[Performance development of a university operating room after implementation of a central operating room management]. / Leistungsentwicklung eines universitären OP-Bereichs nach Implementierung eines zentralen OP-Managements.

The difficult financial situation in German hospitals requires measures for improvement in process quality. Associated increases in revenues in the high income field "operating room (OR) area" are increasingly the responsibility of OR management but it has not been shown that the introduction of an efficiency-oriented management leads to an increase in process quality and revenues in the operating theatre. Therefore the performance in the operating theatre of the University Medical Center Göttingen was analyzed for working days in the core operating time from 7.45 a.m. to 3.30 p.m. from 2009 to 2014. The achievement of process target times for the morning surgery start time and the turnover times of anesthesia and OR-nurses were calculated as indicators of process quality. The number of operations and cumulative incision-suture time were also analyzed as aggregated performance indicators. In order to assess the development of revenues in the operating theatre, the revenues from diagnosis-related groups (DRG) in all inpatient and occupational accident cases, adjusted for the regional basic case value from 2009, were calculated for each year. The development of revenues was also analyzed after deduction of revenues resulting from altered economic case weighting. It could be shown that the achievement of process target values for the morning surgery start time could be improved by 40 %, the turnover times for anesthesia reduced by 50 % and for the OR-nurses by 36 %. Together with the introduction of central planning for reallocation, an increase in operation numbers of 21 % and cumulative incision-suture times of 12% could be realized. Due to these additional operations the DRG revenues in 2014 could be increased to 132 % compared to 2009 or 127 % if the revenues caused by economic case weighting were excluded. The personnel complement in anesthesia (-1.7 %) and OR-nurses (+2.6 %) as well as anesthetists (+6.7 %) increased less compared to the revenues or were slightly reduced. This improvement in process quality and cumulative incision-suture times as well as the increase in revenues, reflect the positive impact of an efficiency-oriented central OR management. The OR management releases due to measures of process optimization the necessary personnel and time resources and therefore achieves the basic prerequisites for increased revenues of surgical disciplines. The method presented can be used by other hospitals as a guideline to analyze performance development.

[Implementation of a rational standard of hygiene for preparation of operating rooms]. / Implementierung eines rationalen Hygienestandards zur Aufbereitung von Operationssälen.

BACKGROUND: The assurance of high standards of care is a major requirement in German hospitals while cost reduction and efficient use of resources are mandatory. These requirements are particularly evident in the high-risk and cost-intensive operating theatre field with multiple process steps. The cleaning of operating rooms (OR) between surgical procedures is of major relevance for patient safety and requires time and human resources. The hygiene procedure plan for OR cleaning between operations at the university hospital in Göttingen was revised and optimized according to the plan-do-check-act principle due to not clearly defined specifications of responsibilities, use of resources, prolonged process times and increased staff engagement. METHODS: The current status was evaluated in 2012 as part of the first step "plan". The subsequent step "do" included an expert symposium with external consultants, interdisciplinary consensus conferences with an actualization of the former hygiene procedure plan and the implementation process. All staff members involved were integrated into this management change process. The penetration rate of the training and information measures as well as the acceptance and compliance with the new hygiene procedure plan were reviewed within step "check". The rates of positive swabs and air sampling as well as of postoperative wound infections were analyzed for quality control and no evidence for a reduced effectiveness of the new hygiene plan was found. After the successful implementation of these measures the next improvement cycle ("act") was performed in 2014 which led to a simplification of the hygiene plan by reduction of the number of defined cleaning and disinfection programs for preparation of the OR. RESULTS: The reorganization measures described led to a comprehensive commitment of the hygiene procedure plan by distinct specifications for responsibilities, for the course of action and for the use of resources. Furthermore, a simplification of the plan, a rational staff assignment and reduced process times were accomplished. Finally, potential conflicts due to an insufficient evidence-based knowledge of personnel was reduced. CONCLUSION: This present project description can be used by other hospitals as a guideline for similar changes in management processes.

Keto/enol epoxy steroids as HIV-1 Tat inhibitors: structure-activity relationships and pharmacophore localization.

Inhibition of the HIV-1 nuclear regulatory protein tat could potentially yield particularly useful drugs because it functions as an activator of transcription. It has no known cellular counterpart, and deletions in the tat gene destroy the ability of HIV-1 to replicate. We recently reported that a structurally unique class of tat inhibitors, 3-keto/enol 4,5-alpha-epoxy steroids bearing electron-withdrawing substituents at position 2, specifically inhibit tat-induced gene expression in virus free transfected SW480 cells. In this paper, we report on additional SAR (structure-activity relationships) for the steroid series and the localization of the pharmacophore to the A-ring functionality. There is a weak enantioselective preference for the natural steroid stereochemistry and hints of additional SAR in the electron-withdrawing group. Compound 34a is of particular interest in that it inhibits HIV replication in H9 cells at a concentration equivalent to its inhibitory level in the primary tat assay.

[PTCA in the acute state of myocardial infarct: hospital course of 785 consecutive patients]. / PTCA im Stadium des akuten Myokardinfarktes: Hospitalverlauf von 785 konsekutiven Patienten.

Rapid reperfusion of the occluded coronary artery is essential for the reduction of mortality and complications of acute myocardial infarctions. Intravenous thrombolytic therapy using various thrombolytic substances has proven to be effective and easy to perform and has gained widespread acceptance for treatment of acute myocardial infarction. Because of several contraindications, as well as failure to achieve patency of the infarcted vessel in 25-30% of patients, severe bleeding complications, a time interval of 6 or more hours after suspected onset of myocardial infarction, and a high rate of recurrent ischemia, this treatment is currently limited to a small percentage of patients with acute myocardial infarction. Immediate percutaneous transluminal coronary angioplasty (PTCA) can be applied to nearly every patient presenting with acute myocardial infarction. Therefore, we offer immediate PTCA as the primary treatment to all of our patients presenting with acute myocardial infarction. Between January 1987 and December 1991, immediate PTCA was performed in 785 of 903 (87%) consecutive patients (aged 23-86 years, mean 61 +/- 10). 82% (640/785) of the patients were men. Anterior myocardial infarction was present in 372 patients (47%), inferior infarction in 413 patients (53%). 245 patients (31%) had 1-vessel disease, 221 patients (28%) two-vessel disease and 319 patients (41%) had three-vessel disease. 97 patients (12%) were in cardiogenic shock. In 675/785 patients (86%) the infarct related vessel was occluded (TIMI < or = 1). 86% of patients had a patent infarct related vessel (TIMI > or = 2) leaving the catheterization laboratory. The overall in-hospital mortality was 6.9% (54/785 patients), after exclusion of high-risk patients (age > 75 years, cardiogenic shock, PTCA under cardiopulmonary resuscitation) mortality decreased to 2.5%. Recurrent ischemia necessitated immediate repeat PTCA in 4.4% of the patients, in 8.1% of patients another elective PTCA was performed during hospitalization and 9.7% of patients were sent to surgery (4.0% on an emergency basis). 87% of all patients presenting with acute myocardial infarction could be treated successfully with immediate PTCA. With respect to the severely ill group of patients the primary success rate is high, the rate of reocclusion is low, and the overall mortality is extremely low. From our data, it is obvious that immediate PTCA compared to thrombolytic therapy is the superior treatment of myocardial infarction.

GAL1-GAL10 divergent promoter region of Saccharomyces cerevisiae contains negative control elements in addition to functionally separate and possibly overlapping upstream activating sequences.

The upstream activating sequence (UASG) of the adjacent and divergently transcribed GAL1 and GAL10 promoters of Saccharomyces cerevisiae regulates the induction of the corresponding genes in response to the presence of galactose. We constructed chimeric yeast promoters in which a different UAS, UASC from the iso-1-cytochrome c (CYC1) gene of S. cerevisiae, was fused at different locations upstream of GAL1 (UASC-GAL1 promoters) or GAL10 (UASC-GAL10 promoters) and used to monitor the activity of UASG in cells grown in the presence or absence of galactose. Though the CYC1 promoter is fully induced in yeast grown in glycerol medium, UASC-GAL chimeric promoters containing UASG were repressed as much as 400-fold (UASC-GAL1) or 1350-fold (UASC-GAL10) in this growth medium. Several distinct portions of the GAL1-GAL10 divergent promoter region blocked the UASC-induced expression of the GAL1 and GAL10 promoters, whereas others did not, suggesting that several distinct negative control elements are present that may repress transcription of GAL1 and GAL10 in the absence of galactose. The approximate locations of these negative control elements were delimited to sites adjacent to or possibly overlapping the sites at which the positive control protein GAL4 binds in UASG. Deletion derivatives of GAL4 that fail to induce transcription from the wild-type GAL promoters but retain the DNA binding domain significantly derepressed the expression of the UASC-GAL chimeric promoters. These results, combined with those of earlier studies, suggest the possibility that GAL4 normally induces transcription of GAL1 and GAL10 by blocking the activity of these negative control elements, in addition to stimulating transcription by a mechanism of positive control.