Hybrid magnetic structures around spinning black holes connected to a surrounding accretion disk.

The hot accretion flow around Kerr black holes is strongly magnetized. Magnetic field loops sustained by a surrounding accretion disk can close within the event horizon. We performed particle-in-cell simulations in Kerr metric to capture the dynamics of the electromagnetic field and of the ambient collisionless plasma in this coupled configuration. We find that a hybrid magnetic topology develops with a closed magnetosphere co-existing with open field lines threading the horizon reminiscent of the Blandford-Znajek solution. Further in the disk, highly inclined open magnetic field lines can launch a magnetically-driven wind. While the plasma is essentially force-free, a current sheet forms above the disk where magnetic reconnection produces macroscopic plasmoids and accelerates particles up to relativistic Lorentz factors. A highly dynamic Y-point forms on the furthest closed magnetic field line, with episodic reconnection events responsible for transient synchrotron emission and coronal heating.

SwissScoring--a nationwide survey of NEMS assessing practices and its accuracy.

BACKGROUND: The nine equivalents of nursing manpower use score (NEMS) is used to evaluate critical care nursing workload and occasionally to define hospital reimbursements. Little is known about the caregivers' accuracy in scoring, about factors affecting this accuracy and how validity of scoring is assured. METHODS: Accuracy in NEMS scoring of Swiss critical care nurses was assessed using case vignettes. An online survey was performed to assess training and quality control of NEMS scoring and to collect structural and organizational data of participating intensive care units (ICUs). Aggregated structural and procedural data of the Swiss ICU Minimal Data Set were used for matching. RESULTS: Nursing staff from 64 (82%) of the 78 certified adult ICUs participated in this survey. Training and quality control of scoring shows large variability between ICUs. A total of 1378 nurses scored one out of 20 case vignettes: accuracy ranged from 63.7% (intravenous medications) to 99.1% (basic monitoring). Erroneous scoring (8.7% of all items) was more frequent than omitted scoring (3.2%). Mean NEMS per case was 28.0 ± 11.8 points (reference score: 25.7 ± 14.2 points). Mean bias was 2.8 points (95% confidence interval: 1.0-4.7); scores below 37.1 points were generally overestimated. Data from units with a greater nursing management staff showed a higher bias. CONCLUSION: Overall, nurses assess the NEMS score within a clinically acceptable range. Lower scores are generally overestimated. Inaccurate assessment was associated with a greater size of the nursing management staff. Swiss head nurses consider themselves motivated to assure appropriate scoring and its validation.

Primary care services provided to adolescents in detention: a cross-sectional study using ICPC-2.

AIM: The aim of this study was to provide a detailed description of the health problems for which primary care services are provided to adolescents in a juvenile detention facility in Europe. METHODS: We reviewed the medical files of all detainees in a juvenile detention centre in Switzerland in 2007. The health problems for which primary care services were provided were coded using the International Classification for Primary Care, version 2. Analysis was descriptive, stratified by gender. RESULTS: A total of 314 adolescents (18% female) aged 11-19 years were included. Most (89%) had a health assessment and 195 (62%) had consultations with a primary care physician; 80% of the latter had a physical health problem, and 60% had a mental health problem. The most commonly managed problems were skin (49.7%), respiratory (23.6%), behavioural (22.6%) and gynaecological problems (females: 23.9%); 13% females (no males) had sexually transmitted infections (STI), and 8.7% were pregnant. Substance abuse was common (tobacco: 64.6%, alcohol: 26.2%, cannabis: 31.3%). CONCLUSION: In addition to health problems known to be more prevalent among young offenders, such as mental health problems and STI, these adolescent detainees required care for a range of common primary care problems. These data should inform the development of comprehensive primary care services in all juvenile detention facilities in Europe.

Economic burden of unjustified medications at hospital discharge.

QUESTION UNDER STUDY: Medication errors are a major concern for health care since they may cause or lead to inappropriate medication use or patient harm. However, little is known regarding the economic burden of unjustified medications. METHODS: Hospital discharge records of 577 patients were prospectively screened for the presence of unjustified medications. From this sample population, 318 (55%) were eligible and their data were used to assess the monthly costs of unjustified discharge medications, their relationship to the total and each individual's drug expenditure, and the relative cost weights of relevant unjustified drug classes. RESULTS: The results found that 619 out of 3691 prescriptions (16.8%) were unjustified. The mean (median; 95% CI) monthly costs of unjustified discharge medications were 32 euro (27 euro; 29 euro to 35 euro). The percentage of unnecessary treatments was inversely linked to the amount of total individual drug expenditure. For this collective, monthly extra costs due to unjustified medications were 18585 euro, and the relative cost weights of the relevant drug classes were 45.8% for gastrointestinal agents (33.8% for proton pump inhibitors), 17.7% for cardiovascular drugs, and 17.2% for psychiatric drugs. CONCLUSIONS: There is a considerable financial burden imposed by unjustified medications at hospital discharge. Discharge medications not motivated by appropriate diagnoses should be questioned. This study should be repeated in other institutions and in a larger population.

Omitted and unjustified medications in the discharge summary.

BACKGROUND: Limited information exists in regard to drug omissions and unjustified medications in the hospital discharge summary (DS). OBJECTIVE: To evaluate the incidence and types of drug omissions and unjustified medications in the DS, and to assess their potential impact on patient health. METHODS: A prospective observational review of the DSs of all patients discharged from our Internal Medicine Department over a 3-month period. Data assessment was made by internists using a structured form. RESULTS: Of the 577 evaluated DSs, 66% contained at least one inconsistency accounting for a total of 1012 irregularities. There were 393 drug omissions affecting 251 patients, 32% of which were potentially harmful. Seventeen per cent of all medications (619/3691) were unjustified, affecting 318 patients. The unjustified medication was potentially harmful in 16% of cases, occurred significantly more frequent in women than in men (61% vs 50%; p = 0.008) and increased linearly with the number of drugs prescribed (p<0.001). Drug omission had a twofold higher potential to cause harm than unjustified medication. CONCLUSIONS: Drug omissions and unjustified medications are frequent, and systemic changes are required to substantially reduce these inconsistencies.

Influence of steroids on procalcitonin and C-reactive protein in patients with COPD and community-acquired pneumonia.

BACKGROUND: The induction of C-reactive Protein (CRP) may be attenuated by corticosteroids, whereas Procalcitonin (PCT) appears to be unaltered. We investigated, whether in community-acquired pneumonia (CAP) a combined antibiotic-corticosteroid therapy may actually lead to different slopes of decline of these inflammatory markers. PATIENTS AND METHODS: We studied the slopes of decline of PCT and CRP serum levels during 7 consecutive days as well as clinical parameters in a group of patients with CAP on or off corticosteroids. Patients with underlying COPD received systemic corticosteroids (n = 10), while non-COPD patients (n = 10) presenting with CAP alone formed the control group. All patients were treated with antibiotics. RESULTS: At baseline, relevant clinical and laboratory characteristics of the two groups were similar. Regarding the decreasing shapes of the curves from PCT and CRP, no significant differences were found (p-value = 0.48 for the groups for CRP, respectively 0.64 for PCT). All patients showed an uneventful recovery. CONCLUSION: In patients with COPD and CAP, the time courses over 7 days of PCT and CRP showed a nearly parallel decline compared to non-COPD patients with CAP. Contrary to the induction phase, corticosteroids do not modify the time-dependent decay of PCT and CRP when the underlying infectious disease (CAP) is adequately treated.

Recommendations for use of everolimus after heart transplantation: results from a Latin-American Consensus Meeting.

Despite improvements during the last decades, heart transplantation remains associated with several medical complications, which limit clinical outcomes: acute rejection with hemodynamic compromise, cytomegalovirus (CMV) infections, allograft vasculopathy, chronic renal failure, and neoplasias. Everolimus, a proliferation signal inhibitor, represents a new option for adjunctive immunosuppressive therapy. Everolimus displays better efficacy in de novo heart transplant patients than azathioprine for prophylaxis of biopsy-proven acute rejection episodes of at least ISHLT grade 3A (P < .001), of allograft vasculopathy (P < .01), and of CMV infections (P < .01). These findings suggest that everolimus potentially play an important role as part of immunosuppressive therapy in heart transplant recipients. Heart transplant investigators from Latin America produced recommendations for everolimus use in daily practice based on available data and their own experience.