Medical Care For People Research Articles

1945 Hospital at Home - developing a novel simulation induction programme through quality improvement

Abstract Introduction The UK is expanding provision of acute medical care in people’s own homes through Hospital at Home (H@H) and virtual wards. Our H@H service is training junior doctors to meet the growing clinical need in this environment. We describe the use of simulation training to improve the H@H induction process. Methods From their experiences in H@H, junior doctors identified specific training needs to build relevant competencies. From this feedback, PDSA cycle one involved junior doctors designing a dedicated simulation training (H@H-SIM). Stations addressed clinical, practical and advanced communication skills required in H@H using high- and low-fidelity simulation. PDSA cycle two used post-course evaluation to refine H@H-SIM through introduction of FP10 prescribing stations, point-of-care testing (POCT) and greater emphasis on practical skills. Revisions were evaluated via participant questionnaire before and after the H@H-SIM. Results Cycle two of H@H-SIM involved twenty doctors. The clinical scenarios, prescribing and practical skills stations, including POCT and IV administration, were perceived as the most useful parts of training. Overall self-rated confidence in knowledge and skills to work in H@H improved from a mean of 6.9 to 7.7/10. Before H@H-SIM, 60% were ‘not confident’ with recognising end of life (EOL), IV administration or decision-making around remaining at home; 10% with advance care planning (ACP). After H@H-SIM, 10% felt ‘not confident’ with recognising EOL or ACP and 5% with IV administration. Concerns persisted with using equipment, prescribing and availability of senior support. An additional station on recording ECGs was suggested. Conclusions Working in a H@H context and seeing patients in their homes can be daunting for junior doctors. H@H-SIM embedded into induction is one way to prepare doctors for this role, improve their confidence and has potential for wider replication.

Screening for osteoporosis in people with MS: A new risk score.

Due to the demographic development and improved treatment options, the role of comorbidities is of increasing importance in the medical care of people with MS (pwMS). A higher risk of osteoporosis is well known in chronic autoimmune diseases, and is also described in MS. While there are several screening guidelines in the elderly or in patients with rheumatoid arthritis, there are no generally accepted recommendations when to perform bone mineral testing in pwMS under the age of 65 years. We aimed to determine risk factors of osteoporosis in pwMS and to develop a risk score which can be applied in daily clinical routine. Densitometry (hip and lumbar spine) was performed in 159 pwMS aged ≤65 years and in 81 age- and sex-matched healthy controls (HC). Osteoporosis was defined according to WHO criteria as a bone density 2.5 standard deviation or more below the mean of young adults. Risk factors were identified by logistic regression analysis. Osteoporosis occurred more frequently in postmenopausal pwMS and male pwMS as compared to HC. Besides age, sex, menopausal status in females, body-mass-index and smoking, a higher degree of disability - as assessed by the Expanded Disability Status Scale - was identified as MS specific risk factor for osteoporosis, whereas the cumulative glucocorticoid dose was not associated with osteoporosis risk. Based on these risk factors, we developed an MS-specific risk score which allows to estimate the individual probability of osteoporosis. This risk score enables individual screening recommendation for pwMS and, subsequently, early prevention of osteoporosis which probably should result in reduction of fractures and morbidity.

Medical Needs of Adults with Down Syndrome Presenting at a Regional Medical and Rehabilitation Center in Japan.

Down syndrome (DS) is the most frequent chromosomal aberration; however, knowledge of associated health issues in adulthood is inadequate. We analyzed health data from Japanese adults with DS. We conducted a retrospective chart review of 151 patients with DS who visited the Internal Medicine Outpatient Department of the Tokyo Metropolitan Kita Medical and Rehabilitation Center for the Disabled. Endocrine disorders such as obesity, hyperlipidemia, and hyperuricemia were most common in adulthood (≤40 years) and senescence (>40 years); neurological diseases were more prevalent in senescence. Multimorbidity was noted even patients with DS who were younger than 30 years, and the prevalence increased with age. Only 21 patients (13.9%) with DS visited our hospital with referral letters from pediatricians; 94 patients (62.3%) visited without such referrals from other medical institutions. Patients without a referral letter had a mean of 3.1 comorbidities per patient. Moreover, medical care for some people with DS was interrupted during childhood. Prevention and detection of comorbidities in patients with DS requires continuous medical care from childhood through adulthood. Recently, DS has been diagnosed by chromosome testing and genetic counseling. Clinical geneticists and genetic counselors can help patients with DS, and their caregivers, to obtain appropriate health care and achieve well-being on their own by seamlessly engaging them throughout childhood and adulthood.

Menschen mit geistiger Behinderung (MmgB) in der ambulanten medizinischen Versorgung: Barrieren beim Zugang und im Untersuchungsablauf

ZusammenfassungHintergrund und ZielMenschen mit geistiger Behinderung (MmgB) weisen eine erhöhte Morbidität auf. Ihr Zugang zur Gesundheitsversorgung könnte ein Einflussfaktor sein. In Deutschland existieren hierzu nur wenige Daten. Die vorliegende Arbeit geht der Frage nach, welche Barrieren und förderlichen Aspekte für MmgB bei der Inanspruchnahme der ambulanten Versorgung bestehen. Dabei wird ihre eigene Perspektive berücksichtigt sowie die der begleitenden Angehörigen und der Hausärzt:innen.MethodenIn dieser Querschnittstudie wurden mittels Fragebögen MmgB in 3 Werkstätten für behinderte Menschen sowie deren Angehörige und Hausärzt:innen befragt. Die Daten wurden deskriptiv ausgewertet und die Antworten der MmgB und der Angehörigen teststatistisch verglichen. Die inhaltliche Gliederung folgt dem Modell nach Cantrell (Erkennen eines Behandlungsbedarfs, Zugang zur Gesundheitsversorgung, Untersuchungsablauf).ErgebnisseMmgB teilen Beschwerden ihren Angehörigen mit, die sie oft zu Arztbesuchen begleiten. Barrieren sind eher organisatorischer als räumlicher Art. Die Behandlungssituation ist teilweise durch Ängste, Unruhe oder auch das Nichtzulassen von Untersuchungen erschwert. Schwierig ist es, erfahrene Praxen zu finden. Daher wünschen sich Angehörige Listen mit solchen Praxen und medizinische Versorgungszentren für MmgB. Die Sicht der MmgB und ihrer Angehörigen zeigt kaum Unterschiede. Hausärzt:innen geben den erhöhten Behandlungsaufwand, Wunsch nach Fortbildung und angemessener Vergütung an.DiskussionDie Angehörigen spielen in der medizinischen Versorgung von MmgB eine wichtige Rolle. Schwierigkeiten in der Versorgung können aus den spezifischen, erhöhten Anforderungen im Umgang mit MmgB entstehen, die sich organisatorisch äußern. Es bedarf einer aktiven Bereitschaft zur Inklusion.

A hospital foundation for research on precariousness and social exclusion

The hospital in Nanterre (92) offers a wide range of services for the reception, orientation and medical care of people in precarious situations on a daily basis, both in the social medicine department and in other departments. The medical teams wanted to create a structure that could document and analyze the life trajectories and experiences of people in precarious situations, but above all innovate, propose adapted systems and evaluate them, in order to develop knowledge and practices. The hospital foundation for research on precariousness and social exclusion was thus created at the end of 2019 [1], with the structuring support of the Île-de-France regional health agency.

Community-based decentralized mental health services are essential to prevent the epidemic turn of post-Covid mental disorders in Bangladesh: A call to action.

Community-based decentralized mental health services are essential to prevent the epidemic turn of post-Covid mental disorders in Bangladesh: A call to action.

Эпидемиологические аспекты и оптимизация организации офтальмологической помощи лицам с катарактой

Purpose. To study the epidemiological features of cataracts and the organization of medical care for people with this pathology. Material and methods. In the population cross-sectional study Ural Eye and Medical Study on the basis of the Ufa Research Institute of Eye Diseases, 5899 people aged 40 years and older took part, among them men – 43.7% (2580 people), women – 56.3% (3319 people). Statistical data analysis was performed using the IBM SPSS Statistic software package. Results. According to the results of the study, the prevalence of cataract in people older than 40 years was 42.8% (95% CI: 41.4–44.2%), the prevalence of cataract surgery was 6.1% (95% CI: 4.0–9.3%). The coverage of surgical treatment of patients with cataracts among the study population was 39.8%, the rate of its effectiveness was 32.1%. The main reason that reduces patients’ adherence to timely treatment is the lack of interest of the patient himself and insufficient awareness of the complications and methods of modern cataract treatment. Conclusion. The introduction of medical and organizational measures contributed to an increase in the overall coverage of surgical treatment of people with cataracts by 25.6% (from 39.8 to 65.4%), the rate of effective coverage of surgical treatment of patients with cataracts – from 32.1 to 57, 7% and the target for maximum visual acuity fr om 80.6 to 88.2%. Key words: population study, cataract surgery, prevalence of cataract surgery

Oral Health Policy and Recommendations for Children with Hemophilia in Bulgaria

BACKGROUND: Hemophilia is the most common inherited coagulopathy, but its diagnosis and treatment are still a challenge for healthcare professionals. Collaborative efforts between National bleeding disorder agencies, World Federation of Hemophilia, Ministries of Health, educational institutions, and non-governmental organizations aim to improve access to care and the quality of life of people with coagulopathies AIM: The aim of this study was to analyze and critically evaluate the oral health policy for children with hemophilia in Bulgaria. MATERIALS AND METHODS: A sociological survey is conducted among dentists in Bulgaria during the period 2019 - 2020 about their attitude toward the oral health policy regarding children with hemophilia in Bulgaria. The oral health legislation of Bulgaria and international guidelines for dental care of people with hemophilia is critically evaluated. Data is revised and synthetized for implementation in the Bulgarian health policy. RESULTS: In 2013, the first European guidelines for the certification of Hemophilia Centers are published, which is the only document accrediting centers for rare diseases. According to the recommendations of the World Federation of Hemophilia, dental and medical care for people with hemophilia should be provided in hemophilia treatment centers. According to the latest guidelines from 2020, dental care for people with hemophilia should be provided by every dentist, regardless of their specialty. Most of the dentists (n = 88; 84.62 ± 3.54%) would be more confident in treating a patient with hemophilia in their practice if they are part of an organized team. In need of a consultation with another doctor, dentists prefer to refer the case to a specialist clinical hematologist (n = 74; 71.15 ± 4.44%), pediatric oncohematologist (n = 60; 57.69 ± 4.84%), or oral surgeon (n = 35; 33.65 ± 4.63%). DISCUSSION: Improvement can be achieved through programs for management of specific dental conditions, targeted at rare disease groups, and successfully implemented in health policy at the local level. CONCLUSION: Potential new policies may offer more dental treatment options for people with hemophilia. In-depth clinical and sociological studies are needed to determine the optimal effect in the current state and situation.

Preface

Diagnostics and condition monitoring are aspects of a field of engineering that aims to manage the health of engineering machinery and structures, but which has increasing applicability to many other complex systems in the world from the medical care of people, through the reliability of supply chain logistics to the secure operation of a large and complex organisation. The management of health generally requires a number of sequential steps, which are usually as follows: the detection of any abnormality in the procedural operation of the system, the location of the abnormal behaviour within the system, an assessment of the severity of the abnormality and identification of the potential system vulnerabilities that result from it, a detailed diagnosis of the problem including the identification of its root cause, and finally a predictive assessment of the future prospects for the continued operation of the system, including any remedial action that should be taken to minimise impact and maximise continued operational performance.

Quality of life and satisfaction with medical care in patients with mental disorders of the schizophrenic spectrum

This review aims at studying the development and application of the provisions of the International Classification of Functioning, Disability and Health in the practice of domestic psychiatry. Publications on the quality of life and satisfaction with medical care for disabled people with schizophrenia spectrum disorders are reviewed. The review shows that with a decrease in the number of patients with mental disorders in the Russian Federation, the number of people with disabilities due schizophrenia spectrum disorders is growing. The study of the aspect of the quality of life of patients with schizophrenia spectrum disorders reveals a slow development of this scientific area, especially due to the lack of standardized and validated methods. The aspect of satisfaction with medical care for people with schizophrenia spectrum disorders is also insufficiently studied, and, being directly related to the quality of life of patients, similarly lacks specialized assessment methods. It is also necessary to assess the influence of these factors on the formation of medical and social significance of the problem of disability of the population.

Lessons learned from people with neurological diseases at the time of COVID-19: The EFNA-EAN survey.

Background and purposeThe European Federation of Neurological Associations (EFNA), in partnership with the NeuroCOVID‐19 taskforce of the European Academy of Neurology (EAN), has investigated the impact of the first wave of the COVID‐19 pandemic on individuals with neurological diseases, as well as the hopes and fears of these patients about the post‐pandemic phase.MethodsAn EFNA‐EAN survey was available online to any person living with a neurological disorder in Europe. It consisted of 18 items concerning the impact of the first wave of the COVID‐19 pandemic on the medical care of people with neurological disorders, and the hopes and fears of these individuals regarding the post‐pandemic phase.ResultsFor 44.4% of the 443 survey participants, the overall care of their neurological disease during the pandemic was inappropriate. This perception was mainly due to significant delays in accessing medical care (25.7%), insufficiently reliable information received about the potential impact of COVID‐19 on their neurological disease (49.6%), and a substantial lack of involvement in their disease management decisions (54.3%). Participants indicated that their major concerns for the post‐pandemic phase were experiencing longer waiting times to see a specialist (24.1%), suffering from social isolation and deteriorating mental well‐being (23.1%), and facing delays in clinical trials with disinvestment in neuroscience research (13.1%).ConclusionsDespite the great efforts of health services to cope with the first wave of the COVID‐19 pandemic, individuals with neurological conditions feel they have been left behind. These findings provide invaluable insights for improving the care of patients with neurological disorders in the further course of the COVID‐19 pandemic.

Affect on Alcheima Disease during Covid-19

The pandemic COVID-19 is generating worldwide disruption, straining health systems, causing morbidity and death, and placing people with ADRD in danger. In this article, we look at the present and anticipated implication son people with ADRD as a result of the epidemic. We examine and offer reducing measures and death in peopleCOVID-19’s effect on ADRD diagnosis and medical care in people with ADRD; and the COVID-19 repercussions of societal reactions in various ADRD care settings. COVID-19’s influence on physicians and caregivers of people with ADRD; stigma, mental health, and trauma during COVID19; and the prospective COVID-19 impact research on ADRD. Despite much uncertainty, we may be able to avoid or lessen the suffering caused by the epidemic of COVID-19implications for persons with ADRD and about their careers. Anticipated the potential patterns of COVID-19 effects in the world dependent on data gathered from Kaggle and used the Optum Labs Data Warehouse (OLDW),

Medical Care for People With Serious Mental Illness in Context of COVID-19

Medical Care for People With Serious Mental Illness in Context of COVID-19

Impact of diabetes on COVID‐19 and other infection: Report from the 22nd Hong Kong Diabetes and Cardiovascular Risk Factors—East Meets West Symposium

The coronavirus disease 2019 (COVID‐19) pandemic has posed enormous challenges to healthcare systems worldwide. The negative impact of COVID‐19 is widespread and includes not only people who contracted the disease but also those with chronic morbidities such as diabetes whose care is compromised due to diversion of medical resources. People with diabetes are generally more susceptible to infection as a result of altered immunity. People with diabetes have a worse prognosis from COVID‐19 and there is evidence to suggest that severe acute respiratory syndrome coronavirus 2 may directly affect pancreatic function precipitating hyperglycaemic crises. In the United Kingdom, one of the most heavily affected countries, guidelines are in place to unify the management of people with diabetes hospitalized for COVID‐19. Diabetes services are re‐organized to ensure that medical care of people with diabetes is maintained despite resource and other practical constraints. Public health measures including social distancing, hand hygiene and the use of face masks are crucial in containing community transmission of the virus. Hong Kong, one of the most densely populated city in the world, is particularly vulnerable and has in place a stringent containment policy and aggressive contact tracing to ensure public safety during this pandemic.

Sexual and mental health of woman suffering from selected connective tissue diseases: an original paper.

The aim of the study was to assess the sexual and mental health of women suffering from connective tissue diseases and to determine the potential interrelationships between the studied clinical variables and sexual and mental health. The study was conducted in a group of women with connective tissue diseases. To assess somatic health, we used The Health Assessment Questionnaire (HAQ-DI), and to assess sexual health, we used the Female Sexual Function Index (FSFI) and Sexual Satisfaction Questionnaire (KSS). The mental health was assessed by using the Hospital Anxiety and Depression Scale (HADS-M) and the PERMA-Profiler (PL). The study involved 81 women suffering from connective tissue diseases, especially rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), ankylosing spondylitis (AS) and juvenile idiopathic arthritis (JIA). Clinical symptoms of sexual dysfunction were observed in 54% women. The biggest difficulties occur in sexual desire, orgasm and arousal. Patients had symptoms of anxiety and depressive disorders. Higher levels of anxiety and depression are associated with poorer overall sexual functioning and better overall sexual functioning, and all its dimensions are associated with a higher level of mental well-being. There was also an observed relationship with the functional limitation due to pain and duration of the disease. The study confirms the existence of difficulties in the sexual functioning of women suffering from connective tissue diseases and shows the relationship between sexual and mental health and basic disease. The observed relationships are important information in the treatment and medical care of people with this group of rheumatic diseases. Key Points • The article presents one of the few studies about sexual functioning of Polish population women with connective tissue diseases. • The aim was to assess the sexual and mental health of women with various connective tissue diseases and determine the potential interrelationships between the clinical variables and sexual and mental health. • The study confirms difficulties in the sexual functioning of women with connective tissue diseases. The biggest difficulties occur in sexual desire, orgasm and arousal. Patients also had mental disorders symptoms. • The study presents conclusions and indications which may be important and help specialists approach the treatment process in an interdisciplinary way.

DYNAMICS OF THE INCIDENCE OF DISEASES OF THE CIRCULATORY SYSTEM AMONG ADULTS AND CHILDREN IN VORONEZH

Relevance. Over the past decade and at the present time, diseases of the circulatory system continue to occupy a leading position. Despite the implementation of Federal and regional programs aimed at improving the level of cardiological care and reducing the mortality of adults and children, the assessment of the level and dynamics of diseases of the circulatory system remains an urgent task for the health system. Aim: to analyze the dynamics of the incidence of diseases of the circulatory system of adults and children in Voronezh. Material and methods. In order to allow territorial comparison of morbidity levels, relative indicators were calculated per 1000 population of the corresponding age (children, adults). The assessment of the level of morbidity was carried out by analyzing medical and statistical data on the population's access to medical care over a five-year period. Results. This study is devoted to the assessment of the incidence of diseases of the circulatory system, which was carried out by analyzing medical statistics on the population's access to medical care for five years. It was found that the average long-term level of cardiovascular diseases in the Voronezh city district is 24.79±1.40 cases per 1000 children under 14 years of age, and 403.14±21.36 cases per 1000 adults 18 years and older for the adult population. Over the past 5 years (2014-2018), there has been an increase in the incidence of both children and adults. Conclusion. Thus, knowledge of information about the morbidity of adults and children makes it possible to rationalize the resources of the urban health system to improve the availability and quality of medical care for people with cardiovascular diseases at the pre-hospital stage.

Доверие как социальное основание развития технологий редактирования генома эмбрионов человека

Доверие является необходимым условием эффективного функционирования сообществ в различных областях человеческой деятельности, но в особенности в медицине. Развитие технологий редактирования генома эмбрионов человека, как утверждают разработчики, обеспечит возможность создания новых форм медицинской помощи людям, страдающим тяжелыми генетически детерминированными заболеваниями. Вместе с тем, существуют серьёзные риски внесения в геном случайных неблагоприятных изменений, которые будут передаваться потомкам. Предполагается, что начало клинических испытаний этих технологий будет возможно после доказательства их клинической значимости, безопасности и моральной приемлемости. Другим необходимым условием должно выступить отношение доверия к экспериментаторам, включающее транспарентность исследований, общественную и правовую подотчётность, ответственность перед пациентами и их семьями за возможные неблагоприятные последствия. Trust is a prerequisite for the effective functioning of communities in various fields of human activity, but especially in medicine. The development of human embryo genome editing technologies, according to the developers, will provide the opportunity to create new forms of medical care for people suffering from severe genetically determined diseases. At the same time, there are serious risks of introducing into the genome random adverse changes that will be transmitted to descendants. It is assumed that the start of clinical trials of these technologies will be possible after proving their clinical relevance, safety and moral acceptability. Another necessary condition should be the attitude of trust towards experimenters, including transparency of research, public and legal accountability, responsibility to patients and their families for possible adverse consequences.

Progression of Diabetic Complications in Subgroups of People with Long Term Diabetes Type 1 According to Clinical Course.

Prevention and prediction of microvascular complications are important aims of medical care in people with type 1 diabetes. Since the course of the disease is heterogenous, we tried to identify subgroups with specific risk profiles for microvascular complications. Retrospective analysis of a cohort of 285 people (22637 consultations) with >10 years of type 1 diabetes. Persons were grouped into slow (<15 years), fast (>15 years) and non progressors according to the average onset of microvascular complications. Generalized estimating equations for binary outcomes were applied and pseudo coefficients of determination were calculated. Progression to microvascular disease was associated with age (OR: 1.034 [1.001-1.068]; p=0.04), diabetes duration (OR: 1.057 [1.021-1.094]; p=0.002), HbA1c (OR: 1.035 [1.011-1.060]; p=0.005), BMI (OR: 0.928 [0.866-0.994]; p=0.034) and the social strata index (OR: 0.910 [0.830-0.998]; p=0.046). Generalized estimating equations predicted 31.02% and exclusion of HbA1c marginally reduced the value to 28.88%. The proportion of patients with LADA was higher in fast than slow progressors [13 (26.5%) vs. 14 (11.9%); p=0.019]. A generalized estimating equation comparing slow to fast progressors revealed no significant markers. In our analysis, we were able to confirm known risk factors for microvascular disease in people with type 1 diabetes. Overall, prediction of individual risk was difficult, the effect of individual markers minor and we could not find differences regarding slow or fast progression. We therefore emphasis the need for additional markers to predict individual risk for microvascular disease.

GENDER FEATURES OF TRAUMATIC EXPERIENCE IN MAXILLOFACIAL TRAUMA

Relevance. Injuries to the maxillofacial area is one of the most relevant medical problems of industrial society. In addition to surgical methods of medical care for people with this trauma type, an important role is dedicated to psychological methods that focused on traumatic experience, postoperative pain and reactions on post-traumatic defects.Aim: to establish the gender characteristics of psychological response to traumatic experience in injuries of the maxillofacial area.Materials and methods. The study was conducted in prospective design on 40 patients of the City Clinical Hospital for Emergency Care (Zaporizhzhya, Ukraine), who were is in the postoperative period of reconstructive surgery for injuries of the maxillofacial area.Study results. According to the results of the psychological status analysis 6 reaction variants to the traumatic experience were found: undifferentiatednegative emotions, motor and sensory reactions, somatofunctional reactions, stomatoform reactions, behavioral reactions, psychosensory reactions.Conclusions. Insignificant differences were found between psychological reactions to traumatic experience in injuries of the maxillofacial region between men and women. Men have a lower level of manifestation of fear and respiratory symptoms of anxiety, but more in terms of gastrointestinalsymptoms of anxiety. Men also have a lower level of disturbances in the feeling of their own body and disturbances in the perception of the environment.

The Medical Care of People With Intellectual Disability.

An estimated 1.5 million persons in Germany are intellectually disabled. Persons with intellectual disability (ID) are especially vulnerable to somatic and mental illnesses. This review is based on pertinent literature retrieved by selective searches in PubMed and the Cochrane Library. Genetic abnormalities are a frequent cause of diseases that affect multiple organs and need interdisciplinary treatment. A number of somatic diseases are more common in persons with ID than in the general population, including epilepsy (30-50% in persons with severe or very severe ID, vs. 0.5% in the general popu- lation) and dementia (five times more common than in the general population). Patients with Down syndrome are 20 times more likely than the general population to develop acute lymphoblastic leukemia. Some mental illnesses, too, are more common in persons with ID, e.g., autism spectrum disorders (7.5-15% vs. 1% in the general population). The history and the findings of the physical and psychiatric examination are assessed in accordance with the biopsychosocial model of disease, and in the light of the patient's mental developmental age. Structured instruments for behavioral evaluation and diagnosis are an important additional component of the diagnostic assessment. A holistic approach is required that takes multiple life areas into account and involves the patient's familial and social environment, while obeying the rules of simple language. Psychotherapeutic and psychosocial measures must be adapted to the patient's cognitive abilities and mental developmental age. Intellectually disabled persons can be treated in a multimodal, multiprofessional approach. As of early 2019, there were 38 medical centers for adults with intellectual disability or severe multiple disabilities in Germany (Medizinische Behandlungszentren für Erwachsene mit geistiger Behinderung oder schweren Mehrfachbehinderungen, MZEB), where they can be cared for with due attention to their special needs.