Guidelines for quality improvement in cardiac surgery. The College of Cardiac Surgery : results of the 2007 survey.

Optimal delivery of health care is a common goal of individual physicians, professional organizations, hospital structures and governmental authorities. A growing concern has emerged from the public, media and third payer organizations concerning the quality of care and the amount of resources spending. In the United States, large databases, guidelines and performance evaluation have been elaborated by medical societies, particularly in the area of cardiac surgery. These tools are useful for improvement of patients' care, resources distribution, pay for performance and public and practitioners' awareness. The evaluation of quality is based on composite models combining structure, process and outcome indices. However, pitfalls such as patients' selection, and risk avoidance in order to improve results must been prevented by adjustment of the treated populations' risk factors by specific scores. The Belgian Health authorities have built a structure directed at delivery of care improvement based on "Care Programs", monitored by Colleges formed by delegates of professional organizations. The College of Cardiac Surgery has promoted several studies aimed at data collection and evaluation. In 2007, a survey was addressed to all the Belgian Cardiac surgeons to define their opinion as to the best indicators of care in their specialty. These results will serve to define further avenues of research. By maintaining the responsibility of care evaluation in the hands of the involved professionals, this kind of cooperation between governmental and physicians' organizations seems to serve the best interests of the public and the practitioners.

Implications of the use of neuromuscular transmission monitoring on immediate postoperative extubation in off-pump coronary artery bypass surgery.

BACKGROUND AND OBJECTIVE: When continuous infusions of neuromuscular blocking drugs are administered during lengthy interventions and no routine antagonism of their effects is applied, there is a dramatic incidence of residual curarization. We have examined whether the use of neuromuscular transmission monitoring results in differences in the incidence of postoperative residual curarization, the use of antagonist agents, and the endotracheal extubation rate and outcome after continuous infusion of rocuronium in patients undergoing off-pump coronary artery bypass surgery. METHODS: Twenty patients were assigned to group 1 (n = 10, non-blinded neuromuscular transmission monitoring) or group 2 (n = 10, blinded neuromuscular transmission monitoring). In group 1, patients were given rocuronium at an infusion rate of 6 microg kg(-1) min(-1). The rate was manually adjusted in order to maintain T1/T0 at 10%. In group 2, a rocuronium infusion was started 30 min after induction of anaesthesia, at a rate of 6 microg kg(-1) min(-1); this rate was left unchanged during surgery. The rocuronium infusion was discontinued on completion of all vascular anastomoses; propofol was stopped at the beginning of closure of the subcutis and pirinitramide (piritramide) 15 mg was administered intravenously. Remifentanil was discontinued at the beginning of skin closure and neostigmine (50 microg kg(-1)) administered at the end of surgery when the train-of-four ratio was < 0.9 in group 1, and routinely in group 2. A 20 min test period for spontaneous ventilation was allowed once surgery had been accomplished. When the train-of-four ratio was > or = 0.9 (group 1), patients were extubated if also breathing spontaneously, fully awake and able to follow commands. When they met the clinical criteria for normal neuromuscular function after induced blockade, patients in group 2 were extubated when fully awake and able to follow commands. RESULTS: In group 1, the rate of rocuronium infusion required to keep T1/T0 at 10% was 5 +/- 1.9 microg kg(-1) min(-1); this was not significantly different from the fixed rate in group 2 (P = 0.15). One patient in group 2 was excluded. Eight out of 10 and eight out of nine patients in groups 1 and 2, respectively, reached the extubation criteria. Three out of eight, and five out of eight, patients from groups 1 and 2, respectively, were extubated in the operating room. At that time of endotracheal extubation, all three patients from group 1, but only four of the five patients from group 2 had a train-of-four ratio > or = 0.9. In group 2, one patient was reintubated in the intensive care unit. The incidence of pharmacological reversal was high in group 1. CONCLUSIONS: Although we found no additional benefit of using neuromuscular transmission monitoring, it seems an absolute necessity for safety reasons. Pharmacological antagonism was mandatory. However, in our opinion, it is not wise routinely to perform immediate postoperative extubation in off-pump coronary artery bypass surgery.

Dynamic mathematical model of high rate algal ponds (HRAP).

This article presents a mathematical model to describe High-Rate Algal Ponds (HRAPs). The hydrodynamic behavior of the reactor is described as completely mixed tanks in series with recirculation. The hydrodynamic pattern is combined with a subset of River Water Quality Model 1 (RWQM1), including the main processes in liquid phase. Our aim is to develop models for WSPs and aerated lagoons, too, but we focused on HRAPs first for several reasons: Sediments are usually less abundant in HRAP and can be neglected, Stratification is not observed and state variables are constant in a reactor cross section, Due to the system's geometry, the reactor is quite similar to a plugflow type reactor with recirculation, with a simple advection term. The model is based on mass balances and includes the following processes: *Phytoplankton growth with NO3-, NO2- and death, *Aerobic growth of heterotrophs with NO3-, NH4+ and respiration, *Anoxic growth of heterotrophs with NO3-, NO2- and anoxic respiration, *Growth of nitrifiers (two stages) and respiration. The differences with regard to RWQM1 are that we included a limiting term associated with inorganic carbon on the growth rate of algae and nitrifiers, gas transfers are taken into account by the familiar Adeney equation, and a subroutine calculates light intensity at the water surface. This article presents our first simulations.

Comparison of oxygen and carbon dioxide balances in HRAP (high-rate algal ponds).

We previously suggested a method to characterize the oxygen balance in High-Rate Algal Ponds (HRAPs). The method was based on a hydrodynamic study of the reactor combined with a tracer gas method to measure the oxygen transfer coefficient. From such a method diurnal variations of photosynthesis and respiration can be quantified and the net oxygen production rate determined. In this paper we propose a similar approach to obtain carbon dioxide balances in HRAPs. Then oxygen and carbon dioxide balances can be compared.

On the use of fluorescence measurements to characterize wastewater.

This paper examines the correlations between some water quality parameters and fluorescence intensities and spectra in filtered wastewater using a 280 nm excitation wavelength. We did not obtain satisfying linear relationships between fluorescence and COD or TOC (r2 approximately 0.4) for any of the emission wavelengths used between 320 and 400 nm (especially at 355 nm, the average emission lambda(max.)). The relationships with NK were better (r2 approximately 0.7); leading us to suggest that one evaluates mainly the organic nitrogen content at lambda(ex.) = 280 nm. Whole spectra processing did not improve the correlations. Gel permeation chromatography yielded markedly different TOC and fluorescence chromatograms, which explains the difficulty of correlating organic content and fluorescence. Other investigations are necessary before spectrofluorimetry can be used as a reliable technique for on-line wastewater pollution estimation.