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A scoping review protocol

Item does not contain fulltext Because of a decrease of the time available for anatomy education, decisions need to be made to reduce the relevant content of the anatomy curriculum. Several expert consensus initiatives resulted in lists of structures, lacking analysis of anatomical competence. This study aims to explore the use of anatomical knowledge by medical doctors in an attempt to delineate the nature of anatomical competence. The research question is: what kind of anatomical knowledge do junior medical doctors use during a consultation with a patient presenting with a shoulder complaint? Ten junior medical doctors participated in this stimulated recall study. Each of them was videotaped while performing a consultation with a standardized patient with a complex shoulder complaint. The recording was viewed immediately after. Participants were videotaped again while verbalizing the thoughts they remembered having during the consultation. Verbatim transcriptions were coded by two coders using the qualitative data analysis ATLAS.ti software. Results were that these junior medical doctors used anatomical knowledge in all phases of the consultation, especially during physical examination. The use of anatomical terms was strongly associated with clinical reasoning and it was apparent that every subject visualized relevant anatomical information. Conclusion is that young medical doctors actively use their anatomical knowledge and it seems that the relevant anatomy consists largely of adequate visual representations in memory. Anatomy teachers should focus the students' learning activity on building an adequate visual representation of anatomical structures. This should be supported by assessments that test the quality of the students' visual representations. Anat Sci Educ. (c) 2015 American Association of Anatomists.

Item does not contain fulltext CONTEXT: Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged. OBJECTIVES: This study describes students' learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment. METHODS: A questionnaire containing open-ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4-week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses. RESULTS: Students' learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self-reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes. CONCLUSIONS: Students' learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under-represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students' professional development are neglected in the first year of medical education. 01 juli 2011

Contains fulltext : 53375.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To explore the relation of changes in measures of bone turnover and changes in bone mineral density (BMD) of the lumbar spine and total hip over 18 months in a double-blinded, randomized trial, comparing the effect of alfacalcidol (101 patients) versus alendronate (100 patients) on BMD in patients who recently started treatment with glucocorticoids for various rheumatic diseases. METHODS: Associations between changes in serum procollagen type I C-propeptide (P1CP), fasting urine N-terminal telopeptide of type I collagen (NTx), serum calcium, parathyroid hormone (PTH), osteocalcin, and change from baseline in BMD over 18 months were explored with regression and correlation analyses. RESULTS: In both treatment groups, there was a statistically significant decrease in NTx. In the alfacalcidol group there was also a significant increase in P1CP and osteocalcin, in contrast to the alendronate group, but BMD in the alfacalcidol decreased versus an increase in the alendronate group (p < 0.001). In neither treatment group were changes in biochemical measures correlated with the change in BMD, with the exception of a negative correlation in the alendronate group between changes in total hip BMD and NTx. Use of alendronate resulted in an increased PTH in 27 patients, but the increase in BMD of these patients was not statistically significantly different compared to patients taking alendronate with normal PTH levels. CONCLUSION: Changes in BMD were not associated with changes in bone measures, with the exception of NTx in the alendronate group. For the patient taking glucocorticoids in clinical practice, the value of serial assessment of bone markers is low; changes in markers are no substitute for changes in BMD. ClinicalTrials.gov number: NCT00138983.

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Item does not contain fulltext OBJECTIVE: To study factors associated with toxicity, final dose, and efficacy of methotrexate (MTX) in patients with rheumatoid arthritis (RA). METHODS: Data were used from a randomised clinical 48 week trial on 411 patients with RA all treated with MTX, comparing folates and placebo. Logistic regression was used to study the relation between baseline variables and various dependent factors, including hepatotoxicity (alanine aminotransferase >/=3 x upper limit of normal), MTX withdrawal, final MTX dose >/=15 mg/week, and MTX efficacy. RESULTS: Addition of folates to MTX treatment was strongly related to the lack of hepatotoxicity. Next to this, high body mass index was related to the occurrence of hepatotoxicity. Prior gastrointestinal (GI) events and younger age were related to the adverse event, diarrhoea. Hepatotoxicity and GI adverse events were the main reason for MTX withdrawal, which in turn was associated with the absence of folate supplementation, body mass index, prior GI events, and female sex. Renal function (creatinine clearance >/=50 ml/min) was not associated with toxicity. Reaching a final dose of MTX of >/=15 mg/week was related to folate supplementation and the absence of prior GI events. Efficacy of MTX treatment was associated with low disease activity at baseline, male sex, use of non-steroidal anti-inflammatory drugs (NSAIDs), and lower creatinine clearance. CONCLUSIONS: MTX toxicity, final dose, and efficacy are influenced by folate supplementation. Baseline characteristics predicting the outcome of MTX treatment are mainly prior GI events, body mass index, sex, use of NSAIDs, and creatinine clearance.

Item does not contain fulltext Assessment is an important aspect of medical education because it tests students' competence and motivates them to study. Various assessment methods, with and without images, are used in the study of anatomy. In this study, we investigated the use of extended matching questions (EMQs). To gain insight into the influence of images on the validity of test items, we focused on students' cognitive processes while they answered questions with and without images. Seventeen first-year medical students answered EMQs about gross anatomy, combined with either labeled images or answer lists, while thinking aloud. The participants' verbal reports were transcribed verbatim and then coded. Initial codes were based on a task analysis and were adapted into final codes during the coding process. Results showed that students used more cues from EMQs with images and visualized more often in EMQs with answer lists. Ready knowledge and verbal reasoning were used equally often in both conditions. In conclusion, EMQs with and without images elicit different results in this think aloud experiment, indicating different cognitive processes. They seem to measure different skills, making them valid for different testing purposes. The take-home message for anatomy teachers is that questions without images seem to test the quality of students' mental images while questions with images test their ability to interpret visual information. It makes sense to use both response formats in tests. Using images from clinical practice instead of anatomical drawings will help to improve test validity. Anat Sci Educ 7: 107-116. (c) 2013 American Association of Anatomists. 10 p.

Item does not contain fulltext OBJECTIVE: To study the possible relationship between the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene and the toxicity and efficacy of treatment with methotrexate (MTX) in patients with rheumatoid arthritis (RA). METHODS: Genotype analysis of the MTHFR gene was done in 236 patients who started MTX treatment with (n = 157) or without (n = 79) folic or folinic acid supplementation. Outcomes were parameters of efficacy of MTX treatment, patient withdrawal due to adverse events, discontinuation of MTX treatment because of elevated liver enzyme levels, and the total occurrence of elevated liver enzyme levels during the study. Multivariate logistic regression analysis was used to study the relationship between the presence of the MTHFR C677T mutation and toxicity outcomes of MTX treatment. RESULTS: Forty-eight percent of the patients showed the homozygous (T/T) or heterozygous (T/C) mutation. The presence of the C677CT or C677TT genotypes was associated with an increased risk of discontinuing MTX treatment because of adverse events (relative risk 2.01; 95% confidence interval 1.09, 3.70), mainly due to an increased risk of elevated liver enzyme levels (relative risk 2.38; 95% confidence interval 1.06, 5.34). Efficacy parameters were not significantly different between the patients with and those without the mutation. CONCLUSION: The C677T mutation is the first identified genetic risk factor for elevated alanine aminotransferase values during MTX treatment in patients with RA. We postulate that the incidence of clinically important elevation of liver enzyme levels during MTX treatment is mediated by homocysteine metabolism. Supplementation with folic or folinic acid reduced the risk of toxicity-related discontinuation of MTX treatment both in patients with and in patients without the mutation.

Item does not contain fulltext We used a visual analog scale (VAS) to assess the satisfaction after total knee arthroplasty (TKA) in a group of 108 patients (126 TKAs) with short-term to medium-term follow-up. We also used the Knee Society scoring system, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), pain VAS, and survival analysis. A comparison between the subjective and objective outcome systems revealed only poor correlations. This comparison suggests that the concerns and priorities of patients and surgeons differ. The outcome assessed with the satisfaction VAS revealed a significantly better subjective outcome in rheumatoid arthritis patients compared with osteoarthritis patients, whereas Knee Society scores were not different. The satisfaction VAS provides additional information about subjective outcome after TKA.

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Item does not contain fulltext Spatial ability is an important factor in learning anatomy. Students with high scores on a mental rotation test (MRT) systematically score higher on anatomy examinations. This study aims to investigate if learning anatomy also oppositely improves the MRT-score. Five hundred first year students of medicine (n = 242, intervention) and educational sciences (n = 258, control) participated in a pretest and posttest MRT, 1 month apart. During this month, the intervention group studied anatomy and the control group studied research methods for the social sciences. In the pretest, the intervention group scored 14.40 (SD: +/- 3.37) and the control group 13.17 (SD: +/- 3.36) on a scale of 20, which is a significant difference (t-test, t = 4.07, df = 498, P < 0.001). Both groups show an improvement on the posttest compared to the pretest (paired samples t-test, t = 12.21/14.71, df = 257/241, P < 0.001). The improvement in the intervention group is significantly higher (ANCOVA, F = 16.59, df = 1;497, P < 0.001). It is concluded that (1) medical students studying anatomy show greater improvement between two consecutive MRTs than educational science students; (2) medical students have a higher spatial ability than educational sciences students; and (3) if a MRT is repeated there seems to be a test effect. It is concluded that spatial ability may be trained by studying anatomy. The overarching message for anatomy teachers is that a good spatial ability is beneficial for learning anatomy and learning anatomy may be beneficial for students' spatial ability. This reciprocal advantage implies that challenging students on spatial aspects of anatomical knowledge could have a twofold effect on their learning. Anat Sci Educ 6: 257-262. (c) 2013 American Association of Anatomists. 01 juli 2013

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Item does not contain fulltext BACKGROUND AND PURPOSE: In the present study a classification system for the rheumatoid forefoot is reported with its intra- and interobserver reliability and clinical relevance. The classification is based on the sequence of anatomical changes resulting from the loss of integrity of the MTP joints, loss of motion and changes regarding the quality and position of the plantar soft tissues. It is hypothesized that with progression of the amount of deformity of the MTP joint(s), patients have more pain and functional loss. PATIENTS AND METHODS: In total 94 patients were included in the study following precise inclusion criteria. The forefeet of the patients were classified according to the introduced classification system by two observers in order to determine the intra- and interobserver reliability. The relation of the suggested classification between pain, function scores, and plantar foot pressure measurements was examined. RESULTS AND CONCLUSION: According to the Cohen's kappa and the ICC, the intra- and inter-observer reliability were high. Despite the large variation between subjects in a certain grade, a clear trend was found between increase in classification and VAS for pain, FFI difficulty with activities, and plantar peak pressure under the metatarsals. The suggested classification is of clinical relevance and can be used to develop therapeutical algorithms and to test interventions.

Contains fulltext : 96832.pdf (Publisher’s version ) (Open Access) BACKGROUND: Osteoporosis is associated with changes in balance and physical performance and has psychosocial consequences which increase the risk of falling. Most falls occur during walking; therefore an efficient obstacle avoidance performance might contribute to a reduction in fall risk. Since it was shown that persons with osteoporosis are unstable during obstacle crossing it was hypothesized that they more frequently hit obstacles, specifically under challenging conditions. METHODS: Obstacle avoidance performance was measured on a treadmill and compared between persons with osteoporosis (n = 85) and the comparison group (n = 99). The obstacle was released at different available response times (ART) to create different levels of difficulty by increasing time pressure. Furthermore, balance confidence, measured with the short ABC-questionnaire, was compared between the groups. RESULTS: No differences were found between the groups in success rates on the obstacle avoidance task (p = 0.173). Furthermore, the persons with osteoporosis had similar levels of balance confidence as the comparison group (p = 0.091). The level of balance confidence was not associated with the performance on the obstacle avoidance task (p = 0.145). CONCLUSION: Obstacle avoidance abilities were not impaired in persons with osteoporosis and they did not experience less balance confidence than the comparison group. These findings imply that persons with osteoporosis do not have an additional risk of falling because of poorer obstacle avoidance abilities.

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Contains fulltext : 87637.pdf (Publisher’s version ) (Closed access) OBJECTIVES: The importance of early clinical experience for medical training is well documented. However, to our knowledge there are no studies that assess the influence of very early nursing attachments on the professional development and identity construction of medical students. Working as an assistant nurse while training to be a doctor may offer valuable learning experiences, but may also present the student with difficulties with respect to identity and identification issues. The aim of the present study was to describe first-year medical students' perceptions of nurses, doctors and their own future roles as doctors before and after a nursing attachment. METHODS: A questionnaire containing open questions concerning students' perceptions of nurses, doctors and their own future roles as doctors was administered to all Year 1 medical students (n=347) before and directly after a 4-week nursing attachment in hospitals and nursing homes. We carried out two confirmatory focus group interviews. We analysed the data using qualitative and quantitative content analyses. RESULTS: The questionnaire was completed by 316 students (response rate 91%). Before starting the attachment students regarded nurses as empathic, communicative and responsible. After the attachment students reported nurses had more competencies and responsibilities than they had expected. Students' views of doctors were ambivalent. Before and after the attachment, doctors were seen as interested and reliable, but also as arrogant, detached and insensible. However, students maintained positive views of their own future roles as doctors. Students' perceptions were influenced by age, gender and place of attachment. CONCLUSIONS: An early nursing attachment engenders more respect for the nursing profession. The ambivalent view of doctors needs to be explored further in relation to students' professional development. It would seem relevant to attune supervision to the age and gender differences revealed in this study. 01 juli 2010

Contains fulltext : 79755.pdf (Publisher’s version ) (Closed access) This internship in care of the elderly should become an obligatory course at all 8 medical schools in the Netherlands. The most important reasons for making it obligatory are increased aging of the population and the current lack of knowledge and skills that leads to insufficient quality and safety of healthcare for the frail elderly. In this article we describe the possible structure of such an internship in care of the elderly, based on the experiences at the Radboud University Nijmegen Medical Centre. The result of this training is that knowledge, skills and attitude in care of the elderly improved significantly. We argue that, just as all medical students are trained in paediatrics, so should all Dutch curricula for the initial medical training include an obligatory training in medicine for the aged.

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Contains fulltext : 52836.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To compare the effects of alendronate and alfacalcidol in the prevention ofglucocorticoid-related osteoporosis in patients with a rheumatic disease. DESIGN: Randomised, double-blind, double-placebo clinical trial (www. clinicaltrials.gov; number: NCT00138983). METHODS: A total of 201 patients with rheumatic disease who were starting glucocorticoid treatment at a daily dose that was equivalent to at least 7.5 mg of prednisone were randomised to alendronate (10 mg) and a placebo capsule ofalfacalcidol daily (n = 100) or alfacalcidol (1 microg) and a placebo tablet ofalendronate daily (n = 101) for 18 months. Primary outcome was change in lumbar spine bone mineral density at 18 months. The main secondary outcome was the incidence of morphometrically confirmed vertebral deformities. RESULTS: Overall, 163 patients completed the study. The bone mineral density of the lumbar spine increased by 2.1% (95% CI: 1.1-3.1) in the alendronate group and decreased by 1.9% (95% CI: -3.I--0.7) in the alfacalcidol group. At 18 months the mean difference in change in bone mineral density between the two groups was 4.0% (95% CI: 2.4-5-5). Three patients in the alendronate group had a new vertebral deformity, compared with 8 patients in the alfacalcidol group, including 5 symptomatic vertebral fractures in 3 patients; the hazard ratio was 0.4 (95% CI: 0.1-1.4). CONCLUSION: Alendronate was more effective than alfacalcidol in preventing glucocorticoid-induced bone loss during this 18-month trial in patients with rheumatic diseases who were starting glucocorticoid treatment.

Item does not contain fulltext OBJECTIVE: To study the hypothalamic-pituitary-adrenal (HPA) axis in patients with rheumatoid arthritis (RA). METHODS: Fifty patients with RA participated in 3 groups: recent onset active RA (n = 20), longstanding active RA (n = 20) and long-standing RA in remission (n = 10), and were compared with 20 healthy controls. The activity of the HPA-axis was assessed under basal conditions and in response to stress (insulin tolerance test, ITT). In addition, patients with recent onset RA underwent a corticotropin releasing hormone (CRH) test and a dexamethasone suppression test. Plasma levels of interleukin (IL)-1beta, tumor necrosis factor-alpha (TNF-alpha) and IL-6 were also measured. RESULTS: Basal plasma, salivary and urinary cortisol levels and plasma adrenocorticotropic hormone (ACTH) levels were not different between patients with RA and healthy controls. During the ITT, cortisol levels were consistently lower in RA patients than in healthy controls. ACTH levels during the ITT were not different between patients with RA and healthy controls. ACTH and cortisol responses to CRH were assessed only in patients with recent onset RA and were found to be within normal limits. Basal circulating plasma IL-6 levels were significantly higher in patients with active RA than in the other groups. CONCLUSION: Under the standardized conditions of the ITT, patients with RA have decreased plasma cortisol levels compared to healthy controls, despite elevated levels of IL-6. The defect is probably located at the adrenal level and may be of pathogenetic significance for the development of chronic arthritis.

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