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Background: In light of the accumulating evidence, awareness and urgency to act upon the three planetary crises - climate change, biodiversity loss, and pollution - the concept of Planetary Health underscores their profound implications for health and promotes actionable solutions to advance both wellbeing and ecological sustainability. Despite (inter)national calls to integrate Planetary Health into health workers' curricula, the current status of Planetary Health Education in undergraduate medical education in Germany is unclear. This study therefore aimed (a) to assess the current implementation of Planetary Health in undergraduate medical education in Germany and (b) to explore its characteristics as a foundation to develop evidence-informed recommendations for mainstreaming Planetary Health Education in medical schools in Germany., Methods: The study comprised structured interviews followed by an online survey, both targeting all 39 medical schools in Germany. In 2021, structured interviews were conducted with students, educators and deanery staff at medical schools. In 2023, educators and deanery staff participated in an online survey based on the findings from the interviews., Findings: In total, 80% of the 39 medical schools participated in the interviews, while 90% took part in the online survey. Based on integrated findings, 35 medical schools (90%) offered Planetary Health Education, with a median of two educational activities, including both stand-alone courses and lectures integrated into other courses. Despite an overall increase since winter semester 2021/2022, most educational activities were electives and not part of the mandatory curriculum. Innovative educational approaches and learning objectives differed significantly between mandatory and elective formats. In contrast to mandatory educational activities, student involvement was reported for the majority of electives and was significantly associated with transformative learning objectives., Interpretation: Despite a steady rise in teaching activities, mandatory Planetary Health Education remains insufficiently integrated into undergraduate medical education in Germany. Key criteria defining high-quality Planetary Health Education, such as innovative educational approaches, practical skills, and transformative learning, were primarily reflected in electives, that reach only a minority of students. To adequately equip the future healthcare workforce, the current barriers to successfully integrating Planetary Health into medical education must be systematically addressed and overcome., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Grieco, Parisi, Simmenroth, Eichinger, Zirkel, König, Jünger, Geck and Schwienhorst-Stich.)

Background: Thyroid Transcription Factor-1 (TTF-1) expression in lung adenocarcinoma (LUAD) has been studied for its prognostic value in early-stage and metastatic disease. Its role in brain metastasis remains unexplored. This study investigates the predictive value and association of TTF-1 status with clinicopathological variables in patients with synchronous LUAD brain metastases., Material and Methods: In this bicentric retrospective study, 245 patients with newly diagnosed, treatment-naïve brain metastasis undergoing resection were included. Patient data were retrieved from electronic records. Outcomes included overall and progression-free survival. Statistical analysis included Kaplan-Meier estimates and Cox proportional hazards regression., Results: Mean Ki67 index in TTF-1 negative patients was 43% [95% CI 38-48%] compared to 32% [95% CI 29-35%] in TTF-1 positive (TTF-1 +) patients (p < 0.001). Tumor volume was significantly larger in TTF-1 negative (TTF-1-) patients (mean volume 24 mL [95% CI 18-31 mL]) vs. 15 mL [95% CI 12-17 mL] in TTF-1 + patients (padjust = 0.003). Perifocal edema was smaller in TTF-1- patients (mean volume: 58 mL [95% CI 45-70 mL]) vs. 84 mL [95% CI 73-94 mL] in TTF-1 + patients (padjust = 0.077). Tumor and edema volume did not correlate. TTF-1- patients showed worse overall, intracranial, and extracranial progression-free survival. In a multivariable Cox model, positive TTF-1 status was independently associated with improved outcomes. Negative TTF-1 status was associated with increased hazard for intracranial disease progression compared to extracranial progression., Conclusion: In synchronous LUAD brain metastases, TTF-1 negativity reflects an aggressive phenotype with larger proliferation capacity and tumor volume. Future research should explore the underlying cellular and molecular alterations of this phenotype., Competing Interests: Declarations. Competing interests: The authors declare no relevant financial or non-financial interests. There were no competing interests with respect to this study. Ethical approval and consent to participate: This study was approved by the local institutional review boards (EA1/399/20 and 20-1799-101). Consent for publication: Not applicable. Previous presentations: Portions of this work were presented at the annual meeting of the European Association of Neurosurgical Societies (EANS), Sofia, Bulgaria, October 13–17, 2024., (© 2024. The Author(s).)

Background: Leptin, an adipokine suspected to play a role in coronary artery disease (CAD), may also be associated with deteriorated mental health. We investigated the prospective impact of recurrent depressed mood (RDM) on heightened plasma leptin levels in CAD patients., Methods: Derived from the randomized SPIRR-CAD trial, plasma leptin were measured by the Human Leptin DuoSet ELISA at baseline in 539 patients (including 115 (21.3 %) women and 424 (78.7 %) men) and in 373 participants after 18-months follow up (T 3 ). RDM was based on the clinical course from baseline to follow-up assessed by the Hamilton Depression Rating Scale (HAMD). Multivariate binary logistic regression models identified predictors for heightened leptin at T 3 ., Results: At baseline, highest leptin level (3rd tertile) was associated with type 2 diabetes (p = 0.009), heart failure symptoms (NYHA III) (p < 0.001), female sex and BMI ≥30 (p < 0.001) but not with age and depression. At study endpoint (T3), RDM was associated with a substantially increased risk of experiencing the highest plasma leptin level (OR 2.92 (95 % CI 1.27-6.75)) followed by increased NT-proBNP (the most prominent indicator of CHF) with an OR of 2.73 (1.22-6.11) - both after adjustment for concurrent factors including weight gain (diff BMI T 3 -T 1 ) over the study period - the latter accounting for an OR of 1.41 (1.17-1.70)., Limitations: Findings are limited to people of Caucasian ancestry which prevents being generalized to other ethnicities. Although relying upon a prospective design, reverse causality cannot be excluded but is unlikely., Conclusions: In CAD patients, RDM is a significant predictor of heightened leptin -a finding opening room for a new pathway of the psychobiological underpinning of depression on CAD risk., Competing Interests: Declaration of competing interest All the authors declare no conflicts of interest. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. Christoph Herrmann-Lingen receives royalties from Hans Huber Publishers (Berne, Switzerland) for the German HADS version and for lecture honoraria from Pfizer and Novatis. Karl-Heinz Ladwig received lecture honoraria from Amgen, AstraZeneca, Bayer Vital and for advisory board activities for Idorsia (Switzerland). Furthermore, all authors have no competing interests to declare that are relevant to the content of this article., (Copyright © 2024. Published by Elsevier B.V.)

Background: Donation after circulatory death (DCD) hearts have to withstand ischemia/reperfusion injury that is partially driven by proinflammatory cytokines and decreases ventricular contractility. We hypothesize that cytokine adsorption during normothermic ex vivo blood perfusion of DCD hearts reduces the cytokine levels and improves ventricular contractility., Methods and Results: Porcine DCD hearts were maintained 4 hours by ex vivo blood perfusion with (DCD-BP CytoS , all groups: N=8) or without (DCD-BP) CytoSorb, followed by 2 hours reperfusion with fresh blood, including left ventricular functional analysis using a balloon catheter. In a control and a DCD group, hearts were evaluated after procurement. We determined lactate and cytokines after ex vivo blood perfusion and the myocardial and left anterior descending artery transcriptome using microarrays after reperfusion. In DCD-BP CytoS , the developed pressure (control: 124±7 mm Hg/s, DCD: 86±4 mm Hg/s, DCD-BP: 69±11 mm Hg/s, DCD-BP CytoS : 112±9 mm Hg/s; P <0.05) and maximal slope of pressure increment (control: 2010±39 mm Hg/s, DCD: 1219±164 mm Hg/s, DCD-BP: 964±163 mm Hg/s, DCD-BP CytoS : 1794±205 mm Hg/s; P <0.05) were higher compared with DCD-BP and DCD hearts. However, contractility decreased later during reperfusion without CytoSorb. After 4 hours, troponin, lactate (45±5% versus 69±9%, P <0.05), IL (interleukin)-1β, -1ra, and -8 were lower in DCD-BP CytoS hearts. In the myocardium of DCD-BP CytoS compared with DCD-BP hearts, inflammatory mediator receptor activity/binding pathways were enriched, and pathways for collagen-containing extracellular matrix and contractile fiber were underrepresented. In the left anterior descending artery of DCD-BP CytoS hearts, serine/threonine/tyrosine kinase activity and wound-healing pathways were enriched, and mitochondrial protein-containing complex and respiratome-associated pathways were underrepresented., Conclusions: CytoSorb during ex vivo blood perfusion enhances the maintenance of DCD hearts and is likely to improve graft function after transplantation.

Objective: A competency-based training of medical students that is adapted to the realities of care is required internationally and is being intended in Germany with the Master Plan for Medical Studies 2020. In order to test these competencies, the German National Institute for state examinations in Medicine, Pharmacy and Psychotherapy (IMPP) has developed a concept for the redesign of the final part of the medical licensing examination in Germany. It focuses on general and interprofessional healthcare in the examination with outpatients. The aim of this work is to assess the feasibility of the new final examination on the basis of pilot examinations in family practices and to derive further steps for the national implementation.Methods: Fourteen medical students in their internship year completed a full examination with patients aged 42 to 84 years. Examiners evaluated the examination performance using standardised evaluation forms. Feasibility was qualitatively assessed in terms of compliance with content and time limits, examination results, patient reflections, and implementation in the practice. Results: Students were able to complete all tasks within the given time frame. Based on the evaluation forms, the examiners assessed the performance of the students. Patients appreciated the structured course of the examination in the familiar location of their family practice. For the nationwide implementation of the examination, 2,500 examination practices are required for about 10,000 examinees per year. Four students can then be examined on two days per year in each practice.Conclusions: Oral-practical examinations with outpatients in general medical practices can be carried out successfully throughout the nation. An implementation of the examinations throughout Germany requires that medical studies are restructured and that this new curriculum is implemented as intended by the Master Plan for Medical Studies 2020. Furthermore, training and remuneration of examiners together with a legal framework for the new examination must be established.

Background: The aim of the project “Communicative Competences of Physicians” (BMG) was the pilot implementation of a longitudinal model communication curriculum. For the Mainz project location, the task was to integrate courses offered in the clinical subjects into a communication curriculum and to expand it longitudinally. In this process, which was both content-related and social, resistance and negative attitudes regarding the continued development of the communication curriculum became apparent at an early stage. How these manifested and which measures were taken to overcome them is laid out in this reflective field report.Method/approach: At the beginning of the project, a SWOT analysis was used to identify the strengths and weaknesses that the faculty presented for the continued development of the communication curriculum. This assessment by the project staff included, among other things, an evaluation of the motivation levels of the faculty’s lecturers and senior teaching staff. The subsequent specific, strategic and content-related planning of the further implementation steps in accordance with change-management concepts made it possible to take this aspect into account. For a more reliable assessment of the situation, the project was first presented to the faculty’s teaching committee. In this situation it was possible to identify individuals with favourable and unfavourable attitudes. With the insight that was gained, the following course of action was decided upon:Results/experiences: In one-on-one meetings, it was possible to first clarify which learning objectives of communication training are already covered in the respective subject and which expertise is therefore available. Furthermore, it was possible to clarify which areas that were still absent in the overall communication curriculum should be taught in this clinical subject in particular. It became possible to involve the lecturers in the development in the spirit of participatory design.In accordance with the action plan, offers to support the development and organisation of as-yet absent portions of the curriculum were presented to the affected departments.Discussion/conclusion: Resistance and negative attitudes often do not represent a rejection of communicative competences – they rather express that teachers fear they do not have the expertise and resources to teach them. With the selected approach of outreach, personal conversation, and action plan, it was possible to provide the individuals in question with goal-oriented support.

Background: The connections between climate, environment, and health as well as the concept of planetary health need to be integrated into the education of health professionals, as is increasingly demanded both internationally and nationally. Planetary health education should also aim to foster transformative action for climate protection and sustainability. In recent years, innovative teaching formats and objective catalogues have emerged internationally. In Germany, these topics have not yet been integrated into medical education everywhere. Since 2021, the Faculty of Medicine in Würzburg has offered an elective course as a first step of a longitudinal curriculum currently in development. The design, content, structure, and results of the evaluation are discussed in this article and will be used for quality assurance as well as the (further) development of this kind of educational interventions elsewhere., Methodology: We developed an elective course for students in their second to tenth semester with 30 onsite and online face-to-face teaching units and an additional project phase. We used an innovative mix of didactic methods with online simulations, training in climate-sensitive health counselling, and interdisciplinary climate communication as well as local sustainability projects in small groups, with a large amount of peer-teaching. A quantitative and qualitative evaluation was done immediately after the teaching units through feedback rounds and online with the evaluation software Evasys®, using closed and open-ended questions exploring learning progress (summer semester) and achievement of learning objectives (winter semester), motivation to participate, acceptance of teaching methods, attitudes, relevance, and further interest. The evaluation questionnaire was slightly modified for the winter semester., Results: In the summer and winter semester of 2021/2022, a total of 34 students (17 per semester) participated in the elective course; of these, 33 participated in the written evaluation. The evaluation in the summer semester (n = 17) showed a significant increase in self-assessed learning gain, the evaluation in the winter semester (n = 16) indicated a substantial achievement of learning objectives (mean = 3.96 of a 5-point Likert scale). Participants of both semesters (n = 33) regarded peer-teaching as a suitable method (mean = 4.2) and well-implemented (mean = 4.3). The topics were considered highly relevant but not adequately integrated into the main curriculum. There was a high level of interest in local impacts of climate and environmental changes and local measures for climate protection and sustainability. The specific projects in small groups may serve as examples of how transformative action can be promoted in education., Discussion: In the current dynamic development of the widely demanded integration of planetary health education into curricula, this elective course shows a possible and well-accepted example with a combination of various innovative didactic methods aiming at the levels of knowledge, attitudes, skills, and self-efficacy (or confidence) alike. The positive evaluation by the students and the high interest in local sustainability projects show the potential for future integration into the main curriculum., Conclusion: The elective can serve as an inspiration to tackle the challenge of taking the steps from knowledge to action in planetary health education. While an elective cannot replace the integration of all relevant aspects of planetary health into the main curriculum, it can serve as a space for piloting of future curricular educational interventions and offer opportunities for developing transformative competencies., (Copyright © 2024. Published by Elsevier GmbH.)

Background: Health professionals are increasingly called upon and willing to engage in planetary health care and management. However, so far, this topic is rarely covered in medical curricula. As the need for professional communication is particularly high in this subject area, this study aimed to evaluate whether the objective structured clinical examination (OSCE) could be used as an accompanying teaching tool., Methods: During the winter semester 2022/2023, 20 third- and fifth-year medical students voluntarily participated in a self-directed online course, three workshops, and a formal eight-station OSCE on planetary health care and management. Each examinee was also charged alternatingly as a shadower with the role of providing feedback. Experienced examiners rated students' performance using a scoring system supported by tablet computers. Examiners and shadowers provided timely feedback on candidates` performance in the OSCE. Immediately after the OSCE, students were asked about their experience using a nine-point Likert-scale survey and a videotaped group interview. Quantitative analysis included the presentation of the proportional distribution of student responses to the survey and of box plots showing percentages of maximum scores for the OSCE performance. The student group interview was analyzed qualitatively., Results: Depending on the sub-theme, 60% -100% of students rated the subject of planetary health as likely to be useful in their professional lives. Similar proportions (57%-100%) were in favour of integrating planetary health into required courses. Students perceived learning success from OSCE experience and feedback as higher compared to that from online courses and workshops. Even shadowers learned from observation and feedback discussions. Examiners assessed students' OSCE performance at a median of 80% (interquartile range: 83%-77%) of the maximum score., Conclusions: OSCE can be used as an accompanying teaching tool for advanced students on the topic of planetary health care and management. It supports learning outcomes, particularly in terms of communication skills to sensitise and empower dialogue partners, and to initiate adaptation steps at the level of individual patients and local communities., (© 2024. The Author(s).)

Neurological symptoms, including cognitive impairment and fatigue, can occur in both the acute infection phase of coronavirus disease 2019 (COVID-19) and at later stages, yet the mechanisms that contribute to this remain unclear. Here we profiled single-nucleus transcriptomes and proteomes of brainstem tissue from deceased individuals at various stages of COVID-19. We detected an inflammatory type I interferon response in acute COVID-19 cases, which resolves in the late disease phase. Integrating single-nucleus RNA sequencing and spatial transcriptomics, we could localize two patterns of reaction to severe systemic inflammation, one neuronal with a direct focus on cranial nerve nuclei and a separate diffuse pattern affecting the whole brainstem. The latter reflects a bystander effect of the respiratory infection that spreads throughout the vascular unit and alters the transcriptional state of mainly oligodendrocytes, microglia and astrocytes, while alterations of the brainstem nuclei could reflect the connection of the immune system and the central nervous system via, for example, the vagus nerve. Our results indicate that even without persistence of severe acute respiratory syndrome coronavirus 2 in the central nervous system, local immune reactions are prevailing, potentially causing functional disturbances that contribute to neurological complications of COVID-19., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: Communication and interprofessional collaboration with patients diagnosed with cancer is challenging. Structured communication training has not yet been integrated into postgraduate medical education. The aim of this study was to evaluate the feasibility of an 80-teaching unit interprofessional communication training (ICT), as recommended in the National Cancer Plan, at a clinic with a uro-oncological focus., Methods: A needs assessment was conducted using focus groups and individual interviews. Learning objectives were aligned with (inter)national learning objective catalogs. The ICT was developed using the six-step approach according to Kern and design-based research. Utilization and acceptance were evaluated. The ICT comprised six face-to-face workshops (50 teaching units) and team supervision sessions (10 teaching units). Six defined settings were identified for the individual workplace-based training (20 teaching units): Ward rounds, handover, reporting of medical findings, admission and discharge interviews, and a freely choosable setting., Results: Physician participation rates in the workshops were 83.0% and nursing participation rates were 58.3%. Utilization of the workplace-based training was 97%. The physicians evaluated the ICT very positively. All participants felt better prepared for discussions with patients and relatives. For continuity, physicians were trained as mentors., Conclusion: The implementation of an ICT with 80 teaching units is successfully feasible in a urological clinic and leads to a sustainable improvement of the communication culture, among other things through mentor training., (© 2022. The Author(s).)

Background: Over multiple years, the didactic concept of „peer-assisted learning“ (PAL) has proved to be valuable for medical education. Particularly in the field of the nowadays widely established Skills-Labs, the assignment of student tutors is both popular and effective. The aim of the underlying study is to assess the current status of PAL programs within German medical faculties’ Skills-Labs regarding their distribution, extent, structure and content based on a nation-wide survey.Methods: All 36 medical faculties in Germany were contacted and asked for their participation (via telephone or in written form) in the survey encompassing 16 central questions as to the structure of established PAL programs. Data obtained were subject to quantitative and qualitative analysis.Results: 35 of 36 (97.2%) medical faculties participated in the survey. A PAL program was shown to be established at 33 (91.7%) faculties. However, the results show distinct differences between different faculties with respect to extent and content of the PAL programs.Conclusions: Among German medical Skills-Labs, PAL has been established almost ubiquitously. Further studies on the conception and standardization of training concepts appear to be pivotal for the advancement of PAL in the context of Skills-Labs.

Aim: To do justice to the need for planetary health in medical education, these are the aims of the online elective course "Planetary Health in Medical Education" (ME elective):1. Enable students to plan and realize their own course sessions on planetary health;2. Encourage communication among university medical faculties regarding planetary health in medical education;3. Reinforce competency in digital teaching and amplify the expert role as multiplicator among students pursuing a Master's degree in Medicinal Education (MME)., Method: The development of the ME elective followed Kern's six-step approach to curriculum development by means of cooperation between the German Medical Students' Association (Bundesvertretung der Medizinstudierenden in Deutschland, abbreviated as bvmd), and the MME study program. Based on general and specific needs analyses, core learning objectives regarding planetary health, medical education and digital education were identified in the National Catalogue of Learning Objectives in Undergraduate Medical Education (NKLM) and the MME study program and relevant teaching methods were selected., Results: The ME elective, consisting of two contact hours per week per semester, was established at 13 medical schools as a four-phase course:1. Introduction to medical education using examples from planetary health;2. Lesson planning on a topic in planetary health under the supervision of MME students;3. Course sessions held by the undergraduate students; and4. Networking with the MME study program through participation in digital courses on planetary health and the pilot OSCE on planetary health.A total of 24 students attended the pilot in the 2022 summer semester., Conclusion: The topic of planetary health combines interests that span many subjects and semester levels. As a collaborative, interdisciplinary and interprofessional subject, it lends itself to training students in a trans-institutional elective course to become multiplicators., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2023 Flägel et al.)

General practitioners play a major role in the health care of the population. Only a small proportion of patients receives care from specialised consultants, in a hospital or in a university hospital. Most of the patients consult a general practitioner. The strengthening of general practice that is called for in the Master Plan for Medical Studies 2020 in new state examination formats, for instance, means that this central position in patient care will be reflected in studies and examinations in the future. The general medical setting is subject to a specific background with unselected patients and a hermeneutic understanding of cases. The format of the new final examination promotes general medical and interdisciplinary competencies in medical interviewing, physical examination, dealing with diseases that can be treated on an outpatient basis, prevention, and the application of general medical guidelines of ethics and law. The standardised oral-practical examination has newly been designed by the Institute for Medical and Pharmaceutical Examination Questions (IMPP). It includes real patients in an outpatient setting. In eight steps, it integrates communicative and technical examination aspects. Two trained examiners will observe and assess the performance of graduates using standardised evaluation forms. The new examination format was developed in 2019 by the IMPP and faculty from various medical schools, was tested in five general medical teaching practices, revised, and then piloted in fourteen examinations. Standardised specifications for the examination process, spatial equipment, and examiner training were developed by IMPP. With approximately 10,000 examinees per year and two students per examination day, a total of 5,000 examination days will be required in general practices. The expertise of the German College of General Practicioners and Family Physicians (DEGAM), the Society of University Teachers of General Medicine (GHA), and the university locations, together with the great potential as the largest specialist group in Germany suggest that the goal of recruiting and motivation of practices appears achievable. With regard to funding, political decisions are necessary. In an increasingly complex care system, the redesign of the oral-practical examination in the outpatient setting contributes to strengthening interdisciplinary and multi-professional cooperation., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)