[Exacerbation of working conditions due to the economic pressures of hospitals : Mandatory staffing ratios for physicians?] / Verschärfung der Arbeitsbedingungen durch Kostendruck der Krankenhäuser : Verpflichtende Personalschlüssel für Ärzte?

BACKGROUND: In current hospital-based urological care, economic pressure and its influence on urological working and further training conditions are a main point of criticism among young urologists. Against the background of a growing need for young talent in our specialist discipline, there is an urgent need for action. With the introduction of the lower limits for nursing staff, there is now a threat of a reduction in the number of physicians with the aim of reducing costs for business reasons. OBJECTIVE: A mandatory staffing ratio is often mentioned to counteract the downsizing in German clinics. The role of the lower staffing limit is explained in the following article. MATERIALS AND METHODS: We have analyzed the current draft laws of the federal government, as well as position papers and statements from federal political representatives such as the Marburger Bund, Bundesverband Deutscher Urologen and the German Medical Association (Bundesärztekammer) since 2018. RESULTS AND CONCLUSION: The analysis of current developments in nursing policy shows that the first step is a needs-based assessment of personnel and subsequent financing in the clinic setting. With adequate staffing, as in the traffic light scheme of the German Medical Association, not only would clinics position themselves as attractive employers and training centers for large parts of the urological medical profession, but would also significantly improve working conditions, patient care and patient safety. Medical training must remain an essential part of everyday hospital life.

[The working time load of specialists and senior physicians in German urology-a critical assessment]. / Die Arbeitszeitbelastung von Fach- und Oberärzten in der deutschen Urologie ­ eine Bestandsaufnahme.

BACKGROUND: The working and continued training conditions of assistant physicians in urology in Germany have already been analyzed. But what about senior urologists in Germany? Under which conditions do they have to work? As far as we know no published data currently exist which illuminate the conditions of this special urological professional group, therefore, the results of this survey are presented. OBJECTIVE: To survey and evaluate the current working conditions of certified and senior urologists in Germany as comprehensively as possible. MATERIAL AND METHODS: The working group of employed physicians of the Professional Association of German Urologists (BvDU) carried out a survey within the framework of the urological senior physician forum 2016 and on-line via the e­mail distributor of the German Society for Urology (DGU). The questions involved the workload, working conditions and satisfaction, overtime performed, working hours and opt out regulations. RESULTS: A total of 176 senior physicians participated in the survey of which 88% were male and 12% female. In Germany there are 1125 senior physicians. The average age of the responders was 44.9 years. In more than 80% of the participants the average weekly working hours were over 50 h and 70% signed an opt out regulation. An association between an increasing job dissatisfaction above a working week over 55 h and an average attendance in on-call service over 4 h could be established. The number of on-call services had no influence on job satisfaction. A total of 43% (70 out of 162) of the participants stated that overtime hours were regularly forfeited and 12% (20 out of 162) that all overtime hours were forfeited. Approximately 30% of senior physicians in German urology were dissatisfied with the current working conditions in the present form. CONCLUSION: Based on the acquired data, adaptation and improvements in the working conditions of senior urologists are necessary in order to maintain the attractiveness of the occupational image and leading positions in German urology.

Photodegradation of the UV filter ethylhexyl methoxycinnamate under ultraviolet light: Identification and in silico assessment of photo-transformation products in the context of grey water reuse.

To prevent water shortages in the future and to reduce domestic water consumption, decentralized grey water (GW) reuse has become increasingly important. This water has, however, to be free of pollutants. Conventional treatment of GW does not fully eliminate micropollutants such as the UV filter substance ethylhexyl methoxycinnamate (EHMC). EHMC, which is commonly used in sunscreens and personal care products, is an endocrine disruptor and shows potential to bioaccumulation, which is also reflected in its low water solubility. Photolysis has been proposed as an alternative treatment method for other micropollutants, but it is not clear yet whether it can also be used to eliminate EHMC. One goal of this study was to better understand the basic pathways involved in this process. It aimed to identify photo-transformation products (photo-TPs) by using, in the test conditions, an initial concentration of EHMC higher than those expected in the environment. Acetonitrile (ACN) was added in low concentrations to the aqueous solution to overcome the low aquatic solubility of EHMC. The influence of this co-solvent on the degradation kinetics was studied. The photolysis experiments were carried out using a medium pressure mercury lamp, which emits UV light in the range of 200-400nm. The quantum yield of the photolysis of EHMC was 0.0042 and 0.0023mol·Einstein-1 (for 0.2 and 0.5% ACN (v/v), respectively), and the relative and absolute UV photon fluxes were determined. HPLC was used to monitor the elimination kinetics of EHMC, which followed first-order kinetics. The results of LC-MSn analyses revealed that beside others, several oxidized and hydroxylized EHMC isomers were formed as photo-TPs in aqueous solution. Using a set of in silico quantitative structure-activity relationship (QSAR) models, this study also offered new insights concerning the environmental fate and toxicity of the TPs of EHMC.

Sample size calculations for a split-cluster, beta-binomial design in the assessment of toxicity.

Mouse embryo assays are recommended to test materials used for in vitro fertilization for toxicity. In such assays, a number of embryos is divided in a control group, which is exposed to a neutral medium, and a test group, which is exposed to a potentially toxic medium. Inferences on toxicity are based on observed differences in successful embryo development between the two groups. However, mouse embryo assays tend to lack power due to small group sizes. This paper focuses on the sample size calculations for one such assay, the Nijmegen mouse embryo assay (NMEA), in order to obtain an efficient and statistically validated design. The NMEA follows a stratified (mouse), randomized (embryo), balanced design (also known as a split-cluster design). We adopted a beta-binomial approach and obtained a closed sample size formula based on an estimator for the within-cluster variance. Our approach assumes that the average success rate of the mice and the variance thereof, which are breed characteristics that can be easily estimated from historical data, are known. To evaluate the performance of the sample size formula, a simulation study was undertaken which suggested that the predicted sample size was quite accurate. We confirmed that incorporating the a priori knowledge and exploiting the intra-cluster correlations enable a smaller sample size. Also, we explored some departures from the beta-binomial assumption. First, departures from the compound beta-binomial distribution to an arbitrary compound binomial distribution lead to the same formulas, as long as some general assumptions hold. Second, our sample size formula compares to the one derived from a linear mixed model for continuous outcomes in case the compound (beta-)binomial estimator is used for the within-cluster variance.

A statewide survey of ECT policies and procedures.

The 1990 American Psychiatric Association (APA) Electroconvulsive Therapy (ECT) Task Force Recommendations include facility policy and procedure guidelines. The objectives of this study were to determine and to improve the adherence to the 1990 APA ECT Task Force Recommendations on policies and procedures among the providers of ECT in Louisiana. Completed surveys on ECT policy and procedures were obtained from the seven major Louisiana ECT providers from the last quarter of 1996. Project coordinators distributed copies of the survey results and a comprehensive set of ECT policies and procedures at a statewide meeting of participating hospitals during the spring of 1997. Most facilities had policies for electrical safety of ECT equipment, testing of new ECT equipment, pre-ECT work-up, ECT informed consent, patient instruction sheets, outpatient ECT, documentation of ECT procedures, clinical privileging, and ECT quality assurance monitoring. Subsequent telephone follow-up found that all participants changed their policies and procedures as a result of the project. Louisiana ECT providers showed general compliance with the facility policy and procedure aspects of the 1990 APA ECT Task Force Recommendations. The awareness model of guideline compliance was applicable to improving facility policies and procedures.

Gambling in the south: implications for physicians.

Three historical cycles of legalized gambling have occurred in the South. Currently, every southern state has legalized some form of gaming. Adult past-year prevalence rates of problem gambling in southern states are within the national range. Higher prevalence rates occur in states with casinos and multiple forms of legalized gambling. States with lotteries have higher prevalence rates of adolescent problem gambling. Problem gambling can cause stress-induced physical diseases and psychiatric symptoms in gamblers and their families. Physicians can reduce personal, family, and social costs of problem gambling through increased awareness, strategic screening, and early intervention. Treatment approaches include inpatient treatment centers, self-help fellowship groups, and cognitive-behavioral and addiction-based psychotherapies. Although no standard pharmacologic treatments for gambling disorders exist, use of selective serotonin re-uptake inhibitors is under investigation. Referral resources are available to physicians in states with state-funded treatment programs for problem gamblers and/or state councils for problem gambling.

The Louisiana Medicare Electro-Convulsive Therapy Quality Improvement Project.

The first collaborative statewide psychiatric quality improvement project, initiated by Louisiana Health Care Review, Inc, focused on the practice of inpatient electro-convulsive therapy (ECT) among Medicare patients. Data from the project indicated that the majority of Medicare patients receiving ECT were white females living at home, in good physical health, in their seventies, and with a diagnosis of major depression or major depression with psychotic features. The quality indicators for the project included: (documentation of) monitoring of cognitive side effects, monitoring of depressive target symptoms, ECT appropriateness, electrode placement, anesthesia evaluation, and dental examination. An additional indicator (administration of possibly detrimental medication during ECT) was developed based on the recommendation by the study group. At project conclusion, significant improvement occurred in all project indicators. ECT as practiced in the participating hospitals was effective and appropriate. Appropriateness was determined as depression refractory to two medication trails or an emergency due to severe suicidal ideation or physical deterioration secondary to malnutrition. Transient hypertension (13%) and cardiac dysrhythmia (3.5%) which resolved in the recovery period were the most frequent complications.

New approach to administrative medical decision-making: evidence-based medicine using high dose chemotherapy/bone marrow transplant for breast cancer.

BACKGROUND: Payment for experimental treatments using medical necessity criteria has been controversial. The process of obtaining a decision on coverage of an experimental treatment can be distressful for the treating physician, the patient, and family members. METHOD: The techniques of evidence-based medicine were used to assist with treatment/coverage decisions concerning high dose chemotherapy with autologous bone marrow transplants (HDC/ABMT) for invasive breast cancer. RESULTS: We reviewed the literature, finding minimal evidence for effectiveness of HDC/ABMT for invasive breast cancer; therefore, it is our opinion that it remains an experimental therapy. Its cost utility is likely to be low (approximately $100,000 per additional quality year gained). Numerous patients have been treated with HDC/ABMT outside of clinical trials, impeding scientific analysis of the treatment's effectiveness. CONCLUSION: Data-based policies and procedures for funding experimental medical treatments need to be developed to eventually replace the medical necessity criteria.

Assessment of biliary excretion of piperacillin-tazobactam in humans.

Piperacillin-tazobactam concentrations in serum and bile were measured intraoperatively in 10 patients undergoing cholecystectomy (group 1) and 5 cholecystectomized patients provided with external bile duct drainage (group 2). Each patient received a single intravenous dose of piperacillin at 4 g plus tazobactam at 0.5 g over 30 min. Drug concentrations in both serum and bile were measured by high-performance liquid chromatography. In group 1 patients, serum and bile specimens and gallbladder wall fragments were collected at mean times of 70 and 83 min postinfusion, respectively. The mean concentrations of piperacillin and tazobactam were, respectively, 69.1 +/- 41.5 (standard deviation) and 9.9 +/- 5.1 microg/ml in serum, 630.4 microg/ml (range, 24.8 to 1,194 microg/ml) and 11.8 microg/ml (range, 3.6 to 22 microg/ml) in choledochal bile, 342.3 microg/ml (range, 1.1 to 1,149 microg/ml) and 7.7 microg/ml, (range, 0.2 to 23.1 microg/ml) in gallbladder bile, and 49.3 microg/g (range, 9.7 to 223 microg/g) and 2.9 microg/g (range, 0.1 to 5.9 microg/g) in the gallbladder wall. In group 2 patients, the amounts of drugs recovered in bile drainage obtained over 12 h were 28.4 +/- 18.0 and 1.0 +/- 0.5 mg for piperacillin and tazobactam, respectively. Peak piperacillin and tazobactam concentrations in bile reached 358 +/- 242 and 10.8 +/- 4.2 microg/ml, respectively. Comparison of drug levels in serum and bile suggests an underlying active secretion process for piperacillin elimination into the bile, unlike that of tazobactam. From a therapeutic viewpoint, given the concentrations of tazobactam recorded in bile fluid and tissue, the addition of this beta-lactamase inhibitor to piperacillin therapy might be of interest in the management of biliary tract infections, mostly in patients at risk of mixed aerobic-anaerobic infections due to beta-lactamase-producing organisms.

Addressing issues of face validity in the application of a clinical guideline.

In 1995, a statewide project to improve the practice of electroconvulsive therapy (ECT) in the Medicare population was started in Louisiana. A retrospective baseline study found high concurrent utilization of lithium and benzodiazepines, medications considered detrimental to ECT by the second American Psychiatric Association Task Force on ECT. Resistance to a clinical guideline because of lack of face validity by clinicians was used as an opportunity to involve clinicians in using data to evaluate their clinical practices. Results of the first two quarters of the project demonstrated that the strategy was successful.

Using automated continual performance assessment to improve health care.

Inefficiency in the work of health care providers is evident and contributes to health care costs. In the early 20th century, industrial engineers developed scientific methods for studying work to improve performance (efficiency) by measuring results--i.e., quality, cost, and productivity. In the mid-20th century, business managers developed ways to apply these methods to improve the work process. These scientific methods and management approaches can be applied to improving medical work. Fee-for-service practice has had incentives to maximize productivity, and prepaid practice has had incentives to minimize costs, but no sector of the health care system has systematically pursued the optimization of all performance variables: quality, cost, and productivity. We have reviewed evolving methods for the automation of continual assessment of performance in health care using touch screen and computer telephone, logging and scheduling software, appropriate combinations of generic or disease-specific health status questionnaires, physiologic measurements or laboratory assays from computerized records, and cost and productivity data from computerized registration logs. We propose that the results of outcome assessment be rapidly and continually transmitted to providers, patients, and managers so that health care processes can be progressively improved. The evolving systems we have described are the practical tools that can help us achieve our performance goals.

Treatment participation and outcome among problem drinkers in a managed care alcohol outpatient treatment program.

This article uses Markov analysis to investigate patterns of treatment participation of 361 patients treated in the alcohol and drug abuse programs of a large group model Health Maintenance Organization (HMO) to examine how participation is related to abstinence. Findings indicate that 82% of the patients in treatment one month after intake were in treatment three months later, and treatment retention dropped to 46% by month 6. Findings also indicate that 74% of patients abstinent and in treatment at month 1 remained so at month 3. Abstinence at the first three-month interval was a strong predictor of abstinence at later time periods. A multivariate analysis showed that an expressed desire to stop alcohol use upon entry into treatment was the most consistent predictor of both treatment participation and abstinence at most time points. Treatment participation was also a significant predictor of abstinence.

Quantifying utilization and practice variation of electroconvulsive therapy.

The objective of this study was to quantify inpatient electroconvulsive therapy (ECT) utilization and its practice variation within the State of Louisiana using Medicare data for beneficiaries age 65 years and older. The Louisiana Medicare claims (MedPar) history and the Medicare beneficiary denominator files for fiscal years 1993 and 1994 were used for analysis. Statistical techniques used were: chi 2 to determine significance of the proposed null hypothesis, and the modified systemic component of variance (SCV) to determine the magnitude of variation between the individual parish utilization rates for ECT. The ECT utilization rate for the Louisiana Medicare population was found to be 2.38 per 10,000 person-years, falling well within the range of previous ECT utilization studies in the United States. The chi 2 value was 0.0003 when comparing parishes, indicating the presence of significant nonrandom variation. The SCVs of inpatient treatment for major depression and impatient ECT were 0.47 and 1.34, respectively. Inpatient ECT in this population demonstrates high geographic variability. Further research is required to determine and quantitate the factors responsible for the geographic variation in inpatient ECT utilization within the Louisiana Medicare population.

Developing a system for automated monitoring of psychiatric outpatients: a first step to improve quality.

OBJECTIVE: To evaluate an automated system of quality monitoring for psychiatric outpatients. DESIGN: Cross-sectional study. SETTING: Large outpatient psychiatry clinic in Kaiser Permanente--Northern California. PARTICIPANTS: Approximately 1500 new psychiatric patients and 20 clinicians. INTERVENTIONS: This system gave clinicians data on new patients from validated instruments before their intake interviews, measured outcomes for the depressed and panic-disordered patients, and monitored the clinic's case-mix. MAIN OUTCOME MEASURES: Clinic case-mix: Axis II disorders (Personality Disorder Questionnaire--Revised); emotional, social and physical functioning (Health Status Questionnaire 2.0); Axis I symptoms (Symptom Checklist-90); depression and panic disorder (Health Outcomes Institute Modules). Clinician reaction to system (telephone interview). RESULTS: The study population was 62.4% female; 73.9% Caucasian; 70% employed; 15.9% had evidence of personality disorder; 63% reduced daily activities because of emotional problems; 18% had depression; 7% had panic disorder. Over 75% of clinicians used the data reports and found them helpful; criticism focused on questionnaire length, inadequate training, numerous false-positives, and insufficient administrative support. CONCLUSION: An automated patient monitoring system can be implemented; clinician involvement needs to be significant; more research is needed to establish the usefulness of standardized data and outcomes management.

[Assessment of the role of enterocyte ion exchange in the intestinal absorption of amoxicillin, based on a study of the interaction with amiloride]. / Evaluation du rôle des échanges ioniques entérocytaires dans l'absorption intestinale de l'amoxicilline par l'étude de l'interaction avec l'amiloride.

Intestinal dipeptide carrier system has been shown in vitro to be involved in intestinal absorption of betalactam antibiotics. Given that efficiency of this transport system depends on a pH gradient (extracellular pH < intracellular pH) at the brush-border membrane of enterocytes, we assessed the effects of amiloride, a known inhibitor of the Na-H exchange, on the bioavilability of oral amoxicillin in eight normal volunteers. Following a single 10 mg oral dose of amiloride, the absolute bioavailability of oral amoxicillin turned out to decrease by 27% (p < 0.01). The extent of reduction of oral amoxicillin AUC appeared to significantly correlate (p = 0.005) with the extent of decrease in potassium renal excretion but not with variations in antibiotic renal clearance under amiloride effect. Such patterns seem to confirm in vivo the role of the Na-H exchange in betalactam absorption and to suggest the underlying regulatory function of intracellular Na concentration, the latter depending on the (NaK)-ATPase activity.

Biliary excretion of cefixime: assessment in patients provided with T-tube drainage.

The biliary excretion profile of cefixime was studied in 10 patients provided with T-tube drainage of the common bile duct after cholecystectomy. Following a single 200-mg oral dose, the peak concentration of cefixime in bile reached 56.9 +/- 70 mg/liter, approximately 20 times as high as the peak concentration in serum, 2.3 +/- 0.85 mg/liter. Cefixime levels in bile proved relatively sustained, since a concentration of 4.3 +/- 3.7 mg/liter was still found 20 h after dosing. The cumulative amount of cefixime recovered in the 24-h bile drainage averaged 10.0 +/- 12.3 mg, which is 5% of the administered dose and positions this beta-lactam antibiotic among the most highly bile-excreted cephalosporins. The presented results show that a single 200-mg oral dose of cefixime provided drug levels in bile consistently higher than the MICs for the most frequently recovered members of the family Enterobacteriaceae in biliary tract infections and maintained these levels for over 20 h after dosing. Accordingly, this cephalosporin deserves further clinical trials to assess its usefulness in both prophylaxis and treatment of biliary tract infections.