Organizational development trajectory of a large academic radiotherapy department set up similarly to a prospective clinical trial: the MAASTRO experience.

OBJECTIVE: To simultaneously improve patient care processes and clinical research activities by starting a hypothesis-driven reorganization trajectory mimicking the rigorous methodology of a prospective clinical trial. METHODS: The design of this reorganization trajectory was based on the model of a prospective trial. It consisted of (1) listing problems and analysing their potential causes, (2) defining interventions, (3) defining end points and (4) measuring the effect of the interventions (i.e. at baseline and after 1 and 2 years). The primary end point for patient care was the number of organizational root causes of incidents/near incidents; for clinical research, it was the number of patients in trials. There were several secondary end points. We analysed the data using two sample z-tests, χ(2) test, a Mann-Whitney U test and the one-way analysis of variance with Bonferroni correction. RESULTS: The number of organizational root causes was reduced by 27% (p < 0.001). There was no effect on the percentage of patients included in trials. CONCLUSION: The reorganizational trajectory was successful for the primary end point of patient care and had no effect on clinical research. Some confounding events hampered our ability to draw strong conclusions. Nevertheless, the transparency of this approach can give medical professionals more confidence in moving forward with other organizational changes in the same way. ADVANCES IN KNOWLEDGE: This article is novel because managerial interventions were set up similarly to a prospective clinical trial. This study is the first of its kind in radiotherapy, and this approach can contribute to discussions about the effectiveness of managerial interventions.

[Hemodynamic effects of an etomidate-flunitrazepam or midazolam- fentanyl combination for induction of anesthesia in patients with heart valve diseases]. / Hämodynamische Effekte einer Kombination von Etomidat, Flunitrazepam oder Midazolam mit Fentanyl zur Anästhesie-Einleitung bei Patienten mit Herzklappenvitien.

A comparison of the haemodynamic effects of 3 anaesthetic techniques, the combinations etomidate + fentanyl (I), flunitrazepam + fentanyl (II) or midazolam + fentanyl (III), respectively was carried out in 45 patients undergoing various types of cardiac valve replacement surgery. Haemodynamics were assessed by continuously measuring the heart rate as well as the blood pressure in the systemic and pulmonary circulations whereas the cardiac output was measured intermittently. In the first 30 minutes after induction of anaesthesia, a mean arterial blood pressure drop of 10% (I), 20% (II) or 15% (III) respectively, was observed; at the same time, the rate did not change significantly. Cardiac index, however, fell significantly in all 3 groups by 33% (I) 30% (II) or 28% (III), respectively. Pulmonary pressure, wedge pressure and systemic vascular resistance rose only in groups I and III and decreased in group II (flunitrazepam + fentanyl). On the other hand, pulmonary vascular resistance as well as left ventricular work index were significantly decreased in all 3 groups. We conclude that all 3 anaesthetic techniques investigated here may be effectively applied for safe induction of anaesthesia in patients with valvular lesions of the heart. On account of the effect of the combination flunitrazepam + fentanyl on decreasing pulmonary artery pressure and wedge pressure, this technique seems to be preferable in patients with pulmonary hypertension.

[Value of spiro-ergometry and stress echocardiography on optimized programming of the upper frequency limit of dual chamber cardiac pacemakers]. / Stellenwert der Spiroergometrie und Stressechokardiographie zur optimierten Programmierung der oberen Grenzfrequenz von Zweikammerschrittmachern.

Patients with a dual chamber pacemaker often suffer from chronic heart failure. The influence of the upper tracking rate on cardiac performance in patients with and without congestive heart failure is unknown. Therefore, twenty patients with a dual chamber pacemaker implanted for high degree AV block were randomly programmed to upper tracking rates of 110, 120, and 130 bpm. Oxygen uptake (VO2), work capacity, and heart rate were determined at the anaerobic threshold (AT) and at peak exercise using spiroergometry every 4 weeks. Nine patients (71 +/- 12 years) had evidence for advanced heart failure (Weber C/D, group I); 11 patients (60 +/- 6 years) had no or only mild heart failure (Weber A/B, group II). Patients in group II achieved a higher mean VO2-AT at 130 bpm (17.3 +/- 3.9 ml/min/kg) than at 110 bpm (13.7 +/- 4.0 ml/min/kg; p = 0.001). Maximum oxygen uptake and work capacity at the anaerobic threshold were also significantly higher in group II with an upper tracking rate of 130 bpm than at 110 bpm (20.5 +/- 4.5 ml/min/kg vs. 18.2 +/- 5.3 ml/min/kg, p = 0.031, and 98 +/- 29 W vs. 86 +/- 27 W, p = 0.04). In group I, mean oxygen uptake at the anaerobic threshold (VO2-AT) was higher at 110 bpm (11.1 +/- 4.0 ml/min/kg) than at 130 bpm, although of only borderline statistical significance (9.2 +/- 2.6 ml/min/kg; p = 0.052). In group I a higher upper rate decreased VO2-AT by 24%, whereas in group II the higher upper rate improved aerobic capacity by 26%. Stressechocardiography (VVI pacing with a maximum tracking rate of 130 bpm) revealed new wall motion abnormalities in all patients of group I, but only in one patient of group II. Wall motion score index increased from 1.20 +/- 0.24 at rest to 1.54 +/- 0.28 under stress (p < 0.001) in group I, but not in group II (1.00 +/- 0 vs. 1.06 +/- 0.19; p = n.s.). Thus, carriers of dual-chamber pacemakers with no or mild heart failure (Weber A/B) benefit from higher programmed upper rates. In contrast, patients with more advanced heart failure (Weber C/D) improve aerobic capacity with lower programmed upper rates. This may be caused by exercise-induced ischemia in group I as indicated by stressechocardiography.

Investigations on recurrent condyle dislocation in patients with temporomandibular joint dysfunction: a therapeutical concept.

In the last 2 years, 30 patients with recurrent condyle dislocation were examined and treated with two different two-phase procedures according to their main clinical symptoms. The success of both procedures, firstly, pericapsular injection of homogenous blood and, if necessary, elimination of occlusal disharmonies, and secondly, functional treatment with occlusal adjustment, in some cases followed by injection therapy, is outlined. Some suspected etiological factors are investigated. In 14 out of 19 patients in Group I injections were successful, three cases improved, and therapy failed in two patients during a follow-up of up to 18 months. Four out of eleven patients treated in Group II with occlusal adjustment first had total relief of symptoms, three improved, and four showed no significant improvement during a mean follow-up of 5 months. Our beneficial results in Group I justify the procedure described here as a valuable alternative to more aggressive approaches and should be the initial modality of choice in this condition.