Critical incident reporting over time: a retrospective, descriptive analysis of 5493 cases

PURPOSE

As recommended by the WHO and many national healthcare authorities, health care institutions of most industrialised countries have employed a critical incident reporting system (CIRS). However, little is known about differences in critical incidents across clinical specialties, the use of CIRSs amongst different professional groups, the types, severity and risk of reoccurrence of critical incidents, their contributing factors and the preventive actions taken in response.

METHODS

In this retrospective, descriptive study we critically reviewed all reports filed in the CIRS of our institution between 2013 and 2019 and analysed characteristics over time.

RESULTS

Of the 5493 analysed incidents, the main types were related to medications (32.8%), clinical procedures (32.6%) or behaviour of employees (23.3%). Only 21.6% of reports were made by physicians, 51.3% were rated at least "high risk". Major contributing factors were personal factors (44.0%), lack of training and knowledge (43.7%) and communication errors (36.1%). Most actions taken to prevent similar events aimed at improving communications (23.6%); in 46.3% no actions whatsoever were taken. Longitudinal analysis revealed that reporting increased in internal medicine and obstetrics but collapsed in laboratory medicine / microbiology. Steady increases in medication-type incidents as well as lack of training and knowledge as contributing factors were observed.

CONCLUSION

This study revealed that the efferent loop (feedback, preventive actions taken) was the weakest part of the CIRS in our institution, indicating that no learning may have resulted from a large number of reports. In particular, the actions taken appeared to not adequately address the major contributing factors. This highlights that special attention must be paid to the efferent loop of a CIRS to fulfil the purpose of such a reporting system and ultimately to improve patient safety.

Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®

Background

Major trauma often comprises fractures of the thoracolumbar spine and these are often accompanied by relevant thoracic trauma. Major complications can be ascribed to substantial simultaneous trauma to the chest and concomitant immobilization due to spinal instability, pain or neurological dysfunction, impairing the respiratory system individually and together. Thus, we proposed that an early stabilization of thoracolumbar spine fractures will result in significant benefits regarding respiratory organ function, multiple organ failure and length of ICU / hospital stay.

Methods

Patients documented in the TraumaRegister DGU®, aged ≥16 years, ISS ≥ 16, AIS_Thorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AIS_Spine) ≥ 3 were analyzed. Penetrating injuries and severe injuries to head, abdomen or extremities (AIS ≥ 3) led to patient exclusion. Groups with fractures of the lumbar (LS) or thoracic spine (TS) were formed according to the severity of spinal trauma (AIS_spine): AIS_LS = 3, AIS_LS = 4–5, AIS_TS = 3 and AIS_TS = 4–5, respectively.

Results

1740 patients remained for analysis, with 1338 (76.9%) undergoing spinal surgery within their hospital stay. 976 (72.9%) had spine surgery within the first 72 h, 362 (27.1%) later on. Patients with injuries to the thoracic spine (AIS_TS = 3) or lumbar spine (AIS_LS = 3) significantly benefit from early surgical intervention concerning ventilation time (AIS_LS = 3 only), ARDS, multiple organ failure, sepsis rate (AIS_TS = 3 only), length of stay in the intensive care unit and length of hospital stay. In multiple injured patients with at least severe thoracic spine trauma (AIS_TS ≥ 4) early surgery showed a significantly shorter ventilation time, decreased sepsis rate as well as shorter time spend in the ICU and in hospital.

Conclusions

Multiply injured patients with at least serious thoracic trauma (AIS_Thorax ≥ 3) and accompanying spine trauma can significantly benefit from early spine stabilization within the first 72 h after hospital admission. Based on the presented data, primary spine surgery within 72 h for fracture stabilization in multiply injured patients with leading thoracic trauma, especially in patients suffering from fractures of the thoracic spine, seems to be beneficial.

Association of bacteria in pancreatic fistula fluid with complications after pancreatic surgery

Background

Pancreatic fistula (PF) is a common complication after pancreatic surgery. It is unclear how microbes in PF fluid affect outcomes and which microbes are present after pancreatoduodenectomy (PD) and distal pancreatectomy (DP). The aim of this study was to compare the microbiological spectrum of PF fluid after PD versus DP, and its association with postoperative complications.

Methods

Bacterial strains and antibiotic resistance rates of bacterial swabs obtained from the PF fluid of patients who underwent DP or PD were analysed. Cultured bacteria were classified as Enterobacterales and as ‘other intestinal and non‐intestinal microorganisms’ based on whether they are typically part of the normal human intestinal flora.

Results

A total of 847 patients had a pancreatic resection (PD 600; DP 247) between July 2007 and December 2016. Clinically relevant PF was detected in 131 patients (15·5 per cent). Bacterial swabs were obtained from 108 patients (DP 47; PD 61), of which 19 (17·6 per cent) were sterile. Enterobacterales were detected in 74 per cent of PF fluid swabs after PD, and in 34 per cent after DP. Infected, polymicrobial or multidrug‐resistant PF fluid was more common after PD (rates of 95, 50 and 48 per cent respectively) than after DP (66, 26 and 6 per cent respectively). Patients with higher grade complications (Clavien–Dindo grade IV–V) or grade C PF had more Enterobacterales and multidrug‐resistant Enterobacterales in the PF fluid after DP.

Conclusion

Enterobacterales and multidrug‐resistant bacteria are detected frequently after PD and DP, and are associated with more severe complications and PF in patients undergoing DP.

Spatial patterns of water quality impairments from point source nutrient loads in Germany's largest national River Basin (Weser River)

We employed the well-established Horton-Strahler, hierarchical, stream-order (ω) scheme to investigate scaling of nutrient loads (P and N) from ~845 wastewater treatment plants (WWTPs) distributed along the river network in urbanized Weser River, the largest national basin in Germany (~46K km²; ~8.4 million population). We estimated hydrologic and water quality impacts at the reach- and basin-scales, at two steady river discharge conditions (median flow, Q_R50; low-flow, Q_R90). Of the five WWTPs class-sizes (1 ≤ k ≤ 5), ~68% discharge to small low-order streams (ω < 3). We found large variations in capacity to dilute WWTP nutrient loads because of variability in (1) treated wastewater discharge (Q_U) within and among different class-sizes, and (2) river discharge (Q_R) within low-order streams (ω < 3) resulting from differences in drainage areas. For Q_R50, reach-scale water quality impairment assessed by nutrient concentration was likely at 136 (~16%) locations for P and 15 locations (~2%) for N. About 90% of these locations were lower-order streams (ω < 3). At Q_R50 and only with dilution, basin-scale cumulative nutrient loads from multiple upstream WWTPs increase impaired locations to 266 (~32% of total) for P. Considering in-stream uptake decreased P-impaired streams to 225 (~27%), suggesting the dominant role of dilution in the Weser River basin. Role of in-stream uptake diminished along the flow paths, while dilution in larger streams (4 ≤ ω ≤ 7) minimizes the impact of WWTP loads. Under Q_R90 conditions [(Q_R50/Q_R90) ~ 2.5], water quality impaired locations will likely double for the basin-scale analyses. Long-term water quality data suggested that diffuse sources are the primary contributors for water quality impairments in large streams. Our data-modeling synthesis approach is transferable to other urbanized river basins and extends understanding of point source impacts on water quality across spatial scales.

Improvement of Perioperative Outcomes in Major Gynecological and Gynecologic-Oncological Surgery with Hemostatic Gelatin-Thrombin Matrix

AIM

To assess the impact of the use of intraoperative hemostatic gelatin-thrombin matrix (HM) (Floseal®, Baxter Healthcare) on transfusion rates and short-term perioperative outcomes in gynecological surgery.

PATIENTS AND METHODS

In this retrospective, single-center study, we evaluated data of 215 patients (83 cases and 132 controls) undergoing extensive gynecological surgery (e.g. oncological procedures) with and without intraoperative HM application.

RESULTS

Cases and controls did not differ according to age, preoperative hemoglobin (Hb) concentration, and Hb or C-reactive protein (CRP) levels at discharge. Patients receiving HM had significantly reduced operative (168 vs. 199 min, p=0.02) and hospitalization (9 vs. 14 days, p<0.001) times. The mean postoperative Hb drop (3.33 vs. 4.51 g/dl, p<0.001), and the mean postoperative increase in CRP (94.9 vs. 149.1 mg/l, p<0.001) were significantly less pronounced within the HM group. Despite more prevalent coagulopathy (48 vs. 31%, p=0.02), e.g. due to anticoagulant use (15.7 vs. 3%, p<0.001), patients treated using HM needed less frequent transfusions of packed red blood cells [odds ratio (OR)= 0.13, 95% confidence interval (CI)=0.07-0.24) and fresh frozen plasma (OR=0.51, 95% CI=0.24-1.05). In comparison to controls, the need for surgical revisions (OR 0.1, CI 95% 0.02-0.42) and intensive-care unit admissions (OR 0.15, 95% CI=0.08-0.30) was lower in patients treated with HM.

CONCLUSION

To our knowledge, our study is the largest case-control study focusing on Floseal® use in gynecology. The use of HM was associated with significantly better short-term perioperative outcomes. Due to its local action, HM seems to be particularly useful in patients in which anticoagulant medication cannot be paused.

Effect of preoperative biliary drainage on bacterial flora in bile of patients with periampullary cancer

BACKGROUND

Patients with obstructive jaundice due to periampullary tumours may undergo preoperative biliary drainage (PBD). The effect of PBD on the microbiome of the biliary system and on postoperative outcome remains unclear.

METHODS

A single-centre retrospective study of patients with obstructive jaundice due to periampullary cancer, treated between July 2007 and July 2015, was undertaken. Intraoperative bile samples were obtained for microbiological analysis after transection of the common bile duct. Postoperative complications were registered.

RESULTS

Of 290 patients treated, intraoperative bile samples were present for 172 patients (59·3 per cent) who had PBD and 118 (40·7 per cent) who did not. Contamination of bile was increased significantly in patients who underwent stenting (97·1 per cent versus 18·6 per cent in those without stenting; P < 0·001). PBD resulted in a shift in the biliary microbiome from Escherichia coli in non-stented patients (45 per cent versus 19·2 per cent in stented patients; P = 0·009) towards increased contamination with Enterococcus faecalis (9 versus 37·7 per cent respectively; P = 0·008) and Enterobacter cloacae (0 versus 20·4 per cent; P = 0·033). This shift was associated with a high incidence of bacterial resistance against ampicillin-sulbactam (63·6 per cent versus 18 per cent in patients with no PBD; P < 0·001), piperacillin-tazobactam (30·1 versus 0 per cent respectively; P = 0·003), ciprofloxacin (28·5 versus 5 per cent; P = 0·047) and imipenem (26·6 versus 0 per cent; P = 0·011). The rate of wound infection was higher in patients with a positive bile culture (21·0 per cent versus 6 per cent in patients with sterile bile; P = 0·002). Regression analysis revealed the presence of Enterococcus faecium (odds ratio 2·83, 95 per cent c.i. 1·17 to 6·84; P = 0·021) and Citrobacter species (odds ratio 5·09, 1·65 to 15·71; P = 0·005) as independent risk factors for postoperative wound infection.

CONCLUSION

There are fundamental differences in the biliary microbiome of patients with periampullary cancer who undergo PBD and those who do not. PBD induces a shift of the biliary microbiome towards a more aggressive and resistant spectrum, which requires a differentiated perioperative antibiotic treatment strategy.

Et3GeH versus Et3SiH: controlling reaction pathways in catalytic C–F bond activations at a nanoscopic aluminum chlorofluoride

Catalytic C–F activations at Lewis-acidic amorphous aluminum chlorofluoride (ACF) with Et₃GeH and Et₃SiH for reaction pathway control are presented.

29Si{27Al} TRAPDOR MAS NMR to distinguish Qn(mAl) sites in aluminosilicates. Test case: Faujasite-type zeolites

²⁹Si{²⁷Al} TRAPDOR MAS NMR was applied to two faujasite-type zeolites with Si/Al ratios of 1.3 (Na-X) and 2.7 (Na-Y). The aim of this test study is to show that different Q⁴(mAl) sites (m =4, 3, 2, 1) can be distinguished by differently strong TRAPDOR effects (ΔS/S₀). Indeed, it was found that the TRAPDOR effect depends on the number m of AlO₄ units connected to the Q⁴ silicon tetrahedrons. For Na-X, the measured ΔS/S₀ values are 1 : 0.81 : 0.56 for Q⁴(4Al), Q⁴(3Al) and Q⁴(2Al), respectively (normalized to Q⁴(4Al)). The corresponding ΔS/S₀ values are the same for Na-Y within the error bars, although the silicon sites are different: Q⁴(3Al), Q⁴(2Al) and Q⁴(1Al) and now normalized to Q⁴(3Al) as no Q⁴(4Al) is present. Nevertheless, the proposed method opens up the possibility to distinguish overlapping ²⁹Si NMR signals of the Qⁿ(mAl) sites in amorphous materials as the main goal of these investigations.

Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care

Background

Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective.

Methods

We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively.

Results

We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs.

Conclusions

This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed.

Trial registration

Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0473-8) contains supplementary material, which is available to authorized users.

Effect of systemic transplantation of bone marrow-derived mesenchymal stem cells on neuropathology markers in APP/PS1 Alzheimer mice

AIMS

Mesenchymal stem cells (MSC) have recently attracted interest as a potential basis for a cell-based therapy of AD. We investigated the putative immune-modulatory effects in neuroinflammation of systemic transplantation of MSC into APP/PS1 transgenic mice.

METHODS

10⁶ MSC were injected into APP/PS1 mice via the tail vein and histological analysis was performed for microglia and amyloid (pE3-Aβ) plaque numbers, glial distribution and pE3-Aβ plaque size. In addition, a biochemical analysis by qPCR for pro-inflammatory, chemoattractant and neurotrophic factors was performed.

RESULTS

MSC are associated with pE3-Aβ plaques. The effects of transplantation on microglia-associated pathology could be observed after 28 days. Animals showed a reduction in microglial numbers in the cortex and in microglia size. Gene expression was reduced for TNF-α, IL-6, MCP-1, and for NGF, in MSC recipients. Also, we investigated for the first time and found no changes in expression of IL-10, CCR5, BDNF, VEGF and IFNγ. PTGER2 expression levels were increased in the hippocampus but were reduced in the cortex of MSC recipients. While there were no transplant-related changes in pE3-Aβ plaque numbers, a reduction in the size of pE3-Aβ plaques was observed in the hippocampus of transplant recipients.

CONCLUSION

This is the first study to show reduction in pE3-Aβ plaque size. pE3-Aβ plaques have gained attention as potential key participants in AD due to their increased aggregation propensity, the possibility for the initial seeding event, resistance against degradation and neurotoxicity. These findings support the hypothesis that MSC-transplants may affect AD pathology via an immune-modulatory function that includes an effect on microglial cells.

Hysteroscopic treatment of uterine tumor resembling ovarian sex cord-like tumor (UTROSCT)

The decision to preserve the uterus in a young nulliparous woman with an extremely rare tumor is challenging. Uterine tumor resembling ovarian sex cord-like tumor (UTROSCT) belongs to the rarest uterine pathologies. A 22-year-old nulligravida with uterine bleeding underwent a hysteroscopic resection of an intrauterine mass presumed as grade-1 submucous myoma. According to the presence of sex cord-like differentiation and positivity for calretinin, CD99, estrogen receptor, vimentin, WT1 and Melan-A, the tumor was diagnosed as UTROSCT. After 28 months, without any adjuvant therapy, the patient is still free of recurrence. This is the youngest patient with UTROSCT reported so far, with the longest follow-up among all five cases treated via hysteroscopy. Although UTROSCT has been traditionally treated with hysterectomy (with or without bilateral salpingo-oophorectomy), no established treatment protocol for UTROSCT exists. UTROSCT shows a low-malignant potential, but metastasizing and recurrent cases occur. In light of the probably less aggressive tumor biology and with respect to the patient's autonomy, a conservative, uterus preserving treatment appears to be justified in selected cases in which close follow-up can be guaranteed. Further case reports are needed to prove the safety of organ-preserving strategy in UTROSCT.

Hymenal anomalies in twins--review of the literature and case report

Subocclusive hymenal variants, such as microperforate or septate hymen, impair somatic functions (e.g., vaginal intercourse or menstrual hygiene) and can negatively impact the quality of life of young women. We know little about the prevalence and inheritance of subocclusive hymenal variants. So far, eight cases of familial occurrence of occlusive hymenal anomalies (imperforate hymen) have been reported. In one of these cases, monozygotic twins were affected. We are reporting the first case of subocclusive hymenal variants (microperforate hymen and septate hymen) in 16-year-old white dizygotic twins. In addition, we review and discuss the current evidence.

CONCLUSION

The mode of inheritance of hymenal variants has not been determined so far. Because surgical corrections of hymenal variants should be carried out in asymptomatic patients (before menarche), gynecologists and pediatricians should keep in mind that familial occurrences may occur.

Progress in Structural Elucidation of Glasses by and 1B Satellite Transition NMR Spectroscopy

The structure of Na2O-Al2O3-B2O3 and Na2O-Al2O3-P2O5 glasses with 70 mole% B2O3 or P2O5 and varied Na/Al ratio is investigated using standard 31P MAS NMR and 27Al and UB Satellite Transition NMR spectroscopy. The role of the two network formers on the glass structure is discussed. For the AlOx units and BO3 and BO4 groups both chemical shifts and quadrupole interaction parameters including their distribution widths are reported. Besides this, the advantages of Satellite Transition spectroscopy are demonstrated both for 27A1 and 11B NMR

2 D 31P Exchange NMR: A new Approach for a Direct Probing of the Connectivities of Qn Units in Glasses

Recently, 31P two-dimensional (2D) NMR has been proposed as a powerful tool for direct investigations of the connectivities between the Qn units in glasses, i.e. the medium-range order. In this paper, the principles of these experiments and applications to both polycrystalline Mg2P2O7 and a Na2O-P205 glass are demonstrated, including a theoretical description and modelling of the polarization transfer between the two inequivalent phosphorus sites in the magnesium pyrophosphate.

Anaplastic pelvic carcinoma secondary to low-grade endometrial carcinoma

BACKGROUND

Low-grade endometrial carcinoma has an excellent prognosis. The risk of secondary cancer after endometrial carcinoma is moderately increased and is mostly related to the field of postoperative radiation (small intestine, colon, vagina, and urinary bladder). Anaplastic (undifferentiated) pelvic carcinoma (APC) is rare and probably under-reported. To date, only one publication has reported six cases of APC that were secondary to low-grade endometrial carcinoma.

CASE REPORT

We have analyzed the fulminant course of APC-preceded by paraneoplastic arthritis-four months after hysterectomy and adnexectomy for low-grade endometrial carcinoma (endometrioid type, moderately differentiated, tumor diameter: 2 cm, infiltration depth 3 of 15 mm). The 73-year-old patient died five weeks after the diagnosis of the second malignancy.

CONCLUSION

The prognosis of APC is poor and the limitations of the therapy result from aggressive tumor biology and rapid deterioration of the patients' general condition. Rheumatological symptoms can precede cancer diagnosis. Immunohistochemistry facilitates the differentiation between primary and secondary carcinoma.

[Salter-Harris type IV epipyseal fracture of the lateral malleolus. A rare injury in childhood]

This is a case presentation of a 9-year-old boy who sustained a rare Salter-Harris type IV distal fibular fracture including an avulsion fracture of the anterior inferior tibiofibular ligament at the fibular attachment. Treatment consisted of open reduction and internal fixation by Kirschner wire and cerclage. Possible posttraumatic growth disturbances and the major implications are highlighted.

Papillary-serous adenocarcinoma of the uterine cervix during tamoxifen therapy after bilateral breast cancer

BACKGROUND

Papillary-serous adenocarcinoma (PSCC) is a very rare subtype of cervical cancer. To our knowledge, this is the first report on PSCC of the uterine cervix following bilateral breast cancer.

CASE REPORT

A 61-year-old Caucasian woman underwent conserving surgery of both breasts at the age of 57 years, because of bilateral invasive ductal carcinoma. Radiation and tamoxifen treatment followed. Routine surveillance examinations, including pelvic examination, Papanicolaou (Pap) smear, and transvaginal ultrasound, were uneventful. Recently, a small contact-bleeding mass of the cervix was found. The Pap smear was II (reactive); HPV-DNA test was negative. The biopsy of the mass revealed PSCC with a high expression of p53, carcinoembryonic antigen (CEA), and Ki67 (50%). Staining for estrogen receptor (ER), progesterone receptor (PR), and vimentin was negative. The serum carbohydrate antigen 125 (CA-125) reached 159 U/ml. The patient was treated with radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymphadenectomy. A poorly-differentiated papillary-serous, non-secretory adenocarcinoma, pT1b1, pN0 (0/44), pM0, G3, R0, V0, L0, was confirmed. According to the German recommendations for early-stage cervical cancer, the patient received no adjuvant treatment. Currently, the patient is free of relapse 38 months after the diagnosis of cervical cancer and 87 months after that of breast cancer.

CONCLUSION

Immunohistochemistry is helpful in diagnosing rare entities. This case adds further evidence that the prognosis for early-stage PSCC is probably not poorer than that for other cervical adenocarcinomas.

Neuroendocrine carcinoma of the breast--diagnostic and clinical implications

BACKGROUND

Neuroendocrine breast carcinomas (NEC) are rare. Carcinomas with mixed composition often behave differently from 'pure' histological types, and the prognosis is determined by the proportion of the more aggressive tumour. The molecular classification helps in making therapeutic decisions.

CASE REPORT

A 56-year-old Caucasian woman with palpable and preoperatively biopsied breast tumour was treated with breast-conserving surgery. The histological specimen revealed a 17-mm invasive carcinoma with an equal proportion of neuroendocrine and invasive-ductal differentiation, accompanied by peritumoural ductal carcinoma in situ. TNM classification was pT1c(is), pN0 (0/1sn), G3, L0, V0, Pn0, R0. The diagnosis was enhanced by immunohistochemistry: high positivity for synaptophysin, neuron-specific enolase (NSE), neural cell adhesion molecule (CD56), Ki-67 (proliferation index 46%), estrogen receptor (ER) and progesterone receptor (PR), negative for Her-2-neu and cytokeratin 5/6, resulting in diagnosis of the molecular 'luminal B' subtype. Radiation and adjuvant chemotherapy with six cycles of 5-fluorouracil, epirubicin and cyclophosphamide, followed by tamoxifen and subsequent exemestane for five years, were recommended.

CONCLUSION

Immunohistochemistry plays a crucial role in the diagnosis of rare cancer subtypes. NEC is characterized by high biological aggressiveness. Molecular classification facilitates therapeutic decisions.

Unique features of extracellular matrix in the mouse medial nucleus of trapezoid body--implications for physiological functions

The medial nucleus of the trapezoid body (MNTB) is a vital structure of sound localization circuits in the auditory brainstem. Each principal cell of MNTB is contacted by a very large presynaptic glutamatergic terminal, the calyx of Held. The MNTB principal cells themselves are surrounded by extracellular matrix components forming prominent perineuronal nets (PNs). Throughout the CNS, PNs, which form lattice-like structures around the somata and proximal dendrites, are associated with distinct types of neurons. PNs are highly enriched in hyaluronan and chondroitin sulfate proteoglycans therefore providing a charged surface structure surrounding the cell body and proximal neurites of these neurons. The localization and composition of PNs have lead investigators to a number of hypotheses about their functions including: creating a specific extracellular ionic milieu around these neurons, stabilizing synapses, and influencing the outgrowth of axons. However, presently the precise functions of PNs are still quite unclear primarily due to the lack of an ideal experimental model system that is highly enriched in PNs and in which the synaptic transmission properties can be precisely measured. The MNTB principal cells could offer such a model, since they have been extensively characterized electrophysiologically. However, extracellular matrix (ECM) in these neurons has not yet been precisely detailed. The present study gives a detailed examination of the ECM organization and structural differences in PNs of the mouse MNTB. The different PN components and their distribution pattern are scrutinized throughout the MNTB. The data are complemented by electron microscopic investigations of the unique ultrastructural localization of PN-components and their interrelation with distinct pre- and postsynaptic MNTB cell structures. Therefore, we believe this work identifies the MNTB as an ideal system for studying PN function.

Practice-based depression case management in primary care: a qualitative study on family doctors' perspectives

BACKGROUND

Case management provided by health care assistants (HCAs) is effective in improving primary care for depressive patients. Little is known on the implementation-related aspects of case management performed in small family practices.

OBJECTIVE

To explore family doctors' perspectives on clinical and organizational aspects of implementation of case management and perceived practice-related aspects associated with patient care after 1 year's experience of HCAs providing case management for depressive patients in their practices.

METHODS

This qualitative study was nested in a cluster-randomized trial on case management provided by practice-based HCAs for patients with major depression in Germany. We used semi-structured interview guides and performed audio-taped interviews with family doctors. Full transcription and thematic content analysis were carried out.

RESULTS

Twenty-three family doctors were interviewed. The family doctors perceived case management as beneficial to patients and reported that it improved their consultation styles and doctor-patient relationships. They implemented case management elements into their everyday day work using 'concrete', 'subsumed' or 'progressive' implementation styles.

CONCLUSIONS

Family doctors perceived practice-based case management by HCAs as beneficial for patient care. Different implementation styles may be appropriate, depending on the health care setting, and this requires further evaluation.

TAPP - Stuttgart technique and result of a large single center series

Laparoscopic hernioplasty is assessed as a difficult operation. Operative technique determines the frequency of complications, the time of recovery and the rate of recurrences. A proper technique is absolutely necessary to achieve results that are superior to open hernia surgery.

[Acute lower leg compartment syndrome]

OBJECTIVE

Decompression of all four muscle compartments of the lower leg to normalize tissue pressure and prevent permanent neuromuscular dysfunction.

INDICATIONS

Incipient compartment syndrome (characterized by excessive pain, muscle pain on extension, tensely swollen and shiny skin, and Δp>30 mmHg without neuromuscular deficit) and no clinical improvement after conservative treatment and/or acute compartment syndrome (symptoms as for incipient compartment syndrome with neuromuscular deficit and Δp<30 mmHg).

CONTRAINDICATIONS

None. There is some dispute about indications and timing of fasciotomy and necrectomy when the need for dermatofasciotomy is recognized late (e.g. intubated intensive care patients).

SURGICAL TECHNIQUE

In unilateral compartment release as described by Matsen, the lateral compartment is decompressed first through a parafibular approach. After identification of the anterior and superficial posterior compartments by transverse incision of the fasciae, these muscles are also decompressed longitudinally. Finally, the deep posterior compartment beneath the lateral compartment is decompressed. In bilateral dermatofasciotomy, the fasciae of the anterior and lateral compartments are incised through a proximal anterolateral approach and the superficial and deep posterior compartments through a distal dorsomedial approach.

POSTOPERATIVE MANAGEMENT

Synthetic skin substitute or vacuum-assisted wound closure until definitive closure by secondary suture or mesh grafting after about 5 days. Patient mobilization generally depends on the concomitant bone injury.

RESULTS

During the period from October 2001 to November 2008, 37 dermatofasciotomies were performed at our hospital to treat acute posttraumatic compartment syndrome. On the day of dismissal, symptoms of neuromuscular dysfunction after acute compartment syndrome had not disappeared completely in 5 patients. One patient received intermittent dialysis for acute kidney failure after crush syndrome. There were perioperative complications in a total of 6 patients: iatrogenic neurotomy (n=1), hematoma requiring revision (n=2), deep wound infection (n=2), and superficial disturbed wound healing (n=1).

Neurons associated with aggrecan-based perineuronal nets are protected against tau pathology in subcortical regions in Alzheimer's disease

The biological basis for the selective vulnerability of neurons in Alzheimer's disease (AD) is elusive. Aggrecan-based perineuronal nets (PNs) of the extracellular matrix have been considered to contribute to neuroprotection in the cerebral cortex. In the present study, we investigated the organization of the aggrecan-based extracellular matrix in subcortical regions known to be preferentially affected by tau pathology in AD. Immunocytochemistry of aggrecan core protein was combined with detection of neurofibrillary degeneration. The results show that many regions affected by tau pathology in AD, such as the basal nucleus of Meynert, the dorsal thalamus, hypothalamic nuclei, raphe nuclei, and the locus coeruleus were devoid of a characteristic aggrecan-based extracellular matrix. Regions composed of nuclei with clearly different intensity of tau pathology, such as the amygdala, the thalamus and the oculomotor complex, showed largely complementary distribution patterns of neurofibrillary tangles and PNs. Quantification in the rostral interstitial nucleus of the longitudinal fascicle potentially affected by tau pathology in AD revealed that tau pathology was not accompanied by loss of aggrecan-based PNs. Neuro-fibrillary tangles in net-associated neurons extremely rarely occurred in the pontine reticular formation. We conclude that the low vulnerability of neurons ensheathed by PNs previously described for cortical areas in AD represents a more general phenomenon that also applies to subcortical regions. The aggrecan-based extracellular matrix of PNs may thus, be involved in neuroprotection.

[Perspectives of improvement of quality in cardiac surgery]

From a care provider's view quality of care should, of course, be the major focus. But should results such as employer quality, quality of cooperation, and the economic outcome not be treated as equally important aims since they interact mutually? By analyzing impacts on the quality of care, we found direct factors like the quality of applied procedures or clinical pathways influenced by secondary factors like quality assurance and research, for instance. As expected, all of these factors are essentially involved by the human factor. In order to sustainably improve results in health care, the human factor requires a new attendance and should be addressed in dimensions of results that are as important as quality of care itself. Optimizing the human factor in health care is a prerequisite to sustainably improve quality and requires an advanced point of view on dimensions of results that mutually interact with the quality of care: Focus on the patient. In order to achieve this goal, we have to primarily focus on the organization hospital.

Phytomedicines prepared from Arnica flowers inhibit the transcription factors AP-1 and NF-kappaB and modulate the activity of MMP1 and MMP13 in human and bovine chondrocytes

Arnica preparations have long been used for the symptomatic treatment of rheumatic complaints and recent clinical trials have demonstrated the beneficial effects of Arnica preparations in the treatment of osteoarthritis (OA). The efficacy of Arnica is presumed to be mainly due to its anti-inflammatory properties and inhibition of the transcription factor NF-kappaB. Here we provide further insights into its molecular mode of action. Arnica preparations suppress MMP1 and MMP13 mRNA levels in bovine and human articular chondrocytes in a concentration-dependent manner and in a low concentration range. This suppression may be due to inhibition of DNA binding of the transcription factors AP-1 and NF-kappaB. Interestingly, sesquiterpene lactones present in the preparations were always more active than the pure compounds, demonstrating the advantage of using plant preparations.

COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer

INTRODUCTION

Laparoscopic resection of rectal cancer has been proven efficacious but morbidity and oncological outcome need to be investigated in a randomized clinical trial.

TRIAL DESIGN

Non-inferiority randomized clinical trial.

METHODS

The COLOR II trial is an ongoing international randomized clinical trial. Currently 27 hospitals from Europe, South Korea and Canada are including patients. The primary endpoint is loco-regional recurrence rate three years post-operatively. Secondary endpoints cover quality of life, overall and disease free survival, post-operative morbidity and health economy analysis.

RESULTS

By July 2008, 27 hospitals from the Netherlands, Belgium, Germany, Sweden, Spain, Denmark, South Korea and Canada had included 739 patients. The intra-operative conversion rate in the laparoscopic group was 17%. Distribution of age, location of the tumor and radiotherapy were equal in both treatment groups. Most tumors are located in the mid-rectum (41%).

CONCLUSION

Laparoscopic surgery in the treatment of rectal cancer is feasible. The results and safety of laparoscopic surgery in the treatment of rectal cancer remain unknown, but are subject of interim analysis within the COLOR II trial. Completion of inclusion is expected by the end of 2009.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT00297791 (www.clinicaltrials.gov).

GOLPH2 protein expression as a novel tissue biomarker for prostate cancer: implications for tissue-based diagnostics

GOLPH2 is coding the 73-kDa type II Golgi membrane antigen GOLPH2/GP73. Upregulation of GOLPH2 mRNA has been recently reported in expression array analyses of prostate cancer. As GOLPH2 protein expression in prostate tissues is currently unknown, this study aimed at a comprehensive analysis of GOLPH2 protein in benign and malignant prostate lesions. Immunohistochemically detected GOLPH2 protein expression was compared with the basal cell marker p63 and the prostate cancer marker alpha-methylacyl-CoA racemase (AMACR) in 614 radical prostatectomy specimens. GOLPH2 exhibited a perinuclear Golgi-type staining pattern and was preferentially seen in prostatic gland epithelia. Using a semiquantitative staining intensity score, GOLPH2 expression was significantly higher in prostate cancer glands compared with normal glands (P<0.001). GOLPH2 protein was upregulated in 567 of 614 tumours (92.3%) and AMACR in 583 of 614 tumours (95%) (correlation coefficient 0.113, P = 0.005). Importantly, GOLPH2 immunohistochemistry exhibited a lower level of intratumoral heterogeneity (25 vs 45%). Further, GOLPH2 upregulation was detected in 26 of 31 (84%) AMACR-negative prostate cancer cases. These data clearly suggest GOLPH2 as an additional ancillary positive marker for tissue-based diagnosis of prostate cancer.

Solid-state NMR spectroscopy using the lost I spin magnetization in polarization transfer experiments

A variation of the cross polarization (CP) experiment is discussed. The method requires two scans where the difference signal is equivalent to the I spin magnetization that is transferred to the S spins. The acquired signal is equivalent to F1 sum projection of a two-dimensional (2D) heteronuclear correlation experiment and is obtained by just two scans without the need to increment the indirect time domain t(1). Any polarization transfer method and any kind of spin manipulations during the t(1) incrementation period of a 2D NMR experiment can be applied. The method allows fast measurements of the CP transfer, particularly if various S spins signal overlap and is good for spectral editing of I spin signals with contact to S spins. Various examples for biomaterials are presented. Most importantly, this novel approach is ideal for detailed investigations of organic-mineral interfaces in bone, here demonstrated for O-phospho-l-serine as simple model compound.