Extending the use of the conceptions of learning and teaching (COLT) instrument to the postgraduate setting.

BACKGROUND: Several studies have shown that conceptions of teachers on teaching and learning can influence the teaching practices and behavior in higher education. This association is also found in undergraduate medical education but not yet established in postgraduate medical setting. An instrument, Conceptions of Learning and Teaching (COLT) was developed to measure conception of teachers in undergraduate medical education. COLT is a 3-factor 18-item questionnaire. The objective of this study is to evaluate if COLT is valid for postgraduate medical education. METHODS: We invited postgraduate clinical faculty from 3 hospitals in the Netherlands to fill out the COLT. Confirmatory and exploratory factor analysis were performed to evaluate the fit of the postgraduate clinical faculty data to the COLT. Analysis of variance was done to evaluate if there was difference among the 3 hospitals in terms of the response by the clinical faculty. RESULTS: Confirmatory factor analysis showed that the postgraduate faculty data had a 2 factor structure after removal of five items. These factors were Teacher Centeredness (TC) and combined Appreciation of Active Learning and Orientation to Professional Practice (A-P) and were considered as comparable to the factors in the original COLT, expressing the post-graduate learning and teaching setting. As several items were removed, the fit was suboptimal, yet did suggest validity for use of the COLT for postgraduate medical education. CONCLUSION: The modified COLT can be used to measure conceptions of teaching and learning in postgraduate medical education. We recommend further study to improve the factor structure of the modified COLT.

An international study on teachers' conceptions of learning and teaching and corresponding teacher profiles.

Introduction: Teachers' conceptions of learning and teaching (COLT) affect their teaching behaviour. The 18 item COLT instrument has been developed in the Netherlands and comprises three scales, 'teacher centredness', 'appreciation of active learning' and 'orientation to professional practice'. Previously we found five teacher profiles. The aim of this study was to find out if the COLT instrument can be used in an international setting.Methods: Data were collected with the web-based COLT. Cronbach's alphas of the three COLT scales were calculated. Subsequently a cluster analysis was conducted to identify different teacher profiles, followed by a split half validation procedure.Results: Respondents (n = 708) worked in 28 countries. Cronbach's alphas were 0.67, 0.54, and 0.66. A six-cluster solution fitted best, based on meaning and explained variance. The sixth teacher profile scored high on 'teacher centredness', average on 'appreciation of active learning' and low on 'orientation to professional practice'. The split half validation resulted in a Cohen's kappa of 0.744.Discussion: Cronbach's alphas indicated acceptable reliablities for all three subscales. The new, sixth profile was labelled 'neo-transmitter'.Conclusion: We found evidence supporting the validity of the use of COLT in an international context and identified a new, sixth teacher profile.

Teachers' conceptions of learning and teaching in student-centred medical curricula: the impact of context and personal characteristics.

BACKGROUND: Gibbs and Coffey (2004) have reported that teaching practices are influenced by teachers' conceptions of learning and teaching. In our previous research we found significant differences between teachers' conceptions in two medical schools with student-centred education. Medical school was the most important predictor, next to discipline, gender and teaching experience. Our research questions for the current study are (1) which specific elements of medical school explain the effect of medical school on teachers' conceptions of learning and teaching? How? and (2) which contextual and personal characteristics are related to conceptions of learning and teaching? How? METHODS: Individual interviews were conducted with 13 teachers of the undergraduate curricula in two medical schools. Previously their conceptions of learning and teaching were assessed with the COLT questionnaire. We investigated the meanings they attached to context and personal characteristics, in relation to their conceptions of learning and teaching. We used a template analysis. RESULTS: Large individual differences existed between teachers. Characteristics mentioned at the medical school and curriculum level were 'curriculum tradition', 'support by educational department' and 'management and finances'. Other contextual characteristics were 'leadership style' at all levels but especially of department chairs, 'affordances and support', 'support and relatedness', and 'students' characteristics'. Personal characteristics were 'agency', 'experience with PBL (as a student or a teacher)','personal development', 'motivation and work engagement'and 'high content expertise'. CONCLUSION: Several context and personal characteristics associated with teachers' conceptions were identified, enabling a broader view on faculty development with attention for these characteristics, next to teaching skills.

Impact of institute and person variables on teachers' conceptions of learning and teaching.

BACKGROUND: Teachers' conceptions of learning and teaching are important for faculty development to result in enduring changes in teaching practices. Until now, studies on these conceptions have mostly focused on traditional, lecture-based curricula rather than on small-group student-centred educational formats, which are gaining ground worldwide. AIM: To explore which factors predict teachers' conceptions in student-centred curricula. METHODS: In two Dutch medical schools with 10 and 40 years of student-centred education, teachers were asked to fill out the Conceptions of Learning and Teaching (COLT) Questionnaire to assess their 'teacher-centredness', 'appreciation of active learning' and 'orientation to professional practice'. Next, we quantitatively assessed the relations of teachers' conceptions with their personal and occupational characteristics and institute. RESULTS: Overall response was 49.4% (N = 319/646). Institute was the main predictor for variance in all three scales, and discipline, gender and teaching experience significantly explained variance in two of the scales. More than 80% of the variance was not explained by these factors. CONCLUSION: Longer exposure to a student-centred curriculum was associated with fewer teacher-centred conceptions, greater 'appreciation of active learning' and stronger 'orientation towards professional practice'. In line with studies on lecture-based curricula, discipline, gender and teaching experience also appeared important for teachers' conceptions in student-centred curricula. More research is necessary to better understand the influence of institute on the three teachers' conceptions scales.

Five teacher profiles in student-centred curricula based on their conceptions of learning and teaching.

BACKGROUND: Teachers' conceptions of learning and teaching are partly unconscious. However, they are critical for the delivery of education and affect students' learning outcomes. Lasting changes in teaching behaviour can only be realized if conceptions of teachers have been changed accordingly. Previously we constructed a questionnaire named COLT to measure conceptions. In the present study, we investigated if different teacher profiles could be assessed which are based on the teachers' conceptions. These teacher profiles might have implications for individual teachers, for faculty development activities and for institutes. Our research questions were: (1) Can we identify teacher profiles based on the COLT? (2) If so, how are these teacher profiles associated with other teacher characteristics? METHODS: The COLT questionnaire was sent electronically to all teachers in the first three years of the undergraduate curriculum of Medicine in two medical schools in the Netherlands with student-centred education. The COLT (18 items, 5 point Likert scales) comprises three scales: 'teacher centredness', 'appreciation of active learning' and 'orientation to professional practice'. We also collected personal information about the participants and their occupational characteristics. Teacher profiles were studied using a K-means cluster analysis and calculating Chi squares. RESULTS: The response rate was 49.4% (N = 319/646). A five-cluster solution fitted the data best, resulting in five teacher profiles based on their conceptions as measured by the COLT. We named the teacher profiles: Transmitters (most traditional), Organizers, Intermediates, Facilitators and Conceptual Change Agents (most modern). The teacher profiles differed from each other in personal and occupational characteristics. CONCLUSIONS: Based on teachers' conceptions of learning and teaching, five teacher profiles were found in student-centred education. We offered suggestions how insight into these teacher profiles might be useful for individual teachers, for faculty development activities and for institutes and departments, especially if involved in a curriculum reform towards student-centred education.

Artificial intelligence electrocardiogram as a novel screening tool to detect a newly abnormal left ventricular ejection fraction after anthracycline-based cancer therapy.

AIMS: Cardiotoxicity is a serious side effect of anthracycline treatment, most commonly manifesting as a reduction in left ventricular ejection fraction (EF). Early recognition and treatment have been advocated, but robust, convenient, and cost-effective alternatives to cardiac imaging are missing. Recent developments in artificial intelligence (AI) techniques applied to electrocardiograms (ECGs) may fill this gap, but no study so far has demonstrated its merit for the detection of an abnormal EF after anthracycline therapy. METHODS AND RESULTS: Single centre consecutive cohort study of all breast cancer patients with ECG and transthoracic echocardiography (TTE) evaluation before and after (neo)adjuvant anthracycline chemotherapy. Patients with HER2-directed therapy, metastatic disease, second primary malignancy, or pre-existing cardiovascular disease were excluded from the analyses as were patients with EF decline for reasons other than anthracycline-induced cardiotoxicity. Primary readout was the diagnostic performance of AI-ECG by area under the curve (AUC) for EFs < 50%. Of 989 consecutive female breast cancer patients, 22 developed a decline in EF attributed to anthracycline therapy over a follow-up time of 9.8 ± 4.2 years. After exclusion of patients who did not have ECGs within 90 days of a TTE, 20 cases and 683 controls remained. The AI-ECG model detected an EF < 50% and ≤ 35% after anthracycline therapy with an AUC of 0.93 and 0.94, respectively. CONCLUSION: These data support the use of AI-ECG for cardiotoxicity screening after anthracycline-based chemotherapy. This technology could serve as a gatekeeper to more costly cardiac imaging and could enable patients to monitor themselves over long periods of time.

Artificial intelligence electrocardiogram can be used to screen for an abnormal heart function after anthracycline chemotherapy, opening the door to new ways of cost-effective screening of cancer survivors at risk of cardiotoxicity over long periods of time.

Clinical teachers' views on how teaching teams deliver and manage residency training.

BACKGROUND: Residents learn by working in a multidisciplinary context, in different locations, with many clinical teachers. Although clinical teachers are collectively responsible for residency training, little is known about the way teaching teams function. AIM: We conducted a qualitative study to explore clinical teachers' views on how teaching teams deliver residency training. METHOD: Data were collected during six focus group interviews in 2010. RESULTS: The analysis revealed seven teamwork themes: (1) clinical teachers were more passionate about clinical expertise than about knowledge of teaching and teamwork; (2) residents needed to be informed about clinical teachers' shared expectations; (3) the role of the programme director in the teaching team needed further clarification; (4) the main topics of discussion in teaching teams were resident performance and the division of teaching tasks; (5) the structural elements of the organisation of residency training were clear; (6) clinical teachers had difficulty giving and receiving feedback and (7) clinical teachers felt under pressure to be accountable for team performance to external parties. CONCLUSION: The clinical teachers did not consider teamwork to be of any great significance to residency training. Teachers' views of professionalism and their own experiences as residents may explain their non-teamwork directed attitude. Efforts to strengthen teamwork within teaching teams may impact positively on the quality of residency training.

Tools to differentiate between Filamin C and Titin truncating variant carriers: value of MRI.

Whereas truncating variants of the giant protein Titin (TTNtv) are the main cause of familial dilated cardiomyopathy (DCM), recently Filamin C truncating variants (FLNCtv) were identified as a cause of arrhythmogenic cardiomyopathy (ACM). Our aim was to characterize and compare clinical and MRI features of TTNtv and FLNCtv in the Belgian population. In index patients referred for genetic testing of ACM/DCM, FLNCtv and TTNtv were found in 17 (3.6%) and 33 (12.3%) subjects, respectively. Further family cascade screening yielded 24 and 19 additional truncating variant carriers in FLNC and TTN, respectively. The main phenotype was ACM in FLNCtv carriers whereas TTNtv carriers showed either an ACM or DCM phenotype. Non-sustained Ventricular Tachycardia was frequent in both populations. MRI data, available in 28/40 FLNCtv and 32/52 TTNtv patients, showed lower Left Ventricular (LV) ejection fraction and lower LV strain in TTNtv patients (p < 0.01). Conversely, both the frequency (68% vs 22%) and extent of non-ischemic myocardial late gadolinium enhancement (LGE) was significantly higher in FLNCtv patients (p < 0.01). Hereby, ring-like LGE was found in 16/19 (84%) FLNCtv versus 1/7 (14%) of TTNtv patients (p < 0.01). In conclusion, a large number of FLNCtv and TTNtv patients present with an ACM phenotype but can be separated by cardiac MRI. Whereas FLNCtv patients often have extensive myocardial fibrosis, typically following a ring-like pattern, LV dysfunction without or limited replacement fibrosis is the common TTNtv phenotype.

Mortality and Major Adverse Cardiac Events in Patients With Breast Cancer Receiving Radiotherapy: The First Decade.

Background Treatment for breast cancer (BC) frequently involves radiotherapy. Guidelines recommend screening for cardiac adverse events starting 10 years after radiotherapy. The rationale for this interval is unclear. Methods and Results We aimed to study cardiovascular event rates in the first decade following curative radiotherapy for BC. We compared mortality and cardiovascular event rates with an age- and risk factor-matched control population. We included 1095 patients with BC (mean age 56±12 years). Two hundred and eighteen (19.9%) women died. Cancer and cardiovascular mortality caused 107 (49.1%) and 22 (10.1%) deaths, respectively. A total of 904 cases were matched to female FLEMENGHO (Flemish Study on Environment, Genes and Health Outcomes) participants. Coronary artery disease incidence was similar (risk ratio [RR], 0.75 [95% CI, 0.48-1.18]), yet heart failure (RR, 1.97 [95% CI, 1.19-3.25]) and atrial fibrillation/flutter (RR, 1.82 [95% CI, 1.07-3.08]) occurred more often in patients with BC. Age (hazard ratio [HR], 1.033 [95% CI, 1.006-1.061], P=0.016), tumor grade (HR, 1.739 [95% CI, 1.166-2.591], P=0.007), and neoadjuvant treatment setting (HR, 2.782 [95% CI, 1.304-5.936], P=0.008) were risk factors for mortality. Risk factors for major adverse cardiac events were age (HR, 1.053 [95% CI, 1.013-1.093]; P=0.008), mean heart dose (HR, 1.093 [95% CI, 1.025-1.167]; P=0.007), history of cardiovascular disease (HR, 2.386 [95% CI, 1.096-6.197]; P=0.029) and Mayo Clinic Cardiotoxicity Risk Score (HR, 2.664 [95% CI, 1.625-4.367]; P<0.001). Conclusions Ten-year mortality following curative treatment for unilateral BC was mainly cancer related, but heart failure and atrial fibrillation/flutter were already common in the first decade following irradiation. Mean heart dose, pre-existing cardiovascular diseases, and Mayo Clinic Cardiotoxicity Risk Score were risk factors for cardiac adverse events. These results suggest a need for early dedicated cardio-oncological follow-up after radiotherapy.

Development of an instrument (the COLT) to measure conceptions on learning and teaching of teachers, in student-centred medical education.

BACKGROUND: Conceptions of medical teachers regarding learning and teaching affect their teaching practice. Therefore conceptions should be addressed in faculty development. AIM: To facilitate this, we constructed the Conceptions Of Learning and Teaching (COLT) instrument. METHOD: The COLT was adapted based on experts' comments during a meeting and interviews, followed by a Delphi procedure (Part I). It was administered to teachers from two Dutch medical schools with different traditions in student-centred education (Part II; N=646). The data were analyzed using confirmatory factor analysis and reliability analysis. RESULTS: 324 Teachers (50.2%) completed the questionnaire. Confirmatory factor analysis did not confirm the underlying theoretical model, but an alternative model demonstrated a good fit. This led to an instrument with eighteen items reflecting three underlying factors: 'teacher centredness', 'appreciation of active learning', and 'orientation to professional practice'. We found significant differences in COLT scores between the faculty of the two medical schools. CONCLUSIONS: The COLT appears to be a construct valid tool resulting in reliable scores of teachers' conceptions of learning and teaching, in student-centred medical education. Two of the three factors are new and may be specific for student-centred medical education. The COLT may be a promising tool to improve faculty development.

Predictability of cardiotoxicity: Experience of a Belgian cardio-oncology clinic.

BACKGROUND: New oncological treatments improved survival but also increased awareness of cardiovascular side-effects during and after cancer therapy. METHODS: We report the experience of the cardio-oncology clinic at a large Belgian tertiary care center and investigated the predictability of cardiotoxicity based on referring department, cardiovascular risk factors, cancer treatment and existing risk scores of the American Society of Clinical Oncologists (ASCO) and Mayo Clinic. Cardiotoxicity was defined as a 10% reduction in Left Ventricular Ejection Fraction (LVEF) compared to the baseline transthoracic echocardiography (TTE) in asymptomatic patients or 5% in symptomatic patients. RESULTS: Of the 324 patients included, 14.5% died during follow-up. Most deaths were oncological, yet 19% of deaths were attributable to cardiovascular diseases. Models based on cardiovascular risk factors alone and cardiovascular risk factors combined with cardiotoxic medication poorly predicted cardiotoxicity. Existing risk scores from ASCO and Mayo Clinic also poorly predicted cardiotoxicity. A weighed model based on the Mayo Clinic cardiotoxicity risk score was the best risk assessment tool with still a limited predictive value with an Area Under the Receiver Operating Characteristic curve of 0.654 (CI 95%: 0.601-0.715). CONCLUSION: Cardiovascular morbidity and mortality are common in cancer patients and survivors and stress the unmet need of adequate risk prediction tools for systematic screening and rigorous cardiovascular follow-up. In our outpatient cohort, cardiotoxicity risk could not be adequately predicted by cancer type, using classic cardiovascular risk factors, nor by the combination of cardiovascular risk factors and the proposed cancer treatment. Furthermore, we showed that existing cardiotoxicity risk scores are suboptimal and should thus be interpreted with caution.

Incidence of Cardiovascular Events in Patients Treated With Immune Checkpoint Inhibitors.

PURPOSE: In rare cases, immune checkpoint inhibitors (ICIs) cause immune-mediated myocarditis. However, true incidence of other major adverse cardiovascular events (MACEs) after ICI treatment remains unknown, mainly because late occurring side effects are rarely reported in prospective clinical trials. The aims of this study were (1) to identify incidence and risk factors of MACE in a real-life ICI-treated cancer cohort and (2) to compare incidence rates with patients with cancer who are not treated with ICIs and population controls. METHODS: In total, 672 patients treated with ICIs were included. The primary end point was MACE, a composite of acute coronary syndrome, heart failure (HF), stroke, and transient ischemic attack. Secondary outcomes were acute coronary syndrome and HF separately. Incidence rates were compared between groups after matching according to age, sex, cardiovascular history, and cancer type. RESULTS: The incidence of MACE was 10.3% during a median follow-up of 13 (interquartile range, 6-22) months. In multivariable analysis, a history of HF (hazard ratio 2.27; 95% CI, 1.03 to 5.04; P = .043) and valvular heart disease (hazard ratio 3.01; 95% CI, 1.05 to 8.66; P = .041) remained significantly associated with MACE. Cumulative incidence rates were significantly higher in the ICI group compared with the cancer cohort not exposed to ICI and the population controls, mainly driven by a higher risk of HF events. CONCLUSION: Cardiovascular events during and after ICI treatment are more common than currently appreciated. Patients at risk are those with a history of cardiovascular disease. Compared with matched cancer and population controls, MACE incidence rates are significantly higher, suggesting a potential harmful effect of ICI treatment besides the underlying risk.

Use of a Telemedicine Team to Improve Guideline-Based Antibiotic Prescribing.

OBJECTIVES: Assessing the impact of a virtual antibiotic team (VAT) on appropriateness of antibiotic prescribing behavior of older care physicians, regarding urinary tract (UTI), respiratory tract (RTI), and skin and soft tissue infections (SSTI), in residents of long-term care facilities (LTCF). DESIGN: Before-after trial; introduction of a VAT consisting of a clinical microbiologist, older care physician, and a pharmacist. SETTING AND PARTICIPANTS: Eight LTCFs in Amsterdam, the Netherlands. METHODS: The VAT was introduced on April 1, 2019. Meetings were held via weekly teleconferencing. VAT advised about treatment indication, antibiotic choice, and additional diagnostics. Data were retrospectively extracted from resident files regarding infection episodes for which antibiotics had been prescribed during 12 months before (period I) and 11 months after VAT introduction (period II). Appropriateness of antibiotic prescriptions was assessed using national guidelines and an algorithm developed for antimicrobial stewardship in nursing homes. Antibiotic prescription rates per 100 person-years (py) were estimated and compared between periods using incidence rate ratio (IRR) with 95% confidence intervals (CIs). Proportions of appropriate antibiotic prescriptions were compared between periods using the chi-squared test. RESULTS: A total of 524 infection episodes for which antibiotics were prescribed were identified: 284 in period I and 240 in period II. Antibiotic prescription rates before VAT introduction were 73 per 100 py in period I and decreased to 68 in period II (IRR 0.9, 95% CI 0.8-1.1). Of all prescriptions, 23.9% were assessed as appropriate during period I, which increased to 40.4% in period II (P < .001). Appropriate antibiotic use increased after VAT introduction for RTI (12.5% to 48.2%, P < .001) and SSTI (47.5% to 74.3%, P = .02) but remained similar for UTI (23.5% to 28.8%, P = .29). CONCLUSIONS AND IMPLICATIONS: After implementation of VAT in LTCFs, appropriate antibiotic use increased significantly overall, and for RTI and SSTI particularly. Improving prescribing behavior regarding UTI might need extra strategies.

Leucobacter chromiiresistens sp. nov., a chromate-resistant strain.

A Gram-positive, irregular rod-shaped, non-motile, yellow-pigmented bacterium, strain JG 31(T), was isolated in the course of identifying chromium-resistant soil bacteria. 16S rRNA gene sequence analysis of the isolated bacterium indicated its phylogenetic position within the genus Leucobacter. Binary 16S rRNA gene sequence alignments of the isolated bacterium with the 11 species of the genus recognized at the time of writing revealed sequence similarities of more than 97 % with Leucobacter alluvii (GenBank accession no: AM072820; 99.4 %), Leucobacter iarius (AM040493; 98.2 %), Leucobacter aridicollis (AJ781047; 97.8 %), Leucobacter komagatae (AB007419; 97.4 %), Leucobacter chironomi (EU346911; 97.1 %) and Leucobacter luti (AM072819; 97.1 %). In contrast, DNA-DNA hybridization experiments showed similarity values below 28 % for DNA samples from the most closely related type strains of L. alluvii, L. aridicollis and L. iarius. Protein analysis by matrix-assisted laser-desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and automated RiboPrinting using the restriction enzyme PvuII differentiated strain JG 31(T) from all type strains of the genus Leucobacter. The dominant fatty acids of the novel isolate were anteiso-C(15 : 0), anteiso-C(17 : 0) and iso-C(16 : 0), while the quinone system consisted of menaquinones MK-11, MK-10, MK-9 and MK-8. In a B-type cross-linked peptidoglycan, the cell-wall amino acids were alanine, glycine, threonine, glutamic acid and 2,4-diaminobutyric acid. Strain JG 31(T) was able to grow in a medium containing up to 300 mM K(2)CrO(4) and showed cellular aggregation in response to chromate stress. From biochemical and genomic analyses, the new strain is considered to represent a novel species of the genus Leucobacter, for which the name Leucobacter chromiiresistens sp. nov. is proposed. The type strain is strain JG 31(T) ( = DSM 22788(T)  = CCOS 200(T)).

How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques.

To identify the evidence for the effectiveness of behaviour change techniques, when used by health-care professionals, in accomplishing health-promoting behaviours in patients. Reviews were used to extract data at a study level. A taxonomy was used to classify behaviour change techniques. We included 23 systematic reviews: 14 on smoking cessation, 6 on physical exercise, and 2 on healthy diets and 1 on both exercise and diets. None of the behaviour change techniques demonstrated clear effects in a convincing majority of the studies in which they were evaluated. Techniques targeting knowledge (n = 210 studies) and facilitation of behaviour (n = 172) were evaluated most frequently. However, self-monitoring of behaviour (positive effects in 56% of the studies), risk communication (52%) and use of social support (50%) were most often identified as effective. Insufficient insight into appropriateness of technique choice and quality of technique delivery hinder precise conclusions. Relatively, however, self-monitoring of behaviour, risk communication and use of social support are most effective. Health professionals should avoid thinking that providing knowledge, materials and professional support will be sufficient for patients to accomplish change and consider alternative strategies which may be more effective.

Understanding teaching and learning conceptions among clinical faculty as a means to improve postgraduate training.

OBJECTIVES: This study aimed to determine the conceptions of teaching and learning of postgraduate medical teachers. METHODS: We invited postgraduate clinical teachers to fill out COLT (Conceptions on Learning and Teaching) questionnaire, an 18-item instrument designed to measure the conceptions of faculty in undergraduate medical education, and did a confirmatory factor analysis (CFA) to test if it was valid to be used in a postgraduate situation. Cluster analysis was done to determine different teacher profiles. We subsequently did a qualitative study among 12 clinical teachers to further explore issues related to conceptions of teaching. We used a semi-structured interview guide with vignettes summarizing five perspectives of teaching. RESULTS: Four criteria of goodness of fit indices were met, although six items had to be removed from the original COLT items. Three clusters were identified, and 51% of participants favored a transmission teaching-style perspective. For the qualitative part, three themes were identified. Majority of the teachers preferred apprenticeship and nurturing teaching-style perspective, even if they were educated through a transmission teaching-style perspective. CONCLUSIONS: Our study has shown that the COLT, although initially designed for undergraduate medical setting in the Netherlands was a valid tool in a different setting and population, with some modifications. Both the survey and the interview studies showed that the majority of the faculty chose the transmission perspective initially, but when introduced to the other perspectives, preferred apprenticeship and nurturing. The faculty readily embraced other perspectives of teaching that they believe to take into consideration the well-being of the trainees.

Spirometry expert support in family practice: a cluster-randomised trial.

AIM: To assess the impact of two modes of spirometry expert support on Family physicians' (FPs') diagnoses and planned management in patients with apparent respiratory disease. METHOD: A cluster-randomised trial was performed with family practices as the unit of randomisation. FPs from 44 family practices recorded their diagnosis and planned management before and after spirometry for 868 patients. Intervention consisted of spirometry interpretation support by either a chest physician or expert software. Both interventions were compared with usual care (i.e. no additional interpretation support). Change in FPs' diagnoses after spirometry served as the primary outcome. Secondary outcomes were referral rate, additional diagnostic tests, and disease management changes. Effects were expressed as percentages and Odds Ratios (OR) with 95% confidence intervals. RESULTS: Diagnoses changed after intervention in all groups: 47.8% (95% CI 41.8 to 53.9) for chest physician support; 45.0% (95% CI 39.5 to 50.6) for software support; and 53.3% (95% CI 47.2 to 59.4) for usual care. Differences in the proportions of changed diagnosis were not statistically significant: chest physician support versus usual care OR 0.79 (95%CI 0.49 to 1.30); software support versus usual care OR 0.72 (95% CI 0.45 - 1.15). There were no differences in secondary outcomes. CONCLUSION: Neither chest physician spirometry support nor expert software spirometry support had a significant impact on FPs' diagnosis of respiratory conditions or management decisions. TRIAL NUMBER: http://www.clinicaltrials.gov/ct/show/NCT00131157?order=1.

Cardiac-sparing radiation therapy using positioning breast shell for patients with left-sided breast cancer who are ineligible for breath-hold techniques.

PURPOSE: Patients with left-sided breast cancer (LSBC) are at increased risk of cardiac morbidity from adjuvant breast radiation therapy (ABRT). Breath-hold (BH) techniques substantially reduce the radiation received by heart during radiation therapy for LSBC. However, a subset of patients with LSBC are ineligible for BH techniques due to an inability to breath-hold or because of other comorbidities. To reduce radiation to the heart, we routinely use a custom-made breast shell for the treatment of patients with LSBC who are ineligible for BH techniques. This study evaluates the dosimetric impact of using a breast shell for patients with LSBC undergoing ABRT. METHODS AND MATERIALS: Sixteen consecutive patients with LSBC who failed BH and underwent ABRT using a breast shell during the period of 2014 to 2016 were identified. Treatment was planned using field-in-field tangents with a prescribed dose of 42.5 Gy in 16 fractions. Comparisons between plans with and without a shell were made for each patient using a paired t test to quantify the sparing of organs at risk (OARs) and target coverage. RESULTS: There was no statistically significant difference in the planning target volume of breast coverage. A statistically significant improvement was observed in sparing the heart, left ventricle (LV), and ipsilateral lung (P-value < .001). Plans with the shell spared OARs better than the no-shell plans with a mean dose of 2.15 Gy versus 5.15 Gy (58.2% reduction) to the heart, 3.27 Gy versus 9.00 Gy (63.7% reduction) to the LV, and 5.16 Gy versus 7.95 Gy (35% reduction) to the ipsilateral lung. The irradiated volumes of OARs for plans with and without shell are 13.3 cc versus 59.5 cc (77.6% reduction) for the heart, 6.2 cc versus 33.2 cc (81.2% reduction) for the LV, and 92.8 cc versus 162.5 cc (42.9% reduction) for the ipsilateral lung. CONCLUSIONS: A positioning breast shell offers significant benefit in terms of sparing the heart for patients with LSBC who are ineligible for BH techniques. It also can be used as a simple cardiac-sparing alternative in centers without BH capability.

Characteristics of patients with COPD in three motivational stages related to smoking cessation.

OBJECTIVE: To characterize patients with chronic obstructive pulmonary disease (COPD) in different motivational stages related to smoking cessation. METHODS: 633 smoking COPD patients from 67 general practices participated in a cross-sectional study. The patients were compared with respect to health indicators, demographics, self-efficacy, nicotine dependence, attitudes, and action plans. RESULTS: In line with previous Dutch results, smokers in precontemplation associated significantly fewer advantages with smoking cessation than smokers contemplating quitting and preparing to quit. Preparers had significantly higher self-efficacy expectations about quitting than the other smokers. Patients preparing to quit suffered from more COPD complaints than precontemplators. Smokers contemplating quitting and preparing to quit developed more plans to turn intentions to quit into action. CONCLUSION: More than 50% of the smokers with COPD are amenable to smoking cessation support. Preparers and contemplators did not differ as much as previous studies found. It would be advantageous to tailor COPD counseling to two distinct groups (unmotivated smokers and smokers motivated to quit), to discuss the advantages of quitting with unmotivated smokers, and to increase self-efficacy, and action planning for smokers motivated to quit. PRACTICE IMPLICATIONS: COPD patients are amenable to counseling to quit smoking. Addressing COPD complaints may contribute to greater motivation.

General practice counseling for patients with chronic obstructive pulmonary disease to quit smoking: impact after 1 year of two complex interventions.

OBJECTIVE: To evaluate two counseling programs in general practice to help smokers with chronic obstructive pulmonary disease (COPD) to quit smoking. METHODS: Cluster randomized controlled trial including 68 general practices (667 patients) using a randomly assigned intervention program with counseling and advice about nicotine replacement therapy (and additional bupropion-SR in one of the programs) or usual care. Usual care consisted of periodic regular check-ups and COPD information. The main outcome measure was biochemically verified point prevalence at 12 months. RESULTS: The two intervention groups were treated as one in the analysis because they were equally effective. The intervention resulted in a significantly self-reported higher success rate (14.5%) compared to usual care (7.4%); odds ratio=2.1, 95% confidence interval=1.1-4.1. Biochemically verified quit rates were 7.5% (intervention) and 3.4% (usual care); odds ratio=2.3, 95% confidence interval=0.9-6.0. CONCLUSION: The program doubled the cessation rates (statistically nonsignificant). Too few participants used the additional bupropion-SR to prove its effectiveness. PRACTICE IMPLICATIONS: The protocols can be used for COPD patients in general practice, but expectations should be modest. If quitting is unsuccessful, a stepped care approach should be considered.