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Binding lower bounds on interest rates and large government deficits limit the scope of fiscal and monetary policies to stimulate households' spending through financial intermediaries and firms. Policy makers have thus been implementing unconventional policies that aim to increase households' spending directly through managing their expectations. We first show theoretically and empirically that higher inflation expectations increase households' consumption. We then design a difference-in-differences strategy to assess the effectiveness of unconventional fiscal policy and forward guidance, both of which aim to raise aggregate demand via managing expectations. Whereas unconventional fiscal policy increases households' expectations and spending, forward guidance announcements do not [ABSTRACT FROM AUTHOR]

Environmental data are the key to defining and addressing water quality and quantity challenges at the catchment scale. Here, we present the first large-sample water quality data set for 1386 German catchments covering a large range of hydroclimatic, topographic, geologic, land use, and anthropogenic settings. QUADICA (water QUAlity, DIscharge and Catchment Attributes for large-sample studies in Germany) combines water quality with water quantity data, meteorological and nutrient forcing data, and catchment attributes. The data set comprises time series of riverine macronutrient concentrations (species of nitrogen, phosphorus, and organic carbon) and diffuse nitrogen forcing data (nitrogen surplus, atmospheric deposition, and fixation) at the catchment scale. Time series are generally aggregated to an annual basis; however, for 140 stations with long-term water quality and quantity data (more than 20 years), we additionally present monthly median discharge and nutrient concentrations, flow-normalized concentrations, and corresponding mean fluxes as outputs from Weighted Regressions on Time, Discharge, and Season (WRTDS). The catchment attributes include catchment nutrient inputs from point and diffuse sources and characteristics from topography, climate, land cover, lithology, and soils. This comprehensive, freely available data collection with a large spatial and temporal coverage can facilitate large-sample data-driven water quality assessments at the catchment scale as well as mechanistic modeling studies. QUADICA is available at 10.4211/hs.0ec5f43e43c349ff818a8d57699c0fe1 (Ebeling et al., 2022b) and 10.4211/hs.88254bd930d1466c85992a7dea6947a4 (Ebeling et al., 2022a). [ABSTRACT FROM AUTHOR]

Improving nitrogen (N) status in European water bodies is a pressing issue. N levels depend not only on current but also past N inputs to the landscape, that have accumulated through time in legacy stores (e.g., soil, groundwater). Catchment‐scale N models, that are commonly used to investigate in‐stream N levels, rarely examine the magnitude and dynamics of legacy components. This study aims to gain a better understanding of the long‐term fate of the N inputs and its uncertainties, using a legacy‐driven N model (ELEMeNT) in Germany's largest national river basin (Weser; 38,450 km2) over the period 1960–2015. We estimate the nine model parameters based on a progressive constraining strategy, to assess the value of different observational data sets. We demonstrate that beyond in‐stream N loading, soil N content and in‐stream N concentration allow to reduce the equifinality in model parameterizations. We find that more than 50% of the N surplus denitrifies (1480–2210 kg ha−1) and the stream export amounts to around 18% (410–640 kg ha−1), leaving behind as much as around 230–780 kg ha−1 of N in the (soil) source zone and 10–105 kg ha−1 in the subsurface. A sensitivity analysis reveals the importance of different factors affecting the residual uncertainties in simulated N legacies, namely hydrologic travel time, denitrification rates, a coefficient characterizing the protection of organic N in source zone and N surplus input. Our study calls for proper consideration of uncertainties in N legacy characterization, and discusses possible avenues to further reduce the equifinality in water quality modeling. Plain Language Summary: Lowering nitrogen (N) amounts in European surface waters is a pressing issue. N levels largely result from fertilizer application in agricultural areas, and deposition of atmospheric N coming from fossil fuel combustion. These N inputs to the landscape can accumulate below the ground surface in so‐called legacy stores (including the soil and aquifer), from which they can be released progressively through time. Therefore, N levels depend not only on the recent N inputs, but also on their history. Our modeling study aims to improve our understanding of the long‐term fate of the N inputs and its uncertainties in Germany's largest national river basin (Weser) over the period 1960–2015. It suggests that more than 50% of the N inputs to land is lost to the atmosphere (denitrification, 1480–2210 kg ha−1) and the stream export amounts to around 18% (410–640 kg ha−1), leaving behind as much as around 16% (264–820 kg ha−1) in the landscape (legacy). However, the uncertainties in these estimates remain large, partly due to a lack of observational data on internal (legacy) components and uncertainties in N inputs. Overall, our study calls for proper consideration of uncertainties in N legacy characterization, and discusses possible avenues to further reduce them. Key Points: We use a parsimonious model to examine the long‐term (1960–2015) fate of nitrogen inputs to the landscape including the legacy buildupMore than 50% of the nitrogen surplus denitrifies and around 491 kg ha−1 accumulates in legacy stores in Germany's largest river basinHydrologic travel time and denitrification rates largely contribute to the residual uncertainty in the simulated nitrogen legacies [ABSTRACT FROM AUTHOR]

Environmental data are the key to define and address water quality and quantity challenges at catchment scale. Here, we present the first large-sample water quality data set for 1386 German catchments covering a large range of hydroclimatic, topographic, geologic, land use and anthropogenic settings. QUADICA (water QUAlity, DIscharge and Catchment Attributes for large-sample studies in Germany) combines water quality with water quantity data, meteorological and nutrient forcing data, and catchment attributes. The data set comprises time series of riverine macronutrient concentrations (species of nitrogen, phosphorus and organic carbon) and diffuse nitrogen forcing data at catchment scale (nitrogen surplus, atmospheric deposition and fixation). Time series are generally aggregated to an annual basis; however, for 140 stations with long-term water quality and quantity data (more than 20 years), we additionally present monthly median discharge and nutrient concentrations, flow-normalized concentrations and corresponding mean fluxes as outputs from weighted regressions on time, discharge, and season (WRTDS). The catchment attributes include catchment nutrient inputs from point and diffuse sources and characteristics from topography, climate, land cover, lithology and soils. This comprehensive, freely available data collection can facilitate large-sample data-driven water quality assessments at catchment scale as well as mechanistic modeling studies. [ABSTRACT FROM AUTHOR]

Elevated nutrient inputs challenge the health and functioning of aquatic ecosystems. To improve riverine water quality management, it is necessary to understand the underlying biogeochemical and physical processes, anthropogenic drivers and their interactions at catchment scale. We hypothesize that the spatial heterogeneity of nutrient sources dominantly controls the variability of in‐stream concentration dynamics among catchments. We investigated controls of mean nitrate (NO3−), phosphate (PO43−), and total organic carbon (TOC) concentrations and concentration‐discharge (C‐Q) relationships in 787 German catchments of a newly assembled data base, covering a wide range of physiographic and anthropogenic settings. We linked water quality metrics to catchment characteristics using partial least squares regressions and random forests. We found archetypal C‐Q patterns with enrichment dominating NO3− and TOC, and dilution dominating PO43− export. Both the mean NO3− concentrations and their variance among sites increased with agricultural land use. We argue that subsurface denitrification can buffer high nitrogen inputs and cause a decline in concentration with depth, resulting in chemodynamic, strongly positive C‐Q patterns. Mean PO43− concentrations were related to point sources, though the low predictive power suggests effects of unaccounted in‐stream processes. In contrast, high diffuse agricultural inputs explained observed positive PO43−C‐Q patterns. TOC levels were positively linked to the abundance of riparian wetlands, while hydrological descriptors were important for explaining TOC dynamics. Our study shows a strong modulation of anthropogenic inputs by natural controls for NO3− and PO43− concentrations and dynamics, while for TOC only natural controls dominate observed patterns across Germany. Plain Language Summary: Phosphorus, nitrogen, and organic carbon are key elements of plants and all living organisms. Humans are altering the nutrient cycles especially, to improve agricultural productivity and through domestic and industrial wastewater. Excess nutrients in surface waters have harmed many aquatic ecosystems by causing toxic algal blooms and a loss of biodiversity. Low nutrient concentrations and habitat variability are similarly important to those ecosystems, but human interference with natural drivers is not yet fully understood. To better understand and disentangle natural or human controls, we investigated nutrient concentrations and their variability across German catchments with varying landscapes and anthropogenic conditions. The human impact is clearly visible for mean nitrate concentrations, while the (natural) subsurface properties mainly controlled the variability of riverine nitrate. In the past, phosphate inputs were usually linked to wastewater, yet we found the control of agricultural activities on concentration dynamics to be unexpectedly high. Organic carbon was mainly associated with natural sources related to riparian wetlands where interactions with other nutrients are possible. This understanding of dominant controls is important in order to adapt management strategies to ensure healthy aquatic ecosystems. Key Points: Riverine NO3− dynamics are controlled by vertical concentration heterogeneity, which can result from subsurface denitrificationDiffuse P sources exert a strong control on the spatial variability of PO43− export patterns in contrast to point sourcesShare of riparian wetlands controls the mean TOC concentrations in German catchments [ABSTRACT FROM AUTHOR]

Defining effective measures to reduce nitrate pollution in heterogeneous mesoscale catchments remains challenging when based on concentration measurements at the outlet only. One reason for this is our limited understanding of the subcatchment contributions to nitrate export and their importance at different time scales. While upstream subcatchments often disproportionally contribute to runoff generation and in turn to nutrient export, agricultural areas (which are typically found in downstream lowlands) are known to be a major source of nitrate pollution. To examine the interplay of different subcatchments, we analyzed seasonal long‐term trends and event dynamics of nitrate concentrations, loads, and the concentration–discharge relationship in three nested catchments within the Selke catchment (456 km2), Germany. The upstream subcatchments (40.4% of total catchment area, 34.5% of N input) had short transit times and dynamic concentration–discharge relationships with elevated nitrate concentrations during wet seasons and events. Consequently, the upstream subcatchments dominated nitrate export during high flow and disproportionally contributed to overall annual nitrate loads at the outlet (64.2%). The downstream subcatchment was characterized by higher N input, longer transit times, and relatively constant nitrate concentrations between seasons, dominating nitrate export during low‐flow periods. Neglecting the disproportional role of upstream subcatchments for temporally elevated nitrate concentrations and net annual loads can lead to an overestimation of the role of agricultural lowlands. Nonetheless, constantly high concentrations from nitrate legacies pose a long‐term threat to water quality in agricultural lowlands. This knowledge is crucial for an effective and site‐specific water quality management. Plain Language Summary: To efficiently remove nitrate pollution, we need to understand how it is transported, mobilized, and stored within large and heterogeneous catchments. Previous studies have shown that upstream catchments often have a disproportional impact on nutrient export, while agriculture (a major nitrate source) is often located in downstream lowlands. To understand which parts of a catchment contribute most to nitrate export and when, we analyzed long‐term (1983–2016) and high‐frequency (2010–2016) data in the Selke catchment (Germany) at three locations. The mountainous upstream part dominated nitrate transport during winter, spring, and rain events. It had a surprisingly high contribution to annual nitrate loads. The agricultural downstream part of the catchment dominated nitrate export during summer and autumn, with relatively constant concentrations between seasons. Here, nitrogen inputs needed more than a decade to travel through the subsurface of the catchment, which causes a time lag between measures to reduce nitrate pollution and their measurable effect. The resulting storage of nitrate in the groundwater threatens drinking water quality for decades to come. While the role of agricultural lowlands for nitrate export can be overestimated if neglecting the disproportional role of upstream subcatchments, their impact poses a long‐term threat to water quality. Key Points: Analyzing the CQ relationship across time scales allows the disentanglement of the impact of catchment heterogeneity on nitrate exportMountainous upstream subcatchments can dominate nitrate export during high flows and disproportionally contribute to nitrate loadsAgricultural downstream subcatchments can dominate nitrate export during low flow and pose a long‐term threat to water quality [ABSTRACT FROM AUTHOR]

Complying with the demands of drinking water supply whilst minimizing environmental impact poses a great challenge in water management. This study investigates the potential of withdrawal management of drinking water reservoirs to alleviate the disruption of the river continuum by a reservoir dam with respect to temperature and discharge. The aim is the identification of an optimal withdrawal strategy to provide a near‐natural discharge temperature and flow for the downstream river without jeopardizing drinking water production. First, we identify the applicability of new withdrawal regimes for raw water security and downstream river demands. Second, we search for an ideal withdrawal regime in scenario simulations using a numerical reservoir model ("General Lake Model"). The scenarios on a drinking water reservoir in Germany demonstrate that we are able to derive an optimized reservoir management. The numerical model is provided for operators as a simple and efficient tool for optimizing the withdrawal strategy within reservoir management. [ABSTRACT FROM AUTHOR]

Background: Observational studies suggest there are gender based differences in the treatment of coronary artery disease, with women receiving evidence based therapy less frequently than suggested by current guidelines. The aim of our study was to evaluate gender based differences in the use of DES.Methods: We analysed prospectively collected data from 100704 stent implantations in the PCI registry of the ALKK between 2005 and 2009.Results: The usage of DES increased from 16.0 to 43.9%. Although women had smaller vessel sizes, they received DES less often compared to men (28.2 vs. 31.3%), with an adjusted odds ratio of 0.93 (95% confidence interval 0.89-0.97) at the age of 75, and an adjusted odds ratio of 0.89 (95% confidence interval 0.84-0.94) at the age of 80.Conclusion: Despite having smaller vessels than men, women were treated less often with DES. These findings apply to women above the age of 75 years. These findings support previous reports, that elderly women with coronary artery disease are treated differently to men. [ABSTRACT FROM AUTHOR]

From an eight-year-span, 99 Candida bloodstream isolates were collected at the University Hospital Wuerzburg, Germany. In this study, all strains were analyzed using molecular and phenotypic typing methods. Confirmatory species identification revealed three isolates that were initially diagnosed as C. albicans to be actually C. dubliniensis . Two isolates contained a mixed culture of C. albicans and C. glabrata , in one of the specimens both species could be separated while it was not possible to recover C. albicans in the other sample. The remaining 95 C. albicans isolates were profiled by multilocus sequence typing (MLST). Phylogenetic analyses showed a highly heterogenous collection of strains, associated with many different clades and constituting a set of new diploid sequence types (DST). For all strains with identical DST, patient data were reviewed for potential nosocomial transmission. In addition, all isolates were tested for their susceptibility to amphotericin B, caspofungin, fluconazole, itraconazole, posaconazole and voriconazole. No clinically relevant resistance could be detected. Furthermore, these data underline that correlation between minimal inhibitory concentrations for caspofungin and anidulafungin is low. [ABSTRACT FROM AUTHOR]

A key question for the development of geothermal plants is the seismic detection and monitoring of fluid injections at several kilometers depth. The detection and monitoring limits are controlled by several parameters, for example, the strength of seismic sources, number of receivers, vertical stacking, and noise conditions. For a known reference reflector at 2.66 km depth at a geothermal site in northern Germany the results of a simple surface seismic experiment were therefore combined with numerical forward modeling for different injection scenarios at 3.8 km depth. The underlying idea is that changes of reflectivity from the injection at 3.8 km must be larger than the variance of the measurements to be observable. Assuming that the injection at 3.8 km depth would produce a subhorizontal disklike target with a fracture porosity of 2% or 5% (the critical porosity) the water injection volume has to be at least 443 and 115 m³, respectively, to be detectable from the surface. If the injection on the other hand does not create subhorizontal but subvertical pathways or only reduces the seismic velocities via the increased pore pressure in the immediate vicinity of the bore hole, the injection is undetectable from the surface. The most promising approach is therefore to move sources and/or receivers closer to the target, that is, the use of borehole instrumentation. [ABSTRACT FROM AUTHOR]

The article focuses on competitiveness in the public health care system in Germany. In particular, the author examines the modernization process of the local government with regard to health services for the public. The buying power of state insurance companies is discussed and measures for ensuring quality in self-administration is examined.

Abstract: This study assumes a high penetration of hydrogen-fuelled vehicles for Germany in 2050 and investigates the structure of a potential pipeline network for hydrogen transmission and distribution under different scenarios for H2 production and demand. All data are georeferenced for their computation and displayed within a Geographical Information System (GIS) environment. Statistical data describing the current vehicle distribution by type and district are computed to evaluate the geographical distribution of hydrogen demand that can be expected. Assumptions on market penetration for hydrogen-fuelled vehicles are also varied. We identified the majority of the approximately 14,000 existing refuelling stations for conventional fuels and expect hydrogen to be delivered at most of them, selected according to their localisation (along or near main roads, within urban areas, etc.). They form the sinks of the modelled distribution network. On the hydrogen production side, we envisage highly differentiated scenarios: electrolysis using offshore wind-generated electricity associated with onshore wind-generated electricity or with lignite gasification. Then we calculate the preliminary layouts and costs of pipeline networks capable of balancing the proposed demand and supply options. Finally, we compare the different options from an infrastructure planning and support perspective. [Copyright &y& Elsevier]

Background: Catheter-based renal denervation has significantly reduced blood pressure in previous studies. Following a positive pilot trial, the SPYRAL HTN-OFF MED (SPYRAL Pivotal) trial was designed to assess the efficacy of renal denervation in the absence of antihypertensive medications., Methods: In this international, prospective, single-blinded, sham-controlled trial, done at 44 study sites in Australia, Austria, Canada, Germany, Greece, Ireland, Japan, the UK, and the USA, hypertensive patients with office systolic blood pressure of 150 mm Hg to less than 180 mm Hg were randomly assigned 1:1 to either a renal denervation or sham procedure. The primary efficacy endpoint was baseline-adjusted change in 24-h systolic blood pressure and the secondary efficacy endpoint was baseline-adjusted change in office systolic blood pressure from baseline to 3 months after the procedure. We used a Bayesian design with an informative prior, so the primary analysis combines evidence from the pilot and Pivotal trials. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT02439749., Findings: From June 25, 2015, to Oct 15, 2019, 331 patients were randomly assigned to either renal denervation (n=166) or a sham procedure (n=165). The primary and secondary efficacy endpoints were met, with posterior probability of superiority more than 0·999 for both. The treatment difference between the two groups for 24-h systolic blood pressure was -3·9 mm Hg (Bayesian 95% credible interval -6·2 to -1·6) and for office systolic blood pressure the difference was -6·5 mm Hg (-9·6 to -3·5). No major device-related or procedural-related safety events occurred up to 3 months., Interpretation: SPYRAL Pivotal showed the superiority of catheter-based renal denervation compared with a sham procedure to safely lower blood pressure in the absence of antihypertensive medications., Funding: Medtronic., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Despite a large amount of data assessing outcomes of out-of-hospital cardiac arrests (OHCAs), little information is available about physician-staffed emergency medical service (EMS) systems. The aim of our study was to investigate the impact of a physician on the outcome of patients after OHCA., Methods: This is a prospective, observational study that included 539 consecutive patients (63.9 +/- 19.1 years old; 349 males) with OHCA in the community of Dachau (135,000 inhabitants) in whom resuscitation was attempted between January 2000 and January 2006 according to Utstein style. Patients were followed up to hospital discharge. The primary end point of the study was that the patients was discharged alive from hospital., Results: Of 412 patients with an OHCA, 180 (43.7%) were admitted to hospital, and 47 (11.4%) were discharged alive. Resuscitation was started by a physician in 117 (28.4%) patients, by a layperson in 118 (28.6%), or by an EMS personnel in 177 (43.0%). A total of 18 patients (18.6%) treated by physicians, 13 patients (8.0%) treated by EMS personnel (P = .02 vs treatment by physician), and 16 patients (16.5%) resuscitated by laypersons were discharged from hospital (P = .8 vs treatment by physician). In 105 patients with bystander-witnessed OHCA of cardiac origin with shockable rhythm, the discharge rate was 32.4% (n = 34). Multivariate analysis identified ventricular fibrillation on first electrocardiogram, observed OHCA, short response time intervals but not the unit that performed the first resuscitation attempt as independent predictors of survival., Conclusions: A physician on board of the advanced life support unit was not identified as an independent factor of improved survival.