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Summary  A recent survey conducted by the publicly funded Competence Network Sepsis (Sep-Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF). [ABSTRACT FROM AUTHOR]

Background Patients surviving critical illnesses, such as sepsis, often suffer from long-term complications. After discharge from hospital, most patients are treated in primary care. Little is known how general practitioners (GPs) perform critical illness aftercare and how it can be improved. Within a randomised controlled trial, an outreach training programme has been developed and applied.Objectives The aim of this study is to describe GPs’ views and experiences of caring for postsepsis patients and of participating a specific outreach training.Design Semistructured qualitative interviews.Setting 14 primary care practices in the metropolitan area of Berlin, Germany.Participants 14 GPs who had participated in a structured sepsis aftercare programme in primary care.Results Themes identified in sepsis aftercare were: continuity of care and good relationship with patients, GP’s experiences during their patient’s critical illness and impact of persisting symptoms. An outreach education as part of the intervention was considered by the GPs to be acceptable, helpful to improve knowledge of the management of postintensive care complications and useful for sepsis aftercare in daily practice.Conclusions GPs provide continuity of care to patients surviving sepsis. Better communication at the intensive care unit–GP interface and training in management of long-term complications of sepsis may be helpful to improve sepsis aftercare.Trial registration number ISRCTN61744782.

This paper discusses different classes of loss models in non-life insurance settings. It then overviews the class of Tukey transform loss models that have not yet been widely considered in non-life insurance modelling, but offer opportunities to produce flexible skewness and kurtosis features often required in loss modelling. In addition, these loss models admit explicit quantile specifications which make them directly relevant for quantile based risk measure calculations. We detail various parameterisations and sub-families of the Tukey transform based models, such as the g-and-h, g-and-k and g-and-j models, including their properties of relevance to loss modelling. One of the challenges that are amenable to practitioners when fitting such models is to perform robust estimation of the model parameters. In this paper we develop a novel, efficient, and robust procedure for estimating the parameters of this family of Tukey transform models, based on L-moments. It is shown to be more efficient than the current state of the art estimation methods for such families of loss models while being simple to implement for practical purposes.

Purpose: Stuttering is associated with disparities in labor market outcomes among young adults, but little is known about how labor market outcomes associated with stuttering change over time. Therefore, this study characterized longitudinal associations between stuttering and early life expectations, job satisfaction, receipt of employer-provided insurance benefits, and income., Method: The analysis used data from three waves of the National Longitudinal Study of Adolescent to Adult Health, which contained 16,653 individuals aged 18-43 years interviewed over 18 years. First, regression models evaluated the likelihood of employment between people who stutter (PWS) and people who do not stutter (PWNS). Second, conditional on employment, two-stage likelihood models quantified differences in their job satisfaction, receipt of employer-provided insurance benefits, and earned income, controlling for age, sex, race, and household characteristics. Finally, the relationship between their reported education and income expectations and these employment outcomes was evaluated., Results: Although stuttering was not related to the likelihood of working or receiving employer-provided benefits, PWS were 20%-22% ( SE = 0.06-0.07) less likely to be satisfied with their jobs than PWNS, and dissatisfaction increased with age. Additionally, the odds of earning a higher income were significantly lower for PWS than for PWNS. PWS who anticipated attending college and earning a middle-class income were more likely to be satisfied with their jobs and earn a higher income. However, PWS were less likely to expect that they would earn a middle-class income (PWNS: 46.4%, PWS: 36.3%) or graduate from college (PWNS: 70.9%, PWS: 58.4%) compared to PWNS., Conclusions: Labor market inequities associated with stuttering persist and increase with age. PWS have significantly lower expectations for their likelihood of future success, and these expectations predict their future occupational outcomes.

Purpose: This executive summary of a German national guideline aims to provide the most relevant evidence-based recommendations on the diagnosis and treatment of nosocomial pneumonia., Methods: The guideline made use of a systematic assessment and decision process using evidence to decision framework (GRADE). Recommendations were consented by an interdisciplinary panel. Evidence analysis and interpretation was supported by the German innovation fund providing extensive literature searches and (meta-) analyses by an independent methodologist. For this executive summary, selected key recommendations are presented including the quality of evidence and rationale for the level of recommendation., Results: The original guideline contains 26 recommendations for the diagnosis and treatment of adults with nosocomial pneumonia, thirteen of which are based on systematic review and/or meta-analysis, while the other 13 represent consensus expert opinion. For this key summary, we present 11 most relevant for everyday clinical practice key recommendations with evidence overview and rationale, of which two are expert consensus and 9 evidence-based (4 strong, 5 weak and 2 open recommendations). For the management of nosocomial pneumonia patients should be divided in those with and without risk factors for multidrug-resistant pathogens and/or Pseudomonas aeruginosa. Bacterial multiplex-polymerase chain reaction (PCR) should not be used routinely. Bronchoscopic diagnosis is not considered superior to´non-bronchoscopic sampling in terms of main outcomes. Only patients with septic shock and the presence of an additional risk factor for multidrug-resistant pathogens (MDRP) should receive empiric combination therapy. In clinically stabilized patients, antibiotic therapy should be de-escalated and focused. In critically ill patients, prolonged application of suitable beta-lactam antibiotics should be preferred. Therapy duration is suggested for 7-8 days. Procalcitonin (PCT) based algorithm might be used to shorten the duration of antibiotic treatment. Patients on the intensive care unit (ICU) are at risk for invasive pulmonary aspergillosis (IPA). Diagnostics for Aspergillus should be performed with an antigen test from bronchial lavage fluid., Conclusion: The current guideline focuses on German epidemiology and standards of care. It should be a guide for the current treatment and management of nosocomial pneumonia in Germany., Competing Interests: Declarations. Conflict of interest: JR received research support from Bundesministerium für Bildung und Forschung (BMBF), Bundesministerium für Gesundheit (BMG) Infectopharm; lecture fees from AstraZeneca, GSK, Chiesi, Esanum, Novartis, ThermoFisher, Berlin-Chemie, MSD, Boehringer, Pfizer, Shionogi; Consultant fees from Shionogi, GSK, Advanz, Gilead, MSD BG received lecture fees from Biotest, Gilead, Infectopharm, MIP, MSD, Pfizer and Shionogi; consultant fees from MSD, Pfizer, Gilead und Mundipharma. SG received speaker fees from Becton Dickinson, bioMérieux and Bio-Rad. SH received research support from Bundesministerium für Bildung und Forschung (BMBF); lecture fees from Pfizer, MSD, Infectopharm, Philips, Advanz, Beckman Coulter, Thermofisher, Shionogi, Tillots; Consultant fees from Advanz, Shionogi, Pfizer CPH received personal fees from Schering-Plough; grants and personal fees from Pfizer, Boehringer Ingelheim, Siemens; personal fees from Basilea, Novartis, Roche, Astellas, Gilead, MSD, Lilly, Intermune, Fresenius, Essex, AstraZeneca, Bracco, MEDA Pharma, Chiesi, Covidien, Pierre Fabre, Grifols, Bayer; and grants from MeVis, German Center for Lung Research. SK received research support from Cytosorbents and Daiichi Sankyo; lecture fees from ADVITOS, Biotest, Daiichi Sankyo, Fresenius Medical Care, Gilead, Mitsubishi Tanabe Pharma, MSD, Pfizer, Shionogi and Zoll; consultant fees from ADVITOS, Fresenius, Gilead, MSD and Pfizer. MK received research support from Pfizer; lecture fees from Astra-Zeneca, Berlin-Chemie, Böhringer-Ingelheim, Gilead, GSK, Insmed, Pfizer; consultant fees from AstraZeneca, Sanofi, GSK, Insmed MP received lecture fees from Siemens Healthineers, Roche, Janssen-Cilag, Diasorin; consultant fees from Sanofi, GR received support for research from BMBF, GSK, and honoraria from AstraZeneca, Boehringer, Bayer, Berlin-Chemie, Grifols, Insmed, MSD, Novartis, Pfizer, GSK, Roche. H.J.F. Salzer received honoraria for lectures or consulting fees from Insmed, GlaxoSmithKline, AstraZeneca, Advanz Pharma, MSD and Chiesi, MAW reports personal fees from MSD, Gilead, Pfizer, Shionogi, Mundipharma, Eumedica, Coulter, Biotest, Sedana, SOBI, and Böhringer; and patent EPA17198330 “Delta- Like Ligand 1 for diagnosing severe infections”. TW received support for research from DFG, BMBF, GSK, and honoraria for lectures/ad board from AstraZeneca, GSK, Jansen, Moderna, MSD, Pfizer, Sanofi-Aventis. TW provides unpaid advice to Leopoldina, EMA, CDC and is honorary Chairman of the Board of Trustees of CAPNETZ Foundation, MWP received support for research from DFG, BMBF, EKFS, Manchot Foundation, Sonnenfeld Foundation, Aptarion, Biotest, Pantherna, Vaxxilon, and honoraria from Aptarion, AstraZeneca, Biotest, Chiesi, Gilead, Insmed, Pantherna, Vaxxilon. All other authors declare no competing interests., (© 2024. The Author(s).)

Stuttering poses challenges to social, occupational, and educational aspects of life. Traditional behavioral therapies can be helpful but effects are often limited. Pharmaceutical treatments have been explored but there are no FDA-approved treatments for stuttering. Interest has grown in the potential use of classic psychedelics, including psilocybin and LSD, which have shown effectiveness in treating disorders with similar symptoms (e.g., anxiety, depression, PTSD). The potential effects of psychedelics on stuttering have not been explored. We conducted a preliminary investigation of self-identified stutterers who report their experiences taking classic psychedelics on the online messaging forum, Reddit. We qualitatively analyzed 114 publicly available posts, extracting meaningful units and assigning descriptor codes inductively. We then deductively organized responses into an established framework of psychedelics which includes behavioral, emotional, cognitive, belief-based, and social effects. These effects were subsequently grouped under organizing themes (positive, negative, neutral). Descriptive statistics revealed that the majority of users (74.0%) reported positive overall short-term effects particularly related to behavioral and emotional change (e.g., reduced stuttering and anxiety), but negative (9.6%), mixed (positive and negative; 4.8%), and neutral overall experiences (11.6%) were also reported. The results support the possibility that psychedelics may impact stuttering, but caution must be applied in their interpretation given the entirely uncontrolled research setting and potential adverse health effects of psychedelics as reported elsewhere. While these results do not encourage the use of psychedelics by stutterers, they suggest that future work could examine the impact of psychedelics on stuttering under supervised and in clinically controlled settings., Competing Interests: Declaration of Competing Interest The enclosed work has not been published previously, is not under consideration for publication elsewhere, and its publication is approved by all authors. If accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to explore experiences with concealing stuttering in children and young people who stutter based on recollections from adults. In addition, we explored how school-based speech therapists can be helpful or unhelpful to children who are concealing stuttering from the perspective of adults who stutter., Method: Thirty adults who stutter, who previously or currently conceal stuttering, participated in semistructured interviews exploring their early experiences with hiding stuttering. Purposeful and random sampling was used to diversify experiences and opinions. Reflexive thematic analysis was used to develop themes and subthemes to describe participants' experiences., Results: All participants in the study reported beginning to conceal stuttering at 18 years of age or younger, with more than two thirds sharing that they began in elementary school. Participants reported that exposure to implicit and explicit ableist messaging about stuttering and traumatic social experiences at school contributed to their inclination to hide disfluencies. Many participants described concealment as a strategy for protecting themselves from stigma. Several participants condemned fluency shaping, calling it harmful and likening it to teaching concealment. Participants believed that speech therapists could be helpful by promoting safe and supportive school environments and by being responsive to the social and emotional challenges that can accompany speaking differently and navigating stigma at school., Conclusions: Some children who stutter may attempt to protect themselves from stigma by concealing their disfluencies, but doing so can feel isolating and confusing. Speech therapists can play an important role in making the school environment safer and more supportive for children who stutter.

Purpose: The purpose of the current study was to document the pros and cons that adults who stutter may consider when deciding to change how they live with stuttering., Methods: Semi-structured interviews were conducted with 11 adults who stutter and 12 speech-language pathologists who specialize in stuttering therapy. Participants were asked to identify and discuss the advantages and disadvantages of making a change to how they live with stuttering. Reflexive thematic analysis was used to generate multilevel themes., Results: Meaningful units were extracted from interview transcripts to develop 37 discrete pros and 15 discrete cons. The pros of change clustered into five organizing themes: enriching one's social relationships, feeling better in social interactions, developing a healthier sense of self, gaining autonomy, and communicating easier. The cons of change clustered into three organizing themes: experiencing discomfort, expending resources, and recognizing that some things may not change., Conclusion: This study documented why adults who stutter may or may not seek change. Identifying the pros and cons of behavior change is an important step in understanding why some clients who stutter are ambivalent about, or resistant to, the therapeutic process., Competing Interests: Declaration of interest We have no conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to document the behaviors that adults who stutter (AWS) may engage in to make positive changes to living with stuttering., Method: We interviewed 23 key stakeholders, including 11 AWS and 12 speech-language pathologists who specialize in stuttering therapy. The semi-structured interviews began with the primary question, "If an adult who stutters was making positive changes to living with stuttering, what would they be doing?" Follow-up probing questions focused the interviews on identifying actionable behaviors that would suggest positive changes. The interviews were transcribed and qualitatively analyzed using applied and reflexive thematic analyses to develop multilevel themes., Results: Meaningful units extracted from the interviews contributed to three high-order global themes: (a) noticing and adjusting physical behaviors involved in speaking, to the extent that it is personally important to do so; (b) developing neutral or positive thoughts and feelings about stuttering; and (c) participating more fully in social and professional activities, even if the person stutters or thinks they might stutter. We developed 35 low-order basic themes, which we grouped into 11 mid-order organizing themes, to richly illustrate the three global themes., Conclusions: These findings extend the ongoing discussion regarding best practices for therapy targets in stuttering intervention. We identified measurable, multidimensional actions that clinicians can integrate in their therapy plans with AWS. While these actions represent a holistic approach to making positive changes, it grants clients and clinicians space to develop individualized intentions and outcomes.

Sepsis is a major reason for preventable hospital deaths. A cluster-randomized controlled trial on an educational intervention did not show improvements of sepsis management or outcome. We now aimed to test an improved implementation strategy in a second intervention phase in which new intervention hospitals (former controls) received a multifaceted educational intervention, while controls (former intervention hospitals) only received feedback of quality indicators. Changes in outcomes from the first to the second intervention phase were compared between groups using hierarchical generalized linear models controlling for possible confounders. During the two phases, 19 control hospitals included 4050 patients with sepsis and 21 intervention hospitals included 2526 patients. 28-day mortality did not show significant changes between study phases in both groups. The proportion of patients receiving antimicrobial therapy within one hour increased in intervention hospitals, but not in control hospitals. Taking at least two sets of blood cultures increased significantly in both groups. During phase 2, intervention hospitals showed higher proportion of adequate initial antimicrobial therapy and de-escalation within 5 days. A survey among involved clinicians indicated lacking resources for quality improvement. Therefore, quality improvement programs should include all elements of sepsis guidelines and provide hospitals with sufficient resources for quality improvement.Trial registration: ClinicalTrials.gov, NCT01187134. Registered 23 August 2010, https://www.clinicaltrials.gov/ct2/show/study/NCT01187134 ., (© 2022. The Author(s).)

Background: Timely antimicrobial treatment and source control are strongly recommended by sepsis guidelines, however, their impact on clinical outcomes is uncertain., Methods: We performed a planned secondary analysis of a cluster-randomized trial conducted from July 2011 to May 2015 including forty German hospitals. All adult patients with sepsis treated in the participating ICUs were included. Primary exposures were timing of antimicrobial therapy and delay of surgical source control during the first 48 h after sepsis onset. Primary endpoint was 28-day mortality. Mixed models were used to investigate the effects of timing while adjusting for confounders. The linearity of the effect was investigated by fractional polynomials and by categorizing of timing., Results: Analyses were based on 4792 patients receiving antimicrobial treatment and 1595 patients undergoing surgical source control. Fractional polynomial analysis identified a linear effect of timing of antimicrobials on 28-day mortality, which increased by 0.42% per hour delay (OR with 95% CI 1.019 [1.01, 1.028], p ≤ 0.001). This effect was significant in patients with and without shock (OR = 1.018 [1.008, 1.029] and 1.026 [1.01, 1.043], respectively). Using a categorized timing variable, there were no significant differences comparing treatment within 1 h versus 1-3 h, or 1 h versus 3-6 h. Delays of more than 6 h significantly increased mortality (OR = 1.41 [1.17, 1.69]). Delay in antimicrobials also increased risk of progression from severe sepsis to septic shock (OR per hour: 1.051 [1.022, 1.081], p ≤ 0.001). Time to surgical source control was significantly associated with decreased odds of successful source control (OR = 0.982 [0.971, 0.994], p = 0.003) and increased odds of death (OR = 1.011 [1.001, 1.021]; p = 0.03) in unadjusted analysis, but not when adjusted for confounders (OR = 0.991 [0.978, 1.005] and OR = 1.008 [0.997, 1.02], respectively). Only, among patients with septic shock delay of source control was significantly related to risk-of death (adjusted OR = 1.013 [1.001, 1.026], p = 0.04)., Conclusions: Our findings suggest that management of sepsis is time critical both for antimicrobial therapy and source control. Also patients, who are not yet in septic shock, profit from early anti-infective treatment since it can prevent further deterioration. Trial registration ClinicalTrials.gov ( NCT01187134 ). Registered 23 August 2010, NCT01187134., (© 2022. The Author(s).)

Purpose: In the current study, stuttering was conceptualized as a concealable stigmatized identity (CSI). The purpose of this investigation was to determine if four specific stigma-identity constructs that contribute to variability in psychological distress among people in other CSI groups also contribute among adult who stutter (AWS)., Method: 505 AWS completed an online survey that included measures of four stigma-identity constructs in addition to general demographics and measures of self-rated stuttering severity, distress, and adverse impact of stuttering on quality of life. Hierarchical regression was performed to determine the extent that stigma-identity constructs explained variability in psychological health outcomes among AWS. Self-rated stuttering severity was investigated as a moderator in these relationships., Results: The stigma-identity constructs accounted for a significant proportion of the variability in distress (∼25 %) and adverse impact of stuttering on quality of life (∼30 %) among AWS. Further, the constructs of salience, centrality, and concealment were positively predictive of distress and adverse impact of stuttering after controlling for demographics and neuroticism. Compared to the other predictor variables (self-rated stuttering severity, demographic characteristics, neuroticism, and the three other stigma-identity constructs), concealment was the strongest predictor of adverse impact of stuttering on quality of life. Finally, self-rated stuttering severity was a moderating variable., Conclusions: The results from this study suggest that there are useful applications in conceptualizing stuttering as a type of CSI. Speech-language pathologists should be aware of the relationships that stigma has with psychological health outcomes among AWS and should consider the implications for intervention., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose This article is the first in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. In this article, we describe the process of developing measures to assess stage of change (SOC) by defining behaviors of stuttering management, as well as the two primary cognitive constructs that underlie one's readiness to make behavioral change: decisional balance (DB) and situational self-efficacy (SSE). This work hinges on the ability to develop an operational definition of what it means to successfully manage or do something positive about one's stuttering. Method We used an iterative process to develop the three scales. Through qualitative analysis of key informant interview and focus group transcripts with 24 adolescents who stutter and 26 clinicians specializing in stuttering, we developed stuttering-specific SOC, DB, and SSE scales. The drafted scales were cognitively tested with nine adolescents who stutter. Results Thematic analysis yielded a three-part definition of successful stuttering management that formed the basis for the SOC scale: (a) learning and using strategies to modify speech or stuttering, (b) changing negative thoughts and attitudes regarding stuttering, and (c) talking without avoiding sounds, words, or situations. Results from this analysis support a broader view of successful stuttering management; that is, it is likely that doing so requires more than just behavior change, which has long been considered the main objective of stuttering treatment. Additional analyses yielded pros and cons of managing stuttering (62 items for the DB scale) and situations in which it is difficult to manage stuttering (39 items for the SSE scale). Conclusions Qualitative analyses provided a three-part definition of "stuttering management" and a comprehensive pool of items that would allow measurement of DB and SSE that underlie readiness to manage stuttering among adolescents. In the companion article in this two-part series, we describe the next step in scale development: exploratory scale validation of the drafted SOC, DB, and SSE scales.

Purpose This article is the second in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. The purpose of this article was to apply and explore the validity of newly developed Transtheoretical measures for adolescents who stutter. Method The online survey was completed by a national sample of 173 adolescents who stutter between the ages of 13 and 21 years. The multipart survey included a Stage of Change scale, Decisional Balance scale, and Situational Self-Efficacy scale. Participants also completed the Overall Assessment of the Speaker's Experience of Stuttering (OASES), either the teenage or adult version depending on the participant's age, so preliminary construct validity of the new scales could be examined. Exploratory factor analyses were conducted to determine model fit and reduce the scales to the most meaningful items. External validity of the three-part survey was examined by comparing OASES scores across stage of change as well as evaluating the functional relations between the three scales. Results Adolescents' readiness to manage stuttering could be clearly described with five discrete stages, although most of the respondents reported being in the Maintenance stage. The pros of managing stuttering reliably predicted stage placement. Internal consistency of the scales ranged from good to excellent. OASES scores differed across stages of readiness in complex but predictable ways. Conclusions These findings suggest that the Transtheoretical Model fits the target behaviors involved stuttering management among adolescents. Further examination of the application of the model to validate a stage-based framework for change among individuals who stutter is warranted.

Background: Fever and hypothermia have been observed in septic patients. Their influence on prognosis is subject to ongoing debates., Methods: We did a secondary analysis of a large clinical dataset from a quality improvement trial. A binary logistic regression model was calculated to assess the association of the thermal response with outcome and a multinomial regression model to assess factors associated with fever or hypothermia., Results: With 6542 analyzable cases we observed a bimodal temperature response characterized by fever or hypothermia, normothermia was rare. Hypothermia and high fever were both associated with higher lactate values. Hypothermia was associated with higher mortality, but this association was reduced after adjustment for other risk factors. Age, community-acquired sepsis, lower BMI and lower outside temperatures were associated with hypothermia while bacteremia and higher procalcitonin values were associated with high fever., Conclusions: Septic patients show either a hypothermic or a fever response. Whether hypothermia is a maladaptive response, as indicated by the higher mortality in hypothermic patients, or an adaptive response in patients with limited metabolic reserves under colder environmental conditions, remains an open question. Trial registration The original trial whose dataset was analyzed was registered at ClinicalTrials.gov (NCT01187134) on August 23, 2010, the first patient was included on July 1, 2011., (© 2021. The Author(s).)

Background: The reported mortality for sepsis and septic shock varies between 15% and 59% in international comparison. For Germany, the number of studies is limited. Previous estimations of mortality in Germany are outdated or based on claims data analyses. Various authors discuss whether lacking quality initiatives and treatment standards in Germany could cause higher mortality for sepsis. This contrasts with the internationally well-recognized performance of the German intensive care infrastructure during the COVID-19 pandemic., Objectives: The objectives of this systematic review and meta-analysis were to estimate 30-day and 90-day mortality of patients with sepsis and patients with septic shock in Germany and to compare the mortality with that of other industrialized regions (Europe, North America)., Material and Methods: A systematic literature search included interventional and observational studies published between 2009 and 2020 in PubMed and the Cochrane Library that analyzed adult patients with sepsis, severe sepsis and septic shock in Europe and North America. Studies with less than 20 patients were excluded. The 30-day and 90-day mortality for sepsis and septic shock were pooled separately for studies conducted in Germany, Europe (excluding Germany) and North America in a meta-analysis using a random effects model. Mortality over time was analyzed in a linear regression model., Results: Overall, 134 studies were included. Of these, 15 studies were identified for the estimation of mortality in Germany, covering 10,434 patients, the number of patients per study ranged from 28 to 4183 patients. The 30-day mortality for sepsis was 26.50% (95% confidence interval, CI: 19.86-33.15%) in Germany, 23.85% (95% CI: 20.49-27.21%) in Europe (excluding Germany) and 19.58% (95% CI: 14.03-25.14%) in North America. The 30-day mortality for septic shock was 30.48% (95% CI: 29.30-31.67%) in Germany, 34.57% (95% CI: 33.51-35.64%) in Europe (excluding Germany) and 33.69% (95% CI: 31.51-35.86%) in North America. The 90-day mortality for septic shock was 38.78% (95% CI: 32.70-44.86%) in Germany, 41.90% (95% CI: 38.88-44.91%) in Europe (excluding Germany) and 34.41% (95% CI: 25.66-43.16%) in North America. A comparable decreasing trend in sepsis 30-day mortality was observed in all considered regions since 2009., Conclusion: Our analysis does not support the notion that mortality related to sepsis and septic shock in Germany is higher in international comparison. A higher mortality would not be obvious either, since intensive care, for example also during the COVID-19 pandemic, is regarded as exemplary in Germany and the structural quality, such as the number of intensive care beds per 100,000 inhabitants, is high in international comparison. Nevertheless, deficits could also exist outside intensive care medicine. A comparison of international individual studies should take greater account of the structure of healthcare systems, the severity of disease and the limitations resulting from the data sources used., (© 2021. The Author(s).)

Background: Preoperative fasting times for clear liquids surpass by far the recommendations of the specialist societies. The aim of this study was to introduce a liberal regimen for preoperative fasting of clear liquids using fasting cards as a training tool and to evaluate the implementation., Material and Methods: We developed a liberalized regimen of preoperative clear fluid fasting times, which allows patients to drink water, apple juice, tea and coffee until being called to the operating theatre. Each patient receives a bed-side fasting card with written information specifying fasting times for solid food and liquids. Patients who are allowed to drink water, apple juice, tea and coffee until the call to the operating theatre receive a blue fasting card. Patients with coexisting diseases or conditions that can affect gastric emptying or who need longer fasting times because of the surgical procedure get a yellow fasting card on which fasting times for fluids and solids can be documented individually. Patients who need to be nil per os (for example patients with ileus or bowel obstruction, emergency care) receive a red fasting card. On the back of the card the information is written in English, Turkish, Russian and Arabic. After a period of 8 months all surgical ward managers were asked to complete a questionnaire to assess the implementation of the new fasting regimen., Results: The response rate of the questionnaire was 100%. Without exception all interviewees would recommend the use of our liberalized fasting regimen. Almost all would also support the implementation of fasting cards. Out of 11 wards 9 found that patients were more relaxed and asked for intravenous fluids less often while waiting for surgery. The multilingual nature of the cards makes it easier to deal with patients who do not speak German. All ward managers consistently approved the new regimen in the event they themselves would need an operation. In order to make the fasting cards also usable in the future for rescue centers and functional units, such as endoscopy, echo or cardiac catheters, the reasons for fasting on the blue and yellow cards have been extended to operation or examination and on the red card to illness, operation or upcoming examination., Conclusion: Patients should be allowed to drink water and hypotonic clear fluids until shortly before an operation to avoid complications of overly long fasting times. Fasting cards help to implement this by providing easy to understand information for patients and healthcare workers. This concept should be clearly structured, transparent for everyone, written down and brought to the attention of the patient without a language barrier.

Background: Geographical and cultural differences have been shown to affect public attitudes towards stuttering. However, increasingly for many individuals in the world one's birthplace culture (or home culture) and culture in their local geographical environment (or host culture) are not the same., Aims: The effects of home culture and host culture in shaping the attitudes towards stuttering among students with British, Arab and Chinese home cultures attending one British university were explored. The effects of host culture were investigated by considering the time lived in the UK for Arab and Chinese students., Methods & Procedures: The study used a descriptive survey design that included a standardized self-delivered questionnaire: the Public Opinion Survey of Human Attributes-Stuttering (POSHA-S). Purposive sampling was carried out thorough volunteer mailing lists, student societies and personal contact. The final sample of 156 university students included 51 British, 52 Arab and 53 Chinese students., Outcomes & Results: Overall stuttering score (OSS), which is indicative of attitudes towards stuttering, was highest for British participants (mean = 30) and lowest for Chinese participants (mean = 13), with Arab participants falling in the middle (mean = 21). The differences in attitudes between the three groups were statistically significant, suggesting that home culture is a contributor to attitudes towards stuttering. A post-hoc item analysis of the POSHA-S revealed numerous specific differences in attitudes towards stuttering between the three groups, including differences in the attribution of the aetiology of stuttering, their role in helping people who stutter (PWS) and sympathy toward PWS. Time lived in the UK-a proxy measure for the role of host culture-did not significantly influence the attitudes of Arab and Chinese respondents., Conclusions & Implications: To varying degrees, all three groups had evidence of stereotypical stuttering attitudes. Nevertheless, given similar ages and student status in the same university, observed respondent differences confirm previous research documenting geographical influences on stuttering attitudes in Western versus East Asian and Middle Eastern samples. The study also provides evidence that home culture was influential in shaping attitudes towards stuttering, but host culture was not a significant contributor. What this paper adds What is already known on the subject Public stereotypical beliefs towards stuttering are found across the world and hinder the quality of life among PWS. Different cultures have unique stereotypical beliefs towards PWS. What this study adds to existing knowledge To the best of our knowledge, no other study has investigated specifically if individuals who live in the same geographical location but have different home cultures, have similar or differing attitudes towards PWS. Results provide preliminary evidence that the home culture of an individual was influential in shaping attitudes towards PWS, but host culture, measured as the length of time living in the current geographical location, did not have a significant relationship with attitudes towards stuttering. What are the potential or actual clinical implications of this work This study highlights that culturally sensitive clinical practice should not be based on just the culture of the region but should take home culture into consideration as well, and clinicians should discuss cultural perceptions of stuttering with clients in clinical practice., (© 2021 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists.)

Large clinical trials testing hydrocortisone therapy in septic shock have produced conflicting results. Subgroups may benefit of hydrocortisone treatment depending on their individual immune response. We performed an exploratory analysis of the database from the international randomized controlled clinical trial Corticosteroid Therapy of Septic Shock (CORTICUS) employing machine learning to a panel of 137 variables collected from the Berlin subcohort comprising 83 patients including demographic and clinical measures, organ failure scores, leukocyte counts and levels of circulating cytokines. The identified theranostic marker was validated against data from a cohort of the Hellenic Sepsis Study Group (HSSG) ( n = 246), patients enrolled in the clinical trial of Sodium Selenite and Procalcitonin Guided Antimicrobial Therapy in Severe Sepsis (SISPCT, n = 118), and another, smaller clinical trial (Crossover study, n = 20). In addition, in vitro blood culture experiments and in vivo experiments in mouse models were performed to assess biological plausibility. A low serum IFNγ/IL10 ratio predicted increased survival in the hydrocortisone group whereas a high ratio predicted better survival in the placebo group. Using this marker for a decision rule, we applied it to three validation sets and observed the same trend. Experimental studies in vitro revealed that IFNγ/IL10 was negatively associated with the load of (heat inactivated) pathogens in spiked human blood and in septic mouse models. Accordingly, an in silico analysis of published IFNγ and IL10 values in bacteremic and non-bacteremic patients with the Systemic Inflammatory Response Syndrome supported this association between the ratio and pathogen burden. We propose IFNγ/IL10 as a molecular marker supporting the decision to administer hydrocortisone to patients in septic shock. Prospective clinical studies are necessary and standard operating procedures need to be implemented, particularly to define a generic threshold. If confirmed, IFNγ/IL10 may become a suitable theranostic marker for an urging clinical need., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 König, Kolte, Ahlers, Oswald, Krauss, Roell, Sommerfeld, Dimopoulos, Tsangaris, Antoniadou, Jaishankar, Bogatsch, Löffler, Rödel, Garcia-Moreno, Tuchscherr, Sprung, Singer, Brunkhorst, Oppert, Gerlach, Claus, Coldewey, Briegel, Giamarellos-Bourboulis, Keh and Bauer.)

Purpose: The purpose of this study was to investigate the relationship between depressive symptoms and suicidal ideation and living with stuttering while accounting for time, sex, and health-related confounders., Method: The data for this study come from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative survey study that has followed 13,564 respondents over the course of 14 years. Responses to the question "Do you have a problem with stuttering or stammering?" at two time points were used to establish stuttering and non-stuttering groups. Regression analysis, propensity score matching, and structural equation modeling were used., Results: Compared to their fluent counterparts, males and females reported significantly elevated symptoms of depression. Although symptoms of depression among males who stutter were stable over time, depressive symptoms among females who stutter increased with age. Compared to males who do not stutter, males who stutter were significantly more likely to report feelings of suicidal ideation. There were no differences in suicidal ideation between females who do and do not stutter., Conclusions: Speech-language pathologists should be aware of the associations between stuttering and depressive symptoms, as well as the increased risk for suicidal ideation among males who stutter. Clinicians should be knowledgeable about symptoms of depression and suicidal ideation and be familiar with processes to refer as needed., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Sepsis and septic shock remain drivers for mortality in critically ill patients. The heterogeneity of the syndrome hinders the generation of reproducible numbers on mortality risks. Consequently, mortality rates range from 15 to 56%. We aimed to update and extend the existing knowledge from meta-analyses and estimate 30- and 90-day mortality rates for sepsis and septic shock separately, stratify rates by region and study type and assess mortality rates across different sequential organ failure assessment (SOFA) scores., Methods: We performed a systematic review of articles published in PubMed or in the Cochrane Database, between 2009 and 2019 in English language including interventional and observational studies. A meta-analysis of pooled 28/30- and 90-day mortality rated separately for sepsis and septic shock was done using a random-effects model. Time trends were assessed via Joinpoint methodology and for the assessment of mortality rate over different SOFA scores, and linear regression was applied., Results: Four thousand five hundred records were identified. After title/abstract screening, 783 articles were assessed in full text for eligibility. Of those, 170 studies were included. Average 30-day septic shock mortality was 34.7% (95% CI 32.6-36.9%), and 90-day septic shock mortality was 38.5% (95% CI 35.4-41.5%). Average 30-day sepsis mortality was 24.4% (95% CI 21.5-27.2%), and 90-day sepsis mortality was 32.2% (95% CI 27.0-37.5%). Estimated mortality rates from RCTs were below prospective and retrospective cohort studies. Rates varied between regions, with 30-day septic shock mortality being 33.7% (95% CI 31.5-35.9) in North America, 32.5% (95% CI 31.7-33.3) in Europe and 26.4% (95% CI 18.1-34.6) in Australia. A statistically significant decrease of 30-day septic shock mortality rate was found between 2009 and 2011, but not after 2011. Per 1-point increase of the average SOFA score, average mortality increased by 1.8-3.3%., Conclusion: Trends of lower sepsis and continuous septic shock mortality rates over time and regional disparities indicate a remaining unmet need for improving sepsis management. Further research is needed to investigate how trends in the burden of disease influence mortality rates in sepsis and septic shock at 30- and 90-day mortality over time.