Impact of Biomass Burning on Arctic Aerosol Composition

Emissions from biomass burning (BB) occurring at midlatitudes can reach the Arctic, where they influence the remote aerosol population. By using measurements of levoglucosan and black carbon, we identify seven BB events reaching Svalbard in 2020. We find that most of the BB events are significantly different to the rest of the year (nonevents) for most of the chemical and physical properties. Aerosol mass and number concentrations are enhanced by up to 1 order of magnitude during the BB events. During BB events, the submicrometer aerosol bulk composition changes from an organic- and sulfate-dominated regime to a clearly organic-dominated regime. This results in a significantly lower hygroscopicity parameter κ for BB aerosol (0.4 ± 0.2) compared to nonevents (0.5 ± 0.2), calculated from the nonrefractory aerosol composition. The organic fraction in the BB aerosol showed no significant difference for the O:C ratios (0.9 ± 0.3) compared to the year (0.9 ± 0.6). Accumulation mode particles were present during all BB events, while in the summer an additional Aitken mode was observed, indicating a mixture of the advected air mass with locally produced particles. BB tracers (vanillic, homovanillic, and hydroxybenzoic acid, nitrophenol, methylnitrophenol, and nitrocatechol) were significantly higher when air mass back trajectories passed over active fire regions in Eastern Europe, indicating agricultural and wildfires as sources. Our results suggest that the impact of BB on the Arctic aerosol depends on the season in which they occur, and agricultural and wildfires from Eastern Europe have the potential to disturb the background conditions the most.

Factorial, Construct, and Predictive Validity of the Motivation for Treatment Scale in Alcohol-Use Disorder Withdrawal Treatment

INTRODUCTION

The aim of the present study was to examine for the first time the factorial, construct, and predictive validity of the motivation for treatment (MfT) scale in a cohort of patients undergoing inpatient-qualified alcohol withdrawal treatment with the goal of referring patients to further treatment. The MfT scale has previously been evaluated in different settings of substance abuse treatment, revealing factorial ambiguity. To the best of our knowledge, the present study is the first study that conducted comprehensive factor analyses versus separate analyses of the factors conducted in prior studies in order to clarify the aforementioned factorial ambiguity.

METHODS

A total of 249 patients (mean age 45.2 years (SD = 10.3); 34.4% females) with alcohol dependence were assessed. Data were obtained from four inpatient clinics specialized in qualified alcohol withdrawal treatment in Germany. First, confirmatory factor analyses were carried out to examine the fit of the four models discussed in the literature. Second, an exploratory factor analysis was conducted. Correlations of the new factors with other motivational constructs and referral to a subsequent treatment were investigated as measures of construct and predictive validity.

RESULTS

None of the four models showed an acceptable fit to the data in confirmatory analyses. The exploratory analysis suggested to eliminate seven items because of inappropriate factor loadings and resulted in a shortened MfT scale, which consists of three factors based on 17 items. For the latent variables "problem recognition," "desire for help," and "treatment readiness," satisfactory composite reliability was found with 0.82, 0.80, and 0.78, respectively. Evidence for predictive validity was found in the correlation between "treatment readiness" and referral to a subsequent treatment.

DISCUSSION/CONCLUSION

The new shortened MfT scale exhibited remarkable parsimony, which is desirable in settings such as withdrawal treatment, where patients frequently are cognitively or physically impaired. Despite its briefness, construct and predictive validity were better than in the original version of the MfT scale. The factorial validity of the suggested scale needs to be corroborated in further research.

Long-term Outcome of Pediatric Liver Transplant Recipients Who Have Reached Adulthood: A Single-center Experience

BACKGROUND

As long-term survival of pediatric liver transplant recipients increases, the assessment of physical, psychological, and social well-being becomes more important.

METHODS

In this retrospective analysis, 120 young adult patients (age ≥18 y) who underwent liver transplantation in childhood were studied. Patients with ideal outcome were defined as patients with perfect graft function, with no complications from the immunosuppressive medication, no late retransplantation, and no steroid treatment. Also, the patients' drug adherence and their psychosocial situation were assessed.

RESULTS

After a median follow-up of 19 y, only 16.7% of the patients (mean age: 26.5 y) were considered patients with ideal outcome. The main reasons precluding ideal outcome were chronic kidney disease (38.3%), elevated liver enzymes (33.3%), and arterial hypertension (31.7%). Ideal outcome decreased over time from 54% to 42%, 26%, and 8% at 10-, 15-, 20-, and 25-y follow-up, respectively. Reduced drug adherence was noted in 24.8% of patients and associated with a significantly higher prevalence of donor-specific antibodies class II ( P  = 0.015), elevated transaminases ( P  = 0.010), and chronic rejection ( P  < 0.001). Also, 15% of patients had a psychiatric disease, mainly depression.

CONCLUSIONS

The morbidity of young adults who underwent liver transplantation as children was high and increased over time. The majority developed complications from immunosuppression or chronic graft dysfunction. More than 1 in 7 patients had a psychiatric disease and 1 in 4 was not perfectly drug adherent. Therefore, immunosuppressive treatment and psychological care should be optimized for these particularly vulnerable patients.

Volatility of Secondary Organic Aerosol from β-Caryophyllene Ozonolysis over a Wide Tropospheric Temperature Range

We investigated secondary organic aerosol (SOA) from β-caryophyllene oxidation generated over a wide tropospheric temperature range (213-313 K) from ozonolysis. Positive matrix factorization (PMF) was used to deconvolute the desorption data (thermograms) of SOA products detected by a chemical ionization mass spectrometer (FIGAERO-CIMS). A nonmonotonic dependence of particle volatility (saturation concentration at 298 K, C298K*) on formation temperature (213-313 K) was observed, primarily due to temperature-dependent formation pathways of β-caryophyllene oxidation products. The PMF analysis grouped detected ions into 11 compound groups (factors) with characteristic volatility. These compound groups act as indicators for the underlying SOA formation mechanisms. Their different temperature responses revealed that the relevant chemical pathways (e.g., autoxidation, oligomer formation, and isomer formation) had distinct optimal temperatures between 213 and 313 K, significantly beyond the effect of temperature-dependent partitioning. Furthermore, PMF-resolved volatility groups were compared with volatility basis set (VBS) distributions based on different vapor pressure estimation methods. The variation of the volatilities predicted by different methods is affected by highly oxygenated molecules, isomers, and thermal decomposition of oligomers with long carbon chains. This work distinguishes multiple isomers and identifies compound groups of varying volatilities, providing new insights into the temperature-dependent formation mechanisms of β-caryophyllene-derived SOA particles.

Psychosocial Diagnosis and Treatment Before and After Organ Transplantation

BACKGROUND

This new clinical practice guideline concerns the psychosocial diagnosis and treatment of patients before and after organ transplantation. Its objective is to establish standards and to issue evidence-based recommendations that will help to optimize decision making in psychosocial diagnosis and treatment.

METHODS

For each key question, the literature was systematically searched in at least two databases (Medline, Ovid, Cochrane Library, and CENTRAL). The end date of each search was between August 2018 and November 2019, depending on the question. The literature search was also updated to capture recent publications, by using a selective approach.

RESULTS

Lack of adherence to immunosuppressant drugs can be expected in 25-30% of patients and increases the odds of organ loss after kidney transplantation (odds ratio 7.1). Psychosocial interventions can significantly improve adherence. Metaanalyses have shown that adherence was achieved 10-20% more frequently in the intervention group than in the control group. 13-40% of patients suffer from depression after transplantation; mortality in this group is 65% higher. The guideline group therefore recommends that experts in psychosomatic medicine, psychiatry, and psychology (mental health professionals) should be involved in patient care throughout the transplantation process.

CONCLUSION

The care of patients before and after organ transplantation should be multidisciplinary. Nonadherence rates and comorbid mental disorders are common and associated with poorer outcomes after transplantation. Interventions to improve adherence are effective, although the pertinent studies display marked heterogeneity and a high risk of bias.

Exposure to naphthalene and β-pinene-derived secondary organic aerosol induced divergent changes in transcript levels of BEAS-2B cells

The health effects of exposure to secondary organic aerosols (SOAs) are still limited. Here, we investigated and compared the toxicities of soot particles (SP) coated with β-pinene SOA (SOAβPin-SP) and SP coated with naphthalene SOA (SOANap-SP) in a human bronchial epithelial cell line (BEAS-2B) residing at the air-liquid interface. SOAβPin-SP mostly contained oxygenated aliphatic compounds from β-pinene photooxidation, whereas SOANap-SP contained a significant fraction of oxygenated aromatic products under similar conditions. Following exposure, genome-wide transcriptome responses showed an Nrf2 oxidative stress response, particularly for SOANap-SP. Other signaling pathways, such as redox signaling, inflammatory signaling, and the involvement of matrix metalloproteinase, were identified to have a stronger impact following exposure to SOANap-SP. SOANap-SP also induced a stronger genotoxicity response than that of SOAβPin-SP. This study elucidated the mechanisms that govern SOA toxicity and showed that, compared to SOAs derived from a typical biogenic precursor, SOAs from a typical anthropogenic precursor have higher toxicological potency, which was accompanied with the activation of varied cellular mechanisms, such as aryl hydrocarbon receptor. This can be attributed to the difference in chemical composition; specifically, the aromatic compounds in the naphthalene-derived SOA had higher cytotoxic potential than that of the β-pinene-derived SOA.

Effect of Atmospheric Aging on Soot Particle Toxicity in Lung Cell Models at the Air–Liquid Interface: Differential Toxicological Impacts of Biogenic and Anthropogenic Secondary Organic Aerosols (SOAs)

Background:

Secondary organic aerosols (SOAs) formed from anthropogenic or biogenic gaseous precursors in the atmosphere substantially contribute to the ambient fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] burden, which has been associated with adverse human health effects. However, there is only limited evidence on their differential toxicological impact.

Objectives:

We aimed to discriminate toxicological effects of aerosols generated by atmospheric aging on combustion soot particles (SPs) of gaseous biogenic (β-pinene) or anthropogenic (naphthalene) precursors in two different lung cell models exposed at the air–liquid interface (ALI).

Methods:

Mono- or cocultures of lung epithelial cells (A549) and endothelial cells (EA.hy926) were exposed at the ALI for 4 h to different aerosol concentrations of a photochemically aged mixture of primary combustion SP and β-pinene (SOAβPIN-SP) or naphthalene (SOANAP-SP). The internally mixed soot/SOA particles were comprehensively characterized in terms of their physical and chemical properties. We conducted toxicity tests to determine cytotoxicity, intracellular oxidative stress, primary and secondary genotoxicity, as well as inflammatory and angiogenic effects.

Results:

We observed considerable toxicity-related outcomes in cells treated with either SOA type. Greater adverse effects were measured for SOANAP-SP compared with SOAβPIN-SP in both cell models, whereas the nano-sized soot cores alone showed only minor effects. At the functional level, we found that SOANAP-SP augmented the secretion of malondialdehyde and interleukin-8 and may have induced the activation of endothelial cells in the coculture system. This activation was confirmed by comet assay, suggesting secondary genotoxicity and greater angiogenic potential. Chemical characterization of PM revealed distinct qualitative differences in the composition of the two secondary aerosol types.

Discussion:

In this study using A549 and EA.hy926 cells exposed at ALI, SOA compounds had greater toxicity than primary SPs. Photochemical aging of naphthalene was associated with the formation of more oxidized, more aromatic SOAs with a higher oxidative potential and toxicity compared with β-pinene. Thus, we conclude that the influence of atmospheric chemistry on the chemical PM composition plays a crucial role for the adverse health outcome of emissions. https://doi.org/10.1289/EHP9413

Patient-centered placement matching of alcohol-dependent patients based on a standardized intake assessment: process evaluation within an exploratory randomized controlled trial

BACKGROUND

In the implementation of placement matching guidelines, feasibility has been concerned in previous research. Objectives of this process evaluation were to investigate whether the patient-centered matching guidelines (PCPM) are consistently applied in referral decision-making from an inpatient qualified withdrawal program to a level of care in aftercare, which factors affect whether patients actually receive matched aftercare according to PCPM, and whether its use is feasible and accepted by clinic staff.

METHODS

The study was conducted as process evaluation within an exploratory randomized controlled trial in four German psychiatric clinics offering a 7-to-21 day qualified withdrawal program for patients suffering from alcohol dependence, and with measurements taken during detoxification treatment and six months after the initial assessment. PCPM were used with patients in the intervention group by feeding back to them a recommendation for a level of care in aftercare that had been calculated from Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff on the treatment unit. As measurements, The MATE, the Client Socio-Demographic and Service Receipt Inventory-European Version, a documentation form, the Control Preference Scale, and the Motivation for Treatment Scale were administered. A workshop for the staff at the participating trial sites was conducted after data collection was finished.

RESULTS

Among 250 patients participating in the study, 165 were interviewed at follow-up, and 125 had received aftercare. Although consistency in the application of PCPM was moderate to substantial within the qualified withdrawal program (Cohen's kappa ≥ .41), it was fair from discharge to follow-up. In multifactorial multinomial regression, the number of foregoing substance abuse treatments predicted whether patients received more likely undermatched (Odds Ratio=1.27; p=.018) or overmatched (Odds Ratio=0.78; p=.054) treatment. While the implementation process during the study was evaluated critically by the staff, they stated a potential of quality assurance, more transparency and patient-centeredness in the use of PCPM.

CONCLUSIONS

While the use of PCPM has the potential to enhance the quality of referral decision making within treatment, it may not be sufficient to determine referral decisions for aftercare.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00005035 . Registered 03/06/2013.

[Lesions of the triceps tendon : Diagnostics, management, treatment]

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents a rare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is a direct fall onto the extended forearm or a blow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

Psychosocial situation, adherence, and utilization of video consultation in young adult long-term pediatric liver transplant recipients during COVID-19 pandemic

BACKGROUND

Young adults who underwent liver transplantation in childhood (YALTs) are highly vulnerable to non-adherent behavior and psychosocial problems. During the COVID-19 pandemic, special efforts may be necessary to maintain contact with these patients and offer support. This can be achieved through the use of telemedicine. The study's objective was to assess adherence and the psychosocial situation of YALTs during the COVID-19 pandemic in Germany and to evaluate the utilization of video consultations.

METHODS

In May 2020, a questionnaire was sent to YALTs treated at the Hamburg University Transplant Center, accompanied by the offer of video appointments with the attending physician. The questionnaire included the Generalized Anxiety Disorder Scale 7, the Patient Health Questionnaire 2, and questions compiled by the authors.

RESULTS

Of 98 YALTs, 12% used the video consultation, while 65% had an in-person appointment. The 56 patients who completed the questionnaire did not report reduced medication adherence during the pandemic, but 40% missed follow-up visits with their primary care physician or check-up laboratory tests. About 70% of YALTs were afraid to visit their physician and the transplant center, and 34% were afraid of a SARS-CoV-2 infection. Mental health and well-being were unimpaired.

CONCLUSIONS

During the COVID-19 pandemic, YALTs in our study did not show an increased need for psychosocial support, but a majority were afraid to attend medical appointments, and 40% reported lower appointment adherence. Acceptance of video consultations was lower than expected. The reasons for this need to be further investigated in order to optimize care.

Barrieren und Umsetzungsstrategien für die Implementierung der S3-Leitlinie Screening, Diagnose und Behandlung alkoholbezogener Störungen aus Sicht von Behandlern und Betroffenen

Ziel der Studie Für die erfolgreiche Implementierung von Leitlinien sind kontextspezifische Umsetzungsstrategien, welche die spezifische Versorgungssituation sowie mögliche Umsetzungsbarrieren berücksichtigen, vielversprechend. Ziel dieser Untersuchung war es, mögliche Barrieren und präferierte Umsetzungsstrategien für die Implementierung der S3-Leitlinie „Screening, Diagnose und Behandlung alkoholbezogener Störungen“ aus der Perspektive von Behandlern und Betroffenen zu erfassen.

Methodik Als Teil des vom Bundesministerium für Gesundheit geförderten Projekts Implementierung und Evaluation der S3-Leitlinie zu Screening, Diagnose und Behandlung alkoholbezogener Störungen (IMPELA) wurden Barrieren und mögliche Strategien für die Umsetzung der Leitlinienempfehlungen mithilfe eines selbst entwickelten Fragebogens querschnittlich erhoben. Sowohl Gesundheitsfachpersonal aus Primärversorgung und Suchthilfe (Behandler) als auch Betroffene von alkoholbezogenen Störungen und deren Angehörige in der Modellregion Bundesland Bremen wurden mithilfe unterschiedlicher Rekrutierungsstrategien (postalisch, persönlich, über ausgelegte Flyer) zur Teilnahme eingeladen. Der Fragebogen konnte in Papierversion oder online bearbeitet werden. Zusätzlich wurde der Fragebogen online über relevante Fachgesellschaften und Patientenorganisationen mithilfe von E-Mailverteilern bundesweit verbreitet.

Ergebnisse Datensätze von 263 Behandlern wurden in die Auswertung eingeschlossen, davon 163 (62%) Behandler aus Bremen und 100 (38%) aus anderen Bundesländern. Die Behandler waren im Mittel zwischen 51,7 (Bremen) und 50,9 (Bundesweit) Jahre alt und hatten 22,8 (Bremen) bzw. 23,7 (Bundesweit) Jahre Berufserfahrung. Die Mehrheit der Befragten waren Ärzte (62,6% Bremen; 50% Bundesweit). Als Hauptbarrieren empfanden die Behandler das mangelnde Wissen über die Existenz der Leitlinie (65,6% Bremen; 44% Bundesweit) und die geringen zeitlichen Ressourcen im Behandlungsalltag (68,7% Bremen; 50% Bundesweit). Als mögliche Umsetzungsstrategien wurden u. a. die stärkere Information der Fachöffentlichkeit (33,7% Bremen; 39% Bundesweit) sowie Fact-Sheets (34,9% Bremen; 38% Bundesweit) genannt. Zusätzlich konnten Daten von 94 Betroffenen/Angehörigen ausgewertet werden (57,7% männlich; Alter M=44,7 Jahre). Von diesen gaben 51 Personen (54,3%) an, bereits selbst eine Suchtbehandlung in Anspruch genommen zu haben. Als Schwierigkeiten für die Versorgung benannten die Betroffenen/Angehörigen am häufigsten, dass Betroffene aus Angst vor Konsequenzen keine Hilfe suchen (n=51; 54%) oder ihre Probleme nicht wahrhaben wollen (n=49, 52,1%), sowie zu lange Wartezeiten auf Behandlungsplätze (n=45; 47,8%). Verbesserungspotential sahen die Betroffenen v. a. in den Bereichen Screening („Ansprechen des Alkoholkonsums“; n=44; 46,8%) und einem nahtlosen Übergang zwischen verschiedenen Behandlungssettings (n=42; 44,6%).

Schlussfolgerungen Zusätzlich zu den bisherigen Bemühungen zur Disseminierung der S3-Leitlinie Screening, Diagnose und Behandlung alkoholbezogener Störungen legen die Ergebnisse dieser Studie die Notwendigkeit einer kontextspezifischen Förderung der Leitlinienumsetzung nahe.

Liver transplantation for acute-on-chronic liver failure predicts post-transplant mortality and impaired long-term quality of life

BACKGROUND

Among patients with cirrhosis, candidate selection and timing of liver transplantation (LT) remain problematic. Acute-on-chronic liver failure (ACLF) is a severe complication of cirrhosis with excessive short-term mortality rates under conservative therapeutic measures. The role of LT in the management of ACLF is uncertain.

OBJECTIVE

To assess the impact of ACLF on post-LT survival and long-term graft function, morbidity and quality of life (QoL).

METHODS

We retrospectively analysed all cirrhosis patients undergoing LT at our institution between 01/2009 and 12/2014. Median follow-up was 8.7 years. Long-term LT survivors were interviewed with established QoL questionnaires.

RESULTS

Of 250 LT recipients, 98 fulfilled the EASL diagnostic ACLF criteria before LT ('ACLF-LT'). ACLF associated with reduced post-LT survival (HR for 6-month survival compared to non-ACLF-LT: 0.18; HR for 10-year-survival: 0.47; both P < .001) depending on ACLF severity before LT, and mainly inferred by infections both in the early and late phases after LT. In ACLF patients, CLIFc-OFs was superior to MELD score in predicting post-LT mortality. Long-term follow-up revealed comparable graft functions and comorbidity burden in ACLF-LT and non-ACLF-LT survivors. ACLF-LT patients reported significantly impaired health and QoL, particularly with regards to anxiety/depression and physical and psychological health (all P < .05). LabMELD score, presence of ACLF at LT and duration of post-LT intensive care associated with poor long-term QoL.

CONCLUSION

ACLF predicts impaired post-LT survival. While long-term graft function and extrahepatic comorbidities are comparable in ACLF and non-ACLF LT survivors, the strikingly low QoL in many ACLF-LT recipients warrants consideration during follow-up patient care.

[Screening for Problematic Alcohol Consumption - A Survey on Guideline Implementation in Transdisciplinary Health Care of a Model Region]

AIM

Recording the frequency of screenings for problematic alcohol consumption by professionals involved in the health care of respective patients. The German S3-guideline "screening, diagnosis and treatment of alcohol-related disorders" recommends the use of questionnaire-based screenings for all patients in all settings.

METHODS

Cross-sectional survey on screening frequency among general practitioners, gynecologists, psychiatrists, child- and adolescent therapists, psychotherapists, social workers and midwives. Logistic regression was used to explore how healthcare professionals' attributes were associated with the implementation of screenings.

RESULTS

With response rates of about 20%, health care professionals reported using screening instruments for an average of 6.9% of all patients during the previous four weeks. Most of the time, custom-made questions were used instead of the recommended instruments (AUDIT, AUDIT-C). Higher screening rates were reported for patients with newly diagnosed hypertension (21.2%), alcohol-related disorders (43.3%) and mental disorders (39.3%). Knowledge of the guideline was associated with implementation of screenings (OR=4.67; 95% KI 1.94-11.25, p<0.001).

CONCLUSIONS

Comprehensive screening for problematic alcohol use with questionnaire-based instruments in accordance with guidelines is far from being routinely implemented in the studied health care settings. Measures to increase the knowledge of the guidelines are necessary in order to increase the frequency of alcohol screening in health care.

Who is shocked and who survives? A multi-state analysis of the NORDIC ICD trial

Background/Purpose

The interaction between the risk of arrhythmic death and a competing non-arrhythmic risk of death in patients suitable for implantable cardioverter defibrillator (ICD) implantation is not well understood. Commonly, identification of subpopulations with the largest benefit of ICD implantation has been performed by separate risk models for the outcomes death and appropriate shock therapy. The interrelation between the outcomes was not sufficiently studied.

Methods

Data were derived from the safety population of the multinational, prospectively randomized NORDIC ICD trial (N=1067) with real-word patients implanted with a single, dual or triple chamber ICD for primary or secondary prevention. Since all outcome adjudication was performed by an independent Clinical Event Committee supported by full telemonitoring data transmission, a high validity of ICD interventions could be achieved. To investigate the impact of baseline characteristics on time to first appropriate shock, death without prior appropriate shock therapy and death after appropriate shock therapy, a multi-state Cox model was computed. Missing data have been multiply imputed before analysis.

Results

At 36 months follow-up, 86.4% of the patients were alive (7.8% after appropriate shock). 11.0% and 2.6% patients died without or after a foregoing appropriate shock, respectively. The primary randomization allocation showed no significant effect on the 3 outcome types. Higher age (per 5 years) and NYHA functional class (≥III vs. ≤II) were associated with an increased risk of death without appropriate shock (HR 1.31, 95% CI 1.14–1.50, p&lt;0.001, and HR 2.17, 95% CI 1.26–3.74, p=0.005, fig.1, accordingly). The presence of diabetes mellitus at baseline was associated with the reduced risk of the occurrence of an appropriate shock (HR 0.57, 95% CI 0.35–0.92, p=0.022). Patients with secondary prevention indication for an ICD had very high risk for an appropriate shock after ICD implantation (HR 3.21, 95% CI 2.02–5.11, p&lt;0.001), but not for death without or with previous appropriate shock (HR 1.42, 95% CI 0.72–2.79, p=0.306, or HR 0.73, 95% CI 0.23–2.34, p=0.594 after ICD shock). Renal insufficiency and ischemic vs. nonischemic disease showed a significantly increased global effect on all three transitions (HR 1.63, 95% CI 1.18–2.24, p=0.003 and HR 1.53, 95% CI 1.06–2.20, p=0.025, respectively).

Conclusion

The new multi-state model shows the interrelation between appropriate shocks and death, as well a remarkable variation of risk factors for the transitions. Specifically, the presence of higher age and NYHA functional class ≥III at baseline were strong prognostic factors for all-cause mortality without a foregoing shock therapy, but were not predictive for an appropriate shock therapy. In this all-comer study, a significant discriminator predictive for appropriate shock therapy, but not for death was an indication for secondary prevention of sudden cardiac death.

Multi-state graph for NYHA class

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This work was supported by Biotronik SE & Co. KG (Berlin, Germany)

Diagnostik und Behandlung alkoholbezogener Störungen – Versorgerbefragung zur Erarbeitung von Strategien der Leitlinienimplementierung

Ziel der Studie Die Art und Häufigkeit durchgeführter Diagnostik, Kurzintervention und Behandlung bei PatientInnen mit bekanntem problematischen Alkoholkonsum und Alkoholkonsumstörungen durch Berufsgruppen der Gesundheitsversorgung soll erfasst werden. Diese Informationen dienen der Bedarfsabschätzung zur Entwicklung von Strategien zur weiteren Implementierung der S3-Leitlinie „Screening, Diagnose und Behandlung alkoholbezogener Störungen“.

Methodik Schriftliche Befragung von FachärztInnen (hausärztlich allgemeinmedizinisch/internistische, gynäkologische, psychiatrische, pädiatrische, Kinder- und jugendpsychiatrische), PsychotherapeutInnen, SozialarbeiterInnen und Hebammen/Entbindungspflegern in einer Querschnittsstudie in der Modellregion Bremen.

Ergebnisse 34% der PatientInnen mit bekanntem problematischen Alkoholkonsum erhielten eine leitlinienkonforme Diagnostik, 39% eine spezifische Kurzintervention. Von den PatientInnen mit diagnostizierter alkoholbezogener Störung wurde bei 34% eine spezifische Behandlung in eigener Praxis durchgeführt und bei 37% eine Weiterbehandlung anderswo empfohlen. Validierte Instrumente zur Diagnostik alkoholbezogener Störungen fanden selten Anwendung. Kurzinterventionen beinhalteten meist informelle motivierende Gespräche. Als Postakutbehandlungen wurden überwiegend Suchtberatungen und Selbsthilfe und nur selten pharmakologische Rückfallprophylaxe durchgeführt.

Schlussfolgerungen Die Umsetzung strukturierter Diagnostik und Kurzinterventionen, sowie die zielgerichtete Empfehlung pharmakologischer Rückfallprophylaxe und ambulanter Angebote ist für eine leitliniengerechte Versorgung unzureichend. Sie sollten daher Gegenstand von Strategien zur weiteren Leitlinienimplementierung sein.

Health care providers' weight management practices for adolescent obesity and alignment with clinical practice guidelines: a multi-centre, qualitative study

Background

Clinical practice guidelines (CPGs) include evidence-based recommendations for managing obesity in adolescents. However, information on how health care providers (HCPs) implement these recommendations in day-to-day practice is limited. Our objectives were to explore how HCPs deliver weight management health services to adolescents with obesity and describe the extent to which their reported practices align with recent CPGs for managing pediatric obesity.

Methods

From July 2017 to January 2018, we conducted a qualitative study that used purposeful sampling to recruit HCPs with experience in adolescent weight management from multidisciplinary, pediatric weight management clinics in Edmonton and Ottawa, Canada. Data were collected using audio-recorded focus groups (4–6 participants/group; 60–90 min in length). We applied inductive, semantic thematic analysis and the congruent methodological approach to analyze our data, which included transcripts, field notes, and memos. Qualitative data were compared to recent CPGs for pediatric obesity that were published by the Endocrine Society in 2017. Of the 12 obesity ‘treatment-related’ recommendations, four were directly relevant to the current study.

Results

Data were collected through three focus groups with 16 HCPs (n = 10 Edmonton; n = 6 Ottawa; 94% female; 100% Caucasian), including dietitians, exercise specialists, nurses, pediatricians, psychologists, and social workers. We identified three main themes that we later compared with CPG recommendations, including: (i) discuss realistic expectations regarding weight management (e.g., shift focus from weight to health; explore family cohesiveness; foster delayed vs instant gratification), (ii) personalize weight management (e.g., address personal barriers to change; consider developmental readiness), and (iii) exhibit non-biased attitudes and practices (e.g., de-emphasize individual causes of obesity; avoid making assumptions about lifestyle behaviors based on weight). Based on these qualitative findings, HCPs applied all four CPG recommendations in their practices.

Conclusions

HCPs provided practical insights into what and how they delivered weight management for adolescents, which included operationalizing relevant CPG recommendations in their practices.

Development of a modular ICF-based core set for the German substance use disorders treatment

PURPOSE

We aimed to develop a modular Core Set based on the International Classification of Functioning, Disability and Health (ICF) for describing functioning in patients with substance use disorders (SUDs). To match the structure of the German health service system, the Core Set was split into modules for different service segments.

METHODS

We followed a consensus process including several preparatory studies. To identify candidate ICF categories, we performed an ICF linking of guideline-recommended assessments, patient focus groups and patient and expert surveys. Categories were prioritized for different service segments and compiled into preliminary modules. The Core Set was tested in 13 treatment sites. Health professionals rated each category's relevance, and contents of the Modular ICF-based Core Set for SUDs (MCSS) were compared to patient-reported treatment goals. An advisory board decided on revisions to the MCSS.

RESULTS

The MCSS consists of a basic module (25 categories) and five additional modules for these treatment segments: counselling (8), qualified withdrawal (6), orientation (7), rehabilitation (32), and social integration services (10).

CONCLUSIONS

The MCSS provides a framework for harmonizing communication, documentation and interface management in German SUD health services. The basic module, consisting of 25 categories, can be employed as a Brief ICF Core Set.Implications for rehabilitationThe MCSS can serve as a standard for describing functioning in patients with SUDs in Germany, as well as harmonize communication and reporting of treatment relevant information.In clinical practice, the MCSS can be used for the structured assessment of psychosocial problems and participation restrictions, goal setting, and outcome evaluation.Although the MCSS was developed in Germany, its proximity to the themes frequently identified in the literature regarding SUDs internationally suggests that it may be of use in other countries as well.The basic module may be employed as a Brief ICF Core Set.

Size-dependent influence of NOx on the growth rates of organic aerosol particles

Atmospheric new-particle formation (NPF) affects climate by contributing to a large fraction of the cloud condensation nuclei (CCN). Highly oxygenated organic molecules (HOMs) drive the early particle growth and therefore substantially influence the survival of newly formed particles to CCN. Nitrogen oxide (NOx) is known to suppress the NPF driven by HOMs, but the underlying mechanism remains largely unclear. Here, we examine the response of particle growth to the changes of HOM formation caused by NOx. We show that NOx suppresses particle growth in general, but the suppression is rather nonuniform and size dependent, which can be quantitatively explained by the shifted HOM volatility after adding NOx. By illustrating how NOx affects the early growth of new particles, a critical step of CCN formation, our results help provide a refined assessment of the potential climatic effects caused by the diverse changes of NOx level in forest regions around the globe.

Outcome of inpatient opiate detoxification treatment in immigrants as compared to native Germans

Background

Immigration is a factor with effects on the course of substance abuse and treatment response, however there is little consistent data regarding outcome of inpatient opiate detoxification treatment in immigrants as compared to native patients.

Methods

Patient history and the success of current detoxification treatment were systematically documented in a multicenter study in Germany which included 10 psychiatric hospitals with specialized detoxification wards.

Results

Out of 893 patients, 240 (27%) had a migration history. We further analyzed the three main groups (German, n = 653; Turkish, n = 58; Russian origin, n = 103). There were significant differences between groups regarding sociodemographic data, drug history, treatment experience and success of current treatment. However, considering the younger age of patients with Russian origin, analysis of younger patients (< 31 years) detected only minor group differences. In multiple logistic regressions age and center showed statistically significant associations with all outcome variables (early dropout, achievement of drug-free urine screen, regular completion of detoxification treatment, and referral to further treatment), while (Russian) origin was associated only with premature termination of treatment.

Conclusion

Young men were the main problem group regardless of origin. Significant center effects raise doubts regarding results from monocenter research.

Patient-Centered Placement Matching of Alcohol-Dependent Patients Based on a Standardized Intake Assessment: Primary Outcomes of an Exploratory Randomized Controlled Trial

BACKGROUND

Placement matching guidelines are promising means to optimize patient-centered care and to match patients' treatment needs. Despite considerable research regarding placement matching approaches to optimize alcohol abuse treatment, findings are inconclusive.

OBJECTIVES

To investigate whether the use of patient-centered placement matching (PCPM) guidelines is more effective in reducing heavy drinking and costs 6 months after discharge from an inpatient alcohol withdrawal treatment compared to usual referral to aftercare. Secondary aims were to investigate whether age, gender, trial site or level of care (LOC) are moderators of efficacy and whether patients who were actually referred to the recommended LOC had better treatment outcomes compared to patients who were treated under- or overmatched.

METHODS

Design. Exploratory randomized controlled trial with measurements during withdrawal treatment and 6 months after initial assessment.

SETTING

Four German psychiatric clinics offering a 7-21 day inpatient qualified withdrawal program for patients suffering from alcohol dependence.

PARTICIPANTS

From 1,927 patients who had a primary diagnosis of alcohol dependence and did not have organized aftercare when entering withdrawal treatment, 299 were invited to participate. Of those, 250 were randomized to the intervention group (IG, n = 123) or the control group (CG, n = 127).

INTERVENTION

The PCPM were applied to patients of the IG by feeding back a recommendation to a LOC for aftercare that was calculated from the Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff of the treatment unit. Patients of the CG received a general feedback regarding their MATE interview on request.

MEASUREMENTS

The MATE, the Client Socio-Demographic and Service Receipt Inventory--European Version and the MATE-Outcomes were administered. Data were analyzed using generalized linear models.

RESULTS

In the intention-to-treat analysis, there were no significant differences between IG and CG regarding days of heavy drinking (incident risk ratio [IRR] 1.09; p = 0.640), direct (IRR 1.06; p = 0.779), indirect (IRR 0.77; p = 0.392) and total costs (IRR 0.89; p = 0.496). Furthermore, none of the investigated moderator variables affected statistically significant drinking or cost-related primary outcomes. Regardless of group allocation, patients who received matched aftercare reported significantly fewer days of heavy drinking than undermatched patients (IRR 2.09; p = 0.004). For patients who were overmatched, direct costs were significantly higher (IRR 1.79; p = 0.024), but with no additional effects on alcohol consumption compared to matched patients.

CONCLUSIONS

While the use of PCPM failed to affect the actual referral to aftercare, our findings suggest that treating patients on the recommended LOC may have the potential to reduce days of heavy drinking compared to undertreatment and costs compared to overtreatment.

Tailored interventions to support the implementation of the German national guideline on screening, diagnosis and treatment of alcohol-related disorders: a project protocol

Abstract. Background: The German Guideline on Screening, Diagnosis and Treatment of Alcohol Use Disorders aims to increase the uptake of evidence-based interventions for the early identification, diagnosis, prevention and treatment of alcohol-related disorders in relevant healthcare settings. To date, dissemination has not been accompanied by a guideline implementation strategy. The aim of this study is to develop tailored guideline implementation strategies and to field-test these in relevant medical and psycho-social settings in the city of Bremen, Germany. Methods: The study will conduct an impact and needs assessment of healthcare provision for alcohol use orders in Bremen, drawing on a range of secondary and primary data to: evaluate existing healthcare services; model the potential impact of improved care on public health outcomes; and identify potential barriers and facilitators to implementing evidence-based guidelines. Community advisory boards will be established for the selection of single-component or multi-faceted guideline implementation strategies. The tailoring approach considers guideline, provider and organizational factors shaping implementation. In field tests quality outcome indicators of the delivery of evidence-based interventions will be evaluated accompanied by a process evaluation to examine patient, provider and organizational factors. Outlook: This project will support the translation of guideline recommendations for the identification, prevention and treatment of AUD in routine practice and therefore contributes to the reduction of alcohol-related burden in Germany. The project is running since October 2017 and will provide its main outcomes by end of 2020. Project results will be published in scientific journals and presented at national and international conferences.

End-user perspectives to inform policy and program decisions: a qualitative and quantitative content analysis of lifestyle treatment recommendations by adolescents with obesity

Background

Lifestyle modifications represent the first line of treatment in obesity management; however, many adolescents with obesity do not meet lifestyle recommendations. Given that adolescents are rarely consulted during health policy development and in the design of lifestyle interventions, their first-hand experiences, preferences, and priorities may not be represented. Accordingly, our purpose was to explore adolescents’ lifestyle treatment recommendations to inform policy and program decisions.

Methods

Conducted from July 2017 to January 2018, this study adhered to a qualitative, crosslanguage, patient-oriented design. We recruited 19 13–17-year-old adolescents (body mass index [BMI] ≥85th percentile) seeking multidisciplinary treatment for obesity in geographically and culturally diverse regions of Canada. Adolescents participated in one-on-one, in-person, semi-structured interviews in English or French. Interviews were audio-recorded, transcribed verbatim, managed using NVivo 11, and analyzed using quantitative and qualitative content analysis by two independent researchers.

Results

Adolescents’ recommendations were organized into five categories, each of which denotes health as a collective responsibility: (i) establish parental support within limits, (ii) improve accessibility and availability of ‘healthy foods’, (iii) limit deceptive practices in food marketing, (iv) improve accessibility and availability of varied physical activity opportunities, and (v) delay school start times. Respect for individual autonomy and decision-making capacity were identified as particularly important, however these were confronted with adolescents’ partial knowledge on nutrition and food literacy.

Conclusions

Adolescents’ recommendations highlighted multi-level, multi-component factors that influenced their ability to lead healthy lifestyles. Uptake of these recommendations by policy-makers and program developers may be of added value for lifestyle treatment targeting adolescents with obesity.

[Rupture of the distal biceps tendon]

With an incidence of 3% of all biceps tendon injuries, rupture of the distal biceps tendon is a rare injury but can be associated with significant functional impairment of the elbow. In case of a complete rupture, the diagnosis can be made clinically with a pronounced power deficit, in particular for supination of the forearm. In cases of unclear symptoms magnetic resonance imaging should be included. Regarding the therapeutic approach, there is general consensus in the current literature that surgical treatment with anatomical reconstruction of the tendon footprint is superior to the conservative approach. Various surgical techniques with good biomechanical and clinical results are currently available but no clear superiority of a single technique has so far been demonstrated.

Edmonton Obesity Staging System for Pediatrics, quality of life and fitness in adolescents with obesity

BACKGROUND

Body mass index (BMI) is often used to diagnose obesity in childhood and adolescence but has limitations as an index of obesity-related morbidity. The Edmonton Obesity Staging System for Pediatrics (EOSS-P) is a clinical staging system that uses weight-related comorbidities to determine health risk in paediatric populations. The purpose of this study was to investigate the associations of EOSS-P and BMI percentile with quality of life (QOL), cardiorespiratory fitness (CRF) and muscular strength in adolescents with obesity.

METHODS

Participants were enrolled at baseline in the Healthy Eating, Aerobic and Resistance Training in Youth trial (BMI = 34.6 ± 4.5 kg m-2, age = 15.6 ± 1.4 years, N = 299). QOL, CRF (peak oxygen uptake, VO2peak) and muscular strength were assessed by the Pediatric QOL Inventory (PedsQL), indirect calorimetry during a maximal treadmill test and eight-repetition maximum bench and leg press tests, respectively. Participants were staged from 0 to 3 (absent to severe health risk) according to EOSS-P. Associations were assessed using age-adjusted and sex-adjusted general linear models.

RESULTS

Quality of life decreased with increasing EOSS-P stages (p < 0.001). QOL was 75.7 ± 11.4 in stage 0/1, 69.1 ± 13.1 in stage 2 and 55.4 ± 13.0 in stage 3. BMI percentile was associated with VO2peak (β = -0.044 mlO2 kg-1 min-1 per unit increase in BMI percentile, p < 0.001), bench press (β = 0.832 kg per unit increase in BMI percentile, p = 0.029) and leg press (β = 3.992 kg, p = 0.003). There were no significant differences in treadmill time or VO2peak between EOSS-P stages (p > 0.05).

CONCLUSION

As EOSS-P stages increase, QOL decreases. BMI percentile was negatively associated with CRF and positively associated with muscular strength.

Secondary Organic Aerosol Formation from Healthy and Aphid-Stressed Scots Pine Emissions

One barrier to predicting biogenic secondary organic aerosol (SOA) formation in a changing climate can be attributed to the complex nature of plant volatile emissions. Plant volatile emissions are dynamic over space and time, and change in response to environmental stressors. This study investigated SOA production from emissions of healthy and aphid-stressed Scots pine saplings via dark ozonolysis and photooxidation chemistry. Laboratory experiments using a batch reaction chamber were used to investigate SOA production from different plant volatile mixtures. The volatile mixture from healthy plants included monoterpenes, aromatics, and a small amount of sesquiterpenes. The biggest change in the volatile mixture for aphid-stressed plants was a large increase (from 1.4 to 7.9 ppb) in sesquiterpenes-particularly acyclic sesquiterpenes, such as the farnesene isomers. Acyclic sesquiterpenes had different effects on SOA production depending on the chemical mechanism. Farnesenes suppressed SOA formation from ozonolysis with a 9.7-14.6% SOA mass yield from healthy plant emissions and a 6.9-10.4% SOA mass yield from aphid-stressed plant emissions. Ozonolysis of volatile mixtures containing more farnesenes promoted fragmentation reactions, which produced higher volatility oxidation products. In contrast, plant volatile mixtures containing more farnesenes did not appreciably change SOA production from photooxidation. SOA mass yields ranged from 10.8 to 23.2% from healthy plant emissions and 17.8-26.8% for aphid-stressed plant emissions. This study highlights the potential importance of acyclic terpene chemistry in a future climate regime with an increased presence of plant stress volatiles.

Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients

Background

Shared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training.

Methods

A mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION⁵, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews.

Results

Initially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION⁵: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations.

Conclusion

The SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

Strategies to evaluate healthcare provider trainings in shared decision-making (SDM): a systematic review of evaluation studies

DESIGN AND OBJECTIVES

We performed a systematic review of studies evaluating healthcare provider (HCP) trainings in shared decision-making (SDM) to analyse their evaluation strategies.

SETTING AND PARTICIPANTS

HCP trainings in SDM from all healthcare settings.

METHODS

We searched scientific databases (Medline, PsycInfo, CINAHL), performed reference and citation tracking, contacted experts in the field and scanned the Canadian inventory of SDM training programmes for healthcare professionals. We included articles reporting data of summative evaluations of HCP trainings in SDM. Two reviewers screened records, assessed full-text articles, performed data extraction and assessed study quality with the integrated quality criteria for review of multiple study designs (ICROMS) tool. Analysis of evaluation strategies included data source use, use of unpublished or published measures and coverage of Kirkpatrick's evaluation levels. An evaluation framework based on Kirkpatrick's evaluation levels and the Quadruple Aim framework was used to categorise identified evaluation outcomes.

RESULTS

Out of 7234 records, we included 41 articles reporting on 30 studies: cluster-randomised (n=8) and randomised (n=9) controlled trials, controlled (n=1) and non-controlled (n=7) before-after studies, mixed-methods (n=1), qualitative (n=1) and post-test (n=3) studies. Most studies were conducted in the USA (n=9), Germany (n=8) or Canada (n=7) and evaluated physician trainings (n=25). Eleven articles met ICROMS quality criteria. Almost all studies (n=27) employed HCP-reported outcomes for training evaluation and most (n=19) additionally used patient-reported (n=12), observer-rated (n=10), standardised patient-reported (n=2) outcomes or training process and healthcare data (n=10). Most studies employed a mix of unpublished and published measures (n=17) and covered two (n=12) or three (n=10) Kirkpatrick's levels. Identified evaluation outcomes covered all categories of the proposed framework.

CONCLUSIONS

Strategies to evaluate HCP trainings in SDM varied largely. The proposed evaluation framework maybe useful to structure future evaluation studies, but international agreement on a core set of outcomes is needed to improve evidence.

PROSPERO REGISTRATION NUMBER

CRD42016041623.

Prospective outcome analysis following tenodesis of the long head of the biceps tendon along with locking plate osteosynthesis for proximal humerus fractures

BACKGROUND

Fractures of the proximal humerus are often associated with lesions of the long head of the biceps (LHB) tendon. This often leads to prolonged shoulder pain. Hence, many surgeons decide to perform a tenodesis of the LHB tendon simultaneous to ORIF. The purpose of this study was to evaluate the postoperative outcome after interlocking plate fixation and biceps tenodesis for treating proximal humerus fractures.

METHODS

56 patients (38 females, 18 male) suffering from proximal humerus fractures who underwent surgery were retrospectively included. 26 of these 56 patients (19% Neer II, 38% Neer III, 43% Neer IV) were treated with simultaneous tenodesis of the LHB tendon when ORIF using interlocking plate fixation was performed. 30 patients (17% Neer II, 40% Neer III, 43% Neer IV) served as control group receiving only interlocking plate fixation. The patients were asked to complete the Munich Shoulder Questionnaire (MSQ) for evaluation of postoperative shoulder function. Results of the Disabilities of the Arm, Shoulder and Hand (DASH) Score and Shoulder Pain and Disability Index (SPADI) were calculated from the MSQ. Patients were clinically evaluated for a positive O'Brien test and Popeye sign.

RESULTS

The tenodesis group demonstrated significant superior outcome regarding the MSQ (mean 90.47 points vs. 79.41 points, p = 0.006), DASH Score (mean 4.2 points vs. 16.81 points, p = 0.017) and SPADI (mean 94.59 points vs. 83.56, p = 0.045). Flexion, external rotation and the capability of throwing a soft ball were significantly improved in the tenodesis group compared to the control group. The O'Brien test as indicator for lesions of the LHB was positive in fewer patients of the tenodesis group (2/26, vs. 21/30, p = 0.001). There was no significant difference of a positive Popeye Sign.

CONCLUSION

Our results show evidence of an improved shoulder function when a simultaneous tenodesis of the LHB tendon is performed during treatment of proximal humerus fractures using interlocking plate fixation.

Fatigue in pediatric liver transplant recipients and its impact on their quality of life

The aim of the study was to investigate the occurrence of fatigue in 100 pediatric liver transplant recipients aged 2-18 years and its impact on their health-related quality of life (HRQL). HRQL and fatigue were measured using the PedsQL 4.0 Inventory and the PedsQL Multidimensional Fatigue Scale, which encompasses three subscales: general fatigue, sleep/rest fatigue, and cognitive fatigue. The impact of the different domains of fatigue and of clinical and sociodemographic factors on the HRQL was identified with stepwise multiple regression analyses. Parent proxy-reports were available for all 100 participants (2-18 years), and child self-reports were available for 71 patients (8-18 years). Across all domains, participants and their parents reported significantly more fatigue than healthy peers in a large PedsQL validation study. Thirty-seven percent of patients and 57% of parents scored clinically relevant levels of fatigue. In the multiple regression analyses, none of the clinical and sociodemographic factors contributed to the HRQL for child self-report. Only general and cognitive fatigue were significant predictors of patients' HRQL, explaining 66% of the variance in the PedsQL total score. For parent proxy-report, general and cognitive fatigue also significantly predicted child's HRQL. Further predictors were child's age and family income. The regression model explained 65% of the variance. These findings demonstrate the importance of assessing fatigue during regular follow-up examinations. Further research is urgently needed to better understand the underlying mechanisms of fatigue. Improvement of fatigue symptoms is essential for better HRQL, for cognitive functioning, and for school achievement.

Vermittlung von Patienten in eine Postakutbehandlung nach dem stationären qualifizierten Alkoholentzug

Ziel der Studie Ziel dieser Studie war es, einen Eindruck über die klinische Praxis der Indikationsstellung und Empfehlung für eine Postakutbehandlung aus dem qualifizierten Alkoholentzug zu gewinnen. Im Einzelnen wurde untersucht, welche möglichen Barrieren für die Empfehlung und Planung einer geeigneten Postakutbehandlung aus Sicht der verantwortlichen Mitarbeiterinnen und Mitarbeiter im qualifizierten Alkoholentzug bestehen. Weiterhin wurde erfasst, welche Kriterien für die Indikationsstellung für Postakutbehandlungen in der klinischen Praxis als relevant erachtet werden.

Methodik Mit insgesamt 3 Erinnerungsrunden wurden 418 Kliniken mit dem Angebot einer stationären qualifizierten Alkoholentzugsbehandlung zu einer schriftlichen Befragung eingeladen. Die Teilnahme war sowohl online als auch schriftlich möglich und sollte von jeweils einem Mitarbeiter stellvertretend für die gesamte Station beantwortet werden. Die Befragung enthielt Fragen zu Barrieren für eine Weiterverweisung, der Bedeutung verschiedener Indikationskriterien sowie Fragen zur Einrichtungsstruktur.

Ergebnisse Von 88 antwortenden Einrichtungen (21% Rücklauf), gaben 81 Behandlungsplätze für den qualifizierten Alkoholentzug an und wurden in die deskriptive Auswertung einbezogen. Die meisten Teilnehmer sahen lange Wartezeiten auf eine psychotherapeutische Weiterbehandlung (65,4%), Rehabilitation (48,1%), fehlende Behandlungsangebote für schwer beeinträchtigte Patienten (61,7%) sowie die Klärung der Kostenübernahme (45,7%) als starke Barriere für die Vermittlung in eine Postakutbehandlung. Für eine differentielle Indikationsstellung wurden symptombezogene Kriterien wie die Schwere der Abhängigkeit und das Rückfallrisiko mit einem Mittelwert über 5 auf einer 6stufigen Skala als besonders relevant erachtet.

Schlussfolgerungen Die benannten Barrieren beziehen sich v. a. auf die Versorgungsorganisation und sollten vor dem Hintergrund aktueller struktureller Änderungen repliziert werden, um einen Vergleich zu ermöglichen. Eine stärkere Betonung auch teilhabeorientierter Kriterien für die Wahl einer Postakutbehandlung sollte angestrebt werden, um die Wiederherstellung der Teilhabe als langfristigem Behandlungsziel stärker zu betonen.

Multicomponent new particle formation from sulfuric acid, ammonia, and biogenic vapors

A major fraction of atmospheric aerosol particles, which affect both air quality and climate, form from gaseous precursors in the atmosphere. Highly oxygenated organic molecules (HOMs), formed by oxidation of biogenic volatile organic compounds, are known to participate in particle formation and growth. However, it is not well understood how they interact with atmospheric pollutants, such as nitrogen oxides (NO _x ) and sulfur oxides (SO _x ) from fossil fuel combustion, as well as ammonia (NH₃) from livestock and fertilizers. Here, we show how NO _x suppresses particle formation, while HOMs, sulfuric acid, and NH₃ have a synergistic enhancing effect on particle formation. We postulate a novel mechanism, involving HOMs, sulfuric acid, and ammonia, which is able to closely reproduce observations of particle formation and growth in daytime boreal forest and similar environments. The findings elucidate the complex interactions between biogenic and anthropogenic vapors in the atmospheric aerosol system.

Excess costs of alcohol-dependent patients in German psychiatric care compared with matched non-alcohol-dependent individuals from the general population: a secondary analysis of two datasets

OBJECTIVES

Heavy alcohol use can cause somatic and mental diseases, affects patients' social life and is associated with social isolation, unemployment and reduced quality of life. Therefore, societal costs of alcohol dependence are expected to be high. The aim of this study was to estimate excess costs of patients with alcohol dependence diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria compared with individuals without alcohol dependence in Germany.

DESIGN

In a secondary analysis, baseline data of patients with alcohol dependence enrolled in a randomised controlled trial (German Clinical Trials Register DRS00005035) were compared with data collected via a telephone survey from individuals without alcohol dependence and that had been matched by entropy balancing. Health service use was evaluated retrospectively for a 6-month period.

SETTINGS

Four German psychiatric university clinics (patients with alcohol dependence) and the German general adult population (individuals without alcohol dependence).

PARTICIPANTS

n=236 adult patients with alcohol dependence and n=4687 adult individuals without alcohol dependence.

PRIMARY AND SECONDARY OUTCOME MEASURES

The excess costs of health service use, absenteeism and unemployment of patients with alcohol dependence were calculated and compared with individuals without alcohol dependence. In subgroup analyses, the associations between excess cost and gender, comorbidities and the duration of disease were investigated.

RESULTS

Total 6-month excess costs of €11 839 (95% CI €11 529 to €12 147) were caused by direct excess costs of €4349 (95% CI €4129 to €4566) and indirect costs of €7490 (95% CI €5124 to €9856). In particular, costs of inpatient treatment, formal long-term care, absenteeism and unemployment were high.

CONCLUSIONS

Alcohol dependence causes substantial direct and indirect excess costs. Cost-effective interventions to prevent and treat alcohol dependence are urgently needed.

TRIAL REGISTRATION NUMBER

DRKS00005035.

Joint versus separate inpatient rehabilitation treatment for patients with alcohol use disorder or drug use disorder: an observational study

Background

In many national treatment systems, patients with alcohol use disorders (AUD) and those with drug use disorders (DUD) are treated separately, while other systems provide joint treatment for both kinds of substance use disorders (SUDs). Regarding long-term rehabilitation treatment of DUD and AUD patients, there is however a lack of empirical studies on the comparison between a separate versus joint treatment modality.

Methods

Data were gathered from 2 rehabilitation units located in small towns from the same German region. One unit provided treatment to a mixed group of AUD and DUD patients, while the other unit treated the 2 groups separately. Staffing, funding, and treatment programs were otherwise similar between facilities. Data were gathered from standardized routine documentation and standardized interviews. In order to understand correlates of premature treatment termination, a logistic regression analysis was performed, with treatment modality and type of SUD as main predictors, and a range of patient characteristics as covariates.

Results

Patients (N=319) were diagnosed with AUD (48%), DUD (34%), or AUD plus DUD (18%). Patients in joint treatment showed a higher prevalence of lapses during treatment than those in separate treatment (26% versus 12%; p=0.009), but there was no significant difference in the prevalence of premature terminations (38% versus 44%, p=0.26). Treatment modality and interaction between modality and type of SUD was not significantly associated with premature termination. Joint treatment completers showed higher satisfaction with treatment than separate treatment completers (p<0.001).

Conclusion

We found no evidence here for a difference between treatment modalities in terms of premature termination rate. Satisfaction level was higher in those who completed joint treatment compared to separate treatment.

How Does a Shared Decision-Making (SDM) Intervention for Oncologists Affect Participation Style and Preference Matching in Patients with Breast and Colon Cancer?

The aims of this study are to assess patients' preferred and perceived decision-making roles and preference matching in a sample of German breast and colon cancer patients and to investigate how a shared decision-making (SDM) intervention for oncologists influences patients' preferred and perceived decision-making roles and the attainment of preference matches. This study is a post hoc analysis of a randomised controlled trial (RCT) on the effects of an SDM intervention. The SDM intervention was a 12-h SDM training program for physicians in combination with decision board use. For this study, we analysed a subgroup of 107 breast and colon cancer patients faced with serious treatment decisions who provided data on specific questionnaires with regard to their preferred and perceived decision-making roles (passive, SDM or active). Patients filled in questionnaires immediately following a decision-relevant consultation (t1) with their oncologist. Eleven of these patients' 27 treating oncologists had received the SDM intervention within the RCT. A majority of cancer patients (60%) preferred SDM. A match between preferred and perceived decision-making roles was reached for 72% of patients. The patients treated by SDM-trained physicians perceived greater autonomy in their decision making (p < 0.05) with more patients perceiving SDM or an active role, but their preference matching was not influenced. A SDM intervention for oncologists boosted patient autonomy but did not improve preference matching. This highlights the already well-known reluctance of physicians to engage in explicit role clarification.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00000539; Funding Source: German Cancer Aid.

Content comparison of guideline-recommended instruments used in treatment for alcohol use disorders

PURPOSE

Practice guidelines recommend the use of standardized instruments in the treatment of alcohol use disorders (AUDs); however, the extent to which these instruments assess patients' functioning is unclear. The aim of this study was to examine the domains of functioning and contextual factors contained in guideline-recommended instruments, using the International Classification of Functioning, Disability, and Health (ICF) as a reference.

MATERIALS AND METHODS

We identified instruments by reviewing AUD treatment guidelines used in Germany, Canada, Australia and New Zealand, United Kingdom, and United States. We included instruments which were available in English free of charge, we excluded instruments developed solely for diagnostic or epidemiological purposes and those for children or adolescents. Following a standardized set of rules, two health care researchers identified the concepts contained in the items on the instruments and independently linked them to ICF categories.

RESULTS

A total of 10 instruments were included. Among 517 items, 752 meaningful concepts (MCs) were derived, and 622 of them were linked to the ICF. Inter-rater agreement was κ = 0.61. One hundred eighty eight MCs referred to personal factors, 175 to body functions, 168 to activity and participation, and 91 to environmental factors. The most frequently linked ICF chapter was b1 (mental functions).

CONCLUSIONS

Instruments recommended in AUD treatment guidelines vary considerably in their assessment of patients' functioning and contextual factors. Within the investigated instruments, environmental factors are under-represented in comparison to body functions and personal factors. ICF linkage provides guidance for clinicians and researchers in the selection of appropriate instruments. Implications for rehabilitation Since instruments that are recommended in alcohol treatment guidelines vary considerably in respect the functioning domains and context factors they cover, it may be challenging for clinicians to select instruments relevant to their treatment context. Using the ICF as framework, our results provide guidance for clinicians in how to select appropriate instruments. Within the investigated instruments, environmental factors and activities and participation are under-represented in comparison to body functions and personal factors. Clinicians may employ AUD-unspecific or ICF-based instruments to cover these components if needed.

Welche Beeinträchtigungen erleben Patienten mit substanzbezogenen Störungen in ihrem Alltag?

Zusammenfassung. Hintergrund: Die Internationale Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) stellt einen konzeptuellen Rahmen und eine standardisierte Sprache zur Verfügung, um Funktionseinschränkungen im täglichen Leben zu beschreiben. Ziel dieser Studie war es, Einschränkungen, die Patienten mit substanzbezogenen Störungen in ihrem Alltag erleben, zu ermitteln und mithilfe der ICF abzubilden. Methodik: Im Rahmen dreier Fokusgruppen wurden Patienten zu ihren Alltagseinschränkungen befragt. Eingeschlossen wurden volljährige Teilnehmer, die sich wegen einer substanzbezogenen Störung zum Zeitpunkt der Untersuchung in einer suchtspezifischen Behandlung befanden und zu einer Teilnahme bereit waren. Zwei unabhängige Studienmitarbeiter teilten die Transkripte der Gespräche in Meaningful Concepts (MCs) auf und ordneten sie anhand der sog. linking rules zu Kategorien der ICF zu. Ergebnisse: 27 Patienten nahmen teil (Alter M = 44.15, 25.9 % weiblich). Es konnten insgesamt 870 MCs zu 185 verschiedenen ICF-Kategorien zugeordnet werden (Cohens κ = .44). Die am häufigsten benannten Kategorien in der Stichprobe waren Dienste des Gesundheitswesens (n = 54; 6.2 % aller MCs), Das Einsichtsvermögen betreffende Funktionen (n = 52; 6 %) und Motivation (n = 30; 3.4 %). Schlussfolgerungen: Die vorliegende Untersuchung gibt Aufschluss über die subjektiven Alltagseinschränkungen, die Patienten mit substanzbezogenen Störungen erleben und übersetzt sie anhand der ICF-Verlinkung in eine universelle Sprache, die einen Abgleich mit den Inhalten gängiger Erhebungsverfahren in der Suchthilfe ermöglicht.

Factors controlling the evaporation of secondary organic aerosol from α-pinene ozonolysis

Secondary organic aerosols (SOA) forms a major fraction of organic aerosols in the atmosphere. Knowledge of SOA properties that affect their dynamics in the atmosphere is needed for improving climate models. By combining experimental and modeling techniques, we investigated the factors controlling SOA evaporation under different humidity conditions. Our experiments support the conclusion of particle phase diffusivity limiting the evaporation under dry conditions. Viscosity of particles at dry conditions was estimated to increase several orders of magnitude during evaporation, up to 10⁹ Pa s. However, at atmospherically relevant relative humidity and time scales, our results show that diffusion limitations may have a minor effect on evaporation of the studied α-pinene SOA particles. Based on previous studies and our model simulations, we suggest that, in warm environments dominated by biogenic emissions, the major uncertainty in models describing the SOA particle evaporation is related to the volatility of SOA constituents.

Environmental conditions regulate the impact of plants on cloud formation

The terrestrial vegetation emits large amounts of volatile organic compounds (VOC) into the atmosphere, which on oxidation produce secondary organic aerosol (SOA). By acting as cloud condensation nuclei (CCN), SOA influences cloud formation and climate. In a warming climate, changes in environmental factors can cause stresses to plants, inducing changes of the emitted VOC. These can modify particle size and composition. Here we report how induced emissions eventually affect CCN activity of SOA, a key parameter in cloud formation. For boreal forest tree species, insect infestation by aphids causes additional VOC emissions which modifies SOA composition thus hygroscopicity and CCN activity. Moderate heat increases the total amount of constitutive VOC, which has a minor effect on hygroscopicity, but affects CCN activity by increasing the particles' size. The coupling of plant stresses, VOC composition and CCN activity points to an important impact of induced plant emissions on cloud formation and climate.

Volatile organic compounds (VOC) emitted by vegetation influence cloud formation, yet the impact of environmental stresses remains little known. Here, manipulation experiments reveal insect infestation and heat stress are linked to induced VOC and constitutive VOC emissions shifts, respectively.

Shared Decision Making and the Use of Decision Aids

BACKGROUND

In shared decision making (SDM), the patient and the physician reach decisions in partnership. We conducted a trial of SDM training for physicians who treat patients with cancer.

METHODS

Physicians who treat patients with cancer were invited to participate in a cluster-randomized trial and carry out SDM together with breast or colon cancer patients who faced decisions about their treatment. Decision-related physician-patient conversations were recorded. The patients filled out questionnaires immediately after the consultations (T1) and three months later (T2). The primary endpoints were the patients' confidence in and satisfaction with the decisions taken. The secondary endpoints were the process of decision making, anxiety, depression, quality of life, and externally assessed physician competence in SDM. The physicians in the intervention group underwent 12 hours of training in SDM, including the use of decision aids.

RESULTS

Of the 900 physicians invited to participated in the trial, 105 answered the invitation. 86 were randomly assigned to either the intervention group or the control group (44 and 42 physicians, respectively); 33 of the 86 physicians recruited at least one patient for the trial. A total of 160 patients participated in the trial, of whom 55 were treated by physicians in the intervention group. There were no intergroup differences in the primary endpoints. Trained physicians were more competent in SDM (Cohen's d = 0.56; p<0.05). Patients treated by trained physicians had lower anxiety and depression scores immediately after the consultation (d = -0.12 and -0.14, respectively; p<0.10), and markedly lower anxiety and depression scores three months later (d = -0.94 and -0.67, p<0.01).

CONCLUSION

When physicians treating cancer patients improve their competence in SDM by appropriate training, their patients may suffer less anxiety and depression. These effects merit further study.

[Participation restrictions in substance use disorders : Registration by screening and assessment instruments]

BACKGROUND

Substance use disorders can contribute to severe participation restrictions. Whether these participation restrictions are covered by assessment instruments that are frequently used in addiction treatment services is not known. The international Classification of Functioning, Disability and Health (ICF) provides a framework to compare the content of different assessments.

OBJECTIVES

The aim of this study was to investigate whether assessments that are frequently used in German addiction treatment services, cover participation restrictions according to the ICF.

MATERIALS AND METHODS

In the summer of 2015, we asked German addiction treatment services to participate in an online survey. Addiction treatment services were approached via the mailing lists of German associations of addiction treatment. Respondents were asked to indicate which assessments from a list of frequently used assessment instruments they were using in their treatment service. The most frequently used assessments were then linked to components of the ICF.

RESULTS

A total of N = 177 addiction treatment services responded to the survey. Most of them offered long-term rehabilitation treatment (n = 97; 61 %) or counselling services (n = 44; 28 %). Twelve assessments were used by more than 10 % of the respondents. The analysis revealed a total of 491 so-called meaningful concepts that could be linked to components of the ICF. Of these, 95 (16 %) referred to the ICF component activity and participation.

CONCLUSIONS

Frequently used assessments in addiction treatment services include contents of the ICF component activity and participation to a substantial degree. However, this does not mean by default that these assessments can be used to assess participation restriction in a meaningful way.

When do cancer patients regret their treatment decision? A path analysis of the influence of clinicians' communication styles and the match of decision-making styles on decision regret

OBJECTIVE

To test the influence of physician empathy (PE), shared decision making (SDM), and the match between patients' preferred and perceived decision-making styles on patients' decision regret.

METHODS

Patients with breast or colon cancer (n=71) completed questionnaires immediately following (T1) and three months after a consultation (T2). Path analysis was used to examine the relationships among patient demographics, patient reports of PE, SDM, the match between preferred and perceived decision-making styles, and patient decision regret at T2.

RESULTS

After controlling for clinician clusters, higher PE was directly associated with more SDM (β=0.43, p<0.01) and lower decision regret (β=-0.28, p<0.01). The match between patients' preferred and perceived roles was negatively associated with decision regret (β=-0.33, p<0.01). Patients who participated less than desired reported more decision regret at T2. There was no significant association between SDM and decision regret (β=0.03, p=0.74).

CONCLUSION

PE and the match between patients' preferred and perceived roles in medical decision making are essential for patient-centered cancer consultations and treatment decisions.

PRACTICE IMPLICATIONS

Ways to enhance PE and matching the consultation style to patients' expectations should be encouraged.