Discrete event simulation of patient admissions to a neurovascular unit.

Evidence exists that clinical outcomes improve for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital created a Neurovascular Unit (NVU) using beds from general internal medicine, Neurology and Neurosurgery to care for patients with stroke and acute neurovascular conditions. Using patient-level data for NVU-eligible patients, a discrete event simulation was created to study changes in patient flow and length of stay pre- and post-NVU implementation. Varying patient volumes and resources were tested to determine the ideal number of beds under various conditions. In the first year of operation, the NVU admitted 507 patients, over 66% of NVU-eligible patient volumes. With the introduction of the NVU, length of stay decreased by around 8%. Scenario testing showed that the current level of 20 beds is sufficient for accommodating the current demand and would continue to be sufficient with an increase in demand of up to 20%.

Power reactor health physics in the 1960s.

This note is a personal re-collection of some of the problems and experiences of the Health Physics Department staff at Dungeness Power Station during the period 1963-1971. This was a period of construction, commissioning, operating and learning. It was an interesting period for power reactor health physicists as appropriate instrumentation; information and experience were all in fairly short supply.

Scheduling emergency room physicians.

This paper introduces the problem of scheduling emergency room physicians. We interviewed physicians from six hospitals in the greater Montreal, Canada area, in order to understand the emergency room scheduling problem. Extracting the real scheduling problem is difficult because physician working conditions are based on informal mutual cooperation which is usually not documented. We present the characteristics of the scheduling problem and the scheduling techniques currently used in the six emergency rooms we analyzed. Using the scheduling problems of Charles-Lemoyne Hospital and the Jewish General Hospital, we show how to modify a hospital's existing scheduling rules to develop techniques which produce better schedules and reduce the time needed to build them.

Activity of ertapenem (MK-0826) versus Enterobacteriaceae with potent beta-lactamases.

Ertapenem (MK-0826; L-749,345), a new carbapenem with a long serum half-life, was tested, in vitro, against beta-lactamase-producing bacteria. The new compound had a MIC at which 90% of the isolates were inhibited of 0.06 microg/ml for extended-spectrum beta-lactamase (ESBL)-producing klebsiellas, compared with 0.5 microg/ml for imipenem, 16 microg/ml for cefepime, and >128 microg/ml for ceftazidime and piperacillin-tazobactam. MICs of ertapenem for AmpC-derepressed mutant Enterobacteriaceae were 0.015 to 0.5 microg/ml, whereas imipenem MICs were 0.25 to 1 microg/ml and those of cefepime were 0.5 to 4 microg/ml, and resistance to ceftazidime and piperacillin-tazobactam was generalized. Despite this good activity, the MICs of ertapenem for ESBL-positive klebsiellas mostly were two- to fourfold above those for ESBL-negative strains, and the MICs for AmpC-hyperproducing Enterobacter cloacae and Citrobacter freundii mutants exceeded those for the corresponding AmpC-basal mutants. These differentials did not increase when the inoculum was raised from 10(4) to 10(6) CFU/spot, contraindicating significant lability. Carbapenemase producers were also tested. The IMP-1 metallo-beta-lactamase conferred substantial ertapenem resistance (MIC, 128 microg/ml) in a porin-deficient Klebsiella pneumoniae strain, whereas a MIC of 6 microg/ml was recorded for its porin-expressing revertant. SME-1 carbapenemase was associated with an ertapenem MIC of 2 microg/ml for Serratia marcescens S6, compared with <0.03 microg/ml for Serratia strains lacking this enzyme. In summary, ertapenem had good activity against strains with potent beta-lactamases, except for those with known carbapenemases.

In vitro activities of ertapenem (MK-0826) against recent clinical bacteria collected in Europe and Australia.

Ertapenem (MK-0826, L-749,345) is a 1-beta-methyl carbapenem with a long serum half-life. Its in vitro activity was determined by broth microdilution against 3,478 bacteria from 12 centers in Europe and Australia, with imipenem, cefepime, ceftriaxone, and piperacillin-tazobactam used as comparators. Ertapenem was the most active agent tested against members of the family Enterobacteriaceae, with MICs at which 90% of isolates are inhibited (MIC(90)s) of < or =1 microg/ml for all species. Ertapenem also was more active than imipenem against fastidious gram-negative bacteria and Moraxella spp.; on the other hand, ertapenem was slightly less active than imipenem against streptococci, methicillin-susceptible staphylococci, and anaerobes, but its MIC(90)s for these groups remained < or =0.5 microg/ml. Acinetobacter spp. and Pseudomonas aeruginosa were also much less susceptible to ertapenem than imipenem, and most Enterococcus faecalis strains were resistant. Ertapenem resistance, based on a provisional NCCLS MIC breakpoint of > or =16 microg/ml, was seen in only 3 of 1,611 strains of the family Enterobacteriaceae tested, all of them Enterobacter aerogenes. Resistance was also seen in 2 of 135 anaerobes, comprising 1 Bacteroides fragilis strain and 1 Clostridium difficile strain. Ertapenem breakpoints for streptococci have not been established, but an unofficial susceptibility breakpoint of < or =2 microg/ml was adopted for clinical trials to generate corresponding clinical response data for isolates for which MICs were as high as 2 microg/ml. Of 234 Streptococcus pneumoniae strains tested, 2 required ertapenem MICs of 2 microg/ml and one required an MIC of 4 microg/ml, among 67 non-Streptococcus pyogenes, non-Streptococcus pneumoniae streptococci, single isolates required ertapenem MICs of 2 and 16 microg/ml. These streptococci also had diminished susceptibilities to other beta-lactams, including imipenem as well as ertapenem. The Etest and disk diffusion gave susceptibility test results in good agreement with those of the broth microdilution method for ertapenem.

Detection of extended-spectrum beta-lactamases in klebsiellae with the Oxoid combination disk method.

The Oxoid combination disk method for detecting extended-spectrum beta-lactamases (ESBLs) depends on comparing the inhibition zones of cefpodoxime (10-microg) and cefpodoxime-plus-clavulanate (10- plus 1-microg) disks. The presence of clavulanate enlarged the zones for all of 180 ESBL-producing klebsiellae by >/=5 mm, whereas zones for cefpodoxime-susceptible isolates and cefpodoxime-resistant isolates with AmpC and K1 beta-lactamases were enlarged by

A developmental toxicity study of tretinoin administered topically and orally to pregnant Wistar rats.

BACKGROUND: Although it is well established that oral tretinoin produces embryofetal developmental toxicity in various laboratory animals, the toxic potential of topical tretinoin has not been clearly established. OBJECTIVE: This study of tretinoin administration to pregnant Wistar rats was conducted to determine whether topical tretinoin is associated with adverse effects on reproductive function or embryofetal growth and development and to compare outcomes with topical and oral tretinoin. METHODS: Topical and oral tretinoin (1 to 20 mg/kg and 1 to 10 mg/kg, respectively) or vehicles alone were administered on gestational days 6 through 16 and 15, respectively. RESULTS: Topical tretinoin: After topical treatment, dams receiving 10 mg/kg daily or greater had severe local and systemic toxicity prompting discontinuation of tretinoin. At doses of 2.5 mg/kg or greater, dam weight gain and food consumption were significantly less than those of control dams. Offspring of dams receiving 5 mg/kg weighed significantly less, and offspring of dams receiving 2.5 mg/kg or greater had a significantly greater occurrence of supernumerary ribs compared with control offspring. Oral tretinoin: After oral treatment, in the absence of maternal toxicity, significantly more offspring of dams receiving 5 mg/kg or greater had supernumerary ribs, and offspring of the 10 mg/kg treatment group had a greater incidence of cleft palate than had control offspring. CONCLUSION: The local and systemic maternal toxicity found in association with supernumerary ribs and low weights in the offspring at topical tretinoin doses of 2.5 and 5 mg/kg suggests that these developmental effects may be nonspecific or maternally mediated. Oral tretinoin at doses of 10 mg/kg, however, is clearly associated with embryofetal alterations in the Wistar rat.

Surgical process scheduling: a structured review.

There is no generally accepted definition of surgical process scheduling available in the literature; nursing researchers, physicians, administrators, and management scientists each view scheduling differently. To overcome this communication problem, a number of authors have proposed conceptual frameworks for surgical process scheduling. These frameworks have unfortunately been either unsatisfactory or incomplete. In this paper, we describe a conceptual framework for surgical process scheduling and use it to classify the existing literature. Results from the review indicate that while operational aspects of advance and allocation scheduling are well understood, further research should be directed towards resolving scheduling issues at strategic and administrative levels. In addition, techniques for integrating operating room (OR) scheduling with other hospital operations are required.

Is measurement of transportability class of inhaled material by in vitro dissolution satisfactory?

Much of the published data on in vitro dissolution of uranium is based on the batch replacement technique. Recent papers have suggested that this technique, though convenient, may produce results that are determined more by the experimental design than by the transportability (solubility) of the material being tested. Re-examination of some of the published data appears to support this suggestion.

A decision support system to meet the fluctuating needs of a hospital nursing unit.

Regardless of the care taken in generating a nursing unit staff schedule, changes in patient census and acuity as well as staff illnesses and unexpected absenteeism create unanticipated "gaps" in a schedule. Due to a lack of timely information on staff availability and nursing preferences, filling these vacancies can be costly and time consuming. We propose that by combining a revised staffing structure with an integrated database management system, a decision support system can be developed. This can enable non-management staff to make substantial time and cost saving decisions while maintaining the highest level of patient care.

Diethylstilbestrol-induced perinatal lethality in the rat. I. Relationship to reduced maternal weight gain.

An analysis was performed to determine the mechanism of depressed maternal weight gain and its effect on perinatal lethality following prenatal exposure to diethylstilbestrol (DES). Pregnant Sprague-Dawley rats were dosed orally by gavage with DES or corn oil (control) during various intervals of gestation. The maternal weight-gain patterns of control and treated dams and the number of live offspring were recorded. The amounts of feed and water intake and feces and urine output in pregnant dams were measured, and metabolic rate and thyroid hormone levels were also determined. DES (at 45 micrograms/kg/day) was embryo- and fetolethal during implantation and parturition, and there was an accompanying decline in maternal weight. Growth of adult males, nonpregnant females, and weanlings of both sexes was also depressed. During pregnancy, the net intake of feed and water was not altered by the drug, but maternal serum thyroxine and metabolic rate were significantly elevated. Reduced metabolic efficiency, then, is the likely mechanism for weight depression. Reduction of maternal weight gain during pregnancy by DES is a diagnostic indicator of fetolethality, but is probably not causally related to it.

Nucleotide sequence and taxonomic value of the major outer membrane protein gene of Chlamydia pneumoniae IOL-207.

Chlamydia pneumoniae IOL-207 genomic DNA was hybridized with a 1.5 kb labelled DNA probe containing the 3' region of the coding sequence for the major outer membrane protein (MOMP) of C. trachomatis serovar L1. An 8.5 kb Bg/II fragment containing the complete MOMP gene was cloned into lambda EMBL3. Two hybridizing EcoRI fragments were sub-cloned into the lambda ZAP II cloning vector and the resulting plasmids were used as templates for sequencing both strands of the C. pneumoniae MOMP gene. Computer taxonomic studies using the nucleotide and inferred amino acid sequence of the MOMP of C. pneumoniae IOL-207 and all known chlamydial MOMP sequences supported the designation of C. pneumoniae as a new species, but electron microscope studies suggested that the presence of pear-shaped elementary bodies (EBs) may not be a reliable taxonomic criterion.

Fetotoxic alterations in the normal ontogenies of rat microsomal and lysosomal enzymes.

The activity patterns during development for acid phosphatase (Ac-P), alkaline phosphatase (A1-P), beta-glucuronidase (beta G), and UDP-glucuronyltransferase (UDPGT) have been determined in various tissues of the rat for corn oil and distilled water controls as well as in animals prenatally exposed to four fetotoxic chemicals. Postnatal assays were performed on both sexes separately. In control animals, tissue-specific differences between male and female activity levels were found for UDPGT. In the liver of mature offspring, enzyme activity was greater in males than in females. Although no sex difference was observed in the intestine, the kidneys of females exhibited higher values than those of males. An original computer-assisted methodology is presented, designed (a) to permit a mathematical description for the complex curves exhibited by these ontogeny profiles, and (b) to assess the statistical significance of chemical-induced alterations in these complex developmental patterns, specifically, to target sensitive periods and subtle changes near the fetotoxic threshold. Oral administration (days 6-18 of gestation) of 3,3',4,4'-tetrachlorobiphenyl (4CB) to pregnant females resulted in an induction of liver UDPGT activity in offspring postnatally, and some alterations in the perinatal pattern of beta G in the same tissue. This treatment also produced differences in the intestinal patterns of Ac-P and male UDPGT. No significant changes were observed in offspring exposed to diethylstilbestrol (DES). Treatment with zeranol (ZN) caused reductions in activity over the entire postnatal period for beta G in liver, brain, intestine, and kidney, for A1-P in brain, and for Ac-P in the intestine. Cadmium-treated dams gave birth to offspring that exhibited slightly altered ontogenies only in intestine for UDPGT and AcP. The alterations in these developmental profiles indicate periods of increased sensitivity, and may be useful in directing more specific studies into the fetotoxic mechanisms of these compounds.

Induction of maternal toxicity in the rat by dermal application of retinoic acid and its effect on fetal outcome.

Time-mated Sprague-Dawley rats were administered all-trans-retinoic acid (RA) dermally on gestational days 11 through 14 at three dosage levels (25, 100, and 250 mg/kg body weight). Dams administered ethylenethiourea (ETU) dermally on gestational days 11 to 12 or RA orally on day 12 were used to indicate the strain's sensitivity to teratogenesis. The chemicals were dissolved in dimethylsulfoxide (DMSO) for dermal application or suspended in corn oil for treatment by gavage. The maternal weight gain, pup weight, number of resorptions and number of fetuses with gross malformations, and skeletal/organ-level anomalies were determined. Beginning with day 15, dams dermally treated with RA exhibited dermal lesions at the site of application, most dams showed vaginal bleeding by day 16, and approximately 20% did not survive to day 19. Relative to the DMSO control group, maternal weight gain in the dermal RA groups was decreased by approximately 50% at the lowest dose, with essentially no weight gain at the intermediate- and high-dose levels. The decrease in average fetal weight at the two higher doses was significant, whereas the resorption and malformation frequencies were not significantly increased by dermal treatment with RA. Without significantly affecting fetal weight or resorption frequency, dermal application of ETU significantly increased the frequency of skeletal anomalies, primarily tail defects. Oral administration of RA did not increase the malformation frequency nor produce significant maternal or fetotoxic effects. In summary, treatment of pregnant Sprague-Dawley rats by dermal application of RA dissolved in DMSO resulted in significant toxicity to the dam.(ABSTRACT TRUNCATED AT 250 WORDS)

Technique for estimating fetal mouse thoracic volumes through image analysis of histological sections.

In a previous study we estimated fetal mouse thoracic volume by use of paraffin casts. While this procedure provided useful information, it did not allow histologic examination of thoracic viscera. In the present study the thoracic volumes of day 14-18 fetal mice were determined through serial histological sections. The thoracic cavity was traced from the sections and the area of each tracing was determined by computer image analysis. These areas were summed and then multiplied by the thickness of each section to derive the thoracic volume. This procedure thus permitted both volumetric determinations and histological inspection of the thoracic viscera. In addition, two randomized sampling methods designed to increase the utility of such volumetric estimates were compared for reliability. The method best suited for this study was a random stratified sampling method because it reproduced estimates with minimal standard deviation.

Sequential morphologic and biochemical studies of naturally occurring wheat-sensitive enteropathy in Irish setter dogs.

This study has investigated the potential role of wheat in the pathogenesis of a naturally occurring enteropathy in Irish setter dogs. At eight months on a cereal-containing diet, jejunal biopsies from affected animals exhibited partial villus atrophy, increased intraepithelial lymphocytes, and distinct biochemical abnormalities in the brush border. Activities of alkaline phosphatase and leucyl-2-naphthylamidase were almost undetectable while disaccharidases were unaltered. Activity of 5'-nucleotidase (basolateral membrane) was low, and reduced malate dehydrogenase reflected a loss of mitochondrial activity, but other organelles were unaffected. Recovery was achieved on a wheat-free diet. Relapse on subsequent wheat challenge was characterized by partial villus atrophy and a selective effect on the brush border: modal density was decreased and there was a severe loss of brush-border alkaline phosphatase activity. These findings document a wheat-sensitive enteropathy in Irish setter dogs and suggest that brush-border alkaline phosphatase is specifically susceptible to damage by wheat.