[Analysis of factors influencing outpatient paediatric antibiotic prescriptions in Bielefeld from 2015 to 2018]. / Analyse von Einflussfaktoren auf ambulante pädiatrische Antibiotikaverordnungen in Bielefeld 2015­2018.

BACKGROUND: There are significant regional differences in antibiotic prescribing behaviour. The reasons for this are still largely unknown. Beneath demographic and morbidity-related factors, doctor-specific or "cultural" factors may also play a role. A differentiated analysis including diagnostic data is needed to put these data into context. METHODS: A data analysis with secondary data available via the Westphalia-Lippe Association of Statutory Health Insurance Physicians (KVWL) was conducted on infection diagnoses and antibiotic prescriptions of outpatient paediatricians in the KV district of Bielefeld from 2015 to 2018. In addition, algorithmized 1:1 connections between diagnoses and prescriptions were performed. RESULTS: For 262,969 "medication patients" (AMP), 28,248 antibiotic prescriptions and 90,044 infection diagnoses were evaluated, from which 11,131 1:1 connections could be generated. Concerning the prescribing behaviour of individual paediatric GP offices, after adjusting for the denominator AMP and despite a comparable age and gender structure, there were some significant differences. This affected both the frequency of prescriptions and the qualitative composition of the substance groups prescribed. DISCUSSION: The differences in antibiotic prescribing behaviour, even at GP office level, cannot be adequately explained by the demographic composition or different morbidities of the respective clientele. Individual attitudes and local prescribing cultures are likely to play a relevant role. To address these offers an important approach for antibiotic stewardship (ABS). In addition to the area of outpatient paediatrics presented here, the methodology described can also be used as a model for more detailed analysis in other outpatient speciality groups.

Physicians' perspectives on family caregivers' roles in elderly cancer patients' therapies: a qualitative, interview-based study.

PURPOSE: Clinical communication and facilitating informed and sound medical decisions become challenging as patients age and suffer from age-associated impairments. Family caregivers are perceived as essential actors in addressing these challenges. Here, we explore physicians' perspectives on family caregivers' roles and their involvement in consultations and therapy decision-making situations of elderly cancer patients. METHODS: We examined 38 semi-structured interviews with physicians from different specialities (oncologists, non-oncology specialists, and general practitioners) in Germany who treated elderly cancer patients. Data were analyzed using reflexive thematic analysis. RESULTS: We identified five general and distinct perspectives on the involvement of family caregivers in the therapy process. Family caregivers are seen as (1) translators of medical information; (2) providers of support for the patient; (3) providers of information about the patient; (4) stakeholders with relevant points of view regarding the treatment decision; or (5) individuals who have a disruptive influence on the consultation. The interviewed physicians rarely involved family caregivers closely in consultations. CONCLUSIONS: Although physicians frequently attribute supportive roles to family caregivers, they rarely include them in consultations. Previous studies have found that a triadic setting is often better suited to agreeing upon a patient-centered and needs-based treatment decision for older cancer patients. We infer that physicians too rarely recognize the potential importance of family caregivers. Educators should further integrate family caregiver involvement and its implications in general medical education and professional training.

Comparison of Electron and Ion Emission from Xenon Cluster-Induced Ignition of Helium Nanodroplets.

The charging dynamics of helium droplets driven by embedded xenon cluster ignition in strong laser fields is studied by comparing the abundances of helium and highly charged Xe ions to the electron signal. Femtosecond pump-probe experiments show that near the optimal delay for highly charged xenon the electron yield increases, especially at low energies. The electron signature can be traced back to the ionization of the helium environment by Xe seed electrons. Accompanying molecular dynamics simulations suggest a two-step ionization scenario in the Xe-He core-shell system. In contrast to xenon, the experimental signal of the helium ions, as well as low-energy electron emission show a deviating delay dependence, indicating differences in the temporal and spacial development of the charge state distribution of Xe core and He surrounding. From the pump-probe dependence of the electron emission, effective temperatures can be extracted, indicating the nanoplasma decay.

Development of quality indicators to evaluate the quality of care for people with Differences of Sex Development (DSD).

Introduction Achieving evidence-based, high quality medical care is the overarching goal of healthcare quality management. Quality indicators (QI) serve as proxies to show whether good quality is reached or not. This article describes the development of QI for the evaluation of healthcare quality in the area of Differences of Sex Development (DSD). Methods Following the model of Donabedian, the aim was to develop QI to assess defined relevant aspects of the quality of structures, processes, and outcomes of care in DSD. Ten DSD clinical centres and two self-advocacy groups in Germany included in the DSDCare project were involved in the development of the QI and a benchmarking system. The development of the QI involved several structured steps: Analysis of guidelines and recommendations, literature review, qualitative interviews with key stakeholders in the field of DSD and patients or their carers. QI were discussed in a multi-stage systematic consensus process and assessed in terms of their relevance, feasibility, and practicability. Results In a multi-stage systematic consensus process involving medical and psychological experts from a range of disciplines, people with DSD and their families, and representatives of self-advocacy groups we have developed a set of 37 QI (22 structure, seven process, and eight outcome quality). The QI serve to evaluate care in the field of DSD and may add to the German criteria for certification of Centres for Rare Conditions formulated by the National Action League for People with Rare Diseases (NAMSE) in this area of expertise. Conclusion We have succeeded in developing and jointly adopting a set of quality indicators that consider a wide range of perspectives on the quality of care for people with DSD and their families. These QI have been found to be relevant, feasible and practicable and they are now used for a yearly quality benchmarking in the participating DSD centres.

Use of Metadata-Driven Approaches for Data Harmonization in the Medical Domain: Scoping Review.

BACKGROUND: Multisite clinical studies are increasingly using real-world data to gain real-world evidence. However, due to the heterogeneity of source data, it is difficult to analyze such data in a unified way across clinics. Therefore, the implementation of Extract-Transform-Load (ETL) or Extract-Load-Transform (ELT) processes for harmonizing local health data is necessary, in order to guarantee the data quality for research. However, the development of such processes is time-consuming and unsustainable. A promising way to ease this is the generalization of ETL/ELT processes. OBJECTIVE: In this work, we investigate existing possibilities for the development of generic ETL/ELT processes. Particularly, we focus on approaches with low development complexity by using descriptive metadata and structural metadata. METHODS: We conducted a literature review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We used 4 publication databases (ie, PubMed, IEEE Explore, Web of Science, and Biomed Center) to search for relevant publications from 2012 to 2022. The PRISMA flow was then visualized using an R-based tool (Evidence Synthesis Hackathon). All relevant contents of the publications were extracted into a spreadsheet for further analysis and visualization. RESULTS: Regarding the PRISMA guidelines, we included 33 publications in this literature review. All included publications were categorized into 7 different focus groups (ie, medicine, data warehouse, big data, industry, geoinformatics, archaeology, and military). Based on the extracted data, ontology-based and rule-based approaches were the 2 most used approaches in different thematic categories. Different approaches and tools were chosen to achieve different purposes within the use cases. CONCLUSIONS: Our literature review shows that using metadata-driven (MDD) approaches to develop an ETL/ELT process can serve different purposes in different thematic categories. The results show that it is promising to implement an ETL/ELT process by applying MDD approach to automate the data transformation from Fast Healthcare Interoperability Resources to Observational Medical Outcomes Partnership Common Data Model. However, the determining of an appropriate MDD approach and tool to implement such an ETL/ELT process remains a challenge. This is due to the lack of comprehensive insight into the characterizations of the MDD approaches presented in this study. Therefore, our next step is to evaluate the MDD approaches presented in this study and to determine the most appropriate MDD approaches and the way to integrate them into the ETL/ELT process. This could verify the ability of using MDD approaches to generalize the ETL process for harmonizing medical data.

Study results from journals with a higher impact factor are closer to "truth": a meta-epidemiological study.

BACKGROUND: Scientists, physicians, and the general public legitimately expect scholarly publications to give true answers to study questions raised. We investigated whether findings from studies published in journals with higher Journal Impact Factors (JIFs) are closer to truth than findings from studies in less-cited journals via a meta-epidemiological approach. METHODS: We screened intervention reviews from the Cochrane Database of Systematic Reviews (CDSR) and sought well-appraised meta-analyses. We used the individual RCT study estimates' relative deviation from the pooled effect estimate as a proxy for the deviation of the study results from the truth. The effect of the JIF on the relative deviation was estimated with linear regression and with local polynomial regression, both with adjustment for the relative size of studies. Several sensitivity analyses for various sub-group analyses and for alternative impact metrics were conducted. RESULTS: In 2459 results from 446 meta-analyses, results with a higher JIF were on average closer to "truth" than the results with a lower JIF. The relative deviation decreased on average by -0.023 per JIF (95% CI -0.32 to -0.21). A decrease was consistently found in all sensitivity analyses. CONCLUSIONS: Our results indicate that study results published in higher-impact journals are on average closer to truth. However, the JIF is only one weak and impractical indicator among many that determine a studies' accuracy.

Contributing and limiting factors to guideline-adherent therapy in senior and elderly breast cancer patients: a questionnaire-based cross-sectional study using clinical and cancer registry data in Germany.

PURPOSE: Elderly cancer patients are less likely to be treated in accordance with evidence-based guideline recommendations. This study examines patient-related factors associated with deviations from guideline recommendations. METHODS: Using medical documentation and cancer registry data, we investigated the treatment courses of female breast cancer patients aged 50 and older in Germany regarding compliance with German guidelines. Participants completed a questionnaire querying factors hypothesized to be associated with guideline adherence. We conducted univariate analyses to explore the data and select variables for multivariate logistic regression to estimate adjusted odds ratios. RESULTS: Of 1150 participants, 206 (17.9%) were treated in deviation from guideline recommendations. Patients 70 years and older were more likely to be treated deviating from guideline recommendations than patients 50-69 years old (OR: 2.07; 95% CI: 1.52-2.80). Patients aged 50-69 years who reported that quality of life guided their treatment decision were more likely to be treated in deviation from guideline recommendations (AOR: 2.08; 95% CI: 1.11-3.92) than the elderly. In older patients, higher age was associated with an increased chance of receiving guideline-discordant care (AOR: 1.06; 95% CI: 1.01-1.11), as was depression diagnosed prior to cancer (AOR: 1.84; 95% CI: 1.00-3.40). CONCLUSION: Reasons for deviations from guideline recommendations in breast cancer patients differ by age. In decision-making concerning elderly patients, particular attention should be paid to those with pre-existing depressive disorders. Adequately addressing their needs and concerns could prevent inappropriate deviations from guideline recommendations.

Kinetic energy distribution of multiply charged ions in Coulomb explosion of Xe clusters.

We report on the calculations of kinetic energy distribution (KED) functions of multiply charged, high-energy ions in Coulomb explosion (CE) of an assembly of elemental Xe(n) clusters (average size (n) = 200-2171) driven by ultra-intense, near-infrared, Gaussian laser fields (peak intensities 10(15) - 4 × 10(16) W cm(-2), pulse lengths 65-230 fs). In this cluster size and pulse parameter domain, outer ionization is incomplete∕vertical, incomplete∕nonvertical, or complete∕nonvertical, with CE occurring in the presence of nanoplasma electrons. The KEDs were obtained from double averaging of single-trajectory molecular dynamics simulation ion kinetic energies. The KEDs were doubly averaged over a log-normal cluster size distribution and over the laser intensity distribution of a spatial Gaussian beam, which constitutes either a two-dimensional (2D) or a three-dimensional (3D) profile, with the 3D profile (when the cluster beam radius is larger than the Rayleigh length) usually being experimentally realized. The general features of the doubly averaged KEDs manifest the smearing out of the structure corresponding to the distribution of ion charges, a marked increase of the KEDs at very low energies due to the contribution from the persistent nanoplasma, a distortion of the KEDs and of the average energies toward lower energy values, and the appearance of long low-intensity high-energy tails caused by the admixture of contributions from large clusters by size averaging. The doubly averaged simulation results account reasonably well (within 30%) for the experimental data for the cluster-size dependence of the CE energetics and for its dependence on the laser pulse parameters, as well as for the anisotropy in the angular distribution of the energies of the Xe(q+) ions. Possible applications of this computational study include a control of the ion kinetic energies by the choice of the laser intensity profile (2D∕3D) in the laser-cluster interaction volume.

The role of family confidants and caregivers in the care of older cancer patients: Extending the concept of "shared decision-making".

BACKGROUND AND AIMS: Family caregivers play an important role in assisting their family members with cancer, but their influence on the treatment decision-making process has not yet been adequately investigated. This exploratory study approached this topic via reconstructive methodology, focusing on assessing patient-caregiver relationships. METHODS: We conducted semi-structured interviews with 37 mostly elderly cancer patients (median age: 74 years) about the context of their diagnosis, treatment decision, and family support. Additionally, we interviewed 34 caregivers of cancer patients. Of these, 25 were related to patients interviewed. We analyzed the interviews via a multi-step coding method informed by Grounded Theory methodology toward characterizing patient-caregiver relationships, the treatment decision-making process, and the caregivers' role therein. RESULTS: In the majority of cases (86%), patients were being supported by caregivers. We categorized patient-caregiver relationships in regards to the caregivers' involvement in the therapy decision-making process. We found patient-caregiver interaction patterns that indicate the potential of caregivers to decidedly influence the therapy decision-making process. Yet, only in 38% of cases, a caregiver attended relevant patient-physician-consultations. CONCLUSION: Depending on the nature of the patient-caregiver relationship, the traditional concept of shared decision-making, which assumes a dyadic relationship, needs to be extended toward a more dynamic concept in which caregivers should be involved more frequently. This could enable physicians to better understand a patient's reasons for or against a therapy proposal and ensure that the patient's wishes are communicated and considered. On the other hand, strong caregiver-involvement bears risks of over-stepping elderly patients' wishes, thus violating patient autonomy.

Reactions of Selected Bismuth Oxide Cluster Cations with Propene.

Bismuth oxide cluster ions are reduced by propene in exactly the same way as solid bismuth oxide (Bi2 O3 ), which is used as a catalyst. Even in the case of the smallest bismuth oxide cluster ions, such as the Bi3 O4+ isomer shown in the picture, the supposedly unreactive bridging oxygen atom can participate in the alkene oxidation.

Extreme dynamics and energetics of Coulomb explosion of Xe clusters.

Unique features of Coulomb explosion (CE) of many-electron elemental Xe(n) (n = 13-2171) clusters driven by ultraintense and ultrashort near-infrared laser pulses (peak intensities 10(15)-10(20) W cm(-2) and pulse lengths of 10-100 fs) manifest ion dynamics and energetics in the extreme, with ultrafast (5-15 A fs(-1)) velocities and ultrahigh (keV-1 MeV) energies. Relations were established between the CE attributes, obtained from molecular dynamics simulations and from electrostatic models, and the extreme cluster inner ionization levels (5-36 per ion), in conjunction with the laser parameters required for the attainment of complete outer ionization, which was approximated by cluster vertical ionization (CVI) initial conditions. Interrelationship between electron dynamics and nuclear dynamics stems from the effects of the laser pulse length on the energetics and from the characterization of the border radius for complete outer ionization. Our computational-theoretical analysis semi-quantitatively describes CE dynamics and energetics in the CVI limit and also the energetics in the presence of a persistent nanoplasma, which is in accord with experiment.

Extreme ionization of Xe clusters driven by ultraintense laser fields.

We applied theoretical models and molecular dynamics simulations to explore extreme multielectron ionization in Xe(n) clusters (n=2-2171, initial cluster radius R(0)=2.16-31.0 A) driven by ultraintense infrared Gaussian laser fields (peak intensity I(M)=10(15)-10(20) W cm(-2), temporal pulse length tau=10-100 fs, and frequency nu=0.35 fs(-1)). Cluster compound ionization was described by three processes of inner ionization, nanoplasma formation, and outer ionization. Inner ionization gives rise to high ionization levels (with the formation of [Xe(q+)](n) with q=2-36), which are amenable to experimental observation. The cluster size and laser intensity dependence of the inner ionization levels are induced by a superposition of barrier suppression ionization (BSI) and electron impact ionization (EII). The BSI was induced by a composite field involving the laser field and an inner field of the ions and electrons, which manifests ignition enhancement and screening retardation effects. EII was treated using experimental cross sections, with a proper account of sequential impact ionization. At the highest intensities (I(M)=10(18)-10(20) W cm(-2)) inner ionization is dominated by BSI. At lower intensities (I(M)=10(15)-10(16) W cm(-2)), where the nanoplasma is persistent, the EII contribution to the inner ionization yield is substantial. It increases with increasing the cluster size, exerts a marked effect on the increase of the [Xe(q+)](n) ionization level, is most pronounced in the cluster center, and manifests a marked increase with increasing the pulse length (i.e., becoming the dominant ionization channel (56%) for Xe(2171) at tau=100 fs). The EII yield and the ionization level enhancement decrease with increasing the laser intensity. The pulse length dependence of the EII yield at I(M)=10(15)-10(16) W cm(-2) establishes an ultraintense laser pulse length control mechanism of extreme ionization products.

Cluster dynamics transcending chemical dynamics toward nuclear fusion.

Ultrafast cluster dynamics encompasses femtosecond nuclear dynamics, attosecond electron dynamics, and electron-nuclear dynamics in ultraintense laser fields (peak intensities 10(15)-10(20) W.cm(-2)). Extreme cluster multielectron ionization produces highly charged cluster ions, e.g., (C(4+)(D(+))(4))(n) and (D(+)I(22+))(n) at I(M) = 10(18) W.cm(-2), that undergo Coulomb explosion (CE) with the production of high-energy (5 keV to 1 MeV) ions, which can trigger nuclear reactions in an assembly of exploding clusters. The laser intensity and the cluster size dependence of the dynamics and energetics of CE of (D(2))(n), (HT)(n), (CD(4))(n), (DI)(n), (CD(3)I)(n), and (CH(3)I)(n) clusters were explored by electrostatic models and molecular dynamics simulations, quantifying energetic driving effects, and kinematic run-over effects. The optimization of table-top dd nuclear fusion driven by CE of deuterium containing heteroclusters is realized for light-heavy heteroclusters of the largest size, which allows for the prevalence of cluster vertical ionization at the highest intensity of the laser field. We demonstrate a 7-orders-of-magnitude enhancement of the yield of dd nuclear fusion driven by CE of light-heavy heteroclusters as compared with (D(2))(n) clusters of the same size. Prospective applications for the attainment of table-top nucleosynthesis reactions, e.g., (12)C(P,gamma)(13)N driven by CE of (CH(3)I)(n) clusters, were explored.

Femtosecond time-resolved geometry relaxation and ultrafast intramolecular energy redistribution in Ag2Au.

The ultrafast dynamics of the bimetallic cluster Ag2Au is investigated by pump-probe negative ion-to-neutral-to-positive ion (NeNePo) spectroscopy. Preparation of the neutral cluster in a highly nonequilibrium state by electron detachment from the mass-selected anion, and subsequent probing of the neutral nuclear dynamics through two-photon ionization to the cationic state, leads to strongly probe-energy-dependent transient cation-abundance signals. The origin of this pronounced time and wavelength dependence of the ionization probability on the femtosecond scale is revealed by ab initio theoretical simulations of the transient spectra. Based on the analysis of underlying dynamics, two fundamental processes involving geometry relaxation from linear to triangular structure followed by ultrafast intramolecular vibrational energy redistribution (IVR) have been identified and for the first time experimentally observed in the frame of NeNePo spectroscopy under conditions close to zero electron kinetic energy.