Quantitative CT imaging of the spatio-temporal distribution patterns of vasa vasorum in aortas of apoE-/-/LDL-/- double knockout mice

OBJECTIVE

To investigate the distribution of vasa vasorum (VV) relative to advanced atherosclerotic lesions (calcified, fibrotic or hemorrhaged) along the aortic wall of apoE-/-/LDL-/- mice at the age of 25 and 80 weeks using high-resolution nano-CT.

METHODS

Aortas from male apoE-/-/LDL-/- mice at the age of 25 weeks (n=4) and 80 weeks (n=7) were infused in situ with contrast agent and harvested for scanning with nano-CT. The spatial distribution of vasa vasorum [number and area/cross-section (mm2)] was compared to aortic luminal cross-sectional area and plaque cross-sectional area in the ascending aorta, aortic arch and descending aorta. Results were complemented with co-localized histology.

RESULTS

The number and total luminal cross-sectional area of VV showed a significant decrease in the ascending aorta and aortic arch from 25 to 80 weeks but not in the descending aorta. The number and cross-sectional area of VV showed significant local differences depending on whether it was near a fibrotic, and hemorrhaged or calcified plaque in animals at the age of 80 weeks. Area of VV progressively increased along the aorta from least in the ascending aorta<aortic arch<descending aorta in animals at the age of 80 weeks and is inverse in animals aged 25 weeks.

CONCLUSION

Atherosclerotic lesion type is correlated to the number and cross-sectional area of VV in different aortic segments in apoE-/-/LDL-/- mice. The chronological development of VV along the aorta proceeds distally from the ascending aorta and aortic arch.

[Patient surveys as an element of quality management in outpatient care: development and assessment of a questionnaire]

OBJECTIVE

The present study was designed to develop and assess a questionnaire measuring all relevant quality dimensions of general practice care from the patients' perspective. Furthermore, the study aimed to evaluate the implementation of a patient survey in outpatient care.

METHODS

Based on the Kölner Patientenfragebogen (KPF) and by developing some additional new items, we created the new questionnaire KPF-A (Kölner Patientenfragebogen-ambulant) which covers all relevant aspects of outpatient care. The questionnaire was distributed to the patients of 41 GP's and specialists in ambulatory care from different regions of Germany. N=3188 patients were included in the sample. We used these data to assess some selected psychometric characteristics of the KPF-A. Factor analysis was used to examine the underlying factor structure. A qualitative study was conducted to evaluate the implementation of the patient survey. Therefore, all N=41 doctors involved were asked to complete five open questions concerning their experience.

RESULTS

Most scales of the KPF-A showed good psychometric characteristics in the present study. Factor analysis revealed a two-factors solution for the new items representing the dimensions "professional competence" and "medical equipment". We have not yet been able to find a sound factor solution for those items representing the dimension "Staff and Organisation". The results of the qualitative study revealed a satisfying implementation of the patient survey in daily routine from the doctors' perspective. The length of the questionnaire was criticised by some participants. In the design of the study patients were supposed to fill in the questionnaires after consultation. This turned out to be difficult. We therefore modified the KPF-A so that patients can fill it in either before or after consultation.

Antikörperkontrollierte zytostatische Therapie des malignen Thymoms bei begleitender Myasthenia gravis

In a 46-year-old female patient with malignant thymoma and concomitant myasthenia gravis relapse with gravitational metastases occurred 6 1/2 years after the first operation. Metastases could be removed surgically only partially and were subsequently irradiated with 50 Gy. After 3 1/2 years renewed metastatic growth occurred. Until then the concomitant myasthenia had been stable during treatment with pyridostigmine and azathioprin and intermittent prednisone; acetylcholine receptor antibody titres had remained largely stable. Combined cytostatic treatment with vincristine, cyclophosphamide, prednisone and doxorubicin or cisplatin led to regression of metastases during the observation period of 1 1/2 years and at the same time to stabilisation of the myasthenia. Acetylcholine receptor antibody titres decreased and this was roughly paralleled by clinical improvement. Whereas there is no obvious correlation of antibodies against acetylcholine-receptor protein and tendency of tumour growth there is good agreement with the course of the accompanying myasthenia.

[Management of the operation room in an university hospital]

The heart of any surgical department is the operation room area. Any disturbances in the daily routine will affect the work flow of the whole hospital. As an example the major complaints of a university surgical department regarding workflow and communication are outlined. To solve these problems a team "OR organization" was established, which started the work based on a new developed OR statute. Within a short period the contentment of the employees as well as the workflow improved. But as a matter of fact, even in the following years of central OR management there is still the need to further stabilize the system and carefully improve the controlling system.

An unusual case of early fulminant post-traumatic fat embolism syndrome

A multiple-injured patient developed a very early onset fulminant fat embolism syndrome that was partially masked by haemorrhagic shock. Despite early diagnosis by transoesophageal echocardiography and aggressive symptomatic treatment, there was a rapid evolution to death. Post mortem examination revealed the presence of both pulmonary and systemic fat emboli. This case highlights the ever present risk of masked fat embolism syndrome shortly after trauma.

Laterale Ischiadikusblockaden

In the present study we examined 41 volunteers using magnetic resonance imaging to obtain biometric data of the thigh used for a planned blockade of the sciatic nerve via the lateral approach. At a needle entry point 12 cm proximal to the gap of the knee joint at the posterior border of the M. vastus lateralis, the sciatic nerve lies on average at a depth of 5.2 cm (39% of the femoral diameter at this site) with an angle of 10.9 degrees to the horizontal in a dorsal direction. Here the popliteal artery lies on average at a depth of 6.4 cm (48% of the femoral diameter) with an angle of 4.7 degrees to the horizontal in a ventral direction. At the marked point in the middle between the gap of the knee joint and the trochanter major at the posterior border of the M. vastus lateralis, the sciatic nerve is at an average depth of 6.2 cm (40% of the femoral diameter at this site) with an angle of 8.2 degrees in a dorsal direction. At a marked point 5 cm distal of the trochanter major at the posterior border of the M. vastus lateralis, the sciatic nerve is at a depth of 9.1 cm at a dorsal angle of 15.5 degrees (49% of the femoral diameter). The lateral blockade of the sciatic nerve at different sites of the thigh is a technique which is easy to plan with the presented biometric data. The popliteal artery could be reached only at the distal puncture point using a deep puncture and an angle in the ventral direction.

[Possibilities in improving patients's turn-over coordination in the OR of an University Hospital]

An efficient Operating Room (OR) management might increase the cost-effectiveness of an OR. For this purpose, we have evaluated the coordination and the times of the solitary processes that are involved in the patient turnover. The mean time between skin suture of the preceding patient and incision of the following patient (SI-time) was, depending on the type of operation, between 44 and 78 minutes. Mean empty-room time (ERT) was 7 minutes. SI-times depended on various factors, including the times necessary to discharge the preceding patient from the OR and the times necessary for induction of anesthesia or for preparation of the OR. Altogether, our data provide evidence for the fact, that optimisation of the patients turnover can decrease SI-times between 10-15 minutes. Although this period appears too short to reliably allow an additional scheduled operation during regular working hours, an improved coordination may result in reduced overtimes of the OR-staff and thus should increase staff satisfaction.

[Fatal outcome after multiple trauma. The thoracic injury as the decisive factor]

In patients suffering from multiple injury, chest trauma is often the main cause of fatality. A case report is given and the literature reviewed.A 49 years old motorcyclist hit a car frontally in a road accident. After primary stabilization and first clinical care, he was transferred to our trauma centre because of severe chest injury, suspected pericardial effusion and lesion of the thoracic aorta. Initial diagnostics (plain radiographs, CT scan of thorax, abdominal ultrasound, echocardiography) showed left-sided serial rib fractures, a fracture of the left scapula, a hematopneumothorax left-sided, bilateral lung contusion, a small pneumothorax of the right side, a minimal pericardial effusion and a small splenic hematoma. The patient was treated in the intensive care unit, and the situation was initially stable. After 12 h, respiration deteriorated and a bronchoscopy showed filling of the airways with mucous fluid. The CT scan showed a worsening of the pulmonary damage and increasing pericardial fluid compression. A pericardiotomy was carried out, but the situation remained unstable. The patient was treated with invasive ventilation (PEEP>10, FiO2>0,5). Sudden severe bleeding out of left lower lobe was managed by thoracotomy and lobectomy. The patient remained unstable and died 95 h after the accident. This case shows that the severity of chest trauma does not necessarily correlate with the initial clinical and radiological findings. Even with all diagnostic and therapeutic procedures, a fatal outcome could not be prevented. This demonstrates the role of chest injury as a major and unforeseeable cause of death in multiple trauma patients.

Balanced Scorecard

The change in hospital funding with diagnosis related groups (DRG), medical advances as well as demographic changes will call for new quantitative and qualitative standards imposed on German hospitals. Increasing costs and competition in the health care sector requires new and innovative strategies for resource management. Today's policy is mainly defined by rationing and intensified workload. The introduction of DRGs will presumably further constrict management perspectives on pure financial aspects. However, to ensure future development, compassionate services and continued existence of hospitals, a balance of seemingly conflicting perspectives, such as finance, customer, process, learning and growth are of utmost importance. Herein doctors and nurses in leading positions should play a key role in changing management practice. For several years the balanced scorecard has been successfully used as a strategic management concept in non-profit organizations, even in the health care sector. This concept complies with the multidimensional purposes of hospitals and focuses on policy deployment. Finally it gives the opportunity to involve all employees in the original development, communication and execution of a balanced scorecard approach.

[OR-manager: surgeon or anaesthetist?]

The heart of any surgical department is the operating room (OR) area. Any disturbances in the daily routine will affect the work flow of the whole hospital. On account of its central function, with numerous connections to other departments, the OR is the crystallisation point for deficiencies in various events and processes. As an example, the major complaints made by a surgical department regarding workflow and communication are outlined. To solve these problems, an "OR organization" team was established, which worked on the basis of a newly developed OR statute. Within 1 year the employees were more contentment and the workflow had improved. However, even in the second year of central OR management there is still the need to further stabilize the system as mismanagement still occurs.

Stress response during weaning after cardiac surgery

We compared the effects of weaning using synchronized intermittent mandatory ventilation (SIMV) with the use of biphasic positive airway pressure (BIPAP) on the stress response, oxygen uptake (VO2) and work of breathing (WOB) in 10 patients after aortocoronary bypass surgery. All three ventilatory settings were investigated in each patient, for example, volume-controlled mechanical ventilation immediately before weaning was followed, in randomized order, by both SIMV and BIPAP. In addition to routine monitoring of continuous and respiratory state, we measured VO2, WOB, and pressure-time product (PTP) as well as the plasma concentrations of epinephrine, norepinephrine, ACTH, cortisol, vasopressin, and prolactin. Although respiratory rate (f), WOB and PTP were greater with both SIMV and BIPAP when compared with control, other variables did not change with the ventilatory mode. In conclusion, weaning from mechanical ventilation using partial support modes does not affect the postoperative stress response in patients who have had uncomplicated cardiac surgery.

Does gastric juice pH influence tonometric PCO2 measured by automated air tonometry?

To determine the influence of changes in gastric juice pH due to intravenous administration of pentagastrin and omeprazole on intramucosal regional PCO2 (Pr(CO2)), we investigated 17 healthy human volunteers. Gastric juice pH was obtained from a glass pH electrode for continuous gastric juice pH measurement and Pr(CO2))was measured by using automated air tonometry. After baseline (8:00 A.M.-9:00 A.M.) the subjects received 0.6 microg/kg/h pentagastrin intravenously for 1 h (9:00 A.M.-10:00 A.M., after stimulation 10:00 A.M.-11:00 A.M.) and 40 mg omeprazole intravenously (after omeprazole 11:00 A.M.-3:00 P.M.). Following pentagastrin administration gastric juice pH significantly decreased from 1.2 +/- 0.4 to 0.6 +/- 0.4 (mean +/- SD, p < 0.007, versus baseline), whereas omeprazole transiently increased luminal pH up to 4.4 +/- 1.7 (p < 0.007 versus baseline). These subsequent changes in gastric juice pH were accompanied by a significant increase in Pr(CO2) from 48 +/- 12 to 61 +/- 17 mm Hg (p < 0.007 versus baseline) and a decrease to 44 +/- 5 mm Hg (p < 0.002 versus pentagastrin), respectively. A gastric juice pH > 4 considerably reduces mean gastric Pr(CO2) and interindividual variability. Thus omeprazole may improve the validity of gastric tonometry data.

Gastrointestinal tract resuscitation in critically ill patients

Particular research interest is currently focusing on the resuscitation of the gastrointestinal tract, because the gut is regarded to be both the "canary of the body", i.e. a sentinel organ during situations of compromised oxygen or substrate supply, as well as the "motor of multiple organ failure". Several therapeutic strategies have recently been proposed for the resuscitation of this organ system, aimed primarily at the augmentation of blood flow and oxygenation but also integrating nutritional or metabolic support and antioxidant administration.