Personal, financial and time burden in inherited ichthyoses: A survey of 144 patients in a university-based setting

BACKGROUND

Patients with inherited ichthyosis suffer from scaling due to mutations affecting the epidermal barrier. Symptomatic treatment with ointments, bathing and mechanical scale removal can alleviate the disease, but therapy is time and cost intensive.

OBJECTIVES

We investigated costs, time and disease burden of ichthyoses. The study addresses difficulties of the healthcare situation for patients with ichthyoses and reveals potential improvements.

MATERIALS AND METHODS

We developed a questionnaire addressing time and financial effort for the treatment. Additionally, we collected data of the Dermatology Life Quality Index (DLQI) and the Pruritus Life Quality (5PLQ) questionnaires to determine the impact of ichthyosis and associated pruritus on quality of life (QoL).

RESULTS

We recruited 144 patients with ichthyosis (median age: 23; 53.5% female) from the Department of Dermatology in Muenster (Germany) and the German patient support group including common, rare and syndromic subtypes. Eighty-seven percent reported applying topical therapeutics at least once per day, 66.4% several times with an overall median duration of 15 min. Highest single expenditure of time was due to balneotherapy (n = 115; median bathing time: 40 min). In 81.9%, the health insurance did not completely cover the costs for topical treatment causing additional financial burden to the patient with a median of 71 € per quarter, herein creams being the largest cost factor (50 €). Patients with Netherton syndrome showed the highest median expenditure (170 €). The QoL impairment under treatment was moderate (median DLQI: 8.5 points). Pruritus was prevalent in 79.9% and showed a distinct impact on QoL (median 5PLQ: 7.5 points) without any significant difference between the subtypes (p = 0.37).

CONCLUSION

Patients suffering from ichthyoses have a large and lifelong overall burden in mild and severe subtypes. Since continuous topical treatment is required, financial and psychosocial support needs to be considered beyond dermatological care.

A probabilistic-deterministic approach for assessing climate change effects on infection risks downstream of sewage emissions from CSOs

The discharge of pathogens into urban recreational water bodies during combined sewer overflows (CSOs) pose a potential threat for public health which may increase in the future due to climate change. Improved methods are needed for predicting the impact of these effects on the microbiological urban river water quality and infection risks during recreational use. The aim of this study was to develop a novel probabilistic-deterministic modelling approach for this purpose building on physically plausible generated future rainfall time series. The approach consists of disaggregation and validation of daily precipitation time series from 21 regional climate models for a reference period (1971-2000, C20), a near-term future period (2021-2050, NTF) and a long-term future period (2071-2100, LTF) into sub-daily scale, and predicting the concentrations of enterococci and Giardia and Cryptosporidium, and infection risks during recreational use in the river downstream of the sewage emissions from CSOs. The approach was tested for an urban river catchment in Austria which is used for recreational activities (i.e. swimming, playing, wading, hand-to-mouth contact). According to a worst-case scenario (i.e. children bathing in the river), the 95th percentile infection risks for Giardia and Cryptosporidium range from 0.08 % in winter to 8 % per person and exposure event in summer for C20. The infection risk increase in the future is up to 0.8 log10 for individual scenarios. The results imply that measures to prevent CSOs may be needed to ensure sustainable water safety. The approach is promising for predicting the effect of climate change on urban water safety requirements and for supporting the selection of sustainable mitigation measures. Future studies should focus on reducing the uncertainty of the predictions at local scale.

[Dermatological care of elderly people with psoriasis before and after entering a nursing home : A qualitative analysis from the perspective of medical providers]

Hintergrund

Demografische Veränderungen bewirken einen steilen Anstieg der Anzahl der über 65-Jährigen. Damit verbunden ist die Zunahme der Anzahl pflegebedürftiger, multimorbid Erkrankter. National wie auch international gibt es keine Informationen insbesondere zur Versorgung von Psoriasiserkrankten im Setting Pflegeheim und zur Frage, wie diese durch den Eintritt in ein Pflegeheim beeinflusst wird.

Fragestellung

Ziel war es, anhand von Interviews bzw. Fokusgruppen die Ergebnisse vorausgehender Routinedatenanalysen zur Versorgung Psoriasiserkrankter in Pflegeheimen mit medizinischen Versorgern (Dermatologen, Allgemeinmediziner, Pflegedienstleitungen und Pflegekräfte) zu diskutieren, Schwierigkeiten der Versorgung aufzudecken und abschließend Handlungsempfehlungen für eine zukunftsfähige gerontodermatologische Versorgung abzuleiten.

Material und Methoden

Durchgeführt wurden qualitative Leitfaden-gestützte Interviews und Fokusgruppen mit Dermatologen (n = 5), Allgemeinmedizinern (n = 7), Pflegekräften (n = 7) und Pflegedienstleitungen (n = 2). Die Daten wurden inhaltsanalytisch ausgewertet.

Ergebnisse

Die Auswertung ergab insgesamt 344 Aussagen, die insgesamt 14 Hauptkategorien zugeordnet werden konnten. Die Ergebnisse zeigen, dass für die Versorgungsqualität von Menschen mit Hautkrankheiten, insbesondere Psoriasis, in Pflegeinrichtungen ein Verbesserungsbedarf besteht. Dieser zeigt sich sowohl auf ärztlicher als auch auf pflegerischer Ebene. Laut der Versorger (N = 21) kann dies insbesondere durch eine verstärkte digitale Versorgung, dermatologische Schulungen für Hausärzte und Pflegefachkräfte sowie engere Kooperationen zwischen den einzelnen Disziplinen adressiert werden.

Schlussfolgerung

Digitale Pflegekonsile, aber auch eine spezifische Leitlinie zur „Haut des alternden Menschen“ können von Nutzen sein, um die dermatologische Versorgungssituation im Pflegeheim zu verbessern und somit das Wohlbefinden der Betroffenen zu steigern.

Assessment of stigma related to visible skin diseases: a systematic review and evaluation of patient-reported outcome measures

Misconceptions about visible skin diseases are widespread, and patients often face discrimination and stigmatization due to their condition. The associated negative health and psychosocial consequences of stigmatization in skin diseases have prompted an increase in research activity in recent times, resulting in a wide variety of assessment measures. This study aimed at aggregating and evaluating evidence of psychometric properties and methodological quality of published measures to assess stigma in visible skin diseases. Studies assessing stigmatization in visible skin diseases were searched in four databases (Medline, PsycINFO, Web of Science and Embase) until February 2021. The review followed PRISMA guidelines. Papers regarding development and/or validation of measures were identified by two independent researchers. Inclusion criteria were defined as follows: (i) quantitative studies in (ii) populations with skin diseases using (iii) questionnaires explicitly assessing (iv) perceived or public stigmatization or discrimination available in (iv) English or German language. The COnsensus-based Standards of health Measurement INstruments (COSMIN) checklist was used to evaluate their psychometric properties and risk of bias. 35 studies using 21 instruments were identified. Twenty instruments focused on assessing the perceived reality of those affected by visible skin diseases, while public stigma was only assessed by two instruments. Twelve scales could be recommended for use, while nine instruments had the potential to be recommended after further studies have assessed their quality. Some limitations are to be noted. Only studies in English and German were included. Research on self-constructed instruments can lead to new validated instruments, but they were not included in the review at this point. Several validated instruments could be recommended for use. Future research is needed regarding the assessment of stigma across different visible skin diseases, in children and adolescents, and in the general public.

Secukinumab effects on disease burden, patient needs and benefits, and treatment satisfaction in patients with plaque psoriasis across European regions: patient perspective data from the PROSE study

BACKGROUND

Cross-cultural differences in healthcare policies and patient-physician communication may influence the quality of care and patients' perceived benefits and satisfaction with psoriasis treatment.

OBJECTIVES

To compare the disease burden and patient needs at baseline, and patient benefits and satisfaction with secukinumab treatment across Europe.

METHODS

PROSE was an open-label, prospective, non-randomized, stratified multicentre study of 52 weeks of secukinumab treatment, in 16 European countries. Secondary analysis of the PROSE study data by European regions was performed to identify cross-cultural differences in disease burden and patient needs at baseline, and in clinical improvement, patient-reported treatment benefits and satisfaction at 52 weeks post-treatment.

RESULTS

At baseline, Dermatology Life Quality Index impairment was reported to be greater in patients from Eastern Europe (EE: 15.4 ± 7.1) vs. Northern Europe (NE: 13.3 ± 6.7) and Western Europe (WE: 13.6 ± 6.9), but while differences were statistically significant (F-test = 5.5, P < 0.001), their clinical significance is uncertain. There were no significant differences between regions in Psoriasis Area and Severity Index at baseline (F-test = 1.6). There were considerable differences in patients' needs (Patient Need Questionnaire) between geographical regions, with WE focused more on reducing physical impairment [vs. Southern Europe (SE)/EE], EE on reducing social impairment (vs. NE/WE) and SE on reducing impairment due to therapy (vs. NE/WE). At Week 52, patients from EE reported more benefits (Patient Benefit Index) with secukinumab treatment (vs. WE/SE), while patients from NE reported higher global treatment satisfaction (vs. SE).

CONCLUSIONS

Differences in patients' needs and treatment satisfaction across Europe are likely a result of diverse medical systems, socio-economic status and infrastructural access. A patient-centred approach to treating psoriasis may fulfil patient needs and maximize treatment satisfaction. (NCT02752776).

Mapping risk factors for cumulative life course impairment in patients with chronic skin diseases - a systematic review

Patients with chronic skin diseases suffer from physical and psychosocial impairments which can lead to a cumulative life-long burden. Therefore, the concept of cumulative life course impairment (CLCI) was introduced, referring to the non-reversible damage due to the persistent life-long burden. This systematic review (PROSPERO registry number: CRD42020179141) aimed at mapping the risk factors and the associated burden over time in patients with psoriasis, atopic dermatitis (AD) and hidradenitis suppurativa (HS). Three electronic databases were searched (date of the last search: December 2019). Studies with a longitudinal study design that assessed the association between a risk factor and the associated burden over time in patients with psoriasis, AD and HS were included. Quality assessment of the included studies was done using Critical Appraisal Skills Programme (CASP) checklists. In total, 40 publications reflecting 25 different studies were included: nine studies addressed patients with psoriasis, 13 patients with AD, two studies included patients with HS and one study enrolled patients with psoriasis and AD, respectively. Twenty-two potential risk factors with underlying evidence were found in this review. These risk factors include mainly sociodemographic (such as age or gender) and clinical (such as disease severity or comorbidities) variables. Disease severity and comorbidities were the most often studied risk factors, while only a few studies evaluated psychosocial risk factors over time. Patients with chronic skin diseases are at high risk to develop a life-long negative impact from the disease. However, there is a lack of data that evaluates the psychosocial burden and its influence on the patients' life course over time. The risk factors found in this review help to identify patients at risk, to treat them adequately and, ultimately, to prevent CLCI. These results can be the basis to develop a highly needed tool to assess the risk for CLCI in the future.

Stigma in visible skin diseases - a literature review and development of a conceptual model

The burden of visible skin diseases (VSDs) includes not only physical symptoms but also psychosocial consequences such as depression, anxiety, impaired quality of life and low self-esteem. Stigmatization was shown to play a major role in people with skin diseases. The aim of the study was to review the evidence for the components, drivers and impacts of (self-)stigma, and to organize the data into a series of conceptual models. A targeted literature search was conducted to identify studies on (self-)stigma in relation to VSD. Conceptual models of stigma in VSDs were developed from existing generic conceptual models for VSD and of generic conceptual models of stigma and were refined after discussion with a board of experts, patient advocacy groups, clinicians and researchers. A total of 580 references were identified, of which 56 references were analysed and summarized. Two conceptual models of stigma were identified: one with external stigma and self-stigma dimensions, the other for self-stigma in mental health. These models were adapted to allow a complete description of stigma in VSDs. For this, a distinction was made between 'discrimination' and 'impact'. Finally, five models were developed: macro-overview; stigma, impact and socio-demographics; stigma, impact and disease characteristics; stigma, impact and quality of life; and stigma, impact and coping. Gaps were identified in available quantitative evidence. To our knowledge, this is the first conceptual model of stigma in VSDs. The model will help to standardize evaluation of stigma and to enhance empirical evaluation of anti-stigma interventions in VSDs. Further research should be conducted to develop a more complete model in stigma due to significant gaps in existing evidence, particularly including the stigma in others (external stigma) and also to cover a broader range of VSDs as their impact on particular dimensions of stigma differs.

Validation of the Spanish Wound-QoL Questionnaire

BACKGROUND AND AIMS

The Wound-QoL is a validated and feasible questionnaire for measuring disease-specific health-related quality of life in chronic wounds, originally developed for use in German. The objective of this study was to translate the Wound-QoL for use in clinical care and in clinical trials in Spain and to validate this version.

MATERIALS AND METHODS

Two independent fourth- and back translations of the Wound-QoL from the original German version were conducted, followed by an expert consensus of the resulting versions. After refinement, the final tool was piloted in N=10 patients and then used in the validation study.

RESULTS

A total of 115 patients were recruited. Mean age was 69.5 (SD 14.5) years, 60.0% were female. The Spanish version of Wound-QoL showed high internal consistency (Cronbach's alpha>0.8 in all scales). Factor analysis resulted in the same scales as the original version. There were satisfactory distribution characteristics of the global score and the subscales. Construct validity and convergent validity with other outcomes (generic QoL, healing rate) were satisfactory. The vast majority of patients considered the Wound-QoL a simple and feasible tool. Mean time needed for completing the questionnaire was 5minutes. Overall, 99.1% of the participants found it easy to understand the questions and 94.7% stated that the questionnaire suits the personal situation.

CONCLUSIONS

The Spanish version of the Wound-QoL shows good validity in clinical practice. It can be recommended for use in clinical routine and trials.

Perception and determinants of stigmatization of people with psoriasis in the German population

BACKGROUND

Perception of psoriasis in the general population is characterized by knowledge deficits and prejudice against those affected. The extent and possible predictors of stigmatizing attitudes remain unclear.

OBJECTIVES

The aim was to assess prejudices and stigmatization of people with psoriasis and to identify sociodemographic and attitude-related variables accounting for stigmatization.

METHODS

Representative telephone surveys of 2004 (in 2017) and 2001 (in 2018) adults using a standardized questionnaire. Descriptive analyses were applied to living area, age, gender, educational status, general knowledge and attitudes about psoriasis. Logistic regression analyses were carried out to determine which variables are associated with the assessment of prejudices of 'others' against people with psoriasis. Those prejudices were specified by the following statements: 'they should take better care of themselves', 'don't want to touch people with psoriasis' and 'disgusted by psoriasis'.

RESULTS

The majority of those surveyed (74%) believe that people with psoriasis are disadvantaged. Similarly, a majority (69%) said that most people find psoriasis disgusting, do not want to touch people with psoriasis (59%) and think that people with psoriasis need to take better care of themselves (45%). 'Willing to enter a relationship with an affected person' (OR = 0.330, P = 0.029), higher age (OR = 1.027, P <0.001) and male gender (OR = 1.263, P = 0.034) proved to be significantly associated with 'psoriasis is disgusting'. Education (OR = 1.648, P = 0.016) and lower age (OR = 0.847, P  <0.001) are significantly associated with 'they need to take better care of themselves'.

CONCLUSIONS

Data suggest that stigmatization of skin diseases is still entrenched. This overview shows the need for interventions against stigmatization of those affected. Results imply that gender, age and education level and related health literacy of the target groups of respective interventions should be taken into account.

Disease burden and patient needs and benefits in anogenital psoriasis: developmental specificities for person-centred healthcare of emerging adults and adults

BACKGROUND

Establishing romantic relationships involving cohabitation and/or sexual intercourse is an overriding task for many people during emerging adulthood, i.e. from their late teens through the twenties. The diagnosis of anogenital psoriasis may hinder social/intimate relationships, resulting in higher disease burden in this age group.

OBJECTIVES

To compare the disease burden and patient needs/benefits between emerging adults (18-30 years) and adults (>30 years) with psoriasis, with and without anogenital involvement; and to identify sociodemographic/clinical variables accounting for better patient-reported outcomes.

METHODS

Patients aged ≥18 years with psoriasis vulgaris were recruited within a cross-sectional nationwide survey randomly assigning 157 dermatology practices/clinics in Germany. Anogenital involvement was established based on a high-resolution grid on the topology of psoriasis. The main outcome measures were the Psoriasis Area and Severity Index (PASI), the EuroQoL visual analogue scale (EQ-VAS), the Dermatology Life Quality Index (DLQI) and the Patient Benefit Index (PBI).

RESULTS

Participants were 1921 patients: 173 emerging adults and 1749 adults >30 years. Anogenital involvement was observed in 621 patients (32.3%). Patient with anogenital psoriasis reported decreased health and more QoL impairments compared with those without anogenital lesions. Emerging adults presented more QoL impairments and less treatment benefits than older patients, and they were more prone to underrate a wide range of needs, except when the anogenital area was affected. Beyond anogenital involvement and higher disease severity, less treatment benefits were associated with more QoL impairments, particularly for emerging adults.

CONCLUSIONS

The developmental instability of many emerging adults may result in difficulties to establish/adhere to treatment goals and thus in decreased perception of treatment benefit and more QoL impairments. Anogenital involvement is a risk factor for increased disease burden regardless of age. Assessing anogenital involvement in all patients and helping younger patients to define/adhere to treatment goals should be prioritized in patient-centred healthcare for psoriasis.

Characterizing treatment-related patient needs in atopic eczema: insights for personalized goal orientation

BACKGROUND

Atopic eczema (AE) is a common and burdensome chronic skin disease. Clinical guidelines suggest an evidence-based, personalized and stepwise treatment approach. Only few studies have so far focused on the specific patient needs in treatment.

OBJECTIVES

To characterize therapeutic needs of patients with AE in routine care.

METHODS

Nationwide cross-sectional study in 91 dermatology practices and outpatient clinics. Descriptive statistics were used for valuation. Comparisons of HRQoL and general health status were performed including subgroups (age, gender and disease duration). Group comparisons of patient needs were performed for age groups, gender and disease duration. Correlations between patients' needs (PNQ) and HRQoL, generic health status and severity were tested. In addition, a hierarchical regression analysis was performed to determine which variables contribute to explain the variance in patient needs.

RESULTS

Analysis of 1678 patients (60.5% female, mean age 38.35 ± 15.92 years) revealed a high disease burden with mean SCORAD of 42.26 ± 18.63, mean DLQI of 8.49 ± 6.45 and mean EQ VAS of 63.62 ± 21.98. Among the patient needs that were most frequently rated as 'quite important'/'very important' were as follows: 'to be free of itching' (96.0%), 'to get better skin quickly' (87.7%) and 'to be healed of all skin defects' (85.7%). In general, older people, women and patients who had been diagnosed with AE for 1 year or less rated the treatment needs as more important than younger patients, men and patients who had been diagnosed with AE for more than 1 year. Major determinants of higher needs were skin-related quality of life impairments, higher disease severity and higher age.

CONCLUSIONS

Patients with AE show a high number and variety of therapeutic needs related to disease signs and symptoms, which are associated with individual disease burden. The patient needs vary substantially according to patient characteristics. Identification of patient-specific needs may support personalized, patient-centred care and shared decision-making.

Strategies to reduce stigma related to visible chronic skin diseases: a systematic review

Many patients with a visible chronic skin disease experience discrimination and stigmatization. This results in psychosocial impairments in addition to the burden of disease and emphasizes the urgency to implement effective stigma-reduction strategies. To synthesize what is known globally about effective interventions to reduce stigma associated with visible chronic skin diseases, a systematic review was conducted. Four electronic databases were searched until May 2018. Studies evaluating interventions to reduce stigmatization in patients with visible chronic skin diseases and applying at least one stigma-related outcome measure were included. Data were extracted on study design, country, study population, outcome measures and main findings. Results were subsequently synthesized in a narrative review. Critical Appraisal Skills Programme tools were used to assess study quality. Nineteen studies were included in the review. Study design was very heterogeneous and study quality rather poor. Thirteen studies addresses patients with leprosy in low- and middle-income countries, and one study each targeted patients with onychomycosis, leg ulcer, facial disfigurement, atopic dermatitis, vitiligo and alopecia. Evaluated interventions were mainly multi-faceted incorporating more than one type of intervention. While 10 studies focused on the reduction in self-stigma and 4 on the reduction in public stigma, another 5 studies aimed at reducing both. The present review revealed a lack of high-quality studies on effective approaches to reduce stigmatization of patients with visible chronic skin diseases. Development and evaluation of intervention formats to adequately address stigma is essential to promote patients' health and well-being.

Translating the WHA resolution in a member state: towards a German programme on 'Destigmatization' for individuals with visible chronic skin diseases

BACKGROUND

Even today, a substantial number of individuals with visible skin diseases still suffer from incomprehension and stigmatization. About 10 million people are affected by such diseases in Germany. The WHO strongly urges member states to take measures against stigmatization in skin diseases.

OBJECTIVES

Objectives are the development of an action programme to raise awareness and address stigmatization. Therefore, conception, development and testing of interventions for the destigmatization of persons with skin diseases in Germany will be carried out.

METHODS

A series of actions addressing decision makers, politicians and the Federal Ministry of Health were initiated, all based on the World Health Assembly (WHA). Argumentation was largely based on data from health services research. Supported by the Federal Ministry of Health, a concept against stigmatization was developed by an expert consortium of researchers, dermatologists and patients. Specific strategies of structured destigmatization between those affected and those not will be developed and scientifically evaluated.

RESULTS

The activities addressed to politics were - to a large extent - successfully and financially supported by a 3-year programme (2018-2020), designed to develop interventions against stigma. It was funded by the Federal Ministry of Health. The project includes conception and development, intervention and evaluation, data analyses and development of a long-term concept.

CONCLUSIONS

The WHO's call against stigmatization in psoriasis (resolution WHA67.9 and global report on psoriasis 2016) was taken into account and developed into a destigmatization programme supported by the German government and German politicians. This has been achieved by successful collaborations between dermatologists, researchers, patients and policymakers. Next step will be the testing of interventions in situations and surroundings, where stigmatization usually occurs. The data will be used for the implementation of a long-term concept that can be used to continue destigmatization in Germany far beyond the project's initial phase.

The psychometric evaluation of the quality of life in short stature youth (QoLISSY) instrument for German children born small for gestational age

PURPOSE

This study aimed to validate the disease-specific "quality of life in short stature youth (QoLISSY)-instrument" that assessesQuery the health-related quality of life (HrQoL) in German children and adolescents diagnosed as small for gestational age (SGA) in a patient and parent report.

METHODS

The psychometric performance of the German version of the QoLISSY questionnaire was examined in terms of reliability and validity in 65 SGA families (17 child reports/64 parent reports) and compared to the psychometric performance of the original European QoLISSY dataset of over 200 children with growth hormone deficiency and idiopathic short stature (ISS).

RESULTS

The analysis yielded psychometrically favorable results with excellent reliability and acceptable discriminant validity. The instrument's operating characteristics were comparable to the results of the original European QoLISSY data. In the parent- as well as child report, children with SGA had lower HrQoL scores than children with ISS. Convergent validity was demonstrated by significant correlations between the QoLISSY scales and the generic KIDSCREEN-10 Index.

CONCLUSION

Psychometric testing suggests that QoLISSY is a promising instrument to assess the HrQoL of young German people with SGA. Both versions (parent- and child report) appear to detect differences between SGA and other conditions (e.g. ISS). QoLISSY can be used in clinical studies, health service research, as well as in practice in children with SGA and their parents. For a cross-cultural application of the instrument in SGA, the tool needs be validated in sufficiently large SGA samples within respective countries.

[Healthcare research in dermatology 2018 - power of the factual : What healthcare research is and who it serves]

In the dermatology practiced in Germany, healthcare research is an established and highly differentiated discipline. In many university dermatological institutions and private practices, studies are carried out on the processes of healthcare research for skin diseases. Commissioned by the German Society of Dermatology and the Professional Association of German Dermatologists, a significant number of the studies and projects are conducted by the German Center for Health Services Research in Dermatology (CVderm) as a nationwide reference center. Important projects include the implementation of patient registers and national care studies, research with secondary data and carrying out methodological studies for the further development of scientific questions. Important results are the national healthcare conferences for psoriasis, skin cancer, wounds and atopic dermatitis, the regional care networks as well as projects and cooperation with health insurance companies, local government and public institutions. In the interests of improved patient care, important factors of care are continuously improved. Future health services research in dermatology will be able to contribute even more efficiently for better care planning and management. Patient registers will facilitate the transfer of innovations into care and help to ensure that new treatment approaches can be implemented. Registers also support the optimization of therapy approaches, which can no longer be carried out on the basis of clinical studies alone, for example in the case of psoriasis, due to the large number of drugs available. In the era of digital medicine, healthcare research has an even more important function.

Multiparametric monitoring of microbial faecal pollution reveals the dominance of human contamination along the whole Danube River

The microbial faecal pollution of rivers has wide-ranging impacts on a variety of human activities that rely on appropriate river water quality. Thus, detailed knowledge of the extent and origin of microbial faecal pollution is crucial for watershed management activities to maintain safe water use. In this study, the microbial faecal pollution levels were monitored by standard faecal indicator bacteria (SFIB) along a 2580 km stretch of the Danube, the world's most international river, as well as the Danube's most important tributaries. To track the origin of faecal pollution, host-associated Bacteroidetes genetic faecal marker qPCR assays for different host groups were applied in concert with SFIB. The spatial resolution analysis was followed by a time resolution analysis of faecal pollution patterns over 1 year at three selected sites. In this way, a comprehensive faecal pollution map of the total length of the Danube was created, combining substantiated information on both the extent and origin of microbial faecal pollution. Within the environmental data matrix for the river, microbial faecal pollution constituted an independent component and did not cluster with any other measured environmental parameters. Generally, midstream samples representatively depicted the microbial pollution levels at the respective river sites. However, at a few, somewhat unexpected sites, high pollution levels occurred in the lateral zones of the river while the midstream zone had good water quality. Human faecal pollution was demonstrated as the primary pollution source along the whole river, while animal faecal pollution was of minor importance. This study demonstrates that the application of host-associated genetic microbial source tracking markers in concert with the traditional concept of microbial faecal pollution monitoring based on SFIB significantly enhances the knowledge of the extent and origin of microbial faecal pollution patterns in large rivers. It constitutes a powerful tool to guide target-oriented water quality management in large river basins.

Validation of the Italian Quality of Life in Short Stature Youth (QoLISSY) questionnaire

PURPOSE

The Quality of Life in Short Stature Youth (QoLISSY) questionnaire is a disease-specific instrument developed to assess health-related quality of life (HrQoL) in children with short stature. While the original instrument was simultaneously developed in five European countries, this study describes the results of the Italian QoLISSY translation, cultural adaptation, and validation.

METHODS

Focus group discussions and a cognitive debriefing process with children (N = 12) diagnosed with growth hormone deficiency or idiopathic short stature and one parent each, as well as parents of younger children (N = 20) were conducted to examine the linguistic and content validity of the Italian version. Psychometric testing was performed using data from the subsequent field- and re-test (N = 32).

RESULTS

The results of the qualitative testing of the Italian sample revealed comparability of content to data of the original five European countries. The following field- and re-test results were psychometrically satisfactory including good item and scale operating characteristics, sufficient evidence of reliability, and acceptable evidence of construct validity.

CONCLUSION

In conclusion, the Italian QoLISSY HrQoL-dimensions are comparable to other European countries. The psychometric quality of the Italian QoLISSY version is satisfactory and the instrument is ready for use in Italian patients and their parents.

Development and pilot-testing of a condition-specific instrument to assess the quality-of-life in children and adolescents born with esophageal atresia

The survival rate of children with esophageal atresia has today reached 95%. However, children are at risk of chronic morbidity related to esophageal and respiratory dysfunction, and associated anomalies. This study describes the pilot testing of a condition-specific health-related quality-of-life instrument for children with esophageal atresia in Sweden and Germany, using a patient-derived development approach consistent with international guidelines. Following a literature review, standardized focus groups were conducted with 30 Swedish families of children with esophageal atresia aged 2-17 years. The results were used for item generation of two age-specific pilot questionnaire versions. These were then translated from Swedish into German with considerations of linguistic and semantical perspectives. The 30-item pilot questionnaire for children aged 2-7 years was completed by 34 families (parent report), and the 50-item pilot questionnaire for children aged 8-17 years was completed by 52 families (51 child report, 52 parent report), with an overall response rate of 96% in the total sample. Based on predefined psychometric criteria, poorly performing items were removed, resulting in an 18-item version with three domains (Eating, Physical health and treatment, Social isolation and stress,) for children aged 2-7 years and a 26-item version with four domains (Eating, Social relationships, Body perception, and Health and well-being) for children aged 8-17 years. Both versions demonstrated good internal consistency reliability and acceptable convergent and known-groups validity for the total scores. The study identified specific health-related quality-of-life domains for pediatric patients with esophageal atresia, highlighting issues that are important for follow-up care. After field testing in a larger patient sample, this instrument can be used to enhance the evaluation of pediatric surgical care.

Review of lattice results concerning low-energy particle physics: Flavour Lattice Averaging Group (FLAG)

We review lattice results related to pion, kaon, D- and B-meson physics with the aim of making them easily accessible to the particle-physics community. More specifically, we report on the determination of the light-quark masses, the form factor [Formula: see text], arising in the semileptonic [Formula: see text] transition at zero momentum transfer, as well as the decay constant ratio [Formula: see text] and its consequences for the CKM matrix elements [Formula: see text] and [Formula: see text]. Furthermore, we describe the results obtained on the lattice for some of the low-energy constants of [Formula: see text] and [Formula: see text] Chiral Perturbation Theory. We review the determination of the [Formula: see text] parameter of neutral kaon mixing as well as the additional four B parameters that arise in theories of physics beyond the Standard Model. The latter quantities are an addition compared to the previous review. For the heavy-quark sector, we provide results for [Formula: see text] and [Formula: see text] (also new compared to the previous review), as well as those for D- and B-meson-decay constants, form factors, and mixing parameters. These are the heavy-quark quantities most relevant for the determination of CKM matrix elements and the global CKM unitarity-triangle fit. Finally, we review the status of lattice determinations of the strong coupling constant [Formula: see text].

MOBILE MAPPING BY FMCW SYNTHETIC APERTURE RADAR OPERATING AT 300 GHZ

While optical cameras or laser systems are widely used for mobile mapping low attention was payed for radar systems. Due to new semiconductor technologies, compact and leight weight SAR systems based on the Frequency Modulated Continuous Wave (FMCW) principle in the millimeter wave domain can serve for mobile radar mapping on cars. For mapping of long stripes along roads in close range a special strategy for focusing of SAR images was developed. Hereby local adapted planes for processing are used considering the IMU data of the sensor. An experimental system was designed for high resolution radar mapping of urban scenes in close range geometry. This small and leight weighted system has a bandwidth of 30 GHz (5 mm resolution) and operates with 300 GHz in the lower terahertz domain. Experiments with a van in an urban scenario were carried out for proof of applicability of an operating SAR system resolving objects in the subcentimeter domain. The results show that narrow cracks in the asphalt of the road are visible and the measuring of small metallic objects placed in the scene is possible. Based on this mobile mapping techniques a first result from an acquisition of vertical facade structure is shown.

Occurrence of human-associated Bacteroidetes genetic source tracking markers in raw and treated wastewater of municipal and domestic origin and comparison to standard and alternative indicators of faecal pollution

This was a detailed investigation of the seasonal occurrence, dynamics, removal and resistance of human-associated genetic Bacteroidetes faecal markers (GeBaM) compared with ISO-based standard faecal indicator bacteria (SFIB), human-specific viral faecal markers and one human-associated Bacteroidetes phage in raw and treated wastewater of municipal and domestic origin. Characteristics of the selected activated sludge wastewater treatment plants (WWTPs) from Austria and Germany were studied in detail (WWTPs, n = 13, connected populations from 3 to 49000 individuals), supported by volume-proportional automated 24-h sampling and chemical water quality analysis. GeBaM were consistently detected in high concentrations in raw (median log10 8.6 marker equivalents (ME) 100 ml(-1)) and biologically treated wastewater samples (median log10 6.2-6.5 ME 100 ml(-1)), irrespective of plant size, type and time of the season (n = 53-65). GeBaM, Escherichia coli, and enterococci concentrations revealed the same range of statistical variability for raw (multiplicative standard deviations s* = 2.3-3.0) and treated wastewater (s* = 3.7-4.5), with increased variability after treatment. Clostridium perfringens spores revealed the lowest variability for raw wastewater (s* = 1.5). In raw wastewater correlations among microbiological parameters were only detectable between GeBaM, C. perfringens and JC polyomaviruses. Statistical associations amongst microbial parameters increased during wastewater treatment. Two plants with advanced treatment were also investigated, revealing a minimum log10 5.0 (10th percentile) reduction of GeBaM in the activated sludge membrane bioreactor, but no reduction of the genetic markers during UV irradiation (254 nm). This study highlights the potential of human-associated GeBaM to complement wastewater impact monitoring based on the determination of SFIB. In addition, human-specific JC polyomaviruses and adenoviruses seem to be a valuable support if highly specific markers are needed.

[Evaluation of a Self-Help Supported Counseling Concept for Children and Adolescents with Disproportional Short Stature]

BACKGROUND

Disproportionate short stature may impair the quality of life (QoL) of patients and their families. This study aimed to evaluate a self-help supported counseling concept to increase the QoL of the participants.

METHODS

QoL data from 58 children/adolescents (8-17 years) with a diagnosis of achondroplasia was collected at 2 measurement points during one year using the the QoLISSY questionnaire (self-/parental report). Differences before and after participation vs. non-participation in the intervention were evaluated using a linear mixed model.

RESULTS

The longitudinal results show a greater increase of QoL in the active intervention group compared to a passive control group (p=0,005). The increase in the self-reported QoL of affected patients was significantly higher than for the parent-report (p=0,048).

CONCLUSIONS

The study shows that patients with achondroplasia benefit from a self-help supported counseling concept. However, this should be tested in a randomized trial.

Review of lattice results concerning low-energy particle physics

We review lattice results related to pion, kaon, [Formula: see text]- and [Formula: see text]-meson physics with the aim of making them easily accessible to the particle-physics community. More specifically, we report on the determination of the light-quark masses, the form factor [Formula: see text], arising in semileptonic [Formula: see text] transition at zero momentum transfer, as well as the decay-constant ratio [Formula: see text] of decay constants and its consequences for the CKM matrix elements [Formula: see text] and [Formula: see text]. Furthermore, we describe the results obtained on the lattice for some of the low-energy constants of [Formula: see text] and [Formula: see text] Chiral Perturbation Theory and review the determination of the [Formula: see text] parameter of neutral kaon mixing. The inclusion of heavy-quark quantities significantly expands the FLAG scope with respect to the previous review. Therefore, we focus here on [Formula: see text]- and [Formula: see text]-meson decay constants, form factors, and mixing parameters, since these are most relevant for the determination of CKM matrix elements and the global CKM unitarity-triangle fit. In addition we review the status of lattice determinations of the strong coupling constant [Formula: see text].

Microorganism inactivation by an ozonation step optimized for micropollutant removal from tertiary effluent

This paper demonstrates the additional benefit of the microbicidal efficacy of an ozonation plant implemented for micropollutant removal from tertiary effluent. Due to the low amount of viruses and protozoa in the tertiary effluent, bacteriophage MS2 and spores of Bacillus subtilis were dosed as surrogates. At specific ozone consumptions of 0.6 and 0.9 g O3/g dissolved organic carbon (DOC) a 2-log colony forming unit (CFU) reduction was achieved for indigenous Escherichia coli and enterococci, and the limits of the European bathing water directive for the excellent quality of inland waters were met. Higher removal was impeded by the shielding effect of suspended solids in the effluent, which implies the combination of ozonation with a preceding filtration step if higher microbicidal performances are required. The surrogate virus MS2 was reduced by 4-5 log while no significant inactivation was detected for B. subtilis spores. Additionally, the impact of ozonation on the biochemical oxygen demand (BOD) was studied. The BOD5 measurement was not adversely affected despite the reduced concentration of microorganisms after ozonation. The intrinsic increase in BOD5 averaged 15% at 0.6-0.7 g O3/g DOC. The impact of the projected increase on the surface water quality is generally not considered a problem but has to be assessed on a case-by-case approach.

Acid phosphatase test proves superior to standard phenotypic identification procedure for Clostridium perfringens strains isolated from water

Clostridium perfringens is used as an indicator for persistent faecal pollution as well as to monitor the efficacy of water treatment processes. For these purposes, differentiation between C. perfringens and other Clostridia is essential and is routinely carried out by phenotypic standard tests as proposed in the ISO/CD 6461-2:2002 (ISO_LGMN: lactose fermentation, gelatine liquidation, motility and nitrate reduction). Because the ISO_LGMN procedure is time consuming and labour intensive, the acid phosphatase test was investigated as a possible and much more rapid alternative method for confirmation. The aim of our study was to evaluate and compare confirmation results obtained by these two phenotypic methods using genotypically identified strains, what to our knowledge has not been accomplished before. For this purpose, a species specific PCR method was selected based on the results received for type strains and genotypically characterised environmental strains. For the comparative investigation type strains as well as presumptive C. perfringens isolates from water and faeces samples were used. The acid phosphatase test revealed higher percentage (92%) of correctly identified environmental strains (n = 127) than the ISO_LGMN procedure (83%) and proved to be a sensitive and reliable confirmation method.

Hypothesis-driven approach for the identification of fecal pollution sources in water resources

Water resource management must strive to link catchment information with water quality monitoring. The present study attempted this for the field of microbial fecal source tracking (MST). A fecal pollution source profile based on catchment data (e.g., prevalence of fecal sources) was used to formulate a hypothesis about the dominant sources of pollution in an Austrian mountainous karst spring catchment. This allowed a statistical definition of methodical requirements necessary for an informed choice of MST methods. The hypothesis was tested in a 17-month investigation of spring water quality. The study followed a nested sampling design in order to cover the hydrological and pollution dynamics of the spring and to assess effects such as differential persistence between parameters. Genetic markers for the potential fecal sources as well as microbiological, hydrological, and chemo-physical parameters were measured. The hypothesis that ruminant animals were the dominant sources of fecal pollution in the catchment was clearly confirmed. It was also shown that the concentration of ruminant markers in feces was equally distributed in different ruminant source groups. The developed approach provides a tool for careful decision-making in MST study design and might be applied on various types of catchments and pollution situations.

Inactivation of Pseudomonas aeruginosa in electrochemical advanced oxidation process with diamond electrodes

The electrochemical advanced oxidation process (EAOP) with diamond electrodes may serve as an additional technology to the currently approved methods for water disinfection. Only few data exist on the microbicidal effect of the EAOP. The aim of our study was to investigate the microbicidal effect of a flow-through oxidation cell with diamond electrodes, using Pseudomonas aeruginosa as the test organism. Without electrical current the EAOP had no measurable effect on investigated microbiological and chemical parameters. For direct electrical current a stronger impact was observed at low flow rate than at higher flow rate. Depending on the contact time of the oxidants and the type of quenching reagent added, inactivation of P. aeruginosa was in the range log 1.6-3.6 at the higher flow rate and log 2.4-4.4 at the lower rate. Direct electrical current showed a stronger microbicidal effect than alternating current (maximum reduction log 4.0 and log 2.9, respectively). The microbiological results of experiments with this EAOP prototype revealed higher standard deviations than expected, based on our experience with standard water disinfection methods. Safe use of an EAOP system requires operating parameters to be defined and used accurately, and thus specific monitoring tests must be developed.

Escherichia coli and enterococci are sensitive and reliable indicators for human, livestock and wildlife faecal pollution in alpine mountainous water resources

AIMS

This study evaluated the applicability of standard faecal indicator bacteria (SFIB) for alpine mountainous water resources monitoring.

METHODS AND RESULTS

Escherichia coli, enterococci (ENTC) and Clostridium perfringens were investigated by standard or frequently applied phenotypic and genotypic methods in a broad range of animal and human faecal sources in a large alpine mountainous area. Clostridium perfringens occurred only in human, livestock and carnivorous source groups in relevant average concentrations (log 4·7-7·0CFU g(-1) ) but not in herbivorous wildlife sources. Escherichia coli proved to be distributed in all faecal source groups with remarkably balanced average concentrations (log 7·0-8·4CFU g(-1) ). Except for single faecal samples from the cattle source group, prevalence rates for ENTC source groups were generally >87% with average concentrations of log 5·3-7·7 CFUg(-1) . To test the faecal indication capacity in the environment, faecal prevalence data were comparatively analysed with results from the concurrently performed multi-parametric microbial source tracking effort on karst spring water quality from the investigated alpine mountainous catchment (Reischer et al. 2008; Environ Microbiol 10:2598-2608).

CONCLUSION

Escherichia coli and enterococci are reliable faecal indicators for alpine mountainous water resources monitoring, although E. coli is the more sensitive one. Clostridium perfringens did not prove to be an indicator of general faecal pollution but is suggested a conservative microbial source tracking marker for anthropogenic faecal influence.

SIGNIFICANCE AND IMPACT OF THE STUDY

Applicability of SFIB is currently hotly debated. This is the first study providing comprehensive information on the applicability of SFIB at alpine mountainous habitats.