Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube.

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

[Structure of hospital care for COVID-19 patients up to July 2020 in Germany]. / Stationäre und intensivmedizinische Versorgungsstrukturen von COVID-19-Patienten bis Juli 2020.

BACKGROUND: Hospitalized coronavirus disease 2019 (COVID-19) patients have a high morbidity and mortality and are often dependent on intensive care, especially mechanical ventilation. Little is as yet known about COVID-19 patient allocation. OBJECTIVES: Analysis of the structures of German hospital care for COVID-19 patients up to July 2020 in terms of number of beds and previous ventilation experience. DATA AND METHODS: For the analysis of the care structures, only completed COVID-19 cases in which the virus was detected by a PCR test were evaluated. Claims data from the German Local Health Care Funds (Allgemeine Ortskrankenkassen, AOK) were analysed. The sample includes 17,094 COVID-19 cases that were treated in 1082 hospitals. RESULTS: A total of 77% of all hospitals participated in the treatment COVID-19 patients and 48% of all hospitals provided intensive care for these patients. One half of the hospitals that treated COVID-19 cases cared for 88% of all cases. Although this suggests a centralization effect of COVID-19 cases in specific hospitals, the remaining 12% of the cases were distributed among many hospitals with often very small numbers of cases. Furthermore, 23% of the ventilated COVID-19 cases were treated in hospitals with below-average ventilation experience. CONCLUSIONS: In the context of increasing numbers of infections, it is both necessary to improve the allocation of hospitalized, and therefore potentially ventilated, COVID-19 cases by means of clearly defined and centrally controlled pyramid-type concepts and to continue to care for patients without COVID-19. For Germany, a comprehensive pyramid-type concept with a greater concentration in the best-qualified hospitals seems reasonable for the care of these patients with complex diseases.

eV-Scale Sterile Neutrino Search Using Eight Years of Atmospheric Muon Neutrino Data from the IceCube Neutrino Observatory.

The results of a 3+1 sterile neutrino search using eight years of data from the IceCube Neutrino Observatory are presented. A total of 305 735 muon neutrino events are analyzed in reconstructed energy-zenith space to test for signatures of a matter-enhanced oscillation that would occur given a sterile neutrino state with a mass-squared differences between 0.01 and 100 eV^{2}. The best-fit point is found to be at sin^{2}(2θ_{24})=0.10 and Δm_{41}^{2}=4.5 eV^{2}, which is consistent with the no sterile neutrino hypothesis with a p value of 8.0%.

Characteristics of the Diffuse Astrophysical Electron and Tau Neutrino Flux with Six Years of IceCube High Energy Cascade Data.

We report on the first measurement of the astrophysical neutrino flux using particle showers (cascades) in IceCube data from 2010-2015. Assuming standard oscillations, the astrophysical neutrinos in this dedicated cascade sample are dominated (∼90%) by electron and tau flavors. The flux, observed in the sensitive energy range from 16 TeV to 2.6 PeV, is consistent with a single power-law model as expected from Fermi-type acceleration of high energy particles at astrophysical sources. We find the flux spectral index to be γ=2.53±0.07 and a flux normalization for each neutrino flavor of ϕ_{astro}=1.66_{-0.27}^{+0.25} at E_{0}=100 TeV, in agreement with IceCube's complementary muon neutrino results and with all-neutrino flavor fit results. In the measured energy range we reject spectral indices γ≤2.28 at ≥3σ significance level. Because of high neutrino energy resolution and low atmospheric neutrino backgrounds, this analysis provides the most detailed characterization of the neutrino flux at energies below ∼100 TeV compared to previous IceCube results. Results from fits assuming more complex neutrino flux models suggest a flux softening at high energies and a flux hardening at low energies (p value ≥0.06). The sizable and smooth flux measured below ∼100 TeV remains a puzzle. In order to not violate the isotropic diffuse gamma-ray background as measured by the Fermi Large Area Telescope, it suggests the existence of astrophysical neutrino sources characterized by dense environments which are opaque to gamma rays.

Time-Integrated Neutrino Source Searches with 10 Years of IceCube Data.

This Letter presents the results from pointlike neutrino source searches using ten years of IceCube data collected between April 6, 2008 and July 10, 2018. We evaluate the significance of an astrophysical signal from a pointlike source looking for an excess of clustered neutrino events with energies typically above ∼1 TeV among the background of atmospheric muons and neutrinos. We perform a full-sky scan, a search within a selected source catalog, a catalog population study, and three stacked Galactic catalog searches. The most significant point in the northern hemisphere from scanning the sky is coincident with the Seyfert II galaxy NGC 1068, which was included in the source catalog search. The excess at the coordinates of NGC 1068 is inconsistent with background expectations at the level of 2.9σ after accounting for statistical trials from the entire catalog. The combination of this result along with excesses observed at the coordinates of three other sources, including TXS 0506+056, suggests that, collectively, correlations with sources in the northern catalog are inconsistent with background at 3.3σ significance. The southern catalog is consistent with background. These results, all based on searches for a cumulative neutrino signal integrated over the 10 years of available data, motivate further study of these and similar sources, including time-dependent analyses, multimessenger correlations, and the possibility of stronger evidence with coming upgrades to the detector.

Constraints on Minute-Scale Transient Astrophysical Neutrino Sources.

High-energy neutrino emission has been predicted for several short-lived astrophysical transients including gamma-ray bursts (GRBs), core-collapse supernovae with choked jets, and neutron star mergers. IceCube's optical and x-ray follow-up program searches for such transient sources by looking for two or more muon neutrino candidates in directional coincidence and arriving within 100 s. The measured rate of neutrino alerts is consistent with the expected rate of chance coincidences of atmospheric background events and no likely electromagnetic counterparts have been identified in Swift follow-up observations. Here, we calculate generic bounds on the neutrino flux of short-lived transient sources. Assuming an E^{-2.5} neutrino spectrum, we find that the neutrino flux of rare sources, like long gamma-ray bursts, is constrained to <5% of the detected astrophysical flux and the energy released in neutrinos (100 GeV to 10 PeV) by a median bright GRB-like source is <10^{52.5} erg. For a harder E^{-2.13} neutrino spectrum up to 30% of the flux could be produced by GRBs and the allowed median source energy is <10^{52} erg. A hypothetical population of transient sources has to be more common than 10^{-5} Mpc^{-3} yr^{-1} (5×10^{-8} Mpc^{-3} yr^{-1} for the E^{-2.13} spectrum) to account for the complete astrophysical neutrino flux.

Search for neutrinos from decaying dark matter with IceCube: IceCube Collaboration.

With the observation of high-energy astrophysical neutrinos by the IceCube Neutrino Observatory, interest has risen in models of PeV-mass decaying dark matter particles to explain the observed flux. We present two dedicated experimental analyses to test this hypothesis. One analysis uses 6 years of IceCube data focusing on muon neutrino 'track' events from the Northern Hemisphere, while the second analysis uses 2 years of 'cascade' events from the full sky. Known background components and the hypothetical flux from unstable dark matter are fitted to the experimental data. Since no significant excess is observed in either analysis, lower limits on the lifetime of dark matter particles are derived: we obtain the strongest constraint to date, excluding lifetimes shorter than 10 28 s at 90% CL for dark matter masses above 10 TeV .

How do Chronically Ill Patients Rate Medical Care by their GPs and Specialists? Results of a Germany-wide Survey.

Introduction: The ability of health systems to respond to the legitimate expectations of the population regarding interpersonal and organizational aspects of healthcare - the so-called Health System Responsiveness - is considered a key competence of health systems. While various studies have assessed the responsiveness of ambulatory care, information on differences between care provided by general practitioners (GP) and specialists is still scarce. Methods: By means of a postal survey, 51 998 chronically ill persons (type 2 diabetes and/or coronary heart disease) insured by a statutory health insurance body (Techniker Krankenkasse) were surveyed regarding their experiences with GP and specialist care. An adapted version of the WHO Health System Responsiveness questionnaires was used for assessing data. Differences in the rating of specialist and GP care were analyzed using McNemar's test. Results: Responses from 13 685 patients were included in data analyses. Overall, ambulatory care was rated mostly as positive. Across all dimensions of health system responsiveness, GP care was rated statistically significantly as more positive than specialist care. Considerable differences were found in the evaluation of waiting times, involvement in decision-making and coordination of care. Conclusion: Overall, the surveyed persons were mostly satisfied with their GP and specialist care. However, some aspects of specialist care need to be optimized.

[Hemodiafiltration compared to hemodialysis regarding all-cause mortality and quality of life: a systematic review]. / Medizinischer Zusatznutzen von Hämodiafiltration gegenüber Hämodialyse bezüglich Mortalität und Lebensqualität: Eine systematische Übersicht.

BACKGROUND: Patients with end-stage renal disease are dependent on chronic renal replacement therapy. Outcomes regarding the clinical benefits of hemodiafiltration (HDF) compared to hemodialysis (HD) have been inconclusive so far. The aim of this systematic review is to evaluate the effect of HDF on all-cause mortality and quality of life compared to HD. METHODS: A systematic review of published literature was conducted using two bibliographic databases and two trial registers. The review was conducted in September and October 2013. RESULTS: The search yielded 14 relevant studies. Out of 3 large randomized controlled trials reporting the outcome mortality, 1 reported a significantly lower mortality in the HDF-arm; the other 2 did not show significant differences between arms. 1 large randomized controlled trial reporting the outcome quality-of-life was identified, no significant differences were reported. The remaining body of evidence was assessed as non-robust. DISCUSSION: A positive influence of HDF on overall survival appears probable if high-volume fluid exchange is achieved. Only one large randomized controlled trial reports significantly lower overall mortality after treatment with HDF for all patients. There is no reliable evidence for better quality-of-life after treatment with HDF.

[Teleradiological report turnaround times: An internal efficiency and quality control analysis]. / Teleradiologische Prozess- und Untersuchungszeiten: Eine institutsinterne Effizienz- und Qualitätsanalyse.

AIMS: The teleradiological examinations performed at the Charité were analyzed for the purpose of internal quality and efficiency control. Data included the type and number of examinations performed, the time of day and week the examination was performed and the differences in teleradiologist report turnaround times. MATERIAL AND METHODS: A retrospective analysis of the radiology information system (RIS) database of all teleradiological computed tomography examinations performed at the Charité from 2011 through 2013 was carried out. The search retrieved 10,200 teleradiological examinations which were included in the analysis. The records were analyzed for the time of the day and week the examination was performed, the interval between examination and time of reporting, the type of teleradiological examination and the campus in which they were performed. RESULTS: The number of teleradiological examinations performed increased continuously during the observation period. Computed tomography of the head was the most frequently performed type of examination with 86%. Taking all forms of examination into consideration it took an average of 34 min until a report was written. Over the 3-year observation period the times remained virtually unaltered. CONCLUSION: During the 3-year observation period nearly constant report times could be observed in spite of the increased numbers of examinations. This indicates an efficiency enhancement and rational integration of teleradiology into the radiological workflow.

Costs and effects of new professional roles: Evidence from a literature review.

One way in which governments are seeking to improve the efficiency of the health care sector is by redesigning health services to contain labour costs. The aim of this study was to investigate the impact of new professional roles on a wide range of health service outcomes and costs. A systematic literature review was performed by searching in different databases for evaluation papers of new professional roles (published 1985-2013). The PRISMA checklist was used to conduct and report the systematic literature review and the EPHPP-Quality Assessment Tool to assess the quality of the studies. Forty-one studies of specialist nurses (SNs) and advanced nurse practitioners (ANPs) were selected for data extraction and analysis. The 25 SN studies evaluated most often quality of life (10 studies), clinical outcomes (8), and costs (8). Significant advantages were seen most frequently regarding health care utilization (in 3 of 3 studies), patient information (5 of 6), and patient satisfaction (4 of 6). The 16 ANP studies evaluated most often patient satisfaction (8), clinical outcomes (5), and costs (5). Significant advantages were seen most frequently regarding clinical outcomes (5 of 5), patient information (3 of 4), and patient satisfaction (5 of 8). Promoting new professional roles may help improve health care delivery and possibly contain costs. Exploring the optimal skill-mix deserves further attention from health care professionals, researchers and policy makers.

Histopathologic lesions in conventional pigs experimentally infected with Haemophilus parasuis serovar 5.

OBJECTIVE: In the present study various tissues of pigs were investigated for the presence of histopathologic lesions after an experimental infection with Haemophilus (H.) parasuis serovar 5. MATERIAL AND METHODS: Conventional pigs (n = 36) were divided into a control group B (n = 9) and a challenge group A (n = 27), which was infected intratracheally. Pigs that did not die prior to study termination were euthanized on day 14 post inoculation. Postmortem samples of the lung, heart, liver, kidney, spleen, left tarsal joint capsule and brain were collected. RESULTS: All but one pig with detectable histopathologic lesions (n = 11) showed typical macroscopic changes. Histopathologic examination of all tissue samples identified pyelitis (n = 10), synovitis (n = 7) and meningitis (n = 7) and all those animals were euthanized prior to study termination. No histopathologic lesions were found in pigs of the control group. The correlations between pyelitis and meningitis, pyelitis and synovitis and synovitis and meningitis were significant (p < 0.001). No significant correlation could be observed between the histopathologic and the clinical examination of the joints. The investigation of samples from the joints by PCR was not significantly correlated with the observed synovitis. The clinical observation of neurologic signs was significantly correlated with meningitis (p = 0.03). A significant correlation (p < 0.001) could be detected between meningitis and the detection of H. parasuis by PCR in brain samples. CONCLUSIONS: H. parasuis constantly causes clinical signs and pathologic lesions as soon as it infects the brain while it can infect the joints without causing histopathologic lesions. Pigs with histopathologic lesions do not always show typical clinical signs. Only few studies described the finding of kidney lesions in pigs with Glässer's disease and this is the first study to describe a pyelitis in pigs experimentally infected with H. parasuis. The observed pyelitis mainly occurred in acute cases.

[Deterministic record linkage with indirect identifiers: data of the Berlin Myocardial Infarction Registry and the AOK Nordost for patients with myocardial infarction]. / Deterministisches Record Linkage mit indirekten Identifikatoren: Daten des Berliner Herzinfarktregisters und der AOK Nordost zum Herzinfarkt.

AIM OF THE STUDY: How can 2 pseudonymised data sets be linked? Using the example of data from the Berlin Myocardial Infarction Registry and from a German sickness fund (AOK Nordost) we will demonstrate how record linkage can be achieved without personal identifiers. METHODS: In different steps the method of deterministic record linkage with indirect identifiers: age, sex, hospital admission date and time, will be explained. RESULTS: We were able to show that 80.6% of the expected maximum number of patients were matched with our approach. As a result we had no duplicate matches in the linkage process, where one AOK patient was linked to 2 or more BMIR patients or vice versa. The matching variables produced enough uniqueness to be used as indirect patient identifiers. CONCLUSION: Deterministic record linkage with the following indirect indicators: age, sex, hospital admission date and time was possible in our study of patients with myocardial infarction in a circumscribed geographical region, which limited the number of cases and avoided mismatches.

[Economic Evaluation of Integrated Care Systems - Scientific Standard Specifications, Challenges, Best Practice Model]. / Ökonomische Erfolgsmessung von integrierten Versorgungsnetzen - Gütekriterien, Herausforderungen, Best-Practice-Modell.

PURPOSE: Transparency of economic performance of integrated care systems (IV) is a basic requirement for the acceptance and further development of integrated care. Diverse evaluation methods are used but are seldom openly discussed because of the proprietary nature of the different business models. The aim of this article is to develop a generic model for measuring economic performance of IV interventions. METHODS: A catalogue of five quality criteria is used to discuss different evaluation methods -(uncontrolled before-after-studies, control group-based approaches, regression models). On this -basis a best practice model is proposed. RESULTS: A regression model based on the German morbidity-based risk structure equalisation scheme (MorbiRSA) has some benefits in comparison to the other methods mentioned. In particular it requires less resources to be implemented and offers advantages concerning the relia-bility and the transparency of the method (=important for acceptance). Also validity is sound. Although RCTs and - also to a lesser -extent - complex difference-in-difference matching approaches can lead to a higher validity of the results, their feasibility in real life settings is limited due to economic and practical reasons. That is why central criticisms of a MorbiRSA-based model were addressed, adaptions proposed and incorporated in a best practice model: Population-oriented morbidity adjusted margin improvement model (P-DBV(MRSA)). CONCLUSION: The P-DBV(MRSA) approach may be used as a standardised best practice model for the economic evaluation of IV. Parallel to the proposed approach for measuring economic performance a balanced, quality-oriented performance measurement system should be introduced. This should prevent incentivising IV-players to undertake short-term cost cutting at the expense of quality.

Incremental validity of the WJ III COG: Limited predictive effects beyond the GIA-E.

This study is an examination of the incremental validity of Cattell-Horn-Carroll (CHC) broad clusters from the Woodcock-Johnson III Tests of Cognitive Abilities (WJ III COG) for predicting scores on the Woodcock-Johnson III Tests of Achievement (WJ III ACH). The participants were children and adolescents, ages 6-18 (n = 4,722), drawn from the WJ III standardization sample. The sample was nationally stratified and proportional to U.S. census estimates for race/ethnicity, parent education level, and geographic region. Hierarchical multiple regression analyses were used to assess for cluster-level effects after controlling for the variance accounted for by the General Intellectual Ability-Extended (GIA-E) composite score. The results were interpreted using the R²/ΔR² statistic as the effect size indicator. Consistent with previous studies, the GIA-E accounted for statistically and clinically significant portions of WJ III ACH cluster score variance, with R2 values ranging from .29 to .56. WJ III COG CHC cluster scores collectively provided statistically significant incremental variance beyond the GIA-E in all of the regression models, although the effect sizes were consistently negligible to small (Average ΔR2(CHC) = .06), with significant effects observed only in the Oral Expression model (ΔR²(CHC) = .23). Individually, the WJ III COG cluster scores accounted for mostly small portions of achievement variance across the prediction models, with a large effect found for the Comprehension-Knowledge cluster in the Oral Expression model (ΔR²(Gc) = .23). The potential clinical and theoretical implications of these results are discussed.

[Nursing tasks left undone in German acute care hospitals - results from the international study RN4Cast]. / Implizite Rationierung von Pflegeleistungen in deutschen Akutkrankenhäusern - Ergebnisse der internationalen Pflegestudie RN4Cast.

BACKGROUND: Implicit rationing of nursing care - likewise as in medical care - has never been empirically measured in German hospitals. Thus, little is known about prevalence and patterns of nursing care left undone as well as its association with nurse work environment and staffing. METHODOLOGY: We surveyed 1,511 registered nurses from 49 German acute hospitals participating in the multi-country cross-sectional study RN4CAST. Analyses were made by descriptive statistics as well as multilevel regression analysis to calculate predictors from the nurse work environment and staffing. RESULTS: On average 4.7 out of 13 nursing tasks were rationed. The range was between 82% for "comfort/talk with patients" and 15% for "treatments and procedures". The analysis revealed that hospital work environments and staffing ratios were significantly associated with the level of nursing care left undone. Further significant associations were found between poor leadership, inadequate organisation of nursing work as well as high emotional exhaustion and rationing. DISCUSSION: The phenomenon of nursing care left undone was prevalent in German hospitals. Those tasks which are most likely to have negative consequences for patients (e. g., pain management and medication on time) seem to receive higher priority than tasks whose potential effects are less immediate or direct (e. g., psychosocial care). With regard to the measured correlation with the nurse work environment, it is recommend to invest in a good environment before (or simultaneously) investing in nurse staffing.

[Do German DRGs appropriately explain the resource consumption of hospitals? An empirical patient-level cost-data analysis across ten episodes of care]. / Können deutsche DRGs den Ressourcenverbrauch eines Krankenhauses sachgerecht abbilden? Eine empirische Analyse auf Grundlage von patientenbezogenen Kosten- und Leistungsdaten für 10 Krankheitsbilder.

AIM OF THE STUDY: The revenues of German hospitals are mainly determined by DRG-based payments. Therefore DRGs should appropriately explain the resource consumption of hospitals in order to avoid unintended consequences. So far little is known about the ability of German DRGs to adequately reflect the cost of a hospital stay. METHODS: Regression techniques were applied using anonymised year 2008 cost and performance data of 50,156 cases from 29 hospitals for 10 common episodes of care in order a) to analyse the impact of patient and treatment characteristics on costs and b) to test if DRG variables are better in explaining resource consumption than this set of patient variables. RESULTS: Depending on the episode of care, patient and treatment variables have a different impact on hospital costs. However, they are better in explaining resource consumption than the DRG variables for each episode of care. In addition, independent of the patient characteristics hospitals have an impact on costs which might be due to factors that are not considered by the DRG-system. CONCLUSION: The analysis shows that the German DRG system requires further research. However, to date this is limited by poor data availability. Compared to other DRG systems the German system shows a weak performance. The incorporation of some of the used variables as well as an increasing international knowledge transfer might help to further improve the German DRG system.

[Turnaround time for reporting results of radiological examinations in intensive care unit patients: an internal quality control]. / Radiologische "report turnaround times" und Untersuchungszeitpunkte bei Patienten auf Intensivstationen : Eine institutsinterne Qualitätskontrolle.

AIMS: The radiological examinations performed in intensive care units (ICUs) were analyzed for the purpose of internal quality control. Data included the type of examination performed, the time of day the examination was performed and the differences in radiologist report turnaround times. MATERIAL AND METHODS: A retrospective analysis of the radiology information system (RIS) database of all radiological examinations performed in the ICU of a large German hospital from 2009 through 2011 was carried out. The search retrieved 75,169 examinations performed in ICU patients which were included in the analysis. The records were analyzed for type of radiological examination performed, i.e. conventional X-ray, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), angiography and nuclear medicine examinations, time of day the examination was performed and the interval between examination and time of reporting and release of the final report. RESULTS: Cross-modality it took on average 52 min until a report was written and approximately 7 h before the final report was released. Turnaround times were shortest for ultrasound, conventional X-ray and CT. Over the 3-year observation period there was an overall tendency toward shorter turnaround times whereby improvement in time until reporting was most marked for conventional X-ray, MRI and ultrasound (reduction of 24, 17, and 15 min, respectively). The time until release of the final report improved most markedly for CT, conventional X-ray and angiography (improvement of approximately 6.67, 5.08 and 0.78 h, respectively). CONCLUSIONS: During the 3-year observation period a reduction in turnaround times for reporting results and release of finalized reports could be observed, despite an increase in the total number of cases.