Search

Objectives The use of remdesivir (RDV) as the first drug approved for coronavirus disease 2019 (COVID-19) remains controversial. Based on the Lean European Open Survey on severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infected patients (LEOSS), we aim to contribute timing-focused complementary real-world insights to its evaluation. Methods SARS-CoV-2 infected patients between January 2020 and December 2021 treated with RDV were matched 1:1 to controls considering sociodemographics, comorbidities and clinical status. Multiple imputations were used to account for missing data. Effects on fatal outcome were estimated using uni- and multivariable Cox regression models. Results We included 9,687 patients. For those starting RDV administration in the complicated phase, Cox regression for fatal outcome showed an adjusted hazard ratio (aHR) of 0.59 (95%CI 0.41–0.83). Positive trends could be obtained for further scenarios: an aHR of 0.51 (95%CI 0.16–1.68) when RDV was initiated in uncomplicated and of 0.76 (95% CI 0.55–1.04) in a critical phase of disease. Patients receiving RDV with concomitant steroids exhibited a further reduction in aHR in both, the complicated (aHR 0.50, 95%CI 0.29–0.88) and critical phase (aHR 0.63, 95%CI 0.39–1.02). Conclusion Our study results elucidate that RDV use, in particular when initiated in the complicated phase and accompanied by steroids is associated with improved mortality. However, given the limitations of non-randomized trials in estimating the magnitude of the benefit of an intervention, further randomized trials focusing on the timing of therapy initiation seem warranted.

Background As a national effort to better understand the current pandemic, three cohorts collect sociodemographic and clinical data from coronavirus disease 2019 (COVID-19) patients from different target populations within the German National Pandemic Cohort Network (NAPKON). Furthermore, the German Corona Consensus Dataset (GECCO) was introduced as a harmonized basic information model for COVID-19 patients in clinical routine. To compare the cohort data with other GECCO-based studies, data items are mapped to GECCO. As mapping from one information model to another is complex, an additional consistency evaluation of the mapped items is recommended to detect possible mapping issues or source data inconsistencies. Objectives The goal of this work is to assure high consistency of research data mapped to the GECCO data model. In particular, it aims at identifying contradictions within interdependent GECCO data items of the German national COVID-19 cohorts to allow investigation of possible reasons for identified contradictions. We furthermore aim at enabling other researchers to easily perform data quality evaluation on GECCO-based datasets and adapt to similar data models. Methods All suitable data items from each of the three NAPKON cohorts are mapped to the GECCO items. A consistency assessment tool (dqGecco) is implemented, following the design of an existing quality assessment framework, retaining their-defined consistency taxonomies, including logical and empirical contradictions. Results of the assessment are verified independently on the primary data source. Results Our consistency assessment tool helped in correcting the mapping procedure and reveals remaining contradictory value combinations within COVID-19 symptoms, vital signs, and COVID-19 severity. Consistency rates differ between the different indicators and cohorts ranging from 95.84% up to 100%. Conclusion An efficient and portable tool capable of discovering inconsistencies in the COVID-19 domain has been developed and applied to three different cohorts. As the GECCO dataset is employed in different platforms and studies, the tool can be directly applied there or adapted to similar information models.

BACKGROUND: Public health actors contribute significantly to health protection, promotion, and prevention at the population level. An overview of the public health landscape can facilitate collaboration among the stakeholders and increase transparency of career paths for young professionals.; OBJECTIVES: This study aims to develop an overview and category system of supra-regional public health actors in Germany.; METHODS: Based on alist of institutional actors that participated in the national conference Future Forum Public Health ("Zukunftsforum Public Health") and atargeted online search by the authors, supra-regional institutions and organizations with apublic health focus were identified. All actors were screened independently by ≥ 2 authors. Community-level actors as well as those without adirect public health focus were excluded. Additional actors were identified via asnowballing process. In order to cluster the actors thematically, acategory system was formed inductively.; RESULTS: Out of atotal of 645 screened actors, 307 (47.6%) were included and subsequently assigned to 12main and 30subcategories. Professional associations (n =60) made up the largest category, followed by civil society (n =49) and state actors (n =40). In addition to atabular and graphical overview, an interactive visualization of the actors was created ( www.noeg.org ).; CONCLUSIONS: This study provides acomprehensive overview of supra-regional institutional public health actors in Germany and highlights the breadth of the German public health landscape. The results of this work offer new opportunities for collaboration and can support young professionals in their career paths. Building on this work, further research on public health actors is recommended. © 2021. The Author(s)., Hintergrund Akteure der öffentlichen Gesundheit (Public Health) tragen wesentlich zu Gesundheitsschutz, -förderung und Prävention auf Bevölkerungsebene bei. Kenntnisse über die Akteurslandschaft erleichtern die Zusammenarbeit und erhöhen die Transparenz des Berufsfeldes für Nachwuchsfachkräfte. Zielsetzung Ziel dieser Arbeit waren eine Bestandsaufnahme und Kategorisierung überregionaler Public-Health-Akteure in Deutschland. Methodik Ausgehend von einer Aufstellung der teilnehmenden Institutionen am Zukunftsforum Public Health und zielgerichteter Onlinerecherche wurden überregionale Organisationen mit Public-Health-Schwerpunkt identifiziert. Alle Akteure wurden durch ≥ 2 Autor:innen unabhängig voneinander gescreent. Rein lokal tätige Akteure und solche ohne erkennbaren Public-Health-Schwerpunkt wurden ausgeschlossen. Mittels Schneeballverfahrens wurden weitere Akteure identifiziert. Zur thematischen Clusterung wurde induktiv ein Kategoriensystem gebildet. Ergebnisse Von 645 gescreenten Akteuren wurden 307 (47,6 %) eingeschlossen und 12 Ober- sowie 30 Subkategorien zugeordnet. Die Oberkategorie Fachverbände (n = 60) weist die höchste Akteursanzahl auf, gefolgt von zivilgesellschaftlichen (n = 49) und staatlichen Akteuren (n = 40). Neben einer tabellarischen und grafischen Darstellung wurde eine interaktive Akteursübersicht erstellt (www.noeg.org). Diskussion Diese Arbeit bietet eine umfangreiche Übersicht über Akteure der öffentlichen Gesundheit in Deutschland und verdeutlicht die Breite der deutschen Public-Health-Landschaft. Die Ergebnisse bieten neue Möglichkeiten zur Vernetzung und können Nachwuchsfachkräften Berufswege aufzeigen. Ausgehend von dieser Arbeit sind ergänzende Forschungsarbeiten zu Public-Health-Akteuren sinnvoll.

Zusammenfassung Ziel der Studie Aus der durch das Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) bedingten Coronavirus-Krankheit-2019 (COVID-19) haben sich Chancen und Herausforderungen für den Aufbau von Registern in der Versorgungsforschung ergeben. Diese sollen exemplarisch am aktuell größten sektorenübergreifenden Register mit einem detaillierten klinischen Datensatz zu mit SARS-CoV-2 infizierten Patient:innen in Deutschland, der Lean European Open Survey on SARS-CoV-2 Infected Patients (LEOSS), aufgezeigt werden. Methodik Ziele von LEOSS waren es, ein kollaboratives und integratives Register zur Erfassung von anonymen Daten aus der Versorgung zu schaffen und die Daten der Wissenschaft im Sinne eines Open Science Ansatzes rasch bereitzustellen. Alleiniges Einschlusskriterium war der virologische Nachweis von SARS-CoV-2. Schlüsselstrategien waren die Reallokation der vorhandenen personellen und technischen Ressourcen, die frühe und direkte Einbeziehung von Vertreter:innen des Datenschutzes und der Ethikkommissionen sowie die Entscheidung zu einem iterativen und agilen Entwicklungs- und Anpassungsprozess. Ergebnisse Getragen von den zahlreichen kollaborierenden Institutionen konnte ein transsektorales und internationales Netzwerk mit aktuell 133 aktiv rekrutierenden Standorten und 7227 dokumentierten Fällen aufgebaut werden (Stand 18.03.2021, ein Jahr seit Rekrutierungsstart von LEOSS). Die Nutzung der Daten wurde über auf der Projektwebseite verfügbare Werkzeuge zur Datenexploration, wie auch über die teilautomatisierte Bereitstellung von Datensätzen verschiedenen Umfangs, innerhalb kurzer Zeit ermöglicht. Es wurden 97 Anträge zur Datennutzung aus 27 Themengebieten begutachtet. Im Peer-Review-Verfahren wurden 9 Arbeiten in internationalen Fachzeitschriften veröffentlicht. Schlussfolgerung Mit LEOSS konnte in kürzester Zeit ein System zur Erfassung klinischer Verlaufsdaten zu COVID-19 in Deutschland etabliert werden. Auch wenn in anderen Projekten für spezifische Fragestellungen weitaus größere Datenbestände durch direkten Zugriff auf Quellsysteme analysiert werden konnten, wurde durch den einheitlich gepflegten und technisch geprüften Dokumentationsstandard mit vielen fachspezifischen Details ein sehr großer Datensatz mit wertvollen Alleinstellungsmerkmalen geschaffen. Aus den Erfahrungen von LEOSS können Implikationen für die zukünftige Gestaltung von Registern und eine rasche Reaktion auf Pandemien abgeleitet werden.

Aims SARS-CoV-2 infection is associated with adverse outcomes in patients with cardiovascular disease. Here, we analyzed whether specific biomarkers predict the clinical course of COVID-19 in patients with cardiovascular comorbidities. Methods and results We enrolled 2147 patients with SARS-CoV-2 infection which were included in the Lean European Open Survey on SARS-CoV‑2 (LEOSS)-registry from March to June 2020. Clinical data and laboratory values were collected and compared between patients with and without cardiovascular comorbidities in different clinical stages of the disease. Predictors for mortality were calculated using multivariate regression analysis. We show that patients with cardiovascular comorbidities display significantly higher markers of myocardial injury and thrombo-inflammatory activation already in the uncomplicated phase of COVID-19. In multivariate analysis, elevated levels of troponin [OR 1.54; (95% CI 1.22–1.96), p p p Conclusion Patients with cardiovascular comorbidities show elevated markers of thrombo-inflammatory activation and myocardial injury, which predict mortality, already in the uncomplicated phase of COVID-19. Starting targeted anti-inflammatory therapy and aggressive anticoagulation already in the uncomplicated phase of the disease might improve outcomes after SARS-CoV-2 infection in patients with cardiovascular comorbidities. Graphic abstract Elevated markers of thrombo-inflammatory activation predict outcome in patients with cardiovascular comorbidities and COVID-19 disease: insights from the LEOSS registry

The German government initiated the Network University Medicine (NUM) in early 2020 to improve national research activities on the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic. To this end, 36 German Academic Medical Centers started to collaborate on 13 projects, with the largest being the National Pandemic Cohort Network (NAPKON). The NAPKON’s goal is creating the most comprehensive Coronavirus Disease 2019 (COVID-19) cohort in Germany. Within NAPKON, adult and pediatric patients are observed in three complementary cohort platforms (Cross-Sectoral, High-Resolution and Population-Based) from the initial infection until up to three years of follow-up. Study procedures comprise comprehensive clinical and imaging diagnostics, quality-of-life assessment, patient-reported outcomes and biosampling. The three cohort platforms build on four infrastructure core units (Interaction, Biosampling, Epidemiology, and Integration) and collaborations with NUM projects. Key components of the data capture, regulatory, and data privacy are based on the German Centre for Cardiovascular Research. By December 01, 2021, 34 university and 34 non-university hospitals have enrolled 4,241 patients with local data quality reviews performed on 2,812 (66%). 47% were female, the median age was 53 (IQR: 38-63)) and 3 pediatric cases were included. 30% of patients were hospitalized, 11% admitted to an intensive care unit, and 4% of patients deceased while enrolled. 7,143 visits with biosampling in 3,595 patients were conducted by November 29, 2021. In this overview article, we summarize NAPKON’s design, relevant milestones including first study population characteristics, and outline the potential of NAPKON for German and international research activities.Trial registration:· https://clinicaltrials.gov/ct2/show/NCT04768998· https://clinicaltrials.gov/ct2/show/NCT04747366· https://clinicaltrials.gov/ct2/show/NCT04679584

The German government initiated the Network University Medicine (NUM) in early 2020 to improve national research activities on the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic. To this end, 36 German Academic Medical Centers started to collaborate on 13 projects, with the largest being the National Pandemic Cohort Network (NAPKON). The NAPKON’s goal is creating the most comprehensive Coronavirus Disease 2019 (COVID-19) cohort in Germany. Within NAPKON, adult and pediatric patients are observed in three complementary cohort platforms (Cross-Sectoral, High-Resolution and Population-Based) from the initial infection until up to three years of follow-up. Study procedures comprise comprehensive clinical and imaging diagnostics, quality-of-life assessment, patient-reported outcomes and biosampling. The three cohort platforms build on four infrastructure core units (Interaction, Biosampling, Epidemiology, and Integration) and collaborations with NUM projects. Key components of the data capture, regulatory, and data privacy are based on the German Centre for Cardiovascular Research. By April 01, 2022, 34 university and 40 non-university hospitals have enrolled 5298 patients with local data quality reviews performed on 4727 (89%). 47% were female, the median age was 52 (IQR 36–62-) and 50 pediatric cases were included. 44% of patients were hospitalized, 15% admitted to an intensive care unit, and 12% of patients deceased while enrolled. 8845 visits with biosampling in 4349 patients were conducted by April 03, 2022. In this overview article, we summarize NAPKON’s design, relevant milestones including first study population characteristics, and outline the potential of NAPKON for German and international research activities.Trial registrationhttps://clinicaltrials.gov/ct2/show/NCT04768998.https://clinicaltrials.gov/ct2/show/NCT04747366.https://clinicaltrials.gov/ct2/show/NCT04679584

The Coronavirus Disease-2019 (COVID-19) pandemic has brought opportunities and challenges, especially for health services research based on routine data. In this article we will demonstrate this by presenting lessons learned from establishing the currently largest registry in Germany providing a detailed clinical dataset on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infected patients: the Lean European Open Survey on SARS-CoV-2 Infected Patients (LEOSS).LEOSS is based on a collaborative and integrative research approach with anonymous recruitment and collection of routine data and the early provision of data in an open science context. The only requirement for inclusion was a SARS-CoV-2 infection confirmed by virological diagnosis. Crucial strategies to successfully realize the project included the dynamic reallocation of available staff and technical resources, an early and direct involvement of data protection experts and the ethics committee as well as the decision for an iterative and dynamic process of improvement and further development.Thanks to the commitment of numerous institutions, a transsectoral and transnational network of currently 133 actively recruiting sites with 7,227 documented cases could be established (status: 18.03.2021). Tools for data exploration on the project website, as well as the partially automated provision of datasets according to use cases with varying requirements, enabled us to utilize the data collected within a short period of time. Data use and access processes were carried out for 97 proposals assigned to 27 different research areas. So far, nine articles have been published in peer-reviewed international journals.As a collaborative effort of the whole network, LEOSS developed into a large collection of clinical data on COVID-19 in Germany. Even though in other international projects, much larger data sets could be analysed to investigate specific research questions through direct access to source systems, the uniformly maintained and technically verified documentation standard with many discipline-specific details resulted in a large valuable data set with unique characteristics. The lessons learned while establishing LEOSS during the current pandemic have already created important implications for the design of future registries and for pandemic preparedness and response.Aus der durch das Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) bedingten Coronavirus-Krankheit-2019 (COVID-19) haben sich Chancen und Herausforderungen für den Aufbau von Registern in der Versorgungsforschung ergeben. Diese sollen exemplarisch am aktuell größten sektorenübergreifenden Register mit einem detaillierten klinischen Datensatz zu mit SARS-CoV-2 infizierten Patient:innen in Deutschland, der Lean European Open Survey on SARS-CoV-2 Infected Patients (LEOSS), aufgezeigt werden.Ziele von LEOSS waren es, ein kollaboratives und integratives Register zur Erfassung von anonymen Daten aus der Versorgung zu schaffen und die Daten der Wissenschaft im Sinne eines Open Science Ansatzes rasch bereitzustellen. Alleiniges Einschlusskriterium war der virologische Nachweis von SARS-CoV-2. Schlüsselstrategien waren die Reallokation der vorhandenen personellen und technischen Ressourcen, die frühe und direkte Einbeziehung von Vertreter:innen des Datenschutzes und der Ethikkommissionen sowie die Entscheidung zu einem iterativen und agilen Entwicklungs- und Anpassungsprozess.Getragen von den zahlreichen kollaborierenden Institutionen konnte ein transsektorales und internationales Netzwerk mit aktuell 133 aktiv rekrutierenden Standorten und 7227 dokumentierten Fällen aufgebaut werden (Stand 18.03.2021, ein Jahr seit Rekrutierungsstart von LEOSS). Die Nutzung der Daten wurde über auf der Projektwebseite verfügbare Werkzeuge zur Datenexploration, wie auch über die teilautomatisierte Bereitstellung von Datensätzen verschiedenen Umfangs, innerhalb kurzer Zeit ermöglicht. Es wurden 97 Anträge zur Datennutzung aus 27 Themengebieten begutachtet. Im Peer-Review-Verfahren wurden 9 Arbeiten in internationalen Fachzeitschriften veröffentlicht.Mit LEOSS konnte in kürzester Zeit ein System zur Erfassung klinischer Verlaufsdaten zu COVID-19 in Deutschland etabliert werden. Auch wenn in anderen Projekten für spezifische Fragestellungen weitaus größere Datenbestände durch direkten Zugriff auf Quellsysteme analysiert werden konnten, wurde durch den einheitlich gepflegten und technisch geprüften Dokumentationsstandard mit vielen fachspezifischen Details ein sehr großer Datensatz mit wertvollen Alleinstellungsmerkmalen geschaffen. Aus den Erfahrungen von LEOSS können Implikationen für die zukünftige Gestaltung von Registern und eine rasche Reaktion auf Pandemien abgeleitet werden.

The impact of preexisting neurodegenerative diseases on superimposed SARS-CoV-2 infections remains controversial. Here we examined the course and outcome of SARS-CoV-2 infections in patients affected by Parkinson's disease (PD) or dementia compared to matched controls without neurodegenerative diseases in the LEOSS (Lean European Open Survey on SARS-CoV-2-infected patients) cohort, a large-scale prospective multicenter cohort study...

(1) Background: The aim of our study was to identify specific risk factors for fatal outcome in critically ill COVID-19 patients. (2) Methods: Our data set consisted of 840 patients enclosed in the LEOSS registry. Using lasso regression for variable selection, a multifactorial logistic regression model was fitted to the response variable survival. Specific risk factors and their odds ratios were derived. A nomogram was developed as a graphical representation of the model. (3) Results: 14 variables were identified as independent factors contributing to the risk of death for critically ill COVID-19 patients: age (OR 1.08, CI 1.06–1.10), cardiovascular disease (OR 1.64, CI 1.06–2.55), pulmonary disease (OR 1.87, CI 1.16–3.03), baseline Statin treatment (0.54, CI 0.33–0.87), oxygen saturation (unit = 1%, OR 0.94, CI 0.92–0.96), leukocytes (unit 1000/μL, OR 1.04, CI 1.01–1.07), lymphocytes (unit 100/μL, OR 0.96, CI 0.94–0.99), platelets (unit 100,000/μL, OR 0.70, CI 0.62–0.80), procalcitonin (unit ng/mL, OR 1.11, CI 1.05–1.18), kidney failure (OR 1.68, CI 1.05–2.70), congestive heart failure (OR 2.62, CI 1.11–6.21), severe liver failure (OR 4.93, CI 1.94–12.52), and a quick SOFA score of 3 (OR 1.78, CI 1.14–2.78). The nomogram graphically displays the importance of these 14 factors for mortality. (4) Conclusions: There are risk factors that are specific to the subpopulation of critically ill COVID-19 patients.

Purpose Knowledge regarding patients’ clinical condition at severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection is sparse. Data in the international, multicenter Lean European Open Survey on SARS-CoV-2-Infected Patients (LEOSS) cohort study may enhance the understanding of COVID-19. Methods Sociodemographic and clinical characteristics of SARS-CoV-2-infected patients, enrolled in the LEOSS cohort study between March 16, 2020, and May 14, 2020, were analyzed. Associations between baseline characteristics and clinical stages at diagnosis (uncomplicated vs. complicated) were assessed using logistic regression models. Results We included 2155 patients, 59.7% (1,287/2,155) were male; the most common age category was 66–85 years (39.6%; 500/2,155). The primary COVID-19 diagnosis was made in 35.0% (755/2,155) during complicated clinical stages. A significant univariate association between age; sex; body mass index; smoking; diabetes; cardiovascular, pulmonary, neurological, and kidney diseases; ACE inhibitor therapy; statin intake and an increased risk for complicated clinical stages of COVID-19 at diagnosis was found. Multivariable analysis revealed that advanced age [46–65 years: adjusted odds ratio (aOR): 1.73, 95% CI 1.25–2.42, p = 0.001; 66–85 years: aOR 1.93, 95% CI 1.36–2.74, p 85 years: aOR 2.38, 95% CI 1.49–3.81, p p = 0.040), cardiovascular disease (aOR 1.37, 95% CI 1.09–1.72, p = 0.007), and diabetes (aOR 1.33, 95% CI 1.04–1.69, p = 0.023) were associated with complicated stages of COVID-19 at diagnosis. Conclusion The LEOSS cohort identified age, cardiovascular disease, diabetes and male sex as risk factors for complicated disease stages at SARS-CoV-2 diagnosis, thus confirming previous data. Further data regarding outcomes of the natural course of COVID-19 and the influence of treatment are required.

Background Corona virus disease 2019 (COVID‐19) patients are at increased risk for thromboembolic events. It is unclear whether the risk for gastrointestinal (GI) bleeding is also increased. Methods We considered 4128 COVID‐19 patients enrolled in the Lean European Open Survey on SARS‐CoV‐2 (LEOSS) registry. The association between occurrence of GI bleeding and comorbidities as well as medication were examined. In addition, 1216 patients from COKA registry were analyzed focusing on endoscopy diagnostic findings. Results A cumulative number of 97 patients (1.8%) with GI bleeding were identified in the LEOSS registry and COKA registry. Of 4128 patients from the LEOSS registry, 66 patients (1.6%) had a GI bleeding. The rate of GI bleeding in patients with intensive care unit (ICU) admission was 4.5%. The use of therapeutic dose of anticoagulants showed a significant association with the increased incidence of bleeding in the critical phase of disease. The Charlson comorbidity index and the COVID‐19 severity index were significantly higher in the group of patients with GI bleeding than in the group of patients without GI bleeding (5.83 (SD = 2.93) vs. 3.66 (SD = 3.06), p

Die ursprunglich publizierte Online-Version des Beitrags enthielt einen fehlerhaften Interessenkonflikt. Dies wurde im Originalbeitrag berichtigt. Bitte beachten Sie die korrigierte Version. Wir bitten, den Fehler zu …

The Archbishop of Canterbury's speech on ‘Civil and Religious Law in England’, delivered in 2008, attracted considerable public and academic attention. In the resulting ‘Sharia debate’, traces of (legal) orientalism became especially visible in an essentialist portrayal of ‘Sharia’ as being in opposition to ‘the West’. What is missing in debates conducted at the abstract level of compatibility–incompatibility, East–West, law–religion is an analysis of the actual practices of family law of Muslims in contemporary Britain. People marry, divorce, bring up their children and deal with death by resorting to a variety of norms such as Sharia law, English family law and customary law. Drawing on legal pluralism scholarship and elements of Pierre Bourdieu's theory of the field, this article challenges the exclusive focus on positivist state law as the sole legal framework within which Western conceptions of citizenship are being imagined. It analyses practices of British-Muslim family law as an incipient ‘legal f...

A new field of British-Muslim family law is arguably evolving from the practices of Muslims in the UK who creatively bring about effective — but by no means uncontested — solutions to everyday problems of arranging family matters (across Muslim and English law). This requires us to abandon certain conventional ideas about law, orientalism, and citizenship. The present chapter contributes to current debates on multiculturalism, secularism, and Islam in Europe by first challenging an orientalized image of Sharia law in past and present European encounters. It then questions legal orientalism for its inability to conceptualize law outside formal legal norms and processes. It also highlights the crucial role of practices of the legal subject in the creative construction of legal fields. The chapter essentially asks questions about the implications of British-Muslim family law for how we think about citizenship.