[Tandem Practices: Pediatric Consultation Hours in General Practitioners' Practices in Rural Areas in Germany - a Collaborative Project]

BACKGROUND

In Germany, patients under the age of 18 receive medical care from pediatricians. In sparsely populated regions, general practitioners often have to do the job of pediatricians and offer medical care to children, which in most cases is adequate. However, it does not meet the goal of demand planning namely, every patient should have equal access to care regardless of their place of residence. One option to help achieve this is the implementation of consultation hours with pediatricians in general practitioners' practices (tandem practices). The aim of this study was to investigate the feasibility and acceptance of this cooperation and whether this improved access to pediatric care.

METHODS

First, general practitioners willing to participate were identified, where the nearest pediatrician's practice was more than 20 kilometers away. The second step was to find suitable pediatricians willing to offer regular weekly pediatric consultations in the practice of a general practitioner. For the evaluation, various data collection methods were used: one-off parent questionnaires at the time of study inclusion, questionnaires filled out by the pediatricians for each consultation, and data from the practice information systems in the participating practices. The distance between the patients' place of residence and the next regular outpatient pediatrician's practice were calculated and compared to the distance to a tandem practice.

RESULTS

In April 2019, in two practices tandem consultation hours were implemented. During 12 months, 192 children and adolescents (50.2% female) were included. They attended the consultation hours a total of 387 times. Of 482 reasons given in the doctor's questionnaire, 36.9% were vaccinations (n=178), 14.9% were preventive examinations (n=72), the most frequently coded ICD-10 diagnostic groups were diseases of the respiratory system (J00-J99: 8.5%, n=41) and mental/behavioral disorders (F00-F99: 7.7%, n=37). Before the project, the patients had an average of 20.2 kilometers (min 0.3; max 34.8) to the next regular outpatient pediatrician's practice; within the project, the distance decreased to 5.1 kilometers (min 0.1; max 26.7).

CONCLUSION

All doctors involved wanted to continue the tandem consultations after the end of the test phase. The project results showed the feasibility and a high level of acceptance of tandem practices, both for the doctors involved and for the patients and their parents.

Effects of Closure of the Paediatric Department of a District Hospital on Regional Care: Analysis of Patient Flows

BACKGROUND

The consequences of economization and staff shortage in the German health care system strongly affect paediatric care structures, especially in rural regions. It is not known how closures of paediatric departments influence patient flows of surrounding hospitals. Here, we investigate the quantitative effects of closure of the paediatric department of a district hospital and the subsequent opening of an alternative inpatient service on the utilisation of inpatient and outpatient care services of the two neighboring hospitals and the emergency services of the region.

METHODOLOGY

In the observation period from 2015 to 2019, patient-related data from the three hospitals in the study region as well as data from the rescue service were evaluated.

RESULTS

In the year after the paediatric department of the district hospital was closed in 2016, the total number of inpatient cases in the region decreased by 33% (2015: n=1,787; 2016: n=1,193) and then decreased by an additional 11% (2019: n=1,005). The number of outpatient cases decreased by further 8% (2015: n=6,250; 2019: n=5,770). In the last observation year, emergency services were used much more frequently than in the year before the closure (2015: n=398; 2019: n=572). This means an increase of 44%.

CONCLUSION

After the closure of the paediatric department, the total number of inpatient cases in the region fell sharply. However, actual gaps in care apparently did not arise. Before closing, the consequences for the surrounding hospitals should be assessed more precisely. Real gaps in care must be counteracted, e. g. through alternative outpatient services.

[Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians]

BACKGROUND

Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9).

METHODS

Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example.

RESULTS

In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions.

CONCLUSION

The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

Mental health-related telemedicine interventions for pregnant women and new mothers: a systematic literature review

BACKGROUND

Pregnancy and the postpartum period are times when women are at increased risk for depression and mental problems. This may also negatively affect the foetus. Thus, there is a need for interventions with low-threshold access and care. Telemedicine interventions are a promising approach to address these issues. This systematic literature review examined the efficacy of telemedicine interventions for pregnant women and/or new mothers to address mental health-related outcomes. The primary objective was to analyse whether telemedicine interventions can reduce mental health problems in pregnant women and new mothers. The secondary aim was to clarify the impact of type of interventions, their frequency and their targets.

METHODS

Inclusion criteria: randomized controlled trials, with participants being pregnant women and/or new mothers (with infants up to twelve months), involving telemedicine interventions of any kind (e.g. websites, apps, chats, telephone), and addressing any mental health-related outcomes like depression, postnatal depression, anxiety, stress and others. Search terms were pregnant women, new mothers, telemedicine, RCT (randomised controlled trials), mental stress as well as numerous synonyms including medical subject headings. The literature search was conducted within the databases PubMed, Cochrane Library, Web of Science and PsycINFO. Screening, inclusion of records and data extraction were performed by two researchers according to the PRISMA guidelines, using the online tool CADIMA.

RESULTS

Forty four articles were included. A majority (62%) reported significantly improved mental health-related outcomes for participants receiving telemedicine interventions compared to control. In particular (internet-delivered) Cognitive Behavioural Therapy was successful for depression and stress, and peer support improved outcomes for postnatal depression and anxiety. Interventions with preventive approaches and interventions aimed at symptom reduction were largely successful. For the most part there was no significant improvement in the symptoms of anxiety.

CONCLUSION

Telemedicine interventions evaluated within RCTs were mostly successful. However, they need to be designed to specifically target a certain mental health issue because there is no one-size-fits-all approach. Further research should focus on which specific interventions are appropriate for which mental health outcomes in terms of intervention delivery modes, content, target approaches, etc. Further investigation is needed, in particular with regard to anxiety.

Evaluation of a Health Information Exchange System for Geriatric Health Care in Rural Areas: Development and Technical Acceptance Study

Background

Patients of geriatrics are often treated by several health care providers at the same time. The spatial, informational, and organizational separation of these health care providers can hinder the effective treatment of these patients.

Objective

This study aimed to develop a regional health information exchange (HIE) system to improve HIE in geriatric treatment. This study also evaluated the usability of the regional HIE system and sought to identify barriers to and facilitators of its implementation.

Methods

The development of the regional HIE system followed the community-based participatory research approach. The primary outcomes were the usability of the regional HIE system, expected implementation barriers and facilitators, and the quality of the developmental process. Data were collected and analyzed using a mixed methods approach.

Results

A total of 3 focus regions were identified, 22 geriatric health care providers participated in the development of the regional HIE system, and 11 workshops were conducted between October 2019 and September 2020. In total, 12 participants responded to a questionnaire. The main results were that the regional HIE system should support the exchange of assessments, diagnoses, medication, assistive device supply, and social information. The regional HIE system was expected to be able to improve the quality and continuity of care. In total, 5 adoption facilitators were identified. The main points were adaptability of the regional HIE system to local needs, availability to different patient groups and treatment documents, web-based design, trust among the users, and computer literacy. A total of 13 barriers to adoption were identified. The main expected barriers to implementation were lack of resources, interoperability issues, computer illiteracy, lack of trust, privacy concerns, and ease-of-use issues.

Conclusions

Participating health care professionals shared similar motivations for developing the regional HIE system, including improved quality of care, reduction of unnecessary examinations, and more effective health care provision. An overly complicated registration process for health care professionals and the patients’ free choice of their health care providers hinder the effectiveness of the regional HIE system, resulting in incomplete patient health information. However, the web-based design of the system bridges interoperability problems that exist owing to the different technical and organizational structures of the health care facilities involved. The regional HIE system is better accepted by health care professionals who are already engaged in an interdisciplinary, geriatric-focused network. This might indicate that pre-existing cross-organizational structures and processes are prerequisites for using HIE systems. The participatory design supports the development of technologies that are adaptable to regional needs. Health care providers are interested in participating in the development of an HIE system, but they often lack the required time, knowledge, and resources.

Optimization of imaging conditions for composition determination by annular dark field STEM

Quantitative scanning transmission electron microscopy (STEM) allows composition determination for nanomaterials at an atomic scale. To improve the accuracy of the results obtained, optimized imaging parameters should be chosen for annular dark field imaging. In a simulation study, we investigate the influence of imaging parameters on the accuracy of the composition determination with the example of ternary III-V semiconductors. It is shown that inner and outer detector angles and semi-convergence angle can be optimized, also in dependence on specimen thickness. Both, a minimum sampling of the image and a minimum electron dose are required. These findings are applied experimentally by using a fast pixelated detector to allow free choice of detector angles.

Cis-regulatory evolution spotlights species differences in the adaptive potential of gene expression plasticity

Phenotypic plasticity is the variation in phenotype that a single genotype can produce in different environments and, as such, is an important component of individual fitness. However, whether the effect of new mutations, and hence evolution, depends on the direction of plasticity remains controversial. Here, we identify the cis-acting modifications that have reshaped gene expression in response to dehydration stress in three Arabidopsis species. Our study shows that the direction of effects of most cis-regulatory variants differentiating the response between A. thaliana and the sister species A. lyrata and A. halleri depends on the direction of pre-existing plasticity in gene expression. A comparison of the rate of cis-acting variant accumulation in each lineage indicates that the selective forces driving adaptive evolution in gene expression favors regulatory changes that magnify the stress response in A. lyrata. The evolutionary constraints measured on the amino-acid sequence of these genes support this interpretation. In contrast, regulatory changes that mitigate the plastic response to stress evolved more frequently in A. halleri. Our results demonstrate that pre-existing plasticity may be a stepping stone for adaptation, but its selective remodeling differs between lineages.

Risk of chronic kidney disease in people living with HIV by tenofovir disoproxil fumarate (TDF) use and baseline D:A:D chronic kidney disease risk score

OBJECTIVES

To assess the risk of chronic kidney disease (CKD) associated with tenofovir disoproxil fumarate (TDF) use by baseline D:A:D CKD risk score.

METHODS

Adult antiretroviral therapy (ART)-naïve people living with HIV (PLWH) initiating treatment, with estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m2 , were identified in the OPERA cohort. CKD was defined as two or more consecutive eGFR < 60 mL/min/1.73 m2 , > 90 days apart. Associations between TDF use, baseline D:A:D CKD risk and incident CKD were assessed with incidence rates (IRs; Poisson regression) and adjusted pooled logistic regression. The impact of pharmacoenhancers on the observed association between TDF and CKD was also evaluated.

RESULTS

Of 9802 PLWH included, 6222 initiated TDF and 3580 did not (76% and 79% low D:A:D CKD risk, respectively). Overall, 125 CKD events occurred over 24 382 person-years of follow-up. Within strata of D:A:D CKD risk score, IRs were similar across TDF exposure, with high baseline CKD risk associated with highest incidence. Compared with the low-risk group without TDF, there was no statistical difference in odds of incident CKD in the low-risk group with TDF (adjusted odds ratio = 0.55, 95% confidence interval: 0.19-1.54). Odds of incident CKD did not differ statistically significantly by pharmacoenhancer exposure, with or without TDF.

CONCLUSIONS

In this large cohort of ART-naïve PLWH, incident CKD following ART initiation was infrequent and strongly associated with baseline CKD risk. TDF-containing regimens did not increase the odds of CKD in those with a low baseline D:A:D CKD risk, the largest group of ART-naïve PLWH, and may remain a viable treatment option in appropriate settings.

Task-Sharing Between Pediatricians and Non-Physician Healthcare Professionals in Outpatient Child Health Care in Germany: Assessment of Need and Acceptance for Concept Development

Although pediatricians in Germany work as general practitioners for children, they are planned and trained as medical specialists. In consequence, distances between practices and residences of patients can be very large. The implementation of task-sharing models is a promising option to sustain pediatric outpatient care in rural regions. In this study we assessed the need for and acceptance of delegation of tasks in outpatient pediatric healthcare to non-physician healthcare professionals and developed a task-sharing concept. A standardized questionnaire was developed and addressed a wide range of healthcare professionals. On the basis of the results of the questionnaire and a subsequent workshop involving representatives of the various fields of pediatric care a delegation-concept was developed. A total of 206 questionnaires were answered (response rate: 17%). About 70% of the respondents (n = 145) agreed with the delegation of counseling on prevention, 66% (n = 135) with the delegation of tasks in the transition process into adult medicine. All proposed tasks were conceivable for at least a third of the respondents. Mostly, pediatricians could envision delegation more than the non-physician health care professionals. A three-dimension-delegation-concept was developed: which tasks can be delegated to whom in which setting. Basically, if nurses or medical practice assistants are adequately qualified, all tasks can be delegated to both. The delegation was approved by most of the respondents. Implementation of task-sharing provides a new option to support pediatricians and create better access to outpatient pediatric health care in rural regions. The next step should be the implementation of the delegation concept in pilot projects.

[Attitude of Parents Towards Pediatric Care and Interprofessional Task-Sharing in Regions Distant Versus Close to Care Facilities: Results of a Standardized Survey]

AIM

The aim of the study was to determine parents' views in regions distant to medical care (dtmc) vs. close to medical care (ctmc) on (1) the assessment of situation in pediatric care and (2) on delegation of medical tasks to qualified members of non-medical health professions.

METHOD

A self-developed questionnaire was sent to parents in kindergartens, who are either nearby (=close to the medical care provider, ctmc) or more than 20 km away from the nearest pediatric practice and a pediatrics department (=distant to the medical care provider, dtmc). The questions covered socio-demographic, pediatric-care-related aspects and attitudes to delegation of defined medical tasks to non-medical health professionals.

RESULTS

Of the n=407 evaluable questionnaires (response rate: 18%), 49% came from parents in ctmc-kindergartens and 51% from parents in dtmc-kindergartens. Significant differences were found in the number of children living in the household (ctmc: 21% with 3 or more children vs. dtmc:13%; p-value 0,044), years of education of parents (ctmc: 50% had more than 10 years vs. dtmc: 39%; p-value 0.026), the number of visits to doctor (ctmc: 50% presented her child 4 or more times to a doctor in the last 12 months vs. dtmc: 32%; p-value <0.001) and the kind of medical doctor present (dtmc: in 51% a pediatrician vs. ctmc: 87%; p-value <0.001). The distance to the doctor was significantly different (p-value <0.001) and parents in dtmc-kindergartens perceived more often problems in pediatric health care (dtmc: 61% confirmed problems vs. ctmc: 47%; p-value 0.032). Dtmc-kindergarten-parents more often approved delegation for all of the defined and proposed medical tasks.

CONCLUSIONS

The results show clear differences between the survey regions. To support pediatric care in regions distant to medical care facilities, innovative care concepts are needed. The positive attitude of the majority of parents on the subject of delegation forms a good basis for the development of concrete concepts and their practical testing in pilot projects.

[Geriatric care in rural areas: Results from two standardized surveys of care providers]

BACKGROUND

Due to a growing elderly population the number of age-related diseases increases and thus the need for geriatric care. In rural areas with low population density and few healthcare providers there is a risk of inadequate care.

AIM OF THE STUDY

The aim of our investigation was to identify gaps in care and preferred improvement approaches in rural areas from the perspective of local care providers.

METHODS

1,545 healthcare providers from two rural regions were surveyed on the care situation (assessment according to the German school grading system), improvement approaches and problems (simple frequencies). The participants' answers were categorized and analyzed by their work location according to the central-place concept of high-order, middle-order and lower-order (basic) centers.

RESULTS

348 healthcare providers participated (response rate: 22.5 %). The outpatient and inpatient care situation in geriatrics was rated "satisfactory" on average. Geriatric care is most often jeopardized by long waiting times for specialist treatment (71.0 %). Significant differences in the rating were found in the coverage of geriatric care by inpatient care (p=0.0018) and the accessibility of medical facilities by public transport (p=<0.001). These were better rated in the higher-order centers. The preferred approach to improve care was intersectoral networking (62.3 %) among care providers.

CONCLUSIONS

In rural areas, supply problems in geriatrics exist, in particular accessibility and waiting times in middle-order and basic centers. Solutions of regional, intersectoral and interprofessional care were approved by a majority of the participants.

AB1249 ASSESSMENT OF FATIGUE IN ADULTS WITH MODERATE-TO-SEVERE SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): A QUALITATIVE STUDY TO EXPLORE WHAT PATIENTS FEEL SHOULD BE MEASURED IN CLINICAL TRIALS

Background:

Fatigue is one of the most common symptoms reported by patients with systemic lupus erythematosus (SLE)—it is responsible for considerable loss of work time and greatly impaired quality of life. The Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) has been used to assess fatigue in SLE clinical trials1; however, assessment of the content validity of the FACIT-F in adults with SLE suggested that closer evaluation may be warranted.2

Objectives:

This qualitative study aimed to understand SLE patients’ experience of fatigue and assess the content validity of the FACIT-F.

Methods:

The evaluation was informed by literature and guided by a project steering committee (PSC; patient advocate, clinical expert, outcomes measure expert). The institutional review board-approved study involved focus groups (Round 1) and cognitive interviews (Round 2) with adults with moderate-to-severely active SLE. All participants provided written informed consent. Round 1 included three focus groups to understand the disease and fatigue-related concepts that were most important to patients; participants also provided high-level feedback on the FACIT-F. Round 2 included 13 one-on-one cognitive interviews on the relevance of content, clarity, and comprehensiveness of the FACIT-F. Interviews were audio-recorded and transcribed and a content analysis was completed. The PSC reviewed results and contributed to decision-making. Specific focus was on determining patient understanding of the FACIT-F, comprehensiveness, and any gaps in concept coverage to evaluate fatigue in the context of a clinical trial.

Results:

Twenty-eight patients with moderate-to-severely active SLE participated; they were mostly female (n=27), had a mean age of 45.5 ± 12.1 years (range: 18–75), and 23 (82%) had moderate and five (18%) severely active SLE. All participants were receiving SLE treatment, and most (n=23, 82%) reported fatigue among their top three most important SLE-related symptoms. Fatigue was described as having a profound impact on daily life, including ability to perform chores and work-related activities, maintain personal hygiene, exercise, and participate in hobbies. Study participants reported the FACIT-F covered concepts most relevant to their fatigue experience. Participants were able to understand the FACIT-F instructions, items, and response options and felt the recall period of seven days was appropriate.

Conclusion:

Fatigue was one of the most important symptoms, having a significant impact on adults with moderate-to-severely active SLE, limiting their ability to perform necessary or desired activities. The FACIT-F was found to be an appropriate measure for the assessment of fatigue in this sample.3Evidence of the content validity of the FACIT-F in adults with SLE was confirmed for use to support endpoints in the Cenerimod Assessing S1P1Receptor Modulation in SLE (CARE) clinical trial.

References:

[1]Izadi Z, Gandrup J, Katz PP, Yazdany J. Patient-reported outcome measures for use in clinical trials of SLE: a review. Lupus Sci Med. 2018;5(1):e000279.

[2]Kosinski M, Gajria K, Fernandes A, Cella D. Qualitative validation of the FACIT-Fatigue scale in systemic lupus erythematosus. Lupus. 2013;22(5):422-430.

[3]Mannix S, Beyer A, Strand V, Hanrahan L, Abel C, Flamion B, Hareendran A. Assessment of Fatigue in Adults with Moderate to Severe Systemic Lupus Erythematosus (SLE): A Qualitative Study to Explore What Patients Feel Should Be Measured in Clinical Trials [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10).

Acknowledgments:

We thank Dr. David Cella, developer of the FACIT-F, for his time discussing the measure, interim findings, and PSC feedback; the site staff for patient recruitment; Andrea Schulz and Rodolfo Matos, who conducted interviews.

Disclosure of Interests:

Sally Mannix Employee of: Evidera, Andrea Beyer Employee of: Idorsia Pharmaceuticals, Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB, Leslie Hanrahan: None declared, Cristina Abél Employee of: Evidera, Bruno Flamion Shareholder of: Idorsia Pharmaceuticals, Employee of: Idorsia Pharmaceuticals, Asha Hareendran Employee of: Evidera

Validation of the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) chronic kidney disease risk score in HIV-infected patients in the USA

Objectives

The aim of the study was to assess the validity of an easy‐to‐calculate chronic kidney disease (CKD) risk score developed by the Data Collection on Adverse Events of Anti‐HIV Drugs (D:A:D) group in a longitudinal observational study of people living with HIV (PLWH) in the USA.

Methods

PLWH (2002–2016) without prior exposure to potentially nephrotoxic antiretroviral agents and with at least three estimated glomerular filtration rate (eGFR) test results were identified in the Observational Pharmaco‐Epidemiology Research and Analysis (OPERA^®) cohort. Three samples were drawn independently using the same eligibility criteria but each using a different eGFR equation, specifically the Cockcroft–Gault (C‐G), Modification of Diet in Renal Disease (MDRD) or Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) eGFR estimation method. Full and short D:A:D risk scores were applied. CKD was defined as a confirmed decrease in eGFR to < 60 mL/min/1.73 m² (stages 3–5). Poisson models estimated the association between CKD incidence and a one‐point increase in the continuous risk score. The incidence rate ratio (IRR), adjusted IRR (aIRR), and Harrell's discrimination statistic were used to assess validity.

Results

There were 19 444, 22 727 and 22 748 PLWH in the OPERA C‐G, CKD‐EPI and MDRD samples, respectively. The median (minimum–maximum) follow‐up duration was 6.1 (0.3–9.1) years in the D:A:D cohort and ranged from 3.2 to 3.5 (0.2–15.5) years in the OPERA validation samples. The observation time for the majority of PLWH in the D:A:D cohort began prior to 2006, in stark contrast to the OPERA validation samples, where the majority of PLWH were observed after 2011. The CKD incidence ranged from 7.3 per 1000 person‐years [95% confidence interval (CI) 6.8, 7.9 per 1000 person‐years] in OPERA C‐G to 11.0 (95% CI 10.4, 11.6 per 1000 person‐years) in OPERA MDRD. In OPERA samples, IRRs by risk group and adjusted IRRs (full risk score) were similar to those in the D:A:D derivation cohort (adjusted IRR 1.3; 95% CI 1.3, 1.3). Harrell's c‐statistic ranged from 0.87 to 0.92 in the OPERA samples, comparable to that in the derivation cohort (0.92). Results for short scores were similar.

Conclusions

The findings support the validity of the D:A:D risk scoring method for assessing CKD (stages 3–5) probability in an exclusively USA‐based sample regardless of eGFR method.

Association between the use of free-of-charge intrauterine devices and a history of induced abortion: a retrospective study

Background

To determine whether use of intrauterine device (IUD) is influenced by a history of induced abortion and the type of contraceptives used until costs are covered.

Methods

We analyzed data from 301 female residents in Mecklenburg-West Pomerania, an economically challenged community. The women, aged between 20 and 35 years, were entitled to receive unemployment benefits, and had access to free-of-charge oral contraceptives, ring or IUD. Cross-sectional data were analyzed using logistic regression.

Results

There were 112 (37.2%) women with a history of induced abortion, and 46 (15.3%) reported exclusively using less effective contraceptives (e.g. condoms). In a univariate logistic regression, use of an IUD was associated with a history of having had an induced abortion. Furthermore, uptake of an IUD was associated with women who had, until costs were covered, exclusively choice to use less effective contraceptives (OR = 3.281, 95% CI: 1.717; 6.273). Both associations remained significant in a multivariate model.

Conclusions

Free contraceptives provided to women receiving unemployment benefits may increase the use of IUDs, especially among those with a history of an induced abortion and those using less effective contraceptives.

Composition determination for quaternary III-V semiconductors by aberration-corrected STEM

Quantitative scanning transmission electron microscopy (STEM) is a powerful tool for the characterization of nano-materials. Absolute composition determination for ternary III-V semiconductors by direct comparison of experiment and simulation is well established. Here, we show a method to determine the composition of quaternary III-V semiconductors with two elements on each sub lattice from the intensities of one STEM image. As an example, this is applied to (GaIn)(AsBi). The feasibility of the method is shown in a simulation study that also explores the influence of detector angles and specimen thickness. Additionally, the method is applied to an experimental STEM image of a (GaIn)(AsBi) quantum well grown by metal organic vapour phase epitaxy. The obtained concentrations are in good agreement with X-ray diffraction and photoluminescence results.

Three-dimensional structure of antiphase domains in GaP on Si(0 0 1)

Antiphase domains are three-dimensional crystal defects commonly arising at the interface of III-V semiconductors and Si. While control over their formation has been achieved, the geometry of the antiphase domain itself that is separated from the mainphase of the crystal by the so-called antiphase boundary, has not yet been fully understood. In this work, we first investigate the interface between GaP and Si itself by cross-sectional scanning tunneling microscopy (XSTM) to reveal possible intermixing within an 8 monolayers wide region. Furthermore, we present an extensive analysis combining transmission electron microscopy and XSTM to elucidate the shape of antiphase domains in GaP. To create a true-to-scale, three-dimensional model of an antiphase domain, firstly, plan-view transmission electron microscopy images are drawn on. Subsequently, the progression of many antiphase boundaries through the GaP crystal as viewed from the (1 1 0) and (1 [Formula: see text] 0) cleavage planes is analyzed all the way down to the atomic level by means of XSTM. This enables a detailed analysis of the shape and physical dimensions of the antiphase domains. A typical measured extension in growth directions is found to be a maximum of 60 nm and the maximum measured extension of the base plane in [[Formula: see text] 1 0] and [1 1 0] directions is about 160 nm and 50 nm, respectively. They appear as pyramids with anisotropic base planes whose side facets kink many times.

Second-harmonic generation as a probe for structural and electronic properties of buried GaP/Si(0 0 1) interfaces

Optical second-harmonic generation is demonstrated to be a sensitive probe of the buried interface between the lattice-matched semiconductors gallium phosphide and silicon with (0 0 1) orientation. Ex situ rotational anisotropy measurements on GaP/Si heterostructures show a strong isotropic component of the second-harmonic response not present for pure Si(0 0 1) or GaP(0 0 1). The strength of the overlaying anisotropic response directly correlates with the quality of the interface as determined by atomically resolved scanning transmission electron microscopy. Systematic comparison of samples fabricated under different growth conditions in metal-organic vapor phase epitaxy reveals that the anisotropy for different polarization combinations can be used as a selective fingerprint for the occurrence of anti-phase domains and twins. This all-optical technique can be applied as an in situ and non-invasive monitor even during growth.

[Utilization of Gynaecological Cancer Screening by Women 20 to 35 Years of Age Receiving Unemployment Benefits Under Social Security Code II]

The aim of the study was to analyze associations between utilization of gynaecological cancer screening (GCS) and the number of months during which state unemployment benefits (Social Security Code II) were drawn by women aged 20 to 35 years. The sample included 223 women with complete interview data (participation rate: 69%). The findings show that more women drawing unemployment benefits for a short-term (<12 months) utilized GCS compared to those receiving long-term benefits (>36 months).

Towards the liquid phase exfoliation of bismuth iodide

Liquid phase exfoliation (LPE) of layered compounds towards few- or monolayers has been established as one of the prime methods in the growing field of 2D material research. Here, we present first steps towards an effective LPE of bismuth(iii) iodide, a semiconductor with potential as a photovoltaic absorber material. We highlight guidelines in the choice of exfoliating solvent, which differ significantly from those used with transition metal dichalcogenides or graphene. We also present first evidence of successful few-layer formation from spectroscopic, electron microscopy and electron diffraction investigations.

Xenopus as a model organism to study heterotrimeric G-protein pathway during collective cell migration of neural crest

Collective cell migration is essential in many fundamental aspects of normal development, like morphogenesis, organ formation, wound healing, and immune responses, as well as in the etiology of severe pathologies, like cancer metastasis. In spite of the huge amount of data accumulated on cell migration, such a complex process involves many molecular actors, some of which still remain to be functionally characterized. One of these signals is the heterotrimeric G-protein pathway that has been studied mainly in gastrulation movements. Recently we have reported that Ric-8A, a GEF for Gα proteins, plays an important role in neural crest migration in Xenopus development. Xenopus neural crest cells, a highly migratory embryonic cell population induced at the border of the neural plate that migrates extensively in order to differentiate in other tissues during development, have become a good model to understand the dynamics that regulate cell migration. In this review, we aim to provide sufficient evidence supporting how useful Xenopus model with its different tools, such as explants and transplants, paired with improved in vivo imaging techniques, will allow us to tackle the multiple signaling mechanisms involved in neural crest cell migration.

Active fiber-based retroreflector providing phase-retracing anti-parallel laser beams for precision spectroscopy

We present an active fiber-based retroreflector providing high quality phase-retracing anti-parallel Gaussian laser beams for precision spectroscopy of Doppler sensitive transitions. Our design is well-suited for a number of applications where implementing optical cavities is technically challenging and corner cubes fail to match the demanded requirements, most importantly retracing wavefronts and preservation of the laser polarization. To illustrate the performance of the system, we use it for spectroscopy of the 2S-4P transition in atomic hydrogen and demonstrate an average suppression of the first order Doppler shift to 4 parts in 10⁶ of the full collinear shift. This high degree of cancellation combined with our cryogenic source of hydrogen atoms in the metastable 2S state is sufficient to enable determinations of the Rydberg constant and the proton charge radius with competitive uncertainties. Advantages over the usual Doppler cancellation based on corner cube type retroreflectors are discussed as well as an alternative method using a high finesse cavity.

Testing clinical competencies in undergraduate nursing education using Objective Structured Clinical Examination (OSCE) – a literature review of international practice

Background: In response to demographic trends in Germany nursing competencies are currently reevaluated. Since these have to be taught and trained in nursing education programs, efficient verification of the success is necessary. OSCEs are internationally well-recognized as a comprehensive tool for that. Aim: In this analysis we identified competencies worldwide, which are tested by OSCEs in undergraduate nursing education programs. Method: An international literature research was conducted. The selection criterion for an article was the specification of at least one verifiable competency. Afterwards the competencies were categorized into knowledge, skills and attitudes according to the German “Fachqualifikationsrahmen Pflege für die hochschulische Bildung”. Results: A total of 36 publications fulfilled all inclusion criteria. Relevant studies were predominantly initiated in the UK, Canada and Australia. Within all categories a total of n = 166 different competencies are mentioned. OSCEs are developed and performed in a broad range of methods. Most frequently skills were verified. The most common topic was sure handling of medication. Other important themes were communicative competencies in relation to patients and the ability of self-evaluation. Discussion/Conclusions: A variation in examination methods is appropriate as different competencies are acquired in preparation of the test. Evaluation took place on an individual or institutional level. Further research is needed.

Novel frameshift mutation in the CACNA1A gene causing a mixed phenotype of episodic ataxia and familiar hemiplegic migraine

Episodic ataxia type 2 (EA2, MIM#108500) is the most common form of EA and an autosomal-dominant inherited disorder characterized by paroxysmal episodes of ataxia. The disease causative gene CACNA1A encodes for the alpha 1A subunit of the voltage-gated P/Q-type calcium channel. We report on a family with a novel mutation in the CACNA1A gene. The clinical symptoms within the family varied from the typical clinical presentation of EA2 with dysarthria, gait ataxia and oculomotor symptoms to migraine and dystonia. A novel nonsense mutation of the CACNA1A gene was identified in all affected family members and is most likely the disease causing molecular defect. The pharmacological treatment with acetazolamide (AAA) was successful in three family members so far. Treatment with AAA led to a reduction of migraine attacks and an improvement of the dystonia. This relationship confirmed the hypothesis that this novel mutation results in a heterogeneous phenotype and confutes the coincidence with common migraine. Dystonia is potentially included as a further part of the phenotype spectrum of CACNA1A gene mutations.

In situ characterization of Cu–Co oxides for catalytic application

In situ emission and absorption FTIR methods were employed to characterize the spatially resolved structure of binary Co–Cu oxides for low-temperature oxidation of CO and propene. Co–Cu oxide catalysts were controllably synthesized by pulsed-spray evaporation chemical vapor deposition. XRD, FTIR, XPS, UV-vis and helium ion microscopy (HIM) were employed to characterize the as-prepared thin films in terms of structure, composition, optical and thermal properties as well as morphology. In situ emission FTIR spectroscopy indicates that Co₃O₄, CuCo₂O₄ and CuO are thermally stable at 650, 655 and 450 °C, respectively. The catalytic tests with absorption FTIR display that the involvement of Co–Cu oxides can initiate CO and C₃H₆ oxidation at lower temperatures. The results indicate that in situ emission and absorption FTIR are useful techniques to explore the thermal properties and catalytic performance of functional materials, allowing many potential applications in tailoring their temporally and spatially resolved structure-property relationships.

Formation of nanogaps in InAs nanowires by selectively etching embedded InP segments

We present a method to fabricate nanometer scale gaps within InAs nanowires by selectively etching InAs/InP heterostructure nanowires. We used vapor-liquid-solid grown InAs nanowires with embedded InP segments of 10-60 nm length and developed an etching recipe to selectively remove the InP segment. A photo-assisted wet etching process in a mixture of acetic acid and hydrobromic acid gave high selectivity, with accurate removal of InP segments down to 20 nm, leaving the InAs wire largely unattacked, as verified using scanning electron and transmission electron microscopy. The obtained nanogaps in InAs wires have potential as semiconducting electrodes to investigate electronic transport in nanoscale objects. We demonstrate this functionality by dielectrophoretically trapping 30 nm diameter gold nanoparticles into the gap.

Formation and structure of copper(II) oxalate layers on carboxy-terminated self-assembled monolayers

Copper(II) oxalate was grown on carboxy-terminated self-assembled monolayers using a step-by-step approach by dipping the surfaces alternately in ethanolic solutions of copper(II) acetate and oxalic acid with intermediate thorough rinsing steps. The deposition was monitored by reflection absorption infrared spectroscopy (RAIRS), a quartz microbalance with dissipation measurement (QCM-D), scanning electron microscopy (SEM), and helium ion microscopy (HIM). Amounts of material corresponding to a coverage of 75% of a monolayer are deposited in each dipping step in copper(II) acetate solution while deposition of oxalic acid produces a viscoelastic layer that is partially removed by rinsing. This points toward initial aggregation but acid not bound to Cu(2+) ions as oxalate ions is removed by the rinsing steps. RAIRS further indicates that the material grows as copper(II) oxalate ribbons similar to the crystal structure but with ribbons oriented roughly parallel to the surface. SEM and HIM give evidence of the formation of needle-shaped structures which are a possible explanation for the viscoelastic behavior of the layer.

Focused electron beam induced processing and the effect of substrate thickness revisited

The current understanding in the study of focused electron beam induced processing (FEBIP) is that the growth of a deposit is mainly the result of secondary electrons (SEs). This suggests that the growth rate for FEBIP is affected by the SE emission from the support. Our experiments, with membranes thinner than the SE escape depth, confirm this hypothesis. We used membranes of 1.4 and 4.3 nm amorphous carbon as supports. At the very early stage, the growth is support-dominated and the growth rate on a 4.3 nm thick membrane is three times higher than on a 1.4 nm thick membrane. This is consistent with Monte Carlo simulations for SE emission. The results suggest that SEs are dominant in the dissociation of W(CO)6 on thin membranes. The best agreement between simulations and experiment is obtained for SEs with energies between 3 and 6 eV.With this work we revisit earlier experiments, working at a precursor pressure 20 times lower than previously. Then, despite using membranes thinner than the SE escape depth, we did not see an effect on the experimental growth rate. We explain our current results by the fact that very early in the process, the growth becomes dominated by the growing deposit itself.

[The home environment of families with children as address for a public health action for reduction of tobacco smoke]

AIM

There is limited research about the acceptance of population-based prevention activities, offered systematically and directly at home. Screening data about smoking behaviour in families with children younger than 3 years were used. We examined associations between family variables (education, employment, number of children in the household), the "proportion of persons on social welfare" (PPSW) in the population aged 15-65 years and the following dependent variables: participation rate in a systematic screening, proportion of smokers within the sample of screened families and participation rate in counselling.

METHODS

For postal and personal contacts reporting data of children aged < 3 years, resident in Stralsund (due date 01.06.2008, N=1 298) were used. A total number of 827 families participated in the screening. The counselling was offered if at least 1 adult had smoked at least 1 cigarette per day in the last 4 weeks. Associations between family variables, PPSW and dependent variables were analysed using multilevel statistics.

RESULTS

The higher the PPSP the lower is the probability for participation in the screening (odds ratio=0.982; 95% confidence interval=0.970-0.996). There was at least one adult smoker in 425 (51.4%) of these 827 families participating in the screening. The counselling was offered in 425 families, whereby 65.9% (280) participated. There was no association between family variables, PPSW and participation in the counselling.

CONCLUSION

Differences in participation in the screening procedure are low: a high proportion of families in districts with a high PPSW took part. Even in districts with a PPSW rate of more than 30%, 71.3% of the families were successfully contacted. There is the recommendation to offer prevention measures in social< deprived city areas in a more proactive way considering the association between the prevalence of smoking in families and the proportion of PPSW.

Efficient animal-serum free 3D cultivation method for adult human neural crest-derived stem cell therapeutics

Due to their broad differentiation potential and their persistence into adulthood, human neural crest-derived stem cells (NCSCs) harbour great potential for autologous cellular therapies, which include the treatment of neurodegenerative diseases and replacement of complex tissues containing various cell types, as in the case of musculoskeletal injuries. The use of serum-free approaches often results in insufficient proliferation of stem cells and foetal calf serum implicates the use of xenogenic medium components. Thus, there is much need for alternative cultivation strategies. In this study we describe for the first time a novel, human blood plasma based semi-solid medium for cultivation of human NCSCs. We cultivated human neural crest-derived inferior turbinate stem cells (ITSCs) within a blood plasma matrix, where they revealed higher proliferation rates compared to a standard serum-free approach. Three-dimensionality of the matrix was investigated using helium ion microscopy. ITSCs grew within the matrix as revealed by laser scanning microscopy. Genetic stability and maintenance of stemness characteristics were assured in 3D cultivated ITSCs, as demonstrated by unchanged expression profile and the capability for self-renewal. ITSCs pre-cultivated in the 3D matrix differentiated efficiently into ectodermal and mesodermal cell types, particularly including osteogenic cell types. Furthermore, ITSCs cultivated as described here could be easily infected with lentiviruses directly in substrate for potential tracing or gene therapeutic approaches. Taken together, the use of human blood plasma as an additive for a completely defined medium points towards a personalisable and autologous cultivation of human neural crest-derived stem cells under clinical grade conditions.

X-ray holographic microscopy with zone plates applied to biological samples in the water window using 3rd harmonic radiation from the free-electron laser FLASH

The imaging of hydrated biological samples - especially in the energy window of 284-540 eV, where water does not obscure the signal of soft organic matter and biologically relevant elements - is of tremendous interest for life sciences. Free-electron lasers can provide highly intense and coherent pulses, which allow single pulse imaging to overcome resolution limits set by radiation damage. One current challenge is to match both the desired energy and the intensity of the light source. We present the first images of dehydrated biological material acquired with 3rd harmonic radiation from FLASH by digital in-line zone plate holography as one step towards the vision of imaging hydrated biological material with photons in the water window. We also demonstrate the first application of ultrathin molecular sheets as suitable substrates for future free-electron laser experiments with biological samples in the form of a rat fibroblast cell and marine biofouling bacteria Cobetia marina.

[Patients with chronic pain syndromes. Impact of an individual outpatient therapy program on pain and health-related quality of life]

BACKGROUND

The study was performed to reveal the effect of an individualized personal outpatient therapy program, based on a multidisciplinary assessment, on pain and health-related quality of life in patients with chronic pain.

METHODS

Fifty patients were prospectively evaluated before and 3 months after establishment of an individualized outpatient therapy program. Health-related quality of life, pain and pain-related disability, depression and motivation to adopt self-management of chronic pain were assessed. Therapy adherence was tested with a structured interview.

RESULTS

Only marginal improvements were observed in terms of pain and health-related quality of life. Therapy adherence varied between the different therapies.

CONCLUSIONS

An individualized personal outpatient therapy program has only marginal effects on pain and health-related quality of life in patients with chronic pain.

Ultrahigh resolution focused electron beam induced processing: the effect of substrate thickness

It is often suggested that the growth in focused electron beam induced processing (FEBIP) is caused not only by primary electrons, but also (and even predominantly) by secondary electrons (SEs). If that is true, the growth rate for FEBIP can be changed by modifying the SE yield. Results from our Monte Carlo simulations show that the SE yield changes strongly with substrate thickness for thicknesses below the SE escape depth. However, our experimental results show that the growth rate is independent of the substrate thickness. Deposits with an average size of about 3 nm were written on 1 and 9 nm thick carbon substrates. The apparent contradiction between simulation and experiment is explained by simulating the SE emission from a carbon substrate with platinum deposits on the surface. It appears that the SE emission is dominated by the deposits rather than the carbon substrate, even for deposits as small as 0.32 nm(3).

Abstract P5-06-02: Loss of Rho GDIa Function and Tamoxifen Resistance in ERa-Positive Breast Cancer Cells

Background: We have previously shown that increased phosphorylation of the S305 site in ERa via mutation of ERa can lead to tamoxifen (Tam) resistance. We have also discovered that shRNA knockdown of the Rho disassociation inhibitor (Rho GDIa) can render estrogen receptor (ERa)- positive breast cancer cells more aggressive via an increase in their metastatic ability. Rho GDIa is a negative regulator of the Rho family of proteins, which play an important role in the regulation of the actin cytoskeleton. While the Rho pathway is known to influence metastasis in breast and other types of cancers, it is unclear how this pathway impacts on Tam sensitivity. Since loss of Rho GDIa causes an increase in the activity of the downstream Rho proteins (Rho, Rac, and Cdc42), it is possible that increased activity of downstream Rho effectors may lead to Tam resistance through crosstalk with the ERa signaling pathway. Materials and Methods: Rho GDIa was stably silenced in MCF-7 cells using shRNA and its levels validated using Western blot analysis. Kinase assays were perfomed using GST-tagged ERa fragments to assess the effect of various kinases on ERa. ERE-luciferase reporter assays were used to look at ERa transactivation with estrogen and Tam treatment. In vitro-derived Tam-resistant cells were generated by culturing MCF-7 cells in Tam for &gt;6 months.

Results: Knockdown of Rho GDIa in ER-positive breast cancer cells resulted in Tam-resistant growth in vivo. Tam stimulated primary tumor growth in athymic nude mice. Mice injected with Rho GDIa knockdown cells exhibited metastatic lesions to the lung when treated with either estrogen or Tam. No lung tumors were detected in vector control transfected MCF-7 cells. Rhotekin pulldown assays revealed that Rho (A, B, and C), Rac1, and Cdc42 had higher activity in the Rho GDIa knockdown cells as compared to vector control cells. Immunecomplex kinase assays revealed that PAK1, a known downstream effector of the Rho pathway, exhibited increased activation in the Rho GDIa knockdown cells, and that this increased activity led to increased phosphorylation of ERa on the S305 residue. As expected, the acetylation of ERa was decreased when S305 was phosphorylated and this decrease in acetylation was dependent on phosphorylation of S305 since transfection of a plasmid containing a S305A mutation did not display decreased acetylation. ERE-luciferase assays showed that Rho GDIa knockdown cells had higher levels of estrogen and tamoxifen-induced activity in Rho GDIa knockdown cells as compared to vector control cells. Further possible effectors of Rho GDIa are being investigated as possible candidates playing roles in the crosstalk between these two pathways. Interestingly, cells which became Tam-resistant due to long term culture in the presence of Tam, also exhibited a decrease in endogenous Rho GDIa levels.

Discussion: Loss of Rho GDIa in ERa-positive breast cancer cells conferred a Tam-resistant and metastatic phenotype. Cells with decreased Rho GDIa levels displayed increased phosphorylation of ERa, suggesting that there is a level of crosstalk between the Rho family of signaling entwork and the ERa signaling pathway. We hypothesize that disruption of this crosstalk may be an approach to prevent or reverse Tam resistance in patients.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-06-02.

Spotlight on measles 2010: preliminary report of an ongoing measles outbreak in a subpopulation with low vaccination coverage in Berlin, Germany, January-March 2010

Since early January 2010, Berlin has been experiencing a measles outbreak with 62 cases as of 31 March. The index case acquired the infection in India. In recent years, measles incidence in Berlin has been lower than the German average and vaccination coverage in school children has increased since 2001. However, this outbreak involves schools and kindergartens with low vaccination coverage and parents with critical attitudes towards vaccination, which makes the implementation of public health interventions challenging.