Structural characteristics and contractual terms of specialist palliative homecare in Germany

BACKGROUND

Multi-professional specialist palliative homecare (SPHC) teams care for palliative patients with complex symptoms. In Germany, the SPHC directive regulates care provision, but model contracts for each federal state are heterogeneous regarding staff requirements, cooperation with other healthcare providers, and financial reimbursement. The structural characteristics of SPHC teams also vary.

AIM

We provide a structured overview of the existing model contracts, as well as a nationwide assessment of SPHC teams and their structural characteristics. Furthermore, we explore whether these characteristics serve to find specifc patterns of SPHC team models, based on empirical data.

METHODS

This study is part of the multi-methods research project "SAVOIR", funded by the German Innovations Fund. Most model contracts are publicly available. Structural characteristics (e.g. number, professions, and affiliations of team members, and external cooperation) were assessed via an online database ("Wegweiser Hospiz- und Palliativversorgung") based on voluntary information obtained from SPHC teams. All the data were updated by phone during the assessment process. Data were descriptively analysed regarding staff, cooperation requirements, and reimbursement schemes, while latent class analysis (LCA) was used to identify structural team models.

RESULTS

Model contracts have heterogeneous contract partners and terms related to staff requirements (number and qualifications) and cooperation with other services. Fourteen reimbursement schemes were available, all combining different payment models. Of the 283 SPHC teams, 196 provided structural characteristics. Teams reported between one and 298 members (mean: 30.3, median: 18), mainly nurses and physicians, while 37.8% had a psychosocial professional as a team member. Most teams were composed of nurses and physicians employed in different settings; for example, staff was employed by the team, in private practices/nursing services, or in hospitals. Latent class analysis identified four structural team models, based on the team size, team members' affiliation, and care organisation.

CONCLUSION

Both the contractual terms and teams' structural characteristics vary substantially, and this must be considered when analysing patient data from SPHC. The identified patterns of team models can form a starting point from which to analyse different forms of care provision and their impact on care quality.

[Concept-dependent and -independent care effects of site-specific care concepts using "pain" as an example]

BACKGROUND

Structures of palliative care, cross-sectoral transitions and care pathways of patients with palliative care needs were investigated at two sites. The systematic comparison of similarities and differences using the topic of 'pain' as an example is intended to provide information on the extent to which these are related to site-specific palliative care concepts (integrated and cooperative).

METHODS

The study follows a mixed-methods design. In addition to a document analysis of anonymised patient records (n = 774), expert interviews (n = 20), as well as interviews with patients, relatives (n = 60) and focus groups (n = 12), were conducted.

RESULTS

The systematic comparative analysis provides evidence for concept-independent commonalities (e.g. sociodemographic distribution, aggravated pain treatment) as well as concept-dependent differences (e.g. care pathways, facilitated continuous symptom control through integrated care structures) in the context of integrated or cooperative palliative care.

DISCUSSION

Commonalities and differences with regard to the topic of pain, as focused on here, and its organisational management become tangible as effects of the respective organisational structure (= concept-dependent) as well as concept-independent external influencing factors.

Palliative care as a digital working world (PALLADiUM) - A mixed-method research protocol

BACKGROUND

In Palliative Care, actors from different professional backgrounds work together and exchange case-specific and expert knowledge and information. Since Palliative Care is traditionally distant from digitalization due to its holistically person-centered approach, there is a lack of suitable concepts enabling digitalization regarding multi-professional team processes. Yet, a digitalised information and collaboration environment geared to the requirements of palliative care and the needs of the members of the multi-professional team might facilitate communication and collaboration processes and improve information and knowledge flows. Taking this chance, the presented three-year project, PALLADiUM, aims to improve the effectiveness of Palliative Care teams by jointly sharing available inter-subjective knowledge and orientation-giving as well as action-guiding practical knowledge. Thus, PALLADiUM will explore the potentials and limitations of digitally supported communication and collaboration solutions.

METHODS

PALLADiUM follows an open and iterative mixed methods approach. First, ethnographic methods - participant observations, interviews, and focus groups - aim to explore knowledge and information flow in investigating Palliative Care units as well as the requirements and barriers to digitalization. Second, to extend this body, the analysis of the historical hospital data provides quantitative insights. Condensing all findings results in a to-be work system. Adhering to the work systems transformation method, a technical prototype including artificial intelligence components will enhance the collaborative teamwork in the Palliative Care unit.

DISCUSSION

PALLADiUM aims to deliver decisive new insights into the preconditions, processes, and success factors of the digitalization of a medical working environment as well as communication and collaboration processes in multi-professional teams.

TRIAL REGISTRATION

The study was registered prospectively at DRKS (Deutsches Register Klinischer Studien) Registration-ID: DRKS0025356 Date of registration: 03.06.21.

Fabrication possibilities and characterisation of chalcogenide glass-based sensors for bromide determination

The fabrication and characterization of potentiometric chalcogenide glass (CG) electrodes with selectivity for bromide in aqueous media are reported. The focus is on the production of chalcogenide glasses of the material system AgBr Ag2S As2S3 and their investigation by means of a series of physico-chemical methods, as well as on their fabrication with the aid of precision mechanical manufacturing and assembly techniques to form usable sensors and their testing. In addition to the production of conventional rod electrodes, it will be examined whether it is also possible to realize planar electrodes using thick-film technology.

[Patient-reported outcomes and quality of care in specialized palliative home care: a nationwide, prospective longitudinal cohort trial]

INTRODUCTION

Since 2007, patients receiving palliative care have been entitled to specialised outpatient palliative care (SAPV). Until now, the quality of care of the SAPV was only regionally focussed or in relation to individual SAPV teams. A nationwide analysis of outcome quality is still awaited. The organisation and design of structures and processes vary greatly from region to region, which complicates a comparative assessment of implementation. One way to measure the quality of the heterogeneous structures and processes is to collect patient-reported outcomes. Here, it is possible to use symptom burden, quality of care and patient satisfaction with SAPV care, since patients' quality of life is a central focus of SAPV care. This article is part of the research project SAVOIR, which is funded by the G-BA Innovation Fund.

METHODS

For this prospective longitudinal survey of the outcome quality of SAPV, structured data were collected at two measurement points (t₁ and t₂ [4-10 days after t₁]). A nationwide, representative sample of SAPV teams was targeted. These teams performed consecutive recruitment of patients included in SAPV. Two questionnaire instruments were used: the IPOS (Integrated Palliative Outcome Scale) at t₁ and t₂, and the QUAPS (quality control in specialized palliative home care) questionnaire at t₂. Patient-reported outcomes measured improvement in symptom burden, patient satisfaction, and quality of care from the patient perspective. In addition, an exploratory stepwise regression analysis of factors associated with satisfaction was conducted.

RESULTS

42 SAPV teams agreed to participate in the study. They recruited a total of 964 patients at measurement time t₁ (t₂: 690 patients). The analyses show that the number and intensity of symptoms from the patient perspective decreased significantly during the course of SAPV treatment, especially pain, gastrointestinal symptoms, but also psychological complaints. 74.7 % of the patients reported a high level of satisfaction with SAPV. Also, the quality of care was considered to be high by the patients. Exploratively, five factors were extracted that explain 55 % of the satisfaction with SAPV: respect for the patient's decision, quality of communication, support with practical problems, and referral to care measures as well as symptom relief between the two measurement points.

CONCLUSIONS

The SAPV patients recruited from a total of nine KV regions reported a reduced symptom burden and a high level of satisfaction with SAPV and rated the quality of care provided by SAPV as high.

The desmin mutation R349P increases contractility and fragility of stem cell-generated muscle micro-tissues

AIMS

Desminopathies comprise hereditary myopathies and cardiomyopathies caused by mutations in the intermediate filament protein desmin that lead to severe and often lethal degeneration of striated muscle tissue. Animal and single cell studies hinted that this degeneration process is associated with massive ultrastructural defects correlating with increased susceptibility of the muscle to acute mechanical stress. The underlying mechanism of mechanical susceptibility, and how muscle degeneration develops over time, however, has remained elusive.

METHODS

Here, we investigated the effect of a desmin mutation on the formation, differentiation, and contractile function of in vitro-engineered three-dimensional micro-tissues grown from muscle stem cells (satellite cells) isolated from heterozygous R349P desmin knock-in mice.

RESULTS

Micro-tissues grown from desmin-mutated cells exhibited spontaneous unsynchronised contractions, higher contractile forces in response to electrical stimulation, and faster force recovery compared with tissues grown from wild-type cells. Within 1 week of culture, the majority of R349P desmin-mutated tissues disintegrated, whereas wild-type tissues remained intact over at least three weeks. Moreover, under tetanic stimulation lasting less than 5 s, desmin-mutated tissues partially or completely ruptured, whereas wild-type tissues did not display signs of damage.

CONCLUSIONS

Our results demonstrate that the progressive degeneration of desmin-mutated micro-tissues is closely linked to extracellular matrix fibre breakage associated with increased contractile forces and unevenly distributed tensile stress. This suggests that the age-related degeneration of skeletal and cardiac muscle in patients suffering from desminopathies may be similarly exacerbated by mechanical damage from high-intensity muscle contractions. We conclude that micro-tissues may provide a valuable tool for studying the organization of myocytes and the pathogenic mechanisms of myopathies.

[Quality of care in specialized palliative homecare from the provider perspective: A qualitative study]

BACKGROUND

Since its introduction in 2007, the quality of care in specialized palliative home care (SAPV) is being measured using the patients' perspective. The perception of beneficial or inhibiting factors on the quality of care from the perspective of care providers received only little attention.

OBJECTIVE

To investigate the factors that promote or impede the quality of care in SAPV from the care providers' perspective.

METHODS

Within the framework of a transregional qualitative study, 113 problem-centered interviews were conducted on-site at 10 SAPV providers with their staff as well as their network partners. Grounded theory methodology was used for data curation and analysis.

RESULTS

The factors that are perceived as either enhancing or inhibiting the quality of care largely depends on the culture of care of the individual SAPV provider. For participating doctors, nurses and psychosocial professionals, successful performance is associated with good symptom control, participation of relatives and the achievement of certainty of action and of interpretation by means of 'good' decision-making procedures. Problematic performances are linked to a lack of time resulting in restlessness and especially in disagreement between the parties involved in the provision of care as well as to the denial of death.

CONCLUSIONS

The results of the study show that the perceived strategies, interpretations and evaluation categories, which are associated with good quality of care, are very heterogenous. On the basis of qualitative data, they do, however, follow three typical patterns in terms of cultures of care: proceduralism, holism and dualism.

A low-cost uniaxial cell stretcher for six parallel wells

Cells in the lungs, the heart, and numerous other organs, are constantly exposed to dynamic forces and deformations. To mimic these dynamic mechanical loading conditions and to study the resulting cellular responses such as morphological changes or the activation of biochemical signaling pathways, cells are typically seeded on flexible 2D substrates that are uniaxially or biaxially stretched. Here, we present an open-source cell stretcher built from parts of an Anet A8 3D printer. The cell stretcher is controlled by a fully programmable open-source software using GCode and Python. Up to six flexible optically clear substrates can be stretched simultaneously, allowing for comparative multi-batch biological studies including microscopic image analysis. The cell yield from the cell culture area of 4 cm² per substrate is sufficient for Western-blot protein analysis. As a proof-of-concept, we study the activation of the Yes-associated protein (YAP) mechanotransduction pathway in response to increased cytoskeletal tension induced by uniaxial stretching of epithelial cells. Our data support the previously observed activation of the YAP transcription pathway by stretch-induced increase in cytoskeletal tension and demonstrate the suitability of the cell stretcher to study complex mechano-biological processes.

micrObs - A customizable time-lapse camera for ecological studies

Camera traps for motion-triggered or continuous time-lapse recordings are readily available on the market. For demanding applications in ecology and environmental sciences, however, commercial systems often lack flexibility to freely adjust recording time intervals, suffer from mechanical component wear, and can be difficult to combine with auxiliary sensors such as GPS, weather stations, or light sensors. We present a robust time-lapse camera system that has been operating continuously since 2013 under the harsh climatic conditions of the Antarctic and Subantarctic regions. Thus far, we have recorded over one million images with individual cameras. The system consumes 122 mW of power in standby mode and captures up to 200,000 high-resolution (16 MPix) images without maintenance such as battery or image memory replacement. It offers time-lapse intervals between 2 s and 1 h, low-light or night-time power saving, and data logging capabilities for additional inputs such as GPS and weather data.

Factors influencing GPs' perception of specialised palliative homecare (SPHC) importance - results of a cross-sectional study

Background

General Practitioners (GPs) are the main providers of primary palliative care (PPC). At the same time they are the main initiators of specialised palliative homecare (SPHC). In Germany, little is known about factors which influence GPs in their involvement of SPHC. Aim of our study is to identify factors that drive GPs to give value to and involve SPHC.

Methods

A cross-sectional survey was performed. In 2018, questionnaires were mailed to 6000 randomly selected GPs from eight German federal states, focusing on the extent of GPs’ palliative care activities and their involvement of SPHC.

Results

With a response rate of 19.4% and exclusion of GPs working in SPHC-teams, n = 1026 questionnaires were appropriate for analysis. GPs valued SPHC support as the most “important/very important” for both “technical/invasive treatment measures” (95%) and availability outside practice opening hours (92%).

The most relevant factor influencing perceived SPHC-importance was GPs’ self-reported extent of engagement in palliative care (β = − 0.283; CI 95% = − 0.384;−0.182), followed by the perceived quality of utilised SPHC (β = 0.119; CI 95% = 0.048;0.190), involvement in treatment of palliative patients after SPHC initiation (β = 0.088; CI 95% = 0.042;0.134), and conviction that palliative care should be a central part of GPs’ work (β = − 0.062; CI 95% = − 0.116;−0.008). Perceived SPHC-importance is also associated with SPHC-referrals (β =0.138; p < 0.001). The lower the engagement of GPs in palliative care, the more they involve SPHC and vice versa.

Conclusions

GPs with low reported activity in palliative care are more likely to initialise SPHC for palliative care activities they do not deliver themselves for various reasons, which might mean that the involvement of SPHC is substitutive instead of complementary to primary palliative care. This finding and its interpretation should be given more attention in the future policy framework for (specialised) palliative homecare.

Trial registration

German Clinical Trials Register DRKS00014726, 14.05.2018.

Study protocol for a multi-methods study: SAVOIR - evaluation of specialized outpatient palliative care (SAPV) in Germany: outcomes, interactions, regional differences

Background

Since 2007, the German statutory health insurance covers Specialized Outpatient Palliative Care (SAPV). SAPV offers team-based home care for patients with advanced and progressive disease, complex symptoms and life expectancy limited to days, weeks or months. The introduction of SAPV is ruled by a directive (SAPV directive). Within this regulation, SAPV delivery models can and do differ regarding team structures, financing models, cooperation with other care professionals and processes of care. The research project SAVOIR is funded by G-BA’s German Innovations Fund to evaluate the implementation of the SAPV directive.

Methods

The processes, content and quality of SAPV will be evaluated from the perspectives of patients, SAPV teams, general practitioners and other care givers and payers. The influence of different contracts, team and network structures and regional and geographic settings on processes and results including patient-reported outcomes will be analyzed in five subprojects: [1] structural characteristics of SAPV and their impact on patient care, [2] quality of care from the perspective of patients, [3] quality of care from the perspective of SAPV teams, hospices, ambulatory nursing services, nursing homes and other care givers, content and extent of care from [4] the perspective of General Practitioners and [5] from the perspective of payers.

The evaluation will be based on different types of data: team and organizational structures, treatment data based on routine documentation with electronic medical record systems, prospective assessment of patient-reported outcomes in a sample of SAPV teams, qualitative interviews with other stakeholders like nursing and hospice services, a survey in general practitioners and a retrospective analysis of claims data of all SAPV patients, covered by the health insurance fund BARMER in 2016.

Discussion

Data analysis will allow identification of variables, associated with quality of SAPV. Based on these findings, the SAVOIR study group will develop recommendations for the Federal Joint Committee for a revision of the SAPV directive.

Trial registration

German Clinical Trials Register (DRKS): DRKS00013949 (retrospectively registered, 14.03.2018), DRKS00014726 (14.05.2018), DRKS00014730 (30.05.2018). Subproject 3 is an interview study with professional caregivers and therefore not registered in DRKS as a clinical study.

Megakaryocytes and Platelets as the Main Cause for Vascular Events in Chronic Myeloproliferative Disorders

Megakaryocytes are part of clonal hematopoiesis in chronic myeloproliferative disorders and are responsible for most of the clinical complications in this disease. About 30-40% of patients with polycythemia vera (PV) and essential thrombocythemia (ET) suffer from thrombotic complications, and microcirculatory disorders are common. Spontaneous bleeding mainly from the gastrointestinal tract is another complication that is especially prevalent in myelofibrosis and advanced stages of chronic myeloid leukemia.

In vivo, the bone marrow is hypercellular and the concentration of megakaryocytes increased with characteristic morphological abnormalities. Megakaryocytes are enlarged and ploidy is increased in PV and ET but small mononuclear cells with decreased ploidy are a feature of CML. Despite spontaneous growth in cul-ture, megakaryocytes in chronic MPD are hypersensitive to added interleukin-3, interleukin-6 and GM-CSF.

Platelets released from these megakaryocytes show abnormal morphology and ultrastructure, reflected in loss of storage granules and organelles, increased volume distribution and low buoyant density. Uptake, storage and secretion of platelet dense granule constituents is abnormal, and the plasma levels of platelet specific proteins which may also include growth factors for fibroblasts are elevated. At high platelet counts, spontaneous aggregation is observed, whereas agonist-induced aggregation in vitro with adrenaline, ADP and collagen is often defective. Platelet thromboxane generation may be stimulated, and production along the lipoxygenase pathway is decreased. Abnormalities of glycoprotein receptors and decreased fibrinogen binding have been reported but their clinical significance is uncertain. Several observations suggest that not only receptor defects but ineffective intracellular signalling may be responsible for platelet function abnormalities.

No single underlying defect has been discovered that could explain this variety of pathological findings. Moreover, a combination of intrinsic megakaryocyte abnormalities and increased susceptibility of platelets to activation makes it difficult to differentiate secondary phenomena from effects of clonal hematopoiesis. How-ever, there are some clinical guidelines for therapy.

Most elderly patients will be treated with cytoreductive therapy. Alkylating drugs and 32P have been shown to be leukemogenic, but even hydroxyurea may have a 10% incidence of leukemia induction after long-term therapy. Therapy with platelet-inhibitory drugs is often not sufficient to control thrombosis, and may aggravate a bleeding tendency, so that younger patients with PV and ET are increasingly treated with anagrelide or interferon alpha (A-IFN). Anagrelide is a quinazolin derivative that specifically inhibits megakaryocytopoiesis, while A-IFN may suppress clonal hematopoiesis by an unknown mechanism.

The Significance of Malate Dehydrogenase Isoenzymes in Human Blood Platelets

Two MDH isoenzymes were detected in the homogenate of normal human blood platelets. According to their properties the cationic isoenzyme is compartmentalized in the mitochondria, the anionic one belongs to the cytoplasma. In spite of the few mitochondria in human blood platelets the proportion of the cationic enzyme is relatively high.

Both of these enzymes could belong to a transfer system for malate transport across the mitochondrial membrane. As human blood platelets do not contain creatine phosphate a system like that could be of significance for platelet function.

Untersuchungen über den In-vitro-Einfluß der kationischen Polypeptide Protaminsulfat und Trasylol auf Aggregation und Retraktion menschlicher Blutplättchen

Basische Polypeptide wie Polylysin, Protaminsulfat, Trasylol oder Lysozym können konzentrationsabhängig die Blutplättchenaggregation auslösen. Die Reaktion läuft im 2,7 mmol EDTA-Plasma ebenso wie in synthetischen Medien ab, ist also offenbar von der Anwesenheit zweiwertiger Kationen oder plasmatischer Kofaktoren weitgehend unabhängig. Eine Temperaturabhängigkeit ließ sich zwischen 4 und 37° C nicht feststellen, trotzdem konnten wir Stoffwechselsteigerungen in den aggregieren-den Plättchen nachweisen, die nach Art und Ausmaß etwa den durch Ca++- oder Mg++-auslösbaren Veränderungen entsprachen. Die Befunde könnten die bei der Heparinneutralisierung nach extrakorporaler Zirkulation in Form von Thrombo-embolien oder verstärkter Blutungsneigung auftretenden Komplikationen erklären.

Chromatographic Isolation of the LDH-Isoenzymes of Human Blood Platelets and an Investigation of Their Enzyme Kinetics

The LDH-isoenzymes of human blood platelets show a distinct predominance of the isoenzymes 2 and 3 upon chromatography on DEAE-cellulose. Small amounts of LDH-1 are also present, while only traces of LDH-4 and -5 can be detected.

Enzyme kinetic investigations of the principal isoenzymes LDH-1, -2 and -3 clearly show that the differences in inhibition constants with pyruvate as substrate which are demonstrable at 25° largely disappear at 37°. On the other hand, the differences among the isoenzymes in their affinity for pyruvate and lactate as substrate as well as in with respect to the optimal substrate concentrations of pyruvate are more marked at 37° than at 25°. Also, the type of inhibition found with lactate as substrate is increasingly the expression of a higher order reaction in going from LDH-1 to LDH-3. A dependence of the LDH distribution pattern upon the metabolism of the cell is discussed. A comparison of our results with thrombocytes with those of other workers with erythrocytes and leucocytes makes it unlikely that the LDH pattern is directly dependent upon the existence of an oxidative metabolism. Rather, the redox potential of the cell could be of importance for the nature of the pattern of isoenzymes and for their differing kinetic properties.

Untersuchungen über das Verteilungsmuster der Laktatdehydrogenase-Isoenzyme menschlicher Blutplättchen

Mit Hilfe der Polyacrylamid-Disc-Elektrophorese wurde das LDH-Isoenzymver-teilungsmuster normaler menschlicher Blutplättchen untersucht und eine Verteilung mit starkem Überwiegen der Banden 2 und 3 bei deutlich geringerem Anteil der LDH-1 gefunden. LDH-4 konnte nur in Spuren, LDH-5 in diesem System nicht nachgewiesen werden. Folgende Anteile wurden für die einzelnen Isoenzyme bestimmt (x ± s, n = 16): LDH-1 = 9,8 ± 7,3, LDH-2 =50,7 ± 7,7, LDH-3 = 38,3 ± 7,5, LDH-4 = 1,2 ± 1,2 rel. %.

Das normale Thrombelastogramm

1. Bei 147 jugendlichen Versuchspersonen beiderlei Geschlechts wurden die thrombelastographischen Normalwerte im Nativblut ermittelt. Dabei ergaben sich die Werte r = 12ʹ 26ʺ (Standardabweichung s = ± 1ʹ 34ʺ), k = 5ʹ 53ʺ (s = ±1ʹ 1ʺ) und mε = 108 (s = ± 17,7) für das Gesamtkollektiv. Eine Gegenüberstellung der Ergebnisse der männlichen und weiblichen Versuchspersonen zeigte keine signifikanten Unterschiede zwischen beiden Gruppen.

2. Es wird gezeigt, daß Thrombelastogramme, die unter Verwendung von Zitratvollblut gewonnen wurden, bei geeigneter Rekalzifizierungstechnik die gleiche Empfindlichkeit und Streuungsbreite der Meßwerte wie bei Verwendung von Nativblut aufweisen. Danach erscheint die Verwendung von Zitratvollblut für klinische Zwecke besonders brauchbar.

Die mit Zitratvollblut an 127 Versuchspersonen beiderlei Geschlechts gewonnenen Normalwerte sind: r = 8ʹ 25ʺ (s = ± 1ʹ 2ʺ), k = 4ʹ 4ʺ (s = 47ʺ) und mε = 109 (s = ± 17,3).

Interrelations of Thrombo-Embolic Diseases and Blood-Group Distribution

A comparison between the repartition of the blood groups in 461 patients suffering from thromboembolic disorders and the normal distribution has shown a statistically ascertained predominance of the group A1. On the other hand the blood groups 0 and A2 are distinctly less frequent than in the normal distribution.

Untersuchungen über den Faktor IX

Unter Berücksichtigung früherer Befunde, nach denen der Nachweis einer vollen Faktor-IX-Aktivität eine vorausgehende, in Gegenwart von Kalzium erfolgende Kontaktaktivierung des zu testenden Substrats durch benetzbare Oberflächen voraussetzt, wird die Aktivität des Faktors IX in Plasma und Serum untersucht. Um dekalzifizierende Maßnahmen zu vermeiden, werden die Bestimmungen der Plasmaaktivität in heparinisiertem, thrombozytenfreiem Nativplasma durchgeführt. Zur Ausschaltung einer möglichen Heparinwirkung wird das zu testende Serum in gleicher Weise wie Nativplasma mit Heparin versetzt. Die Heparinkonzentration war mit 0,075 E/ml Nativplasma oder Serum so gewählt, daß sie die Aktivität des Faktors IX selbst nicht beeinflußte (Tab. 1).

Mit diesen methodischen Voraussetzungen läßt sich im Normalplasma ebenso wie im Plasma eines Patienten mit Hämophilie B keine oder nur eine sehr geringe Faktor-IX-Aktivität nachweisen. Unter gleichen Bedingungen findet sich dagegen in Normalserum eine hohe, in Hämophilie-B-Serum dagegen wiederum keine oder nur eine sehr geringe Faktor-IX-Aktivität. Hinsichtlich der Faktor-IX-Aktivität ergeben sich somit zwischen Normalplasma und Hämophilie-B-Plasma keine Unterschiede. Daraus folgt, daß die Hämophilie B nicht durch einen plasmatischen Defekt, sondern durch eine gestörte Faktor-IX-Bildung während des Gerinnungsablaufes charakterisiert ist.

Das Fehlen einer Faktor-IX-Aktivität in Normalplasma macht es möglich, in Einstufentests zur Bestimmung des Faktors IX Normalplasma als „Faktor-IX-Mangelplasma“ an Stelle von Hämophilie-B-Plasma zu verwenden, was an einigen Beispielen demonstriert wird (Abb. 1 und 2, Tab. 2).

Sowohl bei Verwendung von Hämophilie-B-Plasma als auch bei Verwendung von Normalplasma als „Faktor-IX-Mangelplasma“ läßt sich in Serum, das unter Silikontechnik gewonnen wurde, ebensowenig wie im Serum eines Patienten mit Hageman-Defekt eine nennenswerte Faktor-IX-Aktivität nachweisen. Aus diesen und früheren eigenen Befunden sowie einer kürzlichen Mitteilung von Duckert wird gefolgert, daß die Entstehung einer maximalen Faktor-IX-Aktivität neben einem abgelaufenen Gerinnungsvorgang, der zur Bildung einer „Faktor-IX-Vorstufe“ führt, der Mitwirkung von Hageman-Faktor, PTA und Kalzium sowie eines ausreichenden Kontaktes mit benetzbaren Oberflächen bedarf. Im Unterschied zur inaktiven „Faktor-IX-Vorstufe“ wird der vollaktive Faktor IX als Intermediärprodukt und nicht als isolierter Gerinnungsfaktor angesehen.

Computers in a Human Perspective: an Alternative Way of Teaching Informatics to Health Professionals

An alternative way of teaching informatics, especially health informatics, to health professionals of different categories has been developed and practiced. The essentials of human competence and skill in handling and processing information are presented parallel with the essentials of computer-assisted methodologies and technologies of formal language-based informatics. Requirements on how eventually useful computer-based tools will have to be designed in order to be well adapted to genuine human skill and competence in handling tools in various work contexts are established.

On the basis of such a balanced knowledge methods for work analysis are introduced. These include how the existing problems at a workplace can be identified and analyzed in relation to the goals to be achieved. Special emphasis is given to new ways of information analysis, i.e. methods which even allow the comprehension and documentation ofthose parts of the actually practiced ´human´ information handling and processing which are normally overlooked, as e. g. non-verbal communication processes and so-called ´tacit knowledge´ based information handling and processing activities. Different ways of problem solving are discussed involving in an integrated human perspective - alternative staffing, enhancement of the competence of the staff, optimal planning of premises as well as organizational and technical means. The main result of this alternative way of education has been a considerably improved user competence which in turn has led to very different designs of computer assistance and man-computer interfaces.

It is the purpose of this paper to give a brief outline of the teaching material and a short presentation of the above mentioned results. Special emphasis is given to that part of the course where computer assisted interactive media technology presently is introduced due to the fact that this is the only way of adequately presenting some of the most important parts of human performance in handling and processing information, including communication.

18FDG-PET in 733 consecutive patients with or without side-by-side CT evaluation

Side-by-side analysis of CT and conventional 18FDG-PET in oncological imaging is well established. Aim of this study was to find out which patients or diagnostic groups may benefit the most from the newly introduced integrated PET/CT scanners. Patients, methods: 407 consecutively admitted oncological patients with accompanying CT (groups A-D) and 326 patients without CT (groups E-G) were examined by conventional ring PET. Two nuclear medicine physicians and two radiologists assessed each patient’s PET and CT scans for pathological lesions with regard to localisation and infiltration of adjacent anatomical structures. Patients without pathological PET findings were assigned to groups A (with CT) or E (without CT). If the localisation and/or extent of a pathological PET focus could only be assessed by taking into account the CT scan, the patient was assigned to group C (with CT) or G (without CT). If PET alone was sufficient for both questions the patient was assigned to groups B (with CT) or F (without CT). If neither method allowed for a precise lesion characterisation, the patient was assigned to group D. Results: 38.6% (A, E) of all patients were PET-negative. PET alone sufficed in 20.6% (B, F). Side-by-side reading of PET and CT was needed for 43.5% (C) of patients referred to PET with a current CT. Side-by-side reading of CT and PET did not suffice for 7.3% (D) of patients in that cohort. A total of 28.2% (G) of the cases without CT would have profited from it. The most frequent oncological diagnoses in group D (PET and conventional CT not sufficient) were bronchial carcinoma with abdominal lesions, while in group G (without CT but CT required) head/neck cancer with thoracic lesions was predominant. Conclusions: Side-by-side reading of PET and already existing conventional CT failed to yield conclusive data with regard to lesion characterisation in only 7.4% of patients so that PET/CT might have been helpful in these cases. 28.2% of the patients without current CT would have profited from an initial PET/CT examination. On the other hand, 59.2% of all patients (negative PET or PET alone sufficing) did not require a CT for lesion characterisation.

Unbiased High-Precision Cell Mechanical Measurements with Microconstrictions

We describe a quantitative, high-precision, high-throughput method for measuring the mechanical properties of cells in suspension with a microfluidic device, and for relating cell mechanical responses to protein expression levels. Using a high-speed (750 fps) charge-coupled device camera, we measure the driving pressure Δp, maximum cell deformation εmax, and entry time tentry of cells in an array of microconstrictions. From these measurements, we estimate population averages of elastic modulus E and fluidity β (the power-law exponent of the cell deformation in response to a step change in pressure). We find that cell elasticity increases with increasing strain εmax according to E ∼ εmax, and with increasing pressure according to E ∼ Δp. Variable cell stress due to driving pressure fluctuations and variable cell strain due to cell size fluctuations therefore cause significant variability between measurements. To reduce measurement variability, we use a histogram matching method that selects and analyzes only those cells from different measurements that have experienced the same pressure and strain. With this method, we investigate the influence of measurement parameters on the resulting cell elastic modulus and fluidity. We find a small but significant softening of cells with increasing time after cell harvesting. Cells harvested from confluent cultures are softer compared to cells harvested from subconfluent cultures. Moreover, cell elastic modulus increases with decreasing concentration of the adhesion-reducing surfactant pluronic. Lastly, we simultaneously measure cell mechanics and fluorescence signals of cells that overexpress the GFP-tagged nuclear envelope protein lamin A. We find a dose-dependent increase in cell elastic modulus and decrease in cell fluidity with increasing lamin A levels. Together, our findings demonstrate that histogram matching of pressure, strain, and protein expression levels greatly reduces the variability between measurements and enables us to reproducibly detect small differences in cell mechanics.

Development of the competency-based medical curriculum for the new Augsburg University Medical School

Aim: With the resolution from April 28, 2014, the Bavarian state government in Germany decided to found a new medical school at Augsburg University, thereby requiring the development of a competency-based medical curriculum. Methods: Two interdisciplinary groups developed a spiral curriculum (following Harden) employing the model of Thumser-Dauth & Öchsner. The curriculum focuses on specifically defined competencies: medical expertise, independent scientific reasoning, argumentation and scholarship, as well as communication skills. Results: The spiral curriculum was developed as a hybrid curriculum. Its modular structure incorporates the mandatory subjects required by the German regulations for medical licensure (Approbationsordnung) into organ- and system-centered blocks which are integrated both horizontally and vertically. Basic preclinical sciences are covered in the blocks "Movement," "Balance" and "Contact." The clinical sciences are organized according to six pillars (conservative medicine, surgical medicine, men's-women's-children's medicine, the senses, the nervous system and the mind, and general medicine) which students revisit three times each over the course of the program. A longitudinal clinical course incorporates interdisciplinary education. A particular focus is on scientific education encompassing a longitudinal course in the sciences (including interdisciplinary classes with other university departments), block practicums, and two scientific projects. Conclusion: It is not only the degree of integration und intensity of the Augsburg University undergraduate medical degree program, but also its targeted advancement of academic, social and communication skills that have not yet been realized to such an extent elsewhere in Germany. On July 8, 2016, the German Council of Science and Humanities unanimously gave this concept a positive evaluation. Future research will examine and evaluate the Augsburg medical curriculum and the impact of the new medical school on the hospital and university in Augsburg.

Mining the Gap: Assessing Leadership Needs to Improve 21st Century Plant Pathology

Scientists and plant pathologists are trained in scientific knowledge and critical thinking as part of their career preparation process. However, the extensive training in science-related skills may come at a cost to "soft skills," the competencies needed for interpersonal skills, communication, management, and leadership. A survey of the American Phytopathological Society indicated that the vast majority of its members (91%) were in leadership and management roles. Despite this, a minority of survey participants felt that their scientific training had prepared them to lead (30%) or manage others (36%). Plant pathologists had received the most training in topics that were tied to science. Less common were critical topics such as resilience, entrepreneurship, visioning, and persuasion, and participants were likely to choose skills considered necessary for management, as opposed to leadership. While scientific training is the primary purpose of graduate training, the lack of leadership training and professional development represents a critical deficiency at a time when science is increasingly moving toward larger collaborative projects. Soft skills training options are available, but utilization of these resources needs to be encouraged. An increased emphasis on augmenting leadership and management skills is critical to prepare scientists for a competitive, dynamic, and increasingly collaborative science landscape.

Overview of diagnostic performance and results for the first operation phase in Wendelstein 7-X (invited)

Wendelstein 7-X, a superconducting optimized stellarator built in Greifswald/Germany, started its first plasmas with the last closed flux surface (LCFS) defined by 5 uncooled graphite limiters in December 2015. At the end of the 10 weeks long experimental campaign (OP1.1) more than 20 independent diagnostic systems were in operation, allowing detailed studies of many interesting plasma phenomena. For example, fast neutral gas manometers supported by video cameras (including one fast-frame camera with frame rates of tens of kHz) as well as visible cameras with different interference filters, with field of views covering all ten half-modules of the stellarator, discovered a MARFE-like radiation zone on the inboard side of machine module 4. This structure is presumably triggered by an inadvertent plasma-wall interaction in module 4 resulting in a high impurity influx that terminates some discharges by radiation cooling. The main plasma parameters achieved in OP1.1 exceeded predicted values in discharges of a length reaching 6 s. Although OP1.1 is characterized by short pulses, many of the diagnostics are already designed for quasi-steady state operation of 30 min discharges heated at 10 MW of ECRH. An overview of diagnostic performance for OP1.1 is given, including some highlights from the physics campaigns.

Mechanical plasticity of cells

Under mechanical loading, most living cells show a viscoelastic deformation that follows a power law in time. After removal of the mechanical load, the cell shape recovers only incompletely to its original undeformed configuration. Here, we show that incomplete shape recovery is due to an additive plastic deformation that displays the same power-law dynamics as the fully reversible viscoelastic deformation response. Moreover, the plastic deformation is a constant fraction of the total cell deformation and originates from bond ruptures within the cytoskeleton. A simple extension of the prevailing viscoelastic power-law response theory with a plastic element correctly predicts the cell behaviour under cyclic loading. Our findings show that plastic energy dissipation during cell deformation is tightly linked to elastic cytoskeletal stresses, which suggests the existence of an adaptive mechanism that protects the cell against mechanical damage.

Axillary Hidradenitis Suppurativa: A Further Option for Surgical Treatment

Background:

Hidradenitis suppurativa is a chronic inflammatory disease of the cutis with furuncles, fistulas, and abscesses. The disease is mostly located in groin and axilla. As conservative treatment can usually not prevent recurrence, surgical treatment is the method of choice.

Methods:

We report on 20 patients with axillary hidradenitis suppurativa. The inflammatory region was excised in a rhomboid shape and immediately covered with a transposition flap according to Limberg. Postoperatively, all patients received antibiotic treatment and immobilization of the arm. Physiotherapy started after 2 weeks.

Results:

No flap complications occurred. The functional and aesthetic results were very satisfactory. Movement of shoulder showed no restrictions. A recurrence with single fistulas was seen in 3 patients.

Conclusions:

Conservative treatment of hidradenitis suppurativa is followed by a high rate of recurrence. Only radical debridement offers a cure. The therapy of choice is the radical excision of the affected region and immediate coverage with a flap. Open granulation or split skin grafting often results in a prolonged hospitalization, higher morbidity, and functional problems. Thus, open granulation is inferior to primary closure by a transposition flap. Using the Limberg flap, the donor site is allowed to be closed primarily.

All-optical control and metrology of electron pulses

Short electron pulses are central to time-resolved atomic-scale diffraction and electron microscopy, streak cameras, and free-electron lasers. We demonstrate phase-space control and characterization of 5-picometer electron pulses using few-cycle terahertz radiation, extending concepts of microwave electron pulse compression and streaking to terahertz frequencies. Optical-field control of electron pulses provides synchronism to laser pulses and offers a temporal resolution that is ultimately limited by the rise-time of the optical fields applied. We used few-cycle waveforms carried at 0.3 terahertz to compress electron pulses by a factor of 12 with a timing stability of <4 femtoseconds (root mean square) and measure them by means of field-induced beam deflection (streaking). Scaling the concept toward multiterahertz control fields holds promise for approaching the electronic time scale in time-resolved electron diffraction and microscopy.