Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home.

Objectives: For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home. Methods: Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting. Results: A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study. Conclusion: The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT. Innovation: Adapting family conferences to primary care for frail patients with polypharmacy.

Implementation of a uniform nationwide medical licensing examination in general practice. A feasibility study.

Objective: A competency-based training of medical students that is adapted to the realities of care is required internationally and is being intended in Germany with the Master Plan for Medical Studies 2020. In order to test these competencies, the German National Institute for state examinations in Medicine, Pharmacy and Psychotherapy (IMPP) has developed a concept for the redesign of the final part of the medical licensing examination in Germany. It focuses on general and interprofessional healthcare in the examination with outpatients. The aim of this work is to assess the feasibility of the new final examination on the basis of pilot examinations in family practices and to derive further steps for the national implementation. Methods: Fourteen medical students in their internship year completed a full examination with patients aged 42 to 84 years. Examiners evaluated the examination performance using standardised evaluation forms. Feasibility was qualitatively assessed in terms of compliance with content and time limits, examination results, patient reflections, and implementation in the practice. Results: Students were able to complete all tasks within the given time frame. Based on the evaluation forms, the examiners assessed the performance of the students. Patients appreciated the structured course of the examination in the familiar location of their family practice. For the nationwide implementation of the examination, 2,500 examination practices are required for about 10,000 examinees per year. Four students can then be examined on two days per year in each practice. Conclusions: Oral-practical examinations with outpatients in general medical practices can be carried out successfully throughout the nation. An implementation of the examinations throughout Germany requires that medical studies are restructured and that this new curriculum is implemented as intended by the Master Plan for Medical Studies 2020. Furthermore, training and remuneration of examiners together with a legal framework for the new examination must be established.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. / Behandlung von erwachsenen Patienten mit ambulant erworbener Pneumonie ­ Update 2021.

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention.

BACKGROUND: Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components. METHODS: A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data. RESULTS: Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use. CONCLUSIONS: The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population. TRIAL REGISTRATION: ISRCTN, ISRCTN15061174 . Registered 13 July 2018 - Retrospectively registered.

Spirulina Platensis Affects Factors Involved in Spermatogenesis and Increases Ghrelin Receptors in Testis Tissue of Rats Fed a High-Fat Diet.

Ghrelin is a peptide hormone which plays important role in maintaining growth hormone release and energy homeostasis in vertebrates. Spirulina platensis (SP) has antioxidant and hypolipidemic effects due to its ingredients. In this study we aimed to investigate the effects of SP on the testicular structure and relation between ghrelin and testosterone in the testis of rats fed a high fat diet (HFD). Sixty four young adult male rats were used and divided to 8 equal groups. Experimental groups received addition of 10% cholesterol (CHL), 43% hydrogenated vegetable oil (HVO) and 3% SP alone or in combination to basal diet while the control group received only basal diet. Serum ghrelin and testosterone levels were measured with ELISA. Receptors for ghrelin and androgen were detected with immunohistochemistry. For histomorphometric investigation, tubulus seminiferus, intertubular area, tubulus seminiferus lumen, Leydig cell nucleus, Sertoli cell nucleus, germ cell nucleus, spermatocyte nucleus and elongated spermatid volume densities were determined stereologically. Serum ghrelin level was increased especially in HVO and CHL combination group compared to the control while serum ghrelin levels were close to control levels in SP-received groups. Ghrelin receptor level was increased in tubulus seminiferus with HVO+CHL administration but this effect was, however, limited in HVO+CHL and SP challenged groups. HVO+CHL administration caused a significant decrease in Leydig cell nucleus volume density, as well as in all SP-received groups, compared to the control. Significantly increased spermatocyte nucleus volume density in cholesterol-receiving groups was decreased to control level with SP alone and its combinations.

Protective effect of Spirulina platensis against cell damage and apoptosis in hepatic tissue caused by high fat diet.

Spirulina platensis is a microalga that may be a source of antioxidants that can reduce body fat deposition. Consumption of a high fat diet produces elevated blood lipid levels, inflammation and apoptosis. We investigated the possible effects of S. platensis on the blood lipid profile, and liver inflammation and apoptosis in rats fed a high fat diet. Sixty-four young male rats were divided into eight equal groups. The control group was fed a basic diet. The experimental groups were fed a diet for 60 days that was prepared by mixing variable amounts of 43% vegetable oil and 10% cholesterol with or without 3% S. platensis mixed with the basal diet. Blood and liver tissue samples were collected from each animal. Serum samples were used to analyze lipid parameters, total antioxidant status and total oxidant status. iNOS and eNOS were determined by immunohistochemistry. TUNEL staining was used to detect apoptosis to investigate a possible connection between inflammation and apoptosis in the liver tissue. The relations between fat deposition and liver degeneration were assessed by Sirius red staining and alpha-smooth muscle actin immunostaining. S. platensis reduced serum HDL-C, LDL-C and triglyceride, increased HDL-C levels in rats fed a high fat diet to near control levels, and reduced iNOS levels and increased eNOS levels in the liver tissue compared to vegetable oil and cholesterol treated groups. The apoptotic index was reduced in the groups that were fed a high fat or a basic diet when supplemented with S. platensis.

[What Makes Happy Doctors? Job Satisfaction of General Practitioners in Mecklenburg-Western Pomerania - a Representative Cross-sectional Study]. / Was macht Ärzte glücklich? Berufszufriedenheit von Hausärzten in Mecklenburg-Vorpommern - eine repräsentative Querschnittsstudie.

AIM: Studies provide evidence for the importance of general practitioners (GPs) job satisfaction for a secure and high quality health care provision. This study focuses on job satisfaction of GPs in Mecklenburg-Western Pomerania (MV), a rural area threatened by a lack of GPs. We investigate how satisfied GPs are with their job and which factors influence their job satisfaction. METHODS: All 1 133 GPs working in MV in December 2011 were asked to complete a 57-item-questionnaire. The response rate reached 50.1%. RESULTS: The sample is representative for GPs in MV. Levels of job satisfaction are high and correlate with age and sex: females and GPs below 50 years of age are more satisfied. Factors contributing to high job satisfaction include a good doctor-patient relationship, fair pay, and the variety of reasons for doctor-patient consultations in primary care. Although all GPs were dissatisfied with bureaucracy, this factor has little impact on GPs' overall job satisfaction. CONCLUSION: In light of the imminent lack of GPs, in future it will be important to improve factors that have been demonstrated to increase job satisfaction.

[The Rostock Headache Questionnaire ("Rokoko")--validation of a tool to screen and to qualify primary headaches]. / Der Rostocker Kopfschmerzfragen-Komplex ("Rokoko")--Validierung einer schnellen diagnostischen Hilfe bei der Einordnung primärer Kopfschmerzen.

Primary headache disorders should be diagnosed based on the detailed history of the patient. However, only few questions are necessary to allocate the symptoms to migraine, tension-type headache or other primary headaches in most cases. The "Rostock Headache Questionnaire" (Rokoko) is suitable for being completed by the investigator or the patient him/herself within a few minutes. Validation parameters of a sample of n = 87 patients (median: 44 years), diagnosed by headache experts in a personal interview ("gold standard"), are presented. Sensitivity and specificity for migraine without aura (0.87/0.51), migraine with aura (0.71/0.95), tension-type headache (0.57/0.93), or a combination of both (0.22/0.93) are based on the parameters pain frequency (recurrent vs. permanent), and the presence or absence of aura symptoms. To differentiate tension-type headache into episodic or chronic forms, the questionnaire can be analysed individually based on the frequency of headache days. The questionnaire enables the fast acquisition of relevant data in headache diagnosis and headache research with sufficient sensitivity and specificity. In addition, further information about triggering and symptoms of headaches can be assessed. The questionnaire can be used both by neurologists or psychiatrists and by general practitioners. The questionnaire does not replace the physical examination.

The complexity of managing COPD exacerbations: a grounded theory study of European general practice.

OBJECTIVES: To understand the concerns and challenges faced by general practitioners (GPs) and respiratory physicians about primary care management of acute exacerbations in patients with chronic obstructive pulmonary disease (COPD). DESIGN: 21 focus group discussions (FGDs) were performed in seven countries with a Grounded Theory approach. Each country performed three rounds of FGDs. SETTING: Primary and secondary care in Norway, Germany, Wales, Poland, Russia, The Netherlands, China (Hong Kong). PARTICIPANTS: 142 GPs and respiratory physicians were chosen to include urban and rural GPs as well as hospital-based and out patient-clinic respiratory physicians. RESULTS: Management of acute COPD exacerbations is dealt with within a scope of concerns. These concerns range from 'dealing with comorbidity' through 'having difficult patients' to 'confronting a hopeless disease'. The first concern displays medical uncertainty regarding diagnosis, medication and hospitalisation. These clinical processes become blurred by comorbidity and the social context of the patient. The second concern shows how patients receive the label 'difficult' exactly because they need complex attention, but even more because they are time consuming, do not take responsibility and are non-compliant. The third concern relates to the emotional reactions by the physicians when confronted with 'a hopeless disease' due to the fact that most of the patients do not improve and the treatment slows down the process at best. GPs and respiratory physicians balance these concerns with medical knowledge and practical, situational knowledge, trying to encompass the complexity of a medical condition. CONCLUSIONS: Knowing the patient is essential when dealing with comorbidities as well as with difficult relations in the consultations on exacerbations. This study suggests that it is crucial to improve the collaboration between primary and secondary care, in terms of, for example, shared consultations and defined work tasks, which may enhance shared knowledge of patients, medical decision-making and improved management planning.

Sore throat: effective communication delivers improved diagnosis, enhanced self-care and more rational use of antibiotics.

The majority of throat infections are of viral origin and resolve without antibiotic treatment. Despite this, antibiotic use for sore throat infections remains high, partly because it is difficult to determine when antibiotics may be useful, on the basis of physical findings alone. Antibiotics may be beneficial in bacterial throat infections under certain clinical and epidemiological circumstances; however, even many of those infections in which bacteria play a role do resolve just as quickly without antibiotics. Furthermore, non-medical factors such as patient expectations and patient pressure are also important drivers of antibiotic use. To address these issues, a behavioural change is required that can be facilitated by improved communication between primary healthcare providers and patients. In this article, we provide doctors, nurses and pharmacy staff, working in primary care or in the community, with a structured approach to sore throat management, with the aim of educating and empowering patients to self-manage their condition. The first component of this approach involves identifying and addressing patients' expectations and concerns with regard to their sore throat and eliciting their opinion on antibiotics. The second part is dedicated to a pragmatic assessment of the severity of the condition, with attention to red-flag symptoms and risk factors for serious complications. Rather than just focusing on the cause (bacterial or viral) of the upper respiratory tract infections as a rationale for antibiotic use, healthcare providers should instead consider the severity of the patient's condition and whether they are at high risk of complications. The third part involves counselling patients on effective self-management options and providing information on the expected clinical course. Such a structured approach to sore throat management, using empathetic, non-paternalistic language, combined with written patient information, will help to drive patient confidence in self-care and encourage them to accept the self-limiting character of the illness - important steps towards improving antibiotic stewardship in acute throat infections.

Implementation of the interdisciplinary curriculum Teaching and Assessing Communicative Competence in the fourth academic year of medical studies (CoMeD).

INTRODUCTION: Implementation of a longitudinal curriculum for training in advanced communications skills represents an unmet need in most German medical faculties, especially in the 4rth and 5th years of medical studies. The CoMeD project (communication in medical education Düsseldorf) attempted to establish an interdisciplinary program to teach and to assess communicative competence in the 4th academic year. In this paper, we describe the development of the project and report results of its evaluation by medical students. METHODS: Teaching objectives and lesson formats were developed in a multistage process. A teaching program for simulated patients (SP) was built up and continuous lecturer trainings were estabilshed. Several clinical disciplines co-operated for the purpose of integrating the communication training into the pre-existing clinical teaching curriculum. The CoMeD project was evaluated using feedback-forms after each course. RESULTS: Until now, six training units for especially challenging communication tasks like "dealing with aggression" or "breaking bad news" were implemented, each unit connected with a preliminary tutorial or e-learning course. An OSCE (objective structured clinical examination) with 4 stations was introduced. The students' evaluation of the six CoMeD training units showed the top or second-best rating in more than 80% of the answers. DISCUSSION: Introducing an interdisciplinary communication training and a corresponding OSCE into the 4th year medical curriculum is feasible. Embedding communication teaching in a clinical context and involvement of clinicians as lecturers seem to be important factors for ensuring practical relevance and achieving high acceptance by medical students.

Effect of copper deficiency on blood lipid profile and haematological parameters in broilers.

The aim of the study was to observe the changes in haematological parameters and blood lipid profile through copper (Cu) deficiency. Eighty broiler chicks were used in the study. The chicks were separated into two equal groups (n = 40), feed treatment according to the groups started on day 7. The animals in the control group were fed with normal feed. Those in the Cu-deficient group were fed with feed that did not contain supplemental Cu. Blood samples were taken from all the animals on days 7, 21 and 49. Fibrinogen and prothrombin time were assayed in plasma; total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol (LDL-cholesterol), triglyceride and ceruloplasmin were assayed in sera; and haematocrit and thrombocyte levels were assayed in the blood samples. Total cholesterol, triglyceride and LDL-cholesterol levels were significantly higher in the Cu-deficient group than in the control group. Serum ceruloplasmin levels were lower in the Cu-deficient group than in the control group. Prothrombin time was higher in the Cu-deficient group than in the control group. Haematocrit levels were lower in the Cu-deficient group than in the control group. It was concluded that Cu deficiency created hypertriglyceridaemia, hypercholesterolaemia, insufficient growth and anaemia in broilers.

[A comparison of different methods of performance assessment for the course in general medicine]. / Vergleich verschiedener Methoden der Leistungsüberprüfung im Lehrfach Allgemeinmedizin.

A novel Federal Regulation for Basic Medical Education was issued in Germany, which requires an end of course assessment. General Practice (GP) in Duesseldorf has introduced a written examination. An accompanying study was carried out to understand whether different methods of performance evaluation would show equivalent results intraindividually. Out of the GP class 21 students were randomised to undergo an oral examination on top of the regular written examination. Furthermore their teaching practitioners have appraised these students performance in small group teaching. Finally, the students have been rated following a practical term. At the end the students have been interviewed in a focus group to investigate their preferred method of assessment. The survey of the average grades showed comparable results for the written test, the oral examination and small group teaching while the appraisal at the end of the practical term happened to be significantly higher in grade. The comparison of the individual results, however, showed a statistical spreading in all directions. For example, a poor performance in the written test can come along with excellent results in the oral examination and vice versa. The intra-class correlation across all classes has been as low as 0.1. These results support the conclusion that apparently each method can appropriately evaluate only a very specific part of the complex contents of the GP education and of students' performance. In order to properly examine the performance of GP students a combination of different evaluation methods needs to be applied. As an alternative, different skills can be examined in different practical and theoretical test situations in an OSCE.