[Practice and challenges of delegating medical tasks in the interprofessional everyday work of inpatient healthcare in Germany - An exploratory survey]. / Praxis und Herausforderungen der Delegation ärztlicher Tätigkeiten im interprofessionellen Arbeitsalltag der stationären Krankenversorgung in Deutschland: eine explorative Befragung.

BACKGROUND: The delegation of medical tasks (DMT) plays a significant role in the everyday practice of inpatient care but also presents a potential challenge in interprofessional collaboration. Assessing the conditions of DMT in everyday work is crucial to identify areas for optimization. METHODS: In a nationwide exploratory study, physicians, nursing and allied health professionals working for inpatient care facilities were surveyed regarding various aspects of DMT using a standardized online questionnaire. RESULTS: The majority of the 757 participants (64.9% physicians), perceived DMT to be both economically and time-efficient (88.5% agreement) and in the best interest of patients (74%). For 78.7% of the respondents, DMT represents a potential conflict in their daily work, depending on the quality of interprofessional communication. Inadequate staffing was identified as a barrier to a broader implementation of DMT by 83.8% of participants. 63.2% of the participants considered their knowledge of legal aspects related to DMT to be at least good (participants with less than 5 years of professional experience: 52.6%). Physicians primarily acquire relevant knowledge through professional practice (71.3% vs. non-physicians 39.5%). CONCLUSION: Across the different professional groups DMT was considered beneficial and serving the interests of patients. Targeted promotion of safe and cost-effective DMT should be incorporated into medical education. Achieving greater benefits from DMT requires explicit legal frameworks, effective communication within the team and, in particular, adequate staffing among the professional groups responsible for delegated tasks.

Treatment of esophageal leakages with the Microtech®-VAC-Stent: a monocentric early experience of three cases.

Background: Endoscopic approaches in the treatment of transmural esophageal defects, either after esophageal resection or due to perforation, have demonstrated convincing feasibility. Surgical options are limited and associated with high morbidity and mortality rates. Currently, internal endoscopic drainage with pigtail stents, self-expanding metal stent (SEMS), or endoscopic vacuum therapy (EVT) are options for first-line treatment. Here, we report the outcome of the recently developed combination of SEMS and EVT using the endoscopic Microtech®-VAC-Stent (EVS). Methods: Between June and July 2022, three consecutive patients (one female and two males) with esophageal transmural defects were treated with the Microtech®-VAC-Stent. Two patients suffered from an anastomotic leak after oncologic gastroesophageal surgery, and one patient presented with esophageal perforation due to Boerhaave syndrome. Results: Three consecutive patients were successfully treated with EVS. In one patient, one EVS treatment was sufficient, whereas the other two patients needed two and six EVS exchanges. Exchanges were scheduled every 7 days and no procedural adverse events were observed. Conclusion: In line with the former case series, EVS therapy is a promising new approach for the treatment of esophageal leaks. Exchange of the EVS seems feasible every 7 days reducing interventions for the individual patient. Prospective studies comparing EVS with other endoscopic therapies are needed to define the best therapeutic approach.

[Climate Crisis: What Gastrointestinal Complications of this Medical Emergency Should We Be Aware Of?] / Klimakrise: Welche gastroenterologischen Folgeerkrankungen dieses medizinischen Notfalls sollten wir kennen?

INTRODUCTION: The climate crisis has serious consequences for many areas of life. This applies in particular to human health - also in Europe. While cardiovascular, pneumological and dermatological diseases related to the climate crisis are often discussed, the crisis' significant gastroenterological consequences for health must also be considered. METHODS: A literature search (Pubmed, Cochrane Library) was used to identify papers with relevance particularly to the field of gastroenterology in (Central) Europe. Findings were supplemented and discussed by an interdisciplinary team. RESULTS: The climate crisis impacts the frequency and severity of gastrointestinal diseases in Europe due to more frequent and severe heat waves, flooding and air pollution. While patients with intestinal diseases are particularly vulnerable to acute weather events, the main long-term consequences of climate change are gastrointestinal cancer and liver disease. In addition to gastroenteritis, other infectious diseases such as vector-borne diseases and parasites are important in the context of global warming, heat waves and floods. DISCUSSION: Adaptation strategies must be consistently developed and implemented for vulnerable groups. Patients at risk should be informed about measures that can be implemented individually, such as avoiding heat, ensuring appropriate hydration and following hygiene instructions. Recommendations for physical activity and a healthy and sustainable diet are essential for the prevention of liver diseases and carcinomas. Measures for prevention and the promotion of resilience can be supported by the physicians at various levels. In addition to efforts fostering sustainability in the immediate working environment, a system-oriented commitment to climate protection is important.

Validation of the German Inflammatory Bowel Disease Fatigue (IBD-F) Questionnaire.

INTRODUCTION: Fatigue is a common symptom in patients with inflammatory bowel diseases (IBD). To date, there is no instrument to assess IBD-specific fatigue in German. The aim of this study was to translate the IBD Fatigue (IBD-F) scale and to test its psychometric properties in a German IBD population. METHODS: After completing the translation process, 20 IBD patients participated in a pilot testing phase. For further analyses, 180 IBD patients with fatigue answered the IBD-F (Sections I, II, III) and the IBD Questionnaire (IBDQ-D). Reliability was tested by using Cronbach's alpha and corrected item-total correlation. Exploratory factor analyses (EFA) were carried out. Spearman's correlation was calculated between the IBD-F and IBDQ-D . 78 patients could be included to calculate the test-retest reliability. RESULTS: The German version of the IBD-F shows high face and content validity. Internal consistency was excellent, with a Cronbach's alpha of 0.93-0.98. Corrected item-total correlations ranged from 0.51 to 0.89. The correlation between the IBD-F and the IBDQ-D was statistically significant for Section I (rs=-0.59; p<0.01) and Section II (rs=-0.76; p<0.01) of the IBD-F. The EFA identified one relevant factor for each section. Test-retest reliability was acceptable for Section I (intraclass correlation coefficient (ICC)=0.73) and Section II (ICC=0.84). CONCLUSION: The German version of the IBD-F is a reliable and valid tool to assess fatigue in IBD.

The Patient's Point of View: COVID-19 and Neuroendocrine Tumor Disease.

The assessment of cancer patient care during the COVID-19 pandemic has been mainly reported from a physician's perspective. Patients with rare tumor entities such as neuroendocrine tumors (NET), which require a complex and specialized care infrastructure, were highly affected by the COVID-19 crisis. Using a structured questionnaire consisting of a general section on the disease and a special COVID-19 section to record medical care, vaccination behavior as well as social and psycho-emotional parameters were collected from NET patients. The survey was distributed via direct medical contact and via the patient organization NETZWERK NeT. A total of 684 patients participated in the survey and 79.2% (n = 542) of the participants answered the questionnaire completely (54 questions). Patient characteristics were comparable to those in large NET registries. The majority of participants were patients with pancreatic and small bowel NET on somatostatin analogue (SSA) therapy. Medical care under COVID-19 was adequate and appointment cancellations and postponements were not common. Nevertheless, the majority of patients were worried about adequate treatment for their tumor disease during the crisis. Most of the participants considered themselves to be at risk of severe COVID-19 infection and were therefore very concerned. This was accompanied by an extremely high vaccination readiness rate of 90%. Increased distress in the social and psycho-emotional domains in the course of the crisis reflected a need for optimization in the medical care of NET patients, although the rate of COVID-19 positive participants was low (3.7%). Therefore, patient-reported measurements are required to identify and address all areas of medical care. Overall, our survey provides an essential contribution to the care of NET patients during the COVID-19 pandemic from the patient's perspective.

SARS-CoV-2 vaccination does not induce relapses of patients with inflammatory bowel disease.

BACKGROUND: Vaccination against SARS-CoV-2 is a promising strategy to protect immunocompromised IBD patients from a severe course of COVID-19. As these patients were excluded from initial clinical vaccination trials, patients frequently express concerns regarding the safety of these vaccines, especially whether vaccination might trigger IBD flares ("hit-and-run-hypothesis"). METHODS: In order to assess the risk of an IBD flare after vaccination against SARS-CoV-2, an anonymous survey was performed at five German IBD centers and one patient organization (Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung (DCCV) e.V.) in August and October 2021. RESULTS: The questionnaire was answered by 914 patients, 781 of whom reported a previous vaccination against SARS-CoV-2 (85.4%). Vaccination against SARS-CoV-2 was not associated with an increased risk of IBD flares (p=0.319) or unscheduled visits to the IBD physician (p=0.848). Furthermore, typical symptoms of an IBD flare including abdominal pain, increases in stool frequency, or rectal bleeding were not influenced by the vaccination. CONCLUSION: Vaccination against SARS-CoV-2 is safe in IBD patients. These results may help to reduce fears regarding the vaccination in IBD patients. Our results can help to reduce fears in IBD patients regarding the SARS-CoV-2 vaccine. A close communication between patients and physicians before and after the vaccination may be beneficial.

The Selective 5-HT1A Agonist SR57746A Protects Intestinal Epithelial Cells and Enteric Glia Cells and Promotes Mucosal Recovery in Experimental Colitis.

BACKGROUND: Neurotrophic growth factors can stabilize the intestinal barrier by preventing the apoptosis of enteric glial cells (EGCs) and enterocytes. We reasoned that a selective 5-HT1A receptor agonist may have neuroprotective properties in the gut and that topical application of SR57746A might be an effective treatment strategy in inflammatory bowel disease (IBD). METHODS: The therapeutic potential of 5-HT1A receptor agonist SR57746A in IBD was evaluated in vitro (nontransformed NCM460 colonic epithelial cells, SW480 colorectal carcinoma cells) and in vivo (murine dextran sulfate sodium [DSS] colitis and CD4-T-cell transfer colitis). In vitro, we analyzed the effect of SR57746A on apoptosis in intestinal epithelial cells (IECs) and EGCs, and upon proliferation, migration, and intracellular signaling in IECs. In vivo, the effect of topical application of SR57746 on disease activity and on histological and endoscopic findings was compared with intraperitoneal infliximab and placebo, respectively. RESULTS: The SR57746A activates PI3-K/AKT- and ERK-signaling in IECs. Depending on ERK- and AKT activation, SR57746A potently prevents apoptosis of IECs without inducing proliferation or migration in these cells. Moreover, SR57746A prevented apoptosis in EGCs in vitro. Topical SR57746A treatment significantly reduced mucosal injury in 2 experimental murine colitis models and was as effective as intraperitoneal infliximab treatment. CONCLUSIONS: Treatment with SR57746A prevents inflammatory cell damage and apoptosis in IECs and EGCs, similar to the neurotrophic effects of EGCs on IECs. Topical treatment with SR57746A could be a candidate for clinical evaluation in the treatment of IBD.

Inflammatory Bowel Disease and COVID-19: How Have Patients Coped So Far?

OBJECTIVE: Knowledge about SARS-CoV2 and coronavirus disease 2019 (COVID-19) is growing fast. Massive changes in the health care system imposed by the COVID-19 pandemic clearly impact the overall quality of medical care. In this survey, we aim to explore experiences and concerns of patients with inflammatory bowel disease (IBD) regarding the current pandemic. METHODS: A 40-item web-based questionnaire on disease-related experiences and concerns during the COVID-19 pandemic was made available to patients with IBD from 28 April 2020 to 31 July 2020. RESULTS: An increased risk of SARS-CoV2 infection was a concern for 56.7% of the 1199 patients (aged 41.3±12.8, women 77%, Crohn's disease 58.8%, ulcerative colitis 38.5%); 61.7% feared an increased risk of severe disease course of COVID-19. Effective preventive measures in either outpatient practices or hospitals were observed by 84.7% of the patients. Appointments with an IBD specialist were canceled in 38.7%, frequently on the patients' initiative. Telecommunication visits were considered an acceptable alternative to personal visits by 71.0%. Medication was reduced or paused in 6.9% because of the pandemic. A swab (SARS-CoV2-PCR) was done in 13.2% of the patients; only 3 patients (0.25%) were tested positive. CONCLUSION: The COVID-19 pandemic is a major concern of patients with IBD. However, the cumulative prevalence in our cohort is low. Patients at risk should be identified and counseled individually. When required because of the local COVID-19 situation, telecommunication visits and liberal prescription policies are advisable to reduce in-person contacts, while ensuring continuous therapy and maintaining communication with patients.

[Effects of SARS-CoV-2 Infection on Symptoms and Therapy of Inflammatory Bowel Disease]. / Auswirkungen einer SARS-CoV-2-Infektion auf Symptomatik und Therapie chronisch-entzündlicher Darmerkrankungen.

INTRODUCTION: The influence of a SARS-CoV-2 infection on inflammatory bowel disease (IBD) has not yet been well characterized and it is unclear whether this requires an adaptation of the immunosuppressive therapy. METHODS: A national register was established for the retrospective documentation of clinical parameters and changes in immunosuppressive therapy in SARS-CoV-2 infected IBD patients. RESULTS: In total, only 3 of 185 IBD patients (1.6 %) were tested for SARS-CoV-2 infection because of abdominal symptoms. In the course of COVID-19 disease, 43.5 % developed diarrhea, abdominal pain or hematochezia (risk of hospitalization with vs. without abdominal symptoms: 20.0 % vs. 10.6 %, p < 0.01). With active IBD at the time of SARS-CoV-2 detection, there was an increased risk of hospitalization (remission 11.2 %, active IBD 23.3 % p < 0.05). IBD-specific therapy remained unchanged in 115 patients (71.4 %); the most common change was an interruption of systemic therapy (16.2 %). DISCUSSION: New abdominal symptoms often appeared in SARS-CoV-2 infected IBD patients. However, these only rarely led to SARS-CoV-2 testing. A high IBD activity at the time of SARS-CoV-2 detection was associated with an increased risk of hospitalization.

Family planning with inflammatory bowel disease: the challenge of childlessness and parent concerns.

BACKGROUND: In patients with inflammatory bowel disease (IBD), diagnosis is often established at the beginning of childbearing age. Accordingly, concerns about family planning and pregnancy (FPP) are common. Poor knowledge regarding FPP might contribute to increased childlessness in patients with IBD. METHODS: The Crohn's and Colitis Pregnancy Knowledge Score (CCPKnow, 17 multiple-choice questions) was translated into German and then used for a web-based survey. Childlessness was analyzed with respect to socio-demographic and disease-related information, and the knowledge (CCPKnow) and concerns of IBD patients with children were compared to those of voluntarily childless (VC) and non-voluntarily childless (NVC) IBD patients. RESULTS: Childlessness was observed in 57.4 % of the 533 participants (90.6 % women, 63.0 % Crohn's disease, 31.5 % ulcerative colitis, mean age 33.2 ±â€Š8.6 years), voluntary childlessness in 9 %. The mean overall CCPKnow was adequate (9.38 ±â€Š3.96). Poor knowledge was not associated with increased childlessness (CCPKnow of < 8 was found in 29.8 % of patients with children and 28.9 % of childless patients, p > 0.5). Instead, the patients' education, medical advice, FPP-related concerns, impaired body image, and sexual dysfunction had a significant impact on childlessness. Frequent concerns included adverse effects of the patient's medication on their child (36 % of the respondents), malformation (33 %), miscarriage (34.5 %), and the inheritability of IBD (57 %). CONCLUSIONS: Factual knowledge does not reduce disease-related concerns or childlessness. Correct but possibly bothersome information on FPP might contribute to childlessness in patients with IBD. Our findings underline the need for qualified counseling of IBD patients regarding FPP by an experienced IBD physician.

Fluoroscopy-guided endoscopic sclerotherapy: a novel hybrid approach for symptomatic rectosigmoidal venous malformation (with video).

BACKGROUND AND AIMS: Recommendations for the treatment of lower GI bleeding do not include bleeding from venous malformations (VMs). The aim of this study was to delineate the usefulness of a novel hybrid intervention (fluoroscopy-guided endoscopic sclerotherapy) for the treatment of symptomatic VMs in the rectosigmoidal colon with bleeding. METHODS: The magnetic resonance images of 421 patients with VM, referred to multicenter vascular anomaly centers from 2009 to 2017, were analyzed retrospectively. Treatment was performed for all patients who experienced bleeding from rectosigmoidal VMs using fluoroscopy-guided endoscopic sclerotherapy with polidocanol foam as a novel approach. RESULTS: A total of 27 patients displayed VM in the rectosigmoidal area. Eleven of these presented with acute or previous bleeding and received treatment. Active bleeding was observed in 8 patients (72.7%), whereas 3 patients (27.3%) had signs of previous bleeding. Six of the 11 patients had anemia (54.5%). There were no adverse events within 24 hours of the intervention. In a 2-year follow-up period, only 1 patient (9.1%) presented with recurrent bleeding after 13 months and was successfully treated again with fluoroscopy-guided endoscopic sclerotherapy. CONCLUSIONS: Fluoroscopy-guided endoscopic sclerotherapy was shown to be a safe and effective treatment of symptomatic VMs of the rectosigmoidal area. Thus, fluoroscopy-guided endoscopic sclerotherapy should be considered for patients with bleeding from VMs of the rectosigmoid after a comprehensive workup and interdisciplinary case discussion.

Application of telepresence systems in teaching - transfer of an interprofessional teaching module on digital aided communication into the block training "internal medicine" during the Covid-19 pandemic.

Objective: The contact restrictions caused by the Covid-19 pandemic fundamentally limit patient-centered teaching. To realize a patient-oriented education in the block training "Internal Medicine" at the University Hospital Halle (Saale) despite the challenges, the already established teaching module "Interprofessional Teleconsultation" was adapted. The short article outlines the interprofessional teaching module including first evaluation results and describes the adapted block training. Method: In the "Internal Medicine" block training, students in a lecture hall navigated a telepresence system, which was accompanied by a physician across the ward and conducted an anamnesis via video and audio transmission without actual patient contact. Results: Students, physicians, and patients were open-minded about this form of communication during the Covid-19 pandemic and quickly got accustomed to the use of the telepresence system. To be able to react to technical challenges (e.g. unstable connection between the communication partners), a careful preparation of the lecturers is necessary. Conclusion: In using a telepresence system, patient-oriented teaching of students in the block training "Internal Medicine" can be ensured with low-threshold technical effort during the Covid-19 pandemic. The telepresence system allows for the involvement of patients into teaching while adhering to the necessary hygiene measures. Despite technical challenges, the teaching format based on telepresence is suitable as an alternative to face-to-face teaching if actual patient contact is not possible.

Thumb sucking or nail biting in childhood and adolescence is associated with an increased risk of Crohn's disease: results from a large case-control study.

BACKGROUND: The hygiene hypothesis suggests that a reduction in microbial exposure contributes to an impaired immune response later in life and increases the incidence of immune-mediated diseases such as inflammatory bowel diseases (IBD). Thumb sucking and nail biting are two early habits that modulate the oral microbiota composition and antigen load. OBJECTIVE: We hypothesized a lower risk of Crohn's disease (CD) and ulcerative colitis (UC) in adults with prior thumb sucking and nail biting. METHODS: 918 IBD cases and their 918 siblings without IBD were asked to fill out a survey containing 32 questions on environmental factors in childhood and early adulthood. Prevalence of thumb sucking and/or nail biting at the usually well-remembered time of (1) school enrollment and (2) coming-of-age ceremonies was the predefined combined risk factor of this study. RESULTS: 65% of the patients were female and 57% suffered from CD. About 49% of IBD patients but only 44% of their siblings reported thumb sucking/nail biting at the time of school enrollment or coming-of-age (p = .007). Sensitivity analysis revealed that this difference was observed in patients with CD (50% versus 41%; RR= 1.22; 95% CI 1.09-1.37, p = .001) but not in patients with UC (49% versus 48%; RR= 1.02; 95% CI 0.90-1.17; p = .83). CONCLUSION: Contrary to our expectation and challenging the hygiene hypothesis, we found that common oral habits are not protective against IBD. Instead, nail biting at the time of school enrollment and coming-of-age was a statistically significant risk factor for CD in our cohort. Key summary Evidence available before this study: The hygiene hypothesis suggests that a reduction in microbial exposure due to improved health activities has contributed to an immunological imbalance in the intestine and an increased incidence of allergic and autoimmune diseases. A population-based birth cohort study has demonstrated that thumb-sucking and nail biting in children lead to a reduction of the risk of atopic sensitization, asthma, and hay fever. Added value of this study: Contrary to the hypothesis, thumb sucking and nail biting were not associated with a reduced risk of IBD. Instead, thumb sucking and/or nail biting at the usually well-remembered points in time of school enrollment and of religious or secular coming-of-age ceremonies was associated with a higher risk of Crohn's disease but not of ulcerative colitis. Our data did not support the hygiene hypothesis, one pathogenic concept in the context of IBD.

The nasogastric tube is stuck - and causes coughing and dyspnoea: A rare complication.

For critically ill patients, it is very important that enteral nutrition is established as early as possible. Nasogastric tubes are commonly used for transient enteral nutrition and are generally considered safe to use and handle. However, in unconscious patients special care is needed to detect - possibly life threatening - complications. Here we report the case of a nasogastric tube, which inadvertently looped around the epiglottis. The symptoms and treatment of this rare complication are described and possible measures to prevent this situation are discussed.

High frequency of secondary, but not primary ocular manifestations of inflammatory bowel disease in patients treated at a tertiary care center.

OBJECTIVE: Ocular manifestations of inflammatory bowel disease (IBD) are relevant complications of IBD. Only a few prospective studies are available on the characteristics of these manifestations. The aim of this study was to characterize the frequency of eye disease in patients with IBD, including primary and secondary ocular manifestations of IBD, and to identify patients who may need specialized ophthalmologic care. PATIENTS AND METHODS: In a prospective observational study, patients with IBD were examined for ocular symptoms in comparison with control participants without IBD. All patients with IBD underwent a thorough ophthalmologic examination (including slit-lamp, tonometry, tear breakup time, Schirmer's test, and coherence tomography). The results were analyzed with respect to sociodemographic and disease-related characteristics. RESULTS: A total of 61 patients (33 women, 39 Crohn's disease, 22 ulcerative colitis, age 43.3±12.9 years, disease duration 12.4±9.3 years) were included. Ophthalmologic symptoms were reported by 53 patients (86.9%, most frequently deterioration of vision 42.6%, foreign body sensation 36.1%) compared with 60.6% in healthy controls (P=0.001). A clinically relevant, previously undetected ophthalmologic diagnosis was identified in 56 patients (91.8% - dry eye syndrome 75.4%, cataract 67.2%, blepharitis 45.9%, fundus hypertonicus 14.8%, other 16.4%). CONCLUSION: Although primary ocular manifestations of IBD are rare in intensively treated patients, the high frequency of unrecognized secondary manifestations should give reason to refer especially patients with longstanding or complicated IBD to an eye specialist - irrespective of ocular symptoms.

Risk factors for a delay in medical education: Results of an online survey among four German medical schools.

BACKGROUND: Delayed study progress in medical school is a challenging issue for the tax paying community, the faculty and the medical students themselves. Reasons for a delay might be different from known risk factors for academic difficulties. METHODS: An online survey regarding delays in the study progress and including a personality test (BFI-10) was presented to medical students from four German medical schools after completion of their 3rd year of study. RESULTS: Of 617 students, 51.2% reported a mean delay of 2.1 ± 1.5 semesters. Frequent risk factors were secondary employment (69.5%, odds ratio (OR) 1.7, p = 0.004), female gender (69.8%, OR 1.6, p = 0.007), work or study abroad (35.9%, OR 1.5, p = 0.02), a late graduation (5.9%, OR 2.4, p = 0.02), as well as support through scholarship or mentoring (19.9%, OR 1.8, p = 0.004). "Working on doctoral thesis" (11.3%, OR 1.9, p = 0.03) and structural curricular issues (36.6%, OR 0.9, p = 0.7) were frequently identified as obstacles. "Support by friends/family" was considered helpful by 24.1% (OR 1.4, p = 0.09), as well as a high intrinsic motivation (19.1%, OR 0.5, p = 0.01). In the BFI-10, students with study delay were more prone to openness and agreeableness. CONCLUSIONS: Risk factors for delay are not identical to those for academic difficulties. To decrease the risk for delays, firm curricular structures should be identified and alleviated. Intrinsic motivation is a strong impetus of study progress and additionally might be strengthened by curricular changes.