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Abstract Background This protocol outlines a scoping review with the objective of identifying and exploring planetary health considerations within existing health guidelines and health technology assessments (HTA). The insights gained from this review will serve as a basis for shaping future Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidance on planetary health. Methods We will adhere to the JBI methodology for scoping reviews. We will conduct a comprehensive search and screening of results in all languages across various databases including MEDLINE, EMBASE, CINAHL, Global Health, Health Systems Evidence, Greenfile, and Environmental Issues. Additionally, we will supplement this search with resources such as the GIN library, BIGG database, Epistemonikos, GRADE guidelines repository, GRADEpro Guideline Development Tool Database, MAGICapp, NICE website, WHO websites, and a manual exploration of unpublished relevant documents using Google incognito mode. Two independent reviewers will screen and assess the full texts of identified documents according to the eligibility criteria. The following information from each full text will be extracted: document title; first author’s name; publication year; language; document type; document as a guideline or HTA; the topic/discipline; document purpose/study objective; developing/sponsoring organization; the country in which the study/guideline/HTA report was conducted; definition of planetary health or related concept provided; types of planetary health experts engaged; study methods; suggested methods to assess planetary health; use of secondary data on planetary health outcomes; description for use of life cycle assessment; description for assessing the quality of life cycle; population/intended audience; interventions; category; applicable planetary health boundaries; consideration of social justice/global equity; phase of intervention in life cycle related to planetary health addressed; the measure of planetary health impact; impact on biodiversity/land use; one health/animal welfare mention; funding; and conflict of interest. Data analysis will involve a combination of descriptive statistics and directed content analysis, with results presented in a narrative format and displayed in tables and graphs. Discussion The final review results will be submitted to open-access peer-reviewed journals for publication when they become available. The research findings will also be disseminated at relevant planetary health conferences and workshops. Systematic review registration Open Science Framework ( https://osf.io/3jmsa ).

BackgroundEmergency departments (EDs) are frequently overcrowded and increasingly used by nonurgent patients. Symptom checkers (SCs) offer on-demand access to disease suggestions and recommended actions, potentially improving overall patient flow. Contrary to the increasing use of SCs, there is a lack of supporting evidence based on direct patient use. ObjectiveThis study aimed to compare the diagnostic accuracy, safety, usability, and acceptance of 2 SCs, Ada and Symptoma. MethodsA randomized, crossover, head-to-head, double-blinded study including consecutive adult patients presenting to the ED at University Hospital Erlangen. Patients completed both SCs, Ada and Symptoma. The primary outcome was the diagnostic accuracy of SCs. In total, 6 blinded independent expert raters classified diagnostic concordance of SC suggestions with the final discharge diagnosis as (1) identical, (2) plausible, or (3) diagnostically different. SC suggestions per patient were additionally classified as safe or potentially life-threatening, and the concordance of Ada’s and physician-based triage category was assessed. Secondary outcomes were SC usability (5-point Likert-scale: 1=very easy to use to 5=very difficult to use) and SC acceptance net promoter score (NPS). ResultsA total of 450 patients completed the study between April and November 2021. The most common chief complaint was chest pain (160/437, 37%). The identical diagnosis was ranked first (or within the top 5 diagnoses) by Ada and Symptoma in 14% (59/437; 27%, 117/437) and 4% (16/437; 13%, 55/437) of patients, respectively. An identical or plausible diagnosis was ranked first (or within the top 5 diagnoses) by Ada and Symptoma in 58% (253/437; 75%, 329/437) and 38% (164/437; 64%, 281/437) of patients, respectively. Ada and Symptoma did not suggest potentially life-threatening diagnoses in 13% (56/437) and 14% (61/437) of patients, respectively. Ada correctly triaged, undertriaged, and overtriaged 34% (149/437), 13% (58/437), and 53% (230/437) of patients, respectively. A total of 88% (385/437) and 78% (342/437) of participants rated Ada and Symptoma as very easy or easy to use, respectively. Ada’s NPS was –34 (55% [239/437] detractors; 21% [93/437] promoters) and Symptoma’s NPS was –47 (63% [275/437] detractors and 16% [70/437]) promoters. ConclusionsAda demonstrated a higher diagnostic accuracy than Symptoma, and substantially more patients would recommend Ada and assessed Ada as easy to use. The high number of unrecognized potentially life-threatening diagnoses by both SCs and inappropriate triage advice by Ada was alarming. Overall, the trustworthiness of SC recommendations appears questionable. SC authorization should necessitate rigorous clinical evaluation studies to prevent misdiagnoses, fatal triage advice, and misuse of scarce medical resources. Trial RegistrationGerman Register of Clinical Trials DRKS00024830; https://drks.de/search/en/trial/DRKS00024830

Background: Evidence on the health benefits of spending time in nature has highlighted the importance of provision of blue and green spaces where people live. The potential for health benefits offered by nature exposure, however, extends beyond health promotion to health treatment. Social prescribing links people with health or social care needs to community-based, non-clinical health and social care interventions to improve health and wellbeing. Nature-based social prescribing (NBSP) is a variant that uses the health-promoting benefits of activities carried out in natural environments, such as gardening and walking. Much current NBSP practice has been developed in the UK, and there is increasing global interest in its implementation. This requires interventions to be adapted for different contexts, considering the needs of populations and the structure of healthcare systems. Methods: This paper presents results from an expert group participatory workshop involving 29 practitioners, researchers, and policymakers from the UK and Germany’s health and environmental sectors. Using the UK and Germany, two countries with different healthcare systems and in different developmental stages of NBSP practice, as case studies, we analysed opportunities, challenges, and facilitators for the development and implementation of NBSP. Results: We identified five overarching themes for developing, implementing, and evaluating NBSP: Capacity Building; Accessibility and Acceptability; Networks and Collaborations; Standardised Implementation and Evaluation; and Sustainability. We also discuss key strengths, weaknesses, opportunities, and threats for each overarching theme to understand how they could be developed to support NBSP implementation. Conclusions: NBSP could offer significant public health benefits using available blue and green spaces. We offer guidance on how NBSP implementation, from wider policy support to the design and evaluation of individual programmes, could be adapted to different contexts. This research could help inform the development and evaluation of NBSP programmes to support planetary health from local and global scales.

Abstract Objective This scoping review aims to provide an overview of how theories were used in the development or evaluation of social prescribing (SP) intervention studies. Background SP describes a patient pathway where general practitioners (GPs) connect patients with community activities through referrals to link workers. This review seeks to understand the explanations provided for the outcomes and implementation process of SP. Inclusion criteria Studies using a defined theory to develop or evaluate a specific SP intervention in primary care and the community sector. Methods This scoping review was conducted in accordance with JBI methodology. The following databases were searched on 8th of July 2022: PubMed, ASSIA, Cochrane, Cinahl, PsycINFO, Social Care Online, Sociological Abstracts, Scopus, and Web of Science. The search only considered English language texts. Additional literature was identified by searching relevant web pages and by contacting experts. The selection of sources and the data extraction was done by two reviewers independently. Results The search resulted in 4240 reports, of which 18 were included in the scoping review. Of these, 16 were conducted in the UK, one in Canada and one in Australia. The majority of reports employed a qualitative approach (11/18). Three were study protocols. 11 distinct theories were applied to explain outcomes (4 theories), differences in outcomes (3 theories), and the implementation of the intervention (4 theories). In terms of practical application, the identified theories were predominantly used to explain and understand qualitative findings. Only one theory was used to define variables for hypothesis testing. All theories were used for the evaluation and none for the development of SP. Conclusion The theories influenced which outcomes the evaluation assessed, which causal pathway was expected to generate these outcomes, and which methodological approaches were used. All three groups of theories that were identified focus on relevant aspects of SP: fostering positive patient/community outcomes, addressing inequalities by considering the context of someone’s individual circumstances, and successfully implementing SP by collaboratively working across professions and institutional boundaries. Additional insight is required regarding the optimal use of theories in practical applications.

Abstract Background Breast cancer and cervical cancer are among the most common cancers in women in Germany. Early detection examinations such as mammography and the cervical smear test (Pap-test) have been shown to contribute to the reduction in the mortality and/or incidence of these cancers and can be utilised free of charge by women in certain age groups as part of national screening programmes. Analyses show that the use of health services varies regionally, especially when comparing the federal states of the former German Democratic Republic (GDR, Eastern Germany) and the Federal Republic of Germany (FRG, Western Germany). This study investigated to what extent the utilisation of mammography examinations and Pap-tests by women differs in federal states of former GDR and FRG. Methods For this purpose, we analysed data from the nationwide health survey GEDA14/15 conducted by the Robert Koch Institute (RKI) in 2014 and 2015. We calculated weighted proportions and compared attendance between eastern and western German states by a Chi-Square-test. Additionally, we conducted regression analysis to adjust for socio-economic status, living environment and place of birth. Results 2,772 female participants aged 20–34 years were analysed for Pap-test attendance in the last two years and 4,323 female participants aged 50–69 years old were analysed for mammography screening attendance in the last two years. 50–69-year-old women in eastern German states were with 78.3% (95%-CI 75.3%, 81.2%) more likely to attend mammography screening than in western Germany with 73.4% (95%-CI 71.8%, 74.9%). Pap-test uptake was statistically significantly higher in the East of Germany with 83.3% (95%-CI 79.6%, 87.1%) compared to 77.5% (95%-CI 75.8%, 79.3%) in the West of Germany. This relationship was robust to adjusting for socio-economic status, living environment and place of birth. Conclusions Cultural influences and socialization in the GDR might explain the higher utilisation of these cancer screening examinations at least to some extent. This could have many reasons, for example a higher health awareness through education or a possible greater trust in medical structures and the associated higher compliance of women. These hypotheses should be further explored to increase the uptake of screening examinations by women in Germany.

Abstract Background While reporting of individual conflicts of interest is formalised, it is unclear to what extent the funding of clinical practice guidelines (CPGs) is formally reported. The aim of this study is to explore the accuracy and comprehensiveness of reporting on funding in German CPGs. Methods We searched for CPGs in the registry of the Association of the Scientific Medical Societies in Germany in July 2020. Information on guideline funding was categorised by two reviewers independently and discrepancies were clarified by discussion with a third reviewer. Accuracy and comprehensiveness of reporting on funding was assessed using the German Instrument for Methodological Guideline Appraisal (DELBI). Results We included 507 CPGs published between 2015 and 2020 in the main analysis. 23/507 (4.5%) of the CPGs achieved the highest DELBI score by including information on funding sources, expenses and the amount of funding provided, as well as a statement on the independence of the guideline authors from the funding institution(s). CPGs with more rigorous methodological requirements (systematic review of the literature and/or structured consensus-building) received higher DELBI scores. Conclusion German CPGs do not communicate their funding transparently. Transparency of CPG funding could be achieved by making it mandatory to publish information for all guidelines. For that purpose, a standardised form and guidance should be developed.

Abstract Background Due to the increasing use of online health information, symptom checkers have been developed to provide an individualized assessment of health complaints and provide potential diagnoses and an urgency estimation. It is assumed that they support patient empowerment and have a positive impact on patient-physician interaction and satisfaction with care. Particularly in the emergency department (ED), symptom checkers could be integrated to bridge waiting times in the ED, and patients as well as physicians could take advantage of potential positive effects. Our study therefore aims to assess the impact of symptom assessment application (SAA) usage compared to no SAA usage on the patient-physician interaction in self-referred walk-in patients in the ED population. Methods In this multi-center, 1:1 randomized, controlled, parallel-group superiority trial, 440 self-referred adult walk-in patients with a non-urgent triage category will be recruited in three EDs in Berlin. Eligible participants in the intervention group will use a SAA directly after initial triage. The control group receives standard care without using a SAA. The primary endpoint is patients’ satisfaction with the patient-physician interaction assessed by the Patient Satisfaction Questionnaire. Discussion The results of this trial could influence the implementation of SAA into acute care to improve the satisfaction with the patient-physician interaction. Trial registration German Clinical Trials Registry DRKS00028598 . Registered on 25.03.2022

BackgroundPrevious studies have revealed that users of symptom checkers (SCs, apps that support self-diagnosis and self-triage) are predominantly female, are younger than average, and have higher levels of formal education. Little data are available for Germany, and no study has so far compared usage patterns with people’s awareness of SCs and the perception of usefulness. ObjectiveWe explored the sociodemographic and individual characteristics that are associated with the awareness, usage, and perceived usefulness of SCs in the German population. MethodsWe conducted a cross-sectional online survey among 1084 German residents in July 2022 regarding personal characteristics and people’s awareness and usage of SCs. Using random sampling from a commercial panel, we collected participant responses stratified by gender, state of residence, income, and age to reflect the German population. We analyzed the collected data exploratively. ResultsOf all respondents, 16.3% (177/1084) were aware of SCs and 6.5% (71/1084) had used them before. Those aware of SCs were younger (mean 38.8, SD 14.6 years, vs mean 48.3, SD 15.7 years), were more often female (107/177, 60.5%, vs 453/907, 49.9%), and had higher formal education levels (eg, 72/177, 40.7%, vs 238/907, 26.2%, with a university/college degree) than those unaware. The same observation applied to users compared to nonusers. It disappeared, however, when comparing users to nonusers who were aware of SCs. Among users, 40.8% (29/71) considered these tools useful. Those considering them useful reported higher self-efficacy (mean 4.21, SD 0.66, vs mean 3.63, SD 0.81, on a scale of 1-5) and a higher net household income (mean EUR 2591.63, SD EUR 1103.96 [mean US $2798.96, SD US $1192.28], vs mean EUR 1626.60, SD EUR 649.05 [mean US $1756.73, SD US $700.97]) than those who considered them not useful. More women considered SCs unhelpful (13/44, 29.5%) compared to men (4/26, 15.4%). ConclusionsConcurring with studies from other countries, our findings show associations between sociodemographic characteristics and SC usage in a German sample: users were on average younger, of higher socioeconomic status, and more commonly female compared to nonusers. However, usage cannot be explained by sociodemographic differences alone. It rather seems that sociodemographics explain who is or is not aware of the technology, but those who are aware of SCs are equally likely to use them, independently of sociodemographic differences. Although in some groups (eg, people with anxiety disorder), more participants reported to know and use SCs, they tended to perceive them as less useful. In other groups (eg, male participants), fewer respondents were aware of SCs, but those who used them perceived them to be more useful. Thus, SCs should be designed to fit specific user needs, and strategies should be developed to help reach individuals who could benefit but are not aware of SCs yet.

Introduction: Social prescribing (SP) aims to provide targeted psychosocial support and close the gap between medical and non-medical services. This review assesses the effectiveness of community-based SP interventions. Methods: We performed a systematic review and qualitative synthesis of interventional studies of community referral interventions focused on facilitating psychosocial support. We considered health-related endpoints, other patient reported outcomes, or health care utilization. Six databases, grey literature, and additional trials registers were searched. Results were screened in a two-step process, followed by data extraction, each by two independent reviewers. If data permitted such, effect sizes were calculated. Risk of bias was assessed with the EPHPP and the Cochrane RoB2 tools. Results: We identified 68 reports from 53 different projects, three were controlled studies. Uncontrolled studies with shorter time frames frequently reported positive effects. This could largely not be seen in controlled settings and for longer follow-up periods. Designs, populations, and outcomes evaluated were heterogeneous with high risk of bias for most studies. Discussion and conclusion: Current evidence suggests positive effects of SP on a variety of relevant endpoints. Due to quality deficits in the available studies, scope for conclusions concerning clinical relevance and sustainability is limited. Further methodologically rigorous controlled trials are needed. Zusammenfassung Einleitung: Social prescribing (SP) soll gezielte psychosoziale Unterstützung ermöglichen und die Lücke zwischen medizinischen und nicht-medizinischen Angeboten schließen. Diese Übersichtsarbeit untersucht die Wirksamkeit von gemeindebasierten SP-Interventionen. Methoden: Es erfolgte eine systematische Übersichtsarbeit und qualitative Synthese von Interventionsstudien zu gemeindebasierten Überweisungs-Interventionen, die auf eine Förderung psychosozialer Unterstützung abzielen. Es wurden gesundheitsrelevante Endpunkte, andere patientenberichtete Outcomes, sowie die Inanspruchnahme von Gesundheitsleistungen berücksichtigt. Die Suche erfolgte in sechs Datenbanken, grauer Literatur, sowie zusätzlich in Studienregistern. Die Ergebnisse wurden in einem zweistufigen Prozess gesichtet, gefolgt von der Datenextraktion. Beide Schritte erfolgten durch zwei unabhängige Reviewer. Bei ausreichend verfügbaren Daten wurden Effektstärken errechnet. Das Verzerrungspotenzial wurde mit den EPHPP und Cochrane RoB2 Instrumenten bewertet. Ergebnisse: Es wurden 68 Berichte aus 53 unterschiedlichen Projekten identifiziert, darunter waren drei kontrollierte Studien. Nicht-kontrollierte Studien mit kürzeren Betrachtungszeiträumen berichteten häufig positive Effekte. In kontrollierten Settings und über längere Beobachtungszeiten konnte dies überwiegend nicht gezeigt werden. Betrachtete Designs, Populationen und Endpunkte waren heterogen, das Verzerrungspotential in den meisten Studien hoch. Diskussion und Schlussfolgerungen: Die derzeitige Evidenz legt positive Effekte von SP auf eine Reihe relevanter Endpunkte nahe. Aufgrund von Qualitätsdefiziten in den verfügbaren Studien können die klinische Relevanz und die Langfristigkeit der Effekte nur eingeschränkt beurteilt werden. Zusätzliche methodisch hochwertige Studien sind erforderlich. Schlüsselwörter: soziales Rezept; gemeindebasierte Überweisungs-Interventionen; systematische Übersichtsarbeit; integrierte Versorgungskonzepte

Abstract Background Many patients suffering from peripheral arterial disease (PAD) are dependent on bypass surgery. However, in some patients no suitable replacements (i.e. autologous or prosthetic bypass grafts) are available. Advances have been made to develop autologous tissue engineered vascular grafts (TEVG) using endothelial colony forming cells (ECFC) obtained by peripheral blood draw in large animal trials. Clinical translation of this technique, however, still requires additional data for usability of isolated ECFC from high cardiovascular risk patients. Bovine carotid arteries (BCA) were decellularized using a combined SDS (sodium dodecyl sulfate) -free mechanical-osmotic-enzymatic-detergent approach to show the feasibility of xenogenous vessel decellularization. Decellularized BCA chips were seeded with human ECFC, isolated from a high cardiovascular risk patient group, suffering from diabetes, hypertension and/or chronic renal failure. ECFC were cultured alone or in coculture with rat or human mesenchymal stromal cells (rMSC/hMSC). Decellularized BCA chips were evaluated for biochemical, histological and mechanical properties. Successful isolation of ECFC and recellularization capabilities were analyzed by histology. Results Decellularized BCA showed retained extracellular matrix (ECM) composition and mechanical properties upon cell removal. Isolation of ECFC from the intended target group was successfully performed (80% isolation efficiency). Isolated cells showed a typical ECFC-phenotype. Upon recellularization, co-seeding of patient-isolated ECFC with rMSC/hMSC and further incubation was successful for 14 (n = 9) and 23 (n = 5) days. Reendothelialization (rMSC) and partial reendothelialization (hMSC) was achieved. Seeded cells were CD31 and vWF positive, however, human cells were detectable for up to 14 days in xenogenic cell-culture only. Seeding of ECFC without rMSC was not successful. Conclusion Using our refined decellularization process we generated easily obtainable TEVG with retained ECM- and mechanical quality, serving as a platform to develop small-diameter (

Abstract Background The reliability of clinical practice guidelines has been disputed because guideline panel members are often burdened with financial conflicts of interest (COI). Current recommendations for COI regulation advise not only detailed declaration but also active management of conflicts. To continuously assess COI declaration and management in German guidelines we established the public database LeitlinienWatch (GuidelineWatch). Methods We analyzed all German guidelines at the highest methodological level (S3) that included recommendations for pharmacological therapy (n = 67) according to five criteria: declaration and assessment of COI, composition of the guideline development group, independence of the coordinators and lead authors, imposed abstentions because of COI and public external review. Each criterion was assessed using predefined outcome categories. Results Most guidelines (76%) contained a detailed declaration of COI. However, none of the guidelines provided full transparency of COI assessment results. The guideline group was composed of a majority of participants with COI in 55% of the guidelines, no guideline was free of participants with COI. Only 9% of guidelines had coordinators and lead authors without any financial COI. Most guidelines (70%) did not provide a rule for abstentions for participants with COI. In 21% of guidelines there was a rule, but abstentions were either not practiced or not documented, whereas in 7% partial abstentions and in 2% complete abstentions were documented. Two thirds of the guideline drafts (67%) were not externally reviewed via a public website. Conclusions COI are usually documented in detail in German guidelines of the highest methodological level. However, considerable improvement is needed regarding active management of COI, including recruitment of independent experts for guideline projects, abstention from voting for participants with COI and external review of the guideline draft. We assume that the publicly available ratings on GuidelineWatch will improve the handling of conflicts of interest in guideline development.