelling (which will be discussed in due course) and includes a set of explanatory illustrations. The Section on Terms and Definitions: outlines terms and definitions in trauma care, describing different types of trauma (blunt, penetrating, long bone, major/combined, multiple/polytrauma and predominant trauma). The Section on Factors relating to the circumstances of the injury describes the following items: cause of injury (e.g. type of injury (blunt or penetrating), burns, cold, crush, laceration, amputation, radiation, multiple, etc. Severity of Injury e.g. prehospital basic abbreviated injury score developed by the working group. The score contains anatomical and physiological disability data, with the anatomical scale ranging ordinally from 1. Head to 9. External; the physiological disability scale ranging ordinally from 0--unsurvivable. Mechanism of injury recording for transportation incidents etc. e.g. the type of impact, po

Data Collection↗
PubMed2000

Risks and complications of peripherally and centrally inserted intravenous catheters.

Increased nursing vigilance is needed while caring for critically ill patients who have i.v. catheters. All i.v. sites should be selected based upon the i.v. therapy needs of the patient, using the shortest catheter and smallest size possible to meet the treatment needs of the patient while avoiding excessive repeated insertions of peripheral IVs. Meticulous handwashing, site preparation, and the use of sterile technique during insertion and maintenance are essential to minimize the risk of infection. Use multilumen catheters only when necessary because these catheters have an increased manipulation and associated infection risk. Observe for signs and symptoms of localized, systemic, mechanical, and metastatic (e.g., vertebral osteomyelitis and endocarditis) foci of infection. Additionally, remove all unnecessary or poorly performing i.v. catheters. I.v. sites that do not yield a blood return but will accept i.v. solutions are in the process of becoming occluded. Most likely, there is a fibrin sheath that is developing along the catheter's inner lumen and opening, decreasing the catheter's effectiveness. Accommodate the need to replace a catheter into the patient's plan of care rather than allowing the catheter to occlude and then replacing it under emergent or rushed conditions.

Catheterization, Central Venous↗
PubMedDate not supplied

[Bioethics and scientific training of physicians].

Bioethics is becoming a major current in modern medical thought and action. Given the youth of this field of enquiry, there are still important debates and controversies on its proper role in medicine and in medical education, but the need to foster its integral incorporation into the formative process of the physician is unreservedly accepted, on an equal footing with the scientific, technical, and humanistic components of medical training.

Bioethics↗
PubMed2000

[Interventional treatment of acute myocardial infarct].

BACKGROUND: Randomised trials have shown that primary percutaneous angioplasty (PTCA) may offer advantages over thrombolysis in treating acute myocardial infarction (vessel patency is achieved more often, mortality and reinfarction rate are lower, cerebrovascular accidents are less frequent). Data from several foreign registries have been less clear. Up to now no registry data have been available for Switzerland. Data from registries are very important in planning optimal treatment under "real world" conditions. METHOD: All patients receiving acute PTCA during the first 24 hours of acute myocardial infarction were prospectively included in a registry at a single centre. We assessed times until revascularisation, as well as clinical, angiographic and outcome data. RESULTS: 503 patients (age 59 +/- 12 years, 15% women) were included from 1. 1. 1995 to 30.6.2000. Primary PTCA was performed in 334 patients, and rescue PTCA in 169. Diabetes mellitus was present in 36% of the total. Multivessel disease was present in 61%, anterior infarction in 36%, and 16% were in cardiogenic shock before intervention. The pre-hospital delay was 2:12 h (median). In-hospital decision delay (hospital admission until contact to cardiologist) in patients with primary PTCA was 31 minutes (median). The time from vessel puncture to recanalisation was 19 minutes (median). 273 patients were transferred for coronary angiography and intervention by other hospitals (218 by ground ambulance, 55 per helicopter transfer). The total transfer time (calculated from time of decision to arrival in the catheterization laboratory) was 57 minutes (median). PTCA was successful angiographically in 97% and TIMI 3 flow was obtained in 93% of all patients. Hospital mortality was low in view of the high proportion of patients in cardiogenic shock prior to PTCA (mortality in shock patients was 33%). Mortality in patients without pre-existing cardiogenic shock was 2%. CONCLUSION: Patients with acute myocardial infarction, especially high-risk patients, can be treated successfully by acute PTCA around the clock in Switzerland, in accordance with the strict international recommendations for time delays. The treatment results are similar to those in randomised trials. Transfer of patients from referral hospital is safe, with acceptable delays. Optimisation of the decision process and transport logistics may further improve outcome by reducing the total ischaemia time.

Adult↗
PubMed1976

Kinetic and equilibrium studies of the reactions of heme-substituted horse heart myoglobins with oxygen and carbon monoxide.

In order to study the effects of chemical modifications of the vinyl groups of heme on oxygen and carbon monoxide binding to myoglobin, apomyoglobins from horse heart were reconstituted with six different hemins with various side chains. Laser flash photolysis experiments of these reconstituted myoglobins showed that the combination rate constants for oxygen (k') and carbon monoxide (l') were closely related to the electron-attractive properties of the side chains. The k' values obtained in 0.1 M potassium phosphate buffer, pH 7.0, at 20 degrees were 0.83 (meso-), 2.4 (deutero-), 1.1 (reconstituted proto-), 1.2 (native proto-), 1.5 (2-formyl-4-vinyl-), 1.9 (2-vinyl-4-formyl-), and 2.7 X 10(7) M-1 S-1 (2,4-diformylmyoglobins), and the corresponding l' values were 2.8, 18, 4.8, 5.1, 7.1, 15, and 35 X 10(5) M-1 S-1, respectively. These rate constants tend to increase as the electron-withdrawing power of the side chains increases, indicating that reduced electron density of the iron atom of heme in myoglobin favors the combination reaction for both oxygen and carbon monoxide. Equilibrium constants (L) between carbon monoxide and various myoglobins were also determined by measuring the partition coefficients (M) between oxygen and carbon monoxide for the myoglobins, and were also found to be closely related to the electronic properties (pK3 of porphyrin) of the heme side chains. The equilibrium association constants for carbon monoxide thus obtained increased with a decrease in pK3 value of the porphyrin. This order was completely opposite to the case of the oxygen binding reaction. The dissociation rate constants for oxygen (k) and carbon monoxide (l) were calculated from the equilibrium and the combination rate constants. The dissociation rate constants showed a similar characteristic to the combination rate constants and increased with the increase in electron attractivity of heme side chains. The concomitant increase in both the combination and dissociation rate constants with increase in electronegativity of the iron atom suggests that these reactions have different rate determining steps, although such a reaction process is contradictory to the generally accepted concept that in a reversible reaction, both on and off reactions proceed through the same transition state. In the on reaction sigma bond formation appears to be dominant, while in the off reaction eta bond break-up is more important.

Animals↗
PubMedDate not supplied

Effect of carrier materials on the resistance of spores of Bacillus stearothermophilus to gaseous hydrogen peroxide.

The testing of the H2O2 decontamination process using spores of Bacillus stearothermophilus has gained widespread acceptance. Usually, commercially available Biological Indicators (BIs) with a specified resistance to H2O2 are challenged to qualify the process. The question arises whether the resistance of test spores is dependant on the type of carrier material and whether the resistance is representative for the system under test. The objective of the study is to quantify the effect of different carrier materials on the resistance of spores of Bacillus stearothermophilus to H2O2. Materials from which isolators were built, as well as those used in disposables during daily work were investigated. These materials were inoculated with 106 spores of Bacillus stearothermophilus (ATCC 7953). The spore resistance was tested to a well defined H2O2 decontamination cycle by determining the D-value using the "Fractional Negative" method. This paper reports on the effect of different carrier materials to the resistance of the test organism against H2O2. Various materials have significantly increased resistance of the spores and should be avoided in isolator systems. If commercially available BIs are used for process qualification, the resistance of the BI used, the fluctuation in resistance caused by isolator materials, the required log reduction, and at least the bioload of isolator surfaces need to be known.

Decontamination↗
PubMed2003

Are you prepared for a shortage of anesthesia providers?

The number of anesthesia providers has not kept pace with increasing demand for their services. The supply of certified registered nurse anesthetists is decreasing. Hospital administrators need to recognize that these declining numbers will give anesthesiologists increased leverage during contract negotiations. Hospitals should prepare for negotiations with anesthesia providers by establishing process guidelines before discussions, defining minimally acceptable terms, and exploring a full range of compensation options. Hospitals that anticipate market changes and avoid hard-line responses position themselves for greatest long-term success.

Anesthesia Department, Hospital↗
PubMed1992

Collaborative governance in the postanesthesia care unit.

The administration at Schumpert Medical Center, Shreveport, LA, is committed to empowering the nursing staff. Due to this commitment, the postanesthesia nurses developed a collaborative governance program that is based on empowerment. This article discusses how to begin the development and implementation process, address staff concerns, and facilitate acceptance of the finished program by the staff. This program has become a successful model for the collaborative governance program at the author's hospital and has resulted in a stimulating and caring working environment for the professional.

Humans↗
PubMed1992

[Cancer rehabilitation in the Federal Republic of Germany--a critical review from the perspective of rehabilitation psychology].

Against the background of a common criticism of the rehabilitation system, the situation of rehabilitation research and practice in oncology is reviewed. A lack of efforts aimed at vocational rehabilitation as well as the main emphasis in inpatient services is criticized. Till now, outpatient services as well as psychosocial rehabilitation care are not as well established, as they should be with regard to provide assistance in coping with the disease and in adapting to the various disabilities may be followed by cancer. As rehabilitation research in oncology is still at its very beginning, we know little about the acceptance of rehabilitation measures as well as the rehabilitation process in its correlation between outcome criteria. Our own pilot study provides first results concerning vocational rehabilitation and acceptance of medical rehabilitation services. As conclusion, we need more elaborated research in oncological rehabilitation for optimizing and further developing rehabilitation care system especially with respect to outpatient and psychosocial services.

Ambulatory Care↗
PubMed2003

Plants grown on sewage sludge in South China and its relevance to sludge stabilization and metal removal.

The production of sewage sludge in China has been increasing sharply in order to treat 40% of the municipal sewage in 2005 as planned by central government. The main sludge disposal method is landfill owing to heavy metal contamination, but it presents an attractive potential for agricultural land application. Experiments were carried out to study the simultaneous metal removal and sludge stabilization by plants. The sludge samples were collected from Datansha Wastewater Treatment Plant of Guangzhou, it contained excessive Cu and Zn compared with the Chinese National Standard for Agricultural Use of Sewage Sludge. Plants growing on sludge beds were investigated to follow their growth and metal uptake. 30 sludge plants were identified during 1 year's observation. A Zn high-accumulating and high growth rate plant(Alocasia macrorrhiza) was selected and grown on sludge beds in plots. The water, organic matter, heavy metals and nutrients contents, the E. coli number and the cress seed germination index were monitored for the sludge samples collected monthly. The plant growth parameters and its heavy metals contents were also determined. The sewage sludge treated by plants could be stabilized at about 5 months, the E. coli number was significantly decreased and the cress seed germination index attained 100%. Crop on sludge could ameliorate the sludge drying. The experiments are continuing to find out the appropriate plant combination for simultaneous sludge stabilization and metal removal for an acceptable period. Comparisons between the proposed processes and other methods for treating produced sludge such as composting, chemical andbacterial leaching were discussed.

Alocasia↗
PubMed2003

[The research update on cellular immune abnormality in myelodysplastic syndrome--review].

Myelodysplastic syndrome is a group of diseases characterized by abnormal clonal proliferation of hematopoietic cells and pancytopenia with dysplasia. The pathogenesis of MDS includes factors of chromosome aberrations, gene mutations, immune abnormalities, environmental changes, and so on. Now it is commonly accepted that MDS is a multistep process disorder involving more etiologic alterations. Recently more and more investigations indicate that the abnormality of cellular immunity is one of important reasons related to MDS. Some proofs about the abnormal activation of T-cell and the abnormal expressions of cytokines in different stages of immune response in MDS have been documented, meanwhile, numerous clinical studies on immune therapy in MDS provide a great number of evidences to disclose its immune abnormalities.

Cytokines↗