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Although severe thunderstorms are one of the primary causes of catastrophic loss in the United States, their response to elevated greenhouse forcing has remained a prominent source of uncertainty for climate change impacts assessment. We find that the Coupled Model Intercomparison Project, Phase 5, global climate model ensemble indicates robust increases in the occurrence of severe thunderstorm environments over the eastern United States in response to further global warming. For spring and autumn, these robust increases emerge before mean global warming of 2 °C above the preindustrial baseline. We also find that days with high convective available potential energy (CAPE) and strong low-level wind shear increase in occurrence, suggesting an increasing likelihood of atmospheric conditions that contribute to the most severe events, including tornadoes. In contrast, whereas expected decreases in mean wind shear have been used to argue for a negative influence of global warming on severe thunderstorms, we find that decreases in shear are in fact concentrated in days with low CAPE and therefore do not decrease the total occurrence of severe environments. Further, we find that the shift toward high CAPE is most concentrated in days with low convective inhibition, increasing the occurrence of high-CAPE/low-convective inhibition days. The fact that the projected increases in severe environments are robust across a suite of climate models, emerge in response to relatively moderate global warming, and result from robust physical changes suggests that continued increases in greenhouse forcing are likely to increase severe thunderstorm occurrence, thereby increasing the risk of thunderstorm-related damage.

Background Quality indicators (QIs) are used in many healthcare settings to measure, compare, and improve quality of care. For the efficient development of high-quality QIs, rigorous, approved, and evidence-based development methods are needed. Clinical practice guidelines are a suitable source to derive QIs from, but no gold standard for guideline-based QI development exists. This review aims to identify, describe, and compare methodological approaches to guideline-based QI development. Methods We systematically searched medical literature databases (Medline, EMBASE, and CINAHL) and grey literature. Two researchers selected publications reporting methodological approaches to guideline-based QI development. In order to describe and compare methodological approaches used in these publications, we extracted detailed information on common steps of guideline-based QI development (topic selection, guideline selection, extraction of recommendations, QI selection, practice test, and implementation) to predesigned extraction tables. Results From 8,697 hits in the database search and several grey literature documents, we selected 48 relevant references. The studies were of heterogeneous type and quality. We found no randomized controlled trial or other studies comparing the ability of different methodological approaches to guideline-based development to generate high-quality QIs. The relevant publications featured a wide variety of methodological approaches to guideline-based QI development, especially regarding guideline selection and extraction of recommendations. Only a few studies reported patient involvement. Conclusions Further research is needed to determine which elements of the methodological approaches identified, described, and compared in this review are best suited to constitute a gold standard for guideline-based QI development. For this research, we provide a comprehensive groundwork.

Background Empathy plays an important role in the interaction and communication with patients. Physicians’ empathy has various positive patients’ and physicians’ outcomes. Despite the inclusion of empathy in medical curricula and the relevance of empathy in general and physicians’ concept of it to medical care, there is no common definition of empathy in the clinical context: definitions tend to be abstract and we do not know enough about medical students’ conceptualization of clinical empathy. A clear and consensual definition of empathy is needed to be able to teach and measure empathy adequately. We aimed to explore German medical students’ views and understanding of (clinical) empathy. Methods We interviewed 24 students from the second half of the 3rd year and in their final clinical year (six female and male students in each subgroup) using a semi-structured interview guide. Interviews were digitally recorded and transcribed verbatim. We analysed the transcripts using thematic synthesis (Braun & Clarke). Results We found three overarching themes: (1) empathy means perceiving and understanding patients’ needs and acting accordingly, (2) empathy as an interpersonal, intangible construct and (3) taking time for patients. Showing interests, impartiality and openness towards the patients as well as the need to take patients seriously, treating them with respect, having a holistic view on patients and generate some kind of closeness with patients are subthemes of the first overarching theme. Conclusions Although it is often stated that the various existing definitions of empathy are abstract or far from practice, German medical students seem to have a good idea how to define empathy. Their definition resembles definitions known from the literature and used in education. Further research is needed to compare concepts of empathy of medical students from different countries and cultural backgrounds to inform research and teaching. It would also be interesting to investigate how concepts of empathy change over the course of study and affect perceptions of empathy in third party assessments.

Background Somatic symptom disorder (SSD) is the successor diagnosis of somatoform disorder in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Relevance and frequency of SSD and its clinical symptoms in general practice are still unknown. We estimate frequencies of patients fulfilling the diagnostic criteria of SSD in general practice. Methods Mailed and online survey with general practitioners (GP) in Germany using a cross-sectional representative sample from registries of statutory health insurance physicians. GPs estimated percentages of their patients who show the clinical symptoms of SSD according to DSM-5; that is, one or more burdensome somatic symptoms (A criterion), excessive symptom- or illness-related concern, anxiety, or behaviour (B criterion), and persistence of the symptoms over at least 6 months (C criterion). Statistical analysis used means and confidence intervals of estimated patient proportions showing SSD symptoms. Frequency of full-blown SSD was based on the products of these proportions calculated for each GP. Results Responses from 1728 GPs were obtained. GPs saw the clinical symptoms of SSD fulfilled (A and B criteria) in 21.5% (95% CI: 20.6 to 22.3) of their patients. They further estimated that in 24.3% (95% CI: 23.3 to 25.2) of patients, symptoms would persist, yielding a total of 7.7% (95% CI: 7.1 to 8.4) of patients to have a full-blown SSD. Conclusions We estimate a frequency of 7.7% of patients in general practice to fulfil the diagnostic criteria of SSD. This number may figure as a reference for the yet to be uncovered prevalence of SSD and it indicates a high clinical relevance of the clinical symptoms of SSD in general practice. Registration German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS). DRKS-ID: DRKS00012942. The date the study was registered: October 2nd 2017. The date the first participant was enrolled: February 9th 2018.

Background Low health literacy is believed to be associated with behaviours that increase the risk of type 2 diabetes. But there is limited knowledge on the relation between health literacy (HL) and diabetes risk, and whether improving HL could be a potential prevention strategy. Therefore, the main purpose of this study was to examine the link between HL and diabetes risk among non-diabetic adults. Methods We used data from the Hamburg Diabetes Prevention Survey, a population-based cross-sectional study in Germany. One thousand, two hundred and fifty-five non-diabetic subjects aged 18–60 years were eligible. The German Diabetes Risk Score (GDRS, ranging 0 to 123 points) was used to determine the individual risk of type 2 diabetes. The short version of the European Health Literacy Questionnaire (HLS-EU-Q16, ranging 0 to 16 points) was applied to assess the individual self-reported HL. Subjects were asked to self-estimate their diabetes risk, which was then compared with the calculated GDRS. Descriptive statistics were calculated to investigate group differences in the GDRS and self-estimated diabetes risk. Linear as well as logistic regression models were performed to analyse potential influencing variables of the GDRS as well as incorrect self-estimated diabetes risk. In three nested statistical models for each outcome, these analyses were adjusted for age, gender, educational level and the presence of chronic conditions. Results According to the criteria of the GDRS, 996 (79.4%) subjects showed “low risk”, 176 (14.0%) “still low risk”, 53 (4.2%) “elevated risk”, and 30 (2.4%) “high to very high risk” to develop type 2 diabetes within the next 5 years. In the statistical models including all control variables, subjects with “inadequate HL” scored 2.38 points higher on the GDRS (95% CI 0.378 to 4.336; P  = 0.020) and had a 2.04 greater chance to estimate their diabetes risk incorrectly (OR 2.04; 95% CI 1.33 to 3.14; P  = 0.001) compared to those with “sufficient HL”. Conclusion The risk of type 2 diabetes is increased in people with inadequate self-reported HL. People with high diabetes risk and inadequate HL might be provided with educational programs to improve diabetes knowledge and reduce behavioural risk factors.

Background Chronic heart failure patients typically suffer from tremendous strain and are managed mainly in primary care. New care concepts adapted to the severity of heart failure are a challenge and need to consider health-related quality of life aspects. This is the first psychometric validation of the German EQ-5D-5L™ as a generic instrument for assessing health-related quality of life (HRQOL) in a primary care heart failure patient sample. Methods Confirmatory factor analysis (CFA) was performed on the baseline EQ-5D-5L™ data from the RECODE-HF study (responses to all items from n  = 3225 of 3778 patients). Basic CFA models for HRQOL were calculated based on the EQ-5D-5L™ items using the maximum likelihood (ML) and the asymptotic distribution-free method. In an extended CFA, physical activity and depression were added. The basic CFA ML model was verified for the reduced number of cases of the extended CFA model ( n  = 3064). In analyses of variance the association of the EQ-5D-5L™ visual analogue scale (VAS) and both the German and the British EQ-5D-5L™ crosswalk index with the SF-36 measure of general health were examined. The discriminant validity was analysed using Pearson’s chi-squared tests applying the New York Heart Association classification, for the VAS and indices analyses of variance were calculated. Results In the basic CFA models the root mean square error of approximation was 0.095 with the ML method, and 0.081 with the asymptotic distribution-free method (Comparative Fit Index > 0.90 for both). Physical activity and depression were confirmed as influential factors in the extended model. The VAS and indices were strongly associated with the SF-36 measure of general health (partial eta-squared 0.525/0.454/0.481; all p  <  0.001; n  = 3155/3210/3210, respectively), also for physical activity and depression when included together (partial eta-squared 0.050, 0.200/0.047, 0.213/0.051 and 0.270; all p  <  0.001; n  = 3015/ n  = 3064/n = 3064, respectively). The discriminant validity analyses showed p -values < 0.001 and small to moderate effect sizes for all EQ-5D-5L™ items. Analyses of variance demonstrated moderate effect sizes for the VAS and indices (0.067/0.087/0.084; all p  <  0.001; n  = 3110/3171/3171). Conclusion The German EQ-5D-5L™ is a suitable method for assessing HRQOL in heart failure patients.

Metamizole is used to treat pain in many parts of the world. Information on the safety profile of metamizole is scarce; no conclusive summary of the literature exists. To determine whether metamizole is clinically safe compared to placebo and other analgesics. We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and several clinical trial registries. We screened the reference lists of included trials and previous systematic reviews. We included randomized controlled trials that compared the effects of metamizole, administered to adults in any form and for any indication, to other analgesics or to placebo. Two authors extracted data regarding trial design and size, indications for pain medication, patient characteristics, treatment regimens, and methodological characteristics. Adverse events (AEs), serious adverse events (SAEs), and dropouts were assessed. We conducted separate meta-analyses for each metamizole comparator, using standard inverse-variance random effects meta-analysis to pool the estimates across trials, reported as risk ratios (RRs). We calculated the DerSimonian and Laird variance estimate T2 to measure heterogeneity between trials. The pre-specified primary end point was any AE during the trial period. Of the 696 potentially eligible trials, 79 trials including almost 4000 patients with short-term metamizole use of less than two weeks met our inclusion criteria. Fewer AEs were reported for metamizole compared to opioids, RR = 0.79 (confidence interval 0.79 to 0.96). We found no differences between metamizole and placebo, paracetamol and NSAIDs. Only a few SAEs were reported, with no difference between metamizole and other analgesics. No agranulocytosis or deaths were reported. Our results were limited by the mediocre overall quality of the reports. For short-term use in the hospital setting, metamizole seems to be a safe choice when compared to other widely used analgesics. High-quality, adequately sized trials assessing the intermediate- and long-term safety of metamizole are needed.

Background Patients with multiple long-term conditions often face a variety of challenges arising from the requirements of their health care. Knowledge of perceived treatment burden is crucial for optimizing treatment. In this study, we aimed to create a German version of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and to evaluate its validity. Methods The steps to translate the MTBQ included forward/back translation, cognitive interviews ( n  = 6) and a pilot test ( n  = 7). Psychometric properties of the scale were assessed in a cross-sectional survey with primary care patients aged 65 and older with at least 3 long-term conditions ( n  = 344). We examined the distribution of responses, dimensionality, internal reliability and construct validity. Results Cognitive interviewing and piloting led to minor modifications and showed overall good face validity and acceptability. As expected, we observed a positively skewed response distribution for all items. Reliability was acceptable with McDonald’s omega = 0.71. Factor analysis suggested one common factor while model fit indices were inconclusive. Predefined hypotheses regarding the construct validity were supported by negative associations between treatment burden and health-related quality of life, self-rated health, social support, patient activation and medication adherence, and positive associations between treatment burden and number of comorbidities. Treatment burden was found to be higher in female participants ( Mdn 1  = 6.82, Mdn 2  = 4.55; U  = 11,729, p  = 0.001) and participants with mental health diagnoses ( Mdn 1  = 9.10, Mdn 2  = 4.55; U  = 3172, p  = 0.024). Conclusions The German MTBQ exhibited good psychometric properties and can be used to assess the perceived treatment burden of patients with multimorbidity.

Background Global migration trends have led to a more diverse population in health care services everywhere, which in turn has set off a paradigm shift away from medical paternalism toward more patient autonomy. Consequently, physicians need to provide a more precise patient-centred healthcare. Professional interpreting appears to play a crucial part in tackling the challenges of language barriers adequately. The aim of this study was to conduct process evaluation through the implementing of video remote interpreting (VR) and telephone remote interpreting (TR) within primary care facilities in the northern German metropolis of Hamburg. Methods We conducted a three-armed exploratory pilot trial, which compared VR to TR and to a control group (CG) in different primary care settings. We assessed feasibility of implementation, as well as the acceptance of interpreting tools among their users. In addition, we compared the quality of communication as perceived by patients and physicians, as well as the enabling of patient-centred medicine over all three study groups using quantitative questionnaires. Results 13 practices (7 GPs, 3 Gynaecologists, 3 Paediatricians) took part in this trial. 183 interpreting calls were documented, 178 physicians as well as 127 patients answered their respective questionnaires. The implementation of the VR- und TR-tools went smoothly and they were broadly accepted by their users. However, the tools were used significantly less often than we had anticipated. With regards to quantitative questionnaires, VR scored significantly better than the control group in terms of the perceived quality of communication by both, patients and physicians and enabled of patient-centred medicine. Conclusion Our main findings were the discrepancy between the assumed high demand of professional interpreting solutions on the one hand and the low willingness of practices to participate on the other. The rather low utilisation rates were also noteworthy. This discrepancy indicates a lack of awareness concerning the adverse effects of using informal or no interpreter in medical settings, which needs to be rectified. Due to the small sample size, all statistical results must be viewed with caution. However, our results show that remote interpreting represents a promising approach to tackling language barriers in primary care settings.

To investigate time-dependent predictors of institutionalization in old age using a longitudinal approach. In a representative survey of the German general population aged 75 years and older predictors of institutionalization were observed every 1.5 years over six waves. Conditional fixed-effects logistic regressions (with 201 individuals and 960 observations) were performed to estimate the effects of marital status, depression, dementia, and physical impairments (mobility, hearing and visual impairments) on the risk of admission to old-age home or nursing home. By exploiting the longitudinal data structure using panel econometric models, we were able to control for unobserved heterogeneity such as genetic predisposition and personality traits. The probability of institutionalization increased significantly with occurrence of widowhood, depression, dementia, as well as walking and hearing impairments. In particular, the occurrence of widowhood (OR = 78.3), dementia (OR = 154.1) and substantial mobility impairment (OR = 36.7) were strongly associated with institutionalization. Findings underline the strong influence of loss of spouse as well as dementia on institutionalization. This is relevant as the number of old people (a) living alone and (b) suffering from dementia is expected to increase rapidly in the next decades. Consequently, it is supposed that the demand for institutionalization among the elderly will increase considerably. Practitioners as well as policy makers should be aware of these upcoming challenges.