Medicine in older age-perception and assessment of ageing processes by older people and medical and nursing professionals: study protocol for a qualitative focus group design (FOR TiMed_Life).

BACKGROUND: This study is conducted by a subproject of the DFG research group "Medicine, Time and the Good Life" FOR 5022 (FOR TiMed_Life) and investigates the care preferences of individuals of advanced age and the care priorities of medical and nursing professionals in times of increasing medical options and more complex decision-making processes, especially for elderly patients. We assume that the preference for or rejection of medical treatment is shaped by individual and social age patterns and by the awareness of the finiteness of life. Just like older people themselves, professionals are also influenced by societal images of age(ing) and associated notions of age-appropriate health. These concepts are subject to constant change, which means that what was considered to be a 'normal' symptom of older age 100 years ago is now treated medically as a disease. The aim of the study is to identify the underlying perceptions of ageing and their influence on medical decisions. METHODS: By means of semi-structured focus group discussions and supplementary individual interviews with older people and medical and nursing professionals, the subproject investigates the perception of ageing processes and the resulting care preferences and priorities of these three groups. The evaluation of the interview material is carried out in two stages: First, the recorded group discussions are pre-structured using knowledge mapping. Based on the mapping results, the interview passages are selected, transcribed, and analysed in detail based on qualitative content analysis. DISCUSSION: Because the nature of the research question is exploratory, qualitative methods provide a suitable approach. The mapping technique provides early initial results that are used by the other subprojects. Within the research group, the results of the interviews provide an empirical basis for ethical discourses on the influence of medicine on ideas of a good life, and in particular, on successful ageing. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00027076, 05/11/2021.

Ethical challenges in primary care: a focus group study with general practitioners, nurses and informal caregivers.

BACKGROUND: General practitioners (GPs), nurses and informal caregivers are often jointly involved in healthcare situations in which ethical issues play an important role. OBJECTIVES: To describe ethical problems from the perspective of these three groups and to investigate whether there is a common experience of ethical issues in primary care. METHODS: We conducted six focus groups with general practitioners, nurses and informal caregivers in Germany. We asked the participants to describe at least one experience of ethical problem in detail and documented the findings by an illustration software that visualized and structured the discussion. We used thematic analysis to identify ethical problems and to develop categories of ethical issues. RESULTS: Problems reported barely overlapped. GPs had to do mainly with uncertainty about the scope and limits of their responsibility for patients. Nurses were concerned about bureaucratic and other barriers to professional care and about dual loyalty if they had to consider the conflicting interests of patients and family members. They often felt powerless and unable to act according to their professional standards. Informal caregivers reported problems that resulted from role strain and being both a family member and a caregiver. GPs, nurses and informal caregivers sometimes perceived the other parties as a source of ethical problems. CONCLUSIONS: All parties may benefit from ethics support services, a rarity in German primary care so far. Furthermore, nurses' self-confidence towards GPs, demanding patients and family members has to be strengthened. Informal caregivers, the most vulnerable group, need more attendance and tailored support.

Interprofessional collaboration in nursing homes (interprof): development and piloting of measures to improve interprofessional collaboration and communication: a qualitative multicentre study.

BACKGROUND: Given both the increase of nursing home residents forecast and challenges of current interprofessional interactions, we developed and tested measures to improve collaboration and communication between nurses and general practitioners (GPs) in this setting. Our multicentre study has been funded by the German Federal Ministry of Education and Research (FK 01GY1124). METHODS: The measures were developed iteratively in a continuous process, which is the focus of this article. In part 1 "exploration of the situation", interviews were conducted with GPs, nurses, nursing home residents and their relatives focusing on interprofessional interactions and medical care. They were analysed qualitatively. Based on these results, in part 2 "development of measures to improve collaboration", ideas for improvement were developed in nine focus groups with GPs and nurses. These ideas were revisited in a final expert workshop. We analysed the focus groups and expert workshop using mind mapping methods, and finally drew up the compilation of measures. In an exploratory pilot study "study part 3" four nursing homes chose the measures they wanted to adopt. These were tested for three months. Feasibility and acceptance of the measures were evaluated via guideline interviews with the stakeholders which were analysed by content analyses. RESULTS: Six measures were generated: meetings to establish common goals, main contact person, standardised pro re nata medication, introduction of name badges, improved availability of nurse/GP and standardised scheduling/ procedure for nursing home visits. In the pilot study, the measures were implemented in four nursing homes. GPs and nurses reviewed five measures as feasible and acceptable, only the designation of a "main contact person" was not considered as an improvement. CONCLUSIONS: Six measures to improve collaboration and communication could be compiled in a multistep qualitative process respecting the perspectives of involved stakeholders. Five of the six measures were positively assessed in an exploratory pilot study. They could easily be transferred into the daily routine of other nursing homes, as no special models have to exist in advance. Impact of the measures on patient oriented outcomes should be examined in further research. TRIAL REGISTRATION: Not applicable.

Seminar program for postgraduate specialty training in general practice: proposal for a 5-year thematic catalogue.

Introduction: In different German regions, seminar programs have been conducted for General practice residents. In each region, selection and teaching of learning content is conducted in a different manner. So far, no structured, standardized curriculum has been implemented nationwide. We have investigated, if the development of a common 5-year program of learning topics is conceivable between the different university departments of General practice in Germany. Method: The seminar program working group of the DEGAM (German College of General Practitioners and Family Physicians) has conducted an online survey based on information gathered via preliminary telephone conference (n=7; physicians with postgraduate teaching experience) among all German university departments of General Practice and two non-university teaching institutions, identified via the internet. 884 topics were extracted from 14 Seminar programs. The topics were entered in a database, discussed and categorized: Practice management/practice work flow/standardized documentation forms/quality management (n=33 topics), common acute and chronic diseases, including disease management programs (n=29 topics), communication, neurological, psychological and psychiatric consultations (n=24 topics), common medical problems, including eye, ear, nose, throat, skin and pediatric problems (n=99 Topics) family physicians general approach, including epidemiology, shared decision making, test of time (n=42 Topics). These topics have been rated for priority and desirable number of teaching-units. Results: A catalogue of 111 topics was designed, encompassing 160 teaching units. There is a suggestion of wide topics collections plus an add-on catalogue. Conclusion: A proposal for a 5-year-thematic catalogue for postgraduate training of general practice residents in Germany has been developed. This newly developed curriculum has the potential to improve knowledge and skills that have not been covered during in-house and ambulatory general practice residencies.

Reaching the Elderly: Understanding of health and preventive experiences for a tailored approach - Results of a qualitative study.

BACKGROUND: Often preventive measures are not accessed by the people who were intended to be reached. Programs for older adults may target men and women, older adults, advanced old age groups and/or chronically ill patients with specific indications. The defined target groups rarely participate in the conception of programs or in the design of information materials, although this would increase accessibility and participation. In the German "Reaching the Elderly" study (2008-2011), an approach to motivating older adults to participate in a preventive home visit (PHV) program was modified with the participatory involvement of the target groups. The study examines how older men and women would prefer to be addressed for health and prevention programs. METHODS: Four focus groups (N = 42 participants) and 12 personal interviews were conducted (women and men in 2 age groups: 65-75 years and ≥ 76 years). Participants from two districts of a major German city were selected from a stratified random sample (N = 200) based on routine data from a local health insurance fund. The study focused on the participants' knowledge about health and disease prevention and how they preferred to be approached and addressed. Videos of the focus groups were recorded and analysed using mind mapping techniques. Interviews were digitally recorded, transcribed verbatim and subjected to qualitative content analysis. RESULTS: A gender-specific approach profile was observed. Men were more likely to favor competitive and exercise-oriented activities, and they associated healthy aging with mobility and physical activity. Women, on the other hand, displayed a broader understanding of healthy aging, which included physical activity as only one aspect as well as a healthy diet, relaxation/wellness, memory training and independent living; they preferred holistic and socially oriented services that were not performance-oriented. The "older seniors" (76+) were ambivalent towards certain wordings referring to aging. CONCLUSIONS: Our results suggest that gender-specific needs must be considered in order to motivate older adults to participate in preventive services. Age-specific characteristics seem to be less relevant. It is more important to pay attention to factors that vary according to the individual state of health and life situation of the potential participants.

Polymorphisms of the toll-like receptor 2 and 4 genes are associated with faster progression and a more severe course of sepsis in critically ill patients.

OBJECTIVE: To determine whether the Arg753Gln polymorphism of the toll-like receptor 2 (TLR2) gene and the Asp299Gly polymorphism of the TLR4 gene in critically ill patients affect their clinical outcomes. METHODS: Medical and surgical patients in three intensive care units (ICU) were enrolled in this prospective study. TLR2 and TLR4 gene polymorphisms were determined using restriction fragment length polymorphism analysis. RESULTS: A total of 145 patients were included in this study: 28 patients carried heterozygous mutations (10 in the TLR2 gene, 19 in the TLR4 gene, and one combined) and 117 patients were wild type. Severe sepsis was observed in 33% of wild types (n = 38), 60% of the TLR2 group (n = 6), and 63% of the TLR4 group (n = 12); the difference was significant between the TLR4 and wild type groups. Both TLR groups demonstrated a shorter time-to-onset of severe sepsis or septic shock. Only the TLR4 group demonstrated significant progression towards septic shock compared with the wild type group. Length of ICU stay was significantly prolonged in the TLR4 group compared with the wild type group, but not in the TLR2 group. CONCLUSIONS: Two common SNPs of the TLR2 and TLR4 genes--Arg753Gln and Asp299Gly--were associated with a shorter time-to-onset of severe sepsis or septic shock in patients admitted to the ICU.

Student perceptions of evaluation in undergraduate medical education: A qualitative study from one medical school.

BACKGROUND: Evaluation is an integral part of medical education. Despite a wide use of various evaluation tools, little is known about student perceptions regarding the purpose and desired consequences of evaluation. Such knowledge is important to facilitate interpretation of evaluation results. The aims of this study were to elicit student views on the purpose of evaluation, indicators of teaching quality, evaluation tools and possible consequences drawn from evaluation data. METHODS: This qualitative study involved 17 undergraduate medical students in Years 3 and 4 participating in 3 focus group interviews. Content analysis was conducted by two different researchers. RESULTS: Evaluation was viewed as a means to facilitate improvements within medical education. Teaching quality was believed to be dependent on content, process, teacher and student characteristics as well as learning outcome, with an emphasis on the latter. Students preferred online evaluations over paper-and-pencil forms and suggested circulating results among all faculty and students. Students strongly favoured the allocation of rewards and incentives for good teaching to individual teachers. CONCLUSIONS: In addition to assessing structural aspects of teaching, evaluation tools need to adequately address learning outcome. The use of reliable and valid evaluation methods is a prerequisite for resource allocation to individual teachers based on evaluation results.

Views of German general practitioners on the clinical indicators of the British Quality and Outcomes Framework: a qualitative study.

BACKGROUND: The Quality and Outcomes Framework (QOF) has had a major impact on chronic care provision in British general practice. Various countries are looking at whether a similar initiative could be used in their primary care systems. An extensive quality indicator system like the QOF does not exist in German general practice. AIM: To describe and explore the views of German general practitioners (GPs) on the clinical indicators of the QOF. METHODS: Qualitative study based on focus group discussions and a framework approach for data analysis. Fifty-four German GPs were involved in seven focus groups in German primary care practices. RESULTS: German GPs expressed mixed views regarding the validity of the QOF clinical indicators to measure the quality of primary care. Most thought that these indicators covered areas that were relevant for German general practice and which were only partially covered by German quality initiatives. Participants had mixed opinions regarding linking pay and performance. Many thought that in deprived areas it would be difficult to achieve targets. Exception reporting would make achieving these targets easier, however, some believed it could lead to manipulation of figures. Many GPs saw QOF clinical indicators as a helpful structure, yet feared that introducing something similar would increase the administrative workload and be a threat to patient-centred care. Many participants were anxious that a QOF-like system could be influenced by sickness funds or the pharmaceutical industry. A few feared data protection problems if such a system were to be implemented. Several GPs expressed concerns on who would set and control such quality initiatives, feared for their autonomy and expected that in the future similar systems would be imposed upon them. CONCLUSIONS: Participating German GPs had various concerns regarding the QOF clinical indicators and the idea of implementing a system like the QOF in German primary care. These concerns were mainly related to the validity of the indicators, the link between pay and performance, structured care versus patient centredness and the fear of external influences.

A hierarchy of self-renewing tumor-initiating cell types in glioblastoma.

The neural stem cell marker CD133 is reported to identify cells within glioblastoma (GBM) that can initiate neurosphere growth and tumor formation; however, instances of CD133(-) cells exhibiting similar properties have also been reported. Here, we show that some PTEN-deficient GBM tumors produce a series of CD133(+) and CD133(-) self-renewing tumor-initiating cell types and provide evidence that these cell types constitute a lineage hierarchy. Our results show that the capacities for self-renewal and tumor initiation in GBM need not be restricted to a uniform population of stemlike cells, but can be shared by a lineage of self-renewing cell types expressing a range of markers of forebrain lineage.

Plant breeding on the front: imperialism, war, and exploitation.

This paper examines the development of plant-breeding science in the context of the booming genetic research and autarky policy of the 1930s as well as during World War II in National Socialist-occupied Europe. Soviet scientists, especially Nikolai Vavilov and his VIR institute, had a leading position in the international plant-breeding science of the 1920s. During World War II, German scientists, namely experts from the Kaiser Wilhelm Institute for Plant Breeding, usurped Soviet institutes and valuable seed collections. In contrast, plant-breeding research in occupied Scandinavia continued with relatively little disturbance. The paper compares behavior of German, Soviet, and Norwegian plant-breeding scientists under the Nazi regime.