Modellierung und Prozessoptimierung der Organisationsstruktur in der orthopädischen Poliklinik

Gegenstand dieser Arbeit ist die Identifizierung und quantitative Analyse organisatorischer Schwachstellen in den klinischen Abläufen der orthopädischen Poliklinik der Klinik für Orthopädie und Rheumatologie in Marburg. Ziel dieser Analysen ist, mit Hilfe der gewonnen Daten fundierte Optimierungsvorschläge zu entwickeln, diese mit den Mitarbeitern zu diskutieren und schließlich umzusetzen. Da die langen Wartezeiten der Patienten das Hauptproblem in der orthopädischen Poliklinik darstellen, fokussiert diese Arbeit auf die Wartezeit als entscheidenden Parameter der Analysen und operationalisiert den Erfolg möglicher Reorganisationsmaßnahmen durch die Gesamtaufenthaltsdauer der Patienten. Initial werden die Prozesse durch Beobachtung und Diskussion mit allen Beteiligten untersucht und ein Prozessmodell erstellt. Als Dokumentationswerkzeug dient die am Institut für medizinische Informatik entwickelte Marburger Prozess-Dokumentation (MaPDok). Durch mehrwöchige Zeiterfassungen in der Poliklinik während der Sprechstunden werden anschließend die Arbeitsabläufe zeitlich genau charakterisiert. Neben direkten Zeiterfassungen werden auch vorhanden Informationsquellen, wie z.B. Eingangsbücher, analysiert, um eine detaillierte Datenbasis zu erhalten. Unter Verwendung dieser Daten wird ein warteschlangentheoretischer Ansatz verfolgt. Die Entwicklung eines Warteschlangenmodells erweist sich für die Abbildung des Ist-Zustandes aufgrund spezifischer Eigenschaften der zeitlichen Verteilung der Patientenankünfte als nicht praktikabel, bringt aber im Rahmen der Entwicklung eines neuen Terminvergabemodus wichtige Erkenntnisse. Mithilfe der gewonnenen Daten und der erworbenen Kenntnisse der entscheidenden Prozesse wird anschließend ein dynamisches Modell mit Hilfe der Dicrete-event-Simulation erstellt. Dieses Modell erweist sich für die Standardsprechstunde als valide, sodass verschiedene Sollszenarien mit unterschiedlichen personellen Ressourcen und Einbestellintervallen untersucht werden können. In der Zusammenschau der Ergebnisse werden vier organisatorische Schwächen von hoher zeitlicher Bedeutung identifiziert. Es handelt sich um das Einbestellsystem, die Koordination mit der Abteilung für Strahlendiagnostik, die zahlreichen Nebenaufgaben der Ärzte sowie die mangelnde Verfügbarkeit von Patienteninformationen. Für diese vier Probleme wurden Lösungskonzepte erarbeitet. Zahlreiche Optimierungsvorschläge konnten nach Zustimmung der Beteiligten erfolgreich implementiert werden. Interventionen, die sich aus diesem Projekt ergeben haben, sind dabei u.a. die Einführung eines neuen, EDV-gestützten, die Abteilung für Strahlendiagnostik einbeziehenden Einbestellsystems, die Einrichtung eines festen ärztlichen Poliklinkteams sowie die elektronische Arztbriefschreibung auch im ambulanten Bereich. Seit zwei Jahren bewähren sich diese Reorgansiationsmaßnahmen im klinischen Alltag

Targeted deletion of miR-132/-212 impairs memory and alters the hippocampal transcriptome

miR-132 and miR-212 are structurally related microRNAs that have been found to exert powerful modulatory effects within the central nervous system (CNS). Notably, these microRNAs are tandomly processed from the same noncoding transcript, and share a common seed sequence: thus it has been difficult to assess the distinct contribution of each microRNA to gene expression within the CNS. Here, we employed a combination of conditional knockout and transgenic mouse models to examine the contribution of the miR-132/-212 gene locus to learning and memory, and then to assess the distinct effects that each microRNA has on hippocampal gene expression. Using a conditional deletion approach, we show that miR-132/-212 double-knockout mice exhibit significant cognitive deficits in spatial memory, recognition memory, and in tests of novel object recognition. Next, we utilized transgenic miR-132 and miR-212 overexpression mouse lines and the miR-132/-212 double-knockout line to explore the distinct effects of these two miRNAs on the transcriptional profile of the hippocampus. Illumina sequencing revealed that miR-132/-212 deletion increased the expression of 1138 genes; Venn analysis showed that 96 of these genes were also downregulated in mice overexpressing miR-132. Of the 58 genes that were decreased in animals overexpressing miR-212, only four of them were also increased in the knockout line. Functional gene ontology analysis of downregulated genes revealed significant enrichment of genes related to synaptic transmission, neuronal proliferation, and morphogenesis, processes known for their roles in learning, and memory formation. These data, coupled with previous studies, firmly establish a role for the miR-132/-212 gene locus as a key regulator of cognitive capacity. Further, although miR-132 and miR-212 share a seed sequence, these data indicate that these miRNAs do not exhibit strongly overlapping mRNA targeting profiles, thus indicating that these two genes may function in a complex, nonredundant manner to shape the transcriptional profile of the CNS. The dysregulation of miR-132/-212 expression could contribute to signaling mechanisms that are involved in an array of cognitive disorders

Triplet superconductivity in quasi one-dimensional systems

We study a Hubbard hamiltonian, including a quite general nearest-neighbor interaction, parametrized by repulsion V, exchange interactions Jz, Jperp, bond-charge interaction X and hopping of pairs W. The case of correlated hopping, in which the hopping between nearest neighbors depends upon the occupation of the two sites involved, is also described by the model for sufficiently weak interactions. We study the model in one dimension with usual continuum-limit field theory techniques, and determine the phase diagram. For arbitrary filling, we find a very simple necessary condition for the existence of dominant triplet superconducting correlations at large distance in the spin SU(2) symmetric case: 4V+J<0. In the correlated hopping model, the three-body interaction should be negative for positive V. We also compare the predictions of this weak-coupling treatment with numerical exact results for the correlated-hopping model obtained by diagonalizing small chains, and using novel techniques to determine the opening of the spin gap.Comment: 8 pages, 3 figure

Persistence of Li Induced Kondo Moments in the Superconducting State of Cuprates

We measure the magnetic susceptibility nearby Li spinless impurities in the superconducting phase of the high Tc cuprate YBaCuO. The induced moment which was found to exist above Tc persists below Tc. In the underdoped regime, it retains its Curie law below Tc. In contrast, near optimal doping, the large Kondo screening observed above Tc (T_K=135 K) is strongly reduced below Tc as expected theoretically when the superconducting gap develops. This moment still extends essentially on its 4 near neighbour Cu, showing the persistence of AF correlations in the superconducting state. A direct comparison with recent STM results of Pan et al. is proposed.Comment: accepted for publication in Phys. Rev. Lett. (issue of 30 april 2001) Revised version : 8 pages including 4 pages of text and 4 figure

Guideline adherence in the use of coronary angiography in patients presenting at the emergency department without myocardial infarction – results from the German ENLIGHT-KHK project

Background For patients with acute myocardial infarction (AMI), direct coronary angiography (CA) is recommended, while for non-AMI patients, the diagnostic work-up depends on clinical criteria. This analysis provides initial prospective German data for the degree of guideline-adherence (GL) in the use of CA on non-AMI patients presenting at the emergency department (ED) with suspected acute coronary syndrome (ACS) according to the 2015 ESC-ACS-GL. Furthermore the implications of the application of the 2020 ESC-ACS-GL recommendations were evaluated. Methods Patient symptoms were identified using a standardized questionnaire; medical history and diagnostic work-up were acquired from health records. In accordance with the 2015 ESC-ACS-GL, CA was considered GL-adherent if intermediate risk criteria (IRC) were present or non-invasive, image-guided testing (NIGT) was pathological. Results Between January 2019 and August 2021, 229 patients were recruited across seven centers. Patients presented with chest pain, dyspnea, and other symptoms in 66.7%, 16.2% and 17.1%, respectively, were in mean 66.3 ± 10.5 years old, and 36.3% were female. In accordance with the 2015 ESC-ACS-GL, the use of CA was GL-adherent for 64.0% of the patients. GL-adherent compared to non-adherent use of CA resulted in revascularization more often (44.5% vs. 17.1%, p < 0.001). Applying the 2020 ESC-ACS-GL, 20.4% of CA would remain GL-adherent. Conclusions In the majority of cases, the use of CA was adherent to the 2015 ESC-ACS-GL. With regard to the 2020 and 2023 ESC-ACS-GL, efforts to expand the utilization of NIGT are crucial, especially as GL-adherent use of CA is more likely to result in revascularization

How to detect fluctuating order in the high-temperature superconductors

We discuss fluctuating order in a quantum disordered phase proximate to a quantum critical point, with particular emphasis on fluctuating stripe order. Optimal strategies for extracting information concerning such local order from experiments are derived with emphasis on neutron scattering and scanning tunneling microscopy. These ideas are tested by application to two model systems - the exactly solvable one dimensional electron gas with an impurity, and a weakly-interacting 2D electron gas. We extensively review experiments on the cuprate high-temperature superconductors which can be analyzed using these strategies. We adduce evidence that stripe correlations are widespread in the cuprates. Finally, we compare and contrast the advantages of two limiting perspectives on the high-temperature superconductor: weak coupling, in which correlation effects are treated as a perturbation on an underlying metallic (although renormalized) Fermi liquid state, and strong coupling, in which the magnetism is associated with well defined localized spins, and stripes are viewed as a form of micro-phase separation. We present quantitative indicators that the latter view better accounts for the observed stripe phenomena in the cuprates.Comment: 43 pages, 11 figures, submitted to RMP; extensively revised and greatly improved text; one new figure, one new section, two new appendices and more reference

Understanding the nature and mechanism of foot pain

Approximately one-quarter of the population are affected by foot pain at any given time. It is often disabling and can impair mood, behaviour, self-care ability and overall quality of life. Currently, the nature and mechanism underlying many types of foot pain is not clearly understood. Here we comprehensively review the literature on foot pain, with specific reference to its definition, prevalence, aetiology and predictors, classification, measurement and impact. We also discuss the complexities of foot pain as a sensory, emotional and psychosocial experience in the context of clinical practice, therapeutic trials and the placebo effect. A deeper understanding of foot pain is needed to identify causal pathways, classify diagnoses, quantify severity, evaluate long term implications and better target clinical intervention

Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement

Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions

In vitro models for the study of osteoarthritis

AbstractOsteoarthritis (OA) is a prevalent disease of most mammalian species and is a significant cause of welfare and economic morbidity in affected individuals and populations. In vitro models of osteoarthritis are vital to advance research into the causes of the disease, and the subsequent design and testing of potential therapeutics. However, a plethora of in vitro models have been used by researchers but with no consensus on the most appropriate model. Models attempt to mimic factors and conditions which initiate OA, or dissect the pathways active in the disease. Underlying uncertainty as to the cause of OA and the different attributes of isolated cells and tissues used mean that similar models may produce differing results and can differ from the naturally occurring disease.This review article assesses a selection of the in vitro models currently used in OA research, and considers the merits of each. Particular focus is placed on the more prevalent cytokine stimulation and load-based models. A brief review of the mechanism of these models is given, with their relevance to the naturally occurring disease. Most in vitro models have used supraphysiological loads or cytokine concentrations (compared with the natural disease) in order to impart a timely response from the cells or tissue assessed. Whilst models inducing OA-like pathology with a single stimulus can answer important biological questions about the behaviour of cells and tissues, the development of combinatorial models encompassing different physiological and molecular aspects of the disease should more accurately reflect the pathogenesis of the naturally occurring disease