Демифологизация/ремифологизация в историко-политической парадигме «Саги о Золотом веке, 1776 – 1952» Гора Видала

Zelfredzaamheid en eigen verantwoordelijkheid staan de laatste tijd sterk in de politieke belangstelling. De troonrede van 2013 stelde zelfs dat ‘de klassieke verzorgingsstaat langzaam maar zeker verandert in een participatiesamenleving’. In deze publicatie zijn we geïnteresseerd in twee bewegingen op het gebied van burgerparticipatie:de ‘zelfredzame’, waarbij burgers zelf het heft in handen nemen om hun leefomgeving te verbeteren, en de ‘beleidsbeïnvloedende’, waarbij burgers door lobbyen, stemmen, inspraak en medezeggenschap proberen richting te geven aan het beleid. In vijf Nederlandse gemeenten die veel ervaring hebben met burgerparticipatie is empirisch onderzoek gedaan naar de resultaten en de waardering van de bevolking. In alle vijf gemeenten vindt een meerderheid dat de actieve inbreng van inwoners leidt tot beter beleid dat bovendien meer aansluit bij wat mensen willen. Er is ook gezocht naar mogelijk interessante voorbeelden van burgerparticipatie in het verleden en in andere landen. Voor een vergelijking in de tijd is teruggegaan naar de vroegmoderne Nederlanden (zeventiende eeuw), toen dorpelingen en stedelingen bij gebrek aan een sterke centrale overheid zelf voor publieke voorzieningen zorgden. Voor een vergelijking met andere landen is de keus gevallen op Japan, waar burgers traditioneel de sociale ‘plicht’ hebben hun buurt op orde te houden; Groot-Brittannië, dat vanuit de filosofie van de Big Society de macht probeert te verleggen naar lokale gemeenschappen; en Duitsland, waar veel gemeenten uit financiële noodzaak taken overdragen aan hun inwoners

Games to support teaching clinical reasoning in health professions education:a scoping review

INTRODUCTION: Given the complexity of teaching clinical reasoning to (future) healthcare professionals, the utilization of serious games has become popular for supporting clinical reasoning education. This scoping review outlines games designed to support teaching clinical reasoning in health professions education, with a specific emphasis on their alignment with the 8-step clinical reasoning cycle and the reflective practice framework, fundamental for effective learning.METHODS: A scoping review using systematic searches across seven databases (PubMed, CINAHL, ERIC, PsycINFO, Scopus, Web of Science, and Embase) was conducted. Game characteristics, technical requirements, and incorporation of clinical reasoning cycle steps were analyzed. Additional game information was obtained from the authors.RESULTS: Nineteen unique games emerged, primarily simulation and escape room genres. Most games incorporated the following clinical reasoning steps: patient consideration (step 1), cue collection (step 2), intervention (step 6), and outcome evaluation (step 7). Processing information (step 3) and understanding the patient's problem (step 4) were less prevalent, while goal setting (step 5) and reflection (step 8) were least integrated.CONCLUSION: All serious games reviewed show potential for improving clinical reasoning skills, but thoughtful alignment with learning objectives and contextual factors is vital. While this study aids health professions educators in understanding how games may support teaching of clinical reasoning, further research is needed to optimize their effective use in education. Notably, most games lack explicit incorporation of all clinical reasoning cycle steps, especially reflection, limiting its role in reflective practice. Hence, we recommend prioritizing a systematic clinical reasoning model with explicit reflective steps when using serious games for teaching clinical reasoning.</p

Myocard Infarct en Cerebrovasculair Accident keten (MICK) studie

For patients with acute coronary syndrome (ACS) and stroke prompt diagnosis and treatment is essential. Before a patient reaches the hospital he may have had contact with a general practitioner (GP), a GP cooperative (GPC), ambulance service, or Emergency Department. Optimal use and efficient functioning of the acute health care chain is imperative. The aim of the MICK study is to obtain insight into circumstances in which symptoms of patients occur, medical contacts throughout the acute care chain, delays, door-to-balloon and door-to-needle time. This is a prospective observational study including 202 patients suspected of having ACS and 239 suspected of ischemic stroke. Patients filled out a questionnaire and additional data was obtained using registries.\ud Over 40% of all patients suspected of ACS waited more than 6 hours before contacting a health care provider and over 30% of all patients suspected of having a stroke waited more than 4 hours. Patients reached the hospital through many different health care chains. Once a care provider was contacted, 45% of all patients with ACS were hospitalized within 90 minutes at the CCU and 65% of patients with stroke within 4 hours at the stroke unit.\ud Most patients first contacted the GP or GPC. For patients who immediately called 112 time to hospitalization was the shortest.\ud Overall are noticeable the long patient delays in seeking care, the various chains through which patients reach the CCU or stroke unit and the different throughput times

Statistical models for quantifying diagnostic accuracy with multiple lesions per patient

We propose random-effects models to summarize and quantify the accuracy of the diagnosis of multiple lesions on a single image without assuming independence between lesions. The number of false-positive lesions was assumed to be distributed as a Poisson mixture, and the proportion of true-positive lesions was assumed to be distributed as a binomial mixture. We considered univariate and bivariate, both parametric and nonparametric mixture models. We applied our tools to simulated data and data of a study assessing diagnostic accuracy of virtual colonography with computed tomography in 200 patients suspected of having one or more polyps

Games to support teaching clinical reasoning in health professions education: a scoping review

Introduction: Given the complexity of teaching clinical reasoning to (future) healthcare professionals, the utilization of serious games has become popular for supporting clinical reasoning education. This scoping review outlines games designed to support teaching clinical reasoning in health professions education, with a specific emphasis on their alignment with the 8-step clinical reasoning cycle and the reflective practice framework, fundamental for effective learning. Methods: A scoping review using systematic searches across seven databases (PubMed, CINAHL, ERIC, PsycINFO, Scopus, Web of Science, and Embase) was conducted. Game characteristics, technical requirements, and incorporation of clinical reasoning cycle steps were analyzed. Additional game information was obtained from the authors. Results: Nineteen unique games emerged, primarily simulation and escape room genres. Most games incorporated the following clinical reasoning steps: patient consideration (step 1), cue collection (step 2), intervention (step 6), and outcome evaluation (step 7). Processing information (step 3) and understanding the patient’s problem (step 4) were less prevalent, while goal setting (step 5) and reflection (step 8) were least integrated. Conclusion: All serious games reviewed show potential for improving clinical reasoning skills, but thoughtful alignment with learning objectives and contextual factors is vital. While this study aids health professions educators in understanding how games may support teaching of clinical reasoning, further research is needed to optimize their effective use in education. Notably, most games lack explicit incorporation of all clinical reasoning cycle steps, especially reflection, limiting its role in reflective practice. Hence, we recommend prioritizing a systematic clinical reasoning model with explicit reflective steps when using serious games for teaching clinical reasoning

Invasiveness of previous treatment for peripheral arterial disease and risk of adverse cardiac events after coronary stenting

Patients with peripheral arterial disease (PADs), undergoing percutaneous coronary intervention (PCI), have higher adverse event risks. The effect of invasiveness of PADs treatment on PCI outcome is unknown. This study assessed the impact of the invasiveness of previous PADs treatment (invasive or non-invasive) on event risks after PCI with contemporary drug-eluting stents. This post-hoc analysis pooled 3-year patient-level data of PCI all-comer patients living in the eastern Netherlands, previously treated for PADs. PADs included symptomatic atherosclerotic lesion in the lower or upper extremities; carotid or vertebral arteries; mesenteric arteries or aorta. Invasive PADs treatment comprised endarterectomy, bypass surgery, percutaneous transluminal angioplasty, stenting or amputation; non-invasive treatment consisted of medication and participation in exercise programs. Primary endpoint was (coronary) target vessel failure: composite of cardiac mortality, target vessel-related myocardial infarction, or clinically indicated target vessel revascularization. Of 461 PCI patients with PADs, information on PADs treatment was available in 357 (77.4%) patients; 249 (69.7%) were treated invasively and 108 (30.3%) non-invasively. Baseline and PCI procedural characteristics showed no between-group difference. Invasiveness of PADs treatment was not associated with adverse event risks, including target vessel failure (20.5% vs. 16.0%; HR: 1.30, 95%-CI 0.75–2.26, p = 0.35), major adverse cardiac events (23.3% vs. 20.4%; HR: 1.16, 95%-CI 0.71–1.90, p = 0.55), and all-cause mortality (12.1% vs. 8.3%; HR: 1.48, 95%-CI 0.70–3.13, p = 0.30). In PADs patients participating in PCI trials, we found no significant relation between the invasiveness of previous PADs treatment and 3-year outcome after PCI. Consequently, high-risk PCI patients can be identified by consulting medical records, searching for PADs, irrespective of the invasiveness of PADs treatment. Graphical abstract: (Figure presented.) Comparison of patients with non-invasive and invasive PADs treatment. PADs peripheral arterial disease, PCI percutaneous coronary intervention.</p

Antithrombotic therapy in patients undergoing TAVI: an overview of Dutch hospitals

To assess current antithrombotic treatment strategies in the Netherlands in patients undergoing transcatheter aortic valve implantation (TAVI). For every Dutch hospital performing TAVI (n = 14) an interventional cardiologist experienced in performing TAVI was interviewed concerning heparin, aspirin, thienopyridine and oral anticoagulation treatment in patients undergoing TAVI. The response rate was 100 %. In every centre, a protocol for antithrombotic treatment after TAVI was available. Aspirin was prescribed in all centres, concomitant clopidogrel was prescribed 13 of the 14 centres. Duration of concomitant clopidogrel was 3 months in over two-thirds of cases. In 2 centres, duration of concomitant clopidogrel was based upon type of prosthesis: 6 months versus 3 months for supra-annular and intra-annular prostheses, respectively. Leaning on a small basis of evidence and recommendations, the antithrombotic policy for patients undergoing TAVI is highly variable in the Netherlands. As a standardised regimen might further reduce haemorrhagic complications, large randomised clinical trials may help to establish the most appropriate approac

Prediction meets causal inference: the role of treatment in clinical prediction models

In this paper we study approaches for dealing with treatment when developing a clinical prediction model. Analogous to the estimand framework recently proposed by the European Medicines Agency for clinical trials, we propose a ‘predictimand’ framework of different questions that may be of interest when predicting risk in relation to treatment started after baseline. We provide a formal definition of the estimands matching these questions, give examples of settings in which each is useful and discuss appropriate estimators including their assumptions. We illustrate the impact of the predictimand choice in a dataset of patients with end-stage kidney disease. We argue that clearly defining the estimand is equally important in prediction research as in causal inference

Coronary–aortic interaction during ventricular isovolumic contraction

In earlier work, we suggested that the start of the isovolumic contraction period could be detected in arterial pressure waveforms as the start of a temporary pre-systolic pressure perturbation (AICstart, start of the Arterially detected Isovolumic Contraction), and proposed the retrograde coronary blood volume flow in combination with a backwards traveling pressure wave as its most likely origin. In this study, we tested this hypothesis by means of a coronary artery occlusion protocol. In six Yorkshire × Landrace swine, we simultaneously occluded the left anterior descending (LAD) and left circumflex (LCx) artery for 5 s followed by a 20-s reperfusion period and repeated this sequence at least two more times. A similar procedure was used to occlude only the right coronary artery (RCA) and finally all three main coronary arteries simultaneously. None of the occlusion protocols caused a decrease in the arterial pressure perturbation in the aorta during occlusion (P > 0.20) nor an increase during reactive hyperemia (P > 0.22), despite a higher deceleration of coronary blood volume flow (P = 0.03) or increased coronary conductance (P = 0.04) during hyperemia. These results show that the pre-systolic aortic pressure perturbation does not originate from the coronary arteries