Fatigue during acute systemic inflammation is associated with reduced mental effort expenditure while task accuracy is preserved.

BACKGROUND: Earlier work within the physical domain showed that acute inflammation changes motivational prioritization and effort allocation rather than physical abilities. It is currently unclear whether a similar motivational framework accounts for the mental fatigue and cognitive symptoms of acute sickness. Accordingly, this study aimed to assess the relationship between fatigue, cytokines and mental effort-based decision making during acute systemic inflammation. METHODS: Eighty-five participants (41 males; 18-30 years (M = 23.0, SD = 2.4)) performed a mental effort-based decision-making task before, 2 h after, and 5 h after intravenous administration of 1 ng/kg bacterial lipopolysaccharide (LPS) to induce systemic inflammation. Plasma concentrations of cytokines (interleukin (IL)-6, IL-8 and tumor necrosis factor (TNF)) and fatigue levels were assessed at similar timepoints. In the task, participants decided whether they wanted to perform (i.e., 'accepted') arithmetic calculations of varying difficulty (3 levels: easy, medium, hard) in order to obtain rewards (3 levels: 5, 6 or 7 points). Acceptance rates were analyzed using a binomial generalized estimated equation (GEE) approach with effort, reward and time as independent variables. Arithmetic performance was measured per effort level prior to the decisions and included as a covariate. Associations between acceptance rates, fatigue (self-reported) and cytokine concentration levels were analyzed using partial correlation analyses. RESULTS: Plasma cytokine concentrations and fatigue were increased at 2 h post-LPS compared to baseline and 5 h post-LPS administration. Acceptance rates decreased for medium, but not for easy or hard effort levels at 2 h post-LPS versus baseline and 5 h post-LPS administration, irrespective of reward level. These reductions in acceptance rates occurred despite improved accuracy on the arithmetic calculations itself. Reduced acceptance rates for medium effort were associated with increased fatigue, but not with increased cytokine concentrations. CONCLUSION: Fatigue during acute systemic inflammation is associated with alterations in mental effort allocation, similarly as observed previously for physical effort-based choice. Specifically, willingness to exert mental effort depended on effort and not reward information, while task accuracy was preserved. These results extend the motivational account of inflammation to the mental domain and suggest that inflammation may not necessarily affect domain-specific mental abilities, but rather affects domain-general effort-allocation processes.

Early mobilization after esophageal cancer surgery: a retrospective cohort study.

A key component of the Enhanced Recovery After Surgery pathway for esophagectomy is early mobilization. Evidence on a specific protocol of early and structured mobilization is scarce, which explains variation in clinical practice. This study aims to describe and evaluate the early mobilization practice after esophagectomy for cancer in a tertiary referral center in the Netherlands. This retrospective cohort study included data from a prospectively maintained database of patients who underwent an esophagectomy between 1 January 2015 and 1 January 2020. Early mobilization entailed increase in activity with the first target of ambulating 100 meters. Primary outcomes were the number of postoperative days (PODs) until achieving this target and reasons for not achieving this target. Secondary outcomes were the relationship between preoperative factors (e.g. sex, BMI) and achieving the target on POD1, and the relationship between achieving the target on POD1 and postoperative outcomes (i.e. length of stay, readmissions). In total, 384 patients were included. The median POD of achieving the target was 2 (IQR 1-3), with 173 (45.1%) patients achieving this on POD1. Main reason for not achieving this target was due to hemodynamic instability (22.7%). Male sex was associated with achieving the target on POD1 (OR = 1.997, 95%CI 1.172-3.403, P = 0.011); achieving this target was not associated with postoperative outcomes. Ambulation up to 100 m on POD1 is achievable in patients after esophagectomy, with higher odds for men to achieve this target. ERAS pathways for post esophagectomy care are encouraged to incorporate 100 m ambulation on POD1 in their guideline as the first postoperative target.

[Child psychiatric learning goals for general psychiatric training: a Delphi study]. / Leerdoelen over kinder- en jeugdpsychiatrie in de opleiding psychiatrie: een delphistudie.

BACKGROUND: The new Dutch training plan for psychiatrists puts more emphasis on life course psychiatry. Subsequently, adjustments in the educational program regarding child and adolescent psychiatric knowledge, skills and attitudes are needed. AIM: A broadly supported agreement and consensus on Dutch national learning objectives of education in child and adolescent psychiatry. METHOD: With a modified Delphi method, a set of preliminary learning objectives formulated by a working group of experts was presented to trainees (n = 9), adult psychiatrists (n = 12), child and adolescent psychiatrists (n = 17) and adult patients and their relatives (n = 15). In two rounds, the learning objectives were commented on, supplemented, scored for relevance and prioritized. RESULTS: Out of 27 original learning objectives, 20 were assessed as important or necessary by over 80% of the respondents (knowledge 7/9, skills 8/10, attitudes 5/8). Two learning objectives were rejected (less than 60% considered these to be important or necessary). Seven learning objectives were re-assessed in a second round as these were modified (5) or added (2). Four of them were rated as important or necessary by over 80% of participants. The following goals were most often prioritized: knowledge about healthy development and intergenerational issues; ability to make contact with children and families and to integrate protective and risk factors of the child and environment; and knowing one’s own limitations of child psychiatric themes. CONCLUSION: A Delphi study helped gain support from stakeholders for adjustments in training and education by creating consensus about child psychiatric learning goals for general psychiatric training.

Reward learning deficits in Parkinson's disease depend on depression.

BACKGROUND: Depression is one of the most common and debilitating non-motor symptoms of Parkinson's disease (PD). The neurocognitive mechanisms underlying depression in PD are unclear and treatment is often suboptimal. METHODS: We investigated the role of striatal dopamine in reversal learning from reward and punishment by combining a controlled medication withdrawal procedure with functional magnetic resonance imaging in 22 non-depressed PD patients and 19 PD patients with past or present depression. RESULTS: PD patients with a depression (history) exhibited impaired reward v. punishment reversal learning as well as reduced reward v. punishment-related BOLD signal in the striatum (putamen) compared with non-depressed PD patients. No effects of dopaminergic medication were observed. CONCLUSIONS: The present findings demonstrate that impairments in reversal learning from reward v. punishment and associated striatal signalling depend on the presence of (a history of) depression in PD.

How visual search relates to visual diagnostic performance: a narrative systematic review of eye-tracking research in radiology.

Eye tracking research has been conducted for decades to gain understanding of visual diagnosis such as in radiology. For educational purposes, it is important to identify visual search patterns that are related to high perceptual performance and to identify effective teaching strategies. This review of eye-tracking literature in the radiology domain aims to identify visual search patterns associated with high perceptual performance. Databases PubMed, EMBASE, ERIC, PsycINFO, Scopus and Web of Science were searched using 'visual perception' OR 'eye tracking' AND 'radiology' and synonyms. Two authors independently screened search results and included eye tracking studies concerning visual skills in radiology published between January 1, 1994 and July 31, 2015. Two authors independently assessed study quality with the Medical Education Research Study Quality Instrument, and extracted study data with respect to design, participant and task characteristics, and variables. A thematic analysis was conducted to extract and arrange study results, and a textual narrative synthesis was applied for data integration and interpretation. The search resulted in 22 relevant full-text articles. Thematic analysis resulted in six themes that informed the relation between visual search and level of expertise: (1) time on task, (2) eye movement characteristics of experts, (3) differences in visual attention, (4) visual search patterns, (5) search patterns in cross sectional stack imaging, and (6) teaching visual search strategies. Expert search was found to be characterized by a global-focal search pattern, which represents an initial global impression, followed by a detailed, focal search-to-find mode. Specific task-related search patterns, like drilling through CT scans and systematic search in chest X-rays, were found to be related to high expert levels. One study investigated teaching of visual search strategies, and did not find a significant effect on perceptual performance. Eye tracking literature in radiology indicates several search patterns are related to high levels of expertise, but teaching novices to search as an expert may not be effective. Experimental research is needed to find out which search strategies can improve image perception in learners.

Preoperative functional status is not associated with postoperative surgical complications in low risk patients undergoing esophagectomy.

Preoperative functional status is a risk factor for developing postoperative complications (POC) in major abdominal and thoracic surgery, but this has hardly been evaluated in esophageal cancer patients undergoing esophagectomy. The aim of this prospective cohort study was to determine if preoperative functional status in esophageal cancer patients is associated with POC. From March 2012 to October 2014, esophageal cancer patients scheduled for esophagectomy at the outpatient clinic of a large tertiary referral center were eligible for the study. We measured inspiratory muscle strength, hand grip strength, physical activities, and health related quality of life as indicators of functional status one day before surgery. POC were scored according to the Clavien-Dindo Classification. We used univariate and multivariate backward regression analysis to determine the association between functional status and POC. We included 94 patients in the study and esophagectomy was performed in 90 patients from which 55 developed POC (61.1%). After multivariate analysis, none of the indicators of preoperative functional status were independently associated with POC (inspiratory muscle strength [OR 1.00; P = 0.779], hand grip strength [OR 0.99; P = 0.250], physical activities [OR 1.00; P = 0.174], and health related quality of life [OR 1.02; P = 0.222]). We concluded that preoperative functional status in our study cohort is not associated with POC after esophagectomy.

Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge.

BACKGROUND: The study objective was to obtain consensus on physical therapy (PT) in the rehabilitation of critical illness survivors after hospital discharge. Research questions were: what are PT goals, what are recommended measurement tools, and what constitutes an optimal PT intervention for survivors of critical illness? METHODS: A Delphi consensus study was conducted. Panelists were included based on relevant fields of expertise, years of clinical experience, and publication record. A literature review determined five themes, forming the basis for Delphi round one, which was aimed at generating ideas. Statements were drafted and ranked on a 5-point Likert scale in two additional rounds with the objective to reach consensus. Results were expressed as median and semi-interquartile range, with the consensus threshold set at ≤0.5. RESULTS: Ten internationally established researchers and clinicians participated in this Delphi panel, with a response rate of 80 %, 100 %, and 100 % across three rounds. Consensus was reached on 88.5 % of the statements, resulting in a framework for PT after hospital discharge. Essential handover information should include information on 15 parameters. A core set of outcomes should test exercise capacity, skeletal muscle strength, function in activities of daily living, mobility, quality of life, and pain. PT interventions should include functional exercises, circuit and endurance training, strengthening exercises for limb and respiratory muscles, education on recovery, and a nutritional component. Screening tools to identify impairments in other health domains and referral to specialists are proposed. CONCLUSIONS: A consensus-based framework for optimal PT after hospital discharge is proposed. Future research should focus on feasibility testing of this framework, developing risk stratification tools and validating core outcome measures for ICU survivors.

The don't know option in progress testing.

Formula scoring (FS) is the use of a don't know option (DKO) with subtraction of points for wrong answers. Its effect on construct validity and reliability of progress test scores, is subject of discussion. Choosing a DKO may not only be affected by knowledge level, but also by risk taking tendency, and may thus introduce construct-irrelevant variance into the knowledge measurement. On the other hand, FS may result in more reliable test scores. To evaluate the impact of FS on construct validity and reliability of progress test scores, a progress test for radiology residents was divided into two tests of 100 parallel items (A and B). Each test had a FS and a number-right (NR) version, A-FS, B-FS, A-NR, and B-NR. Participants (337) were randomly divided into two groups. One group took test A-FS followed by B-NR, and the second group test B-FS followed by A-NR. Evidence for impaired construct validity was sought in a hierarchical regression analysis by investigating how much of the participants' FS-score variance was explained by the DKO-score, compared to the contribution of the knowledge level (NR-score), while controlling for Group, Gender, and Training length. Cronbach's alpha was used to estimate NR and FS-score reliability per year group. NR score was found to explain 27 % of the variance of FS [F(1,332) = 219.2, p < 0.0005], DKO-score, and the interaction of DKO and Gender were found to explain 8 % [F(2,330) = 41.5, p < 0.0005], and the interaction of DKO and NR 1.6 % [F(1,329) = 16.6, p < 0.0005], supporting our hypothesis that FS introduces construct-irrelevant variance into the knowledge measurement. However, NR-scores showed considerably lower reliabilities than FS-scores (mean year-test group Cronbach's alphas were 0.62 and 0.74, respectively). Decisions about FS with progress tests should be a careful trade-off between systematic and random measurement error.

An affective disorder in zebrafish with mutation of the glucocorticoid receptor.

Upon binding of cortisol, the glucocorticoid receptor (GR) regulates the transcription of specific target genes, including those that encode the stress hormones corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone. Dysregulation of the stress axis is a hallmark of major depression in human patients. However, it is still unclear how glucocorticoid signaling is linked to affective disorders. We identified an adult-viable zebrafish mutant in which the negative feedback on the stress response is disrupted, due to abolition of all transcriptional activity of GR. As a consequence, cortisol is elevated, but unable to signal through GR. When placed into an unfamiliar aquarium ('novel tank'), mutant fish become immobile ('freeze'), show reduced exploratory behavior and do not habituate to this stressor upon repeated exposure. Addition of the antidepressant fluoxetine to the holding water and social interactions restore normal behavior, followed by a delayed correction of cortisol levels. Fluoxetine does not affect the overall transcription of CRH, the mineralocorticoid receptor (MR), the serotonin transporter (Serta) or GR itself. Fluoxetine, however, suppresses the stress-induced upregulation of MR and Serta in both wild-type fish and mutants. Our studies show a conserved, protective function of glucocorticoid signaling in the regulation of emotional behavior and reveal novel molecular aspects of how chronic stress impacts vertebrate brain physiology and behavior. Importantly, the zebrafish model opens up the possibility of high-throughput drug screens in search of new classes of antidepressants.

Interpretation of radiological images: towards a framework of knowledge and skills.

The knowledge and skills that are required for radiological image interpretation are not well documented, even though medical imaging is gaining importance. This study aims to develop a comprehensive framework of knowledge and skills, required for two-dimensional and multiplanar image interpretation in radiology. A mixed-method study approach was applied. First, a literature search was performed to identify knowledge and skills that are important for image interpretation. Three databases, PubMed, PsycINFO and Embase, were searched for studies using synonyms of image interpretation skills or visual expertise combined with synonyms of radiology. Empirical or review studies concerning knowledge and skills for medical image interpretation were included and relevant knowledge and skill items were extracted. Second, a preliminary framework was built and discussed with nine selective experts in individual semi-structured interviews. The expert team consisted of four radiologists, one radiology resident, two education scientists, one cognitive psychologist and one neuropsychologist. The framework was optimised based on the experts comments. Finally, the framework was applied to empirical data, derived from verbal protocols of ten clerks interpreting two-dimensional and multiplanar radiological images. In consensus meetings adjustments were made to resolve discrepancies of the framework with the verbal protocol data. We designed a framework with three main components of image interpretation: perception, analysis and synthesis. The literature study provided four knowledge and twelve skill items. As a result of the expert interviews, one skill item was added and formulations of existing items were adjusted. The think-aloud experiment showed that all knowledge items and three of the skill items were applied within all three main components of the image interpretation process. The remaining framework items were apparent only within one of the main components. After combining two knowledge items, we finally identified three knowledge items and thirteen skills, essential for image interpretation by trainees. The framework can serve as a guideline for education and assessment of two- and three-dimensional image interpretation. Further validation of the framework in larger study groups with different levels of expertise is needed.

Biomedical students' satisfaction with and engagement in laboratory e-learning support are related to their self-regulation.

Laboratory e-learning support tools can assist students' learning while preparing for laboratory classes. To successfully work in such virtual experimental environments (VEEs) outside class, students require self-regulated learning (SRL) skills. A deeper understanding of the continuous reciprocal interactions between SRL, satisfaction, and online engagement is needed to develop more effective online learning experiences. This study therefore aimed to explore the interconnection between students' satisfaction with, effort/importance and engagement in an exemplary VEE, and to relate this to their perceived SRL and learning outcomes. Based on surveys in 79 university students, SRL was related to VEE engagement, effort/importance, and satisfaction. VEE engagement and satisfaction were not related to learning outcomes, while SRL and effort were. Students with different SRL also tended to interact differently with the VEE and experienced differing degrees of procedural and feedback support by the e-environment. We conclude that, for optimal learning experience and outcomes, students' effort regulation and SRL need to be supported while interacting with the VEE, preferably by interventions that integrate personalized and adaptive features. This study has implications for designing and optimizing VEEs and indicates that future research should focus on VEEs taking students' SRL and effort regulation into account to support individual learners effectively.

Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies.

PURPOSE: Multiple studies have explored the needs and experiences of patients, family members, and healthcare professionals regarding hospital-to-home transitions. Our study aimed to identify, critically appraise, and summarize these studies in a qualitative meta-synthesis. MATERIALS AND METHODS: Medline, CINAHL and Embase were systematically searched to identify eligible articles from inception to June 2024. Qualitative studies were included and critically appraised using the Critical Appraisal Skills Program. Insufficient-quality papers were excluded. We performed a meta-synthesis following (1) open coding by two independent researchers and (2) discussing codes during reflexivity meetings. RESULTS: Ninety-eight studies were appraised, of which 53 were included. We reached thematic saturation, four themes were constructed: (1) care coordination and continuity, (2) communication, (3) patient and family involvement, and (4) individualized support and information exchange. For patients and families, tailored information and support are prerequisites for a seamless transition and an optimal recovery trajectory after hospital discharge. It is imperative that healthcare professionals communicate effectively within and across care settings to ensure multidisciplinary collaboration and care continuity. CONCLUSIONS: This study identifies essential elements of optimal transitional care. These findings could be supportive to researchers and healthcare professionals when (re)designing transitional care interventions to ensure care continuity after hospital discharge.

Patients and their families need to receive tailored information and support, which are prerequisites for a seamless transition from hospital to homeProfessionals must communicate effectively within and across hospital and primary care settingsProfessional roles should be clarified to ensure effective collaboration and continued high-quality care after hospital discharge.Integrated allied health pathways addressing coordination and communication are needed to ensure seamless transitions.

An argument-based approach to the validation of UHTRUST: can we measure how recent graduates can be trusted with unfamiliar tasks?

There is a need for valid methods to assess the readiness for clinical practice of medical graduates. This study evaluates the validity of Utrecht Hamburg Trainee Responsibility for Unfamiliar Situations Test (UHTRUST), an authentic simulation procedure to assess whether medical trainees are ready to be entrusted with unfamiliar clinical tasks near the highest level of Miller's pyramid. This assessment, in which candidates were judged by clinicians, nurses and standardized patients, addresses the question: can this trainee be trusted with unfamiliar clinical tasks? The aim of this paper is to provide a validity argument for this assessment procedure. We collected data from various sources during preparation and administration of a UHTRUST-assessment. In total, 60 candidates (30 from the Netherlands and 30 from Germany) participated. To provide a validity argument for the UHTRUST-assessment, we followed Kane's argument-based approach for validation. All available data were used to design a coherent and plausible argument. Considerable data was collected during the development of the assessment procedure. In addition, a generalizability study was conducted to evaluate the reliability of the scores given by assessors and to determine the proportion of variance accounted by candidates and assessors. It was found that most of Kane's validity assumptions were defendable with accurate and often parallel lines of backing. UHTRUST can be used to compare the readiness for clinical practice of medical graduates. Further exploration of the procedures for entrustment decisions is recommended.

Perspective-Taking and Perspective-Sharing in Pediatric Education: Exploring Connections Between Strategies of Medical Students and Patients' Caregivers.

Introduction: In pediatric education, caregivers are increasingly involved to share their perspective. Yet, an in-depth understanding of the perspective-taking process between medical students and caregivers is lacking. This study explored: 1) Which strategies do medical students use to take a caregiver's perspective and which facilitators and constraints do they perceive? 2) Which strategies do caregivers use to share their perspective with students? and 3) How do students' perspective-taking strategies relate to caregivers' perspective-sharing strategies? Methods: In an online lesson: two caregivers of pediatric patients, shared their story with 27 fourth-year Dutch medical students. After the session, students undertook an assignment where they individually reflected on how they took perspective. Students' reflections were collected via audio recordings. Caregivers were individually interviewed. Data were analyzed through thematic and cross-case analysis. Results: Students used eight perspective-taking strategies, in various combinations. Students used inferential strategies, where they made inferences from available information, and cultivating strategies, where they attempted to elicit more information about the caregiver. Students perceived individual-, contextual- and caregiver-related facilitators and constraints for taking perspective. Caregivers shared their perspective by adopting multiple strategies to share their story and create a trusting learning environment. We visualized connections between students' perspective-taking strategies, facilitators/constraints, and caregivers' perspective-sharing strategies. Discussion: By combining data from both perspective-takers (students) and perspective-sharers (caregivers), this study provides a foundation for future research to study perspective-taking between students and patients in an educational context. On a practical level, our findings provide tools for students, patients, and educators to enhance perspective-taking processes.

A soluble LAG-3 protein (eftilagimod alpha) and an anti-PD-L1 antibody (avelumab) tested in a phase I trial: a new combination in immuno-oncology.

BACKGROUND: Eftilagimod alpha (efti) is a major histocompatibility complex class II agonist activating antigen-presenting cells which leads to greater systemic type 1 T helper response and more cytotoxic CD8+ T-cell activation. This phase I trial evaluated the administration of efti, a soluble lymphocyte activation gene-3 (LAG-3) protein, combined with the anti-programmed death-ligand 1 (PD-L1) antibody avelumab in advanced solid tumors. PATIENTS AND METHODS: Patients with heavily pretreated metastatic solid tumors received intravenous avelumab (800 mg) combined with subcutaneously administered efti (6 or 30 mg) for up to 12 cycles, followed by avelumab monotherapy. The primary endpoint was the assessment of the recommended phase II dose (RP2D) of efti in combination with avelumab. RESULTS: Twelve patients with different tumor entities were enrolled (six patients in each cohort). During treatment, no dose-limiting toxicities occurred, and the severity of most adverse events was grade 1 or 2. In total, nine serious adverse events were documented, resulting in a fatal outcome in two cases, but none of them were assessed to be treatment related. Five patients (42%) achieved partial response. The median progression-free survival was 1.96 months and the median overall survival was not reached, with a 12-month survival rate of 75%. CONCLUSION: Subcutaneously administered efti plus avelumab was well tolerated, and efti of 30 mg was determined to be RP2D. The activity is promising and warrants further investigation in future phase II trials.

A prospective, multicenter head-to-head comparative study in patients with primary high-risk prostate cancer investigating the bone lesion detection of conventional imaging and 18F-PSMA-PET/CT.

PURPOSE: Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) is an emerging staging tool for patients with primary high-risk prostate cancer (PCa). Patients with primary metastatic disease are staged using PSMA-PET/CT imaging, while previously published randomized clinical trials relied on conventional imaging (i.e., bone scintigraphy (BS) results. The aim of this study was to compare the ability of bone metastatic lesion detection and changes in staging for 18F-PSMA-PET/CT versus BS in high-risk PCa patients. METHODS: 79 patients with high-risk PCa were prospectively staged using BS and subsequent 18F-PSMA-PET/CT before initial therapy. Patients who presented with a BS showing no metastases represented Group 1, and patients with a BS showing low-volume disease according to the CHAARTED criteria (<4 bone metastases, no metastases outside vertebral column or pelvis and no visceral metastases) represented Group 2. Metastatic risk group according to CHAARTED and treatment strategies based on both imaging modalities were assessed. RESULTS: A change of CHAARTED risk group was observed in 9/70 (12.8%) of patients in Group 1. In Group 2, a change of risk group was found in 66.7% of patients, due to either upstaging (4/9 patients (44.4%)) and downstaging (2/9 patients (22.2%)). Treatment changes due to use of a different imaging modality occurred in almost 20% of patients. CONCLUSION: In patients with negative for cancer results on BS, upstaging on 18F-PSMA-PET/CT occurred only infrequently. Moreover, 18F-PSMA-PET/CT resulted in both upstaging and downstaging in a substantial subset of patients with low-volume metastatic disease on BS. Treatment changes occurred in almost 20% of cases depending on imaging results.

Patients as Feedback Providers: Exploring Medical Students' Credibility Judgments.

Introduction: Patient feedback is becoming ever more important in medical education. Whether students engage with feedback is partly determined by how credible they think the feedback provider is. Despite its importance for feedback engagement, little is known about how medical students judge the credibility of patients. The purpose of this study was therefore to explore how medical students make credibility judgments regarding patients as feedback providers. Methods: This qualitative study builds upon McCroskey's conceptualization of credibility as a three-dimensional construct comprising: competence, trustworthiness, and goodwill. Since credibility judgments are shaped by the context, we studied students' credibility judgments in both a clinical and non-clinical context. Medical students were interviewed after receiving feedback from patients. Interviews were analyzed through template and causal network analysis. Results: Students based their credibility judgments of patients on multiple interacting arguments comprising all three dimensions of credibility. In estimating a patient's credibility, students reasoned about aspects of the patient's competence, trustworthiness, and goodwill. In both contexts students perceived elements of an educational alliance between themselves and patients, which could increase credibility. Yet, in the clinical context students reasoned that therapeutic goals of the relationship with patients might impede educational goals of the feedback interaction, which lowered credibility. Discussion: Students' credibility judgments of patients were a weighing of multiple sometimes conflicting factors, within the context of relationships and their associated goals. Future research should explore how goals and roles can be discussed between students and patients to set the stage for open feedback conversations.

Imaging breast malignancies with the Twente Photoacoustic Mammoscope 2.

Clinical measurements on breast cancer patients were performed with a three-dimensional tomographic photoacoustic prototype imager (PAM 2). Patients with a suspicious lesion, visiting the center for breast care of a local hospital, were included in the study. The acquired photoacoustic images were compared to conventional clinical images. Of 30 scanned patients, 19 were diagnosed with one or more malignancies, of which a subset of four patients was selected for detailed analysis. Reconstructed images were processed to enhance image quality and the visibility of blood vessels. Processed photoacoustic images were compared to contrast-enhanced magnetic resonance images where available, which aided in localizing the expected tumoral region. In two cases, spotty high-intensity photoacoustic signals could be seen in the tumoral region, attributable to the tumor. One of these cases also displayed a relatively high image entropy at the tumor site, likely related to the chaotic vascular networks associated with malignancies. For the other two cases, it was not possible to identify features indicative of malignancy, because of limitations in the illumination scheme and difficulties in locating the region of interest in the photoacoustic image.

Histopathological concordance between prostate biopsies and radical prostatectomy specimens-implications of transrectal and transperineal biopsy approaches.

BACKGROUND: This study aimed to evaluate the histopathological concordance rates between prostate biopsies and radical prostatectomy specimens according to the applied biopsy approach (transrectal or transperineal). METHODS: We studied patients who had been newly diagnosed with clinically significant prostate cancer and who underwent a radical prostatectomy between 2018 and 2022. Patients were included if they underwent a prebiopsy magnetic resonance imaging and if they had not been previously treated for prostate cancer. Histopathological grading on prostate biopsies was compared with that on radical prostatectomy specimens. Univariable and multivariable logistic regression analyses were performed to assess the effect of the applied biopsy approach on histopathological concordance. Additional analyses were performed to assess the effect of the applied biopsy approach on American Urological Association risk group migration, defined as any change in risk group after radical prostatectomy. RESULTS: In total, 1058 men were studied, of whom 49.3% (522/1058) and 50.7% (536/1058) underwent transrectal and transperineal prostate biopsies, respectively. Histopathological disconcordance was observed in 37.8% (400/1058) of men while American Urological Association risk group migration was observed in 30.2% (320/1058) of men. A transperineal biopsy approach was found to be independently associated with higher histopathological concordance rates (OR 1.33 [95% CI 1.01-1.75], p = 0.04) and less American Urological Association risk group migration (OR 0.70 [95% CI 0.52-0.93], p = 0.01). CONCLUSIONS: The use of a transperineal biopsy approach improved histopathological concordance rates compared to the use of a transrectal biopsy approach. A transperineal biopsy approach may provide more accurate risk stratification for clinical decision-making. Despite recent improvements, histopathologic concordance remains suboptimal and should be considered before initiating management.

Persisting symptoms after intrathoracic anastomotic leak following oesophagectomy for cancer.

BACKGROUND: Intrathoracic anastomotic leak is a major cause of postoperative mortality and morbidity after resection for oesophageal cancer. Little is known about persisting symptoms after this complication. In this Swedish nationwide cohort study, it was hypothesized that intrathoracic anastomotic leak makes patients more susceptible to persisting eating difficulties, odynophagia, dysphagia, trouble swallowing saliva and reflux. METHODS: Patients who underwent oesophagectomy for oesophageal cancer, and had reconstruction with a gastric conduit and an intrathoracic anastomosis, between April 2001 and December 2005 were included. Symptoms were measured using an oesophageal cancer-specific health-related quality-of-life questionnaire (QLQ-OES18), developed by the European Organization for Research and Treatment of Cancer. Multivariable logistic regression models were used to calculate risk estimates for symptoms, expressed as odds ratio (OR) with 95 per cent confidence interval, 6 months after intrathoracic anastomotic leakage. RESULTS: Among the 277 patients included in the study, the 29 patients with an intrathoracic anastomotic leak had a fourfold increased risk (OR 4·05, 1·47 to 11·16) of eating difficulties and a more than twofold greater risk (OR 2·59, 1·15 to 5·82) of odynophagia, 6 months after surgery, compared with patients without a leak. There was a twofold increased risk of trouble swallowing, but this was not statistically significant (OR 1·98, 0·58 to 6·67). CONCLUSION: Patients with an intrathoracic anastomotic leak after oesophageal cancer surgery were at increased risk of eating difficulties and odynophagia 6 months after surgery. Higher risks of reflux and dysphagia were not found among patients with anastomotic leak.