Daily Dose Post-congress edition

The EAHP

Daily dose Post

Thank you for attending the 22nd Congress of the EAHP ”Hospital pharmacists - catalysts for change”

-Con g Editi ress on

Thank you for attending the 22nd Congress of the EAHP ”Hospital pharmacists - catalysts for change”, the central annual event for anyone interested in hospital pharmacy education and development .

We are particularly proud of this year’s keynote presentations, which were centered around the challenging topics of new medicines and big data.

Lastly, but most importantly, EAHP has launched perharps the most important project of all which is the Implementation of the European Statements on Hospital Pharmacy. The statements were agreed upon in 2014 by hopsital pharmacists, patient groups and other healthcare professionals and express common objectives which all national systems should strive to reach.

Thank you all for coming to Cannes and choosing the EAHP Congress for your networking and learning. See you next year in Gothenburg!

Photos by Mariona Ribo

Tevadaptor® proves efficacy and safety when replicating the NIOSH 2016 universal performance draft protocol, with real hazardous drug surrogate.

To view the results and competitive comparison, visit the Tevadaptor® booth #14.

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Report of EAHP’S FMD meeting Falsified Medicines Directive – the big elephant in the room dedicated to the FMD as it evaluated the involvement of the hospital pharmacy profession in the FMD discussion. Especially the second session held on 24th March saw a lively debate on this issue in which both hospital and community pharmacists voiced their opinions.

The seminar started off with presentations on the system, its background and the impact on hospital pharmacists by Philippe De Buck and Thomas Langebner. The Q&A session scheduled after the presentations took a surprising turn, as attendees started debating the requirements of the Commission Delegated Regulation and the system set up by EMVO instead of posing questions to the panel comprised of the two speakers and Roberto Frontini.

There are just two years remaining until hospitals in the European Union (EU) and European Economic Area (EEA) need to enact the requirements of the Commission delegated Regulation (EU) 2016/161 laying down detailed rules for the safety features appearing on the packaging of medicinal products for human use. It requires packages of medicines be scanned by the hospital pharmacy to verify that they are not counterfeit and to check out the identifying code from a central repository of valid identifiers.

This ensures the packaging cannot be used again by counterfeiters.

EAHP Members’ Meeting Hospital pharmacists have increasingly voiced their difficulties with implementing this delegated Regulation that is linked to the Falsified Medicines Directive (FMD). To better support its members the European Association of Hospital Pharmacists (EAHP) decided to hold a members’ meeting dedicated to the problems posed by the FMD implementation to hospital pharmacists on Wednesday 22nd March 2017. Representatives from 18 member associations attended the meeting to discuss the challenges that they are facing at the moment.

András Süle and Robert Moss – both EAHP board members – chaired the meeting. They used this opportunity to share information on the latest FMD developments and EAHP’s progress in joining the European Medicines Verification Organisation (EMVO) with members. EMVO’s monthly progress reports served as a basis for the first round of discussion. These reports display the readiness of the 32 countries (EU and EEA Member States plus Switzerland) implementing the delegated regulation.

Points raised by the representatives taking part in the

meeting concerned their level of participation in the National Medicines Verification Organisation (NMVO), membership fees and the differences in their actual readiness compared to what has been displayed in EMVO’s February 2017 progress report.

The second round of reporting centred around questions András Süle posed to the group. He asked about the engagement of the government within the NMVO, the existence of capacity (human resources) and capability (finances/IT) problems, comments for the European Commission and requested input for desired EAHP actions.

The contributions by the representatives showed that no Member State is ready at the moment and that the present members do not have capacity to implement the requirements of the delegated Regulation by February 2019.

The positive aspects that were taken from the meeting are that a large number of participants advocated for aggregated barcoding. In this regard, it was also remarked that the delegated Regulation does not consider the negative impact that scanning has on patients. Due to capacity constraints it could limit the time that hospital pharmacists spend with patients. Moreover, concerns were raised in relation to false alarms which are always possible when using an IT system. As for EAHP, members asked for assistance in advocating for aggregated barcoding, in inquiring who reports the NMVO data to EMVO and in determining when hospital pharmacists should decommission.

Picking up on the impact assessment mentioned by Mr Langebner, an Irish participant pointed out that in certain cases scanning might take longer than the foreseen 3 seconds. She stated the packaging of medicines as a reason for this. In her hospital, medicines exist that could only be scanned, as envisioned by the delegated Regulation, after they have been taken out of their packaging which would require the investment of additional time per scan.

Others, like a German attendee, questioned the system performance. The amount of medicines used by large hospitals could pose problems since it has not been determined if IT systems are able to cope with multiple large hospitals simultaneously uploading data.

The debate showed that not only hospital pharmacists are dissatisfied, but also community pharmacists are not fully happy with the requirements of the delegated Regulation. In this regard, Jurate Svarcaite, Secretary General of the Pharmaceutical Group of the European Union (PGEU) remarked that talks prior to the adoption of the delegated Regulation did not yield the expected results, wherefore also community pharmacists have to “deal with what they got”.

Robert Moss – board member of EAHP – welcomed this statement, since up until now only hospital pharmacists where portrayed as the ones being difficult in regard to the FMD implementation.

Facilitator Thomas de Rijdt did his best to provide all interested participants with the opportunity to pose questions or raise comments. However, due to time constraints he needed to end the session despite a number of persons still willing to ask questions.

Falsified Medicines Directive - did they forget the hospital pharmacy?

Also, one of the seminars of the congress was

Stephanie Kohl

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Policy piece - mHealth mHealth: the role of healthcare professionals in safeguarding patient safety as well as utilizing the opportunities The purpose of the mHealth assessment guidelines are “to establish a framework of safety, quality, reliability and effectiveness criteria to improve the use, development, recommendation and evaluation of mHealth apps.”

The European Association of Hospital Pharmacists was selected to represent the healthcare professional perspective within the working group alongside the European Society of Cardiology and the Standing Committee of European Doctors (CPME). The patient view is represented by the European Cancer Patient Coalition (ECPC) and PatientView Ltd.

As stated in EAHP’s position paper on the topic of mHealth, European health systems are at the beginning of a journey in learning about the potential uses (and misuses) of mobile technologies such as smartphones, tablets, watches, glasses and other wearable devices when applied to health related purposes.

Undoubtedly many potential opportunities exist from both current applications and future applications in relation to such areas as improving individual patient understanding and self-­ ‐management in relation to prescribed treatments. However, care and vigilance must also be taken in relation to potential ‘rogue’ or unregulated applications, that have not received appropriate oversight in their construction and have the potential negative impact of offering contradictory, inaccurate or low quality advise to patients. Areas where this could become a significant concern include dosing calculators or dosing advice for example.

It is with this in mind that EAHP joined with other

European healthcare professional and patient organisations, and mHealth app developers, in a European Commission sponsored initiative to create European level ‘mHealth assessment guidelines”.

The identified need of such guidelines emanates from a 2014 public consultation by the European Commission to better understand the challenges and opportunities in respect to mHealth as perceived by principal stakeholder groups. Privacy emerged as the single most important issue concerning users, resulting in an initiative to develop a code of conduct for the privacy of mHealth apps.

Distinct from this, safety and transparency of information were also identified as key issues along with data quality when linking mHealth apps to Electronic Health Records (EHR) for the effective uptake in clinical practice. Accordingly, the European Commission appointed a working group of stakeholders, led by Development Leader Consard Limited, to develop common EU guidelines on mHealth assessment.

At the time of writing, lively discussions take place between represented stakeholders as to the breadth of the guidelines, with EAHP and other healthcare professional representatives seeking due attention to such matters as app transparency, reliability, accuracy, desirability, technical stability, privacy, effectiveness and security. Other views expressed within the discussion are for much more limited guidelines.

The guidelines continue to be developed, and EAHP will continue to work with partner healthcare professions and patients to advocate for a governance framework for mHealth that can inspire confidence in greater uptake. However, the very nature of the discussion, and differences of view to be reconciled, between stakeholders on mHealth governance and safety must surely underline the need for healthcare professionals such as hospital pharmacists to ensure their perspective and input is heard – whether at European, national or even local levels.

Robert Moss is a member of EAHP’s Board of Directors, and EAHP’s policy portfolio leader for the topic of mHealth.

Report on the Student Programme Developing an individualised pharmaceutical care plan - How can this be achieved by the hopsital pharmacist?

Students took the first steps in the creation of an individualised pharmaceutical care plan for their patients during the 4-hour dedicated student session organised during the 22nd EAHP Annual Congress.

The session, facilitated by Branislava Miljkovic was hosted by Dr. Antonella Tonna, Dr. Ruth Edwards and Dr. Scott Cunningham from Robert Gordon University in Scotland.

After a brief introduction of the speakers and the participants, the session continued with Dr. Scott Cunningham presenting the main learning outcome of the session, which was familiarizing participants with applying a systematic approach in formulating an individualized pharmaceutical care plan, as well as a brief history and definition of pharmaceutical care.

Although the first steps in clinical pharmacy were taken in the 1960s, the concept of pharmaceutical care evolved because of a changing emphasis on service provision in the pharmacy field, which implied putting the patient at the centre. In 1990, a definition of the process was crystalized by C. Hepler and L. Strand stated that pharmaceutical care is the “…. responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life.”

The steps in the systematic approach model proposed by Hepler and Strand are the following:

1. Gather patient information This can be done through a variety of methods which complement each other: discussions with the patient, checking medical history and health records, discussions with family members, etc. and has the purpose of gaining as much knowledge about the patient as possible, both in terms of diseases, medication and previous conditions, but also about the social factors which can influence the treatment.

2. Identify problems (needs for drug / pharmacy service) Some of the issues that can arise are improper drug selection, wrong dosage or interactions among others. In this stage, the pharmacists analyse the information from the patient and identifies all issues.

3. Prioritise problems Most of the patients in a hospital setting suffer from not one, but multiple conditions, making the treatment regimen complex, which in turn can lead to multiple problems appearing which cannot be solved all at the same time. Therefore, in this stage the pharmacist prioritises and selects the most important and urgent issues to focus on.

4. Relate problems to medicines This point refers especially to adverse drug reactions or interactions which can appear from multiple drugs, hence it is essential to identify the ones which

are causing the issue before starting the intervention.

5. Define goals for problems The establishment of goals for each of the identified issues enables the proper evaluation of the care plan.

This is a collaborative process between patient and pharmacist in order to identify the most important outcomes for the patient.

6. Synthesise care plan - care issues / actions The care plan is formulated in this stage by putting together all the previously set goals and connecting them with the concrete interventions to be made.

7. Implement care plan After the finalisation of the care plan the next step is its implementation which is a continuous process, as it should be adjusted according to the development of the situation.

With this in mind, the students attending the session had the opportunity to implement it on a case study provided by the speakers and deepen their understanding of the process.

All in all, the session was successful in introducing students to what a pharmaceutical plan is and assisting them on their first steps in implementing it in their future professional lives.

Raluca Radu

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Report of thursday’s synergy satellite Good morning pharmacists! Case studies on antimicrobial resistance?

The presenters (Frances Kerr, Inga Urtane and Eva Meyle) showed three interesting case studies focusing on an infectious disease to the audience.

During the case studies, there was an interesting sharing of opinions thanks to the facilitator Torsten Hoppe- Tichy and a proactive interaction between speakers, the other experts (Antonella Tonna, Ines Svestina, Martin Hug) and the participants.

This was a novel approach where the experts were blinded providing input at intervals during the discussion about the case studies giving the possibility to think about the best possible therapeutic choice, step by step, according the information provided by the speakers.

Through these examples, the participants understood the importance of an appropriate antimicrobial treatment and the implications associated with misuse of antimicrobials.

Hospital Pharmacists need to improve their expertise in antibiotic resistance and need to be included in the multidisciplinary teams implementing “Antimicrobial Stewardship Programs” in hospitals. For this reason, there is an important need to implement Hospital Pharmacist knowledges regarding pathogens, different symptoms, diagnoses and different approaches to management of infections.

The first case study was presented by Frances Kerr. It was related to a sepsis infection. Frances evaluated the specific case, according the Scottish Patient Safety Programme (SPSP) – statement regarding the new international consensus definition of sepsis, published in February 2016 and the SOFA, q SOFA scoring.

In addition, she underlined how it is important to evaluate antimicrobial allergy to avoid inappropriate antimicrobial prescribing, especially in patients allergic to penicillin. During the case –study we have learned the importance for adjusting dose for renal function, checking for interactions with drugs and disease conditions, confirming allergy status, and checking microbiology results to ensure effective antibiotic selected for infection. We have known that in Scotland NHS there is a position paper on optimizing antimicrobial prescribing in possible or suspected infections due to multi-drug resistant gram-negative bacteria that suggested a Carbapenem sparing strategy.

The second case study was presented by Inga Urtane.

Through this case presentation we have learned the strategy to use an effective surgical prophylaxis according the dose, the time of onset, the choice of the antibiotic into account local resistance patterns and how the antimicrobial agent chosen (both for prophylaxis and treatment) should be suitable for the

organism likely to be encountered.

The last case study was presented by Eva Meyle. It was related to an adequate empirical broad spectrum – therapy in a patient with a life- threatening infection (Tarragona Strategy). We have learned the need to evaluate the correct dosage of Meropenem in obese patients. High dose or prolonged infusion time of Meropenem is necessary to achieve the treatment goals and when treating pathogens with high MIC. In addition, we have learned about the appropriate treatment for Acinetobacter Baumanni in critically ill’ patients and how Colistin plus Tobramycin maybe be as safe as efficacious for the treatment of A. Baumanni because the maximum activity of antiinfective therapy and the risk of heteroresistant A. Baumanni strain.

Of course, interactive sessions involving all participants in discussion represent an important tool for learning, especially when a panel of experts can discuss about different approaches and different recommendations for the best management of an individual patient and to show ways in which the pharmacist may contribute to antimicrobial stewardship as part of a multidisciplinary team.

Piera Polidori

Report of wednesday’s synergy satellite 10 years of biosimilars - what have we learned?

Photo by Mariona Ribo Biological drugs entered onto the market almost thirty years ago. Made up of peptides or proteins, these drugs have a much more complex and expensive production process than other nonbiological drugs because of the intensive engineering required. Despite these hurdles, biologics are now considered some of the most effective and preferred therapeutics for the treatment of severe diseases such as cancer and rheumatoid arthritis. Given the high costs of these biological treatments, as soon as their patents began expiring, other producers initiated the production of biosimilars, that is, products that are similar, but not copies. In fact, the European Medicine Agency (EMA) approved the first biosimilar growth hormone ten years ago. Biosimilars offer healthcare systems the opportunity to alleviate the burden of costly treatments with biological drugs, freeing resources for other healthcare expenses.

Since the introduction of the first biosimilar, there has been ongoing debate about how similar, how effective and how toxic the biosimilars are. A Pubmed search today for “biosimilar” produces a list of almost fifteen hundred scientific articles, while one on “biosimilars and pharmacovigilance”

produces almost one hundred papers.

Before biosimilars are approved for sale, it must be demonstrated that they do not differ significantly from the reference medicine in terms of quality, safety or efficacy, and pharmacokinetic and pharmacodynamic studies are mandatory.

Comparative safety data should normally be collected pre-authorization, the amount of information required depending on the type and severity of safety issues known for the reference product.

Furthermore, the clinical safety of biosimilars must be monitored closely on an ongoing basis during the post-approval phase, as must their risk-benefit ratio.

Regarding this issue, a recent paper has shown that no new safety concerns have been raised in studies with TNF inhibitors or rituximab biosimilars for the treatment of rheumatoid arthritis, the safety profiles of which have been consistent with those of their reference product.

At the synergy satellite meeting, Paul Declerck, Irene Kramer and Paul Cornes presented their experiences with biosimilars, providing the audience with interesting points for better understanding

the processes of production, safety and interchangeability of these drugs with the reference molecule. In particular, Paul Declerck explained the molecular basis of heterogeneity of biosimilars and the processes through which this happens. He explained the development of biosimilars, through a continuous process of making an ever better drug, and described the regulatory requirements to be met in order to bring a biosimilar to market. Professor Irene Kramer emphasized the safety issues that a hospital pharmacist needs to know in order to record a possible adverse effect. She stressed the importance of the batch number, and defined switching and substitution, in which the decision to substitute one product for another is up to the hospital pharmacist.

Dr. Kramer explained the distinction of a subset of biosimilars, called bioidenticals, which have the same expression system, marketing authorization, and formulation as a biosimilar, but different brand names. Only in this case can a biosimilar be considered interchangeable with another drug.

Emphasis was given to the factors to be taken into consideration in choosing such an interchange, for example, chronic versus short term use, naïve or experienced patients, and co/medication with such products as immunosuppressors. The third speaker, Paul Cornes compared the benefits and the cost savings that these biosimilars have afforded to patients over these years. It was interesting to learn that in the last 10 years of infliximab use, no difference in immunogenicity has been shown between the reference drug and this biosimilar.

In conclusion, although there is space for improving the safety and quality of biosimilars, their impact in the control of health expenditure is greatly appreciated, and the opportunity to use the savings for other important disease treatments is a great prospect.

Carlo Polidori

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Report of eahp members’ meeting Representatives of EAHP’s Member country associations meet in Cannes provides users with information on statements that they want to improve on.

The Statement Implementation website will be complemented by the Self-Assessment Tool which will be made available during the summer. Members were invited to try out the alpha version of the tool at the EAHP Booth. Like representative from member country associations also participants have the possibility to go to booth #52 and find out more about the Self-Assessment Tool.

To help the new website develop further, members were asked to assist the implementation team in building resources for the website through submitting key papers and case studies and in identifying potential Statement Implementation Learning Collaborative Centres (SILCC).

Update on Common Training Framework

Photo by Petr Horák The annual EAHP congress – bringing together thousands of hospital pharmacists from all over the world – is the perfect occasion for updating our national hospital pharmacy associations.

Representatives from 23 of EAHP’s 35 Member country associations gathered the day before Congress on 21st March at the Members’ Meeting in order to hear about the latest news on EAHP activities and European matters that affect hospital pharmacy. EAHP used this opportunity not only to brief members on emerging and ongoing policy issues, but also to update them on the progress of different EAHP projects.

Update on EAHP Survey of Practice 2016 Petr Horák and Jonathan Underhill presented the results from the second EAHP Statement Survey focusing on Sections 1, 3 and 4 of the European Statements of Hospital Pharmacy. With this survey, the first full cycle is now completed. Data gathered per country via the three surveys of the first cycle helps to inform EAHP members, the board, the implementation team as well as the project team about the overall status quo of the profession and the Statement implementation status. In addition, these surveys help identify barriers of implementation.

The members, after being asked by Mr Underhill for their opinion, correctly identified Section 3 on production and compounding as the area that currently poses the least implementation barriers to hospital pharmacists. To better illustrate the findings, figures from the five questions that yielded the least positive results were presented. The presentation was finished off with recommendations centering around encouraging further engagement in raising awareness. Linking the Congress and the European Journal of Hospital Pharmacy (EJHP) with the statements has already slowly impacted the awareness of hospital pharmacists. It was further highlighted that countries with well-developed clinical services should support others.The 2016 Survey Report will be published digitally within this week.

Update on Statement Implementation After thanking the national associations and ambassadors for their great work during the first stage Tony West, the Project Director, provided members with a first glimpse on the new website for the of the Statement Implementation project that was launched during keynote 1 on Wednesday.

It links resources to individual statements and thus

EAHP’s president Joan Peppard gave members a little preview of part of her keynote speech by updating them on the progress of the different Common Training Framework working groups.

She noted that the consultation on the contents of the Common Training Framework (CTF), which is conducted in accordance with Delphi principles, is currently ongoing. After a lively discussion on the practical use of CTF for labour mobility of hospital pharmacists, Ms Peppard closed the presentation by giving the members a forward look on the next steps that will be taken once the CTF Delphi Consultation finishes in April.

Implementation of the Falsified Medicines Directive in the hospital sector To finish off the information-packed event, board members Robert Moss and András Süle briefly update the delegates on the latest developments regarding the Falsified Medicines Directive.

They kept their presentation very short as the Falsified Medicines Directive – which is due to be implemented by hospital pharmacists by February 2019 – was subject to a fuller discussion at the EAHP Members Information sharing event last evening.

Like every year, the different representatives from the member country associations used the Members’ Meeting also as an opportunity for exchanging with each other.

Stephanie Kohl

EAHP WARMLY THANKS OUR INDUSTRY PARTNERS FOR THEIR CONTINUED COMMITMENT TO SUPPORTING THE GOALS OF HOSPITAL PHARMACISTS

PLATINUM PARTNERS

CORPORATE PARTNER

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Winner’s corner Meet the winners of the 22nd EAHP Congress Poster and GPI prizes During the 22nd EAHP Congress, 30 poster nominees had the chance to give a short presentation with feedback provided by the Scientific Committee members during the poster walk.

Photo by Mariona Ribo

This year we have received over a thousand abstracts submitted by hospital pharmacists from around the globe. All accepted abstracts were hung in the poster area and published in the abstract book. Authors were also provided an excellent opportunity to present their work to colleagues interested in their field of expertise.

Here’s a glimpse of the number of abstracts received vs absracts accepted over the years: Received Accepted Paris 2013 950 630 Barcelona 2014 877 525 Hamburg 2015 880 535 Vienna 2016 889 571

1st Prize for the Good Practice Initiatives went to Elin Trapnes for the abstract and poster entitled “National The EAHP Congress poster exhibition and the oral poster communication sessions are the Consensus on Core Competencies for Clinical Pharmacists mainstay of the annual EAHP Congress and only the best are selected! in Norway”

Photo by Mariona Ribo

Photo by Mariona Ribo

Photo by Mariona Ribo

Cannes 2017 1053 607

1st Poster Prize went to Klaus Bertram Nissen for the abstract and poster entitled “Stability Study of Bortezomib (Velcade) with Limit Test for All Degradation Products”

2nd Poster Prize went to Claire Cordelle for the abstract and poster entitled “Relation between Clinical Remission and through Infliximab Levels in Children with Inflammatory Bowel Disease”

3rd Poster Prize went to Dora Mueller for the abstract and poster entitled “Valuation of the Clinical Significance and Value of a Clinical Pharmacy Service at a Teaching Hospital”

Abstract submission deadline for the 23rd EAHP Congress is 15th October 2017 Do you have a Good Practice Initiative that you would like to share?

Visit the website www.eahp.eu/gpis and tell us about your GPI. The submission portal is open all year long!

The European Association of Hospital Pharmacists (EAHP) is collecting examples of good practice initiatives (GPIs).

The overall purpose of collecting and sharing GPIs is: • to inspire and encourage fellow hospital pharmacists in other countries to strive for the next high standard in practice; • to identify how colleague hospital pharmacists were able to overcome barriers and obstacles in order to make improvement happen; and, • to give recognition to those who have completed successful new initiatives in hospital pharmacy service.

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Implementing the European Statements of Hospital Pharmacy academia. The website also provides a range of resources to help with the implementation of the Statements within individual hospitals or at the level of a region or nation.

These resources will include an evidence base for each of the Statements plus general material to assist our member associations with implementation.

Visit us at www.statements.eahp.eu EAHP also presented during the Congress a demo version of the self-assessment tool. This online tool will allow hospital pharmacists to assess the level of implementation within their countries and to show progress. The tool will also provide an action plan with evidence to help hospital pharmacists and other healthcare professionals to move towards implementation. The self-assessment tool was presented to National Associations just before the congress and demonstrated to delegates at the EAHP booth in the exhibition hall. Our members and implementation ambassadors will test the final version of the tool and feedback and input will be collected during the next General Assembly in Malta. Then, the tool will be launched for everybody by late June.

Photo by Mariona Ribo The European Statements of Hospital Pharmacy, adopted in 2014, represent what every European healthcare system should aim in the delivery of hospital pharmacy services.

They were adopted following a Delphi Process and with the collaboration of patients and healthcare groups.

EAHP is working now with its national associations to move towards the implementation of the Statements within all its member countries. The project was formally launched during the 22nd Congress in Cannes. As part of the launch, the EAHP implementation team held meetings and presentations at the EAHP Booth.

In addition to giving an update of the project, the team conducted over 100 presentations of the Statements Implementation website and the self-assessment tool.

Please do not hesitate to contact the team at Statements@ eahp.eu to learn more about the project and to help your country and others to move towards implementation.

A Statement Implementation website was launched during the Congress. The EAHP website has now a section dedicated to the European Statements. This section provides an overview of why the Statements are so important to a variety of stakeholders, ranging from patients and policy makers through to other healthcare practitioners, as well as our many partners in industry and

Gonzalo Marzal Lopez

23rd Congress of

HOSPITAL PHARMACISTS SHOW US WHAT YOU CAN DO! 21st - 23rd March 2018 Gothenburg, Sweden Registration opens 1st August 2017 Abstract submission deadline 15th October 2017

25-27 March, 2015 Hamburg, Germany

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