The impact of medical errors on Swiss anaesthesiologists: a cross-sectional survey.

BACKGROUND: Clinicians involved in medical errors can experience significant distress. This study aims to examine (1) how medical errors impact anaesthesiologists in key work and life domains; (2) anaesthesiologists' attitudes regarding support after errors; (3) and which anaesthesiologists are most affected by errors. METHODS: This study is a mailed cross-sectional survey completed by 281 of the 542 clinically active anaesthesiologists (52% response rate) working at Switzerland's five university hospitals between July 2012 and April 2013. RESULTS: Respondents reported that errors had negatively affected anxiety about future errors (51%), confidence in their ability as a doctor (45%), ability to sleep (36%), job satisfaction (32%), and professional reputation (9%). Respondents' lives were more likely to be affected as error severity increased. Ninety per cent of respondents disagreed that hospitals adequately support them in coping with the stress associated with medical errors. Nearly all of the respondents (92%) reported being interested in psychological counselling after a serious error, but many identified barriers to seeking counselling. However, there were significant differences between departments regarding error-related stress levels and attitudes about error-related support. Respondents were more likely to experience certain distress if they were female, older, had previously been involved in a serious error, and were dissatisfied with their last error disclosure. CONCLUSION: Medical errors, even minor errors and near misses, can have a serious effect on clinicians. Health-care organisations need to do more to support clinicians in coping with the stress associated with medical errors.

Protein oxidative changes in whole and skim milk after ultraviolet or fluorescent light exposure.

We investigated how protein changes occur, at the primary or higher structural levels, when proteins are exposed to UV or fluorescent (FL) light while in the complex matrix, milk. Whole milk (WM) or skim milk (SM) samples were exposed to FL or UV light from 0 to 24h at 4°C. Protein oxidation was evaluated by the formation of protein carbonyls (PC), dityrosine bond (DiTyr), and changes in molecular weight (protein fragmentation and polymerization). Oxidative changes in AA residues were measured by PC. Dityrosine and N'-formylkynurenine (NFK), a carbonylation derivative of Trp, were measured by fluorometry. Protein carbonyls increased as a function of irradiation time for both WM and SM. The initial rate for PC formation by exposure to FL light (0.25 or 0.27 nmol/h for WM and SM, respectively) was slower than that following exposure to UV light (1.95 or 1.20 nmol/h, respectively). The time course of NFK formation resembled that of PC. After 24h of UV exposure, SM had significantly higher levels of NFK than did WM. In contrast, WM samples irradiated with UV had higher levels of DiTyr than did SM samples, indicating different molecular pathways. The formation of intra- or intermolecular DiTyr bonds could be indicative of changes in the tertiary structure or oligomerization of proteins. The existence of NFK suggests the occurrence of protein fragmentation. Thus, proteolysis and oligomerization were analyzed by sodium dodecyl sulfate-PAGE. After 24h of exposing WM to UV or FL light, all the proteins were affected by both types of light, as evidenced by loss of material in most of the bands. Aggregates were produced only by UV irradiation. Hydrolysis by pepsin and enzyme-induced coagulation by rennet were performed to evaluate altered biological properties of the oxidized proteins. No effect on pepsin digestion or rennet coagulation was found in irradiated SM or WM. The oxidative status of proteins in milk and dairy products is of interest to the dairy industry and consumers. These findings provide knowledge that could be useful in determining the optimal lighting conditions in the dairy industry in general and in cheese making in particular.

Can skills assessment on a virtual reality trainer predict a surgical trainee's talent in laparoscopic surgery?

BACKGROUND: A number of studies have investigated several aspects of feasibility and validity of performance assessments with virtual reality surgical simulators. However, the validity of performance assessments is limited by the reliability of such measurements, and some issues of reliability still need to be addressed. This study aimed to evaluate the hypothesis that test subjects show logarithmic performance curves on repetitive trials for a component task of laparoscopic cholecystectomy on a virtual reality simulator, and that interindividual differences in performance after considerable training are significant. According to kinesiologic theory, logarithmic performance curves are expected and an individual's learning capacity for a specific task can be extrapolated, allowing quantification of a person's innate ability to develop task-specific skills. METHODS: In this study, 20 medical students at the University of Basel Medical School performed five trials of a standardized task on the LS 500 virtual reality simulator for laparoscopic surgery. Task completion time, number of errors, economy of instrument movements, and maximum speed of instrument movements were measured. RESULTS: The hypothesis was confirmed by the fact that the performance curves for some of the simulator measurements were very close to logarithmic curves, and there were significant interindividual differences in performance at the end of the repetitive trials. CONCLUSIONS: Assessment of perceptual motor skills and the innate ability of an individual with no prior experience in laparoscopic surgery to develop such skills using the LS 500 VR surgical simulator is feasible and reliable.

[Critical incidents]. / Kritische Zwischenfälle.

In medicine real severe mishaps are rare. On the other hand critical incidents are frequent. Anonymous critical incident reporting systems allow us to learn from these mishaps. This learning process will make our daily clinical work safer Unfortunately, before these systems can be used efficiently our professional culture has to be changed. Everyone in medicine has to admit that errors do occur to see the need for an open discussion. If we really want to learn from errors, we cannot punish the individual, who reported his or her mistake. The interest is primarily in what has happened and why it has happened and not who has committed this mistake. The cause for critical incidents in medicine is in over 80% the human factor Poor communication, work under enormous stress, conflicts and hierarchies are the main cause. This has been known for many years, therefore have already 15 years ago high-tech industries, like e.g. aviation, started to invest in special courses on team training. Medicine is a typical profession were until now only the individual performance decided about the professional career Communication, conflict management, stress management, decision making, risk management, team and team resource management were subjects that have never been taught during our preor postgraduate education. These points are the most important ones for an optimal teamwork. A multimodular course designed together with Swissair (Human Aspect Development medical, HADmedical) helps to cover, as in aviation, the soft factor and behavioural education in medicine and to prepare professionals in health care to work as a real team.

Improving anaesthetists' communication skills.

The attitude, behaviour and communication skills of specialised doctors are increasingly recognised as important and they have been identified as training requirements. We designed a programme to teach communication skills to doctors in a University Department of Anaesthesia and evaluated its effect on patient outcomes such as satisfaction and anxiety. The 20 h programme was based on videotaped reviews of actual pre-operative visits and role-playing. Effects on patient satisfaction and pre-operative anxiety were assessed using a patient questionnaire. In addition, all participating anaesthetists assessed the training. We provide evidence that the training increased patient satisfaction with the pre-operative anaesthetic visit. Training also decreased anxiety associated with specific aspects of anaesthesia and surgery, but the effect was rather small given the intense programme. The anaesthetists agreed that their interpersonal skills increased and they felt better prepared to understand patients' anxieties. Communication skills training can increase patient satisfaction and decrease specific anxieties. The authors conclude that in order to better demonstrate the efficacy of such a training programme, the particular communication skills of anaesthetists rather than indirect patient outcome parameters should be measured.

Team performance in the emergency room: assessment of inter-disciplinary attitudes.

In-hospital emergency medicine in central Europe relies on inter-disciplinary co-operation. To improve team performance in the emergency room (ER), a questionnaire for assessment of attitudes and judgements in resuscitation procedures was developed. A total of 43 items were evaluated according to a five-point Likert scale. With a response rate of 81%, 143 questionnaires were evaluated. Assessment of data was performed with regard to professional speciality and level in the medical hierarchy. Factorial analysis identified four main factors: Assessment of 'quality of performance' (F1), 'importance of structure' (F2), 'quality of team culture' (F3), and 'importance of hierarchy' (F4). Influences from the categories 'speciality' and 'hierarchy' and from the covariate 'gender' on these main factors were evaluated by two-factorial analysis of variance. For all four factors, 'speciality' produced significant differences. Surgeons accorded high values to F1 and low values to F2, whereas anaesthesiologists accorded low values to F1 and high values to F2. F3 showed a low ranking from within the ER nursing staff and the residents in internal medicine, whereas F4 received high scores by medical residents and staff members. For F1 and F3, there was a tendency towards hierarchy dependency, whereas no factor was influenced by gender. In conclusion, team performance in the ER is mainly influenced by different perceptions and attitudes of the different disciplines involved in the resuscitation process.

Migration and function of antigen-primed nonpolarized T lymphocytes in vivo.

Upon antigenic stimulation, naive T lymphocytes proliferate and a fraction of the activated cells acquire a T helper cell type 1 (Th1) or Th2 phenotype as well as the capacity to migrate to inflamed tissues. However, the antigen-primed T cells that receive a short T cell receptor (TCR) stimulation do not acquire effector function and remain in a nonpolarized state. Using TCR transgenic CD4(+) T cells in an adoptive transfer system, we compared the in vivo migratory capacities of naive, nonpolarized, Th1 or Th2 cells. Although all cell types migrated to the spleen, only naive and nonpolarized T cells efficiently migrated to lymph nodes. In addition Th1, but not Th2, migrated to inflamed tissues. In the lymph nodes, nonpolarized T cells proliferated and acquired effector function in response to antigenic stimulation, displaying lower activation threshold and faster kinetics compared with naive T cells. These results suggest that nonpolarized T cells are in an intermediate state of differentiation characterized by lymph node homing capacity and increased responsiveness that allows them to mount a prompt and effective secondary response.

The visual analog scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns.

UNLABELLED: The advent of managed care, reduction of costs, and advances in medical technology place increasing demands on anesthesiologists. Preoperative anxiety may go unnoticed in an environment that stresses increased productivity. The present study compares different methods for measuring preoperative anxiety, identifies certain patient characteristics that predispose to high anxiety, and describes the quantity and quality of anxiety that patients experience preoperatively. Seven hundred thirty-four patients participated in the study. We assessed aspects of anxiety by means of visual analog scales (VAS) and the State Anxiety Score of the Spielberger State-Trait Anxiety Inventory (STAI). The mean STAI anxiety score was 39 +/- 1 (n = 486) and the mean VAS for fear of anesthesia was 29 +/- 1 (n = 539). Patients feared surgery significantly more than anesthesia (P < 0.001). The VAS measuring fear of anesthesia correlated well with the STAI score (r = 0.55; P < 0.01). Young patients, female patients, and patients with no previous anesthetic experience or a previous negative anesthetic experience had higher anxiety scores. Patients worried most about the waiting period preceding surgery and were least concerned about possible awareness intraoperatively. Factor analysis of various anxiety items showed three distinct dimensions of fear: 1) the fear of the unknown 2) the fear of feeling ill, and 3) the fear for one's life. Among these dimensions, fear of the unknown correlated highest with the anxiety measuring techniques STAI and VAS. The simple VAS proved to be a useful and valid measure of preoperative anxiety. IMPLICATIONS: The study of qualitative aspects of anxiety reveals three distinct dimensions of preoperative fear: fear of the unknown, fear of feeling ill, and fear for one's life. Groups of patients with a higher degree of preoperative anxiety and their specific anesthetic concerns can be identified using the visual analog scale.

The interplay between the duration of TCR and cytokine signaling determines T cell polarization.

Development of Th1 and Th2 effector lymphocytes is driven primarily by IL-12 or IL-4, but is also influenced by the strength of antigenic stimulation. However, the mechanism by which TCR signaling contributes to T cell polarization remains elusive. We show that in the presence of IL-12 a short TCR stimulation can lead to efficient Th1 polarization and IL-12 exerts its effect when present during, as well as after, TCR signaling. In contrast, Th2 polarization requires a prolonged TCR stimulation and IL-4 is effective only when present during the period of TCR triggering. The simultaneous stimulation by TCR and IL-4 is required to induce demethylation of IL-4 and IL-13 genes that accompanies the stochastic generation of Th2 cells producing either or both cytokines. Thus, the duration of TCR stimulation represents a crucial parameter that influences the response to polarizing cytokines and the acquisition of T cell effector functions.

What is the future of advanced trauma life support training?

Within the past 20 years, advanced trauma life support has developed from a regional to an international educational programme, with 31 participating countries. Notwithstanding the general acknowledgement of the effectiveness of advanced trauma life support procedures for improving early hospital trauma management and the specific knowledge and skills of participants, some criticism has come from the community of British anaesthetists, regarding course contents, the possibility of participating, the significance of skills for trained anaesthetists, team-related concerns and, of course, costs. Now that we have 10 years' experience from European advanced trauma life support courses, we want to take the opportunity to assess the advantages and possible deficiencies of this programme.

Gastric intramucosal pH-guided therapy in patients after elective repair of infrarenal abdominal aneurysms: is it beneficial?

OBJECTIVE: To determine if gastric intramucosal pH (pHi)-guided therapy reduces the number of complications and length of stay in the intensive care unit (ICU) or the hospital after elective repair of infrarenal abdominal aortic aneurysms. DESIGN: Prospective, randomized study. SETTING: Surgical intensive care unit (SICU) of a University Hospital. PATIENTS: Fifty-five consecutive patients randomized to group 1 (pHi-guided therapy) or to group 2 (control). INTERVENTIONS: Patients of group 1 with a pHi of lower than 7.32 were treated by means of a prospective protocol in order to increase their pHi to 7.32 or more. MEASUREMENTS AND RESULTS: pHi was determined in both groups on admission to the SICU and thereafter at 6-h intervals. In group 2, the treating physicians were blinded for the pHi values. Complications, APACHE II scores, duration of endotracheal intubation, fluid and vasoactive drug treatment, treatment with vasoactive drugs, length of stay in the SICU and in the hospital and hospital mortality were recorded. There were no differences between groups in terms of the incidence of complications. We found no differences in APACHE II scores on admission, the duration of intubation, SICU or hospital stay, or hospital mortality. In the two groups the incidence of pHi values lower than 7.32 on admission to the SICU was comparable (41% and 42% in groups 1 and 2, respectively). Patients with pHi lower than 7.32 had more major complications during SICU stay (p < 0.05), and periods more than 10 h of persistently low pHi values (< 7.32) were associated with a higher incidence of SICU complications (p < 0.01). CONCLUSIONS: Low pHi values (< 7.32) and their persistence are predictors of major complications. Treatment to elevate low pHi values does not improve postoperative outcome. Based on these data, we cannot recommend the routine use of gastric tonometers for pHi-guided therapy in these patients. Further studies are warranted to determine adequate treatment of low pHi values that results in beneficial effects on the patient's postoperative course and outcome.

[Perioperative gastrointestinal ischemia in abdominal aortic aneurysm operations]. / Perioperative gastrointestinale Ischämien bei abdominalen Aortenaneurysma-Operationen.

QUESTIONS UNDER STUDY: Surgery of abdominal aortic aneurysms involves a high risk of postoperative complications. It has been suggested that the incidence of postoperative complications is related to the development of gastrointestinal acidotic episodes of the mucosa. The goal of this study was, therefore, to determine the incidence of gastrointestinal acidotic episodes during repair of abdominal aortic aneurysms, and to test the hypothesis that these episodes predict an adverse postoperative course. METHODS: In 49 consecutive patients undergoing elective surgery for repair of an abdominal aneurysm, intramucosal gastric pH (pHi) was measured perioperatively. The length of the surgical procedure, perioperative intravenous fluid intake, use of vasoactive drugs, APACHE-II scores, days with an endotracheal tube in place, days of intensive care and major postoperative complications were prospectively assessed. The patients were assigned to either a group with a pHi > or = 7.35 or a group with pHi < 7.35 measured towards the end of the surgical procedure, and then compared. RESULTS: The pHi decreased from 7.42 +/- 0.09 after induction of anesthesia to 7.37 +/- 0.07 (p < 0.05) during clamping of the aorta, and continued to decrease to 7.34 +/- 0.08 (p < 0.001) towards the end of surgery and on admission to the surgical intensive care unit (mean +/- standard deviation). The percentage of patients with pHi < 7.35 increased from 10% at the beginning of the operation to 55% on admission to the intensive care unit (p < 0.0001). There was no difference in the postoperative course between patients with pHi > or = 7.35 and those with pHi < 7.35 measured after declamping of the aorta. Patients who had a major complication during their stay in the intensive care unit had lower perioperative pHi values than patients without complications (p < 0.001). CONCLUSIONS: Perioperative gastrointestinal acidotic episodes of the mucosa are common during repair of abdominal aortic aneurysms. The perioperative course, however, is not influenced by these acidotic episodes, despite the fact that patients with complications during their stay in the intensive care unit had lower perioperative pHi values. The routine use of pHi measurements during elective surgery of abdominal aortic aneurysms, therefore, is not justified.

Mannose receptor-mediated uptake of antigens strongly enhances HLA class II-restricted antigen presentation by cultured dendritic cells.

Dendritic cells (DC) efficiently take up antigens by macropinocytosis and mannose receptor-mediated endocytosis. Here we show that endocytosis of mannose receptor-antigen complexes takes place via small coated vesicles, while non-mannosylated antigens were mainly present in larger vesicles. Shortly after internalization the mannose receptor and its ligand appeared in the larger vesicles. Within 10 min, the mannosylated and non-mannosylated antigens co-localized with typical markers for major histocompatibility complex class II-enriched compartments and lysosomes. In contrast, the mannose receptor appeared not to reach these compartments, suggesting that it releases its ligand in an earlier endosomal structure. Moreover, we demonstrate that mannosylation of protein antigen and peptides resulted in a 200-10,000-fold enhanced potency to stimulate HLA class II-restricted peptide-specific T cell clones compared to non-mannosylated peptides. Our results indicate that mannosylation of antigen leads to selective targeting and subsequent superior presentation by DC which may be applicable in vaccine design.

Occlusive mesenteric ischemia and its effects on jejunal intramucosal pH, mesenteric oxygen consumption and oxygen tensions from surfaces of the jejunum in anesthetized pigs.

OBJECTIVE: To investigate the effects of superior mesenteric artery (SMA) flow reduction on the jejunal intramucosal pH (pHi) and to compare these effects with corresponding changes of mesenteric oxygen transport variables and oxygen tensions on the surfaces of the jejunal serosa and mucosa. DESIGN: Prospective, randomized, controlled, experimental study. SETTING: Animal research laboratory. SUBJECTS: 20 domestic pigs. INTERVENTIONS: Mechanical flow reduction in the SMA. The animals were randomized to have an SMA flow of 0%, 25%, 38%, 50% or 100% (control). MEASUREMENTS AND MAIN RESULTS: Measurements (baseline, ischemia, reperfusion) consisted of hemodynamic and oxygen transport variables, SMA blood flow, mesenteric oxygen transport variables, pHi and oxygen tensions of the jejunal serosa and mucosa. Flow reduction in the SMA resulted in a significant decrease of pHi indicating ischemia earlier than mesenteric oxygen transport variables. The relationship between mesenteric oxygen delivery (DO2ms) and pHi during acute ischemia is best described by a sigmoid curve. There was a linear correlation between the changes of the jejunal surface oxygen tensions and pHi due to SMA flow reduction. CONCLUSION: The sigmoid relationship between pHi and DO2ms indicated that pHi is a sensitive parameter for detecting ischemia at 50% of the baseline oxygen delivery and that below 25% there was no further decrease of pHi. In contrast, mesenteric and whole body oxygen transport parameters were not indicative of impaired mucosal oxygen supply.

Effect of different drugs on end-tidal carbon dioxide during rodent CPR.

The purpose of this study was to investigate the effect of non-adrenergic agents on cardiopulmonary resuscitation (CPR) and end-tidal CO2 (ETCO2) during CPR in a rodent model. Our results suggested that: 1) coronary perfusion pressure (CPP) after drugs infusion was increased significantly by methoxamine, arginine vasopresin (AVP) and angiotension-II (ANG-II), but not by endothelin-1 (ET-1); 2) ETCO2 prior to defibrillation was decreased significantly by a pure alpha 1 adrenergic agents, methoxamine and were increased significantly by non-adrenergic agents, ANG-II and ET-1 during rodent CPR; 3) a significant positive correlation between ETCO2 and CPP was observed in AVP group, suggesting that AVP have little effect on pulmonary circulation; and 4) methoxamine, AVP and ANG-II have similar effect on resuscitability during rodent CPR.

Ligation of CD40 on dendritic cells triggers production of high levels of interleukin-12 and enhances T cell stimulatory capacity: T-T help via APC activation.

We investigated the possibility that T helper cells might enhance the stimulatory function of dendritic cells (DCs). We found that ligation of CD40 by CD40L triggers the production of extremely high levels of bioactive IL-12. Other stimuli such as microbial agents, TNF-alpha or LPS are much less effective or not at all. In addition, CD40L is the most potent stimulus in upregulating the expression of ICAM-1, CD80, and CD86 molecules on DCs. These effects of CD40 ligation result in an increased capacity of DCs to trigger proliferative responses and IFN-gamma production by T cells. These findings reveal a new role for CD40-CD40L interaction in regulating DC function and are relevant to design therapeutic strategies using cultured DCs.

A human killer inhibitory receptor specific for HLA-A1,2.

Killer inhibitory receptors (KIRs) are transmembrane glycoproteins, expressed on NK cells and a small subset of T cells, that inhibit cell-mediated cytotoxicity upon binding to polymorphic MHC class I determinants on target cells. Although human KIRs specific for HLA-C and HLA-B molecules have been characterized, none have been shown to interact with HLA-A. Here we demonstrate that a member of the KIR cDNA family, designated NKAT4, encodes a 70-kDa receptor specific for HLA-A3.