Association of Household Deprivation, Comorbidities, and COVID-19 Hospitalization in Children in Germany, January 2020 to July 2021.

Importance: Adults in disadvantaged socioeconomic positions have elevated risks of a severe course of COVID-19, but it is unclear whether this holds true for children. Objective: To investigate whether young people from disadvantaged households have a higher risk of COVID-19 hospitalization and whether differences were associated with comorbidities that predispose children to severe courses. Design, Setting, and Participants: This population-based cohort study included all children and adolescents (aged 0-18 years) who were enrolled in a statutory health insurance carrier in Germany during the observation period of January 1, 2020, to July 13, 2021. Logistic regressions were calculated to compare children from households with and without an indication of poverty. Age, sex, days under observation, nationality, and comorbidities (eg, obesity, diabetes) were controlled for to account for explanatory factors. Exposures: Disadvantage on the household level was assessed by the employment status of the insurance holder (ie, employed, long- or short-term unemployed, low-wage employment, economically inactive). Socioeconomic characteristics of the area of residence were also assessed. Main Outcomes and Measures: Daily hospital diagnoses of COVID-19 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes U07.1 and U07.2) were recorded. Comorbidities were assessed using inpatient and outpatient diagnoses contained in the insurance records. Results: A total of 688 075 children and adolescents were included, with a mean (SD) age of 8.3 (5.8) years and 333 489 (48.4%) female participants. COVID-19 hospital diagnosis was a rare event (1637 participants [0.2%]). Children whose parents were long-term unemployed were 1.36 (95% CI, 1.22-1.51) times more likely than those with employed parents to be hospitalized. Elevated odds were also found for children whose parents had low-wage employment (odds ratio, 1.29; 95% CI, 1.05-1.58). Those living in low-income areas had 3.02 (95% CI, 1.73-5.28) times higher odds of hospitalization than those in less deprived areas. Comorbidities were associated with hospitalization, but their adjustment did not change main estimates for deprivation. Conclusions and Relevance: In this cohort study, children who had parents who were unemployed and those who lived in low-income areas were at higher risk of COVID-19 hospitalization. This finding suggests that attention must be paid to children with SARS-CoV-2 from vulnerable families and closer monitoring should be considered. A number of explanatory factors, including comorbidities, were taken into account, but their analysis yielded no clear picture about underlying processes.

Living through multispecies societies: Approaching the microbiome with Imanishi Kinji.

Recent research about the microbiome points to a picture in which we, humans, are 'living through' nature, and nature itself is living in us. Our bodies are hosting-and depend on-the multiple species that constitute human microbiota. This article will discuss current research on the microbiome through the ideas of Japanese ecologist Imanishi Kinji (1902-1992). First, some of Imanishi's key ideas regarding the world of living beings and multispecies societies are presented. Second, seven types of relationships concerning the human microbiome, human beings, and the environment are explored. Third, inspired by Imanishi's work, this paper develops the idea of dynamic, porous, and complex multispecies societies in which different living beings or species are codependent on others, including microbiota and human beings.

Brightening of a dark monolayer semiconductor via strong light-matter coupling in a cavity.

Engineering the properties of quantum materials via strong light-matter coupling is a compelling research direction with a multiplicity of modern applications. Those range from modifying charge transport in organic molecules, steering particle correlation and interactions, and even controlling chemical reactions. Here, we study the modification of the material properties via strong coupling and demonstrate an effective inversion of the excitonic band-ordering in a monolayer of WSe2 with spin-forbidden, optically dark ground state. In our experiments, we harness the strong light-matter coupling between cavity photon and the high energy, spin-allowed bright exciton, and thus creating two bright polaritonic modes in the optical bandgap with the lower polariton mode pushed below the WSe2 dark state. We demonstrate that in this regime the commonly observed luminescence quenching stemming from the fast relaxation to the dark ground state is prevented, which results in the brightening of this intrinsically dark material. We probe this effective brightening by temperature-dependent photoluminescence, and we find an excellent agreement with a theoretical model accounting for the inversion of the band ordering and phonon-assisted polariton relaxation.

Public Perceptions of Green Roofs and Green Walls in Tokyo, Japan: A Call to Heighten Awareness.

Many cities advocate retrofitting green roofs and green walls (GRGW) to create additional green areas, especially in cramped urban areas. Yet, worldwide, only a handful of studies have evaluated the public views towards the benefits and negative issues and promotion policies of this innovative greening option. To address this gap in the literature, we conducted a survey (N = 500) of residents' opinions towards GRGW in Tokyo, a city with mandatory installation of GRGW for almost two decades. Respondents mostly agreed with the contribution of GRGW to thermal comfort, air quality, and cityscape but weakly endorsed other potential benefits. High costs as well as mosquitoes and plant litter nuisances were the most recognized negative issues. Mandatory installation was the least preferred promotion policy. Instead, respondents expected installation on public buildings and provision of installation guidance. Respondents predominantly held a "moderate" view towards both the benefits and negative issues, showing indifferent attitudes towards GRGW. Income level and housing type shaped the overall perceptions, whereas age, sex, and current living environment influenced perceptions of individual aspects. Our findings signified a need for a bottom-up strategy to heighten public awareness for the advanced development of GRGW to complement and prime the top-down mandatory installation policy.

Hybridized Exciton-Photon-Phonon States in a Transition Metal Dichalcogenide van der Waals Heterostructure Microcavity.

Excitons in atomically thin transition-metal dichalcogenides (TMDs) have been established as an attractive platform to explore polaritonic physics, owing to their enormous binding energies and giant oscillator strength. Basic spectral features of exciton polaritons in TMD microcavities, thus far, were conventionally explained via two-coupled-oscillator models. This ignores, however, the impact of phonons on the polariton energy structure. Here we establish and quantify the threefold coupling between excitons, cavity photons, and phonons. For this purpose, we employ energy-momentum-resolved photoluminescence and spatially resolved coherent two-dimensional spectroscopy to investigate the spectral properties of a high-quality-factor microcavity with an embedded WSe_{2} van der Waals heterostructure at room temperature. Our approach reveals a rich multibranch structure which thus far has not been captured in previous experiments. Simulation of the data reveals hybridized exciton-photon-phonon states, providing new physical insight into the exciton polariton system based on layered TMDs.

Spatial coherence of room-temperature monolayer WSe2 exciton-polaritons in a trap.

The emergence of spatial and temporal coherence of light emitted from solid-state systems is a fundamental phenomenon intrinsically aligned with the control of light-matter coupling. It is canonical for laser oscillation, emerges in the superradiance of collective emitters, and has been investigated in bosonic condensates of thermalized light, as well as exciton-polaritons. Our room temperature experiments show the strong light-matter coupling between microcavity photons and excitons in atomically thin WSe2. We evidence the density-dependent expansion of spatial and temporal coherence of the emitted light from the spatially confined system ground-state, which is accompanied by a threshold-like response of the emitted light intensity. Additionally, valley-physics is manifested in the presence of an external magnetic field, which allows us to manipulate K and K' polaritons via the valley-Zeeman-effect. Our findings validate the potential of atomically thin crystals as versatile components of coherent light-sources, and in valleytronic applications at room temperature.

Improving the continuity and coordination of ambulatory care through feedback and facilitated dialogue-a study protocol for a cluster-randomised trial to evaluate the ACD study (Accountable Care in Germany).

BACKGROUND: Patients in Germany are free to seek care from any office-based physician and can always ask for multiple opinions on a diagnosis or treatment. The high density of physicians and the freedom to choose among them without referrals have led to a need for better coordination between the multiple health professionals treating any given patient. The objectives of this study are to (1) identify informal networks of physicians who treat the same patient population, (2) provide these physicians with feedback on their network and patients, using routine data and (3) give the physicians the opportunity to meet one another in facilitated network meetings. METHODS: The Accountable Care Deutschland (ACD) study is a prospective, non-blinded, cluster-randomised trial comprising a process and economic evaluation of informal networks among 12,525 GPs and office-based specialists and their 1.9 million patients. The units of allocation are the informal networks, which will be randomised either to the intervention (feedback and facilitated meetings) or control group (usual care). The informal networks will be generated by identifying connections between office-based physicians using complete datasets from the Regional Associations of Statutory Health Insurance (SHI) Physicians in Hamburg, Schleswig Holstein, North Rhine and Westphalia Lip, as well as data from three large statutory health insurers in Germany. The physicians will (a) receive feedback on selected indicators of their own treatment activity and that of the colleagues in their network and (b) will be invited to voluntary, facilitated network meetings by their Regional Association of SHI physicians. The primary outcome will be ambulatory-care-sensitive hospitalisations at baseline, at the end of the 2-year intervention period, and at six months and at 12 months after the end of the intervention period. Data will be analysed using the intention-to-treat principle. A pilot study preceded the ACD study. DISCUSSION: Cochrane reviews show that feedback can improve everyday medical practice by shedding light on previously unknown relationships. Providing physicians with information on how they are connected with their colleagues and what the outcomes are of care delivered within their informal networks can help them make these improvements, as well as strengthen their awareness of possible discontinuities in the care they provide. TRIAL REGISTRATION: German Clinical Trials Register DRKS00020884 . Registered on 25 March 2020-retrospectively registered.

Study protocol for a mixed methods exploratory investigation of aftercare services for gestational diabetes in women to develop a new patient-centred model in Germany: the GestDiNa_basic study.

INTRODUCTION: Women with gestational diabetes mellitus (GDM) have a higher risk of developing type 2 diabetes mellitus compared with women who never had GDM. Consequently, the question of structured aftercare for GDM has emerged. In all probability, many women do not receive care according to the guidelines. In particular, the process and interaction between obstetrical, diabetic, gynaecological, paediatric and general practitioner care lacks clear definitions. Thus, our first goal is to analyse the current aftercare situation for women with GDM in Germany, for example, the participation rate in aftercare diabetes screening, as well as reasons and attitudes stated by healthcare providers to offer these services and by patients to participate (or not). Second, we want to develop an appropriate, effective and patient-centred care model. METHODS AND ANALYSIS: This is a population-based mixed methods study using both quantitative and qualitative research approaches. In various working packages, we evaluate data of the GestDiab register, of the Association of Statutory Health Insurance Physicians of North Rhine and the participating insurance companies (AOK Rheinland/Hamburg, BARMER, DAK Gesundheit, IKK classic, pronova BKK). In addition, quantitative (postal surveys) and qualitative (interviews) surveys will be conducted with randomly selected healthcare providers (diabetologists, gynaecologists, paediatricians and midwives) and affected women, to be subsequently analysed. All results will then be jointly examined and evaluated. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (Ethics Committee No.: 2019-738). Participants of the postal surveys and interviews will be informed in detail about the study and the use of data as well as the underlying data protection regulations before voluntarily participating. The study results will be disseminated through peer-reviewed journals, conferences and public information. TRIAL REGISTRATION NUMBER: DRKS00020283.

[Higher risk of COVID-19 hospitalization for unemployed: an analysis of health insurance data from 1.28 million insured individuals in Germany]. / Erhöhtes Risiko eines COVID-19-bedingten Krankenhausaufenthaltes für Arbeitslose: Eine Analyse von Krankenkassendaten von 1,28 Mio. Versicherten in Deutschland.

BACKGROUND AND OBJECTIVE: Unemployment is related to poverty and is a risk factor for poor health. The present study investigates if unemployment increases the risk of COVID-19 hospitalization for men and women of working age in Germany. METHODS: The study uses the health insurance data from AOK Rhineland/Hamburg (from 1 January 2020 until 18 June 2020) of 1,288,745 persons aged between 18 and 65. Four employment situations are distinguished: (1) regular employment, (2) low-wage employment with social support, (3) unemployment with receipt of unemployment benefit 1, and (4) long-term unemployment with receipt of unemployment benefit 2. COVID-19 hospitalizations are measured on the basis of the ICD codes U07.1 and U07.2 reported by the hospitals. Multiple logistic regression models are calculated (adjusted for age and sex). RESULTS: During the observation period, 1521 persons had hospitalization with COVID-19 as primary or secondary diagnosis. Overall, this corresponds to a rate of 118 cases per 100,000 insured persons. Rates varied by employment situation. Compared with regularly employed persons, the odds ratio for a hospitalization was 1.94 (CI 95%: 1.74-2.15) for long-term unemployment, 1.29 (0.86-1.94) for unemployed, and 1.33 (0.98-1.82) for low-wage employment. CONCLUSION: The results are in line with earlier studies from the USA and Great Britain reporting socioeconomic inequalities in COVID-19 hospitalization risk. This provides the first empirical support that socioeconomic inequalities in the severity of COVID-19 also exists in Germany.

Understanding Threats to Young Children's Green Space Access in Unlicensed Daycare Centers in Japan.

Access to green space (GS) is vital for children's health and development, including during daycare. In Japan, deregulation to alleviate daycare shortages has created a new category of so-called unlicensed daycare centers (UDCs) that often lack dedicated GS. UDCs rely on surrounding GS, including parks, temples and university grounds, but reports of conflicts highlight the precarity of children's well-being in a rapidly aging country. Knowledge about GS access in Japanese UDCs remains scarce. Our mail-back survey (n = 173) of UDCs and online survey (n = 3645) of parents investigated threats to GS access during daycare across 14 Japanese cities. Results suggest that UDCs use a variety of GS and aim to provide daily access. Caregivers are vital in mediating children's access, but locally available GS diversity, quality and quantity as well as institutional support were perceived as lacking. Parents did not rank GS high among their priorities when selecting daycare providers, and showed limited awareness of conflicts during GS visits. Implications of this study include the need for caregivers and parents to communicate and collaborate to improve GS access, and the importance of strong public investment into holistically improving GS diversity, quality and quantity from the perspective of public health and urban planning.

Trust me? Consumer trust in expert information on food product labels.

Food product labels can provide consumers with rich, specific, expert-certified product information. However, sources of label information differ. How do consumers then evaluate label trustworthiness of expert labels in comparison to other commonly used label types? We present results from a representative online survey (N = 10,000) of consumers in Japan, the USA, Germany, China and Thailand using professionally designed labels for four food types (milk, honey, oil, wine) and five different sources of food information (farmers, government/administration, producer associations, experts, and consumers). We tested label legibility through identification of the label information source and asked respondents to evaluate the trustworthiness of labels using a six-scale instrument ranging from overall label trust to purchase intent. Results show that label legibility varied between countries, with expert labels scoring lowest. Nevertheless, respondents correctly identifying all label information sources chose expert labels as the most or second-most trustworthy across all countries and food types, while consumer labels scored low. Demographic factors exhibited weak influence. Results suggest expert labels might play an important role as trusted sources of information in an increasingly complex global food system. Finally, we consider the implications of the study for a potential institutionalization of expert labels based on the Japanese context.

Healthcare provision, functional ability and quality of life after proximal femoral fracture - 'ProFem': Study protocol of a population-based, prospective study based on individually linked survey and statutory health insurance data.

INTRODUCTION: Proximal femoral fractures (PFF) are among the most frequent fractures in older people. However, the situation of people with a PFF after hospital discharge is poorly understood. Our aim is to (1) analyse healthcare provision, (2) examine clinical and patient-reported outcomes (PROs), (3) describe clinical and sociodemographic predictors of these and (4) develop an algorithm to identify subgroups with poor outcomes and a potential need for more intensive healthcare. METHODS AND ANALYSIS: This is a population-based prospective study based on individually linked survey and statutory health insurance (SHI) data. All people aged minimum 60 years who have been continuously insured with the AOK Rheinland/Hamburg and experience a PFF within 1 year will be consecutively included (SHI data analysis). Additionally, 700 people selected randomly from the study population will be consecutively invited to participate in the survey. Questionnaire data will be collected in the participants' private surroundings at 3, 6 and 12 months after hospital discharge. If the insured person considers themselves to be only partially or not at all able to take part in the survey, a proxy person will be interviewed where possible. SHI variables include healthcare provision, healthcare costs and clinical outcomes. Questionnaire variables include information on PROs, lifestyle characteristics and socioeconomic status. We will use multiple regression models to estimate healthcare processes and outcomes including mortality and cost, investigate predictors, perform non-responder analysis and develop an algorithm to identify vulnerable subgroups. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (approval reference 6128R). All participants including proxies providing written and informed consent can withdraw from the study at any time. The study findings will be disseminated through scientific journals and public information. TRIAL REGISTRATION NUMBER: DRKS00012554.

[Prevalence of dementia of insured persons with and without German citizenship : A study based on statuatory health insurance data]. / Prävalenz von Demenz bei Versicherten mit und ohne deutsche Staatsangehörigkeit : Eine Studie auf Basis von Daten der gesetzlichen Krankenversicherung.

BACKGROUND: Elderly people with a non-German background are a fast growing population in Germany. OBJECTIVES: Is administrative prevalence of dementia and uptake of nursing-home care similar in the German and non-German insured? MATERIALS AND METHODS: Based on routine data, administrative prevalence rates for dementia were calculated for 2013 from a full census of data from one large sickness fund. Patients with dementia (PWD) were identified via ICD-10 codes (F00; F01; F03; F05; G30). RESULTS: Administrative prevalence of dementia was 2.67% in the study population; 3.06% in Germans, and 0.96% in non-Germans (p value <0.001). Age and sex adjusted prevalence was comparable in the insured with and without German citizenship, except in women aged 80-84 (17.2 vs. 15.4) and for men in the age groups 80-84 (16.5 vs. 14.2), 85-89 years (23.4 vs. 21.5), and above 90 years of age (32.3 vs. 26.3). Standardized to the population of all investigated insured, 31.4% of all Germans with dementia had no longterm care entitlement vs. 35.5% of all patients without German citizenship. Of German patients, 55.1% were institutionalized vs. 39.5% of all patients without German citizenship. CONCLUSIONS: There was a higher prevalence of dementia in the very old insured without German citizenship compared to those with German citizenship, especially in men. Non-Germans showed lower uptake of nursing home care compared to Germans. Additionally, Germans had slightly higher nursing care entitlements. It should be investigated further how much of the difference is due to underdiagnosis, cultural differences, or lack of adequate diagnostic work-up.

Ethical Hurdles in the Prioritization of Oncology Care.

With finite resources, healthcare payers must make difficult choices regarding spending and the ethical distribution of funds. Here, we describe some of the ethical issues surrounding inequity in healthcare in nine major European countries, using cancer care as an example. To identify relevant studies, we conducted a systematic literature search. The results of the literature review suggest that although prevention, access to early diagnosis, and radiotherapy are key factors associated with good outcomes in oncology, public and political attention often focusses on the availability of pharmacological treatments. In some countries this focus may divert funding towards cancer drugs, for example through specific cancer drugs funds, leading to reduced expenditure on other areas of cancer care, including prevention, and potentially on other diseases. In addition, as highly effective, expensive agents are developed, the use of value-based approaches may lead to unacceptable impacts on health budgets, leading to a potential need to re-evaluate current cost-effectiveness thresholds. We anticipate that the question of how to fund new therapies equitably will become even more challenging in the future, with the advent of expensive, innovative, breakthrough treatments in other therapeutic areas.

Informal urban green-space: comparison of quantity and characteristics in Brisbane, Australia and Sapporo, Japan.

Informal urban green-space (IGS) such as vacant lots, brownfields and street or railway verges is receiving growing attention from urban scholars. Research has shown IGS can provide recreational space for residents and habitat for flora and fauna, yet we know little about the quantity, spatial distribution, vegetation structure or accessibility of IGS. We also lack a commonly accepted definition of IGS and a method that can be used for its rapid quantitative assessment. This paper advances a definition and typology of IGS that has potential for global application. Based on this definition, IGS land use percentage in central Brisbane, Australia and Sapporo, Japan was systematically surveyed in a 10×10 km grid containing 121 sampling sites of 2,500 m2 per city, drawing on data recorded in the field and aerial photography. Spatial distribution, vegetation structure and accessibility of IGS were also analyzed. We found approximately 6.3% of the surveyed urban area in Brisbane and 4.8% in Sapporo consisted of IGS, a non-significant difference. The street verge IGS type (80.4% of all IGS) dominated in Brisbane, while lots (42.2%) and gaps (19.2%) were the two largest IGS types in Sapporo. IGS was widely distributed throughout both survey areas. Vegetation structure showed higher tree cover in Brisbane, but higher herb cover in Sapporo. In both cities over 80% of IGS was accessible or partly accessible. The amount of IGS we found suggests it could play a more important role than previously assumed for residents' recreation and nature experience as well as for fauna and flora, because it substantially increased the amount of potentially available greenspace in addition to parks and conservation greenspace. We argue that IGS has potential for recreation and conservation, but poses some challenges to urban planning. To address these challenges, we propose some directions for future research.

[Efficiency of computer-based documentation in long-term care--preliminary project]. / Effizienz der computergestültzten Dokumentation in Pflegeheimen--eine Pilotstudie.

In Germany the documentation of processes in long-term care is mainly paper-based. Planning, realization and evaluation are not supported in an optimal way. In a preliminary study we evaluated the consequences of the introduction of a computer-based documentation system using handheld devices. We interviewed 16 persons before and after introducing the computer-based documentation and assessed costs for the documentation process and administration. The results show that reducing costs is likely. The job satisfaction of the personnel increased, more time could be spent for caring for the residents. We suggest further research to reach conclusive results.

First German disease management program for breast cancer.

The first disease management program contract for breast cancer in Germany was signed in 2002 between the Association of Regional of Physicians in North-Rhine and the statutory health insurance companies in Rhineland. At the heart of this unique breast cancer disease management program is a patient-centered network of health care professionals. The program's main objectives are: (1) to improve the quality of treatment and post-operative care for breast cancer patients, (2) to provide timely information and consultation empowering the patient to participate in decisionmaking, (3) to improve the interface between inpatient and outpatient care, and (4) to increase the number of breast-conserving surgeries.

[Centralisation of breast cancer management by giving minimum work-load. Empirical effects in the region of North-Rhine, Germany]. / Zentralisierung der Behandlung des Mammakarzinoms bei der Vorgabe von Mindestmengen. Empirische Auswirkungen in der Region Nordrhein.

INTRODUCTION: The concentration of treatment on a few hospitals is discussed to improve the outcome of care. For the treatment of the breast cancer the distributional effects are evaluated. METHOD: A systematic literature search in Medline identified six studies dealing with the evidence on the relation between outcome and workload. Using administrative data of a sickness fund in the region of Rhineland, Germany, the number of hospitals and patients affected by minimum work-loads was determined. RESULTS: Study results show that in general a minimum workload of 100 to 150 new diagnosed cases per year and hospital is recommended. These recommendations would lead to 46% of the presently treating hospitals being excluded (minimum work-load of 150 cases; year 2001). If the workload is set to 100 cases, 31% of the hospitals will be excluded from breast cancer management. No significant differences could be detected in the data of the years 2000 and 2001. DISCUSSION: The association between minimum workload and outcome of care seems to be evident. Further studies involving larger regions are needed to evaluate the distributional effects and gains of outcome.