Changes in healthcare utilisation during implementation of remote atrial fibrillation management: TeleCheck-AF project.

AIM: To evaluate changes in healthcare utilisation and comprehensive packages of care activities and procedures (referred in the Netherlands to as 'diagnose-behandelcombinatie (DBC) care products) during the implementation of the TeleCheck-AF approach (teleconsultation supported by app-based heart rate/rhythm monitoring) in a Dutch atrial fibrillation (AF) clinic. METHODS AND RESULTS: In the Maastricht University Medical Centre+ AF Clinic, data on healthcare utilisation and DBC care products for patients consulted by both a conventional approach in 2019 and the TeleCheck-AF approach in 2020 were analysed. A patient experience survey was performed. Thirty-seven patients (median age 68 years; 40% women) were analysed. With the conventional approach, 35 face-to-face consultations and 0 teleconsultations were conducted. After the implementation of TeleCheck-AF, the number of face-to-face consultations dropped by 80% (p < 0.001) and teleconsultations increased to 45 (p < 0.001). While 42 electrocardiograms (ECGs) and 25 Holter ECGs or echocardiograms were recorded when using the conventional approach, the number of ECGs decreased by 71% (p < 0.001) and Holter ECGs or echocardiograms by 72% (p < 0.001) with the TeleCheck-AF approach. The emergency department patient presentations showed no statistically significant change (p = 0.33). Overall, 57% of medium-weight DBC care products were changed to light-weight ones during implementation of the TeleCheck-AF approach. Patient satisfaction with the TeleCheck-AF approach was high. CONCLUSION: The implementation of TeleCheck-AF led to a change in healthcare utilisation, a change from medium-weight to light-weight DBC care products and a reduction in patient burden. These results created the basis for a new reimbursement code for the TeleCheck-AF approach in the Netherlands.

A dermatology E-learning programme is perceived as a valuable learning tool in postgraduate general practice training.

OBJECTIVES: This study aims to explore GP residents' knowledge retention and residents' and clinical teachers' perception on the learning value of a dermatology E-learning programme. METHODS: The study used a mixed-method design with a convergent parallel collection of data. GP residents (n=21) were selected through purposive sampling and were randomized to an E-learning group (n=12) or a traditional teaching methods group (n=9). The pre-and post-intervention knowledge tests of the E-learning group were compared using paired-samples t-tests. Post-knowledge tests scores of both groups were compared using independent t-tests. Cronbach's coefficient α was used to calculate the internal consistency of the questions used in the knowledge tests. Individual semi-structured interviews and clinical teachers (n=16) were conducted and analyzed using King's template analysis. RESULTS: The E-learning group showed a significant increase in mean knowledge test scores from 58.92% (SD=9.55%) to 64.92% (SD=13.65%) (t(11)=2.258, p=0.045, Cohen's d=0.51). The pre-knowledge test consisted of 46 items (Alpha=0.78), and the post-knowledge tests consisted of 45 items (Alpha=0.90). Interview data showed that the E-learning programme aided GP trainees' learning process and favoured a mixed-method teaching design, in which E-learning is used in parallel to the traditional teaching methods. CONCLUSIONS: A dermatology E-learning programme appeared an effective strategy in resident's knowledge acquiring. The key users' perceptions, both residents and clinical teachers, indicated that E-learning was feasible and helpful for learning processes. Further research is required to evaluate the implementation of E-learning programmes in parallel to regular teaching programs.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care.

BACKGROUND: The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch 'Blue Care' pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision. METHODS: This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors. RESULTS: A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient's diagnosis independently influenced the referral decisions following PC+. CONCLUSION: The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

Exploration of Patient Characteristics and Quality of Life in Patients with Lipoedema Using a Survey.

INTRODUCTION: Lipoedema is a chronic disorder in which excessive fat distribution occurs predominantly from the waist down, resulting in a disproportion between the lower extremities and upper torso. Lipoedema is often not recognized, while patients experience pain and easy bruising. As a long-term condition, lipoedema has a massive effect on patients' lives and mental health. The aim of this study is to explore patient characteristics, quality of life, physical complaints and comorbidities in patients with lipoedema. METHODS: A survey was conducted by email amongst lipoedema patients, consisting of informed consent and multiple questionnaires. The questionnaires included general patient characteristics, physical complaints, comorbidities, RAND-36 and EQ-5D-3L. Participants who responded to a message on the Dutch Lipoedema Association website were recruited. RESULTS: All lipoedema patients experience physical complaints, with pain (88.3 %) and easy bruising (85.9 %) as primary complaints. The diagnosis was mostly made by a dermatologist after visiting a mean of 2.8 doctors. Furthermore, mean time from onset until diagnosis was 18 years. Quality of life (59.3) was significantly lower than the Dutch female average (74.9; p < 0.001). Additionally, patients with comorbidities had significant lower quality of life (RAND 54.7, p < 0.001). CONCLUSIONS: Lipoedema patients often have severe complaints and experience lower quality of life regarding physical, emotional and social functioning. Additionally, comorbidities have a large impact on quality of life.

Use of e-learning in clinical clerkships: effects on acquisition of dermatological knowledge and learning processes.

OBJECTIVES: To obtain a deeper understanding of how the e-learning program, Education in Dermatology (ED), affects the acquisition of dermatological knowledge and the underlying learning processes of medical students in their clinical phase. METHODS: The study used a mixed method design with a convergent parallel collection of data. Medical students (n=62) from Maastricht University (The Netherlands) were randomized to either a conventional teaching group (control group n=30) or conventional teaching plus the e-learning program (application on smartphone) group (e-learning group n=32). Pre- and post-intervention knowledge test results were analysed using an independent t-test. Individual semi-structured interviews (n=9) were conducted and verbatim-transcribed recordings were analysed using King's template analysis. RESULTS: The e-learning program positively influenced students' level of knowledge and their process of learning. A significant difference was found in the post-test scores for the control group (M=51.4, SD=6.43) and the e-learning group (M=73.09, SD=5.12); t(60)=-14.75, p<0.000). Interview data showed that the e-learning program stimulated students' learning as the application promoted the identification and recognition of skin disorders, the use of references, creation of documents and sharing information with colleagues. CONCLUSIONS: This study demonstrated that use of the e-learning program led to a significant improvement in basic dermatological knowledge. The underlying learning processes indicated that e-learning programs in dermatology filled a vital gap in the understanding of clinical reasoning in dermatology. These results might be useful when developing (clinical) teaching formats with a special focus on visual disciplines.

"Dots and lines": A melanonychia striata in regression: Report of a case.

A 2-year-old Caucasian boy with melanonychia striata with multiple striking pits on the nail plate of one fingernail is described. Nail disorders often pose diagnostic and therapeutic challenges for clinicians, especially melanonychia striata, because of the fear of a subungual melanoma. Only a few childhood cases of melanonychia striata have been described, and the multiple pits are even less common. Dots distributed along melanotic lines is a finding referred to as "dots and lines" and can be a sign of regression of melanonychia in childeren.

[A child with substantially itchy bumps on the back]. / Een kind met fors jeukende bultjes op de rug.

A 2-year-old boy showed itchy papules and wheals, which were diagnosed as papular urticaria. Papular urticaria are a hypersensitivity reaction after insect bites. The condition can relapse even without the presence of insects or new bites. Topical steroids or antihistamines diminish the symptoms in some cases.

[A woman with hyperkeratotic papules on arms and legs]. / Een vrouw met witte verhardingen op armen en benen.

A 50-year old woman with hyperkeratotic verrucous papules and plaques visited the outpatient clinic of Dermatology. Histopathology showed hyperplasia of verrucous epithelia, orthokeratosis and an infiltrate, leading to the diagnosis 'verrucous (hypertrophic) lichen planus'. This skin condition is often misdiagnosed as psoriasis. Squamous cell carcinoma can develop within skin lesions.

[A girl with hypopigmented skin lesions]. / Een meisje met gehypopigmenteerde huidafwijkingen.

A 9-year-old girl visited the department of Dermatology with an asymptomatic hypopigmented skin eruption on her upper legs, groins and trunk since 7 years. Histopathological analysis established the diagnosis of hypopigmented mycosis fungoides, a rare subtype of cutaneous T-cell lymphoma which is most commonly seen at younger age. The lesions are successfully treated with clobetasol 0.05% ointment 4 days a week.

Topical rapamycin as a treatment for fibrofolliculomas in Birt-Hogg-Dubé syndrome: a double-blind placebo-controlled randomized split-face trial.

BACKGROUND: Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disorder characterised by the occurrence of benign, mostly facial, skin tumours called fibrofolliculomas, multiple lung cysts, spontaneous pneumothorax and an increased renal cancer risk. Current treatments for fibrofolliculomas have high rates of recurrence and carry a risk of complications. It would be desirable to have a treatment that could prevent fibrofolliculomas from growing. Animal models of BHD have previously shown deregulation of mammalian target of rapamycin (mTOR). Topical use of the mTOR inhibitor rapamycin is an effective treatment for the skin tumours (angiofibromas) in tuberous sclerosis complex, which is also characterised by mTOR deregulation. In this study we aimed to determine if topical rapamycin is also an effective treatment for fibrofolliculomas in BHD. METHODS: We performed a double blinded, randomised, facial left-right controlled trial of topical rapamycin 0.1% versus placebo in 19 BHD patients. Trial duration was 6 months. The primary outcome was cosmetic improvement as measured by doctors and patients. Changes in fibrofolliculoma number and size were also measured, as was occurrence of side effects. RESULTS: No change in cosmetic status of fibrofolliculomas was reported in the majority of cases for the rapamycin treated (79% by doctors, 53% by patients) as well as the placebo treated facial sides (both 74%). No significant differences between rapamycin and placebo treated facial halves were observed (p = 1.000 for doctors opinion, p = 0.344 for patients opinion). No significant difference in fibrofolliculoma number or change in size of the fibrofolliculomas was seen after 6 months. Side effects occurred more often after rapamycin treatment (68% of patients) than after placebo (58% of patients; p = 0.625). A burning sensation, erythema, itching and dryness were most frequently reported. CONCLUSIONS: This study provides no evidence that treatment of fibrofolliculomas with topical rapamycin in BHD results in cosmetic improvement. TRIAL REGISTRATION: ClinicalTrials.gov NCT00928798.

The sunny side of lime.

A 26-year-old woman was affected with a maculopapular rash because of a jellyfish sting on her right leg while surfing in Indonesia. A locally-prepared liniment was applied on the affected skin. She presented with hyperpigmented linear tracks that she noted a few days later.

Psoriasiform disorders with joint symptoms.

We present a 49-year-old man seen at the dermatology outpatient department with a 3-year history of painful swollen digits of hands and feet. On enquiry he reported dysuria. On examination we saw extensive swelling of the digits, keratosis of the nails, and some psoriasiform skin lesions on the soles of the feet. The differential diagnosis included acrodermatitis continua suppurativa, reactive arthritis and psoriatic arthritis. Radiographic imaging revealed the presence of arthritis. Testing proved negative for rheumatoid factor and positive for HLA-B27 making spondyloarthropathy the most likely diagnosis, either in the form of reactive arthritis or psoriatic arthritis. The patient was treated with combination therapy of doxycycline, methotrexate and folic acid. Because of insufficient response to therapy, the methotrexate dose was raised and eventually etanercept was added. During the last visit to the outpatient clinic, the patient still showed insufficient response to therapy.