Co-learning and co-teaching in a newly introduced research learning community.

BACKGROUND: Research clerkships are usually designed as individual learning projects focusing on research skills training, such as research design, data analysis and reporting. When the COVID-19 pandemic triggered an urgent need for digital education, we redesigned a research clerkship with the challenging aim to maintain original quality for more students than usual with limited teaching staff. APPROACH: We introduced the concept of a research learning community (RLC) with co-teaching and co-learning to a group of 14 students and seven teaching faculty using digital platforms. Small groups of students participated in the RLC, which was supervised weekly by the teachers. Research experts were continuously involved and led workshops. EVALUATION: Using a qualitative design, we analysed experiences from the perspectives of students and faculty. We performed an inductive thematic content analysis of three focus group interviews and used 14 student reports for triangulation. The results indicate that apart from developing research skills, students valued peer assistance, attention to uncertainty and learning beyond individual research projects. The teachers/research experts reported that co-teaching and co-learning had contributed to their professional development. In terms of organisation, students and faculty recognised that the RLC model allowed for interdisciplinary learning, facilitated by a digital platform. IMPLICATIONS: To develop students' research skills, embedding a clerkship in an RLC is an attractive alternative to individual research clerkships. The obligatory learning goals are met. Co-learning and co-teaching foster faculty's and students' professional development. When translating to other curricula, we recommend stating common goals in addition to individual objectives.

How to coach student professional development during times of challenges and uncertainties.

BACKGROUND: What we teach our (bio)medical students today may differ from the future context under which they will operate as health professionals. This shifting and highly demanding profession requires that we equip these students with adaptive competencies for their future careers. We aimed to develop a framework to promote and facilitate professional development from day one, guided by self-awareness and self-directed learning. APPROACH: Based on self-directed, transformative and experiential learning, patient involvement and teamwork, we developed a 3-year longitudinal personal-professional development (LPPD) program in the (bio)medical sciences undergraduate curriculum to stimulate self-driven professional development in a variable context. Through group meetings and individual coach consultations, students address topics such as self-awareness, self-directed and lifelong learning, collaboration, well-being and resilience. To drive learning students receive extensive narrative feedback on an essay assignment. EVALUATION: Experiences and outcomes were evaluated with questionnaires and in-depth interviews. Students and coaches value personal and professional development in a safe learning environment that encourages self-exploration, diversity and connection. Over time, students show more self-awareness and self-directedness and increasingly apply trained skills, resulting in professional identity formation. Students need more clarification to understand the concept of assessment as learning. IMPLICATIONS: With the generic content of a longitudinal program embedded in a meaningful environment, the personal and professional development of students can be facilitated and stimulated to face future challenges. When translating to other curricula, we suggest considering the complexity of professional development and the time expenditure needed for students to explore, experiment and practice. An early start and thorough integration are recommended.

The teacher as coach: An innovative, longitudinal training for (bio)medical educators.

BACKGROUND: In order to be impactful, to support students to become resilient, adaptive, and collaborative lifelong learning professionals in an ever-changing environment requires the teachers to have a specific set of skills and abilities. Teachers who are not taught these competencies struggle empirically and cannot coach students effectively in the modern professional world. APPROACH: We developed a longitudinal programme for teachers, combining theory and skills training, and performed nine half-day hands-on training modules on campus. Special attention was paid to a common frame of mind, coaching techniques, and dealing with students' emotions and resistance. EVALUATION: All 16 participating teachers indicated their learning goals beforehand and their learning outcomes afterwards. Before and after finishing the course, participants completed a questionnaire in which they evaluated their own evolving coaching competencies. In the next academic year, students of both participants and non-participants evaluated their teachers' coaching competencies. Participants experienced the added value of coaching and understood how to coach. They reported being able to focus on fostering the student's development instead of being knowledge-transferring and advising mentors. Students recognised that coaching teachers (participants) provided less advice and focused more on students' responsibility. IMPLICATIONS: To prepare teachers for coaching students in their professional development, early investment is recommended. A dedicated coach training programme, as outlined by us, can facilitate and stimulate the desired transition from a role-modelling, knowledge-transferring academic teacher, mentor, or adviser to a professional development coaching teacher. When translating to other curricula, we recommend to take into account the adaptation of generic content in the local learning environment.

The effects of methotrexate and hydroxychloroquine combination therapy vs methotrexate monotherapy in early rheumatoid arthritis patients.

Objectives: To investigate the added value of MTX-HCQ combination therapy (CTG) in early RA in a controlled cohort study. MTX monotherapy (MTG) is recommended as (part of) first choice treatment but no head-to-head comparisons are available comparing MTX-HCQ CTG with MTG. Methods: RA patients from the Sint Maartenskliniek and Radboudumc Nijmegen who started MTX with or without concomitant HCQ from April 2010 to October 2015 were included. The primary outcome was the between-group ΔDAS28-CRP at 6 months, and secondary outcomes were ΔDAS28-CRP at 12 months, EULAR response at 6 and 12 months, and treatment intensification. Regression modelling was used to correct for confounding. Results: We included 325 patients, with only small between-group differences at baseline. The DAS28-CRP improvement at 6 months was larger in the CTG (Δ = 0.38 (CI: 0.01, 0.76)), and the difference between groups in DAS28-CRP improvement was smaller at 12 months (Δ = 0.22 points (CI:-0.19, -0.62)). At 6 months, a higher percentage of patients had a good EULAR response in the CTG (Δ = 15% (CI: 2.7%, 27%)). This difference was reduced at 12 months (Δ = 6% (CI -6.4%, 19%)). Treatment intensification with conventional synthetic DMARDs was more likely in the MTG (Δ = 31% (CI: -43%, 19%)). The proportion of patients starting biologic DMARD treatment during the observation period was comparable (Δ = 2% (CI: -8%, 12%)). Discussion: In contrast to indirect comparison review data, MTX-HCQ seems somewhat more effective after 6 months than MTX monotherapy in early RA patients. After 12 months, we observed no significant differences between the two strategies, probably due to treat-to-target efforts.

Discrepancies in how the impact of gout is assessed in outcomes research compared to how health professionals view the impact of gout, using the lens of the International Classification of Functioning, Health and Disability (ICF).

The International Classification of Functioning, Disability and Health (ICF) provides a common language to understand what health means. An ICF core set, a list of ICF categories affected by a certain disease, is useful to objectify the content validity of a health status measurement. This study aims to identify the potential items of a gout specific 'ICF core set'. A three-round Delphi exercise was conducted, using web-based questionnaires. Health professionals, specialized in gout, nominated and subsequently rated the relevance of life areas divided into ICF categories. Agreement was determined by using the UCLA/RAND criteria. Simultaneously, a systematic review of gout measure outcomes was conducted. The results of these studies were compared using the second level of the ICF categories. In the Delphi study, consensus was found for 136 relevant ICF categories. The literature study extracted 134 different ICF categories in 149 articles. Three hundred and ten were non-defined outcomes. A large number of ICF categories were deemed to be relevant for people with gout. Only 29.7 % (19/64) of the level 2 categories, deemed to be relevant by health professionals, had been assessed as relevant in at least 5 % of gout outcome studies. Conversely, 70 % (19/27) of level 2 ICF categories assessed in at least 5 % of outcome studies were deemed relevant by health professionals. These ICF codes, which are found relevant in both studies, should be considered as mandatory in further research to a validated and practical core set of ICF categories. Published gout outcomes research fails to evaluate many life areas that are thought relevant by health professionals.

Personalizing treatment targets in rheumatoid arthritis by using a simple prediction model.

OBJECTIVE: To develop a personalized treatment target approach in patients with rheumatoid arthritis (RA) based on baseline risk factors for joint damage progression in combination with disease activity over time. METHODS: Data were used from the Nijmegen early RA cohort. Presence or absence of anticyclic citrullinated peptide antibodies (anti-CCP), high erythrocyte sedimentation rate, and erosions were translated into 4 risk profiles: 0, 1, 2, and 3. Joint damage progression was assessed with the Ratingen score, and disease activity with the original Disease Activity Score (DAS) over 3 years. The probability for joint damage progression was calculated for each risk profile and each DAS category using logistic regression models. The probabilities were translated into personalized disease activity treatment targets. RESULTS: More risk factors at baseline as well as a higher DAS level resulted in a higher probability for joint damage progression in a dose-dependent way. Low DAS corresponded with a probability of 0.0, 0.08, 0.20, and 0.58 in patients with 0, 1, 2, and 3 risk factors, respectively. Moderate DAS corresponded with a probability of 0.06 in patients with 0 risk factors and 0.35 with 1 risk factor. High DAS resulted in a probability of 0.50 with no risk factors present at baseline. CONCLUSION: Presence of anti-CCP, acute-phase response, and erosions at baseline can be used to set individual treatment targets in RA. In patients without these risk factors, a moderate DAS as a target is sufficient, while for patients with all 3 risk factors, a low DAS is not strict enough to limit the risk for joint damage.

[Systemic sclerosis: a multisystem disease]. / Systemische sclerose: multisysteemaandoening.

Systemic sclerosis is a rare, systemic autoimmune disease, characterized by inflammation, vasculopathy and fibrosis of the skin and internal organs. The disease is associated with a significantly increased morbidity and mortality, and can be rapidly progressive. Interstitial lung disease, renal hypertensive crisis, cardiac involvement and pulmonary arterial hypertension are life-threatening complications. Early treatment with immunosuppressive drugs can prevent progression and decrease morbidity and mortality.

Hepcidin and hemoglobin content parameters in the diagnosis of iron deficiency in rheumatoid arthritis patients with anemia.

OBJECTIVE: To explore the utility of the novel iron indices hepcidin, reticulocyte hemoglobin content (Ret-Hgb), and erythrocyte (red blood cell) hemoglobin content (RBC-Hgb) for detection of iron deficiency in rheumatoid arthritis (RA) patients with anemia and active inflammation and to compare these indices with conventional parameters of iron deficiency. METHODS: Blood samples from 106 outpatients with RA were analyzed in a cross-sectional exploratory study. Forty patients were classified as having either iron deficiency anemia (IDA), anemia of chronic disease (ACD), their combination (IDA/ACD), or "other anemia" based on biochemical parameters for inflammation and iron deficiency. The ability of serum and urine hepcidin, Ret-Hgb, and RBC-Hgb measurement to discriminate among these states was evaluated. RESULTS: Hepcidin content in serum from patients in the IDA group as well as that from patients in the combined IDA/ACD group differed significantly from that in serum from patients in the ACD group. This difference was also observed with hepcidin in urine, Ret-Hgb, and RBC-Hgb, although with less significance. The area under the receiver operating characteristic curve for serum hepcidin was 0.88 for the comparison of IDA/ACD patients with ACD patients and 0.92 for the comparison of the combined IDA group and IDA/ACD group to all other patients with anemia. Hepcidin at <2.4 nmoles/liter had a sensitivity of 89% and a specificity of 88% to distinguish IDA/ACD from ACD. Both Ret-Hgb and RBC-Hgb measurements also allowed differentiation between these latter groups, with a sensitivity of 67% and 89%, respectively, and a specificity of 100% and 75%, respectively. CONCLUSION: Serum hepcidin and, to a lesser extent, urine hepcidin, Ret-Hgb, and RBC-Hgb, are potential useful indicators for detecting iron deficiency in RA patients with anemia and active inflammation.

Immunochemical and mass-spectrometry-based serum hepcidin assays for iron metabolism disorders.

BACKGROUND: Hepcidin is an iron-regulatory peptide hormone that consists of 3 isoforms: bioactive hepcidin-25, and inactive hepcidin-22 and hepcidin-20. Hepcidin is instrumental in the diagnosis and monitoring of iron metabolism disorders, but reliable methods for its quantification in serum are sparse, as is knowledge of their relative analytical strengths and clinical utility. METHODS: We developed a competitive (c)-ELISA and an immunocapture TOF mass-spectrometry (IC-TOF-MS) assay. Exploiting these 2 methods and our previously described weak cation exchange (WCX)-TOF-MS assay, we measured serum hepcidin concentrations in 186 patients with various disorders of iron metabolism and in 23 healthy controls. RESULTS: We found that (a) the relative differences in median hepcidin concentrations in various diseases to be similar, although the absolute concentrations measured with c-ELISA and WCX-TOF-MS differed; (b) hepcidin isoforms contributed to differences in hepcidin concentrations between methods, which were most prominent in patients with chronic kidney disease; and (c) hepcidin concentrations measured by both the c-ELISA and IC-TOF-MS correlated with ferritin concentrations <60 µg/L, and were suitable for distinguishing between iron deficiency anemia (IDA) and the combination of IDA and anemia of chronic disease. CONCLUSIONS: c-ELISA is the method of choice for the large-scale quantification of serum hepcidin concentrations, because of its low limit of detection, low cost, and high-throughput. Because of its specificity for bioactive hepcidin-25, WCX-TOF-MS can be regarded as a valuable special-purpose assay for disorders with variable concentrations of hepcidin isoforms, such as chronic kidney disease.

Etanercept-related extensive pulmonary nodulosis in a patient with rheumatoid arthritis.

OBJECTIVE: Although nodulosis is a common extraarticular manifestation of rheumatoid arthritis, accelerated pulmonary nodulosis is a rare event. The etiology of rheumatoid nodules is still unknown. Nodulosis is not necessarily associated with active joint inflammation, suggesting different pathogenic mechanisms for nodule formation and synovial tissue inflammation. We describe a patient with extensive pulmonary nodulosis, probably related to etanercept treatment. Our case emphasizes the need for careful monitoring for adverse events during treatment with biologicals, especially since the differential diagnosis often includes a broad spectrum of diseases.

Economic evaluation of folate supplementation during methotrexate treatment in rheumatoid arthritis.

OBJECTIVE: To determine cost-effectiveness of folic or folinic acid supplementation in patients with rheumatoid arthritis (RA) who started methotrexate (MTX) treatment. METHODS: An economic evaluation, performed alongside a randomized, double blind, placebo controlled trial with followup of 48 weeks. Patients started MTX with placebo (n = 137), folic acid (n = 133), or folinic acid (n = 141). Outcome measures were drug survival and quality-adjusted life-years (QALY), measured with the EuroQol questionnaire. Both medical and nonmedical costs were analyzed. RESULTS: Drug survival after 48 weeks was 60% for placebo, 81% for folic acid, and 87% for folinic acid. QALY during a 48 week period were 0.55 (95% CI 0.52-0.58) in the placebo group, 0.55 (95% CI 0.52-0.58) in the folic acid group, and 0.58 (95% CI 0.56-0.60) in the folinic acid group. Mean medical costs were 1398 US dollars (placebo), 1409 US dollars (folic acid), and 1776 US dollars (folinic acid). Mean total costs were 3339 US dollars, 3632 US dollars, and 3296 US dollars, respectively. CONCLUSION: In terms of resource deployment, no statistically significant difference was found between the 3 strategies. The preferred strategy consists of folic acid supplementation because of improved drug survival.