[Explosives-based vole traps-A novel injury pattern in the eye region]

BACKGROUND

A novel method for trapping voles is the use of pistol-like explosive tools loaded with bolt-action ammunition. When triggered the vole is killed by the very high gas pressure created. Accidental releases can result in facial and/or eye injuries. The aim of this work was to describe the injury pattern in the patient and to experimentally verify whether there is a risk of penetrating eye injuries.

METHODS

Two emergency patients presented to our eye clinic with eye injuries after unintentional triggering of the explosive trap. Based on the new pattern of injury noted, experiments were performed on enucleated porcine eyes to determine the possible severity. For this purpose, a vole trap was clamped in a holder and loaded with a Cal. 9 × 17 mm cartridge in each case. In front of the muzzle opening, 3 pig eyes each were fixed on Styrofoam at a distance of 20, 40, 60 and 80 cm. The foreign body indentations in the cornea were visualized and measured by spectral domain optical coherence tomography (SD-OCT). The pig eyes were then dissected and searched for foreign bodies using microscopy. The SD-OCT images of an injured patient were also included for human comparison.

RESULTS

On patient examination, in addition to the usual fine gunshot marks on the face and conjunctiva/eye area, wax-like, larger and heavier particles of approximately 0.1-0.2 mm in size were found, which originated from the cartridge end cap. Removal of these foreign bodies, some of which were injected more deeply into the cornea, conjunctiva, and tenon, is much more difficult and extensive than in usual blast trauma. There was no evidence of intraocular foreign bodies in either patient. Likewise, no intraocular foreign bodies could be detected experimentally in any pig eyeball (n = 12). Remnants of the wax-like cartridge end were found deeply penetrating into the corneal stroma. The maximum penetration depth measured against the total corneal thickness was 46% at 20 cm device distance and decreased with greater distance to the vole trap (penetration depth at 40 cm at 37%, at 60 cm at 28% and at 80 cm at 19%). For comparisons on the human eye, a penetration depth of 54% was measured at a distance of about 40 cm. In pig eyes the number of foreign bodies per cm2 decreased with increasing distance from the vole trap (mean: n = 174 foreign bodies, FB, at 20 cm distance, n = 46 FB at 40 cm, n = 23 FB at 60 cm, and n = 9 FB at 80 cm). The largest penetrating foreign bodies measured a mean of 383 ± 43 μm with a maximum of 451 μm.

CONCLUSION

New vole traps with gas-powered mechanisms result in larger deeply penetrating wax-like foreign bodies in the cornea, conjunctiva, and tenon of the eye, which are difficult to remove and only surgically possible. Despite the significant explosion during triggering, there was no evidence of penetrating ocular injury from the foreign bodies either in the patient or experimentally in the pig eyes. Safety goggles should be worn when handling the traps to avoid penetration of foreign bodies into the eye.

[Economics of operating room use at a university eye hospital]

BACKGROUND

In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of a university eye hospital.

MATERIAL AND METHOD

The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on a theoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated.

RESULTS

With a total of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4 additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8 days, would result in an additional revenue of about 2.4 times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit margin II: 701,389 €) for the considered surgical patient collective in 2021.

CONCLUSION

An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for a large hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.

[The most serious incident-Experiences of aggression and violence in ophthalmology]

BACKGROUND

Experiences of aggression/violence influence job satisfaction and can have a long-term psychological and physical impact on employees. In the fall of 2018, the Professional Association of Ophthalmologists (BVA) and the German Ophthalmological Society (DOG) conducted a survey on experiences of aggression and violence. The first results were published in 2020. In the survey it was also possible to describe the most serious incident to date using free text fields, among others.

METHOD

All 9411 members of the DOG and BVA were given the opportunity to complete a questionnaire online in 2018 regarding aggression and violence in ophthalmology.

RESULTS

Overall, 253 of 1508 (16.8%) ophthalmologists participating in the survey reported their most serious incident, 46.8% of which were classified as moderate and 34.3% were related to verbal violence such as insults and threats. The most serious incident was experienced by 171 (67.6%) physicians in a practice setting, 71% were specialists at the time of the incident and 74.3% of the incidents occurred during regular working hours. The main causes were intercultural conflicts, long waiting times, problems with the allocation of appointments, excessive expectations, differences in treatment and basic aggressiveness. The offenders were male in 86.3% of cases, 15.8% of the incidents were reported to the police and 21 (8.3%) physicians issued a practice reprimand or house ban.

DISCUSSION

The description of the most serious incidents illustrates situations that are sometimes hard to imagine and also which incidents were considered serious. There are large subjective variations in the assessment of the incidents. Protective measures in practices and clinics are essential.

[Performance and cost calculation for a university ophthalmological outpatient clinic]

BACKGROUND

Outpatient procedures at a university hospital are generally considered to be unprofitable. In the present publication we evaluate the turnover and costs of the university eye outpatient department of the Hannover Medical School (MHH) in terms of a cost unit accounting as well as providing a summary of the workload.

MATERIAL AND METHOD

Given the data of the hospital information system (IS-H/i.s.h.med from SAP) and a proprietary software (TimeElement), all patient contacts in the year 2019 were evaluated. The latter software is applied in a standardized manner to record the patient flow of our outpatient service in real time electronically. The total costs consist of personnel, material and room costs including infrastructure of the MHH and are compared to the flat-rate revenues according to the university outpatient contract (HSA) as well as further revenues from internal referral services, self-pay patients, outpatient surgery and cooperation contracts for intravitreal injections (IVOM).

RESULTS

With an average full-time equivalent (FTE) headcount of 10.63 assistant physicians, 3.6 specialist physicians, and 21 nonphysicians (plus 4 Federal Volunteer Service, BUFDI) in our policlinic, we have determined € 2,927,022 in personnel costs, including overheads, for the entire year. Including infrastructure (€ 524,942), material and equipment costs with overheads and internal cost allocation of € 258.657, the total costs in 2019 resulted in € 3,710,621. In contrast, the total income in 2019 was € 3,524,737 generated through the abovementioned patient segments, resulting in a deficit of € -185,884 (5%). Our data provide evidence that regular outpatient revenues are insufficient and are mainly balanced by outpatient surgery, IVOMs and self-pay patients. In total, there were 19,453 patient contacts during regular office hours (with 17,305 billable cases). At n = 9943, the majority of the contacts were HSA visits; however, only 82% of the cases could effectively be charged due to multiple visits per quarter. The median total patient attendance was 3.21 h (mean 3.38 h). On average, 78 patient contacts were counted per working day. The analysis with TimeElement unveiled a median of n = 2 physician contacts per patient (mean n = 1.91). The median duration per interaction with a physician was 17.98 min (mean 23.23 min). For diagnostics, we counted a median of n = 2 interactions per patient (mean n = 2.31), with an entire interaction lasting a median of 18.30 min (mean 22.60 min). In total n = 37,363 individual diagnostic procedures were recorded in 2019, with SD-OCT being the primary procedure at n = 10,888.

CONCLUSION

The cost/turnover calculation showed a marginal financial loss through our ophthalmological outpatient department. Thus, the costs of a university eye outpatient department in Lower Saxony do not seem to be sufficiently covered by direct outpatient revenues. Maintaining quarterly flat rates for all cases of the outpatient department would require a fee of about € 214 in our setting to remain cost neutral. Currently, the lower flat rates in the HSA area are compensated by other areas. Obviously, the high content-related workload in our setting requires a high personnel expenditure with a considerable personnel cost contribution of nearly 80%.

[Experiences of aggression and violence against ophthalmologists]

BACKGROUND

The media have reported an increased willingness of patients and relatives to use violence against medical personnel. So far a few studies have been carried out on this topic and the data situation is correspondingly weak. Ophthalmologists in particular have close contact with patients at the slit lamp and are often alone with patients.

METHODS

A questionnaire was developed based on the perception of prevalence of aggression scale (POPAS) questionnaire and the survey on aggression and violence among general practitioners. In autumn 2018, all members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists (BVA) received an invitation by e‑mail to complete the questionnaire online.

RESULTS

Of the 9411 ophthalmologists contacted a total of 1508 (age 49 ± 12 years) took part in the survey (16%). Of the respondents 806 (53.7%) were female and 1139 (75.5%) participants worked in practices. A total of 1264 (83.3%) ophthalmologists had experienced aggression/violence in their work, 986 (65%) respondents had already experienced verbal assaults without threats, 363 (24.1%) doctors reported experiences with threats of physical violence and 30 (2%) participants had received medical treatment for severe physical violence. Sexual intimidation/harassment was affirmed by 322 (21.4%) of respondents, of whom 243 (75.5%) were female and 533 (47.9%) doctors felt that aggressive/violent behavior had increased in the last 5 years.

CONCLUSION

The high number of participants indicates the high relevance of the topic. The survey produced astonishing results, which should lead to further discussion and action to improve the safety of employees.

Urinary miR-210 as a mediator of acute T-cell mediated rejection in renal allograft recipients

MicroRNAs (miRNAs) are small ribonucleotides regulating gene expression. Circulating miRNAs are remarkably stable in the blood. We tested whether miRNAs are also detectable in urine and may serve as new predictors of outcome in renal transplant patients with acute rejection. We profiled urinary miRNAs of stable transplant patients and transplant patients with acute rejection. The miR-10a, miR-10b and miR-210 were strongly deregulated in urine of the patients with acute rejection. We confirmed these data in urine of a validation cohort of 62 patients with acute rejection, 19 control transplant patients without rejection and 13 stable transplant patients with urinary tract infection by quantitative RT-PCR. The miR-10b and miR-210 were downregulated and miR-10a upregulated in patients with acute rejection compared to controls. Only miR-210 differed between patients with acute rejection when compared to stable transplant patients with urinary tract infection or transplant patients before/after rejection. Low miR-210 levels were associated with higher decline in GFR 1 year after transplantation. Selected miRNAs are strongly altered in urine of the patients with acute renal allograft rejection. The miR-210 levels identify patients with acute rejection and predict long-term kidney function. Urinary miR-210 may thus serve as a novel biomarker of acute kidney rejection.

Suppression of experimental autoimmune neuritis by ABR-215062 is associated with altered Th1/Th2 balance and inhibited migration of inflammatory cells into the peripheral nerve tissue

The therapeutic effects of ABR-215062, which is a new immunoregulator derived from Linomide, have been evaluated in experimental autoimmune neuritis (EAN), a CD4(+) T cell-mediated animal model of Guillain-Barré syndrome in man. In previous studies, we reported that Linomide suppressed the clinical EAN and myelin antigen-reactive T and B cell responses. Here EAN induced in Lewis rats by inoculation with peripheral nerve myelin P0 protein peptide 180-199 and Freund's complete adjuvant was strongly suppressed by ABR-215062 administered daily subcutaneously from the day of inoculation. ABR-215062 dose-dependently reduced the incidence of EAN, ameliorated clinical signs and inhibited P0 peptide 180-199-specific T cell responses as well as also the decreased inflammation and demyelination in the peripheral nerves. The suppression of clinical EAN was associated with inhibition of the inflammatory cytokines IFN-gamma and TNF-alpha, as well as the enhancement of anti-inflammatory cytokine IL-4 in lymph node cells and periphery nerve tissues, respectively, in a dose-dependent manner. These effects indicate that ABR-215062 may mediate its effects by regulation of Th1/Th2 cytokine balance and suggest that ABR-215062 is potentially a new chemical entity for effective treatment of autoimmune diseases.

Growth-associated protein GAP-43 in the frontal cortex and in the hippocampus in Alzheimer's disease: an immunohistochemical and quantitative study

We studied the growth-associated protein, GAP-43 (also called neuromodulin and B-50) in post-mortem brain tissue using immunohistochemistry and quantitative Western blotting, from patients with Alzheimer's disease (AD) and age-matched control subjects. By immunohistochemistry, we found a clear reduction of GAP-43 in the frontal cortex, while in the hippocampus, there was a marked reduction in some areas (dentate molecular layer, stratum moleculare and radiale of CA1 and CA4), while not in other areas (stratum lacunosum, pyramidale and oriens of CA1). Moreover, in the hippocampus, neuritic staining was prominent, and was often associated with senile plaques. Quantitative analysis showed that GAP-43 was significantly reduced in AD, both in the frontal cortex (70% of the control value, p < 0.01) and in the hippocampus (81% of the control value, p < 0.05). In the frontal cortex, there was a significant negative correlation between GAP-43 and duration of dementia (r = -0.58; p < 0.02) and a positive correlation between GAP-43 and the synaptic vesicle-specific protein rab3a (r = 0.62; p < 0.05), while no such correlation were found in the hippocampus. In contrast, a significant positive correlation was found between GAP-43 and the number of senile plaques in the hippocampus (r = 0.64; p < 0.05), but not in the frontal cortex. GAP-43 is known to be involved in maintenance of synapses and in neuritic regeneration. Our findings may suggest that in the frontal cortex, GAP-43 levels decline as a consequence of the synaptic degeneration, while in the hippocampus, sprouting processes, involving GAP-43, are active.

Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) blockade enhances incidence and severity of experimental autoimmune neuritis in resistant mice

Experimental autoimmune neuritis (EAN), an autoimmune inflammatory demyelinating disease of the peripheral nervous system, represents an animal model of the human Guillain-Barré syndrome. EAN can be induced by active immunization in several animals, including Lewis rats. In contrast, most strains of mice including the widely used C57BL/6 (B6) strain are reputedly resistant to the induction of EAN. In the present study, we demonstrate that in B6 mice, anti-CTLA-4 monoclonal antibody administration in conjunction with immunization with the P0 protein derived peptide 180-199 can induce clinical and pathological definite EAN. Upregulating effects of CTLA-4 blockade on initial and ongoing EAN are demonstrated. CTLA-4 blockade augmented cellular infiltration and enhanced demyelination in the target organ sciatic nerves as well as increased T cell proliferation in lymph node cells. Moreover, serum levels of IFN-gamma and IL-4 were increased. Thus, manipulation of CTLA-4/B7 costimulatory pathway by CTLA-4 blockade can promote autoreactivity and break the relative tolerance to peripheral autoantigen P0 in resistant B6 mice.

Density profiles of Alzheimer disease regional brain pathology for the huddinge brain bank: pattern recognition emulates and expands upon Braak staging

Density profiles of Alzheimer's disease (AD) regional brain pathology were constructed for 249 subjects in the Huddinge Brain Bank. Counts per square millimeter for neurofibrillary tangles (NFT), diffuse plaques (DP), and neuritic plaques (NP) in 38 areas were investigated using a pattern recognition technique called GoM. The seven distributional profiles of AD neuropathology emulated and expanded upon Braak staging illustrating induction (Groups 1-3) and clinical progression (Groups 4-7). Normal aging represented limited AD changes, few NFT in the entorhinal cortex and hippocampal CA1 (Group 1). The threshold for possible AD was NFT in the subiculum (Group 2), found with DP in the neocortex. Temporal medial NFT was the threshold for probable AD (Group 4). The 'oldest-old', often demented without brain atrophy, had extensive entorhinal/CA1 NFT and cortical DP, but few cortical NFT or NP (Group 5). A second subtype 'disconnection' (Group 6) lacked AD pathology for a specific set of subcortical and cortical areas. Accumulation of NFT in first-affected areas continued through end-stage disease (Group 7), with apparent rapid transition of DP to NP in the cortex during clinical progression. The evolution of AD is a highly ordered sequential process. Pattern recognition approaches such as GoM may be useful in better defining the process.