Search

Background: Within hospice and palliative care, professionals from various disciplines collaborate to deliver comprehensive care to terminal patients and their relatives. Regional hospice and palliative care networks exist in various countries, aimed at facilitating cooperation among health care providers at a local level. To date, little is known about the challenges faced by these networks., Aim: This study aimed to explore the challenges faced by regional hospice and palliative care networks in Germany., Design: A qualitative study with n  = 6 group discussions was conducted. Group discussions were recorded, transcribed verbatim and analysed using qualitative content analysis., Setting/participants: Participants were n  = 19 coordinators or leaders of regional hospice and palliative care networks in Germany or persons with theoretical expertise about these structures., Results: Regional hospice and palliative care networks face numerous challenges relating to: (1) establishment and development, (2) infrastructure, (3) moderation, (4) public relations and information exchange, (5) education and training and (6) the development of regional care services and practices. Network moderation appears crucial for network success and is highly dependent on infrastructural conditions. A key challenge is gaining network acceptance and support from potential network partners. Specifically, this includes securing the commitment of network partners to agree on common goals, develop joint actions and standards and allocate resources effectively., Conclusions: Sustainable infrastructure, competent network governance and adequate resources for network members are essential for the success of regional hospice and palliative care networks. To improve networking, funding conditions should be simplified, the involvement of network partners should be improved and network coordinators should receive training in network management., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: We conducted a cluster-randomized-controlled trial (cRCT) in 18 German nursing homes (NH) to evaluate the cost-effectiveness of reinstruction and remotivation of nursing staff by dental assistants (DAs) over 13 months., Methods: In the intervention arm, dentists examined NH residents, identified oral health conditions, and prescribed individualized oral care interventions. Nursing staff delivered these interventions, with regular follow-up support from DAs (reinstruction and remotivation). In the control group, similar interventions were prescribed via a standardized form, without reinstruction and remotivation (standard of care). The primary outcome was Oral-Health-related Quality-of-Life (OHrQoL) using the Geriatric/General Oral Health Assessment Index (ADD-GOHAI). Secondary outcomes included Health-related Quality-of-Life (HrQoL) using the EQ-5D summary index and caries experience (DMFT index). Costs, including those for staff, materials, and travel, were assessed in Euro 2022. Cost-effectiveness ratios and bootstrapping simulations assessed cost-effectiveness-acceptability at different willingness-to-pay thresholds., Results: Of 358 recruited participants, 68 and 63 in the intervention and control group completed the study. No significant differences existed between groups in demographics or baseline health measures. After 13 months, changes in ADD-GOHAI and DMFT scores were minimal and non-significant, while EQ-5D scores decreased in the intervention group (p < 0.001). Total costs were higher in the intervention arm (median 121.10 Euro) versus the control (median 0 Euro, p < 0.001), mainly due to travel expenses. The intervention increased dental service use but demonstrated lower cost-effectiveness acceptability., Conclusions: DA-led reinstruction did not improve OHrQoL, negatively impacted HrQoL, and increased costs. Notably, our study was suffering from significant attrition, impacting on statistical power., Clinical Significance: Reinstruction and remotivation by dental assistants did not improve OHrQoL, but generated significant costs, mainly due to an uptake of dental services., Trial Registration: ClinicalTrials.gov (Trial registration number NCT04140929)., Competing Interests: Declaration of competing interest The authors have no conflicting interests to declare., (Copyright © 2024. Published by Elsevier Ltd.)

This position paper from the Digital Public Health Section of the German Public Health Association defines digital public health (DiPH) and describes its goals and potential. It also addresses the current situation and challenges as well as the need for action in Germany. The focus here is on the presentation of the nationwide promotion of (digital) health literacy; the application of DiPH in prevention, health promotion, and healthcare; the use of innovative preventive strategies for the prevention of non-communicable diseases; and the teaching of DiPH in academic public health programs. Finally, relevant measures and demands to strengthen DiPH in Germany are summarized., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: L. Maaß, C. Dockweiler, Z. Hocke-Bolte, S. Hoffmann, F. Fischer, S. Forberger, J. Gebert, F. Holl, R. Hrynyschyn, S. Kernebeck, C. Pischke, J. Posselt und J. Spallek geben an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s).)

To address the challenges posed by influenza, its associated complications, and economic burden, the World Health Organization recommends a vaccination rate exceeding 75 % for populations at elevated risk of severe diseases. Presently, vaccination rates in Germany severely lag behind. To augment these rates, pilot projects have been initiated, allowing community pharmacists to administer vaccines. This study aimed to investigate the the acceptability of pharmacy-led influenza vaccinations among clients and pharmacists, clients' motivations to get vaccinated in community pharmacies, and the rate of adverse events during this process. Data were obtained through anonymous questionnaires from influenza vaccination pilot projects in various German regions between 2020 and 2023. The questionnaire consisted of two sections: one for the vaccinating pharmacist to record and document the vaccination process and one for the recipient, focusing on their experiences and views. In total 11,571 responses were evaluated. Notably, 44 % of participants mentioned they would not have sought vaccination outside a pharmacy setting. This percentage was higher (65 %) in those receiving their first influenza vaccination. Vaccinees reported high levels of satisfaction with the supplied information (88.5 %) and vaccination procedure (93.8 %). Furthermore, clients declared a high willingness to repeat the vaccination (93.9 %) and the possibility of receiving other vaccinations in pharmacies (79.7 %). Among all surveyees, only nine reported adverse reactions post pharmacy-administered vaccination, with none necessitating emergency intervention. Pharmacy-led influenza vaccinations were identified as safe, well-received by vaccinees and effective in increasing vaccination acceptability with the potential to enhance vaccination rates across diverse demographics in Germany., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The internet is a key source of health information, but the quality of content from popular search engines varies, posing challenges for users-especially those with low health or digital health literacy. To address this, the "tala-med" search engine was developed in 2020 to provide access to high-quality, evidence-based content. It prioritizes German health websites based on trustworthiness, recency, user-friendliness, and comprehensibility, offering category-based filters while ensuring privacy by avoiding data collection and advertisements., Objective: This study aims to evaluate the acceptance and usability of this independent, noncommercial search engine from the users' perspectives and their actual use of the search engine., Methods: For the questionnaire study, a cross-sectional study design was used. In total, 802 participants were recruited through a web-based panel and were asked to interact with the new search engine before completing a web-based questionnaire. Descriptive statistics and multiple regression analyses were used to assess participants' acceptance and usability ratings, as well as predictors of acceptance. Furthermore, from October 2020 to June 2021, we used the open-source web analytics platform Matomo to collect behavior-tracking data from consenting users of the search engine., Results: The study indicated positive findings on the acceptance and usability of the search engine, with more than half of the participants willing to reuse (465/802, 58%) and recommend it (507/802, 63.2%). Of the 802 users, 747 (93.1%) valued the absence of advertising. Furthermore, 92.3% (518/561), 93.9% (553/589), 94.7% (567/599), and 96.5% (600/622) of those users who used the filters agreed at least partially that the filter functions were helpful in finding trustworthy, recent, user-friendly, or comprehensible results. Participants criticized some of the search results regarding the selection of domains and shared ideas for potential improvements (eg, for a clearer design). Regression analyses showed that the search engine was especially well accepted among older users, frequent internet users, and those with lower educational levels, indicating an effective targeting of segments of the population with lower health literacy and digital health literacy. Tracking data analysis revealed 1631 sessions, comprising 3090 searches across 1984 unique terms. Users performed 1.64 (SD 1.31) searches per visit on average. They prioritized the search terms "corona," "back pain," and "cough." Filter changes were common, especially for recency and trustworthiness, reflecting the importance that users placed on these criteria., Conclusions: User questionnaires and behavior tracking showed the platform was well received, particularly by older and less educated users, especially for its advertisement-free design and filtering system. While feedback highlighted areas for improvement in design and filter functionality, the search engine's focus on transparency, evidence-based content, and user privacy shows promise in addressing health literacy and navigational needs. Future updates and research will further refine its effectiveness and impact on promoting access to quality health information., (©Lisa Specht, Raphael Scheible, Martin Boeker, Erik Farin-Glattacker, Nikolas Kampel, Marina Schmölz, Andrea Schöpf-Lazzarino, Stefan Schulz, Christian Schlett, Fabian Thomczyk, Sebastian Voigt-Radloff, Constanze Wegner, Katharina Wollmann, Andy Maun. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 23.01.2025.)

Background: The treatment of metastatic breast cancer (mBC) focuses on prolonging patient survival, providing adequate symptom management, and maintaining quality of life (QoL). This includes supportive therapy to prevent or treat potential side effects and handle comorbidities. The combination of mBC therapy, supportive therapy, and treatment for comorbidities increases the risk for polypharmacy, potential drug-drug interactions (pDDI), potentially inappropriate medication (PIM), and potentially missing drugs (pMD). Therefore, the aim of this study was to assess medication patterns of mBC patients in routine care within a cohort study from South Germany., Methods: Between July 2022 and February 2024 individuals with advanced or mBC, aged ≥ 18 years, living in Bavaria, and who gave written informed consent, were included in the BRE-BY-MED "Breast Cancer Care in Bavaria for Patients with Metastatic Disease" cohort study (DRKS00026601). BRE-BY-MED was carried out at the University Hospital Würzburg with the primary aim of estimating the prevalence of guideline-concordant treatment. For the present analysis cross-sectional data from the baseline assessment was used. Medication was extracted from routine medical records. PIM, pDDI and pMD were assessed using established criteria. Polypharmacy was defined as ≥ 5 concomitantly prescribed drugs., Results: Ninety-three patients with a median age of 57 years (IQR = 48-64 years), were consecutively enrolled in the BRE-BY-MED study. One patient was male. At baseline, a total of 668 drugs were documented for all patients, including 131 unique substances, of which 44% were mBC therapy, 18% supportive therapy and 38% treatment for comorbidities or supplements. Patients took a median of 6 (IQR = 5-9) concomitant drugs. Polypharmacy (i.e. ≥ 5 concomitant drugs) was observed in 80.6% (n = 75) of the patients. PIM were documented in 9.7% (n = 9), pDDI in 12.9% (n = 12) and pMD in 64.5% (n = 60) of the patients., Conclusion: We observed a high drug burden in mBC patients, largely due to treatment for comorbidities. These drugs might not only be associated with additional risk for side effects, pDDI, or PIM use, yet might also contribute to low medication adherence, higher medication costs and impaired QoL. Considering the burden of mBC and the predicted life expectancy, mBC patients might benefit from closer monitoring of their medication., Competing Interests: Declarations. Ethics approval and consent to participate: The study was performed in full accordance with the principles of the Declaration of Helsinki (as amended in Tokyo, Venice and Hong Kong). All methods of the study were fully approved by the ethics committee of the Medical Faculty of the University Wuerzburg (reference number 137/21). Written informed consent was obtained from all participants. The responsible data protection officer accepted the data management concept. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

As global demand for meat continues to rise, alternative and sustainable methods of production are being explored. Cultivated meat (CM) is one such alternative that holds potential for sustainable production with less environmental impact. This study develops an approach to evaluate CM production based on agricultural feedstock. The specific objectives are to determine the minimum land area required to produce a certain amount of cell medium-feedstock for CM production-on agricultural land and to identify potential future land use scenarios assuming that the macro components of the cell medium are solely produced from common agricultural crops in southern Germany. A linear programming model was developed to analyze four different scenarios of CM production, considering factors such as crop rotation, nutrient sourcing, and solar energy use. The results indicate that CM production using plants as raw material for the cell medium cannot improve land use efficiency substantially compared to conventional pork production. Extraction methods, crop choice, and energy sources will strongly influence future pathways for CM. We also find that there is no substantial benefit from CM in terms of climate change mitigation when feedstock is sourced solely from plants. This study provides valuable insights into the limitations of using agricultural feedstock for sustainable CM production. The findings suggest that future research should focus on optimizing the land use efficiency of CM. This includes exploring alternatives such as sourcing cell media from precision fermentation instead of relying solely on crops, and utilizing upcycling possibilities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Kossmann et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In Germany, digital transformation and legal regulations are leading to the need to integrate digital technologies into the nursing profession. In addition, to nursing practice, they are also being incorporated into nursing training. Despite comprehensive regulations regarding the use of digital teaching and learning media in nursing education, their specific applicability and implementation vary., Objective: This study aims to map evidence and identify the main concepts, theories, sources, and knowledge gaps in the use of digital teaching and learning formats in nursing and health care education in Germany., Methods: The study is planned as a scoping review. The reporting of the study is based on the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) 2020 guidelines. The sources of information for the review include six bibliographic databases (MEDLINE via PubMed, Cochrane Library, Web of Science Core Collection, ERIC, PROSPERO, and APA PsycInfo). The search results will be presented in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. The eligibility of studies is based on the population, concept, and context criteria: (1) learners of nursing and health care professions, (2) digital teaching and learning formats, and (3) forms of implementation in Germany since 2007., Results: The literature search is planned for January 2025. The selection of titles, the coding of the data, and the data analysis are expected to be completed by March 2025., Conclusions: In Germany, there is a growing interest in integrating digital teaching and learning formats into nursing and health care education. Our scoping review will map applications of digital teaching and learning media in the education of nursing and health care professions in Germany. In this way, the scoping review provides relevant impulses for fields of application and design aspects of digital teaching or learning media for nursing and health care education., International Registered Report Identifier (irrid): PRR1-10.2196/60427., (©Jann Niklas Vogel, Jaqueline Letzin, Stefan Schmidt. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 17.01.2025.)

Rationale: The dietary components choline, betaine, and L-carnitine are converted by intestinal microbiota into the molecule trimethylamine (TMA). In the human liver, hepatic flavin-containing monooxygenase 3 oxidizes TMA to trimethylamine-N-oxide (TMAO). TMAO is considered a candidate marker for the risk of cardiovascular disease., Methodology: The Healthy Lifestyle Community Program cohort 3 (HLCP-3) intervention was conducted with participants recruited from the general population in Germany (intervention: n = 99; control: n = 48). The intervention included intensive educational workshops, seminars, and coaching activities. The assessment was conducted using a complete case analysis (CCA) of the participants. The intervention was carried out for a ten-week intensive phase and an alumni phase. The interventional program emphasizes adopting a healthy plant-based diet and reducing meat consumption, as adherence to such a diet may lead to lowering TMAO levels. Additionally, it provides general recommendations about physical activity, stress management, and community support. The control group did not receive any intervention. TMAO was evaluated using stable isotope dilution liquid chromatography, and tandem mass spectrometry was used to measure fasting plasma levels of TMAO., Objectives: The present study aimed to determine the impact of the Healthy Lifestyle Community Program (HLCP-3) on risk profiles for lifestyle-related diseases and TMAO plasma levels., Results: Significant decreases in most risk profile parameters were detected, and a non-significant decrease in plasma TMAO levels was observed in the intervention group (0.37 (-1.33; 0.59) µmol/L). Furthermore, for the intervention group, after a six-month follow-up period, there was a significant negative correlation between higher healthy plant diet index (hPDI) scores and a decrease in plasma TMAO (ß = -0.200, p = 0.027). Additionally, a significant negative correlation was observed between the TMAO level and the scores for adherence to the plant diet index (PDI) (r = -0.195; p = 0.023)., Conclusions: HLCP-3 is effective at improving adherence to a plant-based diet and improving risk profile parameters. However, long-term interventions involving stricter dietary programs in the sense of a plant-based diet are recommended if significant decreases in TMAO levels are to be obtained.

Background/Objectives: The global population is undergoing a significant demographic shift characterised by an increasing proportion of older individuals. Healthy aging has become a priority for personal well-being and sustainable healthcare systems, with nutrition playing a pivotal role. However, the rise in non-communicable diseases (NCDs), malnutrition, and a shift in eating behaviour underscore the need for tailored, effective nutrition communication strategies. This research is intended to provide the basic data needed to support the development of tailored nutritional communication strategies and practices. Methods: To investigate these aspects, a cross-national survey about nutrition and nutrition communication was conducted within the framework of the Innovative Training Network SmartAge, focusing on older adults aged 60 years and above in Germany, Switzerland, Spain, and France (each 25%; N = 1000 persons). This paper specifically focuses on the development, methodology, and discussion of the survey and aims to investigate the characteristics of the sample in relation to their dietary patterns and food choices within the European context. Results: The analysis identified significant associations between various plant- and animal-based food items and the variables gender, age group, and country. Spanish participants showed a dietary pattern towards the Mediterranean Diet, while German participants showed tendencies towards the Western Diet. Furthermore, the findings revealed that protein-rich foods such as meat, fish, nuts and seeds, legumes, and (whole) grains were infrequently consumed, particularly among German and Swiss participants. Conclusions: This study highlights the need to promote adequate protein intake among older adults, emphasising diverse sources like legumes, nuts and seeds, (whole) grains, and lean meats to support healthy aging. For the development of future nutrition communication strategies, the influence of the specific social, cultural, and traditional factors needs to be considered.

Background: Molecular tumor boards (MTBs) play a pivotal role in personalized oncology, leveraging complex data sets to tailor therapy for cancer patients. The integration of digital support and visualization tools is essential in this rapidly evolving field facing fast-growing data and changing clinical processes. This study addresses the gap in understanding the evolution of software and visualization needs within MTBs and evaluates the current state of digital support. Alignment between user requirements and software development is crucial to avoid waste of resources and maintain trust., Methods: In two consecutive nationwide medical informatics projects in Germany, surveys and expert interviews were conducted as stage 1 (n = 14), stage 2 (n = 30), and stage 3 (n = 9). Surveys, via the SoSci Survey tool, covered participants' roles, working methods, and support needs. The second survey additionally addressed requirements for visualization solutions in molecular tumor boards. These aimed to understand diverse requirements for preparation, implementation, and documentation. Nine semi-structured expert interviews complemented quantitative findings through open discussion., Results: Using quantitative and qualitative analyses, we show that existing digital tools may improve therapy recommendations and streamline MTB case preparation, while continuous training and system improvements are needed., Conclusions: Our study contributes to the field by highlighting the importance of developing user-centric, customizable software solutions that can adapt to the fast-paced environment of MTBs to advance personalized oncology. In doing so, it lays the foundation for further advances in personalized medicine in oncology and points to a shift towards more efficient, technology-driven clinical decision-making processes. This research not only enriches our understanding of the integration of digital tools into MTBs, but also signals a broader shift towards technological innovation in healthcare., Competing Interests: Declarations. Ethics approval and consent to participate: The ethics committee of Friedrich-Alexander-University Erlangen-Nürnberg approved stage 1 of the study on January 24, 2022 (approval number: 22–24-ANF) and stage 2 and 3 (including small subsequent survey) on December 22, 2023 (approval number: 23–391-B). All participants provided written informed consent to participate in the study. All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Toxicity testing is an important tool for risk assessment of sediment contamination in estuaries. However, there has been a predominant focus on fitness parameters as toxic endpoints and on crustaceans as test organisms, while effects at the sub-organismal level and on other benthic taxa have received less attention. Also, interactions between sediment contamination and natural stressors such as oxygen are often neglected in traditional toxicity tests. Here we conducted a toxicity test of sediments from the Elbe and Oder (Odra) estuaries under three weeks of continuous and intermittent oxygenation, using biomarkers in an annelid, the ragworm Hediste diversicolor. Contaminated sediments affected worm survival and some biomarkers of antioxidant defense, electrophilic stress, and energy status with response ratios of above 20%. Toxic effects were most pronounced in sediments from the upper Elbe estuary, which contained high levels of heavy metals and organic chemicals. Oxygen regimes hardly changed the sediment effects, suggesting the robustness of the biomarker-based toxicity test with ragworms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Gamma-hydroxybutyrate (GHB) and its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (BD) have become a significant concern due to the increase in their recreational use and the high risks associated with it (e.g., overdose, addiction, life-threatening withdrawal syndromes). However, targeted prevention and treatment strategies are lacking, and little is known about the specific needs of users regarding supportive approaches., Methods: To address this gap, a mixed-methods longitudinal study was conducted with two waves of online data collection (11/2022-01/2023; 11/2023-01/2024) in Germany. The adult convenience sample (N = 2,196, with n = 240 participating in the follow-up) was mostly connected to Berlin's nightlife scene and included GHB/GBL/BD users and their (non-user) social environment. Perceptions and needs regarding prevention and harm-reduction, reasons and measures of decreasing use, and the impact of GHB/GBL/BD use were analyzed both quantitatively and qualitatively., Results: Education, harm reduction strategies, and specialized support options were welcomed by users and non-users, while restrictive approaches were viewed negatively, particularly by heavy users. Many participants expressed a desire to reduce GHB/GBL/BD use, driven primarily by health concerns, immediate use risks, and addiction, but only few participants had previously accessed preventive/therapeutic services. The follow-up showed little change in perceptions and experiences over time., Conclusions: The findings underscore the need for comprehensive and integrative prevention and treatment strategies for GHB/GBL/BD use, with harm reduction approaches prioritized over restrictions. They provide a crucial foundation for future research and interventions and emphasize the necessity of adequately addressing the growing issues related to GHB/GBL/BD use., Trial Registration: The study protocol was pre-registered with the German registry for clinical studies (Deutsches Register Klinischer Studien; drks.de/search/de/trial/DRKS00030608) on October 28, 2022., Competing Interests: Declarations. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Consent to participate: Informed consent was obtained from all individual participants included in the study. Consent for publication: Not applicable. Competing interests: Felix Betzler received honoraria (consulting, lectures) from Takeda Pharmaceuticals and Medice. All remaining authors declare that they have no conflict of interest., (© 2025. The Author(s).)

Background: Patients with Rheumatic and Musculoskeletal Diseases, including axial spondyloarthritis (axSpA), may suffer from stressors like pain and functional impairments leading to limitations in their self-perceived health status. The COping with Rheumatic Stressors (CORS) questionnaire was developed to analyze how patients cope with these stressors. The CORS is currently not available in German., Objective: First, to translate, cross-culturally adapt and to linguistically validate the original Dutch CORS into German. Second, to test the pre-final German translation through cognitive debriefing in patients with axSpA., Methodology: The original Dutch CORS underwent a multistep cross-cultural adaptation process, as described by Beaton. It was first independently translated into German by bilingual Dutch-German lay and expert translators. Subsequently, it was translated back from the German version into Dutch. Remaining discrepancies were resolved by a scientific committee, resulting in a pre-final German version. This version was then tested through cognitive debriefing by 10 patients with axSpA across a broad spectrum of sociodemographic backgrounds., Results: Forward and backward translations of the CORS revealed minor discrepancies, mainly based on the degree of formal versus informal language usage, minor semantic errors or unusual syntax, which led to minor modifications in the wording. Reviewed by the scientific committee, the pre-final consensus German version was linguistically validated by cognitive debriefing by 10 patients with axSpA. Cognitive debriefing confirmed and ensured closest linguistic validity for German in Germany and highest equivalence to the Dutch original version., Conclusion: The German CORS was shown to have high cross-cultural and face validity for the assessment of coping with rheumatic stressors., Competing Interests: Declarations. Ethics approval and consent to participate: For this study, ethics approval was granted by the competent ethics committee of the Ruhr-Universität Bochum (Register No. 21-7179). Consent for publication: Written informed consent was provided by all study participants regarding publication of their data within this research to the Journal of Patient-Reported Outcomes. Competing interests: Not applicable., (© 2024. The Author(s).)

Background: Health professionals play a key role in promoting health literacy, as they continue to be one of the main points of contact and most trusted source of information for healthcare users on questions and concerns regarding health and disease. To adequately support individuals in dealing with health information and services and to strengthen health literacy, health professionals need a corresponding set of knowledge, skills, and attitudes, hence they need a wide range of health literacy competencies. Despite their crucial role in guiding and supporting patients and their relatives in terms of health-related information and services, in-depth studies on health literacy competencies of health professionals are still scarce. Thus, the aim of this study was to identify and prioritize health literacy competencies of health professionals in German-speaking countries., Methods: A modified, two-round Delphi study was conducted with 24 experts in the field of health literacy or a relevant field from Switzerland, Austria, and Germany. The experts were asked to evaluate and rate different competencies of health professionals regarding health literacy., Results: As a result, 14 core competencies have been identified by the experts, including five items referring to the category "knowledge", seven items to the category "skills" and two items referring to the category "attitude". The identified competences indicate that health literate health professionals understand health literacy's importance, employ clear communication techniques, and actively engage patients to ensure comprehension. Furthermore, health literate health professionals recognize cultural barriers, use plain language, and maintain that effective communication is crucial for quality healthcare. Among the 14 core competencies, communication practices were reported to be of particular importance for practice-oriented, professional health literacy skills of health professionals., Conclusions: The identified set of health literacy competencies provides an essential groundwork for future assessments of competencies concerning professional health literacy among health professionals, their integration into curricula, and further development of tailor-made trainings and education., Competing Interests: Declarations. Ethics approval and consent to participate: The study was conducted according to the guidelines of the Declaration of Helsinki. Ethical review and approval were waived for this study, as it is outside the scope of the Human Research Act and did not require approval by the Swiss Association of Research Ethics Committees (BASEC-Nr. Req-2021-01325). Informed consent was obtained from all the participants via a declaration of understanding and consent to participate directly in the questionnaire, which had to be confirmed in order to be able to participate in the study. Participants have also consented to the dissemination of the anonymized study results. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: The COVID-19 pandemic entailed a global health crisis, significantly affecting medical service delivery in Germany as well as elsewhere. While intensive care capacities were overloaded by COVID cases, not only elective cases but also non-COVID cases requiring urgent treatment unexpectedly decreased, potentially leading to a deterioration in health outcomes. However, these developments were only uncovered retrospectively. Especially university hospitals, which were meant to take on a central coordinating role, did not have detailed information on expected healthcare utilization, available resources and capacities, and the quality of medical care. The experience of compromised healthcare and a lack of monitoring during the COVID-19 pandemic made it clear that healthcare systems should be better prepared. Therefore, the aim of this work was to develop a set of indicators suited to detect undesirable developments concerning the provision of inpatient healthcare., Material & Methods: The study employed a literature review, online surveys, expert interviews, and a multistep evaluation process to develop a core set of quality indicators (QIs) suitable for assessing the resilience of university hospitals during pandemics. This initial set of indicators was refined through consultations with a) quality and risk management officials from German university hospitals via an online survey and b) a diverse panel of experts., Results: The comprehensive evaluation identified two primary strands: organizational/management indicators (Strand A, 60 indicators) and disease-specific clinical quality and patient safety indicators (Strand B, 20 indicators for critical conditions like stroke, myocardial infarction, and cancer.) Three additional indicators were added after a final expert panel meeting, resulting in a final set of 83 indicators., Discussion and Conclusion: The developed QIs mark a significant advancement in the operational preparedness of university hospitals for pandemics. The study contributes to quality management in healthcare during pandemics by creating the basis for a structured approach to pandemic preparedness and response. This unique set of QIs within the German context presents an opportunity for establishing quality improvement, underscoring the importance of a robust, adaptable quality management framework as a basis for safeguarding against future health crises., Competing Interests: Declarations. Ethics approval and consent to participate: The study was reviewed by the Ethics Committee of Philipps-University Marburg (Reference Number: 24–352 ANZ). It was confirmed that no ethical approval was necessary, as the study does not involve human participants, human data, or human tissue, but only professional statements from experts. The interviews were conducted with quality managers from hospitals that are cooperation partners within the multicenter study network, and therefore no consent was required. The dataset excludes any patient or person-related data, in accordance with §15 of Germany's Professional Code for Physicians, which exempts such studies from requiring both ethics committee approval and informed consent. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Financing long-term care is a growing challenge in aging societies. To address this challenge, Germany created public long-term care insurance (DPV) more than 25 years ago. Germans still need to prepare for their own care throughout their life course to supplement public insurance. This study presents descriptive statistics and multivariate regression analysis to examine young Germans' experiences and expectations of the relationship between the DPV and private financing sources. We base our analysis on a proprietary data set of young Germans (16-39 years old) that oversamples those with caregiving experience and East Germans. We find that public long-term care insurance is a substitute for rather than a complement to other financing sources. Specifically, many young Germans do not count on public long-term care insurance to finance care. Instead, they see private funding sources as substitutes for long-term care insurance. Those who count on private long-term care insurance are between 48 and 70% less likely to count on DPV benefits. Experience with care increases the likelihood of young Germans expecting future public benefits by factor of six or 18, depending on the specific care familiarity. Young Germans are also more likely to count on future generations to support their own care than they expect themselves to support the care of their parents through the DPV. Given that the DPV provides basic universal insurance that requires some complementary private income sources, our findings suggest that young Germans, who will need to build some of these income sources throughout their careers, are underestimating the value of the DPV and overestimating their own ability to pay for long-term care. Policymakers will need to reduce the political risks to the DPV and increase young Germans' savings over the life-course to address this imbalance.

Objective:  Commercially available large language models such as Chat Generative Pre-Trained Transformer (ChatGPT) cannot be applied to real patient data for data protection reasons. At the same time, de-identification of clinical unstructured data is a tedious and time-consuming task when done manually. Since transformer models can efficiently process and analyze large amounts of text data, our study aims to explore the impact of a large training dataset on the performance of this task., Methods:  We utilized a substantial dataset of 10,240 German hospital documents from 1,130 patients, created as part of the investigating hospital's routine documentation, as training data. Our approach involved fine-tuning and training an ensemble of two transformer-based language models simultaneously to identify sensitive data within our documents. Annotation Guidelines with specific annotation categories and types were created for annotator training., Results:  Performance evaluation on a test dataset of 100 manually annotated documents revealed that our fine-tuned German ELECTRA (gELECTRA) model achieved an F1 macro average score of 0.95, surpassing human annotators who scored 0.93., Conclusion:  We trained and evaluated transformer models to detect sensitive information in German real-world pathology reports and progress notes. By defining an annotation scheme tailored to the documents of the investigating hospital and creating annotation guidelines for staff training, a further experimental study was conducted to compare the models with humans. These results showed that the best-performing model achieved better overall results than two experienced annotators who manually labeled 100 clinical documents., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Smoking is still the largest preventable health risk in Germany, which is why a higher success rate in smoking cessation would benefit both public and individual health. In order to achieve this, a better understanding of the smoking cessation methods used and the factors that facilitate and prevent smoking cessation is required. The RauS study therefore aimed to investigate which methods have been used in attempts to stop smoking, how successful these methods have been, and which factors have been perceived as helping or hindering smoking cessation., Methods: From March to December 2022 a quantitative online survey was conducted among current or former smokers over 14 years of age (N = 6192)., Results: Of the sample, 93% have tried to quit smoking at least once. In general, for the respondents who did or did not use e‑cigarettes/tobacco heaters, "personal willpower" was the most frequently used and perceived as the most helpful method. Among people who have used e‑cigarettes/tobacco heaters to quit smoking, e‑cigarettes with nicotine were used most frequently and were rated as the most helpful. Potential or concrete health consequences were most likely to be perceived as motivating. Rituals associated with smoking were the main barrier to quit smoking, while withdrawal symptoms played a much smaller role., Discussion: Overall, the results show that the focus on "nicotine addiction" in smoking cessation should be reconsidered, and social and ritual dimensions should be addressed more strongly. For at least some of those affected, e‑cigarettes may be a helpful method of reducing harm and/or quitting smoking., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: B. Werse, L. Steimle und H. Stöver geben an, dass kein Interessenkonflikt besteht. Die Studie wurde im Einklang mit der Datenschutzgrundverordnung (DSGVO) durchgeführt. Die Befragten wurden vor ihrer Teilnahme über die Inhalte der Studie und ihre Rechte aufgeklärt und gaben ihre informierte Einwilligung., (© 2024. The Author(s).)

Problem: Restrictions during the COVID-19 pandemic compromised maternal and newborn care., Background: Countries in the German speaking area share several clinical care guidelines but differed significantly in the strictness of COVID-19 protective measures., Aim: To investigate the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic in the German-speaking area and explore associations between the reorganisational changes due to COVID-19 and QMNC, as described with WHO Standards-based Quality Measures., Methods: As part of the IMAgiNE EURO study (ClinicalTrials.gov: NCT04847336), we conducted an online survey on the QMNC in the German-speaking area, including women who gave birth in Germany, Switzerland, and Austria. Descriptive statistics, Spearman rank correlation coefficient and multivariable quantile regression were used., Findings: Out of a total of 70,721 women accessing the online questionnaire, 1,875 were included (Germany: n = 1,053, Switzerland: n = 494, Austria: n = 328). Significant differences across countries were found in Quality Measures. In Switzerland, women scored Quality Measures more favourable than in Germany and Austria in all four sub-indexes of QMNC. In Austria, Quality Measures gaps in the sub-index 'Experience of care' were higher. The sub-index 'Reorganisational changes due to COVID-19' correlated weakly to strongly with the other sub-indexes (between r = 0.33 and r = 0.62, p < 0.001 for all correlations)., Discussion: Midwives and other health professional should pay particular attention to the provision of respectful, high-quality care., Conclusion: To effectively improve QMNC, further research is essential to monitor the quality of care and develop targeted interventions beyond the COVID-19 pandemic addressing inherent challenges in the organisation and delivery of care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

At least in Western Europe, competitive social health insurance systems have implemented systems of morbidity-based risk adjustment to establish a level playing field for insurers. However, insured persons with specific socio-economic characteristics are still underfunded, leaving incentives for risk selection. In Germany, there is an ongoing debate about (re)implementing socio-economic variables to reduce this undercompensation. This study analyses whether the following four socio-economic groups are systematically under- or over-compensated under the present risk equalization system in Germany: insured persons with co-payment exemption (1), recipients of basic income support for unemployment (2), of benefits of social long-term care-insurance (3) and insured persons with reduced earning capacity (4). On this basis, several attempts of incorporating these variables into the German risk adjustment system, allowing a better fit for the socio-economically disadvantaged groups, are examined. With a data set of about 9.2 million insured persons, the performance of the modifications is demonstrated for the German system. The disparate outcomes of the various models in different dimensions necessitate the consideration of trade-offs and their incorporation into the implementation of a model designed to mitigate the undercompensation of the affected insured groups., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier B.V.)

Community development and population-oriented approaches are emphasized to advance the occupational therapy profession's scope of practice to meet the increasing demands created by socio-cultural-political and economic changes. This study explored the practice processes of occupational therapists in community settings outside existing health care structures in Germany. Data was gathered through five individual qualitative interviews and one focus group and analyzed using thematic analysis. Three main themes were identified: navigating parallel processes within the larger context or system; building community connections through occupation; growing professional identity. The utilization of occupational science concepts was essential to work successfully on a community level.

Mitigating ongoing losses of insects and their key functions (e.g. pollination) requires tracking large-scale and long-term community changes. However, doing so has been hindered by the high diversity of insect species that requires prohibitively high investments of time, funding and taxonomic expertise when addressed with conventional tools. Here, we show that these concerns can be addressed through a comprehensive, scalable and cost-efficient DNA metabarcoding workflow. We use 1815 samples from 75 Malaise traps across Germany from 2019 and 2020 to demonstrate how metabarcoding can be incorporated into large-scale insect monitoring networks for less than 50 € per sample, including supplies, labour and maintenance. We validated the detected species using two publicly available databases (GBOL and GBIF) and the judgement of taxonomic experts. With an average of 1.4 M sequence reads per sample we uncovered 10,803 validated insect species, of which 83.9% were represented by a single Operational Taxonomic Unit (OTU). We estimated another 21,043 plausible species, which we argue either lack a reference barcode or are undescribed. The total of 31,846 species is similar to the number of insect species known for Germany (~35,500). Because Malaise traps capture only a subset of insects, our approach identified many species likely unknown from Germany or new to science. Our reproducible workflow (~80% OTU-similarity among years) provides a blueprint for large-scale biodiversity monitoring of insects and other biodiversity components in near real time., (© 2024 The Author(s). Molecular Ecology Resources published by John Wiley & Sons Ltd.)

Based on the relevance of an established and broad foundation of physical activity in healthcare, this position paper of the DNVF working group Physical Activity-Related Health Services research presents current conceptual approaches to physical activity-related health services in Germany and highlights the need for interprofessional and interdisciplinary approaches. Three central positions are outlined and elaborated in order to integrate the evidence on health benefits of physical activity and exercise more strongly into healthcare and to show that, against the background of the challenges in the German healthcare system, physical activity-related health services can make a cost-effective and high-quality contribution to improve healthcare. These three positions include 1) the integration of all professional groups involved in healthcare into physical activity-related health services, 2) the greater integration of physical activity professions and physical activity interventions into all healthcare contexts and 3) the systematic consideration of physical activity- and exercise-related expertise in clinical guidelines., Competing Interests: JW ist Konsortialführer des genannten MOVE-ONKO Projektes und Koordinator der S3-Leitlinie Bewegungstherapie bei onkologischen Erkrankungen. JW und KE haben an der S2k-Leitlinie in der pädiatrischen Onkologie mitgearbeitet. GS ist Konsortialpartner des genannten ImPuls-Projekts. SP ist Mitarbeiter im DVGS e. V., der als Fachverband Bewegungsfachkräfte qualifiziert, für die qualitätsgesicherte Umsetzung von Bewegung in allen Versorgungskontexten eintritt und Mandatstragende für die Mitarbeit an Leitlinien entsendet. CT ist Professor für Physiotherapie an der Hochschule für Gesundheit Bochum, die einen primärqualifizierenden Bachelor-Studiengang „Physiotherapie“ anbietet und für die Vollakademisierung der Physiotherapie eintritt. BW ist im Präsidium der Deutschen Vereinigung für Sportwissenschaft (dvs) und vertritt im Ressort „Gesundheit und Bewegung“ die Interessen der Sportwissenschaft. Alle Autorinnen und Autoren haben Projekterfahrung mit der Entwicklung, Implementierung und/oder Evaluation von bewegungsbezogenen Interventionen in verschiedenen Versorgungskontexten. AS, CT, LG und SP sind im Sprecherrat der AG bewegungsbezogene Versorgungsforschung und verweisen auf die Darlegung ihrer entsprechenden Interessen (https://dnvf.de/gruppen/ag-bewegungsbezogene-versorgungsforschung.html). Alle anderen Autorinnen und Autoren sind Mitglied der AG Bewegungsbezogenen Versorgungsforschung und geben an, keine Interessenkonflikte zu haben., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Introduction: Health literacy is considered a determinant of several health-related behaviors and outcomes. Health literacy can be seen as a particularly relevant resource for health maintenance and promotion for young adults at the beginning of their challenging vocational training in nursing. However, the underlying mechanisms and the roles of other influencing factors such as self-efficacy remain unclear and need to be understood to successfully tailor interventions., Methods: This cross-sectional study aims to examine the relationships between health literacy, self-efficacy, health behavior and health status among 556 German trainees and students in nursing. Data were collected using paper-pencil and online questionnaires between January and June 2021. Mediation models were assessed, consisting of the direct pathways between health literacy and health status; health literacy and health behavior; and indirect pathways via self-efficacy., Results: The findings showed that health literacy positively affected self-rated health status ( ß  = 0.05, t  = 4.35, p  < 0.001) and psychological well-being ( ß  = 0.28, t  = 3.34, p  < 0.001). The effect of health literacy on psychological well-being was fully mediated through self-efficacy ( Z  = 265 4.91, p  < 0.001) while the effect of health literacy on self-rated health status was partially mediated through self-efficacy ( Z  = 5.06, p  < 0.001). In this cohort, there was no significant association between either health literacy or self-efficacy and health behavior., Conclusion: Self-efficacy should be taken into account when investigating health literacy and its possible relationships with health-related outcomes. Furthermore, it should be considered as an objective for health literacy interventions as well as health promotion measures for nursing students and trainees., 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 © 2024 Otto, Jürgensen, Nienhaus and Koch.)

Background: Geriatric comanagement has been shown to improve outcomes of older surgical inpatients. Furthermore, the choice of discharge location, that is, continuity of care, can have a fundamental impact on convalescence. These challenges and demands have led to the SURGE-Ahead project that aims to develop a clinical decision support system (CDSS) for geriatric comanagement in surgical clinics including a decision support for the best continuity of care option, supported by artificial intelligence (AI) algorithms., Objective: This qualitative study aims to explore the current challenges and demands in surgical geriatric patient care. Based on these challenges, the study explores the attitude of interviewees toward the introduction of an AI-supported CDSS (AI-CDSS) in geriatric patient care in surgery, focusing on technical and general wishes about an AI-CDSS, as well as ethical considerations., Methods: In this study, 15 personal interviews with physicians, nurses, physiotherapists, and social workers, employed in surgical departments at a university hospital in Southern Germany, were conducted in April 2022. Interviews were conducted in person, transcribed, and coded by 2 researchers (AU, LB) using content and thematic analysis. During the analysis, quotes were sorted into the main categories of geriatric patient care, use of an AI-CDSS, and ethical considerations by 2 authors (AU, LB). The main themes of the interviews were subsequently described in a narrative synthesis, citing key quotes., Results: In total, 399 quotes were extracted and categorized from the interviews. Most quotes could be assigned to the primary code challenges in geriatric patient care (111 quotes), with the most frequent subcode being medical challenges (45 quotes). More quotes were assigned to the primary code chances of an AI-CDSS (37 quotes), with its most frequent subcode being holistic patient overview (16 quotes), then to the primary code limits of an AI-CDSS (26 quotes). Regarding the primary code technical wishes (37 quotes), most quotes could be assigned to the subcode intuitive usability (15 quotes), followed by mobile availability and easy access (11 quotes). Regarding the main category ethical aspects of an AI-CDSS, most quotes could be assigned to the subcode critical position toward trust in an AI-CDSS (9 quotes), followed by the subcodes respecting the patient's will and individual situation (8 quotes) and responsibility remaining in the hands of humans (7 quotes)., Conclusions: Support regarding medical geriatric challenges and responsible handling of AI-based recommendations, as well as necessity for a holistic approach focused on usability, were the most important topics of health care professionals in surgery regarding development of an AI-CDSS for geriatric care. These findings, together with the wish to preserve the patient-caregiver relationship, will help set the focus for the ongoing development of AI-supported CDSS., (© Adriane Uihlein, Lisa Beissel, Anna Hanane Ajlani, Marcin Orzechowski, Christoph Leinert, Thomas Derya Kocar, Carlos Pankratz, Konrad Schuetze, Florian Gebhard, Florian Steger, Marina Liselotte Fotteler, Michael Denkinger. Originally published in JMIR Aging (https://aging.jmir.org).)

Objective: Stress is an extensive issue in modern society, affecting men and women differently. A better understanding of these patterns is required within the work context. Therefore, this study aimed to identify gender differences in the effects of stressors (quantitative demands, qualitative demands, working time) and resources (job control, quality of leadership, co-worker support) on subjective perceived stress across occupational groups., Methods: This study was conducted as a secondary data analysis based on the 'German Study on Mental Health at Work' data. The national representative cross-sectional sample included 4,118 employees. The data were analyzed using structural equation modeling., Results: Correlations between quantitative demands, working time, co-worker support, quality of leadership, job control, and subjective perceived stress were first confirmed for a total sample of employees. Gender differences in these interactions were then analyzed using multi-group equation modeling and a gender-stratified sample. Men and women showed an increase in subjective perceived stress for high quantitative demands. This increase was more prominent for men. Women further showed an increase in subjective perceived stress in response to long working time. High co-worker support, quality of leadership, and job control had stress-reducing effects but did not result in significant gender differences. No association was found between qualitative demands and subjective perceived stress., Conclusion: The results underline that not all working conditions significantly impact stress for both genders and gender differences exist only within the stressors. Hence, gendered strategies may only be required in some constellations. However, specific contexts require integrating gendered approaches in research and operational practice., 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 © 2024 Heub, Schaller and Lange.)

Objectives: Studies have identified sociodemographic and socioeconomic factors that promote participation in workplace health promotion activities. The present study therefore focuses on what influences nonparticipation within a representative sample of the German population., Methods: In the analysis of possible factors influencing nonparticipation, company characteristics are accounted for in addition to sociodemographic and health behaviour-related variables. The data used for the analysis are from the GEDA study 2014/2015-EHIS of the Robert Koch Institute in Berlin., Results: Age largely increased the probability of nonparticipation (OR: between 1.30 and 1.92, p: between <0.001 and 0.033). Other possible influencing factors, such as weight, smoking status, alcohol consumption, exercise status and diet, seemed to play a rather minor role in the present analysis. Self-rated belonging to a certain socioeconomic status group also had a significant influence (OR: 0.76, p: <0.001)., Conclusion: The influencing factors seem to be of a sociodemographic and socioeconomic nature. These determinants should be accounted for to reduce nonparticipation. However, a comparison with current or longitudinal data would be needed to prove to what extent the results are still valid or influenced by a cohort effect., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2024 Pache, Herbig, Nowak and Janssen.)

Objectives: Clinical guidelines recommend high-frequency speech therapy for people with aphasia. Little is known about the experiences of people with aphasia with high-frequency speech therapy, why they do not receive it, what they expect from it and their general wishes and requirements for therapy. The aim of this qualitative study was to investigate the reasons for refusing high-frequency speech therapy and therapy preferences of patients with aphasia., Design: An interview study with people with aphasia., Setting: Interviewees were recruited via snowball sampling in different settings of healthcare system (eg, speech and language practices, self-help groups, clinics of neurorehabilitation)., Participants: Twenty-one people with aphasia and one relative participated in semi-structured interviews., Results: We identified five categories of not using high-frequency speech therapy: patient-related factors, health system-related factors, disease-related factors, social-economic factors and organisational factors. Most reasons for non-utilisation are within the domain of the healthcare system and are partly attributable to personnel shortages in care provision and knowledge deficits among healthcare practitioners. Patient therapy preferences notably pertain to the enhancement of speech therapy services, encompassing sessions both inclusive and exclusive of family members as well as the facilitation of information dissemination., Conclusions: As expected, there were indications of a lack of staff, poor care in rural areas and the influence of being affected by aphasia for a longer period on utilisation behaviour. These factors in the healthcare system and organisational factors are not unknown to those with practical experience, and some of them must and could be changed quickly. This would require a change from the established face-to-face setting in presence to sufficient digital therapy adjuvants. The results of patient-related factors could be a further reason to reflect on speech therapy and its settings and to view and treat people with aphasia in a more holistic, less language-focused way., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction:  Miscarriage is the most common complication of pregnancy. In this work, the experiences associated with miscarriage and their relevance for the women are analysed on different levels., Method:  In May 2023, 14 guided interviews were conducted with women. The text material obtained will be brought to a higher level of abstraction using Mayring's content analysis approach and then interpreted., Results:  The results of the study underpin the significance of a miscarriage as a dramatic experience and the assumption of a broad taboo experienced as stressful. The deliberately chosen exchange among like-minded people, the concealment of the pregnancy and subsequently the miscarriage for reasons of shame, self-protection from professional disadvantages, and the assumption of overburdening the partner do not weigh as heavily as those mechanisms that operate in the health sector: at this level, mistrust, trivialisation and organisational and spatial inadequacies contribute to tabooing. The stressful circumstance of miscarriage is cushioned by people who recognise the grief and offer support., Conclusions:  Based on the results of the study, improvements can be derived primarily in the area of care: Recognition of miscarriage, needs-based support services, improvement of communicative elements and organisational and spatial framework conditions., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The dramatic growth in the rate of diabetes prompts serious debates about awareness, early diagnosis, and care interventions. This Viewpoint aims to explore, from the perspectives of healthcare sector representatives, what challenges and difficulties they face in dealing with diabetes and how these can be overcome. We applied the World Café method for group discussions, which enabled us to bring together 50 stakeholders. They identified challenges at institutional and structural levels under the concepts of awareness, digitalisation, and new forms of care and shared their suggestions for feasible solutions. We learned there is a need for a diabetes map of Germany to identify risk groups and that hybrid solutions should be implemented for treatment, care, prevention, and early diagnosis, considering digital infrastructure. Also, the demand for digital innovation in the healthcare system raised concerns about information transparency and data management., Competing Interests: Declarations. Competing interests: The funders had no role in the design of the study, in the writing of the manuscript, and in the decision to publish the results., (© 2024. The Author(s).)

Background: Community pharmacy practice is rarely considered in ethical research, although various ethical conflicts are known for this setting. Data on the actual frequency and perceived burden of ethical conflicts occurring in the community pharmacy setting are required., Aim: The survey aimed at investigating the frequency and perceived burden of ethical conflicts, reasons for the perceived burden and influences on decision-making in ethical conflicts in German community pharmacists., Method: An online survey was conducted among community pharmacists. It contained 15 ethical conflicts in which the ethically required action conflicts with another principle (e.g. law). Basing on these conflicting principles, 12 considerations relevant for decision-making were defined (e.g. solidarity principle). Participants were asked to rate the ethical conflicts in terms of frequency and perceived burden and to rate the influence on decision-making for the considerations. Results were analysed descriptively., Results: Five hundred and thirty-five questionnaires were evaluated. The participant's median age was 39 (min-max: 20-78) years, 378 (71%) were female. Seven of the 15 predefined ethical conflicts were rated as occurring predominantly at least once a week. "Generic drug is not most suitable" was rated as the most frequent. Three ethical conflicts were rated mainly with a (very) strong burden. "Concerns for an unborn child" was rated as the most burdensome. Three of the 12 predefined decision-making considerations: pharmaceutical knowledge, legal requirements and personal values were rated primarily as having a very strong influence on decision-making., Conclusion: Pharmacists in community pharmacies are frequently affected by burdensome ethical conflicts in patient care situations., Competing Interests: Conflicts of interest The authors have no conflict of interest to declare., (© 2024. The Author(s).)

Purpose: Next-generation sequencing (NGS) tools have clinical advantages over blood culture but are more expensive. This study assesses the budget impact and break-even point of NGS testing costs from a healthcare provider's perspective in Germany., Methods: The budget impact was calculated based on aggregated data of German post-operative surgery cases. Simulated cost savings were calculated based on a simulated reduction in hospital length of stay (LOS) of four or eight days with a positivity rate of 71% and compared to the costs of one (scenario A) or two tests (scenario B) per case. Furthermore, the break-even point of the cost of two tests compared to saved costs through shortened LOS was conducted., Results: For 9,450 cases, an average budget impact for scenario A and scenario B of €1,290.41 [95% CI €1,119.64 - €1,461.19] and - €208.59 [95% CI - €379.36 - - €37.81] was identified for gastrointestinal and kidney surgery cases, and €1,355.58 [95% CI €1,049.62 - €1,661.55] and €18.72 [95% CI - €324.69 - €287.24] for vascular artery surgery cases, respectively. The break-even analysis showed that using two tests per case could achieve a minimum positive contribution margin with an average of 1.9 tests per case across the study population., Conclusion: The results revealed a positive budget impact for one NGS test and a slightly negative budget impact for two NGS tests per case. Findings suggest that largest cost savings are generated for more severe cases and are highly dependent on the patient population., Competing Interests: Declarations. Ethics approval: Ethics approval is not required for this study in accordance with local or national guidelines. Competing interests: Financial interests: Authors Anne Wenzel, Johanna Röder, Tabea Poos, and Florian Kron are independent employees of VITIS Healthcare Group and received research funding from Noscendo GmbH. Author Fabian Dusse declares that he has no conflicts of interest., (© 2024. The Author(s).)

Background: The loss of hearing and thus communication affects the well-being of millions of people worldwide. Digital tools for coping with everyday life are becoming increasingly important and can have a positive impact on health literacy, especially among young adults. This raises the question of which issues such apps should specifically address in order to meet the needs of young adults with hearing loss or deafness., Methods: The aim was to identify the health issues of young adults (aged 18-28 years) with hearing loss or deafness in order to derive specific recommendations for a conversational agent (chatbot). A multiple embedded case study design consisting of chat interviews (n = 8) and an online-based expert survey (n = 14) was used., Results: The central phenomenon focuses on "The sense of belonging and feeling well in spite of hearing loss", which is influenced by two main categories: a. the ability to be oneself despite one's vulnerability; b. the desire to be strong despite one's vulnerability. Important health issues include depression, drug use, diet, exercise, isolation due to COVID measures and HIV prophylaxis., Conclusion: Written information must be provided in simple and accessible language supported by images and symbols. Conversation agents developed to support people with hearing impairment should be easy to install and self-explanatory to use., (Copyright © 2024. Published by Elsevier GmbH.)

Purpose: To identify dietary patterns of vegetarian, vegan and omnivore children and adolescents in Germany and to examine associations with nutrient intake., Methods: First, three principal component analyses based on 17-22 food groups were used to identify dietary patterns among vegetarians (n = 145, 3-day weighed dietary records), vegans (n = 110) and omnivores (n = 135) from the cross-sectional Vegetarian and Vegan Children and Youth (VeChi Youth) Study (2017-2019, 6-18 years, 57% girls). Secondly, these patterns were correlated (Spearman correlations) with energy and nutrient intakes., Results: Among vegetarians, 3 dietary patterns were identified ("Animal foods", "Vegetables and fruits", "Meat alternatives and potatoes") accounting for 32.7% of the variance in food group intake. In the vegan group, 4 patterns were identified ("Vegetables and legumes", "Refined carbohydrates", "Meat alternatives and juices", "Fruits and convenience foods") accounting for 43.2% of the variance. Among omnivores, 5 ("Flexitarian", "Vegetables and fruits", "Dairy Products", "meat and convenience foods", "Refined grains and juices") patterns accounting for 43.0% of the variance could be identified. Regardless of diet group, both more favorable dietary patterns ("Vegetables and fruits", "Meat alternatives and potatoes", "Vegetables and legumes", "Fruits and convenience food", "Flexitarian") correlated with higher micronutrient density and less favorable dietary patterns ("Animal foods", "Refined carbohydrates", "Meat alternatives and juices", "Dairy products", "Meat and convenience food", "Refined grains and juices") with unfavorable nutrient profiles were found., Conclusion: Various dietary patterns exist within omnivore, vegetarian, and vegan diets of children and adolescents, which differ in their contribution to nutrient intake. It is therefore necessary to distinguish between different dietary patterns, also within the vegetarian and vegan diet., (© 2024. The Author(s).)

Background: In systematic reviews (SRs), geographical limitations in literature searches can aid in focussing research efforts. A methodological review published in 2016 examined the approaches SR authors use to identify studies about Germany, analysing 36 SRs., Objective: The aim of this study was to update the original review., Methods: We conducted a literature search on PubMed for SRs synthesising evidence from studies about Germany published between 22 January 2016 and 7 June 2022. Two reviewers independently performed study selection and data extraction. We evaluated the application of search syntax for restricting studies to those about Germany using the peer review of electronic search strategies criteria. The updated findings were reported and summarised alongside those of the original review., Results: Thirty-two additional SRs were newly included (total = 68). Geographic restrictions were applied in 57 SRs, representing 72% in the original review and increasing to 97% in the newly included SRs. Moreover, there was an increased use of truncations and field tags., Conclusion: Although geographical restriction methods are increasingly utilised, additional tools are necessary to enhance the robustness of search strategies. The development of a dedicated geographical search filter would facilitate the identification of studies about Germany., (© 2024 The Authors Health Information and Libraries Journal published by John Wiley & Sons Ltd on behalf of Health Libraries Group.)

Although the paper industry processes polymeric materials and discharges large amounts of wastewater, no research on microplastics in the wastewater from paper mills has been published to date. This study is the first to investigate this issue. The wastewater treatment plants of twelve representatively selected German paper mills were investigated using an analysis protocol based on µ-Raman spectroscopy. The results show that treated process water from surface waters is negligible as a source of microplastics (MPs) ≥ 20 µm. The microplastics concentrations in untreated wastewater range from 10 6 to 10 8 (MPs ≥ 20 µm)/m 3 . Sources of microplastics in wastewater include recovered paper, functional polymers, and coating colors, among others. The most frequently detected polymers are polyethylene and polystyrene. In four cases, moving bed biofilm reactors were identified as a source of microplastics. The microplastics concentration in treated wastewater ranges from 10 2 to 10 4 (MPs ≥ 20 µm)/m 3 . Hence, the removal rate of the wastewater treatment plants exceeds 99 %. Mechanical treatment and the activated sludge process have the highest removal rates of all treatment stages. The loads emitted into surface waters range from 10 6 to 10 8 (MPs ≥ 20 µm)/h, comparable to municipal wastewater treatment plants with a population equivalent of over 10,000 inhabitants. Compared with other wastewater-related emissions (the total emissions of municipal wastewater treatment plants, or combined sewer overflow), the contribution of paper mills to microplastics in the aquatic environment is low. The results of the removal efficiency can be transferred to other branches of industry and municipal wastewater treatment plants., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Felix Steinfeld reports financial support was provided by German Federal Ministry of Economic Affairs and Climate Action. Antje Kersten reports financial support was provided by German Federal Ministry of Economic Affairs and Climate Action. Samuel Schabel reports financial support was provided by German Federal Ministry of Economic Affairs and Climate Action. Jutta Kerpen reports financial support was provided by German Federal Ministry of Economic Affairs and Climate Action. Felix Steinfeld reports writing assistance was provided by AngloDoc. Felix Steinfeld reports administrative support was provided by Kuratorium für Forschung und Technik in der Papier- und Zellstoffindustrie im VDP e.V. Antje Kersten reports administrative support was provided by Kuratorium für Forschung und Technik in der Papier- und Zellstoffindustrie im VDP e.V. Samuel Schabel reports administrative support was provided by Kuratorium für Forschung und Technik in der Papier- und Zellstoffindustrie im VDP e.V. Jutta Kerpen reports administrative support was provided by Kuratorium für Forschung und Technik in der Papier- und Zellstoffindustrie im VDP e.V. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Socioeconomic inequalities have been associated with poorer mental health outcomes in children and adolescents during the COVID-19 pandemic. Despite numerous studies on individual risk factors, the impact of societal environment, such as neighborhood characteristics, on changes in mental health has rarely been investigated. This study investigates the effect of neighborhood deprivation on mental health problems and health-related quality of life (HRQoL) in children and adolescents during the COVID-19 pandemic in Hamburg, Germany., Methods: Data were derived from the prospective German COPSY Hamburg study. Children and adolescents aged between 11-20 years and their parents participated in the study, which took place in summer 2020 (T1) and summer 2022 (T2). Neighborhood deprivation was assessed by a neighborhood status index. Mental health problems and HRQoL were assessed using internationally validated and established instruments. The prevalence of mental health problems and impaired HRQoL was reported. Analysis of covariance was conducted to examine the effect of neighborhood deprivation of the districts in Hamburg on the (changes in) mental health problems and HRQoL while controlling for social individual-level indicators., Results: The total sample included in the statistical analysis consisted of N = 2,645 families. Children and adolescents living in more deprived areas had higher levels of general mental health problems and depressive symptoms during the COVID-19 pandemic. However, differences in neighborhood deprivation did not relate to the HRQoL and the averaged changes in children and adolescents' mental health problems and HRQoL from summer 2020 to summer 2022., Discussion: Neighborhood deprivation is associated with impaired mental health in youth during the COVID-19 pandemic. Children and adolescents' mental health and overall well-being should be addressed by health promotion measures to create a health-promoting living environment, including diverse neighborhoods. Future research should focus on uniform assessment methods and addressing additional neighborhood factors., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: The concept of "Healing Architecture" addresses the relevance of design and architectural issues on the outcome of medical and therapeutic treatment in hospitals. The questionnaire ARCHI was developed to record data on the opinion of different groups of users on the architectural design of their therapeutic environment in departments of child and adolescent psychiatry., Method: A Questionnaire-based cross-sectional study was conducted in two phases between 2020 and 2022 using ARCHI to gather the perspectives of senior physicians and architects on the significance of architectural design in German child and adolescent psychiatric facilities., Results: In the survey of the senior physicians, 49 heads of child and adolescents psychiatric departments initiated the survey, and 73.5% (n = 36) of them completed the questionnaire in its entirety. During the survey for the architect-specific, 145 individuals commenced the survey, and 60.7% of them completed the questionnaire (n = 88). Significant differences between architects and senior physicians became visible for four of the 93 items, namely "environment of the hospital", "structure of building", "labelling of floors" and "visible cleanliness"., Conclusions: Although senior physicians and architects were characterized by the same opinions on the relevance of architectural design on therapeutic issues for the major part of issues, differences could be obtained for several aspects which are important for the architectural planning of new departments and hospitals. It remains open why both professional groups had different point of views on these four aspects of hospital design which should be clarified to improve the process of hospital development in the future., Competing Interests: Declarations Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Persons with dementia spend a large part of the day without care and encounters, often without activity, as confirmed by numerous studies. However, no scientific analysis has examined how persons with dementia experience these periods. Such knowledge would be highly relevant for health care professionals and relatives to develop adequate strategies for dealing with times without care., Objective: We aim to reconstruct times without care and encounters in persons with dementia in the nursing home and domiciliary care settings and develop a typology. This typology will address the lifeworld understandings of time and the ways of arranging the time of persons with dementia., Methods: Our study is designed as an explorative, sequential multimethods investigation. We aim to systematically reconstruct times without care and encounters over a period of 36 months using ethnographic methods. Afterward, we will examine the resulting typology using a survey. To describe different social and caring cultures, practices, and arrangements, we will analyze time periods across all phases of dementia in (1) institutions exclusively caring for persons with dementia, (2) institutions where persons with dementia and those without live together, and (3) domiciliary care. For each type of care, our target is 10 intensive case observations. These observations will occur in both participatory and nonparticipatory ways. We video record selected situations and conduct situational conversations and interviews with persons with dementia and nurses. We are aiming for a minimum sample of 30 persons with dementia plus their caregivers (ie, relatives of people with dementia and professional caregivers). We will analyze data according to grounded theory methodology. Furthermore, we will perform a hermeneutic sequence analysis of selected text passages. To interpret the video material, we will conduct a video interaction analysis. To obtain complementary information about the newly developed typology, we will survey approximately 400 formal and 150 informal caregivers. We will summarize the ethnography and survey findings into an overall concept of times without care and encounters in persons with dementia. To fulfill the research objectives, our cross-disciplinary and cross-country team comprises researchers with expertise in nursing sciences, gerontology, sociology, psychology, and ethnography., Results: Our approach allows formulating statements about the nature, frequency, and prevalence of times without care and encounters in people with dementia across countries and types of care. Thus, we will contribute to making visible the lifeworld of persons with dementia. Our study commenced in March 2022 and will conclude in May 2025. The results are expected to be published in the fall of 2025., Conclusions: Our research offers points of departure for the representative investigation of times without care and encounters in persons with dementia, for the development of diagnostic instruments, and for dealing critically with possibilities of interruption (eg, by developing targeted interventions)., International Registered Report Identifier (irrid): DERR1-10.2196/58190., (©Thomas Beer, Julian Hirt, Laura Adlbrecht, Ulrike Lindwedel, Matthias Dammert, Carola Maurer, Matthias Kliegel, Peter König, Helma M Bleses. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 18.11.2024.)

Background: Sex differences exist in type 2 diabetes (T2D), and androgens have been implicated in the etiology of T2D in a sex-specific manner. We therefore aimed to investigate whether androgens play a role in explaining sex differences in glucose homeostasis and incidence of T2D., Methods: We used observational data from the German population-based KORA F4 study (n = 1975, mean age: 54 years, 41% women) and its follow-up examination KORA FF4 (median follow-up 6.5 years, n = 1412). T2D was determined through self-reporting and confirmed by contacting the physicians and/or reviewing the medical charts. Multivariable linear and logistic regression models were employed to explore associations. Mediation analyses were performed to assess direct effects (DE) and indirect effects (IE), and the mediating role of androgens (total testosterone (TT), dehydroepiandrosterone (DHEA), dehydroepiandrosterone-sulfate (DHEAs)) in the association between sex (women vs. men) and glucose- and insulin-related traits (cross-sectional analysis) and incidence of T2D (longitudinal analysis)., Results: After adjustment for confounders, (model 1: adjusted for age; model 2: model 1 + smoking + alcohol consumption + physical activity), women had lower levels of TT, DHEAs, fasting glucose levels, fasting insulin levels, 2 h-glucose levels and HOMA-IR, compared to men. An inverse association was observed for TT and glucose- and insulin-related traits in men, while a positive association was observed for TT and fasting glucose levels in women. We found a mediatory role of TT on the association of sex with fasting glucose levels (IE: β = 3.08, 95% CI: 2.04, 4.30), fasting insulin levels (IE: β = 0.39, 95% CI:0.30, 0.47), 2 h-glucose levels (IE: β = 12.77, 95% CI: 9.01, 16.03) and HOMA-IR (IE: β = 0.41, 95% CI: 0.33, 0.50). Also, the inconsistent mediatory role of TT was seen on the association of sex with incidence of T2D (DE: 0.12, 95% CI: 0.06, 0.20 and IE: OR = 7.60, 95% CI: 3.43, 24.54). The opposing DE and IE estimates suggest that the association between sex and either glucose homeostasis or the incidence of T2D may differ when TT is considered as a potential mediator, with higher TT levels being beneficial for glucose metabolism or incidence of T2D in men, while in women, detrimental. No mediatory role was observed for either DHEA or DHEAs on glucose homeostasis or the incidence of T2D., Conclusions: The dimorphic mediatory role of TT highlights its complex role in metabolic health, contributing differently to the glucose dysregulation and risk of T2D in men and women., Competing Interests: Declarations Competing interests The authors declare no competing interests. Ethics approval All study participants have provided written informed consent. The study was approved by the Ethics Committees of the Bavarian Chamber of Physicians (Ethical Approval Number 06068) adhering to the declaration of Helsinki. Informed consent Informed consent was obtained from all individual participants included in the study., (© 2024. The Author(s).)

Background: Refugees are exposed to various risk factors in shared accommodations in Germany where they are housed after their arrival. Due to their often traumatic experiences before, during, and after their flight and socio-structural post-migration stressors, refugees are potentially vulnerable to hazardous substance use. They form a structurally disadvantaged group for substance use prevention and intervention. Various barriers make it difficult for them to access the healthcare system and to get health information. Therefore, a participatory multi-component prevention concept for refugees in shared accommodations was developed. The aim of the trial is to evaluate the efficacy of this concept regarding the increase in knowledge about substance use among refugees living in shared accommodations., Methods: Based on a randomized controlled stepped-wedge design, the study will be conducted in a multicenter setting in nine shared accommodations and will aim to include refugees living in shared accommodations as well as social workers and psychologists working there., Discussion: This trial will be one of the first to generate evidence about effective participatory prevention concepts for refugees in shared accommodations. Evidence-based concepts for refugees can improve access to health care and might be helpful for the multidisciplinary workforce in shared accommodations., Trial Registration: OSF Registry: osf.io/ebnj3. Registered on May 24, 2024. Registration DOI: https://doi.org/10.17605/OSF.IO/EBNJ3., Competing Interests: Declarations Ethics approval and consent to participate {24} The Alice Salomon University Ethics Committee in Berlin (file reference: 01-2024/62) provided ethical approval for this study. Written, informed consent to participate will be obtained from all participants (refugees and workforce in shared accommodations). The study will be accompanied by a psychological background service to deal with emergency situations. Consent for publication {32} See supplemental files for the model consent form in English. This document will also be available in German, French, Farsi, Arabic, Russian, and Turkish. Additionally, there will be multilingual flyers in easy language. Competing interests {28} The authors declare that they have no competing interests., (© 2024. The Author(s).)

Background: During the COVID-19 pandemic, health literacy was found to be an asset to manage health-related information. The HLS-COVID-Q22 has been developed to measure COVID-19 health literacy. External validation needs to be assessed in different populations to verify the questionnaire's functioning. The present study aimed to evaluate the psychometric properties of the HLS-COVID-Q22 in a sample of German school principals., Methods: The sample consisted of 2187 German school principals who completed the HLS-COVID-Q22 online from April to March 2021. The data was analyzed using Rasch analysis, applying the Partial Credit Model for polytomous data. Dimensionality, item fit statistics and rating scale functioning was tested. Values for item difficulty and person ability as well as reliability indices were computed., Results: Unidimensionality could be confirmed. The rating scale categories worked as intended, participants used every rating step category. Generally, item fit was verified. One item showed potential misfit but could remain in the questionnaire as excluding the item did not reduce reliability. A person separation index of 3.41 and person reliability of 0.92 showed excellent differentiation between COVID-19 health literacy levels. Furthermore, the values for item separation of 20.08 and item reliability of 1.0 indicate good construct validity., Conclusions: The German version of the HLS-COVID-Q22 appears to be a reliable measurement tool for the target population. Evidence for construct, statistical and fit validity was collected. Future studies need to test additional types of validity like convergent and divergent validity to further evaluate the questionnaire. Moreover, the psychometric properties of the translated versions of the HLS-COVID-Q22 should be compared using Rasch analysis., Competing Interests: Declarations Ethics approval and consent to participate Participants gave written informed consent prior to taking part in the survey. Participation was voluntary, and the questionnaire was completed anonymously. This study has been performed in accordance with the Declaration of Helsinki and was approved by the Bielefeld University Ethics Board (Reference No 2021-030). Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: The prevalence of mental health problems is increasing worldwide, particularly in the vulnerable group of older people. The limited availability of therapists, long wait periods and increasing shortage of healthcare resources limit adequate care. As a result, digital applications are becoming more commonplace as an alternative to human therapists. However, these tend to be used by younger people with higher education, digital health literacy and experience. In Germany, applications that are approved by the health authorities, so-called digital health applications (DiGAs), can be prescribed by physicians and psychotherapists. It remains unclear to the extent older people are experienced with, are willing and can use a DiGA. Therefore, this research aims to identify specific challenges of older people's accessibility, user experience and engagement with DiGA for depressive disorders. The DiGA4Aged project consists of: (1) a pilot study on usability, (2) a screening study on potential participants for a randomised controlled trial (RCT) evaluating the digital experience of the target population and (3) an RCT to test the effectiveness of a digital nurse as individualised user support in the intervention group. This paper focuses on the pilot study and the screening study., Methods and Analysis: The instrumental components in preparing for the RCT are a mixed-method pilot and observational quantitative screening study, which are described in this manuscript. The pilot study includes questionnaires (covering sociodemographic data, user experience, health literacy, electronic health literacy, media affinity, severity of depression and perceived usability of DiGA), a concurrent think aloud method and a semistructured interview to evaluate two applications with regard to their usability for, acceptance by and needs of older people. The observational screening study collects data of older patients consecutively admitted to an acute care geriatric hospital ward using various questionnaires to identify which clinical and medical factors are associated with the access to, experience with and (non-)use of digital media. Data from the comprehensive geriatric assessment is collected as well as data on their digital media experience and digital health literacy., Ethics and Dissemination: The overall project DiGA4Aged received ethical approval on 17 November 2023 from the ethics committee of the Medical Faculty of Ruhr-University Bochum (registration number 23-7901). Results will be disseminated within the scientific community via publication in peer-reviewed journals as well as presentation at national conferences. The findings from the pilot study and the observational screening study will determine the selection of the DiGA and the recruitment strategy for the subsequent RCT., Trial Registration Numbers: The pilot study has been prospectively registered in the German Clinical Trials Register (DRKS00033640, registered on 18 March 2024, available from https://drks.de/search/de/trial/DRKS00033640). Likewise, the observational screening study has been prospectively registered in the German Clinical Trials Register (DRKS00032931, registered on 29 November 2023, available from https://drks.de/search/de/trial/DRKS00032931)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In musculoskeletal pain (MSP), pain duration, disability, and mental health relate to how a person engages in daily activities. The self-reporting questionnaire Activity Patterns Scale (APS) assesses these activity patterns and their subscales: Pacing (Pacing to increase activity levels,Pacing to conserve energy for valued activities,Pacing to reduce pain); Avoidance (Pain avoidance,Activity avoidance); Pacing (Excessive persistence, Task-contingent persistence, Pain-contingent persistence). This investigation translated the APS into German and estimated its internal consistency, test-retest reliability, and construct validity. The APS translation was conducted following international guidelines for the transcultural adaptation of self-reported measures. For the construct validity, the Avoidance Endurance Fast-Screening (AE-FS), Tampa Scale of Kinesiophobia (TSK), and Coping Strategies Questionnaires (CSQ) scales were employed. Sixty-five participants with MSP contributed to a baseline survey with a follow-up at two weeks. The German version of the APS subscales demonstrated good internal consistency (Cronbach's alpha = 0.670-0.89) and satisfactory test-retest reliability (intraclass correlation coefficient = 0.72-0.82); only Task-contingent persistence revealed a poor result. Construct validity was supported by significant correlations between APS subscales (pacing, avoidance, persistence) with related measures, including the Coping Strategies Questionnaire (0.27 to 0.40; -0.50 to 0.55; 0.27 to 0.50), the Tampa Scale for Kinesiophobia (0.28 to 0.47; 0.36 to 0.37; 0.38), and Avoidance-Endurance Fast Screening Pain Persistence Scale (none; none; 0.40). The findings demonstrate high construct validity by the substantial correlations in the predicted directions for the APS subscales and their corresponding questionnaires. The German version of the APS is a reliable and valid tool for assessing activity pattern subscales in individuals with MSP. This distinction could refine research and customize treatment instructions to regulate people's activity in clinical practice., (© 2024. The Author(s).)

Background: Anemia and deficiency of vitamin D (VDD) are frequently seen in seniors and an association is suspected. Approximately one third of the German population is affected by VDD, with a rising prevalence among seniors., Aim: To analyze the association between anemia and VDD among German seniors aged ≥ 60 years., Methods: Retrospective cross-sectional data analysis (n = 4008) in a nationwide working laboratory medical center (January-December 2019). Study parameters included amongst others: hemoglobin (Hb), calcifediol (25D) and calcitriol (1.25D), glomerular filtration rate (GFR) to assess the kidney disease outcomes quality initiative (KDOQI) state. The inclusion criteria were age ≥ 60 years, normal C‑reactive protein (CRP) and leucocyte levels., Results: The 25D was estimated in 4008 patients and 1.25D only in 411 patients. Mean age 75 years (± 8.61 years; 60-99 years) with 30.6% males; mean GFR 62 ml/min/1.73 m 3 (± 22.74); 20% of patients were anemic, 35% were deficient for 25D (< 50 nmol/l), with men > women (p = 0.014). Linear regression analysis revealed a significant effect of 25D values < 30 nmol/l on hemoglobin in males of KDOQI I-III and females of KDOQI I-IV (R2 = 0.052; p = 0.005; and R2 = 0.124; p < 0.001, respectively). For 1.25D a weak but significant effect on hemoglobin independent of KDOQI was only seen in women (R2 = 0.200; p = 0.005)., Conclusion: In this cohort deficiency of 25D and 1.25D was significantly associated with hemoglobin independent of renal function only in women but not in men., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Connected and autonomous vehicles (CAVs) will greatly impact the lives of individuals with visual impairments, but how they differ in expectations compared to sighted individuals is not clear. The present research reports results based on survey responses from 114 visually impaired participants and 117 panel recruited participants without visual impairments, from Germany. Their attitudes towards autonomous vehicles and their expectations for consequences of wide-spread adoption of CAVs are assessed. Results indicate significantly more positive CAV attitudes in participants with visual impairments compared to those without visual impairments. Mediation analyses indicate that visually impaired individuals' more positive CAV attitudes (compared to sighted individuals') are largely explained by higher hopes for independence, and more optimistic expectations regarding safety and sustainability. Policy makers should ensure accessibility without sacrificing goals for higher safety and lower ecological impact to make CAVs an acceptable inclusive mobility solution.

While geographic search filters exist, few of them are validated and there are currently none that focus on Germany. We aimed to develop and validate a highly sensitive geographic search filter for MEDLINE (PubMed) that identifies studies about Germany. First, using the relative recall method, we created a gold standard set of studies about Germany, dividing it into 'development' and 'testing' sets. Next, candidate search terms were identified using (i) term frequency analyses in the 'development set' and a random set of MEDLINE records; and (ii) a list of German geographic locations, compiled by our team. Then, we iteratively created the filter, evaluating it against the 'development' and 'testing' sets. To validate the filter, we conducted a number of case studies (CSs) and a simulation study. For this validation we used systematic reviews (SRs) that had included studies about Germany but did not restrict their search strategy geographically. When applying the filter to the original search strategies of the 17 SRs eligible for CSs, the median precision was 2.64% (interquartile range [IQR]: 1.34%-6.88%) versus 0.16% (IQR: 0.10%-0.49%) without the filter. The median number-needed-to-read (NNR) decreased from 625 (IQR: 211-1042) to 38 (IQR: 15-76). The filter achieved 100% sensitivity in 13 CSs, 85.71% in 2 CSs and 87.50% and 80% in the remaining 2 CSs. In a simulation study, the filter demonstrated an overall sensitivity of 97.19% and NNR of 42. The filter reliably identifies studies about Germany, enhancing screening efficiency and can be applied in evidence syntheses focusing on Germany., (© 2024 The Author(s). Research Synthesis Methods published by John Wiley & Sons Ltd.)

Background: X-linked hypophosphatemia (XLH) is a rare inherited phosphate-wasting disorder associated with bone and dental complications. Health-related quality of life (HRQoL) is reduced in XLH patients on conventional treatment with phosphate supplements and active vitamin D, while information on patients treated with burosumab is rare., Methods: HRQoL was assessed in 63 pediatric XLH patients participating in a prospective, observational study and patient registry in Germany using the KIDSCREEN-52 survey instrument and standardized qualitative interviews., Results: The median age of the XLH patients was 13.2 years (interquartile range 10.6 - 14.6). At the time of the survey, 55 (87%) patients received burosumab and 8 (13%) conventional treatment. Forty-six patients (84%) currently being treated with burosumab previously received conventional treatment. Overall, HRQoL was average compared to German reference values (mean ± SD: self-report, 53.36 ± 6.47; caregivers' proxy, 51.33 ± 7.15) and even slightly above average in some dimensions, including physical, mental, and social well-being. In general, XLH patients rated their own HRQoL higher than their caregivers. In qualitative interviews, patients and caregivers reported that, compared with conventional therapy, treatment with burosumab reduced stress, bone pain, and fatigue, improved physical health, and increased social acceptance by peers and the school environment., Conclusions: In this real-world study in pediatric XLH patients, HRQoL was average or even slightly above that of the general population, likely due to the fact that the vast majority of patients had their treatment modality switched from conventional treatment to burosumab resulting in improved physical health and well-being., (© 2024. The Author(s).)

Wastewater treatment plant (WWTP) influent sampling is commonly used in wastewater-based disease surveillance to assess the circulation of pathogens in the population aggregated in a catchment area. However, the signal can be lost within the sewer network due to adsorption, degradation, and dilution processes. The present work aimed to investigate the dynamics of SARS-CoV-2 concentration in three sub-catchments of the sewer system in the city of Hildesheim, Germany, characterised by different levels of urbanisation and presence/absence of industry, and to evaluate the benefit of sub-catchment sampling compared to WWTP influent sampling. Our study shows that sampling and analysis of virus concentrations in sub-catchments with particular settlement structures allows the identification of high concentrations of the virus at a local level in the wastewater, which are lower in samples collected at the inlet of the treatment plant covering the whole catchment. Higher virus concentrations per inhabitant were found in the sub-catchments in comparison to the inlet of the WWTP. Additionally, sewer sampling provides spatially resolved concentrations of SARS-CoV-2 in the catchment area, which is important for detecting local high incidences of COVID-19., Competing Interests: The authors declare there is no conflict., (© 2024 The Authors This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/).)