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Background Multimorbidity is a common phenomenon among patients treated in general practices. Key challenges within this group include functional difficulties, polypharmacy, treatment burden, fragmentation of care, reduced quality of life and increased health care utilization. These problems cannot be solved in the short consultation time of a general practitioner (GP) since there is an increasing shortage of GPs. In many countries, advanced practice nurses (APNs) are successfully integrated into primary health care for multimorbid patients. The objective of this study is to examine whether the integration of APNs in the primary care of multimorbid patients in Germany leads to optimized care of the target group and to a reduction in the workload of the GPs. Methods The intervention includes the integration of APNs into the care for multimorbid patients in general practice for twelve months. Qualifications for APNs include a master's level academic degree and 500 hours of project-specific training. Their tasks include in-depth assessment, preparation, implementation, monitoring and evaluation of a person-centred and evidence-based care plan. In this nonrandomized controlled trial, a prospective multicentre mixed methods study will be performed. The main inclusion criterion was the cooccurrence of three chronic diseases. For data collection in the intervention group (n = 817), routine data from health insurance companies and association of statutory health insurance physicians (ASHIP) will be used, as well as qualitative interviews. In addition, the intervention will be assessed through documentation of the care process and standardized questionnaires using a longitudinal design. The control group (n = 1634) will receive standard care. For the evaluation, routine data from health insurance companies are matched at a ratio of 1:2. Outcomes will be measured using emergency contacts and GP visits, treatment costs, health status of the patients and the satisfaction of parties involved. The statistical analyses will include Poisson regression to compare outcomes between the intervention and control groups. Descriptive and analytical statistical methods will be used in the longitudinal analysis of the intervention group data. Cost analysis will compare total costs and subgroup costs between the intervention and control groups. Qualitative data will be analysed using content analysis. Discussion Challenges to this protocol could include the political and strategic environment as well as the planned number of participants. Trial registration DRKS00026172 on DRKS.

Purpose Cancer patients have been shown to frequently suffer from financial burden before, during, and after treatment. However, the financial toxicity of patients with sarcoma has seldom been assessed. Therefore, the aim of this study was to evaluate whether financial toxicity is a problem for sarcoma patients in Germany and identify associated risk factors. Methods Patients for this analysis were obtained from a multicenter prospective cohort study conducted in Germany. Using the financial difficulties scale of the EORTC QLQ-C30, financial toxicity was considered to be present if the score exceeded a pre-defined threshold for clinical importance. Comparisons to an age- and sex-matched norm population were performed. A multivariate logistic regression using stepwise backward selection was used to identify factors associated with financial toxicity. Results We included 1103 sarcoma patients treated in 39 centers and clinics; 498 (44.7%) patients reported financial toxicity. Sarcoma patients had 2.5 times the odds of reporting financial difficulties compared to an age- and sex-matched norm population. Patient age 52.5 years, higher education status, higher income, and disease progression (compared to patients with complete remission) were associated with lower odds of reporting financial toxicity. Receiving a disability pension, being currently on sick leave, and having a disability pass were statistically significantly associated with higher odds of reporting financial toxicity. Conclusion Financial toxicity is present in about half of German sarcoma patients, making it a relevant quality of life topic for patients and decision-makers.

This study investigated how the number of sessions for outpatient psychodynamic psychotherapy among patients with depressive disorders is associated with the severity of the disease.From a random sample of 1000 applications for reimbursement of outpatient psychodynamic psychotherapy, we selected those in which a diagnosis of depression with a severity rating (ICD-10 F32 or F33) was coded. The association of levels of depression severity (mild, moderate, and severe) with the number of sessions requested and the number of sessions endorsed by the reviewer was investigated using Spearman's rank correlation. If the application was for a continuation of an ongoing therapy, the previous sessions were taken into account too.A total of 521 (52%) applications contained a diagnosis of F32 and/or F33. Out of these, 63 (12%) were coded as mild, 349 (67%) as moderate, and 50 (10%) as severe. There were 75 sessions applied for in patients with mild depression (median), 50 in patients with moderate depression, and 50 in patients with severe depression, whereby the range within each severity group was considerable (10 to 327 sessions) and the correlation was low (Rho -0.10). The median number of endorsed sessions was 74 in patients with mild depression, 50 in patients with moderate, and 50 in patients with severe depression. Here, too, the range was high (0 sessions to 327 sessions) and the association weak (Rho -0.11).There is no evidence that psychotherapists determine the necessary number of sessions solely based on the severity of the diagnosis.FRAGESTELLUNG: Vor dem Hintergrund der Debatte um eine mögliche Festlegung des Leistungsumfangs für ambulante Psychotherapie anhand der Diagnose haben wir untersucht, ob in der aktuellen Versorgungspraxis bei Patienten mit Depressionen die Anzahl der beantragten sowie die der vom Gutachter befürworteten Stunden mit dem Schweregrad der Erkrankung zusammenhängen.Aus einer Zufallsstichprobe von 1000 Anträgen auf Kostenübernahme für ambulante analytische oder tiefenpsychologisch fundierte Psychotherapie wurden jene herausgesucht, in denen eine Depressionsdiagnose mit Schweregradeinschätzung (ICD-10 F32 oder F33) entweder im Bericht oder auf dem Antragsformular kodiert worden war. Die Zahl der beantragten und der befürworteten Stunden pro Antrag wurde extrahiert. Bei Umwandlungs- und Fortführungsanträgen wurden dabei auch die im Vorfeld stattgefundenen Therapiestunden berücksichtigt. Ein möglicher Zusammenhang des Schweregrads der Depression mit der Zahl der beantragten bzw. der vom Gutachter befürworteten Stunden wurde anhand von Spearman-Rangkorrelationen überprüft.Insgesamt 521 Anträge (52 %) enthielten eine F32- und/oder eine F33-Diagnose. Davon waren 63 (12 %) als leicht kodiert, 349 (67 %) als mittelgradig und 50 (10 %) als schwer. Im Median wurden 75 h bei leichter sowie je 50 h bei mittelgradiger bzw. bei schwerer Depression beantragt, wobei die Zahlen innerhalb der Gruppen stark variierten (10 bis 327 h) und der Zusammenhang zwischen Schweregrad und beantragter Stundenzahl gering war (Rho −0,10). Die befürworteten Stundenkontingente waren im Median 74 (leichte Depression), 50 (mittelgradig) und 50 (schwer) Stunden, auch hier war die Spannweite hoch (0 bis 327 h) und die Korrelation gering (Rho −0,11).Es gibt keine Anhaltspunkte dafür, dass Psychotherapeuten die benötigten Stundenkontingente allein anhand des Schweregrads der Diagnose festlegen.

Background and purpose — Knee and hip replacement are common and increasing procedures, and an optimized care process that could be implemented in different settings would be useful. The PROMISE trial investigates whether a new care process works equally in different German settings and how the results compare with current non-standardized care. Patients and methods — This multi-center prospective mixed-method study includes 2,000 German patients receiving arthritis-related hip or knee endoprostheses. An interdisciplinary and cross-sectoral care process was developed and implemented in 3 German hospitals with different levels of care, and corresponding rehabilitation centers were included to bridge the gap after acute care. Duration and outcome — The PROMISE trial recruited patients between May 2018 and March 2020. Follow-up will end in February 2021. Assessments are performed at: examination on clinical indication, 1 week before surgery, on the day of surgery, at the end of hospitalization, end of the rehabilitation program, and 3 months, 6 months, and 12 months after surgery. Outcomes include patient-reported outcomes, medical examination findings, and routinely collected data regarding the surgery and complications. Guideline-based interviews are conducted with selected patients and care partners. The primary endpoint is the presence of chronic pain at 12 months after surgery. Secondary endpoints are the number of recognized pre-existing conditions, physical activity at 12 months after surgery, use of medical services, quality of life, and interactions between care partners. Trial registration — The trial is registered with the German Clinical Trials Register (https://www.drks.de; DRKS00013972; March 23, 2018).

Background: While there is evidence on the effectiveness of optimized treatment processes for patients receiving hip and knee endoprostheses, feasibility in various settings has not been adequately investigated. The multicenter PROMISE Trial (Process optimization by interdisciplinary and cross-sectoral care using the example of patients with hip and knee prostheses) was set up to fill this gap. Methods: A complex optimized process was implemented in three German hospitals offering different levels of care and five cooperating rehabilitation centers. For the feasibility question, data on 19 parameters characterizing the defined process were collected. The extent of cross-sectoral collaboration was a special focus. Results: The data show, for almost all parameters in all facilities, an implementation rate of more than 80% with missing data below 5%, n = 1887 study participants. A total of 96.8% attended a rehabilitation program, and for 29.2% rehabilitation took place in a PROMISE-collaborating facility. Conclusions: Adherence to the defined and well-documented process was very high in all three organizationally very different hospitals, so that feasibility is given and transferability of the concept can be assumed. An exception was the targeted integration of rehabilitation into the treatment process. The goal of cross-sectoral networking could only be partially achieved.

In the context of optimized treatment processes for knee and hip replacements, lengths of stay are given for Germany that clearly exceed the internationally published ones. In this context, the present analysis of data from the PROMISE study deals with the relationship between discharge readiness and discharge.In the PROMISE study, a jointly developed, optimized standard of care was established in three hospitals of different levels of care and realized for a typical, largely unselected cohort of patients. Among others, data were collected on achievement of discharge criteria (DC) and actual discharge. Univariate comparisons were performed by chi-square tests or the Mann-Whitney‑U tests.A total of 1782 patients were included, of whom a mean of 85.3% achieved all previously defined DCs at a mean of 2.4 (median 2) days postoperatively. Discharge for this group occurred after a mean of 5.4 (median 5) days. 14.7% of the participants did not achieve at least one DC. This group was discharged after a mean of 6.5 (median 6) days. Significant differences in outcomes were observed for different subgroups.The so-called DCs are used as relative criteria. Achievement generally does not result in timely discharge. If this were to happen, internationally established lengths of stay would also be a reality in Germany. What actually determines discharge from inpatient treatment remains open. A variety of medical, organizational, structural and financial factors could be of importance.HINTERGRUND: Für Deutschland werden im Rahmen optimierter Behandlungsprozesse rund um die Implantation einer Knie- oder Hüftendoprothese stationäre Aufenthaltszeiten angegeben, die die international publizierten Zeiten deutlich übertreffen. Die vorliegende Analyse von Daten der PROMISE-Studie beschäftigt sich in diesem Zusammenhang mit dem Verhältnis von Entlassbarkeit und Entlassung.In drei Krankenhäusern unterschiedlicher Versorgungsstufen wurde ein gemeinsam entwickelter, optimierter Versorgungsstandard etabliert und für eine weitgehend unselektionierte Patientenkohorte umgesetzt. Unter anderem wurden Daten zum Erreichen der Entlasskriterien (EK) und der tatsächlichen Entlassung erhoben. Univariate Vergleiche wurden durch Chi-Quadrat-Tests oder Mann-Whitney-U-Tests durchgeführt.Insgesamt konnten 1782 Patienten eingeschlossen werden, von denen 85,3 % nach im Mittel (MW) 2,4 Tagen (Median 2) postoperativ alle zuvor definierten EK erreicht haben. Die Entlassung für diese Gruppe erfolgte nach 5,4 (MW) Tagen (Median 5). Die restlichen Probanden (14,7 %) hatten bei Entlassung nach 6,5 (MW) Tagen (Median 6) mindestens ein EK nicht erreicht. Für verschiedene Subgruppen konnten signifikante Unterschiede festgestellt werden.Die sogenannten EK werden als relative Kriterien eingesetzt. Das Erreichen führt im Allgemeinen nicht zu einer zeitnahen Entlassung der Patienten aus dem Krankenhaus. Wäre dies der Fall, wären auch in Deutschland international übliche Aufenthaltszeiten Realität. Was die Entlassung tatsächlich bestimmt, bleibt offen. Eine Vielzahl von medizinischen, organisatorischen, strukturellen und finanziellen Einflussfaktoren könnten bedeutend sein.

Various national and international guidelines for the management of thyroid cancer exist. The aim of this survey was to evaluate whether patients experience differences regarding the management of thyroid cancer in Germany and in France. An online survey addressing diagnosis, treatment, aftercare, and information needs of thyroid cancer survivors was set up by the German and the French nationwide thyroid cancer self-help organizations. The survey consisted of up to 70 questions depending on the given answers. Descriptive statistics and univariate comparisons, if appropriate, for comparing thyroid cancer survivors in Germany and France were performed. In total, 1254 thyroid cancer survivors took part in the survey, of whom 1005 were included in the analysis, 618 from Germany and 387 from France. Remarkable differences between the two countries were observed regarding waiting times, diagnostics, surgical complications, radioiodine treatment, and aftercare of the patients. A high disease burden and lack of information regarding the condition and its treatment were reported in both countries. This large survey showed that despite various guidelines for the management of thyroid cancer, thyroid cancer survivors’ experiences are noticeably different between two big European countries. Lack of information and unmet needs are still tasks to be addressed in order to optimize thyroid cancer care.

Patients with thyroid cancer are often assumed to have no quality of life (QOL) impairments after treatment because of thyroid cancer’s good prognosis. However, the QOL implications of surgical complications and the necessity to take lifelong medication are seldom assessed. Patients who had surgery due to thyroid cancer at the University Medical Center Mainz between 2010 and 2015 and who had calcium or parathyroid hormone levels below the reference values immediately following surgery were eligible for this study. QOL was assessed using the EORTC QLQ-C30 and the thyroid cancer module EORTC QLQ-THY34. Multiple logistic regression was used to determine factors associated with a worse QOL compared with a general population. A total of 75 (56%) of 134 eligible patients participated in the study. Patients with persistent/prolonged calcium or vitamin D intake reported worse QOL in the domains of global health, physical functioning, role functioning, emotional functioning, and insomnia than patients without current intake. Current calcium and vitamin D intake, higher education, living with a partner, and age had an effect on the odds of having worse QOL than the age- and sex-adjusted general population. Prolonged calcium and/or vitamin D intake are negatively associated with certain domains of QOL in thyroid cancer patients who are at least 1 year post surgery. Assessment of calcium and vitamin D and diagnosis of hypoparathyroidism are therefore important for the follow-up of thyroid cancer survivors since it may affect their QOL.

Zusammenfassung Fragestellung Vor dem Hintergrund der Debatte um eine mögliche Festlegung des Leistungsumfangs für ambulante Psychotherapie anhand der Diagnose haben wir untersucht, ob in der aktuellen Versorgungspraxis bei Patienten mit Depressionen die Anzahl der beantragten sowie die der vom Gutachter befürworteten Stunden mit dem Schweregrad der Erkrankung zusammenhängen. Methode Aus einer Zufallsstichprobe von 1000 Anträgen auf Kostenübernahme für ambulante analytische oder tiefenpsychologisch fundierte Psychotherapie wurden jene herausgesucht, in denen eine Depressionsdiagnose mit Schweregradeinschätzung (ICD-10 F32 oder F33) entweder im Bericht oder auf dem Antragsformular kodiert worden war. Die Zahl der beantragten und der befürworteten Stunden pro Antrag wurde extrahiert. Bei Umwandlungs- und Fortführungsanträgen wurden dabei auch die im Vorfeld stattgefundenen Therapiestunden berücksichtigt. Ein möglicher Zusammenhang des Schweregrads der Depression mit der Zahl der beantragten bzw. der vom Gutachter befürworteten Stunden wurde anhand von Spearman-Rangkorrelationen überprüft. Ergebnisse Insgesamt 521 Anträge (52 %) enthielten eine F32- und/oder eine F33-Diagnose. Davon waren 63 (12 %) als leicht kodiert, 349 (67 %) als mittelgradig und 50 (10 %) als schwer. Im Median wurden 75 h bei leichter sowie je 50 h bei mittelgradiger bzw. bei schwerer Depression beantragt, wobei die Zahlen innerhalb der Gruppen stark variierten (10 bis 327 h) und der Zusammenhang zwischen Schweregrad und beantragter Stundenzahl gering war (Rho −0,10). Die befürworteten Stundenkontingente waren im Median 74 (leichte Depression), 50 (mittelgradig) und 50 (schwer) Stunden, auch hier war die Spannweite hoch (0 bis 327 h) und die Korrelation gering (Rho −0,11). Diskussion Es gibt keine Anhaltspunkte dafür, dass Psychotherapeuten die benötigten Stundenkontingente allein anhand des Schweregrads der Diagnose festlegen.

Purpose Post-operative outcome after total knee arthroplasty (TKA) in the treatment of end-stage osteoarthritis correlates strongly with pre-operative impairment-driven patient treatment goals. However, a clinical tool for measuring patient treatment goals in correlation to impairments is still missing, which impedes patient-oriented indication in TKA. Methods Patients scheduled for TKA were recruited in four German hospitals. All patients were handed the INDICATE Knee Score pre-operatively. The score contains 31 treatment goals with respective impairments, subdivided into seven categories. They were asked to rank all treatment goals and impairments on a 3-point scale. Treatment goals and impairments were then checked for frequency of occurrence. Correlation of goal and impairment was tested. Analysis for associations of treatment goals and different cohort characteristics (age, sex, BMI) was conducted. Results 1.298 patients were included in the study. Seven treatment goals were categorised as “main goal” from more than 90% of all patients (“knee pain”, “range of motion”, “walking distance”, “overall physical function”, “climbing stairs”, “quality of life”, “implant survival”). Comparing age groups, there were significant associations towards higher expectations regarding working, physical and sports related treatment goals in younger patients (P ≤ .001), “sports activities” (P ≤ .001), “sex life” (P ≤ .001), “dependence on help of others” (P = .015), “preventing secondary impairment” (P = .03), “dependence on walking aids” (P = .005)). Higher BMI resulted in increasing relevance of “weight reduction” (P ≤ .001), “climbing stairs” (P = .039) “global health status” (P = .015) and “long standing” (P = .007) as a “main goal”. Analysis for differences in treatment goals regarding sex showed women choosing more treatment goals as “main goals” than men. Conclusion Seven treatment goals which were expected by > 90% in our collective can be classified as general treatment goals for TKA. Demographic factors (age, sex, BMI) were significantly associated with patients’ expectations for TKA. We conclude physicians should clearly assess their patients’ demands prior to TKA to maximise post-operative outcome. Level of evidence Prognostic Level III.

Zusammenfassung Hintergrund Für Deutschland werden im Rahmen optimierter Behandlungsprozesse rund um die Implantation einer Knie- oder Hüftendoprothese stationäre Aufenthaltszeiten angegeben, die die international publizierten Zeiten deutlich übertreffen. Die vorliegende Analyse von Daten der PROMISE-Studie beschäftigt sich in diesem Zusammenhang mit dem Verhältnis von Entlassbarkeit und Entlassung. Methode In drei Krankenhäusern unterschiedlicher Versorgungsstufen wurde ein gemeinsam entwickelter, optimierter Versorgungsstandard etabliert und für eine weitgehend unselektionierte Patientenkohorte umgesetzt. Unter anderem wurden Daten zum Erreichen der Entlasskriterien (EK) und der tatsächlichen Entlassung erhoben. Univariate Vergleiche wurden durch Chi-Quadrat-Tests oder Mann-Whitney-U-Tests durchgeführt. Ergebnisse Insgesamt konnten 1782 Patienten eingeschlossen werden, von denen 85,3 % nach im Mittel (MW) 2,4 Tagen (Median 2) postoperativ alle zuvor definierten EK erreicht haben. Die Entlassung für diese Gruppe erfolgte nach 5,4 (MW) Tagen (Median 5). Die restlichen Probanden (14,7 %) hatten bei Entlassung nach 6,5 (MW) Tagen (Median 6) mindestens ein EK nicht erreicht. Für verschiedene Subgruppen konnten signifikante Unterschiede festgestellt werden. Fazit Die sogenannten EK werden als relative Kriterien eingesetzt. Das Erreichen führt im Allgemeinen nicht zu einer zeitnahen Entlassung der Patienten aus dem Krankenhaus. Wäre dies der Fall, wären auch in Deutschland international übliche Aufenthaltszeiten Realität. Was die Entlassung tatsächlich bestimmt, bleibt offen. Eine Vielzahl von medizinischen, organisatorischen, strukturellen und finanziellen Einflussfaktoren könnten bedeutend sein.

Hypoparathyroidism (hypoPT) is a rare endocrine disorder. Little is known about what factors are associated with potential quality of life (QOL) impairments.HypoPT patients at a minimum of 6 months' post diagnosis were invited to participate in an online survey through their treating physician or through self-help organisations METHODS: Impairments of clinical importance in QOL were considered present if the score of the respective functioning scale of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 exceeded a pre-defined threshold. Symptom burden was assessed using the HPQ-28. Multivariate logistic regression was used to identify factors associated with impairments in QOL.Data were available for 264 hypoPT patients. Impairments of clinical importance in QOL were reported for 40.4% in role functioning (RF), 40.6% in social functioning (SF), 60.8% in physical functioning (PF), 65.5% in cognitive functioning (CF) and 76.0% in emotional functioning (EF). Higher odds for reporting impaired QOL were seen for higher symptom burden (for almost all domains) and for being unable to work (for PF, RF and SF). Surgery for thyroid cancer being the cause of hypoPT was associated with lower odds in PF for patients and in PF and CF for patients with surgery for other thyroid-related diseases being the hypoPT cause.HypoPT needs to be recognised as a disease which might be associated with impaired QOL and affect daily living. Symptom management is crucial for improving QOL in hypoPT patients but socioeconomic factors like work-ability need to be considered when treating hypoPT patients.

ZusammenfassungHintergrund Im Dezember 2019 begann sich die COVID-19-Pandemie weltweit auszubreiten und sorgte für massive Einschränkungen im täglichen Leben. Viele Bildungseinrichtungen und logopädische Praxen wurden vorübergehend geschlossen (sog. Lockdown). Kinder mit einer Sprachentwicklungsstörung waren gezwungen, ihre Therapie zu pausieren. Ziel dieser Studie war es zu beschreiben, ob und wie die logopädische Therapie während des Lockdowns durchgeführt wurde und welche psychische Belastung für die betroffenen Eltern damit verbunden war.Material und Methoden Eltern von Kindern mit einer Sprachentwicklungsstörung wurden über die Therapie ihres Kindes während des Lockdowns und über ihre damit verbundenen Ängste und Sorgen befragt.Ergebnisse Bei 17 Patienten wurde die Sprachtherapie während des Lockdowns pausiert, während 20 Patienten ihre Therapie fortsetzen konnten. Kinder, die eine andere Sprache als Deutsch sprachen, hatten ein höheres Risiko, dass ihre Therapie pausiert wurde (Odds Ratio (OR) 5,11; 95 %-Konfidenzintervall (KI) 1,09–32,54). Eltern, deren Kinder während des Lockdowns keine Sprachtherapie erhielten, machten sich mehr Sorgen um die Entwicklung ihres Kindes.Schlussfolgerungen Es gibt kein generelles Konzept, wie Logopädie während eines Lockdowns sicher durchgeführt werden kann. Mögliche Barrieren für die Gesundheitsversorgung könnten während der Pandemie stärker ausgeprägt sein. Die betroffenen Eltern erleben eine höhere psychosoziale Belastung.

In December 2019, the COVID-19 pandemic began to spread around the world and caused massive restrictions in our daily life. Many educational facilities and practices delivering speech therapy were temporally closed (so-called lockdown). Children with a speech and language disorder were forced to pause their therapy. The aim of this study was to describe if and how speech therapy was delivered during lockdown and what psychological burden was associated to affected parents. Parents of children with a speech and language disorder were asked about their child´s therapy during lockdown and about their fears and worries associated with it. For 17 patients speech therapy was paused during lockdown while 20 patients could continue their therapy. Children speaking a language other than German had a higher risk for having their therapy paused during lockdown (Odds ratio = 5.11, with 95 % confidence interval = 1.09-32.54). Parents whose children did not receive speech therapy during lockdown were more worried about their child's development. There is no common concept on how speech therapy can be delivered safely during lockdown. Possible barriers to healthcare might be more pronounced during the pandemic and parents experience a high psychosocial burden. Im Dezember 2019 begann sich die COVID-19-Pandemie weltweit auszubreiten und sorgte für massive Einschränkungen im täglichen Leben. Viele Bildungseinrichtungen und logopädische Praxen wurden vorübergehend geschlossen (sog. Lockdown). Kinder mit einer Sprachentwicklungsstörung waren gezwungen, ihre Therapie zu pausieren. Ziel dieser Studie war es zu beschreiben, ob und wie die logopädische Therapie während des Lockdowns durchgeführt wurde und welche psychische Belastung für die betroffenen Eltern damit verbunden war. Eltern von Kindern mit einer Sprachentwicklungsstörung wurden über die Therapie ihres Kindes während des Lockdowns und über ihre damit verbundenen Ängste und Sorgen befragt. Bei 17 Patienten wurde die Sprachtherapie während des Lockdowns pausiert, während 20 Patienten ihre Therapie fortsetzen konnten. Kinder, die eine andere Sprache als Deutsch sprachen, hatten ein höheres Risiko, dass ihre Therapie pausiert wurde (Odds Ratio (OR) 5,11; 95 %-Konfidenzintervall (KI) 1,09–32,54). Eltern, deren Kinder während des Lockdowns keine Sprachtherapie erhielten, machten sich mehr Sorgen um die Entwicklung ihres Kindes. Es gibt kein generelles Konzept, wie Logopädie während eines Lockdowns sicher durchgeführt werden kann. Mögliche Barrieren für die Gesundheitsversorgung könnten während der Pandemie stärker ausgeprägt sein. Die betroffenen Eltern erleben eine höhere psychosoziale Belastung.

The number of total hip (THA) and knee arthroplasties (TKA) grows constantly which causes enormously rising costs for healthcare systems. The aim of this systematic literature review was to evaluate whether a cost reduction can be achieved by THA or TKA fast-track protocols, which is a multidisciplinary approach aiming at faster recovery. A systematic literature research was undertaken for the timeframe from 2007/01/01 to 2019/03/04 in PubMed. Abstracts and title of the identified records were checked for eligible criteria and afterward the full text was assessed. Seven studies were included in the review. All studies showed a reduction in the total cost for fast-track THA and TKA. Most studies based their cost calculations on the amount of days the patients spend in the hospital. Using a fast-track protocol can significantly reduce the overall costs of the treatment.

Hypoparathyreoidismus (HPT) ist eine der haufigsten Komplikationen einer Schilddrusenkrebsoperation. Die Lebensqualitat von Patienten mit HPT ist im Vergleich zu Normpopulationen oder gematchten Kontrollindividuen stark eingeschrankt. Eine reduzierte Lebensqualitat zeigt sich gleichermasen in physischen und psychischen Bereichen. Wenige Studien haben bisher die Lebensqualitat von Schilddrusenkrebsuberlebenden mit postoperativem HPT erhoben. Einschrankungen der Lebensqualitat von Patienten mit postoperativem HPT nach Schilddrusenkrebs lassen sich nicht nur durch die Erkrankung Krebs und ihre Behandlung erklaren, sondern auch durch HPT selbst. Weitere Forschung in Bezug auf die Therapie von HPT in Deutschland und die Lebensqualitat von HPT-Patienten nach Schilddrusenkrebs ist erforderlich. HPT ist die einzige endokrine Funktionsstorung, bei der das fehlende Hormon im Rahmen der Standardtherapie nicht ersetzt werden kann. Die aktuelle Therapie besteht aus Kalzium- und Vitamin-D-Analogen unter regelmasiger Uberprufung von Laborwerten. Die empfohlene Uberprufung der Blutwerte muss haufiger durchgefuhrt werden als es im Rahmen von regularen Krebsnachsorgeuntersuchungen moglich ware. Es gibt aktuell keine systematischen Erhebungen, wie HPT-Patienten in Deutschland behandelt werden.

Background The COVID-19 pandemic caused massive restrictions in our daily life. Kindergartens and schools were closed (lockdown) and children were forced to pause their therapy. Materials and Methods We conducted a survey during August and October 2020 and asked parents of children with a speech and language disorder about their child's therapy during lockdown and their fears and sorrows associated with it. Results Parents of 39 children participated (age: 6,15 years (3,06 - 10,09)). 34 children received speech therapy before lockdown. This therapy was paused for 17 children during lockdown. The other 17 children still received speech therapy during lockdown with the following alterations: hygiene measures (n=12), via internet (Skype, Zoom;n=3) or via work sheets sent by mail (n=1). Parents whose children were forced to pause therapy were more likely to worry about their children to stagnate or even regress in their development. Furthermore, they feared that their children were less motivated to return to therapy after lockdown and/or might develop problems in school. In addition to that, those parents felt more left alone with their sorrows and more burdened by missing support for their children. Discussion Due to the physiological speech development, there is a sensitive time frame for a child with a speech and language disorder to receive therapy. Forcing them to pause therapy might influence their development in a negative manner. Their parents might also be mentally burdened. It is important to acknowledge this in future political decisions, so that children with speech and language disorders won't have a permanent handicap.

Purpose Surgical complications such as hypoparathyroidism (HPT) or vocal cord palsy are seldom assessed when the quality of life (QOL) in thyroid cancer patients is investigated. The aim of this study was to measure the QOL difference in thyroid cancer survivors with and without HPT. Methods Participants for this analysis were enrolled in 13 countries from a study that pilot-tested a thyroid cancer–specific QOL instrument. They were included if they had been diagnosed with thyroid cancer at least 9 months previously. QOL was measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core (EORTC QLQ-C30) and some items on HPT symptoms (eg, tingling in fingers or toes). HPT status and other clinical data were extracted from the patients’ medical charts. Comparisons of QOL domains between patients with and without HPT were performed using Mann-Whitney U test. The occurrence of HPT-related symptoms was compared using chi-square tests. Multiple ordinal regression analysis was performed to evaluate factors that might affect QOL. Results Eighty-nine patients participated in this study, 17 of whom were considered to have HPT. Patients in the HPT group reported significantly reduced QOL in 9 of the 15 scales of the EORTC QLQ-C30 compared to patients without HPT. Regression analysis showed that HPT was independently negatively associated with various scales of the QLQ-C30. Both groups showed a high prevalence of typical HPT symptoms. Conclusion Thyroid cancer patients with HPT report significantly impaired QOL compared to thyroid cancer survivors without HPT. The assessment of HPT should be considered when measuring QOL in thyroid cancer patients.

The disease and treatment of patients with head and neck cancer can lead to multiple late and long-term sequelae. Especially pain, psychosocial problems, and voice issues can have a high impact on patients' health-related quality of life. The aim was to show the feasibility of implementing an electronic Patient-Reported Outcome Measure (PROM) in patients with head and neck cancer (HNC). Driven by our department's intention to assess Patient-Reported Outcomes (PRO) based on the International Classification of Functioning during tumor aftercare, the program ""OncoFunction"" has been implemented and continuously refined in everyday practice. The new version of ""OncoFunction"" was evaluated by 20 head and neck surgeons and radiation oncologists in an interview. From 7/2013 until 7/2017, 846 patients completed the PROM during 2,833 of 3,610 total visits (78.5%). The latest software version implemented newly developed add-ins and increased the already high approval ratings in the evaluation as the number of errors and the time required decreased (6 vs. 0 errors, 1.35 vs. 0.95 min; p

Cancer patients in Germany often face payments related to their disease or treatment which are not covered by their health insurance. The aim of this study was to analyze the amount of out-of-pocket payments (OOPPs) among cancer patients in Germany, to explore potential socioeconomic determinants of OOPPs, and to identify how cancer patients are burdened by these payments. Cancer ptients were consecutively enrolled in 16 clinics in Leipzig, Germany. Data on OOPPs for the past 3 months and on socioeconomic status were obtained at the end of their hospital stay (t0) and 3 (t1) and 15 months (t2) after t0. Financial burden was calculated by dividing the monthly OOPPs by the midpoint of the income category, and the perceived burden was assessed by using the financial difficulties scale of the EORTC QLQ-C30. A two-part regression model was used to estimate the determinants of OOPPs. At baseline (t0), 502 cancer patients participated in the study and provided data on OOPPs and socioeconomic status. The mean 3-month OOPPs were the following: €205.8 at baseline, €179.2 at t1, and €148.1 at t2. Compared to the lowest income group (

Purpose The aim of this study was to investigate whether an association between retinal vessel diameters with blood pressure and other risk factors exists in a healthy working population and whether current risk factors can be used as predictors for retinal vessel changes over time. Methods Retinal photographs and medical data were obtained during a voluntary work health check in 2010 and 2013. The central retinal arterial equivalent (CRAE) and central retinal venular equivalent (CRVE) were assessed using a semi-automated software. Linear regression analysis was carried out to determine associations with systemic parameters and cardiovascular risk factors. Results A total of 1685 participants had gradable photographs and full medical data with a mean age of 44.8 years (SD: 10.2) and 80.8% being male; full data were obtained in both 2010 and 2013 for 365 participants allowing for longitudinal analysis. In the cross-sectional analysis, a mean CRAE of 171.2 ±18.3 μm and a mean CRVE 215.8 ± 18.6 μm were found. A significant negative association for CRAE was seen for age, mean arterial blood pressure (MABP), body mass index (BMI) and high-density lipoprotein (HDL), while triglycerides, spherical equivalent (SAE) and being a current smoker were positively associated. For CRVE age, MABP, HbA1c and HDL were negatively associated, while being female, low-density lipoprotein, white blood cell count, SAE and being a current smoker showed a positive association. The linear regression model for the cross-sectional analysis explained 31% and 21% of the variance of CRAE and CRVE, respectively. The longitudinal analysis showed a mean decrease of -1.6 μm (p = 0.04) for CRAE and -2.0 (p = 0.005) for CRVE within the three-year time frame. Linear regression analysis with longitudinal data showed a significant association for HDL and CRAE, while for other factors no statistically significant association between current risk factors and changes in CRAE and CRVE was observed. Conclusion The width of both arterial and venous retinal vessels shows associations not only with arterial blood pressure but also with biochemical markers of cardiovascular risk. While such effects are partially established for elderly persons, our study results indicate that they apply also in a young population in working age with seemingly unimpaired health.

Aldosterone and mineralocorticoid receptor (MR)-function have been related to depression. We examined central and peripheral parameters of MR-function in order to characterize their relationship to clinical treatment outcome after six weeks in patients with acute depression. 30 patients with a diagnosis of major depression were examined 3 times over a 6 week period. Aldosterone and cortisol salvia samples were taken at 7.00 a.m. before patients got out of bed. Easy to use e-devices were used to measure markers of central MR function, i.e. slow wave sleep (SWS) and heart-rate variability (HRV). Salt-taste intensity (STI) and salt pleasantness (SP) of a 0.9% salt solution were determined by a newly developed scale. In addition, systolic blood pressure (SBP) and plasma electrolytes were determined as markers for peripheral MR activity. The relationship between the levels of these biomarkers at baseline and the change in clinical outcome parameters (Hamilton depression rating scale (HDRS)-21, anxiety, QIDS and BDI) after 6 weeks of treatment was investigated. A higher aldosterone/cortisol ratio (Aldo/Cort) (n = 17 due to missing values; p < 0.05) and lower SBP (n = 24; p < 0.05) at baseline predicted poor outcome, as measured with the HDRS, independent of gender. Only in male patients higher STI, lower SP, lower SWS (all n = 13) and higher HRV (n = 11) at baseline predicted good outcome p < 0.05). Likewise, in male patients low baseline sodium appears to be predictive for a poor outcome (n = 12; p = 0.05; based on HDRS-6). In conclusion, correlates of higher central MR-activation are associated with poorer clinical improvement, particularly in men. This contrasts with the finding of a peripheral MR-desensitization in more refractory patients. As one potential mechanism to consider, sodium loss on the basis of dysfunctional peripheral MR function and additional environmental factors may trigger increased aldosterone secretion and consequently worse outcome. These markers deserve further study as potential biological correlates for therapy refractory depression.

Quality of life measurements are well established in cancer clinical trials. In daily clinical practice, where cancer patients often suffer from disease-specific symptoms and report unmet needs regarding their treatment, these measurements are not systematically implemented. The systematic (often computer-based) assessment of quality of life in daily cancer care has shown to be beneficial for patient-physician communication, symptom management, shared decision-making, and in creating a learning health system. Unfortunately, to date, routine electronic quality of life assessments are usually limited to large cancer facilities. Patient and physician barriers as well as barriers from the administrative side in particular are currently hindering the implementation of these systems into the broad spectrum of clinical cancer care. Cost-effectiveness analyses of existing systems, the inclusion of all relevant stakeholders, and clear implementation guidelines are required to introduce quality of life measurements in clinical cancer practice to improve the treatment of cancer survivors and to create a health care system that addresses all their disease-related needs.

Hypoparathyroidism is a rare endocrine disorder for which replacement therapy of the missing parathyroid hormone is not the standard therapeutic option. Current standard treatment consists of calcium and vitamin D supplementation. The intake of calcium and vitamin D supplementation can lead to complications and therefore might negatively influence patients’ quality of life. A systematic literature review was performed to assess the current knowledge on the influence of hypoparathyroidism on patients’ quality of life. The literature search was conducted in PubMed and Web of Science; all relevant literature published by August 24, 2016, was included. In total 372 records were found. After title and abstract screening, 14 studies remained for a full-text screening. The full-text screening resulted in five studies which were included into the systematic review. Comparing the results with a norm-based reference population, three studies reported lower SF-36 scores for hypoparathyroidism patients. Two studies showed a reduced quality of life in hypoparathyroidism patients when their results were compared to control populations. Most hypoparathyroidism patients receiving standard treatment show stable calcium and vitamin D levels. However, hypoparathyroidism patients still report reduced quality of life and experience physical, mental, and emotional symptoms. Therefore, it is assumed that the lack of parathyroid hormone directly influences the patients’ quality of life. This review indicates that patients with hypoparathyroidism have a reduced quality of life in comparison to norm-based populations or matched controls. Further studies are required to quantify the effect of hypoparathyroidism on patients’ quality of life using disease-specific questionnaires and controlling for the co-morbidities and etiologies of the patients.

The novella "The Judge" by Ernst Wiechert gives testimony to the poet’s critical analysis and examination of the immediate National Socialist past and, at the same time, tries to provide some forward-looking re-orientation in terms of a comprehensive humanism based on Christian ideals. Wiechert’s narrative follows a dramatic structure in accordance with the tragedies of Classical Greek Antiquity. Faced with an existential crisis, the title character has to prove his moral integrity and steadfastness. Deluded by the pervasive Nazi ideology, the judge’s son goes astray by killing a former friend but finally, thanks to his father’s cautious, gentle guidance, finds his way back. At the end of the novella the son even atones for his wrongs while his father, an unfaltering representative and unswerving advocate of law and justice, resigns from his office in the face of the lawlessness he has experienced under the Nazi terror regime. Apart from analysing the plot of Wiechert’s novella, this study also examines the clearly outlined characters as well as the complex theme of guilt, repentance and forgiveness. Finally, the article focuses on the author’s intention of taking part in the social and political discourse of post-war Germany by conveying his message of humanity and moral integrity.

Parapoxviruses (PPV) represent a separate genus within the subfamiliy Chordopoxvirinae of the family Poxviridae. Species members of the genus Parapoxvirus (PPV) within the family Poxviridae cause contagious pustular dermatitis in small ruminants (prototype Orf virus, ORFV) and mostly mild localized inflammation in cattle (bovine papular stomatitis virus, BPSV and pseudocowpox virus, PCPV) and red deer in New Zealand (Parapoxvirus of red deer, PVNZ). All PPVs show a widespread and worldwide occurrence and are known to be zoonotic, leading to circumscribed skin lesions in humans, historically known as milker’s nodules. Human PPV isolates are often ill defined concerning their allocation to an animal origin. PPV cause local infections and are specialized to counteract skin and mucous membrane defense mechanisms after virus entry into damaged skin by micro-lesions or wounds. Sophisticated escape mechanisms mediated by virulence genes of PPV have been elucidated in recent times. Whole genome sequencing (WGS) of various PPV species genomes allows more detailed and comparative determination of virus peculiarities. After PPV transmission to man, molecular conservation of the animal’s virus genome can indicate the origin of the virus. Due to their high stability in the environment and local persistence in the host PPV have established as a worldwide problem in livestock especially in small ruminants. With regard to diagnostic differentiation after manifestation in human patients as well as for reliable differentiation from notifiable diseases in livestock PPV still pose a challenge for clinicians and microbiologists.

Crude brain homogenates of terminally diseased hamsters infected with the 263 K strain of scrapie (PrP Sc) were heated and/or pressurized at 800 MPa at 60 degrees C for different times (a few seconds or 5, 30, 120 min) in phosphate-buffered saline (PBS) of different pH and concentration. Prion proteins were analyzed on immunoblots for their proteinase K (PK) resistance, and in hamster bioassays for their infectivity. Samples pressurized under initially neutral conditions and containing native PrP Sc were negative on immunoblots after PK treatment, and a 6-7 log reduction of infectious units per gram was found when the samples were pressurized in PBS of pH 7.4 for 2 h. A pressure-induced change in the protein conformation of native PrP Sc may lead to less PK resistant and less infectious prions. However, opposite results were obtained after pressurizing native infectious prions at slightly acidic pH and in PBS of higher concentration. In this case an extensive fraction of native PrP Sc remained PK resistant after pressure treatment, indicating a protective effect possibly due to induced aggregation of prion proteins in such buffers.

Major depression (MDE) has metabolic and neuroendocrine correlates, which point to a biological overlap between MDE and cardiovascular diseases. Whereas the hypothalamic-pituitary-adrenocortical axis has long been recognized for its involvement in depression, the focus was mostly on cortisol/corticosterone, whereas aldosterone appears to be the ‘forgotten' stress hormone. Part of the reason for this is that the receptors for aldosterone, the mineralocorticoid receptors (MR), were thought to be occupied by glucocorticoids in most parts of the brain. However, recently it turned out that aldosterone acts selectively in relevant mood-regulating brain areas, without competing with cortisol/corticosterone. These areas include the nucleus of the solitary tract (NTS), the amygdala and the paraventricular nucleus of the hypothalamus. These regions are intimately involved in the close relationship between emotional and vegetative symptoms. Genetic analysis supports the role of aldosterone and of MR-related pathways in the pathophysiology of depression. Functional markers for these pathways in animal models as well as in humans are available and allow an indirect assessment of NTS function. They include heart rate variability, baroreceptor reflex sensitivity, blood pressure, salt taste sensitivity and slow-wave sleep. MR activation in the periphery is related to electrolyte regulation. MR overactivity is a risk factor for diabetes mellitus and a trigger of inflammatory processes. These markers can be used not only to assist the development of new treatment compounds, but also for a personalized approach to treat patients with depression and related disorders by individual dose titration with an active medication, which targets this system.

Prevention of graft-versus-host disease by depletion of CD6-positive T cells was studied in the dog. Donors were DLA-homozygous, recipients DLA-heterozygous with one DLA haplotype identical to the donor. Seven control dogs received untreated marrow and died of GvHD after full hemopoietic recovery within 28 days of transplantation. For prevention of GvHD, immunomagnetic separation of T cells with a monoclonal antibody against human CD6 that crossreacted with canine T cells was evaluated. Depletion of CD6-positive cells depleted CD4-positive cells completely, but only part of CD8-positive cells and DR-positive cells. CD6-depleted marrow exhibited strong nonspecific “natural” suppression of the generation of cytotoxic T cells in vitro. Eleven dogs received CD6-depleted marrow. Only 1 dog developed GvHD and died. Sustained engraftment was seen in 8 dogs. Hemopoietic recovery was delayed and slower after transplantation of CD6-depleted marrow than after transplantation of untreated marrow. Four of these dogs were treated with G-CSF, and this accelerated the recovery of leukocytes, but did not prevent rejection. Chimerism was mixed in 7 of 10 evaluable dogs and 1 dog recovered its own hemopoiesis 2 years after transplantation. CD6 depletion prevents GvHD across a DLA-haplotype difference, but rejection and mixed chimerism may occur. Treatment with G-CSF accelerates leukocyte recovery, but cannot prevent rejection.

High hydrostatic pressure is a mild technology compared with high temperatures and is commonly used for food pasteurization. Crude brain homogenates of terminally diseased hamsters infected with scrapie 263K strain were heated at 60 degrees C and/or pressurized up to 1000 MPa for 2 h. Prion proteins were analysed for their proteinase K sensitivity using a Western blot technique. PrP(Sc) pressurized with 500 MPa or above proved to be proteinase K sensitive. To test the remaining infectivity of the pressurized material, hamsters were infected intracerebrally. Results showed a greatly delayed onset of disease (from 80 up to 153 days) when samples had been pressurized at 500 MPa and above. An increase in the survival rate was also observed: 47 % survival over 180 days was seen following infection with homogenates pressurized at 700-1000 MPa.

Die Sammlung der Aufsatze von Hans-Christoph Schmitt, die damit Fachpublikum und Studierenden leichter zuganglich gemacht werden, bietet einen reprasentativen UEberblick uber die von ihm vertretenen Forschungsgebiete unter den UEberschriften "Prophetie", "Pentateuch", "Spatdeuteronomistische Endredaktion des Pentateuch" und "Theologie".

This study describes genetic differences in resistance/susceptibility to pseudorabies virus (PrV) between European Large White and Chinese Meishan pigs, with a mapping of quantitative trait loci (QTL) obtained from a genome-wide scan in F2animals. Eighty-nine F2pigs were challenged intranasally at 12 weeks with 105p.f.u. of the wild-type PrV strain NIA-3. For QTL analysis, 85 microsatellite markers, evenly spaced on the 18 porcine autosomes and on the pseudoautosomal region of the X chromosome, were genotyped. All pigs developed clinical signs, i.e. fever, from 3 to 7 days p.i. The pure-bred Large White pigs, the F1and three-quarters of the F2animals, but none of the Meishan pigs, developed neurological symptoms and died or were euthanized. QTLs for appearance/non-appearance of neurological symptoms were found on chromosomes 9, 5, 6 and 13. They explained 10·6–17·9% of F2phenotypic variance. QTL effects for rectal temperature after PrV challenge were found on chromosomes 2, 4, 8, 10, 11 and 16. Effects on chromosomes 9, 10 and 11 were significant on a genome-wide level. The results present chromosomal regions that are associated with presence/absence of neurological symptoms as well as temperature course after intranasal challenge with NIA-3. The QTLs are in proximity to important candidate genes that are assumed to play crucial roles in host defence against PrV.

Long-term culture of canine marrow cells allows in vitro studies of the hematopoietic system of the dog and characterization of early progenitor cells. Colonies of fresh marrow cells grew equally good in both agar or methylcellulose supplemented with fetal calf serum, while colonies of long-term cultures required agar-based medium containing human serum. Optimum colony growth was obtained when stem cell factor (SCF) and granulocyte-macrophage-colony-stimulating factor (GM-CSF) were used as growth stimuli of colony forming units (CFU). Similar results were achieved with several cell culture media. Addition of hydrocortison to long-term cultures improved clonogenic growth of cultured cells. Addition of 2-mercaptoethanol had no effect. Strong differences were observed in long-term culture with different horse serum lots and the addition of fetal calf serum to long-term culture suppressed CFU growth of cultured cells. Recharging of cultures with fresh marrow cells on day 7 of culture improved CFU growth only in the following week but had little effect on the outcome. Adding SCF to long-term cultures led to differentiation of more primitive cells and destruction of the stromal layer. Investigation of purified and cultured cell populations was possible when preestablished long-term cultures as stromal layers were used. Loss of long-term culture-initiating ability could be demonstrated in this system with lineage negative marrow cells expanded ex vivo with SCF and GM-CSF.

The present study investigates the potential capacity of the immunostimulant Corynebacterium parvum (C.p.) to induce tumor necrosis factor-alpha (TNF-alpha) in human peripheral blood mononuclear cells (PBMC) and blood monocytes (BMo) in vitro. Both at the mRNA and protein level, stimulation of PBMC and BMo upon C.p. induces TNF-alpha. Compared to the hitherto used TNF-alpha inducers in vitro such as Sendai virus, phytohemagglutinin or lipopolysaccharide the C.p. stimulus displayed a threefold stronger induction of TNF-alpha production (p less than 0.001). Using C.p. as an inducer it was possible to demonstrate that TNF-alpha production is regulated by prostaglandin E2; preincubation of the cells with prostaglandin E2 resulted in a reduced C.p.-mediated TNF-alpha production (p less than 0.001). Coincubation of interferon-gamma (IFN-gamma) together with C.p. led to an enhanced release of TNF-alpha, supporting the assumption that C.p. is a potent TNF-alpha inducer. The additive effect of IFN-gamma and TNF-alpha on the receptor level was demonstrated by addition of IFN-gamma antibodies to the PBMC cultures. Under these conditions TNF-alpha production, stimulated by C.p. and IFN-gamma, was decreased by 30%, compared to the production in assays supplemented with C.p. alone. From these data we conclude that C.p. is a new inducer of TNF-alpha in vitro and a useful tool to study TNF-alpha production of PBMC and BMo from either healthy donors or from patients.