Rheumatoid arthritis and glucocorticoids; the contribution of a literature search to the development of a EULAR recommendation on treatment with glucocorticoids in RA.

In 2010 the EULAR recommendations on the treatment of rheumatoid arthritis (RA) was published. The search for evidence for treatment of rheumatoid arthritis with glucocorticoids and the development of a EULAR Task Force Guideline on this subject is described in this paper.

Intensive care medicine trainees' perception of professionalism: a qualitative study.

The Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows' views on professionalism is available. A nationwide qualitative study was performed. The moderator asked participants to clarify the terms professionalism and professional behaviour, and to explore the questions "How do you learn the mentioned aspects?" and "What ways of learning do you find useful or superfluous?". Qualitative data analysis software (MAXQDA2007) facilitated analysis using an inductive coding approach. Thirty-five fellows across eight groups participated. The themes most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organisation and management. Medical knowledge, expertise and technical skills seem to become more tacit when training progresses. Topics can be categorised into themes of workplace-based learning, by gathering practical experience, by following examples and receiving feedback on action, including learning from own and others' mistakes. Formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. The emerging themes considered most relevant for intensivists were adequate communication skills and keeping boundaries with patients and relatives. Professionalism is mainly learned 'on the job' from role models in the intensive care unit. Formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. Self-reflection as a starting point for learning professionalism was stressed.

Current evidence for the management of rheumatoid arthritis with glucocorticoids: a systematic literature review informing the EULAR recommendations for the management of rheumatoid arthritis.

Glucocorticoids (GCs) rapidly reduce disease activity in early and advanced rheumatoid arthritis (RA). This systematic review on behalf of the task force on recommendations for the management of RA addresses the efficacy of GCs in RA. A literature search was performed in Medline, Embase, the Cochrane database, and the ACR/EULAR abstracts 2007 and 2008 on a set of questions relating to the use of GCs in RA. Eleven publications (including three Cochrane reviews comprising 33 trials) that met the criteria for detailed assessment were found. Robust evidence that GCs are effective as bridging therapy was obtained. The addition of GCs, to either standard synthetic disease-modifying antirheumatic drug (DMARD) monotherapy or combinations of synthetic DMARDs, yields clinical benefits and inhibition of radiographic progression that may extend over many years. In early RA, the addition of low-dose GCs (<7.5 mg/day) to DMARDs leads to a reduction in radiographic progression; in longstanding RA, GCs (up to 15 mg/day) improve disease activity. There is some evidence that appropriate timing of GC administration may result in less morning stiffness. Only indirect information was found on the best tapering strategy, supporting the general view that GCs should be tapered slowly in order to avoid clinical relapses. GCs are effective in relieving signs and symptoms and inhibiting radiographic progression, either as monotherapy or in combination with synthetic DMARD monotherapy or combination therapy.

The role of a computerised case-based testing procedure in practice performance assessment.

INTRODUCTION: For postgraduate training of doctors there is a need for valid and reliable instruments to assess their daily performance. Various instruments have been suggested, some of which use incognito simulated patients (SPs). These methods are resource intensive. Computerised Case-based testing (CCT) is logistically simpler and may still predict performance well. The research question was to evaluate the predictive validity of CCT for performance. METHODS: Seventeen rheumatologists were each visited by eight incognito SPs presenting various rheumatological complaints, and scoring the performance of the rheumatologists using a predefined checklist. From this checklist a panel of experts identified essential items. In addition the rheumatologists sat a CCT test containing 55 cases with a total of 121 items. RESULTS: Negative correlations were found between the SP scores and the CCT scores. This was unexpected. Therefore, background variables on experience were used to compare both methods. The correlation between these and CCT were high and positive and with the SP scores high and negative. This pattern did not differ when using the essential items of the checklist. Reliabilities of the SP scores were markedly high. DISCUSSION: Although CCT was not predictive of SP scores, it was related to working experience. There are good reasons to assume that although SP-scores were more authentic, they were less valid than CCT scores, mainly because they focussed more on thoroughness than on efficiency in data gathering. The results underpin the assumption that for valid performance assessment the most important issue is what information about the candidate is collected and now how authentic the method is.

Unique reactivity of a tetradentate N(2)S(2) complex of nickel: intermediates in the production of sulfur oxygenates.

Complex 1 [(N,N'-dimethyl-N,N'-bis(2-sulfanylethyl)ethylenediamine)nickel(II)], previously shown to react with H(2)O(2) to produce the fully oxygenated disulfonate 5 [diaqua(N,N'-dimethyl-N,N'-bis(2-sulfonatoethyl)ethylenediamine)nickel(II)], has been explored in detail to explain the observed reactivity of this compound and to discern intermediates in the oxygenation reaction. Reaction of 1 with 1 equiv of methyl iodide results in the monomethylated square-planar nickel complex 2 [[(N,N'-dimethyl-N-(2-sulfanylethyl)-N'-(2-methylthioethyl)(ethylenediamine)nickel(II)] iodide], while a slight excess of methyl iodide results in the dimethylated complex 3 [diiodo(N,N'-dimethyl-N,N'-bis(2-methylthioethyl)ethylenediamine)nickel(II)], an X-ray structure of which has shown that the nickel ion is in an octahedral N(2)S(2)I(2) environment. Crystal data of 3: monoclinic, a = 8.865(3) A, b = 14.419(4) A, c = 14.389(6) A, beta = 100.19(3) degrees, V = 1810.2(12) A(3), space group P2(1)/n, Z = 4. The equatorial positions are occupied by the two cis-amine N-atoms and the coordinated iodides, while the axial positions are occupied by the thioether sulfur atoms. In organic solvents, the dithiolate complex 1 reacts with molecular oxygen or H(2)O(2) to produce the mixed sulfinato/thiolato complex 4 [(N,N'-dimethyl-N-(2-sulfanylethyl)-N'-(2-sulfinatoethyl)(ethylenediamine)nickel(II)], and the fully oxidized product 5. X-ray analysis of complex 4 reveals a square-planar geometry in which the nickel ion is coordinated by two cis-amine nitrogens, one thiolate sulfur donor, and one sulfinato sulfur donor. Crystal data of 4: orthorhombic, a = 11.659(2) A, b = 13.119(3) A, c = 16.869(3) A, V = 2580.2(9) A(3), space group Pbca, Z = 8. This complex is the only intermediate in the oxygenation reaction that could be isolated, and it is shown to be further reactive toward O(2) to yield the fully oxidized product 5. For a better understanding of the reactivity observed for 4, DFT calculations have been undertaken, which show a possible reaction path toward the fully oxidized product 5.

Psoriatic arthritis: performance of rheumatologists in daily practice.

OBJECTIVES: To assess, using standardised patients (SPs), how rheumatologists diagnose psoriatic arthritis, whether the diagnostic efficiency is influenced by specific characteristics of the rheumatologists, and to study the relationship with costs. METHODS: Twenty three rheumatologists were each visited by one of two SPs (one male, one female) presenting as a patient with psoriatic arthritis. SPs remained incognito for all meetings for the duration of the study. Immediately after the encounter, SPs completed case-specific checklists on the medical content of the encounter. Information on ordered laboratory and imaging tests was obtained from each hospital. RESULTS: Fourteen rheumatologists diagnosed psoriatic arthritis correctly. They inspected the skin for psoriatic lesions more often than those rheumatologists who established other diagnoses. Rheumatologists diagnosing psoriatic arthritis spent more on additional laboratory and imaging investigations. These were carried out after the diagnosis to confirm it and to record the extent and severity of the disease. No differences in type of practice, number of outpatients seen each week, working experience, or sex were found between rheumatologists who made the correct diagnosis and those who made other diagnoses. The correct diagnosis was more often missed by rheumatologists who saw the male SP, who presented with clear distal interphalangeal DIP joint arthritis only, causing confusion with osteoarthritis of the DIP joints. CONCLUSION: There is a considerable amount of variation in the delivery of care among rheumatologists who see an SP with psoriatic arthritis. Rheumatologists focusing too much on the most prominent features (DIP joint arthritis) sometimes seem to forget "the hidden (skin) symptoms".

Rhemulatologists' performance in dailiy practice.

OBJECTIVE: To assess rheumatologists' performance for 8 rheumatologic conditions and to explore possible explanatory factors. METHODS: After written informed consent was obtained, 27 rheumatologists (21% of all Dutch rheumatologists) practicing in 16 outpatient departments were each visited by 8 incognito "standardized patients" (SPs). The diagnoses of these 8 cases account for about 23% of all new referred patients in the Netherlands. Results for ordered lab tests as well as real radiographs with corresponding results from a radiologist were simulated. Information from the visits was obtained from the SPs, who completed predefined case-specific checklists, and by collecting data on resource utilization. Feedback was provided. RESULTS: Altogether 254 encounters took place, of which 201 were first visits and 53 were followup visits. SPs were unmasked twice during a visit. There was considerable variation in resource utilization (lab tests and imaging) between cases and between rheumatologists. Mean costs per rheumatologist ranged from US $ 4.67 to $ 65.36 per visit for lab tests and from US $ 33.15 to $ 226.84 per visit for imaging tests. No significant correlations were seen between resource utilization costs and number of years of clinical experience or performance on checklist scores. Rheumatologists with longer experience had lower total item checklist scores (r = -0.47; P < 0.05). CONCLUSION: A considerable variation in resource utilization was found among 27 Dutch rheumatologists. The information obtained is an excellent source for discussion on the appropriateness of care.

Developing case-specific checklists for standardized-patient-based assessments in internal medicine: A review of the literature.

PURPOSE: To review the literature on the methods used in writing case-specific checklists for studies of internal medicine physicians' performances that were assessed by standardized patients. METHOD: The authors searched Medline, Embase, Psychlit, and ERIC for articles in English published between 1966 and February 1998. The following search string was used: "[(standardi(*) or simulat(*) or programm(*)) near (patient(*) or client(*) or consultati(*))] and internal medicine." The authors then searched the reference lists of papers retrieved from the database searches, as well as those from seven proceedings of the International Ottawa Conference on Medical Education and Assessment. RESULTS: The procedure yielded 29 relevant articles: database searches yielded 14 published reports dealing with case-specific checklists, 11 articles were culled from the reference lists of these papers, and the Ottawa Conference proceedings yielded four articles. Only 12 articles reported specifically on the development of checklists. In general, there were three sources used for developing checklists: panels of experts, the investigators themselves, and responses from expert physicians to written protocols. No article indicated that researchers had relied exclusively on data from the literature to compose their checklists. Only three articles indicated that literature sources had informed their checklist development. All articles except one relied on explicit criteria for the inclusion of items on the checklists. In 21 of the 29 articles, the checklists had been scored by SPs, but the scoring of specific items on the checklists varied according to the purpose of the SP-physician encounter. Only four of the articles made the checklists available or indicated that the checklists could be obtained from the authors. CONCLUSION: The development of case-specific checklists for SP examinations of physicians' performance has received little attention. To judge the validity of studies of physicians' performances that use SPs, the development processes for the checklists need to be more fully described to enable readers to evaluate the validity and reliability of the studies.

[Various opinions of family physicians and rheumatologists about the management of patients with rheumatoid arthritis]. / Verschillende visies van huisartsen en reumatologen op de zorg voor patiënten met reumatoïde artritis.

OBJECTIVE: To make an inventory of the opinions about professional duties and of the cooperation of general practitioners (GPs) and rheumatologists in the care of patients with rheumatoid arthritis (RA), after the publication of the standard 'Rheumatoid arthritis' issued by the Dutch College of General Practitioners in 1994. DESIGN: Descriptive. SETTING: Maastricht University, the Netherlands. METHOD: Information was collected by means of a written questionnaire submitted to a random sample of 500 GPs and all 148 (assistant) rheumatologists in the Netherlands, and by means of focus group interviews with GPs, rheumatologists and RA patients. This information focused on the opinion of both groups of professionals on their professional duties in diagnosis and management of RA, existing models of cooperation, the satisfaction with mutual consultations, experienced problems and possibilities to improve cooperation. RESULTS: Substantial differences existed between both groups of professionals in their views on the duties of the GP and the rheumatologist respectively, in the care of RA patients. GPs tended to an expectative policy in cases of suspected or even diagnosed RA, whereas rheumatologists preferred early referral. Hardly any cooperation model was found with agreements committed to paper on the mutual duties regarding RA patients. CONCLUSION: Inadequate mutual contacts and inadequate insight of both parties into each other's abilities appeared to be major problems impeding improvement of the mutual communication. Both groups recognized the need to improve the mutual cooperation.

The neuroprotective actions of a calcium channel antagonist, flunarizine, in the infant rat.

One postulated final common pathway leading to neuronal death after hypoxic-ischemic insults is an increase in intracellular calcium concentrations. We examined the effect of pretreatment with flunarizine, a calcium channel antagonist known to pass the blood brain barrier, on the behavioral and histologic changes after an hypoxic-ischemic insult in the infant rat. The 21-d-old rats were subjected to unilateral carotid ligation, then to 2 h of hypoxia. They were pretreated with either flunarizine (30 mg/kg, intraperitoneally) or with an equal volume of diluent. After 5 days of observation they were killed for histology. Acute behavioral abnormalities were observed in more controls than treatment animals, 52 vs 11% (p less than 0.002). Cerebral injury was almost entirely confined to the ligated side and was significantly worse in the control rats. Full thickness cortical infarction was noted in 56% of controls (n = 27) vs 4% of flunarizine-treated rats (n = 24), (p less than 0.001). Mean and maximum damage scores for all areas assessed including cortex, corpus striatum, thalamus, amygdala, and hippocampus were improved markedly in treatment rats (p less than 0.005). These observations confirm that flunarizine, when given prophylactically, has a neuroprotective effect against hypoxic-ischemic injury in the developing brain.