[Physician Numbers and Employment in Bavaria: Trends in statistics of the Bavarian Medical Association and the Association of Statutory Health Insurance Physicians of Bavaria]. / Entwicklung der Ärzt*innenzahlen und Beschäftigungsverhältnisse in Bayern ­ Trends in den Ärzt*innenstatistiken der Bayerischen Landesärztekammer und der Kassenärztlichen Vereinigung Bayerns.

BACKGROUND: Although the number of places at medical schools and physicians in Germany has increased continuously over the past 25 years, there is a threat of a shortage of physicians. Based on data from the Bavarian Medical Association (BLÄK) and the Association of Statutory Health Insurance Physicians of Bavaria (KVB), an analysis of the number of physicians in Bavaria over a longer period of time was carried out in order to understand current developments and possible starting points for the future organization of medical care. The figures were analyzed with regard to the distribution of physicians by outpatient and inpatient sector as well as with regard to the development of the number of employees, the scope of employment and the gender distribution in the outpatient sector. METHODS: Data were taken from the annually published and systematically compiled numbers of physicians from the BLÄK (2000 to 2022) as well as the outpatient billing data of practicing and employed physicians in Bavaria (2010 to 2022), processed by the KVB. Descriptive analyses were performed. RESULTS: Since 2000, the number of physicians in Bavaria has risen by 83% in the inpatient setting and by 35% in the outpatient setting. As a result, more physicians have been working in hospitals than in outpatient care since 2010. In the outpatient setting the trend is moving away from establishing one's own practice and full-time work towards salaried and part-time employment. Employed physicians have lower average working hours than self-employed physicians. The proportion of women among physicians has steadily increased, with female physicians more likely to be employed and working part-time compared with male physicians. Nevertheless, part-time employment is also prominent among male physicians in some specialties today. CONCLUSION: The trend towards practicing in salaried and part-time positions continues unabated and is represented across all specialties, suggesting that more physicians are needed to maintain the number of working hours over time. In addition to incentives and subsidies, this reality must be taken into account when planning care. At the same time, it is questionable whether increasing medical school places without managing them according to need is the right way to address the shortage of physicians in outpatient care when an ever-increasing proportion of physicians is working in inpatient care.

Structured interviews on self-regulated learning strategies of medical students in the final year of medical school.

BACKGROUND: In the final year of medical school, the educational focus is on experiences in the clinical environment. This is where students acquire most of their practical knowledge for their future career and need to optimise their Self-Regulated Learning (SRL) strategies. Hence, the current study aims to explore which SRL strategies medical students use during their clerkships in different learning settings. METHODS: Structured interviews were conducted between May 2019 and December 2020 with 43 medical students during their final year in Munich, Germany. The students were surveyed about their SRL strategies. The transcribed data were thematically analysed using the measurements Strategy Use (SU) and Strategy Frequency (SF). RESULTS: Interview data were organized into 11 SRL strategy categories. The most used SRL strategy in general was "seeking information in the internet in form of a text" (SU: 1; SF: 2.605), with an e-learning tool; followed by "seeking social assistance from doctors" (SU: 0.977; SF: 1.884), and "seeking information in books" (SU: 0.884; SF: 1.419). There were differences in the usage of SRL in different learning contexts between female and male students. For example, 95.3% of students are "seeking social assistance from doctors" when having difficulties on the ward, but only 55.8% when they need help with written tasks (e.g. medical letter). The results show a difference in SRL usage when preparing for oral-practical (79.1% books) and written (97.7% e-learning tool) exam. However, it also appears that some students do not have SRL strategies for certain situations, mostly due to a lack of time. CONCLUSION: Medical students in the clinical phase are adapting their SRL strategy to the learning situation. To better support students´ SRL, it is necessary to ensure availability for their preferred resources: e-learning tool and experienced physicians as supervisors. Future research should focus on strategies to handle the limited time during clerkships.

Experiences of medical students and nursing trainees from unexpected death through simulation training.

BACKGROUND: Dying in simulation training is controversially discussed. On the one hand, the danger of an emotional overload of the learners is pointed out. On the other hand, dying in simulation settings is addressed as an opportunity to prepare future health professionals to deal with patient death. The present study investigates how medical students and nursing trainees experience the sudden death of a simulated patient and how and under which conditions it can be valuable to simulate the patient's death. METHODS: At the TUM School of Medicine in Munich, Germany, we developed an interprofessional, simulation-based course in which participants were unexpectedly confronted with a cardiac arrest scenario within which resuscitation had to be discontinued due to an advanced directive. After the course, focus groups were conducted with nine medical students and six nursing trainees. Data were analysed using Grounded Theory techniques. RESULTS: The participants reported low to high emotional involvement. The active renunciation of life-sustaining measures was felt to be particularly formative and caused a strange feeling and helplessness. Questions of what could have been done differently determined interviewees' thoughts. The participants appreciated the opportunity to experience what it feels like to lose a patient. The course experience encouraged interviewees to reflect on dying and the interviewees explained that they feel better prepared to face death after the course. The unexpected character of the confrontation, presence of the advanced directive and debriefing positively affected the impact of the simulation. CONCLUSIONS: The study recognises simulation training as a promising approach for preparing future health care professionals to encounter a patient's death.

Cryoglobulinaemic vasculitis at diagnosis predicts mortality in primary Sjögren syndrome: analysis of 515 patients.

OBJECTIVE: To evaluate the fulfilment of classification criteria for cryoglobulinaemic vasculitis (CV) at diagnosis in a large cohort of patients with primary SS and their correlation with poor outcomes. METHODS: We included 515 consecutive patients tested for serum cryoglobulins who fulfilled the 2002 classification criteria for primary SS. CV classification criteria and serum cryoglobulins at diagnosis were assessed as predictors of death and lymphoma using Cox proportional-hazards regression analysis adjusted for age and gender. RESULTS: Positive serum cryoglobulins were detected in 65 (12%) patients, of whom 21 (32%) fulfilled CV classification criteria. Compared with patients positive for cryoglobulins who did not fulfil CV criteria, patients with CV had a higher frequency of type II cryoglobulinaemia (86% vs 43%, P = 0.04), a higher mean cryocrit level (6.58% vs 1.25%, P < 0.001) and a higher cumulated mean EULAR-SS disease activity index score (35.3 vs 16.2, P < 0.001). After a mean follow-up of 110 months, 45 (9%) patients developed B-cell lymphoma and 33 (6%) died. Compared with patients without cryoglobulins, patients with cryoglobulins who fulfilled [hazard ratio (HR) = 7.47, 95% CI: 3.38, 16.53] and did not fulfil (HR = 2.56, 95% CI: 1.03, 6.35) CV criteria both showed a higher risk of B-cell lymphoma in the univariate analysis, but not in the multivariate models. Compared with patients without cryoglobulins, patients with CV had a higher risk of death in both the univariate (HR = 11.68, 95% CI: 4.44, 30.74) and multivariate (HR = 4.36, 95% CI: 1.32, 14.47) models. CONCLUSION: Patients with primary SS who fulfilled criteria for cryoglobulinaemic vasculitis at diagnosis are at higher risk of death.

Efficacy of belimumab and targeting of rheumatoid factor-positive B-cell expansion in Sjögren's syndrome: follow-up after the end of the phase II open-label BELISS study.

OBJECTIVES: Belimumab, a monoclonal anti-B lymphocyte Stimulator (BLyS) antibody, appeared effective in Sjögren's syndrome (SS) in the phase II open-label 52-week BELISS study. Herein, the follow-up after the end of the BELISS study and suspension of the drug was reported in order to further verify the efficacy of belimumab in SS. METHODS: 13 SS patients were followed after the end of the belimumab treatment. The patients were all female, aged 54±15 years; all the patients presented anti-SSA and/or anti-SSB positivity. Composite scores for SS disease activity were collected at month 6 and month 12 after the end of the trial. The changes of IgG, IgA, IgM immunoglobulin serum levels, and rheumatoid factor (RF) level were reported. BLyS serum levels were also analysed. Statistics for paired comparisons were used. RESULTS: ESSDAI score increased from 3.5±3.7 at week 52 (end of the trial) to 7.0±5.7 at month 12 after the end of the trial (p=0.003). RF level increased from 31.0 (8.0-224.6) IU/ml at week 52 to 69 (11-666) IU/ml at month 12 after the end of the trial (p=0.008). IgM level increased from 131.9±73.6 mg/dl at week 52 to 165±84.6 mg/dl at month 12 after the end of the trial (p=0.04). A significant increase of serum BLyS levels also increased from 1304 (667-3835) pg/ml at week 52 to 2882 (1353-6178) pg/ml twelve months after belimumab suspension (p=0,04). CONCLUSIONS: Targeting BLyS by belimumab appears effective in SS, with the inhibition of RF-positive B cell proliferation.

Retreatment regimen of rituximab monotherapy given at the relapse of severe HCV-related cryoglobulinemic vasculitis: Long-term follow up data of a randomized controlled multicentre study.

OBJECTIVE: To evaluate the efficacy and safety in the long term of a retreatment regimen with Rituximab (RTX) alone administered at clinical relapse in cryoglobulinemic vasculitis (CV). METHODS: Thirty patients with severe HCV-related CV, previously enrolled in the multicentre Italian trial on RTX in the treatment of CV, were retrospectively evaluated after the end of the trial. All of them were managed with RTX alone at clinical relapse, if any. Disease activity at the last available follow up was defined as complete remission (absence of active disease), partial remission (response > 50% of at least one manifestation among glomerulonephritis, peripheral neuropathy or skin ulcers) or active disease. RESULTS: The mean follow up after the first RTX cycle was 72.6 (20.4) months. After the end of the trial, 21/30 (70%) patients showed an active follow up [81.7 (10.9) months)], 3/30 (10%) lost follow up and 6/30 (20%) died. 12/21 (57.1%) patients were in complete disease remission, 5/21 (23.8%) showed a partial response and 4/21 (19%) had an active disease. 17/30 (56.7%) patients needed retreatment for relapse with a mean time to retreatment of 22.3 (12.1) months. Treatment survival of this regimen was 7.6 (0.3) years. Recurrent non-severe infections occurred in 3/30, with chronic hypogammaglobulinemia in 2/3 patients. CONCLUSIONS: A long-term regimen of retreatment with RTX alone given at clinical relapse seems to be effective and safe in CV, with a low rate of infections and severe hypogammaglobulinemia.

Validation of the classification criteria for cryoglobulinaemic vasculitis.

OBJECTIVE: The aim of this study was to validate the classification criteria for cryoglobulinaemic vasculitis (CV). METHODS: Twenty-three centres were involved. New patients with CV (group A) and controls, i.e. subjects with serum cryoglobulins but lacking CV based on the gold standard of clinical judgment (group B) and subjects without cryoglobulins but with clinical features that can be observed in the course of CV (group C), were studied. Positivity of serum cryoglobulins was necessary for CV classification. Sensitivity and specificity of the criteria were calculated by comparing group A vs group B. The group A vs group C comparison was done to demonstrate the possible diagnostic utility of the criteria. RESULTS: The study included 268 patients in group A, 182 controls in group B and 193 controls in group C (small vessel vasculitis, 51.8%). The questionnaire (at least 2/3 positive answers) showed 89.0% sensitivity and 93.4% specificity; the clinical item (at least 3/4 clinical involvement) showed 75.7% sensitivity and 89.0% specificity and the laboratory item (at least 2/3 laboratory data) showed 80.2% sensitivity and 62.4% specificity. The sensitivity and specificity of the classification criteria (at least 2/3 positive items) were 89.9% and 93.5%, respectively. The comparison of group A with group C demonstrated the clinical utility of the criteria in differentiating CV from CV mimickers. CONCLUSION: Classification criteria for CV were validated in a second, large, international study confirming good sensitivity and specificity in a complex systemic disease.

Developing a societal impact evaluation framework for sustainable European University Alliances.

European University alliances, formally introduced in 2019, are rapidly expanding, as more than 400 million euros have been dedicated in 2023 by the European Commission to foster international collaborations to promote new forms of development within and beyond university communities. By undertaking interventionist research on UNITA - Universitas Montium, one of the largest European alliances, representing 160.000 students, this paper aims to illustrate how a university alliance is tasked with developing an internal assessment methodology to account for the societal benefits created by the project for the academic and civil communities. The elaboration of the assessment tool to assess the contribution to higher education and societal sustainable communities has brought researchers to discover etic and emic implications, revealing the existence of an accountability layer in which the international alliance directly engages with rural and mountain communities in marginalized areas. This research marks a significant advancement in the field of higher education sustainability, providing both a novel analytical perspective on the benefits of university alliances for the development of local sustainable communities and a methodological tool for their assessment.

An assessment of priorities in handling climate change impacts on infrastructures.

Climate change (CC) will likely significantly impact the world's infrastructure significantly. Rising temperatures, increased precipitation, and rising sea levels are all likely to stress critical infrastructures (CI). Rising temperatures can lead to infrastructure damage from extreme heat events. This can cause roads and bridges to buckle or crack, leading to costly repairs and potential traffic disruptions. In addition, heat waves can damage vital electrical infrastructure, leading to widespread power outages. In light of this context, this article reports on a study which examined the connections and impacts of CC on infrastructure. The study employed a mixed-method approach, combining bibliometric analysis for the period 1997-2022 with a series of relevant case studies from the five continents to offer insight into the impact of CC on infrastructure. The article fills a research gap in respect of assessments of the extent to which climate change (CC) negative influences the infrastructure, with a special focus on developing countries. It also showcases CI projects and adaptation measures being currently deployed, to address CC. The results show that the current infrastructure is vulnerable to CC. The selected case studies on CI adaptation show that in developing and industrialised countries, there is a perceived need to understand better the connections and potential impacts of CC on critical areas such as transport, settlements, and coastal infrastructure. In order to protect infrastructure from CC impacts, governments need to invest in measures such as flood control, early warning systems, and improved building codes. Additionally, they need to work to reduce greenhouse gas emissions more actively, which are the primary cause of CC.

Cryoglobulinaemia related to Sjogren's syndrome or HCV infection: differences based on the pattern of bone marrow involvement, lymphoma evolution and laboratory tests after parotidectomy.

OBJECTIVE: The relationship of cryoglobulinaemia with lymphoproliferation of mucosa-associated lymphoid tissue (MALT) as risk factors for lymphoma evolution in SS remains to be clarified. The different biologic background of SS-related cryoglobulinaemia as compared with cryoglobulinaemia linked to HCV infection was clarified by different clinical and biologic approaches. METHODS: B-cell clonal expansion was analysed in the bone marrow of 27 consecutive cases with primary SS and mixed cryoglobulinaemia, HCV unrelated, in comparison with 55 HCV-related patients with cryoglobulinaemic vasculitis (CV) without SS. The results were related to the possible occurrence and localization of B-cell lymphoma in the single case. Secondly, the prevalence of mixed cryoglobulinaemia was investigated in 41 unselected patients with primary SS showing either parotid myoepithelial sialadenitis (MESA) or a frank B-cell non-Hodgkin's lymphoma. Thirdly, the levels of serum cryoglobulins and RF were followed in one patient with primary SS, CV and parotid B-cell lymphoma of MALT after bilateral subtotal parotidectomy. RESULTS: A polyclonal pattern of B expansion in the bone marrow was significantly more frequent in SS-related (19/27 cases) than in HCV-related cryoglobulinaemia (19/55) (P = 0.003). Cryoglobulins were positive in a fraction of patients with SS and malignant lymphoma or with parotid MESA (13/18 and 7/23, respectively), whereas MALT involvement by the lymphoproliferative disorder was the rule. Finally, the levels of serum cryoglobulins and RF markedly decreased in the SS patient undergoing bilateral subtotal parotidectomy. CONCLUSION: Lymphoproliferation of MALT appears as the biologic background of cryoglobulinaemia in SS, differently from HCV-related cryoglobulinaemia.

Performance of the preliminary classification criteria for cryoglobulinaemic vasculitis and clinical manifestations in hepatitis C virus-unrelated cryoglobulinaemic vasculitis.

BACKGROUND: Cryoglobulinaemic vasculitis (CV) is often related to hepatitis C virus (HCV) infection, but it can develop in other diseases (e.g. other infections, connective tissue diseases, malignancies) in the absence of HCV infection. A comparison of the performance of the recently published classification criteria for the CV was made between HCV-positive and HCV negative patients with serum cryoglobulins. METHODS: 500 patients with serum cryoglobulins were studied. Their mean age was 60.77±13.75 years, they were 356 females (71.2%) and 144 males (28.8%). CV was diagnosed in 272 patients (54.4%), while other diseases associated with serum cryoglobulins without CV (CwV) were diagnosed in 228 patients (45.6%). RESULTS: 117 HCV negative patients were collected (23.4%) and they were 42/272 (15.4%) among the CV group, while they were 75/228 (32.9%) among the CwV. In HCV negative patients the sensitivity and specificity of the classification criteria of CV were 89.5% CI 95% [79.5-99.5] and 90.3% CI 95% [82.8-97.8], respectively, while in HCV positive patients they were 88.3% CI 95% [83.6%-93.1%] and 96.1% CI 95% [91.8-100], respectively. The most frequent disease recognised among the HCV negative patients was Sjögren's syndrome (SS) (55/117, 47.0%), and the sensitivity and the specificity of the CV classification criteria were 88.9% CI 95% [76.5-100] and 91.3% CI 95% [79.2-100], respectively. CONCLUSIONS: The classification criteria for CV showed a good performance even in HCV-unrelated patients. A slightly lower specificity was observed for the classification of HCV-unrelated CV, since some clinical manifestations included in the clinical item for the classification criteria occurred more frequently in HCV-negative rather than HCV-positive controls with CWV.

Anti-SSA/SSB-negative Sjögren's syndrome shows a lower prevalence of lymphoproliferative manifestations, and a lower risk of lymphoma evolution.

OBJECTIVE: This study aims to compare clinical and laboratory features of patients who, while satisfying the American European Consensus Group (AECG) criteria for primary Sjögren's syndrome (SS), do not present the positivity for anti-Ro/SSA and/or anti-La/SSB, with patients that meet the AECG criteria and are positive for anti-Ro/SSA and/or anti-La/SSB. METHODS: 548 patients were selected based on the following criteria, and exclusion of patients negative for histopathology but positive for anti-Ro/SSA and anti-La/SSB: 1. Fulfilment of the AECG criteria, 2. Performance of minor salivary gland biopsy, 3. Search for anti-Ro/SSA and anti-La/SSB, 4. Absence of hepatitis C virus infection. Univariate and multivariate analyses were performed. RESULTS: Two groups were compared: 342 patients were positive for both the histopathology and for anti-Ro/SSA and/or anti-La/SSB (H-only) and 206 patients were positive for histopathology, but negative for autoantibodies (H+SSA/SSB). The following variables were statistically found to be associated with H+SSA/SSB: younger age at diagnosis (p<0.0001), glandular swelling (p=0.01), purpura (p=0.04), leucopoenia (p=0.0001), lymphoma (p=0.002), low C3 (p=0.04), low C4 (p=0.01), hypergammaglobulinemia (p<0.0001), ANA (p<0.0001), rheumatoid factor (p<0.0001), and serum cryoglobulins (p=0.039). ANA positivity (OR 6.9), hypergammaglobulinemia (OR 5.1), positive rheumatoid factor (OR 2.3), and age at diagnosis (OR 0.97) were also selected by multivariate analyses as associated with H+SSA/SSB. CONCLUSION: Primary SS negative for anti-Ro/SSA and anti-La/SSB antibodies appears to be characterized by a lower risk of lymphoma and by a lower level of B-cell expansion.