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Contains fulltext : 293465.pdf (Publisher’s version ) (Open Access) INTRODUCTION: Medical students regularly transition between clerkships. These transitions can lead to discontinuity in their development because of the need to adapt to a new environment. The use of entrustable professional activities (EPAs) might facilitate less disruptive transitions across clerkships, as they could provide support at the start of a clerkship. This study aims to shed light on how an EPA-based curriculum contributes to medical students' learning processes during transitions. METHODS: The authors used a constructivist rapid ethnographic design. They conducted observations and interviews with 11 medical students in their Pediatrics clerkship; six of them were in clerkships not utilizing EPAs, and five were using EPAs. Data collection was followed by template analysis such that all data were coded with a template that was continually updated until the authors all agreed upon a definitive template. RESULTS: Four themes proved important when considering the impact of EPAs during transitions between clerkships: transitions as a learning opportunity, building relationships in context, taking leadership in the landscape of practice and feedback-seeking behavior. DISCUSSION: EPAs smooth clerkship transitions, as they establish continuity in the student's development and facilitate navigating discontinuity in transitions. Students build skills and confidence in order to grow and work with increasing independence within the clerkships. Transitions offer important learning opportunities for students, which can be fully exploited by using EPA guidance.

Supplemental Digital Content is available in the text., Purpose Although shared decision making (SDM) is considered the preferred approach in medical decision making, it is currently not routinely used in clinical practice. To bridge the transfer gap between SDM training and application, the authors aimed to reach consensus on entrustable professional activities (EPAs) for SDM and associated behavioral indicators as a framework to support self-directed learning during postgraduate medical education. Method Using existing literature on SDM frameworks and competencies; input from an interview study with 17 Dutch experts in SDM, doctor–patient communication, and medical education; and a national SDM expert meeting as a starting point, in 2017, the authors conducted a modified online Delphi study with a multidisciplinary Dutch panel of 32 experts in SDM and medical education. Results After 3 Delphi rounds, consensus was reached on 4 EPAs—(1) the resident discusses the desirability of SDM with the patient, (2) the resident discusses the options for management with the patient, (3) the resident explores the patient’s preferences and deliberations, and (4) the resident takes a well-argued decision together with the patient. Consensus was also reached on 18 associated behavioral indicators. Of the 32 experts, 30 (94%) agreed on this list of SDM EPAs and behavioral indicators. Conclusions The authors succeeded in developing EPAs and associated behavioral indicators for SDM for postgraduate medical education to improve the quality of SDM training and the application of SDM in clinical practice. These EPAs are characterized as process EPAs for SDM in contrast with content EPAs related to diverse medical complaints. A next step is the implementation of the SDM EPAs in existing competency-based workplace curricula.

ObjectiveTo develop a valid and reliable tool to measure triadic decision making between older adults with multiple chronic conditions (MCC), their informal caregivers and geriatricians.MethodsVideo observational study with cross-sectional assessment of interaction during medical consultations between geriatricians (n = 10), patients (n = 108) and informal caregivers (68) by three calibrated raters at the geriatric outpatient department of two Dutch hospitals.The Observer OPTIONMCC instrument was developed, based on the 'Dynamic model of SDM in frail older patients' and the 'Observing Patient Involvement in Decision Making - 5 item scale' (Observer OPTION-5).ResultsFactor analysis confirms that it is acceptable to regard the new scale as a single construct. The 7-item single factor solution explained 62.76% of the variability for geriatricians, 61.60% of the variability for patients and 54.32% of the variability for informal caregivers. The inter-rater ICC for the total Observer OPTIONMCC score was .96, .96, and .95 (resp. geriatricians, patients, informal caregivers), with values ranging from .60 to .95 for individual items, showing good levels of agreement.Conclusion and Practice ImplicationsWe conclude that Observer OPTIONMCC is sufficiently valid and reliable to be used for the assessment of triadic SDM in populations of older patients with MCC.

Background Shared decision making (SDM) contributes to personalized decisions that fit the personal preferences of patients when choosing a treatment for a condition. However, older adults frequently face multiple chronic conditions (MCC). Therefore, implementing SDM requires special features. The aim of this paper is to describe the development of an intervention to improve SDM in older adults with MCC. Methods Following the Medical Research Council framework for developing complex interventions, the SDMMCC intervention was developed step-wise. Based on a literature review and empirical research in a co-creation process with end users, we developed training for geriatricians and a preparatory tool for older patients with MCC and informal caregivers. After assessing feasibility, the intervention was implemented in a pilot study (N = 108) in two outpatient geriatric clinics of an academic and a non-academic teaching hospital in Amsterdam, the Netherlands. Results Key elements of the training for geriatricians include developing skills to involve older adults with MCC and informal caregivers in SDM and following the six-step ‘Dynamic model for SDM with frail older patients’, as well as learning how to explore personal goals related to quality of life and how to form a partnership with the patient and the informal caregiver. Key elements of the preparatory tool for patients include an explicit invitation to participate in SDM, nomination that the patient’s own knowledge is valuable, invitation to form a partnership with the geriatrician, encouragement to share information about daily and social functioning and exploration of possible goals. Furthermore, the invitation of informal caregivers to share their concerns was also a key element. Conclusions Through a process of co-creation, both training for geriatricians and a preparatory tool for older adults and their informal caregivers were developed, tailored to the needs of the end users and based on the ‘Dynamic model of SDM with frail older patients’.

Contains fulltext : 220901.pdf (Publisher’s version ) (Open Access) OBJECTIVES: Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care. DESIGN: A single-blinded cluster randomized controlled trial. SETTING AND PARTICIPANTS: In 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged ≥65 years at any stage and with any type of dementia, from their practice. METHODS: Intervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering. RESULTS: 38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P = .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P = .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P

Goede toepassing van Evidence Based Medicine (EBM) bestaat uit het wegen van de best beschikbare evidence, de wensen en voorkeuren van de patient en de klinische expertise van de arts. In de praktijk worden ouderen echter vaak uitgesloten van deelname aan wetenschappelijke studies en is er vaak sprake van multimorbiditeit, hetgeen het toepassen van EBM bemoeilijkt. Gezamenlijke besluitvorming (SDM), een proces waarbij hulpverlener en patient samen tot een passende behandeling komen kan helpen om EBM voor deze groep patienten vorm te geven.

Older people form a very diverse group with large differences in their preferred communication styles. Respect for the older person, his choices, and autonomy is the fundamental attitude underlying person-centered communication. Communication often starts with history taking. It depends largely on the patient characteristics and circumstances how to obtain a medical history. Discussing patient goals and wishes should be an integral part of history taking and assessment and form the root of person-centered communication.

Contains fulltext : 190717.pdf (Publisher’s version ) (Open Access) Geriatrics continues to draw insufficient numbers of medical students today. Currently, little is known regarding how education can motivate students to choose geriatrics. The authors' aim was to examine geriatrics from the students' perspective to identify elements that can be useful in education and improving attitudes toward, interest in, and knowledge about geriatrics. The authors analyzed narrative reflection essays of 36 students and clarified the themes from the essays during focus group sessions. Four overarching themes that influenced students' perspective on geriatrics were identified: professional identity, perception of geriatrics, geriatric-specific problems, and learning environment. Students have an inaccurate image of clinical practice and the medical professional identity, which has a negative impact on their attitude toward, interest in, and knowledge of geriatrics. Furthermore, this study yielded the important role of the hidden curriculum on professional identity, the novelty of geriatric-specific problems to students, and the importance of educational approach and good role models.

In frail older patients, an atypical disease presentation such as a sudden mobility problem or hyperactivity in delirium is often the only signal that a new disease episode occurred. Classical signals of disease may be lacking completely. In fact, atypical symptoms are the most typical characteristics of geriatric patients and urge for a comprehensive geriatric assessment (CGA) to find the causes. Frailty causes close interactions between organs with decreased physiological reserve. The atypical symptoms originate from the individual patient’s most frail organ, which is closely linked to the ill or stressed organ at which the disease episode started. Atypical symptoms mostly have a multifactorial causality with a recent precipitating factor, also called acute geriatric syndromes or geriatric giants. Similarly, more chronic atypical presentations may result in chronic geriatric syndromes, such as malnutrition or cognitive decline. The chapter closes with general guidelines on how to apply evidence-based medicine (EBM) and shared decision-making (SDM) to frail older adults with their complex multicausality and varying treatment wishes.

Contains fulltext : 153775.pdf (Publisher’s version ) (Closed access) BACKGROUND: In recent years, primary health care for the ageing population has become increasingly complex. AIM: This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people. DESIGN AND SETTING: This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands. METHOD: All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached. RESULTS: Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another's perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: 'autonomy and independence', 'organisational barriers', and 'professional expertise'. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals. CONCLUSION: Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements.

Evidence based medicine (EBM) is the integration of the best research evidence, clinical expertise and patient values in the decision making process for patient care. However, elderly people are often excluded from participating in scientific studies and they often have multiple morbidities, which complicates the application of EBM. Shared decision making (SDM), a process where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve appropriate treatment can help to shape EBM for this group of patients.In this article, we provide tools for finding relevant literature for the geriatric patient population and for shaping the SDM process to achieve personalized care.

Contains fulltext : 177946.pdf (Publisher’s version ) (Open Access) This study has two aims: The first aim is to identify core competencies for shared decision making (SDM) with frail older persons, and the second is to determine key elements of a teaching framework, based on the authors' recently developed model for SDM with older patients who are frail. To this end the authors conducted a qualitative inquiry among health professionals (n = 53) and older patients who are frail (n = 16). Participants formulated core competencies and educational needs for SDM with older patients who are frail, which were further explored in the literature. This resulted in practice recommendations and a teaching framework with the following key elements: create a knowledge base for all health professionals, offer practical training, facilitate communication, identify discussion partners, engage patients, and collaborate. The authors' teaching framework for SDM with older patients who are frail may be useful for clinicians, educators, and researchers who aim to promote SDM with older patients who are frail.

Shared decision making (SDM) contributes to personalised decisions that fit the personal preferences of patients. However, older adults frequently face multiple chronic conditions (MCC). Therefore, implementing SDM requires special features. The aim of this paper is to describe the development of an intervention to improve SDM in older adults with MCC. Following the Medical Research Council framework for developing complex interventions, the SDMMCC intervention was developed step-wise. Based on a literature review and empirical research we developed in a co-creation process with the end-users a training for geriatricians and a preparatory tool for older patients with MCC and informal caregivers. After assessing feasibility the intervention was implemented at two outpatient geriatric clinics in a pilot study (N=108). Key elements of the training for geriatricians include: developing skills how to involve older adults with MCC and informal caregivers in SDM and learning how to explore personal goals related to quality of life. Key elements of the preparatory tool for patients include: an explicit invitation to participate in SDM, nomination that the patient’s own knowledge is valuable, invitation to form a partnership with the geriatrician, encouragement to share information about daily and social functioning and exploration of possible goals. Furthermore, invitation of informal caregivers to share their concerns. Through a process of co-creation both a training for geriatricians and a preparatory tool for older adults and their informal caregivers were developed, tailored to the needs of the end-users and based on the ‘Dynamic model of SDM with frail older adults’.

Alopecia androgenetica komt bij 80% van de blanke mannen voor, maar vroeg kaal worden kan leiden tot psychische klachten en significante lijdensdruk. In die gevallen is finasteride (dosering 1 mg) het meestvoorgeschreven medicament. De auteurs doorzochten de literatuur om het effect van het middel na te gaan. Hun conclusie: finasteride heeft een positief effect, maar onafhankelijk langetermijnonderzoek naar het middel ontbreekt en finasteride heeft ook nadelen.

Contains fulltext : 167790.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Shared decision-making (SDM) is widely recommended as a way to support patients in making healthcare choices. Due to an ageing population, the number of older patients will increase. Existing models for SDM are not sufficient for this patient group, due to their multi-morbidity, the lack of guidelines and evidence applicable to the numerous combinations of diseases. The aim of this study was to gain consensus on a model for SDM in frail older patients with multiple morbidities. METHODS: We used a three-round Delphi study to reach consensus on a model for SDM in older patients with multiple morbidities. The expert panel consisted of 16 patients (round 1), and 59 professionals (rounds 1-3). In round 1, the SDM model was introduced, rounds 2 and 3 were used to validate the importance and feasibility of the SDM model. RESULTS: Consensus for the proposed SDM model as a whole was achieved for both importance (91% panel agreement) and feasibility (76% panel agreement). CONCLUSIONS: SDM in older patients with multiple morbidities is a dynamic process. It requires a continuous counselling dialogue between professional and patient or proxy decision maker. PRACTICE IMPLICATIONS: The developed model for SDM in clinical practice may help professionals to apply SDM in the complex situation of the care for older patients.

Item does not contain fulltext Given the increasingly aging population, nearly every doctor will encounter elderly adults who present with multiple complex comorbidities that can challenge even experienced physicians. This may explain why many medical students do not have a positive attitude toward elderly adults and find the complexity of their problems overwhelming. It was hypothesized that a recently developed medical school geriatrics course, based on the game GeriatriX and designed specifically to address the complexities associated with decision-making in geriatrics, can have a positive effect on attitudes toward geriatrics and on perceived knowledge of geriatrics. The effects of this game-based course were evaluated as a proof of concept. The assessment was based on the Aging Semantic Differential (ASD) and a validated self-perceived knowledge scale of geriatric topics. The usability of (and satisfaction with) GeriatriX was also assessed using a 5-point Likert scale. After completion of the course, the ASD changed significantly in the geriatrics course group (n = 29; P = .02) but not in a control group that took a neuroscience course (n = 24; P = .30). Moreover, the geriatrics course group had a significant increase in self-perceived knowledge for 12 of the 18 topics (P = .002), whereas in the control group self-perceived knowledge increased significantly for one topic only (sensory impairment) (P = .04). Finally, the geriatrics students reported enjoying GeriatriX. This proof-of-concept study clearly supports the hypothesis that a 4-week course using a modern educational approach such as GeriatriX can improve students' self-perceived knowledge of geriatrics and their attitudes toward elderly adults. 7 p.

Contains fulltext : 138484.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Medical students often lack training in complex geriatric medical decision making. We therefore developed the serious game, GeriatriX, for training medical decision making with weighing patient preferences, and appropriateness and costs of medical care. We hypothesized that education with GeriatriX would improve the ability to deal with geriatric decision making and also increase cost consciousness. DESIGN: A randomized, controlled pre-post measurement design. PARTICIPANTS: Fifth-year medical students. INTERVENTION: Playing the serious game GeriatriX as an additive to usual geriatric education. MEASUREMENTS: We evaluated the effects of playing GeriatriX on self-perceived knowledge of geriatric themes and the self-perceived competence of weighing patient preferences, appropriateness, and costs of medical care in geriatric decision making. Cost consciousness was evaluated with a postmeasurement to estimate costs of different diagnostic tests. RESULTS: There was a large positive increase in the self-perceived competence of weighing patient preferences, appropriateness, and costs of medical care in the intervention group (n = 71) (effect sizes of 0.7, 1.0, and 1.2, respectively), which was significantly better for the last 2 aspects than in the control group (n = 63). The intervention group performed better on cost consciousness. Although the self-perceived knowledge increased substantially on some geriatric topics, this improvement was not different between the intervention and control groups. CONCLUSIONS: After playing the serious game, GeriatriX, medical students have a higher self-perceived competence in weighing patient preferences, appropriateness, and costs of medical care in complex geriatric medical decision making. Playing GeriatriX also resulted in better cost consciousness. We therefore encourage wider use of GeriatriX to teach geriatrics in medical curricula and its further research on educational and health care outcomes.

Contains fulltext : 48447.pdf (Publisher’s version ) (Closed access) Systemic inflammation may be present in patients with chronic obstructive pulmonary disease (COPD). Exercise is known to elicit an inflammatory response. We hypothesized that the systemic inflammatory response to exercise might be exaggerated in COPD patients compared to healthy subjects. Sixteen COPD patients and 11 healthy subjects performed a maximal incremental bicycle test. Before and at maximal exercise arterial blood samples were taken to determine circulating catecholamines, (subsets of) leukocytes, acute phase proteins, creatine kinase and myoglobin. At rest, increased levels of norepinephrine and systemic inflammation were present in COPD. The response of catecholamines to exercise was lower in COPD patients (P

DDAVP-frusemide test revealed that the release of AQP2 into urine is not caused by hypertonicity of Background. It has been suggested that urinary excre- tion of the vasopressin-dependent water channel of the tubular fluid. kidney collecting duct, aquaporin-2 (AQP2), reflects Keywords: aquaporin-2; osmolality; urinary excretion; renal vasopressin action and might be used clinically. vasopressin; volunteers It is unclear, however, what relation exists between urine osmolality and urinary excretion of AQP2 ( UAQP2) and it is unknown whether UAQP2 is influenced by hyperosmolality of urine or tubular Introduction flow rates. Methods. We measured urine osmolality and UAQP2 Homeostasis of the body osmolality is partly governed in healthy volunteers in various conditions: (i) over- by water reabsorption through aquaporin-2 (AQP2), night dehydration continued during the day, (ii) after the vasopressin (AVP)-dependent water channel, pre- infusion of 700 ml hypertonic saline (NaCl 2.5%), and sent in cells of the cortical and medullary collecting (iii) after intranasal administration of 40 mg ducts (1,2). Binding of AVP to the basolaterally located 1-desamino-8--arginine vasopressin (DDAVP). The AVP receptor ( V-2) of these cells leads to formation last two tests were performed after water loading. In of 3∞,5∞-cyclic adenosine monophosphate (cAMP), addition, a DDAVP test was performed, after adminis- which triggers the fusion of subapically located tration of frusemide. AQP2-containing vesicles with the apical membrane, Results. After overnight dehydration, the urine osmol- resulting in water reabsorption through the cell (3) if ality increased from 888±18 to 1004±17 mosmol/kg a favourable osmotic gradient is present. Patients with during additional hours of thirsting, whereas UAQP2 inactivating mutations in either the V-2 receptor or the doubled from 140±45 to 285±63 fmol AQP2/mmol AQP2 gene present with severe nephrogenic diabetes creatinine. Infusion of hypertonic saline increased urine insipidus (NDI ), which reflects the importance of the osmolality from 70±3 to 451±68 mosmol/kg, while V-2 receptor and AQP2 in the water balance of humans UAQP2 remained almost zero. Urine osmolality (4,5). In addition, acquired forms of NDI can be increased from 101±17 to 860±30 mosmol/kg after caused by various drugs. Lithium, for instance, a administration of DDAVP, with a parallel increase in widely used treatment for bipolar affective disorders, UAQP2 from 32±14 to 394±81 fmol AQP2/mmol often causes NDI after prolonged use. It has been creatinine. Pre-treatment with frusemide attenuated demonstrated previously that AQP2 is detectable in the increase in urine osmolality, but had no effect on urine and that its excretion increases in response to UAQP2 after DDAVP. AVP (6-8). Two possible explanations for the release Conclusions. Our data demonstrate that a simple rela- of AQP2 into urine have been postulated: first, osmotic tionship between urine osmolality and UAQP2 does stress on collecting duct cells during antidiuresis could not exist. Therefore, random or once-only measure- cause lysis of these cells, thus releasing AQP2 into the ments of UAQP2 as an index of renal vasopressin urine; second, secretion or exocytosis of AQP2 molec- action are not useful. In contrast, intranasal application ules with or without apical membrane fragments upon of DDAVP resulted in a parallel rise in urine osmolality AVP action could explain urinary excretion of AQP2. and UAQP2. Therefore this test might be useful in Although the mechanism of AQP2 excretion in urine studying patients with urine concentration defects. The remains to be identified, it has been suggested that

PEARLS bieden de lezer bruikbare wetenschap voor de werkvloer, op basis van de Cochrane Database of Systematic Reviews. De coordinatie is in handen van dr. F.A. van de Laar, Cochrane Primary Health Care Field, UMC St Radboud Nijmegen. Correspondentie: f.vandelaar@elg.umcn.nl onderzoeker, kaderhuisarts ouderengeneeskunde Correspondentie huisarts, onderzoeker kaderhuisarts ouderengeneeskunde Correspondentie