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This article examines the implementation, participation rates, and potential determinants of participation in the digital addiction prevention program "ready4life." A two-arm cluster-randomized trial recruited German vocational students via class-based strategies. Intervention group received 16 weeks of in-app coaching; the control group received health behavior information, with coaching offered after 12 months. Potential determinants of participation were analyzed based on class and individual characteristics. Out of 525 contacted schools, 35 participated, enrolling 376 classes. Implementation during the pandemic required flexible adjustments, with 49.7% of introductions conducted in person, 43.1% digitally via online streaming, and 7.2% received a video link via email. Despite challenges, 72.3% of the vocational students downloaded the app, and 46.7% gave informed consent. Participation rates were highest among (associate) professionals, vocational grammar school classes, classes introduced by females, younger individuals, members of the project team, and classes introduced face-to-face. Female gender, lower social competencies, lifetime cannabis use, higher problematic internet use, and higher perceived stress were associated with higher individual participation. The study highlights the importance of proactive outreach and personalized interventions for addiction prevention programs in vocational schools. While reached students aligned with the aims of the app, tailored recruitment strategies could enhance engagement among under-represented groups.

Following implementation of a national prevention program against iodine deficiency-related disorders in 1993 in Germany, the prevalence of thyroid disorders declined, but aggregated drug dispensation data suggested a recent increase in thyroid hormone use. We aimed to systematically investigate trends in the use of thyroid diagnostic and treatment measures between 2008 and 2019 in Germany. Using the GePaRD database (claims data from ~ 20% of the German population), we determined the annual age-specific and age-standardized prevalence of the use of thyroid diagnostics (thyroid-stimulating hormone (TSH) measurement, thyroid ultrasound, scintiscan, biopsy) and treatment (medication, surgery, radioiodine therapy) from 2008 to 2019 stratified by sex. Between 2008 and 2019, the age-standardized prevalence of TSH measurement increased by 44% in males (from 165 to 238 per 1,000 persons) and by 31% in females (from 134 to 176 per 1,000). The prevalence of thyroid ultrasound use showed no clear time trend, while there was a decrease in the prevalence of scintiscan use (males/females: decrease by 42/43%) and biopsy (males/females: decrease by 42/34%). The prevalence of levothyroxine use increased by ~ 31% both in males (from 36 to 47 per 1,000) and females (from 134 to 175 per 1,000), while the prevalence of thionamide use, iodine use, thyroidectomy, and radioiodine therapy decreased. Our study suggests a continued decline in the prevalence of clinically significant thyroid disorders between 2008 and 2019. The substantial increase in the prevalence of TSH measurement and levothyroxine use during this time period might indicate overuse of diagnostics and overtreatment, warranting further investigation. [ABSTRACT FROM AUTHOR]

New media are an important resource for the political participation of marginalized groups. However, there is still a lack of knowledge about the factors that influence whether this opportunity is used. Influencing factors emerge from both the Civic Voluntarism Model and previous research on migrants' political activity. Using data collected in 2019/2020 from 486 refugees living in Bavaria, we estimate linear probability models to investigate facilitating factors for the use of new media for political participation. The analysis shows that refugees in Germany who inform themselves about politics online tend to be predominantly male, higher educated, and politically involved. Language skills and the duration of stay also appear to be important. For the expression of one's political opinion online, gender and language skills have an impact, but informing oneself about German politics, political interest, and offline political activity in Germany are the most relevant factors. This indicates that there is a close link between on- und offline activity. However, using the internet requires particular resources, so that people with lower language skills, for example, are particularly disadvantaged. [ABSTRACT FROM AUTHOR]

Studies show that many students struggle with properly organizing their academic activities; what makes things even worse is that up to 90% of students are at least part-time procrastinators. In order to clarify how these students could be supported, the article at hand deals with the influences and possible benefits of implementation intentions in an academic learning context and substantiates the literature discussion with data collected among students. Aiming at studying the antecedents of academic performance from a cognitive perspective, the research complements an extended form of the Theory of Planned Behaviour by integrating procrastination and experience. Unlike many other studies, this paper does not focus on reasons for nor different forms of procrastination, but rather develops a comprehensive framework for understanding academic learning. A structural equation modelling approach is applied for this purpose using an empirical data base. For the outcome of this research different hypotheses are investigated especially in reference to implementation intentions. In the majority of cases the theories presented during the literature review can be substantiated with the empirical data used for the study. Key findings are the significant influences of goal intentions, as well as experience, and their positive effect on implementation intentions. Furthermore, the negative influence of procrastination is underlined by the results of the paper and identified as a major problem for college students. Other findings of the paper are the effects of subjective norms and PBC (Perceived Behaviour Control) on the formation of goal intentions. Nevertheless, the study brings up several further questions and identifies areas where research should be deepened, that is behaviour itself.

Background: Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners. Methods: Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30–61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation. Results: Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour. Conclusions: Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates. [ABSTRACT FROM AUTHOR]

Millennial-scale climate variations during the last glacial period, such as Dansgaard–Oeschger (DO) cycles and Heinrich events, have been extensively studied using ice core and marine proxy records. However, there is a limited understanding of the magnitude of these temperature fluctuations in continental regions, and questions remain about the seasonal signal of these climate events. This study presents a 60 000-year-long temperature reconstruction based on branched glycerol dialkyl glycerol tetraethers (brGDGTs) extracted from lake sediments from the Eifel Volcanic Field, Germany. brGDGTs are bacterial membrane-spanning lipids that are known to have a strong relationship with temperature, making them suitable for temperature reconstructions. We test several temperature calibration models on modern samples taken from soils and multiple maar lakes. We find a negative bias in brGDGT-based temperature estimates associated with water depth and anoxic conditions that can be corrected for by accounting for a brGDGT isomer that is only produced in anoxic conditions. The corrected temperature reconstruction correlates with proxy and climate model estimates of temperature spanning the same time period, validating the calibration approach we selected. However, millennial-scale variability is significantly dampened in the brGDGT record, and in contrast to other Northern Hemisphere climate records, during several Heinrich stadials, temperatures actually increase. We demonstrate that these apparent discrepancies can be explained by the unique seasonal response of the brGDGT paleothermometer to temperatures of months above freezing (TMAF). Our data support the view that warm-season temperatures in Europe varied minimally during the last glacial period and that abrupt millennial-scale events were defined by colder, longer winters. Our continuous high-resolution temperature reconstruction provides important information about the magnitude of seasonal climate variability during the last glacial period that can be used to test climate models and inform studies of paleoecological change. [ABSTRACT FROM AUTHOR]

Electric vehicles (EVs) are expected to be vital in transitioning to a low-carbon energy system. However, integrating EVs into the power grid poses significant challenges for grid operators and energy suppliers, especially regarding the uncertainty and variability of EV charging demand. Accurate forecasting of EV charging demand is essential for optimal power system integration, yet previous studies have often only considered point predictions that are inadequate for risk assessment. Therefore, this paper compares different probabilistic forecasting models for the short-term prediction of EV charging demand at various aggregation levels, using a large and novel dataset of over 350,000 charging processes at more than 500 locations across Germany. The performance of both machine learning and deep learning methods is evaluated against a naïve benchmark model, and the impact of data availability on the forecasting models is investigated. Further, the paper examines the effects of forecast accuracy on energy procurement, which has so far received minor attention in the literature. The results show that machine learning methods such as Ada Boosting and Random Forest yield robust results with a normalized root mean square error of 0.42 and 0.41 and a mean absolute scaled error of 0.36 and 0.34 at the highest aggregation level. Furthermore, the results show the influence of different site compositions on the forecast quality and how many charging points are likely to yield a robust forecast. Energy and fleet managers can use the described method to reliably predict the required energy quantities for fleets of sufficient size and procure them at low risk. [ABSTRACT FROM AUTHOR]

Introduction: Comparing antibiotic prescribing between countries can provide important insights into potential needs of improving antibiotic stewardship programs. We aimed to compare outpatient antibiotic prescribing in early life between children born in Denmark and Germany. Methods: Using the Danish nationwide healthcare registries and a German claims database (GePaRD, ~ 20% population coverage), we included children born between 2004 and 2016, and followed them regarding outpatient antibiotic prescriptions until end of enrollment or the end of 2018. We then determined the median time to first antibiotic prescription. Based on all prescriptions in the first 2 years of life, we calculated the rate of antibiotic treatment episodes and for the children's first prescriptions in this period, we determined established quality indicators. All analyses were stratified by birth year and country. Results: In the 2016 birth cohorts, the median time to first antibiotic prescription was ~ 21 months in Denmark and ~ 28 in Germany; the rate of antibiotic treatment episodes per 1000 person-years was 537 in Denmark and 433 in Germany; the percentage of prescribed antibiotics with higher concerns regarding side effects and/or resistance potential was 6.2% in Denmark and 44.2% in Germany. In the 2016 birth cohorts, the age at first antibiotic prescription was 50–59% higher compared to the 2004 birth cohorts; the rate of antibiotic treatment episodes was 43–44% lower. Conclusions: Infants in Denmark received antibiotics markedly earlier and more frequently than in Germany, while quality indicators of antibiotic prescribing were more favorable in Denmark. Although both countries experienced positive changes towards more rational antibiotic prescribing in early life, our findings suggest potential for further improvement. This particularly applies to prescribing antibiotics with a lower potential for side effects and/or resistance in Germany. [ABSTRACT FROM AUTHOR]

Background: Exposure to isotretinoin during pregnancy must be avoided due to its teratogenicity, but real-world data on its use are scarce. We aimed to describe (i) isotretinoin use in women of childbearing age in Germany; (ii) the occurrence of isotretinoin-exposed pregnancies; and (iii) malformations among children exposed in utero. Methods and findings: Using observational data from the German Pharmacoepidemiological Research Database (GePaRD, claims data from approximately 20% of the German population), we conducted annual cross-sectional analyses to determine age-standardized prevalence of isotretinoin use between 2004 and 2019 among girls and women aged 13 to 49 years. In cohort analyses, we estimated the number of exposed pregnancies by assessing whether there was prescription supply overlapping the beginning of pregnancy (estimated supply was varied in sensitivity analyses) or a dispensation within the first 8 weeks of pregnancy. Data of live-born children classified as exposed in a critical period according to these criteria were reviewed to assess the presence of congenital malformations. The age-standardized prevalence of isotretinoin use per 1,000 girls and women increased from 1.20 (95% confidence interval [CI]: 1.16, 1.24) in 2004 to 1.96 (95% CI: 1.92, 2.01) in 2019. In the base case analysis, we identified 178 pregnancies exposed to isotretinoin, with the number per year doubling during the study period, and at least 45% of exposed pregnancies ended in an induced abortion. In sensitivity analyses, the number of exposed pregnancies ranged between 172 and 375. Among live-born children, 6 had major congenital malformations. The main limitation of this study was the lack of information on the prescribed dose, i.e., the supply had to be estimated based on the dispensed amount of isotretinoin. Conclusions: Isotretinoin use among girls and women of childbearing age increased in Germany between 2004 and 2019, and there was a considerable number of pregnancies likely exposed to isotretinoin in a critical period. This highlights the importance of monitoring compliance with the existing risk minimization measures for isotretinoin in Germany. Jonas Reinold and colleagues investigate how isotretinoin use has changed over a 15 year period in Germany and the potential for in-utero exposure. Author summary: Why was this study done?: Systemic (oral) isotretinoin is used in the treatment of moderate to severe acne. Given that isotretinoin is one of the strongest human teratogens known today, it is important to monitor the use of isotretinoin in girls and women of childbearing age as well as the occurrence of pregnancies exposed to this drug. There is a lack of population-based studies addressing these research questions. What did the researchers do and find?: Using a database covering 20% of the German population, we conducted cross-sectional analyses to assess the prevalence of isotretinoin use between 2004 and 2019 in girls and women of childbearing age. We found that the age-standardized prevalence of isotretinoin use increased from 1.20 to 1.96 per 1,000 girls/women during this period. In cohort analyses, we estimated the number of pregnancies likely exposed to isotretinoin in a critical period. In the base case analysis, we identified 178 of such pregnancies. Sensitivity analyses considering the recommended one-month washout period suggested that there could have been additional pregnancies exposed to isotretinoin because they started before the end of the washout period. What do these findings mean?: Isotretinoin use among girls and women of childbearing age increased in Germany between 2004 and 2019, and there were a considerable number of pregnancies likely exposed to isotretinoin in a critical period. This highlights the importance of monitoring compliance with the existing risk minimization measures for isotretinoin in Germany. It also seems important to increase awareness regarding the component of the pregnancy prevention program that recommends contraception also in the month after treatment cessation. The main limitation of this study was the lack of information on the prescribed dose of isotretinoin. We therefore estimated the dose based on the dispensed amount of isotretinoin and varied the underlying assumptions. [ABSTRACT FROM AUTHOR]

Poorer survival in cancer patients with vs. without comorbidity has been reported for various cancer sites. For patients with colorectal cancer (CRC), limited data are available so far. Patients with CRC diagnosed between 2010 and 2018 were identified in a health claims database covering 20% of the German population. We assessed the prevalence of comorbidities at cancer diagnosis and categorized the patients into the groups: 'none', 'somatic only', 'mental only' or 'both' types of comorbidities. Hazard ratios (HR, with 95% confidence intervals) for five-year overall survival were estimated by Cox proportional hazard models, adjusted for age, sex and stage at diagnosis (advanced vs. non-advanced). We included 92,991 patients (females: 49.1%, median age: 72 years) with a median follow-up of 30 months. The proportions assigned to the groups 'none', 'somatic only', 'mental only' or 'both' were 24.7%, 65.5%, 1.4% and 8.4%. Overall, 32.8% of the patients died during follow-up. Compared to patients without comorbidities ('none'), the adjusted HR regarding death from any cause was 1.11 (95% CI: 1.07–1.14) in the group 'somatic only', 1.74 (95% CI: 1.58–1.92) in the group 'mental only' and 1.92 (95% CI: 1.84–2.00) in the group 'both'. For patients with 'mental only' comorbidities, the adjusted HR was higher in males than in females (HR = 2.19, 95% CI: 1.88–2.55 vs. HR = 1.55, 95% CI: 1.37–1.75). Our results suggest that patients with CRC and with mental comorbidities, particularly males, have a markedly lower overall survival compared to those without any or only somatic comorbidities. [ABSTRACT FROM AUTHOR]

Patient education is an essential part of the treatment of coronary heart disease in cardiac rehabilitation. In Germany, no standardized and evaluated patient education programs for coronary heart disease have been available so far. In this article, we report the evaluation of a patient-oriented program. A multicenter quasi-experimental, sequential cohort design study of patients with coronary heart disease (n = 434) in inpatient cardiac rehabilitation was conducted. Intervention patients received the new patient-oriented program, control patients a traditional lecture-based program (usual care). Primary outcome illness knowledge and secondary behavioral and health outcomes were assessed at admission, discharge and 6- and 12-months follow-up. We found a significant, small between-group intervention effect in both patients' medical illness and treatment knowledge and behavior change knowledge at discharge (medical: ?[superscript 2] = 0.013; behavior change: ?[superscript 2] = 0.011) and after 12 months (medical: ?[superscript 2] = 0.015). Furthermore, a significant, small effect was observed for physical activity after 12 months (?[superscript 2] = 0.011), but no effects on healthy diet and medication adherence emerged. Superiority of the patient-oriented educational program for patients with coronary heart disease was partially confirmed. The program produced improved illness knowledge and physical activity compared with usual care after 1 year.

Background and Objective: Acitretin has long-lasting teratogenic properties. Therefore, pregnancies must be avoided during and within 3 years after acitretin treatment. We aimed to describe (i) acitretin use in women of childbearing age in Germany, (ii) the occurrence of acitretin-exposed pregnancies, and (iii) malformations among children exposed in utero. Methods: Using 2004–2019 data from the German Pharmacoepidemiological Research Database (GePaRD—claims data from ~ 20% of the German population), we determined annual age-standardized prevalence of acitretin use among girls and women aged 13–49 years. In longitudinal analyses, we estimated the number of exposed pregnancies by assessing whether the exposure window assigned to the last dispensation before pregnancy (days covered by dispensation plus 3 years) overlapped the onset of pregnancy or whether there was a dispensation in the first eight weeks of pregnancy. Data of live-born children with in utero exposure to acitretin were reviewed to assess the presence of congenital malformations. Results: The age-standardized prevalence of acitretin use per 1000 girls and women was 0.04 in 2019. We identified 35 acitretin-exposed pregnancies; 94.3% of these pregnancies were classified as exposed because they occurred within 3 years after stopping acitretin treatment. Among 18 live-born children linked to their mother, four children (22.2%) had congenital malformations (three children with a major malformation). Conclusions: We observed 35 acitretin-exposed pregnancies mainly because treatment ended too late before pregnancy. Approximately one in five children born from these pregnancies had malformations, highlighting the importance of drawing more attention to the long-lasting teratogenicity of this drug. [ABSTRACT FROM AUTHOR]

Millennial-scale climate variations during the last glacial period, such as Dansgaard–Oeschger (D/O) cycles and Heinrich events, have been extensively studied using ice core and marine proxy records. However, there is a limited understanding of the magnitude of these temperature fluctuations in continental regions, and questions remain about the seasonal signal of these climate events. This study presents a 60,000-year long temperature reconstruction based on branched glycerol dialkyl glycerol tetraethers (brGDGTs) extracted from lake sediments from the Eifel volcanic field, Germany. brGDGTs are bacterial membrane lipids that are known to have strong relationship with temperature, making them suitable for temperature reconstructions. We test several temperature calibration models on modern samples taken from soils and multiple maar lakes. We find a bias associated with water depth and anoxic conditions that can be corrected for by accounting for a brGDGT isomer that is only produced in anoxic conditions. The corrected temperature reconstruction correlates with proxy and model temperature record spanning the same time period, validating the calibration model. However, millennial-scale variability is significantly dampened in the brGDGT record, and in contrast to other northern hemisphere climate records, during several Heinrich stadials, temperatures actually increase. We demonstrate that these apparent discrepancies can be explained by the unique seasonal response of the brGDGT paleothermometer to temperatures of months above freezing (TMAF). Our data support the view that warm season temperatures in Europe varied minimally during the last glacial period, and that abrupt millennial-scale events were defined by colder, longer winters. Our continuous high-resolution temperature reconstruction provides important information about the magnitude of seasonal climate variability during the last glacial period that can be used to test climate models and inform studies of paleoecological change. [ABSTRACT FROM AUTHOR]

Despite the current need for reliable and valid test instruments in different countries in order to monitor the sign language acquisition of deaf children, very few tests are commercially available that offer strong evidence for their psychometric properties. This mirrors the current state of affairs for many sign languages, where very little research is available. No previous empirical study has focused explicitly on the linguistic, methodological, and theoretical issues involved in the process of adapting a test from a source sign language to a target sign language. Problems during the adaptation process can arise from linguistic differences between the source and the target language and differences in the source and the target cultures. Both are important aspects that need to be considered in the adaptation of a sign language test from a source to a target language. This study proposes a model for sign language test adaptation, based on the adaptation of the British Sign Language Receptive Skills Test to German Sign Language. The model includes different methodological steps, with a particular focus on construct validation. (Contains 4 notes, 4 tables, and 4 figures.)

New communication technologies offer novel possibilities for the prevention of mental illness, in which geographical and psychosocial distances often hamper help-seeking. This paper introduces ES[S]PRIT, an Internet-based eating disorders (ED) prevention programme for university students. The programme follows a stepped-care approach combining various support components of increasing intensity. These components comprise psychoeducation, symptom monitoring, supportive feedback, peer support, and professional online counselling. Participants who develop substantial ED symptoms during their participation are referred to the University Student Counselling Center. We outline the underlying concepts and various components of the programme and report first experiences with the approach in a sample of German college students. Finally, potentials of the approach are highlighted and the need for further research is stressed. (Contains 1 figure and 2 tables.)

Background: In Germany, all women aged 50–69 have been invited to biennial mammography screening since 2009. We aimed to assess longitudinal adherence over ten years in women aged 50 in 2009 and characterize the different adherence groups. Methods: Using the German Pharmacoepidemiological Research Database (GePaRD, ~ 20% of the German population), we included women aged 50 in 2009 (baseline) with continuous health insurance coverage and without breast cancer or in-situ-carcinoma. We followed them until age 59 and categorized them according to mammography screening participation into the following groups: never, 1–2, 3–4, 5–6 times. We characterized these groups, inter alia, regarding the use of other preventive measures, non-screening mammography (i.e., mammography outside the organized screening program) and menopausal hormone therapy. Results: Overall, 82,666 women were included. Of these, 27.6% never participated in the screening program, 15.1% participated 1–2 times, 31.7% participated 3–4 times and 25.6% participated regularly (5–6 times). Among regular participants, 91% utilized other preventive measures (e.g., cervical cancer screening, general health checkup) before baseline as compared to 66% among non-participants. Menopausal hormone therapy was least common among non-participants (11% vs. 18% among regular participants). Among non-participants, the proportions using ≥ 1, ≥ 2, and ≥ 3 non-screening mammographies between age 50–59 were 25%, 18%, and 15%, respectively. Conclusions: Using a large cohort based on claims data, this study provides novel insights into longitudinal adherence to the mammography screening program and the use of mammography outside of the program in Germany. Between age 50–59, 57% of eligible women participated at least three times in the German mammography screening program and 28% (~ 3 in 10 women) never participated. Among non-participants, 15% had at least three non-screening mammographies during this period, indicating potential gray screening. Participants more often utilized other preventive measures as compared to non-participants. [ABSTRACT FROM AUTHOR]

Purpose: Over the last decade, the use of direct oral anticoagulants (DOACs) has strongly increased. We aimed to describe and compare risk profiles including potential changes over time among persons with non-valvular atrial fibrillation initiating treatment with different DOACs or phenprocoumon (vitamin K antagonist) between 2011 and 2019 in Germany.Patients and Methods: Using the German Pharmacoepidemiological Research Database (GePaRD; claims data of ~20% of the German population), we identified persons with a first dispensing of phenprocoumon or a DOAC and a diagnosis of non-valvular atrial fibrillation between August 2011 and December 2019. We described the morbidity of included patients prior to treatment initiation, stratified by year of treatment initiation.Results: Overall, we included 448,028 new users (phenprocoumon: N = 118,117, rivaroxaban: N = 130,997, apixaban: N = 130,300, edoxaban: N = 38,128, dabigatran: N = 30,486). Comparing new DOAC users in 2019, the proportion with prior ischemic stroke was highest for dabigatran (17%) and lowest for rivaroxaban (8%). The proportion with prior major bleeding was also highest for dabigatran (25%) and lowest for edoxaban (20%). New users of apixaban were oldest and, eg, showed the highest prevalence of congestive heart failure. Changes over time were most pronounced for phenprocoumon. For example, among persons initiating phenprocoumon in 2012 vs 2019, the proportion with prior major bleeding increased from 18% to 35%; the proportion with renal disease increased from 20% to 36% and the proportion with liver disease from 18% to 24%.Conclusion: This study demonstrated differences in risk profiles between new users of different oral anticoagulants and substantial changes over time among new phenprocoumon users. These differences have to be considered in head-to-head comparisons of these drugs based on observational data, especially regarding potential unmeasured confounding. [ABSTRACT FROM AUTHOR]

Background: Use of the direct oral anticoagulant rivaroxaban has strongly increased in Europe since its market approval for non-valvular atrial fibrillation in 2011. Patients characteristics of rivaroxaban initiators may have changed over time but this has not been investigated so far. Objective: We aimed to describe time trends of patient baseline characteristics among new rivaroxaban users with non-valvular atrial fibrillation from 2011 to 2016/17 in two European countries. Methods: We used data from Germany (German Pharmacoepidemiological Research Database) and the Netherlands (PHARMO Database Network). We included new rivaroxaban users with (i) a first dispensing between 2011 and 2016/17, (ii) ≥ 2 years of age, and (iii) a diagnosis of non-valvular atrial fibrillation and described their baseline medication and comorbidity prior to starting rivaroxaban stratified by year of inclusion. Results: Overall, 130,652 new rivaroxaban users were included during the study period (Germany: N = 127,743, the Netherlands: N = 2909). The sex ratio and median age remained relatively stable over time. The proportion of patients without prior use of oral anticoagulants before initiation of rivaroxaban increased in both countries between 2011 and 2016/17 (Germany: from 51 to 76%, the Netherlands: from 57 to 85%). In Germany, we observed a relative decrease by 27% in the proportion of new rivaroxaban users with a history of ischemic stroke and by 18% in the proportion with a transient ischemic attack at baseline. No such a pattern was observed in the Netherlands. The proportion of patients with heart failure at baseline showed a three-fold increase in the Netherlands, while there was a relative decrease by 12% in Germany. Conclusions: Patient characteristics of new rivaroxaban users with non-valvular atrial fibrillation changed between 2011 and 2016/17, but changes differed between countries. These patterns have methodological implications. They have to be considered in the interpretation of observational studies comparing effectiveness and safety of oral anticoagulants, especially regarding potential bias due to unmeasured confounding. [ABSTRACT FROM AUTHOR]

Studies have shown that the quality of colonoscopy influences the incidence of post‐colonoscopy colorectal cancer (PCCRC). However, data from Germany on this association are lacking. We aimed to assess cumulative incidence of PCCRC in persons undergoing colonoscopy in Germany according to the physician's polyp detection rate (PDR). Using the German Pharmacoepidemiological Research Database (GePaRD) with claims data of ~20% of the German population, we included persons with a baseline colonoscopy between 2008 and 2017 and categorized them according to the procedure at baseline (snare polypectomy, forceps polypectomy, no polypectomy). In each subgroup, we distinguished between persons examined by physicians with a PDR in the lowest quartile vs higher quartiles and described cumulative CRC incidence during follow‐up. Overall, 822 715 persons examined by 1752 physicians were included. One quarter of the physicians had a PDR ≤21.8% (lowest quartile). In all subgroups, the 5‐year cumulative CRC incidence was statistically significantly higher in persons examined by physicians with a PDR ≤21.8% vs >21.8%: It was 69% higher in persons with snare polypectomy (0.88% vs 0.52%), 87% higher in persons with forceps polypectomy (0.58% vs 0.31%), and 48% higher in persons without polypectomy at baseline (0.31% vs 0.21%). In conclusion, we found a substantially increased PCCRC risk in persons examined by physicians with a low PDR in Germany, irrespective of the baseline findings. Our study highlights the importance of a high‐quality colonoscopy to maximize the preventive effect of colonoscopy on CRC incidence. [ABSTRACT FROM AUTHOR]

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Background and Objective: Methotrexate should be withdrawn before pregnancy because of its teratogenic potential. We aimed to describe the use of methotrexate in women of childbearing age in Germany and the occurrence and outcomes of pregnancies exposed to methotrexate. Methods: Using the German Pharmacoepidemiological Research Database (GePaRD, covering ~ 20% of the German population), we determined the age-specific and age-standardized prevalence of methotrexate use for each year between 2004 and 2019 among women aged 13–49 years (cross-sectional analyses). In a cohort analysis, we assessed the number and outcomes of pregnancies exposed to methotrexate in the critical time window. Exposure was defined as a dispensation overlapping with the onset of pregnancy or a dispensation in the first 8 weeks of pregnancy. For children born from exposed pregnancies, the mother's and children's data were linked and the occurrence of malformations was assessed by reviewing all available data of these children. Results: The age-standardized prevalence of methotrexate use per 1000 females increased from 1.5 in 2004 to 2.3 in 2019, i.e., by 52%. Overall, we identified 184 pregnancies exposed to methotrexate. Of these, 53% ended in a live birth (21% preterm) and 11% in an induced abortion. Among 81 live-born children linked to their mothers, five children (6%) had relevant malformations including congenital heart defects and musculoskeletal malformations. Conclusions: In Germany, the use of methotrexate in women of childbearing age has substantially increased since 2004. Despite the known teratogenic effect, there was a considerable number of exposed pregnancies. Also, malformations likely associated with methotrexate and thus avoidable were observed. [ABSTRACT FROM AUTHOR]

Background: The efficacy of mammography screening in reducing breast cancer mortality has been demonstrated in randomized trials. However, treatment options - and hence prognosis – for advanced tumor stages as well as mammography techniques have considerably improved since completion of these trials. Consequently, the effectiveness of mammography screening under current conditions is unclear and controversial. The German mammography screening program (MSP), an organized population-based screening program, was gradually introduced between 2005 and 2008 and achieved nation-wide coverage in 2009. Objective: We describe in detail a study protocol for investigating the effectiveness of the German MSP in reducing breast cancer mortality in women aged 50 to 69 years based on health claims data. Specifically, the proposed study aims at estimating per-protocol effects of several screening strategies on cumulative breast cancer mortality. The first analysis will be conducted once 10-year follow-up data are available. Methods and Analysis: We will use claims data from five statutory health insurance providers in Germany, covering approximately 37.6 million individuals. To estimate the effectiveness of the MSP, hypothetical target trials will be emulated across time, an approach that has been demonstrated to minimize design-related biases. Specifically, the primary contrast will be in terms of the cumulative breast cancer mortality comparing the screening strategies of "never screen" versus "regular screening as intended by the MSP". Ethics and Dissemination: In Germany, the utilization of data from health insurances for scientific research is regulated by the Code of Social Law. All involved health insurance providers as well as the responsible authorities approved the use of the health claims data for this study. The Ethics Committee of the University of Bremen determined that studies based on claims data are exempt from institutional review. The findings of the proposed study will be published in peer-reviewed journals. [ABSTRACT FROM AUTHOR]

Background: Given the paucity of epidemiological studies on thyroid storm, we aimed to estimate the incidence rate and case fatality of thyroid storm in Germany based on a large claims database. Methods: Using the German Pharmacoepidemiological Research Database (GePaRD) we identified patients with at least one inpatient discharge diagnosis of thyroid storm (International Statistical Classification of Diseases and Related Health Problems, 10th revision, German modification; ICD-10-GM E05.5) between 2007 and 2017 and calculated age-standardized and age-specific incidence rates in males and females (no age restriction). We defined deaths occurring within 30 days of the diagnosis as thyroid storm-associated and determined case fatality by sex and age group. Point estimates were reported with confidence intervals [CIs]. Results: We identified 1690 patients with an incident diagnosis of thyroid storm. Of these, 72% were females (n = 1212). The mean age was 60 years (standard deviation: 18.6 years). The age-standardized incidence rate per 100,000 persons per year was 1.4 [CI 1.2–1.7] in females and 0.7 [CI 0.5–0.9] in males. In females ≤60 and >60 years of age, the incidence rate was 0.9 [CI 0.9–1.0] (males: 0.4 [CI 0.3–0.4]) and 2.7 [CI 2.5–2.9] (males: 1.7 [CI 1.5–1.9]), respectively. The case fatality of thyroid storm was 1.4% [CI 0.6–2.8] in females ≤60 years and 10.9% [CI 8.6–13.7] in females >60 years. In males, the case fatality was 1.0% [CI 0.2–4.0] in those aged ≤60 years and 16.7% [CI 12.6–21.7] in those >60 years. Conclusions: Incidence rates of thyroid storm were markedly higher in females than in males and were three times higher in persons >60 years compared with younger age groups. The case fatality was below 2% in persons aged ≤60 years and markedly higher in older persons (males: 17 times and females: 8 times). [ABSTRACT FROM AUTHOR]

Purpose: In older adults, fractures are associated with mortality, disability, loss of independence and high costs. Knowledge on their predictors can help to identify persons at high risk who may benefit from measures to prevent fractures. We aimed to assess the potential of German claims data to predict fractures in older adults. Patients and Methods: Using the German Pharmacoepidemiological Research Database (short GePaRD; claims data from ~20% of the German population), we included persons aged ≥ 65 years with at least one year of continuous insurance coverage and no fractures prior to January 1, 2017 (baseline). We randomly divided the study population into a training (80%) and a test sample (20%) and used logistic regression and random forest models to predict the risk of fractures within one year after baseline based on different combinations of potential predictors. Results: Among 2,997,872 persons (56% female), the incidence per 10,000 person years of any fracture in women increased from 133 in age group 65– 74 years (men: 71) to 583 in age group 85+ (men: 332). The maximum predictive performance as measured by the area under the curve (AUC) across models was 0.63 in men and 0.60 in women and was achieved by combining information on drugs and morbidities. AUCs were lowest in age group 85+. Conclusion: Our study showed that the performance of models using German claims data to predict the risk of fractures in older adults is moderate. Given that the models used data readily available to health insurance providers in Germany, it may still be worthwhile to explore the cost–benefit ratio of interventions aiming to reduce the risk of fractures based on such prediction models in certain risk groups. [ABSTRACT FROM AUTHOR]

A comprehensive small area description of regional variations in outpatient antibiotic prescribing in Germany is lacking. Using the German Pharmacoepidemiological Research Database (GePaRD), a claims database covering ~20% of the German population, we determined the age- and sex-standardized prescription rates of antibiotics (number of outpatient prescriptions per 1000 persons/year). We calculated these prescription rates overall and on the level of 401 German districts for the calendar years 2010 and 2018. In 2018, the standardized prescription rate of antibiotics in the total study population was 23% lower than in 2010 (442 vs. 575 per 1000 persons/year). Among 0–17-year-olds, prescription rates across districts ranged from 312 to 1205 in 2010 and from 188 to 710 in 2018 per 1000 persons/year; among adults (≥18 years), they ranged from 388 to 841 in 2010 and from 300 to 693 in 2018 per 1000 persons/year. Despite the overall decline in outpatient antibiotic prescribing between 2010 and 2018, regional variations at the district level remained high in all age groups in Germany. Identifying reasons that explain the persistently high prescription rates in certain regions will be helpful in designing effective and tailored measures to further improve antibiotic stewardship in these regions. [ABSTRACT FROM AUTHOR]

Known from at least the Silurian (c. 435 Ma) up to the Late Cretaceous (c. 85 Ma), thylacocephalans are among the most intriguing fossil euarthropods. They are characterized by a prominent shield enveloping most of the body, hypertrophied compound eyes, three pairs of large, raptorial appendages and a trunk with 8–22 stout segments bearing appendages. Despite this knowledge of their anatomy, the phylogenetic affinities of Thylacocephala are controversial due to a lack of knowledge on their body organization and tagmosis. This study focuses on Mayrocaris bucculata Polz, 1994 from the Solnhofen Lagerstätte, Germany (c. 150 Ma, early Tithonian, Jurassic). We document new specimens of Mayrocaris bucculata from the Solnhofener Plattenkalke sensu lato and provide new descriptions for previously reported specimens. We demonstrate that the raptorial appendages of Thylacocephala are most probably maxillulae, maxillae and maxillipeds. Additionally, we report new details on the posterior trunk appendages, including the description of a paddle-like proximal part and of a rod-like distal part, but also of a specialized terminal trunk appendage. These new findings, in addition to the reinterpretation of a cephalic appendage of Clausocaris lithographica as a possible mandible, are essential for a better understanding of the body organization in thylacocephalans and their phylogenetic affinities within Eucrustacea. [ABSTRACT FROM AUTHOR]

The Solnhofen Konservat‐Lagerstätte yields a great number of remarkably preserved fossils of eumalacostracan crustaceans that help us understand the early radiation of several groups with modern representatives. One fossil from there, Francocaris grimmi Broili, 1917 is a small shrimp‐like crustacean originally described about 100 years ago as a mysidacean crustacean (opossum shrimps and relatives) from latest Kimmeridgian – early Tithonian (Upper Jurassic) of the Solnhofen Lithographic Limestones of Southern Germany. New material with exceptionally preserved specimens, allied with modern imaging techniques (mostly composite fluorescence microscopy), allows us to provide a detailed re‐description of this species. The most striking feature of Francocaris grimmi is an extremely elongated thoracopod 7 with its distal elements forming a spiny sub‐chela. This character supports a sister group relationship of Francocaris grimmi with Eucopiidae, an ingroup of Lophogastrida, pelagic peracaridans common in marine environments throughout the world. We also discuss other supposed fossil representatives of Lophogastrida, identifying all of them as problematic at best. The structure of the sub‐chela in F. grimmi indicates an original use in raptorial behaviour. Francocaris grimmi appears to be unique in possessing such a far posterior sub‐chelate appendage as a major raptorial structure. In most representatives of Euarthropoda in which sub‐chelate appendages occur and are used for food intake, they are usually closer to the mouth. [ABSTRACT FROM AUTHOR]

Achelatan lobsters, also known as spiny and slipper lobsters, develop via a highly specialised larval form. This special larva, phyllosoma, is flat, translucent, possesses elongate legs and can grow to enormous sizes. Although these larvae may appear very fragile, they are well-known as fossils. Thousands of specimens have been found in the lithographic limestone of Southern Germany (Tithonian, Upper Jurassic, about 150 mya). At least three types of fossil, but modern-appearing phyllosoma larvae are known. Additionally, fossil larvae that possess only some of the characters of modern-day phyllosoma larvae are known from the same Lagerstätte, but also from the younger limestone beds of Lebanon. Here we report a new achelatan fossil from the older Posidonia Shale (Toarcian, Lower Jurassic, 175-183 mya). The specimen shows certain characters of a phyllosoma larva, but other characters appear like those of post-phyllosoma stages of achelatan lobsters. This specimen is therefore the oldest occurrence of an achelatan lobster larva. We compare the new specimen with other fossil larvae with such mixed or "intermetamorphic" morphologies. [ABSTRACT FROM AUTHOR]

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The group Xiphosurida (horseshoe "crabs") is today only represented by four species. However, in the fossil record, several dozen species have been described, especially from the Carboniferous (about 300 million years ago). Several species have been interpreted as representatives of Euproops or Belinurus, but there is ongoing discussion which of these species are valid and how they can be differentiated. Recent studies suggested that differences in the timing of individual development could provide information for species distinction, exemplified by studies on Euproops danae (Mazon Creek, USA) and Euproops sp. ("Piesproops"; Piesberg, Germany). For this study, we reinvestigated all Carboniferous xiphosurids from the British Coal Measures stored in the collections of the Natural History Museum London. Size comparisons of the specimens revealed nine size groups; the smaller specimens were originally labelled as Belinurus, the larger ones as Euproops. The nine size groups exhibit five different morphotypes differing in structures surrounding the posterior shield (= thoracetron): spines of different lengths and, in larger specimens, a more or less developed flange. Two of these morphotypes show significantly longer spines than the remaining specimens and could be conspecific as E. anthrax. The remaining specimens are interpreted as growth series of another species, presumably of E. rotundatus. An ontogenetic flange formation is also known from E. danae and the "Piesproops", but the timing differs between all three species. In E. rotundatus, the flange develops rather late, but then comparably abruptly, which makes this development more metamorphic in relation to development in the other species. [ABSTRACT FROM AUTHOR]

Achelatan lobsters, also known as spiny and slipper lobsters, develop via a highly specialised larval form. This special larva, phyllosoma, is flat, translucent, possesses elongate legs and can grow to enormous sizes. Although these larvae may appear very fragile, they are well-known as fossils. Thousands of specimens have been found in the lithographic limestone of Southern Germany (Tithonian, Upper Jurassic, about 150 mya). At least three types of fossil, but modern-appearing phyllosoma larvae are known. Additionally, fossil larvae that possess only some of the characters of modern-day phyllosoma larvae are known from the same Lagerstätte, but also from the younger limestone beds of Lebanon. Here we report a new achelatan fossil from the older Posidonia Shale (Toarcian, Lower Jurassic, 175-183 mya). The specimen shows certain characters of a phyllosoma larva, but other characters appear like those of post-phyllosoma stages of achelatan lobsters. This specimen is therefore the oldest occurrence of an achelatan lobster larva. We compare the new specimen with other fossil larvae with such mixed or "intermetamorphic" morphologies. [ABSTRACT FROM AUTHOR]

Background: Investigating drug utilization in large and unselected samples of children and adolescents is an important component of public health monitoring. Most existing studies in this field focused on any drug use (i.e., ≥1 prescription of a certain drug) although chronic drug use may be more relevant. This study aimed to provide a comprehensive overview of prevalence and types of prescription drugs used repeatedly in children and adolescents in Germany in 2016. Methods: We used the German Pharmacoepidemiological Research Database (GePaRD)—a claims database covering ∼20% of the German population. We included children and adolescents aged 0–17 years and assessed repeated use of prescription drugs (≥3 prescriptions in 2016) on two levels: therapeutic subgroups (ATC 2nd level) and chemical substances (ATC 5th level). Analyses were stratified by sex and age groups (<2, 2–5, 6–12, and 13–17 years). Results: Overall, 2.5 million children and adolescents were included. In the age groups below 13 years, the prevalence rates of repeated use of prescription drugs (ATC 2nd level) were higher in boys than in girls (113–152 vs. 83–130 per 1,000 person-years), whereas in the age group 13–17 years, they were twice as high in girls than in boys (236 vs. 118 per 1,000 person-years). In boys and girls aged below six years, systemic antibiotics, topical ocular antibiotics, and drugs for constipation were among the most common drugs used repeatedly. For higher ages, methylphenidate, levothyroxine, and combined hormonal contraceptives, were among the most common drugs used repeatedly. Conclusions: Overall, about one in ten children in Germany repeatedly used prescription drugs. This proportion as well as the type of drugs used repeatedly markedly varied by sex and age. For certain drugs, our findings raise concerns regarding appropriateness of prescribing that should be addressed in future studies. [ABSTRACT FROM AUTHOR]

Aims: Premarketing clinical trials are typically conducted under controlled conditions and in selected study populations, so real-world information on the utilization of new cancer drugs is limited. We aimed to explore the potential of German claims data in this regard, exemplified by the ALK inhibitor crizotinib, used in non-small-cell lung cancer therapy. Materials & methods: We identified patients treated with crizotinib in the German Pharmacoepidemiological Research Database (2004-2017; 20% of the German population) and assessed patient characteristics, treatment and survival. Results: We identified 348 crizotinib-treated patients (56% female; 25% first-line users). After 2 years, overall survival was 48%, with higher survival in men than in women (58 vs 40%). Overall, 76% of patients discontinued crizotinib treatment. Of those, 41% received another ALK inhibitor afterward. Conclusion: The results underline the potential of German claims data for real-world monitoring of oncological drug utilization. [ABSTRACT FROM AUTHOR]

Aim: To estimate the extent of off‐label prescribing of antidepressants in older adults and to characterize patients with off‐label vs on‐label prescriptions of antidepressants using a large German health claims database. Methods: Using data from the German Pharmacoepidemiological Research Database (GePaRD), we conducted a cross‐sectional study in adults aged 65 years or older with a dispensation of an antidepressant between 1 January 2009 and 31 December 2015 after a period of 365 days without such a dispensation. We assessed the overall and annual proportion of off‐label prescriptions of antidepressants by class and individual substance. Results: Among 263 276 incident users of antidepressants, the proportion of off‐label prescribing was 43.6% (95% CI 43.4‐43.8%) with little variation between 2009 and 2015 (42.2‐44.4%). The proportion of off‐label use was higher in men (49%) than women (41%). While the proportion of off‐label prescriptions was highest for tri‐ and tetracyclic antidepressants with 56.2% (amitriptyline 54.6%, maximum 65.9% for trimipramine), it amounted to 41.8% for selective serotonin reuptake inhibitors (citalopram 41.6%, maximum 46.0% for escitalopram) and was 51.2% for mirtazapine. Indicators of overall morbidity were similar in both groups, eg, pain was coded in 72% of off‐label users vs 77% of on‐label users (insomnia 20% vs 24%). Conclusion: Our study suggests a high prevalence of off‐label antidepressant use among older adults in Germany, which was not restricted to certain classes of antidepressants or individual antidepressants. Given the unclear risk‐benefit ratio, studies investigating the safety of off‐label use among older adults for individual antidepressants are urgently needed. [ABSTRACT FROM AUTHOR]

Currently, patients seek healthcare information online. An up-to-date online presence is vital for success among the competition amid hospitals. Hospital websites have become an important medium to communicate with patients, provide information about certain diseases/conditions, and advertise healthcare services. This study aims to evaluate burn centers websites verified by the American Burn Association (ABA). The online presence of the 73 ABA-verified burn centers was evaluated according to criteria previously published by Benedikt et al. This included general information on burns, first aid, treatment at the burn unit, research, and education. ABA-verified burn centers were then compared with 48 German-speaking burn centers evaluated by Benedikt et al. Online information about patient care including treatment options and techniques was more often present in ABA-verified burn centers. However, this information was still provided in only half of the websites. Furthermore, ABA-verified burn centers more often used multimedia-based elements and social media platforms. On the other hand, German-speaking burn centers more often provided translations, general information (eg, staff and ward) about the burn center, as well as research and education. This study demonstrates that although many burn centers have well-designed websites, relevant burn-related information on patient care, research, and education is often missing or sparse. Today, most patients look for healthcare information online. Also, applicants for residency or fellowship programs tend to get a first picture of their potential employer on websites or social media. Keeping websites and social media up-to-date and informative can improve recruitment of patients and employees. [ABSTRACT FROM AUTHOR]

This study examines women's attitudes toward the own use of assisted reproductive technologies (ART) by their religious affiliation in Germany. The social relevance of ART is increasing in Western countries due to overall low birth rates, a high rate of childlessness, and a gap between the desired and the actual numbers of children. Previous literature has been scarce, however, on attitudes toward ART, and religious diversity has not been included in studies on ART. Our analysis is based on data collected in a pilot study in 2014 and 2015. The sample includes 944 women aged 18 to 50 living in Germany. The results show that Muslim women were significantly more likely than Christian women to say they would consider using ART; having no religious affiliation was associated with the least open attitude toward ART usage. [ABSTRACT FROM AUTHOR]

Objectives: To compare diclofenac use before and after implementation of European risk minimization measures in 2013, focusing on diclofenac initiators and prevalence of congestive heart failure (NYHA class II-IV), ischaemic heart disease, peripheral arterial disease and cerebrovascular disease (new contraindications) in these patients in Germany.Methods: We included adults with health insurance coverage on 1 January 2011 (cohort 2011) or 1 January 2014 (cohort 2014) and during a 1-year pre-observation period. We defined diclofenac initiators as persons filling a prescription of systemic diclofenac in 2011 (cohort 2011) or 2014 (cohort 2014) and without such a prescription during the respective pre-observation period.Results: Each cohort comprised >10 million persons. Between 2011 and 2014, the age-standardized proportion of persons initiating diclofenac decreased by 29% (from 8.2% to 5.8%) amongst female patients and by 26% (from 8.5% to 6.3%) amongst male patients; in the subgroup of persons with new contraindications, this proportion decreased by 33% (from 9.8% to 6.6%) amongst female patients and by 31% (from 10.0% to 6.7%) amongst male patients. Amongst diclofenac initiators, the proportion of those with new contraindications did not change between 2011 (12.0%) and 2014 (11.8%).Conclusion: The overall decline of about 30% in diclofenac initiation between 2011 and 2014 was largely independent of the presence or absence of new contraindications. The proportion of diclofenac initiators with a new contraindication remained at a high level (more than one in ten patients), demonstrating the need for research at the prescriber level (e.g. interventional studies) and further measures to improve patient safety. [ABSTRACT FROM AUTHOR]

The concept of cognitive age refers to people's tendency to view themselves as younger than they really are. Especially among elderly people this phenomenon is exceptionally strong. There have been few studies which investigated differences among elderly people concerning their self-perceived age in the context of IT adoption. However, to date it is not quite sure where the cognitive age originates from. This research focuses on justifications for the cognitive age to identify on which basis elderlies estimate their cognitive age. 8 seniors with various backgrounds were interviewed in southern Germany. The results show that seniors rather already have a rough estimation of their cognitive age, which does not necessarily is a sum of distinct dimensions as suggested by the literature. [ABSTRACT FROM AUTHOR]

This paper analyses the relationship between intermunicipal cooperation and efficiency of public service provision. Organisational arrangements of public service production, including self-provision, joint provision or contracting, affect incentives and internal transaction costs. Hence, cooperation gains from scale effects need to be balanced against technical inefficiencies. We analyse relative efficiency of wastewater disposal for German municipalities. We employ a conditional analysis in conjunction with a metafrontier approach to calculate relative efficiency measures and technology gap ratios controlling for organisational arrangements and further environmental variables. Jointly providing municipalities and contractor municipalities exhibit lower technical efficiency than self-providing and contracting municipalities. As confirmed by previous research, scale effects from cooperation and contracting apply to small municipalities primarily. [ABSTRACT FROM PUBLISHER]

We report fragmentary specimens from the Piesberg quarry (Upper Carboniferous, Northwestern Germany) that represent exuviae of nymphal blattoids (Dictyoptera). Most of the remains are isolated abdomina, one specimen also preserves a wing pad. The specimens document two developmental stages and include the smallest Palaeozoic blattoid nymph found to date. The specimens from the Piesberg quarry closely resemble other Palaeozoic blattoid nymphs, for example, specimens from the famous Mazon Creek Lagerstatte (Upper Carboniferous, Illinois, USA), at least as far as external morphology is concerned. As for preservation, the specimens from the Piesberg quarry show strong resemblance to specimens from the Lower Permian Elmo Lagerstatte (Kansas and Oklahoma, USA). The two Lagerstatten, although differing in age, appear therefore to be interesting candidates for a palaeoecological comparison. The find of immature insects at the Piesberg quarry is another example of fossilised development in arthropods from this Lagerstatte, other examples are known from Euproops, Arthropieura and Aphantomartus pustulatus. [ABSTRACT FROM AUTHOR]

Specimens of Euproops sp. (Xiphosura, Chelicerata) from the Carboniferous Piesberg quarry near Osnabrück, Germany, represent a relatively complete growth series of 10 stages. Based on this growth sequence, morphological changes throughout the ontogeny can be identified. The major change affects the shape of the epimera of the opisthosoma. In earlier stages, they appear very spine-like, whereas in later stages the bases of these spine-like structures become broader; the broadened bases are then successively drawn out distally. In the most mature stage known, the epimera are of trapezoidal shape and approach each other closely to form a complete flange around the thoracetron (=fused tergites of the opisthosoma). These ontogenetic changes question the taxonomic status of different species of Euproops, as the latter appear to correspond to different stages of the ontogenetic series reconstructed from the Piesberg specimens. This means that supposed separate species could, in fact, represent different growth stages of a single species. It could alternatively indicate that heterochrony (=evolutionary change of developmental timing) plays an important role in the evolution of Xiphosura. We propose a holomorph approach, i.e., reconstructing ontogenetic sequences for fossil and extant species as a sound basis for a taxonomic, phylogenetic, and evolutionary discussion of Xiphosura. [ABSTRACT FROM AUTHOR]

Developmental biology has become a major issue for understanding the evolution of Arthropoda. While usually only the ontogenies of extant species are studied, developmental information of fossil arthropods may exhibit developmental patterns not present in living ones. Crustacea possess, basically, a more gradual development than, for example, pterygote insects and would, therefore, be appropriate candidates for the study of fossil ontogenies. Remarkably, famous fossil deposits like the Devonian Rhynie Chert or the Early Palaeozoic 'Orsten'-type deposits do not comprise the generally macroscopic malacostracan Crustacea (although most probably adult malacostracan fossils have already been found in the Cambrian). By contrast, the Late Jurassic Solnhofen Lithographic Limestones of southern Germany provide thousands of specimens (although only few morphotypes) that can be identified as malacostracan larvae, together with juvenile specimens differing in certain morphological aspects from their conspecific adults. More recent investigations with up-to-date imaging methodology on additional malacostracan crustacean larvae yielded also reconstructible developmental sequences of species from the Solnhofen deposits. The very similar fossil deposits of the Cretaceous lithographic limestones of Lebanon have also yielded malacostracan larvae and juvenile specimens. We present a summary of the occurrences of crustacean fossils providing developmental information and a demonstration of the potential of the lithographic limestones in this context. The importance of developmental data for understanding crustacean evolution is also highlighted. [ABSTRACT FROM AUTHOR]

The ruling of the German Federal Constitutional Court's on the election threshold of the European Electoral Law fails to clearly establish an Electoral Law that can provide for a functional and operational parliament. Numerous national centered stands are taken in the ruling which are in stark contrast to the pro-European spirit of the Grundgesetz. It does not appreciate adequately the importance of the EP as a democratically and directly legitimized organ of integration and representation for about half a billion people. The Court furthermore lacks in understanding the political dimension of the EP's and its factions' mode of operation. In addition the ruling disregards former verdicts of the Court and the distinction between the authority realms of the constitutional jurisdiction and the legislature, whose interests and motivations are depicted in a partial and negative manner. Here, the Court takes its prerogative of interpretation in regard to the Grundgesetz to such an extreme that its actions bear more resemblance to that of a political agent than that of a supervising organ. [ABSTRACT FROM AUTHOR]

Background In public health settings, short message service ( SMS) appears to be a promising low-cost modality for reducing alcohol consumption. Here, we test a simple interactive SMS-based helpline with detoxified alcohol-dependent patients to extend findings to curative settings. Methods This controlled, prospective, 2-group before-after block-assignment, open pilot study tested the feasibility and efficacy of an 8-week outpatient interactive mobile phone SMS intervention ( n = 42) against treatment as usual ( TAU; n = 38) after inpatient detoxification. Patients were asked whether they needed any help via an automatically generated text message twice a week. A therapist called the individual back when notified. Alcohol consumption was assessed using the telephone version of Form-90 4 and 8 weeks after discharge from inpatient detoxification. The primary end point was defined as attaining low-risk consumption (males ≤30 g or 3.75 units per drinking day ( DDD); females ≤20 g or 2.5 units per DDD) 8 weeks after discharge. Missing data were replaced by multiple imputation. Results Among all messages sent, 20.5% were followed by a phone call. Feasibility and acceptability were good, as indicated by successful implementation of the SMS procedure and the rapid inclusion of patients. Adherence was satisfactory with 57.14% of the participants replying to at least 50% of the prompts. Patients reported a typical preadmission DDD of 281.25 ± 244.61 g. In the SMS group, 55.7% of 42 patients, and 40% of 38 patients in the TAU group, achieved low-risk consumption (risk diff: 0.16; 95% CI −0.06 to 0.37; p = 0.122). Conclusions In detoxified alcohol-dependent patients, relapse prevention based on SMS was well received and implemented efficiently and rapidly. An adequately powered multicenter study is currently being conducted to test the nonsignificant but encouraging findings of this exploratory study with more rigorous trial methods ( ISRCTN78350716). [ABSTRACT FROM AUTHOR]