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Verbesserung der Prozessqualität in der prähospitalen Notfallmedizin der Hansestadt Greifswald
(2010)
In dieser Arbeit erfolgte eine Untersuchung der Qualität des in der Hansestadt Greifswald verwendeten Notarzteinsatzprotokolls und der Qualitätssicherung im Rettungsdienst Greifswald durch Analyse der Übereinstimmungen der Einsatzprotokolle mit den Daten, die in die EDV-Software Uni Pro eingegeben wurden. 869 Notarzteinsatzprotokolle der Boden- und Luftrettung aus den Monaten März 2002, Oktober 2002 und Oktober 2003 wurden nach 37 Feldern ausgewertet. Die Gesamtauswertung ergab, dass nur 45,3% der Felder übereinstimmend dokumentiert und bis zu 38,69% der Felder nicht ausgefüllt wurden. Durch eine Fortbildung konnte der Anteil übereinstimmend ausgefüllter Felder von initial 41,42% auf 48,41% erhöht sowie der Anteil nicht ausgefüllter Felder von 38,69% auf 27,35% gesenkt werden. Ein diagnosespezifischer Vergleich bei Fällen mit ACS/MI bzw. TIA/Apoplex zeigte Defizite in der Dokumentation relevanter Parameter. Bei ACS/MI wurden in über 98% systolischer Blutdruck und in 96,26% Puls, aber nur in 86,92% SpO2, in 82,24% EKG und in 73% diastolischer Blutdruck übereinstimmend dokumentiert. Bei TIA/Apoplex wurden systolischer Blutdruck in 95,5%, Puls in 87,88%, SpO2 in 71,21%, EKG in 77,27% und diastolischer Blutdruck in 70% der Fälle übereinstimmend dokumentiert. Häufig erfolgte keine Dokumentation der Psyche (25,76%) oder der Bewusstseinslage (18,18%). Blutzucker und Pupillenfunktion wurden in 19,7% bzw. 18,18% nicht übereinstimmend dokumentiert.
The Accuracy of On-Call CT Reporting in Teleradiology Networks in Comparison to In-House Reporting
(2021)
Accelerated drug release tests are essential for quality control (QC) of long acting (non-oral) controlled release formulations. Real-time release experiments are usually required for product development, to understand the mechanism of release and to establish a correlation with in vivo release. Ideally, the accelerated test should maintain the biorelevant aspect of the in vitro method and the mechanism of release should not change under accelerated test conditions. At the same time adequate discriminatory ability is a prerequisite as the accelerated test should be able to discriminate between batches with respect to manufacturing variables that can impact on bioavailability. The objective of this thesis was to develop accelerated drug release tests for intravaginal rings (IVRs) and to gain a mechanistic understanding of the principles that facilitate in vitro drug release under accelerated test conditions. A detailed evaluation of the in vitro release characteristics of the formulations under real-time test conditions was considered as a prerequisite for developing predictive accelerated tests. Two formulations were subject of this study, in which the mechanism of release is primarily governed by drug diffusion. One formulation was the commercially available Nuvaring®, a combined hormonal contraceptive IVR that releases etonogestrel and ethinylestradiol with a constant rate over a duration of 3 weeks. The second formulation was a prototype of an investigational IVR that is supposed to be bioequivalent to the marketed formulation. The Nuvaring® provides an example of a reservoir system in which a membrane mediates diffusion, resulting in release rates that are almost constant with time, whereas the investigational IVR is a matrix-type IVR. In these devices drug release is driven by Fickian diffusion through a homogeneous matrix and decays with time. Both IVRs are based on different grades of polyethylene vinyl acetate (PEVA). Accelerated drug release tests were performed at elevated temperature and in hydro-organic solvents since these two parameters were expected to increase drug diffusion through the semicrystalline EVA copolymer. Release experiments with IVRs or endcapped segments were performed in an incubator shaker. The devices were placed in stoppered flasks containing an adequate release medium that was continuously shaken and completely replaced at predetermined time points. Release experiments with endcapped segments were also performed in a small volume version of UPS apparatus 7 (the Reciprocating Holder). Results from release experiments in these two setups were in general comparable when the release from segments was standardized to release per ring with respect to the mass ratio (segment/IVR). Real-time drug release in an aqueous release medium at a temperature of 37 °C from the Nuvaring® was slightly affected by variations in the in vitro test conditions, i.e. media volume and composition (addition of solubility enhancing agents). These variations, however, did not affect the release kinetics that continued to be zero-order with exception of the initial burst. In contrast, real-time drug release from the matrix IVR was affected by the steroid solubility in the release medium, increased with increasing media volume and reached a maximum in release media containing solubility enhancing agents, resulting in distinct release kinetics. Interestingly the steroid solubility had a distinct influence on the release rate under conditions that are commonly assumed to provide sink conditions. Even under experimental conditions that provided minimum drug solubility, the concentration of ethinylestradiol in the receptor medium never exceeded 3 % of the saturation solubility. Accelerated drug release from both IVRs could be observed after exposure to elevated temperature and/or hydro-organic release media. Overall, increased drug release in different hydro-organic media correlated with polymer swelling. The higher swelling capacity of the investigational IVR, when compared with the Nuvaring®, was accounted for a stronger degree of acceleration in different hydro-organic release media. These observations were in agreement with literature sources that report that swelling as well as diffusivity in EVA copolymers increases with increasing VA content, which is lower in the rate-controlling membrane of the Nuvaring®. For the investigational IVR a good correlation between accelerated and real-time release profiles could be obtained if changes in steroid solubility under accelerated conditions were taken into consideration. For example, a good correlation could be observed between accelerated release profiles in hydro-organic media and real-time release profiles in media containing surfactants that provide maximum drug solubility and thus eliminate boundary layer effects. This observation appears reasonable since hydro-alcoholic release media also enhance steroid solubility in the receptor compartment. In case of the Nuvaring® variations in the in vitro test parameters under real-time test conditions did not affect the release kinetics. For this IVR, the mechanism of release was maintained in hydro-organic release media and at elevated temperature. The quantitative relationship between the zero-order release constants and the test temperature could be described by the Arrhenius equation, indicating that accelerated release is governed by an increase in drug diffusion. Validation of the accelerated method with a prototype of the investigational IVR with a different drug load demonstrated that the accelerated methods were able to detect formulation changes with similar discriminatory ability as the real-time test. However, the temperature-controlled accelerated method was less sensitive to detect changes in the release characteristics of a Nuvaring® that have been induced by preliminary heat-treatment, indicating that the accelerated method may be less sensitive to detect changes in IVRs that are a result of physical aging. When the aim is to develop an accelerated method for batch release it is therefore crucial to validate the accelerated method with appropriate samples from non-conforming batches that are out of specification under real-time test conditions and have been obtained by small but deliberate variations in the critical process parameters. In both formulations the degree of acceleration could be further increased by combining the effect of hydro-organic release media with an increase in temperature. Under these test conditions the ability to differentiate between the different prototypes of the investigational IVR was maintained. Moreover, in both IVRs the mechanism of release was not affected by an additional increase in temperature when compared with release profiles in hydro-organic solvents. In conclusion, the results of this study indicate that both temperature and hydro-organic release media are valid parameters to accelerate drug release from delivery systems in which the mechanism of release is primarily governed by diffusion through dense (inert) polymer matrices (i.e. inserts, implants). A correlation between real time and accelerated release will be facilitated if drug release under real-time test conditions is independent of the test parameters. To assure the outcome of the test with respect to quality and safety it is crucial to validate the accelerated method with appropriate batches.
Disregarded Measurement Uncertainty Contributions and Their Magnitude in Measuring Plasma Glucose
(2020)
Background:
Each measurement is subject to measurement uncertainty (MU). Consequently, each measurement of plasma glucose concentration used for diagnosis and monitoring of diabetes mellitus (DM) is affected. Although concepts and methods of MU are well established in many fields of science and technology, they are presently only incompletely implemented by medical laboratories, neglecting MU of target values of internal quality control (IQC) materials.
Methods:
An empirical and practical approach for the estimation of MU based on the analysis of routine IQC using control samples with assigned target values is presented. Its feasibility is demonstrated exemplarily by analyzing IQC data from one year obtained for glucose employing the hexokinase method with IQC of two different concentrations.
Results:
Combined relative extended (k = 2) MU comprising bias, coefficient of variation (CV), and MU of the target values assigned to control materials were about 9% with a lower (~ 56 mg/dL; ~3.1 mmol/L) and 8% with a higher (~ 346 mg/dL; ~19.2 mmol/L) concentration sample, analyzing IQC of one year from three different devices.
Conclusions:
Estimation of MU in this study is quite reliable due to the large number of IQC data from one year. The MU of the target values of the commercial control material in this study was considerably larger than other MU contributions, ie, standard deviation and bias. In the future, the contribution of MU of commercial IQC should be addressed more carefully and technologies to measure glucose should be geared toward smaller MU possible, as needed, especially for glucose concentration measurements in diagnosis and management of DM.