[Safety of patient care on an interprofessional training ward in visceral surgery]

BACKGROUND

Interprofessional training wards (ITW) are increasingly being integrated into teaching and training concepts in visceral surgery clinics.

OBJECTIVE

How safe is patient care on an ITW in visceral surgery?

MATERIAL AND METHODS

Data collection took place from November 2021 to December 2022. In this nonrandomized prospective evaluation study the frequency and severity of adverse events (AE) in 3 groups of 100 patients each in a tertiary referral center hospital for visceral surgery were investigated. The groups consisted of patients on the ITW and on the conventional ward before and after implementation of the ITW. The Global Trigger Tool (GTT) was used to search for AE. Simultaneously, a survey of the treatment was conducted according to the Picker method to measure patient reported outcome.

RESULTS

Baseline characteristics and clinical outcome parameters of the patients in the three groups were comparable. The GTT analysis found 74 nonpreventable and 5 preventable AE in 63 (21%) of the patients and 12 AE occurred before the hospital stay. During the hospital stay 50 AE occurred in the operating theater and 17 on the conventional ward. None of the five preventable AE (in 1.7% of the patients) was caused by the treatment on the ITW. Patients rated the safety on the ITW better than in 90% of the hospitals included in the Picker benchmark cohort and as good as on the normal ward.

CONCLUSION

The GTT-based data as well as from the patients' point of view show that patient care on a carefully implemented ITW in visceral surgery is safe.

[Teaching patient safety during undergraduate medical studies]

BACKGROUND

In the professional public there is agreement that healthcare professionals worldwide should already be prepared for safety in patient care during their education.

OBJECTIVE

How can the topic of patient safety be successfully integrated into the curricula of healthcare professions?

MATERIAL AND METHODS

Overview of the Marburg curriculum on patient safety during the practical year as well as of other approaches to teaching patient safety described in the literature.

RESULTS

In recent years teaching initiatives on patient safety have significantly increased; however, they are still not comprehensively distributed in German-speaking countries or throughout Europe. In the context of implementation, the multiprofessional edition of the World Health Organization (WHO) patient safety curriculum guide may be used as guideline. A current, very promising development in connection with acquiring and examining the competences that are necessary for safe patient care is the establishment of interprofessional training wards.

CONCLUSION

In the meantime, there are clearly defined strategies for the integration of the topic of patient safety into the curricula of healthcare professionals. On the way towards a successful restructuring of the curricula including the necessary competences and behavioral changes of the students, however, relevant support by the management of faculties and teaching hospitals is essential.

Abstract P236: Sodium Accumulates in the Skin of Patients and Mice With Psoriasis

Sodium can be buffered in the skin, which mechanism is altered during aging and in certain diseases such as hypertension. High salt environment can promote autoimmunity by expanding pathogenic IL-17 producing T helper (Th17) cells. Psoriasis is a relapsing and remitting inflammatory autoimmune disease affecting the skin and joints and involves proinflammatory Th17 cells. Here we tested the hypothesis if psoriatic skin has a higher sodium content in mice and humans. We used two psoriasis mouse models; the K14-IL-17A ind/+ mice overexpressing IL-17A in K14-positive keratinocytes and the imiquimod (IMQ) mouse model by applying 62.5 mg IMQ cream (5%) on the shaved back and ears of FVB/N mice for 5 days daily. End of the study skins of mice were collected, weighted, dried and ashed to measure water and sodium content. Additionally, skin sodium and water content were measured in psoriasis patients and aged matched healthy controls by non-invasive 23 Na-MRI on non-affected flexor site of the lower leg and by 23 Na-spectroscopy to compare affected and non-affected sites of the leg. K14-IL-17A ind/+ mice had significantly higher sodium content compared to control IL-17A ind/+ mice (0.191±0.021 vs. 0.137±0.023 mg/g dry weight) together with an elevated water content. IMQ-treated back skin had significantly higher sodium content compared to untreated ventral skin of the same mice (0.175±0.023 vs. 0.143±0.014 mg/g dry weight), whereas sham mice had a significantly lower content in both regions (0.116±0.010 vs. 0.107±0.005 mg/g dry weight). IMQ treatment led to significant expansion of IL-17 producing γδT cells in the skin, regional lymph nodes and in the spleen with typical skin lesions. Patients with psoriasis area and severity index (PASI) >5 had significantly higher sodium content in the skin compared to those with lower PASI or with healthy controls (17.73±1.52 vs. 14.32±1.54 vs. 14.30±2.59 AU, respectively); this elevation was water coupled. PASI significantly correlated with skin sodium content (Pearson’s r=0.598, P<0.001). Additionally, patients with PASI>5 has higher sodium content in the affected skin compared to non-affected skin of the same patient. Data from animal models and humans argue for higher sodium accumulation in the inflamed skin.

Defining the optimal animal model for translational research using gene set enrichment analysis

The mouse is the main model organism used to study the functions of human genes because most biological processes in the mouse are highly conserved in humans. Recent reports that compared identical transcriptomic datasets of human inflammatory diseases with datasets from mouse models using traditional gene‐to‐gene comparison techniques resulted in contradictory conclusions regarding the relevance of animal models for translational research. To reduce susceptibility to biased interpretation, all genes of interest for the biological question under investigation should be considered. Thus, standardized approaches for systematic data analysis are needed. We analyzed the same datasets using gene set enrichment analysis focusing on pathways assigned to inflammatory processes in either humans or mice. The analyses revealed a moderate overlap between all human and mouse datasets, with average positive and negative predictive values of 48 and 57% significant correlations. Subgroups of the septic mouse models (i.e., Staphylococcus aureus injection) correlated very well with most human studies. These findings support the applicability of targeted strategies to identify the optimal animal model and protocol to improve the success of translational research.

Impairment of immunoproteasome function by β5i/LMP7 subunit deficiency results in severe enterovirus myocarditis

Proteasomes recognize and degrade poly-ubiquitinylated proteins. In infectious disease, cells activated by interferons (IFNs) express three unique catalytic subunits β1i/LMP2, β2i/MECL-1 and β5i/LMP7 forming an alternative proteasome isoform, the immunoproteasome (IP). The in vivo function of IPs in pathogen-induced inflammation is still a matter of controversy. IPs were mainly associated with MHC class I antigen processing. However, recent findings pointed to a more general function of IPs in response to cytokine stress. Here, we report on the role of IPs in acute coxsackievirus B3 (CVB3) myocarditis reflecting one of the most common viral disease entities among young people. Despite identical viral load in both control and IP-deficient mice, IP-deficiency was associated with severe acute heart muscle injury reflected by large foci of inflammatory lesions and severe myocardial tissue damage. Exacerbation of acute heart muscle injury in this host was ascribed to disequilibrium in protein homeostasis in viral heart disease as indicated by the detection of increased proteotoxic stress in cytokine-challenged cardiomyocytes and inflammatory cells from IP-deficient mice. In fact, due to IP-dependent removal of poly-ubiquitinylated protein aggregates in the injured myocardium IPs protected CVB3-challenged mice from oxidant-protein damage. Impaired NFκB activation in IP-deficient cardiomyocytes and inflammatory cells and proteotoxic stress in combination with severe inflammation in CVB3-challenged hearts from IP-deficient mice potentiated apoptotic cell death in this host, thus exacerbating acute tissue damage. Adoptive T cell transfer studies in IP-deficient mice are in agreement with data pointing towards an effective CD8 T cell immune. This study therefore demonstrates that IP formation primarily protects the target organ of CVB3 infection from excessive inflammatory tissue damage in a virus-induced proinflammatory cytokine milieu.

Differential interferon responses enhance viral epitope generation by myocardial immunoproteasomes in murine enterovirus myocarditis

Murine models of coxsackievirus B3 (CVB3)-induced myocarditis mimic the divergent human disease course of cardiotropic viral infection, with host-specific outcomes ranging from complete recovery in resistant mice to chronic disease in susceptible hosts. To identify susceptibility factors that modulate the course of viral myocarditis, we show that type-I interferon (IFN) responses are considerably impaired in acute CVB3-induced myocarditis in susceptible mice, which have been linked to immunoproteasome (IP) formation. Here we report that in concurrence with distinctive type-I IFN kinetics, myocardial IP formation peaked early after infection in resistant mice and was postponed with maximum IP expression concomitant to massive inflammation and predominant type-II IFN responses in susceptible mice. IP activity is linked to a strong enhancement of antigenic viral peptide presentation. To investigate the impact of myocardial IPs in CVB3-induced myocarditis, we identified two novel CVB3 T cell epitopes, virus capsid protein 2 [285-293] and polymerase 3D [2170-2177]. Analysis of myocardial IPs in CVB3-induced myocarditis revealed that myocardial IP expression resulted in efficient epitope generation. As opposed to the susceptible host, myocardial IP expression at early stages of disease corresponded to enhanced CVB3 epitope generation in the hearts of resistant mice. We propose that this process may precondition the infected heart for adaptive immune responses. In conclusion, type-I IFN-induced myocardial IP activity at early stages coincides with less severe disease manifestation in CVB3-induced myocarditis.

Improving pathway compliance and clinician performance by using information technology

To deliver patient-specific advice at the time and place of a consultation is an important contribution to improving clinician performance. Using computer-based decision support on the basis of clinical pathways is a promising strategy to achieve this goal. Thereby integration of IT applications into the clinical workflow is a core precondition for success. User acceptance and usability play a critical role: additional effort has to be balanced with enough benefit for the users and interaction design and evaluation should be handled as an intertwined, continuous process. Experiences from routine use of an online surgical pathway at Marburg University Medical Center show that it is possible to successfully address this issue by seamlessly integrating patient-specific pathway recommendations with documentation tasks which have to be done anyway, by substantially reusing entered data to accelerate routine tasks (e.g. by automatically generating orders and reports), and by continuously and systematically monitoring pathway conformance and documentation quality.

Improving pathway compliance and clinician performance by using information technology

To deliver patient-specific advice at the time and place of a consultation, to improve clinician performance and compliance by using computer-based decision support, and to integrate such IT solutions with the clinical workflow are important strategies for the implementation of clinical pathways. User acceptance plays a critical role: additional effort has to be balanced with enough benefit for the users. Experiences from routine use of an online surgical pathway at Marburg University Medical Center show that it is possible to successfully address this issue by seamlessly integrating patient-specific pat documentation tasks which have to be done anyway and by substantially reusing entered data to accelerate routine tasks (e.g. by automatically generating orders and reports).

[Selection of a hospital information system--experiences and critical aspects]

Due to typical problems (heterogeneity, lack of clinical functionality, Y2K problems) the board of directors of the university hospital of Marburg decided in 1997 to replace major components of the existing system by commercially available software. The products available on the market were analyzed, and, under participation of different user groups, a comprehensive functional specification was generated. This was the basis for a Europe-wide vendor selection process. In this context, several key aspects were identified, which are critically important for realizing a HIS that fulfills the specified functional requirements. Among these key aspects are the integration of heterogeneous system components, the support of cross-departmental workflow, and flexibility as well as adaptability to specific clinical requirements. As a result, we found that with today's commercially available products and standards there is no single solution that fully meets all requirements. However, some "generalist" vendors are offering integrated systems with acceptable clinical functionality. Tools are emerging which enable the clinical user to generate forms for data input and data flow. Still, a hospital information system will consist of separate components that have to be integrated, but the role of integrated, component-based approaches is becoming more important.

[Overview, analysis and evaluation of the 1995 public health structural law and the federal social care law from the viewpoint of the trauma surgery department of a university clinic. Measures for preparation of a new reimbursement system and documentation requirements]

All doctors in Germany are required to cooperate in the implementation of the health system reform and the new system for reimbursement of the hospitals to limit the negative consequences to the patients. It would be absolutely wrong to leave the medical services of the insurance companies to define the diagnosis-related groups and determine the charges. The revision of the health system is beneficial in that it supports the economical independence of hospital departments. It is a good idea for them to be paid by results; however, there are no established methods of measuring results or efficacy in medicine. Germany is about 10 years behind the USA in this, so that our country is not yet ready for this reform. Hospital departments do have the freedom to make economic decisions, being heavily dependent on the insurances and the government, because most people who work in hospital are paid from these sources. Departments of trauma or orthopaedic surgery are disadvantaged by the reform, because of the number and kind of diagnosis related groups and the method of reimbursement. This leads to a profit-oriented system of medical documentation, with possible upcoding of diagnoses in future. The present health reform most probably will not increase the efficiency of hospitals; it will not be possible to attain cost reductions with the same level of medical care. The reduced reimbursement will force doctors to cut down their expenses and restrict diagnostic and therapeutic procedures. On the other hand the administration sector in hospitals and insurances will expand dramatically in future.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical wound infections documented after hospital discharge

Shorter lengths of hospitalization may result in more surgical wound infections being documented after hospital discharge. The current investigation analyzed 1644 surgical procedures performed over a 3-month period, and documented surgical wound infections both before and for 1 month after hospital discharge. Physician and patient questionnaires were used. One hundred eight infections were noted, of which 50 (46%) were seen after hospital discharge by either the patient or the surgeon. Rates of infection were 5.2%, 7.5%, and 7.5% for clean, clean-contaminated, and contaminated-dirty categories, respectively. Had postdischarge surveillance not been used, rates would have appeared to be 2.5%, 6.5%, and 6.8% for the same surgical classes. Infections following clean and clean-contaminated procedures were more likely to be noticed after hospital discharge. Excluding those that were patient-documented, wound infection rates would have been 4.2% (clean), 6.3% (clean-contaminated) and 6.8% (contaminated-dirty). Postdischarge surveillance is imperative to meaningfully document true rates of surgical wound infection, inasmuch as increasing numbers are likely to occur only after patients leave the hospital.

[Malignant fibrous histiocytoma of the mandible in a 1 6/12-year-old boy]

A report on malignant fibrous histiocytoma of the mandible in a 1 6/12-year-old boy, a condition rarely seen in children. Because of inoperability radiotherapy was used resulting in complete tumour remission. The clinical course was complicated by a tracheo-oesophageal fistula and aspiration pneumonia. The spontaneous closure of the fistula occurred 5 months after tracheostomy and catheter jejunostomy. After 2 10/12 years there is no evidence of tumour disease. Possibilities and problems of therapy are discussed.

A comparison of infections in different ICUs within the same hospital

Infections identified between 1981 and 1983 in a hospital's medical/surgical, pediatric, neonatal, coronary care, and cardiac surgery ICUs were compared. Among 14,360 admissions, 1840 infections occurred in 1360 patients. Total infection rates ranged from 1.0% (cardiac surgery ICU) to 23.5% (medical/surgical ICU). Rates of ICU-acquired infection ranged from 0.8% (cardiac surgery ICU) to 11.2% (medical/surgical ICU), indicating that only about half of infections in the latter unit were acquired from within. Primary bacteremias comprised 14.5% of neonatal ICU infections, a rate 500% higher than in other ICUs. Meningitis and genitourinary infections were more common in pediatric and coronary care ICUs. Candida and Pseudomonas species and Klebsiella-Enterobacter-Serratia were most common in the medical/surgical ICU. Survival rate of infected patients was over 87% in pediatric and neonatal ICUs, compared with only 55.4% in the medical/surgical ICU. These differences in types and rates of infection have an important bearing on infection-control activities in the ICU, and also provide a yardstick against which similar institutions can gauge their ICU infection status.

Comparative parental MMPI protocols of children evaluated at a child development clinic

All parents completed an MMPI upon evaluation of their child at a clinic before diagnosis. For this study, 144 pairs of parents were selected to reflect the sex ratio of the clinic population. This sample was divided into three groups according to the diagnostic classification of the child: (1) minimal cerebral dysfunction, (2) behavior disorder, and (3) normal child. Separate multivariate analyses, computed for the groups by comparing the mean MMPI scores on the validity scales and the clinical scales for fathers and mothers, showed no significant differences in MMPIs of fathers on the validity scales. Also, no difference appeared on the three sex-determined analyses of the clinical scales. However, significant differences were found when scores for both the mothers and combined fathers and mothers were analyzed across the validity scales. The mothers of children with behavior disorders produced lower K scores (test-taking attitude). It was concluded that, while these parents could not be differentiated on the basis of clinical scales of the MMPI, they could be on the test-taking attitude of the mothers of those children evidencing behavior disorders.

Unusual palm creases and unusual children. The Sydney line and "type C" palmar lines and their clinical significance in a child development clinic

Inspection of palm creases should be a routine part of the pediatric physical examination. Any variation in the basic configuration should be cause for concern, irrespective of the age of the child. Is the "nor mal" child with an SPC, SL, or other type C palm really normal? Will time or psychologic evaluation uncover an unsuspected abnormality? An otherwise normal infant with palmar crease abnormalities should be considered at risk of developmental problems appearing later.