[Cost unit accounting of strabismus surgery at a university eye hospital]. / Kostenträgerrechnungen von strabologischen Operationen an einer Universitäts-Augenklinik.

BACKGROUND: Strabismus surgery is frequently carried out in university centers. The aim of this work was to calculate the costs of strabismus surgery at a university hospital and to assess the remuneration of costs for outpatient procedures. MATERIAL AND METHODS: Of all strabismus surgeries at the Hanover Medical School in the years 2018 and 2019, relevant surgical data, such as patient age, number of muscles operated on, incision to suture time, attendance time of the surgeons and anesthetists as well as the nursing staff, were evaluated based on the clinics own information system. During this process, the costs for personnel, material, room rental charges and overheads were computed applying cost unit accounting. RESULTS: A total of 302 operations (inpatient proportion 92.1%) were carried out in most cases with the patient under general anesthesia. The mean patient age was 31 years (median 26 years), with 33 patients being children under 6 years of age. On average 1.84 muscles were treated per intervention. The mean incision to suture time was 51.5 min, mean anesthesia time was 85 min, the attendance time of surgical as well as anesthesia nursing staff each accounted for 104 min, the additional time in the postanesthesia care unit added 66 min. Average personnel costs originating from the overall process amounted to 642.14 €, with the addition of 109.23 € for material and medication (surgery and anesthesia) and costs for cleaning and room rental (including overheads) of 178.71 €. Therefore, the overall costs of an average strabismus surgery in our collective added up to 930.08 € (minimum 491.01 €, maximum 1729.29 €). Cost accounting of subgroups yielded substantially higher costs for anesthesia in children as well as for higher numbers of muscles operated on due to different treatment duration (37 min for 1 muscle to 72 min for 3 muscles) and anesthesia time, especially in children <6 years of age (on average 22 min longer than adults and children >5 years; the differences being 11 min for 1 muscle, 25 min for 2 muscles and 30 min for 3 or more muscles). The pure costs of a strabismus surgery at this clinic seem on average to exceed the revenues for strabismus surgery in the outpatient sector calculated by the German uniform evaluation benchmark (EBM) by about a factor of 2. CONCLUSION: It could be shown that the purely economically calculated costs for strabismus surgery at a university clinic are significantly higher than the revenues achieved in the outpatient sector according to paragraph 115b, section 1, of the Social Security Act V (SGB V). Under these circumstances, such operations cannot be performed in a cost-effective manner.

Molecular surveillance of measles and rubella in the WHO European Region: new challenges in the elimination phase.

BACKGROUND: The WHO European Region (EUR) has adopted the goal of eliminating measles and rubella but individual countries perform differently in achieving this goal. Measles virus spread across the EUR by mobile groups has recently led to large outbreaks in the insufficiently vaccinated resident population. As an instrument for monitoring the elimination process and verifying the interruption of endemic virus transmission, molecular surveillance has to provide valid and representative data. Irrespective of the country's specific situation, it is required to ensure the functionality of the laboratory surveillance that is supported by the WHO Global Measles and Rubella Laboratory Network. AIMS: To investigate whether the molecular surveillance in the EUR is adequate for the challenges in the elimination phase, we addressed the quality assurance of molecular data, the continuity and intensity of molecular monitoring, and the analysis of transmission chains. SOURCES: Published articles, the molecular External Quality Assessment Programme of the WHO, the Centralized Information System for Infectious Diseases of the WHO EUR and the WHO Measles and Rubella Nucleotide Surveillance databases served as information sources. CONTENT: Molecular proficiency testing conducted by the WHO in 2016 has shown that the expertise for measles and rubella virus genotyping exists in all parts of the EUR. The analysis of surveillance data reported nationally to the WHO in 2013-2016 has revealed some countries with outbreaks but not sufficiently representative molecular data. Long-lasting supranational MV transmission chains were identified. IMPLICATIONS: A more systematic molecular monitoring and recording of the transmission pattern for the whole EUR could help to create a meaningful picture of the elimination process.

Connectivity of diagnostic technologies: improving surveillance and accelerating tuberculosis elimination.

In regard to tuberculosis (TB) and other major global epidemics, the use of new diagnostic tests is increasing dramatically, including in resource-limited countries. Although there has never been as much digital information generated, this data source has not been exploited to its full potential. In this opinion paper, we discuss lessons learned from the global scale-up of these laboratory devices and the pathway to tapping the potential of laboratory-generated information in the field of TB by using connectivity. Responding to the demand for connectivity, innovative third-party players have proposed solutions that have been widely adopted by field users of the Xpert(®) MTB/RIF assay. The experience associated with the utilisation of these systems, which facilitate the monitoring of wide laboratory networks, stressed the need for a more global and comprehensive approach to diagnostic connectivity. In addition to facilitating the reporting of test results, the mobility of digital information allows the sharing of information generated in programme settings. When they become easily accessible, these data can be used to improve patient care, disease surveillance and drug discovery. They should therefore be considered as a public health good. We list several examples of concrete initiatives that should allow data sources to be combined to improve the understanding of the epidemic, support the operational response and, finally, accelerate TB elimination. With the many opportunities that the pooling of data associated with the TB epidemic can provide, pooling of this information at an international level has become an absolute priority.

Add Control: plant virtualization for control solutions in WWTP.

This paper summarizes part of the research work carried out in the Add Control project, which proposes an extension of the wastewater treatment plant (WWTP) models and modelling architectures used in traditional WWTP simulation tools, addressing, in addition to the classical mass transformations (transport, physico-chemical phenomena, biological reactions), all the instrumentation, actuation and automation & control components (sensors, actuators, controllers), considering their real behaviour (signal delays, noise, failures and power consumption of actuators). Its ultimate objective is to allow a rapid transition from the simulation of the control strategy to its implementation at full-scale plants. Thus, this paper presents the application of the Add Control simulation platform for the design and implementation of new control strategies at the WWTP of Mekolalde.

Biofilm model calibration and microbial diversity study using Monte Carlo simulations.

Mathematical models are useful tools for studying and exploring biological conversion processes as well as microbial competition in biological treatment processes. A single-species biofilm model was used to describe biofilm reactor operation at three different hydraulic retention times (HRT). The single-species biofilm model was calibrated with sparse experimental data using the Monte Carlo filtering method. This calibrated single-species biofilm model was then extended to a multi-species model considering 10 different heterotrophic bacteria. The aim was to study microbial diversity in bulk phase biomass and biofilm, as well as the competition between suspended and attached biomass. At steady state and independently of the HRT, Monte Carlo simulations resulted only in one unique dominating bacterial species for suspended and attached biomass. The dominating bacterial species was determined by the highest specific substrate affinity (ratio of µ/KS ). At a short HRT of 20 min, the structure of the microbial community in the bulk liquid was determined by biomass detached from the biofilm. At a long HRT of 8 h, both biofilm detachment and microbial growth in the bulk liquid influenced the microbial community distribution.

Systematic evaluation of biofilm models for engineering practice: components and critical assumptions.

Biofilm models are valuable tools for the design and evaluation of biofilm-based processes despite several uncertainties including the dynamics and rate of biofilm detachment, concentration gradients external to the biofilm surface, and undefined biofilm reactor model calibration protocol. The present investigation serves to (1) systematically evaluate critical biofilm model assumptions and components and (2) conduct a sensitivity analysis with the aim of identifying parameter subsets for biofilm reactor model calibration. AQUASIM was used to describe submerged-completely mixed combined carbon oxidation and nitrification IFAS and MBBR systems, and tertiary nitrification and denitrification MBBRs. The influence of uncertainties in model parameters on relevant model outputs was determined for simulated scenarios by means of a local sensitivity analysis. To obtain reasonable simulation results for partially penetrated biofilms that accumulated a substantial thickness in the modelled biofilm reactor (e.g. 1,000 microm), an appropriate biofilm discretization was applied to properly model soluble substrate concentration gradients and, consistent with the assumed mechanism for describing biofilm biomass distribution, biofilm biomass spatial variability. The MTBL thickness had a significant impact on model results for each of the modelled reactor configurations. Further research is needed to develop a mathematical description (empirical or otherwise) of the MTBL thickness that is relevant to modern biofilm reactors. No simple recommendations for a generally applicable calibration protocol are provided, but sensitivity analysis has been proven to be a powerful tool for the identification of highly sensitive parameter subsets for biofilm (reactor) model calibration.

Evaluating operating conditions for outcompeting nitrite oxidizers and maintaining partial nitrification in biofilm systems using biofilm modeling and Monte Carlo filtering.

In practice, partial nitrification to nitrite in biofilms has been achieved with a range of different operating conditions, but mechanisms resulting in reliable partial nitrification in biofilms are not well understood. In this study, mathematical biofilm modeling combined with Monte Carlo filtering was used to evaluate operating conditions that (1) lead to outcompetition of nitrite oxidizers from the biofilm, and (2) allow to maintain partial nitrification during long-term operation. Competition for oxygen was found to be the main mechanism for displacing nitrite oxidizers from the biofilm, and preventing re-growth of nitrite oxidizers in the long-term. To maintain partial nitrification in the model, a larger oxygen affinity (i.e., smaller half saturation constant) for ammonium oxidizers compared to nitrite oxidizers was required, while the difference in maximum growth rate was not important for competition under steady state conditions. Thus, mechanisms for washout of nitrite oxidizing bacteria from biofilms are different from suspended cultures where the difference in maximum growth rate is a key mechanism. Inhibition of nitrite oxidizers by free ammonia was not required to outcompete nitrite oxidizers from the biofilm, and to maintain partial nitrification to nitrite. But inhibition by free ammonia resulted in faster washout of nitrite oxidizers.

Practical identifiability of biokinetic parameters of a model describing two-step nitrification in biofilms.

Parameter estimation and model calibration are key problems in the application of biofilm models in engineering practice, where a large number of model parameters need to be determined usually based on experimental data with only limited information content. In this article, identifiability of biokinetic parameters of a biofilm model describing two-step nitrification was evaluated based solely on bulk phase measurements of ammonium, nitrite, and nitrate. In addition to evaluating the impact of experimental conditions and available measurements, the influence of mass transport limitation within the biofilm and the initial parameter values on identifiability of biokinetic parameters was evaluated. Selection of parameters for identifiability analysis was based on global mean sensitivities while parameter identifiability was analyzed using local sensitivity functions. At most, four of the six most sensitive biokinetic parameters were identifiable from results of batch experiments at bulk phase dissolved oxygen concentrations of 0.8 or 5 mg O(2)/L. High linear dependences between the parameters of the subsets (KO2,AOB,muAOB) and (KO2,NOB,muNOB) resulted in reduced identifiability. Mass transport limitation within the biofilm did not influence the number of identifiable parameters but, in fact, decreased collinearity between parameters, especially for parameters that are otherwise correlated (e.g., muAOB) and KO2,AOB, or muNOB and KO2,NOB). The choice of the initial parameter values had a significant impact on the identifiability of two parameter subsets, both including the parameters muAOB and KO2,AOB. Parameter subsets that did not include the subsets muAOB and KO2,AOB or muNOB and KO2,NOB were clearly identifiable independently of the choice of the initial parameter values.

Comparing global sensitivity analysis for a biofilm model for two-step nitrification using the qualitative screening method of Morris or the quantitative variance-based Fourier Amplitude Sensitivity Test (FAST).

Two different methods for global sensitivity analysis were compared exemplarily for a biofilm model for two-step nitrification. Especially for biofilm models, local sensitivity analysis is not very useful as parameters can vary over a large range. Parameters that were evaluated included kinetic and stoichiometric parameters, and also biofilm parameters, such as internal and external mass transfer, the biofilm thickness, and the biomass density. Global sensitivity analyses were performed for a range of operating conditions of a biofilm reactor. The results of the qualitative screening method of Morris were compared with the results of the quantitative variance-based method FAST regarding the input parameters indicated as unimportant. Both methods resulted in similar sets of parameters with a small influence on the model output, but the screening method of Morris required a much smaller number of model evaluations to compute the sensitivity measures than the FAST method.

Estimation of kinetic parameters of a model for deammonification in biofilms and evaluation of the model.

A systematic approach to estimate and evaluate parameters for deammonification in biofilms from available experimental data was evaluated. Parameter estimation was based on a regional steady state sensitivity analysis to select relevant parameters and design of experiments based on a local identifiability analysis. The calibrated model was evaluated under different experimental conditions. Nine of the 16 kinetic and stoichiometric parameters had a significant influence on model predictions. Of these nine parameters only six kinetic parameters were identifiable from batch experiments regardless of the experimental design. More parameters were not identifiable due to high correlations between growth rates and the corresponding affinity constant for oxygen. Data from a batch experiment at 2 mg/L dissolved oxygen (DO) were used to estimate inactivation rates and affinity constants for oxygen for ammonium oxidisers (AO), nitrite oxidisers (NO) and anaerobic ammonium oxidisers (AN). In addition, it was found that not only kinetic and stoichiometric parameters but also the external mass transfer resistance significantly affected model predictions. The resulting model was able to reproduce batch test and continuous reactor operation where DO concentrations were similar to those in the batch experiment used for parameter estimation. However, the model overestimated deammonification for a batch experiment at a much higher DO concentration (5 mg/L). Thus, parameter values that are identifiable and are estimated for given environmental conditions may not necessarily be valid for significantly different experimental conditions.

The scaling laws of human travel.

The dynamic spatial redistribution of individuals is a key driving force of various spatiotemporal phenomena on geographical scales. It can synchronize populations of interacting species, stabilize them, and diversify gene pools. Human travel, for example, is responsible for the geographical spread of human infectious disease. In the light of increasing international trade, intensified human mobility and the imminent threat of an influenza A epidemic, the knowledge of dynamical and statistical properties of human travel is of fundamental importance. Despite its crucial role, a quantitative assessment of these properties on geographical scales remains elusive, and the assumption that humans disperse diffusively still prevails in models. Here we report on a solid and quantitative assessment of human travelling statistics by analysing the circulation of bank notes in the United States. Using a comprehensive data set of over a million individual displacements, we find that dispersal is anomalous in two ways. First, the distribution of travelling distances decays as a power law, indicating that trajectories of bank notes are reminiscent of scale-free random walks known as Lévy flights. Second, the probability of remaining in a small, spatially confined region for a time T is dominated by algebraically long tails that attenuate the superdiffusive spread. We show that human travelling behaviour can be described mathematically on many spatiotemporal scales by a two-parameter continuous-time random walk model to a surprising accuracy, and conclude that human travel on geographical scales is an ambivalent and effectively superdiffusive process.

Forecast and control of epidemics in a globalized world.

The rapid worldwide spread of severe acute respiratory syndrome demonstrated the potential threat an infectious disease poses in a closely interconnected and interdependent world. Here we introduce a probabilistic model that describes the worldwide spread of infectious diseases and demonstrate that a forecast of the geographical spread of epidemics is indeed possible. This model combines a stochastic local infection dynamics among individuals with stochastic transport in a worldwide network, taking into account national and international civil aviation traffic. Our simulations of the severe acute respiratory syndrome outbreak are in surprisingly good agreement with published case reports. We show that the high degree of predictability is caused by the strong heterogeneity of the network. Our model can be used to predict the worldwide spread of future infectious diseases and to identify endangered regions in advance. The performance of different control strategies is analyzed, and our simulations show that a quick and focused reaction is essential to inhibiting the global spread of epidemics.

Particle dispersion on rapidly folding random heteropolymers.

We investigate the dynamics of a particle moving randomly along a disordered heteropolymer subjected to rapid conformational changes which induce superdiffusive motion in chemical coordinates. We study the antagonistic interplay between the enhanced diffusion and the quenched disorder. The dispersion speed exhibits universal behavior independent of the folding statistics. On the other hand it is strongly affected by the structure of the disordered potential. The results may serve as a reference point for a number of translocation phenomena observed in biological cells, such as protein dynamics on DNA strands.

Lévy flights in inhomogeneous media.

We investigate the impact of external periodic potentials on superdiffusive random walks known as Lévy flights and show that even strongly superdiffusive transport is substantially affected by the external field. Unlike ordinary random walks, Lévy flights are surprisingly sensitive to the shape of the potential while their asymptotic behavior ceases to depend on the Lévy index mu. Our analysis is based on a novel generalization of the Fokker-Planck equation suitable for systems in thermal equilibrium. Thus, the results presented are applicable to the large class of situations in which superdiffusion is caused by topological complexity, such as diffusion on folded polymers and scale-free networks.

The multifunctional role of E1A in the transcriptional regulation of CREB/CBP-dependent target genes.

Oncoproteins encoded by the early region 1A (E1A) of adenoviruses (Ads) have been shown to be powerful tools to study gene regulatory mechanisms. As E1A proteins lack a sequence-specific DNA-binding activity, they modulate viral and cellular gene expression by interacting directly with a diverse array of cellular factors, among them sequence-specific transcription factors, proteins of the general transcription machinery, co-activators and chromatin-modifying enzymes. By making use of these factors, E1A affects major cellular events such as cell cycle control, differentiation, apoptosis, and oncogenic transformation. In this review we will focus on the interaction of E1A with cellular components involved in the cAMP/PKA signal transduction pathway and we will discuss the consequences of these interactions in respect to the activation of CREB/CBP-dependent target genes.

The histone acetyltransferase activity of PCAF cooperates with the brahma/SWI2-related protein BRG-1 in the activation of the enhancer A of the MHC class I promoter.

Major histocompatibility complex (MHC) class I proteins are an essential component of the immune system allowing the organism to protect from viral infections and neoplastic transformation. Expression of the MHC class I genes is regulated by a variety of cis-regulatory promoter elements among which the enhancer A is of particular importance. This enhancer is synergistically activated through AP-1/ATF and NF-kappa B transcription factors. NF-kappa B recruits the histone acetyltransferase (HAT) p300/CREB-binding protein (CBP) to the multiprotein complex bound to the enhancer A. Here we present evidence that acetylation and deacetylation processes are involved in the activation of the enhancer A. The p300/CBP associated factor PCAF, but not p300/CBP, counteracts the repression of the enhancer A mediated by the histone deacetylase HDAC1. Furthermore, overexpression of PCAF results in an increase in the acetylation of histone H4 bound to the enhancer A and HDAC1 counteracts the PCAF-mediated H4 acetylation. The activation function of PCAF requires the p300/CBP binding motif indicating that PCAF might be recruited to the enhancer A through an association with p300/CBP. Moreover, PCAF and the Brahma/SWI2-related protein BRG-1, which is a key factor of the human ATP-dependent chromatin remodelling complex SWI/SNF, synergistically up-regulate the enhancer A. Synergistic activation requires the HAT domain of PCAF. Taken together our data suggest that members of two different groups of chromatin modifying complexes are involved in the activation of the enhancer A of the MHC class I promoter.

Binding of PKA-RIIalpha to the Adenovirus E1A12S oncoprotein correlates with its nuclear translocation and an increase in PKA-dependent promoter activity.

The adenovirus type 12 (Ad12) E1A12S oncoprotein utilizes the cAMP/protein kinase A (PKA) signal transduction pathway to activate expression of the viral E2 gene, the products of which are essential for viral replication. A central unsolved question is, however, whether E1A12S interacts directly with PKA in the process of promoter activation. We show here that E1A12S binds to the regulatory subunits (R) of PKA in vitro and in vivo. Interaction depends on the N-terminus and the conserved region 1 (CR1) of E1A12S. Both domains are also essential for the activation of viral E2 gene expression. Infection of cells with Ad12 leads to the cellular redistribution of RIIalpha from the cytoplasm into the nucleus. Furthermore, RIIalpha is also located in the nucleus of cells transformed by E1 of Ad12 and transient expression of E1A12S leads to the redistribution of RIIalpha into the nucleus in a N-terminus- and CR1-dependent manner. Cotransfection of E1A12S with RIIalpha results in strong activation of the E2 promoter. Based on these results we conclude that E1A12S functions as a viral A-kinase anchoring protein redistributing RIIalpha from the cytoplasm into the nucleus where it is involved in E1A12S-mediated activation of the E2 promoter.

E1A12S-mediated activation of the adenovirus type 12 E2 promoter depends on the histone acetyltransferase activity of p300/CBP.

Activation of the transcription unit early region 2 (E2) promoter of the oncogenic adenovirus serotype 12 (Ad12), which regulates the expression of proteins essential for viral replication, requires the assembly of a ternary complex consisting of cAMP response element-binding protein (CREB)-1/activating transcription factor (ATF)-1, the Ad12 12S oncogene product of early region 1A (E1A(12S)), and the co-activator p300/CBP on the E2(Ad12) cAMP response element (E2-CRE). Here we show that the active E2(Ad12) promoter is associated with acetylated histone H4 whereas an E2-CRE point-mutated promoter which is transcriptionally inactive due to its inability to assemble this ternary complex is not bound by acetylated histone H4. The histone deacetylase 1 as well as Roscovitine, which blocks the activation of the histone acetyltransferase (HAT) activity of CBP by cyclin E-Cdk2, prevents E2(Ad12) promoter activation through E1A(12S). p300/CBP counteracts the repressive function of histone deacetylase 1 in a HAT domain-dependent manner whereas the p300/CBP-associated factor PCAF failed to rescue E2(Ad12) promoter activity. E1A(12S) bound p300/CBP displays strong HAT activity. Most interestingly, E1A(12S)-mediated activation of the E2(Ad12) promoter correlates well with the ability of the viral protein to associate with the HAT activity of p300/CBP in vivo. Taken together these data indicate that the recruitment of the HAT activity of p300/CBP by E1A(12S) plays an important role in E2(Ad12) promoter activation.

cAMP-independent activation of the adenovirus type 12 E2 promoter correlates with the recruitment of CREB-1/ATF-1, E1A(12S), and CBP to the E2-CRE.

Expression of the transcription unit early region 2 (E2) is of crucial importance for adenoviruses because this region encodes proteins essential for viral replication. Here, we demonstrate that the E1A(12S) protein of the oncogenic adenovirus serotype 12 activates the E2 promoter in dependence of the N terminus and the conserved region 1. Activation is mediated through a cAMP-response element that is bound by CREB-1 and ATF-1. Moreover, the Ad12 E2 promoter is inducible by protein kinase A and repressed by either a dominant-negative cAMP-response element-binding protein (CREB) mutant or the highly specific protein kinase A inhibitor protein underscoring the participation of CREB-1/ATF-1 in promoter activation. E1A(12S) binds to CREB-1 and ATF-1 in dependence of the N terminus and CR1 and is recruited to the E2 cAMP-response element through both cellular transcription factors. Most interestingly, point mutations revealed that E1A(12S) domains essential for binding to CREB-1/ATF-1 and for activation of the Ad12 E2 promoter are also essential for binding to the CREB-binding protein. Due to these data and results obtained in DNA-dependent protein-protein interaction assays, we propose a model in which the cAMP-independent activation of the Ad12 E2 promoter is mediated through a ternary complex consisting of CREB-1/ATF-1, E1A(12S), and CREB-binding protein, which assembles on the E2 cAMP-response element.