[Incidence of nosocomial infections as an element of cost-conscious quality management of inpatient care]

The prevention of nosocomial infections is a result of many variables in a wide range of architectural, personal and organisational decisions taken into account in modern hospital plannings. The frequency of nosocomial infections in a given period can be used as one possible indicator of outcome quality of our hospitals. Contrary to the frequently uttered claims of many experts, who demand for a continuous hygienic monitoring in hospitals [1;2;3;4], routine procedures have not been unanimously established until now. Assessment and evaluation of nosocomial infections seem to be anything but trivial. Purpose of the described pilot study at the University of Lubeck was the development and test of a set of practicable routines to early discover and assess nosocomial infections. Methods of epidemiologic evaluation have been implemented to grant a perpetuos hygienic monitoring even on a limited base of personal, structural and financial resources. In a next step, further adaptations and improvements are planned, thus making assessment and evaluation independent of central institutions.

[Persistent pulmonary hypertension in premature and newborn infants: selective pulmonary vasodilation with inhaled nitric oxide (iNO)]

Severe respiratory failure of the newborn often results in persistent pulmonary hypertension, which is characterized by increased pulmonary vascular resistance, decreased pulmonary blood flow and severe hypoxaemia. Since 3 years inhaled nitric oxide (iNO) has been used as a selective pulmonary vasodilator with variable success in the treatment of persistent pulmonary hypertension. In the present clinical pilot study 10 patients (4 newborns and 6 preterm infants) suffering from severe respiratory failure were treated with iNO. The aim of this study was to evaluate the effectiveness of inhaled NO and to discuss whether or not extracorporeal membrane oxygenation (ECMO) could be delayed or avoided. In all patients oxygenation improved without a decrease in systemic blood pressure. The median OI decreased from 41 to 16.5 during the first 4 hours of treatment and to 12 during the first 12 hours. One patient with congenital diaphragmatic hernia required ECMO therapy and died post operative. One preterm infant with primary pulmonary hypertension died during prolongated hypotension and hypoxemia. iNO may have reduced the need for ECMO which however should be available as an ultimate therapeutic option.

[Quality management and quality assurance in the hospital with special reference to hospital public health]

Due to the law of health reform and health structure the hospitals in the Federal Republic of Germany are asked to not only think about cost reduction but at the same time to also face the requirements of quality management (QM) and quality assurance (QA). For the field of medical and care taking treatment of patients in the hospital the term "quality" can be described as the total of characteristics of the medical services necessary for the realization of all requirements which lead to an optimal patient treatment. Hospital hygiene as part of hygiene in the broader sense deals with the bases of disease prevention of all persons actively or passively connected with the institution hospital as well as with the natural and social hospital environment and, thus, in every respect proves to be a guide discipline for the realization of QM and QA in the hospital. For the realization of an overall concept for QM and QA in the hospital three categories of quality have proved to be worthwhile, namely the structure quality which deals with the quality related arrangement of the frame conditions of hospital productivity the process quality which comprises the improvement of diagnostic, therapeutic, care taking and medical activities in the hospital as well as interactions between the hospital staff and the patient or his relatives, and the outcome quality, which judges the changes in the patient's condition by means of predefined target values. Furthermore, QM in the hospital needs detailed informative activities (initial stage of information) as well as motivating measures (initial stage of conduct) whereas latter has to be considered as an essential basis for a staff-related realization of quality assurance measures in the hospital. Possibilities for a practical realization of QM and QA are shown by means of the modular concept established in the Clinics of the University of Heidelberg. Thereby, one could experience that a successful QM in the hospital requires the declared willingness of the hospital leadership to regard quality as the main theme of medical services and that QM has to be carried out staff-orientated for only by improvement of the employers' activities on all levels of the hospital gains the medical process of service its quality.

Microspectrometer with slab-waveguide transmission gratings

An integrated transmission diffraction grating in a planar optical waveguide is presented for broadband spectroscopic analysis of liquids and gases. Silicon oxynitride slab waveguides on silicon substrates with low optical loss in the visible range are combined with a phase transmission grating exhibiting a blaze effect at 500 nm to achieve high-efficiency diffraction and high spectral dispersion. Collimated white light propagates through the waveguide and couples into air at a stepped formed planar grating. The beams of each adjacent step interfere constructively at the focal line of a cylindrical lens, its focal line positioned perpendicular to the waveguide plane. We used a common silicon photodiode array to detect the spectral data. Our approach is to develop a compact and economic spectrometer without moving parts that can be applied for UV-visible analysis and near-infrared industrial process control as well.

[Modular concept for quality in the hospital--"Heidelberg model"]

The Heidelberg University Hospital meets the standards required of medical services in terms of efficiency, optimizing procedures, cost-effectiveness, staff-satisfaction, and reducing infection rates etc., by implementing the Modular concept for quality within hospitals that has now proven its worth in practice. This concept combines a number of functional modules, including the hygiene, nursing, environment, and casualty modules, to name just four of them, within an overall framework incorporating guidelines focusing on quality, strategies, and management policies. Relevant European quality guidelines and the principles of Good Laboratory Practice (GLP), and Good Manufacturing Practice (GMP) are all taken into account to facilitate the required inter-hospital comparison with regard to continuous improvement of quality. It clearly demonstrates that expertise within the hospital and proven practicability in terms of numbers take definite precedence over theoretical approaches from outside experts.

Small-Angle X-ray Scattering Size Parameters and Higher Moments of the Particle-Size Distribution Function in the Asymptotic Stage of Ostwald Ripening

Small-angle X-ray scattering (SAXS) is a powerful tool to study the kinetics of phase separation in materials. A simple procedure is presented that allows one to prove if the particle-size distribution established in a system in the late stages of phase separation corresponds to the predictions of the classical Lifshitz–Slyozov–Wagner (LSW) theory for the asymptotic stage of Ostwald ripening. The method is based on the correlations between certain SAXS size parameters and the higher moments of the LSW size distribution functions for diffusion-limited or reaction-limited ripening. It is suggested that the use of these size parameters, which can be obtained with high accuracy from the scattering curve, is frequently more advantageous than a direct comparison of the experimentally obtained size distributions with the asymptotic size-distribution functions predicted by the LSW theory. The method is applicable if the suppositions made in the LSW theory that the precipitated particles should be homogeneous spheres with volume fraction tending to zero are fulfilled. The method is applied to a photochromic glass; although the silver-halide precipitates contained in the glass develop according to the power law of diffusion-limited Ostwald ripening, their size distribution is shown not to correspond to the features of the LSW size distribution. Consequently, in this case the LSW theory cannot describe quantitatively the kinetics of ripening.

[Churg-Strauss syndrome. A differential diagnosis in chronic polypoid sinusitis]

BACKGROUND

The Churg-Strauss syndrome (CSS) is a rare multiple organ disease, that belongs to the group of systemic granulomatous vasculitis. The initial symptoms are often bronchial asthma and allergic rhinitis; later in the course of the disease, the patients exhibit lung, heart and kidney manifestations.

PATIENTS

We report on a thirty-one year old female patient who initially presented with asthma and polypous sinusitis. Three years later, after undergoing endonasal sinus surgery three times, she was diagnosed with CSS. Within a review of the literature, we discuss symptomatology, differential diagnosis, and therapy of the CSS.

RESULTS

Worldwide about 200 cases are published. The patient presented in this case report is now in a good health condition after a four-year therapy with steroids. The patient is free of sinusitis symptoms without the need of renewed surgical intervention.

CONCLUSIONS

CSS should be considered in the differential diagnosis if bronchial asthma and resistant polypous sinusitis occur coincidentally. Often it is very difficult to diagnose CSS. Frequently it is only diagnosed after several years. Therapy of choice is the treatment with steroids, sometimes supplemented by cytotoxical drugs.

Teratogenic effects in a case of maternal treatment for acute myelocytic leukaemia--neonatal and infantile course

Experience with the use of cytotoxic drugs in the first trimester of pregnancy is limited. We report on the clinical phenotype and infantile development of a girl born to a 36-year-old mother. Before recognition of pregnancy, the latter had been treated for acute myelocytic leukaemia receiving cytarabine, daunorubicin and doxorubicin at conception and cytarabine and thioguanine at about 35-37 days post conception. At delivery, there were severe brachycephaly, hypoplasia of the anterior cranial base and the midface as well as synostoses of both coronal and metopic sutures. Further findings included bilateral four-finger hands with hypoplastic thumbs and absent radii. This phenotype is reminiscent of the Baller-Gerold syndrome. The child, at present 15 months old, has had to undergo two operations for fronto-orbital advancement because of insufficient growth of the mid-face, nasal airway hypoplasia and increased intracranial pressure. Motor milestones are slightly retarded--neurodevelopment is otherwise normal. These findings are discussed in the context of the few previous reports and are particularly important for future genetic counselling.

Plasma concentration of elastase-alpha 1-proteinase inhibitor complex in surfactant-treated preterm neonates with respiratory distress syndrome

Although exogenous surfactant replacement improves respiratory distress syndrome (RDS) of immature neonates, it may not prevent subsequent lung damage and development of bronchopulmonary dysplasia associated with polymorphonuclear neutrophil (PMN)-activation. We therefore wanted to assess whether surfactant administration would be associated with activation of circulating PMNs. Since elastase-alpha 1-proteinase inhibitor (E-alpha 1-PI) has proved to be a sensitive indicator of intravascular PMN activation, we studied E-alpha 1-PI plasma concentration in preterm neonates during the treatment of RDS with a bovine surfactant preparation (group I: n = 23). Results were compared with those from a retrospective control group treated by ventilation alone (group II: n = 13), and with a reference group of 92 newborns (group III). Following surfactant administration, median E-alpha 1-PI concentration increased significantly (day 1 80.5 vs Day 2,234 micrograms.l-1), and exceeded the upper limit of the reference range of 274 micrograms.l-1 in seven patients, with a maximal value of 1,881 micrograms.l-1 after multiple surfactant administrations. In contrast, 12 infants from Group II showed no increase in median E-alpha 1-PI levels (Day 1,107 vs Day 2,107 micrograms.l-1), and remained within the reference range (Day 1,125 micrograms.l-1; Day 2,107 micrograms.l-1) of the 92 newborns without respiratory impairment, infection, birth-trauma or asphyxia. From these results, it is concluded that surfactant may trigger a transient, mainly local, inflammatory response, reflected by increased levels of E-alpha 1-PI, and may exert a dose-related pathogenic influence on the course and prognosis of RDS.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in plasma levels of oxygen radical scavenging enzymes during extracorporeal membrane oxygenation in a lamb model

We studied levels of superoxide dismutase, glutathione, reductase, glutathione peroxidase and lipoperoxides in 12 healthy lambs below 1 year of age (8-19 kg) under therapy with extracorporeal membrane oxygenation (ECMO). Plasma levels of these free oxygen radical scavenging enzymes and lipoperoxides were taken 1 day before the ECMO experiment, at the beginning of ECMO after the first rotations of the roller pump, during, and after ECMO. The pre-ECMO results of days 1 and 2 were compared with the during-ECMO results and those with the post-ECMO results using the t test for paired samples. We found a significant decrease of both superoxide dismutase and glutathione reductase on ECMO, a trend to increased lipoperoxide levels, and unchanged levels of glutathione peroxidase. After discontinuing bypass the levels began to normalize again. We conclude that ECMO reduces some oxygen radical scavenging enzyme levels and exhibits a trend to increased lipoperoxide levels. Near total lung collapse with consecutive reperfusion injury might be harmful considering these results. However, the nonsignificant increase in lipoperoxide levels excludes considerable oxygen toxicity during this short ECMO trial.

Influence of medium composition on penicillin V production in a stirred tank reactor

Penicillin production with a high-producing strain Penicillium chrysogenum was investigated under well-controlled conditions in a stirred tank reactor with complex media containing lard oil and lactose on the one hand, and lactose on the other hand. With lard oil, cell growth and product formation rates were higher, and the production time was shorter by 40 h than without lard oil. On account of the longer production time without lard oil, the amount of beta-lactam compounds was higher (29.93 g l-1), but the mole fraction of the decomposed products (penicilloic acid and penilloic acid) was larger (0.282) than the amount of penicillin V (23.25 g l-1) and the decomposed mole fraction (0.0747) with lard oil. The final product concentrations were about the same (20.86 g l-1 or 35,462 IU ml-1 with lard oil, and 20.43 g l-1 or 34510 IU ml-1 without lard oil). The mole fractions of the by-product (p-OH-penicillin V) were 0.0365 and 0.066. The substitution of lard oil with lactose is possible without a considerable reduction of process performance.

[The significance of the initial respiratory parameters in assessing the severity of ARDS in children]

In adults, the course and outcome of the acquired respiratory distress syndrome (ARDS) are closely related to the initial respiratory situation. Respiratory indices are frequently used for prognostic purposes and hence for the institution of new techniques such as extracorporeal lung support. The validity of these indices to predict the outcome in pediatric ARDS patients has not been examined as yet. We studied respiratory indices in 69 pediatric ARDS patients. METHODS. Out of 69 pediatric ARDS patients with various underlying diseases (Table 1), we chose 21 with a paO2/FiO2 ratio less than 150 mm Hg at some point to test the prognostic significance of a respiratory severity index (RSI), i.e., mean airway pressure x alveolar-arterial pO2 difference (A-aDo2)/paO2, a respiratory index (RI), i.e., A-aDO2-paO2/paO2, and other respiratory parameters (Table 2). Postsurgical patients, patients with incurable diseases, clearly non-respiratory deaths, and those treated with extracorporeal membrane oxygenation were excluded. We looked for statistical differences between survivors and nonsurvivors and correlations between ventilator days, intensive care unit (ICU) days, and hospital days and these indices. RESULTS. We did not find a significant difference between all respiratory indices tested at admission to the ICU and 24 h later between survivors and nonsurvivors (Table 3). Nonsurvivors initially had significantly higher blood pressures and lower heart rates. Both RSI and RI were significantly correlated to days on the ventilator, days in the ICU, and days in the hospital (Table 4). Initial multiorgan failure was significantly more common in nonsurvivors. CONCLUSIONS. Initial lung dysfunction as indicated by respiratory indices does not predict the outcome in pediatric ARDS. The underlying disease, hemodynamic situation, and age have to be considered in relation to the degree of lung dysfunction to determine new therapeutic strategies such as extracorporeal support.

The influence of preculture on the process performance of penicillin V production in a 100-l air-lift tower loop reactor

The influence of stirrer speed in the third preculture on the performance of penicillin V production by Penicillium chrysogenum in complex medium in a 100-l air-lift tower loop reactor was investigated. The process performance in the main culture was improved by increasing the stirrer speed from 500 to 750 rpm: the pellet size was reduced to half, the cell growth was influenced only slightly, but the production phase was extended considerably, and the final penicillin concentration was increased from 5.1 g l-1 to 10.4 g l-1.

[Characteristics of an intervertebral disk herniation in spondylolisthesis]

Treatment of intervertebral disc herniation associated with spondylolisthesis is not different from common procedures concerning indication for surgery and surgical technique as far as sciatica is not related to retrolisthetic soft tissue or the posterior edge of the vertebral body. In a case of a disc herniation L5/S1 and an olisthesis grade I with radicular pain L5 a microdiscectomy of the prolapse and parts of the retrolisthetic soft tissue was performed. An immediate reintervention was necessary due to postoperative symptoms of paralysis. Derangement of the retrolisthetic soft tissue was found to cause the increased L5-symptoms.

Bioavailability assessment of the lipophilic benfotiamine as compared to a water-soluble thiamin derivative

The bioequivalence of thiamin in 2 therapeutically used preparations was tested in 10 healthy young men. Thiamin was orally administered either as lipophilic benfotiamine or as water-soluble thiamin mononitrate. Biokinetic data, measured as area under the curve and maximal concentration in plasma and hemolysate after ingestion, demonstrated a significantly improved bioavailability from the lipophilic derivative despite an ingested dose of only 40% as compared with the water-soluble salt. A superior cellular efficacy of benfotiamine was also concluded from the short-term stimulation of the thiamin-dependent transketolase activity in erythrocytes.

Air embolism and pulmonary interstitial emphysema in a preterm infant with hyaline membrane disease

A preterm infant with severe hyaline membrane disease requiring extreme mechanical ventilation developed pulmonary air leaks with consecutive shock. The chest roentgenogram showed bilateral pulmonary interstitial emphysema and gas within the heart silhouette as well as in the hepatic veins, inferior v. cava, portal vein, and many abdominal vessels. The respiratory and circulatory failure by massive systemic gas embolism resulted in death.

Guidelines for description of immunoassay kits

A provisional recommendation in order to improve manufacturers' and marketers' information to users of immunoassay kits has been compiled by a Nordic Clinical Chemistry project working group.

[Results of dorsal lumbosacral distraction spondylodesis without implant in previously surgically treated back patients]

Lumbosacral fusions of the L4/5 and L5/S1 segment were performed in 168 patients with a tricortical iliac crest bone graft between the spinal processes L4 and S1 and two posterolateral fusions (LSDS). At follow-up five or more years after surgery, 46 of 55 patients with prior back surgery had a solid bony fusion. Pain was reduced in 94% of the failed back patients; 61.8% were satisfied with the result. On a ten-point scale from no (0) up to unacceptable (10) pain, the degree of back-pain decreased five years after fusion from 9.1 to 4.9 points, while the leg pain was reduced from 8.5 to 4.3. During surgery and the early postoperative period four major complications occurred in 168 patients. Twice the dura was perforated and two graft luxations were seen. No deep wound infections and no nerve root lesions were seen after surgery. The average blood loss was substituted by 2.4 erythrocyte concentrates. The lumbosacral distraction spondylodesis is a fusion of the two lower lumbar segments with satisfactory clinical and radiological results and a low complication rate. In patients with a failed back syndrome the pain in most cases decreased. The fact that 38.2% of the patients are unsatisfied with the result is most likely due to the severe scar tissue following prior surgery.

[Neonatal emergency: bupivacaine poisoning following maternal caudal anesthesia]

After maternal caudal anesthesia with bupivacaine life-threatening symptoms of bupivacaine intoxication occurred in the newborn. The local anesthetic had been injected directly into the fetal scalp. Cardiac shock caused by sinus bradycardia and impaired intracardial conduction (wide QRS-complex) was treated successfully. Seizures were absent. The bupivacain plasma level 90 min post partum was 3.6 mg/l, the elimination half-life 14 h. The symptoms presented in the newborn--especially the cardiovascular changes--coincide well with the results of animal experiments reported in the literature.

Bone cement improved by vacuum mixing and chilling

Two mixing methods, hand and vacuum mixing, were compared using high viscosity, high molecular, antibiotic containing polymethylmethacrylate kept at two different temperatures, 4 degrees C and 21 degrees C, prior to mixing. The mechanical properties, i.e., fracture strength, maximum deflection, modulus of elasticity and hardness, were improved by vacuum mixing when compared with hand mixing at both temperatures. The fatigue life was 10 times longer after vacuum mixing. Chilling prior to mixing made the mixing easier and improved the handling characteristics. Vacuum mixing delayed the setting time by 1 minute, but also decreased the peak temperature. Radiographic analysis showed that vacuum mixing mainly reduced the microporosity, but also the macroporosity. The mechanical properties deteriorated slightly after 2 months in Ringer's solution, but the differences between the mixing procedures remained unchanged.

Strength of polymethylmethacrylate increased by vacuum mixing

The mechanical strength of high and low viscosity gentamicin-containing cement was analysed using three different mixing procedures: hand, vibration, and vacuum stirring. Vacuum mixing improved the flexural and compression strength and the modulus of elasticity by 15-30 per cent, especially for high viscosity cement.

Gastroesophageal sphincter pressure and serum gastrin: reaction to food stimulation in normal subjects and in patients with gastric or duodenal ulcer

Gastroesophageal sphincter pressure and serum gastrin concentration were determined in the fasting state and after the intake of a protein food in 6 normal subjects, 6 patients with gastric ulcer, and in 6 patients with duodenal ulcer. No significant differences in the fasting state were found. After the food intake, gastroesophageal sphincter pressure increased significantly over basal values in normals and in patients with duodenal ulcer, but in patients with gastric ulcer a decrease in pressure was noted. Serum gastrin rose in all subjects studied after the food stimulation, but it was significant only in the gastric and duodenal ulcer group. In two normals and two patients with duodenal ulcer the ingestion of a potato meal of similar weight to that of the protein meal showed no change either in serum gastrin or in sphincter pressure. In one additional normal subject and one duodenal ulcer patient the constant intravenous infusion of Aminosol for 2 h produced no change in serum gastrin or sphincter pressure. These results indicate that the effect of protein food on sphincter pressure is different for gastric or duodenal ulcers, and, furthermore, that this effect is mediated by proteins in the gastrointestinal tract.

Gastroesophageal sphincter pressure and serum gastrin: reaction to food stimulation in normal subjects and in patients with gastric or duodenal ulcer

Gastroesophageal sphincter pressure and serum gastrin concentration were determined in the fasting state and the intake of a protein food in 6 normal subjects, 6 patients with gastric ulcer, and in 6 patients with duodenal ulcer. No significant differences in the fasting state were found. After the food intake, gastroesophageal sphincter pressure increased significantly over basal values in normals and in patients with duodenal ulcer, but in patients with gastric ulcer a decrease in pressure was noted. Serum gastrin rose in all subjects studied after the food stimulation, but it was significant only in the gastric and duodenal ulcer group. In two normals and two patients with duodenal ulcer the ingestion of a potato meal similar in weight to the protein meal showed no change either in serum gastrin or in sphincter pressure. In one additional nromal and one duodenal ulcer, the constant intravenous infusion of Aminosol during 2 hours produced no change in serum gastrin or sphincter pressure. These results indicate that the effect of protein food on sphincter pressure is different for gastric or duodenal ulcers; furthermore, that this effect is mediated by proteins in the gastrointestinal tract.

Gastroesophageal sphincter pressure and serum gastrin studies following food intake before and after vagotomy for duodenal ulcer

Gastroesophageal sphincter pressure (GESP) and serum gastrin concentration (SGC) were determined in the basal state and after a protein meal in 6 patients with duodenal ulcer (DU) 6 patients after parietal cell vagotomy (PCV) 6 patients after selective gastric vagotomy plus drainage (SGV + D), and 6 patients after selective gastric vagotomy plus precise antrectomy (SGV + A). No correlation in the resting state between GESP and SGC was observed. After food ingestion, DU patients showed a sustained rise in GESP which lasted up to the end of the experiment. The vagotomized patients, however, showed no rise in sphincter pressure after food intake--rather a tendency to decrease in pressure occurred. On the contrary, SGC rose significantly after food ingestion in patients with SGV + D or PCV, while in DU patient this rise was less significant. Patients with vagotomy and antrectomy showed no rise in SGC. These results do not suggest that SGC and extrinsic vagal innervation in the resting state play a significant role in the maintenance of the tone of GES. After food ingestion an interaction may occur between intact vagal innervation and rise in SGC in order to obtain an adequate rise in GESP.

Gastroesophageal sphincter pressure and serum gastrin studies following food intake before and after vagotomy for duodenal ulcer

Gastroesophageal sphincter pressure (GESP) and serum gastrin concentration (SGC) were determined in the basal state and after a protein meal in six patients with duodenal ulcer (DU), six patients after parietal cell vagotomy (PCV), six patients after selective gastric vagotomy plus drainage (SGV + D), and six patients after selective gastric vagotomy plus precise antrectomy (SGV + A). No correlation in the resting state between GESP and SGC was observed. After food ingestion, DU patients showed a sustained rise in GESP which lasted up to the end of the experiment. The vagotomized patients, however, showed no rise in sphincter pressure after food intake--rather a tendency to a decrease in pressure occurred. On the contrary, SGC rose significantly after food ingestion in patients with SGV + D or PCV, while in DU patients this rise was less significant. Patients with vagotomy and antrectomy showed no rise in SGC. These results do not suggest that SGC and extrinsic vagal innervation in the resting state play a significant role in the maintenance of the tone of GES. After food ingestion an interaction may occur between intact vagal innervation and rise in SGC in order to obtain an adequate rise in GESP.

Induction of amylase in mustard seedlings by phytochrome

In the cotyledons of mustard seedlings (Sinapis alba L.) amylase activity can be induced by phytochrome. In the dark amylase activity remains low. Gibberellic acid (GA3) does not stimulate an increase of amylase activity in this system. Inhibitors of RNA and protein synthesis strongly inhibit the increase of amylase activity mediated by phytochrome. In gel electrophoresis amylase from mustard seedlings reveals 3 bands. The electrophoretic pattern is the same for extracts from dark-grown and from irradiated seedlings. When mustard amylases were incubated with starch the pattern of products was similar to that produced by commercially available barley β-amylase and not similar to that produced by Bacillus subtilis α-amylase.