Less invasive ventilation in extremely low birth weight infants from 1997 to 2011: survey versus evidence.

UNLABELLED Evidence for target values of arterial oxygen saturation (SaO2), CO2, and pH has changed substantially over the last 20 years. A representative survey concerning treatment strategies in extremely low-birth-weight infants (ELBW) was sent to all German neonatal intensive care units (NICUs) treating ELBW infants in 1997. A follow-up survey was conducted in 2011 and sent to all NICUs in Germany, Austria, and Switzerland. During the observation period, NICUs targeting SaO2 of 80, 85, and 90 % have increased, while units aiming for 94 and 96 % decreased (all p < 0.001). Similarly, NICUs aiming for pH 7.25 or lower increased, while 7.35 or higher decreased (both p < 0.001). Furthermore, more units targeted a CO2 of 50 mmHg (7.3 kPa) or higher (p < 0.001), while fewer targeted 40 or 35 mmHg (p < 0.001). Non-invasive ventilation (NIV) was used in 80.2 % of NICUs in 2011. The most frequently used ventilation modes were synchronized intermittent mandatory ventilation (SIMV) (67.5 %) and intermittent positive pressure ventilation (IPPV) (59.7 %) in 1997 and SIMV (77.2 %) and synchronized intermittent positive pressure ventilation (SIPPV) (26.8 %) in 2011. NICUs reporting frequent or always use of IPPV decreased to 11.0 % (p < 0.001). SIMV (77.2 %) and SIPPV (26.8 %) did not change from 1997 to 2011, while high-frequency oscillation (HFO) increased from 9.1 to 19.7 % (p = 0.018). Differences between countries, level of care, and size of the NICU were minimal. CONCLUSIONS Target values for SaO2 decreased, while CO2 and pH increased significantly during the observation period. Current values largely reflect available evidence at time of the surveys. WHAT IS KNOWN • Evidence concerning target values of oxygen saturation, CO 2 , and pH in extremely low-birth-weight infants has grown substantially. • It is not known to which extent this knowledge is transferred into clinical practice and if treatment strategies have changed. WHAT IS NEW • Target values for oxygen saturation in ELBW infants decreased between 1997 and 2011 while target values for CO 2 and pH increased. • Similar treatment strategies existed in different countries, hospitals of different size, or university versus nonuniversity hospitals in 2011.

Does the use of mobile devices (tablets and smartphones) affect survey quality and choice behaviour in web surveys?

Web surveys are becoming increasingly popular in survey research including stated preference surveys. Compared with face-to-face, telephone and mail surveys, web surveys may contain a different and new source of measurement error and bias: the type of device that respondents use to answer the survey questions. This is the first study that tests whether the use of mobile devices, tablets or smartphones, affects survey characteristics and stated preferences in a web-based choice experiment. The web survey on expanding renewable energy production in Germany was carried out with 3182 respondents, of which 12% used a mobile device. Propensity score matching is used to account for selection bias in the use of mobile devices for survey completion. We find that mobile device users spent more time than desktop/laptop users to answer the survey. Yet, desktop/laptop users and mobile device users do not differ in acquiescence tendency as an indicator of extreme response patterns. For mobile device users only, we find a negative correlation between screen size and interview length and a positive correlation between screen size and acquiescence tendency. In the choice experiment data, we do not find significant differences in the tendency to choose the status quo option and scale between both subsamples. However, some of the estimates of implicit prices differ, albeit not in a unidirectional fashion. Model results for mobile device users indicate a U-shaped relationship between error variance and screen size. Together, the results suggest that using mobile devices is not detrimental to survey quality.

Power Games in Strategy Formation Processes – A Performative Interpretation

The article approaches an understanding of power within strategy formation processes established by verbal and bodily communication. On this note, we examined concepts of power constituted by hierarchy and developed a conceptual framework for a performative interpretation of power. In line with Austin’s (1962) and Butler’s (1990, 1993, 1997) concept of performativity as well as strategy-as-practice research (Balogun et al., 2007; Jarzabkowski & Spee, 2009) we ask: How is persuasion achieved by strategic actors during strategy formation processes? To explore verbal and bodily communication empirically we developed an experimental setting in a small high-tech company located in Germany in December, 2012. The Results indicate that (1) during critical incidents – when perspectives clash – actors use arguments to gain persuasion. (2) The data illustrates that independently of their hierarchical position within the company, strategic actors show an equal distribution of argumentative techniques.

Heiligenspielrezeption in der Schweiz 1929: Das Bruderklausenspiel von Oskar Eberle

Based on Hansjürgen Linke’s study about the history of the reception of religious and secular medieval plays in twentieth-century Germany, the paper examines the respective situation in Switzerland. It focusses on the Bruderklausenspiel (1929), written and staged by Oskar Eberle. The director and scholar Oskar Eberle, and the Schweizerische Gesellschaft für Theaterkultur (SGTK) were the most influential supporters of the reception of religious plays in twentieth-century Switzerland. While in Germany the revival of medieval theatre emphasized a Renaissance of a former national importance, in Switzerland, the situation was very different. The revival of religious plays had a certain confessional background, and the political idea was to strengthen national self-confidence, and to confirm the nation’s historical neutrality concerning foreign affairs.

Publication activities of German junior researchers in academic medicine: which factors impact impact factors?

Previous studies have shown medical students in Germany to have little interest in research while at the same time there is a lack of physician scientists. This study’s aim is to investigate factors influencing publication productivity of physicians during and after finishing their medical doctorate. We conducted a PubMed search for physicians having received their doctoral degree at Ludwig-Maxmilians-University Munich Faculty of Medicine between 2011 and 2013 (N = 924) and identified the appropriate impact factor (IF) for each journal the participants had published in. Gender, age, final grade of the doctorate, participation in a structured doctoral study program and joint publication activities between graduate and academic supervisor were defined as factors. For analyses we used nonparametric procedures. Men show significantly more publications than women. Before their doctoral graduation men publish 1.98 (SD ± 3.64) articles on average, women 1.15 (±2.67) (p < 0.0001, d = 0.27). After completion of the doctorate (up to 06/2015), 40 % of men still publish, while only 24.3 % of women (p < 0.0001, φ = 0.17) continue to publish. No differences were found concerning the value of IFs. Similar results were found regarding the variable ‘participation in a structured doctoral study program’. Until doctoral graduation, program participants publish 2.82 (±5.41) articles, whereas participants doing their doctorate individually only publish 1.39 (±2.87) articles (p < 0.0001, d = 0.46). These differences persist in publication activities after graduation (45.5 vs. 29.7 %, p = 0.008, φ = 0.09). A structured doctorate seems to have positive influence on IFs (4.33 ± 2.91 vs. 3.37 ± 2.82, p = 0.006, d = 0.34). Further significant results concern the variables ‘final grade’ and ‘age’: An early doctoral graduation and an excellent or very good grade for the doctoral thesis positively influence publication productivity. Finally, joint publication activities between the graduate and his/her academic supervisor result in significantly higher IFs (3.64 ± 3.03 vs. 2.84 ± 2.25, p = 0.007, d = 0.28). The study’s results support the assumption about women’s underrepresentation in science as well as the relevance of structured doctoral study programs for preparing and recruiting young academics in medicine for scientific careers. Promoting women and further development of structured doctoral study programs are highly recommended.

Prevalence of findings compatible with carotid artery calcifications on dental panoramic radiographs

Cerebrovascular accidents are responsible for killing or disabling more than half a million Americans every year. They are the third leading cause of death in this country. In Germany, the annual stroke incidence reaches 182 cases per 100,000 inhabitants. Stroke there is the fourth leading cause of death. There is a need of finding cost-effective means of decreasing stroke mortality and morbidity. Instruments for early diagnosis are of great humanitarian and economic importance. All possible clinical findings should be taken into account. It is not the demand of this study to present the panoramic radiograph as a screening test method for early diagnosis of atherosclerosis. The aim is to show the potential of this radiograph used in everyday clinical dental practice by the prevalence of radiopaque findings in the carotid region. This study included panoramic dental radiographs of 2,557 patients older than 30 years of age. Fifty-nine percent of the patients were women and 41% were men. The radiographs were adjudged for signs compatible with carotid arterial calcifications appearing as a radiopaque nodular mass adjacent to the cervical vertebrae at or below the intervertebral space C3-4. Of all these radiographs, 4.8% showed radiopaque findings compatible with atherosclerotic lesions. The proportion of women reached 64.8% and that of men reached 35.2%. In accordance to recent literature, the results of this study show that about 5% of the patients show radiological findings compatible with carotid arterial calcifications. Some of these patients at risk for a cerebrovascular accident may be identified in the dentist's office by appropriate review of the panoramic dental radiograph. The suspicion of carotid artery calcifications demands an impetuous referral to an appropriate practitioner who can assist in the control of risk factors and if necessary arrange surgical removal of the carotid arterial plaque. So, the dentist should be aware of this problem and able to make a contribution to stroke prevention.

[Homicide by bow and arrow]

Since the invention of firearms, arrow wounds represent a rarity in the daily routine of forensic pathologists. In the present paper, we describe a homicide by a broadhead arrow shot from a compound bow in a domestic environment. Based on this homicide, we discuss the characteristics of the lesion caused by broadhead arrows and field-tip arrows. We look critically at the free saleability of this equipment mostly used for sport shooting in Germany.

Urine tested positive for ethyl glucuronide and ethyl sulphate after the consumption of "non-alcoholic" beer

In abstinence maintenance programs, for reissuing the driving licence and in workplace monitoring programs abstinence from ethanol and its proof are demanded. Various monitoring programs that mainly use ethyl glucuronide (EtG) as alcohol consumption marker have been established. To abstain from ethanol, but not from the taste of alcoholic beverages, in particular non-alcoholic beer has become more and more popular. In Germany, these "alcohol-free" beverages may still have an ethanol content of up to 0.5vol.% without the duty of declaration. Due to severe negative consequences resulting from positive EtG tests, a drinking experiment with 2.5L of non-alcoholic beer per person was performed to address the question of measurable concentrations of the direct metabolites EtG and EtS (ethyl sulphate) in urine and blood. Both alcohol consumption markers - determined by LC-MS/MS - were found in high concentrations: maximum concentrations in urine found in three volunteers were EtG 0.30-0.87mg/L and EtS 0.04-0.07mg/L, i.e., above the often applied cut-off value for the proof of abstinence of 0.1mg EtG/L. In the urine samples of one further volunteer, EtG and EtS concentrations cumulated over-night and reached up to 14.1mg/L EtG and 16.1mg/L EtS in the next morning's urine. Ethanol concentrations in blood and urine samples were negative (determined by HS-GC-FID and by an ADH-based method).

Attacks on German public figures, 1968-2004: warning behaviors, potentially lethal and non-lethal acts, psychiatric status, and motivations

Fourteen non-terrorist attackers of public figures in Germany between 1968 and 2004 were intensively studied, with a particular focus on warning behaviors, attack behaviors, and the relationship between psychiatric diagnosis, symptoms, and motivations for the assault. A large proportion of the attackers were severely mentally ill, and most likely to be in the potentially lethal rather than the non-lethal group. A new typology of seven warning behaviors was applied to the data, and all were present, most frequently fixation and pathway warning behavior, and least frequently a direct threat. Psychiatric diagnosis could be closely linked to motivation when analyzed at the level of symptom and content of thought, often delusional. Most of the attacks were directed at political figures, and the majority occurred after 1995.

[Oral medicine: a specialty placed between medicine and dentistry]

Oral medicine is a dental specialty that bridges the traditional areas of health between dentistry and medicine. International descriptions reflect this and oral medicine is defined as "the dental speciality placed at the interface between medicine and dentistry and is concerned with the diagnosis and management of (non-dental) pathology affecting the oral and maxillofacial region." Oral medicine specialists provide clinical care to patients with a wide variety of orofacial conditions, including oral mucosal diseases, orofacial pain syndromes, salivary gland disorders, and oral manifestations of systemic diseases. There is a growing need to implement this specialty globally: due to the rapid progress in both medicine and dentistry, and to the growing percentage of senior citizens in many countries, the adequate diagnosis and treatment of oral diseases will become even more complex in the future. In this article, the authors' intention is to point out that oral medicine is neither a recognized specialty nor a distinct field of study in Germany, Austria, or Switzerland; thus, the need for postgraduate training in this field in countries where oral medicine is not a specialization is emphasized.

Double-blinded, randomized controlled trial comparing real versus placebo acupuncture to improve tolerance of diagnostic esophagogastroduodenoscopy without sedation: a study protocol

Background Sedation prior to performance of diagnostic esophagogastroduodenoscopy (EGDE) is widespread and increases patient comfort. But 98% of all serious adverse events during EGDEs are ascribed to sedation. The S3 guideline for sedation procedures in gastrointestinal endoscopy published in 2008 in Germany increases patient safety by standardization. These new regulations increase costs because of the need for more personnel and a prolonged discharge procedure after examinations with sedation. Many patients have difficulties to meet the discharge criteria regulated by the S3 guideline, e.g. the call for a second person to escort them home, to resign from driving and working for the rest of the day, resulting in a refusal of sedation. Therefore, we would like to examine if an acupuncture during elective, diagnostic EGDEs could increase the comfort of patients refusing systemic sedation. Methods/Design A single-center, double blinded, placebo controlled superiority trial to compare the success rates of elective, diagnostic EGDEs with real and placebo acupuncture. All patients aged 18 years or older scheduled for elective, diagnostic EGDE who refuse a systemic sedation are eligible. 354 patients will be randomized. The primary endpoint is the rate of successful EGDEs with the randomized technique. Intervention: Real or placebo acupuncture before and during EGDE. Duration of study: Approximately 24 months. Discussion Organisation/Responsibility The ACUPEND - Trial will be conducted in accordance with the protocol and in compliance with the moral, ethical, and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and Good Clinical Practice (GCP). The Interdisciplinary Endoscopy Center (IEZ) of the University Hospital Heidelberg is responsible for design and conduct of the trial, including randomization and documentation of patients' data. Data management and statistical analysis will be performed by the independent Institute for Medical Biometry and Informatics (IMBI) and the Center of Clinical Trials (KSC) at the Department of General, Visceral and Transplantation Surgery, University of Heidelberg.

Capitals and capabilities: linking structure and agency to reduce health inequalities

While empirical evidence continues to show that low socio-economic position is associated with less likely chances of being in good health, our understanding of why this is so remains less than clear. In this paper we examine the theoretical foundations for a structure-agency approach to the reduction of social inequalities in health. We use Max Weber's work on lifestyles to provide the explanation for the dualism between life chances (structure) and choice-based life conduct (agency). For explaining how the unequal distribution of material and non-material resources leads to the reproduction of unequal life chances and limitations of choice in contemporary societies, we apply Pierre Bourdieu's theory on capital interaction and habitus. We find, however, that Bourdieu's habitus concept is insufficient with regard to the role of agency for structural change and therefore does not readily provide for a theoretically supported move from sociological explanation to public health action. We therefore suggest Amartya Sen's capability approach as a useful link between capital interaction theory and action to reduce social inequalities in health. This link allows for the consideration of structural conditions as well as an active role for individuals as agents in reducing these inequalities. We suggest that people's capabilities to be active for their health be considered as a key concept in public health practice to reduce health inequalities. Examples provided from an ongoing health promotion project in Germany link our theoretical perspective to a practical experience.

[Analgesia for pediatric patients. Standards and special aspects]

In this paper we describe the assessment and medical treatment of pain in children according to the concept of the Centre of Pediatrics and Adolescent Medicine at the university of Freiburg, Germany. Opiate therapy in children as well as novel data about the association of paracetamol (acetaminophen) and wheezing/asthma bronchiale in children are discussed. Special aspects of analgesia for painful procedures and a nitrous oxide/oxygen mixture which has been recently introduced in Germany are described. The second part of the paper presents results of our prospective study about continuous infusion of fentanyl and midazolam in a fixed combination in 19 critically ill patients with a median age of 46 months, 40% of these patients had an ARDS. The mortality rate was 21%. A median dose of fentanyl of 3.9 microg/kg/h (midazolam 0.26 mg/kg/h) was infused. The fentanyl serum level (median 4.2 ng/ml, range 1.7-17.8 ng/ml) correlated significantly with the administered dose while the midazolam serum levels (median 911 ng/ml, range 234-4 651 ng/ml) correlated neither with the administered dose nor with any of the analysed parameters. Conclusion: A standard protocol for the assessment and treatment of pain should be established in every pediatric hospital. The data about the association of asthma bronchiale and paracetamol cannot be interpreted conclusively, but show that even for well known substances clinical trials may lead to new awareness. The study data about continuous infusion of fentanyl and midazolam show a good correlation of the fentanyl application to serum levels, while midazolam appears to be not the optimal substance for continuous sedation in this setting.

Trauma registry record linkage: methodological approach to benefit from complementary data using the example of the German Pelvic Injury Register and the TraumaRegister DGU(®)

In Germany, hospitals can deliver data from patients with pelvic fractures selectively or twofold to two different trauma registries, i.e. the German Pelvic Injury Register (PIR) and the TraumaRegister DGU(®) (TR). Both registers are anonymous and differ in composition and content. We describe the methodological approach of linking these registries and reidentifying twofold documented patients. The aim of the approach is to create an intersection set that benefit from complementary data of each registry, respectively. Furthermore, the concordance of data entry of some clinical variables entered in both registries was evaluated.

[How can the mentally ill achieve sustained employment? Supported employment versus pre-vocational training]

People with severe mental disorders are often without work, although work may have a positive effect on their health. The paper presents some results in this field from the German S3 guidelines on psychosocial therapies. In terms of evidence-based medicine supported employment (SE - first place then train) has proven to be most effective. Nevertheless, SE is still rare in Germany. Pre-vocational training, however, follows the concept first train then place and is offered in rehabilitation of the mentally ill (RPK) centres in Germany. There is some evidence that the programs are beneficial for users. The UN Convention for the Rights of Persons with Disabilities outlines an obligation for work on an equal basis with others and for vocational training. So far, the German mental health system only partly meets these requirements.