Optimal Significance Levels and Sample Sizes for Signal Detection Methods Based on Non-constant Hazards.

BACKGROUND AND OBJECTIVES: Statistical methods for signal detection of adverse drug reactions (ADRs) in electronic health records (EHRs) need information about optimal significance levels and sample sizes to achieve sufficient power. Sauzet and Cornelius proposed tests for signal detection based on the hazard functions of Weibull type distributions (WSP tests) which use the time-to-event information available in EHRs. Optimal significance levels and sample sizes for the application of the WPS tests are derived. METHOD: A simulation study was performed with a range of scenarios for sample size, rate of event due (ADRs), and not due to the drug and random time to ADR occurrence. Based on the area under the curve of the receiver operating characteristic graph, we obtain optimal significance levels of the different WSP tests for the implementation in a hypothesis free signal detection setting and approximate sample sizes required to reach a power of 80% or 90%. RESULTS: The dWSP-pPWSP (combination of double WSP and power WSP) test with a significance level of 0.004 was recommended. Sample sizes needed for a power of 80% were found to start at 60 events for an ADR rate equal to the background rate of 0.1. The number of events required for a background rate of 0.05 and an ADR rate equal to a 20% increase of the background rate was 900. CONCLUSION: Based on this study, it is recommended to use the dWSP-pWSP test combination for signal detection with a significance level of 0.004 when the same test is applied to all adverse events not depending on rates.

Chronic disease onset and wellbeing development: longitudinal analysis and the role of healthcare access.

BACKGROUND: Experiencing the onset of a chronic disease is a serious health event impacting living conditions and wellbeing. Investigating wellbeing development and its predictors is crucial to understand how individuals adapt to chronic illnesses. This study (i) analyzed the impact of a chronic disease on wellbeing development, and (ii) explored spatial healthcare access as potential moderating factor. METHODS: Data were obtained from the German Socio-economic Panel, a nationally representative household survey. A prospective sample of 3847 individuals was identified for whom the onset of cancer, cardiopathy, diabetes or stroke was observed between 2008 and 2020. Mixed models using an interrupted time series approach were performed to identify immediate level changes and longitudinal trend changes in wellbeing (operationalized with health and life satisfaction) after disease onset. Further, spatial access to healthcare (operationalized by two-stage floating catchment area measures) as potential moderating factor was examined using interaction effects. RESULTS: Chronic disease onset had an immediate negative level impact on health and life satisfaction. For health satisfaction, a negative pre-onset wellbeing trend was offset (but not reversed). A small positive trend was observed for life satisfaction after disease onset. Spatial access to healthcare was not associated with the magnitude of wellbeing reduction at onset. CONCLUSIONS: Health and life satisfaction levels drop with the onset of a chronic disease with no recovery trend for health and little recovery for life satisfaction, implying persistently lower wellbeing levels after a chronic illness onset. Spatial access to healthcare does not affect the wellbeing change after disease onset.

Correction: Youth and healthcare workers' perspectives on the feasibility and acceptability of self-testing for HIV, Hepatitis and Syphilis among young people: Qualitative findings from a pilot study in Gaborone, Botswana.

[This corrects the article DOI: 10.1371/journal.pone.0288971.].

Gravity models for potential spatial healthcare access measurement: a systematic methodological review.

BACKGROUND: Quantifying spatial access to care-the interplay of accessibility and availability-is vital for healthcare planning and understanding implications of services (mal-)distribution. A plethora of methods aims to measure potential spatial access to healthcare services. The current study conducts a systematic review to identify and assess gravity model-type methods for spatial healthcare access measurement and to summarize the use of these measures in empirical research. METHODS: A two-step approach was used to identify (1) methodological studies that presented a novel gravity model for measuring spatial access to healthcare and (2) empirical studies that applied one of these methods in a healthcare context. The review was conducted according to the PRISMA guidelines. EMBASE, CINAHL, Web of Science, and Scopus were searched in the first step. Forward citation search was used in the second step. RESULTS: We identified 43 studies presenting a methodological development and 346 empirical application cases of those methods in 309 studies. Two major conceptual developments emerged: The Two-Step Floating Catchment Area (2SFCA) method and the Kernel Density (KD) method. Virtually all other methodological developments evolved from the 2SFCA method, forming the 2SFCA method family. Novel methodologies within the 2SFCA family introduced developments regarding distance decay within the catchment area, variable catchment area sizes, outcome unit, provider competition, local and global distance decay, subgroup-specific access, multiple transportation modes, and time-dependent access. Methodological developments aimed to either approximate reality, fit a specific context, or correct methodology. Empirical studies almost exclusively applied methods from the 2SFCA family while other gravity model types were applied rarely. Distance decay within catchment areas was frequently implemented in application studies, however, the initial 2SFCA method remains common in empirical research. Most empirical studies used the spatial access measure for descriptive purposes. Increasingly, gravity model measures also served as potential explanatory factor for health outcomes. CONCLUSIONS: Gravity models for measuring potential spatial healthcare access are almost exclusively dominated by the family of 2SFCA methods-both for methodological developments and applications in empirical research. While methodological developments incorporate increasing methodological complexity, research practice largely applies gravity models with straightforward intuition and moderate data and computational requirements.

[Self-help measures as determinants of emergency department utilization among people with and without a migration history in Germany]. / Selbsthilfemaßnahmen als Determinanten der Inanspruchnahme einer Notfallambulanz bei Menschen mit und ohne Migrationsgeschichte in Deutschland.

INTRODUCTION: We analyzed whether there were differences between people with and without migration history in their implementation of self-help measures before they accessed the services of an emergency department and if there was an association between self-help measures and an appropriate utilization of emergency departments. METHODS: The data basis of this secondary analysis is the EUMaR study, which was conducted from July 2018 to July 2019 and aimed to identify causes contributing to inappropriate and frequent use of emergency departments by migrants. Our study aimed to analyze the differences in self-help measures carried out by the population groups using several multiple logistic regressions. The association between self-help measures implemented and appropriate emergency department utilization was quantified using a multiple logistic regression as well as interactions. RESULTS: The odds of first-generation migrants visiting an emergency department on their own initiative (OR=1.28; 95% CI, 1.01-1.61) was high compared to people without migrant history. Furthermore, the odds of their doing something by themselves against their complaints (OR=0.70; 95% CI, 0.56-0.86) were low. The odds of appropriate utilization of emergency services by respondents who self-initiated a visit to an emergency department were lower (OR=0.41; 95% CI, 0.34-0.50). The odds of appropriate utilization of emergency department services by respondents who had previously measured vital signs (e. g., blood pressure) were higher (OR=1.28; 95% CI, 1.02-1.59). CONCLUSION: Barriers to the health care system as well as to general practitioners, medicines or medical aids among first-generation migrants could explain the increased odds of their visiting an emergency department on their own and the lower odds of their doing something by themselves about their complaints. A hypothesis of our study is that measuring vital signs may help to better assess individual health status.

Type of Refugee Accommodation and Health of Residents: A Cross-Sectional, Population-Based Cluster Analysis in South-West Germany.

Objectives: Few studies have assessed whether refugees' health is associated with accommodation characteristics. We aimed to devise a typology of refugee accommodation based on variables on the accommodation and its physical context before assessing its association with health in multivariate analyses. Methods: We performed a cluster analysis based on a hierarchal, agglomerative clustering algorithm using Euclidean Distance and Ward's method. We analysed accommodation clusters based on number of inhabitants, degree of housing deterioration, urbanity of location (urban/rural distinction), and remoteness (walking distance to shops, medical or administrative services). In total, we analysed health and accommodation data of 412 refugees and asylum seekers from 58 different accommodation facilities in the federal state of Baden-Württemberg in the south-west of Germany. Results: Accommodations with a moderate occupation, lowest levels of deterioration, and a central urban location showed the best health outcomes in terms of subjective general health status, depression, and generalized anxiety disorder (GAD). Associations were strongest for GAD and weakest for depression. Conclusion: Our findings inform policymakers on layout and location of refugee collective accommodation centres.

Impact of COVID-19-adapted guidelines using different airway management strategies on resuscitation quality in out-of-hospital-cardiac-arrest - a randomised manikin study.

BACKGROUND: Although airway management for paramedics has moved away from endotracheal intubation towards extraglottic airway devices in recent years, in the context of COVID-19, endotracheal intubation has seen a revival. Endotracheal intubation has been recommended again under the assumption that it provides better protection against aerosol liberation and infection risk for care providers than extraglottic airway devices accepting an increase in no-flow time and possibly worsen patient outcomes. METHODS: In this manikin study paramedics performed advanced cardiac life support with non-shockable (Non-VF) and shockable rhythms (VF) in four settings: ERC guidelines 2021 (control), COVID-19-guidelines using videolaryngoscopic intubation (COVID-19-intubation), laryngeal mask (COVID-19-Laryngeal-Mask) or a modified laryngeal mask modified with a shower cap (COVID-19-showercap) to reduce aerosol liberation simulated by a fog machine. Primary endpoint was no-flow-time, secondary endpoints included data on airway management as well as the participants' subjective assessment of aerosol release using a Likert-scale (0 = no release-10 = maximum release) were collected and statistically compared. Continuous Data was presented as mean ± standard deviation. Interval-scaled Data were presented as median and Q1 and Q3. RESULTS: A total of 120 resuscitation scenarios were completed. Compared to control (Non-VF:11 ± 3 s, VF:12 ± 3 s) application of COVID-19-adapted guidelines lead to prolonged no-flow times in all groups (COVID-19-Intubation: Non-VF:17 ± 11 s, VF:19 ± 5 s;p ≤ 0.001; COVID-19-laryngeal-mask: VF:15 ± 5 s,p ≤ 0.01; COVID-19-showercap: VF:15 ± 3 s,p ≤ 0.01). Compared to COVID-19-Intubation, the use of the laryngeal mask and its modification with a showercap both led to a reduction of no-flow-time(COVID-19-laryngeal-mask: Non-VF:p = 0.002;VF:p ≤ 0.001; COVID-19-Showercap: Non-VF:p ≤ 0.001;VF:p = 0.002) due to a reduced duration of intubation (COVID-19-Intubation: Non-VF:40 ± 19 s;VF:33 ± 17 s; both p ≤ 0.01 vs. control, COVID-19-Laryngeal-Mask (Non-VF:15 ± 7 s;VF:13 ± 5 s;p > 0.05) and COVID-19-Shower-cap (Non-VF:15 ± 5 s;VF:17 ± 5 s;p > 0.05). The participants rated aerosol liberation lowest in COVID-19-intubation (median:0;Q1:0,Q3:2;p < 0.001vs.COVID-19-laryngeal-mask and COVID-19-showercap) compared to COVID-19-shower-cap (median:3;Q1:1,Q3:3 p < 0.001vs.COVID-19-laryngeal-mask) or COVID-19-laryngeal-mask (median:9;Q1:6,Q3:8). CONCLUSIONS: COVID-19-adapted guidelines using videolaryngoscopic intubation lead to a prolongation of no-flow time. The use of a modified laryngeal mask with a shower cap seems to be a suitable compromise combining minimal impact on no-flowtime and reduced aerosol exposure for the involved providers.

Psychosocial Attributes of Housing and Their Relationship With Health Among Refugee and Asylum-Seeking Populations in High-Income Countries: Systematic Review.

Objectives: Housing as a social determinant of health should provide not only shelter, but also a feeling of home. We explored psychosocial pathways creating a sense of home and influencing the relationship between housing and health among asylum seekers and refugees (ASR) in high-income countries. Methods: We performed a systematic review. To be included, studies had to be peer-reviewed, published between 1995 and 2022, and focus on housing and health of ASR in high-income countries. We conducted a narrative synthesis. Results: 32 studies met the inclusion criteria. The psychosocial attributes influencing health most often identified were control, followed by expressing status, satisfaction, and demand. Most attributes overlap with material/physical attributes and have an impact on ASR's mental health. They are closely interconnected with each other. Conclusion: Psychosocial attributes of housing play an essential role in the health of ASR; they are closely associated with material/physical attributes. Therefore, future research on housing and health of ASR should routinely study psychosocial attributes, but always in association with physical ones. The connections between these attributes are complex and need to be further explored. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021239495.

Recurrent Respiratory Papillomatosis (RRP)-Meta-analyses on the use of the HPV vaccine as adjuvant therapy.

Recurrent Respiratory Papillomatosis(RRP) is a rare disease with severe morbidity. Treatment is surgical. Prevailing viewpoint is that prophylactic HPV vaccines do not have therapeutic benefit due to their modus operandi. Studies on HPV vaccination alongside surgery were meta-analysed to test effect on burden of disease. Databases were accessed Nov and Dec 2021 [PubMed, Cochrane, Embase and Web of Science]. Main outcome measured was: Mean paired differences in the number of surgeries or recurrences per month. Analyses was performed using: Random effect maximal likelihood estimation model using the Stata module Mataan(StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX:StataCorp LLC.) Our results found n = 38 patients, suitable for syntheses with one previous meta-analyses (4 published, 2 unpublished studies) n = 63, total of n = 101 patients. Analyses rendered an overall reduction of 0.123 recurrences or surgeries per month (95% confidence interval [0.064, 0.183]). Our meta-analyses concludes that HPV vaccine is a beneficial adjunct therapy alongside surgery.

AED delivery at night - Can drones do the Job? A feasibility study of unmanned aerial systems to transport automated external defibrillators during night-time.

BACKGROUND: In their recent guidelines the European Resuscitation Council have recommended the use of Unmanned Aerial systems (UAS) to overcome the notorious shortage of AED. Exploiting the full potential of airborne AED delivery would mandate 24 h UAS operability. However, current systems have not been evaluated for nighttime use. The primary goal of our study was to evaluate the feasibility of night-time AED delivery by UAS. The secondary goal was to obtain and compare operational and safety data of night versus day missions. METHODS: We scheduled two (one day, one night) flights each to ten different locations to assess the feasibility of AED delivery by UAS during night-time. We also compared operational data (mission timings) and safety data (incidence of critical events) of night versus day missions. RESULTS: All missions were completed without safety incident. The flights were performed automatically without pilot interventions, apart from manually choosing the landing site and correcting the descent. Flight distances ranged from 910 m to 6.960 m, corresponding mission times from alert to AED release between 3:48 min and 11:20 min. Night missions (T¯m:night = 7:26 ± 2:29 min) did not take longer than day missions (T¯m:day = 7:59 ± 2:27 min). Despite slightly inferior visibility of the target site, night landings (T¯land:night = 64 ± 15 sec) were on average marginally quicker than day landings (T¯land:day = 69 ± 11sec). CONCLUSIONS: Our results demonstrate the feasibility of UAS supported AED delivery during nighttime. Operational and safety data indicate no major differences between day- and night-time use. Future research should focus on integration of drone technology into the chain of survival.

Examining the role of affective states in relation to exercise intentions and participation in extra-curricular exercise classes at university: A repeated measurement observational study.

Background: Previous research has shown evidence on the role of affective states for physical activity behavior. However, there is a lack of research investigating the interplay between affective states, intentions, and exercise behavior, especially with respect to maintaining regular exercise over time. The study aimed to investigate whether post-exercise affective states and changes in affect during exercise (i) are related to exercise intentions; (ii) moderate the relationship between intention and subsequent exercise behavior, and (iii) directly predict future exercise. Methods: Participants from weekly voluntary sports and gym classes at two universities were recruited. For 13 weeks, 268 individuals' (M age = 24.5 years, SD = 5.6, 90% students, 67.4% female) class attendance was documented on a weekly basis. Before and immediately after training, participants self-reported affective states, including affective valence (Feeling Scale) and perceived arousal (Felt Arousal Scale). Participants also reported their intention to re-attend the class the following week. Mixed-effect linear models and Cox proportional hazard models were used to examine the relationships between affective states, change in affective states, re-attendance intentions, and class re-attention. Results: Affective valence at the end of training was significantly positively associated with the intention to re-attend the class on the within-person level (ß = 0.880, p < 0.001) as well as the between-person level (ß = 0.831, p < 0.001), while higher increases of valence during class were related to smaller intention. For class re-attendance, significant effects of affective states were only found on the within-person level. A one-point increase on the valence scale increased the hazard ratio to re-attend by 8.4% (p < 0.05), but this effect was no longer meaningful after adjusting for intention. No moderation of the relationship between intention and subsequent class re-attendance was found. Conclusion: The results suggest that positive affective state immediately after exercise does not facilitate translation of intentions into subsequent exercise behavior (i.e., do not close the intention-behavior gap). Rather, affective valence was found to be an important predictor of exercise intentions but seemed indirectly related to behavior via intentions. Practitioners should plan exercise programs that allow for positive affective states especially at the end of a training.

Generalised weibull model-based approaches to detect non-constant hazard to signal adverse drug reactions in longitudinal data.

Pharmacovigilance is the process of monitoring the emergence of harm from a medicine once it has been licensed and is in use. The aim is to identify new adverse drug reactions (ADRs) or changes in frequency of known ADRs. The last decade has seen increased interest for the use of electronic health records (EHRs) in pharmacovigilance. The causal mechanism of an ADR will often result in the occurrence being time dependent. We propose identifying signals for ADRs based on detecting a variation in hazard of an event using a time-to-event approach. Cornelius et al. proposed a method based on the Weibull Shape Parameter (WSP) and demonstrated this to have optimal performance for ADRs occurring shortly after taking treatment or delayed ADRs, and introduced censoring at varying time points to increase performance for intermediate ADRs. We now propose two new approaches which combined perform equally well across all time periods. The performance of this new approach is illustrated through an EHR Bisphosphonates dataset and a simulation study. One new approach is based on the power generalised Weibull distribution (pWSP) introduced by Bagdonavicius and Nikulin alongside an extended version of the WSP test, which includes one censored dataset resulting in improved detection across time period (dWSP). In the Bisphosphonates example, the pWSP and dWSP tests correctly signalled two known ADRs, and signal one adverse event for which no evidence of association with the drug exist. A combined test involving both pWSP and dWSP is reliable independently of the time of occurrence of ADRs.

Influence of appropriate emergency department utilization and verbal communication on physicians' (dis)satisfaction with doctor-patient interactions with special consideration of migrational backgrounds.

In recent years, utilization of emergency departments (EDs) has increased continuously, both in Germany and internationally. Inappropriate use of EDs is believed to be partly responsible for this trend. The topic of doctor-patient interaction (DPI) has received little attention in research. However, successful DPI is not only important for adherence and treatment success, but also for the satisfaction of medical staff. This non-interventionl cross-sectional study attempts to identify factors influencing physicians' satisfaction with DPIs, with a particular focus on the appropriate utilization of EDs and verbal communication. We carried out tripartite data collection in three EDs of major referral hospitals in Berlin between July 2017 and July 2018. Migration experience, communication and language problems, level of education, and a large gap between physicians' and patients' perceived urgency regarding the utilization of EDs influence the quality of the doctor-patient relationships and interactions.

[Is There a Association Between the Conditions in Accommodations and the Mental Health of Refugees in Germany? - A Cross-Sectional Study]. / Gibt es einen Zusammenhang zwischen der Zufriedenheit mit der Unterkunft und der psychischen Gesundheit Geflüchteter in Deutschland? ­ Eine Querschnittstudie.

BACKGROUND: Crowded conditions, noise and little privacy and other characteristics of refugee accommodations can have a negative impact on the mental health of the partially traumatized refugees. The study investigates, whether there are correlations between satisfaction with certain accommodation features in individual and shared accommodation and mental health. METHOD: We used the IAB-BAMF-SOEP survey from Germany 2016 (n=4491 refugees). Linear regression models are calculated to test the association between mental health and the type of accommodation (single accommodation/shared accommodation) and satisfaction with the accommodation (general satisfaction, satisfaction with food quality/noise level/privacy/leisure activities/access to public transport/security, german language courses). We adjust for sociodemographic factors, potentially traumatic experiences prior to arrival in Germany and postmigrant exposures (e. g. asylum status). RESULTS: Within the two accommodation types, there is high heterogeneity with respect to the characteristics examined. Refugees with poor mental health were significantly more likely to live in shared accommodation. When the above covariates were controlled for, the association disappeared. The other eight accommodation characteristics remained significantly associated with poorer mental health. The largest effects on mental health were observed for the satisfaction with safety, privacy, and general satisfaction. Here, the difference between persons who were barely satisfied compared with persons who were very satisfied amounted to 5-6 points on the SF-12 mental sum scale. CONCLUSION: International results on the relationship between accommodation conditions and mental health of refugees were confirmed for Germany. This results in an increased need for mental health services in subjectively worse housing. Questions about satisfaction (especially safety, privacy, and general satisfaction) are more suitable for identifying critical accommodations than the classification into single or shared accommodations, because shared accommodations were assessed very differently. Screening instruments can help identify problematic shelters. However, reverse causality cannot be conclusively ruled out.

Using agent-based modelling to test hypotheses on the role of neighbourhood social mechanisms in the development of small-area health inequalities.

BACKGROUND: Small-area health inequalities may originate from differentials in the spatial distribution of environmental stressors on health. The role played by neighbourhood social mechanisms on small-area health inequalities is difficult to evaluate. We demonstrate that agent-based modelling (ABM) is a useful technique to overcome existing limitations. It allows testing hypotheses that social contagion has the potential to modify the effects of environmental stressors by reducing or increasing small-area health inequalities. METHODS: Parameters defining the strength of the effect of social contagion on health behaviour were used together with a stochastic model to obtain for every year the health outcome of every agent based on health the previous year, environmental stressors and health behaviour. Unequal spatial distribution of stressors was operationalised with spatial correlation structure. We measured changes in health inequalities using parameters of the spatial correlation structure of health after 10 years. In a further round of simulations, social contagion depended on the environmental stressors. RESULTS: A social contagion mechanism led to a reduction of small-area health inequalities together with an increase in the spatial reach of the effect of environmental stressors. An association between environmental stressor and social contagion mechanism led to a stronger localisation of the effect of environmental stressors. CONCLUSIONS: Hypotheses about the role of neighbourhood social mechanisms can be tested using ABM. The respective models provide a better understanding of mechanisms in the causal chain between environmental stressors and health inequalities. This can pave the way to the development of a new type of neighbourhood-based intervention informed by social mechanisms.

Incidence, characteristics and predictors of mortality following cardiac arrest in ICUs of a German university hospital: A retrospective cohort study.

BACKGROUND: Cardiac arrest in intensive care is a rarely studied type of in-hospital cardiac arrest. OBJECTIVE: This study examines the incidence, characteristics, risk factors for mortality as well as long-term prognosis following cardiac arrest in intensive care. DESIGN: Retrospective cohort study. SETTING: Five noncardiac surgical ICUs (41 surgical and 37 medical beds) at a German university hospital between 2016 and 2019. PATIENTS: Adults experiencing cardiac arrest defined as the need for chest compressions and/or defibrillation occurring for the first time on the ICU. MAIN OUTCOME MEASURES: Primary endpoint: occurrence of cardiac-arrest in the ICU. Secondary endpoints: diagnostic and therapeutic measures; risk factors and marginal probabilities of no-return of spontaneous circulation; rates of return of spontaneous circulation, hospital discharge, 1-year-survival and 1-year-neurological outcome. RESULTS: A total of 114 cardiac arrests were observed out of 14 264 ICU admissions; incidence 0.8%; 95% confidence interval (CI) 0.7 to 1.0; 45.6% received at least one additional diagnostic test, such as blood gas analysis (36%), echocardiography (19.3%) or chest x-ray (9.9%) with a resulting change in therapy in 52%, (more frequently in those with a return of spontaneous circulation vs none, P  = 0.023). Risk factors for no-return of spontaneous circulation were cardiac comorbidities (OR 5.4; 95% CI, 1.4 to 20.7) and continuous renal replacement therapy (OR 5.9; 95% CI, 1.7 to 20.8). Bicarbonate levels greater than 21 mmol 1 were associated with a higher mortality risk in combination either with cardiac comorbid-ities (bicarbonate <21 mmol I-1: 13%; 21 to 26 mmolI-1 45%; >26mmolI-1:42%)orwithaSOFA at least 2 (bicarbonate <21 mmolI-1 8%; 21 to 26 mmolI-1: 40%; >26mmolI-1: 37%). "In-hospital mortality was 78.1% (n = 89); 1-year-survival-rate was 10.5% (95% CI, 5.5 to 17.7) and survival with a good neurological outcome was 6.1% (95% CI, 2.5 to 12.2). CONCLUSION: Cardiac arrest in ICU is a rare complication with a high mortality and low rate of good neurological outcome. The development of a structured approach to resuscitation should include all available resources of an ICU and adequately consider the complete diagnostic and therapeutic spectra as our results indicate that these are still underused. The development of prediction models of death should take into account cardiac and hepatic comorbidities, continuous renal replacement therapy, SOFA at least 2 before cardiac arrest and bicarbonate level. Further research should concentrate on identifying early predictors and on the prevention of cardiac arrest in ICU.

Association between housing and health of refugees and asylum seekers in Germany: explorative cluster and mixed model analysis.

BACKGROUND: Accommodation for asylum seekers and refugees (ASR) in Germany differs in many ways depending on a range of political, structural, social, and environmental factors. These contextual differences present a challenge for assessing health impacts of refugee accommodation. We aimed to devise a broad typology of refugee accommodation that allows to assess associations between housing and health of ASR. METHODS: We performed a cluster analysis of population-based, cross-sectional secondary data in Germany to identify clusters of refugee accommodation. We then assessed health disparities across clusters by performing bivariate analysis and linear mixed model regression analysis. RESULTS: We identified four clusters, three of them reflected different types of private accommodation and one pointed to collective accommodation. The collective accommodation cluster clearly differed from the private accommodation clusters in terms of space, area, level of restrictions, social connections and respondent satisfaction. Across private accommodation clusters we also found differences in space, area, and level of restrictions. In regression analysis, belonging to one of the private accommodation cluster was significantly associated with better mental health compared to belonging to the collective accommodation cluster. Physical health was significantly lower in one private accommodation cluster characterized by poor access to public transport and a higher level of restrictions compared to a private accommodation cluster showing better connections and a lower level of restrictions. CONCLUSION: We demonstrate that unfavourable conditions cluster in collective accommodation with negative outcomes for mental health but not for physical health. We also found health disparities across types of private accommodation. We conclude that housing plays a role in the production of health inequalities in ASR but needs to be assessed in a differentiated, multidimensional way.

Development of a gender score in a representative German population sample and its association with diverse social positions.

Background: Gender as a relational concept is rarely considered in epidemiology. However, an in-depth reflection on gender conceptualisation and operationalisation can advance gender analysis in quantitative health research, allowing for more valid evidence to support public health interventions. We constructed a context-specific gender score to assess how its discriminatory power differed in sub-groups defined by social positions relevant to intersectional analyses, i.e., sex/gender, race, class, age and sexual attraction. Methods: We created a gender score with the help of multivariable logistic regression models and conditional probabilities based on gendered social practices and expressed on a masculinity-femininity continuum, using data of the German Socioeconomic Panel. With density plots, we exploratively compared distributions of gendered social practices and their variation across social groups. Results: We included 13 gender-related variables to define a gender score in our sample (n = 20,767). Variables on family and household structures presented with the highest weight for the gender score. When comparing social groups, we saw that young individuals, those without children, not living with a partner or currently living in a same-sex/gender partnership, showed more overlap between feminine/masculine social practices among females and males. Conclusions: The distribution of gendered social practices differs among social groups, which empirically backs up the theoretical notion of gender being a context-specific construct. Economic participation and household structures remain essential drivers of heterogeneity in practices among women and men in most social positions. The gender score can be used in epidemiology to support concerted efforts to overcome these gender (in)equalities-which are important determinants of health inequalities.

Minimal clinically important difference in means in vulnerable populations: challenges and solutions.

INTRODUCTION AND MOTIVATION: Many health studies measure a continuous outcome and compare means between groups. Since means for biological data are often difficult to interpret clinically, it is common to dichotomise using a cut-point and present the 'percentage abnormal' alongside or in place of means. Examples include birthweight where 'abnormal' is defined as <2500 g (low birthweight), systolic blood pressure with abnormal defined as >140 mm Hg (high blood pressure) and lung function with varying definitions of the 'limit of normal'. In vulnerable populations with low means, for example, birthweight in a population of preterm babies, a given difference in means between two groups will represent a larger difference in the percentage with low birthweight than in a general population of babies where most will be full term. Thus, in general, the difference in percentage of patients with abnormal values for a given difference in means varies according to the reference population's mean value. This phenomenon leads to challenges in interpreting differences in means in vulnerable populations and in defining an outcome-specific minimal clinically important difference (MCID) in means since the proportion abnormal, which is useful in interpreting means, is not constant-it varies with the population mean. This has relevance for study power calculations and data analyses in vulnerable populations where a small observed difference in means may be difficult to interpret clinically and may be disregarded, even if associated with a relatively large difference in percentage abnormal which is clinically relevant. METHODS: To address these issues, we suggest both difference in means and difference in percentage (proportion) abnormal are considered when choosing the MCID, and that both means and percentages abnormal are reported when analysing the data. CONCLUSIONS: We describe a distributional approach to analyse proportions classified as abnormal that avoids the usual loss of precision and power associated with dichotomisation.

Impact of COVID-19-adapted guidelines on resuscitation quality in out-of-hospital-cardiac-arrest: a manikin study.

BACKGROUND: The aim of this study is to evaluate the effects of European Resuscitation Council (ERC) COVID-19-guidelines on resuscitation quality emphasizing advanced airway management in out-of-hospital-cardiac-arrest. METHODS: In a manikin study paramedics and emergency physicians performed advanced cardiac life support in three settings: ERC guidelines 2015 (control), COVID-19-guidelines as suggested with minimum staff (COVID-19-minimal-personnel); COVID-19-guidelines with paramedics and an emergency physician (COVID-19-advanced-airway-manager). Main outcome measures were no-flow-time, quality metrics as defined by ERC and time intervals to first chest compression, oxygen supply, intubation and first rhythm analysis. Data were presented as mean±standard deviation. RESULTS: Thirty resuscitation scenarios were completed. No-flow-time was markedly prolonged in COVID-19-minimal-personnel (113±37 s) compared to control (55±9 s) and COVID-19-advanced-airway-manager (76±38s; P<0.001 each). In both COVID-19-groups chest compressions started later (COVID-19-minimal-personnel: 32±6 s; COVID-19-advanced-airway-manager: 37±7 s; each P<0.001 vs. control [21±5 s]), but oxygen supply (COVID-19-minimal-personnel: 29±5 s; COVID-19-advanced-airway-manager: 34±7 s; each P<0.001 vs. control [77±19 s]) and first intubation attempt (COVID-19-minimal-personnel: 111±14 s; COVID-19-advanced-airway-manager: 131±20 s; each P<0.001 vs. control [178±44 s]) were performed earlier. However, time interval to successful intubation was similar (control: 198±48 s; COVID-19-minimal-personnel: 181±42 s; COVID-19-advanced-airway-manager: 130±25 s) due to a longer intubation time in COVID-19-minimal-personnel (61±35 s) compared to COVID-19-advanced-airway-manager (P=0.002) and control (19±6 s; P<0.001). Time to first rhythm analysis was more than doubled in COVID-19-minimal-personnel (138±96 s) compared to control (50±12 s; P<0.001). CONCLUSIONS: Delayed chest compressions and prolonged no-flow-time markedly reduced the quality of resuscitation. These negative effects were attenuated by increasing the number of staff and by adding an experienced airway manager. The use of endotracheal intubation for reducing aerosol release during resuscitation should be discussed critically as its priorization is associated with an increase in no-flow-time.