Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system

OBJECTIVE

Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation.

METHODS

This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project.

RESULTS

A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor.

CONCLUSION

This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

Fluvial Depositional Systems of the African Humid Period: An Analog for an Early, Wet Mars in the Eastern Sahara

A widely hypothesized but complex transition from widespread fluvial activity to predominantly aeolian processes is inferred on Mars based on remote sensing data observations of ancient landforms. However, the lack of analysis of in situ martian fluvial deposits hinders our understanding of the flow regime nature and sustainability of the martian fluvial activity and the hunt for ancient life. Studying analogs from arid zones on Earth is fundamental to quantitatively understanding geomorphic processes and climate drivers that might have dominated during early Mars. Here we investigate the formation and preservation of fluvial depositional systems in the eastern Sahara, where the largest arid region on Earth hosts important repositories of past climatic changes. The fluvial systems are composed of well-preserved single-thread sinuous to branching ridges and fan-shaped deposits interpreted as deltas. The systems' configuration and sedimentary content suggest that ephemeral rivers carved these landforms by sequential intermittent episodes of erosion and deposition active for 10-100s years over ∼10,000 years during the late Quaternary. Subsequently, these landforms were sculpted by a marginal role of rainfall and aeolian processes with minimum erosion rates of 1.1 ± 0.2 mm/yr, supplying ∼96 ± 24 × 10¹⁰ m³ of disaggregated sediment to adjacent aeolian dunes. Our results imply that similar martian fluvial systems preserving single-thread, short distance source-to-sink courses may have formed due to transient drainage networks active over short durations. Altogether, this study adds to the growing recognition of the complexity of interpreting climate history from orbital images of landforms.

Effects of supplementing a CP-reduced diet with rumen-protected methionine on Fleckvieh bull fattening

The objective of this study was to evaluate the effect of supplementing a CP-reduced diet with rumen-protected methionine on growth performance of Fleckvieh bulls. A total of 69 bulls (367 ± 25 kg BW) were assigned to three feeding groups (n = 23 per group). The control (CON) diet contained 13.7% CP and 2.11 g methionine/kg diet (both DM basis) and was set as positive control. The diet reduced in CP (nitrogen) (RED) diet as negative control and the experimental RED + rumen-protected methionine (MET) diet were characterised by deficient CP concentrations (both 9.04% CP). The RED + MET diet differed from the RED diet in methionine concentration (2.54 g/kg DM vs. 1.56 g/kg DM, respectively) due to supplementation of rumen-protected methionine. Rumen-protected lysine was added to both RED and RED + MET at 2.7 g/kg DM to ensure a sufficient lysine supply relative to total and metabolisable protein intake. Metabolisable energy (ME) and nutrient composition were similar for CON, RED, and RED + MET. Bulls were fed for 105 days (d) on average. Individual feed intake was recorded daily; individual BW was recorded at the beginning of the experiment, once per month, and directly before slaughter. At slaughter, blood samples were collected and carcass traits were assessed. Reduction in dietary CP concentration reduced feed intake, and in combination with lower dietary CP concentration, daily intake of CP for RED and RED + MET was lower compared with CON (P < 0.01). Daily ME intake was reduced in RED and RED + MET compared with CON (P < 0.01). Consequently growth performance and carcass weights were reduced (both P < 0.01) in both RED and RED + MET compared with CON. Supplemental rumen-protected methionine was reflected in increased serum methionine concentration in RED + MET (P < 0.05) as compared to RED but it did not affect growth performance, carcass traits and serum amino acid (AA) concentrations, except for lysine which was reduced (P < 0.01) compared to CON and RED. In conclusion, bulls fed RED or RED + MET diets were exposed to a ruminal CP deficit and subsequently a deficit of prececal digestible protein, but methionine did not appear to be the first-limiting essential AA for growth under the respective experimental conditions.

[Delayed incision time of the first case : Analysis of incidences and causes and the effect of list planning instability]

BACKGROUND

Delays in beginning operations in the morning lead to a loss of valuable operating time and can cause frustration among the medical personnel involved.

OBJECTIVE

So far there are no prospective, multicentric investigations of the incidence and reasons for delayed first incision times in the morning. The effect of planning list instability of first cases on late operating room starts has not yet been evaluated.

MATERIAL AND METHODS

In this multicenter prospective study delays in surgical incision time in all first cases of the day were investigated in 36 German and Swiss hospitals (14 surgical specialties) over a period of 2 weeks.

RESULTS

A total of 3628 first of the day cases were included in the study. Looking at all subspecialties combined 50.8% of the first cases of the day were delayed by more than 5 min and in 30.2% of cases longer than 15 min. Incidences of delayed surgical incision time >5 min ranged from 40.0% (gynecology) to 66.8% (neurosurgery). The main reasons for delays in ascending order were prolonged induction of anesthesia compared to the planned time, the delayed appearance of the surgeon and prolonged preparation for surgery. The incidence of delays in incision times for planning list instability was increased by 10% and the average delay increased by 7 min.

CONCLUSION

Delays in surgical incision times of the first operation of the day have a high incidence in most surgical specialties; however, the reasons for delays are manifold. Plan instability of operating room lists with respect to the first cases has a negative effect on the punctuality of the incision time and should therefore be avoided.

Combined Phenyl Silane and Immunoaffinity Column Cleanup with Liquid Chromatography for Determination of Ochratoxin A in Roasted Coffee: Collaborative Study

A collaborative study was conducted to evaluate a liquid chromatography (LC) method for ochratoxin A using sequential phenyl silane and immunoaffinity column cleanup. The method was tested at 3 different levels of ochratoxin A in roasted coffee, which spanned the range of possible future European regulatory limits. The test portion was extracted with methanol and sodium bicarbonate by shaking for 30 min. The extract was filtered, centrifuged, and then cleaned up on a phenyl silane column before being eluted from the washed column with methanol–water. The eluate was diluted with phosphate-buffered saline (PBS) and applied to an ochratoxin A immunoaffinity column, which was washed with water. The ochratoxin A was eluted with methanol, the solvent was evaporated, and the residue was redissolved in injection solvent. After injection of this solution onto a reversed-phase LC apparatus, ochratoxin A was measured by fluorescence detection. Eight laboratory samples of low-level naturally contaminated roasted coffee and 2 laboratory samples of blank coffee (&lt; 0.2 ng/g ochratoxin A at the signal-to-noise ratio of 3:1), along with ampules of ochratoxin A calibrant and spiking solutions, were sent to 15 laboratories in 13 different European countries. Test portions of the laboratory samples were spiked at levels of 4 ng/g ochratoxin A, and recoveries ranged from 65 to 97%. Based on results for spiked blank material (blind duplicates) and naturally contaminated material (blind duplicates at 3 levels), the relative standard deviation for repeatability (RSDr) ranged from 2 to 22% and the relative standard deviation for reproducibility (RSDR) ranged from 14 to 26%. The method showed acceptable within- and between-laboratory precision, as evidenced by HORRAT values, at the low level of determination for ochratoxin A in roasted coffee.

[Does hospital volume correlate with surgical process time? : Retrospective analysis of the five most common procedures for visceral surgery, trauma and orthopedic surgery and gynecology/obstetrics from the benchmarking program of the Berufsverband Deutscher Anästhesisten (BDA), Berufsverband Deutscher Chirurgen (BDC) and Verband für OP-Management (VOPM)]

BACKGROUND

Minimum volume thresholds for specific surgical procedures in German hospitals were established in 2004 but remain controversial. For the first time, this study investigated the relationship between hospital performance volume and surgical procedure duration in a multicenter approach. The question here was whether a concentration on frequently performed procedures leads to a reduction in surgical process times.

METHODS

In a retrospective analysis, the 5 most common procedures from visceral, trauma/orthopedic and gynecological/obstetrics surgery were examined in hospitals participating in a benchmarking program. For each procedure performed between 2013 and 2015, hospitals were divided into 4 groups depending on the hospital volume provided. The average surgical duration of incision to suture time was calculated between the group with "very low" hospital volume and the other three groups ("low", "high" and "very high").

RESULTS

OR cases from 75 hospitals were analyzed. The number of included cases per procedure ranged from 31,940 to 2705. The average number of operations performed in a specific procedure was 3-4 times higher in high-volume hospitals compared to very low-volume hospitals. A linear relationship between hospital volume and surgical process time only appeared to be clearly seen in laparoscopic cholecystectomy, appendectomy and arthroscopic meniscus surgery: a higher case load led to a reduction in incision to suture time. For the other procedures, the surgical process times were inconsistent between the hospital groups.

CONCLUSION

The case volume only appeared to have a direct but limited influence on incision to suture times in laparoscopic and arthroscopic procedures. Overall, the hospital performance volume appeared to be of subordinate importance in terms of OR-economics.

A cross-sectional study on preoperative anxiety in adults

OBJECTIVE

The main objective of this study was a detailed comparison of the level of anxiety about surgery and anesthesia. Other objectives included the assessment of the prevalence and intensity of preoperative anxiety.

METHODS

This cross-sectional single-center survey used the validated Amsterdam anxiety and information scale (APAIS) and a modified numeric rating scale (mNRS) to assess preoperative anxiety, anxiety about surgery and anxiety about anesthesia. Prevalences and intensities of anxieties were predominantly analyzed descriptively.

RESULTS

3200 patients were enrolled and 3087 (57% females) were analyzed. 92.6% reported preoperative anxiety according to APAIS scores. The average total APAIS anxiety score (APAIS-A-T) was 9.9 (SD 3.6). 40.5% reported high anxiety (defined as APAIS-A-T > 10). Mean anxiety about surgery (APAIS-A-Su) was higher than mean anxiety about anesthesia (APAIS-A-An): 5.5 (SD 2.1) vs. 4.3 (SD 1.9), p < 0.0001. Accordingly, more patients were substantially more afraid (score difference > 2) of surgery (642, 20.8%, 95% CI 19.4-22.3) than of anesthesia (48, 1.6%, 95% CI 1.2-2.1).

CONCLUSION

Preoperative anxiety is still very common among adult patients scheduled to undergo an elective procedure. Therefore, it should be evaluated routinely. Anxiety about surgery and anxiety about anesthesia differ in many patients. For this reason, anxiety about surgery and anxiety about anesthesia should be assessed separately. This would allow providing a more individualized support of patients to cope with their anxiety and could require particular attention by the surgeon or the anesthetist.

The Laryngectomee Substitute Voice: Image Processing of Endoscopic Recordings by Fusion with Acoustic Signals

Objectives: The most radical cancer therapy of the throat is the total excision of the larynx which postoperatively results in the loss of voice. A widely-used method of voice rehabilitation is the insertion of a silicone valve, which establishes an unidirectional connection between trachea and esophagus. Thus, during exhalation, air can be directed from the trachea into the esophagus. This air stream excites tissue vibrations of the esophagus and the hypo-pharynx which act as a substitute voice generator. Purpose of the current study is to present a technique for visualizing the dynamics of the substitute voice generating element.

Methods: Digital high speed videos of the vibrating tissue are simultaneously recorded with the emitted acoustic signal. The high speed sequences are directly evaluated by a three-step knowledge based algorithm. It considers correlation between image and acoustic data, information about the gray value of each pixel, and continuity of tissue vibration. The temporal properties of an image series are investigated by evaluating the time dependent gray value at each pixel position.

Results: The applicability of the algorithm is exemplar-ily demonstrated using the data of one male patient. It enables the identification of the regions within an image series which are mainly responsible for the acoustic signal. Additionally, the dynamics of tissue vibrations are visualized. The main propagation direction can be clearly identified.

Conclusions: The new methodology summarizes the information about endoscopic and acoustic recordings of substitute voice into a single image. The results allow a first estimation of tissue velocity and elastic properties of oscillating tissue.

[Palliative therapy concepts in intensive care medicine]

Involvement of palliative care is so far not common practice for critically ill patients on surgical intensive care units (ICUs) in Germany. The objectives of palliative care concepts are improvement of patient quality of life by relief of disease-related symptoms using an interdisciplinary approach and support of patients and their relatives considering their current physical, psychological, social and spiritual needs. The need for palliative care can be identified via defined screening criteria. Integration of palliative care can either be realized using a consultative model which focusses on involvement of palliative care consultants or an integrative model which embeds palliative care principles into the routine daily practice by the ICU team. Early integration of palliative care in terms of advance care planning (ACP) can lead to an increase in goals of care discussions and quality of life as well as a decrease of mortality and length of stay on the ICU. Moreover, stress reactions of relatives and ICU staff can be reduced and higher satisfaction with therapy can be achieved. The core of goal of care discussions is professional and well-structured communication between patients, relatives and staff. Consideration of palliative care principles by model-based integration into ICU practice can improve complex intensive care courses of disease in a productive but dignified way without neglecting curative attempts.

Effects of functional endoscopic sinus surgery on the acoustics of the sinonasal tract

BACKGROUND

Nasal and paranasal cavities are supposed to contribute substantially to the vocal tract resonator properties. However, their acoustical effects as well as the effects of sinus surgery on the voice remain unclear. In this work we investigate resonance phenomena of paranasal sinuses prior to and after various rhinosurgical procedures in cadaveric human sinonasal tracts and corresponding 3D casts.

METHODOLOGY

Nasal and paranasal cavities of formalin-preserved cadavers and corresponding 3D replicas were excited by sine-tone sweeps from an earphone placed in the epipharynx. The response was picked up by a microphone at the nostrils. Different FESS procedures were performed and the acoustical responses following excitation were recorded. The measured acoustical changes in the obtained transfer functions were then evaluated.

RESULTS

Marked low frequency dips were detected in the transfer functions when sinus cavities were included in the nasal resonator system. These dips showed a significant correlation with sinus volumes. Following FESS procedures they moved upwards in frequency depending on the extent of the surgical intervention.

CONCLUSIONS

The transfer functions obtained in cadaveric situs and 3D replicas showed dips at the resonance frequencies of the paranasal cavities. Marked acoustic effects in terms of increase in dip frequency following FESS procedures were reproducibly documented.

Fluorescent markers of various organelles in the wheat pathogen Zymoseptoria tritici

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17 vectors are described that allow labelling of 7 subcellular structures.

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The fluorescent markers target the plasma membrane, endoplasmic reticulum, nucleus.

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Markers also target the actin cytoskeleton, peroxisomes and autophagosomes.

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These markers complete are toolkit of fluorescent reporters.

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Reporters allow cell biological studies in the Septoria tritici blotch fungus.

Development of novel strategies to control fungal plant pathogens requires understanding of their cellular organisation and biology. Live cell imaging of fluorescent organelle markers has provided valuable insight into various aspects of their cell biology, including invasion strategies in plant pathogenic fungi. Here, we introduce a set of 17 vectors that encode fluorescent markers to visualize the plasma membrane, endoplasmic reticulum (ER), chromosomes, the actin cytoskeleton, peroxisomes and autophagosomes in the wheat pathogen Zymoseptoria tritici. We fused either enhanced green-fluorescent protein (eGFP) or a codon-optimised version of GFP (ZtGFP) to homologues of a plasma membrane-located Sso1-like syntaxin, an ER signalling and retention peptide, a histone H1 homologue, the LifeAct actin-binding peptide, a mitochondrial acetyl-CoA dehydrogenase, a peroxisomal import signal and a homologue of the ubiquitin-like autophagosomal protein Atg8. We expressed these markers in wildtype strain IPO323 and confirmed the specificity of these markers by counterstaining or physiological experiments. This new set of molecular tools will help understanding the cell biology of the wheat pathogen Z. tritici.

[Speech Ability and Psychological Outcome After Treatment of Oral Cancer]

BACKGROUND

In recent years interactions between surgical treatment of oral carcinoma and incidence of anxiety or depression have become a subject of discussions. This prospective study is a comparison between the extent of loss of speech intelligibility and presence of depressive symptoms or anxiety as a result of oral carcinoma.

MATERIAL AND METHODS

One year after surgical therapy for oral carcinoma, 90 patients of an average age of 60±12 years were examined. Their speech intelligibility degree was measured using standardized automatic speech recognition (word recognition rate, WR). Symptoms of anxiety and depression were detected by use of HAD-Scales (HADS). Next to the relationship between WR and HADS other influential variables related to WR and HADS were statistically evaluated.

RESULTS

The WR average was 53.2±17.2. Female WR was better than male. The difference between tumor classifications T1 and T4 compared to the WR reached statistical significance. Significant differences were detected between WR and "tumor localization", "graft donor site", "graft morphology", "tongue motility", and "tracheostoma" groups. There was a relationship between tongue motility and graft morphology, graft donor site and tumor localization. HAD-Scores in the mean were elevated: HADS-Total=43.3%, HADS-A=43.3% und HADS-D= 51.1%. WR correlates with HADS-D-Subscale, but not with HADS-A-Subscale.

CONCLUSION

Communication disorders as a result of neoplasmic orofacial surgery may be related to extent of the treatment and to affective impairments. This should receive attention in the concept of rehabilitation.

Fluorescent markers for the Spitzenkörper and exocytosis in Zymoseptoria tritici

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We establish Z. tritici polarity markers ZtSec4, ZtMlc1, ZtRab11, ZtExo70 and ZtSpa2.

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All markers localize correctly, labeling the Spitzenkörper and sites of polar exocytosis.

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We provide 5 carboxin-resistance conveying vectors for integration of all markers into the sdi1 locus.

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We provide 5 hygromycin B-resistance conveying vectors for random integration of all markers.

Fungal hyphae are highly polarized cells that invade their substrate by tip growth. In plant pathogenic fungi, hyphal growth is essential for host invasion. This makes polarity factors and secretion regulators potential new targets for novel fungicides. Polarization requires delivery of secretory vesicles to the apical Spitzenkörper, followed by polarized exocytosis at the expanding cell tip. Here, we introduce fluorescent markers to visualize the apical Spitzenkörper and the apical site of exocytosis in hyphae of the wheat pathogen Zymoseptoria tritici. We fused green fluorescent protein to the small GTPase ZtSec4, the myosin light chain ZtMlc1 and the small GTPase ZtRab11 and co-localize the fusion proteins with the dye FM4-64 in the hyphal apex, suggesting that the markers label the hyphal Spitzenkörper in Z. tritici. In addition, we localize GFP-fusions to the exocyst protein ZtExo70, the polarisome protein ZtSpa2. Consistent with results in the ascomycete Neurospora crassa, these markers did localize near the plasma membrane at the hyphal tip and only partially co-localize with FM4-64. Thus, these fluorescent markers are useful molecular tools that allow phenotypic analysis of mutants in Z. tritici. These tools will help develop new avenues of research in our quest to control STB infection in wheat.

A codon-optimized green fluorescent protein for live cell imaging in Zymoseptoria tritici

Fluorescent proteins (FPs) are powerful tools to investigate intracellular dynamics and protein localization. Cytoplasmic expression of FPs in fungal pathogens allows greater insight into invasion strategies and the host-pathogen interaction. Detection of their fluorescent signal depends on the right combination of microscopic setup and signal brightness. Slow rates of photo-bleaching are pivotal for in vivo observation of FPs over longer periods of time. Here, we test green-fluorescent proteins, including Aequorea coerulescens GFP (AcGFP), enhanced GFP (eGFP) from Aequorea victoria and a novel Zymoseptoria tritici codon-optimized eGFP (ZtGFP), for their usage in conventional and laser-enhanced epi-fluorescence, and confocal laser-scanning microscopy. We show that eGFP, expressed cytoplasmically in Z. tritici, is significantly brighter and more photo-stable than AcGFP. The codon-optimized ZtGFP performed even better than eGFP, showing significantly slower bleaching and a 20-30% further increase in signal intensity. Heterologous expression of all GFP variants did not affect pathogenicity of Z. tritici. Our data establish ZtGFP as the GFP of choice to investigate intracellular protein dynamics in Z. tritici, but also infection stages of this wheat pathogen inside host tissue.

Conditional promoters for analysis of essential genes in Zymoseptoria tritici

Development of new fungicides, needed for sustainable control of fungal plant pathogens, requires identification of novel anti-fungal targets. Essential fungal-specific proteins are good candidates, but due to their importance, gene deletion mutants are not viable. Consequently, their cellular role often remains elusive. This hindrance can be overcome by the use of conditional mutants, where expression is controlled by an inducible/repressible promoter. Here, we introduce 5 inducible/repressible promoter systems to study essential genes in the wheat pathogen Zymoseptoria tritici. We fused the gene for enhanced green-fluorescent protein (egfp) to the promoter region of Z. tritici nitrate reductase (Pnar1; induced by nitrogen and repressed by ammonium), 1,4-β-endoxylanase A (Pex1A; induced by xylose and repressed by maltodextrin), l-arabinofuranosidase B (PlaraB; induced by arabinose and repressed by glucose), galactose-1-phosphate uridylyltransferase 7 (Pgal7; induced by galactose and repressed by glucose) and isocitrate lyase (Picl1; induced by sodium acetate and repressed by glucose). This was followed by quantitative analysis of cytoplasmic reporter fluorescence under induced and repressed conditions. We show that Pnar1, PlaraB and Pex1A drive very little or no egfp expression when repressed, but induce moderate protein production when induced. In contrast, Pgal7 and Picl1 show considerable egfp expression when repressed, and were strongly induced in the presence of their inducers. Normalising the expression levels of all promoters to that of the α-tubulin promoter Ptub2 revealed that PlaraB was the weakest promoter (∼20% of Ptub2), whereas Picl1 strongly expressed the reporter (∼250% of Ptub2). The use of these tools promises a better understanding of essential genes, which will help developing novel control strategies that protect wheat from Z. tritici.

A gene locus for targeted ectopic gene integration in Zymoseptoria tritici

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We establish the sdi1 of Z. tritici locus for targeted integration of constructs as single copies.

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Integration of constructs conveys carboxin resistance.

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We provide a vector for integration of eGFP-expressing construct into the sdi1 locus.

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Integration into sdi1 locus is not affecting virulence of Z. tritici.

Understanding the cellular organization and biology of fungal pathogens requires accurate methods for genomic integration of mutant alleles or fluorescent fusion-protein constructs. In Zymoseptoria tritici, this can be achieved by integrating of plasmid DNA randomly into the genome of this wheat pathogen. However, untargeted ectopic integration carries the risk of unwanted side effects, such as altered gene expression, due to targeting regulatory elements, or gene disruption following integration into protein-coding regions of the genome. Here, we establish the succinate dehydrogenase (sdi1) locus as a single “soft-landing” site for targeted ectopic integration of genetic constructs by using a carboxin-resistant sdi1^R allele, carrying the point-mutation H267L. We use various green and red fluorescent fusion constructs and show that 97% of all transformants integrate correctly into the sdi1 locus as single copies. We also demonstrate that such integration does not affect the pathogenicity of Z. tritici, and thus the sdi1 locus is a useful tool for virulence analysis in genetically modified Z. tritici strains. Furthermore, we have developed a vector which facilitates yeast recombination cloning and thus allows assembly of multiple overlapping DNA fragments in a single cloning step for high throughput vector and strain generation.

Fluorescent markers of the endocytic pathway in Zymoseptoria tritici

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We establish Z. tritici fimbrin (ZtFim1) and small GTPases (ZtRab5, ZtRab7) as endocytic markers.

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All markers localize correctly, proven by live cell imaging and co-staining and pharmaceutical studies.

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We provide 3 carboxin-resistance conveying vectors for integration of all markers into the sdi1 locus.

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We provide 3 hygromycin B-resistance conveying vectors for random integration of all markers.

Hyphal growth in filamentous fungi is supported by the uptake (endocytosis) and recycling of membranes and associated proteins at the growing tip. An increasing body of published evidence in various fungi demonstrates that this process is of essential importance for fungal growth and pathogenicity. Here, we introduce fluorescent markers to visualize the endocytic pathway in the wheat pathogen Zymoseptoria tritici. We fused enhanced green-fluorescent protein (eGFP) to the actin-binding protein fimbrin (ZtFim1), which is located in actin patches that are formed at the plasma membrane and are participating in endocytic uptake at the cell surface. In addition, we tagged early endosomes by eGFP-labelling a Rab5-homologue (ZtRab5) and late endosomes and vacuoles by expressing eGFP-Rab7 homologue (ZtRab7). Using fluorescent dyes and live cell imaging we confirmed the dynamic behavior and localization of these markers. This set of molecular tools enables an in-depth phenotypic analysis of Z. tritici mutant strains thereby supporting new strategies towards the goal of controlling wheat against Z. tritici.

[How many patient transfer rooms are necessary for my OR suite? : Effect of the number of OR transfer rooms on waiting times and patient throughput in the OR - analysis by simulation]

INTRODUCTION

In most hospitals the operating rooms (OR) are separated from the rest of the hospital by transfer rooms where patients have to pass through for reasons of hygiene. In the OR transfer room patients are placed on the OR table before surgery and returned to the hospital bed after surgery. It could happen that the number of patients who need to pass through a transfer room at a certain point in time exceed the number of available transfer rooms. As a result the transfer rooms become a bottleneck where patients have to wait and which, in turn, may lead to delays in the OR suite. In this study the ability of a discrete event simulation to analyze the effect of the duration of surgery and the number of ORs on the number of OR transfer rooms needed was investigated.

METHODS

This study was based on a discrete event simulation model developed with the simulation software AnyLogic®. The model studied the effects of the number of OR transfer rooms on the processes in an OR suite of a community hospital by varying the number of ORs from one to eight and using different surgical portfolios. Probability distributions for the process duration of induction, surgery and recovery and transfer room processes were calculated on the basis of real data from the community hospital studied. Furthermore, using a generic simulation model the effect of the average duration of surgery on the number of OR transfer rooms needed was examined.

RESULTS

The discrete event simulation model enabled the analysis of both quantitative as well as qualitative changes in the OR process and setting. Key performance indicators of the simulation model were patient throughput per day, the probability of waiting and duration of waiting time in front of OR transfer rooms. In the case of a community hospital with 1 transfer room the average proportion of patients waiting before entering the OR was 17.9 % ± 9.7 % with 3 ORs, 37.6 % ± 9.7 % with 5 ORs and 62.9 % ± 9.1 % with 8 ORs. The average waiting time of patients in the setting with 3 ORs was 3.1 ± 2.7 min, with 5 ORs 5.0 ± 5.8 min and with 8 ORs 11.5 ± 12.5 min. Based on this study the community hospital needs a second transfer room starting from 4 ORs so that there is no bottleneck for the subsequent OR processes. The average patient throughput in a setting with 4 ORs increased significantly by 0.3 patients per day when a second transfer room is available. The generic model showed a strong effect of the average duration of surgery on the number of transfer rooms needed.

CONCLUSION

There was no linear correlation between the number of transfer rooms and the number of ORs. The shorter the average duration of surgery, the earlier an additional transfer room is required. Thus, hospitals with shorter duration of surgery and fewer ORs may need the same or more transfer rooms than a hospital with longer duration of surgery and more ORs. However, with respect to an economic analysis, the costs and benefits of installing additional OR transfer rooms need to be calculated using the profit margins of the specific hospital.

Red fluorescent proteins for imaging Zymoseptoria tritici during invasion of wheat

The use of fluorescent proteins (FPs) in plant pathogenic fungi provides valuable insight into their intracellular dynamics, cell organization and invasion mechanisms. Compared with green-fluorescent proteins, their red-fluorescent "cousins" show generally lower fluorescent signal intensity and increased photo-bleaching. However, the combined usage of red and green fluorescent proteins allows powerful insight in co-localization studies. Efficient signal detection requires a bright red-fluorescent protein (RFP), combined with a suitable corresponding filter set. We provide a set of four vectors, suitable for yeast recombination-based cloning that carries mRFP, TagRFP, mCherry and tdTomato. These vectors confer carboxin resistance after targeted single-copy integration into the sdi1 locus of Zymoseptoria tritici. Expression of the RFPs does not affect virulence of this wheat pathogen. We tested all four RFPs in combination with four epi-fluorescence filter sets and in confocal laser scanning microscopy, both in and ex planta. Our data reveal that mCherry is the RFP of choice for investigation in Z. tritici, showing highest signal intensity in epi-fluorescence, when used with a Cy3 filter set, and laser scanning confocal microscopy. However, mCherry bleached significantly faster than mRFP, which favors this red tag in long-term observation experiments. Finally, we used dual-color imaging of eGFP and mCherry expressing wild-type strains in planta and show that pycnidia are formed by single strains. This demonstrates the strength of this method in tracking the course of Z. tritici infection in wheat.

How to deal with vaccine hesitancy?

Based on the concerns about vaccine hesitancy and its impact on vaccine uptake rates and the performance of national immunization programmes, the Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on Vaccine Hesitancy [1], carried out a review, and proposed a set of recommendations directed to the public health community, to WHO and its partners, and to the World Health Organization (WHO) member states. The final recommendations issued by SAGE in October 2014 fall into three categories: (1) those focused on the need to increase the understanding of vaccine hesitancy, its determinants and the rapidly changing challenges it entails; (2) those focused on dealing with the structures and organizational capacity to decrease hesitancy and increase acceptance of vaccines at the global, national and local levels; (3) and those focused on the sharing of lessons learnt and effective practices from various countries and settings as well as the development, validation and implementation of new tools to address hesitancy.

Measuring vaccine hesitancy: The development of a survey tool

In March 2012, the SAGE Working Group on Vaccine Hesitancy was convened to define the term "vaccine hesitancy", as well as to map the determinants of vaccine hesitancy and develop tools to measure and address the nature and scale of hesitancy in settings where it is becoming more evident. The definition of vaccine hesitancy and a matrix of determinants guided the development of a survey tool to assess the nature and scale of hesitancy issues. Additionally, vaccine hesitancy questions were piloted in the annual WHO-UNICEF joint reporting form, completed by National Immunization Managers globally. The objective of characterizing the nature and scale of vaccine hesitancy issues is to better inform the development of appropriate strategies and policies to address the concerns expressed, and to sustain confidence in vaccination. The Working Group developed a matrix of the determinants of vaccine hesitancy informed by a systematic review of peer reviewed and grey literature, and by the expertise of the working group. The matrix mapped the key factors influencing the decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine-specific. These categories framed the menu of survey questions presented in this paper to help diagnose and address vaccine hesitancy.

Fluorescent markers of the microtubule cytoskeleton in Zymoseptoria tritici

The microtubule cytoskeleton supports vital processes in fungal cells, including hyphal growth and mitosis. Consequently, it is a target for fungicides, such as benomyl. The use of fluorescent fusion proteins to illuminate microtubules and microtubule-associated proteins has led to a break-through in our understanding of their dynamics and function in fungal cells. Here, we introduce fluorescent markers to visualize microtubules and accessory proteins in the wheat pathogen Zymoseptoria tritici. We fused enhanced green-fluorescent protein to α-tubulin (ZtTub2), to ZtPeb1, a homologue of the mammalian plus-end binding protein EB1, and to ZtGrc1, a component of the minus-end located γ-tubulin ring complex, involved in the nucleation of microtubules. In vivo observation confirms the localization and dynamic behaviour of all three markers. These marker proteins are useful tools for understanding the organization and importance of the microtubule cytoskeleton in Z. tritici.

Why are young adults affected? Estimating measles vaccination coverage in 20-34 year old germans in order to verify progress towards measles elimination

BACKGROUND

The introduction of measles vaccination into routine childhood vaccination programmes has led to a shift of disease burden and incidence among young adults. This was confirmed by the recent rise in measles cases and outbreaks throughout Europe. To prevent outbreaks and eliminate measles, one of the key objectives of the WHO Europe measles elimination framework is achieving overall vaccination coverage of ≥95% in the population on a district level. In the absence of national registers, data on vaccination coverage in Germany is recorded at the age of school entry, through insurance refund claim data and population studies. Vaccination status (VS) of young adults is largely unknown.

METHODS

We assessed measles vaccination coverage in young adults aged 20-34 years on a district level of the German Federal State of Rhineland-Palatinate. The knowledge and attitude towards immunization of unvaccinated to vaccinated young adults were compared using Likert questions. We used proportional allocation for stratified random sampling across 36 counties. We mailed a self-administered questionnaire with pre-paid return envelopes along with an offer to complete online. Prior to calculating coverage we tested for non-responder bias using logistic regression.

RESULTS

465 (28%) of 1,637 persons contacted responded (mail: 23%, online: 5%). More women responded than men (odds ratio (OR)=2.1; 95% confidence intervall (CI)=1.7-2.6) but age did not vary between responders and non-responders. Vaccination coverage was 90% (95%CI=87%-93%) for one and 56% (95%CI=51%-61%) for two doses. We found a statistically significant association between receiving two doses and age group. The 20-24 years age group had a 2.3 higher incidence rate ratio (95%CI=1.7-3.2) than the reference group of 30-34 year old to have received two doses of measles vaccination. The group of 25-29 year old had a 1.5 higher incidence rate (95%CI=1.0-2.1) than the reference group to have received two doses of measles vaccination.

CONCLUSIONS

Coverage has failed to reach the WHO Europe elimination goal of 95% measles vaccination in the general population. Targeted approaches including enlistment of occupational health services and checking vaccination status during general practitioner (GP) visits are needed to increase vaccination uptake in this age group in order to achieve measles elimination.

Amino acids as possible alternative nitrogen source for growth of Euglena gracilis Z in life support systems

In recent times Euglena gracilis Z was employed as primary producer in closed environmental life-support system (CELSS), e.g. in space research. The photosynthetic unicellular flagellate is not capable of utilizing nitrate, nitrite, and urea as nitrogen source. Therefore, ammonium is supplied as an N-source in the lab (provided as diammonium-dihydrogenphosphate, (NH4)2HPO4) to E. gracilis cultures. While nitrate exerts low toxicity to organisms, ammonium is harmful for many aquatic organisms especially, at high pH-values, which causes the ionic NH4+ (low toxicity) to be partially transformed into the highly toxic ammonia, NH3. In earlier reports, Euglena gracilis was described to grow with various amino acids as sole N-source. Our aim was to investigate alternatives for (NH4)2HPO4 as N-source with lower toxicity for organisms co-cultivated with Euglena in a CELSS. The growth kinetics of Euglena gracilis cultures was determined in the presence of different amino acids (glycine, glutamine, glutamic acid, leucine, and threonine). In addition, uptake of those amino acids by the cells was measured. Cell growth in the presence of glycine and glutamine was quite comparable to the growth in (NH4)2HPO4 containing cultures while a delay in growth was observed in the presence of leucine and threonine. Unlike, aforementioned amino acids glutamate consumption was very poor. Cell density and glutamate concentration were almost unaltered throughout the experiment and the culture reached the stationary phase within 8 days. The data are compared with earlier studies in which utilization of amino acids in Euglena gracilis was investigated. All tested amino acids (glutamate with limitations) were found to have the potential of being an alternative N-source for Euglena gracilis. Hence, these amino acids can be used as a non-toxic surrogate for (NH4)2HPO4.

Mapping vaccine hesitancy--country-specific characteristics of a global phenomenon

The term vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite the availability of vaccination services. Different factors influence vaccine hesitancy and these are context-specific, varying across time and place and with different vaccines. Factors such as complacency, convenience and confidence are involved. Acceptance of vaccines may be decreasing and several explanations for this trend have been proposed. The WHO Strategic Advisory Group of Experts (SAGE) on Immunization has recognized the global importance of vaccine hesitancy and recommended an interview study with immunization managers (IMs) to better understand the range of vaccine hesitancy determinants that are encountered in different settings. Interviews with IMs in 13 selected countries were conducted between September and December 2013 and various factors that discourage vaccine acceptance were identified. Vaccine hesitancy was not defined consistently by the IMs and most interpreted the term as meaning vaccine refusal. Although vaccine hesitancy existed in all 13 countries, some IMs considered its impact on immunization programmes to be a minor problem. The causes of vaccine hesitancy varied in the different countries and were context-specific, indicating a need to strengthen the capacity of national programmes to identify the locally relevant causal factors and to develop adapted strategies to address them.

NOTCH1 activation in breast cancer confers sensitivity to inhibition of SUMOylation

Breast cancer is genetically heterogeneous, and recent studies have underlined a prominent contribution of epigenetics to the development of this disease. To uncover new synthetic lethalities with known breast cancer oncogenes, we screened an epigenome-focused short hairpin RNA library on a panel of engineered breast epithelial cell lines. Here we report a selective interaction between the NOTCH1 signaling pathway and the SUMOylation cascade. Knockdown of the E2-conjugating enzyme UBC9 (UBE2I) as well as inhibition of the E1-activating complex SAE1/UBA2 using ginkgolic acid impairs the growth of NOTCH1-activated breast epithelial cells. We show that upon inhibition of SUMOylation NOTCH1-activated cells proceed slower through the cell cycle and ultimately enter apoptosis. Mechanistically, activation of NOTCH1 signaling depletes the pool of unconjugated small ubiquitin-like modifier 1 (SUMO1) and SUMO2/3 leading to increased sensitivity to perturbation of the SUMOylation cascade. Depletion of unconjugated SUMO correlates with sensitivity to inhibition of SUMOylation also in patient-derived breast cancer cell lines with constitutive NOTCH pathway activation. Our investigation suggests that SUMOylation cascade inhibitors should be further explored as targeted treatment for NOTCH-driven breast cancer.

Resonator properties of paranasal sinuses: preliminary results of an anatomical study

BACKGROUND

The contribution of the nasal and paranasal cavities to vocal tract resonator properties is unclear as are voice effects of sinus surgery. Here we investigate resonance phenomena of paranasal sinuses with and without selective occlusion of the middle meatus and maxillary ostium in a cadaver.

METHODOLOGY

Nasal and paranasal cavities of a Thiel-embalmed cadaver were excited by sine-tone sweeps from an earphone in the epipharynx. The response was picked up by a microphone at the nostrils. Different conditions with blocked and unblocked middle meatus were tested. Additionally, infundibulotomy was performed allowing direct access to and selective occlusion of the maxillary ostium.

RESULTS

Responses showed high reproducibility. Minor effects appeared after removal of meatal occlusion. A marked low frequency dip was detected after removal of occlusion of maxillary ostium following infundibulotomy.

CONCLUSION

Reproducible frequency responses of nasal tract can be derived from cadaver measurements. Marked acoustic effects of the maxillary sinus appeared only after direct exposure of the maxillary ostium following infundibulotomy.

(Se,O)-Koordinierte Komplexe niedervalenter Hauptgruppenmetalle: Die Kristallstruktur von Bis(N,N-Diethyl-N′-benzoylselenoureato)blei(II) / (S e,O)-Coordinated Complexes of Subvalent Main Group Metals: The Crystal Structure of Bis(N ,N -diethyl-N′-benzoylselenoureato)lead(II)

Bis(N,N-diethyl-N′-benzoylselenoureato)lead(II) has been prepared and characterized by single-crystal structure analysis. Pb(C12H15N2OSe)2 crystallizes in the non-centrosymmetric orthorhombic space group Iba2. The cell parameters are a = 13.206(3), b = 20.542(4), c = 10.089(2) A and Z = 4. R = 0.025. The direction of the polar axis was determined unambig­ uously. Pb(II) is bidentally coordinated to two N,N-diethyl-N′-benzoylselenourea molecules. The coordination polyhedron is a distorted pseudo-trigonal bi-pyramid with one equatorial position occupied by an electron lone-pair. The Pb-Se and Pb-O bond lengths are 2.876(1) and 2.444(4) Å, respectively. In the crystal lattice, each Pb atom also shows interactions with two Se atoms of a neighboring molecule. The Pb-Se distance of that interaction is 3.643 Å.