[Economics of operating room use at a university eye hospital]. / Wirtschaftlichkeit der Operationssaalnutzung an einer Universitäts-Augenklinik.

BACKGROUND: In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of a university eye hospital. MATERIAL AND METHOD: The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on a theoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated. RESULTS: With a total of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4 additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8 days, would result in an additional revenue of about 2.4 times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit margin II: 701,389 €) for the considered surgical patient collective in 2021. CONCLUSION: An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for a large hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.

[Cost unit accounting of strabismus surgery at a university eye hospital]. / Kostenträgerrechnungen von strabologischen Operationen an einer Universitäts-Augenklinik.

BACKGROUND: Strabismus surgery is frequently carried out in university centers. The aim of this work was to calculate the costs of strabismus surgery at a university hospital and to assess the remuneration of costs for outpatient procedures. MATERIAL AND METHODS: Of all strabismus surgeries at the Hanover Medical School in the years 2018 and 2019, relevant surgical data, such as patient age, number of muscles operated on, incision to suture time, attendance time of the surgeons and anesthetists as well as the nursing staff, were evaluated based on the clinics own information system. During this process, the costs for personnel, material, room rental charges and overheads were computed applying cost unit accounting. RESULTS: A total of 302 operations (inpatient proportion 92.1%) were carried out in most cases with the patient under general anesthesia. The mean patient age was 31 years (median 26 years), with 33 patients being children under 6 years of age. On average 1.84 muscles were treated per intervention. The mean incision to suture time was 51.5 min, mean anesthesia time was 85 min, the attendance time of surgical as well as anesthesia nursing staff each accounted for 104 min, the additional time in the postanesthesia care unit added 66 min. Average personnel costs originating from the overall process amounted to 642.14 €, with the addition of 109.23 € for material and medication (surgery and anesthesia) and costs for cleaning and room rental (including overheads) of 178.71 €. Therefore, the overall costs of an average strabismus surgery in our collective added up to 930.08 € (minimum 491.01 €, maximum 1729.29 €). Cost accounting of subgroups yielded substantially higher costs for anesthesia in children as well as for higher numbers of muscles operated on due to different treatment duration (37 min for 1 muscle to 72 min for 3 muscles) and anesthesia time, especially in children <6 years of age (on average 22 min longer than adults and children >5 years; the differences being 11 min for 1 muscle, 25 min for 2 muscles and 30 min for 3 or more muscles). The pure costs of a strabismus surgery at this clinic seem on average to exceed the revenues for strabismus surgery in the outpatient sector calculated by the German uniform evaluation benchmark (EBM) by about a factor of 2. CONCLUSION: It could be shown that the purely economically calculated costs for strabismus surgery at a university clinic are significantly higher than the revenues achieved in the outpatient sector according to paragraph 115b, section 1, of the Social Security Act V (SGB V). Under these circumstances, such operations cannot be performed in a cost-effective manner.

Highly reduced binding to high and low affinity mouse Fc gamma receptors by L234A/L235A and N297A Fc mutations engineered into mouse IgG2a.

The effects of the Fc silencing mutations such as leucine (L) to alanine (A) substitution at the position 234 and 235 (LALA) and the alanine (A) to asparagine (N) substitution at position 297 (N297A) are well investigated for human IgG. However, the effects of the same two silencing Fc mutations in a mouse IgG backbone are not yet well investigated in respect to binding to mouse Fc gamma receptors (FcγRs), complement and subsequent effector functions. By using a mouse IgG2a tool antibody directed against mouse OX40L, we demonstrate a strongly reduced binding of the two Fc mutants to high and low affinity recombinant and cell expressed mouse FcγRs, when compared to the mouse IgG2a with the wild type (wt) backbone. Reduced FcγR binding by the two investigated Fc mutants could further be confirmed on primary mouse macrophages expressing their native FcγRs. In addition, we reveal that the LALA and N297A mutations in the mIgG2a also slightly reduced binding to C1q of human origin. Thus, here we provide experimental evidence that the two investigated Fc mutations in the mouse IgG backbone lead to similar "silencing" properties as previously demonstrated for the human IgG and thus represent a useful method to alter effector functions in tool antibodies to be used in mouse models.

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline.

BACKGROUND AND AIM: This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy. METHODS: This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence. RESULTS: The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).

Feasibility and accuracy of confocal endomicroscopy in comparison with narrow-band imaging and chromoendoscopy for the differentiation of colorectal lesions.

OBJECTIVES: Several advanced imaging techniques have been developed to improve differentiation of colorectal lesions. These techniques need to be assessed for both feasibility and accuracy in order to prove their value in daily clinical practice. The current study assessed the feasibility of probe-based confocal laser endomicroscopy (pCLE) in acquiring videos of sufficient quality. Furthermore, the accuracy of pCLE for the differentiation of colorectal lesions was assessed and compared with narrow-band imaging (NBI) and chromoendoscopy (CE). METHODS: Consecutive patients scheduled for surveillance colonoscopy at our centre were included. All procedures were performed by two expert colonoscopists, who previously participated in studies evaluating pCLE, NBI, and CE. All detected lesions during colonoscopy were differentiated real-time with NBI and CE for Kudo pit pattern. Lesions were also assessed real-time for vascular pattern intensity (VPI) during NBI. Subsequently, pCLE videos of each lesion were acquired and biopsies were taken for histopathology. All pCLE videos were assessed post-hoc for the percentage of time demonstrating sufficient image quality (i.e., depicting at least one crypt or vessel). Finally, pCLE videos were assessed post-hoc for diagnostic accuracy by two experts. RESULTS: A total of 154 lesions detected in 64 patients were included. Accuracy of Kudo pit pattern with NBI for predicting neoplasia (88.7%) was significantly better than accuracy of VPI (77.5%, P = 0.05) but not significantly different from CE (89.3%, P = 0.125). During pCLE, no histology was shown at all on the video in 19 lesions (12%). The mean time to acquire a pCLE video of the remaining 135 lesions was 50 seconds (s.d. 47) per lesion. The median percentage demonstrating sufficient quality per video was 40.5% (interquartile range 21.2-67.0). Accuracy of pCLE for both observers (66.7 and 71.9%) was significantly lower than accuracy of CE (P < 0.001) and NBI (P < 0.001). CONCLUSIONS: Video acquisition with pCLE could not be achieved in a small number of lesions. The majority of pCLE videos demonstrated insufficient quality in more than half of the time recorded. Moreover, post-hoc accuracy of pCLE was significantly lower in comparison with real-time accuracy of CE and NBI. Future research should assess whether further increase in experience could improve pCLE video acquisition and determine the real-time accuracy of pCLE for differentiating colorectal lesions.

The prevalence of dysplasia in the ileoanal pouch following restorative proctocolectomy for ulcerative colitis with associated dysplasia.

AIM: A recent systematic review indicated that dysplasia present before restorative proctocolectomy is a predictor of subsequent dysplasia in the pouch. This prospective study was carried out to assess the prevalence of dysplasia in the ileal pouch in patients having RPC for ulcerative colitis with co-existing dysplasia in the operation specimen. METHOD: Eligible patients were invited for a surveillance endoscopy. The afferent and blind efferent ileal loop, ileoanal pouch and rectal cuff were examined by standard endoscopy using a dye-spray technique with methylene blue. Mucosal abnormalities were biopsied and random biopsies were taken from the afferent and blind ileal loop, pouch and rectal cuff. RESULTS: Fourty-four patients (25 male, mean 49 years) underwent pouch endoscopy at a mean interval from RPC of 8.6 years. Dysplasia was detected in two (4.5%) patients. In one, low-grade dysplasia was found in the rectal cuff and in the other low-grade dysplasia was detected in random biopsies from the pouch and the efferent ileal loop. CONCLUSION: This prospective pouch-endoscopy study detected dysplasia in < 5% of patients over nearly 10 years. The benefit of routine surveillance for dysplasia in the pouch is uncertain, as the significance of low-grade dysplasia in the pouch is not clear.

New classification for probe-based confocal laser endomicroscopy in the colon.

BACKGROUND AND AIMS: Probe-based confocal laser endomicroscopy (pCLE; Cellvizio, Mauna Kea Technologies, Paris, France) enables in vivo histology during colonoscopy and may allow endoscopists to make real-time diagnoses. A collaboration of five experts proposed a new pCLE classification for colonic use. The aim of this study was to assess interobserver agreement and accuracy of the new pCLE classification in the colon. PATIENTS AND METHODS: Eligible patients were prospectively investigated by pCLE. A subset of 13 pCLE video sequences was reviewed post hoc for the establishment of a new classification, which comprised three vessel categories and seven crypt categories. All five blinded observers then scored another set of 102 video sequences, using the new classification. Histopathology was used as a reference standard. RESULTS: The interobserver agreements on vessel and crypt architecture were 'fair' with kappa values of 0.29 and 0.27, respectively. When the classification was reduced to neoplasia vs. non-neoplasia (i.e. vessel or crypt type 3), overall agreement became 'moderate' (κ = 0.56). Overall sensitivity and specificity for predicting neoplasia was 66 % and 83 %, respectively. When all observers agreed (69 % of videos), the corresponding figures became 80 % and 95 %. CONCLUSION: A new classification for pCLE in the colon had a 'moderate' interobserver agreement for differentiating neoplasia from non-neoplastic tissue in the colon. The overall accuracy (81 %) for predicting neoplasia was acceptable and became excellent (94 %) when all five observers agreed. Future research should focus on refinement and validation of the classification.

Clinical identification of dysarthria types among neurologists, residents in neurology and speech therapists.

BACKGROUND: Classification of dysarthria types comprises flaccid, spastic, ataxic, hypo- and hyperkinetic and mixed dysarthria. This study focussed on the ability of neurologists to clinically identify the correct type of dysarthria in neurological patients. METHODS: Eighteen patients with dysarthria and 4 healthy controls were enrolled in the study. The gold standard for dysarthria type was the underlying neurological disease. Recordings of a standard reading passage and free speech were made. Raters were neurologists, residents in neurology and speech therapists, whose scores were compared. RESULTS: Neurologists correctly identified 40% of the recordings, residents 41%, and speech therapists 37%. Interrater agreement was fair among all 3 groups; intrarater agreement was fair to moderate. CONCLUSION: This study suggests that neurologists should be aware of the unreliability of identifying the dysarthria type without the use of additional validated instruments or rating scales in a clinical setting.

First astronomical detection of the cumulene carbon chain molecule H2C6 in TMC-1.

The cumulene carbenes are important components of hydrocarbon chemistry in low-mass star-forming cores. Here we report the first astronomical detection of the long-chain cumulene carbene H2C6 in the interstellar cloud TMC-1, from observations of two of its rotational transitions: J(K,K') = 7(1,7) --> 6(1,6) at 18.8 GHz and 8(1,8) --> 7(1,7) at 21.5 GHz, using NASA's Deep Space Network 70 m antenna at Goldstone, California. In addition we also observed the shorter cumulene carbene H2C4 at the same position. The fractional abundance of H2C6 relative to H2 is about 4.7 x 10(-11) and that of H2C4 is about 4.1 x 10(-9). The abundance of H2C6 is in fairly good agreement with gas-phase chemical models for young molecular cloud cores, but the abundance of H2C4 is significantly larger than predicted.

Evolutionary status of the pre-protostellar core L1498.

L1498 is a classic example of a dense cold pre-protostellar core. To study the evolutionary status, the structure, dynamics, and chemical properties of this core we have obtained high spatial and high spectral resolution observations of molecules tracing densities of 10(3)-10(5) cm-3. We observed CCS, NH3, C3H2, and HC7N with NASA's DSN 70 m antennas. We also present large-scale maps of C18O and 13CO observed with the AT&T 7 m antenna. For the high spatial resolution maps of selected regions within the core we used the VLA for CCS at 22 GHz, and the Owens Valley Radio Observatory (OVRO) MMA for CCS at 94 GHz and CS (2-1). The 22 GHz CCS emission marks a high-density [n(H2) > 10(4) cm -3] core, which is elongated with a major axis along the SE-NW direction. NH3 and C3H2 emissions are located inside the boundary of the CCS emission. C18O emission traces a lower density gas extending beyond the CCS boundary. Along the major axis of the dense core, CCS, NH3 and C3H2 emission show evidence of limb brightening. The observations are consistent with a chemically differentiated onion-shell structure for the L1498 core, with NH3 in the inner and CCS in the outer parts of the core. The high angular resolution (9"-12") spectral line maps obtained by combining NASA Goldstone 70 m and VLA data resolve the CCS 22 GHz emission in the southeast and northwest boundaries into arclike enhancements, supporting the picture that CCS emission originates in a shell outside the NH3 emitting region. Interferometric maps of CCS at 94 GHz and CS at 98 GHz show that their emitting regions contain several small-scale dense condensations. We suggest that the differences between the CCS, CS, C3H2, and NH3 emission are caused by a time-dependent effect as the core evolves slowly. We interpret the chemical and physical properties of L1498 in terms of a quasi-static (or slowly contracting) dense core in which the outer envelope is still growing. The growth rate of the core is determined by the density increase in the CCS shell resulting from the accretion of the outer low-density gas traced by C18O. We conclude that L1498 could become unstable to rapid collapse to form a protostar in less than 5 x 10(6) yr.

Resource Letter ETC-1: extraterrestrial civilization.

This Resource Letter provides a guide to the literature about intelligent life beyond the human sphere of exploration. It offers a starting point for professionals and academics interested in participating in the debate about the existence of other technological civilizations or in the search for extraterrestrial intelligence (SETI). It can also serve as a reference for teaching. This Letter is not intended as an exhaustive bibliography, but several extensive bibliographies have been cited. The letter E after an item indicates elementary, nontechnical material of general interest to persons becoming informed in the field. Intermediate level material, of a somewhat more specialized nature, is indicated by the Letter I. The annotation A indicates advanced, technical material. An asterisk (*) precedes items to be included in an accompanying Reprint Book.

Searching for extraterrestrial civilizations.

We have argued that planning for a search for extraterrestrial intelligence should involve a minimum number of assumptions. In view of the feasibility (at our present level of understanding) of using nuclear fusion to effect interstellar travel at a speed of 0.1c, it appears unwarranted (at this time) to assume that it would not occur for at least some technologically advanced civilizations. One cannot even conclude that humans would not attempt this within the next few centuries. On the contrary, the most likely future situation, given the maintenance of technological growth and the absence of extraterrestrial interference, is that our civilization will explore and colonize our galactic neighborhood. A comparison of the time scales of galactic evolution and interstellar travel leads to the conclusion that the galaxy is either essentially empty with respect to technological civilizations or extensively colonized. In the former instance, a SETI would be unproductive. In the latter, a SETI could be fruitful if a signal has been deliberately directed at the earth or at an alien outpost, probe, or communication relay station in our solar system. In the former case, an existing antenna would probably be sufficient to detect the signal. In the latter case, success would depend on the way in which the communications were coded. Failure to detect a signal could permit any of the following conclusions: (i) the galaxy is devoid of technological civilizations, advanced beyond our own, (ii) such civilizations exist, but cannot (for some reason which is presently beyond our ken) engage in interstellar colonization, or (iii) such civilizations are not attempting overt contact with terrestrial civilizations and their intercommunications, if present, are not coded in a simple way. To plan at this time for a high-cost, large-array SETI based on the last two possibilities appears to be rather premature.