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Background: To assess quality of life and unmet needs after stroke, patient-reported outcome measures (PROMs) have gained increasing attention. However, patients' perspectives on assessing PROMs remain unclear, potentially hindering implementation into clinical practice. Therefore, this study explored patients' preferences on assessing PROMs after ischemic stroke. Methods: A paper-based questionnaire was sent to stroke survivors treated at the Department of Neurology, University of Leipzig, Germany. Health-related quality of life (HRQoL, EQ-5D-5L) and preferences regarding different aspects of data collection to assess PROMs were investigated and linked to socio-demographic and medical characteristics. Results: 158 persons were contacted and 80 replies were subsequently analyzed. Mean age was 70.16 years and mean HRQoL was 68.79 (visual analogue scale with a theoretical maximum of 100). Participants showed positive attitudes towards PROMs as they saw potential to improve care of other patients (n = 66/79; 83.54%) or to improve their own situation (n = 53/74; 71.62%). Participants preferred an annual interview after stroke (n = 39/80; 48.75%) and would preferably spend 15–30 min (n = 41/79; 51.90%) to answer a written survey (n = 69/80; 86.25%). The initially treating clinic was preferred as initiator of such surveys (n = 43/79; 54.43%). Stratification revealed that participants with more than 1 h of daily digital media usage preferred email as way of communication. Conclusions: For the first time, this study showed individual preferences on assessing PROMs after ischemic stroke, focusing on the way, time interval, duration, and initiation site of surveys. These insights might help to successfully implement PROMs after stroke and subsequently detect unmet needs and deficits in stroke care. [ABSTRACT FROM AUTHOR]

Background: Research has shown that routinely assessed, patient-reported outcome measures (PROMs) have positive effects in patients with advanced oncologic diseases. However, the transferability of these results to specialist palliative care is uncertain because patients are more impaired and staff doubt the feasibility and benefits. The aim of this study is to evaluate the feasibility of patient self-assessment of PROMs, their use by staff and the benefits in palliative care wards. Method: A multicentre observational study was conducted in the context of the implementation of the Integrated Patient Outcome Scale (IPOS) in three specialist palliative care wards at university hospitals in Germany. All admitted patients who screened positive regarding their ability to complete questionnaires were asked to participate and complete the IPOS on paper weekly, with assistance if necessary. Feasibility of questionnaire completion (e.g. proportion of patients able to complete them), use (e.g. involvement of different professional groups) and benefit (e.g. unexpected information in IPOS as rated by treating physicians) were assessed. Staff members' opinion was obtained in a written, anonymous evaluation survey, patients' opinion in a short written evaluation. Results: A total of 557 patients were screened for eligibility, 235 were assessed as able to complete the IPOS (42.2%) and 137 participated in the study (24.6%). A majority needed support in completing the IPOS; 40 staff members and 73 patients completed the evaluation. Unexpected information was marked by physicians in 95 of the 137 patient questionnaires (69.3%). The staff differed in their opinions on the question of whether this also improved treatment. A majority of 32 staff members (80.0%) were in favour of continuing the use of IPOS (4 against continuation, 4 no answer); 43 (58.9%) patients rated their overall experience of IPOS use as 'positive', 29 (39.7%) as 'neutral' and 1 (1.4%) as 'negative'. Conclusions: While most staff wished to continue using IPOS, it was a challenge to integrate the effort to support the completion of IPOS into daily practice. Digital implementation was not successful, despite various attempts. To explore the effects on care and patient outcomes, multicentre cluster-randomised trials could be employed. Trial registration: German Clinical Trials Register DRKS-ID: DRKS00016681 (24/04/2019). [ABSTRACT FROM AUTHOR]

Background: The results of recent surveys indicate that more than 50% of the German population has experience with complementary and alternative medicine (CAM) or uses CAM regularly. This study investigated the CAM usage and CAM-related needs of hospitalized patients at university medical centres in the state of Baden-Württemberg, Germany., Methods: A multi-centre, paper-based, pseudonymous survey was carried out by the members of the Academic Centre for Complementary and Integrative Medicine. Patients of all ages, regardless of sex, diagnosis and treatment, who were hospitalized in the Department of Cardiology, Gastroenterology, Oncology, Gynaecology or Surgery at the university medical centres in Freiburg, Heidelberg, Tübingen and Ulm were eligible for inclusion., Results: Of the 1275 eligible patients, 67% (n = 854) consented to participate in the survey. Forty-eight percent of the study participants stated that they were currently using CAM. The most frequently used therapies were exercise (63%), herbal medicine (54%) and dietary supplements (53%). Only 16% of the patients discussed CAM usage with their attending physician. Half of the patients (48%) were interested in CAM consultations. More than 80% of the patients desired reliable CAM information and stated that physicians should be better informed about CAM., Conclusions: The frequency of CAM usage and the need for CAM counselling among hospitalized patients at university medical centres in Baden-Württemberg are high. To better meet patients' needs, CAM research and physician education should be intensified., Trial Registration: German Clinical Trial register ( DRKS00015445 )., (© 2021. The Author(s).)

The reproducibility crisis triggered worldwide initiatives to improve rigor, reproducibility, and transparency in biomedical research. There are many examples of scientists, journals, and funding agencies adopting responsible research practices. The QUEST (Quality-Ethics-Open Science-Translation) Center offers a unique opportunity to examine the role of institutions. The Berlin Institute of Health founded QUEST to increase the likelihood that research conducted at this large academic medical center would be trustworthy, useful for scientists and society, and ethical. QUEST researchers perform "science of science" studies to understand problems with standard practices and develop targeted solutions. The staff work with institutional leadership and local scientists to incentivize and support responsible practices in research, funding, and hiring. Some activities described in this paper focus on the institution, whereas others may benefit the national and international scientific community. Our experience, approaches, and recommendations will be informative for faculty leadership, administrators, and researchers interested in improving scientific practice., Competing Interests: The authors have declared that no competing interests exist.

Simple Summary: When we consider nutrition in patients with head and neck cancer (HNC), we mostly focus on the type of nutrition; studies on the type of nutrition at different time points are sparse. This retrospective study analyzed patients with HNC according to their nutritional status and association with percutaneous endoscopic gastrostomy (PEG) from admission to six months after treatment at a tertiary hospital in Germany from 2017 to 2019. Results showed that 14.9% required PEG before starting therapy. The need for PEG increased to 22.7% at six weeks after therapy and remained stable at 23% six months later. PEG placement was more frequently required for alcohol or nicotine use, oropharyngeal and hypopharyngeal carcinoma, squamous cell carcinoma, cancer stage III/IV, chemotherapy and impaired feeding. There has been an increase in the percentage of PEG over the observation period. This retrospective monocentric cohort study analyzed patients with head and neck cancer according their nutritional status and association of percutaneous endoscopic gastrostomy (PEG) from admission to six months after treatment at a tertiary hospital in Germany from 2017 to 2019. A total of 289 patients (76.5% men; median age 62 years; 63.3% stage IV) were included. Univariate analyses and ANOVAs with repeated measures were performed to analyze differences over time. The percentage of patients requiring PEG was 14.9% (43 of 289 patients) before start of treatment (Z0), 14% (40 of 286 patients alive) after one week (Z1), 22.7% (58 of 255 patients) after six weeks (Z2) and 23% (53 of 230 patients) after six months (Z3) from the end of treatment. PEG placement was associated with alcohol or nicotine consumption, in oropharyngeal and hypopharyngeal carcinoma, squamous cell carcinoma, cancer stage III/IV, chemotherapy and impairment of food intake (all p < 0.05). Weight loss between Z1 and Z3 with PEG did not differ from patients without PEG at Z0 (p = 0.074), although patients with PEG at Z0 had a lower mean weight at the beginning. PEG was important for a quarter of the patients alive at Z3 and helped to prevent weight loss. [ABSTRACT FROM AUTHOR]

Background: Checklists are a common tool used in order to mitigate risks caused by human factors and can facilitate the safe induction of anesthesia as well as handovers. SBAR (Situation, Background, Assessment, Recommendation) is a checklist recommended by the WHO and DGAI for handovers, while SOAP-M (Suction, Oxygen, Airway, Pharmaceuticals, Monitoring) is a checklist for the induction of anesthesia. This study investigates the implementation and adoption of these two checklists. Methods: We conducted a single-center online survey one year after the implementation of SOAP-M and SBAR at a university hospital's anesthesiology department, using scales from three validated questionnaires to assess safety attitudes as well as the behavior of staff and the perceived usefulness of the checklists. Results: Staff with a high score in general attitude towards patient safety, as determined by the safety attitudes questionnaire, considered both checklists useful additions to their work environment. Nurses and physicians (p = 0.102) as well as groups divided according to work experience (p = 0.077) showed no significant differences in using SOAP-M and SBAR. Perceived usefulness was significantly higher (p < 0.001) among users of the checklists, and the same goes for positive reinforcement (p < 0.001), social cues (p = 0.0215) and goal cues (p = 0.0252). Conclusion: SOAP-M and SBAR are perceived as useful checklists for patient handovers and anesthesia induction by tertiary referral hospital's employees with high score in general safety attitude and were therefore commonly used one year after their introduction. No significant difference in checklist adoption between occupations as well as groups divided according to work experience could be found. Perceived usefulness is significantly higher among users of the checklist, who feel using the checklists provides more support. [ABSTRACT FROM AUTHOR]

Simple Summary: Sacrectomy represents a radical indication for bone sarcomas (e.g., osteosarcoma or chondrosarcoma) and chordomas, as well as selected carcinomas with invasion of the sacrum. Extralesional en bloc excision is surgically demanding and associated with resection-induced neurologic deficits and risks. Due to the low incidence of bone sarcomas, the rare localization in the sacrum and the complexity of the surgical procedure, studies reporting on the oncological outcome and corresponding complications in larger patient numbers are rare. The aim was to describe the oncosurgical management and the complication profile and to analyze our own treatment results after partial/total sacrectomy, with attention paid to a possible benefit by using intraoperative 3D navigation. There was a significant difference in progression-free and metastasis-free survival between sarcoma, chordoma and carcinoma patients. Complications were common, but no independently influencing causative factors could be identified. Although there was a subjective impression of improved intraoperative 3D orientation and easier identification of resection planes, the use of navigation did not significantly influence resection status or oncological patient outcome. Introduction: Bone sarcoma or direct pelvic carcinoma invasion of the sacrum represent indications for partial or total sacrectomy. The aim was to describe the oncosurgical management and complication profile and to analyze our own outcome results following sacrectomy. Methods: In a retrospective analysis, 27 patients (n = 8/10/9 sarcoma/chordoma/locally recurrent rectal cancer (LRRC)) were included. There was total sacrectomy in 9 (incl. combined L5 en bloc spondylectomy in 2), partial in 10 and hemisacrectomy in 8 patients. In 12 patients, resection was navigation-assisted. For reconstruction, an omentoplasty, VRAM-flap or spinopelvic fixation was performed in 20, 10 and 13 patients, respectively. Results: With a median follow-up (FU) of 15 months, the FU rate was 93%. R0-resection was seen in 81.5% (no significant difference using navigation), and 81.5% of patients suffered from one or more minor-to-moderate complications (especially wound-healing disorders/infection). The median overall survival was 70 months. Local recurrence occurred in 20%, while 44% developed metastases and five patients died of disease. Conclusions: Resection of sacral tumors is challenging and associated with a high complication profile. Interdisciplinary cooperation with visceral/vascular and plastic surgery is essential. In chordoma patients, systemic tumor control is favorable compared to LRRC and sarcomas. Navigation offers gain in intraoperative orientation, even if there currently seems to be no oncological benefit. Complete surgical resection offers long-term survival to patients undergoing sacrectomy for a variety of complex diseases. [ABSTRACT FROM AUTHOR]

Simple Summary: In the present study, the intraoperative fluorescence of brain metastases after the administration of 5-aminolevulinic acid (5-ALA) is investigated in 80 cases. Brain metastases fluoresced in 57.5% of cases, with no significant correlation between fluorescence and primary tumor or histological subtype. Complete resection of brain metastases was detected in 82.5%, of which 56.1% were fluorescence positive, compared to 43.9% which were non-fluorescent. Thus, prior administration of 5-ALA tended to improve the resectability rate by 12.1%. Fluorescence-positive and -negative metastases showed significantly different overall survival in this study. Therefore, administration of 5-ALA as a surgical adjuvant may be beneficial in resecting brain metastases and may potentially optimize the surgical procedure. (1) Background: In this study, the intraoperative fluorescence behavior of brain metastases after the administration of 5-aminolevulinic acid (5-ALA) was analyzed. The aim was to investigate whether the resection of brain metastases using 5-ALA fluorescence also leads to a more complete resections and thus to a prolongation of survival; (2) Methods: The following variables have been considered: age, sex, number of metastases, localization, involvement of eloquent area, correlation between fluorescence and primary tumor/subtype, resection, and survival time. The influence on the degree of resection was determined with a control MRI within the first three postoperative days; (3) Results: Brain metastases fluoresced in 57.5% of cases. The highest fluorescence rates of 73.3% were found in breast carcinoma metastases and the histologic subtype adenocarcinoma (68.1%). No correlation between fluorescence behavior and localization, primary tumor, or histological subtype was found. Complete resection was detected in 82.5%, of which 56.1% were fluorescence positive. There was a trend towards improved resectability (increase of 12.1%) and a significantly longer survival time (p = 0.009) in the fluorescence-positive group; (4) Conclusions: 5-ALA-assisted extirpation leads to a more complete resection and longer survival and can therefore represent a low-risk addition to modern surgery for brain metastases. [ABSTRACT FROM AUTHOR]

Simple Summary: This study explored advanced diagnostic methods that are used for identifying skin cancer in high-risk melanoma patients. A total of 410 patients were examined using a combination of three advanced imaging techniques: 3D total body photography, digital dermoscopy, and reflectance confocal microscopy. These methods were used in addition to regular skin exams. Results showed that the specialized imaging detected 16 melanomas in 39 removed pigmented lesions, while regular exams detected only 7 melanomas in 163 removed lesions. This indicates that specialized imaging was much more efficient. Each imaging method found melanomas that the others did not. The study concludes that combining these three imaging techniques improves melanoma detection and reduces unnecessary skin removals in high-risk patients. Modern diagnostic procedures, such as three-dimensional total body photography (3D-TBP), digital dermoscopy (DD), and reflectance confocal microscopy (RCM), can improve melanoma diagnosis, particularly in high-risk patients. This study assessed the benefits of combining these advanced imaging techniques in a three-step programme in managing high-risk patients. This study included 410 high-risk melanoma patients who underwent a specialised imaging consultation in addition to their regular skin examinations in outpatient care. At each visit, the patients underwent a 3D-TBP, a DD for suspicious findings, and an RCM for unclear DD findings. The histological findings of excisions initiated based on imaging consultation and outpatient care were compared. Imaging consultation detected sixteen confirmed melanomas (eight invasive and eight in situ) in 39 excised pigmented lesions. Outpatient care examination detected seven confirmed melanomas (one invasive and six in situ) in 163 excised melanocytic lesions. The number needed to excise (NNE) in the imaging consultation was significantly lower than that in the outpatient care (2.4 vs. 23.3). The NNE was 2.6 for DD and 2.3 for RCM. DD, 3D-TBP, or RCM detected melanomas that were not detected by the other imaging methods. The three-step imaging programme improves melanoma detection and reduces the number of unnecessary excisions in high-risk patients. [ABSTRACT FROM AUTHOR]

Simple Summary: Functional MRI has become established in the surgery of brain metastases (BM) as a preoperative diagnostic tool to identify intact eloquent cortex areas. Evidence shows that by allowing surgeons to spare these intraoperatively, patients' postoperative outcome is improved in terms of significantly reduced mortality and morbidity. The influence specifically of BM on the fMRI signal and brain networks has scarcely been investigated, as most studies to date refer only to primary brain tumors or include various tumor entities. Our work examined how BM affect cortical activation and brain networks using task-based fMRI. We found a qualitative attenuation of patients' fMRI signal in the metastasis-affected hemisphere compared to the contralateral hemisphere and alterations in all examined brain networks of the patients compared to healthy controls, and also in the contralateral hemisphere. Thus, our results provide insights into the behavior of BM during fMRI examination and their impact on the integrity of the brain. To date, there are almost no investigations addressing functional connectivity (FC) in patients with brain metastases (BM). In this retrospective study, we investigate the influence of BM on hemodynamic brain signals derived from functional magnetic resonance imaging (fMRI) and FC. Motor-fMRI data of 29 patients with BM and 29 matched healthy controls were analyzed to assess percent signal changes (PSC) in the ROIs motor cortex, premotor cortex, and supplementary motor cortex and FC in the sensorimotor, default mode, and salience networks using Statistical Parametric Mapping (SPM12) and marsbar and CONN toolboxes. In the PSC analysis, an attenuation of the BOLD signal in the metastases-affected hemisphere compared to the contralateral hemisphere was significant only in the supplementary motor cortex during hand movement. In the FC analysis, we found alterations in patients' FC compared to controls in all examined networks, also in the hemisphere contralateral to the metastasis. This indicates a qualitative attenuation of the BOLD signal in the affected hemisphere and also that FC is altered by the presence of BM, similarly to what is known for primary brain tumors. This transformation is not only visible in the infiltrated hemisphere, but also in the contralateral one, suggesting an influence of BM beyond local damage. [ABSTRACT FROM AUTHOR]

Simple Summary: Colorectal cancer is one of the most commonly diagnosed cancers worldwide with a high probability of developing metastasis over the course of the disease. Only certain patients with colorectal liver metastases can be treated by surgical resection. Different interventional treatments such as laser-induced thermotherapy, microwave ablation, as well as transarterial chemoembolization can be applied for treating colorectal liver metastases. These therapies have been discussed in various studies. However, the current medical literature is still lacking research from large long-term studies. This retrospective monocentric study includes 2140 patients with colorectal liver metastases treated by different locoregional treatments. It is based upon data collected over a period of more than 26 years at the University Hospital Frankfurt of Goethe University. The aim of this study was to analyze the long-term results of different locoregional treatments for colorectal cancer liver metastases (CRLM), including transarterial chemoembolization (TACE), laser-induced thermotherapy (LITT) and microwave ablation (MWA). A total of 2140 patients with CRLM treated at our department between 1993 and 2020 were included in this retrospective study. The patients were divided into the following groups: LITT (573 patients; median age: 62 years), TACE + LITT (346 patients; median age: 62 years), MWA (67 patients; median age: 59 years), TACE + MWA (152 patients; median age: 65 years), and TACE (1002 patients; median age: 62 years). Median survival was 1.9 years in the LITT group and 1.7 years in the TACE + LITT group. The median survival times in the MWA group and TACE + MWA group were 3.1 years and 2.1 years, respectively. The median survival in the TACE group was 0.8 years. The 1-, 3-, and 5-year survival rates were 77%, 27%, and 9% in the LITT group and 74%, 18%, and 5% in the TACE + LITT group, respectively. The corresponding survival rates were 80%, 55%, and 33% in the MWA group, 74%, 36%, and 20% in the TACE + MWA group and 37%, 3%, and 0% in the TACE group, respectively. The long-term results of this study demonstrate the efficacy of locoregional treatments in treating patients with CRLM. The longest survival was found in the MWA group, followed by the combination therapy of TACE and MWA. [ABSTRACT FROM AUTHOR]

Background: In hemodynamically unstable patients, the passive leg raise (PLR) test is recommended for use as a self-fluid challenge for predicting preload responsiveness. However, to interpret the hemodynamic effects and reliability of the PLR, the method of performing it is of the utmost importance. Our aim was to determine the current practice of the correct application and interpretation of the PLR in intensive care patients. Methods: After ethical approval, we designed a cross-sectional online survey with a short user-friendly online questionnaire. Using a random sample of 1903 hospitals in Germany, 182 hospitals with different levels of care were invited via an email containing a link to the questionnaire. The online survey was conducted between December 2021 and January 2022. All critical care physicians from different medical disciplines were surveyed. We evaluated the correct points of concern for the PLR, including indication, contraindication, choice of initial position, how to interpret and apply the changes in cardiac output, and the limitations of the PLR. Results: A total of 292 respondents participated in the online survey, and 283/292 (97%) of the respondents completed the full survey. In addition, 132/283 (47%) were consultants and 119/283 (42%) worked at a university medical center. The question about the performance of the PLR was answered correctly by 72/283 (25%) of the participants. The limitations of the PLR, such as intra-abdominal hypertension, were correctly selected by 150/283 (53%) of the participants. The correct effect size (increase in stroke volume ≥ 10%) was correctly identified by 217/283 (77%) of the participants. Conclusions: Our results suggest a considerable disparity between the contemporary practice of the correct application and interpretation of the PLR and the practice recommendations from recently published data at German ICUs. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 outbreak necessitated physical distancing, as part of secondary prevention, at a personal and professional level. Working from home (WFH) became increasingly important. In this study, the impact of the COVID-19 pandemic restrictions on physical and mental health is investigated, compared with pre-pandemic data, and with employees who WFH and are on-site. Methods: Data from the German Saxon longitudinal study population were used. Attitudes towards WFH as well as mental and physical health assessments during the COVID-19 pandemic were examined. Comparisons were made with corresponding pre-pandemic scores and between employees WFH and on-site in 2022. Results: In total, 319 participants with equal gender distribution were included. Of those, 86 worked from home stating better organizability of their work, more time for partnership, less stress, and greater work satisfaction. Compared to pre-pandemic data, the D-score, PHQ-4, G-Score, and PHQ-SSS-8 showed a significant increase. No difference in physical or mental health between employees WFH and on-site was observed. Conclusion: In general, COVID-19 restrictions had a negative impact on mental and physical health. Although WFH is well accepted, it did not show significant health benefits. [ABSTRACT FROM AUTHOR]

Demographic development and continuing improvements in supportive and antineoplastic therapies are reasonable predictors of increasing travel activities carried out by patients with malignant diseases. There is a lack of data on travel habits of patients with end-stage oncological diseases. We performed a multi-phased cross-sectional study to gain insights into the intersection of travel medicine and oncology. A total of 82 patients with 21 different cancer entities at a median age of 63 years completed the final questionnaire. 90.2% of all participants rated travelling as an important or very important aspect in their lives, of whom 73.2% had participated in a short- or holiday trip after the cancer diagnosis. All but one (98.8%) participant were about to plan a short- or holiday trip in the near future. Germany (home country) was the most important travel destination, 'Relaxing' and 'enjoying nature' were the most important travel motives. Fatigue and overall (medical) insecurities were major obstacles to carry out travel plans. In conclusion, a high proportion of patients enjoy travelling. Physicians and patients are encouraged to openly discuss holiday-taking in accordance with available guidelines. More research is needed to fully understand needs and obstacles at the crossroads of travel medicine and oncology. [ABSTRACT FROM AUTHOR]

Background: Esophagectomy carries a high risk of morbidity and mortality compared to other major surgeries. With the aim of creating an easy-to-use clinical preoperative risk assessment tool and to validate previously described risk factors for major complications following surgery, esophagectomies at two tertiary medical centers were analyzed. Methods: A total of 450 patients who underwent esophagectomy for esophageal carcinoma at the University Medical Centre, Hamburg, or at the Medical Center University Duisburg-Essen, Germany (January 2008 to January 2020) were retrospectively analyzed. Epidemiological and perioperative data were analyzed to identify the risk factors that impact major complication rates. The primary endpoint of this study was to determine the incidence of major complications. Results: The mean age of the patients was 63 years with a bimodal distribution. There was a male predominance across the cohort (81% vs. 19%, respectively). Alcohol abuse (p = 0.0341), chronic obstructive pulmonary disease (p = 0.0264), and cardiac comorbidity (p = 0.0367) were associated with a significantly higher risk of major complications in the multivariate analysis. Neoadjuvant chemotherapy significantly reduced the risk of major postoperative complications (p < 0.0001). Conclusions: Various patient-related risk factors increased the rate of major complications following esophagectomy. Patient-tailored prehabilitation programs before esophagectomy that focus on minimizing these risk factors may lead to better surgical outcomes and should be analyzed in further studies. [ABSTRACT FROM AUTHOR]

Background: To ensure high quality of nurses' communication as part of patient-centered care, training of communication skills is essential. Previous studies indicate that communication skills trainings can improve communication skills of nurses and have a positive effect on emotional and psychological burden. However, most show methodological limitations, are not specifically developed for nurses or were developed for oncological setting only. Methods: This study aims to evaluate the effectiveness of a needs-based communication skills training for nursing professionals and to derive indications for future implementation. A two-armed randomized controlled trial including components from both effectiveness and implementation research will be applied. Additionally, a comprehensive process evaluation will be carried out to derive indications for future implementation. Nurses (n=180) of a university medical center in Germany will be randomized to intervention or waitlist-control group. The intervention was developed based on the wishes and needs of nurses, previously assessed via interviews and focus groups. Outcomes to measure effectiveness were selected based on Kirkpatrick's four levels of training evaluation and will be assessed at baseline, post-training and at 4-weeks follow-up. Primary outcome will be nurses' self-reported self-efficacy regarding communication skills. Secondary outcomes include nurses' communication skills assessed via standardized patient assessment, knowledge about patient-centered communication, mental and work-related burden, and participants' satisfaction with training. Discussion: To our knowledge, this is the first study systematically evaluating the effectiveness of a patient-centered communication skills training for nursing professionals in Germany. Results will yield insight whether a needs-based intervention can improve nurses' self-efficacy regarding communication skills and other secondary outcomes. Trial registration: Clinical trial registration number: NCT05700929, trial register: ClinicalTrials.gov (date of registration: 16 November 2022). [ABSTRACT FROM AUTHOR]

Background: Intensive care units (ICUs) are often too noisy, exceeding 70–80 dBA, which can have negative effects on staff. The corresponding recommendation of the World Health Organization (average sound pressure level below 35 dBA) is often not achieved. To date there is a lack of intervention studies examining the extent to which unit-based noise management in ICUs contributes to a reduction in noise exposure for the staff. The study therefore aims to provide answers to 1) how unit-based noise management sustainably reduces the subjective noise exposure among staff, and 2) how this intervention affects other noise-related topics. Methods: We performed a monocentric prospective longitudinal study with three measurement points in a German university hospital in three ICUs. We collected data from different healthcare professionals and other professional groups between October 2021 and August 2022 using an online questionnaire. Data were analyzed using descriptive and inference statistics. Results: A total of n = 179 participants took part in the surveys. The majority of participants were nurses or pediatric nurses. Most participants worked more than 75% full-time equivalent. Staff on the three ICUs reported high levels of noise exposure. No significant changes in noise exposure over time were observed. Participants were already aware of the topic and believed that a behavior change could positively influence the noise environment. Conclusions: This study provides an initial insight into how a unit-based noise management could contribute to a reduction in the subjective noise exposure among staff in ICUs. The results of this study highlight the importance of this topic. Future studies should aim to research aspects of adherence and their facilitators or barriers, which promote the sustained implementation of noise-reducing measures by staff. Trial registration: German Clinical Trials Register (DRKS): DRKS00025835; Date of registration: 12.08.2021. [ABSTRACT FROM AUTHOR]

Simple Summary: This opinion paper describes the regulatory hurdles for a clinical oncologist and physician scientist to activate an Investigator-Initiated Trial (IIT) before and after 2004 with German regulation as an example. Changes in legal framework with impacts on time and costs to activate a clinical trial are described. Evidence needed to reach the objective of higher patient safety and trial quality by European Union (EU) Clinical Trial Directive (CTD) 2001/20 is discussed. Shortly after the beginning of the year 2000, multiple legal changes with impacts on the regulatory framework of clinical trials became effective almost simultaneously. They included the European Union (EU) Clinical Trial Directive (CTD) 2001/20 followed by major changes in national drug laws, the change in the legal status of German University Hospitals (1998), and a new disease-related groups (DRG)-based reimbursement system for hospitals in Germany (2000). Together, these changes created enormous bureaucratic and financial inhibition of activation and conduct of academic investigator-initiated clinical trials (IIT). Examples for activating clinical trials in oncology before and after 2004 are outlined and discussed, focussing on extended time frames, the establishment of centralized responsibility structures and the exploding financial consequences. In addition, the evolution of trial numbers and the distribution of trial initiators between "commercial" and "academic" over time are discussed together with the occurrence of clinical registries. At the same time, progress in molecular biology led to a plethora of new targets for effective pharmacological therapy of life-threatening diseases such as cancer, and the overall number of clinical trials has not decreased. Yet, judging the regulatory and administrative hurdles between scientific study design and first-patient on trial before and after 2004 and weighing these against the lack of evidence that this regulation has achieved its goal to enhance patient safety and trial quality, the necessity to completely overhaul this CTD becomes obvious. A main goal of such an initiative should be to minimize bureaucracy. For the specific situation in Germany, relocation of responsibility and freedom to operate in University Hospitals and Medical Faculties back to the physician–scientists and reduction in interference by legal divisions should be a goal as well as increasing the public financial support for IITs. [ABSTRACT FROM AUTHOR]

Simple Summary: Hyperthermic intrathoracic chemotherapy (HITOC) is an intraoperative treatment after a surgical cytoreduction of pleural malignancies. The pleural cavity is perfused with high doses of cytostatic drugs that are consequentially excreted via various body fluids. These are potential occupational health risk factors for medical staff and safety measurements must be established based on scientific evidence. Hyperthermic intrathoracic chemotherapy (HITOC) is an additional intraoperative treatment option within the multimodality therapy of pleural malignancies. A chemotherapy perfusion with high-dose cisplatin is performed over a period of 60 min after surgical cytoreduction to improve local tumour control through the eradication of residual tumour cells. Although HITOC is increasingly used, there is only little scientific evidence about the necessary safety measures after HITOC. Therefore, the objective of this study was an analysis of cisplatin excretion via various body fluids after HITOC, with the aim of providing recommendations on occupational health and safety. Five patients undergoing HITOC were included. Before and after the HITOC, as well as during the following days, serum, urine, and bronchial secretion, as well as pleural effusion, were sampled. The platinum levels in the samples were measured using ICP-MS (inductively coupled plasma-mass spectrometry). Immediately after the HITOC, the mean levels of cisplatin increased dramatically in the serum (from 0.79 to 1349 µg/L), urine (from 3.48 to 10,528 µg/g creatinine), and bronchial secretion (from 0.11 to 156 µg/L). Thereafter, the cisplatin levels dropped to 133 µg/L in the serum and 994 µg/g creatinine in the urine within nine days after the HITOC. The AUC ratio shows 59% of the cisplatin being excreted via the urine after 48 h. The sampling of pleural effusion started 24 h after the HITOC, and the cisplatin levels decreased from 618 to 93 µg/L within nine days. Although the cisplatin levels in the body fluids of HITOC patients are much lower compared to patients receiving intravenous chemotherapy, a significant amount of cisplatin is excreted via these body fluids. Consequently, safety precautions must be implemented in the post-HITOC care of patients to avoid occupational exposure to cisplatin. [ABSTRACT FROM AUTHOR]

Colorectal cancer remains one of the most commonly diagnosed cancers. Advanced rectal cancer patients receive neoadjuvant radiochemotherapy as well as surgery and suffer from reduced health-related quality of life due to various side effects. We were interested in the role of the COVID-19 pandemic and how it affected those patients' quality of life. A total of 489 advanced rectal cancer patients from the University Hospital Erlangen in Germany were surveyed between May 2010 and March 2022 and asked to fill out the EORTC QLQ-C30 and QLQ-CR38 questionnaires over eight different time points: at the beginning, during and after radiochemotherapy, right before surgery, and in yearly intervals after surgery for up to four years. Answers were converted to scores to compare the COVID-19 period to the time before March 2020, focusing on the follow-ups, the developments over time—including by sex and age—and the influence of the TNM cT-stage. Overall, a trend of impaired functional and symptom scores was found across all surveys with few significances (body image −10.6 percentage points (pp) after one year; defecation problems +13.5 pp, insomnia +10.2 pp and weight loss +9.8 pp after three years; defecation problems +11.3 pp after four years). cT4-stage patients lost significantly more weight than their cT1-3-stage counterparts (+10.7 to 13.7 pp). Further studies should be conducted to find possible causes and develop countermeasures for future major infectious diseases. [ABSTRACT FROM AUTHOR]

Background There is limited knowledge of whether cognitive-behavioral therapy (CBT) or second-generation antipsychotics (SGAs) should be recommended as the first-line treatment in individuals at clinical high risk for psychosis (CHRp). Hypothesis To examine whether individual treatment arms are superior to placebo and whether CBT is non-inferior to SGAs in preventing psychosis over 12 months of treatment. Study Design PREVENT was a blinded, 3-armed, randomized controlled trial comparing CBT to clinical management plus aripiprazole (CM + ARI) or plus placebo (CM + PLC) at 11 CHRp services. The primary outcome was transition to psychosis at 12 months. Analyses were by intention-to-treat. Study Results Two hundred eighty CHRp individuals were randomized: 129 in CBT, 96 in CM + ARI, and 55 in CM + PLC. In week 52, 21 patients in CBT, 19 in CM + ARI, and 7 in CM + PLC had transitioned to psychosis, with no significant differences between treatment arms (P  = .342). Psychopathology and psychosocial functioning levels improved in all treatment arms, with no significant differences. Conclusions The analysis of the primary outcome transition to psychosis at 12 months and secondary outcomes symptoms and functioning did not demonstrate significant advantages of the active treatments over placebo. The conclusion is that within this trial, neither low-dose aripiprazole nor CBT offered additional benefits over clinical management and placebo. [ABSTRACT FROM AUTHOR]

Purpose: SARS‐CoV‐2 vaccines cause acute ipsilateral lymph node swelling in an important proportion of vaccines. Thus far, no malignant lymphadenopathies have been reported in temporal context to vaccination in the ipsilateral draining lymph node areas. Experimental design: Prompted by two cases with unilateral axillary lymphomas that occurred ipsilaterally to prior SARS‐CoV‐2 vaccination, we systematically retrieved all B‐cell non‐Hodgkin lymphomas at two German University Medical Centers diagnosed before and after introduction of SARS‐CoV‐2 vaccines in Germany. Available lymphoma tissue (n=19) was subjected to next‐generation immunosequencing of the IGH locus. Malignant clonotypes were mined in the CoVabDab database and published data sets from 342 uninfected individuals, 55 individuals 28 days after anti‐SARS‐CoV‐2 vaccination and 139 individuals with acute COVID‐19 together encompassing over 1 million CDR3 sequences in total. Results: Of 313 newly diagnosed cases in the two centers and observation periods, 27 unilateral manifestations in the defined deltoid draining regions were identified. The majority thereof were diffuse large B‐cell lymphomas (18 of 27 cases). Eleven unilateral cases were diagnosed in the era of SARS‐CoV‐2 vaccination and 16 in the control period before introduction of such vaccines. Of the 11 unilateral lymphomas that occurred during the vaccination period, ten had received a SARS‐CoV‐2 vaccine prior to lymphoma diagnosis. These cases were further evaluated. While left‐sided were more frequent than right‐sided lymphomas (19 vs 8 cases), no statistically significant association of vaccination site and laterality of the lymphoma manifestation was found. The unilateral lymphomas showed a normal range of B‐cell receptors typically found in these lymphoma subtypes with no evidence for anti‐SARS‐CoV‐2 sequences in the malignant clonotype. Conclusions: Together, we found no evidence that the current SARS‐CoV‐2 vaccines could serve as a trigger for lymphomagenesis in the draining lymph node areas of the deltoid region used for vaccination. [ABSTRACT FROM AUTHOR]

Background: Centers for rare diseases serve as contact points for patients with complex, often undiagnosed complaints and persistent somatic symptoms of heterogeneous origin. Little is known about psychological distress of patients consulting these centers. Objectives: To better understand psychological distress of adult patients presenting at a center for rare diseases by determining the proportion of patients screening positive for depressive, anxiety, and somatic symptom disorders (SSD) and to identify factors associated with increased psychopathology. Methods: Cross-sectional data from the routine care registry of the Martin Zeitz Center for Rare Diseases (MZCSE) at the University Medical Center Hamburg-Eppendorf in Germany was retrieved and analyzed. We included all adult patients presenting between October 01,2020 and September 30,2021, who gave written informed consent. Measures: Sociodemographic variables, medical history and healthcare utilization, as well as validated measures to screen for a depressive disorder (PHQ-8), an anxiety disorder (GAD-7), and SSD (PHQ-15, SSD-12). Results: N = 167 patients were included (age 44.5 ± 14.3 years, 64.7% female). A total of 40.7% of the patients screened positive for a depressive disorder (PHQ-8 ≥ 10), 27.5% for an anxiety disorder (GAD-7 ≥ 10) and 45.0% screened positive for SSD (PHQ-15 ≥ 9 & SSD-12 ≥ 23). Factors associated with increased psychopathology included the number of symptoms, the number of different specialties consulted before and past psychotherapy. Conclusions: Patients presenting at centers for rare diseases are likely to experience high rates of psychological distress. Systematically screening patients with rare and undiagnosed diseases for mental disorders can help to detect those at risk at an early stage and initiate adequate psychological care. [ABSTRACT FROM AUTHOR]

Simple Summary: Human papillomavirus (HPV) association is the most important predictor of survival in squamous cell carcinomas in the head and neck region (HNSCC). The role of HPV in cancer of unknown origin at this anatomic site (CUPHNSCC) is less well understood. The objective of this study was to identify prognostic classification markers in CUPHNSCC. Therefore, we investigated a consecutive cohort by multivariate modeling and testing for HPV DNA, mRNA, and p16INK4a (p16) expression. In 31% of CUPHNSCC, p16 was overexpressed, and high-risk HPV DNA was detected in 18/32 (56.3%) of them, which was mostly consistent with mRNA detection. In contrast to oropharyngeal cancer, detection of p16 without additional detailed HPV testing appears to be more appropriate for the classification of CUPHNSCC. Three risk groups can be stratified based on performance status and p16, but additional factors may become important in future data or for cases with particular risk profiles. Background: Human papillomavirus (HPV) status is the most important predictor of survival in oropharyngeal squamous cell carcinoma (OPSCC). In patients with cervical lymph node metastases of squamous cell carcinoma of unknown origin (CUPHNSCC), much less is known. Methods: We assessed a consecutive cohort of CUPHNSCC diagnosed from 2000–2018 for HPV DNA, mRNA, p16INK4a (p16) expression, and risk factors to identify prognostic classification markers. Results: In 32/103 (31%) CUPHNSCC, p16 was overexpressed, and high-risk HPV DNA was detected in 18/32 (56.3%). This was mostly consistent with mRNA detection. In recursive partitioning analysis, CUPHNSCC patients were classified into three risk groups according to performance status (ECOG) and p16. Principal component analysis suggests a negative correlation of p16, HPV DNA, and gender in relation to ECOG, as well as a correlation between N stage, extranodal extension, and tobacco/alcohol consumption. Conclusions: Despite obvious differences, CUPHNSCC shares similarities in risk profile with OPSCC. However, the detection of p16 alone appears to be more suitable for the classification of CUPHNSCC than for OPSCC and, in combination with ECOG, allows stratification into three risk groups. In the future, additional factors besides p16 and ECOG may become important in larger studies or cases with special risk profiles. [ABSTRACT FROM AUTHOR]

Background: Satisfaction with care is an important indicator of health care quality. However, if this process measure is associated with patients' outcomes in real-world data is largely unknown. We, therefore, aimed to evaluate if satisfaction with physician- and nurse-related care is associated with quality of life and self-rated health among inpatients at the University Hospital Hamburg-Eppendorf in Germany. Method: We used standard hospital quality survey data of 4925 patients treated at various departments. We used multiple linear regressions to examine an association between satisfaction with staff-related care and quality of life as well as self-rated health, adjusted for age, gender, mother tongue, and treating ward. Patients rated their satisfaction with physician- and nurse-related care from 0 "not at all" to 9 "very much". The outcomes regarding quality of life and self-rated health were evaluated on five-point Likert scales ranking from 1 "bad" to 5 "excellent". Results: We found that satisfaction with physician-related care was positively associated with quality of life (ß = 0.16; p < 0.001) as well as with self-rated health (ß = 0.16; p < 0.001). Similar findings were observed for satisfaction with nurse-related care and the two outcomes (ß = 0.13; p < 0.001 and ß = 0.14; p < 0.001, respectively). Conclusion: We show that patients who are more satisfied with staff-related care report better quality of life and self-rated health than patients less satisfied with care. Thus, patient satisfaction with care, is not only a process measure indicating the quality of care but is also positively associated with patient-reported outcomes. [ABSTRACT FROM AUTHOR]

This study aims at evaluating the use case potential of breast cancer care for artificial intelligence and blockchain technology application based on the patient data analysis at Marburg University Hospital and, thereupon, developing a digital workflow for breast cancer care. It is based on a retrospective descriptive data analysis of all in-patient breast and ovarian cancer patients admitted at the Department of Gynecology of Marburg University Hospital within the five-year observation period of 2017 to 2021. According to the German breast cancer guideline, the care workflow was visualized and, thereon, the digital concept was developed, premised on the literature foundation provided by a Boolean combination open search. Breast cancer cases display a lower average patient case complexity, fewer secondary diagnoses, and performed procedures than ovarian cancer. Moreover, 96% of all breast cancer patients originate from a city with direct geographical proximity. Estimated circumference and total catchment area of ovarian present 28.6% and 40% larger, respectively, than for breast cancer. The data support invasive breast cancer as a preferred use case for digitization. The digital workflow based on combined application of artificial intelligence as well as blockchain or distributed ledger technology demonstrates potential in tackling senological care pain points and leveraging patient data safety and sovereignty. [ABSTRACT FROM AUTHOR]

Objective: In Germany, multimodal psychosomatic inpatient treatment can be initiated for patients with substantial mental disorders (e.g., depression, anxiety, somatoform disorders) and comorbid physical disease. However, studies investigating changes in psychological and functional treatment outcomes, and predictors of long-term treatment effects in patients undergoing psychosomatic inpatient treatment are needed. Methods: This cohort study analyzed 160 patients aged ≥18 who were treated on an integrated psychosomatic inpatient unit at the University of Göttingen Medical Center. Its aim was to analyze changes in psychological and functional outcomes, and to identify predictors of long-term improvements in health-related quality of life (HRQoL) in patients with comorbid mental and physical illness who were undergoing integrated inpatient psychosomatic treatment. Assessments were completed at admission, discharge, and 12- or 24-month follow-up. Outcomes included physical complaints [Giessen Subjective Complaints List (GBB-24)], psychological symptoms [Brief Symptom Inventory (BSI)], and HRQoL [European Quality of Life Questionnaire (EQ-5D)]. Results: One-hundred sixty inpatients were included (mean age = 53.1 ± 12.6; 53.8% female). There were significant, medium- to large-sized improvements in psychological symptoms (BSI-Global Severity Index; d = −0.83, p < 0.001), physical symptom burden (d = −0.94, p < 0.001), and HRQoL (d = 0.65, p < 0.001) from admission to discharge, and significant, small- to medium-sized greater improvements in all psychological outcomes from admission to follow-up (BSI-GSI: d = −0.54, p < 0.001; GBB-24 total symptom burden: d = −0.39, p < 0.001; EQ-5D: d = 0.52, p < 0.001). Furthermore better improvement in HRQoL during hospitalization (partial η² = 0.386; p < 0.001) was associated with higher HRQoL at follow-up. Finally, intake of antidepressant at discharge was associated with impaired HRQoL at follow-up (η² = 0.053; p = 0.03). Conclusion: There were significant short- and long-term improvements in psychological symptoms, physical complaints, and HRQoL after treatment on an integrated psychosomatic inpatient unit in patients with mental disorders and a comorbid physical disease. [ABSTRACT FROM AUTHOR]

Simple Summary: Pancreatic ductal adenocarcinoma (PDAC) is frequently seen in elderly patients. The aim of our retrospective study was to evaluate the impact of age on postoperative short-term and long-term outcomes in patients undergoing curative pancreatic resection for PDAC. Our data confirm that pancreatic resections can be performed with equal short-term outcomes even in older age. However, patient age significantly influenced the overall and disease-free survival of patients with PDAC undergoing primary resection in curative intent. Therefore, the choice of the optimal therapy concept for each patient should be individualized taking into account the patient's age. (1) Purpose: to evaluate the impact of age on postoperative short-term and long-term outcomes in patients undergoing curative pancreatic resection for PDAC. (2) Methods: This retrospective single-center study comprised 213 patients who had undergone primary resection of PDAC from January 2000 to December 2018 at the University Hospital of Erlangen, Germany. Patients were stratified according the age into two groups: younger (≤70 years) and older (>70 years) patients. Postoperative outcome and long-term survival were compared between the groups. (3) Results: There were no significant differences regarding inhospital morbidity (58% vs. 67%, p = 0.255) or inhospital mortality (2% vs. 7%, p = 0.073) between the two groups. The median overall survival (OS) and disease-free survival (DFS) were significantly shorter in elderly patients (OS: 29.2 vs. 17.1 months, p < 0.001, respectively; DFS: 14.9 vs. 10.4 months, p = 0.034). Multivariate analysis revealed that age was a significant independent prognostic predictor for OS and DFS (HR 2.23, 95% CI 1.58–3.15; p < 0.001 for OS and HR 1.62, 95% CI 1.17–2.24; p = 0.004 for DFS). (4) Conclusion: patient age significantly influenced overall and disease-free survival in patients with PDAC undergoing primary resection in curative intent. [ABSTRACT FROM AUTHOR]

Introduction. Managing polypharmacy is particularly demanding for general practitioners as coordinators of care. Recently, a German guideline for polypharmacy in primary care has been published. This paper describes the content and delivery of a tailored intervention, which aims at improving the implementation of guideline recommendations for polypharmacy into practice, considering individual barriers. Materials and Methods. Firstly, barriers for implementation and the corresponding strategies to address them have been identified. On this basis, an intervention consisting of a workshop for health care professionals and educational materials for patients has been developed. The workshop focused on knowledge, awareness, and skills. The educational materials included a tablet computer. Practice teams will elaborate individual concepts of how to implement the recommendations into their practice. The workshop has been evaluated by the participants by means of a questionnaire. Results. During the workshop 41 possible sources of medication errors and 41 strategies to improve medication management have been identified. Participants evaluated the workshop overall positively, certifying its relevancy to practice. Discussion. The concept of the workshop seemed appropriate to impart knowledge about medication management to the participants. It will have to be evaluated, if the intervention finally resulted in an improved implementation of the guideline recommendations. [ABSTRACT FROM AUTHOR]

Background: As robotics in nursing care is still in an early explorative research phase, it is not clear which changes robotic systems will ultimately bring about in the long term. According to the approach of "Responsible Research and Innovation", the research project "PfleKoRo" aims to anticipate and mitigate ethical risks that might be expected when starting to develop a robot. The robot under investigation is intended to be a hands-on support in nursing care in due course. Therefore, the question is which ethical risks and requirements must be considered when developing the robot. Methods: Guided by the British Standard for the design of robotic systems, ethical risks related to the robot's use were identified at the outset (Step 1). This was followed by the definition of the requirements needed to mitigate ethical risks (Step 2). Professional nurses, patients and relatives were involved in focus groups and interviews in Step 1. The transcribed interviews and focus groups were then analysed using content analysis. The available literature and expert guidance were taken into account in both steps. Finally, validation and verification methods were defined (Step 3). Results: Sixteen professional nurses participated in three focus groups. Individual interviews were held with a total of eight patients and relatives. Ethical risks and requirements could be defined in the context of dignity, autonomy, privacy, human relationships and safety in the project. Professional nurses feared most issues relating to safety and that the robot would lead to more workload instead of relief, whereas patients and relatives frequently raised the issue of the staffing ratio. Despite the focus on possible negative consequences, participants also made uncritical or optimistic comments regarding the robot's use in the future. Conclusion: Focus groups, individual interviews and existing literature revealed to some extent different ethical issues. Along with identified risks, the results suggest a general open-mindedness of nurses, patients and relatives towards the introduced robot. When investigating the ethical implications of robots for nursing care, one should include multiple perspectives and, in particular, potentially affected individuals. [ABSTRACT FROM AUTHOR]

Background. Much work has been done to evaluate the outcome of integrative inpatient treatment but scarcely the costs. This paper evaluates the costs for inpatient treatment in three anthroposophic hospitals (AHs). Material and Methods. Cost and performance data from a total of 23,180 cases were analyzed and compared to national reference data. Subgroup analysis was performed between the cases with and without anthroposophic medical complex (AMC) treatment. Results. Costs and length of stay in the cases without AMC displayed no relevant differences compared to the national reference data. In contrast the inlier cases with AMC caused an average of € 1,394 more costs. However costs per diem were not higher than those in the national reference data. Hence, the delivery of AMC was associated with a prolonged length of stay. 46.6% of the cases with AMC were high outliers. Only 10.6% of the inlier cases with AMC were discharged before reaching the mean length of stay of each DRG. Discussion. Treatment in an AH is not generally associated with an increased use of resources. However, the provision of AMC leads to a prolonged length of stay and cannot be adequately reimbursed by the current G-DRG system. Due to the heterogeneity of the patient population, an additional payment should be negotiated individually. [ABSTRACT FROM AUTHOR]

Background and aims: Patients with liver cirrhosis (LC) are considered to be at increased risk for mortality when acquiring SARS-CoV-2 infection and subsequently developing Corona Virus Disease 2019 (COVID-19). During the COVID-19 pandemic, hospitals are regarded as sites with increased risk of infection. Therefore, patient contacts are often limited to urgent indications, which could negatively affect disease monitoring. However, data regarding actual infection rates in cirrhotic patients is limited. The aim of this prospective study was to assess the incidence of COVID-19 in patients with LC with/without hepatocellular carcinoma (HCC) with physical presentation at our University Medical Center. Methods: Patients were enrolled between 1st April and 30th June 2020 at the University Medical Center Hamburg-Eppendorf, Germany. Symptoms of upper airway infection at baseline and presence of SARS-CoV-2 antibodies (IgG/IgM/IgA) were assessed at baseline and follow-up (FU) using an Electro-chemiluminescence immunoassay (Roche Elecsys). FU visits, including liver function test, clinical assessment and symptom questionnaire, were conducted after 6–8 weeks (FU-1) and 6 months (FU-2). Prior to inclusion of the first patient, obligatory face masks and personal distance were implemented as protective measures. Results: A total of 150 patients were enrolled, 23% (n = 35) also had diagnosis of HCC (median age: 64 years, range: 19–86), 69% were male. Liver function according to Child-Pugh score (CPS) was: CPS A: 46% (n = 62); CPS B: 37% (n = 50); CPS C: 17% (n = 23). Clinical symptoms indicating upper airway infection were present in 53% (n = 77): shortness of breath (n = 40) and coughing (n = 28) were the most frequent. For the 150 patients enrolled, 284 outpatient visits were registered and 33 patients were admitted to the University Medical Center during the follow-up period. After a median of 52 days, n = 110 patients completed FU-1 and n = 72 completed FU-2 after a median of 6.1 months. Only in one patient, an 80-year-old man with stable liver function (CPS A) and advanced HCC, SARS-CoV-2 antibodies were detected at baseline and FU-1, while antibody testing was negative in the remaining patients at baseline, FU-1 and FU-2. Conclusion: The incidence of COVID-19 at our tertiary medical center during the pandemic was low in LC and HCC patients, when simple protective measures were implemented. Therefore, a routine care for patients with chronic liver diseases does not increase the risk of SARS-CoV-2 infection and should be maintained with protective measures. [ABSTRACT FROM AUTHOR]

Background: Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline. Methods: We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression. Results: During the four-year period, 138 children (median age 21 months, minimum-maximum 9–101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3–11.3 g/dL) and 10.7 (7–13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p < 0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines. Conclusions: Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines. [ABSTRACT FROM AUTHOR]

Background: The theory and practice of ethics consultations (ECs) in health care are still characterized by many controversies, including, for example, the practice of giving recommendations. These controversies are complicated by an astonishing lack of evidence in the whole field. It is not clear how often a recommendation is issued in ethics consultations and when and why this step is taken. Especially in a facilitation model in which giving recommendations is optional, more data would be helpful to evaluate daily practice, ensure that this practice is in line with the overarching goals of this approach and support the development of standards.Methods: We analyzed all consultations requested from an EC service working under a facilitation approach at a maximum-care university hospital in Germany over a period of more than 10 years. Our aim was to better understand why-and under what circumstances-some consultation requests result in a recommendation, whereas others can be sufficiently addressed solely by facilitated meetings. We especially wanted to know when and why clients felt the need for clear advice from the EC service while in other cases they did not. We compared ethics consultations in terms of the differences between cases with and without recommendations issued by the ethics consultants using χ2 difference tests and Welch's t-test.Results: A total of 243 ECs were carried out between September 2008 and December 2019. In approximately half of the cases, a recommendation was given. All recommendations were issued upon the request of clients. When physicians asked for an EC, the consultation was significantly more likely to result in a recommendation than when the EC was requested by any other party. ECs in cases on wards with ethics rounds resulted in comparably fewer recommendations than those in wards without ethics rounds. When interpersonal conflicts were part of the problem or relatives were present in the meeting, clients less frequently asked for a recommendation.Conclusion: From the client's point of view, there does not seem to be only one "right" way to provide ethics consultations, but rather several. While facilitated meetings are obviously appreciated by clients, there also seem to be situations in which a recommendation is desired (especially by physicians). Further empirical and theoretical research is needed to validate our single-center results and re-evaluate the role of recommendations in ethics consultations. [ABSTRACT FROM AUTHOR]

Objectives: Non-publication and publication bias are topics of considerable importance to the scientific community. These issues may limit progress toward the 3R principle for animal research, promote waste of public resources, and generate biased interpretations of clinical outcomes. To investigate current publishing practices and to gain some understanding of the extent to which research results are reported, we examined publication rates of research projects that were approved within an internal funding program of the Faculty of Medicine at a university medical center in Germany, which is exemplary for comparable research funding programs for the promotion of young researchers in Germany and Europe. Methods: We analyzed the complete set (n = 363) of research projects that were supported by an internal funding program between 2004 and 2013. We divided the projects into four different proposal types that included those that required an ethics vote, those that included an animal proposal, those that included both requirements, and those that included neither requirement. Results: We found that 65% of the internally funded research projects resulted in at least one peer-reviewed publication; this increased to 73% if other research contributions were considered, including abstracts, book and congress contributions, scientific posters, and presentations. There were no significant differences with respect to publication rates based on (a) the clinic/institute of the applicant, (b) project duration, (c) scope of funding or (d) proposal type. Conclusion: To the best of our knowledge, this is the first study to explore publication rates associated with early-career medical research funding. As >70% of the projects ultimately generated some form of publication, the program was overall effective toward this goal; however, non-publication of research results is still prevalent. Further research will explore the reasons underlying non-publication. We hope to use these findings to develop strategies that encourage publication of research results. [ABSTRACT FROM AUTHOR]

Background: Calcitonin gene related peptide (CGRP) monoclonal antibodies (mAB) are the first specific migraine prophylactic medication. Erenumab is the only CGRP mAB targeting the CGRP receptor. Clinical data regarding efficacy and tolerability of erenumab in highly therapy-refractory patients are not available, yet, although many patients treated with CGRP mAB under real world conditions can be considered as highly therapy-refractory. Methods: Clinical routine data of highly therapy-refractory migraine patients treated with erenumab 70 mg for 3 months between November 2018 and December 2019 in the West German Headache Center, University Hospital Essen, Germany, were analysed. Monthly migraine days (MMD), monthly headache days (MHD) and days of acute medication intake (AMD) were assessed. Statistical analysis was performed using the Wilcoxon test. Descriptive statistics were performed to evaluate changes of vegetative symptoms, acute medication response, side effects, as well as treatment satisfaction. Results: Complete clinical data were available for 26 episodic (EM) and 74 chronic (CM) migraineurs. Sixty-six % (n = 49) of CM patients had an additional medication overuse headache (MOH). After 3 months 57.7% of EM patients and 41.9% of CM patients had a 50% or greater reduction of MMD. The mean number of MMD was reduced by 3.43 (SE 1.26) in EM, and by 4.72 (SE 0.87) in CM. Thirty-nine patients (52.7%) returned from chronic to episodic course of migraine. After 3 months, 23 patients (46.9%) were not suffering from a MOH anymore. Conclusions: Erenumab seems to be a promising therapeutic option in highly therapy-refractory migraine patients. Trial registration: Retrospective registered. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) pandemic poses an unprecedented challenge to health-care systems around the world. As approximately one-third of the world´s population is living under "lockdown" conditions, medical resources are being reallocated and hospital admissions are limited to emergencies. We examined the decision-making impact of these actions and their effects on access to hospital treatment in patients with neurosurgical conditions. Methods: This retrospective cohort study analyzes hospital admissions of two major neurosurgical services in Germany during the nationwide lockdown period (March 16th to April 16th, 2020). Spinal or cranial conditions requiring immediate hospital admission and treatment constituted emergencies. Results: A total of 243 in-patients were treated between March 16th and April 16th 2020 (122 patients at the University Medical Center Mainz, 121 patients at the University Medical Center Göttingen). Of these, 38.0±16% qualified as emergency admission. Another 1,688 admissions were reviewed during the same periods in 2018 and 2019, providing a frame of reference. Overall, emergency admissions declined by 44.7±0.7% during lockdown. Admissions for cranial emergencies fell by 48.1±4.44%, spinal emergencies by 30.9±14.6%. Conclusion: Above findings indicate that in addition to postponing elective procedures, emergency admissions were dramatically curtailed during the COVID-19 lockdown. As this surely is unexpected and unintended, reasons are undoubtedly complex. As consequences in morbidity and mortality are still unpredictable, efforts should be made to accommodate all patients in need of hospital access going forward. [ABSTRACT FROM AUTHOR]

Background: In the emergency room, distinguishing between a migraine with aura and a transient ischemic attack (TIA) is often not straightforward and mistakes can be harmful to both the patient and to society. To account for this difficulty, the third edition of the International Classification of Headache disorders (ICHD-3) changed the diagnostic criteria of migraine with aura. Methods: One hundred twenty-eight patients referred to the emergency room at the University Hospital of Lübeck, Germany with a suspected TIA were prospectively interviewed about their symptoms leading to admission shortly after initial presentation. The diagnosis that resulted from applying the ICHD-3 and ICHD-3 beta diagnostic criteria was compared to the diagnosis made independently by the treating physicians performing the usual diagnostic work-up. Results: The new ICHD-3 diagnostic criteria for migraine with aura and migraine with typical aura display an excellent specificity (96 and 98% respectively), and are significantly more specific than the previous ICHD-3 beta classification system when it comes to diagnosing a first single attack (probable migraine with aura and probable migraine with typical aura). Conclusions: The ICHD-3 is a highly useful tool for the clinical neurologist in order to distinguish between a migraine with aura and a TIA, already at the first point of patient contact, such as in the emergency department or a TIA clinic. [ABSTRACT FROM AUTHOR]

Child health is central to the SDG agenda. Universities in the UK and other European countries provide leadership in research and education for global child health to inform related policy and practice, but the German contribution is inadequate. German paediatricians and other child health professionals could make more substantial contributions to the debate at home and internationally, but lack opportunities for scholarship and research. We argue, that there is a momentum to advance global child health in academia and call on German universities to realise this potential. [ABSTRACT FROM AUTHOR]

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We estimated numbers of hospitalizations for norovirus gastroenteritis (NGE) and associated medical costs in Germany, where norovirus testing is high because reimbursement is affected. We extracted aggregate data for patients hospitalized with a primary or secondary code from the International Classification of Diseases, 10th Revision (ICD-10), NGE diagnosis during 2007-2012 from the German Federal Statistics Office. We assessed reliability of the coding system in patient records from a large academic hospital. Approximately 53,000-90,000 NGE hospitalizations occurred annually in Germany (21,000-33,000 with primary and 32,000-57,000 with secondary ICD-10-coded NGE diagnoses). Rates of hospitalization with NGE as primary diagnosis were highest in children <2 years of age; rates of hospitalization with NGE as secondary diagnosis were highest in adults >85 years of age. The average annual reimbursed direct medical cost of NGE hospitalizations was €31-43 million. Among patients with a NGE ICD-10 code, 87.6% had positive norovirus laboratory results. [ABSTRACT FROM AUTHOR]

Background: Biologically-based complementary medicines (BB-CAM) including herbs and nutritional supplements are frequently taken by breast- and gynecological cancer patients undergoing systemic therapy. The aim of this study was to analyze the use of these natural CAM methods under systemic therapy. Methods: From September 2014 to December 2014 and February 2017 to May 2017 all patients (n= 717) undergoing systemic therapy at the day care unit, Department of Gynecology and Obstetrics, Technical University Munich, Germany, with breast- and/or gynecological cancer were included in this survey. The self-administered 8-item questionnaire was developed to obtain information on complementary medication intake during systemic therapy. Results: Among 448 respondents 74.1% reported to use complementary medication simultaneous to their systemic therapy. The most frequently applied methods during therapy were vitamins and minerals supplements (72.3%), medicinal teas (46.7%), phytotherapy (30.1%), and mistletoe (25.3%). The analysis showed that various patients-, disease- and therapy characteristics like receiving chemotherapy (p= 0.002), and younger age (younger than 60 years; p=0.017) are significantly associated with BB-CAM use. Conclusions: Our data suggest that female cancer patients undergoing systemic therapy frequently use BB-CAM medicine. Therefore, it is indispensable to implement counseling and evidence-based complementary treatments into clinical routine of cancer centers. A counseling service for integrative medicine concepts and an outpatient program (ZIGG) was therefore implemented in our cancer center in 2013. Further research on the CAM intake of cancer patients is needed in order to verify drug interactions and implement specific guidelines for integrative medication concepts. [ABSTRACT FROM AUTHOR]

Background: Women's participation in medicine and the need for gender equality in healthcare are increasingly recognised, yet little attention is paid to leadership and management positions in large publicly funded academic health centres. This study illustrates such a need, taking the case of four large European centres: Charité - Universitätsmedizin Berlin (Germany), Karolinska Institutet (Sweden), Medizinische Universität Wien (Austria), and Oxford Academic Health Science Centre (United Kingdom).Case: The percentage of female medical students and doctors in all four countries is now well within the 40-60% gender balance zone. Women are less well represented among specialists and remain significantly under-represented among senior doctors and full professors. All four centres have made progress in closing the gender leadership gap on boards and other top-level decision-making bodies, but a gender leadership gap remains relevant. The level of achieved gender balance varies significantly between the centres and largely mirrors country-specific welfare state models, with more equal gender relations in Sweden than in the other countries. Notably, there are also similar trends across countries and centres: gender inequality is stronger within academic enterprises than within hospital enterprises and stronger in middle management than at the top level. These novel findings reveal fissures in the 'glass ceiling' effects at top-level management, while the barriers for women shift to middle-level management and remain strong in academic positions. The uneven shifts in the leadership gap are highly relevant and have policy implications.Conclusion: Setting gender balance objectives exclusively for top-level decision-making bodies may not effectively promote a wider goal of gender equality. Academic health centres should pay greater attention to gender equality as an issue of organisational performance and good leadership at all levels of management, with particular attention to academic enterprises and newly created management structures. Developing comprehensive gender-sensitive health workforce monitoring systems and comparing progress across academic health centres in Europe could help to identify the gender leadership gap and utilise health human resources more effectively. [ABSTRACT FROM AUTHOR]

Background: Medical errors have been recognized as a relevant public health concern and research efforts to improve patient safety have increased. In palliative care, however, studies on errors are rare and mainly focus on quantitative measures. We aimed to explore how palliative care patients perceive and think about errors in palliative care and to generate an understanding of patients' perception of errors in that specialty. Methods: A semistructured qualitative interview study was conducted with patients who had received at least 1 week of palliative care in an inpatient or outpatient setting. All interviews were transcribed verbatim and analysed according to qualitative content analysis. Results: Twelve patients from two centers were interviewed (7 women, median age 63.5 years, range 22-90 years). Eleven patients suffered from a malignancy. Days in palliative care ranged from 10 to 180 days (median 28 days). 96 categories emerged which were summed up under 11 umbrella terms definition, difference, type, cause, consequence, meaning, recognition, handling, prevention, person causing and affected person. A deductive model was developed assigning umbrella terms to error-theory-based factor levels (definition, type and process-related factors). 23 categories for type of error were identified, including 12 categories that can be considered as palliative care specific. On the level of process-related factors 3 palliative care specific categories emerged (recognition, meaning and consequence of errors). Conclusion: From the patients' perspective, there are some aspects of errors that could be considered as specific to palliative care. As the results of our study suggest, these palliative care-specific aspects seem to be very important from the patients' point of view and should receive further investigation. Moreover, the findings of this study can serve as a guide to further assess single aspects or categories of errors in palliative care in future research. [ABSTRACT FROM AUTHOR]

Background: Acceptable short-term survival rates (>90 %) of mini-implants (diameter < 3.0 mm) are only documented for mandibular overdentures. Sound data for mini-implants as strategic abutments for a better retention of partial removable dental prosthesis (PRDP) are not available. Methods/design: The purpose of this study is to test the hypothesis that immediately loaded mini-implants show more bone loss and less success than strategic mini-implants with delayed loading. In this four-center (one university hospital, three dental practices in Germany), parallel-group, controlled clinical trial, which is cluster randomized on patient level, a total of 80 partially edentulous patients with unfavourable number and distribution of remaining abutment teeth in at least one jaw will receive supplementary min-implants to stabilize their PRDP. The mini-implant are either immediately loaded after implant placement (test group) or delayed after four months (control group). Follow-up of the patients will be performed for 36 months. The primary outcome is the radiographic bone level changes at implants. The secondary outcome is the implant success as a composite variable. Tertiary outcomes include clinical, subjective (quality of life, satisfaction, chewing ability) and dental or technical complications. Discussion: Strategic implants under an existing PRDP are only documented for standard-diameter implants. Mini-implants could be a minimal invasive and low cost solution for this treatment modality. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown medical students in Germany to have little interest in research while at the same time there is a lack of physician scientists. This study's aim is to investigate factors influencing publication productivity of physicians during and after finishing their medical doctorate. Methods: We conducted a PubMed search for physicians having received their doctoral degree at Ludwig-Maxmilians-University Munich Faculty of Medicine between 2011 and 2013 (N = 924) and identified the appropriate impact factor (IF) for each journal the participants had published in. Gender, age, final grade of the doctorate, participation in a structured doctoral study program and joint publication activities between graduate and academic supervisor were defined as factors. For analyses we used nonparametric procedures. Results: Men show significantly more publications than women. Before their doctoral graduation men publish 1.98 (SD ± 3.64) articles on average, women 1.15 (±2.67) (p < 0.0001, d = 0.27). After completion of the doctorate (up to 06/2015), 40% of men still publish, while only 24.3% of women (p < 0.0001, φ = 0.17) continue to publish. No differences were found concerning the value of IFs. Similar results were found regarding the variable 'participation in a structured doctoral study program'. Until doctoral graduation, program participants publish 2.82 (±5.41) articles, whereas participants doing their doctorate individually only publish 1.39 (±2.87) articles (p < 0.0001, d = 0.46). These differences persist in publication activities after graduation (45.5 vs. 29.7%, p = 0.008, φ = 0.09). A structured doctorate seems to have positive influence on IFs (4.33 ± 2.91 vs. 3.37 ± 2.82, p = 0.006, d = 0.34). Further significant results concern the variables 'final grade' and 'age': An early doctoral graduation and an excellent or very good grade for the doctoral thesis positively influence publication productivity. Finally, joint publication activities between the graduate and his/her academic supervisor result in significantly higher IFs (3.64 ± 3.03 vs. 2.84 ± 2.25, p = 0.007, d = 0.28). Conclusions: The study's results support the assumption about women's underrepresentation in science as well as the relevance of structured doctoral study programs for preparing and recruiting young academics in medicine for scientific careers. Promoting women and further development of structured doctoral study programs are highly recommended. [ABSTRACT FROM AUTHOR]

Background: We evaluated the periodontal conditions in patients with type 2 diabetes mellitus compared to metabolically healthy controls, and determined whether periodontal interleukin genotypes and microorganisms differed between participants with and without type 2 diabetes mellitus. Methods: From April 2011 to July 2012, we prospectively enrolled healthy controls and patients with type 2 diabetes mellitus. Evaluation included assessment of medical and periodontal findings. We also recorded the presence of several interleukin gene variants and specific microorganisms, both available through commercially available diagnostic kits. Statistical significance was tested by the chi-square test and student's t-test. Results: We enrolled 52 patients with type 2 diabetes mellitus and 52 healthy controls. Compared with controls, periodontal disease was significantly more severe in patients with type 2 diabetes mellitus for the following: plaque index, bleeding on probing, pocket probing depth, clinical attachment loss, severe periodontal destruction (i.e., clinical attachment loss ≥ 5 mm), and number of teeth. However, statistical analysis failed to detect significant differences with respect to the periodontal-related interleukin genotypes (p ≥ 0.58) or the selected oral microbiota (p ≥0.15). Conclusion: Based on these results, it may be assumed that chronic periodontitis in patients with type 2 diabetes mellitus is most strongly associated with inadequate oral hygiene. Periodontal interleukin genotypes and differences in oral microbiota seem to play a subordinate role. [ABSTRACT FROM AUTHOR]

Background: Traumatic dental injuries present complex injuries of the dentoalveolar system. Aim of this study was to investigate the frequency and patterns of traumatic dental injuries in a University dental emergency service over four years. Methods: A retrospective investigation on all dental trauma patients presenting at the dental emergency service of the University Medical Center Mainz, Germany between 01/2010 and 12/2013 was conducted. Demographic data, the cause and type of trauma and the initial therapy were analyzed. Results: Out of 16,301 patients, 1,305 patients (8 %; average age 14.7 years ±15.7; 60.1 % male, 39.9 % female) came due to trauma. 63.9 % of the traumas occurred on weekends. The most frequent reason for injuries was falls (54.6 %). No correlation could be found between the cause and the kind of trauma. In 48.6 % of the cases only one tooth was involved, in 33.5 % two. The permanent dentition was traumatized in 56.6 % of cases, the deciduous teeth in 41.1 %. The most frequently affected tooth was the central upper incisor (61.0 %). Hard-tissue injuries were significantly more frequent in the permanent dentition, while periodontal injuries were seen significantly more often in the deciduous dentition. Conclusion: Eight percent of all patients seeking help at the dental emergency service presented with trauma, meaning that dental traumatology is one of the major topics in emergencies. To improve the quality of care, further public education, expert knowledge among dental professionals and a well-structured emergency service are necessary. [ABSTRACT FROM AUTHOR]

Background: Abnormal regional cerebral blood flow (rCBF) and grey matter volume have been frequently reported in patients with major depressive disorder (MDD). However, it is unclear to what extent structural and functional change co-occurs in patients with MDD and whether markers of neural activity, such as rCBF, can be predicted by structural change. Methods: Using MRI, we investigated resting-state rCBF and brain structure in patients with MDD and healthy controls between July 2008 and January 2013. We acquired perfusion images obtained with continuous arterial spin labelling, used voxel-based morphometry to assess grey matter volume and integrated biological parametric mapping analyses to investigate the impact of brain atrophy on rCBF. Results: We included 43 patients and 29 controls in our study. Frontotemporal grey matter volume was reduced in patients compared with controls. In patients, rCBF was reduced in the anterior cingulate and bilateral parahippocampal areas and increased in frontoparietal and striatal regions. These abnormalities were confirmed by analyses with brain volume as a covariate. In patients with MDD there were significant negative correlations between the extent of depressive symptoms and bilateral parahippocampal rCBF. We found a positive correlation between depressive symptoms and rCBF for right middle frontal cortical blood flow. Limitations: Medication use in patients has to be considered as a limitation of our study. Conclusion: Our data suggest that while changes of cerebral blood flow and brain volume co-occur in patients with MDD, structural change is not sufficient to explain altered neural activity in patients at rest. Abnormal brain structure and function in patients with MDD appear to reflect distinct levels of neuropathology. [ABSTRACT FROM AUTHOR]

Background: This article investigates the importance of regional health care availability for old age survival. Using German reunification as a natural experiment, we show that spatial variation in health care in East Germany considerably influenced the convergence of East German life expectancy toward West German levels. Method: We apply cause-deleted life tables and continuous mortality decomposition for the years 1982-2007 to show how reductions in circulatory mortality among the elderly affected the East German catch-up in life expectancy. Results: Improvements in remaining life expectancy at older ages were first seen in towns with university hospitals, where state-of-the-art services became available first. Conclusion: Our results suggest that the modernization of the health care system had a substantial effect on old-age life expectancy and helped to significantly reduce circulatory diseases as the main cause of death in East Germany. [ABSTRACT FROM AUTHOR]