A system of networks and continuing education for physical therapists in rheumatology: a feasibility study

PURPOSE: To evaluate the feasibility of regional physical therapy networks including continuing education in rheumatology. The aim of these networks was to improve care provided by primary care physical therapists by improving specific knowledge, technical and communicative skills and the collaboration with rheumatologists. METHODS: In two regions in The Netherlands continuing education (CE) programmes, consisting of a 5-day postgraduate training course followed by bimonthly workshops and teaching practices, were organised simultaneously. Network activities included consultations, newsletters and the development of a communication guideline. Endpoint measures included the participation rate, compliance, quality of the CE programme, teaching practices, knowledge, network activities, communication, number of patients treated and patient satisfaction. RESULTS: Sixty-three physical therapists out of 193 practices (33%) participated in the project. They all completed the education programmes and were formally registered. All evaluations of the education programmes showed positive scores. Knowledge scores increased significantly directly after the training course and at 18 months. A draft guideline on communication between physical therapists and rheumatologists was developed, and 4 newsletters were distributed. A substantial proportion of physical therapists and rheumatologists reported improved communication at 18 months. The mean number of patients treated by physical therapists participating in the networks increased significantly. Patients' satisfaction scores within the networks were significantly higher than those from outside the networks at 18 months. CONCLUSIONS: Setting up a system of networks for continuing education for physical therapists regarding the treatment of patients with rheumatic diseases is feasible. Further research will focus on the effectiveness of the system and its implementation on a larger scale

Final height in girls with turner syndrome after long-term growth hormone treatment in three dosages and low dose estrogens

Although GH treatment for short stature in Turner syndrome is an accepted treatment in many countries, which GH dosage to use and which age to start puberty induction are issues of debate. This study shows final height (FH) in 60 girls with Turner syndrome treated in a randomized dose-response trial, combining GH treatment with low dose estrogens at a relatively young age. Girls were randomly assigned to group A (4 IU/m(2).d; approximately 0.045 mg/kg/d), group B (first year, 4 IU/m(2).d; thereafter 6 IU/m(2).d), or group C (first year, 4 IU/m(2).d; second year, 6 IU/m(2).d; thereafter, 8 IU/m(2).d). After a minimum of 4 yr of GH treatment, at a mean age of 12.7 +/- 0.7 yr, low dose micronized 17beta-estradiol was given orally. After a mean duration of GH treatment of 8.6 +/- 1.9 yr, FH was reached at a mean age of 15.8 +/- 0.9 yr. FH, expressed in centimeters or SD score, was 157.6 +/- 6.5 or -1.6 +/- 1.0 in group A, 162.9 +/- 6.1 or -0.7 +/- 1.0 in group B, and 163.6 +/- 6.0 or -0.6 +/- 1.0 in group C. The difference in FH in centimeters, corrected for height SD score and age at start of treatment, was significant between groups A and B [regression coefficient, 4.1; 95% confidence interval (CI), 1.4, 6.9; P < 0.01], and groups A and C (coefficient, 5.0; 95% CI, 2.3, 7.7; P < 0.001), but not between groups B and C (coefficient, 0.9; 95% CI, -1.8, 3.6). Fifty of the 60 girls (83%) had reached a normal FH (FH SD score, more than -2). After starting estrogen treatment, the decrease in height velocity (HV) changed significantly to a stable HV, without affecting bone maturation (change in bone age/change in chronological age). The following variables contributed significantly to predicting FH SD score: GH dose, height SD score (ref. normal girls), chronological age at start of treatment, and HV in the first year of GH treatment. GH treatment was well tolerated. In conclusion, GH treatment leads to a normalization of FH in most girls, even when puberty is induced at a normal pubertal age. The optimal GH dosage depends on height and age at the start of treatment and first year HV

Asymptomatic testicular adrenal rest tumours in adolescent and adult males with congenital adrenal hyperplasia: basal and follow-up investigation after 2.6 years.

Contains fulltext : 58608.pdf (publisher's version ) (Open Access)AIM: To study the course of asymptomatic testicular adrenal rest tumours in patients with congenital adrenal hyperplasia (CAH) and the association between tumour changes and glucocorticoid therapy adjustments. PATIENTS AND METHODS: Fifteen male patients with CAH (21-hydroxylase deficiency), in whom asymptomatic testicular adrenal rest tumours had been found at a baseline investigation, underwent scrotal ultrasonography and venous blood sampling (for LH, FSH and testosterone) on average 2.6 years later. The level of hormonal control was assessed by measurement of androstenedione in three diurnal saliva samples. Data on changes in glucocorticoid therapy since baseline were obtained from the patients' records. RESULTS: Tumour decrease, defined as > or =30% decrease in the sum of the longest diameter(s) of the lesion(s), was found in six patients; tumour increase, defined as > or =20% increase, in six and stable tumours in three patients. All three patients with overtreatment showed tumour decrease and of the six patients with undertreatment only one showed tumour decrease. Tumour increase was not only observed in undertreated patients but also in patients with adequate treatment. Changing the night dose of hydrocortisone into dexamethasone, to obtain prolonged ACTH suppression, had resulted in better adrenal suppression in only one patient. CONCLUSIONS: Tumour decrease could be achieved by aiming at adrenal oversuppression, but the required high glucocorticoid doses may induce side effects. In asymptomatic tumours in young male patients with CAH, a practical guideline could be to optimise adrenal suppression to a maximal tolerable glucocorticoid dose and to offer analysis and cryopreservation of semen as soon as the patient can be motivated

Modern scleral lenses part II: patient satisfaction.

Item does not contain fulltextPURPOSE: To evaluate the subjective performance of modern scleral lenses in patients of the clinics of Visser Contact Lens Practice. METHODS: In this cross-sectional survey, all the necessary data were collected at the first follow-up visit during the 5-month study period. In accordance with the preformed fitting technique developed at Visser Contact Lens Practice, four types of scleral lenses were used: spherical, front-surface toric, back-surface toric, and bitoric. Subjective performance was investigated during an interview that included the use of a five-point Likert scale and by means of a questionnaire supplemented by a 100-mm visual analog scale (VAS). RESULTS: The interview and questionnaire showed high scores for patient satisfaction with the current scleral lens in the 178 patients (284 eyes) (median score, 4; range Likert scale, 1-5; median score, >or=75; range VAS, 1-100). Significant increases in scores were seen with the current scleral lens compared to the former correction: 78.9% for comfort, 78.2% for visual quality, and 87.7% for overall satisfaction (n=284 eyes) (P<0.001). In the 99 eyes that switched from back-surface spherical to back-surface toric designs, the following significant increases were seen: 61.6%, 37.4%, and 65.7%, respectively (P<0.001). CONCLUSIONS.: High patient satisfaction was seen with all the modern scleral lens designs in the management of several forms of corneal abnormality. The interview showed differences in comfort, visual quality, and overall satisfaction in favor of the back-surface toric designs compared to the back-surface spherical designs

Verschillen in hulpverlening bij patienten met vage klachten: het ontwikkelen van instrumenten voor het meten van huisartsgeneeskundig handelen.

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Modern scleral lenses part I: clinical features.

Item does not contain fulltextPURPOSE: To evaluate the indications for modern scleral lenses and their clinical performance in patients who were fitted with scleral lenses at the authors' practices. METHODS: In this cross-sectional survey, all the necessary data were obtained at the first follow-up visit during the 5-month study period. There were four types of scleral lenses: spherical, front-surface toric, back-surface toric, and bitoric. The preformed scleral lens fitting technique developed at Visser Contact Lens Practice was used in all patients. The lenses were cut by precise Sub Micron Lathing from a Boston Equalens II blank at Procornea. Visual acuity and slitlamp findings were recorded. A specially designed classification for scleral lens fitting was used to investigate clinical performance. RESULTS: The largest proportion of the 178 patients (284 eyes) were diagnosed with keratoconus (143 [50.4%] eyes) followed by postpenetrating keratoplasty (56 [19.7%] eyes). The remaining diagnoses were irregular astigmatism, keratitis sicca, corneal dystrophy, and multiple diagnoses. The ratio of spherical to back-surface toric designs was 1:1.1. Clinical examination showed sharp increases in visual acuity (median increase, 0.45) and safe physiologic responses of the anterior eye. All the patients could continue to wear scleral lenses, with 79.2% with the same lens parameters. CONCLUSIONS: Several types of corneal abnormality were managed successfully with modern scleral lenses. The main indication was optical correction of an irregular corneal surface. Satisfactory clinical performance meant that all the patients could continue to wear their scleral lenses

Emotional, external and restrained eating behaviour and BMI trajectories in adolescence

Contains fulltext : 116481.pdf (publisher's version ) (Closed access)Individual differences in eating behaviours might partly explain the variations in development of weight gain and subsequent overweight and obesity. In the current study, identified trajectories of BMI in adolescence and their associations with restrained, emotional and external eating were tested. For the assessment of BMI trajectories growth mixture modelling was used; a method used to identify clusters of individuals within a population that follow distinct developmental trajectories. In total 328 Dutch adolescents (13-15 years old at baseline) self-reported their height and weight at five annual waves and their eating behaviour at baseline. Development of BMI was best fitted in five distinct trajectories that showed similar moderate increase of BMI over time; parallel but at a different level. High restrained eaters had a higher chance of being in the higher BMI trajectories. Emotional and external eating were unrelated to the BMI trajectories. In conclusion, adolescents in this study followed very parallel patterns of moderate increases in BMI which suggests that factors acting on individual differences in weight status have had their influence mostly at a - perhaps much - younger age. Restraint eating was related to BMI in early adolescence, but not to an increases or decreases in BMI over the course of adolescence

Written simulation of patient-doctor encounters (1): research instrument for registration of the performance of general practitioners.

A written simulation of patient-doctor encounters is described, involving five patients with vague complaints, an 'instruction' patient with sinusitis and a 'test' patient with acute appendicitis. Nineteen general practitioners were confronted with it. The extent to which the simulation distorted reality and the implications of such distortions were considered in an attempt to assess the content validity. The conclusion was that the simulation gave a realistic impression of the general practitioners' diagnostic and therapeutic approach to patients with vague complaints. The searching procedures in relation to the complaint and the patient's perception of the complaint were adequately depicted, and the therapeutic procedures approximated closely to reality. There was some distortion in the attention paid to psychosocial aspects as these were given more attention in the simulation than they receive in reality. (aut. ref.

Written Simulation of Patient-Doctor Encounters (3): Comparison of the Performance in the Simulation with prescription an Referral Date in Reality.

The performance of 19 general practitioners in a written simulation of patient-doctor encounters was compared with real data on prescription and referral from 'sick-fund' patients. Two issues were studied: the amounts of certain drugs prescribed (analgesics and antirheumatics; sypnotics /sedatives and tranquillizers; neuroleptics and antidepressants) and the number of referrals to specialists. In the simulation, experts assessed the 'risk of unnecessary harm to the patient' induced by the therapeutic procedures of these general practitioners, as described previously. A close correlation was found between the ratings of the risk of unnecessary harm in the simulation and the prescription and referral data in reality for general practitioners who were consistently generous or frugal in prescribing the above drugs and referring the patients to specialists. The tentative conclusion is that the written simulation with its rating procedure discriminates reliably between general practitioners who induce less risk of unnecessary harm from those who are likely to cause harm to the patient. (aut. ref.