In an analysis of a critical incident reporting system (CIRS) in out-of-hospital emergency medicine, it was demonstrated that in 30% of cases deficient communication led to a threat to patients; ...however, the analysis did not show what exactly the most dangerous work processes are. Current research shows the impact of poor communication on patient safety.
An out-of-hospital workflow analysis collects data about key work processes and risk areas. The analysis points out confounding factors for a sufficient communication. Almost 70% of critical incidents are based on human factors. Factors, such as communication and teamwork have an impact but fatigue, noise levels and illness also have a major influence.
(I) CIRS database analysis The workflow analysis was based on 247 CIRS cases. This was completed by participant observation and interviews with emergency doctors and paramedics. The 247 CIRS cases displayed 282 communication incidents, which are categorized into 6 subcategories of miscommunication. One CIRS case can be classified into different categories if more communication incidents were validated by the reviewers and four experienced emergency physicians sorted these cases into six subcategories. (II) Workflow analysis The workflow analysis was carried out between 2015 and 2016 in Jena and Berlin, Germany. The focal point of research was to find accumulation of communication risks in different parts of prehospital patient care. During 30 h driving with emergency ambulances, the author interviewed 12 members of the emergency medical service of which 5 were emergency physicians and 7 paramedics. A total of 11 internal medicine cases and one automobile accident were monitored. After patient care the author asked in a 15-min interview if miscommunication or communication incidents occurred.
(I) CIRS analysis Between 2005 and 2015, 845 reports were reported to the database. The experts identified 247 incident reports with communication failure. All communication aspects were analyzed and classified. We identified 282 communication incidents. (II) Workflow analysis The analysis showed three phases of prehospital patient care: 1. incoming emergency call and dispatch of ambulance service, 2. prehospital treatment, 3. transportation to a hospital. Overall, the number of incidences is increasing as a consequence of parallel workflows. Category 1 was particularly significant and predominantly, paramedics criticized that emergency physicians did not acknowledge their advice (n = 73 vs. n = 9). Category 3 with n = 63, category 4 with n = 20 and category 2 with n = 13 were the major reasons for incidents.
A better interface communication helps to coordinate patient transfer and is an option for optimizing resources. Frequent training in communication is an option to avoid incidents.
Zusammenfassung
Hintergrund
Die Analyse der notfallmedizinischen Einträge im Critical Incident Reporting System (CIRS) zeigte Defizite in der Kommunikation auf, die in 30 % der Fälle zu einer ...Gefährdung von Patienten führten. Aus dieser Untersuchung geht allerdings nicht hervor, bei welchen Arbeitsabläufen und Übergabeprozessen diese Zwischenfälle besonders häufig auftreten.
Ziele der Arbeit
Die Arbeitsprozessanalyse identifiziert Kumulationspunkte in der prähospitalen Notfallversorgung, die Kommunikationsrisiken bergen. Sie soll zusätzlich Störfaktoren für eine suffiziente Kommunikation in unterschiedlichen Abschnitten der Patientenversorgung aufzeigen.
Material und Methoden
(I) CIRS-Datenbankanalyse
Die Arbeitsprozessanalyse basiert auf 247 ausgewerteten CIRS-Fällen. Sie zeigten insgesamt 282 Kommunikationszwischenfälle in der prähospitalen Patientenversorgung auf, die in 6 Kategorien (KAT I–VI) eingeteilt sind.
(II) Arbeitsprozessanalyse
Teilnehmende Beobachtungen und Interviews von Rettungsdienstmitarbeitern, erweitert durch die 6 Kategorien der CIRS-Auswertung, bilden Grundlage der Arbeitsprozessanalyse.
Ergebnisse
(I) CIRS-Datenbankanalyse
Von 845 eingegebenen Fällen zeigen 247 CIRS-Eintragungen mit insgesamt 282 Zwischenfällen Kommunikationsdefizite auf.
(II) Arbeitsprozessanalyse
Die Analyse identifiziert 3 Abschnitte der prähospitalen Patientenversorgung. Zwischenfälle treten gehäuft im Abschnitt der direkten Patientenversorgung durch parallele Arbeitsprozesse auf. Dort kritisiert mehrheitlich das nichtärztliche Personal die Notärzte, Hinweise zur Patientenversorgung auszuschlagen (KAT I mit
n
= 73 vs.
n
= 9). Medikamentenverwechslungen (KAT III mit
n
= 63) und unverständliche oder ausbleibende Kommunikation im Team (KAT IV mit
n
= 20) sind ebenso Ursache für Patientengefährdung wie fehlerhafte Informationen in der Patientenübergabe (KAT II mit
n
= 13).
Diskussion
Eine verbesserte Schnittstellenkommunikation kann Zwischenfälle in der Patientenversorgung verhindern, da sie Rettungsmittel gezielter zuordnet und Patienten besser in weiterbehandelnde Kliniken überführt. Ressourcen zur Versorgung stehen so koordinierter zur Verfügung. Kommunikationstraining und ein Übergabeschema sind denkbare Strategien, um kommunikationsassoziierte Zwischenfälle zu vermeiden.
A wide variety of new phenomena such as novel magnetization configurations have been predicted to occur in three dimensional magnetic nanostructures. However, the fabrication of such structures is ...often challenging due to the specific shapes required, such as magnetic tubes and spirals. Furthermore, the materials currently used to assemble these structures are predominantly magnetic metals that do not allow to study the magnetic response of the system separately from the electronic one. In the field of spintronics, the prototypical material used for such experiments is the ferrimagnetic insulator yttrium iron garnet (Y\(_3\)Fe\(_5\)O\(_{12}\), YIG). YIG is one of the best materials especially for magnonic studies due to its low Gilbert damping. Here, we report the first successful fabrication of YIG thin films via atomic layer deposition. To that end we utilize a supercycle approach based on the combination of sub-nanometer thin layers of the binary systems Fe\(_2\)O\(_3\) and Y\(_2\)O\(_3\) in the correct atomic ratio on Y\(_3\)Al\(_5\)O\(_{12}\) substrates with a subsequent annealing step. Our process is robust against typical growth-related deviations, ensuring a good reproducibility. The ALD-YIG thin films exhibit a good crystalline quality as well as magnetic properties comparable to other deposition techniques. One of the outstanding characteristics of atomic layer deposition is its ability to conformally coat arbitrarily-shaped substrates. ALD hence is the ideal deposition technique to grant an extensive freedom in choosing the shape of the magnetic system. The atomic layer deposition of YIG enables the fabrication of novel three dimensional magnetic nanostructures, which in turn can be utilized for experimentally investigating the phenomena predicted in those structures.
To attempt to determine the relative value of preclinical cardiac electrophysiology data (in vitro and in vivo) for predicting risk of torsade de pointes (TdP) in clinical use.
Published data on hERG ...(or I(Kr)) activity, cardiac action potential duration (at 90% repolarisation; APD(90)), and QT prolongation in dogs were compared against QT effects and reports of TdP in humans for 100 drugs. These data were set against the free plasma concentrations attained during clinical use (effective therapeutic plasma concentrations; ETPC(unbound)). The drugs were divided into five categories: (1) Class Ia and III antiarrhythmics; (2) Withdrawn from market due to TdP; (3) Measurable incidence/numerous reports of TdP in humans; (4) Isolated reports of TdP in humans; (5) No reports of TdP in humans.
Data from hERG (or I(Kr)) assays in addition to ETPC(unbound) data were available for 52 drugs. For Category 1 drugs, data for hERG/I(Kr) IC(50), APD(90), QTc in animals and QTc in humans were generally close to or superimposed on the ETPC(unbound) values. This relationship was uncoupled in the other categories, with more complex relationships between the data. In Category 1 (except amiodarone), the ratios between hERG/I(Kr) IC(50) and ETPC(unbound) (max) ranged from 0.1- to 31-fold. Similar ranges were obtained for drugs in Category 2 (0.31- to 13-fold) and Category 3 (0.03- to 35-fold). A large spread was found for Category 4 drugs (0.13- to 35700-fold); this category embraced an assortment of mechanisms ranging from drugs which may well be affecting I(Kr) currents in clinical use (e.g. sparfloxacin) to others such as nifedipine (35700-fold) where channel block is not involved. Finally, for the majority of Category 5 drugs there was a >30-fold separation between hERG/I(Kr) activity and ETPC(unbound) values, with the notable exception of verapamil (1.7-fold), which is free from QT prolongation in man; this is probably explained by its multiple interactions with cardiac ion channels.
The dataset confirms the widely-held belief that most drugs associated with TdP in humans are also associated with hERG K(+) channel block at concentrations close to or superimposed upon the free plasma concentrations found in clinical use. A 30-fold margin between C(max) and hERG IC(50) may suffice for drugs currently undergoing clinical evaluation, but for future drug discovery programmes, pharmaceutical companies should consider increasing this margin, particularly for drugs aimed at non-debilitating diseases. However, interactions with multiple cardiac ion channels can either mitigate or exacerbate the prolongation of APD and QT that would ensue from block of I(Kr) currents alone, and delay of repolarisation per se is not necessarily torsadogenic. Clearly, an integrated assessment of in vitro and in vivo data is required in order to predict the torsadogenic risk of a new candidate drug in humans.
Background and purpose:
Inhibition of cholesteryl ester transfer protein (CETP) with torcetrapib in humans increases plasma high density lipoprotein (HDL) cholesterol levels but is associated with ...increased blood pressure. In a phase 3 clinical study, evaluating the effects of torcetrapib in atherosclerosis, there was an excess of deaths and adverse cardiovascular events in patients taking torcetrapib. The studies reported herein sought to evaluate off‐target effects of torcetrapib.
Experimental approach:
Cardiovascular effects of the CETP inhibitors torcetrapib and anacetrapib were evaluated in animal models.
Key results:
Torcetrapib evoked an acute increase in blood pressure in all species evaluated whereas no increase was observed with anacetrapib. The pressor effect of torcetrapib was not diminished in the presence of adrenoceptor, angiotensin II or endothelin receptor antagonists. Torcetrapib did not have a contractile effect on vascular smooth muscle suggesting its effects in vivo are via the release of a secondary mediator. Treatment with torcetrapib was associated with an increase in plasma levels of aldosterone and corticosterone and, in vitro, was shown to release aldosterone from adrenocortical cells. Increased adrenal steroid levels were not observed with anacetrapib. Inhibition of adrenal steroid synthesis did not inhibit the pressor response to torcetrapib whereas adrenalectomy prevented the ability of torcetrapib to increase blood pressure in rats.
Conclusions and implications:
Torcetrapib evoked an acute increase in blood pressure and an acute increase in plasma adrenal steroids. The acute pressor response to torcetrapib was not mediated by adrenal steroids but was dependent on intact adrenal glands.
British Journal of Pharmacology (2008) 154, 1465–1473; doi:fn2; published online 9 June 2008
Colorectal cancers are a leading cause of cancer mortality, and their primary prevention by diet is highly desirable. The relationship of vegetarian dietary patterns to colorectal cancer risk is not ...well established.
To evaluate the association between vegetarian dietary patterns and incident colorectal cancers.
The Adventist Health Study 2 (AHS-2) is a large, prospective, North American cohort trial including 96,354 Seventh-Day Adventist men and women recruited between January 1, 2002, and December 31, 2007. Follow-up varied by state and was indicated by the cancer registry linkage dates. Of these participants, an analytic sample of 77,659 remained after exclusions. Analysis was conducted using Cox proportional hazards regression, controlling for important demographic and lifestyle confounders. The analysis was conducted between June 1, 2014, and October 20, 2014.
Diet was assessed at baseline by a validated quantitative food frequency questionnaire and categorized into 4 vegetarian dietary patterns (vegan, lacto-ovo vegetarian, pescovegetarian, and semivegetarian) and a nonvegetarian dietary pattern.
The relationship between dietary patterns and incident cancers of the colon and rectum; colorectal cancer cases were identified primarily by state cancer registry linkages.
During a mean follow-up of 7.3 years, 380 cases of colon cancer and 110 cases of rectal cancer were documented. The adjusted hazard ratios (HRs) in all vegetarians combined vs nonvegetarians were 0.78 (95% CI, 0.64-0.95) for all colorectal cancers, 0.81 (95% CI, 0.65-1.00) for colon cancer, and 0.71 (95% CI, 0.47-1.06) for rectal cancer. The adjusted HR for colorectal cancer in vegans was 0.84 (95% CI, 0.59-1.19); in lacto-ovo vegetarians, 0.82 (95% CI, 0.65-1.02); in pescovegetarians, 0.57 (95% CI, 0.40-0.82); and in semivegetarians, 0.92 (95% CI, 0.62-1.37) compared with nonvegetarians. Effect estimates were similar for men and women and for black and nonblack individuals.
Vegetarian diets are associated with an overall lower incidence of colorectal cancers. Pescovegetarians in particular have a much lower risk compared with nonvegetarians. If such associations are causal, they may be important for primary prevention of colorectal cancers.
Carbon fibre reinforced polymer is a widely used material in engineering applications and is expected to be extensively used in the transportation sector due to its light-weight properties. It is a ...high value, energy intensive material, which is mostly landfilled at its End-of-life, however, it could potentially be recycled and replace virgin material in different sectors. Therefore, considering also the significant amounts of End-of-life aircrafts and automotive expected in the future, it is imperative to identify circular economy pathways for this waste stream. This study investigates the feasibility of a cross-sectoral circular economy pathway of carbon fibre material waste thermal recycling and proposes a four-tier reverse supply chain network for the waste in the aeronautic and automotive sector. A novel MILP optimisation model is developed, in order to optimise the network structure and minimise the costs of the proposed design problem with an end-to-end scope. The model is applied in the geographical context of Europe, for 2023 and 2050. The results indicate that the optimum reverse supply chain network design is relatively centralised with processing facilities in central Europe. The proposed circular economy pathway is economically viable; however, the process is even more attractive when the resin is recycled too.
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