Learning from complex elderly care: a qualitative study on motivating residents in family medicine.

BACKGROUND: More and more patients need complex care, especially the elderly. For various reasons, this is becoming increasingly difficult. The onus is essentially on family physicians to provide this care and family medicine residency programs should therefore prepare their residents for this task. We know from self-determination theory (SDT) that motivation plays a key role in learning and that in order to boost motivation, fulfillment of 3 basic psychological needs - for autonomy, competence, and relatedness - is crucial. As residents often lack motivation, residency programs face the important challenge to motivate them to learn about and engage in complex elderly care. How to do so, however, is not yet sufficiently understood. METHODS: We conducted a qualitative multi-institutional case study across four universities in Belgium and the Netherlands. In the period between June, 2015, and May, 2019, we triangulated information from semi-structured interviews, document analysis, and observations of educational moments. Guided by SDT concepts, the analysis was performed iteratively by a multidisciplinary team, using ATLAS.ti, version 8. In this process, we gained more insights into residents' motivation to learn complex elderly care. RESULTS: We scrutinized 1,369 document pages and 4 films, observed 34 educational moments, and held 41 semi-structured interviews. Although we found all the 3 basic psychological needs postulated by SDT, each seemed to have its own challenges. First, a tension between the need to guide residents and to encourage their independent learning complicated fulfillment of the need for autonomy. Second, the unpredictability of complex care led to reduced feelings of competence. Yet, guidelines and models could help residents to capture and apprehend its complexity. And third, family medicine practice, patients, and educational practice, by either satisfying or thwarting the need for relatedness, were identified as key mediators of motivation. By setting the right example and encouraging residents to discuss authentic dilemmas and switch their health care approach from cure to care, educators can boost their motivation. CONCLUSION: Our study has demonstrated that the degree of perceived autonomy, guidance by the education program, use of authentic dilemmas, as well as involvement of group facilitators can aid the process of motivation. TRIAL REGISTRATION: NVMO, ERB number 482.

Two-year effects and cost-effectiveness of pelvic floor muscle training in mild pelvic organ prolapse: a randomised controlled trial in primary care.

OBJECTIVE: To compare effects and cost-effectiveness of pelvic floor muscle training (PFMT) and watchful waiting in women with pelvic organ prolapse. DESIGN: Randomised controlled trial. SETTING: Dutch general practice. POPULATION: Women (≥55 years) with symptomatic mild prolapse, identified by screening. METHODS: Linear multilevel analysis. MAIN OUTCOME MEASURES: Primary outcome was change of pelvic floor symptoms (Pelvic-Floor-Distress-Inventory-20 [PFDI-20]) during 24 months. Secondary outcomes were condition-specific and general quality of life, costs, sexual functioning, prolapse stage, pelvic floor muscle function and women's perceived improvement of symptoms. RESULTS: PFMT (n = 145) resulted in a 12.2-point (95% CI 7.2-17.2, P < 0.001) greater improvement in PFDI-20 score during 24 months compared with watchful waiting (n = 142). Participants randomised to PFMT more often reported improved symptoms (43% versus 14% for watchful waiting). Direct medical costs per person were €330 for PFMT and €91 for watchful waiting but costs for absorbent pads were lower in the PFMT group (€40 versus €77). Other secondary outcomes did not differ between groups. Post-hoc subgroup analysis demonstrated that PFMT was more effective in women experiencing higher pelvic floor symptom distress at baseline. CONCLUSION: PFMT resulted in greater pelvic floor symptom improvement compared with watchful waiting. The difference was statistically significant, but below the presumed level of clinical relevance (15 points). PFMT more often led to women's perceived improvement of symptoms, lower absorbent pads costs, and was more effective in women experiencing higher pelvic floor symptom distress. Therefore, PFMT could be advised in women with bothersome symptoms of mild prolapse. TWEETABLE ABSTRACT: Pelvic floor muscle training can be effective in women with bothersome symptoms of mild prolapse.

Decreased plasma levels of activated factor VII in patients with deep vein thrombosis.

BACKGROUND: The initiating trigger in the development of deep vein thrombosis (DVT) remains unidentified. It has been suggested that tissue factor (TF)-bearing microparticles play a key role, which indicates a role for the TF pathway in the initiation of DVT. OBJECTIVE: To assess the role of the TF pathway in the initiation of venous thrombosis, we measured plasma levels of factor VII and VIIa in patients with acute DVT and in controls. METHODS: We included 148 patients diagnosed with acute DVT and 179 controls in this study. Antigen levels of FVII and FVIIa were measured by using assays recently developed in our laboratory. RESULTS: Median FVII levels in patients were 109.8% (interquartile range [IQR] 86.0-153.2) compared with 102.2% (IQR 76.1-141.7) in controls. Individuals with FVII levels in the upper quartile had a 1.6-fold increased risk for the presence of a DVT (odds ratio 1.6, 95% confidence interval 0.8-3.1). Median FVIIa levels in patients were 50.2 ng mL(-1) (IQR 25.2-86.1) compared with 96.6 ng mL(-1) (69.9-168.9) in controls. Individuals with FVIIa levels in the lowest quartile had a > 5-fold increased risk for the presence of a DVT (odds ratio 5.5, 95% confidence interval 2.8-10.6). Both risks did not change substantially after adjustment for potential confounders. CONCLUSION: Decreased plasma levels of FVIIa in patients with deep vein thrombosis may indicate ongoing consumption of FVIIa and suggest a contributory role for TF in venous thrombus formation.

Colloidal stability and chemical reactivity of complex colloids containing Fe³âº.

The reactivity of iron contained within insoluble colloidal metal-pyrophosphate salts was determined and compared to the reactivity of a soluble iron salt (FeCl3). As a model system for the reactivity of iron in food products, the formation of an iron-polyphenol complex was followed with spectrophotometry. Three types of systems were prepared and their colloidal stability and reactivity studied: Fe(3+) pyrophosphate, protein-coated Fe(3+) pyrophosphate and mixed-metal pyrophosphates containing Fe(3+) and a second cation M. The additional cation used was either monovalent (sodium) or divalent (M(2+)). It was found that: (i) incorporating iron in a colloidal salt reduced its reactivity compared to free Fe(3+) ions; (ii) coating the particles with a layer of hydrophobic protein (zein) increased stability and further decreased the reactivity. Finally, the most surprising result was that (iii) a mixed system containing more Fe(3+) than M actually increased the reactivity of the contained iron, while the reverse, a system containing excess M, inhibited the reactivity completely.

Repeptization by dissolution in a colloidal system of iron(III) pyrophosphate.

Repeptization (redispersion) from an aggregated state is usually only possible in charge-stabilized colloidal systems if the system is either coagulated in the secondary minimum of the interaction potential or if the system cannot settle completely into the primary minimum. In this work, we analyze the zeta potential, conductivity, and long-term stability of colloidal systems of iron(III) pyrophosphate and surprisingly find that the system seems to defy conventional wisdom as it can be repeptized from its coagulated state regardless of aging time and background ions. Moreover, after having been stored for up to a month in 2 M NaCl, dialysis of iron pyrophosphate will yield a colloidal dispersion that is actually stable for a longer period of time than a fresh system with background electrolyte removed.

Stabilization through precipitation in a system of colloidal iron(III) pyrophosphate salts.

The ionic strength of a solution decreases during the precipitation of an insoluble salt, which can cause an initially unstable colloidal system to stabilize during its formation. We show this effect in the precipitation and aging of colloidal iron(III) pyrophosphate, where we observe two distinct stages in the aggregation process. The first stage is the formation of nanoparticles that immediately aggregate into clusters with sizes on the order of 200 nm. In the second stage these clusters slowly grow in size but remain in dispersion for days, even months for dialyzed systems. Eventually these clusters become macroscopically large and sediment out of dispersion. Noting the clear instability of the nanoparticles, it is interesting to find two stages in their aggregation even without the use of additives such as surface active molecules. This is explained by accounting for the rapid decrease of ionic strength during precipitation, rendering the nanoparticles relatively stable when precipitation is complete. Calculating the interaction potentials for this scenario we find good agreement with the experimental observations. These results indicate that coupling of ionic strength to aggregation state can be significant and should be taken into account when considering colloidal stability of insoluble salts.

Development of a severe von Willebrand factor/ADAMTS13 dysbalance during orthotopic liver transplantation.

Patients with liver disease show profound changes in their hemostatic system, which may further change during liver transplantation. We previously demonstrated that highly elevated levels of the platelet adhesive protein von Willebrand factor (VWF) in patients with cirrhosis lead to an increased VWF-dependent platelet deposition under flow as compared to healthy controls. In this study we examined VWF parameters during the course of liver transplantation. We collected serial plasma samples from 20 patients undergoing liver transplantation in which we determined plasma levels of VWF and the VWF-cleaving protease ADAMTS13. Furthermore, we performed functional tests of VWF-dependent platelet adhesion. We found persistently elevated levels of VWF during and after liver transplantation. The capacity of VWF to interact with platelets normalized during the course of transplantation, and flow-mediated VWF-dependent platelet adhesion remained at levels far exceeding those observed in healthy individuals during and after transplantation. Plasma levels of ADAMTS13 dropped during transplantation, and in four patients levels below 10% of normal were observed after reperfusion. We observed the development of a hyperreactive primary hemostatic system, as evidenced by high levels of fully functional VWF and a temporary ADAMTS13 deficiency, during liver transplantation, and speculate that these changes contribute to postoperative thrombotic complications.

Field gradient imaging of nanoparticle systems: analysis of geometry and surface coating effects.

In this work we compare the standard imaging of various types of nanoparticles deposited on surfaces by atomic force microscopy (AFM) with a complementary analysis of the same samples by either electrostatic force microscopy (EFM) or magnetic force microscopy (MFM). Experiments were carried out on gold nanoparticles (decahedrons and stars) and two different iron oxide systems: goethite (alpha-FeOOH) and hematite (alpha-Fe(2)O(3)). Regardless of the particular geometry, the EFM signal appears to be stronger on edges or tips of pure gold nanoparticles. Both EFM and MFM experiments were also carried out on iron oxide particles. Apart from the structural analysis, we analyzed the influence of a shell layer deposited on the gold and iron oxide particles, the shell being amorphous SiO(2). Although the silica layer was found to have an insulating effect around the particles, in all cases EFM/MFM measurements could still be performed by the proper choice of the scan lift height (with an eventual slight increase of the sample bias, where applicable).

Effects of CYP2C9 and VKORC1 on INR variations and dose requirements during initial phase of anticoagulant therapy.

INTRODUCTION: Anticoagulants of the coumarin type are effective drugs for the treatment and prevention of thromboembolic diseases. However, they have a narrow therapeutic range and show inter- and intra-individual variability in dose requirement, largely conditioned by both environmental and genetic factors. METHODS: This prospective study investigated, during the initial phase of acenocoumarol therapy, the effect of CYP2C9 variant alleles and VKORC1 haplotypes, single and in combination, in 220 Italians. RESULTS: CYP2C9*3 was associated with a 25% dose reduction and an increased risk of over-anticoagulation (International Normalized Ratio [INR] > 6) on day 4. Two copies of the VKORC1*2 haplotype were associated with a 45% dose reduction and an increased risk of over-anticoagulation. Homozygosity for VKORC1*3 and VKORC1*4 was associated with an increased dose requirement and a reduced risk of over-anticoagulation. The VKORC1*3 or *4 plus CYP2C9*1 genotype combination was associated with the highest dose requirement and the lowest INR on day 4; VKORC1*2 plus CYP2C9*3 was associated with the lowest dose requirement, the highest INR and an increased risk of over-anticoagulation. Even though they spent approximately 50% of the time within the target therapeutic range, VKORC1*3 or *4 plus CYP2C9*1 carriers spent a large percentage of the remaining time below and carriers of VKORC1*2 plus CYP2C9*3 above the target range. DISCUSSION: The determination of VKORC1*3 and VKORC1*4 haplotypes may be an important addition to CYP2C9 and VKORC1*2 genotyping to identify patients at risk of being outside the target range during initial anticoagulation with acenocoumarol.

Clinical fluctuations in MuSK myasthenia gravis are related to antigen-specific IgG4 instead of IgG1.

We studied the longitudinal relation between disease severity and titers of antigen-specific IgG subclasses in sera of patients with myasthenia gravis and antibodies to Muscle Specific Kinase (MuSK MG). Six patients were included of whom 55 samples had been collected during 2.5-13.4 years. Anti-MuSK antibodies were determined by ELISA and with a cell-based immunofluorescence assay. Disease severity was scored on a semi continuous scale. Only antigen-specific IgG4, and not IgG1, titers were significantly associated with disease severity in a linear mixed effect model (p = 0.036). Levels of IgG4 antibodies were above IgG1 in all samples except in one patient who went into clinical remission while switching from IgG4 to IgG1. The results support an important role for IgG4 in the pathogenesis of MuSK MG, in contrast to MG with anti-acetylcholine receptor antibodies.

[Cardiac symptoms due to pectus excavatum in a man over the age of 55]. / Cardiale klachten door een pectus excavatum bij een 55-plusser.

A healthy 59-year-old man, a retired general practitioner, suffered from increasing palpitations, fatigue and postural dyspnoea: bending over led to a significant increase in his shortness of breath. Cardiological and pulmonological examination, performed at regular intervals, showed occasional supraventricular arrhythmia and nodal tachycardia but did not yield a satisfactory explanation for the symptoms. In the years that followed, the physical impairment became a considerable handicap. Finally, the patient himself suggested a possible explanation on the basis of an Internet search: his pectus excavatum. A literature search confirmed this hypothesis. A lateral chest X-ray in bending position and a CT-scan of the chest revealed compression of the heart by the sternum. Ten years after the onset of symptoms, a modified Ravitch operation finally brought nearly complete recovery.

Prediction of hemorrhagic and thrombotic events in patients with mechanical heart valve prostheses treated with oral anticoagulants.

BACKGROUND: Variability in the intensity of anticoagulant therapy is considered a risk factor for complications, but it is unclear how best to quantify variability. OBJECTIVE: We evaluated the association of three methods to measure variability with complications of oral anticoagulant therapy. METHODS: We conducted a nested case-control study within a cohort of patients with prosthetic heart valves. 210 patients with a first hemorrhagic or thrombotic event during follow-up were selected with two controls per case, matched on age and sex. We calculated the time spent at an International Normalized Ratio below, above, and between 2.5 and 4.0, and the variance growth rate according to three different methods (A, B1, B2); method A combines variability and time in range, and methods B1 and B2 purely look at variability. RESULTS: Odds ratios of the variance growth rates for thrombotic events for patients in the second and third tertiles varied between 2 and 3, with the highest odds ratio for complications for the method that purely looked at variability. For hemorrhagic complications, the highest odds ratios were found for method A, which also incorporated time in range, with odds ratios of 2.6 (95% CI: 1.3-5.1) and 3.1 (95% CI: 1.6-6.0) for the second and third tertiles as compared to the first. The combination of time spent out of range with the highest tertile of variability increased the risk 2.6-fold (95% CI: 1.6-4.2) as compared to subjects with stable anticoagulation within the target range. CONCLUSION: Unstable anticoagulation was associated with hemorrhagic and thrombotic complications. Method A was best associated with complications, but methods B1 and B2, in combination with time spent in range, were equally well associated. As we prefer to disentangle variability and intensity of anticoagulation, we propose to use methods B1 or B2 to reflect pure variability of oral anticoagulant therapy.

Improved control of oral anticoagulant dosing: a randomized controlled trial comparing two computer algorithms.

BACKGROUND: Efforts to improve dosing quality in oral anticoagulant control include the use of computer algorithms. As current algorithms are simplistic and give dosage proposals in a small fraction of patients, we developed an algorithm based on principles of system and control engineering that gives proposals in nearly all patients. OBJECTIVE: To evaluate the new algorithm in clinical practice. PATIENTS AND METHODS: We conducted a double-blind randomized controlled trial among 712 patients with an indication for long-term anticoagulant treatment at the Leiden Anticoagulation Clinic. We compared oral anticoagulant dosing supported by the new algorithm (ICAD) with the standard algorithm (TRODIS). RESULTS: The percentage of time spent in the therapeutic range was similar for the new and standard algorithm groups, 79.8% vs. 80.2% (difference 0.4%, 95% CI: -1.7-2.6%). The new algorithm produced a dosage proposal in 97.5% of visits, and the standard algorithm in 60.8% (difference 36.7%, 95% CI: 35.4-38.0%). Of proposals of the new algorithm, 79.3% were accepted by the physician vs. 90.9% for the standard algorithm (difference 11.6%, 95% CI: 10.2-13.0%). This implies that the new algorithm gave an acceptable proposal in 77.4% of all patient visits vs. 55.3% for the standard algorithm (difference 22.1%, 95% CI 20.4-23.8%). CONCLUSIONS: Substantially more dosage proposals were generated and accepted with the new than with the standard algorithm, and the new algorithm will therefore improve the efficiency of anticoagulant monitoring without loss of quality.

Protection against meningococcal serogroup ACYW disease in complement-deficient individuals vaccinated with the tetravalent meningococcal capsular polysaccharide vaccine.

Individuals with properdin, C3 or late complement component deficiency (LCCD) frequently develop meningococcal disease. Vaccination of these persons has been recommended, although reports on efficacy are scarce and not conclusive. We immunized 53 complement-deficient persons, of whom 19 had properdin deficiency, seven a C3 deficiency syndrome and 27 had LCCD with the tetravalent (ACYW) meningococcal capsular polysaccharide vaccine. Serological studies were performed in 43 of them. As controls 25 non-complement-deficient relatives of the complement-deficient vaccinees and 21 healthy non-related controls were vaccinated. Post-vaccination, complement-deficient individuals and controls developed a significant immunoglobulin-specific antibody response to capsular polysaccharides group A, C, Y, W135, but a great individual variation was noticed. Also, the proportion of vaccinees of the various vaccinated groups with a significant increase in bactericidal titre (assayed with heterologous complement) was similar. Opsonization of meningococci A and W135 with sera of the 20 LCCD individuals yielded in 11 (55%) and eight (40%) sera a significant increase of phagocytic activity after vaccination, respectively. Despite vaccination, four complement-deficient patients experienced six episodes of meningococcal disease in the 6 years post-vaccination. Four episodes were due to serogroup B, not included in the vaccine. Despite good response to serogroup Y upon vaccination, disease due to serogroup Y occurred in two C8beta-deficient patients, 3.5 and 5 years post-vaccination. These results support the recommendation to vaccinate complement-deficient individuals and to revaccinate them every 3 years.

Selection for postgraduate training for general practice: the role of knowledge tests.

BACKGROUND: Postgraduate training for general practice is a legal requirement in most countries of the European Community, and includes posts in general practice as well as in hospitals. The effectiveness of the training has not been fully evaluated, and it is largely unknown whether the results are satisfactory or what the impact of the separate training components is--nor is it known which characteristics or prior achievements of the trainee influence the end-of-training performance. AIM: To determine the value of knowledge tests in the context of entry selection for postgraduate training in general practice. METHODS: Three (equated) knowledge tests were administered during the two years' postgraduate training of 85 Dutch trainees. The first test was taken at entrance, the second eight months later, and the third shortly before the end of the entire training period. Complete data for 57 trainees were available for analysis. A multiple regression analysis was performed to estimate the predictive values of test 1 and test 2 scores, separately and in combination, for test 3 scores. Since the knowledge test may be used for selection purposes, the analysis was repeated using logistic regression with two pass/fail criteria: a 'minimum criterion' and an 'excellence criterion'. RESULTS: Neither of the two analyses yielded a predictive value of test 1 that was high enough to warrant the use of knowledge tests in the context of entry selection. A 'below minimum' score on test 2 correlated 100% with a 'below minimum' score on test 3. However, the positive predictive value of an above minimum score on test 2 was only 86%. CONCLUSIONS: The knowledge tests used in this study are not suitable in the context of entry selection. However, trainees that score 'below minimum' after eight months of training may be regarded as 'at risk' in that they will probably score 'below minimum' at the end of training.

Factors influencing the growth in knowledge of trainees in general practice.

OBJECTIVES: The relation between the content of postgraduate training for general practice and the outcome in terms of the growth in knowledge of trainees was investigated. The training variables included were: (1) the number of patients seen per day, (2) the trainer, (3) the practice and (4) the theoretical curriculum. METHODS: Subjects were 58 trainee-trainer pairs. Growth in knowledge was assessed by two written tests administered with eight months interval. Training variables were evaluated by means of questionnaires and logbook-registration. The correlation was explored between each of the training variables and the knowledge tests scores. To correct for interactional effects, a step-wise multiple regression analysis was performed with the second test as dependent variable and the first test as well as the training variables as independent variables. RESULTS: Significant growth in knowledge was demonstrated. Non of all training variables investigated explained the variance in scores on the second test equally good or better than the scores on the entry test. CONCLUSIONS: The impact of the separate training-components on the growth in knowledge, remains unclear. We may speculate, that the sort of knowledge assessed with the written literature based true/false test is different from the sort of knowledge transferred during every day training: evidence based knowledge versus experience based knowledge. Equally valid is the conclusion that these findings fit into the theory that in adult learning the outcome is more learner than teacher dependent.

Change in knowledge of general practitioners during their professional careers.

In this study the level of knowledge of general practitioners (GPs) in different stages of their career, from the undergraduate level onwards to more than 20 years after certification, has been investigated. The total body of knowledge as well as the knowledge about different aspects of care was established. Participants were 108 medical students, 445 postgraduate trainees in six different stages of their training and 351 GPs with 5 to more than 20 years of experience. They all took the same written test, designed to assess knowledge closely related to patient care. An increase in test score was found from the start of postgraduate training onwards followed by a decrease starting 5-10 years after certification. The curves for the different aspects of care varied. It is concluded that the body of knowledge of GP-trainees increases during postgraduate training and reaches the level of knowledge of GPs who are less than 10 years certified. From 10 years after certification onwards the knowledge decreases as well as changes over time. The latter had also been found in two American studies relating to the knowledge of certified GPs and internists. The results seem important for the organization and content of postgraduate training and continuous medical education.