[Central in-hospital emergency coordinator. Concept to optimize the interface between emergency medical services and hospitals]. / Zentraler innerklinischer Notfallkoordinator. Konzept zur Optimierung der Schnittstelle zwischen Rettungsdienst und Klinik.

BACKGROUND: Although the prognosis of many diseases relies on timely diagnosis and treatment, the admission process of patients taken into hospitals by emergency medical services (EMS) is often affected by delays or rejection of patients. A smooth interaction between these two phases is critical for the prognosis in time-critical situations. The implementation of an in-hospital coordinating emergency physician (ZINK) responsible for the admission of EMS patients, a concept which was developed and introduced in our hospital, is suggested. CONCEPT: The ZINK represented by the most senior anaesthesiologist on duty is responsible for the registration of emergency patients from all departments under one telephone number, decides on admittance, alerts necessary resources and documents inquiries. RESULTS: After an initial three calls the ZINK is currently contacted on average 8 times per day and experiences the satisfaction of EMS personnel and EMS dispatch centers. The number of rejected emergency patients has decreased by over 80%. CONCLUSION: Implementation of a ZINK can optimize the process of hospital admission in emergency patients. This can decrease the legal risk of hospitals and improve the external representation. Hospitals should consider designating a ZINK.

[What is anaesthesiology worth in the German DRGs?--First experience with German DRGs]. / Was ist Anästhesiologie in den G-DRGs wert?--Erste Erfahrungen mit den G-DRGs.

This overview reports on first experience with German DRGs version 1.0 from 2003, with special regard to relevant procedures and diagnoses of anaesthesiology. Basically, the G-DRGs are a translation of the AR-DRGs 4.1. Only the 2004 version represents a first "real" German DRG system. Particularly anaesthesiological measures for procedures which are normally performed without narcosis can lead to essentially relevant remuneration. In intensive care medicine, the hours of artificial ventilation must be recorded exactly. In the 2004 version of the G-DRGs, intensive medical performances are mainly differentiated regarding the time of ventilation, which leads to better payment than under version 1.0. In intensive care medicine, additional remuneration is only intended for dialyses and other organ-supporting procedures. Pain therapy is insufficiently documented in the G-DRGs. Although new codes of pain treatment are included in the G-DRGs, they do not lead to relevant remuneration. Diagnoses and procedures coded by the anaesthetist should be registered in the clinic information system without delay. Only non-anaesthesia-associated diagnoses, i.e. additional diagnoses resulting from the preanaesthetic check-up of the patient in the preanaesthetic department, should be checked by non-anaesthesiological physicians. The correct documentation and transfer of ASA classifications is necessary for additional charges in external quality management and to avoid financial sanctions. In our experience, regarding operated patients, anaesthetists can contribute a lot to enquiries by health insurance companies, e.g. whether the payment code for an in- or an out-patient should be used. Departments of anaesthesia should appoint an anaesthetist as DRG representative to supervise anaesthesiological coding and DRG-relevant procedures.

[How to establish an preoperative anaesthetic clinic]. / Die Etablierung einer Anästhesieambulanz. Erfahrungen und praktische Hinweise zur Einrichtung und Organisation.

The preoperative anaesthetic clinic has established at large german hospital since 1980 because of shorter ways, waiting times and best preoperative risk-management. Now there is an increasing need for the preoperative anaesthetic clinic in all german hospitals because of the introduction of DRGs for hospital billing since 2003. Organization, leadership, equipment and aspects of the personnel are discussed. Tasks of a "anaesthetic management center" can be fulfilled by the preoperative anaesthetic clinic like OP-organization, distribution of intensive care units, implementation of clinical pathways and quality management. Thus requires an adequate equipment and personnel. An model of rotation for the physician personnel is introduced. Cooperation of the OP departments is necessary. At least our preoperative anaesthetic day clinic has become an logistic centre and an speaking point for patients and the OP-department.

A point mutant of GAP-43 induces enhanced short-term and long-term hippocampal plasticity.

The growth-associated protein GAP-43 (or neuromodulin or B-50) plays a critical role during development in mechanisms of axonal growth and formation of synaptic networks. At later times, GAP-43 has also been implicated in the regulation of synaptic transmission and properties of plasticity such as long-term potentiation. In a molecular approach, we have analyzed transgenic mice overexpressing different mutated forms of GAP-43 or deficient in GAP-43 to investigate the role of the molecule in short-term and long-term plasticity. We report that overexpression of a mutated form of GAP-43 that mimics constitutively phosphorylated GAP-43 results in an enhancement of long-term potentiation in CA1 hippocampal slices. This effect is specific, because LTP was affected neither in transgenic mice overexpressing mutated forms of non-phosphorylatable GAP-43 nor in GAP-43 deficient mice. The increased LTP observed in transgenic mice expressing a constitutively phosphorylated GAP-43 was associated with an increased paired-pulse facilitation as well as an increased summation of responses during high frequency bursts. These results indicate that, while GAP-43 is not necessary for LTP induction, its phosphorylation may regulate presynaptic properties, thereby affecting synaptic plasticity and the induction of LTP.

Cell-cell signaling in the shoot meristem.

The shoot meristem is a proliferating, changing cell population yet displays a stable organization. Recent studies have addressed how signaling processes coordinate the behaviour of shoot meristem cells.

Termination of stem cell maintenance in Arabidopsis floral meristems by interactions between WUSCHEL and AGAMOUS.

Floral meristems and shoot apical meristems (SAMs) are homologous, self-maintaining stem cell systems. Unlike SAMs, floral meristems are determinate, and stem cell maintenance is abolished once all floral organs are initiated. To investigate the underlying regulatory mechanisms, we analyzed the interactions between WUSCHEL (WUS), which specifies stem cell identity, and AGAMOUS (AG), which is required for floral determinacy. Our results show that repression of WUS by AG is essential for terminating the floral meristem and that WUS can induce AG expression in developing flowers. Together, this suggests that floral determinacy depends on a negative autoregulatory mechanism involving WUS and AG, which terminates stem cell maintenance.

Shared and unique roles of CAP23 and GAP43 in actin regulation, neurite outgrowth, and anatomical plasticity.

CAP23 is a major cortical cytoskeleton-associated and calmodulin binding protein that is widely and abundantly expressed during development, maintained in selected brain structures in the adult, and reinduced during nerve regeneration. Overexpression of CAP23 in adult neurons of transgenic mice promotes nerve sprouting, but the role of this protein in process outgrowth was not clear. Here, we show that CAP23 is functionally related to GAP43, and plays a critical role to regulate nerve sprouting and the actin cytoskeleton. Knockout mice lacking CAP23 exhibited a pronounced and complex phenotype, including a defect to produce stimulus-induced nerve sprouting at the adult neuromuscular junction. This sprouting deficit was rescued by transgenic overexpression of either CAP23 or GAP43 in adult motoneurons. Knockin mice expressing GAP43 instead of CAP23 were essentially normal, indicating that, although these proteins do not share homologous sequences, GAP43 can functionally substitute for CAP23 in vivo. Cultured sensory neurons lacking CAP23 exhibited striking alterations in neurite outgrowth that were phenocopied by low doses of cytochalasin D. A detailed analysis of such cultures revealed common and unique functions of CAP23 and GAP43 on the actin cytoskeleton and neurite outgrowth. The results provide compelling experimental evidence for the notion that CAP23 and GAP43 are functionally related intrinsic determinants of anatomical plasticity, and suggest that these proteins function by locally promoting subplasmalemmal actin cytoskeleton accumulation.

GAP43, MARCKS, and CAP23 modulate PI(4,5)P(2) at plasmalemmal rafts, and regulate cell cortex actin dynamics through a common mechanism.

The dynamic properties of the cell cortex and its actin cytoskeleton determine important aspects of cell behavior and are a major target of cell regulation. GAP43, myristoylated alanine-rich C kinase substrate (MARCKS), and CAP23 (GMC) are locally abundant, plasmalemma-associated PKC substrates that affect actin cytoskeleton. Their expression correlates with morphogenic processes and cell motility, but their role in cortex regulation has been difficult to define mechanistically. We now show that the three proteins accumulate at rafts, where they codistribute with PI(4,5)P(2), and promote its retention and clustering. Binding and modulation of PI(4, 5)P(2) depended on the basic effector domain (ED) of these proteins, and constructs lacking the ED functioned as dominant inhibitors of plasmalemmal PI(4,5)P(2) modulation. In the neuron-like cell line, PC12, NGF- and substrate-induced peripheral actin structures, and neurite outgrowth were greatly augmented by any of the three proteins, and suppressed by DeltaED mutants. Agents that globally mask PI(4,5)P(2) mimicked the effects of GMC on peripheral actin recruitment and cell spreading, but interfered with polarization and process formation. Dominant negative GAP43(DeltaED) also interfered with peripheral nerve regeneration, stimulus-induced nerve sprouting and control of anatomical plasticity at the neuromuscular junction of transgenic mice. These results suggest that GMC are functionally and mechanistically related PI(4,5)P(2) modulating proteins, upstream of actin and cell cortex dynamics regulation.

The stem cell population of Arabidopsis shoot meristems in maintained by a regulatory loop between the CLAVATA and WUSCHEL genes.

The higher-plant shoot meristem is a dynamic structure whose maintenance depends on the coordination of two antagonistic processes, organ initiation and self-renewal of the stem cell population. In Arabidopsis shoot and floral meristems, the WUSCHEL (WUS) gene is required for stem cell identity, whereas the CLAVATA1, 2, and 3 (CLV) genes promote organ initiation. Our analysis of the interactions between these key regulators indicates that (1) the CLV genes repress WUS at the transcript level and that (2) WUS expression is sufficient to induce meristem cell identity and the expression of the stem cell marker CLV3. Our data suggest that the shoot meristem has properties of a self-regulatory system in which WUS/CLV interactions establish a feedback loop between the stem cells and the underlying organizing center.

Shoot meristem formation and maintenance.

The shoot apical meristem of higher plants is a self-maintaining stem cell system which gives rise to the entire above-ground part of a plant. In the past year, genetic and molecular studies have provided increasing insight into the processes of shoot meristem formation and maintenance, as well as into the relation between the apical meristem and its products.

Role of WUSCHEL in regulating stem cell fate in the Arabidopsis shoot meristem.

The shoot meristem gives rise to the aerial parts of higher plants by continuously initiating new organs. The basis of this activity is its ability to maintain a pool of pluripotent stem cells, which are the ultimate source of all tissues of the shoot. In Arabidopsis plants mutant for the WUSCHEL (WUS) gene, the stem cells are misspecified and appear to undergo differentiation. Here, we show that WUS encodes a novel homeodomain protein which presumably acts as a transcriptional regulator. The pattern of WUS expression suggests that stem cells in the shoot meristem are specified by an underlying cell group which is established in the 16-cell embryo and becomes localized to its prospective domain of function by asymmetric cell divisions.

Role of the ZWILLE gene in the regulation of central shoot meristem cell fate during Arabidopsis embryogenesis.

Postembryonic development in higher plants is marked by repetitive organ formation via a self-perpetuating stem cell system, the shoot meristem. Organs are initiated at the shoot meristem periphery, while a central zone harbors the stem cells. Here we show by genetic and molecular analyses that the ZWILLE (ZLL) gene is specifically required to establish the central-peripheral organization of the embryo apex and that this step is critical for shoot meristem self-perpetuation. zll mutants correctly initiate expression of the shoot meristem-specific gene SHOOT MERISTEMLESS in early embryos, but fail to regulate its spatial expression pattern at later embryo stages and initiate differentiated structures in place of stem cells. We isolated the ZLL gene by map-based cloning. It encodes a novel protein, and related sequences are highly conserved in multicellular plants and animals but are absent from bacteria and yeast. We propose that ZLL relays positional information required to maintain stem cells of the developing shoot meristem in an undifferentiated state during the transition from embryonic development to repetitive postembryonic organ formation.

Cell fate regulation in the shoot meristem.

The shoot meristem is a proliferative centre containing pluripotent stem cells that are the ultimate source of all cells and organs continuously added to the growing shoot. The progeny of the stem cells have two developmental options, either to renew the stem cell population or to leave the meristem and to differentiate, possibly according to signals from more mature tissue. The destiny of each cell depends on its position within the dynamic shoot meristem. Genetic data suggest a simple model in which graded positional information is provided by antagonistic gene functions and is interpreted by genes which regulate cell fate.

The SHOOT MERISTEMLESS gene is required for maintenance of undifferentiated cells in Arabidopsis shoot and floral meristems and acts at a different regulatory level than the meristem genes WUSCHEL and ZWILLE.

The function of the SHOOT MERISTEMLESS (STM) gene in shoot and floral meristems throughout Arabidopsis development has been analyzed. The results show that STM plays a major role in maintaining shoot and floral meristems. In an allelic series of stm mutants the shoot meristem was either reduced or completely absent in mature embryos and mutant seedling cotyledons showed partial fusion, indicating that the STM gene affects embryonic shoot meristem development and spacing of cotyledons. Postembryonically, stm mutants initiated adventitious shoot development at a position corresponding to the shoot meristem in wild-type. Repetitively initiated defective mutant shoot and floral meristems were consumed during primordia formation and typically terminated prematurely in fused ectopic primordia, indicating that STM is required for continuous shoot and floral meristem function. Analogous defects were observed in stm embryonic and postembryonic development suggesting that similar mechanisms are employed in embryonic and postembryonic organ primordia initiation. Allelic combination suggest different thresholds for STM requirement during plant development. STM requirement could not be bypassed by standard growth factor regimes or by shoot regeneration from calli. The results suggest that STM functions by preventing incorporation of cells in the meristem center into differentiating organ primordia and that this role can completely account for all defects observed in stm mutants. Mutations in the WUSCHEL (WUS) and ZWILLE (ZLL) genes result in defective organization and premature termination of shoot meristems. Genetic interactions between STM, WUS and ZLL were analyzed and the results indicate that STM acts upstream of WUS and ZLL. Therefore, while STM appears to function in keeping central meristem cells undifferentiated, WUS and ZLL seem to be subsequently required for proper function of these cells.

The WUSCHEL gene is required for shoot and floral meristem integrity in Arabidopsis.

Self perpetuation of the shoot meristem is essential for the repetitive initiation of shoot structures during plant development. In Arabidopsis shoot meristem maintenance is disrupted by recessive mutations in the WUSCHEL (WUS) gene. The defect is evident at all developmental stages and is restricted to shoot and floral meristems, whereas the root meristem is not affected. wus mutants fail to properly organize a shoot meristem in the embryo. Postembryonically, defective shoot meristems are initiated repetitively but terminate prematurely in aberrant flat structures. In contrast to wild-type shoot meristems, primordia initiation occurs ectopically across mutant apices, including the center, and often new shoot meristems instead of organs are initiated. The cells of wus shoot apices are larger and more vacuolated than wild-type shoot meristem cells. wus floral meristems terminate prematurely in a central stamen. Double mutant studies indicate that the number of organ primordia in the center of wus flowers is limited, irrespective of organ identity and we propose that meristem cells are allocated into floral whorl domains in a sequential manner. WUS activity also appears to be required for the formation of supernumerary organs in the center of agamous, superman or clavata1 flowers, suggesting that the WUS gene acts upstream of the corresponding genes. Our results suggest that the WUS gene is specifically required for central meristem identity of shoot and floral meristems to maintain their structural and functional integrity.

Pattern formation in the Arabidopsis embryo: a genetic perspective.

During embryogenesis, a single cell gives rise to different cell types, tissues and organs which are arranged in a biologically meaningful context, or pattern. The resulting basic body organization of higher plants, which is expressed in the seedling, provides a reference system for postembryonic development during which the meristems of the shoot and the root produce the adult body. The seedling may be viewed as the superimposition of two patterns: one along the apical-basal axis of polarity and the other perpendicular to the axis. To analyse mechanisms underlying pattern formation in the embryo, a genetic approach has been taken in Arabidopsis. Mutations in a small number of genes alter one or the other of the two patterns. The mutant phenotypes suggest that early partitioning of the axis is followed by region-specific development, including the formation of the primary shoot and root meristems. The cloning of two genes involved in pattern formation provides a basis for mechanistic studies of how cells adopt specific fates in the developing embryo.

Overexpression of the neural growth-associated protein GAP-43 induces nerve sprouting in the adult nervous system of transgenic mice.

Regulation of neurite outgrowth and structural plasticity may involve the expression of intrinsic determinants controlling growth competence. We have tested this concept by targeting constitutive expression of the growth-associated protein GAP-43 to the neurons of adult transgenic mice. Such mice showed striking spontaneous nerve sprouting at the neuromuscular junction and in the terminal field of hippocampal mossy fibers. In control mice, these nerve fibers did not express GAP-43, and did not sprout spontaneously. Lesion-induced nerve sprouting and terminal arborization during reinnervation were greatly potentiated in GAP-43-overexpressing mice. A mutant GAP-43 that cannot be phosphorylated by PKC had reduced sprout-promoting activity. The results establish GAP-43 as an intrinsic presynaptic determinant for neurite outgrowth and plasticity.

Cell Differentiation and Morphogenesis Are Uncoupled in Arabidopsis raspberry Embryos.

We identified two Arabidopsis embryo mutants, designated as raspberry1 and raspberry2, by screening T-DNA-mutagenized Arabidopsis lines. Embryogenesis in these mutants is indistinguishable from that of wild-type plants until the late-globular stage, after which raspberry1 and raspberry2 embryos fail to undergo the transition to heart stage, remain globular shaped, and proliferate an enlarged suspensor region. raspberry1 and raspberry2 embryo-proper regions enlarge during embryogenesis, become highly vacuolate, and display prominent convex, or "raspberry-like" protuberances on their outer cell layers. In situ hybridization studies with several embryo cell-specific mRNA probes indicated that the raspberry1 and raspberry2 embryo-proper regions differentiate tissue layers in their correct spatial contexts and that the regulation of cell-specific genes within these layers is normal. Surprisingly, a similar spatial and temporal pattern of mRNA accumulation occurs within the enlarged suspensor region of raspberry1 and raspberry2 embryos, suggesting that a defect in embryo-proper morphogenesis can cause the suspensor to take on an embryo-proper-like state and differentiate a radial tissue-type axis. We conclude that cell differentiation can occur in the absence of both organ formation and morphogenesis during plant embryogenesis and that interactions occur between the embryo-proper and suspensor regions.