Search

Background: In the Netherlands, general practitioners (GPs) play a key role in provider-initiated HIV testing, but opportunities for timely diagnosis are regularly missed. We implemented an educational intervention to improve HIV testing by GPs from 2015 to 2020, and observed a 7% increase in testing in an evaluation using laboratory data. The objective for the current study was to gain a deeper understanding of whether and how practices and perceptions of GPs' HIV/sexually transmitted infection (STI) testing behaviour changed following the intervention. Methods: We performed a mixed-methods study using questionnaires and semi-structured interviews to assess self-reported changes in HIV/STI testing by participating GPs. Questionnaires were completed by participants at the end of the final educational sessions from 2017 through 2020, and participating GPs were interviewed from January through March 2020. Questionnaire data were analysed descriptively, and open question responses were categorised thematically. Interview data were analysed following thematic analysis methods. Results: In total, 101/103 participants completed questionnaires. Of 65 participants that were included in analyses on the self-reported effect of the programme, forty-seven (72%) reported it had changed their HIV/STI testing, including improved STI consultations, adherence to the STI consultation guideline, more proactive HIV testing, and more extragenital STI testing. Patients' risk factors, patients' requests and costs were most important in selecting STI tests ordered. Eight participants were interviewed and 15 themes on improved testing were identified, including improved HIV risk-assessment, more proactive testing for HIV/STI, more focus on HIV indicator conditions and extragenital STI testing, and tools to address HIV during consultations. However, several persistent barriers for optimal HIV/STI testing by GPs were identified, including HIV-related stigma and low perceived risk. Conclusions: Most GPs reported improved HIV/STI knowledge, attitude and testing, but there was a discrepancy between reported changes in HIV testing and observed increases using laboratory data. Our findings highlight challenges in implementation of effective interventions, and in their evaluation. Lessons learned from this intervention may inform follow-up initiatives to keep GPs actively engaged in HIV testing and care, on our way to zero new HIV infections. [ABSTRACT FROM AUTHOR]

Background: In Western countries, better knowledge about patient-related determinants of treatment adherence (medication and lifestyle) is needed to improve treatment adherence and outcomes among hypertensive ethnic minority patients of African descent. Objective: To identify patient-related determinants of adherence to lifestyle and medication recommendations among hypertensive African Surinamese and Ghanaian patients with suboptimal treatment results (SBP≥140) living in the Netherlands and how culturally appropriate hypertension education (CAHE) influenced those determinants. Methods: This study analysed data of 139 patients who participated in the CAHE trial. Univariate logistic regression analysis was used to measure the association between patient-related determinants (medication self-efficacy, beliefs about medication and hypertension, social support, and satisfaction with care) and treatment adherence. We also tested whether CAHE influenced the determinants. Results: Medication self-efficacy and social support were associated with medication adherence at baseline. At six months, more medication self-efficacy and fewer concerns about medication use were associated with improved medication adherence. Self-efficacy was also associated with adherence to lifestyle recommendations at baseline. CAHE influenced patients’ illness perceptions by creating more understanding of hypertension, its chronic character, and more concerns about the associated risks. Conclusion: In this high-risk population, health care providers can support medication adherence by paying attention to patients’ medication self-efficacy, the concerns they may have about medication use and patients’ perceptions on hypertension. The CAHE intervention improved patients’ perception on hypertension. [ABSTRACT FROM AUTHOR]

Patients with Marfan syndrome have a tall stature, which could be associated with low orthostatic tolerance. Fatigue, a common complaint of these patients, is also related to orthostatic intolerance. Treatment with beta-blockers, to prevent aortic complications, could be a reinforcing factor of both. This study aimed to investigate (1) the relationship between symptoms of orthostatic tolerance and in patients with Marfan syndrome, and (2) whether termination of beta-blocker therapy improves orthostatic tolerance. Symptoms of fatigue and orthostatic complaints were assessed in 49 subjects using questionnaires (MFI-20 and Autonomic Symptoms Profile). Marfan patients have a high level of fatigue and orthostatic complaints when compared to the general population. Fatigue and orthostatic tolerance are significantly correlated. Orthostatic tolerance was assessed in 9 additional subjects by an active-standing test and head-up tilt for 5 minutes, and 24 hours blood pressure monitoring, once during beta-blocker therapy and once after ceasing beta-blockers for 2 weeks. During hemodynamic testing Marfan patients frequently showed Initial Orthostatic Hypotension and an abnormally high initial heart rate response. Ceasing beta-blockers did not affect the initial blood pressure response. Patients with Marfan syndrome are fatigued and have low orthostatic tolerance, which are significantly correlated. Patients could be educated in physical counterpressure maneuvers to increase orthostatic tolerance. [ABSTRACT FROM AUTHOR]

The clinical history is the cornerstone of diagnosing patients with transient loss of consciousness (TLOC). Reflex syncope is the most common cause of TLOC in patients across all ages. Knowledge of the variation in incidence and clinical features of reflex syncope by age and gender provides important background information to acquire an accurate diagnosis. In a cohort of 503 patients presenting with TLOC we established a final diagnosis after systematic evaluation and two years of follow-up. The occurrence of prodromal signs, symptoms, and triggers in patients with reflex syncope was analyzed by both age (< 40 yrs, 40–59 yrs and ≥ 60 years) and gender. Reflex syncope was the most frequently obtained diagnosis (60.2%) in patients of all ages presenting with TLOC. Its occurrence was higher in patients under 40 years (73.4%), than above 60 years of age (45.3%). Pallor (79.9%), dizziness (73.4%), and diaphoresis (63.0%) were the most frequently reported prodromal signs and symptoms. Most triggers and prodromal signs and symptoms were more common in patients under 40 years of age and in women. Reflex syncope is nearly twice as common in patients under 40 years of age than in patients aged 60 years or above. Typical signs and symptoms of reflex syncope are more common in younger patients and in women. Therefore, age and gender provide important diagnostic information and can help to decide whether additional testing is necessary. [ABSTRACT FROM AUTHOR]

Background: Transient loss of consciousness (TLOC) is a common clinical problem. Objective: The aim of this study was to assess the yield and accuracy of the initial evaluation, consisting of standardized history, physical examination, and ECG performed by attending physicians in patients with TLOC. Methods and Results: Five hundred and three adult patients (mean age 53 ± 19; 56% male) presenting with TLOC to the Academic Medical Center Amsterdam between February 2000 and May 2002 were included in this study. After initial evaluation, the physician made a certain, a highly likely (>80% certain), or no initial diagnosis. Initially undiagnosed patients received additional cardiological testing, additional history taking, and autonomic function tests. After 2 years of follow-up, an expert committee determined the final diagnoses. Two-year follow-up was obtained in 99% of the patients. The yield of certain diagnoses after the initial evaluation was 24%, increasing to 63% after including the highly likely diagnoses. The diagnostic accuracy of the initial certain diagnoses was 93% (95% CI 87–97%), decreasing to 88% (95% CI 84–91%) after inclusion of the initial highly likely diagnoses. Conclusion: Attending physicians can make a diagnosis based on initial evaluation in 63% of patients with TLOC, with an overall diagnostic accuracy of 88%. The use of additional testing, beyond history, physical examination, and ECG can be avoided in many patients with TLOC. [ABSTRACT FROM AUTHOR]

The purpose of this study was to examine (1) changes in quality of life (QoL) within 1 year after presentation with transient loss of consciousness (TLOC) and (2) which factors are predictive of these changes. This study was part of the Fainting Assessment Study (FAST), which assessed diagnostic strategies in patients with TLOC. Adult patients presenting to Academic Medical Center, Amsterdam, The Netherlands, with TLOC were included in the study. QoL was assessed with the generic Short Form 36 and the disease-specific Syncope Functional Status Questionnaire at presentation and 1 year of follow-up. Of 468 included patients, 82% completed questionnaires at presentation and 72% after 1-year follow-up. QoL improved on 7 of 8 subscales of the Short Form 36 and on all summary scales of the Syncope Functional Status Questionnaire. Older age, recurrence, higher level of co-morbidity, and a neurologic or psychogenic diagnosis were predictive of poorer QoL. In conclusion, QoL in patients with TLOC improves significantly over time. Physicians should particularly pay attention to patients who are older, have recurrent episodes, a neurologic or psychogenic diagnosis, and a higher level of co-morbidity because these patients are vulnerable to a relatively poorer QoL. [Copyright &y& Elsevier]

Objectives: In this study, we assessed the effectiveness of physical counterpressure maneuvers (PCM) in daily life. Background: There is presently no evidence-based therapy for vasovagal syncope. Current treatment consists of explanation and life-style advice. Physical counterpressure maneuvers have been shown to raise blood pressure and to control or abort vasovagal episodes in laboratory conditions. Methods: We performed a multicenter, prospective, randomized clinical trial, which included 223 patients age 38.6 (±15.4) years with recurrent vasovagal syncope and recognizable prodromal symptoms. One hundred and seventeen patients were randomized to standardized conventional therapy alone, and 106 patients received conventional therapy plus training in PCM. Results: The median yearly syncope burden during follow-up was significantly lower in the group trained in PCM than in the control group (p = 0.004). During a mean follow-up period of 14 months, overall 50.9% of the patients with conventional treatment and 31.6% of the patients trained in PCM experienced a syncopal recurrence (p = 0.005). Actuarial recurrence-free survival was better in the treatment group (log-rank p = 0.018), resulting in a relative risk reduction of 39% (95% confidence interval, 11% to 53%). No adverse events were reported. Conclusions: Physical counterpressure maneuvers are a risk-free, effective, and low-cost treatment method in patients with vasovagal syncope and recognizable prodromal symptoms, and should be advised as first-line treatment in patients presenting with vasovagal syncope with prodromal symptoms. (The PC-Trial; http://www.controlled-trials.com/isrctn/trial/45146526/0/45146526.html; ISRCTN45146526) [Copyright &y& Elsevier]

Introduction: Transient loss of consciousness (TLOC) is common and can be lethal. Although the patients with the most prevalent causes of TLOC have a benign prognosis, morbidity is considerable. Aim of this article, therefore, was to compare the generic quality of life (QoL) of patients presenting with TLOC with that of the general population, to compare the disease-specific QoL with that of an American referral sample, and to examine which sociodemographic and clinical factors are associated with QoL in these patients. Methods: This study was part of the fainting assessment study (FAST), which assessed diagnostic strategies for adult patients presenting with TLOC to the Academic Medical Center Amsterdam, between February 2000 and May 2002. The generic short form-36 (SF-36) health survey and the disease-specific syncope functional status questionnaire (SFSQ) were used to assess QoL. Results: Of 468 included patients, 82% completed the questionnaires. Patients with TLOC scored poorer on all scales of the SF-36 than the Dutch population, with effect sizes ranging from 0.43 to 1.11 (>0.5 = moderate effect; >0.8 = large effect). The SFSQ indicated mean impairment in 33% of the listed activities (such as driving). Female gender, higher level of comorbidity, shorter duration of complaints, having had more than one syncopal episode, and the presence of presyncopal episodes were associated with poorer QoL. Conclusion: TLOC seriously affects QoL, especially in patients with a recent onset of clinical symptoms and those suffering from both syncopal and presyncopal episodes. [ABSTRACT FROM AUTHOR]

Introduction: Entrustable Professional Activities (EPAs) have been applied differently in many postgraduate medical education (PGME) programmes, but the reasons for and the consequences of this variation are not well known. Our objective was to investigate how the uptake of EPAs is influenced by the workplace environment and to what extent the benefits of working with EPAs are at risk when the uptake of EPAs is influenced. This knowledge can be used by curriculum developers who intend to apply EPAs in their curricula. Method: For this qualitative study, we selected four PGME programmes: General Practice, Clinical Geriatrics, Obstetrics & Gynaecology, and Radiology & Nuclear Medicine. A document analysis was performed on the national training plans, supported by the AMEE Guide for developing EPA-based curricula and relevant EPA-based literature. Interviews were undertaken with medical specialists who had specific involvement in the development of the curricula. Content analysis was employed and illuminated the possible reasons for variation in the uptake of EPAs. Results: An important part of the variation in the uptake of EPAs can be explained by environmental factors, such as patient population, the role of the physician in the health-care system, and the setup of local medical care institutions where the training programme takes place. The variation in uptake of EPAs is specifically reflected in the number and breadth of the EPAs, and in the way the entrustment decision is executed within the PGME programme. Discussion: Due to variation in uptake of EPAs, the opportunities for trainees to work independently during the training programme might be challenging. EPAs can be implemented in the curriculum of PGME programmes in a meaningful way, but only if the quality of an EPA is assessed, future users are involved in the development, and the key feature of EPAs (the entrustment decision) is retained. [ABSTRACT FROM AUTHOR]

Objective: The VASE-(M)HC is an instrument to evaluate Motivational Interviewing (MI) skills. We adjusted the previous version for use in the broader (mental) healthcare context, incorporated new MI insights, expanded the scoring system and created a parallel version. Feasibility and validity evidence in the general practice setting was explored.Methods: The teaching staff of the GP specialty-training, GP-, and PN-trainees (N = 156) completed the VASE-(M)HC. In this mixed-methods study, we examined psychometric characteristics, compared parallel versions, and interviewed assessors.Results: Our adjustments enable assessment of a wider range of MI skills, and allow differentiation of basic and advanced skills. Inter-rater reliability was excellent and internal consistency of the total scale was good for both versions. The parallel versions are comparable in terms of difficulty.Conclusion: The VASE-(M)HC is improved by our revisions and adds multiple advantages to the domain of available MI assessment tools.Practice Implications: Due to the adjustments, the instrument can be used in the GP setting (instead of sole focus on substance abuse). The parallel version is useful for research (pretest/posttest) and selective assessment (retake of a test). It is promising to further explore its applicability in the broader (mental) healthcare context and as training material. [ABSTRACT FROM AUTHOR]

Objectives: Research has suggested beneficial effects of self‐regulated learning (SRL) for medical students' and residents' workplace‐based learning. Ideally, learners go through a cyclic process of setting learning goals, choosing learning strategies and assessing progress towards goals. A clear overview of medical students' and residents' successful key strategies, influential factors and effective interventions to stimulate SRL in the workplace is missing. This systematic review aims to provide an overview of and a theoretical base for effective SRL strategies of medical students and residents for their learning in the clinical context. Methods: This systematic review was conducted according to the guidelines of the Association for Medical Education in Europe. We systematically searched PubMed, EMBASE, Web of Science, PsycINFO, ERIC and the Cochrane Library from January 1992 to July 2016. Qualitative and quantitative studies were included. Two reviewers independently performed the review process and assessed the methodological quality of included studies. A total of 3341 publications were initially identified and 18 were included in the review. Results: We found diversity in the use of SRL strategies by medical students and residents, which is linked to individual (goal setting), contextual (time pressure, patient care and supervision) and social (supervisors and peers) factors. Three types of intervention were identified (coaching, learning plans and supportive tools). However, all interventions focused on goal setting and monitoring and none on supporting self‐evaluation. Conclusions: Self‐regulated learning in the clinical environment is a complex process that results from an interaction between person and context. Future research should focus on unravelling the process of SRL in the clinical context and specifically on how medical students and residents assess their progress towards goals. [ABSTRACT FROM AUTHOR]

A quality system (named GEAR; acronym for Combined Evaluation Audit Round in English), has been introduced in eight institutes of the Dutch general practitioner specialty training. This paper focuses on the local and national effects of GEAR. Seventeen semi-structured interviews were conducted with the directors and quality co-ordinators. At a local level, GEAR provided the institutes with insights into their current practice. The institutes designed and implemented several improvement plans based on feedback. Furthermore, GEAR addressed quality management more systematically, and it enhanced the quality culture. At a national level, the institutes formulated national priorities. In addition, GEAR stimulated collaboration as a result of more frequent contacts. Institutes differed in their perception of the extent to which GEAR offered added value. Integrating the quality system into the local policy was sometimes a problem. Despite some scepticism at the start, GEAR provoked enthusiasm that can contribute to the quality of medical education. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, general practitioners (GPs) play a key role in HIV testing. However, the proportion of people diagnosed with late-stage HIV remains high, and opportunities for earlier diagnosis are being missed. We implemented an educational intervention to improve HIV and STI testing in primary care in Amsterdam, the Netherlands. Methods: GPs were invited to participate in an educational program between 2015 and 2020, which included repeat sessions using audit and feedback and quality improvement plans. Data on HIV, chlamydia and gonorrhoea testing by GPs were collected from 2011 through 2020. The primary outcome was HIV testing frequency, which was compared between GPs before and after participation using Poisson regression. Secondary outcomes were chlamydia and gonorrhoea testing frequencies, and positive test proportions. Additional analyses stratified by patient sex and age were done. Findings: GPs after participation performed 7% more HIV tests compared to GPs before participation (adjusted relative ratio [aRR] 1.07, 95%CI 1.04–1.09); there was no change in the proportion HIV positive tests (aRR 0.87, 95%CI 0.63–1.19). HIV testing increased most among patients who were female and ≤19 or 50–64 years old. After participation, HIV testing continued to increase (aRR 1.02 per quarter, 95%CI 1.01–1.02). Chlamydia testing by GPs after participation increased by 6% (aRR 1.06, 95%CI 1.05–1.08), while gonorrhoea testing decreased by 2% (aRR 0.98, 95%CI 0.97–0.99). We observed increases specifically in extragenital chlamydia and gonorrhoea testing. Conclusions: The intervention was associated with a modest increase in HIV testing among GPs after participation, while the proportion positive HIV tests remained stable. Our results suggest that the intervention yielded a sustained effect. [ABSTRACT FROM AUTHOR]

Background: Breast cancer survivors can be at high risk of having work-related problems. Previous studies suggest that GPs could discuss work participation with cancer patients and provide guidance. The aim this study is to explore the experiences and expectations of breast cancer survivors with their GPs' role regarding guidance on work participation and return to work. Methods: A qualitative study with Dutch female breast cancer survivors was held in the Netherlands. Four focus groups with 25 participants were conducted and audio-taped. Transcripts were analysed using thematic analysis. Results: Breast cancer survivors reported a wide range of experiences with guidance from their GPs regarding work participation. Patients who contacted their GPs with work-related issues felt listened to during the consultation. Some patients experienced very limited or no guidance, while others were intensively guided by their GPs. The guidance was provided in the form of counseling, psychosocial support, and referral to other health care professionals. When cancer patients experienced problems with reintegration in work, they expected GPs to have a supportive and referring role in work participation guidance. Conclusion: In returning to work, breast cancer survivors expect their GPs to play a supportive role, especially when they encounter difficulties in reintegrating. However, their actual experience of guidance received from their GPs varied, from none received at all, to intensive support provided. [ABSTRACT FROM AUTHOR]

Work-based learning depends on patients' consent to have trainees involved in their care. However, patients can refuse trainees, which might lead to the loss of learning experiences. Improved understanding of patients' views on consulting trainees may provide useful insights to further optimise learning for trainees. We performed a qualitative study with 28 patients in The Netherlands. Participants were recruited from GP practices, and were purposively sampled on (un)willingness to consult GP trainees. In semi-structured interviews patients' perspectives and willingness to consult a trainee were explored. Transcripts were thematically analysed using an inductive approach. Two themes explained patients' views on consulting GP trainees: Presenting complaint-driven preferences and Trust in trainees' capabilities. Patients select their doctor based on complaint-driven preferences and chose trainees if they fulfilled these preferences. For urgent, gender-specific and minor complaints, patients prefer timeliness, gender concordance or availability. Patients with more complex, long-term problems prefer to consult a trusted doctor with whom they have a longitudinal relationship. Through repeated visits and empathic behaviour trainees can become this doctor. Before patients consider consulting a trainee, they need to have trust in the trainee's capabilities. This trust is related to the basic trust patients have in the education of the trainee, their knowledge about trainees' capabilities and supervisory arrangements. Patients' decision to visit a trainee is fluid. Patients will visit a trainee when their complaint-driven preferences are satisfied. Influencing trainees' fulfilment of these preferences and patients' trust in trainees can make patients more willing to consult trainees. [ABSTRACT FROM AUTHOR]

Entrustable Professional Activities (EPAs) are developed to support the practical application of competency frameworks in postgraduate medical education (PGME) programmes. EPAs are used for the assessment of the trainees' competence development, which takes place by means of an entrustment decision, aiming to stimulate learning and independent practice in trainees. In this pilot study, we explore the feasibility and validity of EPA-based assessment in a General Practice (GP) training programme. We used questionnaires to evaluate trainers' and trainees' experiences with the use of six EPAs for trainee learning, assessment and independent practice at the Out-of-Hours GP Center. Data were analysed quantitatively and qualitatively. Additionally, we examined the inter-item correlation between scores on EPA-based assessment and competency-based assessment using Spearman's Rho. EPA-based assessment provided opportunities for giving concrete feedback and substantiating competency-based assessment. No consistent correlation between EPA-based assessment and competency-based assessment could be detected. Only later in the course of the training programme a correlation was found between the EPA scores and the degree of independence of trainees. Results of this pilot study confirm the theories behind EPAs, as well as earlier research on EPAs in the workplace regarding trainee learning, assessment and independent practice. An important limitation of this study was the COVID-19 pandemic, as it influenced the results through reduced inclusion and follow-up, and through the impact on the workplace and trainee learning possibilities. Further research is needed to determine how EPAs support independent practice of trainees, as well as the assessment of trainee competency development. [ABSTRACT FROM AUTHOR]

Objective: The participation of students from both undergraduate medical education (UGME) and postgraduate medical education (PGME) in independent patient care contributes to the development of knowledge, skills and the professional identity of students. A continuing collaboration between students and their preceptor might contribute to opportunities for students to independently provide patient care. In this systematic review, we aim to evaluate whether longitudinal training models facilitate the independent practice of students and what characteristics of longitudinal training models contribute to this process. Method: This systematic review was performed according to the PRISMA guidelines. In May 2020, we performed a search in three databases. Articles evaluating the impact of longitudinal training models on the independent practice of students from both UGME and PGME programmes were eligible for the study. A total of 68 articles were included in the study. Quality of the included studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Results: Both UGME and PGME students in longitudinal training models are more frequently allowed to provide patient care independently when compared with their block model peers, and they also feel better prepared for independent practice at the end of their training programme. Several factors related to longitudinal training models stimulate opportunities for students to work independently. The most important factors in this process are the longitudinal relationships with preceptors and with the health care team. Conclusion: Due to the ongoing collaboration between students and their preceptor, they develop an intensive and supportive mutual relationship, allowing for the development of a safe learning environment. As a result, the professional development of students is fostered, and students gradually become part of the health care team, allowing them the opportunity to engage in independent patient care. This work demonstrates how longitudinal rotation models can make an important contribution to the entrustment of patient care to students. [ABSTRACT FROM AUTHOR]

Background: Little is known about the prevalence of modifiable risk factors of falling in elderly persons with a fall-history who do not visit the Accident and Emergency (A&E) Department after one or more falls. The objective of this study was to determine the prevalence of modifiable risk factors in a population that visited the A&E Department after a fall (A&E group) and in a community-dwelling population of elderly individuals with a fall history who did not visit the A&E Department after a fall (non-A&E group). Methods: Two cohorts were included in this study. The first cohort included 547 individuals 65 years and older who were visited at home by a mobile fall prevention team. The participants in this cohort had fall histories but did not visit the A&E Department after a previous fall. These participants were age- and gender-matched to persons who visited the A&E Department for care after a fall. All participants were asked to complete the CAREFALL Triage Instrument. Results: The mean number of modifiable risk factors in patients who did not visit the A&E Department was 2.9, compared to 3.8 in the group that visited the A&E Department (p<0.01). All risk factors were present in both groups but were more prevalent in the A&E group, except for the risk factors of balance and mobility (equally prevalent in both groups) and orthostatic hypotension (less prevalent in the A&E group). The risk factors of polypharmacy, absence of orthostatic hypotension, fear of falling, impaired vision, mood and high risk of osteoporosis were all independently associated with visiting the A&E Department. Conclusion: All modifiable risk factors for falling were found to be shared between community-dwelling elderly individuals with a fall history who visited the A&E Department and those who did not visit the Department, although the prevalence of these factors was somewhat lower in the A&E group. Preventive strategies aimed both at patients presenting to the A&E Department after a fall and those not presenting after a fall could perhaps reduce the number of recurrent falls, the occurrence of injury and the frequency of visits to the A&E Department. [ABSTRACT FROM AUTHOR]

Background: General Practitioners (GPs) and Practice Nurses (PNs) collaboratively play an important role in preventing and monitoring chronic diseases. They are trained in Motivational Interviewing (MI), which is a communication style to intrinsically motivate patients to a healthier lifestyle. However, being trained in MI skills does not necessarily mean that it is implemented in daily practice so patients actually benefit. The aim of this study is to identify factors that facilitate or impede the implementation of MI in General Practice. Methods: A total of 152 participants (93 GP-trainees and 59 PN-trainees) who were trained in MI completed a questionnaire regarding the implementation of MI. Semi-structured interviews (N = 17) were conducted with GPs and PNs (ranging from almost graduated to highly experienced) who were selected through the process of maximum variation sampling. The interview guide was based on the five-stage implementation model of Grol and Wensing. Results: Thirteen factors that influence the implementation of MI in General Practice were identified. They can be allocated to three categories: (1) setting factors such as time, (2) GP/PN factors such as self-efficacy, and (3) patient factors such as cultural background. Conclusions: Overall, GPs and PNs considered MI to be useful and part of their professional responsibility. Most difficulties become apparent in stage 4 (change: applying MI skills in practice) and 5 (consolidation: integrating MI into daily routine and embedment in organisation) of Grol and Wensing's model. Therefore, it is important that training does not only focus on MI skills. It is essential to pay explicit attention to the factors that impact implementation, as well as the appropriate tools to tackle the barriers. These insights can help trainers to effectively support GPs and PNs to apply and maintain their MI skills in daily practice. [ABSTRACT FROM AUTHOR]

Background: Clinical workplace-based learning has been the means to becoming a medical professional for many years. The importance of an adequate patient mix, as defined by the number of patients and the types of medical problems, for an optimal learning process is based on educational theory and recognised by national and international accreditation standards. The relationship between patient mix and learning in work-based curricula as yet remains unclear. Aim: To review research addressing the relationship between patient mix and learning in work-based clinical settings. Method: The search was conducted across Medline, Embase, Web of Science, ERIC and the Cochrane Library from the start date of the database to July 2011. Original quantitative studies on the relationship between patient mix and learning for learners at any level of the formal medical training/career were included. Methodological quality was assessed and two reviewers using prespecified forms extracted results. Results: A total of 10,420 studies were screened on title and abstract. Of these, 298 articles were included for full-text analysis, which resulted in the inclusion of 22 papers. The quality of the included studies, scored with the Medical Education Research Study Quality Instrument (MERSQI), ranged from 8.0 to 14.5 (of 18 points). A positive relationship was found between patient mix and self-reported outcomes evaluating the progress in competence as experienced by the trainee, such as self-confidence and comfort level. Patient mix was also found to correlate positively with self-reported outcomes evaluating the quality of the learning period, such as self-reported learning benefit, experienced effectiveness of the rotation, or the instructional quality. Variables, such as supervision and learning style, might mediate this relationship. A relationship between patient mix and formal assessment has never been demonstrated. Conclusion: Patient mix is positively related to self-reported learning outcome, most evidently the experienced quality of the learning programme. [ABSTRACT FROM AUTHOR]

Vasovagal syncope (VVS) is a consistent, but infrequent (0.1%-0.3%) complication of volunteer, whole blood donation. Given the large number of blood donations, a significant number of donors is involved. Syncope occasionally leads to injury. Recent rigorous data collection and analysis have led to the association of a small number of donor and donation factors with the risk of syncope. An analysis of the time course of syncope reactions among approximately 500,000 whole blood donors suggests that there are three distinct periods of risk for vasovagal reactions before, during, and after phlebotomy. This review examines the physiologic mechanisms that contribute to these periods of increased risk including the direct effects of removal of approximately 500 mL of whole blood, the psychological stress of instrumentation and giving blood (i.e., fear of needles, pain, and the sight of blood), and the orthostatic effects superimposed on a hypovolemic state after the donation. Specifically, we describe interventions that have been useful in controlling VVS in patients with fainting syndromes and we examine the potential of these interventions in the blood donation context, based on the physiologic principles involved. Finally, we propose an intervention (dietary replacement of salt lost with blood donation) that has not been applied in transfusion medicine previously but which has the potential to reduce risk. [ABSTRACT FROM AUTHOR]

Background fear of falling (FOF) is a major health problem among the elderly living in communities, present in older people who have fallen but also in older people who have never experienced a fall. The aims of this study were 4-fold: first, to study methods to measure FOF; second, to study the prevalence of FOF among fallers and non-fallers; third, to identify factors related to FOF; and last, to investigate the relationship between FOF and possible consequences among community-dwelling older persons. Methods several databases were systematically searched, and selected articles were cross-checked for other relevant publications. Results a systematic review identified 28 relevant studies among the community-dwelling elderly. Due to the many different kinds of measurements used, the reported prevalence of FOF varied between 3 and 85%. The main risk factors for developing FOF are at least one fall, being female and being older. The main consequences were identified as a decline in physical and mental performance, an increased risk of falling and progressive loss of health-related quality of life. Conclusion this review shows that there is great variation in the reported prevalence of FOF in older people and that there are multiple associated factors. Knowledge of risk factors of FOF may be useful in developing multidimensional strategies to decrease FOF and improve quality of life. However, the only identified modifiable risk factor of FOF is a previous fall. In order to measure the impact of interventions, a uniform measurement strategy for FOF should be adopted, and follow-up studies should be conducted. [ABSTRACT FROM AUTHOR]

Objectives: We set out to determine the effect of sublingual nitroglycerin (NTG), as used during routine tilt testing in patients with unexplained syncope, on hemodynamic characteristics and baroreflex control of heart rate (HR) and systemic vascular resistance (SVR).Background: Nitroglycerin is used in tilt testing to elicit a vasovagal response. It is known to induce venous dilation and enhance pooling. Also, NTG is lipophilic and readily passes cell membranes, and animal studies suggest a sympatho-inhibitory effect of NTG on circulatory control.Methods: Routine tilt testing was conducted in 39 patients with suspected vasovagal syncope (age 36 ± 16 years, 18 females). Patients were otherwise healthy and free of medication. Before a loss of consciousness set in, oncoming syncope was cut short by tilt-back or counter-maneuvers. Finger arterial pressure was monitored continuously (Finapres). Left ventricular stroke volume (SV) was computed from the pressure pulsations (Modelflow). Spontaneous baroreflex control of HR was estimated in the time and frequency domains.Results: During tilt testing, 22 patients developed presyncope. After NTG administration but before presyncope, SV and cardiac output (CO) decreased (p < 0.001), whereas SVR and HR increased (p < 0.001) in all patients. Arterial pressure was initially maintained. Baroreflex sensitivity decreased after NTG. On Cox regression analysis, the occurrence of a vasovagal response was related to a drop in SV after NTG (hazard ratio 0.86, p = 0.005).Conclusions: The cardiovascular response to NTG is similar in vasovagal and non-vasovagal patients, but more pronounced in those with tilt-positive results. The NTG-facilitated presyncope appears to be CO-mediated, and there is no evidence of NTG-induced sympathetic inhibition. [Copyright &y& Elsevier]

Objectives: In the Netherlands, general practitioners (GPs) perform two-thirds of sexually transmitted infection (STI) consultations and diagnose one-third of HIV infections. GPs are, therefore, a key group to target to improve provider-initiated HIV testing. We describe the design and implementation of an educational intervention to improve HIV testing by Amsterdam GPs and explore trends in GPs' testing behaviour.Methods: Interactive sessions on HIV and STI using graphical audit and feedback started in 2015. Participating GPs developed improvement plans that were evaluated in follow-up sessions. Laboratory data on STI testing by Amsterdam GPs from 2011 to 2017 were collected for graphical audit and feedback and effect evaluation. The primary outcome was the HIV testing rate: number of HIV tests per 10 000 person-years (PY). Secondary endpoints were chlamydia and gonorrhoea testing rates and HIV positivity ratios.Results: Since 2015, 41% of GPs participated. HIV testing rate declined from 2011 to 2014 (from 175 to 116 per 10 000 PY), more in women than men (176 to 101 versus 173 to 132), and stabilized from 2015 to 2017. The HIV positivity ratio declined from 0.8% in 2011 to 0.5% in 2017. From 2011 to 2017, chlamydia and gonorrhoea testing rates declined in women (from 618 to 477 per 10 000 PY) but remained stable in men (from 270 to 278).Conclusions: The stabilization of the downward trend in HIV testing coincided with this educational intervention. Follow-up data are needed to formally assess the intervention's impact on GP testing behaviour whilst considering contextual factors and secular trends. [ABSTRACT FROM AUTHOR]

Objective: Motivational Interviewing (MI) is increasingly used in healthcare. The Motivational Interviewing Target Scheme 2.1 (MITS) can be used to assess MI in short consultations. This quantitative validation study is a sequel to a qualitative study, which showed that the MITS is suitable for low-stakes assessment. We collected validity evidence to determine whether its suitability for high-stakes assessment in the GP-setting.Methods: Consultations of GPs and GP-trainees were assessed using the MITS. The internal structure was studied using generalizability theory; intra class correlation (ICC), convergent and divergent validity was determined.Results: Two coders and seven consultations were found to be necessary for high stakes assessment. We found higher ICCs as coders were more experienced. Convergent validity was found; results for divergent validity were mixed.Conclusion: The MITS is a suitable instrument for high-stakes MI assessments in GP-setting. The number of consultations and coders that are needed for assessment are comparable to other instruments for assessing communication skills.Practice Implications: The MITS can be used to assess conversations for their MI consistency in GP-setting where most consultations are relatively short and are only partially dedicated to behaviour change. As the MITS assesses complex communication skills, experienced coders are needed. [ABSTRACT FROM AUTHOR]

Introduction: Role modelling is a key component in the training of doctors that influences professional behaviour, identity and career choices. Clinical teachers and residents are often unaware of this, thereby risking transmission of negative behaviour. On the other hand, awareness positively affects role model behaviour. To assess role model behaviour, the Role Model Apperception Tool (RoMAT) was developed and validated in general practice training. The aim of the current study was to validate the RoMAT in the hospital-based training setting. Methods: The authors asked first to last year residents, regardless of their specialty, to participate after written approval from their clinical teachers. The tool was completed online in 2017. The authors performed a principal component analysis and investigated internal consistency, construct validity, inter-rater reliability, known-groups comparisons and floor and ceiling effects. Results: Of the 473 residents contacted, 187 (40%) completed the questionnaire. As in the primary validation study, the authors extracted two components: 'Caring Attitude' and 'Effectiveness', explaining 67% of the variation with a Cronbach's alpha of 0.94 and 0.93 respectively. Evidence for construct validity was found and there were no floor or ceiling effects, but inter-rater reliability was low. Discussion: The RoMAT was internally consistent and valid to assess role model behaviour of the clinical teacher towards the resident in the hospital-based training of medical specialists. The poor inter-rater reliability, most likely due to homogeneous RoMAT responses, should be borne in mind when evaluating RoMAT scores on individual clinical teachers. [ABSTRACT FROM AUTHOR]

Introducing Entrustable Professional Activities (EPAs) into primary care postgraduate medical education (PGME) programmes may be challenging, due to the general nature of primary care medicine, but trainers and trainees both stand to benefit from their use. We investigated the expectations of trainers and trainees in a primary care PGME programme regarding the use of EPAs. We held two focus group discussions with trainers and four with trainees from the Dutch General Practice training programme, to explore their views on the use of EPAs in their training programme. Focus group discussions were audio-recorded and transcribed verbatim. The transcripts were analysed using conventional content analysis. Trainers and trainees felt that the large number of EPAs in the training programme, and the general way they are formulated, made them unsuitable for use in formal assessments. However, they felt that EPAs can be a useful aid to trainee learning. EPAs may help trainers to give trainees specific feedback on their performance. While the use of the classic EPA method in primary care PGME programmes may be challenging, EPAs in such programmes might be more suitable as design and learning tools than as a tool for formal assessment. [ABSTRACT FROM AUTHOR]

Background: In Western countries, hypertension and hypertension-related complication are more common in ethnic minority groups of African descent than in indigenous populations. Addressing ethnic minority patients’ perceptions of hypertension and its treatment through the use of cultural appropriate hypertension education (CAHE) increases adherence to medication and lifestyle recommendations. Given these effects, it seems warranted to develop a training program on how to deliver this type of patient education for Primary Care Nurse Practitioners (PCNPs). Objective: Development and evaluation of a training program for PCNPs aimed at providing culturally appropriate hypertension patient education. Design: Prospective cohort study evaluating attitude and intended behavioral changes. Participants: Both experienced PCNPs and PCNPs in training participated in this study. Main measures: The effects of the CAHE-training were measured by 3 different questionnaires on 1) the satisfaction with the training program, 2) the attitude towards culturally appropriate care, and 3) the commitment to change. Results: The CAHE-training program consists of 10 different components divided over two 4-hour sessions and was taught to 87 participating PCNPs. The program utilizes constructivist-learning principles and educational evidence on adult learning. The content of the program is based on the knowledge obtained from our previous studies on culturally appropriate care. The mean satisfaction-score was 7.5 (1–10 scale), with the role-play exercise with patient-actors scoring highest (8.2). We observed non-significant but positive changes in attitude. PCNPs who reported on the implementation of their intended behavior change showed significant attitude changes after three months. Conclusion: We demonstrated that our evidence based training program for PCNPs resulted in a positive learning experience with adequate intended behavioral changes in practice. Unfortunately, response rates were too low to demonstrate persistent changes in attitude. [ABSTRACT FROM AUTHOR]

Background: Primary health-care professionals play an important role in the treatment and prevention of Sexually Transmitted Infections (STI). Continuing Medical Education (CME)-courses can influence the knowledge and behavior of health-care professionals concerning STI. We performed a prospective cohort study to evaluate if the individual and online e-learning program "The STI-consultation", which uses the Commitment-to-Change (CtC)-method, is able to improve the knowledge, attitude and behavior of Dutch General Practitioners (GPs), concerning the STI-consultation. This e-learning program is an individual, accredited, online CME-program, which is freely available for all GPs and GP-trainees in the Netherlands. Methods: In total 2192 participants completed the questionnaire before completing the e-learning program and 249 participants completed the follow-up questionnaire after completing the e-learning program. The effect of the program on their knowledge, attitude and behavior concerning the STI-consultation was evaluated. Results: In total 193 participants formulated 601 learning points that matched the learning objectives of the program. The knowledge and attitude of the participants improved, which persisted up to two years after completing the program. Another 179 participants formulated a total of 261 intended changes concerning the sexual history taking, additional investigation and treatment of STI, 97.2% of these changes was partially or fully implemented in daily practice. Also, 114 participants formulated a total of 180 "unintended" changes in daily practice. These changes concerned the attitude of participants towards STI and the working conditions concerning the STI-consultation. Conclusion: The individual, online e-learning program "The STI-consultation", which uses the CtC-method, has a small but lasting, positive effect on the knowledge, attitude, and behavior of GPs concerning the STI-consultation. [ABSTRACT FROM AUTHOR]

Background: Continuing Professional Development (CPD) and Faculty Development (FD) courses have been designed in the expectation that a cascade effect will occur, consisting of a conveyance of information from the courses to clinical trainers to daily practice and/or to trainees by means of role modeling. Purpose: The aims of this study were to gain insight into factors that encourage clinical trainers to incorporate what they have learned in CPD/FD into their role model function and the factors that influence conveyance from master to apprentice. Method: We conducted a qualitative study using semi-structured interviews with GP trainers and their trainees. Results: Twenty-four GP trainers who completed a CPD/FD course and sixteen of their trainees participated in the study. Analysis of their statements enabled the identification of factors that affect the amplification of the competences of clinical trainers and their awareness of being a role model, the applicability in training practice and conveyance to the trainee. Conclusions: As a result of interactions between the trainer, trainee and patient, it seems more accurate to represent the conveyance of competences from master to apprentice using the image of a whirlpool rather than a cascade, with the influential factors and interactions functioning as filters, causing a decline in the effectiveness of CPD/FD. Using the filters as a basis for turning-points for improvements around the whirlpool could increase the effectiveness of CPD/FD. [ABSTRACT FROM AUTHOR]

Objective To identify and compare tools to assess Evidence-Based Practice (EBP) behaviour among healthcare professionals. Design Systematic review. Data sources MEDLINE, EMBASE, Cochrane Library, PsychInfo and CINAHL up to July 2011. Study selection Titles, abstracts and eligible full text articles were screened by two reviewers independently. Data extraction Relevant data were extracted by one reviewer and checked by a second reviewer. Eligibility criteria for selecting studies: original studies among all healthcare professionals that described the development or use of EBP behaviour assessment tools. Results Of 19 310 identified articles, 172 studies were included. We identified 117 questionnaires, 10 interviews or focus groups, nine observational studies, 27 chart evaluations and nine studies used a combination of methods. Psychometric properties of the questionnaires used were reported in about half of the studies, in seven studies that assess a single EBM step and in six studies that assess a combination of EBM steps. One of these assessed all five steps of EBP. Conclusions Valid and reliable EBP behaviour assessment tools are available. However, only one questionnaire validly assessed all five EBP steps, covering the entire concept of EBP. [ABSTRACT FROM AUTHOR]

Background: Little is known about the prevalence of modifiable risk factors of falling in elderly persons with a fall-history who do not visit the Accident and Emergency (A&E) Department after one or more falls. The objective of this study was to determine the prevalence of modifiable risk factors in a population that visited the A&E Department after a fall (A&E group) and in a community-dwelling population of elderly individuals with a fall history who did not visit the A&E Department after a fall (non-A&E group).Methods: Two cohorts were included in this study. The first cohort included 547 individuals 65 years and older who were visited at home by a mobile fall prevention team. The participants in this cohort had fall histories but did not visit the A&E Department after a previous fall. These participants were age- and gender-matched to persons who visited the A&E Department for care after a fall. All participants were asked to complete the CAREFALL Triage Instrument.Results: The mean number of modifiable risk factors in patients who did not visit the A&E Department was 2.9, compared to 3.8 in the group that visited the A&E Department (p<0.01). All risk factors were present in both groups but were more prevalent in the A&E group, except for the risk factors of balance and mobility (equally prevalent in both groups) and orthostatic hypotension (less prevalent in the A&E group). The risk factors of polypharmacy, absence of orthostatic hypotension, fear of falling, impaired vision, mood and high risk of osteoporosis were all independently associated with visiting the A&E Department.Conclusion: All modifiable risk factors for falling were found to be shared between community-dwelling elderly individuals with a fall history who visited the A&E Department and those who did not visit the Department, although the prevalence of these factors was somewhat lower in the A&E group. Preventive strategies aimed both at patients presenting to the A&E Department after a fall and those not presenting after a fall could perhaps reduce the number of recurrent falls, the occurrence of injury and the frequency of visits to the A&E Department. [ABSTRACT FROM AUTHOR]

Vasoconstrictor capacity, skeletal muscle tone, and renal sodium retention are involved in the pathogenesis of fainting. As muscle contractility and ion transport are highly energy-demanding processes, we hypothesized that a low activity of the energy-generating enzyme creatine kinase (CK) is associated with a higher risk of fainting. The aim of this observational study was to explore the association of vasovagal syncope with low CK. A random sample of 1,000 subjects aged 34–60 years was drawn from the general population, with 442 subjects eventually included in the study. Data on fainting history were collected with the investigators blinded to participants’ CK level. We prepared this report according to the “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) statement. The main outcome was the lifetime cumulative incidence of vasovagal syncope in subjects with low versus high-normal serum CK after a 3 days rest. The proportion of fainters within the high CK group was 29 out of 130 (22%) versus 121 out of 312 (39%) in the low CK group; a 73% greater occurrence of fainting with low CK ( P = 0.0005). This finding was consistent across recurrent fainters, and in men and women. Low CK is associated with a 73% higher incidence of fainting in a random population sample. The association is biologically plausible, as CK enhances cardiovascular and skeletal muscle contractility and salt retention. The presented data suggest that low CK activity is a potential new risk factor for vasovagal syncope. [ABSTRACT FROM AUTHOR]

Introduction: There are limited and conflicting data on the lifetime cumulative incidence of syncope in the general population. The aim of our study was to determine the lifetime cumulative incidence and triggers of syncope in the general population. Methods: Questions about syncope were added to a cross-sectional survey on cardiovascular risk factors carried out between 2001 and 2003 in 549 native Dutch respondents, aged 35–60 years. Results: The lifetime cumulative incidence of syncope in our study population was 35% (95% confidence interval 31–39%). Syncope occurred more often in women than in men (41% vs 28%; P = 0.003). A peak in the incidence of syncope occurred around the age of 15 years in both men and women. The median number of episodes in persons with syncope was 2 (Inter Quartile Range 1–5). The top five most frequently mentioned triggers of syncope included warm environment, pain, insufficient food intake, seeing blood/venipuncture, and emotion. Conclusion: In conclusion, our study shows that the lifetime cumulative incidence of syncope in the general population is high. Females experience syncope more often than males. The majority of the syncope triggers were related to conditions that affect orthostatic blood pressure regulation and vasomotor responses. [ABSTRACT FROM AUTHOR]

Background:We aimed to develop and test a literature-based model for symptoms that associate with cardiac causes of syncope. Methods and Results:Seven studies (the derivation sample) reporting ≥2 predictors of cardiac syncope were identified (4 Italian, 1 Swiss, 1 Canadian, and 1 from the United States). From these, 10 criteria were identified as diagnostic predictors. The conditional probability of each predictor was calculated by summation of the reported frequencies. A model of conditional probabilities and a priori probabilities of cardiac syncope was constructed. The model was tested in four datasets of patients with syncope (the test sample) from Calgary (n=670; 21% had cardiac syncope), Amsterdam (n=503; 9%), Milan (n=689; 5%) and Rochester (3877; 11%). In the derivation sample ten variables were significantly associated with cardiac syncope: age, gender, structural heart disease, low number of spells, brief or absent prodrome, supine syncope, effort syncope, and absence of nausea, diaphoresis and blurred vision. Fitting the test datasets to the full model gave C-statistics of 0.87 (Calgary), 0.84 (Amsterdam), 0.72 (Milan) and 0.71 (Rochester). Model sensitivity and specificity were 92% and 68% for Calgary, 86% and 67% for Amsterdam, 76% and 59% for Milan, and 73% and 52% for Rochester. A model with 5 variables (age, gender, structural heart disease, low number of spells, and lack of prodromal symptoms) was as accurate as the total set. Conclusion:A simple literature-based Bayesian model of historical criteria can distinguish patients with cardiac syncope from other patients with syncope with moderate accuracy. [ABSTRACT FROM AUTHOR]