Balancing supply and demand for dementia care in the Netherlands

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The Paradox of More Flexibility in Education: Better Control of Educational Activities as a Prerequisite for More Flexibility

International audienceThe paradigm shift towards competency-based education in the Netherlands has a logical counterpart: the need for more flexibility in the curricula. After all, in competency-based education it is recognized that learning not only takes place in designated places (school, university), but may happen every time when the learner is confronted with a challenge. This observation leads to the necessity to incorporate the learning outcomes of formal and informal education in one curriculum. As a result, the educational process becomes more complex and must be better structured to control the individual learning outcomes. In this paper we discuss this paradox: how more flexibility in the program creates the need for more control in the process. We also discuss what kind of IT-tools are helpful in controlling flexibility in curricula for higher professional education

Commitment and competence in solving work performance problems

In this article, three authors from Nijenrode University and one from the Hotelschool at The Hague, bridge the gap between theory and practice in solving problems of employees' work performance. They explain that an integration of a conceptual framework in this field with a problem-orientated approach will allow management to take better decisions. The authors list critical questions to be asked, in this problem-solving process. They also argue that competence and commitment should be added to existing variables affecting work performance.

The prognostic importance of heart failure and age in patients treated with primary angioplasty

Background: Effective risk stratification is essential in the management of patients with acute myocardial infarction. Available models have not yet been studied and validated in patients treated with primary angioplasty for acute myocardial infarction. Methods: The prognostic value of heart failure defined by Killip class and age upon admission and the impact of success and failure of the angioplasty procedure was studied in 1702 consecutive patients treated with primary angioplasty. Findings: The combination of Killip class and age is a strong predictor of 30-day mortality and categorizes patients in subgroups with 30-day mortality risk ranging from 0.5 to 70%. Angioplasty failure results in a high 30-day mortality, in particular in patients with Killip class greater than or equal toII and/or age greater than or equal to70 years. A large majority of patients (72%), characterized by Killip class I and ag

Unsuccessful reperfusion in patients with ST-segment elevation myocardial infarction treated by primary angioplasty

Background Several studies have shown that patency of the epicardial vessel does not guarantee optimal myocardial perfusion in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify clinical and angiographic correlates of unsuccessful reperfusion by the use of myocardial blush grade in a large consecutive cohort of STEMI patients. Methods Our population is represented by a total of 1548 consecutive patients with STEMI treated by primary angioplasty at our institution. All clinical and angiographic data were prospectively collected. Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow with myocardial blush grades 2 to 3. Results Poor myocardial reperfusion was observed in 358 patients (23.1%) and was associated with a significantly larger infarct size (1838 [350-3387] vs 1187 [607-2257], P <.0001) and lower ejection fraction (41 [31-48.2] vs 65 [36.5-52.5], P <.0001). At multivariate analysis, preprocedural TIMI flow 0 to 1, anterior infarction, ischemic time, postprocedural residual stenosis, advanced Killip class at presentation, and age were identified as independent predictors of poor myocardial reperfusion. At 1-year follow-up, a total of 92 patients (5.9%) had died. At multivariate analysis, including clinical and angiographic variables, unsuccessful reperfusion was an independent predictor of 1-year mortality (relative risk 3.11, 95% CI 1.99-4.87, P <.0001). Conclusions The prevalence of poor myocardial reperfusion is relatively high in patients undergoing primary angioplasty for STEMI, with a significant impact on 1-year mortality. Preprocedural TIMI flow, anterior infarction, ischemic time, Killip class at presentation, and age were independently associated with unsuccessful reperfusion. Future research should be focused on these high-risk patients, and treatment strategies should be developed to improve myocardial perfusion and clinical outcome

Pre-treatment with clopidogrel and postprocedure troponin elevation after elective percutaneous coronary intervention

Elevated troponin after elective percutaneous coronary intervention (PCl) has been associated with a worse prognosis. Pretreatment with clopidogrel may be beneficial in patients undergoing PCl. Therefore, a prospective observational study was conducted to address the potential role of clopidogrel in reducing troponin release after elective PCl.Troponin T was measured 12 hours after elective PCl in 656 patients without elevated troponin before PCl. To assess the independent association between pre-treatment with clopidogrel and increased troponin, multivariate analyses were performed. Mean age of the 656 patients was 63.5 years (SD 10.2), 194 patients (30%) were female and 114 patients (17.4%) had diabetes. In 217 patients (33%) troponin was increased after PCl. Of the 330 patients who were not pre-treated with dopidogrel, 118 patients (34%) had increased troponin after the PCl compared to 99 patients (30%) of the 326 patients who were treated with clopidogrel longer than 24 hours before the procedure (p=0.14). Stratified analyses showed that patients with older age (p=0.03), previous PCl (p=0.013), angina CCS 4 (p=0.03) and multivessel disease (p=0.04) had a significantly lower risk of troponin increase after pre-treatment with clopidogrel compared to patients without pre-treatment. After adjusting for differences in the other variables, patients who were pre-treated with clopidogrel had a significant lower risk of post-PCl increase of troponin T (odds ratio 0.69, 95% confidence interval 0.49-0.99). Pre-treatment with clopidogrel is associated with a significantly lower incidence of increased troponin after elective PCl. Combined with results of other studies, pre-treatment should be advised in patients waiting for elective PCl

A quantitative analysis of the benefits of pre-hospital infarct angioplasty triage on outcome in patients undergoing primary angioplasty for acute myocardial infarction

Primary coronary angioplasty has been shown to be a very effective reperfusion modality in patients with acute myocardial infarction (MI). However, the time from diagnosis to therapy is often very long, often due to interhospital transfer of the patient. This study evaluates the effect of improving logistics by early infarct diagnosis in the ambulance (ambulance group) and subsequent transportation to a percutaneous coronary intervention (PCI) centre without visiting a nearby non-PCI clinic (referred group). Pre-hospital infarct diagnosis and triage in the ambulance (n=209) were compared with triage at a referral non-PCI centre (n=258) in patients included in the On-TIME (Ongoing Tirofiban In Myocardial infarction Evaluation) study. Baseline characteristics of the two patient groups did not differ significantly, with the exception of a higher prevalence of males in the ambulance group. The ambulance group had a significantly shorter time to treatment (177 vs. 208 min; P <0.01), a higher initial patency rate (44 vs. 35%; P=0.045), a better extent of myocardial reperfusion (myocardial blush grade 3: 59 vs. 47%; P=0.02), a trend toward a higher prevalence of aborted MI (15 vs. 10%; P=0.08), and a significantly lower rate of death or re-MI at 1 year of follow-up (3 vs. 10%; P=0.004). It was concluded that early, pre-hospital infarct diagnosis in the ambulance with immediate transportation to the nearest PCI centre is associated with a shorter time to treatment and improved angiographic and clinical outcomes compared with referral from a non-PCI centre in patients who are candidates to undergo primary angioplasty for acute MI

Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction

OBJECTIVES This study was designed to investigate whether elevated glucose is associated with impaired Thrombolysis In Myocardial Infarction (TIMI) flow before primary percutaneous coronary intervention (PCI). BACKGROUND Reperfusion before primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) is associated with an improved outcome. Hyperglycemia in patients with STEMI is associated with an adverse prognosis. Hyperglycemia may induce a pro-thrombotic state and therefore be of influence on TIMI flow before PCI. METHODS A total of 460 consecutive patients with STEMI treated with primary PCI were included in this analysis. Hyperglycemia was defined as a glucose >= 7.8 mmol/l (140 mg/dl). RESULTS Hyperglycemia was observed in 70% and TIMI flow grade 3 before primary PCI in 17% of the patients. Patients with hyperglycemia less often had TIMI flow grade 3 before primary PCI (12% vs. 28%, p <0.001). After adjustment for differences in baseline variables, hyperglycemia was a strong predictor of absence of reperfusion before primary PCI (odds ratio 2.6, 95% confidence interval 1.5 to 4.5). CONCLUSIONS Hyperglycemia in patients with STEMI is an important predictor of impaired epicardial flow before reperfusion therapy has been initiated. Investigation of methods improving coronary flow before primary PCI in these patients is warranted. (c) 2005 by the American College of Cardiology Foundation

Glucose-insulin-potassium infusion inpatients treated with primary angioplasty for acute myocardial infarction: The glucose-insulin-potassium study: a randomized trial

Objectives\ud In this study we considered the question of whether adjunction of glucose-insulin-potassium (GIK) infusion to primary coronary transluminal angioplasty (PTCA) is effective in patients with an acute myocardial infarction (MI).\ud \ud Background\ud A combined treatment of early and sustained reperfusion of the infarct-related coronary artery and the metabolic modulation with GIK infusion has been proposed to protect the ischemic myocardium.\ud \ud Methods\ud From April 1998 to September 2001, 940 patients with an acute MI and eligible for PTCA were randomly assigned, by open-label, to either a continuous GIK infusion for 8 to 12 h or no infusion.\ud \ud Results\ud The 30-day mortality was 23 of 476 patients (4.8%) receiving GIK compared with 27 of 464 patients (5.8%) in the control group (relative risk [RR] 0.82, 95% confidence interval [CI] 0.46 to 1.46). In 856 patients (91.1%) without signs of heart failure (HF) (Killip class 1), 30-day mortality was 5 of 426 patients (1.2%) in the GIK group versus 18 of 430 patients (4.2%) in the control group (RR 0.28, 95% CI 0.1 to 0.75). In 84 patients (8.9%) with signs of HF (Killip class ≥2), 30-day mortality was 18 of 50 patients (36%) in the GIK group versus 9 of 34 patients (26.5%) in the control group (RR 1.44, 95% CI 0.65 to 3.22).\ud \ud Conclusions\ud Glucose-insulin-potassium infusion as adjunctive therapy to PTCA in acute MI did not result in a significant mortality reduction in all patients. In the subgroup of 856 patients without signs of HF, a significant reduction was seen. The effect of GIK infusion in patients with signs of HF (Killip class ≥2) at admission is uncertain\u