The impact of a tele-ICU on provider attitudes about teamwork and safety climate.

OBJECTIVE: To measure teamwork and safety climate in three intensive care units (ICUs) before and after remote monitoring by intensivists using telemedicine technology (tele-ICU). DESIGN: Controlled pre tele-ICU and post tele-ICU cross-sectional survey. SETTING: ICUs in two non-teaching community hospitals and one tertiary care teaching hospital. Subjects ICU physicians and nurses. INTERVENTIONS: Remote monitoring of ICU patients by intensivists. OUTCOME MEASUREMENTS: Teamwork Climate Scale (TWS), a Safety Climate Score (SCS) and survey items related to tele-ICU. MAIN RESULTS: The mean (SD) teamwork climate score was 69.7 (25.3) and 78.8 (17.2), pre and post tele-ICU (p = 0.009). The mean SCS score was 66.4 (24.6) and 73.4 (18.5), pre and post tele-ICU (p = 0.045). While SCS scores within the ICUs improved, the overall SCS scores for these hospitals decreased from 69.0 to 65.4. Three of the non-scaled items were significantly different pre and post tele-ICU at p<0.001. The item means (SD) pre and post tele-ICU were: "others interrupt my work to tell me something about my patient that I already know" 2.5 (1.2) and 1.6 (1.3); "I am confident that my patients are adequately covered when I am off the unit" 3.2 (1.3) and 4.2 (1.1); and "I can reach a physician in an urgent situation in a timely manner" 3.8 (1.2) and 4.6 (0.6). CONCLUSIONS: Implementation of a tele-ICU was associated with improved teamwork climate and safety climate in some ICUs, especially among nurses. Providers were also more confident about patient coverage and physician accessibility, and did not report unnecessary interruptions.

[MRI after renal transplantation with dysfunctional allograft: are there typical diagnoses in the early and late postoperative phases?]. / MRT bei Nierentransplantatdysfunktion: Gibt es typische Diagnosen im frühen und späten postoperativen Verlauf?

PURPOSE: The aim of this study was to evaluate the different MRI diagnoses in the early and late post-operative period after renal transplantation with dysfunctional allograft. MATERIALS AND METHODS: Due to unknown transplant dysfunction, 49 patients (30-male, 19 female) received a total of 74 MRI studies. According to the date of examination all MRI studies were divided in an early (< or = 60 days, ETP) and a late post-transplant time period (> 60 days, LTP). All MRI studies were performed on 1.5 T MRI systems using a standardised imaging protocol consisting of a morphological (pre- and post-contrast enhanced T (1)- and T (2)-weighted TSE sequences), a vascular (contrast-enhanced 3D MRA) and a urographical part (Flash 3D sequences). Frequencies of diagnoses in ETP and LTP, and diagnoses within each transplant time period were analysed. RESULTS: 44/74 MRI studies were performed in ETP, 30/74 in LTP. In total 80 diagnoses were obtained: Renal artery stenosis (ETP, n = 21; LTP, n = 5), renal vein stenosis (ETP, n = 2), renal vein thrombosis (ETP, n = 2), renal perfusion defect (ETP, n = 11), rejection (ETP, n = 1; LTP, n = 2), abscess (ETP, n = 1), urinary outflow obstruction (LTP, n = 4), without MRI pathology (ETP, n = 11; LTP, n = 20). Renal artery stenosis was the most prevalent diagnosis in ETP, and a more frequent finding in ETP compared to LTP (p < 0.05). Renal perfusion defects were more frequent in ETP than in LTP (p < 0.05). In the ETP vascular diseases (34/49 diagnoses) were more frequent (p < 0.05) than uropathological diseases (0/49 diagnoses). CONCLUSIONS: Our results indicate that vascular diseases are a more frequent occurrence in the early post-operative course after renal transplantation than uropathological diseases. However, a transplant follow-up MRI study needs to contain a morphological, vascular and functional imaging part to answer combined clinical questions.

Non-invasive imaging in a rare case of main pulmonary artery aneurysm.

Report of an incidental chest X-ray finding of a large vessel dilation at the root of the ascending aorta in a 65-year-old female patient while pre-operative routine diagnostic. Due to prior allergic reaction to iodine contrast agent, non-invasive imaging was performed with magnetic resonance imaging (MRI), where the rare finding of a large aneurysm of the left pulmonary artery was diagnosed. Initial considerations of a surgical intervention were turned down as no clinical symptoms or risk factors were apparent.

[Evaluation of coronary calcifications with 64-slice CT - variability of the scores and the influence of the reconstruction interval]. / Bestimmung des koronaren Kalzium-Scores mittels 64-Zeilen-CT - Variabilität der Scores und Einfluss des Rekonstruktionszeitpunktes.

PURPOSE: To evaluate the variability of coronary calcium scores depending on the image reconstruction interval using a 64-slice CT scanner. MATERIALS AND METHODS: 30 patients (18 male, 12 female; mean age 57 +/- 9 yrs; mean heart rate 66 +/- 10 bpm) underwent coronary calcium scoring using a 64-slice CT scanner (Somatom Sensation 64, Siemens Medical Solutions, Erlangen) and a standardized scanning protocol. Oral beta-blockers were administered to 12 patients with a baseline heart rate > 70 bpm. Images were reconstructed in 10 % increments from 10 - 100 % of the RR interval. Two blinded experienced observers independently calculated Agatston (AS), calcium mass (MS) and volume scores (VS) for every reconstructed image series. The results were compared to similar studies for 16-slice CT scanners. RESULTS: The mean values and mean coefficients of variation among all patients were as follows: AS, 397 +/- 829, 109 % MS, 88 +/- 225, 154 % VS, 335 +/- 669, 100 %. Regarding the reconstruction intervals, the mean coefficients of variation were as follows: 107 % (AS), 97 % (VS), 116 % (MS). No specific image reconstruction interval with statistically significant lower variability for each score could be identified. High inter-observer agreement was achieved (K = 0.98). With statistical significance (p < 0.05) 10/30 patients (pts) were able to be allocated to more than one risk group (RG): 6 pts = 2 RG; 3 pts = 3 RG; 1 pts = 4 RG. The scores for 5/30 patients were zero for at least one reconstruction interval, but further reconstructions revealed calcifications. The number of patients assignable to different risk groups was significantly lower compared to published data using a 16-slice scanner (p < 0.05). CONCLUSION: Coronary calcium scores determined using a 64-slice scanner display a wide range of variability depending on the image reconstruction interval as already described for 16-slice CT scanners. However, compared to previous studies, our data indicate that this vendor's generation of scanners reduces the influence of score variations on the risk stratification.

Evaluation of the optimal image reconstruction interval for coronary artery imaging using 64-slice computed tomography.

BACKGROUND: Cardiac computed tomography (CT) has become an established complement in cardiac imaging. Thus, optimized image quality is diagnostically crucial. PURPOSE: To prospectively evaluate whether, by using 64-slice CT, a specific reconstruction interval can be identified providing best image quality for all coronary artery segments and each individual coronary artery. MATERIAL AND METHODS: 311 coronary segments of 14 men and seven women were analyzed using 64-slice CT. Data reconstruction was performed in 5% increments from 5-100% of the R-R interval. Four experienced observers independently evaluated image quality of the coronary arteries according to the AHA classification. A three-point ranking scale was applied: 1, very poor, no evaluation possible; 2, diagnostically sufficient quality; 3, highest image quality, no artifacts. RESULTS: The best reconstruction point for all segments was found to be 65% of the R-R interval (mean value 2.4+/-0.5; P<0.05). On a per-artery basis, best image quality was again achieved at 65% of the R-R interval: RCA 2.2+/-0.4, LCA 2.4+/-0.5, LM 2.5+/-0.2, LAD 2.3+/-0.4, LCX 2.3+/-0.5. CONCLUSION: By using 64-slice CT, the need for adjusting the reconstruction point to each coronary segment might be overcome. Best image quality was achieved with image reconstruction at 65% of the R-R interval for all coronary segments as well as each coronary artery.

Anti-vascular endothelial growth factor antibody bevacizumab in conjunction with chemotherapy in metastasising melanoma.

PURPOSE: The combination of the antiangiogenic antibody bevacizumab with standard chemotherapy has improved the prognosis in patients with metastastic colorectal cancer and other advanced cancers. The role of combined anti-VEGF and chemotherapy in metastastic melanoma is just starting to be elucidated. METHODS: We tested this notion in three patients with advanced and therapy-refractory melanoma. RESULTS: Interestingly, two patients achieved objective regressions after three courses of therapy; the third patient, albeit progressing demonstrated a pronounced liquid necrosis in bulky lymphnode metastasis. CONCLUSION: Further studies are warranted to scrutinize these impressive therapeutic effects on the combination of bevacizumab and chemotherapy in melanoma.

[Perianal abscess and anal fistula in infancy and childhood. A congenital etiology?]. / Perianale Fisteln und Abszesse im Säuglings- und Kleinkindesalter. Eine kongenitale Atiologie?

BACKGROUND: Perianal abscess and anal fistula in childhood are commonly treated in the same way as abscess and fistula in adults. We questioned whether they represent a cryptoglandular infection, as in adults, or two different diseases with the same symptoms. MATERIALS AND METHODS: We retrospectively analyzed all medical records of 80 children (seven male, 73 female) who underwent surgical treatment for primary perianal abscess or primary anal fistula during a 10-year period. The records were analyzed concerning age at appearance of lesion, sex, diagnosis (fistula and/or abscess), and anatomic localization of the lesion. RESULTS: Of all the children, 67.5% were treated during their 1st year of life and another 10% during their 2nd year (group 1: 77.5%, n=62). Only 22.5% were 3 or older (group 2, n=18). Group 1 contained significantly more male infants (m:f 30:1). However, much more balanced sex distribution was detected in group 2 (m:f 2.6:1), similarly to adults. Analyzing anatomic localization, a second important difference could be found: in contrast to group 2, almost two thirds of all anal fistulas/abscesses in group 1 were localized horizontally between 3:00 and 9:00 o'clock in crown-rump position. CONCLUSIONS: Divergences in preference of age, sex, and localization suggest a congenital etiology for anal fistulas and perianal abscesses in children.

Molecular symmetry of the MoFe protein of nitrogenase. Structural homology/nitrogen fixation/x-ray crystallography.

X-ray diffraction data to 2.4-A resolution have been collected for native monoclinic crystals of the MoFe protein of nitrogenase from Clostridium pasteurianum. The MoFe protein is an alpha 2 beta 2 tetramer of 220,000 molecular weight with 1 molecule in the crystallographic asymmetric unit. A 6-A resolution rotation function shows the orientation of the crystallographic diad and pseudo mutually perpendicular diads representing 2-fold relationships between alpha and beta chains. Hence, at least at low resolution, there exists structural homology between these two polypeptide chains.

Crystallographic properties of the MoFe proteins of nitrogenase from Clostridium pasteurianum and Azotobacter vinelandii.

Preliminary x-ray diffraction data from single crystals of the MoFe proteins of nitrogenase from Clostridium pasteurianum and Azotobacter vinelandii have been obtained. Both protein crystals belong to the P2(1) space group. The MoFe protein crystals from C. pasteurianum and A. vinelandii diffract to angles corresponding to resolutions as great as 2.4 A and 3.0 A, respectively. The cell dimensions of the MoFe protein crystals from the two species have been determined from precession photographs.

Mercury complexes of thionicotinamide adenine dinucleotide.

One-to-one mercury complexes of thionicotinamide adenine dinucleotide (TNAD+) were prepared by using HgSO4 and Hg(CH3 COO-)2. Optical absorption spectroscopy indicated that the mercury probably binds to the TNAD+ through the thio-keto group on the pyridine ring. X-ray diffraction patterns of crystals of mitochondrial malate dehydrogenase soaked in solution containing TNAD+ . mercury complex indicated binding and the X-ray intensity differences are different from mercurials alone.