'I think there is nothing . . . that is really comprehensive': healthcare professionals' views on recommending online resources for pain self-management.

OBJECTIVES: To explore healthcare professionals' views on, and attitudes, towards recommending online resources for persistent pain self-management. METHODS: This study was the qualitative phase of a two-phase mixed method study. Thirty-one New Zealand health professionals involved in the management of persistent pain were interviewed via focus groups and individual interviews. Data were analysed using the general inductive approach. RESULTS: The major themes were as follows: (1) risks and limits of online information outweigh benefits, (2) a blended model, of online resources with healthcare professional support, could work, (3) only trustworthy resources can be recommended, (4) need for personalisation and (5) perceived barriers to adoption. CONCLUSION: Online resources were perceived as a useful adjunct to support pain self-management; however, due to potential risks of misinterpretation and misinformation, healthcare professionals proposed a 'blended model' where curated online resources introduced during face-to-face consultations could be used to support self-management. Participants needed 'trustworthy online resources' that provide evidence-based, updated information that is personalised to clients' health literacy and cultural beliefs. PRACTICE IMPLICATIONS: Training for healthcare professionals on critical appraisal of online resources or curation of evidence-based online resources could increase recommendation of online resources to support pain self-management as an adjunct to in-person care.

[Focused ultrasound in the emergency room]. / Fokussierte Sonographie im Schockraum.

Ultrasound is an important tool in diagnosis and treatment of critically ill patients. For trauma patients the eFAST (extended focused assessment with sonography for trauma) algorithm is already implemented in the diagnostic pathway. However, critically ill patients without trauma also need a structured approach including an early focused ultrasonographic exam. National and international guidelines regarding critical illnesses such as acute coronary syndrome, cardiogenic shock complicating myocardial infarction, pulmonary embolism or acute aortic syndromes recommend the use of ultrasound. We present pathways how ultrasound can be used in the diagnostic approach of common symptoms such as dyspnea, shock and abdominal pain. Using the ABCDE approach this article shows how ultrasound can be incorporated into the diagnostic pathway.

[Sonography in intensive care and emergency medicine : A new training concept]. / Sonographie in der internistischen Intensiv- und Notfallmedizin : Ein neues Ausbildungskonzept.

Structured sonography training in internal medicine intensive care and emergency medicine (SIN) comprises two levels and was proposed by three national societies in Germany (DGIIN, DGK and DEGUM). The curriculum consists of a basic level (SIN-I) and an expert level (SIN-II) which are consecutive levels teaching both theoretical and hands-on skills using a symptom-based approach. Competency is assessed using written, oral and practical structured assessments at the end of each level. The goal is to implement national and international recommendations regarding the use of point-of-care ultrasound into clinical practice.

[Ultrasound training in emergency and intensive care medicine : Integration already in medical school?] / Sonographieausbildung in der Notfall- und Intensivmedizin : Integration schon im Medizinstudium?

Ultrasound is an important diagnostic tool especially in emergency and intensive care medicine. It is always available at the bedside and shortens time to diagnosis. Many specialties have integrated ultrasound into diagnostic algorithms as part of the extended physical exam. Numerous differential diagnoses can be easily excluded using point-of-care ultrasound and therefore adequate treatment is initiated faster. Emergency or focused ultrasound is therefore of outstanding relevance to any emergency or critical care physician. Integration into medical school curricula is becoming more common tough no nationwide standards are in place yet.

Emergency ultrasound and echocardiography in patients with infarct-related cardiogenic shock : A survey among members of the German Society of Medical Intensive Care and Emergency Medicine.

Current international and national guidelines promote the use of emergency echocardiography in patients with cardiogenic shock. We assessed whether these recommendations are followed in clinical practice of infarct-related cardiogenic shock patients. For this purpose we conducted a web-based survey among all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN); 40% of the DGIIN members completed the survey. Participants reported that in their department emergency echocardiography/ultrasound is performed on most patients in infarct-related cardiogenic shock presenting to the emergency department/chest pain unit or intensive care unit (58.6% versus 81.4%). Only 33% stated that on patients admitted directly to the catheterization laboratory emergency ultrasound/echocardiography is applied in their institution. Local availability of a standardized algorithm was lacking in the majority of departments (77.2%). A great proportion (38.3%) of participants stated that they personally had no formal training in emergency ultrasound. In order to meet the demands of the current guidelines, in addition to integration of ultrasound examinations into diagnostic algorithms, a structured training of all emergency and intensive care physicians is necessary.

[Focused echocardiography in acute medicine]. / Fokussierte Echokardiographie in der Akutmedizin.

Focused echocardiography has become increasingly important for bedside diagnostics in acute medicine. Focused echocardiography can detect various cardiac pathologies, such as pericardial effusion, left ventricular dysfunction, right heart strain, relevant heart valve defects and dissection of the ascending aorta. Echocardiographic findings should be interpreted in the clinical context.

[Structured bedside-ultrasound in intensive care medicine]. / Strukturierte bettseitige Sonographie in der Intensivmedizin.

The so-called point-of-care ultrasound (POCUS) is of increasing importance for diagnostics and therapy control in intensive care medicine. Based on focused thorax sonography, echocardiography, and abdominal sonography, the most important working and differential diagnoses can be demonstrated or excluded depending on the leading symptom. Sonographic-based algorithms allow a structured evaluation especially of patients with the common leading symptoms dyspnea and thoracic pain.

[Circulatory failure : Out- and inpatient management]. / Kreislaufschwäche : Ambulantes und stationäres Management.

Circulatory insufficiency is often understood as symptomatic hypotension due to various causes. The clinical result of circulatory dysregulation is arterial hypotension. The manifestation of hypotension is often divided into chronic and acute forms. Chronic hypotension can be distinguished etiopathogenetically into primary and secondary hypotension. Acute hypotension is usually equated to circulatory shock. While patients with chronic hypotension should be seen primarily by their general practitioner, patients with acute hypotension and a frequently severe clinical manifestation should be evaluated in the emergency department or, if there is a specific cause, directly in the acute clinic. Standardization of diagnostic and therapeutic pathways in both out- and inpatient care-not only for the management of circulatory weakness-would be an improvement not only in regards to patient care, but also with respect to healthcare economics.

[Recommendations for education in ultrasound in medical intensive care and emergency medicine: position paper of DGIIN, DEGUM and DGK]. / Empfehlungen zur Ultraschallausbildung in der internistischen Intensiv- und Notfallmedizin: Positionspapier der DGIIN, DEGUM und DGK.

Point-of-care ultrasound in acute care medicine is a prerequisite for diagnosis and therapy monitoring of critically ill patients. There is currently no uniform education strategy for medical intensive care and emergency medicine. As part of the basic level, the trainee takes theoretical and clinical training covering abdominal and thoracic ultrasonography and focused cardiovascular ultrasound. In a second step, special knowledge and skills can be acquired at an expert level. This two-stage concept is intended to guarantee quality assurance in ultrasound education in medical intensive care and emergency medicine.

[Hemodynamic monitoring in intensive care and emergency medicine : Integration of clinical signs and ultrasound findings]. / Hämodynamisches Monitoring in der Intensiv- und Notfallmedizin : Integration klinischer und sonographischer Befunde.

Hemodynamic monitoring is required in critically ill patients presenting with circulatory shock. Besides the clinical evaluation, noninvasive technologies can be used. Guidelines on volume resuscitation and cardiogenic shock already recommend bedside ultrasound as a diagnostic tool. To differentiate the cause of circulatory shock and monitor the effects of therapies, hemodynamic monitoring is necessary. This review discusses possibilities of the different invasive and noninvasive monitoring tools with a focus on the integration of clinical and sonographic parameters.

[Which learning methods are expected for ultrasound training? Blended learning on trial]. / Welche Lehrmethoden werden für die Ultraschallausbildung erwartet? : "Blended learning" auf dem Prüfstand.

BACKGROUND: Current teaching methods in graduate and postgraduate training often include frontal presentations. Especially in ultrasound education not only knowledge but also sensomotory and visual skills need to be taught. This requires new learning methods. AIM: This study examined which types of teaching methods are preferred by participants in ultrasound training courses before, during and after the course by analyzing a blended learning concept. It also investigated how much time trainees are willing to spend on such activities. MATERIAL AND METHODS: A survey was conducted at the end of a certified ultrasound training course. Participants were asked to complete a questionnaire based on a visual analogue scale (VAS) in which three categories were defined: category (1) vote for acceptance with a two thirds majority (VAS 67-100%), category (2) simple acceptance (50-67%) and category (3) rejection (< 50%). RESULTS: A total of 176 trainees participated in this survey. Participants preferred an e-learning program with interactive elements, short presentations (less than 20 min), incorporating interaction with the audience, hands-on sessions in small groups, an alternation between presentations and hands-on-sessions, live demonstrations and quizzes. For post-course learning, interactive and media-assisted approaches were preferred, such as e-learning, films of the presentations and the possibility to stay in contact with instructors in order to discuss the results. Participants also voted for maintaining a logbook for documentation of results. CONCLUSION: The results of this study indicate the need for interactive learning concepts and blended learning activities. Directors of ultrasound courses may consider these aspects and are encouraged to develop sustainable learning pathways.

Purine receptors modulate chondrocyte extracellular inorganic pyrophosphate production.

OBJECTIVE: Extracellular inorganic pyrophosphate (ePPi) plays a key role in the regulation of normal and pathologic mineralization. The purpose of this work was to evaluate the role of P1 and P2 purine receptors in modulating ePPi production by articular chondrocytes. METHODS: Porcine cartilage explants and chondrocyte monolayers were cultured in the presence of P1 agonists, or a P2 agonist or antagonist and inhibitors of P2 signaling. Ambient media ePPi concentrations were measured after 48-96h. RESULTS: The P1 agonists NECA and CGS 21680 significantly decreased ePPi concentrations surrounding chondrocytes and cartilage explants. The P2 agonist, ADP, increased ePPi levels, and the P2 antagonist, suramin, decreased ePPi concentrations. Thapsigargin and 1,2 bis-(2-aminophenoxy)ethane-N,N,N'N'-tetra acetic acid (BAPTA), which dampen Ca(2+)-related P2 signaling, suppressed the response to ADP. CONCLUSIONS: Purine receptors are important regulators of ePPi production by chondrocytes. P1 receptor stimulation diminishes and P2 receptor stimulation enhances ePPi production. Alterations in receptor signaling or aberrations of extracellular purine nucleotide metabolism resulting in abnormal quantities or proportions of P1 and P2 receptor ligands could foster changes in ePPi production that in turn affect mineralization. We propose a homeostatic role for extracellular purine nucleotides and purine receptors in stabilizing ePPi concentrations.

Effective diffusivities and mass fluxes in fungal biopellets.

Mass transport within biological aggregates is a key process that can determine overall turnover rates in submerged cultivations. A parameter commonly used for its description is the effective diffusion coefficient D(eff), which is highly dependent on biomass density and structure. Different approaches have been used to estimate or measure D(eff), yet the data still shows broad scattering. This study provides experimental data on effective diffusivities of oxygen within fungal pellets. A correlation is found with the hyphal gradient (dh/dr), which is a morphological parameter describing the structure of the pellet periphery. Furthermore, the dependency of D(eff) on fluid dynamic conditions at the pellet is investigated. The comparison of the results with data from literature clearly demonstrates the influence of the experimental methodology applied for determination of D(eff). Moreover, it is shown that while diffusion limitation of whole pellets is mainly a function of size, the influence of advection in the outer zone of pellets that is supplied with oxygen is actually rather high. Thus, it is concluded that the effective diffusion coefficient might not be sufficient for the description of mass transport within the pellet periphery for a broad range of realistic fluid dynamic conditions during cultivation. Nevertheless, although actual mass transport rates inside pellets are unknown, mass fluxes can be calculated on the basis of spatially resolved data of oxygen and biomass distribution within the pellet.

Population balance modeling of the conidial aggregation of Aspergillus niger.

Numerous biotechnological production processes are based on the submerse cultivation of filamentous fungi. Process design, however, is often hampered by the complex growth pattern of these organisms. In the morphologic development of coagulating filamentous fungi, like Aspergillus niger, conidial aggregation is the first step of filamentous morphogenesis. For a proper description of this phenomenon it is necessary to characterize conidial populations. Kinetic studies performed with an in-line particle size analyzer suggested that two distinct aggregation steps have to be considered. The first step of conidial aggregation starts immediately after inoculation. Both the rate constants of formation and disintegration of aggregates have been determined by measuring the concentration of conidia at the beginning of the cultivation and the concentration of particles at steady state during the first hours of cultivation. In contrast to the first aggregation step, where the collision of conidia is presumed to be responsible for the process, the second aggregation step is thought to be initiated by germination of conidia. Growing hyphae provide additional surface for the attachment of non- germinated conidia, which leads to a strong decrease in particle concentration. The specific hyphal length growth rate and the ratio of particle concentration to the growing adhesion hyphal surface are decisive matters of the second aggregation step. Both aggregation steps can be described by population dynamics and simulated using the program package PARSIVAL (PARticle SIze eVALution) for the treatment of general particle population balances.

Selection of reference genes for normalisation of specific gene quantification data of Aspergillus niger.

Aspergillus niger is a widely used expression host for homologous and heterologous protein production in biotechnological processes. In order to increase product yields, a thorough optimisation of these cultivation processes is necessary. Considering mRNA as the key molecule, which transports the genetic information between DNA and protein production side, the quantification of product specific gene expression provides useful information about product formation already on the level of transcription. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) is a powerful tool to obtain data about gene transcription. However, using this technique the choice of an appropriate reference system is a crucial aspect to provide optimal data normalisation. A prominent approach is the use of so called housekeeping genes as internal references. However, validation of the usability of these reference genes is the fundamental step before starting with qRT-PCR experiments. Adequate reference genes for A. niger have not been published so far. Therefore, 10 possible candidate genes from different functional classes were selected and their applicability as internal references validated. Transcript levels of these genes were compared in sets of 9, 41 and 19 samples from diverse cultivations of A. niger. Under the chosen experimental conditions, the genes act, sarA and cox5 have been identified as genes with the most stable gene expression. The three reference genes were used to normalise qRT-PCR data for glaA gene expression which showed a high correlation with glucoamylase production in continuous cultivations.

Morphology and productivity of filamentous fungi.

Cultivation processes involving filamentous fungi have been optimised for decades to obtain high product yields. Several bulk chemicals like citric acid and penicillin are produced this way. A simple adaptation of cultivation parameters for new production processes is not possible though. Models explaining the correlation between process-dependent growth behaviour and productivity are therefore necessary to prevent long-lasting empiric test series. Yet, filamentous growth consists of a complex microscopic differentiation process from conidia to hyphae resulting in various macroscopically visible appearances. Early approaches to model this morphologic development are recapitulated in this review to explain current trends in this area of research. Tailoring morphology by adjusting process parameters is one side of the coin, but an ideal morphology has not even been found. This article reviews several reasons for this fact starting with nutrient supply in a fungal culture and presents recent advances in the investigation of fungal metabolism. It illustrates the challenge to unfold the relationship between morphology and productivity.

Influence of mechanical stress and surface interaction on the aggregation of Aspergillus niger conidia.

Productivity of fungal cultures is closely linked with their morphologic development. Morphogenesis of coagulating filamentous fungi, like Aspergillus niger, starts with aggregation of conidia, also denominated as spores. Several parameters are presumed to control this event, but little is known about their mode of action. Rational process optimization requires models that mirror the underlying reaction mechanisms. An approach in this regard is suggested and supported by experimental data. Aggregation kinetics was examined for the first 15 h of cultivation under different cultivation conditions. Mechanical stress was considered as well as pH-dependent surface interaction. Deliberations were based on a two-step aggregation mechanism. The first aggregation step is only affected by the pH-value, not by the fluid dynamic conditions in the bioreactor. The second aggregation step, in contrast, depends on the pH-value as well as on agitation and aeration induced power input. For the given experimental set-up, agitation had much more influence than aeration. In addition, hyphal growth rate was determined to be the driving force for the second aggregation step.

Oxygen profiles and biomass distribution in biopellets of Aspergillus niger.

Morphology of fungal pellets has a significant influence on mass transfer and turnover processes in submerged cultures. There are many reports in literature that biomass is not distributed homogeneously over the pellet radius, yet quantitative data is rare. This study presents a method for the quantification of fungal pellet structure (Aspergillus niger). Confocal laser scanning microscopy (CLSM) is used in combination with image analysis freeware (Image J). Hyphal distribution is resolved spatially in radial direction. Quantitative morphological parameters are derived from digital images especially from the peripheral regions of the pellet that are not oxygen limited. This morphological information is combined with data of microelectrode measurements in the same pellets. Results show that the morphological parameters obtained can describe the impact of pellet structure on oxygen gradients much better than average biomass density. It is concluded that CLSM and image analysis are powerful tools not only to generate valuable data for quantitative description of pellet morphology. In addition, this data may be used in mathematical models to improve predictions of mass transfer and substrate conversion in mycelial aggregates.

Volumetric measurements of bacterial cells and extracellular polymeric substance glycoconjugates in biofilms.

In this study an enrichment culture developed from activated sludge was used to investigate the architecture of fully hydrated multispecies biofilms. The assessment of biofilm structure and volume was carried out using confocal laser scanning microscopy (CLSM). Bacterial cell distribution was determined with the nucleic acid-specific stain SYTO 60, whereas glycoconjugates of extracellular polymeric substances (EPS) were stained with the Alexa-488-labeled lectin of Aleuria aurantia. Digital image analysis was employed for visualization and quantification of three-dimensional CLSM data sets. The specific volumes of the polymeric and cellular biofilm constituents were quantified. In addition, gravimetric measurements were done to determine dry mass and thickness of the biofilms. The data recorded by the CLSM technique and the gravimetric data were then compared. It was shown that the biofilm thicknesses determined with both methods agree well for slow-growing heterotrophic and chemoautotrophic biofilms. In addition, for slow-growing biofilms, the volumes and masses calculated from CLSM and the biomass calculated from gravimetric measurements were also comparable. For fast-growing heterotrophic biofilms cultivated with high glucose concentrations the data sets fit to a lesser degree, but still showed the same common trend. Compared with traditional gravimetric measurements, CLSM allowed differential recording of multiple biofilm parameters with subsequent three-dimensional visualization and quantification. The quantitative three-dimensional results recorded by CLSM are an important basis for understanding, controlling, exploiting, and modeling of biofilms.