[The judgment of the Federal Social Court on the involvement of psychological psychotherapists in interdisciplinary multimodal pain therapy : A critical comment]. / Das Urteil des Bundessozialgerichts zur Einbindung von Psychologischen Psychotherapeuten in die interdisziplinäre multimodale Schmerztherapie : Eine kritische Kommentierung.

In the context of their offer of interdisciplinary multimodal pain therapy (day-patient and inpatient), hospitals repeatedly have to contend with strict detailed checks of the procedure codes (OPS 8-918.xx; 8-91c) by health insurers and the medical service. The necessity of day-patient or inpatient treatment in the respective sector, documented therapy components, and the qualifications of the therapists are regularly reviewed. On 27 October 2020, the Federal Social Court ruled on the specific qualification of psychological psychotherapists (BSG, 27 October 2020, Ref.: B 1 KR 25/19 R). The ruling and its potential impact are explained and discussed in this overview.

[Is interdisciplinary multimodal pain therapy threatened? : Increasing controversy on the necessity for inpatient treatment]. / Ist die interdisziplinäre multimodale Schmerztherapie in Gefahr? : Zunehmende Kontroversen zur Notwendigkeit der stationären Behandlung.

Interdisciplinary multimodal pain therapy (IMST) is recognized as a scientifically founded form of therapy for inpatient treatment of chronic pain conditions. The indications are assessed by private practitioners and must be confirmed by physicians at the inpatient institution. The health insurance companies are obliged to remunerate this treatment but are allowed to test the conditions in individual cases. Recently, reports from members of the German Pain Society on a drastic increase in testing and rejection quotas have become more frequent. Therefore, this article discusses the legal foundations of the treatment of patients with chronic pain in the inpatient sector. Hard criteria for treatment in a certain sector could not be established. A decision in individual cases will depend on the complexity of the disease in the individual patient. A treatment in hospital is principally only necessary when the treatment corresponds to the generally recognized state of medical knowledge and treatment options in daycase units have not been successful. Important guidance can be found in the treatment guidelines of the medical specialist societies. The transfer to a more intensive treatment sector must be made dependent on the severity and complexity of the symptoms and the insufficient effectiveness of the treatment in the previous sector. Simple ICD-10 diagnoses are not suitable as decision-making criteria and therefore, also not as testing criteria for the indications for inpatient treatment. Decompensated and acutely exacerbated chronic pain conditions must as a rule be treated in hospital, also due to the mental component of the pain disease.

Training emotion regulation through real-time fMRI neurofeedback of amygdala activity.

Being in control of one's emotions is not only desirable in many everyday situations but is also a great challenge in a variety of mental disorders. Successful intentional emotion regulation is related to down-regulation of amygdala activity. Training mental interventions supported by neurofeedback of one's own amygdala activity using real-time (rt-)fMRI might be beneficial for mental health and well-being. Rt-fMRI guided amygdala-downregulation using cognitive interventions such as a "reality check", however, have not been well-investigated. Fifteen healthy subjects underwent four rt-fMRI sessions with neurofeedback of their own amygdala activity while applying a reality check as an emotion regulation strategy in order to down-regulate their amygdala signal during a stimulation with emotional pictures. The Control group comprised of eleven subjects also trained emotion regulation but without obtaining feedback. We hypothesized more prominent down-regulation of amygdala activity at the end of the training in the Feedback group. We investigated effects over time and between groups and further task specific connectivity of the amygdala by using psychophysiological interaction analyses. Four weekly amygdala-based feedback sessions resulted in significantly decreased amygdala activity (p = 0.003, d = 0.93), also compared to the Control group (p = 0.014, d = 1.12). Task specific connectivity of the amygdala with the anterior cingulate cortex, hippocampus and distinct prefrontal areas was increased in the Feedback group. Training of emotion regulation supported by rt-fMRI neurofeedback resulted in a prominent amygdala down-regulation compared to training without feedback. The finding implicates successful emotion regulation, compliant with emotion control models, through an easily applicable reality check strategy. Rt-fMRI neurofeedback may support emotion regulation learning and bears clinical potential for psychotherapy.

Functionalized and Degradable Polyphthalaldehyde Derivatives.

Polymers that depolymerize back to monomers can be repeatedly chemically recycled, thereby reducing their environmental impact. Polyphthalaldehyde is a metastable polymer that can rapidly and quantitatively depolymerize due to its low ceiling temperature. However, the effect of substitution on the physical and chemical properties of polyphthalaldehyde derivatives has not been systematically studied. Herein, we investigate the cationic polymerization of seven o-phthalaldehyde derivatives and demonstrate that judicious choice of substituent results in materials with a wide range of ceiling temperatures (<-60 to 106 °C) and decomposition temperatures (109-196 °C). We anticipate that these new polymers and their derivatives will enable researchers to access degradable materials with tunable thermal, physical, and chemical properties.

[Cross-sectoral interdisciplinary multimodal pain therapy : Recommendations on structural and process parameters of the ad hoc commission "Interdisciplinary Multimodal Pain Therapy" of the German Pain Society (Deutsche Schmerzgesellschaft e.  V.)]. / Sektorenübergreifende interdisziplinäre multimodale Schmerztherapie : Empfehlungen zu Struktur- und Prozessparametern der Ad-hoc-Kommission "Interdisziplinäre Multimodale Schmerztherapie" der Deutschen Schmerzgesellschaft e. V.

Based on the fundamental concept of the biopsychosocial model, interdisciplinary multimodal pain therapy (IMPT) has developed to one of the most important components in the treatment of patients suffering from chronic pain. The process criteria for IMPT in Germany are described in the German OPS catalogue and IMPT is mainly offered as an inpatient treatment only. This article updates some of the fundamental criteria for IMPT for adult inpatient treatment and the task force defines basic structural and process criteria for the implementation of IMPT for outpatients.

[Traveling with immunodeficiency-Problems and prevention]. / Reisen mit Immundefekt ­ Probleme und Prävention.

Advances in medical care have led to an increasing number of immunocompromised travellers. Travellers with immunodeficiencies have a higher risk of infections and can acquire infectious diseases that are rare in immunocompetent travellers. Of central interest are travellers' diarrhea, diseases of the respiratory tract, tuberculosis and inhalative mycoses as well as diseases transmitted by vectors such as malaria. For every such journey a timely consultation in travel medicine is indicated. First the individual risk must be assessed according to the degree of immunodeficiency. An individual counselling is then related to the itinerary, the travel destination and any activities planned. This information is the basis for an individual set of prophylactic measures with respect to infections and other risks through certain modes of behavior, medication, and vaccinations. Post-travel counselling and evaluation are equally important. This requires physicians experienced in both immunosuppression and travel medicine.

Ni-Catalyzed Carbon-Carbon Bond-Forming Reductive Amination.

This report describes a three-component, Ni-catalyzed reductive coupling that enables the convergent synthesis of tertiary benzhydryl amines, which are challenging to access by traditional reductive amination methodologies. The reaction makes use of iminium ions generated in situ from the condensation of secondary N-trimethylsilyl amines with benzaldehydes, and these species undergo reaction with several distinct classes of organic electrophiles. The synthetic value of this process is demonstrated by a single-step synthesis of antimigraine drug flunarizine (Sibelium) and high yielding derivatization of paroxetine (Paxil) and metoprolol (Lopressor). Mechanistic investigations support a sequential oxidative addition mechanism rather than a pathway proceeding via α-amino radical formation. Accordingly, application of catalytic conditions to an intramolecular reductive coupling is demonstrated for the synthesis of endo- and exocyclic benzhydryl amines.

[Implementation of interdisciplinary multimodal pain therapy according to OPS 8­918 : Recommendations of the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association]. / Umsetzung der interdisziplinären multimodalen Schmerztherapie nach OPS 8­918 : Empfehlungen der Ad-hoc-Kommission "Interdiziplinäre multimodale Schmerztherapie" der Deutschen Schmerzgesellschaft.

With the implementation of the German diagnosis-related groups (DRG) reimbursement system in hospitals, interdisciplinary multimodal pain therapy was incorporated into the associated catalogue of procedures (OPS 8­918). Yet, the presented criteria describing the procedure of interdisciplinary multimodal pain therapy are neither precise nor unambiguous. This has led to discrepancies in the interpretation regarding the handling of the procedure-making it difficult for medical services of health insurance companies to evaluate the accordance between the delivered therapy and the required criteria. Since the number of pain units has increased in recent years, the number of examinations by the medical service of health insurance companies has increased. This article, published by the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association, provides specific recommendations for correct implementation of interdisciplinary multimodal pain therapy in routine care. The aim is to achieve a maximum level of accordance between health care providers and the requirements of the medical examiners from health insurance companies. More extensive criteria regarding interdisciplinary multimodal pain treatment in an in-patient setting, especially for patients with chronic and complex pain, are obviously needed. Thus, the authors further discuss specific aspects towards further development of the OPS-code. However, the application of the OPS-code still leaves room regarding treatment intensity and process quality. Therefore, the delivery of pain management in sufficient quantity and quality still remains the responsibility of each health care provider.

[Fulminant sepsis after Capnocytophaga canimorsus infection]. / Fulminante Sepsis nach Capnocytophaga-canimorsus-Infektion.

Capnocytophaga canimorsus is a Gram-negative bacterium present in the oral cavities of cats and dogs. It is known for its capability to cause life-threatening sepsis following a dog bite, especially in immunocompromised patients. We report the case of a 67-year-old man who suffered from septic shock and multiorgan failure presumably following contamination of a pre-existing minor skin lesion by canine saliva. The purpose of this report is to raise awareness of Capnocytophaga canimorsus among physicians when faced with a patient presenting with fulminant septic shock and Gram-negative bacteremia, who has been exposed to dogs.

Surotomycin versus vancomycin in adults with Clostridium difficile infection: primary clinical outcomes from the second pivotal, randomized, double-blind, Phase 3 trial.

BACKGROUND: The available treatment options for Clostridium difficile infection (CDI) are limited by high recurrence rates. Surotomycin was a novel bactericidal cyclic lipopeptide in development to treat CDI that demonstrated non-inferiority to vancomycin in a Phase 2 trial. OBJECTIVES: To assess surotomycin safety and clinical response (non-inferiority versus vancomycin) at the end of treatment (EOT) of CDI. Additionally, to assess surotomycin response over time and sustained response at 30-40 days post-EOT (superiority versus vancomycin). PATIENTS AND METHODS: Patients with CDI were randomized (1:1) to receive twice-daily oral surotomycin 250 mg alternating with twice-daily placebo or four-times-daily oral vancomycin 125 mg for 10 days in this Phase 3, double-blind, multicentre, international trial. Clinical response over time and sustained clinical response were monitored until the end of the trial, through a follow-up period of 30-40 days. Clinical Trial Registration: NCT01598311. RESULTS: A total of 285 and 292 patients with confirmed CDI were randomized to receive surotomycin and vancomycin, respectively. Surotomycin-associated clinical response at EOT was non-inferior to vancomycin (surotomycin/vancomycin: 83.4%/82.1%; difference 1.4%, 95% CI - 4.9, 7.6). Following treatment with surotomycin, both clinical response over time (stratified log-rank test, P = 0.277) and sustained clinical response (63.3%/59.0%; difference 4.3%, 95% CI - 3.6, 12.2) did not demonstrate superiority versus vancomycin at end of trial. Both treatments were generally well tolerated. CONCLUSIONS: Surotomycin demonstrated non-inferiority to vancomycin for CDI clinical response at EOT. Surotomycin did not demonstrate superiority to vancomycin for clinical response over time or sustained clinical response rate.

[Interdisciplinary pain assessment in the hospital setting : Merely a door-opener to multimodal pain therapy?] / Interdisziplinäres Schmerzassessment im stationären Setting : Nur ein Türöffner zur multimodalen Schmerztherapie?

BACKGROUND: Chronic pain is characterized by a complex interaction of somatic, mental and social factors. Assessing these factors in patients with chronic pain is vital during the diagnostic work-up and when making a structured treatment plan. Interdisciplinary pain assessment (ISA) is the most promising method to deal with these challenges. This article presents our experience in performing pain assessments in the hospital setting and also illustrates the characteristic features of chronic pain patients undergoing such assessments. METHODS: This study reviews and evaluates patient data from 2704 ISAs performed at the Interdisciplinary Pain Centre of the Zentralklinik Bad Berka, Germany, between 2008 and 2015. RESULTS: The majority of our ISA patients are severely handicapped and show distinct signs of chronic disease. A large proportion of patients is either unable to work or receiving benefits (invalidity pension or retirement pension). In addition, patients reported long disease durations and high emotional distress. Treatment recommendations were based on the patients' individual clinical presentations and examination results. More than half of the patients required multimodal pain management, while adjustments or therapeutic withdrawal of pain medications, in particular of opioids, were indicated in many patients. DISCUSSION: Our study shows that ISA enables fast, high-quality diagnostic assessments of chronic pain while taking the biopsychosocial model of pain in particular into account. In addition, ISA is not biased with regard to outcome results and recommends the further treatment that appears best for the individual patient. ISA leads not only to inpatient treatment, but also to treatment in other therapeutic settings and, as such, is not merely a door-opener to multimodal pain therapy.

[Chronic pain disorder with somatic and psychological factors (F45.41) : Validation criteria on operationalization of the ICD-10-GM diagnosis]. / Chronische Schmerzstörung mit somatischen und psychischen Faktoren (F45.41) : Prüfkriterien zur Operationalisierung der ICD-10-GM-Diagnose.

In 2009 the diagnosis chronic pain disorder with somatic and psychological factors (F45.41) was integrated into the German version of the International Classification of Diseases, version 10 (ICD-10-GM). In 2010 Paul Nilges and Winfried Rief published operationalization criteria for this diagnosis. In the present publication the ad hoc commission on multimodal interdisciplinary pain therapy of the German Pain Society now presents a formula for a clear validation of these operationalization criteria of the ICD code F45.41.

Altered processing of self-related emotional stimuli in mindfulness meditators.

Mental health benefits of mindfulness techniques are thought to involve changes in self-processing, such as decreased attachment to the self, higher self-compassion and lower emotional reactivity to inner experience. However, self-related emotion processing in regular mindfulness practitioners is not extensively studied. In the current work we investigate differential neural and behavioral correlates of self-criticism and self-praise in 22 mid-to-long-term mindfulness meditators (LTM) compared to 22 matched meditation-naïve participants (MNP). In an fMRI experiment, participants were presented with blocks of individually selected positive (self-praise, SP), negative (self-critical, SC), negative but not-self-critical (NNSC), and general, neutral (NT) adjectives, and reported their affective state after the blocks. On the neural level, both SP and SC yielded more activation in the dorso-medial prefrontal cortex (DMPFC) in LTM compared to MNP. Activation in this region correlated positively with non-react scores of the Five Facets Mindfulness Questionnaire (FFMQ) and showed decreased functional connectivity to posterior midline and parietal regions in LTM compared to MNP during both self-related appraisals. Further, we found evidence for emotional reactivity in LTM on the neural level, particularly during SP. On the behavioral level, a mixed effects analysis revealed significantly higher differences in affective ratings after blocks of SC compared to SP in MNP compared to LTM. Differences in DMPFC activation and affective ratings point towards increased awareness, potentially mindful regulation of SC and SP in LTM, while decreased connectivity to other regions of the default mode network could reflect a decreased self-focus in this group. As such, our results illustrate differences in self-related emotional processes in meditators and offer clinically relevant insights into mechanisms of mindful emotion regulation when facing self-criticism and self-praise.

Generation of 64 GBd 4ASK signals using a silicon-organic hybrid modulator at 80°C.

We demonstrate a silicon-organic hybrid (SOH) Mach-Zehnder modulator (MZM) generating four-level amplitude shift keying (4ASK) signals at symbol rates of up to 64 GBd both at room temperature and at an elevated temperature of 80°C. The measured line rate of 128 Gbit/s corresponds to the highest value demonstrated for silicon-based MZM so far. We report bit error ratios of 10-10 (64 GBd BPSK), 10-5 (36 GBd 4ASK), and 4 × 10-3 (64 GBd 4ASK) at room temperature. At 80 °C, the respective bit error ratios are 10-10, 10-4, and 1.3 × 10-2. The high-temperature experiments were performed in regular oxygen-rich ambient atmosphere.

Common and differential alterations of general emotion processing in obsessive-compulsive and social anxiety disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) and social anxiety disorder (SAD) are characterized by biased perception and processing of potentially threatening stimuli. A hyper-reactivity of the fear-circuit [e.g. amygdala, anterior cingulate (ACC)] has been consistently reported using functional magnetic resonance imaging (fMRI) in SAD in comparison with healthy controls (HCs). Studies investigating the processing of specific emotional stimuli in OCD reported mainly orbitofrontal-striatal abnormalities. The goal of this study was to examine similar/common and differential neurobiological responses in OCD and SAD using unspecific emotional stimuli. METHOD: Fifty-four subjects participated: two groups (each n = 18) of outpatients with a current diagnosis of OCD or SAD, and 18 HCs. All subjects underwent fMRI while anticipating and perceiving unspecific visual stimuli with prior announced emotional valence (e.g. positive). RESULTS: Compared to HCs, the combined patient group showed increased activation in amygdala, caudate and prefrontal/orbitofrontal cortex while anticipating unspecific emotional stimuli. Caudate was more active in the combined patient group during perception. A comparison between the OCD and the SAD samples revealed increased amygdala and decreased rostral ACC activation in OCD patients during perception, but no differences in the anticipation phase. CONCLUSIONS: Overall, we could identify common fronto-subcortical hyper-reactivity in OCD and SAD while anticipating and perceiving unspecific emotional stimuli. While differential neurobiological responses between OCD and SAD when processing specific stimuli are evident from the literature, differences were less pronounced using unspecific stimuli. This could indicate a disturbance of emotion regulation common to both OCD and SAD.

Diffusion tensor imaging of the trigeminal nerve in patients with trigeminal neuralgia due to multiple sclerosis.

INTRODUCTION: Neurovascular compression (NVC) is the most common cause of trigeminal neuralgia (TN), leading to microstructural changes in the affected nerve detectable using diffusion tensor imaging (DTI). But TN may also emerge as a symptom of multiple sclerosis (MS). The aim of this study was to evaluate if patients with MS-related TN feature the same DTI characteristics as patients with TN caused by NVC. METHODS: Twelve patients with MS-related TN, 12 age-matched patients with NVC-related TN, and 12 healthy controls were included. Using 3T-DTI, mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated for each affected and contralateral trigeminal nerve in patients with MS and NVC-related TN as well as healthy controls. Furthermore, presence of NVC was evaluated for patients with TN. RESULTS: There was no significant difference concerning FA or ADC when comparing the affected and the non-affected sides in patients with MS. FA was significantly lower and ADC higher in patients with MS on the TN affected as well as on the non-affected side compared to the non-affected side of patients with idiopathic TN or healthy controls. Likewise, FA was significantly lower on the affected side compared to the non-affected side in patients with idiopathic TN or healthy controls. NVC was evident in 41.7/0% on the affected/contralateral side in MS patients and 100/8% in the patients with NVC-related TN. CONCLUSION: In patients with MS-related TN, DTI reveals microstructural changes within the trigeminal nerve not only on the affected side but also on the clinically non-affected side.

[Acute inpatient multimodal pain therapy and rehabilitation: Framework conditions, tasks and differentiated patient allocation]. / Akutstationäre multimodale Schmerztherapie und Rehabilitation: Rahmenbedingungen, Aufgaben und differenzierte Patientenzuweisung.

Multimodal pain treatment programs are widely accepted as the medical treatment standard in the management of patients with chronic pain syndromes. The concepts and treatment strategies are based on the biopsychosocial model of pain and programs for early restoration of function. Although this concept is primarily implemented in the curative field, i.e. in hospitals for the treatment of patients with chronic pain diseases, modified programs based on the International Classification of Functioning (ICF) can now also be found in rehabilitation clinics. Despite the assumed similarities, significant differences in, for example the aims of the therapy and relevant structural and process variables have to be kept in mind when allocating patients to a program as provided by a hospital or a rehabilitation clinic. The aim of this article is to present the framework structures of both treatment levels with respect to the implementation of multimodal pain therapy programs and to elucidate the differential diagnostic approach to the indications.

The DIEP flap breast reconstruction: Starting from scratch in a university hospital.

PURPOSE: The deep inferior epigastric perforator (DIEP) flap provides excellent results when performed by a trained surgical team. However, the beginning of the procedure is often complicated. To date, few authors have published their initial experiences. This study presents our team's experience using a DIEP flap in breast reconstruction. METHODS: From June 2008 until December 2013, the same leading operator performed 132 consecutive DIEP flaps. Breast reconstructions were immediate (n=18) or delayed (n=114), unilateral (n=110) or bilateral (n=11). The learning curve was assessed using the operating time, ischemic time, postoperative hospital stay, and complications. For statistical comparisons, unilateral reconstructions were divided into five chronologic groups of 22 consecutive DIEP flaps and two chronologic groups of 55 flaps. RESULTS: The average time of surgery was 291 min (range, 185-645) for unilateral breast reconstruction and 513 min (range, 400-790) for bilateral breast reconstruction. The global complication rate was 24.5%. In the unilateral series, the time of surgery decreased progressively from 415 min to 233 min (P=4.8×10(-8)). The mean postoperative hospital stay was reduced from 7.14 days to 6.32 days (P=0.042). The complications and flap failure rates had regular time distributions. Initially, the revision rate reached 50% for the first ten unilateral cases but decreased rapidly and remained steady at 6% for the following cases (P=0.0012). CONCLUSIONS: Our initial experience of DIEP flap breast reconstruction showed a significant improvement of surgical performances exceeding 50 cases, with a critical ten first case period.

Does closure of children's medical home impact their immunization coverage?

OBJECTIVES: Little is known about the impact closing a health care facility has on immunization coverage of children utilizing that facility as a medical home. The authors assessed the impact of closing a Medicaid managed care facility in Philadelphia on immunization coverage of children, primarily low income children from racial/ethnic minority groups, utilizing that facility for routine immunizations. STUDY DESIGN: Observational longitudinal cohort case study. METHODS: Eligible children were born 03/01/05-06/30/07, present in Philadelphia's immunization information system (IIS), and were active clients of the facility before it closed in September 2007. IIS-recorded immunization coverage at ages 5, 7, 13, 16 and 19 months through January 2009 was compared between clinic children age-eligible to receive specific vaccines before clinic closing (preclosure cohorts) and children not age-eligible to receive those vaccines prior to closing (postclosure cohorts). RESULTS: Of 630 eligible children, 99 (16%) had no additional IIS-recorded immunizations. Third dose DTaP vaccine coverage at age seven months among preclosure cohorts was 54.4% vs. 40.3% among postclosure cohorts [risk ratio 1.31 (1.15,1.49)]. Fourth dose DTaP coverage at 19 months was 65.9% vs. 57.7% [risk ratio 1.24 (1.08,1.42)]. MMR coverage at 16 months was 79.5% vs. 69.9% [risk ratio 1.47 (1.22, 1.76)]. Coverage for the 431331 vaccination series at 19 months was 63.8% vs. 53.8% [risk ratio 1.28 (1.12,1.88)]. CONCLUSIONS: Immunization coverage declined at key age milestones for active clients of a Medicaid managed care that closed as compared with preclosure cohorts of clients from the same facility. When a primary health care facility closes, efforts should be made to ensure that children who had received vaccinations at that facility quickly establish a new medical home.

[Multimodal pain therapy for treatment of chronic pain syndrome. Consensus paper of the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society on treatment contents]. / Multimodale Schmerztherapie für die Behandlung chronischer Schmerzsyndrome. Ein Konsensuspapier der Ad-hoc-Kommission Multimodale interdisziplinäre Schmerztherapie der Deutschen Schmerzgesellschaft zu den Behandlungsinhalten.

Multimodal pain management is a comprehensive treatment of complex chronic pain syndromes. In addition to medical therapy various other specialized therapeutic interventions based on the biopsychosocial model of pain origin and chronic pain development, are added. During the last few years treatment centers for chronic pain have been established throughout Germany. Multimodal pain management has been included in the official catalogue of the recognized medical procedures for day clinic units as well as for inpatient pain management. In daily practice there is, however, still a lack of clarity and of consistency about the components that multimodal pain management should contain. This is the reason for the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society to propose the following position paper that has been worked out in a multilevel and interdisciplinary consensus process. The paper describes the mandatory treatment measures in the four core disciplines of multimodal pain management, pain medicine, psychotherapy, exercise therapy including physiotherapy and assistant medical professions including nurses.