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The Atlantic Meridional Overturning Circulation (AMOC) and its surface limb, the Gulf Stream, are in their weakest state since the last millennium. The consequences of this weakening in the Northeast Atlantic are not yet known. We show that the slowdown of the Gulf Stream in the 1960s, 1970s, and after 2000 may have caused a delayed weakening of the Azores Current. Concurrently, the Azores Front associated with the Azores Current migrated northward since the 1970s due to gradual changes in the Atlantic Multidecadal Oscillation and ocean heat content. We argue that the AMOC slowdown is also detectable in the low-energy region of the Northeast Atlantic and that the dynamics of Azores Current tightly connects to that of the dynamics of the Gulf Stream and AMOC on decadal and longer time scales.

Abstract Background Healthcare providers’ (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs. Methods We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR—Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries. Results Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education. Conclusions In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

Zusammenfassung: Vor dem Hintergrund der wachsenden Bedeutung der Stadt als Lebensraum wird in der Humangeographie seit 50 Jahren diskutiert, wie sich dieser Raum gerecht gestalten und nutzen lässt. Einen klassischen Beitrag zu dieser Diskussion liefern Henri Lefebvres Überlegungen zum „Recht auf Stadt“ (2016 [1968]). Anlass für unsere aktuelle Beschäftigung mit der Frage ist die zunehmende Digitalisierung städtischer Infrastrukturen und des städtischen Alltagslebens: Dazu gehören erstens die Smart-City-Strategien mit ihren digital gesteuerten Verkehrsleit- und Energieversorgungssystemen etc.; zweitens der sogenannte Plattformurbanismus, der Dienstleistungsaktivitäten plattformbasiert organisiert (z. B. uber, airbnb oder lieferando). In diesem interdisziplinär angelegten Beitrag fragen wir, welche Herausforderungen die in den letzten Jahren zunehmende Durchdringung der Stadt mit digitalen Infrastrukturen und plattformbasierten Ökonomien im Hinblick auf das Recht auf Stadt stellt. Wir argumentieren, dass diese Entwicklungen zu Ungerechtigkeiten führen, und nehmen dafür Nancy Frasers Theorie der Gerechtigkeit und ihr Grundprinzip gleicher Teilhabe zur Hilfe (Fraser 2003; 2009; 2013). Mit der Konzentration auf Frasers These, dass Ungerechtigkeiten der Verteilung und der Anerkennung gemeinsam auftreten, beleuchten wir die Smart City und den Plattformurbanismus. Dabei setzen wir uns kritisch mit bereits existierenden Arbeiten auseinander, um darüber hinausgehend zu zeigen, dass und wie Ungerechtigkeiten in der Dimension der Verteilung und der Anerkennung miteinander wechselwirken.

ObjectiveThe molecular mechanisms underlying sex differences in dyslipidemia are poorly understood. We aimed to distinguish genetic and hormonal regulators of sex differences in plasma lipid levels.Approach and resultsWe assessed the role of gonadal hormones and sex chromosome complement on lipid levels using the four core genotypes mouse model (XX females, XX males, XY females, and XY males). In gonadally intact mice fed a chow diet, lipid levels were influenced by both male-female gonadal sex and XX-XY chromosome complement. Gonadectomy of adult mice revealed that the male-female differences are dependent on acute effects of gonadal hormones. In both intact and gonadectomized animals, XX mice had higher HDL cholesterol (HDL-C) levels than XY mice, regardless of male-female sex. Feeding a cholesterol-enriched diet produced distinct patterns of sex differences in lipid levels compared with a chow diet, revealing the interaction of gonadal and chromosomal sex with diet. Notably, under all dietary and gonadal conditions, HDL-C levels were higher in mice with 2 X chromosomes compared with mice with an X and Y chromosome. By generating mice with XX, XY, and XXY chromosome complements, we determined that the presence of 2 X chromosomes, and not the absence of the Y chromosome, influences HDL-C concentration.ConclusionsWe demonstrate that having 2 X chromosomes versus an X and Y chromosome complement drives sex differences in HDL-C. It is conceivable that increased expression of genes escaping X-inactivation in XX mice regulates downstream processes to establish sexual dimorphism in plasma lipid levels.

Background: A colosplenic fistula (CsF) is an extremely rare complication. Its diagnosis and management remain poorly understood, owing to its infrequent incidence. Our objective was to systematically review the etiology, clinical features, diagnosis, management, and prognosis to help clinicians gain a better understanding of this unusual complication and provide aid if it is to be encountered. Methods: A systematic review of studies reporting CsF diagnosis in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, and Wiley Cochrane Library from 1946 to June 2022. Additionally, a retrospective review of four cases at our institution were included. Cases were evaluated for patient characteristics (age, sex, and comorbidities), CsF characteristics including causes, symptoms at presentation, diagnosis approach, management approach, pathology findings, intraoperative complications, postoperative complications, 30-day mortality, and prognosis were collected. Results: Thirty patients with CsFs were analyzed, including four cases at our institution and 26 single-case reports. Most of the patients were male (70%), with a median age of 56 years. The most common etiologies were colonic lymphoma (30%) and colorectal carcinoma (17%). Computed tomography (CT) was commonly used for diagnosis (90%). Approximately 87% of patients underwent a surgical intervention, most commonly segmental resection (81%) of the affected colon and splenectomy (77%). Nineteen patients were initially managed surgically, and 12 patients were initially managed nonoperatively. However, 11 of the nonoperative patients ultimately required surgery due to unresolved symptoms. The rate of postoperative complications was (17%). Symptoms resolved with surgical intervention in 25 (83%) patients. Only one patient (3%) had had postoperative mortality. Conclusions: Our review of 30 cases worldwide is the largest in literature. CsFs are predominantly complications of neoplastic processes. CsF may be successfully and safely treated with splenectomy and resection of the affected colon, with a low rate of postoperative complications. [ABSTRACT FROM AUTHOR]

Subterranean estuaries the, subsurface mixing zones of terrestrial groundwater and seawater, substantially influence solute fluxes to the oceans. Solutes brought by groundwater from land and solutes brought from the sea can undergo biogeochemical reactions. These are often mediated by microbes and controlled by reactions with coastal sediments, and determine the composition of fluids discharging from STEs (i.e., submarine groundwater discharge), which may have consequences showing in coastal ecosystems. While at the local scale (meters), processes have been intensively studied, the impact of subterranean estuary processes on solute fluxes to the coastal ocean remains poorly constrained at the regional scale (kilometers). In the present communication, we review the processes that occur in STEs, focusing mainly on fluid flow and biogeochemical transformations of nitrogen, phosphorus, carbon, sulfur and trace metals. We highlight the spatio-temporal dynamics and measurable manifestations of those processes. The objective of this contribution is to provide a perspective on how tracer studies, geophysical methods, remote sensing and hydrogeological modeling could exploit such manifestations to estimate the regional-scale impact of processes in STEs on solute fluxes to the coastal ocean.

Background Adverse long-term effects of playing football due to repetitive head impact exposure on neurocognition and mental health are controversial. To date, no studies have evaluated such effects in women.Aims To (1) compare neurocognitive performance, cognitive symptoms and mental health in retired elite female football players (FB) with retired elite female non-contact sport athletes (CON), and to (2) assess whether findings are related to history of concussion and/or heading exposure in FB.Methods Neurocognitive performance, mental health and cognitive symptoms were assessed using computerised tests (CNS-vital signs), paper pen tests (Category fluency, Trail-Making Test, Digit Span, Paced Auditory Serial Addition Test), questionnaires (Hospital Anxiety and Depression Scale, SF-36v2 Health Survey) and a symptom checklist. Heading exposure and concussion history were self-reported in an online survey and in a clinical interview, respectively. Linear regression was used to analyse the effect of football, concussion and heading exposure on outcomes adjusted for confounders.Results FB (n=66) performed similar to CON (n=45) on neurocognitive tests, except for significantly lower scores on verbal memory (mean difference (MD)=−7.038, 95% CI −12.98 to –0.08, p=0.038) and verbal fluency tests (MD=−7.534, 95% CI –13.75 to –0.46, p=0.016). Among FB weaker verbal fluency performance was significantly associated with ≥2 concussions (MD=−10.36, 95% CI –18.48 to –2.83, p=0.017), and weaker verbal memory performance with frequent heading (MD=−9.166, 95% CI –17.59 to –0.123, p=0.041). The depression score differed significantly between study populations, and was significantly associated with frequent heading but not with history of concussion in FB.Conclusion Further studies should investigate the clinical relevance of our findings and whether the observed associations point to a causal link between repetitive head impacts and verbal memory/fluency or mental health.

Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. We present a case of a 74-year-old male who was brought to our emergency department with worsening shortness of breath, fever, and dry cough and was found to have COVID-19 pneumonia. Early in his hospital course, he was admitted to the intensive care unit, and was found to have significant abdominal distension with large amounts of simple fluid on bedside ultrasound. Bedside paracentesis returned succus and enteric feeds, and a methylene blue test confirmed a likely gastrointestinal perforation. The patients’ family refused surgical intervention and the patient underwent bedside drainage. This case represents several critical dilemmas clinicians faced during the recent surge of the COVID-19 pandemic.

Abstract Background Continuous epidural infusion (CEI) is the standard application setting for epidural infusion. A new mode, the programmed intermittent epidural bolus (PIEB) technique, showed reduced local anesthetic (LA) consumption and improved analgesia in obstetric analgesia. Goal of this trial was to evaluate the effects of PIEB versus CEI [combined with patient-controlled bolus (PCEA)] on LA consumption and pain scorings in major abdominal cancer surgery. Methods Following ethical approval, patients scheduled for major abdominal cancer surgery under general anesthesia in combination with epidural analgesia were randomized to receive either a PIEB mode of 6 mL/h or a CEI mode set at 6 mL/h of ropivacaine 0.2%, both combined with a PCEA mode set at a 4 mL bolus. LA consumptions and pain scorings were documented until the second postoperative evening. Results Eighty-four datasets were analyzed (CEI: n = 40, PIEB: n = 44). Regarding the primary endpoint, cumulative LA PCEA bolus volumes until day 2 differed significantly between the groups [PIEB 10 mL (2–28 mL) versus CEI, 28 mL (12–64 mL), median (25th–75th percentiles), p = 0.002]. Overall, LA consumption volumes were significantly lower in the PIEB group versus in the CEI group [PIEB: 329 mL (291–341 mL) vs. CEI: 350 mL (327–381 mL), p = 0.003]. Pain scores were comparable at each time point. Conclusions This trial demonstrates reduced needs for PCEA bolus in the PIEB group. There were no clinically relevant benefits regarding morphine consumption, pain scorings, or other secondary outcome parameters. Trial registration This study has been registered retrospectively in the ClinicalTrials.gov registry (NCT03378804), date of registration: December, 20th 2017.

Polydimethylsiloxane (PDMS) has been introduced the first time about 20years ago. This polymer is worldwide used for the rapid prototyping of microfluidic device through a replica molding process. However, the great popularity of PDMS is not only related to its easy processability, but also to its chemical and physical properties. For its interesting properties, the polymer has been implied for several applications, including sensing. In this work, we investigated how to use functionalized PDMS membranes as sensing elements in optical sensors for gas detection in water samples. Keywords: Polydimethylsiloxane (PDMS), Surface Plasmon Resonance (SPR) sensors, Gas sensor

Abstract Background The variability of published acupuncture protocols for patients undergoing In-Vitro Fertilization (IVF) complicates the interpretation of data and hinders our understanding of acupuncture’s impact. In 2012, an acupuncture treatment protocol developed by a Delphi consensus process was published to describe the parameters of best practice acupuncture for Assisted Reproductive Technology and future research. However, there has been no clinical trial utilizing this protocol to assess the effects of acupuncture. This study aims to a sse ss the implementation of Dephi consensus acupuncture protocol and to examine the impact of acupuncture on stress and uterine and ovarian blood flow among women between ages 21-42 years seeking IVF. Methods/Design This study is a one site prospective, two-arm randomized controlled non-blind clinical trial conducted in a medical school-affiliated fertility center . Participants will be randomized 1:1 into either the acupuncture group or the standard of care (no acupuncture) group using computer generated tables. Both groups will have 3 regular clinical visits as their standard IVF care during an approximately 2 to 3 weeks window. Women who are randomized into the acupuncture group would receive three sessions based on the Delphi consensus acupuncture protocol in addition to the standard care. The first treatment will be administered between days 6 to 8 of the stimulated IVF cycle. The second session will be performed on the day of embryo transfer at least 1 h prior to the transfer. The third session will be performed within 48 h post-embryo transfer. Participants will be followed for their pregnancy test and pregnancy outcome when applicable. The outcomes stress and blood flow will be measured by a validated perceived stress scale and vasoactive molecules, respectively. Discussion Although recruitment and scheduling could be challenging at times, the Delphi consensus acupuncture protocol was implemented as planned and well-accepted by the patients. Because of the time-specified sessions around patients’ IVF cycle, it is highly recommended to have on-site study acupuncturist(s) to accommodate the schedule. Trial Registration ClinicalTrials NCT02591186 registered on October 7, 2015.

BackgroundGlobal attention to antimicrobial resistance has increased interest in tackling the widespread inappropriate dispensing of antibiotics by informal, for-profit healthcare providers (HCPs). We provide new evidence on an understudied group of informal HCPs: invisible medicine sellers (IMS) who operate without any marked facility. We investigated factors that influence community decisions on which HCPs to purchase medicines from, focusing on reasons for using IMS, and compared different HCPs’ knowledge of antibiotic use.MethodsWe conducted community focus group discussions (FGDs) in seven purposively selected villages representing high and low informal HCPs use in two peri-urban districts in Phnom Penh, Cambodia. Using information from the FGDs to identify HCPs that sell medicines, we interviewed 35 participants: 21 HCPs (including five IMS) and 14 key informants, including government HCPs and village leaders. We adopted an interpretative approach and conducted a thematic analysis.ResultsCommunity members typically knew of several formal and informal HCPs selling medicines nearby, and IMS were common, as were doctors that sell medicines covertly. Two factors were most salient in influencing the choice of HCP for medicine purchasing. The first was trust in the effectiveness of medicines provided, judged by the speed of symptomatic relief. This pushed HCPs to provide several medicines, including antibiotics, at the first consultation. The second was the convenience offered by IMS and other informal HCPs: supplying medicines when other facilities are closed, accepting delayed payments, providing incomplete courses of medication and selling human antibiotics for animal use.ConclusionThis first study focusing on IMS indicates that it is important, but challenging, for public health agencies to engage with them to reduce inappropriate use of antibiotics. Although public health facilities must fill some gaps that informal HCPs are currently addressing, such as access to medicines at night, reducing demand for unnecessary antibiotics is also critical.

Objective: To compare the effect of liver transplantation (LT) on ileal pouch-anal anastomosis (IPAA) outcomes in patients with primary sclerosing cholangitis and inflammatory bowel disease (PSC-IBD). Background: Patients with PSC-IBD may require both IPAA for colitis and LT for PSC. Methods: Patients with PSC-IBD from out institutional pouch registry (1985--2022) were divided according to LT status and timing of LT (before and after IPAA) and their outcomes analyzed. Results: A total of 160 patients were included: 112 (70%) nontransplanted at last follow-up; 48 (30%) transplanted, of which 23 (14%) before IPAA and 25 (16%) after. Nontransplanted patients at IPAA had more laparoscopic procedures [37 (46%) vs 8 (18%), P= 0.002] and less blood loss (median 250 vs 400 mL, P=0.006). Morbidity and mortality at 90 days were similar. Chronic pouchitis was higher in transplanted compared with nontransplanted patients [32 (67%) vs 51 (45.5%), P=0.03], but nontransplanted patients had a higher rate of chronic antibiotic refractory pouchitis. Overall survival was similar, but nontransplanted patients had more PSC-related deaths (12.5% vs 2%, P=0.002). Pouch survival at 10 years was 90% for nontransplanted patients and 100% for transplanted patients (log-rank P=0.052). Timing of LT had no impact on chronic pouchitis, pouch failure, or overall survival. PSC recurrence was 6% at 10 years. For transplanted patients, graft survival was similar regardless of IPAA timing. Conclusions: In patients with PSC-IBD and IPAA, LT is linked to an increased pouchitis rate but does not affect overall and pouch survival. Timing of LT does not influence short-term and long-term-pouch outcomes. [ABSTRACT FROM AUTHOR]

This note describes a profiling mooring with an interdisciplinary suite of sensors taking profiles between 180 and 30 m depth. It consists of an underwater winch, moored below 180 m depth, and a profiling instrumentation platform. In its described setup it can take about 200 profiles at pre-programmed times or intervals with one set of batteries. This allows for studies over an extended period of time (e.g. two daily profiles over a time of 3 months). The Gotland Deep Environmental Sampling Station (GODESS) in the Eastern Gotland Basin of the Baltic Sea is aimed at investigations of redoxcline dynamics. The described system can be readily adapted to other research foci by changing the profiling instrumentation platform and its payload.

Evaluating the health status of marine ecosystems becomes ever increasingly important especially against the backdrop of rising pressures from human activities. This is true especially for coastal seas such as the Baltic Sea that is surrounded by highly industrialized countries. Nutrients and pollutants such as nitrate and hydrogen sulfide, which have a major impact on ecosystem functioning, are two of several key environmental indicators for assessing the status of natural waters, and therefore of considerable interest. The frequency and the spatial coverage of the nitrate and hydrogen sulfide measurements are currently limited by the cost of the laboratory analysis and personnel. Optical in situ sensors can help to overcome this challenge by allowing reagentless and fast detection of dissolved chemical species. A chemical-free optical sensor has been used for direct and simultaneous measurements of both key parameters, and the results were compared with traditional methods. The data were collected during an observational program conducted in the Baltic Sea in February 2018. We used the OPUS UV spectral sensor, which was deployed for the first time in coastal waters, in combination with a deep-sea telemetry system to enable near-real time measurements during CTD profiling. Data processing was carried out using a multiple linear regression procedure. Measurements from both OPUS and on-board analysis were in good agreement. The results showed, that in situ UV-VIS spectrophotometry provides the capability to determine the concentration distributions of nitrate and hydrogen sulfide in the brackish waters of the Baltic Sea.

Idiopathic myointimal hyperplasia of the mesenteric veins is an extremely rare non-thrombotic mesenteric veno-occlusive disease. The management of idiopathic myointimal hyperplasia of the mesenteric veins is not well-established, and although surgery is the mainstay of treatment, the optimal operation remains unclear. Therefore, we aimed to perform a systematic review to assess the various surgical procedures and associated outcomes for patients with idiopathic myointimal hyperplasia of the mesenteric veins. A systematic search for articles published from 1946 to April 2022 in MEDLINE, EMBASE, Cinahl, Scopus, Web of Science, and Cochrane Library databases is reported. In addition, we report 4 cases of idiopathic myointimal hyperplasia of the mesenteric veins managed at our institution until March 2023. A total of 53 studies and 88 patients with idiopathic myointimal hyperplasia of the mesenteric veins were included. Most (82%) were male patients, with a mean age of 56.6 years old. The majority (99%) of patients required surgery. Most reports described the involvement of the rectum and sigmoid colon (81%). The most common surgical procedures were Hartmann's procedure (24%) and segmental colectomy (19%); completion proctectomy with ileal pouch-anal anastomosis was performed in 3 (3.4%) cases. In 6 (6.8%) cases, idiopathic myointimal hyperplasia of the mesenteric veins was suspected preoperatively and managed with elective surgery. Four (4.5%) complications were reported. Nearly all (99%) patients achieved remission with surgical intervention. Idiopathic myointimal hyperplasia of the mesenteric veins is a rare pathologic entity infrequently suspected preoperatively and typically diagnosed after surgical resection. Surgical resection with Hartmann's procedure or segmental colectomy was most commonly performed, with completion proctectomy and ileal pouch-anal anastomosis reserved for cases of extensive rectal involvement. Surgical resection was safe and effective, with a low risk of complications and recurrence. Surgical decision-making should be based on the extent of the disease at the time of presentation. [ABSTRACT FROM AUTHOR]

In this paper we provide an overview of new knowledge on oxygen depletion (hypoxia) and related phenomena in aquatic systems resulting from the EU-FP7 project HYPOX ("In situ monitoring of oxygen depletion in hypoxic ecosystems of coastal and open seas, and landlocked water bodies", http://www.hypox.net). In view of the anticipated oxygen loss in aquatic systems due to eutrophication and climate change, HYPOX was set up to improve capacities to monitor hypoxia as well as to understand its causes and consequences. Temporal dynamics and spatial patterns of hypoxia were analyzed in field studies in various aquatic environments, including the Baltic Sea, the Black Sea, Scottish and Scandinavian fjords, Ionian Sea lagoons and embayments, and Swiss lakes. Examples of episodic and rapid (hours) occurrences of hypoxia, as well as seasonal changes in bottom-water oxygenation in stratified systems, are discussed. Geologically driven hypoxia caused by gas seepage is demonstrated. Using novel technologies, temporal and spatial patterns of water-column oxygenation, from basin-scale seasonal patterns to meter-scale sub-micromolar oxygen distributions, were resolved. Existing multidecadal monitoring data were used to demonstrate the imprint of climate change and eutrophication on long-term oxygen distributions. Organic and inorganic proxies were used to extend investigations on past oxygen conditions to centennial and even longer timescales that cannot be resolved by monitoring. The effects of hypoxia on faunal communities and biogeochemical processes were also addressed in the project. An investigation of benthic fauna is presented as an example of hypoxia-devastated benthic communities that slowly recover upon a reduction in eutrophication in a system where naturally occurring hypoxia overlaps with anthropogenic hypoxia. Biogeochemical investigations reveal that oxygen intrusions have a strong effect on the microbially mediated redox cycling of elements. Observations and modeling studies of the sediments demonstrate the effect of seasonally changing oxygen conditions on benthic mineralization pathways and fluxes. Data quality and access are crucial in hypoxia research. Technical issues are therefore also addressed, including the availability of suitable sensor technology to resolve the gradual changes in bottom-water oxygen in marine systems that can be expected as a result of climate change. Using cabled observatories as examples, we show how the benefit of continuous oxygen monitoring can be maximized by adopting proper quality control. Finally, we discuss strategies for state-of-the-art data archiving and dissemination in compliance with global standards, and how ocean observations can contribute to global earth observation attempts.

Background: Depression is one of the most common mental disorders worldwide. The German National Disease Management Guideline on Unipolar Depression (NDGM), (Nationale Versorgungsleitlinie, NVL), updated in 2022, contains recommendations on the diagnosis and treatment of acute and chronic depressive disorders. Methods: The update was based on the findings of a systematic review of the evidence (2013-2022) and was issued by a multidisciplinary panel after a formalized consensus process. Results: The structure of the guideline was fundamentally revised and is now based on the phases of depression and/or its treatment, as well as on the severity of the disease. There is newly added material with recommendations on Internet- and mobile-device based treatments, esketamine, repetitive magnetic stimulation, psychosocial therapies, rehabilitation, social participation, and complex forms of care. The guideline also emphasizes better coordination of all services in the care of patients with depression. This article covers the most important changes and additions among the 156 recommendations in the guideline. More information and accompanying materials are available at www.leitlinien.de/depression. Conclusion: There are effective treatments for depression and a variety of supportive measures that can be applied with great benefit by primary care physicians, psychiatrists, psychotherapists, and complementary care providers. The updated guideline aims to further improve the early detection, definitive diagnosis, treatment, and interdisciplinary care of people with depression. [ABSTRACT FROM AUTHOR]