The molecular basis for pore pattern morphogenesis in diatom silica.

Biomineral-forming organisms produce inorganic materials with complex, genetically encoded morphologies that are unmatched by current synthetic chemistry. It is poorly understood which genes are involved in biomineral morphogenesis and how the encoded proteins guide this process. We addressed these questions using diatoms, which are paradigms for the self-assembly of hierarchically meso- and macroporous silica under mild reaction conditions. Proteomics analysis of the intracellular organelle for silica biosynthesis led to the identification of new biomineralization proteins. Three of these, coined dAnk1-3, contain a common protein-protein interaction domain (ankyrin repeats), indicating a role in coordinating assembly of the silica biomineralization machinery. Knocking out individual dank genes led to aberrations in silica biogenesis that are consistent with liquid-liquid phase separation as underlying mechanism for pore pattern morphogenesis. Our work provides an unprecedented path for the synthesis of tailored mesoporous silica materials using synthetic biology.

Trajectories of post-traumatic stress in sepsis survivors two years after ICU discharge: a secondary analysis of a randomized controlled trial.

BACKGROUND: Post-traumatic stress has been identified as a frequent long-term complication in survivors of critical illnesses after sepsis. Little is known about long-term trajectories of post-traumatic stress and potentially modifiable risk factors following the ICU stay. Study objective was to explore and compare different clinical trajectories of post-traumatic stress symptoms in sepsis survivors up to two years after discharge from ICU. METHODS: Data on post-traumatic stress symptoms by means of the Post-traumatic Symptom Scale (PTSS-10) were collected in sepsis survivors at one, six, 12 and 24 months after discharge from ICU. Data on chronic psychiatric diagnoses prior ICU were derived from the primary care provider's health records, and data on intensive care treatment from ICU documentation. Trajectories of post-traumatic symptoms were identified ex post, discriminating patterns of change and k-means clustering. Assignment to the trajectories was predicted in multinomial log-linear models. RESULTS: At 24 months, all follow-up measurements of the PTSS-10 were completed in N = 175 patients. Three clusters could be identified regarding clinical trajectories of PTSS levels: stable low symptoms (N = 104 patients [59%]), increasing symptoms (N = 45 patients [26%]), and recovering from symptoms (N = 26 patients [15%]). Patients with initially high post-traumatic symptoms were more likely to show a decrease (OR with 95% CI: 1.1 [1.05, 1.16]). Females (OR = 2.45 [1.11, 5.41]) and patients reporting early traumatic memories of the ICU (OR = 4.04 [1.63, 10]) were at higher risk for increasing PTSS levels. CONCLUSION: Post-traumatic stress is a relevant long-term burden for sepsis patients after ICU stay. Identification of three different trajectories within two years after ICU discharge highlights the importance of long-term observation, as a quarter of patients reports few symptoms at discharge yet an increase in symptoms in the two years following. Regular screening of ICU survivors on post-traumatic stress should be considered even in patients with few symptoms and in particular in females and patients reporting traumatic memories of the ICU.

"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care.

BACKGROUND: Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP. METHOD: Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis. RESULTS: Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity. CONCLUSION: Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Shedding light on silica biomineralization by comparative analysis of the silica-associated proteomes from three diatom species.

Morphogenesis of the intricate patterns of diatom silica cell walls is a protein-guided process, yet to date only very few such silica biomineralization proteins have been identified. Therefore, it is currently unknown whether all diatoms share conserved proteins of a basal silica forming machinery, and whether unique proteins are responsible for the morphogenesis of species-specific silica patterns. To answer these questions, we extracted proteins from the silica of three diatom species (Thalassiosira pseudonana, Thalassiosira oceanica, and Cyclotella cryptica) by complete demineralization of the cell walls. Liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) analysis of the extracts identified 92 proteins that we name 'soluble silicome proteins' (SSPs). Surprisingly, no SSPs are common to all three species, and most SSPs showed very low similarity to one another in sequence alignments. In-depth bioinformatics analyses revealed that SSPs could be grouped into distinct classes based on short unconventional sequence motifs whose functions are yet unknown. The results from the in vivo localization of selected SSPs indicates that proteins, which lack sequence homology but share unconventional sequence motifs may exert similar functions in the morphogenesis of the diatom silica cell wall.

Patients' and GPs' duties and responsibilities in long-term care after myocardial infarction: a qualitative study of patients' perspectives.

BACKGROUND: Cardiovascular disease is one of the main causes of death in Europe and around the world. Effective and individualized long-term treatment of patients with chronic diseases such as cardiovascular disease and myocardial infarction reduces mortality and the risk of recurrence and prevents secondary disease. However, there is little data on patients' views. OBJECTIVE: To examine patients' perspectives on long-term care after myocardial infarction. METHODS: A qualitative interview study with patients after myocardial infarction in Berlin and Brandenburg, Germany. Fifteen episodic interviews were conducted, transcribed, coded, and analyzed using framework analysis. RESULTS: Participants consistently emphasized major functions fulfilled by general practitioners: monitoring, advice, diagnosis, referral, coordination. Furthermore, other functions such as empathy and feeling emotionally valued. Major patient roles emerged such as information sharing, lifestyle change, and coping. Responsibility toward doctors was expressed in terms of active participation in describing their symptoms, following the doctor's directions, and sharing in decision-making. Self-responsibility in participants showed 2 contrasting approaches. On the one hand, a passive attitude (acceptance, helplessness), and on the other, active resistance and taking action. CONCLUSION: The study underlines the importance of communication and awareness of the patient's perspective. General practitioners must address patients' aims and fears, encourage their initiative, and focus on empathy and education.

Transparency of clinical practice guideline funding: a cross-sectional analysis of the German AWMF registry.

BACKGROUND: While reporting of individual conflicts of interest is formalised, it is unclear to what extent the funding of clinical practice guidelines (CPGs) is formally reported. The aim of this study is to explore the accuracy and comprehensiveness of reporting on funding in German CPGs. METHODS: We searched for CPGs in the registry of the Association of the Scientific Medical Societies in Germany in July 2020. Information on guideline funding was categorised by two reviewers independently and discrepancies were clarified by discussion with a third reviewer. Accuracy and comprehensiveness of reporting on funding was assessed using the German Instrument for Methodological Guideline Appraisal (DELBI). RESULTS: We included 507 CPGs published between 2015 and 2020 in the main analysis. 23/507 (4.5%) of the CPGs achieved the highest DELBI score by including information on funding sources, expenses and the amount of funding provided, as well as a statement on the independence of the guideline authors from the funding institution(s). CPGs with more rigorous methodological requirements (systematic review of the literature and/or structured consensus-building) received higher DELBI scores. CONCLUSION: German CPGs do not communicate their funding transparently. Transparency of CPG funding could be achieved by making it mandatory to publish information for all guidelines. For that purpose, a standardised form and guidance should be developed.

[Do General Practitioners have Experience with Social Care Points? A Berlin-Wide Survey]. / Haben Hausärzt*innen Erfahrungen mit Pflegestützpunkten? Eine berlinweite Fragebogenerhebung.

Primary care for multimorbid patients involves social counseling in addition to medical care. Community care points are established institutions for social counseling at district level in Berlin. A Berlin-wide questionnaire survey examined primary care physicians' knowledge of and experience with community care points. 700 questionnaires were analysed exploratively and descriptively. General practitioners were only partially familiar with the services of community care points (60% barely or not at all). 57% of the general practitioners stated that they already had contact with community care points. General practitioners who had not yet had contact with a community care point recommended other advice centers for social (76%) and care-related advice (79%) to their patients. A majority of general practitioners expressed a wish to get more information about community care points.

[Attitudes of general practitioners and medical practice assistants towards the delegation of medical services: Results of a survey in Berlin, Brandenburg and Thuringia]. / Einstellungen von Hausärzt:innen und Medizinischen Fachangestellten zur Delegation ärztlicher Leistungen ­ Ergebnisse einer Befragung in Berlin, Brandenburg und Thüringen.

INTRODUCTION: The delegation of tasks and responsibilities from general practitioners (GPs) to medical practice assistants (MPAs) can contribute to ensuring primary care in Germany. The aim of the study was to collect and analyze attitudes and procedures of GPs and MPAs regarding the delegation of physician-related tasks and activities. METHODOLOGY: A self-designed, piloted questionnaire was sent to all GPs listed within the regional Associations of Statutory Health Insurance Physicians (KV) in Thuringia, Berlin, and Brandenburg (n=5,516) and their MPAs. Participants were asked to indicate which physician-related activities were already delegated and on which occasions further delegations could be considered. RESULTS: 890 GPs (response rate: 16.1%) and 566 MPAs participated in the written survey. The participants were predominantly female and most of them worked in urban areas. Numerous activities, such as medical history taking, triage, Disease Management Program (DMP) controls, vaccinations and home visits, have already been delegated. The willingness to delegate further tasks (e. g., follow-up prescriptions and referrals, independent takeover of simple consultations, assessing the necessity of physician consultation) was high. CONCLUSION: The survey showed a high level of willingness of both occupational groups to delegate physician-related activities to MFAs. An expansion seems possible under certain conditions. Many activities have already been delegated to MPAs in primary care practices. Our survey provides suggestions regarding further tasks suitable for delegation, some of which go beyond the delegation agreement valid in Germany.

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients' perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany.

BACKGROUND: Only few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95 days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends. METHODS: The follow-up survey included items on satisfaction with care received, benefit from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between-subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as beneficial. RESULTS: Follow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as beneficial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not differ significantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were significantly improved at follow-up, while general life satisfaction for the overall sample was unchanged. CONCLUSIONS: Most patients retrospectively assess the ED visit as satisfactory and beneficial. Possible sex differences in perception of care and its outcomes should be further investigated. Conceivable efforts at diversion of ED utilizers to primary care should consider patients' views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

Redirecting emergency medical services patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany.

BACKGROUND: Against the backdrop of emergency department (ED) overcrowding, patients' potential redirection to outpatient care structures is a subject of current political debate in Germany. It was suggested in this context that suitable lower-urgency cases could be transported directly to primary care practices by emergency medical services (EMS), thus bypassing the ED. However, practicality is discussed controversially. This qualitative study aimed to capture the perspective of EMS personnel on potential patient redirection concepts. METHODS: We conducted qualitative, semi-structured phone interviews with 24 paramedics. Interviews were concluded after attainment of thematic saturation. Interviews were transcribed verbatim, and qualitative content analysis was performed. RESULTS: Technical and organizational feasibility of patients' redirection was predominantly seen as limited (theme: "feasible, but only under certain conditions") or even impossible (theme: "actually not feasible"), based on a wide spectrum of potential barriers. Prominently voiced reasons were restrictions in personnel resources in both EMS and ambulatory care, as well as concerns for patient safety ascribed to a restricted diagnostic scope. Concerning logistics, alternative transport options were assessed as preferable. Regarding acceptance by stakeholders, the potential for releasing ED caseload was described as a factor potentially promoting adoption, while doubt was raised regarding acceptance by EMS personnel, as their workload was expected to conversely increase. Paramedics predominantly did not consider transporting lower-urgency cases as their responsibility, or even as necessary. Participants were markedly concerned of EMS being misused for taxi services in this context and worried about negative impact for critically ill patients, as to vehicles and personnel being potentially tied up in unnecessary transports. As to acceptance on the patients' side, interview participants surmised a potential openness to redirection if this would be associated with benefits like shorter wait times and accompanied by proper explanation. CONCLUSIONS: Interviews with EMS staff highlighted considerable doubts about the general possibility of a direct redirection to primary care as to considerable logistic challenges in a situation of strained EMS resources, as well as patient safety concerns. Plans for redirection schemes should consider paramedics' perspective and ensure a provision of EMS with the resources required to function in a changing care environment.

REDuction of Antibiotic RESistance (REDARES) in urinary tract infections using treatments according to national clinical guidelines: study protocol for a pragmatic randomized controlled trial with a multimodal intervention in primary care.

BACKGROUND: Urinary tract infections (UTIs) are a common cause of prescribing antibiotics in family medicine. In Germany, about 40% of UTI-related prescriptions are second-line antibiotics, which contributes to emerging resistance rates. To achieve a change in the prescribing behaviour among family physicians (FPs), this trial aims to implement the guideline recommendations in German family medicine. METHODS/DESIGN: In a randomized controlled trial, a multimodal intervention will be developed and tested in family practices in four regions across Germany. The intervention will consist of three elements: information on guideline recommendations, information on regional resistance and feedback of prescribing behaviour for FPs on a quarterly basis. The effect of the intervention will be compared to usual practice. The primary endpoint is the absolute difference in the mean of prescribing rates of second-line antibiotics among the intervention and the control group after 12 months. To detect a 10% absolute difference in the prescribing rate after one year, with a significance level of 5% and a power of 86%, a sample size of 57 practices per group will be needed. Assuming a dropout rate of 10%, an overall number of 128 practices will be required. The accompanying process evaluation will provide information on feasibility and acceptance of the intervention. DISCUSSION: If proven effective and feasible, the components of the intervention can improve adherence to antibiotic prescribing guidelines and contribute to antimicrobial stewardship in ambulatory care.  Trial registration DRKS, DRKS00020389, Registered 30 January 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020389 .

[The Delegation Agreement and its Implementation Inside and Outside the GP Office from the Perspective of Practice Owners]. / Die Delegations-Vereinbarung und ihre Umsetzung innerhalb und außerhalb der hausärztlichen Praxis aus Sicht der Niedergelassenen.

BACKGROUND: In many regions in Germany, demographic changes are affecting general practitioners (GPs). The 2017 "Delegation Agreement" (D-A) rolled out the 2015 reform and was introduced initially only for regions with GP shortages, allowing delegation to non-medical practice personnel for all regions in Germany. OBJECTIVES: This article explores GPs' knowledge regarding current regulations and the task-based delegation inside and outside their office. MATERIALS AND METHODS: We conducted a quantitative anonymous postal questionnaire survey of a randomized sample of 30% of GPs working in Nord Rhine-Westphalia. The response rate was 32%. Outcomes included attitude towards delegation, self-perceived level of information about the D-A and task-based attitude towards delegation (is being delegated/is not delegable) for 34 medical tasks. RESULTS: Over two-thirds of GPs had a positive attitude towards delegation, but only 24% reported having a good/very good level of Information regarding the D-A. "Diagnostic tasks" were most frequently delegated. Agreement on what can be delegated in the areas of "general tasks" and "counselling/education" showed significant differences based on level of information. Both well-informed and poorly informed GPs delegated in equal measure "therapeutic tasks". Two distinct groups of "diagnostic tasks" were distinguished based on GPs' information level. CONCLUSIONS: The list of tasks being currently delegated to PAs in the fields of "diagnostics", "organization/administration" and "general tasks" shows further potential for expansion. This could be supported by improved information communicated to GPs about the health policy reform introduced by the D-A.

[Support for General Practitioners in the Care of Patients with Complex Needs: A Questionnaire Survey of General Practitioners in Berlin]. / Unterstützungsbedarf und -möglichkeiten für Hausärzte in der Versorgung von Patienten mit komplexem Bedarf: Eine Fragebogenerhebung Berliner Hausärzte.

OBJECTIVES: Because of demographic changes, new models of care are important for supporting general practitioners in the care of patients with complex needs. This study addresses the question of the type of support that is requested by general practitioners working in Berlin. METHODS: All general practitioners working in Berlin (n=2354) were asked between August and September 2018 to return a questionnaire by post which has been developed for this study. Questions addressed support needs as well as support models within the practice (delegation, substitution) and outside the practice (social worker, navigator, community care points). Data were analysed descriptively and by exploratory multivariate analysis to show the influence of practice and doctor characteristics on the preference of support models (age, gender, location of the practice, type of practice, working hours). RESULTS: A total of 557 questionnaires (response rate 23.7%) were included in the analysis. Need for support was seen particularly for administrative, coordinative and organisational tasks and for advice on social issues. The majority of the study participants approved delegation and substitution. In their view, it was conceivable to get support from professionals or institutions outside their practice, such as mobile care services, community care points, social workers or navigators. Particularly younger and female doctors working in group practices were open for cooperative care models integrating other health professions. CONCLUSIONS: There is unused potential for delegation and cooperation within existing structures. Further research should investigate the acceptance and feasibility of different support models.

Implications for post critical illness trial design: sub-phenotyping trajectories of functional recovery among sepsis survivors.

BACKGROUND: Patients who survive critical illness suffer from a significant physical disability. The impact of rehabilitation strategies on health-related quality of life is inconsistent, with population heterogeneity cited as one potential confounder. This secondary analysis aimed to (1) examine trajectories of functional recovery in critically ill patients to delineate sub-phenotypes and (2) to assess differences between these cohorts in both clinical characteristics and clinimetric properties of physical function assessment tools. METHODS: Two hundred ninety-one adult sepsis survivors were followed-up for 24 months by telephone interviews. Physical function was assessed using the Physical Component Score (PCS) of the Short Form-36 Questionnaire (SF-36) and Activities of Daily Living and the Extra Short Musculoskeletal Function Assessment (XSFMA-F/B). Longitudinal trajectories were clustered by factor analysis. Logistical regression analyses were applied to patient characteristics potentially determining cluster allocation. Responsiveness, floor and ceiling effects and concurrent validity were assessed within clusters. RESULTS: One hundred fifty-nine patients completed 24 months of follow-up, presenting overall low PCS scores. Two distinct sub-cohorts were identified, exhibiting complete recovery or persistent impairment. A third sub-cohort could not be classified into either trajectory. Age, education level and number of co-morbidities were independent determinants of poor recovery (AUROC 0.743 ((95%CI 0.659-0.826), p < 0.001). Those with complete recovery trajectories demonstrated high levels of ceiling effects in physical function (PF) (15%), role physical (RP) (45%) and body pain (BP) (57%) domains of the SF-36. Those with persistent impairment demonstrated high levels of floor effects in the same domains: PF (21%), RP (71%) and BP (12%). The PF domain demonstrated high responsiveness between ICU discharge and at 6 months and was predictive of a persistent impairment trajectory (AUROC 0.859 (95%CI 0.804-0.914), p < 0.001). CONCLUSIONS: Within sepsis survivors, two distinct recovery trajectories of physical recovery were demonstrated. Older patients with more co-morbidities and lower educational achievements were more likely to have a persistent physical impairment trajectory. In regard to trajectory prediction, the PF score of the SF-36 was more responsive than the PCS and could be considered for primary outcomes. Future trials should consider adaptive trial designs that can deal with non-responders or sub-cohort specific outcome measures more effectively.

Self-referred walk-in patients in the emergency department - who and why? Consultation determinants in a multicenter study of respiratory patients in Berlin, Germany.

BACKGROUND: Emergency department (ED) consultations are on the rise, and frequently consultations by non-urgent patients have been held accountable. Self-referred walk-in (SRW) consulters supposedly represent a predominantly less urgent patient population. The EMACROSS study aimed to explore consultation determinants and motives in SRW patients with respiratory symptoms. METHODS: Multicenter survey of adult ED patients with respiratory complaints in eight emergency departments in central Berlin, Germany. Secondary hospital records data including diagnoses was additionally assessed. Characteristics of SRW and non-SRW patients were compared. Determinants of SRW consultation were evaluated by binary logistic regression. Consultation motives were analyzed descriptively. As a supplemental approach, network analysis (lasso-regularized mixed graphical model) was performed to explore connections between consultation determinants, consultation features and motives. RESULTS: Between June 2017 and November 2018, n = 472 participants were included, the median age was 55 years (range 18-96), 53.2% of patients were male and n = 185 cases (39.2%) were SRW consulters. The SRW group showed lower proportions of potentially severe (pneumonia and respiratory failure, p < 0.001, χ2 test) and chronic pulmonary conditions. Determinants of SRW consultation identified by logistic regression were younger age (p < 0.001), tertiary education (p = 0.032), being a first-generation migrant (p = 0.002) or tourist (p = 0.008), having no regular primary care provider (p = 0.036) and no chronic pulmonary illness (p = 0.017). The area under the curve (AUC) for the model was 0.79. Personal distress and access problems in ambulatory care were stated most frequently as consultation motives in the SRW group; network analysis showed the scarcity of associations between demographic and medical SRW determinants and motives triggering the actual decision to consult. CONCLUSIONS: As to "who" consults, this study identified demographic and medical predictors of SRW utilization. The said markers seem only remotely connected to "why" people decide for SRW visits. To alleviate ED crowding by addressing frequent SRW consultation motives, interventions focused on the ability for symptom self-assessment and at better-accessible alternative care seem sensible. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

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

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

What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany.

BACKGROUND: While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit. METHODS: Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research). RESULTS: Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED. CONCLUSIONS: With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.

Coordination of care for multimorbid patients from the perspective of general practitioners - a qualitative study.

BACKGROUND: In Germany, a decreasing number of general practitioners (GPs) face a growing number of patients with multimorbidity. Whilst care for patients with multimorbidity involves various healthcare providers, the coordination of this care is one of the many responsibilities of GPs. The aims of this study are to identify the barriers to the successful coordination of multimorbid patient care and these patients' complex needs, and to explore the support needed by GPs in the care of multimorbid patients. Interviewees were asked for their opinion on concepts which involve the support by additional employees within the practice or, alternatively, external health care professionals, providing patient navigation. METHODS: Thirty-two semi-structured, qualitative interviews were conducted with 16 GPs and 16 medical practice assistants (MPAs) from 16 different practices in Berlin. A MPA is a qualified non-physician practice employee. He or she undergoes a three years vocational training which qualifies him or her to provide administrative and clinical support. The interviews were digitally recorded, transcribed and analysed using the framework analysis methodology. RESULTS: The results of this paper predominantly focus on GPs' perspectives of coordination within and external to general practice. Coordination in the context of care for multimorbid patients consists of a wide range of different tasks. Organisational and administrative obstacles under the regulatory framework of the German healthcare system, and insufficient communication with other healthcare providers constitute barriers described by the interviewed GPs and MPAs. In order to ensure optimal care for patients with multimorbidity, GPs may have to delegate responsibilities associated with coordinating tasks. GPs consider the deployment of an additional specifically qualified employee inside the general practice to take on coordinative and social and legal duties to be a viable option. CONCLUSIONS: The cross-sectoral cooperation between all involved key players working within the healthcare system, as well as the coordination of the whole care process, is seemingly challenging for GPs within the complex care system of multimorbid patients. GPs are generally open to the assignment of a person to support them in coordination tasks, preferably situated within the practice team.

Reconstituting the formation of hierarchically porous silica patterns using diatom biomolecules.

The genetically-controlled formation of complex-shaped inorganic materials by living organisms is an intriguing phenomenon. It illustrates our incomplete understanding of biological morphogenesis and demonstrates the feasibility of ecologically benign routes for materials technology. Amorphous SiO2 (silica) is taxonomically the most widespread biomineral, with diatoms, a large group of single-celled microalgae, being the most prolific producers. Silica is the main component of diatom cell walls, which exhibit species-specific patterns of pores that are hierarchically arranged and endow the material with advantageous properties. Despite recent advances in characterizing diatom biomolecules involved in biosilica morphogenesis, the mechanism of this process has remained controversial. Here we describe the in vitro synthesis of diatom-like, porous silica patterns using organic components that were isolated from biosilica of the diatom Cyclotella cryptica. The synthesis relies on the synergism of soluble biomolecules (long-chain polyamines and proteins) with an insoluble nanopatterned organic matrix. Biochemical dissection of the process revealed that the long-chain polyamines rather than the proteins are essential for efficient in vitro synthesis of the hierarchically porous silica patterns. Our results support the organic matrix hypothesis for morphogenesis of diatom biosilica and introduce organic matrices from diatoms as a new tool for the synthesis of meso- to microporous inorganic materials.

Antibiotic prescribing behavior among general practitioners - a questionnaire-based study in Germany.

BACKGROUND: This study investigates the barriers and facilitators of the use of antibiotics in acute respiratory tract infections by general practitioners (GPs) in Germany. METHODS: A multidisciplinary team designed and pre-tested a written questionnaire addressing the topics awareness of antimicrobial resistance (7 items), use of antibiotics (9 items), guidelines/sources of information (9 items) and sociodemographic factors (7 items), using a five-point-Likert-scale ("never" to "very often"). The questionnaire was mailed by postally to 987 GPs with registered practices in eastern Germany in May 2015. RESULTS: 34% (340/987) of the GPs responded to this survey. Most of the participants assumed a multifactorial origin for the rise of multidrug resistant organisms. In addition, 70.2% (239/340) believed that their own prescribing behavior influenced the drug-resistance situation in their area. GPs with longer work experience (> 25 years) assumed less individual influence on drug resistance than their colleagues with less than 7 years experience as practicing physicians (Odds Ratio [OR] 0.32, 95% Confidence Interval [CI] 0.17-0.62; P < 0.001). 99.1% (337/340) of participants were familiar with the "delayed prescription" strategy to reduce antibiotic prescriptions. However, only 29.4% (74/340) answered that they apply it "often" or "very often". GPs working in rural areas were less likely than those working in urban areas to apply delayed prescription. CONCLUSION: The knowledge on factors causing antimicrobial resistance in bacteria is good among GPs in eastern Germany. However measures to improve rational prescription are not widely implemented yet. Further efforts have to be made in order to improve rational prescription of antibiotic among GPs. Nevertheless, there is a strong awareness of antimicrobial resistance among the participating GPs.