Wieviel stationäre Innere Medizin benötigen angehende Hausärzte in Ihrer Weiterbildung? - ein Werkstattbericht

Die Länge der Pflichtzeit in stationärer Innere Medizin im Rahmen der Facharztweiterbildung Allgemeinmedizin ist umstritten. Vor dem Hintergrund der stärkeren Kompetenzorientierung der Facharztweiterbildung, fand auf dem Kongress der Deutschen Gesellschaft für Allgemeinmedizin (DEGAM) in München einen Workshop mit der Frage wieviel stationäre Innere Medizin angehende Hausärzte benötigen und welche Kompetenzen in der stationären inneren Medizin erlangt werden sollen statt. In dem Workshop wurden als zentrale Kompetenzen Kennen und Erkennen von Krankheiten und Befunden, technische Fertigkeiten, Notfallmanagement und die Kenntnis stationären Arbeitens zusammengetragen. Welche Kompetenzen nur in der stationären Versorgung erlangt werden können und wieviel Zeit dafür notwendig ist, war umstritten. Notwendig erscheint vielmehr eine Individualisierung der Weiterbildung entsprechend der Bedürfnisse der einzelnen Ärzte in Weiterbildung und der Patienten

Spontaneous Emergence of Spatio-Temporal Order in Class 4 Automata

We report surprisingly regular behaviors observed for a class 4 cellular automaton, the totalistic rule 20: starting from disordered initial configurations the automaton produces patterns which are periodic not only in time but also in space. This is the first evidence that different types of spatio-temporal order can emerge under specific conditions out of disorder in the same discrete rule based algorithm.Comment: 5 pages, 6 color figures, Proceedings Medyfinol 2004, Physica A in prin

Prescribing and medical non-adherence after myocardial infarction: qualitative interviews with general practitioners in Germany

Background: An increasing prevalence of having survived a myocardial infarction increases the importance of medical secondary prevention. Although preventive medication reduces mortality, prescribing and adherence are known to be frequently insufficient. General practitioners are the most important prescriber. However, their perspective on prescribing and medical non-adherence following myocardial infarction has not yet been explored. Thus, the aim of this study was to explore the general practitioners' perspective on long-term care after myocardial infarction focussing on medical prevention. Methods: In this qualitative interview study we conducted episodic interviews with sixteen general practitioners from rural and urban surgeries in Germany. Framework analysis with focus on general practitioners' prescribing and patients' non-adherence was performed. Results: Almost all general practitioners reported following guidelines for myocardial infarction aftercare and prescribing the medication that was initiated in the hospital; however, they described deviating from guidelines because of drugs' side effects or patients' intolerances. Some questioned the benefits of medical secondary prevention for the oldest of patients. General practitioners perceived good adherence among their patients who had had an MI while they regarded their methods for assessing medical non-adherence as limited. They perceived diverse reasons for non-adherence, particularly side effects, patients' freedom from symptoms and patients' indifference to health. They attributed mainly negative characteristics, like lack of knowledge and understanding, to non-adherent patients. These characteristics contribute to the difficulty of convincing these patients to take medications as prescribed. General practitioners improved adherence by preventing side effects, explaining the medication's necessity, facilitating intake and involving patients in decision-making. However, about half of the general practitioners reported threatening their patients with negative consequences of non-adherence. Conclusions: General practitioners should be aware that discharge medication can be insufficient and thus, should always check hospital recommendations for accordance with guideline recommendations. Improving physicians' communication skills and informing and motivating patients in an adequate manner, for example in simple language, should be an important goal in the hospital and the general practitioner setting. General practitioners should assess patients' motivations through motivational interviewing, which no general practitioner mentioned during the interviews, and talk with them about adherence and long-term treatment goals regularly

Social Prescribing: Systematic Review of the Effectiveness of Psychosocial Community Referral Interventions in Primary Care

Introduction: Social prescribing (SP) aims to provide targeted psychosocial support and close the gap between medical and non-medical services. This review assesses the effectiveness of community-based SP interventions. Methods: We performed a systematic review and qualitative synthesis of interventional studies of community referral interventions focused on facilitating psychosocial support. We considered health-related endpoints, other patient reported outcomes, or health care utilization. Six databases, grey literature, and additional trials registers were searched. Results were screened in a two-step process, followed by data extraction, each by two independent reviewers. If data permitted such, effect sizes were calculated. Risk of bias was assessed with the EPHPP and the Cochrane RoB2 tools. Results: We identified 68 reports from 53 different projects, three were controlled studies. Uncontrolled studies with shorter time frames frequently reported positive effects. This could largely not be seen in controlled settings and for longer follow-up periods. Designs, populations, and outcomes evaluated were heterogeneous with high risk of bias for most studies. Discussion and conclusion: Current evidence suggests positive effects of SP on a variety of relevant endpoints. Due to quality deficits in the available studies, scope for conclusions concerning clinical relevance and sustainability is limited. Further methodologically rigorous controlled trials are needed

Determinants of COVID-19 vaccine acceptance and access among people experiencing homelessness in Germany: A qualitative interview study

Introduction: People experiencing homelessness face lower life expectancy, higher prevalence of somatic and mental diseases and a more difficult access to healthcare compared to people in secure living. During the COVID-19 pandemic transmission rates were higher among people experiencing homelessness and preventive public health measures were not properly adapted to the specific needs of people experiencing homelessness. Thus, goal of our study was understanding the determinants of acceptability and access of the COVID-19 vaccine. Materials and methods: We conducted a qualitative interview study with twenty guideline interviews with adult people currently experiencing homelessness in Berlin, Germany (August 2021 - April 2022). Participants were approached in a purposive sampling strategy. The interviews were analyzed with qualitative content analysis according to Mayring. Results: Acceptance and attitude toward the COVID-19 vaccine is influenced by confidence in the vaccine as well as in the political and healthcare system, the individual COVID-19 risk perception and sense of collective responsibility. Overall, the acceptance of the vaccine was high among our participants. Facilities offering low threshold COVID-19 vaccines for people experiencing homelessness were perceived as helpful. Language barriers and the need for identity documents were major barriers to access the COVID 19 vaccine. Discussion: People experiencing homelessness are a marginalized and vulnerable group often underrepresented in the public and scientific discourse. During the COVID-19 pandemic, preventive public health measures, including the COVID-19 vaccine, failed to consider specific needs of people experiencing homelessness. Multidimensional strategy to enhance inclusive healthcare are needed to improve access and to reduce discrimination and stigmatization

The Strange Man in Random Networks of Automata

We have performed computer simulations of Kauffman's automata on several graphs such as the regular square lattice and invasion percolation clusters in order to investigate phase transitions, radial distributions of the mean total damage (dynamical exponent $z$) and propagation speeds of the damage when one adds a damaging agent, nicknamed "strange man". Despite the increase in the damaging efficiency, we have not observed any appreciable change at the transition threshold to chaos neither for the short-range nor for the small-world case on the square lattices when the strange man is added in comparison to when small initial damages are inserted in the system. The propagation speed of the damage cloud until touching the border of the system in both cases obeys a power law with a critical exponent $\alpha$ that strongly depends on the lattice. Particularly, we have ckecked the damage spreading when some connections are removed on the square lattice and when one considers special invasion percolation clusters (high boundary-saturation clusters). It is seen that the propagation speed in these systems is quite sensible to the degree of dilution.Comment: AMS-LaTeX v1.2, 7 pages with 14 figures Encapsulated Postscript, to be publishe

Strongly hyperbolic Hamiltonian systems in numerical relativity: Formulation and symplectic integration

We consider two strongly hyperbolic Hamiltonian formulations of general relativity and their numerical integration with a free and a partially constrained symplectic integrator. In those formulations we use hyperbolic drivers for the shift and in one case also for the densitized lapse. A system where the densitized lapse is an external field allows to enforce the momentum constraints in a holonomically constrained Hamiltonian system and to turn the Hamilton constraint function from a weak to a strong invariant. These schemes are tested in a perturbed Minkowski and the Schwarzschild space-time. In those examples we find advantages of the strongly hyperbolic formulations over the ADM system presented in [arXiv:0807.0734]. Furthermore we observe stabilizing effects of the partially constrained evolution in Schwarzschild space-time as long as the momentum constraints are enforced.Comment: This version clarifies some points concerning the interpretation of the result

General practitioner care in nursing homes during the first wave of the COVID-19 pandemic in Germany: a retrospective survey among nursing home managers

Background: Though evidence on the detrimental impact of the COVID-19 pandemic in nursing homes is vast, research focusing on general practitioners' (GP) care during the pandemic in nursing homes is still scarce. Methods: A retrospective online survey among 1,010 nursing home managers in Germany was conducted during the first wave of the COVID-19 pandemic between November 2020 and February 2021. Associations between perceived deficits in GP care (routine and acute visits) and both general and COVID-19-related characteristics of nursing homes were analysed using multiple logistic regression analyses. Results: The majority of nursing home managers reported no deficits in GP care (routine visits, 84.3%; acute visits, 92.9%). Logistic regression analyses revealed that deficits in GP care (routine visits) were significantly associated with visiting restrictions for GPs and nursing home size. Small nursing homes (1-50 residents) were significantly more likely to report deficits in GP care (routine visits) compared to medium (51-100 residents) and large nursing homes (> 100 residents). Further, deficits in GP care (acute visits) were significantly associated with dementia as a focus of care and the burden of insufficient testing for SARS-CoV-2 among residents. Moreover, visiting restrictions for GPs were significantly associated with dementia as the focus of care and the COVID-19 incidence at the federal state level. Finally, COVID-19 cases in nursing homes were significantly associated with size of nursing homes, COVID-19-incidence on the federal state level and the burden of insufficient testing capacities for SARS-CoV-2 among residents. Conclusion: We found structural factors associated with GP care deficits during the pandemic. New concepts for GP care should be implemented in pandemic preparedness plans to ensure high quality, consistent, and reliable GP care as well as effective infection prevention measures in nursing homes

Characterisation of Australian MRSA Strains ST75- and ST883-MRSA-IV and Analysis of Their Accessory Gene Regulator Locus

Background: Community-acquired methicillin-resistant Staphylococcus aureus have become a major problem in Australia. These strains have now been isolated throughout Australia including remote Indigenous communities that have had minimal exposure to healthcare facilities. Some of these strains, belonging to sequence types ST75 and ST883, have previously been reported to harbour highly divergent alleles of the housekeeping genes used in multilocus sequence typing. Methodology/Principal Findings: ST75-MRSA-IV and ST883-MRSA-IV isolates were characterised in detail. Morphological features as well as 16S sequences were identical to other S. aureus strains. Although a partial rnpB gene sequence was not identical to previously known S. aureus sequences, it was found to be more closely related to S. aureus than to other staphylococci. Isolates also were screened using diagnostic DNA microarrays. These isolates yielded hybridisation results atypical for S. aureus. Primer directed amplification assays failed to detect species markers (femA, katA, sbi, spa). However, arbitrarily primed amplification indicated the presence of unknown alleles of these genes. Isolates could not be assigned to capsule types 1, 5 or 8. The allelic group of the accessory gene regulator (agr) locus was not determinable. Sequencing of a region of agrB, agrC and agrD (approximately 2,100 bp) revealed a divergent sequence. However, this sequence is more related to S. aureus agr alleles I and IV than to agr sequences from other Staphylococcus species. The predicted autoinducing peptide (AIP) sequence of ST75 was identical to that of agr group I, while the predicted AIP sequence of ST883 was identical to agr group IV. Conclusions/Significance: The genetic properties of ST75/ST883-MRSA may be due to a series of evolutionary events in ancient insulated S. aureus strains including a convergent evolution leading to agr group I- or IV-like AIP sequences and a recent acquisition of SCCmec IV elements