Experiences with remote interpreting tools in primary care settings: a qualitative evaluation of the implementation and usage of remote interpreting tools during a feasibility trial in Germany.

OBJECTIVE: This study aims to evaluate the usage and implementation of video remote (VR) interpreting and telephone remote (TR) interpreting in primary healthcare settings. DESIGN: This publication forms part of a larger three-pronged study in which we compared both remote interpreting modalities to each other and to a control group. This paper conveys the findings of the qualitative evaluation of the implementation and usage of both remote interpreting solutions. The quantitative evaluation of the 6-month intervention period (September 2018-February 2019) has been reported previously. After this period, we conducted focus groups with the healthcare professionals involved. The focus groups were recorded, transcribed verbatim and analysed using the structured qualitative content analysis. SETTING: We provided either VR or TR tools to 10 different primary healthcare practices (general medicine, gynaecology and paediatrics) in the city of Hamburg, Germany. PARTICIPANTS: Three physicians and two physician's assistants took part in the TR focus group. The VR focus group consisted of four physicians. RESULTS: The main topics identified were the importance of communication for diagnostic and therapeutic processes, previous solutions to language barriers, as well as advantages and disadvantages of the two remote interpreting solutions. Advantages included the possibility to adequately communicate with language discordant patients and the high quality of the interpreting. Disadvantages included the habituation time required for new technology as well as time constraints. CONCLUSION: Our evaluation found that these solutions were highly appreciated, if not considered indispensable, for the delivery of appropriate medical care to language-discordant patients. Differences between the two modalities were named and concrete suggestions for improvement were made. Policy-makers should consider providing VR or TR as an adequate and safe interpreting service alternative when professional in-person interpreters are not available or too expensive.

Remote interpreting in primary care settings: a feasibility trial in Germany.

BACKGROUND: Global migration trends have led to a more diverse population in health care services everywhere, which in turn has set off a paradigm shift away from medical paternalism toward more patient autonomy. Consequently, physicians need to provide a more precise patient-centred healthcare. Professional interpreting appears to play a crucial part in tackling the challenges of language barriers adequately. The aim of this study was to conduct process evaluation through the implementing of video remote interpreting (VR) and telephone remote interpreting (TR) within primary care facilities in the northern German metropolis of Hamburg. METHODS: We conducted a three-armed exploratory pilot trial, which compared VR to TR and to a control group (CG) in different primary care settings. We assessed feasibility of implementation, as well as the acceptance of interpreting tools among their users. In addition, we compared the quality of communication as perceived by patients and physicians, as well as the enabling of patient-centred medicine over all three study groups using quantitative questionnaires. RESULTS: 13 practices (7 GPs, 3 Gynaecologists, 3 Paediatricians) took part in this trial. 183 interpreting calls were documented, 178 physicians as well as 127 patients answered their respective questionnaires. The implementation of the VR- und TR-tools went smoothly and they were broadly accepted by their users. However, the tools were used significantly less often than we had anticipated. With regards to quantitative questionnaires, VR scored significantly better than the control group in terms of the perceived quality of communication by both, patients and physicians and enabled of patient-centred medicine. CONCLUSION: Our main findings were the discrepancy between the assumed high demand of professional interpreting solutions on the one hand and the low willingness of practices to participate on the other. The rather low utilisation rates were also noteworthy. This discrepancy indicates a lack of awareness concerning the adverse effects of using informal or no interpreter in medical settings, which needs to be rectified. Due to the small sample size, all statistical results must be viewed with caution. However, our results show that remote interpreting represents a promising approach to tackling language barriers in primary care settings.

Comparing susceptibility and contagiousness in concurrent outbreaks with a non-VOC and the VOC SARS-CoV-2 variant B.1.1.7 in daycare centers in Hamburg, Germany.

We describe two outbreaks of SARS-CoV-2 in daycare centers in the metropolitan area of Hamburg, Germany. The outbreaks occurred in rapid chronological succession, in neighborhoods with a very similar sociodemographic structure, thus allowing for cross-comparison of these events. We combined classical and molecular epidemiologic investigation methods to study infection entry, spread within the facilities, and subsequent transmission of infections to households. Epidemiologic and molecular evidence suggests a superspreading event with a non-variant of concern (non-VOC) SARS CoV-2 strain at the root of the first outbreak. The second outbreak involved two childcare facilities experiencing infection activity with the variant of concern (VOC) B.1.1.7 (Alpha). We show that the index cases in all outbreaks had been childcare workers, and that children contributed substantially to secondary transmission of SARS-CoV-2 infection from childcare facilities to households. The frequency of secondary transmissions in households originating from B.1.1.7-infected children was increased compared to children with non-VOC infections. Self-reported symptoms, particularly cough and rhinitis, occurred more frequently in B.1.1.7-infected children. Especially in light of the rapidly spreading VOC B.1.617.2 (Delta), our data underline the notion that rigorous SARS-CoV-2 testing in combination with screening of contacts regardless of symptoms is an important measure to prevent SARS-CoV-2 infection of unvaccinated individuals in daycare centers and associated households.

[Healthcare provision for asylum seekers in reception centres : Qualitative survey from the perspective of healthcare providers]. / Medizinische Versorgung von Asylsuchenden in Erstaufnahmeeinrichtungen : Eine qualitative Bestandsaufnahme aus Versorgungsperspektive.

During the time of increased in-migration of asylum seekers to Germany in 2015 and 2016, different models of healthcare provision were established in reception centres, often on an ad hoc basis and influenced by local actors. The goal of this study was to map different care models and identify challenges in the implementation of effective and needs-based health service structures.Data was generated through 13 semi-structured interviews and in an interactive workshop with group discussions. An analysis was conducted using a qualitative content analysis method. Participants were stakeholders from clinics in reception centres, including medical and healthcare personnel, administrators, representatives of public health offices and researchers.Different models of ambulatory care have formed as a response to the particular medical needs of asylum seekers and the complex context in which care takes place, often exceeding the simple offer of primary care. The facilities fundamentally differ with regard to objectives and organisational aspects, e.g. the responsible carrier, structure of human resources and the extent of health services provided. Shared challenges include planning needs-based care, the lack of shared guidelines and a lack of opportunities for exchange between the different actors working in the clinics. Action is required to transform ad hoc initiatives into resilient health care practices, particularly regarding structured and continued opportunities for exchange, as well as the development and implementation of nation-wide guidelines. Jointly developed areas for action and proposed solutions presented here can serve as a basis for further work in this area.

Referrals to secondary care in an outpatient primary care walk-in clinic for refugees in Germany: results from a secondary data analysis based on electronic medical records.

OBJECTIVES: The aims of our study were to describe the disease spectrum of refugees, to analyse to what extent their healthcare needs could be met in an outpatient primary care walk-in clinic and which cases required additional services from secondary care (ie, outpatient specialists or hospitals). DESIGN: Retrospective longitudinal observational study. SETTING: The study was based on routine data from a walk-in clinic in the largest central first reception centre in Hamburg, Germany between 4 November 2015 and 21 July 2016. PARTICIPANTS: 1467 asylum seekers with 4006 episodes of care (ie, distinctive health problems) resulting in 5545 consultations. The patients were 60% men and had a mean age of 23.2 years. About 90% of the patients were from Central Asia or from the Middle East and North Africa. PRIMARY AND SECONDARY OUTCOME MEASURES: The endpoint of our analyses was referral to secondary care. Time to event was defined as days under treatment until the first referral. Predictor variables were the patients' diagnoses grouped in 46 categories. The data set was analysed by Cox regression allowing for multiple failure times per patient. This analysis was adjusted for age, sex and country of origin. RESULTS: Referrals to secondary care occurred in 15.5% of the episodes. The diagnosis groups with the highest referral rates were 'eye' (HR 4.9; 95% CI 3.12 to 7.8; p≤0.001), 'teeth/gum symptom/complaint or disease' (3.51; 2.52 to 4.9; p≤0.001) and 'urological system/female or male genital' (2.50; 1.66 to 3.77; p≤0.001). Age, sex and country of origin had no significant effect on time until referral. CONCLUSIONS: In most cases, the walk-in clinic physicians could provide first-line medical care for the health problems of patients not integrated in the German healthcare system. Additional resources were needed particularly not only for visual impairment and dental problems but also for psychological disorders, antenatal care and certain infections and injuries.

Feedback in medical education - a workshop report with practical examples and recommendations.

Background: As a teaching method, feedback is an integral part of medical education. However, there is a lack of a uniform theoretical basis or generally recognized guidelines for its specific design. Against this background, the aim of this article is to discuss conceptual considerations and empirical findings regarding feedback using various practical examples. Procedure and conceptual considerations: Building on the results of a workshop of the Committee for Communicative and Social Competences of the Society for Medical Education (GMA), this article first explains central conceptual considerations and empirical results on the topic of feedback. A particular focus is on various variables that influence the effect of feedback. This includes the feedback source, the frequency of feedback, starting points of feedback, the connection between feedback and reflection as well as the motivation and meta-cognitive skills of the feedback recipient. Practical examples: The implementation of feedback in practice is illustrated using eight examples from the field of medical and dental education. They stem from various settings and the focus is on formative oral feedback. It will become evident that the focus is more on the givers of feedback than the recipients of feedback. Instructions for recipients of feedback on how to reflect on it is still the exception. Discussion: Many of the relevant aspects for the effect of feedback described in the literature are already taken into account in the practical examples discussed. In conclusion, seven recommendations are made for implementing feedback in practice.

Episodes of care in a primary care walk-in clinic at a refugee camp in Germany - a retrospective data analysis.

BACKGROUND: From 2015 to 2016 Germany faced an influx of 1.16 million asylum seekers. In the state of Hamburg Primary Care walk-in clinics (PCWC) were commissioned at refugee camps because the high number of residents (57,000 individuals) could not be provided with access to regular healthcare services. Our study aims were (1) to describe the utilization of a PCWC by camp residents, (2) to compare episodes of continuous care with shorter care episodes and (3) to analyse which diagnoses predict episodes of continuous care in this setting. METHODS: A retrospective longitudinal observational study was conducted by reviewing all anonymized electronic medical records of a PCWC that operated from 4th November 2015 to 22nd July 2016 at a refugee camp in Hamburg. Episodes of care (EOC) were extracted based on the international classification of primary care-2nd edition (ICPC-2). Outcome parameters were episode duration, principal diagnoses, and medical procedures. RESULTS: We analysed 5547 consultations of 1467 patients and extracted 4006 EOC. Mean patient age was 22.7 ± 14.8 years, 37.3% were female. Most common diagnoses were infections (44.7%), non-communicable diseases (22.2%), non-definitive diagnoses describing symptoms (22.0%), and injuries (5.7%). Most patients (52.4%) had only single encounters, whereas 19.8% had at least one EOC with a duration of ≥ 28 days (defined as continuous care). Several procedures were more prevalent in EOC with continuous care: Blood tests (5.2 times higher), administrative procedures (4.3), imaging (3.1) and referrals to secondary care providers (3.0). Twenty prevalent ICPC-2-diagnosis groups were associated with continuous care. The strongest associations were endocrine/metabolic system and nutritional disorders (hazard ratio 5.538, p < 0.001), dermatitis/atopic eczema (4.279, p < 0.001) and psychological disorders (4.056, p < 0.001). CONCLUSION: A wide spectrum of acute and chronic health conditions could be treated at a GP-led PCWC with few referrals or use of medical resources. But we also observed episodes of continuous care with more use of medical resources and referrals. Therefore, we conclude that principles of primary care like continuity of care, coordination of care and management of symptomatic complaints could complement future healthcare concepts for refugee camps.

Study protocol for a randomised controlled trial evaluating an evidence-based, stepped and coordinated care service model for mental disorders (RECOVER).

INTRODUCTION: Healthcare systems around the world are looking for solutions to the growing problem of mental disorders. RECOVER is the synonym for an evidence-based, stepped and cross-sectoral coordinated care service model for mental disorders. RECOVER implements a cross-sectoral network with managed care, comprehensive psychological, somatic and social diagnostics, crisis resolution and a general structure of four severity levels, each with assigned evidence-based therapy models (eg, assertive community treatment) and therapies (eg, psychotherapy). The study rationale is the investigation of the effectiveness and efficiency of stepped and integrated care in comparison to standard care. METHODS AND ANALYSIS: The trial is conducted in accordance to the Standard Protocol Items: Recommendations for Interventional Trials Statement. The study aims to compare the RECOVER model with treatment as usual (TAU). The following questions are examined: Does RECOVER reduce healthcare costs compared with TAU? Does RECOVER improve patient-relevant outcomes? Is RECOVER cost-effective compared with TAU? A total sample of 890 patients with mental disorders will be assessed at baseline and individually randomised into RECOVER or TAU. Follow-up assessments are conducted after 6 and 12 months. As primary outcomes, cost reduction, improvement in symptoms, daily functioning and quality of life as well as cost-effectiveness ratios will be measured. In addition, several secondary outcomes will be assessed. Primary and secondary outcomes are evaluated according to the intention-to-treat principle. Mixed linear or logistic regression models are used with the direct maximum likelihood estimation procedure which results in unbiassed estimators under the missing-at-random assumption. Costs due to healthcare utilisation and productivity losses are evaluated using difference-in-difference regressions. ETHICS AND DISSEMINATION: Ethical approval from the ethics committee of the Hamburg Medical Association has been obtained (PV5672). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications. TRIAL REGISTRATION NUMBER AND REGISTRY NAME: ClinicalTrials.gov (NCT03459664), RECOVER PROTOCOL VERSION: 19 March 2020 (V.3.0).

[Scope of Initial Examinations of Unaccompanied Minor Foreigners: A Nationwide Population Survey]. / Umfang der Erstuntersuchungen bei unbegleiteten minderjährigen Ausländern: eine bundesweite Bestandsaufnahme.

BACKGROUND: When unaccompanied minors (UMA) are taken into provisional care by the youth welfare offices, it is legally obligatory to carry out an initial medical examination and obtain a statement as to whether the state of health of minors excludes the implementation of the distribution procedure according to the Königsberg Key and, in the case of 15-year-olds and non-pregnant persons, an X-ray thorax scan to exclude infectious tuberculosis of the lungs. The supreme state health authorities of the German federal states determine the further scope of the investigations. The aim of this nationwide survey is a comparison of the different concepts of the individual states with regard to the scope of the initial UMA investigations. METHODS: Between September 2016 and May 2018, a survey on the scope of the UMA initial investigations was conducted by e-mail with official contact persons. At the same time, a web-based search of the websites of the supreme health authorities of the federal states for official statements was carried out. RESULTS: In the areas of TB screening of under 15-year-olds and pregnant women as well as screenings for other diseases, the picture across Germany was sometimes very mixed. There was agreement above all in the recommendations for vaccination. CONCLUSION: Efforts to harmonise the scope of the investigation at the federal level should be pursued further.

Implementation of "social and communicative competencies" in medical education. The importance of curriculum, organisational and human resource development.

OBJECTIVE: With this article we want to support teachers and curriculum planners to be aware of and apply knowledge and recommendations of organisational (OD), curriculums (CD) and human resource development (HRD) ideas already in the planning phase of a project. Taking these into account can influence the process of change successfully and controlled during the introduction and establishment of curricula in the field of communication and social skills in medical education. APPROACH AND RESULTS: In the context of a multi-stage developmental process, a recommendation on CD for "Communicative and social competencies" was developed. The basis for it was made during two workshops of the GMA-committee "Communicative and social competencies" and supplemented by the available literature and the experience of communication experts. The "Undeloher Recommendation" (see attachment ) includes a compilation of recommendations and guiding questions, which is geared to the various phases of CD. Additionally, general approaches and recommendations of organisational and human resource development were integrated, which turned out to be particularly relevant in the process of CD. Thus, the "Undeloher recommendation" includes an orientation for each phase of the curriculum development process, the organisation and the staff in order to successfully implement a longitudinal curriculum. In addition to theoretical models the long-term discussion process and the personal experiences of a variety of curriculum planners and teachers have been integrated. CONCLUSION: The "Undeloher recommendation" can support the implementation processes of curricula in communication and social skills during development and realisation. Its application was reviewed in the context of workshops based on concrete examples. The participating teachers and curriculum planners assessed it to be very helpful. The recommendation goes beyond of what has been described in terms of content models in the CD so fare. In particular, the organisational and human resource development related aspects such as the formation of a steering committee and recommendations for the phase of sustainability.

Communication and social competencies in medical education in German-speaking countries: the Basel consensus statement. Results of a Delphi survey.

OBJECTIVE: To propose a comprehensive set of competencies and educational objectives for communication and social competencies in undergraduate medical education and to support the nationwide implementation of these issues in all medical schools. METHODS: Thirty experts from different medical and psychosocial disciplines participated in a 2-day workshop using the Nominal Group Technique (NGT) to develop an initial set of educational objectives. These were refined, structured, and rated according to their importance by means of a two-step Delphi Survey involving additional experts in medical education. RESULTS: The initial workshop resulted in 188 educational objectives assigned to 26 different topics. After the Delphi Survey, 131 objectives remained, assigned to 19 different topics. Some objectives that could be assigned to more than one topic were subsumed under a new more general category. CONCLUSION: The described consensus process proved successful as one method to develop a set of educational objectives. PRACTICAL IMPLICATIONS: The Basel consensus statement can be used to orientate curriculum reform and development in medical education.

Medical students' attitudes towards science and involvement in research activities: a comparative study with students from a reformed and a traditional curriculum.

BACKGROUND AND AIMS: Little is known about medical students' attitudes towards science and scientific methodology. We aimed to evaluate these attitudes and students' involvement in research activities. METHODS: Cross-sectional study comparing fifth-year medical students from the reformed and the traditional curriculum of the Charité University Medical Centre Berlin, Germany. Students filled out a standardised questionnaire containing three domains: research project for a dissertation; self-reported behaviour, knowledge/attitudes towards evidence-based medicine (EBM) and scientific methodology; and attitudes towards science. RESULTS: Two-thirds of the students had already started research for their dissertation and 70% agreed that reading articles and conducting research was challenging. Reformed curriculum students showed a higher involvement in scientific activities and felt more secure about their own scientific competencies. The odds for involvement in different research activities were significantly higher (odds ratios from 1.8 to 2.4) for students who agreed that 'science enables medical progress' or who felt 'secure in understanding medical articles and statistics' compared with students without these attitudes. CONCLUSION: The general attitude towards science and scientific methodology was positive among students from both the traditional and the reformed medical curriculum. Specific attitudes predicted involvement in research activities; however, they should be examined in other settings and student populations.

Anticancer agents are potent neurotoxins in vitro and in vivo.

Neurotoxicity of anticancer agents complicates treatment of children with cancer. We investigated neurotoxic effects of common cytotoxic drugs in neuronal cultures and in the developing rat brain. When neurons were exposed to cisplatin (5-100 microM), cyclophosphamide (5-100 microM), methotrexate (5-100 microM), vinblastin (0.1-1 microM), or thiotepa (5-100 microM), a concentration-dependent neurotoxic effect was observed. Neurotoxicity was potentiated by nontoxic glutamate concentrations. The N-methyl-D-aspartate receptor antagonist MK 801 (10 microM), the AMPA receptor antagonists GYKI 52466 (10 microM) and NBQX (10 microM), and the pancaspase inhibitor Ac-DEVD-CHO (1 nM) ameliorated neurotoxicity of cytotoxic drugs. To investigate neurotoxicity in vivo, we administered to 7-day-old rats the following: cisplatin (5-15 mg/kg i.p.), cyclophosphamide (200-600 mg/kg i.p.), thiotepa (15-45 mg/kg), or ifosfamide (100-500 mg/kg) and their brains were analyzed at 4 to 24 hours. Cytotoxic drugs produced widespread lesions within cortex, thalamus, hippocampal dentate gyrus, and caudate nucleus in a dose-dependent fashion. Early histological analysis demonstrated dendritic swelling and relative preservation of axonal terminals, which are morphological features indicating excitotoxicity. After longer survival periods, degenerating neurons displayed morphological features consistent with active cell death. These results demonstrate that anticancer drugs are potent neurotoxins in vitro and in vivo; they activate excitotoxic mechanisms but also trigger active neuronal death.