Implementation study of the 2021 German guideline for diagnosis and treatment of multiple sclerosis

BACKGROUND

In May 2021, a new guideline on the diagnosis and treatment of multiple sclerosis and related disorders was released in Germany. Since the success of a guideline depends on how it integrates into everyday clinical practice, the German Society for Neurology (DGN) has launched a multimethod implementation project. Here we report on the results based on the consultation version of the guideline.

METHODS

We used qualitative and quantitative data analyses to capture the nature and extent of barriers and facilitating factors to the implementation. We centered on the guideline's chapter A on diagnosis, relapse therapy, and immunotherapy of multiple sclerosis. We performed nine online focus group discussions and a web-based survey and analyzed emails and letters with comments from stakeholders and independent parties that were sent spontaneously or by invitation.

RESULTS

94 neurologists answered the survey, and ≥70% agreed with the recommendations of the guideline on each major content topic. Barriers to implementation were detected in group discussions and written input. The most controversial issues of the guideline were "early treatment", "criteria for starting or switching therapy", "stepwise escalation versus early aggressive treatment", "classification of drugs into three categories of efficacy" and the scenarios on "treatment cessation". Some appreciated the highly structured recommendations, but others felt that the guideline restricts the free choice of therapy, or they were afraid of recourse claims. Some considered the guideline as too cautious regarding treatment initiation, possibly delaying necessary therapies. Others appreciated that conflicts of interests of the guideline's authoring group were minimized and thought that the new guideline is clearer, more extensive and practical.

CONCLUSION

In contrast to the survey, feedback in the focus group discussions and from individuals was diverse and sometimes more critical. Based on the overall feedback rate of about 250 people in relation to the number of 6500 board-certified neurologists in Germany, the overall appreciation of the guideline can only be considered as an indicator and not proof of acceptance. Results of this analysis were incorporated into several adjustments to the final guideline of 2021. Since the guideline is to be updated regularly under the auspices of a "living guideline", active interaction with users will continue to matter and help to improve it.

Effect of spin-orbit coupling on decay widths of electronic decay processes

Auger-Meitner processes are electronic decay processes of energetically low-lying vacancies. In these processes, the vacancy is filled by an electron of an energetically higher lying orbital, while another electron is simultaneously emitted to the continuum. In low-lying orbitals, relativistic effects can not, even for light elements, be neglected. At the same time, lifetime calculations are computationally expensive. In this context, we investigate which effect spin-orbit coupling has on Auger-Meitner decay widths and aim for a rule of thumb for the relative decay widths of initial states split by spin-orbit coupling. We base this rule of thumb on Auger-Meitner decay widths of Sr4p^-1 and Ra6p^-1 obtained by relativistic FanoADC-Stieltjes calculations and validate it against Auger-Meitner decay widths from the literature.

The DIRAC code for relativistic molecular calculations

DIRAC is a freely distributed general-purpose program system for one-, two-, and four-component relativistic molecular calculations at the level of Hartree-Fock, Kohn-Sham (including range-separated theory), multiconfigurational self-consistent-field, multireference configuration interaction, electron propagator, and various flavors of coupled cluster theory. At the self-consistent-field level, a highly original scheme, based on quaternion algebra, is implemented for the treatment of both spatial and time reversal symmetry. DIRAC features a very general module for the calculation of molecular properties that to a large extent may be defined by the user and further analyzed through a powerful visualization module. It allows for the inclusion of environmental effects through three different classes of increasingly sophisticated embedding approaches: the implicit solvation polarizable continuum model, the explicit polarizable embedding model, and the frozen density embedding model.

Charge Exchange Dominates Long-Range Interatomic Coulombic Decay of Excited Metal-Doped Helium Nanodroplets

Atoms and molecules attached to rare-gas clusters are ionized by an interatomic autoionization process traditionally termed "Penning ionization" when the host cluster is resonantly excited. Here we analyze this process in the light of the interatomic Coulombic decay (ICD) mechanism, which usually contains a contribution from charge exchange at a short interatomic distance and one from virtual photon transfer at a large interatomic distance. For helium (He) nanodroplets doped with alkali metal atoms (Li, Rb), we show that long-range and short-range contributions to the interatomic autoionization can be clearly distinguished by detecting electrons and ions in coincidence. Surprisingly, ab initio calculations show that even for alkali metal atoms floating in dimples at a large distance from the nanodroplet surface, autoionization is largely dominated by charge-exchange ICD. Furthermore, the measured electron spectra manifest the ultrafast internal relaxation of the droplet mainly into the 1s2s¹S state and partially into the metastable 1s2s³S state.

Interatomic decay of inner-valence ionized states in ArXe clusters: relativistic approach

In this work we investigate interatomic electronic decay processes taking place in mixed argon-xenon clusters upon the inner-valence ionization of an argon center. We demonstrate that both interatomic Coulombic decay and electron-transfer mediated decay (ETMD) are important in larger rare gas clusters as opposed to dimers. Calculated secondary electron spectra are shown to depend strongly on the spin-orbit coupling in the final states of the decay as well as the presence of polarizable environment. It follows from our calculations that ETMD is a pure interface process taking place between the argon-xenon layers. The interplay of all these effects is investigated in order to arrive at a suitable physical model for the decay of inner-valence vacancies taking place in mixed ArXe clusters.