[Certification in the healthcare system. What happens when the certificate is not awarded?]. / Zertifizierungen im Gesundheitswesen. Was passiert, wenn das Zertifikat nicht erreicht wird?

A quality certification is nowadays an important competitive factor for clinics and other institutions in Germany. The best known procedures are certification according to the norm DIN EN ISO, the German certification procedure in the healthcare system KTQ (Cooperation for Quality and Transparency in Healthcare) and the procedures of the German Cancer Society or medical professional societies. The majority of German clinics, centers, practices and nursing institutions are certified according to one of these procedures. In some areas certification is mandatory and a prerequisite for patient care, e.g. for rehabilitation institutions. But even in the field of acute medicine certification is an important proof that quality requirements have been fulfilled and has an effect on the economic situation. The aim of a visitation or audit is always to check whether the requirements of the appropriate certification procedure have been fulfilled. The actual procedure and the course can however, be organized differently. The failure to obtain certification is a very unpleasant situation for all concerned and can have negative effects on the image of the institution. Such a failure can most probably be avoided by good preparation and if necessary external consultation or internal qualification by colleagues. In most cases the certificate can be successfully obtained at least by the second attempt. Appropriate regulations are made by all procedures. Basically a thorough cost-benefit analysis should be carried out before deciding to apply for certification.

Endothelial nitric oxide synthase gene haplotypes affect nitrite levels in black subjects.

Polymorphisms in the endothelial nitric oxide synthase (eNOS) gene have been associated with variations in nitric oxide (NO) formation and response to drugs in white subjects. We examined whether genetic polymorphisms (T-786C, b/a intron 4 and Glu298Asp) and haplotypes of the eNOS gene affect NO formation in 179 healthy black subjects. To assess NO formation, we measured the concentrations of nitrite in the plasma, red blood cells and whole blood. Although we found no effects of individual eNOS polymorphisms on NO formation, we found that the 'C-4b-Glu' haplotype is significantly more common in subjects with low circulating plasma and whole blood nitrite concentrations compared with subjects with high circulating nitrite concentrations (both P<0.0007). These findings reproduce previous findings in white subjects and are consistent with the idea that defining genetic markers is more important than ethnic classification, at least in terms of NO formation.

eNOS haplotype associated with hypertension in obese children and adolescents.

OBJECTIVE: The aim of our study is to investigate whether genetic polymorphisms in the endothelial nitric oxide synthase (eNOS) gene (in the promoter region T(-786)C, in exon 7 (Glu298Asp) and in intron 4 (4b/4a)) or eNOS haplotypes are associated with hypertension in obese children and adolescents. METHODS: We genotyped 175 healthy (controls), 110 normotensive obese and 73 hypertensive obese children and adolescents. Genotypes were determined by Taqman allele discrimination assay and real-time PCR, and by PCR followed by fragment separation by electrophoresis. We compared the distribution of eNOS genotypes, alleles and haplotypes in the three study groups of subjects. We have also measured whole-blood nitrite concentrations. RESULTS: The 4a4a genotype for the intron 4 polymorphism was more common in normotensive obese and hypertensive obese (P<0.01). The AspAsp genotype for Glu298Asp polymorphism was less common in normotensive obese (P<0.02). No significant differences were found in allele distributions for the three eNOS polymorphisms. However, the haplotype combining the C, 4b and Glu variants for the three polymorphisms was more common in hypertensive obese than in normotensive obese or control children and adolescents (odds ratio=2.28 and 2.79, respectively; 95% confidence interval: 1.31-4.31 and 1.39-5.64, respectively; both P<0.00625). This haplotype was not associated with significantly different nitrite concentrations (P>0.05). CONCLUSIONS: Our findings suggest that the eNOS haplotype, C b Glu, is associated with hypertension in obese children and adolescents. Further studies examining the possible interactions of eNOS haplotypes with environmental factors and other genetic markers involved in the development of obesity and its complications are warranted.

Relationship between systemic nitric oxide metabolites and cyclic GMP in healthy male volunteers.

AIM: Nitric oxide (NO) is an endogenous mediator of many physiological processes, many of which are mediated by cyclic guanosine 3',5'-monophosphate (cGMP). Much effort has been made to validate clinical markers of NO production or bioavailability. While the measurement of plasma nitrate, nitrite, and cGMP concentrations have been suggested to reflect endogenous production of NO, there is no study showing whether there is correlation between these three markers. In the present study, we investigate whether there is correlation between the plasma concentrations of nitrate, nitrite, and cGMP in a relatively homogeneous group of 141 healthy subjects. METHODS: Venous blood samples were collected from healthy male subjects and plasma aliquots were then immediately removed and stored at -70 degrees C until analysed in duplicate for their nitrite and nitrate content using ozone-based chemiluminescence assays. Plasma cGMP levels were determined by using a commercial enzyme immunoassay. RESULTS: While we found no significant correlation between plasma nitrite and nitrate concentrations (P = 0.747), or between plasma nitrate and cGMP concentrations (P = 0.221), a significant positive correlation was found between plasma cGMP and nitrite concentrations (P = 0.017, r(s) = 0.270). CONCLUSIONS: The significant correlation we found between plasma nitrite and cGMP concentrations is consistent with the notion that nitrite or cGMP concentrations in plasma may be useful clinical markers of NO formation in healthy subjects.

[Methods of process analysis, instruments of quality management. Successful implementation of quality projects]. / Methoden der Prozessanalyse, Instrumente des Qualitätsmanagements. Qualitätsprojekte erfolgreich durchführen.

Meaningful experience and knowledge--the prerequisite for the successful implementation of quality projects--are described in terms of their practical importance on the basis of the experience gained with quality management in the municipal hospital at München-Schwabing (HMS). Against the background of the process of quality assurance or PDCA (Plan Do Check Act), the approach to the selection of suitable themes (problem selection), the prioritization of projects, the appropriate composition of the project group, the description of the problem, and the organization of the project, are discussed. The authors describe the implementation of methods of process analysis such as flow diagrams and cause-and-effect diagrams. The importance of evaluation is justified, and pragmatic approaches are presented. The importance of project documentation and essential contents are discussed.

Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD).

OBJECTIVE: To determine the influence of selective oropharyngeal decontamination (SOD) on the rate of colonization and infection of the respiratory tract in intensive care patients requiring mechanical ventilation for more than 4 days. A financial assessment was also performed. DESIGN: Randomized, prospective, controlled study using amphotericin B, colistin sulfate (polymyxin E), and tobramycin applied to the oropharynx and systemic cefotaxime prophylaxis. SETTING: Anesthesiology intensive care unit (ICU) of a 1500-bed hospital. PATIENTS: A total of 88 patients admitted as emergencies and intubated within less than 24 h were enrolled. Fifty-eight patients received SOD and 30 patients served as controls. Randomization was in the proportion of 2 : 1 study patients to controls. INTERVENTIONS: Microbiological samples from the oropharynx and other infected sites were taken at the time of admission, then twice a week and after extubation. MEASUREMENTS AND RESULTS: With the use of SOD, colonization was significantly reduced. Furthermore, the infection rate decreased from 77% in the controls to 22% in the study patients. Staphylococcus aureus was the main potential pathogen causing colonization and pneumonia. Number of days in the ICU, duration of ventilation, and mortality were not significantly decreased. The total cost of antibiotics was reduced. Development of resistance was not observed. CONCLUSIONS: The use of SOD significantly reduced the colonization and pneumonia and the total charge for antibiotics. The length of stay in the ICU, duration of ventilation, and mortality were similar. No resistance was observed. Staphylococcus aureus was selected by SOD in some patients and the clinical relevance needs further observation.

[Meaning of assimilation pelvis according to Kirchhoff in modern obstetrics]. / Die Bedeutung des Langen Beckens nach Kirchhoff in der heutigen Geburtshilfe.

OBJECTIVE: To what extent is the cesarean section indication "arrest of labour" due to pathological forms of the pelvis and what is the meaning of the assimilation pelvis in modern obstetrics. PATIENTS: NMR-pelvimetries were performed in 166 post partum women from June 1993 to August 1995. The patients were divided into 4 groups. Group 1: patients who had had cesarean section owing to arrest of labour (n = 56), group 2: patients who had had cesarean section due to breech presentation (n = 20), group 3: patients who had had cesarean section owing to another indication (threatening fetal asphyxia, multiple pregnancy, premature delivery, placental abruption, gestosis, n = 40), group 4: patients who had a spontaneous delivery (control group, n = 50). After analysing the NMR pictures all the pelves were alloted to one of the case studies according to their pelvic form. The diagnosis "assimilation pelvis" was made according to the criteria of Kirchhoff (1949). The four groups were compared and analysed. RESULTS: In group 1 an assimilation pelvis was found in 61%. The obstetrically most unfavourable canal pelvis occurred most frequently, amounting to 29%. In only 9% we found a contracted pelvis. In group 2 the proportion of the assimilation pelvis was even higher, rising to 65%. Only 35% of all pelves had a normal shape. In group 3 we found an assimilation pelvis in 50% of all cases. 66% of all patients with spontaneous delivery had a normal pelvis. An assimilation pelvis was found in 34%. In these cases duration of labour was prolonged by 4 hours on average (mean value: 9.5 hours). CONCLUSIONS: Due to its frequency in our days the assimilation pelvis plays a major obstetrical role. This is true in particular when there is a pathological course of labour. From this results that pelvic parameters other than the conjugata vera will be of diagnostic importance, especially those parameters which are able to characterise the assimilation pelvis with its high promontory, the steepness of the pelvic inlet, the lengthening of the birth canal and the decrease of the hollow of the sacrum. We take the view that the angle of the pelvic inlet, the pelvic inclination and the direct length of the pelvis are of outstanding importance.

Stereotaxic add-on device for MR-guided biopsy of breast lesions.

Breast biopsy and lesion localization were performed with gadolinium-enhanced magnetic resonance (MR) imaging guidance, with use of a stereotaxic biopsy system consisting of a flexible circular surface coil with an acrylic cylinder as an add-on guidance device. Twenty-five procedures (23 localizations, two core biopsies) were performed in lesions depicted at diagnostic MR imaging, without technical failure. The guidance system permitted easy, precise, and flexible biopsy and localization of all breast lesions.