An Observational Study to Identify Drug-related Problems (DRP) in Routine Care and An Expert Panel Assessment to Rate Clinical Risk and Preventability by Unit-dose Dispensing Systems (UDDS) with Computerized Physician Order Entry (CPOE) and Clinical Decision-Support Systems (CDSS).

Background and aim: Drug-related problems (DRP) jeopardize patient safety. Unit-dose dispensing systems (UDDS) with computerized-physician-order-entry (CPOE) and clinical-decision-support-systems (CDSS) were reported as a promising concept for preventing DRP. We aimed at identifying and categorizing DRP in peroral drug administration considering their clinical risk and preventability by UDSS/CPOE/CDSS. Investigations: In surgical and internal-medicine departments, we observed routine procedures in peroral drug administration for DRP. An expert panel including pharmaceutical and nursing expertise categorized the identified 18 DRP categories into three levels: DRP that have not yet resulted in medication errors (ME) (Level-I), DRP where ME have occurred but have not yet reached the patient (Level-II), and DRP where ME have occurred and have reached the patient (Level-III). Additionally, the panel categorized DRP according to their clinical risk and whether the implementation of UDSS/CPOE/CDSS can prevent them. Results: In 77 surgical patients, 1,849 peroral drug administration procedures, and in 149 internal-medicine patients, 1,405 procedures were observed. The 18 DRP categories were identified with a frequency of 0.6%-26.7% (Level-I), 0.1%-21.5% (Level-II), and 0.0%-1.0% (Level-III). Of those, four categories were considered of high clinical risk: "Name of the medication is not readable", "Prescribed medication is not prepared for administration", "An incorrect or non-prescribed medication is prepared", and "A medication is prepared for the wrong patient (mix-up)". Twelve DRP categories were categorized as highly preventable by UDSS/CPOE/CDSS. Conclusions:Under routine conditions, we identified a substantial number of DRPs. An expert panel categorized many of those DRPs as clinically highly relevant and highly preventable by UDSS/CPOE/CDSS.

[Mild head injury in children and adults: Diagnostic challenges in the emergency department]. / Leichtes Schädel-Hirn-Trauma bei Kindern und Erwachsenen: Diagnostische Herausforderungen in der Notfallaufnahme.

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

[Mild head injury in children and adults. Diagnostic challenges in the emergency department]. / Leichtes Schädel-Hirn-Trauma bei Kindern und Erwachsenen. Diagnostische Herausforderungen in der Notfallaufnahme.

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

Evaluation of molecular typing methods for Salmonella enterica serovar Typhimurium DT104 isolated in Germany from healthy pigs.

The discriminatory power of four different DNA based typing methods was tested for the molecular subtyping of Salmonella Typhimurium phage type DT104 isolates. German DT104 strains (n = 133) originating from slaughter pigs were analysed by plasmid profiling, and 32 of them by pulsed-field gel electrophoresis (PFGE) using the restriction enzymes XbaI, SpeI or BlnI, random amplification of polymorphic DNA (RAPD) using 13 different primers and IS200 typing. A resulting subtyping scheme was obtained which is based on the most discriminatory power of the individual methods i.e. plasmid profiling and PFGE with all three enzymes. The index of discrimination obtained by the subtyping scheme was 0.909 closely approaching the maximum value of one. Although minor differences occurred in the molecular DNA pattern of single DT104 strains, a dominating subtyping pattern was observed confirming other studies which showed, that S. Typhimurium DT104 isolates are highly clonal.

[Technical measuring procedures for 3-dimensional movement analysis of experimentally-induced fractures of the thoracolumbar spine and initial results]. / Messtechnisches Verfahren zur dreidimensionalen Bewegungsanalyse von experimentell erzeugten Frakturen der thorakolumbalen Wirbelsäule und erste Ergebnisse.

Biomechanics and motion following fractures of the thoracolumbar spine have not yet been clarified. The motion acts in 6 degrees of freedom: three rotations and three translations parallel to the system of coordinates. The problem is to measure each rotation and each translation individually. This requires a method allowing precise three-dimensional evaluation of the motion that takes place in the genesis of a spine fracture. This technique should not influence the experiment, should give exact data over a wide range of measurement and, finally, should require as little equipment as possible. To fulfil these conditions we have developed a "double cube" model. Cadaver spine units from T11 to L3 were used. T11 was blocked with T12 and L2 with L3. These blocks were used to fix the spine in a testing machine so that a wedge-compression fracture could be produced in L1. Dorsal to each of the blocks one cube was mounted, the caudal one fixed while the cranial one could be moved by the machine. In the caudal cube a right-handed cartesian system of coordinates was defined, in which the vertebrate above would move and break. This technique can be used to describe either physiological or fracture experiments or, for example, to compare stability tests for different fixation devices. It is demonstrated that precise three-dimensional description of the biomechanics of vertebral fractures is possible with little and simple equipment. The cubes in this model are easily to integrate in the experiment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Molecular biologic methods for epidemiological precision characterization of disease agents using Salmonella enteritidis from poultry as an example]. / Molekularbiologische Methoden zur epidemiologischen Feincharakterisierung von Krankheitserregern am Beispiel von Salmonella enteritidis aus Geflügel.

The principles of molecular biological methods for epidemiological investigation of infectious bacteria are described. They were applied for differentiating S. enteritidis isolates originating from poultry. Among the methods described are the determination of the chromosomal DNA fingerprints (BRENDA), the methods of multilocus enzyme electrophoresis, plasmid profiles, and the outer membrane protein as well as lipopolysaccharide pattern. It turned out, that S. enteritidis strains isolated before 1987, in 1988 and the ones originating from Great Britain did not differ in anyone of these criteria. Consequently one has to assume, that the strains recently causing problems originate from the population of S. enteritidis which had existed in poultry before.

Epidemiology of virulence-associated plasmids and outer membrane protein patterns within seven common Salmonella serotypes.

Antibiotic-sensitive Salmonella isolates belonging to seven common serotypes and originating from 29 different countries from all continents were investigated for their plasmid DNA content (337 isolates) and their outer membrane protein profiles (216 isolates). Of the S. typhimurium, S. enteritidis, S. dublin, and S. choleraesuis isolates, 90% or more carried a serotype-specific plasmid. The molecular sizes of the plasmids were 60 megadaltons (Md) for S. typhimurium, 37 Md for S. enteritidis, 56 Md for S. dublin, and 30 Md for S. choleraesuis. The outer membrane protein profiles were homogeneous within each of the seven serotypes, except that a minority of S. enteritidis and S. dublin strains were lacking one major outer membrane protein. Virulence studies were performed with 39 representative strains by measuring the 50% lethal doses (LD50S) after oral infection of mice. The LD50 values obtained for plasmid-positive strains of S. typhimurium, S. enteritidis, and S. dublin were up to 10(6)-fold lower than the values obtained for the plasmid-free strains of the same serotype. Only the plasmid-positive strains could invade the livers of orally infected mice, and only they were resistant to the bactericidal activity of 90% guinea pig serum. Strains of S. infantis were generally plasmid free, whereas S. panama and S. heidelberg isolates carried heterogeneous plasmid populations. The virulence properties of the latter three serotypes could not be correlated with the predominant plasmids found in these strains.

Metabolic profiles in diabetic subjects treated with human insulin (Novo) and porcine insulin.

Twenty-four-hour metabolic profiles were used to compare the efficacy of twice-daily injections of purified porcine and human Actrapid and Monotard insulins (Novo) in six insulin-treated diabetic subjects. Although both insulin regimens resulted in similar plasma glucose profiles, values were lower during the night with porcine insulin treatment. These differences in plasma glucose response may represent an increased effectiveness of porcine insulin. Alternatively, evaluation of the plasma glucose profiles by the mean of the daily differences suggests that inherent day-to-day variations in diabetic control could explain the differences observed. Also, the potency of the porcine insulin used was greater than that of the human insulin and may have contributed to the differences in glucose response. No differences were observed in pyruvate, lactate, total ketones, and insulin profiles over the 24-h period. No adverse reactions to human insulin occurred.

Home blood glucose analysers. A consumer survey.

The seven home glucose analysers available on the Australian market were evaluated with respect to accuracy, ease of operation, price and additional features. At the same time, the BM-Test-Glycemie 20-800 dual sticks were assessed. The Boehringer Reflomat and Ames Eyetone can be regarded primarily as hospital instruments. The Ames Dextrometer, the Hypo-Count and both Stan Clark R.A.H.C. Glucose Testers were all adequate for home glucose monitoring. However, the Stan Clark R.A.H.C. Glucose Tester operating on Ames blood glucose reagent strips achieved the highest recommendation over all. The Glucochek was found to be an inconsistent instrument.

Male pseudohermaphrodite reared as a female.

A 31-year-old male pseudohermaphrodite has been brought up as a female. The parents had told their child not to discuss the problem of ambiguous genitalia with anyone. As a teenager masculinization had occurred. Chromosome analysis of both peripheral blood and gonadal tissue was 46XY. The internal gonads were testes surrounded by a rim of ovarian stroma. A rudimentary cervix opened into a small vagina, as did the urethra in a valve-like fashion. The phallus was amputated during surgical reconstruction of the external genitalia to create a phenotypic female and the vagina was enlarged. Oestrogen therapy resulted in breast development.

The urinary excretion of cortisol and cortisone glucosiduronates in pregnancy.

The urinary excretions of cortisol and cortisone glucosiduronates were measured at monthly intervals in three normal pregnancies by a double isotope dilution derivative method. The excretions were mostly within the normal range, but some were above the normal range suggesting that these excretions may increase in some pregnancies.

An evaluation of laboratory tests for the detection and differential diagnosis of Cushing's syndrome.

1. Results of tests for the diagnosis of Cushings syndrome of varoius aetiologies are discussed for twenty-five patients in whom the pathology was established by operation or autopsy. 2. Control values for the urinary excretion of free cortisol, 17-OHCS, Porter-Silber chromogens (P-SC) and 17-OS and plasma levels of P-SC are compared with those for normal subjects. 3. The results indicated that urinary values are within the normal range for some patients with Cushing's syndrome. 4. Plasma levels of P-SC in the morning were within the normal range for the majority and elevated for the rest. 5. Some patients showed day-night variation of plasma P-SC but evening values were above the normal range. 6. The expected response for low dosage dexamethasone was found in all patients tested but unexpected responses followed high dosage in some. 7. Plasma 11-OHCS in the five patients tested failed to respond to insulin induced hypoglycaemia. 8. Metyrapone administration and corticotrophin infusion tests had limited usefulness in establishing the aetiology of the disease. The 17-OHCS excretion became raised in the response to corticotrophin and the evaluation was prolonged beyond normal responsiveness.

[The development of antibiotics resistance among Salmonella bacteria of animal origin in the Federal Republic of Germany and Berlin (West). 5th communication: 1974 Annual report (author's transl)]. / Die Entwicklung der Antibiotikaresistenz von Salmonellabakterien tierischer Herkunfit in der Bundesrepublik Deutschland einschliesslich Berlin (West). 5. Mitteilung: Jahresbericht 1974

2713 salmonella strains having been isolated by veterinary laboratories in the Federal Republic of Germany including West Berlin in 1974 were tested for resistance to tetracyclines, ampicillin, chloramphenicol, kanamycin, gentamycin, furazolidone, nitrofurazone, and trimethoprim. 21.7% of the strains tested were resistant to one or several of the antibacterially effective substances examined. The proportion of the resistant strains amounted to 52% for S. typhimurium and 4.7% for S. typhimurium var. copenhagen, 16.8% for S. enteritidis, and 22.1% for S. panama, 85.1% of all resistant strains belonged to these types. Out of 589 resistant strains found, resistance determinants were present in 93.7% to tetracyclines, 34.6% to ampicillin, 32.4% to chloramphenicol, 25.3% to kanamycin, 3.4% to furazolidone, and 0.5% to nitrofurazone. 1 strain of S. typhimurium var. copenhagen had a transmissible determinant of resistance to trimethoprim. No strain was resistant to gentamycin. 93.4% of the strains transmitted resistance determinants to E. coli K-12. A transmission of resisance to furazolidone and nitrofurazone could not be demonstrated. The serotypes were exhibiting clear-cut differences in their resistances patterns.

[The development of antibiotics resistance among Salmonella bacteria of animal origin in the Federal Republic of Germany and Berlin (West). 6th communication: 1975 Annual report (author's transl)]. / Die Entwicklung der Antibiotikaresistenz von Salmonellabakterien tierischer Herkunft in der Bundesrepublik Deutschland einschliesslich Berlin (West) 6. Mitteilung: Jahresbericht 1975

2563 salmonella strains having been isolated by veterinary laboratories in the Federal Republic of Germany including West Berlin in 1975 were tested for resistance to tetracyclines, ampicillin, chloramphenicol, kanamycin, gentamycin, furazolidone, nitrofurazone, and trimethoprim. 11.4% of the strains tested were resistant to one or several of the above mentioned substances. The proportion of the resistant strains amounted to 36.0% for S. typhimurium, and 4.3% for S. typhimurium var. copenhagen, as well as 70% for S. dublin. 79.4% of all resistant strains belonged to these types. For S. panama, the proportion of resistant strains decreased to 6.7%. Out of 291 resistant strains found, resistance determinants were present in 89.0% to tetracyclines, 47.0% to chloramphenicol, 28.5% to ampicillin, 24.1% to kanamycin, and 4.1% to furazolidone. Resistance determinants to gentamycin, nitro-furazone, and trimethoprim did not occur, 81.1% of the strains transmitted resistance determinants to E. coli K-12. A transmission of resistance to furazolidone could not be demonstrated. The different serotypes exhibited clear-cut differences in their resistance patterns.

Total body water content in normal and grossly obese women.

Total body water content was estimated for 27 normal and 27 obese women by an isotope dilution technique using tritiated water. The mean total body water content expressed in absolute amounts was significantly raised in the obese group (P less than 0-001), but was significantly lower (P less than 0-001) when the values were expressed as a percentage of body weight. Significant correlations were found between weight and total body water content (P less than 0-001 and P less than 0-05) for the normal and obese subjects respectively. Separate regression equations based on height and weight were calculated for the normal and obese subjects, and good agreement was found in most instances between the measured and calculated total body water contents. The overweight women, with two exceptions, had total body water values in the expected range, which indicated that they were accumulating fat, not water. Although excess water was found in 2 women, this contributed only about 50% to their overweight.

The urinary excretion of glucosiduronates of cortisol and cortisone.

Cortisol and cortisone glucosiduronic acids were synthesised in a 14C-labelled from and utilised in a double-isotope derivative procedure for the analysis of cortisol glucosiduronate (FG) and cortisone glucosiduronate (EG) in human urine. Normal adults were found to excrete between 16 and 100 mug/24 h of FG (n = 14) and between 55 and 120 mug/24 h of EG (n = 15). Elevated values were observed in subjects with Cushing's syndrome and following ACTH stimulation. Abnormal excretion was noted in one patient with hepatic cirrhosis and in one case of cholestatic jaundice. The ratio FG/EG was markedly increased after ACTH stimulation and, in the normal group, was positively correlated to a highly significant degree (P less than 0.001) with FG excretion. These two observations suggest that EG excretion is less sensitive than FG excretion to variations in cortisol production.

Pregnanetriolone, a normal steroid metabolite: its excretion by normal, Cushing's syndrome and congenital adrenal hyperplasia subjects.

Synthesis of 3H-pregnanetriolone permitted the estimation of pregnanetriolone in urine with a sensitivity in excess of most previous claims. A good correlation (r = +0.97) was obtained between the values from gas liquid chromatography and those of a double isotope derivative method. In contrast to previous reports, these methods indicated that pregnanetriolone is excreted by normal adults. Urinary pregnanetriolone levels were 18-59 mug/24hr for normal subjects, 35-290mug/24hr in Cushing's syndrome and 250-7000 mug/24hr with congenital adrenal hyperplasia. It is concluded that pregnanetriolone is a normal steroid metabolite and its occurrence in Cushing's syndrome does not necessary indicate an abnormal steroid biosynthetic pathway.