The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries.

BACKGROUND: Hospital governance is broadening its orientation from cost and production controls towards 'improving performance on clinical outcomes'. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a 'black-box' thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems. METHODS: This study draws both on a quick scan amongst country coordinators in OECD's Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals. RESULTS: This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems. CONCLUSIONS: Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making

Antibiotic resistance peculiarities of S. aureus isolates, obtained from nasal and throat mucosa of outpatients, Chernivtsi city

The purpose of this study was to determine the specificity of sensitivity to antibiotics of S. aureus strains isolated from nasal mucous membranes and tonsils, as well as to identify the factors of antibiotic resistance. Materials and methods. The pure culture method was used to study smears of the palatine tonsils, the nose and the secret of the external auditory canal of 561, 56 and 15 cultures, respectively. Identification of isolated cultures was carried out according to morphological, tinctorial, physiological and biochemical characteristics. The sensitivity of S. aureus strains to antibiotics was studied and analyzed, 211 of which were isolated from the mucous of the palatine tonsils and 18 - from the nasal mucous. All the isolated strains of S. aureus were determined for the presence of antibiotic resistance factors (FA) -ß-lactamases (BL) and penicillin-binding protein (PВPs). Results. High percentage of strains resistant to ß-lactam antibiotics and macrolides was found in both groups of studied cultures. However, the number of resistant forms to these antibiotics was higher among nasal strains. At the same time, none of the resistant strain to aminoglycosides, fluoroquinolones, lincosamides, tetracyclines, and vancomycin was detected among them. 9.57 % of the strains isolated from the tonsillar mucosa were resistant to the last one. BL and PВPs antibiotic resistance factors of isolated S. aureus strains were more frequent among nasal isolates (BL – 83.3 %, PВPs – 66.7 %) than in strains isolated from the palatine tonsils (BL – 66.3 %, PВPs – 38.6 %), P < 0.05. Sensitivity to antibiotics of S. aureus strains having both FA simultaneously (30 strains) and strains having none of them (26 strains) turned out to be different. Among the strains having both FA, 100 % were resistant to penicillin, 93.3 % to oxacillin, and 36.7 % to vancomycin. Whereas there were 3.9 %, 0.0 %, and 7.7 % strains without FA resistant to these antibiotics, respectively. Resistance to azithromycin was greater in the group of strains with FA: 26.7 % versus 7.7 % in the group without FA. The strains of both groups were highly sensitive with an insignificant difference to other studied antibiotics (aminoglycosides, fluoroquinolones, macrolides, lincosamides and tetracyclines). Conclusions. S. aureus strains isolated from the mucous membranes of the nose and tonsils differ in sensitivity to antibiotics and the presence of FA. The nasal strains of S. aureus are more likely to be resistant to ß-lactam antibiotics and macrolides. Vancomycin resistant strains of S. aureus are significantly more common among strains with FA

Хірургічна тактика лікування гострого некротичного панкреатиту

The aim of the work: to estimate efficacy of proposed tactic of surgical treatment of acute necrotizing pancreatitis. Materials and Methods. We analyzed results of treatment of 317 patients with acute necrotizing pancreatitis in whom proposed tactic of surgical interventions was used during 2013–2019. New onset of organ failure after operation, duration of intensive care treatment, postoperative complications and mortality rates were studied. Results and Discussion. We used the step-up approach of surgical treatment which started from either diapeutic transcutaneous ultrasound-guided procedures in 48.2 % and endoscopic ultrasound-guided – in 46.2 % observations. Transcutaneous procedures were followed by less complication rate in acute necrotic collections cases whereas endoscopic interventions – in walled-off pancreatic necrosis patients. Wide laparotomic necrosectomies was applied in 14.5 % of patients after 4th week from onset. Overall mortality rate was 3.5&nbsp;%, after interventional treatment – 6.5 %. Application of step-up tactic of surgical&nbsp; treatment in patients with ANP decreases necessary in wide laparotomic necrosectomies and reduces level of postoperative complications.Цель работы: оценить эффективность разработанной хирургической тактики лечения острого некротического панкреатита. Материалы и методы. Проведенный анализ результатов лечения 317 больных острым некротическим панкреатитом, у которых в течение 2013-2019 годов использовали предложенную тактику проведения хирургических вмешательств. Для оценки эффективности лечения изучали впервые обнаруженную органную недостаточность после операции, продолжительность интенсивной терапии, послеоперационные осложнения и летальность. Результаты исследований и их обсуждение. Применяли пошаговую тактику хирургического лечения, которая начиналась с диапевтических транскутанных вмешательств у 48,2 % и эндоскопических – в 46,2 % наблюдений. Транскутанные вмешательства сопровождались меньшей частотой осложнений у больных с острыми некротическими скоплениями, а эндоскопические – у пациентов с ограниченными очагами панкреатического некроза. Широкие лапаротомные некрсеквестрэктомии выполнялись у 14,5 % наблюдений после 4 недели от начала заболевания. Общая летальность составила 3,5 %, послеоперационная – 6,5 %. Использование пошаговой хирургической тактики лечения больных острым некротическим панкреатитом уменьшает потребность в широких лапаротомных некрсеквестрэктомиях и способствует снижению уровня послеоперационных осложнений.Мета роботи: оцінити ефективність розробленої хірургічної тактики лікування гострого некротичного панкреатиту. Матеріали і методи. Проведений аналіз результатів лікування 317 хворих на гострий некротичний панкреатит, в яких протягом 2013–2019 рр. використовували запропоновану тактику проведення хірургічних втручань. Для оцінки ефективності лікування вивчали вперше виявлену органну недостатність після операції, тривалість інтенсивної терапії, післяопераційні ускладнення та летальність. Результати досліджень та їх обговорення. Застосовували покрокову тактику хірургічного лікування, яка розпочиналася з діапевтичних транскутанних втручань у 48,2 % та ендоскопічних – у 46,2 % спостережень. Транскутанні втручання супроводжувалися меншою частотою ускладень у хворих із гострими некротичними скупченнями, а ендоскопічні – у пацієнтів із відмежованими вогнищами панкреатичного некрозу. Широкі лапаротомні некрсеквестректомії виконані в 14,5 % спостережень після 4 тижня від початку захворювання. Загальна летальність становила 3,5 %, післяопераційна – 6,5 %. Використання покрокової хірургічної тактики лікування хворих на гострий некротичний панкреатит зменшує потребу в широких лапаротомних некрсеквестректоміях та сприяє зниженню рівня післяопераційних ускладнень

An improvement of the Berry--Esseen inequality with applications to Poisson and mixed Poisson random sums

By a modification of the method that was applied in (Korolev and Shevtsova, 2009), here the inequalities $$\rho(F_n,\Phi)\le\frac{0.335789(\beta^3+0.425)}{\sqrt{n}}$$ and $$\rho(F_n,\Phi)\le \frac{0.3051(\beta^3+1)}{\sqrt{n}}$$ are proved for the uniform distance $\rho(F_n,\Phi)$ between the standard normal distribution function $\Phi$ and the distribution function $F_n$ of the normalized sum of an arbitrary number $n\ge1$ of independent identically distributed random variables with zero mean, unit variance and finite third absolute moment $\beta^3$. The first of these inequalities sharpens the best known version of the classical Berry--Esseen inequality since $0.335789(\beta^3+0.425)\le0.335789(1+0.425)\beta^3<0.4785\beta^3$ by virtue of the condition $\beta^3\ge1$, and 0.4785 is the best known upper estimate of the absolute constant in the classical Berry--Esseen inequality. The second inequality is applied to lowering the upper estimate of the absolute constant in the analog of the Berry--Esseen inequality for Poisson random sums to 0.3051 which is strictly less than the least possible value of the absolute constant in the classical Berry--Esseen inequality. As a corollary, the estimates of the rate of convergence in limit theorems for compound mixed Poisson distributions are refined.Comment: 33 page

ASSOCIATION OF THE METABOLIC SYNDROME CONSTITUENTS WITH MARKERS OF SUBCLINICAL TARGET ORGAN DAMAGE DURING FOLLOW-UP OF INTELLECTUAL LABORERS

Aim. To evaluate the relation of metabolic syndrome (MS) and its constituents with markers of subclinical damage of target organs (TOD) in follow-up of almost healthy intellectual laborers.Material and methods. From the selection of 1600 employees of a bank we randomly selected 383 with at least one component of MS without cardiovascular disorders, of those by the end of 2 years period 331 came to final visit (response 86%). Mean age 46,6±9,0 y., mostly women (214 (64,6%)). All patients underwent anthropometry, blood pressure measurement (BP), lipids investigation, creatinine and fasting glucose, echocardiography with the assessment of the left ventricle hypertrophy (LVH), ultrasound study of carotid arteries (intima-media complex thickness — CIM, and atherosclerotic plaques), vascular rigidity assessment, anklebrachial index, albumin concentration in single portion of urine at both stages of observation.Results. While performing multiple logistic regression, presence of arterial hypertension (AH) associated with increased probability of LVH, thickening of CIM and higher vessel rigidity in standardization by gender and age. Relation of MS with the markers of TOD has not been found. In 2 years of follow-up there was a significant increase of patients with thickening of CIM (from 81 (24,5%) to 146 (44,1%), p&lt;0,001) and decrease of LVH prevalence (from 154 (46,7%) to 109 (32,9%), p=0,003) together with significant decrease of BP and total cholesterol.Conclusion. Presence of AH is associated with higher probability of LVH and increased vessel rigidity, as atherosclerotic changes in carotid arteries. MS was not related with an increased prevalence of TOD, and the main predetermining factors for structural heart abnormalities, the vessels and kidneys, were gender and age. In 2 years of observation there was markedly decreased number of patients with LVH and kidney dysfunction at the background of BP pattern improvement, and increase of the number of patients with thicker CIM, regardless of a decrease of the hypercholesterolemia patients. In MS patients there was more common to use antihypertension treatments, that led to more prominent LVH regression

Індивідуалізована хірургічна тактика при синдромі діабетичної стопи

The aim of the work: to develop an individualized algorithm for surgical treatment of patients with diabetic foot syndrome (DFS). Materials and Methods. The comprehensive clinical study covers 123 cases of surgical treatment of DFS (patients of various degrees according to the PEDIS classification, I–V stages according to F. Wagner, with mild, moderate, severe infection according to IDSA). The development of the algorithm of surgical activity in DFS was carried out according to the recommendations of the Institute for Algorithmic Medicine (Houston, USA), using software (HTML/XML/GMT) package Document Exploration and Linking Tool/ ddons (DELTA) developed by Vienna University of Technology, Institute of Software Technology and Interactive Systems, Information Angi­neering Group, Vienna, Austria. Results and Discussion. Angiographic or technical success of endovascular interventions, which leads to a significant increase in the lumen of the vessel in the area of ​​stenosis or occlusion, was obtained in 94.3 % of cases. The technical success of balloon angioplasty was observed in almost all cases; the slightly worse angiographic results were obtained with interventions on several arteries of the shin – 55.0–94.1 % of successful angioplasties. In ischemic and mixed neuroischemic forms, most patients were able to compensate for critical ischemia by performing vascular interventions. The proposed algorithm of surgical interventions for DFS requires further study under conditions of greater randomization and expansion of the cohort of patients.Цель работы: разработать индивидуализированный метод хирургического лечения больных синдромом диабетической стопы (СДС). Материалы и методы. Комплексное клиническое исследование охватывает 123 случая хирургического лечения СДС (больные различной степени по классификации PEDIS, I–V стадий за F. Wagner, с легкой, умеренной, тяжелой инфекцией с IDSA). Разработку алгоритма хирургической активности при СДС осуществляли согласно рекомендациям Institute for Algorithmic Medicine (Хьюстон, США) с использованием программного (HTML / XML / GMT) пакета Document Exploration and Linking Tool / Addons (DELTA) разработанного Vienna University of Technology, Institute of Software Technology and Interactive Systems, Information Engineering Group, Vienna, Austria. Результаты исследований и их обсуждение. Ангиографический или технический успех эндоваскулярных вмешательств, что приводит к существенному увеличению просвета сосуда в зоне стеноза или окклюзии, был нами получен в 94,3 % наблюдений. Технический успех баллонной ангиопластики наблюдался практически во всех случаях, несколько хуже ангиографические результаты получены при вмешательствах на нескольких артериях голени – 55,0–94,1 % успешных ангиопластики. При ишемической и смешанной нейроишемической формах у большинства больных удавалось компенсировать критическую ишемию выполнением сосудистых вмешательств. Предложенный алгоритм хирургических вмешательств при СДС требует дальнейшего изучения в условиях большей рандомизации и расширения когорты пациентов.Мета роботи: розробити індивідуалізований алгоритм хірургічного лікування хворих на синдром діабетичної стопи (СДС). Матеріали і методи. Комплексне клінічне дослідження охоплює 123 випадки хірургічного лікування СДС (хворі різних ступенів за класифікацією PEDIS, І-V стадій за F. Wagner, з легкою, помірною, тяжкою інфекцією за IDSA). Розробку алгоритму хірургічної активності при СДС здійснювали згідно з рекомендаціями Institute for Algorithmic Medicine (Гʼюстон, США), з використанням програмного (HTML/XML/GMT) пакету Document Exploration and Linking Tool / Addons (DELTA), розробленого Vienna University of Technology, Institute of Software Technology and Interactive Systems, Information Engineering Group, Vienna, Austria. Результати досліджень та їх обговорення. Ангіографічний або технічний успіх ендоваскулярних втручань, що призводить до істотного збільшення просвіту судини в зоні стенозу або оклюзії, ми отримали в 94,3 % спостережень. Технічний успіх балонної ангіопластики спостерігали практично в усіх випадках, дещо гірші ангіографічні результати отримано при втручаннях на декількох артеріях гомілки – 55,0–94,1 % успішних ангіопластик. При ішемічній та змішаній нейроішемічній формах у більшості хворих вдавалося компенсувати критичну ішемію виконанням судинних втручань. Запропонований алгоритм хірургічних втручань при СДС потребує подальшого вивчення за умов більшої рандомізації та розширення когорти пацієнтів