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Purpose: Incisional hernia (IH) is one of the most common complications after abdominal surgeries and may bring great suffering to patients. This study aims to evaluate the global trends in IH research from 2003 to 2023 and visualize the frontiers using bibliometric analysis., Methods: The literature search was conducted on the Web of Science for IH studies published from 2003 to 2023 and sorted by citation frequency. The top 100 most-cited articles were analyzed by the annual publication number, prolific countries and institutions, influential author and journal, and the number of citations through descriptive statistics and visualization., Results: The top paper was cited 1075 times and the median number of citations was 146. All studies were published between 2003 and 2019 and the most prolific year was 2003 with 14 articles. Jeekel J and Rosen M were regarded as the most productive authors with ten articles each and acquired 2738 and 2391 citations, respectively. The top three institutions with the most productive articles were Erasmus Mc, Carolinas Med Ctr, and Univ Utah, while the top three countries were the United States, Netherlands and Germany. The most frequent keyword was "incisional hernia" with 55 occurrences, followed by "mesh repair", "randomized controlled trial", and "polypropylene"., Conclusion: The 100 most-cited papers related to IH were published predominantly by USA and European countries, with randomized controlled trial (RCT) and observational study designs, addressing topics related to risk factors, complications, mesh repair, and mesh components., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Irma Weinberg, a German-Jewish Neuropsychiatrist/Physician, authored the fourth report from the German Research Institute for Psychiatry in Munich examining the risk for dementia praecox (DP) in particular relatives of DP probands, here first-cousins. She examined 977 cousins of 54 DP probands and found a best-estimate risk of 1.4%. She conducted within-study analyses, showing a much higher risk for DP in the siblings than cousins of DP probands. She studied DP-related personalities showing a familial link between these conditions and risk for DP. She demonstrated that the risk for DP in cousins was impacted substantially by the distribution, in ancestors, of psychosis and personality abnormalities. After completing work on this article, Weinberg worked in private practice in Frankfurt, emigrating to the Netherlands in 1934, where she worked at a Jewish psychiatric hospital. In 1943, German occupiers evacuated the hospital, transporting the patients and staff, either directly to Auschwitz or, like Weinberg, to the Westerbork transit camp. On September 4, 1944, Dr. Weinberg was transported to Theresienstadt and soon thereafter to Auschwitz, where she was murdered at the age of 53. Her history raises painful questions about the relationship between genetic studies of psychiatric illness in prewar Germany and the Holocaust., (© 2023 The Authors. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics published by Wiley Periodicals LLC.)

Objective:  The aim was to develop a new curriculum for radiology in medical studies, to reach a national consensus and to integrate it into the new national competence-based learning objectives catalog (NKLM 2.0). In this statement of the German Radiological Society (DRG), the process of curriculum development is described and the new curriculum is presented together with suggestions for practical implementation., Materials and Methods:  The DRG has developed a new curriculum for radiology. This was coordinated nationally among faculty via an online survey and the result was incorporated into the NKLM 2.0. Furthermore, possibilities for the practical implementation of the competency-based content are shown and different teaching concepts are presented., Results:  The developed curriculum is competency-based and aims to provide students with important skills and abilities for their future medical practice. The general part of the curriculum is divided into the topics "Radiation Protection", "Radiological Methods" and radiologically-relevant "Digital Skills". Furthermore, there is a special part on the individual organ systems and the specific diseases. In order to implement this in a resource-saving way, new innovative teaching concepts are needed that combine the advantages of face-to-face teaching in small groups for practical and case-based learning with digital teaching offers for resource-saving teaching of theoretical content., Conclusion:  We have created a uniform radiology curriculum for medical studies in Germany, coordinated it nationally and integrated it into the NKLM 2.0. The curriculum forms the basis of a uniform mandatory radiology teaching and should be the basis for the individual curriculum development of each faculty and strengthen the position of radiology in the interdisciplinary context., Key Points:   · A radiology curriculum for undergraduate medical education was developed.. · The curriculum was brought into agreement among the faculties in Germany and integrated into the NKLM 2.0.. · This curriculum is intended to be the basis for curriculum development and to strengthen the position of radiology.. · In order to implement the competence-based teaching, new innovative teaching concepts are necessary.., Citation Format: · Dettmer S, Barkhausen J, Volmer E et al. White Paper: Radiology Curriculum for Undergraduate Medical Education in Germany and Integration into the NKLM 2.0. Fortschr Röntgenstr 2021; 193: 1294 - 1303., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Traditionally, direct medical competences are taught in medical studies, whereas leadership and quality management competences are hardly taught, although graduates are already confronted with management tasks at the beginning of their clinical work. With the upcoming amendment of the Medical Licensing Regulations, this topic area will probably be addressed and must be adequately taught by the faculties. The learning objectives in the area of quality management listed in the current working version of the German National Catalogue of Learning Objectives in Medicine (NKLM) 2.0 have so far been formulated in rather general terms and need to be concretized., Aim: To develop a competence-based learning objectives catalog for the topic area of quality management in medical studies as a structured framework recommendation for the design of faculty teaching-learning programs and as a suggestion for further development of the NKLM., Methods: The competence-based learning objectives catalog was developed by an eight-member working group "Quality Management in Education, Training and Continuing Education" of the Gesellschaft für Qualitätsmanagement in der Gesundheitsversorgung e.V. (GQMG) within the framework of a critical synthesis of central publications. The members of the project group have many years of project experience in quality management in health care as well as in university didactics., Results: Six basic competence goals as well as 10 specific competence goals could be formulated and consented upon. These are each flanked by a list of essential basic concepts and examples. These focus on quality improvements, including patient safety and treatment success against the background of a physician leadership role in an interprofessional context., Discussion: A competency-based set of learning objectives has been compiled that encompasses the necessary concepts and basic knowledge of quality management required for those entering the profession to understand and actively participate in quality management after completing medical school. To the authors' knowledge, no comparable learning objectives catalog is currently available for medical studies, even internationally., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2023 Vogeser et al.)

On September 27, 1922, Ernst Rüdin gave an address to the Annual Conference of the German Society of Genetics entitled "Regarding the Heredity of Mental Disturbances." Published in a 37-page article, Rüdin reviewed the progress in the field of Mendelian psychiatric genetics, then hardly more than a decade old. Topics included (a) the status of Mendelian analyses of dementia praecox and manic-depressive insanity which had expanded to include two and three locus and early polygenic models and sometimes included, respectively, schizoid and cyclothymic personalities; (b) a critique of theories for the explanation of co-occurrence of different psychiatric disorders within families; and (c) a sharp methodologic critique of Davenport and Rosanoff's contemporary work which emphasized Rüdin's commitment to careful, expert phenotyping, a primary focus on well-validated psychiatric disorders and not broad spectra of putatively inter-related conditions, and an emphasis on rigorous statistical modeling as seen in his continued collaboration with Wilhelm Weinberg., (© 2023 The Authors. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics published by Wiley Periodicals LLC.)

Thermal papers (e.g. point of sale receipts, adhesive labels, tickets) significantly contribute to contamination of paper material cycles and the environment with substances of (eco-) toxicological concern. In particular, they contain color developers like endocrine disrupting bisphenols in typical concentrations of about 1-2 percent per weight (wt%). Bisphenol A (BPA) was used as the common color developer over the last decades, but it will be restricted for thermal paper application in the European Union to a limit of 0.02 wt% from 2020 onwards. Consequently, a variety of BPA substituents such as bisphenol S (BPS) and its derivatives gain importance in thermal paper application. In this study, a rapid, reliable and cost-effective method for identification and quantification of BPA, alternative color developers and related substances like sensitizers is presented based on HPLC separation coupled with diode array detection (DAD) and Corona charged aerosol detection (CAD). Quantification was performed with regard to the intended use of the substances in thermal papers. Besides traditional UV external calibration using reference standards, alternative quantification approaches, in particular UV chromophore concentration for BPS derivatives and CAD universal response technique for low-volatile color developers, were applied and compared in order to allow quantification without reference substances. A market analysis for intended used color developers and sensitizers was performed on thermal paper samples (n = 211) collected in Germany during 2018 and 2019. Pergafast 201 (in 41.7% of the samples) was the most common color developer with concentrations above 0.02 wt%, followed by BPA (36.0%), BPS (13.3%) and other BPS derivatives known as D8, D-90, BPS-MAE and TGSA, that are mainly present in adhesive labels. Sensitizers were determined in over 90% of the samples., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background and Objectives: In March 2020, the WHO declared the SARS-CoV-2 corona virus a pandemic which caused a great disruption to global society and had a pronounced effect on the worldwide supply of blood., Materials and Methods: In 2022 an on-line meeting was organised with experts from Austria, Canada, Germany, Greece, Netherlands and United States to explore the opportunities for increasing preparedness within blood systems for a potential future pandemic with similar, or more devastating, consequences. The main themes included the value of preparedness, current risks to the blood supply, supply chain vulnerabilities, and the role of innovation in increasing resiliency and safety., Results: Seven key recommendations were formulated and including required actions at different levels., Conclusion: Although SARS-CoV-2 might be seen as a unique event, global health risks are expected to increase and will affect blood transfusion medicine if no preparedness plans are developed., (© 2022 International Society of Blood Transfusion.)

(1) Background: The main basis for the public recognition of the merits of scientists has always been the system of scientific publications and citations. Our goal is to identify and analyze the most cited articles in the Public, Environmental & Occupational Health category. (2) Methods: We searched the Web of Science for all articles published in the "Public, Environmental & Occupational Health" category up to March 2022 and selected the 100 most cited articles. We recorded the number of citations, the journal, the year of publication, quartile, impact factor, institution, country, authors, topic, type of publication and collaborations. (3) Results: 926,665 documents were analyzed. The top 100 had 401,620 citations. The journal with the most articles was the Journal of Clinical Epidemiology and the one with the highest number of citations was Medical Care. The year with the highest number of articles in the top 100 was 1998. The country with the highest percentage of publications was the USA and the most productive institution was Harvard. The most frequent keywords were bias, quality, and extension. The largest collaboration node was between the USA, Canada, Germany, Spain, Australia, France, and Sweden. (4) Conclusions: This bibliometric study on Public, Environmental & Occupational Health provides valuable information not only to identify topics of interest in the analyzed category, but also to identify the differences in the topics they study.

This brief introduction summarizes and gives the biographical context of Roger Money-Kyrle's 1934 paper "A psychological analysis of the causes of war". It also contextualizes his interest in the interplay between the psychological mechanisms operating within the individual, the society and groups and his personal experience with Germany in between and after two catastrophic wars.

Background: A large part of the population in Germany makes use of naturopathic, complementary and integrative medical treatments. There are now numerous scientific studies that provide evidence of efficacy for certain indications. At German medical faculties, selected procedures and their application are taught within the cross-sectoral unit called QB 12 and some elective courses, with a focus on specific aspects are offered. So far, however, there has been no structured curriculum that longitudinally anchors teaching across medical studies and enables all students to consider naturopathic and complementary medical options for patient care later on and to integrate them effectively into the diagnostic and treatment process., Objective: The aim of this position paper is to show the relevance of this topic for medical education, to clarify terminology and to present core competencies and possible implementation options for training., Method: The Integrative Medicine and Perspective Pluralism Committee of the German Association for Medical Education developed this position paper in a multi-stage consensual process, in cooperation with the Forum of University Work Groups on Naturopathic Treatment and Complementary Medicine., Results: First, different umbrella terms were discussed and an existing definition of integrative medicine and health was chosen for subsequent use. Building on this step, the status of education and its scientific foundation in Germany was considered in an international context. In the next step, a competency profile for medical training, consisting of seven areas of competency, was developed and described in detail with regard to naturopathic, complementary and integrative medicine. Implementation options were identified using possible starting points in the curriculum and using established examples of best practice., Conclusion: Despite different priorities at each faculty, it was possible to find an agreement on the development of competencies and anchoring them in medical education on the basis of a common definition of terms. Currently, the implementation in the mandatory and elective areas is very heterogeneous. As part of the current revision of the Medical Licensure Act, there are many possible starting points for the integration of naturopathic and complementary medical teaching content, especially in interprofessional and general practice courses. The implementation and accompanying research of targeted teaching settings should lay the foundations for a long-term and binding integration into medical education. Overall, it is clear that medical education in the field of naturopathy and complementary and integrative medicine has the potential to develop comprehensive core medical competencies., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2022 Homberg et al.)

The Tibetan Plateau works as an important environmental and ecological barrier for the Asian continent. The researches on Tibetan environment and ecology are becoming extensive, but there is no systematic summary of research hotspots and trends in this field. Here, we analyzed 9180 publications retrieved from the WOS and CNKI during 2000 ~ 2020. The characteristics of publication, keywords with a 5-year interval and co-occurrence analysis were carried out so as to reveal the evolution and development trends of topics. The results show that articles increase dramatically since 2012. Except for common concerns like evolution, climate change, and precipitation, diversity was been studied more by Chinese scholars, while the USA, Germany, UK, and Australia researchers focused more on adaptability, basin western Tibet, lake, barley, and ore-related themes, respectively. Besides, China closely collaborated with the USA, Australia, and Germany in topics of evolution, climate change and degradation, precipitation, and diversity. The institutions located in Chinese different economic regions focused on different research keywords, such as vegetation, growth, trace elements, and geochemistry. The CAS contributed the most articles with 4254, showed advantages both in quantity and quality. Few articles were published by researchers affiliated to Free University of Berlin but with higher citations. It is the only one institute outside of China in the top 20. Main research hotspots include climate change, geology, and diversity. In future researches, ecological management and rehabilitation of mining area and tailings ponds, waste disposal, and changes of soil and water quality are worthy of attention and funding., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The aim of this study was to explore the geographic distribution and number of papers published in international and Science Citation Index (SCI)-indexed cytology journals based on their country of origin., Materials and Methods: A country-based geographic analysis of studies published over a 5.5-year period from January 2016 to June 2021 in 5 cytopathology journals indexed as SCI and SCI-E with an impact factor higher than 1 (Cancer Cytopathology, Cytopathology, Diagnostic Cytopathology, Acta Cytologica, and CytoJournal) and papers categorized as "original" and "other" was performed., Results: A total of 3,063 papers were found, with 1,466 (47.8%) categorized as "original" papers and 1,597 (52.1%) designated as "other" papers. These papers were submitted from 62 different countries. The five countries with the greatest number of papers were the USA (38.4%), India (16.8%), Japan (7.4%), Italy (5.5%), and Brazil (3.1%). A general subgroup analysis was also performed on the original studies without a country breakdown. Cytomorphological, cytomorphological-immunohistochemical, and molecular assessments compose 38.5%, 45.7%, and 15% of the subgroups, respectively., Conclusion: The number of academic papers originating from developing countries in the field of cytopathology has increased in recent years. Although most scientific papers are produced in developed countries, the rate in these countries is much lower than that in some developing countries as the rate of academic growth in developed countries has stabilized. Despite the widespread and sophisticated implementation of cytology in daily practice in Western European countries outside the UK, such as Germany and the Netherlands, and in Scandinavian countries and other developed countries, such as Australia and Canada, these countries rank in the middle to lower end of countries producing cytology papers. Meanwhile, there has been an increase in the number of cytology papers published by authors from Southern European countries, such as Italy (ranked 4th) and Spain (ranked 6th), and Turkey (ranked 8th). There is a remarkable increase in cytology papers originating from Asia, particularly India, Japan, and China., Summary: We aimed to present a basic survey of the geographic distribution of manuscript submissions to high-impact cytopathology journals and to point out emerging trends in cytology utilization and basic research. However, our results show that the landscape of cytology is changing and suggest geographic regions that are ripe for the production of novel "points of view" and new research findings., (© 2022 S. Karger AG, Basel.)

Citation rates can be used as an indicator of the influence and relevance of scientific papers. The present study analyzed the 100 most-cited articles related to erosive tooth wear (ETW). The top 100 most-cited papers focusing on ETW topics were collected from the Web of Science database on November 11, 2020. The following bibliometric data were extracted from papers: title, authorship, institutions, countries, number of citations, year of publication, journal title, study design, topic, and keywords. Scopus and Google Scholar were searched to compare the number of citations. The VOSviewer software was used to generate collaborative network maps for the authors and keywords. The number of citations of the 100 most-cited papers ranged from 71 to 330 (average: 97.44). The papers were published between 1949 and 2015. Caries Research (28%) and The Journal of Dentistry (16%) presented the majority of papers. Laboratorial (44%) and observational studies (33%) were the most common study designs. The most studied topics were epidemiology (31%) and the erosive potential of substances (drinks, foods, or medicines) (22%). The countries with the highest number of most-cited papers were England (32%), Germany (18%), and Switzerland (10%). The University of Bern was the institution with the most papers (10%). Lussi A was the author with the highest number of papers in the top 100 (14%). The most common keyword was "dental erosion" with 64 occurrences. The top 100 most-cited papers related to ETW were composed mainly of laboratorial and observational studies focusing on epidemiology and the erosive potential of substances., (© 2022 S. Karger AG, Basel.)

Background  MRI is attractive for the guiding and monitoring of interventional procedures due to its high intrinsic soft tissue contrast and the possibility to measure physiologic parameters like flow and cardiac function. Method  The current status of interventional MRI for the clinical routine was analyzed. Results  The effort needed for the development of MR-safe monitoring systems and instruments initially resulted in the application of interventional MRI only for procedures that could not be performed by other means. Accordingly, biopsy of lesions in the breast, which are not detectable by other modalities, has been performed under MRI guidance for decades. Currently, biopsies of the prostate under MRI guidance are established in a similar fashion. At many sites blind biopsy has already been replaced by MR-guided biopsy or at least by the fusion of MR images with ultrasound. Cardiovascular interventions are performed at several centers for ablation as a treatment for atrial fibrillation. Conclusion  Interventional MRI has been established in the clinical routine for a variety of indications. Broader application can be expected in the clinical routine in the future owing to the multiple advantages compared to other techniques. Key points   · Due to the significant technical effort, MR-guided interventions are only recommended in the long term for regions in which MRI either facilitates or greatly improves the intervention.. · Breast biopsy of otherwise undetectable target lesions has long been established in the clinical routine. Prostate biopsy is currently being introduced in the clinical routine for similar reasons. Other methods such as MR-guided focused ultrasound for the treatment of uterine fibroids or tumor ablation of metastases represent alternative methods and are offered in many places.. · Endovascular MR-guided interventions offer advantages for a number of indications and have already been clinically established for the treatment of children with congenital heart defects and for atrial ablation at individual centers. Greater application can be expected in the future.. Citation format · Barkhausen J, Kahn T, Krombach GA et al. White Paper: Interventional MRI: Current Status and Potential for Development Considering Economic Perspectives, Part 1: General Application. Fortschr Röntgenstr 2017; 189: 611 - 623., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

While working under Kraepelin in Munich, Ernst Rüdin, a Swiss-born Psychiatrist, at the age of 26, outlined in a 1911 98-page article, a detailed plan for a future Mendelian-informed family research program for psychiatry. Rüdin would go on to head the Department of Genealogical and Demographic Studies at Kraepelin's Research Institute which became one of the world's leading programs in psychiatric genetics. I here summarize this article, providing a complete translation online. Rüdin's review outlined a paradigm shift in psychiatric genetics research moving from calculations of aggregate hereditary burden, as they applied to the proband, to examining patterns of transmission within family pedigrees which involved careful individual assessments of relatives. He references widely clinical and statistical genetic studies, many focusing on the newly discovered Mendelian laws. However, Rüdin was no genetic reductionist but recognized the contribution of environmental risk factors to psychiatric illness arguing that they should be studied as part of a comprehensive research program. As a committed eugenicist, Rüdin also explored the implications of such a program for "racial hygiene." Rüdin's contributions should be viewed in the context of his extensive collaboration from 1933 to 1945 with the National Socialists and his support for their eugenics program, including involuntary sterilizations., (© 2021 Wiley Periodicals LLC.)

Unlabelled: CONSTRUCT: In this study, we examine the differences in test performance between the paper-based and the computer-based version of the Berlin formative Progress Test. In this context it is the first study that allows controlling for students' prior performance., Background: Computer-based tests make possible a more efficient examination procedure for test administration and review. Although university staff will benefit largely from computer-based tests, the question arises if computer-based tests influence students' test performance., Approach: A total of 266 German students from the 9th and 10th semester of medicine (comparable with the 4th-year North American medical school schedule) participated in the study (paper = 132, computer = 134). The allocation of the test format was conducted as a randomized matched-pair design in which students were first sorted according to their prior test results. The organizational procedure, the examination conditions, the room, and seating arrangements, as well as the order of questions and answers, were identical in both groups., Results: The sociodemographic variables and pretest scores of both groups were comparable. The test results from the paper and computer versions did not differ. The groups remained within the allotted time, but students using the computer version (particularly the high performers) needed significantly less time to complete the test. In addition, we found significant differences in guessing behavior. Low performers using the computer version guess significantly more than low-performing students in the paper-pencil version., Conclusions: Participants in computer-based tests are not at a disadvantage in terms of their test results. The computer-based test required less processing time. The reason for the longer processing time when using the paper-pencil version might be due to the time needed to write the answer down, controlling for transferring the answer correctly. It is still not known why students using the computer version (particularly low-performing students) guess at a higher rate. Further studies are necessary to understand this finding.

Veterinarians have to face many communicative challenges in their professional capacity. Successful professional communication increases satisfaction among pet owners, staff members and colleagues, and ultimately also the veterinarians' own satisfaction. On the other hand, unsuccessful communication can easily lead to rejection, distrust and dissatisfaction. However, communicative skills are not explicitly taught as part of the compulsory courses in veterinary medicine in Germany. The position paper of the GMA Veterinary Medicine Committee and the DVG work group Didactics and Communication Competence describes the importance of successful communication for working veterinarians as well as the training situation in Germany and addresses topics that are often discussed in connection with the implementation. The authors come to the conclusion that there is both a necessity and a possibility for the introduction of communicative training content and provide recommendations that are intended to support the sustainable introduction of courses and exams to develop the communicative skills of veterinary students., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2021 Gruber et al.)

Competing Interests: AM and SA are authors of the work disputed by Gandjour. Previous work related to the letter of Gandjour was financed by Gilead. Further study grants in the last five years were received from Abbvie, Janssen Cilag and Johnson & Johnson.

2,4,7,9-Tetramethyl-5-decyne-4,7-diol (TMDD) is a non-ionic surfactant which is preferentially used as defoamer in paints and printing ink and for the treatment of surfaces. Effluents of wastewater treatment plants (WWTPs) have been identified as the domination point sources for TMDD in rivers since the removal rate of the compound in the WWTPs is in general less than 70%. However, the dominating entry pathways of TMDD into the sewage were unknown so far. In this study effluents from both, municipal WWTPs with and without treatment of indirect industrial dischargers and from industrial WWTPs with direct discharge of wastewater into receiving rivers were analyzed for the first time to identify the proportions of TMDD coming from domestic wastewater and from various industrial sources. Moreover, rivers were samples before and after the influent of sewage water from WWTPs. The TMDD concentrations in the water samples were measured using solid phase extraction (SPE) followed by gas chromatography/mass spectrometry (GC/MS). High TMDD concentrations were found in rivers (up to 63.5 μg/L), and in effluents of WWTPs (up to 310 μg/L) affected by wastewater from paper recycling industry and factories producing paint and printing ink. Concentrations of TMDD revealed to be far higher in wastewater from factories processing recycled paper (up to 113 μg/L) compared to wastewater from factories not processing recycled paper (0.066 μg/L). The results indicate that the use of recycling paper in the paper production process is the dominating reason for increased TMDD concentrations in wastewaters and receiving rivers due to the wash out of TMDD from the paper impregnated with printing ink. Very high TMDD concentrations (up to 3300 μg/L) were also detected in wastewater from a printing ink factory and a paint factory., (© 2013 Elsevier B.V. All rights reserved.)

Introduction: Medical quality indicators (QI) are important tools in the evaluation of medical quality. Their development is subject to specific methodological requirements, which include practical applicability. This is especially true for intensive care medicine with its complex processes and their interactions. This methods paper presents the status quo and shows necessary methodological developments for intensive care QI. For this purpose, a cooperation with the Association of the Scientific Medical Societies' Institute for Medical Knowledge Management (AWMF-IMWi) was established. Methodology: Review of published German manuals for QI development from guidelines and narrative review of quality indicators with a focus on evidence and consensus-based guideline recommendations. Future methodological adaptations of indicator development for improved operationalization, measurability and pilot testing are presented, and a development process is proposed. Results: The development of intensive care quality indicators in Germany is based on an established process. In the future, additional evaluation criteria (QUALIFY criteria) will be applied to assess the evidence base. In addition, a continuous exchange between the national steering committee of the DIVI responsible for QI development and guideline development groups involved in intensive care medicine is planned. Conclusion: Intensive care quality indicators will have to meet improved methodological requirements in the future by means of an improved development process. Future QI development is intended to improve the structure of the development process, with a focus on scientific evidence and a link to guideline projects. This is intended to achieve the goal of a broad application of QI and to further evaluate its relevance for patient outcome and performance of institutions., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 Kumpf et al.)

The acute and long-lasting side effects of modern multimodal tumour therapy significantly impair quality of life and survival of patients afflicted with malignancies. The key components of this therapy include radiotherapy, conventional chemotherapy, immunotherapy and targeted therapies. In addition to established tumour therapy strategies, up to 30 new therapies are approved each year with only incompletely characterised side effects. This consensus paper discusses the risk factors that contribute to the development of a potentially adverse reaction to tumour therapy and, in addition, defines specific side effect profiles for different treatment groups. The focus is on novel therapeutics and recommendations for the surveillance and treatment of specific patient groups.

Having teaching staff with didactic qualifications in university teaching leads to a measurable improvement in academic skills among students. Previous recommendations on the type and scope of medical didactic qualification measures primarily apply to teaching staff at university and in-patient settings. The situation of primary care medicine, which often employs external lecturers and whose teaching takes place to a considerable extent in decentralized training facilities (teaching practices) is not adequately addressed. Taking into account a survey on the status quo at higher education institutions for General Practice in Germany, recommendations for minimum standards are made, based on national and international recommendations on the content and scope of medical didactic qualification measures. These recommendations include preliminary work by the Personnel and Organizational Development in Teaching (POiL) Committee of the Society for Medical Education (GMA), the MedicalTeachingNetwork (MDN), the Society of University Teaching Staff in General Medicine (GHA) as well as the experiences of the committee members, who hail from the field of general medicine, internal medicine and pediatrics amongst others., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 Böhme et al.)

Background and Rationale: Xerosis cutis (also referred to as xeroderma, dry skin, asteatosis) affects more than 10 million individuals in Germany. It is among the most common dermatological diagnoses and a cardinal symptom of many dermatological, internal and neurological diseases. Even though it has been established that basic skin care plays a significant role in the management of patients with xerosis cutis, there are as yet no evidence-based algorithms for diagnosis and treatment., Objective: The present position paper provides physicians across all specialties with a practical, symptom-based approach to the prevention, diagnosis and treatment of xerosis cutis., Methods: Within a structured decision-making process, a panel of experienced dermatologists first defined questions relevant to everyday clinical practice, which were then addressed by a systematic review of the literature. Based on the evidence available as well as expert consensus, diagnostic and treatment algorithms were subsequently developed and agreed upon., Results: Xerosis cutis is generally diagnosed on clinical grounds. Possible trigger factors must be avoided, and comorbidities should be adequately and specifically treated. Suitable skin care products should be chosen with a view to improving skin hydration and restoring its barrier function. They should therefore contain both rehydrating and lipid-replenishing components. The "drier" the skin appears, the greater the lipid content should be (preferably using water-in-oil formulations). The choice of ingredients is based on a patient's individual symptoms, such as scaling (e.g., urea), fissures/rhagades (e.g., urea or dexpanthenol), erythema (e.g., licochalcone A) and pruritus (e.g., polidocanol). Other factors to be considered include the site affected and patient age. Ingredients or rather combinations thereof for which there is good clinical evidence should be preferentially used. The best evidence by far is available for urea, whose efficacy in the treatment of xerosis is further enhanced by combining it with other natural moisturizing components and ceramides. The "xerosimeter" is a tool developed in an effort to facilitate patient management and for training purposes. It not only includes practical tools for diagnosis and follow-up but also a classification of ingredients and a structured treatment algorithm., Conclusion: The structured symptom- and evidence-based approach proposed herein contains a road map for diagnosis and treatment of xerosis cutis. It aims to raise awareness in terms of prevention and early treatment of this condition and may thus improve quality of life and prevent potential sequelae., (© 2019 The Authors Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaf.)

Background: The Syria crisis has forced more than 4 million people to leave their homeland. As a result, in 2016, an overwhelming number of refugees reached Germany. In response to this, it was of utmost importance to set up refugee camps and to provide humanitarian aid, but a health surveillance system was also implemented in order to obtain rapid information about emerging diseases., Objective: The present study describes the effects of using digital paper and pen (DPP) technology on the speed, sequence, and behavior of epidemiological documentation in a refugee camp., Methods: DPP technology was used to examine documentation speed, sequence, and behavior. The data log of the digital pens used to fill in the documentation was analyzed, and each pen stroke in a field was recorded using a timestamp. Documentation time was the difference between first and last stroke on the paper, which includes clinical examination and translation., Results: For three months, 495 data sets were recorded. After corrections had been made, 421 data sets were considered valid and subjected to further analysis. The median documentation time was 41:41 min (interquartile range 29:54 min; mean 45:02 min; SD 22:28 min). The documentation of vital signs ended up having the strongest effect on the overall time of documentation. Furthermore, filling in the free-text field clinical findings or therapy or measures required the most time (mean 16:49 min; SD 20:32 min). Analysis of the documentation sequence revealed that the final step of coding the diagnosis was a time-consuming step that took place once the form had been completed., Conclusions: We concluded that medical documentation using DPP technology leads to both an increase in documentation speed and data quality through the compliance of the data recorders who regard the tool to be convenient in everyday routine. Further analysis of more data sets will allow optimization of the documentation form used. Thus, DPP technology is an effective tool for the medical documentation process in refugee camps., (©Kai Kehe, Roland Girgensohn, Walter Swoboda, Dan Bieler, Axel Franke, Matthias Helm, Martin Kulla, Kerstin Luepke, Thomas Morwinsky, Markus Blätzinger, Katalyn Rossmann. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 19.08.2019.)

Tick-borne diseases are a public health issue. To predict vector tick abundance and activity, it is necessary to understand the driving factors for these variables. In this study, the activity of Ixodes ricinus was investigated in forest and meadow habitats in Germany with a focus on abiotic factors. Ixodes ricinus adults, nymphs and larvae were caught by flagging over a period of 2 years. Microclimatic and weather conditions were recorded at the collection sites. Statistical models were applied to describe correlations between abiotic factors and tick activity in univariable and multivariable analyses. Tick activity was observed in a broad range of air temperature between 3 and 28 °C, and air humidity varied between 35 and 95%. In general, tick activity of nymphs and larvae was higher in forest habitats than that in meadows. With the exception of a single specimen of Dermacentor reticulatus, all ticks were Ixodes ricinus, most of them nymphs (63.2% in 2009 and 75.2% in 2010). For the latter, a negative binomial mixed-effects model fitted best to the observed parameters. The modelling results showed an activity optimum between 20 and 23 °C for air temperature and between 13 and 15 °C for ground temperature. In univariable analyses, the collection site, month, season, ground and air temperature were significant factors for the number of ticks caught and for all life stages. In the multivariable analysis, temperature, season and habitat turned out to be key drivers. Ixodes ricinus positive for RNA of tick-borne encephalitis virus was only found at a single sampling site. The results of this study can be used in risk assessments and to parameterise predictive models.

Purpose: Current trials on adjunctive treatment with antiseizure drugs often do not reveal results which are relevant for clinical practice., Method: Therefore, an interdisciplinary group of German experts discussed a new framework for future antiseizure drug (ASD) trials in adults. This group included members of the executive board of the German Society of Epileptology, of the German institutes for health technology assessment (HTA), of patient organizations and of drug manufacturers. Agreement was reached by consensus decision making after intensive discussion of the findings of a narrative review of the current literature., Results: The group jointly recommends that ASD trials in adults should be based on and include relevant patient groups, e.g. elderly patients and patients with relevant co-morbidities, should adopt a study duration of at least 12 months, should avoid placebo arms, should include active comparators of clinical relevance, may be designed as open label trials with blinded outcome measurements, should focus on patient relevant outcomes that reflect the impact of benefits and harms of treatments on daily living, such as seizure freedom and seizure severity as well as retention rate, functional outcomes and quality of life as compound measures, and should avoid arbitrary and non-sensitive primary endpoints such as dichotomized changes in seizure frequency., Conclusions: This paper focused on improved head-to-head trials on adjunctive treatment with antiseizure drugs. The group welcomes any further work and discussion to enhance future studies which can be applied to the entire spectrum of potentially meaningful study populations and outcomes., (Copyright © 2020 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background: The Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW) is a prevalent face-to-face interview method for measuring quality of life by integrating respondent-generated dimensions. To apply this method in clinical trials, a paper-administered alternative would be of interest. Therefore, our study aimed to analyze the agreement between the SEIQoL-DW and a paper questionnaire version (SEIQoL-PF/G)., Methods: In a crossover design, both measures were completed in a random sequence. 104 patients at a heart surgery hospital in Germany were randomly assigned to receive either the SEIQoL-DW or the SEIQoL-PF/G as the first measurement in the sequence. Patients were approached on their earliest stable day after surgery. The average time between both measurements was 1 day (mean 1.3; SD 0.8). Agreement regarding the indices, ratings, and weightings of nominated life areas (cues) was explored using Bland-Altman plots with 95% limits of agreement (LoA). Agreement of the SEIQoL indices was defined as acceptable if the LoA did not exceed a threshold of 10 scale points. Data from n = 99 patients were included in the agreement analysis., Results: Both measures led to similarly nominated cues. The most frequently nominated cues were "physical health" and "family". In the Bland-Altman plot, the indices showed a mean of differences of 2 points (95% CI, - 1 to 6). The upper LoA showed a difference of 36 points (95% CI, 30 to 42), and the lower LoA showed a difference of - 31 points (95% CI, - 37 to - 26). Thus, the LoAs and confidence intervals exceeded the predefined threshold. The Bland-Altman plots for the cue levels and cue weights showed similar results. The SEIQoL-PF/G version showed a tendency for equal weighting of cues, while the weighting procedure of the SEIQoL-DW led to greater variability., Conclusions: For cardiac surgery patients, use of the current version of the SEIQoL-PF/G as a substitute for the SEIQoL-DW is not recommended. The current questionnaire weighting method seems to be unable to distinguish weighting for different cues. Therefore, the further design of a weighting method without interviewer support as a paper-administered measure of individual quality of life is desirable.

Background: 5-Fluorouracil (FU) is one of the most commonly used cytostatic drugs in the systemic treatment of cancer. Treatment with FU may cause severe or life-threatening side effects and the treatment-related mortality rate is 0.2-1.0%., Summary: Among other risk factors associated with increased toxicity, a genetic deficiency in dihydropyrimidine dehydrogenase (DPD), an enzyme responsible for the metabolism of FU, is well known. This is due to variants in the DPD gene (DPYD). Up to 9% of European patients carry a DPD gene variant that decreases enzyme activity, and DPD is completely lacking in approximately 0.5% of patients. Here we describe the clinical and genetic background and summarize recommendations for the genetic testing and tailoring of treatment with 5-FU derivatives. The statement was developed as a consensus statement organized by the German Society for Hematology and Medical Oncology in cooperation with 13 medical associations from Austria, Germany, and Switzerland. Key Messages: (i) Patients should be tested for the 4 most common genetic DPYD variants before treatment with drugs containing FU. (ii) Testing forms the basis for a differentiated, risk-adapted algorithm with recommendations for treatment with FU-containing drugs. (iii) Testing may optionally be supplemented by therapeutic drug monitoring., (© 2020 S. Karger AG, Basel.)

Against the background of the pandemic caused by infection with the SARS-CoV-2 virus, the German Respiratory Society has appointed experts to develop therapy strategies for COVID-19 patients with acute respiratory failure (ARF). Here we present key position statements including observations about the pathophysiology of (ARF). In terms of the pathophysiology of pulmonary infection with SARS-CoV-2, COVID-19 can be divided into 3 phases. Pulmonary damage in advanced COVID-19 often differs from the known changes in acute respiratory distress syndrome (ARDS). Two types (type L and type H) are differentiated, corresponding to early- and late-stage lung damage. This differentiation should be taken into consideration in the respiratory support of ARF. The assessment of the extent of ARF should be based on arterial or capillary blood gas analysis under room air conditions, and it needs to include the calculation of oxygen supply (measured from the variables of oxygen saturation, hemoglobin level, the corrected values of Hüfner's factor, and cardiac output). Aerosols can cause transmission of infectious, virus-laden particles. Open systems or vented systems can increase the release of respirable particles. Procedures in which the invasive ventilation system must be opened and endotracheal intubation carried out are associated with an increased risk of infection. Personal protective equipment (PPE) should have top priority because fear of contagion should not be a primary reason for intubation. Based on the current knowledge, inhalation therapy, nasal high-flow therapy (NHF), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) can be performed without an increased risk of infection to staff if PPE is provided. A significant proportion of patients with ARF present with relevant hypoxemia, which often cannot be fully corrected, even with a high inspired oxygen fraction (FiO2) under NHF. In this situation, the oxygen therapy can be escalated to CPAP or NIV when the criteria for endotracheal intubation are not met. In ARF, NIV should be carried out in an intensive care unit or a comparable setting by experienced staff. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring and readiness for intubation are to be ensured at all times. If the ARF progresses under CPAP/NIV, intubation should be implemented without delay in patients who do not have a "do not intubate" order., (© 2020 S. Karger AG, Basel.)

Introduction: Multiple-choice-examinations are still fundamental for assessment in medical degree programs. In addition to content related research, the optimization of the technical procedure is an important question. Medical examiners face three options: paper-based examinations with or without computer support or completely electronic examinations. Critical aspects are the effort for formatting, the logistic effort during the actual examination, quality, promptness and effort of the correction, the time for making the documents available for inspection by the students, and the statistical analysis of the examination results., Methods: Since three semesters a computer program for input and formatting of MC-questions in medical and other paper-based examinations is used and continuously improved at Wuerzburg University. In the winter semester (WS) 2009/10 eleven, in the summer semester (SS) 2010 twelve and in WS 2010/11 thirteen medical examinations were accomplished with the program and automatically evaluated. For the last two semesters the remaining manual workload was recorded., Results: The cost of the formatting and the subsequent analysis including adjustments of the analysis of an average examination with about 140 participants and about 35 questions was 5-7 hours for exams without complications in the winter semester 2009/2010, about 2 hours in SS 2010 and about 1.5 hours in the winter semester 2010/11. Including exams with complications, the average time was about 3 hours per exam in SS 2010 and 2.67 hours for the WS 10/11., Discussion: For conventional multiple-choice exams the computer-based formatting and evaluation of paper-based exams offers a significant time reduction for lecturers in comparison with the manual correction of paper-based exams and compared to purely electronically conducted exams it needs a much simpler technological infrastructure and fewer staff during the exam.

Background: In the last years, there has been an increase in publication of systematic reviews of normative ("argument-based") literature or of normative information (such as ethical issues) in bioethics. The aim of a systematic review is to search, select, analyse and synthesise literature in a transparent and systematic way in order to provide a comprehensive and unbiased overview of the information sought, predominantly as a basis for informed decision-making in health care. Traditionally, one part of the procedure when conducting a systematic review is an appraisal of the quality of the literature that could be included., Main Text: However, while there are established methods and standards for appraising e.g. clinical studies or other empirical research, quality appraisal of normative literature (or normative information) in the context of a systematic review is still rather a conundrum - not only is it unclear how it could or should be done, but also the question whether it necessarily must be done is not settled yet. Based on a pragmatic definition of "normative literature" as well as on a typology of different types of systematic reviews of normative literature/information, this paper identifies and critically discusses three possible strategies of conducting quality appraisal., Conclusions: The paper will argue that none of the three strategies is able to provide a general and satisfying solution to the problems associated with quality appraisal of normative literature/information. Still, the discussion of the three strategies allows outlining minimal conditions that elaborated strategies have to meet in future, and facilitates sketching a theoretically and practically promising strategy.

Background: Psychosocial factors in cardiovascular diseases are increasingly acknowledged by patients, health care providers and payer organizations. Due to the rapidly increasing body of evidence, the German Cardiac Society has commissioned an update of its 2013 position paper on this topic. The German version was published in 2018 and the current manuscript is an extended translation of the original version., Methods: This position paper provides a synopsis of the state of knowledge regarding psychosocial factors in the most relevant cardiovascular diseases and gives recommendations with respect to their consideration in clinical practice., Results: Psychosocial factors such as low socioeconomic status, acute and chronic stress, depression, anxiety and low social support are associated with an unfavorable prognosis. Psychosocial problems and mental comorbidities should be assessed routinely to initiate targeted diagnostics and treatment. For all patients, treatment should consider age and gender differences as well as individual patient preferences. Multimodal treatment concepts should comprise education, physical exercise, motivational counseling and relaxation training or stress management. In cases of mental comorbidities, brief psychosocial interventions by primary care providers or cardiologists, regular psychotherapy and/or medications should be offered. While these interventions have positive effects on psychological symptoms, robust evidence for possible effects on cardiac outcomes is still lacking., Conclusions: For coronary heart disease, chronic heart failure, arterial hypertension, and some arrhythmias, there is robust evidence supporting the relevance of psychosocial factors, pointing to a need for considering them in cardiological care. However, there are still shortcomings in implementing psychosocial treatment, and prognostic effects of psychotherapy and psychotropic drugs remain uncertain. There is a need for enhanced provider education and more treatment trials.

Background: Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project ("National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany") has used the "German Emergency Department Medical Record" (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry., Methods: Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time., Results: All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001)., Conclusions: We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.

Objective: We conducted a trial embedded within the German National Cohort comparing the responses to study invitations sent in recycled envelopes of grey color vs. envelopes of white color. We analyzed paradata for reactions to the invitation letters by potential subjects, the duration between mailing date of the invitation and active responses, and study participation., Results: Grey envelopes only slightly increased the chance of active responses (OR 1.16, 95% CI 0.83, 1.62) to the invitation letter. Potential study subjects with German nationality (OR 3.75, 95% CI 2.07, 7.66) and age groups above 50 years (50-59: OR 1.78, 95% CI 1.19, 2.69; 60-69: OR 2.25, 95% CI 1.48, 3.43) were more likely to actively respond to the invitation letter. The duration between mailing date of the invitation and active response was not associated with envelope color, sex, nationality, or age. Our trial replicates previous observations that the color of the envelope of a study invitation does not influence the likelihood of an active response or study participation.

Background, Aim and Scope: The applicability of the Whole Effluent Assessment concept for the proof of compliance with the "best available techniques" has been analysed with paper mill wastewater from Germany by considering its persistency (P), potentially bio-accumulative substances (B) and toxicity (T)., Materials and Methods: Twenty wastewater samples from 13 paper mills using different types of cellulose fibres as raw materials have been tested in DIN or ISO standardised bioassays: the algae, daphnia, luminescent bacteria, duckweed (Lemna), fish-egg and umu tests with lowest ineffective dilution (LID) as test result. The potentially bio-accumulative substances (PBS) were determined by solid-phase microextraction and referred to the reference compound 2,3-dimethylnaphthalene. Usually, a primary chemical-physical treatment of the wastewater was followed by a single or multi-stage biological treatment. One indirectly discharged wastewater sample was pre-treated biologically in the Zahn-Wellens test before determining its ecotoxicity., Results: No toxicity or genotoxicity at all was detected in the acute daphnia and fish egg as well as the umu assay. In the luminescent bacteria test, moderate toxicity (up to LIDlb=6) was observed. Wastewater of four paper mills demonstrated elevated or high algae toxicity (up to LIDA=128), which was in line with the results of the Lemna test, which mostly was less sensitive than the algae test (up to LIDDW=8). One indirectly discharged wastewater sample was biodegraded in the Zahn-Wellens test by 96% and was not toxic after this treatment. Low levels of PBS have been detected (median 3.27 mmol L(-1)). The colouration of the wastewater samples in the visible band did not correlate with algae toxicity and thus is not considered as its primary origin. Further analysis with a partial wastewater stream from thermomechanically produced groundwood pulp (TMP) revealed no algae or luminescent bacteria toxicity after pre-treatment of the sample in the Zahn-Wellens test (chemical oxygen demand elimination 85% in 7 days). Thus, the algae toxicity of the respective paper mill cannot be explained with the TMP partial stream; presumably other raw materials such as biocides might be the source of algae toxicity., Discussion: Comparative data from wastewater surveillance of authorities confirmed the range of ecotoxicity observed in the study. Wastewater from paper mills generally has no or a moderate ecotoxicity (median LID 1 and 2) while the maximum LID values, especially for the algae and daphnia tests, are considerably elevated (LIDA up to 128, LIDD up to 48)., Conclusions: Wastewater from paper mills generally is low to moderately ecotoxic to aquatic organisms in acute toxicity tests. Some samples show effects in the chronic algae growth inhibition test which cannot be explained exclusively with colouration of the samples. The origin of elevated algae ecotoxicity could not be determined. In the algae test, often flat dose-response relationships and growth promotion at higher dilution factors have been observed, indicating that several effects are overlapping., Recommendations and Perspectives: At least one bioassay should be included in routine wastewater control of paper mills because the paper manufacturing industry is among the most water consuming. Although the algae test was the most sensitive test, it might not be the most appropriate test because of the complex relationship of colouration and inhibition and the smooth dose-effect relationship or even promotion of algae growth often observed. The Lemna test would be a suitable method which also detects inhibitors of photosynthesis and is not disturbed by wastewater colouration.

Introduction: The term variations of sex development subsumes a large number of congenital conditions including chromosomal mosaics and variations of chromosomal, gonadal, and phenotypic sex. A situation of this nature may cause severe distress to both, parents and affected persons. One of the reasons for this is the binary form of gender classification in the society. In the past, because of a fear of possible stigmatization and an inability to cope with complex situations, it has been medical policy and practice for newborns to undergo early, mostly 'feminizing' elective surgery with the aim of achieving an outer genital appearance that is unambiguously male or female. Protests by advocacy groups for the most part as well as the results of outcome studies have shown that the development of affected persons may be very different to what has been expected and often does not result in the intended clear female or male gender identity as had been intended. It, therefore, seemed a matter of urgency to implement this new awareness as well as the ethical and personal human rights perspectives in the recommendations for the medical and psychosocial management of diverse sex development (DSD) in the future., Study Design: In 2012, an interdisciplinary group of German academics engaged in the field of DSD decided to work on a consensus paper for this topic. It involved the participation of all faculties and non-scientific groups dealing with DSD, in particular advocacy and service-user groups. In a structured consensus, process recommendations were developed based on scientific literature as well as personal experiences of clinicians and affected individuals., Results: Finally, 37 recommendations were agreed on. The strength of consensus is reflected in the degree of agreement as expressed in percentages., Conclusion: The introduction of the consensus paper reflects on the emerging paradigm shift and the necessity for a more open view of gender within society. The paper is intended to aid the performance of appropriate diagnostics in DSD-affected newborns and especially to help parents and affected persons cope with the biological and social consequences of DSD. With regard to medical or surgical therapy, it gives information about the most recent treatment trends., (Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: The authors declare that they have no competing interests.

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs., (© 2018 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

The aim of this survey was to examine differences in personality profiles among 198 vegan (n = 64; 32.3%), vegetarian (n = 78; 39.4%) and omnivore (n = 55; 27.8%) medical professionals. Outcomes were motives for the nutritional approaches, WHO QoL-BREF, Big Five SOEP Inventory, Portraits Value Questionnaire, and Empathizing Scale. Regarding motives for particular diets, omnivores rated influence of guardians (p < 0.001), physical health (p = 0.017) and food taste (p = 0.001) as more and love of animals as less important (p < 0.001) than vegans and vegetarians. Vegans and vegetarians consumed less coffee (p = 0.007) and alcohol compared to omnivores (p = 0.017). The duration of adhering to a specific diet was significantly shorter in vegans. Data suggest that vegan medical professionals do not differ from vegetarians or omnivores regarding empathy, values or personality traits. Differences to a related internet sample were observed for a number of outcomes. Given the small sample size and potential selection bias through the specific subpopulation attending a plant-based nutrition conference, further studies are warranted to confirm these results. Particularly, potential reciprocities between empathy and individual nutritional choices deserve further attention.

Objective: To investigate if paper-based documentation in the authors' emergency medical service (EMS) satisfies scientific requirements., Methods: From 1 July 2007 to 28 February 2008, data from all paper-based protocols of a physician-run EMS in Aachen, Germany, were transferred to a SQL database (n=4815). Database queries were conducted after personal data had been anonymised. Documentation ratios of 11 individual parameters were analysed at two points in time (T1, scene; T2, arrival in emergency department). The calculability of the Mainz Emergency Evaluation Score (MEES, embracing seven vital parameters) was investigated. The calculability of the Revised Trauma Score (RTS) was also determined for all trauma patients (n=408). Fisher's exact test was used to compare differences in ratios at T1 versus T2., Results: The documentation ratios of vital parameters ranged from 99.33% (Glasgow Coma Scale, T1) to 40.31% (respiratory rate, T2). The calculability of the MEES was poor (all missions: 28.31%, T1; 22.40%, T2; p<0.001). In missions that required cardiopulmonary resuscitation (n=87), the MEES was calculable in 9.20% of patients at T1 and 29.89% at T2 (p<0.001). In trauma missions, the RTS was calculable in 37.26% at T1 and 27.70% at T2 (p=0.004)., Conclusions: Documentation of vital parameters is carried out incompletely, and documentation of respiratory rate is particularly poor, making calculation of accepted emergency scores infeasible for a significant fraction of a given test population. The suitability of paper-based documentation is therefore limited. Electronic documentation that includes real-time plausibility checks might improve data quality. Further research is warranted.

Thanks to multiple recirculation of process water, the German paper industry has succeeded in decreasing the specific fresh water demand from an average of 50 m3/t thirty years ago to 13 m3/t today. Although the increasing closure of white water loops creates many problems, it is bound to be part of the German paper industry's ongoing development. For a few years, in the production of packaging paper, two paper mills have been running with a totally closed water system including different process water treatment plants as 'kidneys'. This paper presents a comprehensive survey of the pros and cons of closed process water systems followed by significant examples of effluent-free production of corrugating medium and test liner. Additionally, operation experiences and economic aspects are discussed.