Human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis.

BACKGROUND: Sepsis is one of the leading causes of death. Treatment attempts targeting the immune response regularly fail in clinical trials. As HCMV latency can modulate the immune response and changes the immune cell composition, we hypothesized that HCMV serostatus affects mortality in sepsis patients. METHODS: We determined the HCMV serostatus (i.e., latency) of 410 prospectively enrolled patients of the multicenter SepsisDataNet.NRW study. Patients were recruited according to the SEPSIS-3 criteria and clinical data were recorded in an observational approach. We quantified 13 cytokines at Days 1, 4, and 8 after enrollment. Proteomics data were analyzed from the plasma samples of 171 patients. RESULTS: The 30-day mortality was higher in HCMV-seropositive patients than in seronegative sepsis patients (38% vs. 25%, respectively; p = 0.008; HR, 1.656; 95% CI 1.135-2.417). This effect was observed independent of age (p = 0.010; HR, 1.673; 95% CI 1.131-2.477). The predictive value on the outcome of the increased concentrations of IL-6 was present only in the seropositive cohort (30-day mortality, 63% vs. 24%; HR 3.250; 95% CI 2.075-5.090; p < 0.001) with no significant differences in serum concentrations of IL-6 between the two groups. Procalcitonin and IL-10 exhibited the same behavior and were predictive of the outcome only in HCMV-seropositive patients. CONCLUSION: We suggest that the predictive value of inflammation-associated biomarkers should be re-evaluated with regard to the HCMV serostatus. Targeting HCMV latency might open a new approach to selecting suitable patients for individualized treatment in sepsis.

Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]. / Implementierung anästhesiologischer Qualitätsindikatoren in Deutschland : Eine prospektive, nationale, multizentrische Qualitätssteigerungsstudie German version.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

Determination of 'recruited volume' following a PEEP step is not a measure of lung recruitability.

BACKGROUND: It has been proposed that the analysis of positive end-expiratory pressure (PEEP)-induced volume changes can quantify alveolar recruitment. The potential of a lung to be recruited is expected to be high in acute respiratory distress syndrome (ARDS), where collapsed lung tissue is very common. The volume change that is beyond the delta volume because of the patient's compliance has been termed 'recruited volume' (RecV). However, data of patients with low and high RecV showed less severe lung disease in high 'recruiters', indicating that RecV may not equal the 'potentially recruitable lung tissue' seen in computed tomography scans. We hypothesized that RecV is higher in lung-healthy (LH) patients with little collapsed lung compared with ARDS patients. METHODS: RecV and inspiratory capacity (IC) were determined in 12 LH and in 25 ARDS patients during incremental PEEP (steps of 2 cmH2 O). RecV was determined as the time-dependent increase in end-expiratory volume following the first expiration to the new PEEP level (ΔTDV). Gas distribution in LH patients was analyzed by electric impedance tomography. RESULTS: Cumulative RecV(ΔTDV) and IC were higher (P < 0.01) in LH compared with ARDS patients, 1739 ml vs. 832 ml and 4432 ml vs. 2020 ml, respectively. In both groups, RecV correlated excellently with IC (R(2) = 0.86). In LH, RecV emanated mainly from nondependent lung regions at PEEP below 15 cmH2O. Maximum plateau pressure was reached with fewer PEEP steps in ARDS compared with LH patients (11 vs. 14, P < 0.01). CONCLUSION: Our findings suggest that RecV predominately measures a slow fraction of inflation of already aerated lung tissue and not recruitment of collapsed alveoli.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI).

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]. / Kurzversion S2e-Leitlinie - "Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen".

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Pumpless arterio-venous extracorporeal lung assist compared with veno-venous extracorporeal membrane oxygenation during experimental lung injury.

BACKGROUND: Extracorporeal lung support is effective to prevent hypoxaemia and excessive hypercapnia with respiratory acidosis in acute respiratory distress syndrome. Miniaturized veno-venous extracorporeal membrane oxygenation (mECMO) and arterio-venous pumpless extracorporeal lung assist (pECLA) were compared for respiratory and haemodynamic response and extracorporeal gas exchange and device characteristics. METHODS: After induction of acute lung injury by repeated lung lavage, 16 anaesthetized and mechanically ventilated pigs were randomized to mECMO (Medos Hilite/Deltastream) or pECLA (iLA Novalung) for 24 h. RESULTS: Improved gas exchange allowed reduced ventilation and plateau pressure in both groups. An arterio-venous shunt flow of up to 30% of cardiac output resulted in a left cardiac work of 6.8 (2.0) kg m for pECLA compared with 5.0 (1.4) kg m for mECMO after 24 h (P<0.05). Both devices provided adequate oxygen delivery to organs. The oxygen transfer of pECLA was lower than mECMO due to inflow of arterial oxygenated blood [16 (5) compared with 64 (28) ml min(-1) after 24 h, P<0.05]. Unexpectedly, the carbon dioxide transfer rate was also lower [58 (28) compared with 111 (42) ml min(-1) after 24 h, P<0.05], probably caused by a Haldane effect preventing higher transfer rates in combination with lower extracorporeal blood flow. CONCLUSIONS: Both devices have the potential to unload the lungs from gas transfer sufficiently to facilitate lung-protective ventilation. Although technically less complex, oxygen uptake and carbon dioxide removal are limited in pECLA, and cardiac work was increased. mECMO overcomes these limitations and might provide better cardiopulmonary protection.

[Surgery in the balance between humanity, ethics and economics]. / Chirurgie im Spannungsfeld "Humanität-Ethik-Ökonomie".

BACKGROUND: The economic pressure in the healthcare system has noticeably increased in the past few years. The manifestation of an "economization in medicine" development raises questions about the compatibility of physicians' duties and economic incentives in the healthcare system. OBJECTIVE: Against this background the article analyzes areas of conflict in the German healthcare system and surgery in particular. The main questions focus on: what lines of conflict can arise between ethical duties and economic requirements and what possibilities for conflict resolution can provide orientation on the macrolevel and microlevel? MATERIAL AND METHODS: The article is based on the analysis of normative regulations, guidelines and statements from the self-administrative institutions and multidisciplinary literature from medicine, medical ethics and health economics. Core issues in the conflict area between "humanity-ethics-economics" are structured and recommendations for action are derived. RESULTS AND DISCUSSION: Superordinate regulatory framework conditions and their subsequent incentives must not conflict with the ethical principles of medical care, especially the primary orientation to patient welfare. Institutional and individual healthcare providers have a responsibility towards patients first and only secondarily for an economically appropriate spending of public resources. The provision of medical care for people must enable an adequate livelihood. Institutional maximization of profits is to be avoided, especially concerning financial investors. In the corona pandemic, economic disincentives are becoming apparent and necessitate readjustments. Possible recommendations for action are the empowerment of the medical profession and management to engage in a qualified exchange.

[Positioning therapy and early mobilization in intensive care units : Findings from the current 2015 guidelines]. / Lagerungstherapie und Frühmobilisation auf der Intensivstation : Erkenntnisse aus der aktuellen Leitlinie 2015.

The 2007 guidelines "Positioning for prophylaxis and therapy of pulmonary disorders" were completely revised in 2015 on behalf of the German Society of Anaesthesiology and Intensive Care Medicine. With regard to practical and scientific relevance, early mobilization of patients in critical care has been included in the guidelines for the first time. Furthermore, the recommendations for prone positioning have been updated, based on current evidence in medicine and nursing. In addition, recommendations regarding unsuitable positions that may actually harm patients were made. As such, the flat supine position should only be used in cases of urgent medical or nursing needs. This underlines the importance of a moderately elevated head of bed position (20(o)-45(o)) in mechanically ventilated patients.

HVEM ultrastructural analysis of mouse fungiform taste buds, cell types, and associated synapses.

We have used high voltage electron microscopy and computer-generated three-dimensional reconstructions from serial sections to elucidate the structure of taste bud cells and their associated synapses in fungiform taste buds of the mouse. Five fungiform taste buds (two of which were serially sectioned) were examined with the high-voltage electron microscope (HVEM). We identified the synaptic connections from taste cells onto sensory nerve fibers and classified the presynaptic taste cells based on previously established ultrastructural criteria. From those data we have distinguished dark, intermediate, and light cells in murine fungiform taste buds. Synapses in murine fungiform taste buds are fewer in number, but contain many more vesicles than synapses in either foliate or circumvallate taste buds. Synapses in mouse circumvallate and foliate taste buds typically contain a few to several synaptic vesicles per section, whereas fungiform synapses may have in excess of 100 vesicles per profile. The significance of these differences in the numbers of synapses and synaptic structure between fungiform and circumvallate/foliate synapses is not known. Based on the small number of synapses observed in fungiform taste buds, we speculate that fungiform taste buds have only a few cells transducing sensory stimuli at any given time. Alternatively, communication of sensory information from the taste receptor cells to the afferent nerve fibers may be mediated by some other mechanism(s) in addition to classical chemical synapses.

The role of mice in the epizootiology of Salmonella enteritidis infection on chicken layer farms.

A microbiological survey of 10 mice-infested poultry farms was conducted to determine the role of mice in the epizootiology of S. enteritidis infection. Five of the farms were rated as clean of S. enteritidis and five as contaminated based on culture results of environmental samples for S. enteritidis. Of 2103 environmental samples and 715 mice and rats tested, 5.1% and 16.2%, respectively, were culture-positive for S. enteritidis. On contaminated farms, S. enteritidis was isolated from 24.0% of the mice and 7.5% of the environmental samples, which represented 75.3% of all Salmonella isolations from mice but only 18.0% of Salmonella isolations from environmental samples on these farms. S. enteritidis was not detected in mice on clean farms. Phage types 13a and 14b were the two most frequently isolated phage types from mice and environmental samples. Although only a single phage type was isolated from single free-standing poultry houses, multiple phage types were isolated from multi-house complexes. A bacterial count from the feces of one mouse yielded 2.3 x 10(5) S. enteritidis bacteria per fecal pellet. S. enteritidis persisted at least for 10 months in an infected mouse population.

Salmonella enteritidis in eggs from commercial chicken layer flocks implicated in human outbreaks.

Eggs were cultured from four commercial chicken layer houses implicated in three human outbreaks of Salmonella enteritidis serotype enteritidis infection as part of the activities of the USDA-APHIS, VS, Salmonella enteritidis Task Force. Each house was part of a multiple in-line complex, ranging from three to seven houses. Houses were located on three separate farms, and each house contained between 50,000 and 80,000 chickens. S. enteritidis phage types 8, 13a, and 23 were isolated from samples taken from environmental and organ tissue samples, but only phage type 8 was cultured from eggs. Phage type 8 was isolated from humans in all three S. enteritidis outbreaks. Frequency estimates of contaminated eggs ranged from 0.03% to 0.90%.

Field observations with Salmonella enteritidis bacterins.

A study involving 11 commercial layer flocks was conducted to determine the efficacy of Salmonella enteritidis bacterins (autogenous or federally licensed). The criterion for evaluation of vaccine efficacy was the presence or absence of S. enteritidis in the environment, the organs of the bird (including ovary and oviduct), and eggs. Environmental, rodent, and organ specimens from dead birds as well as eggs were cultured throughout the life of the flock. All layers were obtained from pullet sources that were negative for S. enteritidis, as determined by organ and environmental cultures. Despite the use of S. enteritidis vaccination, 63.6% of the houses had S. enteritidis-positive environmental cultures and 100% of the flocks had S. enteritidis organ-culture-positive birds. The range of positive cultures for S. enteritidis in the environment in vaccinated flocks was between 0 and 45.5%. Birds in vaccinated flocks were organ-culture positive for S. enteritidis between 10% and 40% of the time. The unvaccinated portion of flocks in the same house and the unvaccinated flock in a complex had similar results compared with the vaccinated portion of the flocks.

Survival of avian influenza virus H7N2 in SPF chickens and their environments.

The survival or clearance of the avian influenza virus (AIV) of subtype H7N2 in its chicken host was evaluated using experimentally infected specific pathogen free (SPF) chickens of different age groups. Birds of different ages were successfully infected with infectious doses ranging between 10(4.7) and 10(5.7) ELD50 per bird. In infected birds, the infective virus was undetectable usually by the third week following exposure. The infectivity or inactivation time of the H7N2 AIV in various environmental conditions was studied using chicken manure, heat, ethanol, pH, and disinfectants. The H7N2 AIV was effectively inactivated by field chicken manure in less than a week at an ambient temperature of 15-20 degrees C. At a pH 2, heating at 56 degrees C, and exposure to 70% ethanol or a specific disinfectant, the AIV infectivity was destroyed in less than 30 min.

Summary of the 2001-02 Pennsylvania H7N2 low pathogenicity avian influenza outbreak in meat type chickens.

H7N2 low-pathogenicity (LP) avian influenza (AI) virus was isolated from chickens submitted to the Pennsylvania Animal Diagnostic Laboratory System on December 4 and 5, 2001. The cases were from two broiler breeder flocks in central Pennsylvania that had clinical signs of an acute, rapidly spreading respiratory disease. Seroconversion to AI virus was detected on follow-up sampling. Subsequently, H7N2 LPAI virus was isolated in five different broiler flock cases submitted between December 14, 2001, and January 3, 2002. Clinical signs and lesions in broilers, when present, were compatible with multicausal respiratory disease. With the exception of one broiler flock that was processed, birds from all of the virus positive flocks were euthanatized in-house within 11 days of the original case submission date. Increased surveillance of poultry flocks within 10-mile radius zones centered at the foci of the positive farms continued until March 1, 2002. No additional cases were detected.

Epidemiology, production losses, and control measures associated with an outbreak of avian influenza subtype H7N2 in Pennsylvania (1996-98).

An outbreak of H7N2 low-pathogenicity (LP) avian influenza (AI) occurred in a two-county area in Pennsylvania from December of 1996 through April of 1998. The outbreak resulted in infection of 2,623,116 commercial birds on 25 premises encompassing 47 flocks. Twenty-one (one premise with infection twice) of the twenty-five infected premises housed egg-laying chickens and one premise each had turkeys, layer pullets, quail, and a mixed backyard dealer flock. Despite dose proximity of infected flocks to commercial broiler flocks, no infected broilers were identified. Experimentally, when market age broilers were placed on an influenza-infected premise they seroconverted and developed oviduct lesions. The outbreak was believed to have originated from two separate introductions into commercial layer flocks from premises and by individuals dealing in sales of live fowl in the metropolitan New York and New Jersey live-bird markets. Source flocks for these markets are primarily in the northeast and mid-Atlantic areas, including Pennsylvania. Mixed fowl sold include ducks, geese, guinea hens, quail, chukar partridges, and a variety of chickens grown on perhaps hundreds of small farms. Infections with the H7N2 AI virus were associated with variable morbidity and temporary decreases in egg production ranging from 1.6% to 29.1% in commercial egg-laying chickens. Egg production losses averaged 4.0 weeks duration. Mortality ranged from 1.5 to 18.3 times normal (mean of 4.3 times normal). Duration of mortality ranged from 2 to 13 weeks (average of 3.9 weeks) in flocks not depopulated. Lesions observed were primarily oviducts filled with a mucous and white gelatinous exudates and atypical egg yolk peritonitis. Quarantine of premises and complete depopulation were the early measures employed in control of this outbreak. Epidemiological studies suggested that depopulation furthered the spread of influenza to nearby flocks. Thereafter, later control measures included quarantine, strict biosecurity, and controlled marketing of products.

Management and environmental risk factors for Salmonella enteritidis contamination of eggs.

OBJECTIVE: To analyze data for 60 poultry flocks voluntarily enrolled in the Pennsylvania Salmonella enteritidis Pilot Project and determine management and environmental risk factors associated with production of S enteritidis-contaminated eggs. SAMPLE POPULATION: 60 flocks for which at least 1 environmental sample (manure or egg-handling equipment) was positive for S enteritidis. PROCEDURE: Samples of manure, egg-handling equipment, and mice were submitted for bacterial culture of S enteritidis. When S enteritidis was isolated from environmental samples, 1,000 eggs were collected from the flock every 2 weeks for 8 weeks and submitted for bacterial culture. RESULTS: 18 flocks were found to have produced contaminated eggs. Estimated overall prevalence of contaminated eggs was 2.64/10,000 eggs produced, but flock-specific prevalence ranged from 0 to 62.5/10,000 eggs. Flocks with high levels of manure contamination were 10 times as likely to produce contaminated eggs as were flocks with low levels. However, 5 flocks with low levels of manure contamination produced contaminated eggs. CONCLUSIONS: Evaluation of the level of manure contamination could be used to help identify flocks at risk of producing S enteritidis-contaminated eggs. CLINICAL RELEVANCE: Flocks with high levels of S enteritidis-contaminated manure appeared to pose the greatest public health threat, and on-farm programs to reduce the prevalence of egg contamination should be developed for farms with high levels of manure contamination. Efforts to reduce the overall number of on-farm pathogens should decrease the incidence of foodborne disease in humans.

Effects of hypercapnia and hypercapnic acidosis on attenuation of ventilator-associated lung injury.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are associated with impaired gas exchange, severe inflammation and alveolar damage including cell death. Patients with ALI or ARDS typically experience respiratory failure and thus require mechanical ventilation for support, which itself can aggravate lung injury. Recent developments in this field have revealed several therapeutic strategies that improve gas exchange, increase survival and minimize the deleterious effects of mechanical ventilation. Among those strategies is the reduction in tidal volume and allowing hypercapnia to develop during ventilation, or actively inducing hypercapnia. Here, we provide an overview of hypercapnia and the hypercapnic acidosis that typically follows, as well as the therapeutic effects of hypercapnia and acidosis in clinical studies and experimental models of ALI. Specifically, we review the effects of hypercapnia and acidosis on the attenuation of pulmonary inflammation, reduction of apoptosis in alveolar epithelial cells, improvement in sepsis-induced ALI and the therapeutic effects on other organ systems, as well as the potentially harmful effects of these strategies. The clinical implications of hypercapnia and hypercapnic acidosis are still not entirely clear. However, future research should focus on the intracellular signaling pathways that mediate ALI development, potentially focusing on the role of reactive biological species in ALI pathogenesis. Future research can also elucidate how such pathways may be targeted by hypercapnia and hypercapnic acidosis to attenuate lung injury.

[Airway management]. / Atemwegsmanagement.

Managing the difficult airway poses an enormous challenge for anaesthesiologists, intensivists and A&E physicians, particularly because of the high probability of a potentially fatal outcome. Development and (pre-) clinical distribution of supraglottic airway devices (e.g. LMA, LT) and their enhancements, as well as the broad acceptance of awake fibre-optic intubation, led to a profound change in the strategy for managing the difficult airway. This is reflected in the revised ASA guidelines, implementing the use of the laryngeal mask airway and fibre-optic intubation. In view of the utmost importance of this topic the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) framed an independent German guideline, considering German national terms and conditions. In analogy algorithms and guidelines of the ILCOR, ERC and ATLS were revised as well as those of many other national anaesthesiological boards. Nevertheless, massive national and international deficits exist in implementing these guidelines into practice and the implicated structural requirements with respect to education, reflection, team building and equipment concerning the individual institution.