Biomedical subjects

R Feyrer

Publications and source records attributed to R Feyrer.

7 recordsLinked to original sources

PubMed2006

[Computer-assisted process simulation: a suitable instrument for process optimization in hospitals].

The increasing financial pressure on hospitals resulting from changes in the health system demands detailed knowledge about the cost and earnings situation in the hospital. An essential part of strategic controlling now entails establishing structured cost-unit accounting. This can then be used for example through process optimization to ascertain savings potential and rationalization measures. This paper illustrates a possibility of using computer-assisted process simulation to find ways for prozess optimization. The simulation has been based on the treatment process "operative procedure" of a clinical pathway "CABG" developed in our hospital. The starting points for simulation possible prozess optimization consisted in the elimination of existing waiting times, respectively the parallel organization of certain partial processes. The software used for the simulation was Coral iGrafix Process 2003. The results of 1000 simulation processes reveal a clear reduction in the whole lead-time for the patient, both in avoiding waiting times and also in parallel process organization. In contrast to the initial situation (triangular distribution), the overall duration of the treatment section can be described approximately with normal distribution and a clear cluster of minimum overall durations. Computer-assisted process simulation is a suitable instrument for revealing and establishing possibilities for process optimization in hospitals, and therefore makes a valuable contribution to strategic controlling.

Cardiac Surgical Procedures↗

PubMed2005

Cost unit accounting based on a clinical pathway: a practical tool for DRG implementation.

Setting up a reliable cost unit accounting system in a hospital is a fundamental necessity for economic survival, given the current general conditions in the healthcare system. Definition of a suitable cost unit is a crucial factor for success. We present here the development and use of a clinical pathway as a cost unit as an alternative to the DRG. Elective coronary artery bypass grafting was selected as an example. Development of the clinical pathway was conducted according to a modular concept that mirrored all the treatment processes across various levels and modules. Using service records and analyses the process algorithms of the clinical pathway were developed and visualized with CorelTM iGrafix Process 2003. A detailed process cost record constituted the basis of the pathway costing, in which financial evaluation of the treatment processes was performed. The result of this study was a structured clinical pathway for coronary artery bypass grafting together with a cost calculation in the form of cost unit accounting. The use of a clinical pathway as a cost unit offers considerable advantages compared to the DRG or clinical case. The variance in the diagnoses and procedures within a pathway is minimal, so the consumption of resources is homogeneous. This leads to a considerable improvement in the value of cost unit accounting as a strategic control instrument in hospitals.

Accounting↗

PubMed2002

Early increase of procalcitonin after cardiovascular surgery in patients with postoperative complications.

OBJECTIVE: Type and frequency of postoperative abnormalities were registered after cardiovascular surgery to evaluate the aetiology and diagnostic value of increased concentrations of procalcitonin (PCT) and C-reactive protein (CRP) during the early postoperative period. DESIGN: Prospective, observational study. PATIENTS: Two hundred and eight patients undergoing coronary artery bypass grafting or valve replacement requiring cardiopulmonary bypass were monitored for 7 days postoperatively for various types of infectious or non-infectious complications. Plasma PCT and CRP levels were measured on day 1 and day 2 after surgery and, when increased, until day 7. RESULTS: More patients with PCT above 2 ng/ml on day 1 or 2 (n=55) had postoperative abnormalities (95%) than patients with lower PCT (59%). Specifically, the incidence of three or more criteria of the "systemic inflammatory response syndrome" was 45% versus 4% (area under the curve of the receiver operating characteristic 0.866); positive inotropic support was needed in 65% versus 9% (0.870); respiratory insufficiency (PaO(2)/FIO(2)<200) 38% versus 12% (0.704); proven and suspected bacterial infection 9% versus 1% (0.900) and 24% versus 1% (0.897), respectively. For CRP, the respective areas under the curve were all below 0.63, while all patients had elevated CRP levels, whether they had a complication or not. CONCLUSIONS: Elevated PCT, but not CRP, correlates with evidence of systemic inflammation and other complications early postoperatively after cardiac surgery. Although the PCT levels do not rise as quickly as the criteria of the systemic inflammatory response syndrome appear, they do reflect systemic inflammation. Early identification and quantification of a systemic inflammatory response may help reduce postoperative complications.

APACHE↗

PubMed1999

Reducing the post-pump syndrome by using heparin-coated circuits, steroids, or aprotinin.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response called 'post-pump syndrome'. As a part of a complex interaction between white cells and vascular endothelium, proinflammatory cytokines IL-6 and IL-8 are part of a phased immune response that is also balanced by anti-inflammatory cytokines such as IL-10. We compared the influence of heparin-coated circuits, steroids, and aprotinin on these cytokines, looking for ways to reduce the syndrome. METHODS: 40 patients with coronary artery disease (CAD) undergoing elective CABG were prospectively studied in four randomized groups of 10. Group A received prednisolone pre- and postoperatively (2 x 250 mg), group B received aprotinin perioperatively (6 Mio. KIU). In group C, heparin-coated circuits ('Bioline' by Jostra) were used and in group D no special measures were taken (controls). Plasma levels of cytokines were measured before and during CPB and until 12 h after surgery using an ELISA technique. RESULTS: In group A IL-6 was significantly (p<0.05) suppressed in contrast to the control group (A: peak at 4 h, 155 pg/ml vs. control: peak at 8 h, 565 pg/ml). IL-8 was also suppressed (A: peak at 30', 22 pg/ml vs. control: peak at 30', 55 pg/ml). IL-10 level changed first and was markedly upregulated in contrast to the control (A: peak at 30', 1600 pg/ml vs. control: peak at 30', 130 pg/ml; p<0.05). In group B (aprotinin) the cytokine release was similar to group A. Using heparin-coated circuits (group C) also led to a significant (p<0.05) IL-10 upregulation (C: peak at 2 h, 1380 pg/ml) and IL-6 suppression (C: peak at 4 h, 290 pg/ml). IL-8 was not influenced significantly. CONCLUSIONS: The results show a similar reduction of the inflammatory cytokine release (IL-6 and IL-8 as markers) using early steroid application and aprotinin in high dosage. Heparin coating reduces IL-6 and increases IL-10 release, whereas IL-8 is not affected. Further studies should investigate the effects of a combined application for reducing inflammatory cytokine release and the post-pump syndrome.

Aged↗

PubMed1998

High-risk mitral valve replacement in severe pulmonary hypertension--30 years experience.

OBJECTIVE: In the past 30 years, 2316 patients underwent mitral valve replacement (MVR) at our institution; 382 of them had severe pulmonary hypertension (pulmonary artery pressure (PAP) > 50 mmHg; pulmonary vascular resistance (PVR), 690 +/- 46 dyn/s per m2). We reviewed our early and late results in this high-risk subgroup. METHODS: We used 336 mechanical and 46 biological devices for MVR. The follow-up was 95%, with an observation period of 3208 patient-years and a mean of 8.4 +/- 0.2 years per patient. The overall early mortality rate was 10.5% (n = 40) and stayed at about the same level over the years, although patients characteristics have changed to much older patients and more reoperations. To clarify this fact we divided our data in results according to the decades in which the operations were carried out. The clinical preoperative status and results were as follows (*P < 0.05; **P < 0.01 compared with previous decade). In the decades between 1963 and 1973 (I), 1974 and 1983 (11) and 1984 and 1993 (III) we operated on n = 95 (I), n = 185 (II), and n = 102 (III) patients with a mean age of 43 +/- 1 (I), 50 +/- 1** (II), and 58 +/- 1** (III) years. The incidence of reoperations among these patients was 3.2 (I), 4.9 (II), and 22.6%** (III). The early mortalities were 13.7 (I), 8.6* (II) and 10.8% (III); late mortalities lowered from 5.77 (I), over 4.95 (II), and up to 3.39%** (III) patients/year. The mean functional status according to New York Heart Association (NYHA) class improved from preoperatively 3.0 +/- 0.1 (I), 3.2 +/- 0.1 (II) and 3.3 +/- 0.1 (III) to 2.4 +/- 0.2 (I), 2.4 +/- 0.1 (II) and 2.3 +/- 0.1 (III) postoperatively. RESULTS: Compared with routine elective MVR with a mortality rate of 3.6% (P < 0.01), early mortality is high. But once the patient survives the perioperative course, late results show no difference compared with patients without pulmonary hypertension. The functional results as well are not significantly different. In spite of on average 15 years older multimorbid patients with therefore higher complication rates, early results improved slightly, which could be explained by better operative techniques, perioperative treatment and nursing (online monitoring with immediate therapeutic substitution). Surprisingly the increased number of reoperations had no negative impact on patients' outcomes. CONCLUSION: According to our results, we recommend MVR in severe pulmonary hypertension even in the elderly, with a high but acceptable risk and good long-term results.

Adult↗

PubMed1996

Results of a 1 to 31 years follow-up after aortic valve replacement in 2327 patients.

We studied the outcome of 2327 patients after aortic valve replacement from October 1962 to December 1993. 1840 mechanical (mostly STJ bi-leaflet and BS tilting disc valves) and 487 biological (IS and CE valves) prostheses were implanted. The mean follow-up period of 1458 surviving patients was 7.1 years. There were 688 non-survivors and 181 lost cases. The mean age was 50.1 years, 73% of the patients were male and 27% were female. Early mortality was about 20% in the 1960's and about 4.5% in the last years. Mortality following valve replacement was influenced by preoperative NYHA classification, cardiac index, pressure gradient and simultaneous CHD. The long term results of all valves showed a survival rate of 80% after 5 years, 73% after 10 and 60% after 15 years following operative treatment. There was no significant difference in survival rates between all mechanical and biological valves. Non-lethal complications of all mechanical valves showed no significant difference but there was a clearly lower rate of paraprosthetic leakages, haemolysis and thromboembolism in biografts. The biological valves showed a high rate of degeneration (2.7%/pty). Reoperation was performed in 170 patients. Most valve changes consisted of biological to mechanical and mechanical to mechanical valves. The main reason of reoperation was degeneration (biological), paraprosthetic leakage and haemolysis (mechanical). The cause of death of the 688 non-survivors was valve related in 17.9%. 37% of these were due to thromboembolism and 38% due to bleeding. 55.6% of survivors (group 2) could be ascribed to NYHA class III and 17.2% to class IV prior to operation. Postoperative outcome demonstrated an improvement in NYHA classification in about 80%. Of surviving patients 80% pronounced an increase of physical activity after operation.

Aortic Valve↗

PubMed1984

[Rooming-in as a therapeutic possibility for a 6-year-old autistic girl].

The possibilities of rooming-in as a form of therapy for the psychic abnormal child are demonstrated on the basis of the example of a mother-child-therapy, which lasted six weeks and happened during the stay of mother and child on our station. The patient was a six year old, intellectually retarded girl with autistic behavior disturbances. The points of main effort in our therapeutical interventions were set on reaching a higher selfreliance of the patient as far as every day life-routine was concerned, further more on increasing the child's social and intellectual capabilities and on eliminating the girl's sleeping troubles. In order to reach these aims we started a training in behavior modification (operant conditioning, modeling) for mother and child. The remarkable developmental progresses of our patient are attributed most of all to the thorough efforts that were made in order to improve the abilities of the girl by modifying the contact between mother and child. Besides, the possibility of being able to use the whole day for therapy, to discuss and,--if necessary--to correct immediately the learning experiences that have been made, seems to be a great chance for reaching the appropriate forms of action and interaction in a quicker way.

Autistic Disorder↗