The European Grief Conference, Copenhagen 2022: An effort to unite the field of bereavement care in Europe

Bereavement care in Europe varies in quality and availability. Through greater collaboration across Europe, there could potentially be an opportunity to improve care. This article discusses the inaugural European Grief Conference held in Denmark in 2022: "Bereavement and Grief in Europe - Emerging Perspectives & Collaborations". The conference was structured around a 4-tiered public health model of bereavement care needs. It included practice, research, policy, and educational perspectives. A total of 250 people from 27 different countries participated. To determine if the conference had appealed to a broad European audience of grief professionals and to assess how the conference was received by participants, we examined registration/submission data, the results of a one-word real-time feedback exercise, and the answers to an online satisfaction survey. The results indicated wide interest in greater information sharing and collaboration across Europe among bereavement care, research, and education professionals.

Impact of individualized treatment on recovery from fatigue and return to work in survivors of advanced-stage Hodgkin's lymphoma: results from the randomized international GHSG HD18 trial

BACKGROUND

Persisting cancer-related fatigue impairs health-related quality of life (HRQoL) and social reintegration in patients with Hodgkin's lymphoma (HL). The GHSG HD18 trial established treatment de-escalation for advanced-stage HL guided by positron emission tomography after two cycles (PET-2) as new standard. Here, we investigate the impact of treatment de-escalation on long-term HRQoL, time to recovery from fatigue (TTR-F), and time to return to work (TTR-W).

PATIENTS AND METHODS

Patients received European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and life situation questionnaires at baseline, interim, end of treatment, and yearly follow-up. TTR-F was defined as time from the end of chemotherapy until the first fatigue score <30. TTR-W was analyzed in previously working or studying patients and measured from the end of treatment until the first documented work or education. We compared duration of treatment on TTR-F and TTR-W using Cox proportional hazards regression adjusted for confounding variables.

RESULTS

HRQoL questionnaires at baseline were available in 1632 (83.9%) of all randomized patients. Overall, higher baseline fatigue and age were significantly associated with longer TTR-F and TTR-W and male sex with shorter TTR-W. Treatment reduction from eight to four chemotherapy cycles led to a significantly shorter TTR-F [hazard ratio (HR) 1.41, P = 0.008] and descriptively shorter TTR-W (HR 1.24, P = 0.084) in PET-2-negative patients. Reduction from six to four cycles led to non-significant but plausible intermediate accelerations. The addition of rituximab caused significantly slower TTR-F (HR 0.70, P = 0.0163) and TTR-W (HR 0.64, P = 0.0017) in PET-2-positive patients. HRQoL at baseline and age were the main determinants of 2-year HRQoL.

CONCLUSIONS

Individualized first-line treatment in patients with advanced-stage HL considerably shortens TTR-F and TTR-W in PET-2-negative patients. Our results support the use of response-adapted shortened treatment duration for patients with HL.

Design strategies to influence health behaviour and mental wellbeing in the urban setting

The design of objects, spaces and systems can have a profound influence on the behaviours as well as emotional and cognitive states of the people confronted with it. With regards to health behaviour, elaborating on Schwarzer's HAPA model (1992), the Design Model for Health Behaviour Change - DMHBC (Rehn, 2018) proposes the use of the built environment to act as situative barriers or opportunities to change health behaviours and overall health promoting mindsets. Regarding urban space and mental health, most environmental stimuli and related behavioural patterns focus on consumption (e.g. retail stores) or daily routines (e.g. commuting). Using objects such as specifically designed furniture, installations and other elements to act as perceived affordances and stimuli can affect both cognitive-emotional states as well as specific behavioural responses. For instance, based on the research on mindfulness, drawing people's attention towards their own bodily sensations (e.g. breath) by playful interactive installations or information signs can increase feelings of calm, appreciation and contentment. The same applies to design interventions that guide one's view towards otherwise overlooked urban features (e.g. natural scenery). While mindfulness and relaxation are powerful techniques for increasing mental health, many other approaches (such as physical activity, social interactions etc.) can be found to have similar benefits. In fact, the orchestrated combination of various forms of stimuli might prove to be more effective than the sum of the individual interventions as they create a subsequent chain of stimuli that form a coherent experience. This approach poses particular potentials to foster mental health in vulnerable groups that usually suffer most from urban environmental risk factors. Thus, providing public and open access stimuli and affordances in this way, can have a significant effect on overall urban public health and reduce social inequalities at the same time.

Risk factors and potentials for fostering mental health and wellbeing in urban space

People shape their physical environments - and vice versa. As such, cities provide both resources (e.g., job opportunities, cultural diversity) as well as stressors (e.g., crowding, noise pollution) to their residents and visitors. In this context, numerous studies illustrate a considerable influence of the built environment (townscape, architecture) on health and well-being of interacting people. This impact ranges from physical aspects (e.g., traffic safety, particulate matter) to psychological processes (e.g., stress, loneliness) and behavioral aspects (e.g., physical activity, social behavior). At the same time, phenomena such as homelessness, crime, or mental disorders (e.g., substance addictions, schizophrenia) occur more frequently in cities compared to rural areas, illustrating causal as well as selective processes in the relation of urban environment and mental health. Increasing overall incidences in mental disorders (especially anxiety disorders and depression), the short-term shortage of psychotherapeutic care as well as the long-term economic burden on the health care system ask for a twofold strategy in public health: a) an extension of preventive measures with low threshold, i.e., accessible by large shares of the population, b) an extension of mental health literacy, which will empower the population to be attentive to mental health issues in themselves and others and which in turn can help to reduce stigmatization. While urban green and blue spaces have been researched in terms of restorative environments - allowing to regenerate resources consumed during the day - the built environment is still a resource for this strategy that has received insufficient attention to date. Utilizing the urban built environment not only as restorative but also informative and engaging environments thus affords an opportunity to address and potentially foster mental health and mental health literacy in citizens across socioeconomic backgrounds.

Potentials of participatory approaches for urban mental health

Aspects of mental health, society, space and environment share entangled relations being studied in health geography. Recreational spaces as well as places that are commonly perceived as strenuous, unsafe, or highly stressful are unevenly distributed within urban areas, which is also associated with spatial differences in mental disorders. Spaces in general represent social constructions that reflect power inequalities; they are filled with subjective emotional resonances and sometimes visualize stigmatization of specific groups. As such, the interplay of socio-demographic factors, socio-economic factors and built environment is complex. To capture these entanglements represented in heterogeneous user groups, participatory approaches promise valuable insights. Yet, despite their great potential for fostering mental health in urban space, participatory approaches are still less common in health geography. Therefore, critical voices question whether the limitations of marginalized groups have been sufficiently considered in this field of study so far. Similar challenges arise in urban planning processes: Specific (vulnerable) groups such as children, women, foreign residents, and people with disabilities or elderly people are insufficiently included in planning processes, leading to an underrepresentation of their needs in the resulting environments. To tackle this shortcoming, the approach of co-creation offers a process in which participants jointly develop a solution without being the object of research or interview partners, but creators. Using rather practical or creative (e.g., joint mapping of the built environment, photo-elicitation) than discursive techniques allows contributions from population groups otherwise often excluded from planning processes. Despite certain limitations, participatory approaches promise the possibility to develop appropriate and just solutions in urban mental health.

Chronic ozone exposure preferentially modifies root rather than foliar metabolism of date palm (Phoenix dactylifera) saplings

In their natural environment, date palms are exposed to chronic atmospheric ozone (O₃) concentrations from local and remote sources. In order to elucidate the consequences of this exposure, date palm saplings were treated with ambient, 1.5 and 2.0 times ambient O₃ for three months in a free-air controlled exposure facility. Chronic O₃ exposure reduced carbohydrate contents in leaves and roots, but this effect was much stronger in roots. Still, sucrose contents of both organs were maintained at elevated O₃, though at different steady states. Reduced availability of carbohydrate for the Tricarboxylic acid cycle (TCA cycle) may be responsible for the observed reduced foliar contents of several amino acids, whereas malic acid accumulation in the roots indicates a reduced use of TCA cycle intermediates. Carbohydrate deficiency in roots, but not in leaves caused oxidative stress upon chronic O₃ exposure, as indicated by enhanced malonedialdehyde, H₂O₂ and oxidized glutathione contents despite elevated glutathione reductase activity. Reduced levels of phenolics and flavonoids in the roots resulted from decreased production and, therefore, do not indicate oxidative stress compensation by secondary compounds. These results show that roots of date palms are highly susceptible to chronic O₃ exposure as a consequence of carbohydrate deficiency.

[Effect of a multimodal pain management protocol and age on wound healing after thermal disbudding of female German Holstein calves]

INTRODUCTION

Hot-iron disbudding of calves is a stressful and painful procedure and leaves a burn wound. Pain management procedures and the effects of hot-iron disbudding on biochemical markers of pain perception and stress response have been widely investigated in recent years. The aim of this study was to investigate the potential effects of pain management and age of the calf on the healing of burn wounds caused by disbudding. 327 healthy female German Holstein calves were included in this randomised, triple-blinded, prospective study. Calves were either disbudded at the age of four to 10 or 15 to 28 days using a gas-powered hot iron. Each calf was randomly allocated to one of nine possible treatment groups (BG). All calves received either the active ingredients to be tested (xylazine hydrochloride with 0.2 or 0.05 mg / kg body mass (BM) intramuscular for sedation, procaine hydrochloride (2 %) each 8 ml locally on both sides subcutaneously (SC) to the cornual nerves, meloxicam with 0,5 mg / kg BM SC for anti-inflammatory purposes) or an identical amount of saline solution (placebo). Calves in the group `thermE` and `ScheinE` received only placebo. In group `ScheinE` disbudding was simulated and in `thermE` it was carried out. The calves were clinically monitored starting one day before and ending 28 days after the procedure and the burn wounds were assessed. Both the rectal temperature and parameters of wound healing changed significantly during the study period and had characteristic profiles over time. Wound healing was not influenced by the different analgesic protocols, indicating that a multimodal analgesia does not pose a risk for wound healing after thermal disbudding. There were no observed differences between the age groups. The results of this study show, that disbudding of young calves and a multimodal pain management protocol does not affect wound healing in calves.

[Cortisol concentrations in sheep before, during and after sham foot trimming on a tilt table - the suitability of different matrices]

INTRODUCTION

Matrices that can be collected non-invasively for quantification of a stress response in sheep have received little attention in the veterinary literature. This study examines the suitability of blood, tears and saliva for determining a stress response in sheep undergoing sham foot trimming on a tilt table. The cortisol concentration of blood, tears and saliva and the concentration of cortisol metabolites in faeces were measured in 13 healthy Meat Merino ewes once a day for six days. Sham foot trimming on a tilt table was used as the stressor and was done during a one-hour period on day 4; cortisol concentrations of blood and tears were measured at 0, 10, 20, 30, 40 and 60 minutes. Cortisol concentrations of blood (maximum at 30 minutes) and tears (maximum at 40 minutes) increased during the procedure and then decreased. There were significant correlations between cortisol concentrations of blood and tears (p = 0,04) during sham foot trimming (area under the curve, 0 to 60 minutes). Over the entire 6-day study period, significant correlations were seen between the cortisol concentrations of blood and tears (r = 0,55; p.

On the psychological importance of control and valorisation in psychiatric environments

When people suffering from severe mental illnesses are treated in psychiatric facilities, there appear conflicting priorities between security and individual control that are often skewed towards security. As a result, patients admitted to highly institutionalised psychiatric wards do not only suffer from mental illness but also from loss of control as a basic human need (Grawe, 2000). Through this loss of control (e.g., not being able to choose where to go), people become especially dependent on their immediate social and spatial surroundings. From a psychological point of view, the concept of control reflects in concepts such as self-efficacy (Bandura, 1977), internal vs. external locus of control (Rotter, 1966), or environmental mastery (Ryff, 1989), all pointing to a beneficial influence on well-being and health. Yet, depending on their current situation, psychiatric patients may also feel overwhelmed by an excess of choices. Increasing patients' sense of control by offering them small choices during their stay at a psychiatric environment, however, might increase well-being (cf. Langer & Rodin, 1968). This possibility of control has the potential to also activate the feeling of valorisation in patients: As a positive fundamental attitude towards another person, implying appreciation and respect, valorisation poses an important element of psychotherapy (e.g., Rogers, 1951). Especially as people with psychiatric disorders are still stereotyped and stigmatized (e.g., as a homogenous group of “the mentally ill”), actively searching for new ways to foster valorisation in psychiatric environments may further contribute to patients' well-being and individualisation. Transferring the concept of valorisation to physical objects as primes affords an opportunity to extend feeling appreciated beyond immediate social interaction.

[Thermographic monitoring of skin surface temperature associated with hot-iron disbudding in calves]

INTRODUCTION

The goal of this study was to determine the skin surface temperatures of the head using thermography in 28 German Holstein heifer calves at the time of hot iron disbudding. Calves were divided into group 1 (hot-iron disbudding, n = 14) and 2 (sham disbudding, n = 14). Thermographic measurements were made at eight locations of the head (area surrounding both horn buds, both horn buds, muzzle, mucous membranes of the muzzle, both eyes) at nine time points (- 60 min (basal value), time of disbudding, 5, 30, 60, 90, 120, 240 and 480 min after disbudding) using a high-end thermographic camera (ThermoPro TP8, Firma DIAS Infrared GmbH). The rectal temperature was measured 60 min before and 5, 240 and 480 min after disbudding. The statistical software SAS version 9.4 was used for analysis. Skin surface temperatures and rectal temperature correlated at several locations (rp ≥ 0.45; p ≤ 0.05). The maximum temperature (approx. 67 ºC) was measured at the horn buds immediately after the hot-iron procedure. By five and 30 min after hot-iron disbudding, the temperature of the horn buds had decreased by up to 50%, whereas the temperatures at the other locations had increased significantly (p.

Cognitive and emotional empathy in individuals at clinical high risk of psychosis

BACKGROUND

Impairments of social cognition are considered core features of schizophrenia and are established predictors of social functioning. However, affective aspects of social cognition including empathy have far less been studied than its cognitive dimensions. The role of empathy in the development of schizophrenia remains largely elusive.

METHODS

Emotional and cognitive empathy were investigated in large sample of 120 individuals at Clinical High Risk of Psychosis (CHR-P) and compared with 50 patients with schizophrenia and 50 healthy controls. A behavioral empathy assessment, the Multifaceted Empathy Test, was implemented, and associations of empathy with cognition, social functioning, and symptoms were determined.

RESULTS

Our findings demonstrated significant reductions of emotional empathy in individuals at CHR-P, while cognitive empathy appeared intact. Only individuals with schizophrenia showed significantly reduced scores of cognitive empathy compared to healthy controls and individuals at CHR-P. Individuals at CHR-P were characterized by significantly lower scores of emotional empathy and unspecific arousal for both positive and negative affective valences compared to matched healthy controls and patients with schizophrenia. Results also indicated a correlation of lower scores of emotional empathy and arousal with higher scores of prodromal symptoms.

CONCLUSION

Findings suggest that the tendency to 'feel with' an interaction partner is reduced in individuals at CHR-P. Altered emotional reactivity may represent an additional, early vulnerability marker, even if cognitive mentalizing is grossly unimpaired in the prodromal stage. Different mechanisms might contribute to reductions of cognitive and emotional empathy in different stages of non-affective psychotic disorders and should be further explored.

Thrombosis as a treatment complication in Hodgkin lymphoma patients: a comprehensive analysis of three prospective randomized German Hodgkin Study Group (GHSG) trials

BACKGROUND

The prognosis of Hodgkin lymphoma (HL) is excellent rendering research into treatment complications highly important. An important complication of cancer and its treatment is thrombosis. Thrombotic events are regularly observed in HL patients but precise information on incidence and risk factors is lacking and the value of prophylactic anticoagulation unclear.

PATIENTS AND METHODS

Thus, we comprehensively studied thrombotic events in 5773 patients from the German Hodgkin Study Group (GHSG) HD13-15 trials in early-favorable, intermediate and advanced HL. We estimated the incidence of and identified risk factors for thrombotic events. Additionally, we provide detailed data on the time course and characteristics of thrombotic events.

RESULTS

A total of 193 thrombotic events occurred for an incidence of 3.3%. Out of these, 175 (90.7%) were venous thromboses, 3 (1.5%) newly emerging post-thrombotic syndromes and 15 (7.8%) arterial thromboses. There were 11 (0.7%) events in early-favorable, 27 (1.3%) in early-unfavorable and 155 (7.3%) in advanced patients, the latter incidence being significantly higher (P < 0.001). The most common locations were deep vein thrombosis of the arm (46.3%) and leg (24.6%). Most venous thrombotic events occurred during chemotherapy (78.9%). We observed 59 (30.6%) catheter-associated events and a descriptively increased risk of venous thrombotic events in patients with oral contraception use during treatment (6.8% versus 3.9%). In advanced HL, the incidence of venous thrombotic events was increased upon treatment with BEACOPP-14 (9.4%, P = 0.0079) compared with 5.1% with 6×BEACOPPesc and 5.7% with 8×BEACOPPesc. Among commonly applied risk factors, including the Khorana score, only age and smoking were prognostic.

CONCLUSIONS

The incidence of thrombotic events in advanced stage HL is comparable to other high-risk cancer patients, especially if treated with dose-dense regimens. Additional risk factors are higher age and smoking. Selected HL patients could benefit from prophylactic anticoagulation, however, further interventional studies are needed before general recommendations can be made.

[Patient safety: current problems and challenges]

Two decades after "To Err Is Human", the groundbreaking report published by the Institute of Medicine in the US, the German Patient Safety Alliance (Aktionsbündnis Patientensicherheit, APS) has published the "White Paper on Patient Safety". Based on the throughput model of health services research, the paper proposes a revised concept and definition of patient safety that focuses not only on the presence of adverse events (AE), but also on the ability of organizations and systems to adequately prioritize patient safety and implement this sustainably with improvement processes. Accordingly, a concept for measuring patient safety will be developed that no longer only quantitatively records AE, but also focuses on patient safety indicators that describe innovation competence. The epidemiological data will be updated; the rates of approximately 2-4% avoidable AE and 0.1% avoidable deaths among hospital patients appear to be highly conservative estimates. Data from non-representative sources, such as on legal procedures, underestimate frequencies by a factor of 30 ("litigation gap"). The most important obstacles to improving the situation are analyzed and give rise to the recommendation that, instead of one-point interventions (e.g., of a technical nature, such as IT-supported procedures), complex multicomponent interventions should increasingly be used in Germany, combining interventions with different approaches. Interventions at team level and with regard to management structures are focused on here.

[Thermographic examination of head surface temperatures of calves under field conditions]

INTRODUCTION

Thermographic examination of 157 German Holstein heifer calves was performed to investigate the feasibility of this technique for on-farm recording of surface temperature of the head and to examine potential factors that affect the recordings. Baseline values were obtained from six defined locations on the head including both eyes, both horn buds, the muzzle and the mucous membrane of the muzzle using a high-end thermographic camera (ThermoPro TP8, Firma DIAS Infrared GmbH). Evaluation of the influence of various factors on thermographic measurements showed that ambient temperature had the largest effect on surface temperature of the head (regression coefficient, 0.10 to 0.32, p ≤ 0.01) whereas humidity had no effect (in t-test p ≥ 0.33 over all locations). There was a no correlation between rectal temperature and surface temperature (rp ≤ 0.05). The surface temperature decreased with increasing age of the calves (regression coefficient, - 0.42 to - 0.14, p ≤ 0.01). The agreement between double readings made shortly after one another was excellent at all locations (r ≥ 0.95). The emission of infrared energy varied among different locations; the most infrared energy was emitted by the eyes and the least by the muzzle. Paired locations (eyes and horn buds) had symmetric emission patterns of infrared energy. Measuring the surface temperature of the head of calves in their normal barn environment using a standardised protocol was feasible and thus could potentially be used for monitoring calves under field conditions.