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Abstract Background Acute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits. Methods For the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator “Abdominal pain in adults”. Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit. Main results We identified 28,085 adults aged ≥ 20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]). Conclusions prOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Fewer ED re-visits in prOC users indicate effective care in this subgroup.

Abstract Musical activities (MA) such as singing, playing instruments, and listening to music may be associated with health benefits. However, evidence from epidemiological studies is still limited. This study aims at describing the relation between MA and both sociodemographic and health-related factors in a cross-sectional approach. A total of 6717 adults (50.3% women, 49.7% men, median age: 51 years (IQR 43–60) were recruited from the study center Berlin-Mitte of the German National Cohort (NAKO), a population-based prospective study. This study is based on a sample randomly selected from the population registry of Berlin, Germany, aged 20 to 69 years. 53% of the participants had been musically active at least once in their life (56.1% women, 43.9% men). Playing keyboard instruments (30%) and singing (21%) were the most frequent MA. Participants listened to music in median 90 min per day (IQR 30.0–150.0). Musically active individuals were more likely to have a higher education, higher alcohol consumption, were less likely to be physically active, and had a lower BMI compared to musically inactive individuals. This large population-based study offers a comprehensive description of demographic, health, and lifestyle characteristics associated with MA. Our findings may aid in assessing long-term health consequences of MA.

Objective To assess the presence of mental health disorders in persons with rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), systemic lupus erythematosus (SLE) and Sjögren’s disease (SjD) (all: inflammatory rheumatic disease, iRMD) in a population-based cohort.Methods Baseline data from 101 601 participants of the German National Cohort (NAKO) were analysed. Self-reported physician’s diagnoses of depression and anxiety, the depression scale of the Patient Health Questionnaire (PHQ-9), the Generalised Anxiety Disorder Symptoms Scale (GAD-7), the depression section of the Mini-International Neuropsychiatric Interview (MINI) and cognitive tests on memory and executive functions were analysed. Results of participants with iRMD were compared with participants with osteoarthritis (OA), stratified by age and sex. Cognitive function was described for iRMD and OA using a linear regression model, adjusted for sex and education.Results n=3257 participants (3.2%) had an iRMD (2.3% RA, 0.6% AS, 0.5% PsA, 0.2% SLE, 0.1% SjD) and n=24 030 (24%) had OA. Physicians’ diagnoses of depression (26% vs 21%), anxiety (15% vs 11%), current depressive (PHQ-9 ≥10: 13% vs 9.0%) and anxiety symptoms (GAD-7 ≥10: 8.6% vs 5.8%) were more frequent in iRMDs compared with OA. In all age groups, women were more often affected than men. Linear regression models showed no differences in neuropsychological test results between iRMD and OA.Conclusion Individuals with iRMD frequently experience mental disorders. The study provides an assessment of both self-report and test-based occurrences in this group. Depression and anxiety are more frequent in iRMD compared with OA, whereas levels of cognitive dysfunction were comparable.

The long-term health effects of football (soccer) have received significant attention in recent years. While brain health is currently the focus of this interest, potential long-term risks or benefits related to cardiovascular and metabolic diseases and cancer are also of interest to sports medicine professionals. However, studies assessing the overall health risks for professional football players remain scarce. We introduce ‘SoccHealth’, a satellite project to the German National Cohort (NAKO), Germany’s largest population-based cohort study. SoccHealth examined 348 former professional football players aged 40–69 using the infrastructure and comprehensive examination programme of NAKO. The German Statutory Accidental Insurance for Professional Athletes identified and invited male players, while female players were recruited among former national team members. Details of the examination programme and the sociodemographic and career-related characteristics of the participants are described. The identical examination programme for the NAKO participants provides the opportunity to draw general population controls according to various definitions and focus on the respective research question to be analysed. This report delineates one approach to evaluate the long-term health effects of football across a broad range of diseases.

BackgroundThe COVID-19 pandemic prompted a range of studies on mental health, with mixed results. While numerous studies reported worsened conditions in individuals with pre-existing mental disorders, others showed resilience and stability in mental health. However, longitudinal data focusing on the German population are sparse, especially regarding effects of age and pre-existing mental disorders during the early stages of the pandemic.ObjectivesTo assess the interplay between psychiatric history, age, and the timing of the pandemic, with a focus on understanding how these factors relate to the severity of depression and anxiety symptoms.MethodsExploratory analyses were based on 135,445 individuals aged 20–72 years from the German National Cohort (NAKO). Depressive and anxiety symptoms were assessed before and after the first wave of the pandemic. Inferential statistical analyses and negative binomial regression models were calculated.ResultsPersons with a self-reported psychiatric history exhibited comparable levels of depression and anxiety symptom severity after the first wave of the pandemic compared to the time before. In contrast, individuals without a psychiatric history, particularly those in their 20s to 40s, experienced an increase in mental health symptom severity during the first wave of the pandemic.LimitationsAnalyses focuses on the first wave of the pandemic, leaving the long-term mental health effects unexplored.ConclusionFuture research should consider age-specific and mental-health-related factors when addressing global health crises. Additionally, it is important to explore factors influencing resilience and adaptation, aiming to develop targeted interventions and informed policies for effective mental health management during pandemics.

IntroductionRespiratory viral infections (RVIs) are a major global contributor to morbidity and mortality. The susceptibility and outcome of RVIs are strongly age-dependent and show considerable inter-population differences, pointing to genetically and/or environmentally driven developmental variability. The factors determining the age-dependency and shaping the age-related changes of human anti-RVI immunity after birth are still elusive. MethodsWe are conducting a prospective birth cohort study aiming at identifying endogenous and environmental factors associated with the susceptibility to RVIs and their impact on cellular and humoral immune responses against the influenza A virus (IAV), respiratory syncytial virus (RSV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The MIAI birth cohort enrolls healthy, full-term neonates born at the University Hospital Würzburg, Germany, with follow-up at four defined time-points during the first year of life. At each study visit, clinical metadata including diet, lifestyle, sociodemographic information, and physical examinations, are collected along with extensive biomaterial sampling. Biomaterials are used to generate comprehensive, integrated multi-omics datasets including transcriptomic, epigenomic, proteomic, metabolomic and microbiomic methods. DiscussionThe results are expected to capture a holistic picture of the variability of immune trajectories with a focus on cellular and humoral key players involved in the defense of RVIs and the impact of host and environmental factors thereon. Thereby, MIAI aims at providing insights that allow unraveling molecular mechanisms that can be targeted to promote the development of competent anti-RVI immunity in early life and prevent severe RVIs.Clinical trial registrationhttps://drks.de/search/de/trial/, identifier DRKS00034278.

Abstract Background Multiple Sclerosis (MS) represents the most common inflammatory neurological disease causing disability in early adulthood. Childhood and adolescence factors might be of relevance in the development of MS. We aimed to investigate the association between various factors (e.g., prematurity, breastfeeding, daycare attendance, weight history) and MS risk. Methods Data from the baseline assessment of the German National Cohort (NAKO) were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the association between childhood and adolescence factors and risk of MS. Analyses stratified by sex were conducted. Results Among a total of 204,273 participants, 858 reported an MS diagnosis. Male sex was associated with a decreased MS risk (HR 0.48; 95% CI 0.41–0.56), while overweight (HR 2.03; 95% CI 1.41–2.94) and obesity (HR 1.89; 95% CI 1.02–3.48) at 18 years of age compared to normal weight were associated with increased MS risk. Having been breastfed for ≤ 4 months was associated with a decreased MS risk in men (HR 0.59; 95% CI 0.40–0.86) compared to no breastfeeding. No association with MS risk was observed for the remaining factors. Conclusions Apart from overweight and obesity at the age of 18 years, we did not observe considerable associations with MS risk. The proportion of cases that can be explained by childhood and adolescence factors examined in this study was low. Further investigations of the association between the onset of overweight and obesity in childhood and adolescence and its interaction with physical activity and MS risk seem worthwhile.

Abstract Large population-based cohort studies utilizing device-based measures of physical activity are crucial to close important research gaps regarding the potential protective effects of physical activity on chronic diseases. The present study details the quality control processes and the derivation of physical activity metrics from 100 Hz accelerometer data collected in the German National Cohort (NAKO). During the 2014 to 2019 baseline assessment, a subsample of NAKO participants wore a triaxial ActiGraph accelerometer on their right hip for seven consecutive days. Auto-calibration, signal feature calculations including Euclidean Norm Minus One (ENMO) and Mean Amplitude Deviation (MAD), identification of non-wear time, and imputation, were conducted using the R package GGIR version 2.10-3. A total of 73,334 participants contributed data for accelerometry analysis, of whom 63,236 provided valid data. The average ENMO was 11.7 ± 3.7 mg (milli gravitational acceleration) and the average MAD was 19.9 ± 6.1 mg. Notably, acceleration summary metrics were higher in men than women and diminished with increasing age. Work generated in the present study will facilitate harmonized analysis, reproducibility, and utilization of NAKO accelerometry data. The NAKO accelerometry dataset represents a valuable asset for physical activity research and will be accessible through a specified application process.

Objective: Evaluation of the participant satisfaction with a newly developed interdisciplinary, modular education program for children, adolescents, and young adults with differences of sex development (DSD) and their parents. Methods: The two-day program including tailored medical information, peer consultation and psychological support aimed to improve diagnosis-specific knowledge and empowerment. Post-training satisfaction was measured using an adapted ZUF-8 questionnaire, scoring from 5 (worst) to a maximum of 26 (best) for persons aged 6–17 and from 10 to 40 points for adults, including 2 open-ended questions. Results: The questionnaire, completed by 89 children (6–13 years), 92 adolescents (14–17 years), 47 young adults (18–24 years), and 345 parents, revealed consistent high satisfaction with the program regardless of age or diagnosis (children 24.4 ± 2.1, adolescents 23.5 ± 2.7; young adults 36.0 ± 4.0, parents 36.6 ± 3.4). Neither sociodemographic factors nor diagnosis burden, shame, or informedness showed relevant associations with satisfaction levels. Participants highlighted exchange and open atmosphere as key satisfaction elements. Conclusion: Satisfaction with the new education program was high in all examined groups. Implementing it in routine care requires further analysis to determine the program's long-term effects on well-being and knowledge. Innovation: The first educational program for young people with DSD addressing their specific challenges through inclusive language, an open approach to sex and gender and the inclusion of self-help groups.

ObjectivesTo investigate the association of musical activity with mental health during the COVID-19 pandemic.MethodsA total of 3,666 participants reported their musical activity before and mental health indicators before and during the pandemic. Depression was assessed with the Patient Health Questionnaire, anxiety with the Generalized Anxiety Disorder scale. The association between mental health scores and musical activities was investigated using linear regression.ResultsWithin the last 12 months, 22.1% of the participants reported musical activity (15.1% singing, 14.5% playing an instrument). Individuals with frequent singing as their main musical activity had higher scores before the pandemic than non-musicians and the worsening during the pandemic was more pronounced compared to non-musicians. Instrumentalists tended to have slightly lower scores than non-musicians indicating a possible beneficial effect of playing an instrument on mental health.ConclusionThe pandemic led to a worsening of mental health, with singers being particularly affected. Singers showed poorer mental health before the pandemic. The tendency for instrumentalists to report lower depression scores compared to non-musicians may support the hypothesis that music-making has a beneficial effect on health.

Abstract In magnetic resonance imaging (MRI), the perception of substandard image quality may prompt repetition of the respective image acquisition protocol. Subsequently selecting the preferred high-quality image data from a series of acquisitions can be challenging. An automated workflow may facilitate and improve this selection. We therefore aimed to investigate the applicability of an automated image quality assessment for the prediction of the subjectively preferred image acquisition. Our analysis included data from 11,347 participants with whole-body MRI examinations performed as part of the ongoing prospective multi-center German National Cohort (NAKO) study. Trained radiologic technologists repeated any of the twelve examination protocols due to induced setup errors and/or subjectively unsatisfactory image quality and chose a preferred acquisition from the resultant series. Up to 11 quantitative image quality parameters were automatically derived from all acquisitions. Regularized regression and standard estimates of diagnostic accuracy were calculated. Controlling for setup variations in 2342 series of two or more acquisitions, technologists preferred the repetition over the initial acquisition in 1116 of 1396 series in which the initial setup was retained (79.9%, range across protocols: 73–100%). Image quality parameters then commonly showed statistically significant differences between chosen and discarded acquisitions. In regularized regression across all protocols, ‘structured noise maximum’ was the strongest predictor for the technologists’ choice, followed by ‘N/2 ghosting average’. Combinations of the automatically derived parameters provided an area under the ROC curve between 0.51 and 0.74 for the prediction of the technologists’ choice. It is concluded that automated image quality assessment can, despite considerable performance differences between protocols and anatomical regions, contribute substantially to identifying the subjective preference in a series of MRI acquisitions and thus provide effective decision support to readers.

Objective: To determine the association between personality characteristics and use of different cancer screenings. Methods: We used data from the German National Cohort (NAKO; mean age was 53.0 years (SD: 9.2 years)) – a population-based cohort study. A total of 132,298 individuals were included in the analyses. As outcome measures, we used (self-reported): stool examination for blood (haemoccult test, early detection of bowel cancer), colonoscopy (screening for colorectal cancer), skin examination for moles (early detection of skin cancer), breast palpation by a doctor (early detection of breast cancer), x-ray examination of the breast (“mammography”, early detection of breast cancer), cervical smear test, finger examination of the rectum (early detection of prostate cancer), and blood test for prostate cancer (determination of Prostate-Specific Antigen level). The established Big Five Inventory-SOEP was used to quantify personality factors. It was adjusted for several covariates based on the Andersen model. Unadjusted and adjusted multiple logistic regressions were computed. Results: A higher probability of having a skin examination for moles, for example, was associated with a higher conscientiousness (OR: 1.07, p

Summary: Background: Despite the high prevalence and major disability associated with fatigue and cognitive deficits after SARS-CoV-2 infection, little is known about long-term trajectories of these sequelae. We aimed to assess long-term trajectories of these conditions and to identify risk factors for non-recovery. Methods: We analyzed longitudinal data from the population-based COVIDOM/NAPKON-POP cohort in Germany. Participants with confirmed SARS-CoV-2 infection were assessed at least 6 months (baseline) and again at least 18 months (follow-up) after infection using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue) Scale (cutoff ≤ 30) and the Montreal Cognitive Assessment (MoCA, cutoff ≤ 25). Predictors of recovery from fatigue or cognitive deficits between assessments were identified through univariate and multivariable logistic regression models. The COVIDOM study is registered at the German registry for clinical studies (DRKS00023742) and at ClinicalTrials.gov (NCT04679584). Findings: Between 15 November 2020 and 9 May 2023, a total of 3038 participants were assessed at baseline (median 9 months after infection) and 83% responded to invitations for follow-up (median 26 months after infection). At baseline, 21% (95% confidence interval (CI) [20%, 23%]) had fatigue and 23% (95% CI [22%, 25%]) had cognitive deficits according to cutoff scores on the FACIT-Fatigue or MoCA. Participants with clinically relevant fatigue (at baseline) showed significant improvement in fatigue scores at follow-up (Hedges’ g [95% CI] = 0.73 [0.60, 0.87]) and 46% (95% CI [41%, 50%]) had recovered from fatigue. Participants with cognitive deficits showed a significant improvement in cognitive scores (g [95% CI] = 1.12 [0.90, 1.33]) and 57% (95% CI [50%, 64%]) had recovered from cognitive deficits. Patients with fatigue exhibiting a higher depressive symptom burden and/or headache at baseline were significantly less likely to recover. Significant risk factors for cognitive non-recovery were male sex, older age and

Background/Objectives: Early childhood can be a stressful period for families with a significant impact on parents’ mental health, the child’s healthy development, and the development of a secure mother–child attachment. The goal of the cross-sectional study part of SKKIPPI was to assess the occurrence of psychosocial stress and mental health disorders in parents as well as in their offspring in early childhood in three German regions. Methods: Based on random samples from three residents’ registration offices, parents with infants aged up to 12 months were invited to participate. An online screening questionnaire was developed in four languages to assess common psychosocial stressors and mental health problems of parents with small children. Results: The study enrolled 4984 mothers and 962 fathers. The most common potential psychosocial stressors were professional problems (mothers 22%, fathers 33%), lack of social support (20%, 14%), and severe, negative experiences in childhood (22%, 16%). Obsessive–compulsive thoughts (21%, 16%) and depressive (9%, 9%) and anxiety symptoms (11%, 7%) were the most frequently reported mental health problems by both parents. Regulatory problems of the child were reported by between 1.5% and 5.1% of parents. Conclusions: The study showed that a substantial proportion of parents are burdened by psychosocial problems and suffer from mental health problems in the first years after the birth of their children. Early preventive and low-threshold support measures should be available in the health and social care system. Low-threshold questionnaires, which cover a wide range of possible stress factors, should be further developed for the practical healthcare of this group of people.

Abstract The concept of “one-airway-one-disease”, coined over 20 years ago, may be an over-simplification of the links between allergic diseases. Genomic studies suggest that rhinitis alone and rhinitis with asthma are operated by distinct pathways. In this MeDALL (Mechanisms of the Development of Allergy) study, we leveraged the information of the human interactome to distinguish the molecular mechanisms associated with two phenotypes of allergic rhinitis: rhinitis alone and rhinitis in multimorbidity with asthma. We observed significant differences in the topology of the interactomes and in the pathways associated to each phenotype. In rhinitis alone, identified pathways included cell cycle, cytokine signalling, developmental biology, immune system, metabolism of proteins and signal transduction. In rhinitis and asthma multimorbidity, most pathways were related to signal transduction. The remaining few were related to cytokine signalling, immune system or developmental biology. Toll-like receptors and IL-17-mediated signalling were identified in rhinitis alone, while IL-33 was identified in rhinitis in multimorbidity. On the other hand, few pathways were associated with both phenotypes, most being associated with signal transduction pathways including estrogen-stimulated signalling. The only immune system pathway was FceRI-mediated MAPK activation. In conclusion, our findings suggest that rhinitis alone and rhinitis and asthma multimorbidity should be considered as two distinct diseases.

Abstract Large epidemiological studies such as the UK Biobank (UKBB) or German National Cohort (NAKO) provide unprecedented health-related data of the general population aiming to better understand determinants of health and disease. As part of these studies, Magnetic Resonance Imaging (MRI) is performed in a subset of participants allowing for phenotypical and functional characterization of different organ systems. Due to the large amount of imaging data, automated image analysis is required, which can be performed using deep learning methods, e. g. for automated organ segmentation. In this paper we describe a computational pipeline for automated segmentation of abdominal organs on MRI data from 20,000 participants of UKBB and NAKO and provide results of the quality control process. We found that approx. 90% of data sets showed no relevant segmentation errors while relevant errors occurred in a varying proportion of data sets depending on the organ of interest. Image-derived features based on automated organ segmentations showed relevant deviations of varying degree in the presence of segmentation errors. These results show that large-scale, deep learning-based abdominal organ segmentation on MRI data is feasible with overall high accuracy, but visual quality control remains an important step ensuring the validity of down-stream analyses in large epidemiological imaging studies.

Objectives: We analyze whether the prevalence of depressive symptoms differs among various migrant and non-migrant populations in Germany and to what extent these differences can be attributed to socioeconomic position (SEP) and social relations.Methods: The German National Cohort health study (NAKO) is a prospective multicenter cohort study (N = 204,878). Migration background (assessed based on citizenship and country of birth of both participant and parents) was used as independent variable, age, sex, Social Network Index, the availability of emotional support, SEP (relative income position and educational status) and employment status were introduced as covariates and depressive symptoms (PHQ-9) as dependent variable in logistic regression models.Results: Increased odds ratios of depressive symptoms were found in all migrant subgroups compared to non-migrants and varied regarding regions of origins. Elevated odds ratios decreased when SEP and social relations were included. Attenuations varied across migrant subgroups.Conclusion: The gap in depressive symptoms can partly be attributed to SEP and social relations, with variations between migrant subgroups. The integration paradox is likely to contribute to the explanation of the results. Future studies need to consider heterogeneity among migrant subgroups whenever possible.

The COVID-19 pandemic and the ongoing lockdowns might have had a strong impact on mental health of mothers and their infants/toddlers. For example, families had to deal with health issues and social isolation, which might have affected mental health and parent-child interactions. The aim of this study is to evaluate differences in (1) infantile regulatory disorders, (2) maternal mental health, (3) the impact of maternal mental health on infantile regulatory disorders, and (4) alterations in the mother-child interaction for participants recruited before versus after the onset of the first German lockdown. For this reason, mother-child dyads have been divided into two groups and were compared by analyzing clinical interviews on psychopathology of mother and child (M.I.N.I. & DC:05) and mother-child-interactions (Emotional Availability Scales). Results showed that (1) differences in infantile sleeping disorders emerged (phi = 0.243; p = 0.016) compared to the pre-lockdown group, while (2) the occurrence of maternal panic and anxiety increased in the post-lockdown group (phi = 0.229; p = 0.022). Moreover, there was (3) an association for maternal panic and child’s sleep disorder, and (4) specific associations with maternal non-hostility in the mother-child-interaction. In conclusion, the present study highlights the differences of maternal mental health occurrences and infants’ regulatory problems, as well as the possible effects of the COVID-19 pandemic for infants. In the pre-lockdown group, maternal non-hostility might have acted as a promotive factor against regulatory disorders, while this mechanism was mitigated in the post-lockdown group.

Abstract Background Differences in sexual development (DSD) are rare diseases, which affect the chromosomal, anatomical or gonadal sex differentiation. Although patient education is recommended as essential in a holistic care approach, standardised programmes are still lacking. The present protocol describes the aims, study design and methods of the Empower-DSD project, which developed an age-adapted multidisciplinary education programme to improve the diagnosis-specific knowledge, skills and empowerment of patients and their parents. Methods The new patient education programme was developed for children, adolescents and young adults with congenital adrenal hyperplasia, Turner syndrome, Klinefelter syndrome or XX-/or XY-DSD and their parents. The quantitative and qualitative evaluation methods include standardised questionnaires, semi-structured interviews, and participatory observation. The main outcomes (assessed three and six months after the end of the programme) are health-related quality of life, disease burden, coping, and diagnosis-specific knowledge. The qualitative evaluation examines individual expectations and perceptions of the programme. The results of the quantitative and qualitative evaluation will be triangulated. Discussion The study Empower-DSD was designed to reduce knowledge gaps regarding the feasibility, acceptance and effects of standardised patient education programmes for children and youth with DSD and their parents. A modular structured patient education programme with four generic and three diagnosis-specific modules based on the ModuS concept previously established for other chronic diseases was developed. The topics, learning objectives and recommended teaching methods are summarised in the structured curricula, one for each diagnosis and age group. At five study centres, 56 trainers were qualified for the implementation of the training programmes. A total of 336 subjects have been already enrolled in the study. The recruitment will go on until August 2022, the last follow-up survey is scheduled for February 2023. The results will help improve multidisciplinary and integrated care for children and youth with DSD and their families. Trial registration German Clinical Trials Register, DRKS00023096 . Registered 8 October 2020 – Retrospectively registered.

IntroductionFamily history of depression and childhood maltreatment are established risk factors for depression. However, how these factors are interrelated and jointly influence depression risk is not well understood. The present study investigated (i) if childhood maltreatment is associated with a family history of depression (ii) if family history and childhood maltreatment are associated with increased lifetime and current depression, and whether both factors interact beyond their main effects, and (iii) if family history affects lifetime and current depression via childhood maltreatment.MethodsAnalyses were based on a subgroup of the first 100,000 participants of the German National Cohort (NAKO), with complete information (58,703 participants, mean age = 51.2 years, 53% female). Parental family history of depression was assessed via self-report, childhood maltreatment with the Childhood Trauma Screener (CTS), lifetime depression with self-reported physician's diagnosis and the Mini-International Neuropsychiatric Interview (MINI), and current depressive symptoms with the depression scale of the Patient Health Questionnaire (PHQ-9). Generalized linear models were used to test main and interaction effects. Mediation was tested using causal mediation analyses.ResultsHigher frequencies of the childhood maltreatment measures were found in subjects reporting a positive family history of depression. Family history and childhood maltreatment were independently associated with increased depression. No statistical interactions of family history and childhood maltreatment were found for the lifetime depression measures. For current depressive symptoms (PHQ-9 sum score), an interaction was found, with stronger associations of childhood maltreatment and depression in subjects with a positive family history. Childhood maltreatment was estimated to mediate 7%–12% of the effect of family history on depression, with higher mediated proportions in subjects whose parents had a depression onset below 40 years. Abuse showed stronger associations with family history and depression, and higher mediated proportions of family history effects on depression than neglect.DiscussionThe present study confirms the association of childhood maltreatment and family history with depression in a large population-based cohort. While analyses provide little evidence for the joint effects of both risk factors on depression beyond their individual effects, results are consistent with family history affecting depression via childhood maltreatment to a small extent.

Background: In Germany, current school-based first aid training recommendations do not include children under 13 years. Our aim was therefore to evaluate a primary school-based first aid course for children aged 6–13 years. Methods: Our 2-day course (4 hours per day) for primary schools in the German rural state Brandenburg included basic elements of scene safety, compression bandages, recovery position, and resuscitation. The evaluation of specific knowledge and skills took place 1-day post-course. Results: Among the 1,268 included children (median age 9y, 49% girls) from six primary schools, 25% had previously attended first aid courses. Most children knew emergency phone number(s) pre-course. Afterward, this knowledge improved by 15% in the 6–7-year age group (reaching 80%) whereas it remained at 90% in children aged 8–13 years. After the course, about 80% of the 8–13-year-old children (40% in 6–7-year age group) answered at least one resuscitation question correctly. In the practical skill assessments, about 80% of the 8–13-year-old children (60% in the 6–7-year age group) chose a correct or almost-correct chest compression rate during resuscitation. The correct depth of compression was achieved by about 80% (10–13 years), 60% (8–9 years), and 40% (6–7 years). Three-quarters successfully put another child in the recovery position; more than two-thirds applied a compression bandage appropriately. Conclusions: A 2-day course in a primary school setting showed considerable improvement in first aid and resuscitation skills of children aged 6–13 years. Future studies should examine these effects’ sustainability and the appropriate timing for refresher courses. Zusammenfassung Hintergrund: In Deutschland umfassen die aktuellen schulbasierten Erste-Hilfe-Schulungsempfehlungen keine Kinder unter 13 Jahren. Unser Ziel war es daher, einen Erste-Hilfe-Kurs für Grundschulen zu evaluieren. Material und Methode: Unser zweitägiger Kurs (4 Stunden pro Tag) für Grundschulen im Bundesland Brandenburg umfasste Basiselemente der eigenen Sicherheit am Unfallort, Kompressionsverbände, stabile Seitenlage und Wiederbelebung. Nach der Basiserhebung kurz vor Schulungsbeginn fand die Evaluation spezifischer Kenntnisse (mit Fragebogen) und Fertigkeiten einen Tag nach dem Kurs statt. Ergebnisse Unter den 1.268 eingeschlossenen Kindern (Altersmedian 9 Jahre, 49% Mädchen) von sechs Grundschulen hatten 25% bereits früher an einem Erste-Hilfe-Kurs teilgenommen. Die meisten Kinder kannten vor dem Kurs bereits die Notrufnummer(n). Danach verbesserte sich dieses Wissen um 15% und erreichte 80% in der Altersgruppe der 6-7-Jährigen, während es bei älteren Kindern (8-13 Jahre) bei 90% blieb. Nach dem Kurs beantworteten 40% der 6-7-Jährigen und etwa 80% der 8-13-jährigen Kinder mindestens eine Frage zur Reanimation richtig. Bei den Bewertungen der praktischen Fertigkeiten wählten 60% der 6-7-Jährigen und etwa 80% der 8-13-jährigen Kinder während der Wiederbelebung die korrekte oder nahezu korrekte Rate der Kompression des Brustkorbs aus. Die richtige Kompressionstiefe wurde von 40% (6-7 Jahre), 60% (8-9 Jahre) und etwa 80% (10-13 Jahre) erreicht. Drei Viertel der Teilnehmenden setzten erfolgreich ein anderes Kind in die Stabile Seitenlage; mehr als zwei Drittel legten einen Kompressionsverband angemessen an. Schlussfolgerungen Ein zweitägiger Kurs in der Grundschule führte in allen Altersgruppen von 6-13 Jahren zu einer deutlichen Verbesserung ihrer Kenntnisse in Erster-Hilfe und Fähigkeiten bei der Wiederbelebung. Zukünftige Studien sollten die Nachhaltigkeit dieser Effekte und den geeigneten Zeitpunkt für Auffrischungskurse untersuchen. Streszczenie Tło Obecne zalecenia dotyczące szkolenia z pierwszej pomocy w niemieckich szkołach nie obejmują dzieci poniżej 13 roku życia. Naszym celem było zatem ocenienie kursu pierwszej pomocy dla dzieci w wieku od 6 do 13 lat prowadzonego w szkole podstawowej. Metody Nasz dwudniowy kurs (4 godziny dziennie) dla szkół podstawowych na obszarach wiejskich w niemieckim kraju związkowym Brandenburgia obejmował podstawowe elementy bezpieczeństwa w miejscu zdarzenia, bandażowanie uciskowe, pozycję bezpieczną i resuscytację. Ocena konkretnych umiejętności i wiedzy odbyła się dzień po zakończeniu kursu. Wyniki Wśród 1268 uwzględnionych dzieci (średni wiek 9 lat, 49% dziewczyn) z sześciu szkół podstawowych, 25% uczestniczyło wcześniej w kursach pierwszej pomocy. Większość dzieci przed kursem znała już numer(y) alarmowy. Po kursie wiedza ta poprawiła się o 15% w grupie wiekowej 6-7 lat (osiągając 80%), podczas gdy w grupie wiekowej 8-13 lat pozostała na poziomie 90%. Po kursie około 80% dzieci w wieku od 8 do 13 lat (40% w grupie wiekowej 6-7 lat) poprawnie odpowiedziało na co najmniej jedno pytanie dotyczące resuscytacji. W ocenach praktycznych umiejętności, około 80% dzieci w wieku od 8 do 13 lat (60% w grupie wiekowej 6-7 lat) wybrało właściwe lub prawie właściwe tempo ucisków klatki piersiowej podczas resuscytacji. Prawidłowa głębokość ucisków była osiągana przez około 80% (w wieku od 10 do 13 lat), 60% (w wieku od 8 do 9 lat) i 40% (w wieku od 6 do 7 lat). Trzy czwarte dzieci skutecznie ułożyło inne dziecko w pozycji bezpiecznej, a ponad dwie trzecie odpowiednio zastosowało bandaż uciskowy. Wnioski Dwudniowy kurs przeprowadzony w szkole podstawowej wykazał znaczną poprawę umiejętności pierwszej pomocy i resuscytacji u dzieci w wieku od 6 do 13 lat. W przyszłych badaniach należy zbadać trwałość tych efektów oraz odpowiedni czas na odświeżenie wiedzy pozyskanej na kursach. Schlüsselwörter: Grundschule, Erste Hilfe, Wiederbelebung, Laienschulung, Schulkinder, Schüler, Basisreanimation, Klassenzimmer, Blutungsstillung, Kompressionsverband, Stabile Seitenlage, Wiederbelebung, Laien-Wiederbelebung Słowa kluczowe: szkoła podstawowa, pierwsza pomoc, resuscytacja, szkolenie dla laików, dzieci szkolne, uczniowie

BackgroundThe COVID-19 symptom-monitoring apps provide direct feedback to users about the suspected risk of infection with SARS-CoV-2 and advice on how to proceed to prevent the spread of the virus. We have developed the CoronaCheck mobile health (mHealth) platform, the first free app that provides easy access to valid information about the risk of infection with SARS-CoV-2 in English and German. Previous studies have suggested that the clinical characteristics of individuals infected with SARS-CoV-2 vary by age, gender, and viral variant; however, potential differences between countries have not been adequately studied. ObjectiveThe aim of this study is to describe the characteristics of the users of the CoronaCheck mHealth platform and to determine country-specific and sociodemographic associations of COVID-19–related symptoms and previous contacts with individuals infected with COVID-19. MethodsBetween April 8, 2020, and February 3, 2022, data on sociodemographic characteristics, symptoms, and reports of previous close contacts with individuals infected with COVID-19 were collected from CoronaCheck users in different countries. Multivariable logistic regression analyses were performed to examine whether self-reports of COVID-19–related symptoms and recent contact with a person infected with COVID-19 differed between countries (Germany, India, South Africa), gender identities, age groups, education, and calendar year. ResultsMost app users (N=23,179) were from Germany (n=8116, 35.0%), India (n=6622, 28.6%), and South Africa (n=3705, 16.0%). Most data were collected in 2020 (n=19,723, 85.1%). In addition, 64% (n=14,842) of the users were male, 52.1% (n=12,077) were ≥30 years old, and 38.6% (n=8953) had an education level of more than 11 years of schooling. Headache, muscle pain, fever, loss of smell, loss of taste, and previous contacts with individuals infected with COVID-19 were reported more frequently by users in India (adjusted odds ratios [aORs] 1.3-8.3, 95% CI 1.2-9.2) and South Africa (aORs 1.1-2.6, 95% CI 1.0-3.0) than those in Germany. Cough, general weakness, sore throat, and shortness of breath were more frequently reported in India (aORs 1.3-2.6, 95% CI 1.2-2.9) compared to Germany. Gender-diverse users reported symptoms and contacts with confirmed COVID-19 cases more often compared to male users. ConclusionsPatterns of self-reported COVID-19–related symptoms and awareness of a previous contact with individuals infected with COVID-19 seemed to differ between India, South Africa, and Germany, as well as by gender identity in these countries. Viral symptom–collecting apps, such as the CoronaCheck mHealth platform, may be promising tools for pandemics to support appropriate assessments. Future mHealth research on country-specific differences during a pandemic should aim to recruit representative samples.

Abstract MASK‐air®, a validated mHealth app (Medical Device regulation Class IIa) has enabled large observational implementation studies in over 58,000 people with allergic rhinitis and/or asthma. It can help to address unmet patient needs in rhinitis and asthma care. MASK‐air® is a Good Practice of DG Santé on digitally‐enabled, patient‐centred care. It is also a candidate Good Practice of OECD (Organisation for Economic Co‐operation and Development). MASK‐air® data has enabled novel phenotype discovery and characterisation, as well as novel insights into the management of allergic rhinitis. MASK‐air® data show that most rhinitis patients (i) are not adherent and do not follow guidelines, (ii) use as‐needed treatment, (iii) do not take medication when they are well, (iv) increase their treatment based on symptoms and (v) do not use the recommended treatment. The data also show that control (symptoms, work productivity, educational performance) is not always improved by medications. A combined symptom‐medication score (ARIA‐EAACI‐CSMS) has been validated for clinical practice and trials. The implications of the novel MASK‐air® results should lead to change management in rhinitis and asthma.

Background: Primary hazelnut allergy is a common cause of anaphylaxis in children, as compared to birch-pollen associated hazelnut allergy. Population-based data on hazelnut and concomitant birch-pollen allergy in children are lacking. We aimed to investigate the prevalence of primary and pollen-associated hazelnut allergy and sensitization profiles in school-aged children in Berlin, Germany. Methods: 1570 newborn children were recruited in Berlin in 2005–2009. The school-age follow-up (2014–2017) was based on a standardized web-based parental questionnaire and clinical evaluation by a physician including skin prick tests, allergen specific immunoglobulin E serum tests and placebo-controlled double-blind oral food challenges, if indicated. Results: 1004 children (63.9% response) participated in the school-age follow-up assessment (52.1% male). For 1.9% (n = 19, 95%-confidence interval 1.1%–2.9%) of children their parents reported hazelnut-allergic symptoms, for half of these to roasted hazelnut indicating primary hazelnut allergy. Symptoms of birch-pollen allergy were reported for 11.6% (n = 116 95%-CI 9.7%–13.7%) of the children. Both birch-pollen allergy and hazelnut allergy associated symptoms affected 0.6% (n = 6, 95%-CI 0.2%–1.3%) of children. Assessment of allergic sensitization was performed in 261 participants and showed that almost 20% of these children were sensitized to hazelnut, being the most frequent of all assessed food allergens, or birch-pollen, the majority to both. Conclusions: Based on parental reports hazelnut-allergic symptoms were far less common than sensitization to hazelnut. This needs to be considered by physicians to avoid unnecessary changes in diet due to sensitization profiles only, especially when there is a co-sensitization to hazelnut and birch-pollen.

Summary: Background: Post-COVID syndrome (PCS) is an important sequela of COVID-19, characterised by symptom persistence for >3 months, post-acute symptom development, and worsening of pre-existing comorbidities. The causes and public health impact of PCS are still unclear, not least for the lack of efficient means to assess the presence and severity of PCS. Methods: COVIDOM is a population-based cohort study of polymerase chain reaction (PCR) confirmed cases of SARS-CoV-2 infection, recruited through public health authorities in three German regions (Kiel, Berlin, Würzburg) between November 15, 2020 and September 29, 2021. Main inclusion criteria were (i) a PCR confirmed SARS-CoV-2 infection and (ii) a period of at least 6 months between the infection and the visit to the COVIDOM study site. Other inclusion criteria were written informed consent and age ≥18 years. Key exclusion criterion was an acute reinfection with SARS-CoV-2. Study site visits included standardised interviews, in-depth examination, and biomaterial procurement. In sub-cohort Kiel-I, a PCS (severity) score was developed based upon 12 long-term symptom complexes. Two validation sub-cohorts (Würzburg/Berlin, Kiel-II) were used for PCS score replication and identification of clinically meaningful predictors. This study is registered at clinicaltrials.gov (NCT04679584) and at the German Registry for Clinical Studies (DRKS, DRKS00023742). Findings: In Kiel-I (n = 667, 57% women), 90% of participants had received outpatient treatment for acute COVID-19. Neurological ailments (61·5%), fatigue (57·1%), and sleep disturbance (57·0%) were the most frequent persisting symptoms at 6–12 months after infection. Across sub-cohorts (Würzburg/Berlin, n = 316, 52% women; Kiel-II, n = 459, 56% women), higher PCS scores were associated with lower health-related quality of life (EQ-5D-5L-VAS/-index: r = -0·54/ -0·56, all p

Abstract Background Self-reported health (SRH) and life satisfaction (LS) are patient-reported outcomes (PROs) that independently predict mortality and morbidity in older adults. Emergency department (ED) visits due to serious health problems or accidents might pose critical life events for patients. This study aimed (a) to characterize older patients’ SRH and LS during the distinct event of an ED stay, and (b) to analyze concomitant associations of PROs with ED patients’ sociodemographic, disease-specific and care-related variables. Methods Study personnel recruited mostly older ED patients from three disease groups during a two-year period (2017–2019) in eight EDs in central Berlin, Germany, in the context of the health services research network EMANet. Cross-sectional data from the baseline patient survey and associated secondary data from hospital information systems were analyzed. Multilevel linear regression models with random intercept were applied to assess concomitant associations with SRH (scale: 0 (worst) to 100 (best)) and LS (scale: 0 (not at all satisfied) to 10 (completely satisfied)) as outcomes, including sensitivity analyses. Results The final sample comprised N = 1435 participants. Mean age was 65.18 (SD: 16.72) and 50.9% were male. Mean ratings of SRH were 50.10 (SD: 23.62) while mean LS scores amounted to 7.15 (SD: 2.50). Better SRH and higher LS were found in patients with cardiac symptoms (SRH: β = 4.35, p = .036; LS: β = 0.53, p = .006). Worse SRH and lower LS were associated with being in need of nursing care (SRH: β = − 7.52, p

Abstract Background Sudden unexpected infant death (SUID) continues to be a major contributor to infant mortality in the United States. The objective was to analyze time trends in SUID and their association with immunization coverage. Methods The number of deaths and live births per year and per state (1992–2015) was obtained from the Centers for Disease Control and Prevention (CDC). We calculated infant mortality rates (i.e., deaths below one year of age) per 1000 live births for SUID. We obtained data on immunization in children aged 19–35 months with three doses or more of diphtheria-tetanus-pertussis (3+ DTP), polio (3+ Polio), and Haemophilus influenzae type b (3+ Hib) as well as four doses or more of DTP (4+ DTP) from the National Immunization Survey, and data on infant sleep position from the Pregnancy Risk Assessment Monitoring System (PRAMS) Study. Data on poverty and race were derived from the Current Population and American Community Surveys of the U.S. Census Bureau. We calculated mean SUID mortality rates with 95% confidence interval (CI) as well as the annual percentage change using breakpoint analysis. We used Poisson regression with random effects to examine the dependence of SUID rates on immunization coverage, adjusting for sleep position and poverty (1996–2015). In a second model, we additionally adjusted for race (2000–2015). Results Overall, SUID mortality decreased in the United States. The mean annual percent change was − 9.6 (95% CI = − 10.5, − 8.6) between 1992 and 1996, and − 0.3 (95% CI = − 0.4, − 0.1) from 1996 onwards. The adjusted rate ratios for SUID mortality were 0.91 (95% CI = 0.80, 1.03) per 10% increase for 3+ DTP, 0.88 (95% CI = 0.83, 0.95) for 4+ DTP, 1.00 (95% CI = 0.90, 1.10) for 3+ polio, and 0.95 (95% CI = 0.89, 1.02) for 3+ Hib. After additionally adjusting for race, the rate ratios were 0.76 (95% CI = 0.67, 0.85) for 3+ DTP, 0.83 (95% CI = 0.78, 0.89) for 4+ DTP, 0.81 (95% CI = 0.73, 0.90) for 3+ polio, and 0.94 (95% CI = 0.88, 1.00) for 3+ Hib. Conclusions SUID mortality is decreasing, and inversely related to immunization coverage. However, since 1996, the decline has slowed down.

IntroductionMind-body medicine (MBM) focuses on stress reduction and lifestyle changes. The primary objective of this pilot trial was to test study feasibility of a complex integrative MBM program for patients with Crohn's disease (CD), especially in rural regions, and under pandemic conditions.MethodsPatients were stratified and randomized to the intervention group (IG) or the control group (CG). The intervention included a weekly 6-h session for 10 weeks. The CG (waiting list) received an initial 90-min workshop and started the intervention 9 months later. The primary outcome for study feasibility was recruitment and retention rates, as well as reasons for drop-out. The trial took place in Bamberg, Germany (September 2020 to December 2021).ResultsTotally 700 members of the German Crohn's and Colitis Organization—DCCV—were contacted. A total of 15% (102/700; 95% CI 12–17%) expressed interest to participate. Following screening, 41% (95% CI 32–50) were randomized to IG (n = 22) and CG (n = 20). The patients were on average (±standard deviation) 48 ± 13 years old, 67% were female, and have been suffering from CD for 20 ± 12 years. Patients traveled 71.5 ± 48.7 km (range: 9–227 km) to the intervention with no differences between IG and CG. At the 6-month follow-up, 36/42 (86%, 95% CI 74–95%) participants completed final assessment and 19/22 (86%, 95% CI 70–100%) the intervention. The most important reasons for non-responding were work-related (12/60; 20%) and for or drop-out pandemic-related anxiety (3/6). No patient and staff member became infected with SARS-CoV-2 during the study.ConclusionThe feasibility of the MBM study was confirmed in terms of predefined recruitment and retention criteria, both despite difficult conditions (including the rural setting) and patients' fears associated with the pandemic. It was crucial to develop appropriate hygiene and safety concepts that enable chronically ill patients to participate in helpful group-based interventions even under pandemic conditions.Clinical trial registrationClinicalTrials.gov, identifier: NCT05182645.

Abstract Background The first years of life are a significant period for child development, when children are particularly sensitive and prone to crises. This early phase lays the foundation for healthy growth. Clinical assessment of psychological symptoms in early infancy and adequate treatment are both important in improving the diagnostic outcome and preventing later long-term developmental consequences. The most common psychological problems in the first 3 years of life are regulatory disorders. The aim of this trial is to investigate the efficacy of Parent-Infant Psychotherapy (PIP) for infants and young children (aged 0–36 months, diagnosed with at least one regulatory disorder) and their mothers, compared to care as usual (CAU). Methods In this open multicentre randomised controlled trial, 160 mother-infant dyads are randomised to receive PIP or CAU for 6 weeks of intervention in clinical or outpatient (including home treatment) settings. The primary outcome is the maternal sensitivity (sensitivity scale of the Emotional Availability Scales (EAS)) after 6 weeks. Secondary outcomes include assessment of interaction, mental health problems, attachment, development, psychological factors, treatment adherence, health care system utilisation, and costs, after 6 weeks and 12 months. Discussion This study will evaluate whether a manualised focus-based short-term psychodynamic psychotherapeutic intervention in mother-child dyads improves the care situation for families of children diagnosed with regulatory disorders, and helps prevent long-term psychopathologies. Assessment of the intervention in different settings will support the development of more tailored interventions for affected infants and their mothers. Trial registration German Clinical Trial Register, ID: DRKS00017008 . Registered 03/20/2019.

Abstract Background Sudden unexpected infant death (SUID) - including sudden infant death syndrome (SIDS) - continues to be a major contributor to infant mortality worldwide. Our objective was to analyse time trends and to identify country-clusters. Methods The National Statistical Offices of 52 countries provided the number of deaths and live births (1969–2012). We calculated infant mortality rates per 1000 live births for SUID, SIDS, and all-cause mortality. Overall, 29 countries provided sufficient data for time course analyses of SUID. To sensitively model change over time, we smoothed the curves of mortality rates (1980–2010). We performed a hierarchical cluster analysis to identify clusters of time trends for SUID and SIDS, including all-cause infant mortality. Results All-cause infant mortality declined from 28.5 to 4.8 per 1000 live births (mean 12.4; 95% confidence interval 12.0–12.9) between 1969 and 2012. The cluster analysis revealed four country-clusters. Clusters 1 and 2 mostly contained countries showing the typical peak of SUID mortality during the 1980s. Cluster 1 had higher SUID mortality compared to cluster 2. All-cause infant mortality was low in both clusters but higher in cluster 1 compared to cluster 2. Clusters 3 and 4 had low rates of SUID without a peak during the 1980s. Cluster 3 had the highest all-cause infant mortality of all clusters. Cluster 4 had an intermediate all-cause infant mortality. The time trends of SUID and SIDS mortality were similar. Conclusions The country-specific time trends in SUID varied considerably. The identification of country-clusters may promote research into how changes in sleep position, smoking, immunisation, or other factors are related to our findings.

Abstract Background In all societies, the burden and cost of allergic and chronic respiratory diseases are increasing rapidly. Most economies are struggling to deliver modern health care effectively. There is a need to support the transformation of the health care system into integrated care with organizational health literacy. Main body As an example for chronic disease care, MASK (Mobile Airways Sentinel NetworK), a new project of the ARIA (Allergic Rhinitis and its Impact on Asthma) initiative, and POLLAR (Impact of Air POLLution on Asthma and Rhinitis, EIT Health), in collaboration with professional and patient organizations in the field of allergy and airway diseases, are proposing real-life ICPs centred around the patient with rhinitis, and using mHealth to monitor environmental exposure. Three aspects of care pathways are being developed: (i) Patient participation, health literacy and self-care through technology-assisted “patient activation”, (ii) Implementation of care pathways by pharmacists and (iii) Next-generation guidelines assessing the recommendations of GRADE guidelines in rhinitis and asthma using real-world evidence (RWE) obtained through mobile technology. The EU and global political agendas are of great importance in supporting the digital transformation of health and care, and MASK has been recognized by DG Santé as a Good Practice in the field of digitally-enabled, integrated, person-centred care. Conclusion In 20 years, ARIA has considerably evolved from the first multimorbidity guideline in respiratory diseases to the digital transformation of health and care with a strong political involvement.

Abstract Objectives Our aim was to examine the effects of an early perinatal prevention program offered to mothers and families suffering from significant psychosocial burden. Methods All mothers giving birth in a Berlin university hospital during Jan-Aug 2013 were screened with a standardized 27-item questionnaire by trained staff. Mothers with a screening-score ≥ 3, who were not enrolled in other public support programs, were defined as psychosocially burdened. They received a detailed needs assessment and were followed up with counseling. When necessary, affected mothers were voluntarily guided through to specialized ‘early support’ institutions during the 12-month-intervention period. The historical control group (care-as-usual) consisted of children born at the same hospital the year before. At 12 months postnatally, we interviewed mothers in both groups to assess their stress burden and coping skills by Parenting Stress Index and assessed the current childcare condition. Differences between the groups were compared by multivariable logistic regression analyses adjusting for potential confounders. Results The intervention group and the control group included 225 and 157 families, respectively. After 12-months, mothers in the ‘early support’ intervention group had significantly less often depression (adjusted odds ratio 0.25, 95%-confidence interval 0.07–0.94), less often a disturbed relationship with the parenting partner (0.34, 0.10–1.14) and reported reduced stress due to the child’s demands (0.40, 0.15–1.10) compared to the control group. Childcare indicators did not differ between the 2 groups. Conclusions In mothers at high psychosocial risk, the ‘early support’ intervention program Babylotse-Plus seemed to reduce the occurrence of depression and several stress indicators in the first postnatal year.

Abstract Background Until now, herpes zoster (HZ)-related disease burden in Germany has been estimated based on health insurance data and clinical findings. However, the validity of self-reported HZ is unclear. This study investigated the validity of self-reported herpes zoster (HZ) and its complication postherpetic neuralgia (PHN) using data from the pretest studies of the German National Cohort (GNC) in comparison with estimates based on health insurance data. Methods Data of 4751 participants aged between 20 and 69 years from two pretest studies of the GNC carried out in 2011 and 2012 were used. Based on self-reports of physician-diagnosed HZ and PHN, age- and sex-specific HZ incidence rates and PHN proportions were estimated. For comparison, estimates based on statutory health insurance data from the German population were considered. Results Eleven percent (95%-CI, 10.4 to 12.3, n = 539) of the participants reported at least one HZ episode in their lifetime. Our estimated age-specific HZ incidence rates were lower than previous estimates based on statutory health insurance data. The PHN proportion in participants older than 50 years was 5.9% (1.9 to 13.9%), which was in line with estimates based on health insurance data. Conclusion As age- and sex-specific patterns were comparable with that in health insurance data, self-reported diagnosis of HZ seems to be a valid instrument for overall disease trends. Possible reasons for observed differences in incidence rates are recall bias in self-reported data or overestimation in health insurance data.

Abstract Background Vitamin D levels may differ between migrant and non-migrant populations, especially among non-western immigrants living in a country with limited sun exposure such as Germany. This study examined serum vitamin D concentration and associated factors among Berliners with and without Turkish background. Methods Two samples (with and without Turkish roots) were recruited in the inner city of Berlin for a cross-sectional study assessing serum vitamin D concentration. Linear regression analyses were used to examine sociodemographic, lifestyle and medical factors associated with serum vitamin D levels. Results In the analyses, we included 537 subjects (39% men and 61% women, age 43.2 ± 12.5 (mean ± standard deviation) years) with and 112 without Turkish background (46% men and 54% women, age 46.7 ± 14.6 years). The Turkish sample had lower mean (95%-Confidence Interval) vitamin D levels than the non-Turkish sample: 22.7 nmol/L (21.5;23.9) vs 34.7 nmol/L (31.9;37.5), p

Introduction: The crowding of emergency departments (ED) has been a growing problem for years, putting the care of critically ill patients increasingly at risk. The INDEED project's overall aim is to get a better understanding of ED utilization and to evaluate corresponding primary health care use patterns before and after an ED visit while driving forward processes and methods of cross-sectoral data merging. We aim to identify adequate utilization of EDs and potentially avoidable patient contacts as well as subgroups and clusters of patients with similar care profiles.Methods: INDEED is a joint endeavor bringing together research institutions and hospitals with EDs in Germany. It is headed by the Charité–Universitätsmedizin Berlin, collaborating with Otto von Guericke University Magdeburg, Technische Universität Berlin, the Central Research Institute of Ambulatory/Outpatient Health Care in Germany (Zi), and the AOK Research Institute as part of the Federal Association of AOK, as well as experts in the technological, legal, and regulatory aspects of medical research (TMF). The Institute for Information Technology (OFFIS) was involved as the trusted third party of the project. INDEED is a retrospective study of approximately 400,000 adult patients with statutory health insurance who visited the ED of one of 16 participating hospitals in 2016. The routine hospital data contain information about treatment in the ED and, if applicable, about the subsequent hospital stay. After merging the patients' hospital data from 2016 with their outpatient billing data from 2 years before to 1 year after the ED visit (years 2014–2017), a harmonized dataset will be generated for data analyses. Due to the complex data protection challenges involved, first results will be available in 2021.Discussion: INDEED will provide knowledge on extracting and harmonizing large scale data from varying routine ED and hospital information systems in Germany. Merging these data with the corresponding outpatient care data of patients offers the opportunity to characterize the patient's treatment in outpatient care before and after ED use. With this knowledge, appropriate interventions may be developed to ensure adequate patient care and to avoid adverse events such as ED crowding.

Abstract Background This review aims to (1) consolidate evidence regarding the association between socioeconomic status (SES) and cardiorespiratory fitness (CRF), (2) conduct a meta-analysis of the association between SES and CRF using methodologically comparable data, stratified by sex, and (3) test whether the association varies after adjustment for physical activity (PA). Methods A systematic review of studies from MEDLINE, EMBASE, Latin American and Caribbean Health Sciences (LILACS), Scientific Electronic Library Online (ScIELO), and Cochrane Library without time or language restrictions, which investigated associations between SES and CRF. Risk of bias within studies was assessed using a customized quality assessment tool. Results were summarized in table format and methodologically similar studies were synthesized using meta-analysis of Hedges’ g effect sizes. Synthesized results were appraised for cross-study bias. Results were tested for the impact of PA adjustment using meta-regression. Results Compared to individuals with low education, both men and women showed higher CRF among individuals with high education (men 0.12 [0.04–0.20], women 0.19 [0.02–0.36]), while participants with medium education showed no significant difference in CRF (men 0.03 [− 0.04–0.11], women 0.09 [− 0.03–0.21]). Adjustment for PA did not significantly impact the association between education and CRF. Conclusions There is fair evidence for an association between high levels of education and increased CRF. This could have implications for monitoring, of health target compliance and of chronic disease risk among higher risk populations, to detect and prevent non-communicable diseases (NCDs) and to diminish social health inequalities. Trial Registration PROSPERO, CRD42017055456

Abstract Background Cardiorespiratory fitness (CRF) is a physical condition that is now well established as a predictor of numerous adverse health outcomes, independent of physical activity levels. In order to be able to improve CRF at the population level and to develop effective interventions and public health programmes, it is important to understand why some people are more fit than others. Therefore, the primary aim of the systematic review described in this protocol is to examine individual and interpersonal factors that are correlated with or determine CRF among adults. Methods The review will focus on quantitative studies that investigate any personal and interpersonal correlates and/or determinants of objectively measured CRF among the general, non-symptomatic, non-institutionalized adult population (aged 18–65 years) worldwide. The databases MEDLINE, Embase, and Cochrane Library will be searched to identify all relevant published journal articles, and Google Scholar and Scopus will be searched for grey literature. Studies where CRF is not an outcome variable and experimental studies where participants specifically receive a fitness intervention that increases CRF will be excluded. For each study, data extracted will include, among other variables, study characteristics, methodology for selecting participants into the study as well as the participants’ demographic characteristics, types of correlates and determinants of CRF investigated and their measurement methods, the objective measure of CRF used and its measurement method and validity, and the main reported results on the association between the correlates or determinants and CRF. In addition, observational studies will be assessed for methodological quality and risk of bias using a customized version of the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies by the National Heart, Lung, and Blood Institute. Experimental studies will be assessed using the 27-item Downs and Black “Checklist for Measuring Study Quality”. The final results will be presented as a narrative synthesis of the main findings of all included studies. Discussion By consolidating and synthesizing the current research on possible individual and interpersonal correlates and determinants of CRF among adults worldwide, we aim to aid future public health actions, as well as identify gaps in our full understanding of what influences CRF. Systematic review registration PROSPERO CRD42017055456 .

Introduction To understand the puberty-related sex shift in the prevalence of asthma and rhinitis as single entities and as respiratory multimorbidities, we investigated if there is also a sex-specific and puberty-related pattern of their incidences.Methods We used harmonised questionnaire data from 18 451 participants in five prospective observational European birth cohorts within the collaborative MeDALL (Mechanisms of the Development of Allergy) project. Outcome definitions for IgE-associated and non-IgE-associated asthma, rhinitis and respiratory multimorbidity (first occurrence of coexisting asthma and rhinitis) were based on questionnaires and the presence of specific antibodies (IgE) against common allergens in serum. For each outcome, we used proportional hazard models with sex–puberty interaction terms and conducted a one-stage individual participant data meta-analysis.Results Girls had a lower risk of incident asthma (adjusted HR 0.67, 95% CI 0.61 to 0.74), rhinitis (0.73, 0.69 to 0.78) and respiratory multimorbidity (0.58, 0.51 to 0.66) before puberty compared with boys. After puberty onset, these incidences became more balanced across the sexes (asthma 0.84, 0.64 to 1.10; rhinitis 0.90, 0.80 to 1.02; respiratory multimorbidity 0.84, 0.63 to 1.13). The incidence sex shift was slightly more distinct for non-IgE-associated respiratory diseases (asthma 0.74, 0.63 to 0.87 before vs 1.23, 0.75 to 2.00 after puberty onset; rhinitis 0.88, 0.79 to 0.98 vs 1.20, 0.98 to 1.47; respiratory multimorbidity 0.66, 0.49 to 0.88 vs 0.96, 0.54 to 1.71) than for IgE-associated respiratory diseases.Discussion We found an incidence ‘sex shift’ in chronic respiratory diseases from a male predominance before puberty to a more sex-balanced incidence after puberty onset, which may partly explain the previously reported sex shift in prevalence. These differences need to be considered in public health to enable effective diagnoses and timely treatment in adolescent girls.

Background Web portals providing health information online have the potential to reach large numbers of people. Yet few studies have assessed usage and costs of health portals, especially over an extended period of time. Objectives First, to assess the usage of a web portal on prevention and health promotion that was initiated by the German states of Berlin and Brandenburg. Second, to estimate average cost per pageview over the full web portal life-cycle. Methods Usage data were gathered through Google Analytics. The main usage metric assessed was pageviews originating from an IP address in Berlin or Brandenburg. Project cost data were reported by the local government and from own records. Descriptive and regression analyses were used to determine time trends in pageviews. Results The redesigned web portal Praeventionsatlas.de launched August 2011 and was discontinued March 2018. Analyzing the full calendar years only, the annual pageview number increased from 2012 (8492) to its peak in 2014 (11,876) and steadily decreased to its minimum in 2017 (7232). Pages of the web portal were most often viewed around lunchtime (12 to 1 p.m.), in the middle of the week (Wed to Thu), and at the beginning of the year (Jan to Feb). Adjusting for year, month, and weekday, the number of daily pageviews dropped on major public holidays (Easter −9, Pentecost −12, Christmas −12 and New Year’s Eve and Day −20; p