Formation of extraterrestrial peptides and their derivatives.

The formation of protein precursors, due to the condensation of atomic carbon under the low-temperature conditions of the molecular phases of the interstellar medium, opens alternative pathways for the origin of life. We perform peptide synthesis under conditions prevailing in space and provide a comprehensive analytic characterization of its products. The application of 13C allowed us to confirm the suggested pathway of peptide formation that proceeds due to the polymerization of aminoketene molecules that are formed in the C + CO + NH3 reaction. Here, we address the question of how the efficiency of peptide production is modified by the presence of water molecules. We demonstrate that although water slightly reduces the efficiency of polymerization of aminoketene, it does not prevent the formation of peptides.

Formation of Complex Organic and Prebiotic Molecules in H2O:NH3:CO2 Ices at Temperatures Relevant to Hot Cores, Protostellar Envelopes, and Planet-Forming Disks.

Photochemistry in H2O:NH3:CO2 cosmic ice analogues was studied at temperatures of 75, 120, and 150 K, relevant to hot cores and warmer regions in protostellar envelopes and planet-forming disks. A combination of two triggers of surface chemistry in cosmic ice analogues, heat and UV irradiation, compared to using either just heat or UV irradiation, leads to a larger variety and an increased production of complex organic molecules, including potential precursors of prebiotic molecules. In addition to complex organic molecules detected in previous studies of H2O:NH3:CO2 ices, ammonium carbamate, carbamic acid, ammonium formate and formamide, we detected acetaldehyde, urea, and, tentatively, glycine, the simplest amino acid. Water ice hampers reactions at low temperature (75 K) but allows the parent molecules, CO2 and NH3, to stay in the solid state and react at higher temperatures (120 and 150 K, above their desorption temperatures). The experiments were performed on the surface of KBr substrates and amorphous silicate grains, analogs of cosmic silicate dust. The production of complex molecules on the silicate surface is decreased compared to KBr. This result suggests that the larger surface area and/or surface properties of the silicate grains play a role in controlling the chemistry, preventing it taking place to the same extent as on the flat KBr substrate. This is further evidence of the fact that cosmic dust grains play an important role in the chemistry taking place on their surface.

Ice Coverage of Dust Grains in Cold Astrophysical Environments.

Surface processes on cosmic solids in cold astrophysical environments lead to gas-phase depletion and molecular complexity. Most astrophysical models assume that the molecular ice forms a thick multilayer substrate, not interacting with the dust surface. In contrast, we present experimental results demonstrating the importance of the surface for porous grains. We show that cosmic dust grains may be covered by a few monolayers of ice only. This implies that the role of dust surface structure, composition, and reactivity in models describing surface processes in cold interstellar, protostellar, and protoplanetary environments has to be reevaluated.

Formation of a long-lived cyclic isomer of ethylenedione.

A century of unsuccessful attempts to identify the neutral ethylenedione molecule combined with the results of quantum-chemical computations resulted in the conclusion on the instability of this molecule. In this article, we demonstrate that although the lowest energy isomer of ethylenedione with linear geometry is indeed unstable, a higher energy three-membered cyclic isomer can be stabilized, and at low temperature has a life-time longer than one millisecond. In our study, the ethylenedione C2O2 molecule was synthesized in the low-temperature reaction CO2 + C → C2O2 inside liquid helium nanodroplets. To study the reaction, a newly developed calorimetric technique was applied. Single pairs of reactants were incorporated into tiny helium droplets having a temperature of 0.37 K. The reaction energy was transferred to liquid helium stabilizing an intermediate gas-phase reaction product. The energy transfer also resulted in the evaporation of helium atoms. Therefore, the change of the helium droplets' size allowed precise calorimetry on a molecular scale.

Quantitative Structure-Retention Relationships for Polycyclic Aromatic Hydrocarbons and their Oligoalkynyl-Substituted Derivatives.

Reversed-phase high-performance liquid chromatography (RP-HPLC) has been carried out for a series of unsubstituted polycyclic aromatic hydrocarbons (PAHs) and the corresponding ethynyl, 1,3-butadiynyl, and 1,3,5-hexatriynyl derivatives. Theoretical values of the isotropic polarizability and several polarity descriptors have been computed for each compound by using semiempirical models and density functional theory (DFT), with the aim of evaluating linear functions as quantitative structure-retention relationships (QSRRs). The polarity has been described by using either the permanent electric dipole moment, the subpolarity, or a topological electronic index. Three types of partial atomic charges have been used to calculate the subpolarity and a topological index. The choice of the theoretical model, of the polarity descriptor, and of the partial atomic charges is discussed and the resulting QSRRs are compared. Calculating the retention times from the polarizability and the topological electronic index (AM1, PM3, or DFT-B3LYP/6-31+G(d,p)) gives the best agreement with the experimental values.

Aerosol Mass Spectrometer for Simultaneous Detection of Polyaromatic Hydrocarbons and Inorganic Components from Individual Particles.

Online studies of single airborne particles represent a demanding challenge in aerosol chemistry. New technologies that help to unravel the role of ambient aerosols in earth climate and to assess local and specific health risks from air pollution are highly desired. Of particular relevance are polycyclic aromatic hydrocarbons (PAHs) from combustion processes that are associated with both acute and long-term health effects. Usually, online single particle analyses apply laser desorption/ionization (LDI) in a bipolar mass spectrometer, revealing elemental constituents and limited molecular information by detection of both positive and negative ions. Approaches for the detection of PAHs from single particles have been developed but the elemental information from LDI that allows particle classification and source apportionment is lost in that case. Here we present a novel laser desorption and ionization method delivering both the PAH-profile and the inorganic composition from the same, individual particle. Test measurements demonstrate the technique's capability to reveal the single-particle PAH-distribution in aerosols (mixing state) and its assignment to specific pollution sources in a new and direct way.

A tailored programme to implement recommendations for multimorbid patients with polypharmacy in primary care practices-process evaluation of a cluster randomized trial.

BACKGROUND: We developed and evaluated a tailored programme to implement three evidence-based recommendations for multimorbid patients with polypharmacy into primary care practices: structured medication counselling including brown bag reviews, the use of medication lists and medication reviews. No effect on the primary outcome was found. This process evaluation aimed to identify factors associated with outcomes by exploring nine hypotheses specified in the logic model of the tailored programme. METHODS: The tailored programme was developed with respect to identified determinants of practice and consisted of a workshop for practice teams, elaboration of implementation action plans, aids for medication reviews, a multilingual info-tool for patients on a tablet PC, posters and brown paper bags as reminders for patients. The tailored programme was evaluated in a cluster randomized trial. The process evaluation was based on various data sources: interviews with general practitioners and medical assistants of the intervention group and a survey with general practitioners of the intervention and control group, written reports on the implementation action plans, documentation forms for structured medication counselling and the log file of the info-tool. RESULTS: We analyzed 12 interviews, 21 questionnaires, 120 documentation forms for medication counselling, 5 implementation action plans and one log file of the info-tool. The most frequently reported effect of the tailored programme was the increase of awareness for the health problem and the recommendations, while implementation of routine processes was only reported for structured medication counselling. The survey largely confirmed the usefulness of the applied strategies, yet the interviews provided a more detailed understanding of the actual use of the strategies and several suggestions for modifications of the tailored programme. CONCLUSIONS: The tailored programme seemed to have induced awareness as a first step of behaviour change. Several modifications of the tailored programme may enhance its effectiveness such as conducting outreach visits instead of a workshop, improved targeting, provision of evidence, integration of tools into the practice software and information materials in tailored formats. TRIAL REGISTRATION: This study is linked to an outcome evaluation study with the registration ISRCTN34664024 , assigned 14/08/2013.

Luminescence Spectroscopical Properties of Plagioclase Particles from the Hayabusa Sample Return Mission: An Implication for Study of Space Weathering Processes in the Asteroid Itokawa.

We report a systematic spectroscopical investigation of three plagioclase particles (RB-QD04-0022, RA-QD02-0025-01, and RA-QD02-0025-02) returned by the Hayabusa spacecraft from the asteroid Itokawa, by means of scanning electron microscopy, cathodoluminescence microscopy/spectroscopy, and micro-Raman spectroscopy. The cathodoluminescence properties are used to evaluate the crystallization effects and the degree of space weathering processes, especially the shock-wave history of Itokawa. They provide new insights regarding spectral changes of asteroidal bodies due to space weathering processes. The cathodoluminescence spectra of the plagioclase particles from Itokawa show a defect-related broad band centered at around 450 nm, with a shoulder peak at 425 nm in the blue region, but there are no Mn- or Fe-related emission peaks. The absence of these crystal field-related activators indicates that the plagioclase was formed during thermal metamorphism at subsolidus temperature and extreme low oxygen fugacity. Luminescence characteristics of the selected samples do not show any signatures of the shock-induced microstructures or amorphization, indicating that these plagioclase samples suffered no (or low-shock pressure regime) shock metamorphism. Cathodoluminescence can play a key role as a powerful tool to determine mineralogy of fine-grained astromaterials.

Impact of a tailored program on the implementation of evidence-based recommendations for multimorbid patients with polypharmacy in primary care practices-results of a cluster-randomized controlled trial.

BACKGROUND: Multimorbid patients receiving polypharmacy represent a growing population at high risk for negative health outcomes. Tailoring is an approach of systematic intervention development taking account of previously identified determinants of practice. The aim of this study was to assess the effect of a tailored program to improve the implementation of three important processes of care for this patient group: (a) structured medication counseling including brown bag reviews, (b) the use of medication lists, and (c) structured medication reviews to reduce potentially inappropriate medication. METHODS: We conducted a cluster-randomized controlled trial with a follow-up time of 9 months. Participants were general practitioners (GPs) organized in quality circles and participating in a GP-centered care contract of a German health insurance. Patients aged >50 years, suffering from at least 3 chronic diseases, receiving more than 4 drugs, and being at high risk for medication-related events according to the assessment of the treating GP were enrolled. The tailored program consisted of a workshop for GPs and health care assistants, educational materials and reminders for patients, and the elaboration of implementation action plans. The primary outcome was the change in the degree of implementation between baseline and follow-up, measured by a summary score of 10 indicators. The indicators were based on structured surveys with patients and GPs. RESULTS: We analyzed the data of 21 GPs (10 - intervention group, 11 - control group) and 273 patients (130 - intervention group, 143 - control group). The increase in the degree of implementation was 4.2 percentage points (95% confidence interval: -0.3, 8.6) higher in the intervention group compared to the control group (p = 0.1). Two of the 10 indicators were significantly improved in the intervention group: medication counseling (p = 0.017) and brown bag review (p = 0.012). Secondary outcomes showed an effect on patients' self-reported use of medication lists when buying drugs in the pharmacy (p = 0.03). CONCLUSIONS: The tailored program may improve implementation of medication counseling and brown bag review whereas the use of medication lists and medication reviews did not improve. No effect of the tailored program on the combined primary outcome could be substantiated. Due to limitations of the study, results have to be interpreted carefully. The factors facilitating and hindering successful implementation will be examined in a comprehensive process evaluation. TRIAL REGISTRATION NUMBER: ISRCTN34664024 , assigned 14/08/2013.

[Changing to a career in general practice - a qualitative study reveals motives of specialists]. / Liebe auf den zweiten Blick - qualitative Erhebung von Motiven für den Quereinstieg in die Allgemeinmedizin.

BACKGROUND: In 2011, the national German Medical Association (Bundesärztekammer) published guidelines for a slim-lined training program in general practice (Quereinstieg) for qualified medical specialists in other fields (e. g., surgeons, internists or anesthesiologists). This step is part of a strategy to prevent further shortages of general practitioners in Germany. In the state of Baden-Wuerttemberg, qualified medical specialists are allowed to complete their general practice training in approximately two years instead of five. The aim of this study was to understand the reasons of specialists for changing to a career in general practice. METHODS: The postgraduate training program VerbundweiterbildungplusBaden-Württemberg had 597 trainees at the time of the study in December 2015. Previously qualified specialists in another medical discipline were identified and invited to participate in this study. Qualitative data was gathered using semi-structured interviews with content analysis of the interviews performed by three independent members of the research team. RESULTS: In total, 36 out of 597 trainees were identified as previously qualified specialists in another medical discipline. All 36 were invited to take part and 15 agreed to participate in this study. Overall, 15 interviews were performed, with a mean time of 24.19minutes. Participants with a median age of 40 years (33-59 years) - mainly anesthesiologists (n=7), surgeons (n=3) and internists (n=3) - presented with an average of 6.5 years of professional experience in their specialty. First, the participants' motivation to switch career arose from the wish to intensify the quality of patient contacts with a holistic approach including family and social background and from the infinite variety of general practice. Another reason given for a career change was self-employment opportunities. Finally, feelings of frustration over poor working conditions in hospitals resulted in a job search elsewhere in medicine, taking account of the challenges of ageing and family life. A major finding was that without the slim-lined program, the majority of participants would not have changed their career. DISCUSSION: The slim-lined training program in general practice attracts experienced medical doctors. Specialists decide to change career because of the particular ways of working in general practice and with the intention to improve their daily work as a physician, either to improve individual working conditions and/or to improve their individual curative work profile. In addition, specialists are attracted by the concept of self-employment in general practice. Therefore, appreciation of the specific ways of working in general practice as well as management skills are most important during the reduced 2-year training. Further studies should investigate if facilitating a career switch to general practice is a good way to improve the shortage of general practitioners.

Medication Lists and Brown Bag Reviews: Potential Positive and Negative Impacts on Patients Beliefs about Their Medicine.

INTRODUCTION: Medication lists and structured medication counselling (SMC) including "brown bag reviews" (BBR) are important instruments for medication safety. The aim of this study was to explore whether patients' use of a medication list is associated with their beliefs about their medicine and their memory of SMC. METHODS: Baseline data of 344 patients enrolled into the "Polypharmacy in Multimorbid Patients study" were analysed. Linear regression models were calculated for the "specific necessity subscale" (SNS) and the "specific concerns subscale" (SCS) of the German "Beliefs About Medicine Questionnaire," including self-developed variables assessing patients' use of a medication list, their memory of SMC, and sociodemographic data. RESULTS: 62.8% (n = 216) remembered an appointment for SMC and 32.0% (n = 110) BBR. The SNS correlated positively with regular receipt of a medication list (ß = 0.286, p < 0.01) and negatively with memory of a BBR (ß = -0.268; p < 0.01). The SCS correlated positively with memory of a BBR (ß = 0.160, p = 0.02) and negatively with the comprehensiveness of the mediation list (ß = -0.224; p < 0.01). CONCLUSIONS: A comprehensive medication list may reduce patients' concerns and increase the perceived necessity of their medication. A potential negative impact of BBR on patients' beliefs about their medicine should be considered and quality standards for SMC developed.

Tailored interventions to address determinants of practice.

BACKGROUND: Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants. OBJECTIVES: To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants. SEARCH METHODS: We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals. SELECTION CRITERIA: Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified. MAIN RESULTS: We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression. AUTHORS' CONCLUSIONS: Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

Design and delivery of a tailored intervention to implement recommendations for multimorbid patients receiving polypharmacy into primary care practices.

Introduction. Managing polypharmacy is particularly demanding for general practitioners as coordinators of care. Recently, a German guideline for polypharmacy in primary care has been published. This paper describes the content and delivery of a tailored intervention, which aims at improving the implementation of guideline recommendations for polypharmacy into practice, considering individual barriers. Materials and Methods. Firstly, barriers for implementation and the corresponding strategies to address them have been identified. On this basis, an intervention consisting of a workshop for health care professionals and educational materials for patients has been developed. The workshop focused on knowledge, awareness, and skills. The educational materials included a tablet computer. Practice teams will elaborate individual concepts of how to implement the recommendations into their practice. The workshop has been evaluated by the participants by means of a questionnaire. Results. During the workshop 41 possible sources of medication errors and 41 strategies to improve medication management have been identified. Participants evaluated the workshop overall positively, certifying its relevancy to practice. Discussion. The concept of the workshop seemed appropriate to impart knowledge about medication management to the participants. It will have to be evaluated, if the intervention finally resulted in an improved implementation of the guideline recommendations.

Stakeholders' contributions to tailored implementation programs: an observational study of group interview methods.

BACKGROUND: Tailored strategies to implement evidence-based practice can be generated in several ways. In this study, we explored the usefulness of group interviews for generating these strategies, focused on improving healthcare for patients with chronic diseases. METHODS: Participants included at least four categories of stakeholders (researchers, quality officers, health professionals, and external stakeholders) in five countries. Interviews comprised brainstorming followed by a structured interview and focused on different chronic conditions in each country. We compared the numbers and types of strategies between stakeholder categories and between interview phases. We also determined which strategies were actually used in tailored intervention programs. RESULTS: In total, 127 individuals participated in 25 group interviews across five countries. Brainstorming generated 8 to 120 strategies per group; structured interviews added 0 to 55 strategies. Healthcare professionals and researchers provided the largest numbers of strategies. The type of strategies for improving healthcare practice did not differ systematically between stakeholder groups in four of the five countries. In three out of five countries, all components of the chosen intervention programs were mentioned by the group of researchers. CONCLUSIONS: Group interviews with different stakeholder categories produced many strategies for tailored implementation of evidence-based practice, of which the content was largely similar across stakeholder categories.

Cold condensation of dust in the ISM.

The condensation of complex silicates with pyroxene and olivine composition under conditions prevailing in molecular clouds has been experimentally studied. For this purpose, molecular species comprising refractory elements were forced to accrete on cold substrates representing the cold surfaces of surviving dust grains in the interstellar medium. The efficient formation of amorphous and homogeneous magnesium iron silicates at temperatures of about 12 K has been monitored by IR spectroscopy. The gaseous precursors of such condensation processes in the interstellar medium are formed by erosion of dust grains in supernova shock waves. In the laboratory, we have evaporated glassy silicate dust analogs and embedded the released species in neon ice matrices that have been studied spectroscopically to identify the molecular precursors of the condensing solid silicates. A sound coincidence between the 10 microm band of the interstellar silicates and the 10 microm band of the low-temperature siliceous condensates can be noted.

[Developing a tailored intervention: implementing recommendations for polypharmacy in multimorbid patients (PomP)]. / Entwicklung einer maßgeschneiderten Intervention (Tailoring) am Beispiel der Implementierung von Empfehlungen zur Polypharmakotherapie bei multimorbiden Patienten (PomP).

INTRODUCTION: Implementation research deals with the question of how to ensure that evidence-based knowledge is put into practice. One approach is the development of "tailored interventions (TI)". These are designed to address previously identified barriers and enablers. A common definition or methodological concept for TI has not yet been established. In this paper, a concept for TI is introduced. We describe the stepwise development of an implementation intervention for GP settings where recommendations based on current evidence are provided for the treatment of multimorbid patients receiving polypharmacy. Each step will be explained and illustrated by original data. METHODS/RESULTS: A stepwise approach was used to develop a TI: problem analysis, identification and prioritisation of determinants, identification and prioritisation of strategies and the design of a complex intervention and its underlying logic model. DISCUSSION: The stepwise exemplary description of this tailoring strategy may support other researchers in this field when designing a TI.

Tailored implementation of evidence-based practice for patients with chronic diseases.

BACKGROUND: When designing interventions and policies to implement evidence based healthcare, tailoring strategies to the targeted individuals and organizations has been recommended. We aimed to gather insights into the ideas of a variety of people for implementing evidence-based practice for patients with chronic diseases, which were generated in five European countries. METHODS: A qualitative study in five countries (Germany, Netherlands, Norway, Poland, United Kingdom) was done, involving overall 115 individuals. A purposeful sample of four categories of stakeholders (healthcare professionals, quality improvement officers, healthcare purchasers and authorities, and health researchers) was involved in group interviews in each of the countries to generate items for improving healthcare in different chronic conditions per country: chronic obstructive pulmonary disease, cardiovascular disease, depression in elderly people, multi-morbidity, obesity. A disease-specific standardized list of determinants of practice in these conditions provided the starting point for these groups. The content of the suggested items was categorized in a pre-defined framework of 7 domains and specific themes in the items were identified within each domain. RESULTS: The 115 individuals involved in the study generated 812 items, of which 586 addressed determinants of practice. These largely mapped onto three domains: individual health professional factors, patient factors, and professional interactions. Few items addressed guideline factors, incentives and resources, capacity of organizational change, or social, political and legal factors. The relative numbers of items in the different domains were largely similar across stakeholder categories within each of the countries. The analysis identified 29 specific themes in the suggested items across countries. CONCLUSION: The type of suggestions for improving healthcare practice was largely similar across different stakeholder groups, mainly addressing healthcare professionals, patient factors and professional interactions. As this study is one of the first of its kind, it is important that more research is done on tailored implementation strategies.

Tailored Implementation for Chronic Diseases (TICD): a protocol for process evaluation in cluster randomized controlled trials in five European countries.

BACKGROUND: In the 'Tailored Implementation for Chronic Diseases (TICD)' project, five tailored implementation programs to improve healthcare delivery in different chronic conditions have been developed. These programs will be evaluated in distinct cluster-randomized controlled trials. This protocol describes the process evaluation across these trials, which aims to identify determinants of change in chronic illness care, to examine the validity of the tailoring methods that were applied, and to analyze the association of implementation activities and the effectiveness of the program. METHODS: A multilevel approach was used to develop five tailored implementation interventions. In order to guide the process evaluation in five distinct trials, the study protocols for the cluster randomized trials and the related process evaluations were developed simultaneously and iteratively. RESULTS: The process evaluation comprises three main components: a structured survey with health professionals in the trials, semi-structured interviews with a purposeful sample of this study population, and standardized documentation of organizational practice characteristics. Norway will only conduct the qualitative part of the analysis because the survey and documentation of practice characteristics are considered to be not feasible. The evaluation is guided by 'logic models' of the implementation programs: frameworks that specify the linkages between the strategies used, the determinants addressed by tailoring, and the anticipated outcomes. Standardization of measures across trials is sought to facilitate analysis of aggregated data from the trials. CONCLUSIONS: This process evaluation will need to find a balance between standardization of methods across trials and the tailoring of measures to the specificities of each trial.

A tailored implementation intervention to implement recommendations addressing polypharmacy in multimorbid patients: study protocol of a cluster randomized controlled trial.

BACKGROUND: Multimorbid patients frequently receive complex medication regimens and are at higher risk for adverse drug reactions and hospitalisations. Managing patients with polypharmacy is demanding, because it requires coordination of multiple prescribers and intensive monitoring. Three evidence-based recommendations addressing polypharmacy in primary care are structured medication counselling, use of medication lists and medication reviews to avoid potentially inappropriate medication (PIM). Although promising to improve patient outcomes, these recommendations are not well implemented in German routine care. Implementation of guidelines is often hindered by specific "determinants of change". "Tailored" interventions are designed to specifically address previously identified determinants. This study examines a tailored intervention to implement the aforementioned recommendations into German primary care practices. This study is part of the European Tailored Interventions for Chronic Diseases project, which aims at contributing knowledge about the methods used for tailoring. METHODS/DESIGN: The study is designed as a cluster randomized controlled trial with primary care practices of general practitioners (GPs) who are organized in quality circles. Quality circles will be the unit of randomization with a 1:1 ratio. Follow-up time is 6 months. GPs and healthcare assistants in the intervention group will receive training on medication management. Each GP will create a tailored concept of how to implement the three recommendations into his/her practice. Evidence-based checklists for medication counselling and medication reviews will be provided for physicians. A tablet PC with an interactive educational tool and information leaflets will be provided for use by patients to inform about the necessity of continuous medication management. Control practices will not receive special training and will provide care as usual. Primary outcome is the degree of implementation of the three recommendations, which will be measured using a prespecified set of indicators. Additionally, the PIM prescription rate, patient activation, patients' beliefs about medicine, medication adherence and patients' social support will be measured. DISCUSSION: This study will contribute knowledge about the feasibility of implementing recommendations for managing patients with polypharmacy in primary care practices. Additionally, this study will contribute knowledge about methods for tailoring of implementation interventions. TRIAL REGISTRATION: Clinicaltrials.gov ISRCTN34664024.

Patients' perspectives on depression case management in general practice - a qualitative study.

OBJECTIVE: General practice-based case management is effective in improving symptoms, adherence, and the perceived process of care of patients living with major depression. The aim was to explore the patients' perceptions of practice-based depression case management, their satisfaction with it and how living with depression contextualizes case management. METHODS: This qualitative study was nested in a large cluster-randomized controlled trial on the effectiveness of case management for patients living with major depression. Case management was provided over 12 months by practice-based health care assistants, who monitored symptoms. We undertook semi-structured interviews with 41 patients, then transcribed and analysed them using qualitative content analysis. RESULTS: Patients described depression as the unfortunate situation, where loneliness and lack of energy lead to being unable to actively seek help. Case management was appreciated because of regular, proactive contact and support by health care assistants. It was crucial to patients that they could trust the health care assistant. Some patients complained that case management was undertaken too mechanically and lacked empathy. CONCLUSION: Patients living with depression may perceive practice-based case management as beneficial if carried out in a trustworthy and empathetic manner. PRACTICE IMPLICATIONS: General practices should ensure that depression case management is patient-centered and non-mechanical.