Regional health workforce monitoring as governance innovation: a German model to coordinate sectoral demand, skill mix and mobility.

BACKGROUND: As health workforce policy is gaining momentum, data sources and monitoring systems have significantly improved in the European Union and internationally. Yet data remain poorly connected to policy-making and implementation and often do not adequately support integrated approaches. This brings the importance of governance and the need for innovation into play. CASE: The present case study introduces a regional health workforce monitor in the German Federal State of Rhineland-Palatinate and seeks to explore the capacity of monitoring to innovate health workforce governance. The monitor applies an approach from the European Network on Regional Labour Market Monitoring to the health workforce. The novel aspect of this model is an integrated, procedural approach that promotes a 'learning system' of governance based on three interconnected pillars: mixed methods and bottom-up data collection, strong stakeholder involvement with complex communication tools and shared decision- and policy-making. Selected empirical examples illustrate the approach and the tools focusing on two aspects: the connection between sectoral, occupational and mobility data to analyse skill/qualification mixes and the supply-demand matches and the connection between monitoring and stakeholder-driven policy. CONCLUSION: Regional health workforce monitoring can promote effective governance in high-income countries like Germany with overall high density of health workers but maldistribution of staff and skills. The regional stakeholder networks are cost-effective and easily accessible and might therefore be appealing also to low- and middle-income countries.

[Long-term care in Europe. Challenges and strategies in nursing staff management]. / Langzeitpflege im europäischen Vergleich. Herausforderungen und Strategien zur Sicherung der Pflegepersonalressourcen.

Across Europe, long-term care (LTC) is one of the most challenging areas of social policy. Despite a growing awareness of the problems and improved data, current institutional reforms are an ineffective response to demographic change. This article aims to provide an overview of the challenges of future nursing and care staff in LTC in Europe, and to discuss the German case in a wider European context. We focus on the nursing workforce and on the link between current and prospective analyses on the demand and offer of LTC services and LTC professionals/nursing staff. We draw on a secondary analysis of the literature and public statistics, especially OECD data. The European comparison shows a high variation in the future demand for LTC. In Germany, a number of problematic trends create a negative scenario: the growing demand for LTC meets with a decrease in nursing staff on the supply side. We conclude by suggesting intervention strategies that may reduce this negative scenario.

'A sorrow shared ': a qualitative content analysis of what couples with recurrent miscarriages expect from one another and their families and friends.

STUDY QUESTION: When couples have to face recurrent pregnancy loss (RPL), what are the partners' wishes and needs and what is their perception of helpful and unhelpful factors with regard to their own, their partners' and their families' and friends' ways of dealing with the problem? SUMMARY ANSWER: Women and men with repeated miscarriages want open communication about their losses, but expect a sensitive and empathetic attitude from others, not pity or trivialization. WHAT IS KNOWN ALREADY: RPL not only causes the women affected and their partners considerable emotional distress; it also has an impact on the couples' relationships and the way they relate to their families and friends. Studies suggest that women have a greater need than their male partners to talk about their losses and that these differences may lead to dissatisfaction and cause relational tension. In addition, men often assume a 'mainstay' role, supporting their partners and displaying fortitude in the face of distress. As yet, however, little research has been conducted so far on the question of what the members of couples with RPL expect from one another and from their families and friends. STUDY DESIGN SIZE DURATION: The study sample consisted of 147 couples and 17 women with at least 2 miscarriages attending the special unit for RPL at the University Women's Hospital in Heidelberg (Germany) for the first time between September 2018 and October 2020 (response rate: 82.7%). The patients were asked to participate in this combined qualitative and questionnaire study. PARTICIPANTS/MATERIALS SETTING METHODS: In order to explore the wishes and needs of those affected in more detail, the free text responses obtained were examined in this study by using qualitative content analysis. Categories and subcategories were created inductively to summarize and systematize content. MAIN RESULTS AND THE ROLE OF CHANCE: Patients affected by RPL want their partners and their families and friends to deal with the topic openly and empathically. In the partnership itself, acceptance of individual grieving modes and sharing a common goal are important factors. Men, in particular, want their partners to be optimistic in facing up to the situation. Regarding communication with family and friends, it transpired that 'good advice', playing the matter down, inquiries about family planning, pity and special treatment are explicitly not appreciated. LIMITATIONS REASONS FOR CAUTION: The sample was a convenience sample, so self-selection effects cannot be excluded. In addition, the level of education in the sample was above average. Accordingly, the sample cannot be regarded as representative. The results of the content analysis are based on the respondents' written answers to open-ended questions in the questionnaire. Unlike qualitative interview studies, further questioning was not possible in the case of ambiguities or to request more details. WIDER IMPLICATIONS OF THE FINDINGS: Frank and sincere communication about miscarriages and about one's own emotions and needs should be promoted both in the partnership and among family members and friends in order to strengthen the potential of social support as a resource. Open communication about the different needs of both partners is necessary to create mutual understanding. The results show the importance not only of empathy and consideration for the couples concerned but also their desire not to be pitied. Striking a fine balance between fellow-feeling and pity may also lead to tension, and this potential dilemma should be addressed in psychosocial counselling. Overall, the study contributes to a better understanding of what couples want from their families and friends when they are attempting to come to terms with RPL and highlights potential challenges in the interaction between affected couples and their families and friends. STUDY FUNDING/COMPETING INTERESTS: No funding was received for this study. None of the authors declared any conflicts of interest. TRIAL REGISTRATION NUMBER: DRKS00014965.

[Quality assurance in physiotherapeutic management: a gender-based analysis of health insurance data]. / Qualitätssicherung in der physiotherapeutischen Versorgung: eine geschlechterbezogene Analyse von Krankenkassendaten.

PURPOSE: Studies on the gender equivalence of health-care reveal differences in the handling of men and women that cannot be justified medically. This contribution analyses, for the example of physiotherapeutic management, whether a gender bias, as found for other medical fields, also exists in the provision of remedial interventions. METHODS: On the basis of the prescription data from a health insurance company (Gmünder Ersatzkasse, GEK), a gender-differential analysis of physiotherapy was undertaken. Prescription data for medications in the year 2005 were evaluated, differentiated according to the type of prescribed treatment, the age and gender of the insured person and the prescribing specialist group. Random samples were taken from the medicament prescriptions for further analyses. RESULTS: The analysis of prescription data revealed that, of the 1.6 million insured persons, 16.1% of the women (absolute: 119,354) and 11.7%of the men (absolute: 101,002) received at least one prescription for physiotherapy, the average age of all the insured persons receiving prescriptions for physiotherapeutic measures was 46 years for both sexes. Differential evaluation showed that women received a follow-on prescription slightly more frequently and that the number of treatment units per prescription was higher. Differences were also seen in the forms of the prescribed treatments. The data reveal a gender bias in physiotherapeutic management that can be explained by a differing compliance behaviour of the patient and prescribing behaviour of the physician. CONCLUSIONS: Accordingly, quality deficits also occur in the field of remedial interventions as a result of a gender bias, as has also been documented in other fields of medical management, especially with regard to the provision of medicaments.

Enhancement of pancreatic carcinogenesis by a dietary unsaturated fat in rats treated with saline or N-nitroso(2-hydroxypropyl)(2-oxopropyl)amine.

The effect of diets high in an unsaturated fat on the enhancement of pancreatic carcinogenesis in saline-treated rats and in rats treated with N-nitroso(2-hydroxypropyl)(2-oxopropyl)amine (HPOP) was examined. Young male LEW rats were treated with a single dose of HPOP (160 mg/kg body wt) or saline, fed diets containing 5 or 20% corn oil, and then autopsied 12 months later. The pancreata of HPOP-treated rats fed the diet with 5% fat contained multiple foci and nodules of atypical acinar cells (AACN), acinar cell adenomas, and localized carcinomas. Rats fed the diet with 20% fat developed a similar spectrum of pancreatic lesions and also developed carcinomas that showed local invasion or metastasis to regional lymph nodes. The incidence and multiplicity of localized carcinomas was significantly higher in the group that was fed the high-fat diet. HPOP also induced neoplasms in the liver, lungs, and kidneys, but none of these had a higher incidence in the group fed the high-fat diet. Among rats that received no carcinogen, the incidence of AACN was high, but the multiplicity of these lesions was low, an average of three per pancreas in groups fed both levels of fat; however, the average area of AACN transections was larger in the high-fat diet group. One acinar cell adenoma and 1 carcinoma developed in the group of 11 rats fed the 20% corn oil diet, whereas no neoplasms developed in the group of 12 rats fed the 5% corn oil diet. Although the incidence of pancreatic neoplasms is not significantly different in these 2 groups, the data are consistent with the hypothesis that initiated foci are promoted to grow and become neoplasms in the pancreas of rats that are fed diets with a high content of unsaturated fat--as was demonstrated in the HPOP-treated rats.

Induction of pancreatic carcinomas in rats with N-nitroso(2-hydroxypropyl)(2-oxopropyl)amine: histopathology.

The carcinogenicity of N-nitroso(2-hydroxypropyl)(2-oxopropyl)amine (HPOP) for rat pancreas was evaluated. Two-week-old male LEW rats were given a single ip injection of HPOP, 160 mg/kg body weight; the rats were autopsied 4, 6, or 12 months later. Histologic examination showed that the pancreata contained multiple foci of atypical acinar cells and nodules of atypical acinar cells (AACN), acinar cell adenomas, localized carcinomas, and carcinomas. The incidence of carcinomas was 77%. The carcinomas were composed of poorly differentiated acinar cells and ductlike structures. Pancreatic ducts were unaffected. The prominence of AACN, the histologic type of the neoplasms, and the absence of hyperplastic changes in ductal epithelium suggest that the pancreatic carcinomas were derived from acinar cells. The incidence of liver cell carcinomas and pulmonary adenomas was similar to that of localized pancreatic carcinomas. Neoplasms of other organs were less frequent. HPOP has been shown to induce pancreatic carcinomas in hamsters but has not previously been reported to be a pancreatic carcinogen in rats.

Experimental induction of pancreatic carcinomas in the hamster with N delta-(N-methyl-N-nitrosocarbamoyl)-L-ornithine.

Carcinomas of the pancreas, stomach, and breast, as well as mesotheliomas and ovarian stromal tumors, were induced in Syrian golden hamsters treated with N delta-(N-methyl-N-nitrosocarbamoyl)-L-ornithine (MNCO), which has previously been shown to cause pancreatic acinar cell carcinomas in rats. The pancreatic carcinomas in hamsters appeared ductlike. The nonneoplastic and preneoplastic lesions induced in the hamster pancreas included cystic ductal complexes, tubular complexes, intraductal hyperplasia and atypical hyperplasia, focal eosinophilic metaplasia, and foci of atypical acinar cells. High doses of 654 mg MNCO/kg body weight were cytotoxic for acinar cells and caused atrophy of the pancreas. Alkaline elution analysis of DNA from acinar cells treated in culture with MNCO showed an increased rate of elution characteristic of single-strand breaks. A group of hamsters treated with a low dose of N-nitrosobis(2-oxopropyl)amine (BOP) developed pancreatic lesions similar to those seen when a subcarcinogenic dose of MNCO was given. The results suggest that MNCO affects both acinar and ductal cells in the hamster and that the response of the hamster pancreas to MNCO and BOP is similar in many respects.

Divergent effects of retinoids on pancreatic and liver carcinogenesis in azaserine-treated rats.

Chemoprevention by synthetic retinoids of the progression of carcinomas of the pancreas induced in rats by azaserine was evaluated. Lewis rats were given five weekly injections of azaserine, 30 mg/kg, while being fed a chow diet. Two weeks after completion of carcinogen treatment, groups of rats were fed the chow diet supplemented with four different retinoids at the level of 0.5 to 2 mmol/kg of diet for 1 year. The incidence of pancreatic and other neoplasms was determined by autopsy and histological study. The incidence of localized pancreatic carcinoma among male and female non-retinoid-treated controls was 25 and 17%, respectively. No invasive or metastatic carcinomas were found in the control group. The combined incidence of localized and invasive pancreatic carcinomas among male and female rats treated with retinoids was: N-(4-pivaloyloxyphenyl)retinamide, 4 and 0%; N-(2-hydroxypropyl)retinamide, 14 and 6%; N-(3-hydroxypropyl)retinamide, 16 and 4%; and N-(2,3-dihydroxypropyl)retinamide, 12 and 6%. High- and low-dose groups are combined in this summary of data. Thus, there was a trend towards fewer pancreatic carcinomas among all retinoid-treated groups. The reduction in incidence was significant in both male and female rat groups given N-(4-pivaloyloxyphenyl)retinamide and N-(2,3-dihydroxypropyl)retinamide. The principal evidence of retinoid toxicity was growth failure, which was most severe in animals treated with N-(4-pivaloyloxyphenyl)retinamide, and testicular atrophy, which was most severe among male animals treated with N-(3-hydroxypropyl)retinamide. Among the females, groups treated with three of the four retinoids showed a dose-related increase in incidence of hepatocellular carcinomas. Since the retinoids were fed after the completion of exposure to the carcinogen, the effects on both pancreatic and liver carcinogenesis were exerted during the postinitiation phase of carcinogenesis.

Characterization of the elastase 1-simian virus 40 T-antigen mouse model of pancreatic carcinoma: effects of sex and diet.

Elastase 1-simian virus transgenic mice, strain Tg(Ela-1, SV40E) Bri18, were studied to characterize the development of pancreatic neoplasms. The incidence of pancreatic carcinomas was compared in groups of male and female mice fed one of three diets chosen because of their effect on the development of pancreatic carcinomas in other animal models. Male mice developed more exocrine carcinomas than female mice and their tumors were larger. Groups fed chow had fewer exocrine carcinomas than groups fed purified diets. The level of fat in the latter diets, 5 versus 20% corn oil, did not alter tumor incidence. An unexpectedly high incidence of islet cell tumors was found in all dietary groups, with a higher incidence in females than in males.

Effects of four retinoids in N-nitrosobis(2-oxopropyl)amine-treated hamsters.

Four synthetic retinoids were evaluated with regard to chemo-prevention of pancreatic carcinomas in carcinogen-treated hamsters. Syrian golden hamsters were given two injections of N-nitrosobis(2-oxopropyl)amine (20 mg/kg) and then were fed retinoid-supplemented diets for 1 year. The incidence of pancreatic carcinomas was lower in six of eight retinoid-fed groups than in the control group, although the differences were not statistically significant. The lowest incidence was observed in groups fed N-(4-pivaloyloxyphenyl)retinamide and N-(2-hydroxypropyl)retinamide. Testicular atrophy with decreased spermatogenesis was noted in males fed N-(2-hydroxypropyl)retinamide, N-(3-hydroxypropyl)retinamide, and N-(2,3-dihydroxypropyl)retinamide.

Overexpression of cholecystokinin receptors in azaserine-induced neoplasms of the rat pancreas.

Cholecystokinin (CCK) is a growth factor for normal pancreas. Numerous studies also suggest that CCK promotes pancreatic carcinogenesis in the rat. Our previous studies suggested that growth of preneoplastic pancreatic foci was stimulated by CCK more than that of normal pancreas. We hypothesized that such differential growth might be due to increased numbers of CCK receptors in neoplastic tissue. Azaserine-induced pancreatic carcinoma (DSL6) had an increased high-affinity CCK receptor binding capacity of 122 +/- 23 (SD) fmol/mg protein compared to 12 +/- 2 fmol/mg protein in normal pancreas (P less than 0.001). The Kd of the high-affinity site was 0.33 +/- 0.04 nM for carcinoma and 0.46 +/- 0.08 nM for normal pancreas (P less than 0.01). The amount of cholecystokinin octapeptide (CCK-8) bound to high-affinity receptor was 8.6 +/- 1.9 fmol/mg protein for DSL6 compared to 0.6 +/- 0.2 fmol/mg protein in normal pancreas (P less than 0.001). Azaserine-induced premalignant nodules were compared to remaining internodular pancreas. Nodules demonstrated a mean high-affinity CCK receptor binding capacity of 38 +/- 9 fmol/mg protein compared to 6 +/- 3 fmol/mg protein in internodular pancreas (P less than 0.001). The amount of CCK-8 bound to high-affinity receptor was 3.1 +/- 0.8 fmol/mg protein in nodules compared to 0.6 +/- 0.3 fmol/mg protein in internodular pancreas (P less than 0.001). Overexpression of high-affinity CCK-8 receptor in premalignant and malignant azaserine-induced tumors may result in a growth advantage relative to normal pancreas.

Inhibition of pancreatic carcinogenesis by retinoids in azaserine-treated rats.

Chemoprevention by retinoids of the progression of carcinomas induced in rats by azaserine was evaluated. Wistar/Lewis rats were given 15 weekly injections of azaserine, 10 mg/kg, while fed a chow diet; after the completion of carcinogen treatment, they were fed a chow diet supplemented with four different retinoids at the level of 0.5 to 2 mmol/kg diet for 1 year. The incidence of neoplasms was determined by autopsy and histological study. The incidence of pancreatic carcinoma among a male positive control group (azaserine treated, but not retinoid treated) was 42%. The incidence of pancreatic carcinoma among male rats treated with retinoids was: N-2-hydroxyethylretinamide, 6%; N-4-propionyloxyphenylretinamide, 17%; and retinylidene dimedone, 12%. The incidence in rats fed these three retinoids was significantly (p less than 0.05) below the control group incidence. Thus, these three retinoids appeared to be effective in inhibiting the progression of pancreatic carcinomas in the azaserine-induced model. A similar trend was demonstrated in females, but statistical significance was shown only in rats fed N-2-hydroxyethylretinamide. A fourth retinoid, N-4-carboxyphenylretinamide, was more toxic and less effective in chemoprevention. Since retinoids were fed after exposure to carcinogen, the effect was exerted during the postinitiation phase of carcinogenesis. The ratio of invasive pancreatic carcinomas to localized carcinomas (carcinoma in situ) was clearly higher among non-retinoid-treated rats than among those treated with retinoids. This is consistent with retarded progression in the retinoid-treated groups.

The visual cycle retinol dehydrogenase: possible involvement in the 9-cis retinoic acid biosynthetic pathway.

The 11-cis-retinol dehydrogenase (11-cis-RoDH) gene encodes the short-chain alcohol dehydrogenase responsible for 11-cis-retinol oxidation in the visual cycle. The structure of the murine 11-cis-RoDH gene was used to reinvestigate its transcription pattern. An 11-cis-RoDH gene transcript was detected in several non-ocular tissues. The question regarding the substrate specificity of the enzyme was therefore addressed. Recombinant 11-cis-RoDH was found capable of oxidizing and reducing 9-cis-, 11-cis- and 13-cis-isomers of retinol and retinaldehyde, respectively. Dodecyl-beta-1-maltoside used to solubilize the enzyme was found to affect the substrate specificity. This is the first report on a visual cycle enzyme also present in non-retinal ocular and non-ocular tissues. A possible role in addition to its role in the visual cycle is being discussed.

Experimental autoimmune anterior uveitis. The preparation of uveitogenic ocular melanin.

PURPOSE: The purpose of this study was to develop a rapid procedure for the preparation of melanin with a specific, highly uveitogenic activity. METHODS: A crude melanosome fraction was isolated from bovine choroids (containing remnants of adhering retinal pigment epithelium). The fraction was extracted with hot 2% sodium dodecyl sulfate, and Lewis rats were immunized with the purified melanin, using pertussis toxin as coadjuvant. RESULTS: The purified melanin was free from pathogenic photoreceptor antigens and other accompanying or adsorbed proteins. It was able to evoke severe, acute, anterior uveitis with the typical characteristics of experimental autoimmune anterior uveitis (EAAU; without retinitis or pinealitis), even at the level of 1 micrograms melanin protein. CONCLUSIONS: The rapidly prepared ocular melanin exhibits the same qualities as purified choroidal or retinal pigment melanins obtained by much more laborious procedures (which also deliver other subcellular fractions for investigation). It is suitable for the study of the immunopathogenesis of EAAU, which is a new model for human acute anterior uveitis.

Transplantation of azaserine-induced carcinomas of pancreas in rats.

Two pancreatic adenocarcinomas which had been induced in Wistar/Lewis rats by azaserine treatment were transplanted into rats of the same strain by subcutaneous and intraperitoneal injection of minced tumor. Subsequently, we have serially transplanted into non-radiated recipients. Transplanted tumors have maintained evidence of acinar cell differentiation including the presence of zymogen granules in tumors studied by electron microscopy, and of lipase, amylase and trypsin activity in the supernatant of tumor homogenates. Histologically, the tumors vary from poorly differentiated solid carcinomas to well differentiated variants which form acini. Transplanted tumors are locally invasive and have metastasized to lung and liver in some recipients.

Studies of pancreatic nodule induction and DNA damage by D-azaserine.

The ability of the D-isomer of azaserine to induce atypical acinar cell nodules (AACN) in pancreas and to cause DNA damage in pancreas and liver was evaluated. Rats were injected with equivalent doses of D- or L-azaserine and numbers of AACN were counted after 4 months. DNA damage in pancreas and liver of rats treated in vivo, and in pancreatic acinar cells treated in vitro with D- or L-azaserine was determined by alkaline elution. Results show that D-azaserine does not significantly induce AACN in pancreas, nor does it cause extensive DNA damage in comparison with L-azaserine, suggesting that the differential effect of the 2 isomers is related to stereospecificity in either transport or metabolism.

Retinoic acid delays transcription of human retinal pigment neuroepithelium marker genes in ARPE-19 cells.

The effect of retinoic acid on the differentiation of a human retinal pigment epithelium-derived cell line ARPE-19 was studied. Differentiation of ARPE-19 cells is delayed by retinoic acid. The minimum all-trans-retinoic acid concentration needed for delay of ARPE-19 differentiation is 1 microM. A delay of differentiation was also observed using 1 microM 9-cis or 13-cis-retinoic acid. Differentiation at the molecular level was studied by analyzing transcription of two RPE-marker genes, RPE65 and peropsin. In the presence of 1 microM retinoic acid the onset of transcription of both genes was delayed by 2-3 weeks. We conclude that all-trans-, 9-cis-, and 13-cis-retinoic acid delay differentiation of ARPE-19 cells into cells that phenotypically resemble cells from the human retinal pigment epithelium.

Inhibition of pancreatic and liver carcinogenesis in rats by retinoid- and selenium-supplemented diets.

Chemoprevention by a synthetic retinoid, selenium, and these agents in combination during the postinitiation stages of carcinogenesis induced in rats by azaserine was evaluated. Male Lewis rats were given three weekly injections of 30 mg/kg azaserine while being fed a purified diet. One week after completion of carcinogen treatment, groups of rats were switched to the purified diet supplemented with either a retinoid, N-(2-hydroxyethyl)retinamide, at a level of 0.5 or 1 mmol/kg diet, or with 5 ppm sodium selenite, or with a combination of retinoid and selenium. One year after the diet change, the incidence of pancreatic and other neoplasms was determined by autopsy and histologic study. The incidence of pancreatic carcinoma (including carcinoma-in-situ, CIS) among nonretinoid-treated controls was 68%. Since the dietary supplements were fed after completion of exposure to the carcinogen, the effects on both pancreatic and liver carcinogenesis were exerted during the postinitiation phase of carcinogenesis. As in previous studies, the retinoid inhibited the progression of pancreatic carcinogenesis in a dose-related fashion. Selenium alone had no effect. However, the combination of retinoid plus selenium was more effective than retinoid alone, although the increase in inhibition was not large. The retinoid was also found to inhibit liver carcinogenesis induced by azaserine. Selenium, either alone or in combination with retinoid, was ineffective. Finally, testicular atrophy, noted as a toxic effect of retinoids in other studies, was not observed in this work.

Effects of retinoids in N-nitrosobis(2-oxopropyl)amine-treated hamsters.

The effect of feeding four synthetic retinoids was evaluated in carcinogen-treated hamsters. Syrian golden hamsters were injected with 20 mg/kg of N-nitrosobis(2-oxopropyl)amine (BOP) and then fed retinoid-supplemented diets for 39 weeks. All retinoid-treated groups grew more slowly than controls, and average survival was shorter in female retinoid-treated groups. A significant incidence of testicular atrophy was noted in male hamsters fed 2-hydroxyethylretinamide or 4-carboxyphenylretinamide. The incidence of pancreatic carcinomas was lower in 12 of 14 retinoid-fed groups than in the corresponding control groups, although the differences approached significance only in groups fed two of the retinoids--male hamsters fed N-4-propionyloxyphenylretinamide and those fed retinylidene dimedone. A low incidence of carcinoma in the control groups limits the conclusions that can be drawn from this study, but it is of note that there was no evidence of promotion.