Effects of training physicians in electronic prescribing in the outpatient setting on clinical, learning and behavioural outcomes: a cluster randomized trial.

AIMS: Electronic prescribing systems may improve medication safety, but only when used appropriately. The effects of task analysis-based training on clinical, learning and behavioural outcomes were evaluated in the outpatient setting, compared with the usual educational approach. METHODS: This was a multicentre, cluster randomized trial [EDUCATional intervention for IT-mediated MEDication management (MEDUCATE trial)], with physicians as the unit of analysis. It took place in the outpatient clinics of two academic hospitals. Participants comprised specialists and residents (specialty trainees, in the UK) and their patients. Training took the form of a small-group session and an e-learning. The primary outcome was the proportion of medication discrepancies per physician, measured as discrepancies between medications registered by physicians in the electronic prescribing system and those reported by patients. Clinical consequences were estimated by the proportion of patients per physician with at least one missed drug-drug interaction with the potential for causing adverse drug events. A questionnaire assessed physicians' knowledge and skills. RESULTS: Among 124 participating physicians, primary outcome data for 115 (93%) were available. A total of 1094 patients were included. A mean of 48% of registered medications per physician were discrepant with the medications that their patients reported in both groups (P = 0.14). Due to registration omissions, a mean of 4% of patients per physician had one or more missed drug-drug interactions with the potential to cause a clinically relevant adverse drug event in the intervention group, and 7% in controls (P = 0.11). The percentages of correct answers on the knowledge and skills test were higher in the intervention group (57%) compared with controls (51%; P = 0.01). CONCLUSION: The training equipped outpatient physicians with the knowledge and skills for appropriate use of electronic prescribing systems, but had no effect on medication discrepancies.

Improving shared decision-making in a clinical obstetric ward by using the three questions intervention, a pilot study.

BACKGROUND: Shared decision-making (SDM) is an important aspect of modern health care. Many studies evaluated different interventions to improve SDM, however, none in an inpatient clinical setting. A tool that has been proven effective in an outpatient department is the three questions intervention. These questions are created for patients to get optimal information from their medical team and to make an informed medical decision. In this study, we evaluated the feasibility and effectiveness of this simple intervention on SDM in the obstetric inpatient department of a university hospital in the Netherlands. METHOD: This is a clinical pilot before and after study, using mixed methods with quantitative and qualitative data collection. The three questions were stated on a card; (i.e. 1) What are my options; 2) What are the possible benefits and harms of those options; 3) How likely are each of those benefits and harms to happen to me?). The study period lasted 6 weeks in which all patients admitted to the obstetric ward were asked to participate in the study. In the first 3 weeks patients did not receive the three questions intervention (pre-intervention group). In the final 3 weeks all patients included received the intervention (intervention group). The main quantitative outcome measure was the level of SDM measured using the SDM-Q9 questionnaire at discharge (range 0-100). In addition, interviews with four patients of the intervention group were conducted and qualitatively analyzed. RESULTS: Thirty-three patients were included in the pre-intervention group, 29 patients in the intervention group. The mean score of the SDM-Q9 in the pre-intervention group was 65.5 (SD 22.83) and in the intervention group 63.2 (SD 20.21), a not statistically significant difference. In the interviews, patients reported the three questions to be very useful. They used the questions mainly as a prompt and encouragement to ask more specific questions. DISCUSSION: No difference in SDM was found between the two groups, possibly because of a small sample size. Yet the intervention appeared to be feasible and simple to use in an inpatient department. Further studies are needed to evaluate the impact of implementation of these three questions on a larger scale.

Imaging pulsed laser deposition growth of homo-epitaxial SrTiO3 by low-energy electron microscopy.

By combining low-energy electron microscopy with in situ pulsed laser deposition we have developed a new technique for film growth analysis, making use of both diffraction and real-space information. Working at the growth temperature, we can use: the intensity and profile variations of the specular beam to follow the coverage in a layer-by-layer fashion; real-space microscopy to follow e.g. atomic steps at the surface; and electron reflectivity to probe the unoccupied band structure of the grown material. Here, we demonstrate our methodology for homo-epitaxial growth of SrTiO3. Interestingly, the same combination of techniques will also be applicable to hetero-epitaxial oxide growth, largely extending the scope of research possibilities.

Task analysis of information technology-mediated medication management in outpatient care.

AIMS: Educating physicians in the procedural as well as cognitive skills of information technology (IT)-mediated medication management could be one of the missing links for the improvement of patient safety. We aimed to compose a framework of tasks that need to be addressed to optimize medication management in outpatient care. METHODS: Formal task analysis: decomposition of a complex task into a set of subtasks. First, we obtained a general description of the medication management process from exploratory interviews. Secondly, we interviewed experts in-depth to further define tasks and subtasks. SETTING: Outpatient care in different fields of medicine in six teaching and academic medical centres in the Netherlands and the United States. PARTICIPANTS: 20 experts. Tasks were divided up into procedural, cognitive and macrocognitive tasks and categorized into the three components of dynamic decision making. RESULTS: The medication management process consists of three components: (i) reviewing the medication situation; (ii) composing a treatment plan; and (iii) accomplishing and communicating a treatment and surveillance plan. Subtasks include multiple cognitive tasks such as composing a list of current medications and evaluating the reliability of sources, and procedural tasks such as documenting current medication. The identified macrocognitive tasks were: planning, integration of IT in workflow, managing uncertainties and responsibilities, and problem detection. CONCLUSIONS: All identified procedural, cognitive and macrocognitive skills should be included when designing education for IT-mediated medication management. The resulting framework supports the design of educational interventions to improve IT-mediated medication management in outpatient care.

Controlled mechnical modification of manganite surface with nanoscale resolution.

We investigated the surfaces of magnetoresistive manganites, La(1-x)Ca(x)MnO3 and La(2-2x)Sr(1+2x)Mn2O7, using a combination of ultrahigh vacuum conductive, electrostatic and magnetic force microscopy methods. Scanning as-grown film with a metal tip, even with zero applied bias, was found to modify the surface electronic properties such that in subsequent scans, the conductivity is reduced below the noise level of conductive probe microscopy. Scanned areas also reveal a reduced contact potential difference relative to the pristine surface by ∼0.3 eV. We propose that contact-pressure of the tip modifies the electrochemical potential of oxygen vacancies via the Vegard effect, causing vacancy motion and concomitant changes of the electronic properties.

Mechanical control of electroresistive switching.

Hysteretic metal-insulator transitions (MIT) mediated by ionic dynamics or ferroic phase transitions underpin emergent applications for nonvolatile memories and logic devices. The vast majority of applications and studies have explored the MIT coupled to the electric field or temperarture. Here, we argue that MIT coupled to ionic dynamics should be controlled by mechanical stimuli, the behavior we refer to as the piezochemical effect. We verify this effect experimentally and demonstrate that it allows both studying materials physics and enabling novel data storage technologies with mechanical writing and current-based readout.

Dental technology services and industry trends in New Zealand from 2010 to 2012.

OBJECTIVE: To provide a snapshot of the New Zealand dental technology industry and influencing factors. BACKGROUND: Developing an understanding of the commercial dental laboratory environment in New Zealand can provide insight into the entire dental industry. METHODS: A web-based survey was the primary method for data collection, with separate questionnaires used for dental laboratory owners and dental technician employees. RESULTS: The mean net income for dental laboratory owners in New Zealand was similar to that of the United Kingdom, at $40.50 per hour. Clinical dental technicians are the highest paid employees, with a mean of $33.49 per hour. The mean technical charge for complete dentures was $632.59; including clinical services, it was $1907.00. The mean charge for a porcelain-fused-to-metal (PFM) crown was $290.27. Dental laboratory owners expressed fear about the possibility of losing dental clients to overseas laboratories due to the availability and cheap charge of offshore work. Only 25.4% of dental laboratories surveyed had computer-aided design (CAD) facilities, and even fewer (7.9%) had computer-aided manufacturing (CAM) systems. CONCLUSION: Clinical dental technology appears to be prospering. The dental technology industry appears to be adapting and remains viable, despite facing many challenges.

Giant magnetic susceptibility of gold nanorods detected by magnetic alignment.

We have determined the magnetic properties of single-crystalline Au nanorods in solution using an optically detected magnetic alignment technique. The rods exhibit a large anisotropy in the magnetic volume susceptibility (Δχ(V)). Δχ(V) increases with decreasing rod size and increasing aspect ratio and corresponds to an average volume susceptibility (χ(V)), which is drastically enhanced relative to bulk Au. This high value of χ(V) is confirmed by SQUID magnetometry and is temperature independent (between 5 and 300 K). Given this peculiar size, shape, and temperature dependence, we speculate that the enhanced χ(V) is the result of orbital magnetism due to mesoscopic electron trajectories within the nanorods.

Interface-induced room-temperature ferromagnetism in hydrogenated epitaxial graphene.

We show ferromagnetic properties of hydrogen-functionalized epitaxial graphene on SiC. Ferromagnetism in such a material is not directly evident as it is inherently composed of only nonmagnetic constituents. Our results nevertheless show strong ferromagnetism with a saturation of 0.9µ(B)/hexagon projected area, which cannot be explained by simple magnetic impurities. The ferromagnetism is unique to hydrogenated epitaxial graphene on SiC, where interactions with the interfacial buffer layer play a crucial role. We argue that the origin of the observed ferromagnetism is governed by electron correlation effects of the narrow Si dangling bond states in the buffer layer exchange coupled to localized states in the hydrogenated graphene layer. This forms a quasi-three-dimensional ferromagnet with a Curie temperature higher than 300 K.

How patient-centred care relates to patients' quality of life and distress: a study in 427 women experiencing infertility.

BACKGROUND: The aim of this study was to investigate to what extent patients' experiences with fertility care are associated with their quality of life (QoL), and levels of anxiety and depression. METHODS: We performed a cross-sectional questionnaire study within 29 Dutch fertility clinics, including women with fertility problems. Through multilevel regression analyses, associations between patients' QoL (FertiQoL) and distress [anxiety and depression; Hospital Anxiety and Depression Scale (HADS)] and their experiences with fertility care [patient-centredness questionnaire (PCQ)-infertility] were determined. For all multilevel models, R² and intra-cluster correlation coefficients were calculated. RESULTS: This study included 427 non-pregnant patients who filled out the FertiQoL, HADS and PCQ-infertility (response rate 76%). Multilevel regression analysis showed significant associations between the PCQ total scale, the total FertiQoL scale (B = 0.25), and HADS subscales (B = -0.22 and -0.18). Of the variance in patients' experiences, 13% (=R²) could be explained by their perceived QoL, 12% by their level of anxiety and 10% by their level of depression. CONCLUSIONS: Patient-centredness in fertility care and the patients' QoL and anxiety and depression scores are related. Paying attention to these variables could lead to positive care experiences and improved patient-centredness of care. Future research should focus on identifying causal relationships among these variables.

Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL.

BACKGROUND: This study examined the relationship between emotional distress as measured by the Hospital Anxiety and Depression Scale (HADS) and the Fertility Quality of Life (FertiQoL) questionnaire. METHODS: The FertiQoL and HADS were distributed to a random sample of 785 patients attending 29 Dutch clinics for medically assisted reproduction. FertiQoL was psychometrically tested for reliability. Pearson's correlations were calculated between subscales of FertiQoL and HADS. Using an independent t-test, differences between patient subgroups were computed for both instruments. The threshold for clinically meaningful depression/anxiety on the HADS subscales was used to ascertain the critical threshold for high distress on the FertiQoL scales. RESULTS: FertiQoL and HADS were completed by 583 patients (response 74%). Reliability of FertiQoL scales was high (reliability coefficient between 0.72 and 0.91). Significant negative correlations were found between FertiQoL subscales and HADS scores for anxiety and depression, ranging from -0.29 to -0.71. Means on FertiQoL scales and HADS scales of couples undergoing an assisted reproductive technology (ART) treatment and a non-ART treatment did not differ significantly. Patients scoring above the HADS threshold for pathology on anxiety had an average FertiQoL score of 58.8, whereas patients exceeding the HADS depression threshold had a FertiQoL total score of 51.9 (range 0-100). CONCLUSIONS: Our study confirms the expected negative relation between quality of life as measured by FertiQoL and anxiety and depression. The data support that FertiQoL reliably measures QoL in women facing infertility. FertiQoL enables clinicians to tailor care more specifically to the patient in a comprehensive way.

Professionals' perceptions of their patients' experiences with fertility care.

BACKGROUND: Patient-centredness is one of the core dimensions of quality of care. It can be monitored with surveys measuring patients' experiences with care. The objective of the present study was to determine to what extent gynaecologists, physicians specializing in infertility and nurses can estimate the level of patient-centredness of their clinic. METHODS: A random sample of 1189 couples with fertility problems and 194 physicians and nurses from 29 Dutch fertility clinics participated in this cross-sectional study. Differences between patients' experiences with fertility care and professionals' perceptions of these experiences as measured with the patient-centredness questionnaire-infertility (PCQ-infertility) were calculated. The questionnaire's structure, comprising one total scale (level 1), seven subscales (level 2) and 46 single items (level 3), was used as a framework. RESULTS: Response rates were 75% (n = 888) in the patient sample and 83% (n = 160) in the professional sample. Independent sample t-tests, corrected for multiple comparisons with the Bonferroni correction method (P < 0.05), showed no significant differences in mean scores on the total scale of patient-centredness for either professionals or patients. At level 2, professionals underestimated most subscales, namely, 'Accessibility', 'Communication', 'Patient involvement' and 'Competence', whereas 'Continuity of care' was overestimated. Professionals significantly and clinically relevantly misjudged 29 care aspects. CONCLUSIONS: Professionals within fertility care cannot adequately evaluate their performance regarding patient-centredness, and specifically the care aspects to which their own patients attribute the greatest improvement potential. Providing detailed feedback might start improvement of patient-centredness and quality of care.

[Chlamydia mimics suspected ovarian cancer in a 21-year-old patient]. / Chlamydia-infectie imiteert ovariumcarcinoom.

BACKGROUND: The antigen CA125 is mainly known as a tumour marker in ovarian cancer, but may also be elevated in benign gynaecological disorders and non-gynaecological diseases. CASE DESCRIPTION: We examined a 21-year-old patient in the gynaecological oncology outpatient clinic, after she was referred with abnormal ovaries on ultrasound and a significantly elevated CA125. The patient had seen a gynaecologist four weeks earlier because of persistent abdominal pain, deep dyspareunia and vaginal bleeding after insertion of a Mirena IUD that has since been removed. The IUD turned out to be placed in the presence of an undiagnosed STD (Chlamydia), which seems to explain the abnormal ovaries and elevated tumour marker due to pelvic inflammatory disease (PID). CONCLUSION: PID can present atypically resembling ovarian carcinoma. Before inserting an IUD, evaluation of sexual history is essential to estimate the risk of an STI and, if necessary, to perform diagnostics.

Gate-tuned anomalous Hall effect driven by Rashba splitting in intermixed LaAlO3/GdTiO3/SrTiO3.

The Anomalous Hall Effect (AHE) is an important quantity in determining the properties and understanding the behaviour of the two-dimensional electron system forming at the interface of SrTiO3-based oxide heterostructures. The occurrence of AHE is often interpreted as a signature of ferromagnetism, but it is becoming more and more clear that also paramagnets may contribute to AHE. We studied the influence of magnetic ions by measuring intermixed LaAlO3/GdTiO3/SrTiO3 at temperatures below 10 K. We find that, as function of gate voltage, the system undergoes a Lifshitz transition while at the same time an onset of AHE is observed. However, we do not observe clear signs of ferromagnetism. We argue the AHE to be due to the change in Rashba spin-orbit coupling at the Lifshitz transition and conclude that also paramagnetic moments which are easily polarizable at low temperatures and high magnetic fields lead to the presence of AHE, which needs to be taken into account when extracting carrier densities and mobilities.

Elemental composition of imported porcelain-fused-to-metal crowns--a pilot study.

OBJECTIVES: To identify any potentially toxic elements in porcelain-fused-to-metal (PFM) crowns and a bridge manufactured in China. MATERIALS AND METHODS: Eight PFM crowns and part of a bridge were sourced from China for testing. They were given a typical glaze firing cycle prior to scanning electron microscope analysis. Electron dispersive spectroscopic spot and mapping analysis was carried out on the porcelain/metal collar interface areas in order to determine their elemental composition and distribution. RESULTS: No toxic elements were detected. The alloy used in the crowns was a nickel-chromium base metal, and that in the bridge was a gold-palladium noble alloy. The veneering porcelain was similar to a standard dental veneering porcelain. CONCLUSIONS: Within the limitations of the testing method and small sample size, no toxic elements were detected.

Inhomogeneous superconductivity and quasilinear magnetoresistance at amorphous LaTiO3/SrTiO3 interfaces.

We have studied the transport properties of LaTiO3/SrTiO3 (LTO/STO) heterostructures. In spite of 2D growth observed in reflection high energy electron diffraction, transmission electron microscopy images revealed that the samples tend to amorphize. Still, we observe that the structures are conducting, and some of them exhibit high conductance and/or superconductivity. We established that conductivity arises mainly on the STO side of the interface, and shows all the signs of the two-dimensional electron gas usually observed at interfaces between STO and LTO or LaAlO3, including the presence of two electron bands and tunability with a gate voltage. Analysis of magnetoresistance (MR) and superconductivity indicates the presence of spatial fluctuations of the electronic properties in our samples. That can explain the observed quasilinear out-of-plane MR, as well as various features of the in-plane MR and the observed superconductivity.

TGFß-mediated expression of TGFß-activating integrins in SSc monocytes: disturbed activation of latent TGFß?

INTRODUCTION: The pathophysiology of systemic sclerosis (SSc) is closely linked to overactive TGFß signaling. TGFß is produced and circulates in latent form, making its activation crucial for signaling. This activation can be mediated via integrins. We investigated the balance between active and latent TGFß in serum of SSc patients and investigated if this correlates with integrin expression on monocytes. METHODS: A TGFß/SMAD3- or BMP/SMAD1/5-luciferase reporter construct was expressed in primary human skin fibroblasts. Both acidified and non-acidified sera of ten SSc patients and ten healthy controls were tested on these cells to determine total and active TGFß and BMP levels respectively. A pan-specific TGFß1/2/3 neutralizing antibody was used to confirm TGFß signaling. Monocytes of 20 SSc patients were isolated using CD14+ positive selection, and integrin gene expression was measured using qPCR. Integrin expression was modulated using rhTGFß1 or a small molecule inhibitor of TGFBR1: SB-505124. RESULTS: SSc sera induced 50% less SMAD3-reporter activity than control sera. Serum acidification increased reporter activity, but a difference between healthy control and SSc serum was no longer observed, indicating that total TGFß levels were not different. Addition of a pan-specific TGFß1/2/3 neutralizing antibody fully inhibited SMAD3-reporter activity of both acidified and not-acidified control and SSc sera. Both HC and SSc sera induced similar SMAD1/5-reporter activity, and acidification increased this, but not differently between groups. Interestingly, expression of two integrin alpha subunits ITGA5 and ITGAV was significantly reduced in monocytes obtained from SSc patients. Furthermore, ITGB3, ITGB5, and ITGB8 expression was also reduced in SSc monocytes. Stimulation of monocytes with TGFß1 induced ITGA5 and ITGAV but lowered ITGB8 expression, whereas the use of the TGFß receptor inhibitor SB-505124 had the opposite effect. CONCLUSION: Total TGFß serum levels are not different between SSc patients and controls, but TGFß activity is. This coincides with a reduced expression of TGFß-activating integrins in monocytes of SSc patients. Because TGFß regulates expression of these integrins in monocytes, a negative feedback mechanism possibly underlies these observations.

Gene expression profiling in Caco-2 human colon cells exposed to TCDD, benzo[a]pyrene, and natural Ah receptor agonists from cruciferous vegetables and citrus fruits.

Cruciferous vegetables and citrus fruits are reported to possess health-beneficial properties, but also have been shown to contain natural aryl hydrocarbon receptor (AhR) agonists (NAhRAs). Binding to the AhR is widely assumed to activate the main pathway by which dioxins, like 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exert their toxicity. To establish whether or not activation of the AhR pathway by NAhRAs and dioxin-like substances results in similar cellular responses, gene expression profiles induced in Caco-2 cells were studied using microarray analysis. Cells were exposed to indolo[3,2-b]carbazole (ICZ), an acid reaction product from cruciferous vegetables, and to extracts of citrus pulp and grapefruit juice. Gene expression profiles induced by these NAhRAs were compared to those of the xenobiotic AhR agonists TCDD and benzo[a]pyrene (B[a]P). Over 20 genes were found more than 1.5 times up- or down-regulated by TCDD, and the expression of most of these genes was modulated in the same direction and to a similar extent by B[a]P and the NAhRAs. Results were confirmed by RT-PCR, and many of these genes may be involved in dioxin-related toxic effects. In conclusion, this in vitro study showed similar effects induced by NAhRAs, TCDD and B[a]P at the transcriptome level in a human intestinal cell line.

An alternative ICU staffing model: implementation of the non-physician provider.

INTRODUCTION: Literature in Europe regarding implementation of nurse practitioners or physician assistants in the intensive care unit (ICU) is lacking, while some available studies indicate that this concept can improve the quality of care and overcome physician shortages on ICUs. The aim of this study is to provide insight on how a Dutch ICU implemented non-physician providers (NPP), besides residents, and what this staffing model adds to the care on the ICU. METHODS: This paper defines the training course and job description of NPPs on a Dutch ICU. It describes the number and quality of invasive interventions performed by NPPs, residents, and intensivists during the years 2015 and 2016. Salary scales of NPPs and residents are provided to describe potential cost-effectiveness. RESULTS: The tasks of NPPs on the ICU are equal to those of the residents. Analysis of the invasive interventions performed by NPPs showed an incidence of central venous catheter insertion for NPPs of 20 per fulltime equivalent (FTE) and for residents 4.3 per FTE in one year. For arterial catheters the NPP inserted 61.7 per FTE and the residents inserted 11.8 per FTE. The complication rate of both groups was in line with recent literature. Regarding their salary: after five years in service an NPP earns more than a starting resident. CONCLUSION: This is the first European study which describes the role of NPPs on the ICU and shows that practical interventions normally performed by physicians can be performed with equal safety and quality by NPPs.

Interventions to support shared decision-making for women with heavy menstrual bleeding: A systematic review.

This review studies women's preferences for shared decision-making about heavy menstrual bleeding treatment and evaluates interventions that support shared decision-making and their effectiveness. PubMed, Cochrane, Embase, Medline and ClinicalTrials.gov were searched. Three research questions were predefined: 1) What is the range of perspectives gathered in studies that examine women facing a decision related to heavy menstrual bleeding management?; 2) What types of interventions have been developed to support shared decision-making for women experiencing heavy menstrual bleeding?; and 3) In what way might women benefit from interventions that support shared decision-making? All original studies were included if the study population consisted of women experiencing heavy menstrual bleeding. We used the TIDieR (Template for Intervention: Description and Replication) checklist to assess the quality of description and the reproducibility of interventions. Interventions were categorized using Grande et al. guidelines and collated and summarized outcomes measures into three categories: 1) patient-reported outcomes; 2) observer-reported outcomes; and 3) doctor-reported outcomes. Fifteen studies were included. Overall, patients preferred to decide together with their doctor (74%). Women's previsit preference was the strongest predictor for treatment choice in two studies. Information packages did not have a statistically significant effect on treatment choice or satisfaction. However, adding a structured interview or decision aid to increase patient involvement did show a positive effect on treatment choice and results, patient satisfaction and shared decision-making related outcomes. In conclusion shared decision-making is becoming more important in the care of women with heavy menstrual bleeding. Structured interviews or well-designed (computerized) tools such as decision aids seem to facilitate this process, but there is room for improvement. A shared treatment choice is only possible after careful provision of information, elicitation of patients' preferences and integrating those preferences. Interventions should be designed accordingly.