Assessing the implementation of a comprehensive quality management system for cross-sectoral psycho-oncology in Germany.

INTRODUCTION: Quality management in healthcare is essential for safe, effective, and patient-centered services. Quality management systems (QMS) monitor and improve healthcare quality. Integrating QMS is crucial for optimal quality of care, but previous studies show gaps in integration. This study aims to assess program adherence to a QMS in cross-sectoral psycho-oncological care and to develop strategies for better integration, ultimately improving healthcare quality. MATERIALS AND METHODS: The study used a utility analysis to assess the program adherence of a cross-sectoral psycho-oncology care program using a 5-point scale. The evaluation process involved breaking down the program into distinct areas, and used key figures and developed indicators to assess adherence. Descriptive statistics were used. RESULTS: The study conducted a comprehensive assessment of program adherence in a complex care program, analysing 4460 evaluation cases based on 128 quality indicators. The results showed a score of 4.2 out of 5 points (84%), indicating a highly effective implementation of the QMS. Notably, the study observed successful implementation of top-down elements, while encountering more challenges in integrating bottom-up aspects. CONCLUSION: The study demonstrates effective implementation of a comprehensive QMS. Successful integration was observed in areas such as care concept, care management, quality assurance, and IT-based documentation, while challenges remain in quality development and indicators. Active leadership involvement, staff training, data collection, and a learning culture are essential for successful implementation. Future research should assess the impact and cost-effectiveness of QMSs and develop tailored approaches to sustain healthcare professionals' motivation in quality improvement efforts.

[Experiences of older multimorbid persons during the COVID-19 pandemic: a qualitative study]. / Erfahrungen älterer, multimorbider Menschen in der COVID-19-Pandemie: eine qualitative Studie.

BACKGROUND/OBJECTIVE: The COVID-19 pandemic and the accompanying preventive measures have shaped social life in unexpected ways. Because older persons with multiple chronic conditions have a high risk of a severe medical outcome, it has been strongly recommended that social contacts be curtailed in order to minimize risks of infection. While this appears to be alarming from a psychosocial point of view, it has been shown that older persons exhibit a high degree of equanimity and a good ability to cope with the crisis. The aim of the study was to describe the attitudes of multimorbid older people to the pandemic, their social contacts and their experiences with medical care. MATERIAL AND METHODS: This cross-sectional qualitative survey was based on 21 semi-structured short interviews of older patients with multiple chronic conditions during inpatient health care, at 4 different points in time: July 2020, September 2020, November 2020 and January 2021. The data were analyzed by qualitative content analysis. RESULTS: The statements of 21 participants (aged 58-88 years) were assessed. Over the course of the COVID-19 pandemic it became apparent that participants experienced the pandemic differently, both from an individual perspective and over time. While high infection rates were accompanied by serious concerns about health, periods of moderate infection risk were dominated by worry about social changes. In older persons there was a great sense of acceptance of the preventive measures. CONCLUSION: Our study exemplarily illustrates the attitudes and concerns of older persons who suffer from multiple chronic conditions over the course of the pandemic. Our data show that older persons reacted with equanimity to the novel medical and social circumstances.

Assessing the perspective of well-being of older patients with multiple morbidities by using the LAVA tool - a person-centered approach.

BACKGROUND: Older patients with multiple morbidities are a particularly vulnerable population that is likely to face complex medical decisions at some time in their lives. A patient-centered medical care fosters the inclusion of the patients' perspectives, priorities, and complaints into clinical decision making. METHODS: This article presents a short and non-normative assessment tool to capture the priorities and problems of older patients. The so-called LAVA ("Life and Vitality Assessment") tool was developed for practical use in seniors in the general population and for residents in nursing homes in order to gain more knowledge about the patients themselves as well as to facilitate access to the patients. The LAVA tool conceptualizes well-being from the perspectives of older individuals themselves rather than from the perspectives of outside individuals. RESULTS: The LAVA tool is graphically presented and the assessment is explained in detail. Exemplarily, the outcomes of the assessments with the LAVA of three multimorbid older patients are presented and discussed. In each case, the assessment pointed out resources as well as at least one problem area, rated as very important by the patients themselves. CONCLUSIONS: The LAVA tool is a short, non-normative, and useful approach that encapsulates the perspectives of well-being of multimorbid patients and gives insights into their resources and problem areas.

Recovery from apraxic deficits and its neural correlate.

BACKGROUND AND OBJECTIVE: Apraxia is a deficit of motor cognition leading to difficulties in actual tool use, imitation of gestures, and pantomiming object use. To date, little data exist regarding the recovery from apraxic deficits after stroke, and no statistical lesion mapping study investigated the neural correlate of recovery from apraxia. Accordingly, we here examined recovery from apraxic deficits, differential associations of apraxia task (imitation vs. pantomime) and effector (bucco-facial vs. limb apraxia) with recovery, and the underlying neural correlates. METHODS: We assessed apraxia in 39 patients with left hemisphere (LH) stroke both at admission and approximately 11 days later. Furthermore, we collected clinical imaging data to identify brain regions associated with recovery from apraxic deficits using voxel-based lesion-symptom mapping (VLSM). RESULTS: Between the two assessments, a significant recovery from apraxic deficits was observed with a tendency of enhanced recovery of limb compared to bucco-facial apraxia. VLSM analyses revealed that within the lesion pattern initially associated with apraxia, lesions of the left insula were associated with remission of apraxic deficits, whereas lesions to the (inferior) parietal lobe (IPL; supramarginal and angular gyrus) and the superior longitudinal fasciculus (SLF) were associated with persistent apraxic deficits. CONCLUSIONS: Data suggest that lesions affecting the core regions (and white matter) of the fronto-parietal praxis network cause more persistent apraxic deficits than lesions affecting other regions (here: the left insula) that also contribute to motor cognition and apraxic deficits.

Factor VIII assay mimicking in vivo coagulation conditions.

Under certain circumstances, the determination of coagulation factor VIII (FVIII) is hampered by assay discrepancies between clotting and chromogenic approaches. These are observed in certain patients' plasma as well as in certain concentrates. We intended to develop a novel assay for the quantification of coagulation FVIII which reflects the physiological situation better than the established assays. It is based on plasma without chelation of divalent cations and simultaneously minimizes the generation of activated factors which could function as uncontrolled triggers of coagulation. FVIII deficient plasma is prepared with the aid of biotinylated antibodies against FVIII from normal plasma in presence of inhibitors of contact activation. To start the assay only tiny amounts of activated FIX serve as trigger. The FVIII determination is performed in a kinetic experiment and is based on the cleavage of a fluorogenic substrate for activated FX. FVIII concentrations between 0.01 and 1 IU mL(-1) are easily determined. Plasma-derived and recombinant FVIII concentrates were compared. All plasma-derived concentrates were found to contain FVIII activities within the specification of the manufacturer. Recombinant concentrates yielded only 35-50% of the claimed potency. The novel in vivo-like assay avoids the undue advantage or disadvantage of certain product characteristics by eliminating unphysiological assay conditions. Its usefulness could turn out in future experiments with plasma from haemophilia A patients.

A simple clinical model to estimate the probability of Marfan syndrome.

BACKGROUND: Marfan syndrome is a heritable connective tissue disease. Definitive diagnosis is complex, and requires sequencing of a large gene, FBN1. AIM: We aimed to develop a simple model to estimate the pre-test probability of Marfan syndrome. DESIGN: Prospective cross-sectional study. METHODS: We applied diagnostic standards for definitive diagnosis or exclusion of Marfan syndrome in 329 consecutive persons. In 208 persons with random assignment to our derivation group, we performed multivariate logistic regression to assess 14 clinical variables for inclusion in a prediction model with derivation of score points from the estimated coefficients. We created cut-offs to classify low, moderate and high probability of Marfan syndrome. For validation, we applied the model to the remaining 121 persons. RESULTS: We identified seven variables for inclusion in the final model, where we assigned four score points to ectopia lentis, two points to a family history of Marfan syndrome, and one point to previous thoracic aortic surgery, to pectus excavatum, to a wrist and thumb sign, to previous pneumothorax, and to skin striae. In the derivation group 12, 42 and 92% of persons with low (≤1 point), moderate (>1-3.5 points) or high pre-test probability (>3.5 points) had Marfan syndrome, compared to 12, 57 and 91%, respectively, in the validation group. Positive likelihood ratios were 13.96 and 8.54 in the high probability group of the derivation and validation group, respectively. CONCLUSION: A simple prediction model provides evidence for Marfan syndrome. This model can be used to identify patients who require definitive diagnostic work-up.

Validity of a swimming snorkel for metabolic testing.

Two models of a swimming snorkel connected to a portable metabolic cart (Cosmed K4 b2, Rome, Italy) were assessed using a gas exchange simulation system. Four standardized testing protocols were designed to mimic different swimming conditions and were performed similarly in three conditions so that both snorkels could be compared to measured values obtained by connecting the simulator directly with the gas analyzer. Simulated and measured values were highly correlated (R2 = 0.891 to 0.998) and in good agreement, with only a small overestimation of expiratory tidal volume (4 %, p = 0.005), not large enough to significantly affect the accuracy of ventilation or gas exchange parameters. Values measured using both swimming snorkels also highly correlated with simulated values, particularly for the ventilatory and primary gas exchange variables (R2 = 0.996 and 0.998 in both models for VO2 and VCO2, respectively). A moderate overestimation of FEO2 was observed in both models (2.65 % and 2.48 % relative, p = 0.03) and attributed to minimal mixing of inspiratory and expiratory gases, although not affecting VO2 measurements. We conclude that both snorkels are valid devices for measuring pulmonary breath-by-breath gas exchange parameters in connection with the K4 b2 across a wide physiological range.

Structuring psychosocial care in pediatric oncology.

The requirements for high quality psychosocial care for children with cancer and their families are steadily increasing. As an additional supplement to medical and nursing care, psychosocial work has to consider both the requirements of the medical treatment and the associated stress factors. It is essential to structure the different possibilities of intervention in a way which guarantees the practice of psychosocial care within the ongoing medical care. This requires a standardized psychosocial care manual. In July 1994, a 'Manual for Psychological Care in Pediatric Oncology' was put into practice and has been continually improved in the Department of Pediatric Hematology/Oncology of the University of Bonn. It contains special indications for different standards of psychosocial care, is oriented according to the phases and situations of medical treatment, and consists of a health education program as well as special care measurements. The latter are related to both the stressors primarily caused by the requirements of familial adherence to medical and nursing care and the stressors primarily caused by factors of the individual or the familial life circumstances. The theoretical basis of this manual and concrete information for its use are described in this paper.

[Psychological interventions for acute pain in childhood]. / Psychologische Interventionen bei akutem Schmerz im Kindesalter.

BACKGROUND: Pain sensation depends on individual anxiety and situational circumstances. It is attributed a psychological and social basis. In children, the sensation of pain generally exceeds its perception. ACUTE PAIN IN CHILDHOOD: Facing acute pain in childhood - especially during medical procedures -, interventions derived from behavioural medicine may help minimize the sensation of fear and pain as well as maximize the experience of internal control. But, it is impossible to totally eliminate acute pain that way. Although it is undisputed that children benefit from psychological intervention, in clinical practice its potential is largely underestimated. Factors with impact on the sensation of acute pain and resulting behavioural and coping strategies are presented. The psychological preparation for a painful medical procedure is demonstrated in detail as an example of a behavioural medicine derived procedure.

High sensitivity detection of activated factor IX: application to the analysis of different therapeutical factor IX concentrates and prothrombin complexes.

A very sensitive and highly reliable test system for the detection of activated coagulation factor IX (FIXa) has been established. This assay system is based on the cleavage of a fluorogenic substrate by activated factor X (FXa) which is generated by FIXa. This assay can be used to process a large number of samples at a time and, being based on the convenient microtiter plate format, can easily be adapted to automated processing for routine screening of large sample numbers. With this assay at hand we determined the FIXa content of different commercially available therapeutic FIX sources, such as high purity FIX (HPFIX) and prothrombin complex concentrates (PCC). Here we demonstrate that PCC from several suppliers do not contain significantly higher levels of FIXa as compared to HPFIX from the same supplier. In fact, there is a tendency for HPFIX to contain more FIXa than PCC. Moreover, HPFIX from certain manufacturers who do not produce PCC are characterized by an exceptionally high content of FIXa. Therefore, the higher thrombogenic potential of PCC which is well documented clinically cannot be explained solely -- if at all -- by an increased content of FIXa. Rather, it will be necessary to identify other components responsible for this phenomenon.

[Psychology of patient management: evaluation and quality assurance of psychosocial management in pediatric oncology]. / Versorgungspsychologie: Erprobung und Qualitätssicherung der psychosozialen Versorgung in der pädiatrischen Onkologie.

Since the introduction of health-care reform in Germany, quality assurance of inpatient care is required. In paediatric oncology this also includes quality assurance measures of psycho-social care. Care Psychology deals with the development, testing and continual improvement of high-quality psycho-social care. Based on clinical experience, scientific knowledge and ascertained requirements a handbook and manual of service delivery of psycho-social care is formulated and tested in everyday practice. Service performance analyses are carried out, and verified improvements are re-tested in practice. This, as well as additional attempts, should lead to total quality management (TQM) of psycho-social care in paediatric oncology according to the criteria of the European Foundation of Quality Management (EFQM).

[Differences in current state and at the beginning of cancer therapy and possible sequelae: a pilot study in pediatric oncology]. / Unterschiede im aktuellen Befinden zu Beginn der Krebstherapie und mögliche Folgen: eine Pilotstudie in der pädiatrischen Onkologie.

The psycho-social and medical care of families with a cancer sick child can be more effective if the team can identify those parents who need help most desperately from the very beginning. In a retrospective study of 20 patients and their families two groups of parents with different levels of stress could be seperated. Highly stressed parents demonstrated already at the time of diagnosis unfavorable coping strategies with the possibility of a cancer disease. They experience a high degree of guilt feelings and believe that they might be responsible for the occurrence of the disease. However they refuse more often than the other parents psycho-social help offered by the professionals. The results suggest to implement special kind of help for the more stressed families already in the early phase of diagnosis and treatment.

[Inpatient psychological management in pediatric oncology: the concept of liaison management]. / Stationäre psychologische Betreuung in der pädiatrischen Onkologie: Konzept einer behandlungsbegleitenden Versorgung.

Concepts for counseling and long term support have been the major interest in the psychosocial care of pediatric oncology patients and their families. Similar methods for psychosocial care on the ward are still rare. This paper presents the psychological care of the oncology patients during their stay on the ward, complimentary to the medical treatment. The concept is based on the process of coping with the phases and specific situations (L.P.; B.M.A.; diagnosis; medication ect.) of the cancer therapy. This process contains on the part of the patients and their parents the need for information, active involvement in treatment regimes and relaxation (before, during and after the stressful situation). The concepts of informed consent, adherence and recovery-counseling are related to the coping methods of the patients and their parents. The aims of our concept are to create and utilize diagnostic tests and psychological methods to enable the families to help themselves. To reach this goal, the technique of semantic and pragmatic information is very important because this kind of social communication helps us to make the medical implications of the treatment understandable and suitable for the patients and families.

[The quality of life of tumor patients as a multidimensional concept]. / Lebensqualität von Tumorkranken als multidimensionales Konzept.

An important aim of supportive care for cancer patients (pts) is the maintenance or improvement of their life quality. Therefore it is interesting to measure pts' LQ while testing new cytotoxic drugs or palliative therapy like artificial nutrition. A short questionnaire also is helpful in order to inform physicians and psychooncologists about pts' needs for psychosocial intervention. Based on coping-research, gerontology and well-being-psychology we have developed a 69-item-questionnaire "Scales for Measuring LQ" with good test-statistics. This instrument emphasizes pts' life experiences and subjective appraisal of objective life conditions. Basic state, internalized life experiences and life orientations in a sample of 179 pts with chemo- or radiotherapy are more important for LQ than objective symptoms, subjectively perceived physical condition and mood. The surprisingly high LQ scores in cancer pts can best be explained by their reduced aspiration levels. Correlations with emotional and belonging support obtained from the partner or confidant are significant. Social support is before all related to our pts' positive life experiences (.68; .59) and to their life satisfaction (.58; .47).

[The psychosocial questionnaire for pediatric oncology]. / Der Psycho-Soziale Fragebogen für die Pädiatrische Onkologie (PSFPO).

A concept based on empirical data is needed for psychological support of children with cancer and their families. A number of concepts are already available, but a psychological assessment is needed, which controls the feasibility of these concepts. The psychosocial questionnaire is such an assessment, which transforms individual data into the practical psychosocial work during the entire course of cancer treatment. The diagnostical procedure includes aspects of coping with cancer, such as stress, protective and risk factors and health behavior. Data are collected before, during and after the intensive cancer treatment and in a follow-up after 6 or 12 months respectively. The questionnaire has four parts. Each contains a "handbook for parents", which informs the parent in detail on each part. Thus, we enforce the potential of each parent to help him-/herself.

[Autistic children with mental handicap: differential etiologic, diagnostic, and therapy related principles]. / Autistische Kinder mit geistiger Behinderung: Differentialätiologische, -diagnostische und therapiebezogene Grundlagen.

Almost 70% of the autistic children are developmentally deviated and developmentally delayed too. There are still no sufficient diagnostical or intervation-oriented strategies recognizing this fact. Problems of diagnosis and developmental facilitation of autistic, developmental delayed children could be found in the field of unresolved questions of differential-aetiology and differential-diagnosis and of intervention-orientated assessment. This work is an attempt to develop some theoretical foundations and practical issues.