Direct volumetric flow cytometric quantitation of CD34+ stem and progenitor cells.

OBJECTIVES: In this study, we compared a classic single-platform (SP) method applying beads for enumeration of CD45+ or CD34+ cells with a new device allowing direct volumetric measurements of stem and progenitor cells. BACKGROUND: Following apheresis and cyropreservation, the precise enumeration of CD34+ cells as key parameter of graft quality is mandatory for the clinical course after transplantation. Currently, flow cytometry with SP technique represents the 'gold standard' for such determinations. METHODS/MATERIALS: Fresh samples, 14 from mobilised peripheral blood (PB), 9 from apheresis products (AP) and 13 samples from frozen-thawed (FT) haematopoietic progenitor cell grafts, were analysed for CD34+ cells, CD45+ cells, and in frozen-thawed samples for viability by a bead-based flow cytometric method and in parallel by a direct, volumetric flow cytometric method. RESULTS: Comparison of CD34+ analyses revealed a significant correlation (P < 0·01) for each material between both techniques with r = 0·95 (PB), r = 0·933 (AP) and r = 0·929 (FT). Also, for analysis of CD45+ cells µL(-1) , the measured numbers evaluated with the different techniques did not significantly differ for all three materials analysed. In frozen-thawed samples, the analysis of viability was comparable for both techniques. CONCLUSIONS: The results of this study demonstrate that a direct volumetric analysis of CD34+ cells µL(-1) or CD45+ cells µL(-1) is feasible. This technique represents a simple and economical approach for standardisation of progenitor and stem cell analyses.

Allergic asthma after flour inhalation in subjects without occupational exposure to flours: an experimental pilot study.

OBJECTIVE: Cross-reactivity between grass pollen and grain flour allergens is well known, but their significance in apprentice bakers with primary sensitization to grass pollen is not known. METHODS: Twenty-five subjects with mild asthma (most of them with hay fever), but without prior occupational flour exposure, underwent standardized experimental inhalation challenges with placebo and wheat and rye flours in randomized order on three consecutive days. Sensitization to flours and environmental allergens was assessed by skin prick tests and specific IgE antibodies in sera. IgE inhibition experiments were performed with wheat and rye flours as solid phases, and grass and tree pollen as inhibitors. RESULTS: Five subjects experienced a positive reaction after flour inhalation (responders), whereas 20 subjects did not show such a reaction (non-responders). All responders showed sensitizations to flours, whereas only 25% of the non-responders demonstrated the same sensitization. Specific IgE concentrations to flours, but also to grass and tree pollen, were higher in responders. Inhibition experiments demonstrated cross-reactivity between flours and grass or tree pollen, with higher inhibition rates in responders. CONCLUSIONS: Subjects with pronounced sensitizations to grass or tree pollen, but without prior occupational exposure to flours, may experience both sensitization and allergic asthmatic reactions to flours due to cross-reactive grass and tree pollen allergens.

[Quality assurance of rehabilitation by the German pension insurance: an overview]. / Ein aktueller Überblick zur Reha-Qualitätssicherung der Rentenversicherung.

The German pension insurance has in recent years developed a comprehensive programme for quality assurance in rehabilitation, and has implemented the programme into routine practice. Different aspects of rehabilitation are evaluated with differentiated instruments. Issues dealt with inter alia include the quality of rehabilitative care in a narrower sense, the structure and organisation of the rehabilitation centres, as well as quality from the patients' perspective. On the whole, positive results predominate. Big differences in quality however have been found between the rehabilitation centres. The data collections and data evaluations carried out make a continuous process of quality assurance reporting possible for use by rehabilitation centres and pension insurance agencies. This will enable targeted initiatives for quality improvement. The methods and procedures of quality assurance are enhanced at regular intervals, and the scope of quality assurance is extended. Thus, rehab quality assurance is also expanded to cover ambulant rehabilitation or rehabilitation of children and young people.

[Empowerment and health literacy in medical rehabilitation - recommendations for strengthening patient education]. / Teilhabebefähigung und Gesundheitskompetenz in der medizinischen Rehabilitation - Empfehlungen zur Stärkung von Patientenschulungen.

UNLABELLED: The recommendations aim to increase patient participation and health literacy by strengthening the role of patient education in medical rehabilitation. Research shows patient education to be effective and efficient; making the implementation of high quality patient education a top priority. To strengthen the role of patient education it is important to address known obstacles, identify potential for improvement, and define future demands for rehabilitative care. Led by the German Society for Medical Rehabilitation (DEGEMED), the Centre for Patient Education at the Würzburg University, and the Institute for Quality Management and Clinical Audit in Medical Rehabilitation (IQEM) an inter- and multidisciplinary panel of 28 experts from research and practice developed recommendations to further patient education in medical rehabilitation. The recommendations address topics such as the implementation of legal requirements under book IX of the German Social Code, SGB 9, structural and organisational prerequisites to promote the importance of patient education in rehabilitation units, the incorporation of quality criteria for patient education in quality assurance, quality management, and certification, as well as networking between medical rehabilitation and other health care sectors. CONCLUSION: Providers of medical rehabilitation hold the power to strengthen patient education: by implementing patient education programmes that are well-evaluated, manual-based, and standardised, by providing sufficient resources within their institutions, and by placing patient education in the centre of their quality policy, i.e. by nomination of a patient education representative. Stakeholders need to acknowledge these activities by incorporating quality criteria for patient education in clinical audit, and last but not least by adequate funding of medical rehabilitation.

Postoperative euglycaemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitors (gliflozins): a report of two cases and review of the literature.

Sodium-glucose cotransporter 2 inhibitor (SGLT2i)-associated euglycaemic diabetic ketoacidosis (euDKA) is a serious and increasingly recognised complication of treatment with this class of oral hypoglycaemic agents and can present a diagnostic challenge, resulting in delayed recognition, inappropriate treatment and potentially life-threatening acidosis. We present two cases of patients developing SGLT2i-associated euDKA in the early postoperative period. We support ceasing SGLT2i for 72 hours preoperatively and would suggest continuing to withhold the medication until oral intake is restored, and recommend a wider awareness of SGLT2i-associated diabetic ketoacidosis (DKA) amongst patients and their healthcare providers with an emphasis on checking ketone levels irrespective of blood glucose levels in the postoperative setting.

Factors associated with reintubation in intensive care: an analysis of causes and outcomes.

INTRODUCTION: Reports on reintubation have focused on patients in whom planned extubation has been unsuccessful or those who have been accidentally extubated. However, reintubation is often required in events not related to accidental extubation. These cases have not been well described previously. OBJECTIVES: To examine the causes, outcomes, and contributing factors associated with patients who required reintubation for events not including accidental extubation. METHODS: Appropriate reintubation incidents were extracted from the Australian Incident Monitoring Study in Intensive Care database and analyzed using descriptive methodology. RESULTS: One hundred forty-three incidents were identified with prominent precipitating events, including tube malposition (17%), securing/taping problems (17%), pilot tube/cuff problem (16%), blocked/kinked airway (14%), failed extubation (14%), and poor planning for extubation (6%). Narrative description of morbidity included hypoxia in 25% of reports, hypercarbic respiratory failure in 12%, aspiration in 7%, sputum retention in 7%, and cardiac arrhythmias in 6%. The reporter selected "major physiologic complications" and "prolonged hospital stay" as prominent adverse outcomes in 52% and 16% of patients, respectively. Major factors contributing to reintubation involved "error of judgement/problem recognition" (identified in 62% of reports), "high unit activity" (20%), "difficult patient habitus" (26%), and "lack of patient cooperation" (14%). Rechecking patient and equipment, and skilled assistance were prominent factors in limiting the adverse consequences of the incident. CONCLUSION: This study indicated that reintubation not related to accidental extubation resulted in major physiologic complications and potentially contributed to increased length of stay. Its findings suggest that the adequate provision of highly qualified, intensive-care-trained staff is essential for the avoidance or minimization of these incidents.

ORSAT and modifications of SEFT and APT.

Up to now, three subspectra are usually needed for the complete assignment of all signals in 13C spectrum: two DEPT spectra (phi = 90 degrees and phi = 135 degrees) and a proton decoupled spectrum. In this paper, we present a method in which a complete assignment becomes possible with merely two spectra. For this purpose, a new pulse sequence (ORSAT) has been elaborated by using off-resonance irradiation. The method described here is a further development of SEFT and APT. The second required spectrum is a DEPT (phi = 135 degrees). Signal assignment of cholesteryl acetate is demonstrated as an example. 13C routine spectroscopy can be significantly accelerated by applying this method.

The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs.

Although many studies have attempted to define levels of staff experience appropriate for the care of critically ill patients, minimal data is available on the effect of nursing staff inexperience (NSI) on the occurrence of incidents in the intensive care environment. The Australian Incident Monitoring Study in Intensive Care Units (AIMS-ICU), an anonymous, voluntary incident reporting system, can help to identify problems in which NSI may be implicated. NSI may be an incident in itself or contribute to the occurrence of other incidents. The objective of this paper was to identify incidents associated with NSI and estimate their effect on the quality of patient care. Incidents related to NSI were extracted from the AIMS-ICU database and analysed using descriptive methodology. Seven hundred and thirty five reports covering 1,472 incidents were identified as relating to NSI. Of these, 282 were described in the narrative section and 453 were selected as a contributing factor by the reporter. Major categories for the 1,472 incidents included airway and ventilation (317) drugs and therapeutics (468), procedures, lines and equipment (219), patient environment (234) and unit management (234). An undesirable major adverse patient outcome was selected in 20 per cent of reports. NSI associated incidents reported to AIMS-ICU suggest that NSI can have a negative impact on the quality of care delivered to critically ill patients as shown by the occurrence and outcome of incidents related to such inexperience. Errors are more likely to occur when NSI is combined with staff shortage, inadequate supervision and high unit activity. When rostering or employing staff, nurse managers and educators must consider the special requirements of inexperienced nurses. Safe patient care requires these issues be included in discussions about ICU resource allocation.

Conflicts of thermal adaptation and fever--a cybernetic approach based on physiological experiments.

Cold adaptation aims primarily at a better economy, i.e., preservation of energy often at the cost of a lower mean body temperature during cold stress, whereas heat adaptation whether achieved by exposure to a hot environment or by endogenous heat produced by muscle exercise, often brings about a higher efficiency of control, i.e., a lower mean body temperature during heat stress, at the cost of a higher water loss. While cold adaptation is beneficial in a cold environment, it may constitute a detrimental factor for exposure to a hot environment, mainly because of morphological adaptation. Heat adaptation may be maladaptive for cold exposure, mainly because of functional adaptation. Heat adaptation clearly is best suited to avoid higher body temperatures in fever, no matter which environmental conditions prevail. On the other hand, cold adaptation is detrimental for coping with fever in hot environment. Yet, in the cold, preceding cold adaptation may, because of reduced metabolic heat production, result in lower febrile increase of body temperature. Apparently controversial effects and results may be analyzed in the framework of a cybernetic approach to the main mechanisms of thermal adaptation and fever. Morphological adaptations alter the properties of the heat transfer characteristics of the body ("passive system"), whereas functional adaptation and fever concern the subsystems of control, namely sensors, integrative centers and effectors. In a closed control-loop the two types of adaptation have totally different consequences. It is shown that the experimental results are consistent with the predictions of such an approach.

The dust halo of Saturn's largest icy moon, Rhea.

Saturn's moon Rhea had been considered massive enough to retain a thin, externally generated atmosphere capable of locally affecting Saturn's magnetosphere. The Cassini spacecraft's in situ observations reveal that energetic electrons are depleted in the moon's vicinity. The absence of a substantial exosphere implies that Rhea's magnetospheric interaction region, rather than being exclusively induced by sputtered gas and its products, likely contains solid material that can absorb magnetospheric particles. Combined observations from several instruments suggest that this material is in the form of grains and boulders up to several decimetres in size and orbits Rhea as an equatorial debris disk. Within this disk may reside denser, discrete rings or arcs of material.

[Quality assurance in outpatient medical rehabilitation - concept and results of a pilot project to develop a quality assurance programme for musculoskeletal and cardiac diseases]. / Qualitätssicherung in der ambulanten medizinischen Rehabilitation: Konzeption und Ergebnisse eines Pilotprojekts zur Entwicklung eines Qualitätssicherungsprogramms für die Indikationsbereiche muskuloskeletale und kardiologische Erkrankungen.

PURPOSE: The concept and results of a pilot project to develop a quality assurance programme for outpatient medical rehabilitation in musculoskeletal and cardiac diseases are discussed. The processes developed and the results that were achieved using the instruments in 24 pilot institutions are described. METHODS: The quality of structure was assessed by defining and applying basic and detailed criteria; a version of peer review for outpatient treatment was developed to test the quality of process. The quality of results was determined by means of a prospective study with two or three measurement times and implementation of generic and disease-specific measurement instruments. The process was tested on n=1475 patients with musculoskeletal diseases and n=843 patients with cardiac diseases. RESULTS: The level of the quality of structure in the participating centres is quite high; 89-93% of the structure features required were fulfilled. The peer review indicated that the process had 25-40% serious shortcomings in cardiology and 15-20% for musculoskeletal diseases. The quality of results measurements show that the participating outpatient rehab centres achieved medium effects for the majority of the core rehab dimensions for the respective indications, but the findings also showed that at the time the follow-up reports were made there was often a reduction of positive effects and high effects were quite rare. While there were marked differences in quality of structure and process among the various institutions, there were only slight differences among the outpatient centres regarding quality of results. CONCLUSIONS: A scientifically sound quality assurance programme was developed that covers specific aspects of outpatient rehabilitation, to a great extent using the same structures that have been implemented in the quality assurance programmes for inpatient treatment. To implement the results presented here, the scientific findings will need to be evaluated in the respective committees of the cost-carriers. The tests of the programme in 24 pilot institutions showed an overall high level of quality, but also revealed potential for improvement in some areas.

The physical therapist's role in neonatal intensive care: a survey.

A survey was undertaken to investigate the current practice and the actual need for physical therapy in the relatively new area of neonatal intensive care. The opinions of professionals within five groupings at six hospitals with neonatal intensive care units were solicited. A hypothetical situation of the ideal physical therapy service in neonatal intensive care was presented to the respondents who were then asked to compare such ideal services with those currently provided in the units surveyed. The results indicated that the majority of those surveyed consider the physical therapist to be an important member of the health team in a neonatal intensive care unit. Expansion of physical therapy services, with regard to both availability and areas of involvement, appears desirable. Both the conclusions derived from a review of the literature and the survey's results indicate that more research in neonatal physical therapy is needed.

Incidents relating to arterial cannulation as identified in 7,525 reports submitted to the Australian incident monitoring study (AIMS-ICU).

Arterial cannulation is frequently used in the critical care environment. Literaturefocuses on insertion techniques and complications. This report utilized data from the Australian Incident Monitoring Study (AIMS-ICU) national database to identify common problems and contributing factors associated with the use and maintenance of arterial lines. A review of narratives, keywords and contributing factors yielded 251 reports outlining 376 incidents. Of these, 15% describing line insertion problems, 66% line use and maintenance problems and 19% patient injuries. Inadequate line securing, accidental line dislodgement, incorrect set-up, distal ischaemia and infection featured prominently. As a result of the incident, 49% of patients involved suffered no ill effect, 28% minor physiological complications and 15% suffered major adverse effects. Multiple contributing factors were selected for each report, with lack of knowledge, rule-based errors, high unit activity, and lack of support staff or supervision selected most frequently. This study highlights the need to employ meticulous insertion technique, line set-up, securing, frequent line assessment and the early removal of lines no longer essential to patient care. Support and education of staff as well as the development of protocols are important for the safe use of arterial lines.

1,2-bis(pyridine-2-carboxamido)benzenate(2-), (bpb)2-: a noninnocent ligand. Syntheses, structures, and mechanisms of formation of [(n-Bu)4N][FeIV2(mu-N)(bpb)2(X)2] (X = CN-, N3-) and the electronic structures of [MIII(bpbox1)(CN)2] (M = Co, Fe).

The well-known tetradentate ligand 1,2-bis(pyridine-2-carboxamido)benzenate(2-), (bpb)2-, and its 4,5-dichloro analogue, (bpc)2-, are shown to be "noninnocent" ligands in the sense that in coordination compounds they can exist in their radical one- and diamagnetic two-electron-oxidized forms (bpbox1)- and (bpbox2)0 (and (bpcox1)- and (bpcox2)0), respectively. Photolysis of high-spin [(n-Bu)4N][FeIII(bpb)(N3)2] and its (bpc)2- analogue in acetone solution at room temperature generates the diamagnetic dinuclear complex [(n-Bu)4N][FeIV2(mu-N)(bpb)2(N3)2] and its (bpc)2- analogue; the corresponding cyano complex [(n-Bu)4N][FeIV2(mu-N)(bpb)2(CN)2] has been prepared via N3- substitution by CN-. Photolysis in frozen acetonitrile solution produces a low-spin ferric species (S = 1/2) which presumably is [FeIII(bpbox2)(N)(N3)]-, as has been established by EPR and Mössbauer spectroscopy. The mononuclear complexes [(n-Bu)4N][FeIII(bpb)(CN2)] (low spin), [Et4N][CoIII(bpb)(CN)2] and Na[CoIII(bpc)-(CN)2].3CH3OH can be electrochemically or chemically one-electron-oxidized to give [FeIII(bpbox1)(CN)2]0 (S = 0), [CoIII(bpbox1)(CN)2]0 (S = 1/2), and [CoIII(bpcox1)(CN)2]0 (S = 1/2). All complexes have been characterized by UV-vis, EPR, and Mössbauer spectroscopy, and their electro- and magnetochemistries have been studied. The crystal structures of [(n-Bu)4N][FeIII(bpb)(N3)2].1/2C6H6CH3, Na[FeIII(bpb)(CN)2], Na[CoIII(bpc)(CN)2].3CH3OH, [(n-Bu)4N][FeIV2(mu-N)(bpb)2(CN)2], and [(n-Bu)4N][FeIV2(mu-N)(bpb)(N3)2] have been determined by single-crystal X-ray diffraction.

Health risk in hospitals through airborne allergens for patients presensitised to latex.

Two nurses had to stop practicing because of severe work-related allergic respiratory or systemic symptoms. Both developed similar symptoms within a short time when they attended hospitals as outpatients or visitors or consulted a doctor or dentist, even when they had no direct contact with latex articles. The airborne latex allergen concentration in one room that induced symptoms was 128 ng per m3. In skinprick tests both women showed positive reactions to the phosphated cornstarch powder used to prevent latex gloves sticking together, but only when the powder had been in contact with latex. This powder seems a likely vehicle for the airborne latex allergen.

The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An analysis of the first year of reporting.

The AIMS-ICU project is a national study set up to develop, introduce and evaluate an anonymous voluntary incident reporting system for intensive care. ICU staff members reported events which could have reduced, or did reduce, the safety margin for the patient. Seven ICUs contributed 536 reports, which identified 610 incidents involving the airway (20%), procedures (23%), drugs (28%), patient environment (21%), and ICU management (9%). Incidents were detected most frequently by rechecking the patient or the equipment, or by prior experience. No ill effects or only minor ones were experienced by most patients (short-term 76%, long-term 92%) as a result of the incident. Multiple contributing factors were identified, 33% system-based and 66% human factor-based. Incident monitoring promises to be a useful technique for improving patient safety in the ICU, when sufficient data have been collected to allow analysis of sets of incidents in defined "clinical situations".

Problems associated with nursing staff shortage: an analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU).

Although many studies have attempted to define appropriate nursing staff levels, allocation and patient dependency, minimal data is available on the effect of nursing staff shortage (NSS) on quality of care provided in intensive care. This study aimed to identify incidents associated with staff shortage as reported to the Australian Incident Monitoring Study-ICU (AIMS-ICU) project and to assess their estimated effect on patient outcome. A search of narrative keywords and contributing factors identified 89 nursing staff shortage incidents (NSS-INCIDENTS) and 373 incidents involving nursing staff shortage contributing factors (NSS-CF). NSS resulted from inappropriate rostering for current patient load (81%) and inability to respond to increased unit activity (19%). Most frequent associated incidents included problems with: drug administration/documentation (47), patient supervision (20), set-up of ventilators/equipment (16), and accidental extubation (14). Undesirable patient outcomes included: major physiological change (22%), patient/relative dissatisfaction (12%), and physical injury (3%). This study suggests that inadequate staffing results in incidents and compromised patient safety.

The effect of graded immersion on heart volume, central venous pressure, pulmonary blood distribution, and heart rate in man.

The present experiments have been conducted to study the immediate effects of graded immersion on the central circulation. When taking heart volume as an indicator, it was found that immersion to the diaphragm of a standing subject produces the same changes as assumption of the supine posture. Heart volume increases by approximately 130 ml. When the water level is raised to the neck, an extra pressure corresponding to a water column extending from the diaphragm to the surface of the water of approximately 25 cm H2O forces blood into the thorax. The heart becomes distended by an additional 120 ml. Correspondingly the central venous pressure at the height of the right atrium increases from 2.5 to 12.8 mm HG when the water level rises from the diaphragm to the neck. The greater filling of the pulmonary circulation is accompanied by a decrease in vital capacity and visualized by scintigrams. The preferential increase in blood volume of the apical regions is striking. When raising the water level from the symphysis to the xiphoid heart rate falls by about 15%.